American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Disordered Eating and Eating Disorders (DE and ED)

Abstract

Approved April 2011 by the Quality Management Committee of the American Dietetic Association (ADA) House of Delegates and the Executive Committee of the Behavioral Health Nutrition Dietetic Practice Group of the ADA. Scheduled review date: August 2016. Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED) may be addressed to ADA quality management staff: Sharon McCauley, MS, MBA, RD, LDN, FADA, director, Quality Management, at [email protected] .The Behavioral Health Nutrition Dietetic Practice Group (BHN-DPG) of the American Dietetic Association (ADA), under the guidance of the ADA Quality Management Committee and Scope of Dietetics Practice Framework Sub-Committee, has developed Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians (RDs) in Disordered Eating and Eating Disorders (DE and ED). These documents build on the ADA 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: 1538-1542e9Google Scholar). ADA's 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: 1461-1467Google Scholar) and the 2008 SOP 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: 1538-1542e9Google Scholar) are tools within 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: 634-640Google 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: 459-463Google Scholar), changing in response to the expansion of knowledge, the health care environment, and technology. An RD's legal scope of practice is defined by state legislation (eg, state licensure law) 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: 634-640Google 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.ADA's Revised 2008 SOP and SOPP (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: 1538-1542e9Google 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: 1061-1072Google 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.These focus area standards for RDs in DE and ED 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 DE and ED dietetics 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 Revised SOP in Nutrition Care and SOPP, the indicators (ie, measureable action statements that illustrate how each standard can be applied in practice) (see Figure 1, Figure 2, Figure 3, available online at www.adajournal.org) for the SOP and SOPP for RDs in DE and ED were developed with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDs in DE and ED were reviewed and approved by the Executive Committee of the BHN-DPG, the Scope of Dietetics Practice Framework Sub-Committee, and ADA's Quality Management Committee.Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Three Levels of PracticeCompetent PractitionerA competent RD dietetics practitioner is starting practice after having obtained 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 attained RD status and is starting in professional employment acquires on-the-job skills and engages in tailored continuing education to enhance knowledge and skills. An RD starts with technical training and professional interaction for advancement and expanding breadth of competence. The practice of a competent RD may 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.Proficient PractitionerA proficient practitioner is an RD who is generally ≥3 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 may acquire specialist credentials, if available, to demonstrate proficiency in a focus are of practice.Expert PractitionerAn 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 dietetics through additional knowledge, experience, and/or training. An expert practitioner exhibits a set of characteristics that include 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 (6American Dietetic Association Web siteScope of Dietetic Practice Framework definition of terms.http://www.eatright.org/scopeGoogle Scholar).These Standards, along with the ADA's 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: 1461-1467Google Scholar), answer the questions: Why is an RD uniquely qualified to provide DE and ED nutrition services? What knowledge, skills, and competencies does an RD need to demonstrate for the provision of safe, effective, and quality DE and ED nutrition care at the competent, proficient, and expert levels?OverviewThe main types of eating disorders are defined by the American Psychiatric Association (APA). Currently, the APA's fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) describes anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS)—which encompasses all other disorders of eating, including binge-eating disorder (7American Psychiatric AssociationDiagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision. American Psychiatric Publishing, Arlington, VA2000Google Scholar). Problems exist in applying current DSM-IV criteria to children and adolescents, the age group at which eating disorders typically have onset. The DSM-V is being developed and will address the issue of appropriate criteria for children and adolescents (8DSM-5: The future manual.http://www.psych.org/MainMenu/Research/DSMIV/DSMV.aspxGoogle Scholar). Publication of the fifth edition is anticipated in 2013.Eating disorders represent a class of serious biologically based mental illnesses resulting from interplay among genetics, biology, temperament, and environment. These disorders are characterized by distorted perception of body image, disturbances in eating, and use of compensatory behaviors (eg, inappropriate or excessive physical activity, vomiting, or laxative or diuretic use) (9Miller C.A. Golden N.H. An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.Nutr Clin Pract. 2010; 25: 110-115Google Scholar). About 20% of child and adolescent inpatient psychiatric beds are occupied by those with an eating disorder, more than any other psychiatric diagnosis (10Klump K.L. Bulik C.M. Kaye W.E. Treasure J. Tyson E. Academy for Eating Disorders position paper: Eating disorders are serious mental illnesses.Int J Eat Disord. 2009; 42: 97-103Google Scholar). Furthermore, utilization of health care benefits for eating disorders surpasses that of any other mental health illness (10Klump K.L. Bulik C.M. Kaye W.E. Treasure J. Tyson E. Academy for Eating Disorders position paper: Eating disorders are serious mental illnesses.Int J Eat Disord. 2009; 42: 97-103Google Scholar). Adolescents who diet and develop disordered eating behaviors carry these unhealthy practices into young adulthood and beyond (11Neumark-Sztainer D. Wall M. Larson N.I. Eisenberg M.E. Loth K. Dieting and disordered eating behaviors from adolescence to young adulthood: Findings from a 10-year longitudinal study.J Am Diet Assoc. 2011; 111: 1004-1011Google Scholar). The prevalence and incidence of eating disorders is underestimated (12Hoek H.W. van Hoeken D. Review of the prevalence and incidence of eating disorders.Int J Eat Disord. 2003; 34: 384-396Google Scholar) as a result of suboptimal recognition of signs, inadequate screening, and inadequate referral network. There is variability in interpretation of diagnostic criteria, choice to not seek treatment, and limited access to health care resources (13van Son G.E. van Hoeken D. Bartelds A.I.M. van Furth E.F. Hoek H.W. Time trends in the incidence of eating disorders: A primary care study in the Netherlands.Int J Eat Disord. 2006; 39: 565-569Google Scholar, 14Herpertz-Dahlmann B. Adolescent eating disorders: Definitions, symptomology, epidemiology and comorbidity.Child Adolesc Psychiatr Clin North Am. 2008; 18: 31-47Google Scholar, 15Becker A.E. Eddy K.T. Perloe A. Clarifying criteria for cognitive signs and symptoms for eating disorders in DSM-V.Int J Eat Disord. 2009; 42: 611-619Google Scholar). As such, up to 90% of those with an eating disorder may go unrecognized or not receive treatment (16Schumann S.A. Hickner J. Suspect an eating disorder? Suggest CBT.J Fam Pract. 2009; 58: 265-268Google Scholar).The incidence of AN ranges from 4.2 to 8.3 per 100,000 persons per year and 11.5 to 13.5 per 100,000 for BN (9Miller C.A. Golden N.H. An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.Nutr Clin Pract. 2010; 25: 110-115Google Scholar). The peak age of onset for AN is estimated to be 15 to 19 years, with BN peaking somewhat later (9Miller C.A. Golden N.H. An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.Nutr Clin Pract. 2010; 25: 110-115Google Scholar). The EDNOS category accounts for approximately 60% of patients treated in outpatient settings, but it is the least studied diagnostic category (9Miller C.A. Golden N.H. An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.Nutr Clin Pract. 2010; 25: 110-115Google Scholar). Results from a large-scale national survey based on data from the National Insitutes of Health-funded National Comorbidity Survey Replication revealed that an estimated 0.6% of the US adult population has AN, 1.0% has BN, and 2.8% have binge-eating disorder (17Hudson J.I. Hiripi E. Pope H.G. Kessler R.C. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.Biological Psychiatry. 2007; 61: 348-358Google Scholar). Over the course of life, females are three times more likely than males to be diagnosed with either AN (0.9% vs 0.3%) or BN (1.5% vs 0.5%) (17Hudson J.I. Hiripi E. Pope H.G. Kessler R.C. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.Biological Psychiatry. 2007; 61: 348-358Google Scholar). The diagnosis of binge-eating disorder between females and males is more similar, although prevalence among females is higher than that of males (3.5% vs 2.0%) (17Hudson J.I. Hiripi E. Pope H.G. Kessler R.C. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.Biological Psychiatry. 2007; 61: 348-358Google Scholar).People with eating disorders frequently have coexisting mood, anxiety, impulse control, or substance use disorders (17Hudson J.I. Hiripi E. Pope H.G. Kessler R.C. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.Biological Psychiatry. 2007; 61: 348-358Google Scholar). The medical complications of an eating disorder represent the highest of any psychiatric disorder and may result in profound disability, death, or contribute to suicide (10Klump K.L. Bulik C.M. Kaye W.E. Treasure J. Tyson E. Academy for Eating Disorders position paper: Eating disorders are serious mental illnesses.Int J Eat Disord. 2009; 42: 97-103Google Scholar). Standardized mortality rates from AN are 12 times higher than the annual death rate from all causes of death among females aged 15 to 24 years among the general population (17Hudson J.I. Hiripi E. Pope H.G. Kessler R.C. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.Biological Psychiatry. 2007; 61: 348-358Google Scholar). Death from AN is reported to be anywhere from 5% to 16% (9Miller C.A. Golden N.H. An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.Nutr Clin Pract. 2010; 25: 110-115Google Scholar).The prevalence of an eating disorder among male and female athletes appears to be growing, reaching rates 10 to 50 times higher than previously thought (18Glazer J.L. Eating disorders among male athletes.Curr Sports Med Rep. 2008; 7: 332-337Google Scholar). Recent studies suggest that males experience similar levels of body dissatisfaction as females. Moreover, males who exhibit preoccupation with physique and pursuit of hypermuscularity often are found to have psychological profiles similar to that found in eating disorders and frequently exhibit disturbances in eating secondary to the central pathological exercise behavior (19Murray S.T. Rieger E. Touyz S.W. De la Garza Garcia Y. Muscle dysmorphia and the DSM-V conundrum: Where does it belong? A review paper.Int J Eat Disord. 2010; 43: 483-491Google Scholar).Miller and Golden (9Miller C.A. Golden N.H. An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.Nutr Clin Pract. 2010; 25: 110-115Google Scholar) report that estimates for prognosis of recovery from an eating disorder vary depending on diagnosis, study population, and length of follow-up. Persons with AN have a greater incidence of relapse and a higher mortality rate in comparison with persons diagnosed with other eating disorders. More than 20% of patients/clients still have an eating disorder at long-term follow-up. Adolescents with AN seem to f