Next-Generation Solutions to Address Adaptive Challenges in Dietetics Practice: The I+PSE Conceptual Framework for Action.

Abstract

Obesity, diabetes, and heart disease; health care expenditures; food insecurity and hunger; climate change; food waste; reimbursement rates for dietetics services; nutrition research funding; and, most recently, the unprecedented coronavirus disease 2019 (COVID-19) pandemic. These complex problems or “adaptive challenges” are commonplace for registered dietitian nutritionists (RDNs). An adaptive challenge is a complex situation without known solutions to the problem or too many solutions without clear choices.1Heifetz R. Grashow A. Linsky M. The Practice of Adaptive Leadership. Tools and Tactics for Changing Your Organization and the World. Cambridge Leadership Associates, 2009Google Scholar The COVID-19 pandemic has introduced unprecedented tribulations to public health, health care, and food-supply chains, and has disrupted dietetics practice, settings in which RDNs work, and the individuals and populations RDNs serve. In the face of adversity, RDNs need to reflect and ask, “Is what I am doing making a difference?” “Are there other evidence-based tools I should use?” “Who can I partner with to advance my work?” and “What can I do differently to help achieve the goals for the individuals and communities I serve?” Although many of these issues are not new, the approaches to addressing these issues are perhaps new territory for RDNs. Adaptive challenges require new learning and new behaviors for RDNs to be better prepared and to more effectively respond to emergent, complex problems. It also requires RDNs to embrace systems thinking, that is, to dig deep and uncover the root causes of the adaptive challenge, to partner with others, to be innovative and design coordinated actions, take calculated risks, and invest the time needed to shift the trajectory of complex problems.1Heifetz R. Grashow A. Linsky M. The Practice of Adaptive Leadership. Tools and Tactics for Changing Your Organization and the World. Cambridge Leadership Associates, 2009Google Scholar This article describes the Individual plus Policy, System, and Environmental (I+PSE) Conceptual Framework for Action (known as the “Framework”) as a roadmap for RDNs across all areas of practice (eg, research, education, clinical, community, and management) to better address adaptive challenges and to formulate multidimensional strategies for optimal impact. The Framework has cross-cutting practice implications for all areas of dietetics practice and can lead to the next generation of solutions to tackle adaptive challenges that better support nutrition and health. The I+PSE Conceptual Framework for Action in Figure 1 is a blueprint for RDNs and their partners to develop and implement multidimensional strategies using a systems orientation to achieve greater responsiveness to adaptive challenges and realize greater impacts.1Heifetz R. Grashow A. Linsky M. The Practice of Adaptive Leadership. Tools and Tactics for Changing Your Organization and the World. Cambridge Leadership Associates, 2009Google Scholar, 2Carey G. Malbon E. Carey N. et al.Systems science and systems thinking for public health: A systematic review of the field.BMJ Open. 2015; 5 (12)e009002Google Scholar, 3Honeycutt S. Leeman J. McCarthy W.J. et al.Evaluating policy, systems, and environmental change interventions: Lessons learned from CDC's Prevention Research Centers.Prev Chronic Dis. 2015; 12: E174Crossref PubMed Scopus (45) Google Scholar, 4Leeman J. Meyers A.E. Ribisl K.M. Ammerman A.S. Disseminating policy and environmental change interventions: Insights from obesity prevention and tobacco control.Int J Behav Med. 2015; 22: 301-311Crossref PubMed Scopus (24) Google Scholar, 5Stroh D.P. Systems Thinking for Social Change. A Practical Guide to Solving Complex Problems, Avoiding Unintended Consequences, and Achieving Lasting Results. Chelsea Green Publishing, 2015Google Scholar, 6Glanz K. Bishop D.B. The role of behavioral science theory in development and implementation of public health interventions.Annu Rev Public Health. 2010; 31: 399-418Crossref PubMed Scopus (1122) Google Scholar, 7O’Connor J. Chronic disease prevention as an adaptive leadership problem.J Ga Public Health Assoc. 2017; 6: 398-400Google Scholar Once an adaptive challenge is identified, RDNs can apply a determinants of health lens (Figure 1, phase 1) to closely examine nutrition and health problems and better identify why problems are worsening despite best efforts to solve them. The result of this focused assessment is a stronger diagnosis of the root causes that supports strategic decision-making1Heifetz R. Grashow A. Linsky M. The Practice of Adaptive Leadership. Tools and Tactics for Changing Your Organization and the World. Cambridge Leadership Associates, 2009Google Scholar,2Carey G. Malbon E. Carey N. et al.Systems science and systems thinking for public health: A systematic review of the field.BMJ Open. 2015; 5 (12)e009002Google Scholar in phase 2. Phase 2 is the formation of coordinated multidimensional strategies that produce a sustainable and synergistic effect. Phase 3 is the evaluation of outcomes and impacts of the suite of strategies and the degree to which change has occurred at the individual, practice, program, organizational, policy, and population levels.3Honeycutt S. Leeman J. McCarthy W.J. et al.Evaluating policy, systems, and environmental change interventions: Lessons learned from CDC's Prevention Research Centers.Prev Chronic Dis. 2015; 12: E174Crossref PubMed Scopus (45) Google Scholar, 4Leeman J. Meyers A.E. Ribisl K.M. Ammerman A.S. Disseminating policy and environmental change interventions: Insights from obesity prevention and tobacco control.Int J Behav Med. 2015; 22: 301-311Crossref PubMed Scopus (24) Google Scholar, 5Stroh D.P. Systems Thinking for Social Change. A Practical Guide to Solving Complex Problems, Avoiding Unintended Consequences, and Achieving Lasting Results. Chelsea Green Publishing, 2015Google Scholar Encircling the Framework is systems thinking and reflection to support an iterative cycle of robust assessment, planning, implementation, and impact evaluation. The Framework is versatile and can be adapted to a wide range of nutrition issues, areas of dietetics practice, and diverse partnerships. The first step in addressing an adaptive challenge is to assemble all relevant qualitative and quantitative information and answer the questions “What does the evidence tell us?” “Where are the gaps?” and “How does this impact the nutrition and health of the individuals or communities we serve?” To inspire a broad examination of contextual influences on health and support root cause analyses,1Heifetz R. Grashow A. Linsky M. The Practice of Adaptive Leadership. Tools and Tactics for Changing Your Organization and the World. Cambridge Leadership Associates, 2009Google Scholar RDNs and their partners are encouraged to use a determinants of health lens (Figure 1, phase 1). This phase includes 3 categories of information—social, commercial, and political—that have demonstrated influence on the nutritional health of individuals and populations. Strong evidence supports that where individuals live, work, learn, and play is associated with health risks, well-being, and lifespan.8Institute of Medicine, Committee on Accelerating Progress in Obesity PreventionAccelerating Progress in Obesity Prevention: Solving the Weight of the Nation. National Academies Press, 2012Google Scholar Social Determinants of Health (SDOHs) are the interconnections between social, physical, and economic characteristics and how they influence health status at a community or population level.9Sims J. Aboelata M.J. A system of prevention: Applying a systems approach to public health.Health Promot Pract. 2019; 20: 476-482Crossref PubMed Scopus (13) Google Scholar,10Centers for Disease Control and Prevention, Division of Community HealthA Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease. US Department of Health and Human Services, 2013Google Scholar An SDOH approach examines disparities and serves as the catalyst for a root cause matrix to identify nutrition and health inequities.10Centers for Disease Control and Prevention, Division of Community HealthA Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease. US Department of Health and Human Services, 2013Google Scholar The SDOH assessment includes economic, education, social and cultural, health, neighborhood, and built environment information.11Healthy People 2020. Social Determinants of Health. Office of Disease Prevention and Health Promotion, US Health and Human Services.https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-healthGoogle Scholar However, in the context of nutrition and health, the dimensions of food systems, natural environments and ecosystems, and public health capacity need to be considered. Greater awareness of these linkages within a nutrition context drives informed solutions that advance healthy choices as the default choices.12Ten essential public health services and how they can include addressing social determinants of health inequities. Social Determinants of Health: Know What Affects Health. Centers for Disease Control and Prevention.https://www.cdc.gov/publichealthgateway/publichealthservices/pdf/ten_essential_services_and_sdoh.pdfGoogle Scholar The rise of diet-related chronic diseases as an adaptive challenge is regarded as a symptom of a global culture in which profits are prioritized over health.13Kickbusch I. Allen L. Franz C. The commercial determinants of health.Lancet. 2016; 4: e895-e896PubMed Scopus (228) Google Scholar, 14Millar J.S. The corporate determinants of health: How big business affects our health, and the need for government action!.Can J Public Health. 2013; 104: e327Crossref PubMed Scopus (35) Google Scholar, 15Ireland R. Bunn C. Reith G. et al.Commercial determinants of health: Advertising of alcohol and unhealthy foods at sporting events.Bull World Health Ogan. 2019; 97: 290-295Crossref PubMed Scopus (21) Google Scholar Commercial determinants of health are described as tactics used by the private sector to market products and services that sway consumer decisions that can impact their health,14Millar J.S. The corporate determinants of health: How big business affects our health, and the need for government action!.Can J Public Health. 2013; 104: e327Crossref PubMed Scopus (35) Google Scholar, 15Ireland R. Bunn C. Reith G. et al.Commercial determinants of health: Advertising of alcohol and unhealthy foods at sporting events.Bull World Health Ogan. 2019; 97: 290-295Crossref PubMed Scopus (21) Google Scholar, 16McKee M. Stuckler D. Revisiting the corporate and commercial determinants of health.Am J Public Health. 2018; 108: 1167-1170Crossref PubMed Scopus (104) Google Scholar while simultaneously driving profits.16McKee M. Stuckler D. Revisiting the corporate and commercial determinants of health.Am J Public Health. 2018; 108: 1167-1170Crossref PubMed Scopus (104) Google Scholar Specifically, corporations influence markets, policies, physical landscapes and environments, and consumer behavior by using strategic marketing of palatable, yet often unhealthy foods and beverages.15Ireland R. Bunn C. Reith G. et al.Commercial determinants of health: Advertising of alcohol and unhealthy foods at sporting events.Bull World Health Ogan. 2019; 97: 290-295Crossref PubMed Scopus (21) Google Scholar,16McKee M. Stuckler D. Revisiting the corporate and commercial determinants of health.Am J Public Health. 2018; 108: 1167-1170Crossref PubMed Scopus (104) Google Scholar Corporations lobby policymakers and are often an invisible influence on public policy.15Ireland R. Bunn C. Reith G. et al.Commercial determinants of health: Advertising of alcohol and unhealthy foods at sporting events.Bull World Health Ogan. 2019; 97: 290-295Crossref PubMed Scopus (21) Google Scholar,16McKee M. Stuckler D. Revisiting the corporate and commercial determinants of health.Am J Public Health. 2018; 108: 1167-1170Crossref PubMed Scopus (104) Google Scholar Furthermore, corporations grow global supply chains, which increases market control and they can mislead consumers using disingenuous “citizenship” and social responsibility efforts, including health and environmental claims.14Millar J.S. The corporate determinants of health: How big business affects our health, and the need for government action!.Can J Public Health. 2013; 104: e327Crossref PubMed Scopus (35) Google Scholar, 15Ireland R. Bunn C. Reith G. et al.Commercial determinants of health: Advertising of alcohol and unhealthy foods at sporting events.Bull World Health Ogan. 2019; 97: 290-295Crossref PubMed Scopus (21) Google Scholar, 16McKee M. Stuckler D. Revisiting the corporate and commercial determinants of health.Am J Public Health. 2018; 108: 1167-1170Crossref PubMed Scopus (104) Google Scholar When combined, these strategies alter social values and norms that are often counter to healthy behaviors.17US Preventive Services Task ForceThe Guide to Clinical Preventative Services. Agency for Healthcare Research and Quality, 2006Google Scholar,18Huang T.T. Drewnowski A. Kumanyika S.K. Glass T.A. A systems-oriented multilevel framework for addressing obesity in the 21st century.Prev Chronic Dis. 2009; 6: 1-10Google Scholar In 2017, almost US$14 billion was spent on marketing food and beverages in the United States, with more than 80% of the advertising promoting fast food, sugar-sweetened beverages, candy, and unhealthy snacks.19Food marketing. Rudd Center for Food Policy and Obesity.http://www.uconnruddcenter.org/food-marketingGoogle Scholar Food and beverage marketing has shifted from traditional print and television formats to digital platforms. A recent study found that half of online food and beverage promotions were for unhealthy products.20McCarthy J. Minovi D. Wootan M. Scroll and shop. Food marketing migrates online. Center for Science in the Public Interest.https://cspinet.org/sites/default/files/attachment/Scroll_and_Shop_report.pdfGoogle Scholar Although corporate behaviors and their influence on nutrition and health are not always transparent, failure to acknowledge commercial determinants of health will result in gaps in the determinants of health assessment, in addition to missed opportunities for RDNs and their partners to change dominant narratives.16McKee M. Stuckler D. Revisiting the corporate and commercial determinants of health.Am J Public Health. 2018; 108: 1167-1170Crossref PubMed Scopus (104) Google Scholar Many agree that the underlying stimuli to SDOHs are corporate and political influences.21Mishori R. The social determinants of health? Time to focus on the political determinants of health?.Med Care. 2019; 57: 491-493Crossref PubMed Scopus (13) Google Scholar, 22Kickbusch I. The political determinants of health—10 years on.BMJ. 2015; 350: h81https://doi.org/10.1136/bmj.h81Crossref PubMed Scopus (78) Google Scholar, 23Mackenbach J.P. Political determinants of health.Eur J Public Health. 2014; 24: 2https://doi.org/10.1093/eurpub/ckt183Crossref PubMed Scopus (45) Google Scholar Public policy and politics play significant roles in all areas of dietetics practice. This includes, but is not limited to, the Dietary Guidelines for Americans, food and nutrition assistance programs, food safety, food security, food labeling, consumer education, dietetics education, reimbursement for nutrition services, and licensure of RDNs. Political determinants of health are defined as how various power constellations, institutions, interests, and ideologic platforms affect health within political systems and levels of governance.22Kickbusch I. The political determinants of health—10 years on.BMJ. 2015; 350: h81https://doi.org/10.1136/bmj.h81Crossref PubMed Scopus (78) Google Scholar When conducting a determinants of health assessment, RDNs and their partners should closely study how power, policy, politics, and processes impact the adaptive challenge and influence individuals, organizations, and communities. Policy development requires RDNs to recognize that the determinants of health are dependent on policy and political action24Bambra C. Fox D. Scott-Samuel A. Towards a politics of health.Health Promot Int. 2005; 20: 187-193Crossref PubMed Scopus (228) Google Scholar to produce change. Public policies generate downstream impacts on individuals and families, institutions, communities, and populations, and require RDNs to be engaged in and to drive the needed changes to improve health and well-being. Complacency on food and nutrition policy is a disservice to students, patients, clients, communities, and the dietetics profession because it denies opportunities to tackle adaptive challenges, decreases the value proposition of RDNs, and limits opportunities to optimize individual and population nutrition and health status. Once the determinants of health are assessed and root causes are diagnosed, RDNs and their partners can formulate, plan, and implement strategic solutions using the components in Phase 2 (Figure 1). Inspired by the Spectrum of Prevention25Cohen L. Swift S. The spectrum of prevention: Developing a comprehensive approach to injury prevention.Inj Prev. 1999; 5: 203-207Crossref PubMed Scopus (124) Google Scholar and the System of Prevention Framework,9Sims J. Aboelata M.J. A system of prevention: Applying a systems approach to public health.Health Promot Pract. 2019; 20: 476-482Crossref PubMed Scopus (13) Google Scholar the center of the Framework highlights 7 action components that support the planning and implementation of a continuum of strategies. The direction and complexity of the strategies are driven by the scope and depth of the determinants of health assessment; capacity of practitioners, organizations, and stakeholders; and availability of resources to garner the greatest benefits.26Abson D.J. Fischer J. Leventon J. et al.Leverage points for sustainability transformation.Ambio. 2017; 46: 30-39Crossref PubMed Scopus (487) Google Scholar, 27Johnston L.M. Matteson C.L. Finegood D.T. Systems science and obesity policy: A novel framework for analyzing and rethinking population-level planning.Am J Public Health. 2014; 104: 1270-1278Crossref PubMed Scopus (80) Google Scholar, 28Meadows D. Thinking in Systems. A Primer. Earthscan, 2008Google Scholar The aim of phase 2 of the I+PSE Conceptual Framework for Action is to develop coordinated strategies within each action component. When synergistic solutions are implemented, they begin to alter the contextual influences (ie, determinants of health), while amplifying and sustaining positive health impacts.18Huang T.T. Drewnowski A. Kumanyika S.K. Glass T.A. A systems-oriented multilevel framework for addressing obesity in the 21st century.Prev Chronic Dis. 2009; 6: 1-10Google Scholar This produces additive or multiplicative effects, including greater reach, higher dose response, longer-term outcomes, and increased sustainability.3Honeycutt S. Leeman J. McCarthy W.J. et al.Evaluating policy, systems, and environmental change interventions: Lessons learned from CDC's Prevention Research Centers.Prev Chronic Dis. 2015; 12: E174Crossref PubMed Scopus (45) Google Scholar, 4Leeman J. Meyers A.E. Ribisl K.M. Ammerman A.S. Disseminating policy and environmental change interventions: Insights from obesity prevention and tobacco control.Int J Behav Med. 2015; 22: 301-311Crossref PubMed Scopus (24) Google Scholar, 5Stroh D.P. Systems Thinking for Social Change. A Practical Guide to Solving Complex Problems, Avoiding Unintended Consequences, and Achieving Lasting Results. Chelsea Green Publishing, 2015Google Scholar The Framework, and specifically the action components, are highly versatile and can be tailored to the adaptive challenge and area of dietetics practice. For the purposes of this article, descriptions of each action component are presented and are accompanied by healthy eating and active living examples in Figure 2.Figure 2Examples of multidimensional strategies for healthy eating and active living (HEAL) by Individual Plus Policy, System, and Environmental (I+PSE) action component.I+PSE componentHEAL definitionbDefinitions for each action components can be tailored based on topic, area of dietetics practice, or community need.Example strategiesStrengthen Individual Knowledge and BehaviorEnhance individual, or household’s decision-making and capability of participating in or benefitting from HEALUse US Department of Agriculture’s MyPlate29MyPlateUS Department of Agriculture.MyPlate.govGoogle Scholarresources to promote fruit and vegetable consumptionMake referrals to a lactation consultant for new breastfeeding mothersProvide resources and tools for low-income families to eat healthy on a budgetPromote Community Engagement and EducationConnect with diverse groups of people to inform them about the benefits of HEAL and to establish bidirectional communication, trust, and support to advance HEAL approachesIdentify gaps in access to healthy foods and facilitate discussions with community leaders to identify solutionsEngage community groups such as girls’ and boys’ clubs, YWCA and YMCA, summer camps, fitness centers, to promote consistent HEAL messagesInclude children and youth with special health care needs in programming for physical activityActivate Intermediaries and Service ProvidersInform and educate intermediaries and service providers who transmit information about HEAL to othersWork with the health care system to launch a fruit and vegetable prescription programConduct HEAL trainings for early education and care professionals (eg, teachers, Head Start, and childcare providers)Develop nutrition and active living education materials for Early Periodic Screening, Diagnostic and Treatment providersFacilitate Partnerships and Multisector CollaborationsFoster relationships and cultivate multisector collaborations with stakeholders about individual, community and/or population approaches to HEALLeverage local media to promote HEAL messages and events, for example, in the WICcWIC = Special Supplemental Nutrition Program for Women, Infants, and Children. programWork with municipal planners and engineers to assess walkability of neighborhoods and propose enhancements to increase community walkabilityInitiate a Community of Practice or Community of Learning (peer-to-peer network) focused on HEAL strategiesAlign Organizational Policies and PracticesRevise or adapt policies, procedures, and practices within institutions that support HEALIncorporate nutrition standards that align with the Dietary Guidelines for Americans into institutional procurement policies and concessionsPromote active transport to schools (eg, walking school bus)Be an active member within a professional organization and provide input on educational competencies, standards of practice, or standards of professional performanceFoster Physical, Natural, and Social EnvironmentsDesign, foster, and maintain physical (built), natural (ecosystems), and social settings within institutions and public environments that support HEALEquip schools with adequate food storage and preparation spaces in kitchens/cafeteriasRemove unhealthy food and beverage advertising in schools, worksite cafeterias, and childcare centersConnect food retail to the emergency food system to decrease food wasteRedesign/refresh school playgrounds and incorporate gardens or edible landscapesAdvance Public Policies and LegislationDevelop strategies to inform change to laws, regulations, and public policies (local, state, federal) that support HEALProvide comment on regulation proposals and state strategic planning processesWrite a nutrition and health impact statement of a proposed public policyProvide testimony at a hearing or serve on a government advisory committeeMonitor and engage in annual Federal appropriations and omnibus legislation, such as the Child Nutrition Act, Farm Bill, or Older Americans ActaThis figure can be adapted to any area of nutrition and/or dietetics practice.b Definitions for each action components can be tailored based on topic, area of dietetics practice, or community need.c WIC = Special Supplemental Nutrition Program for Women, Infants, and Children. Open table in a new tab aThis figure can be adapted to any area of nutrition and/or dietetics practice. RDNs are trained to enhance an individual’s knowledge, skills, and behavior using evidence-based behavioral change approaches and nutrition education. It is well-established that the efficacy in establishing long-term healthy eating and activity behaviors among individuals is limited due to a myriad of social ecological influences.30Smedley B.D. Syme S.L. Institute of Medicine Committee on Capitalizing on Social Science and Behavioral Research to Improve the Public's HealthPromoting Health: Intervention Strategies from Social and Behavioral Research. National Academies Press, 2000Google Scholar However, combining individual behavior-change strategies with strategies from other action components is likely to stimulate stronger interventions and more sustainable results. The intent of this action component is to strengthen individual and household decision-making and capabilities of participating in or being a beneficiary of an activity or service that is essential to improving their nutrition and health status. This may include providing direct services to individuals and families to build their knowledge and skills to support their nutrition and health goals in both clinical and nonclinical settings. Connecting with diverse community members, leaders, and stakeholders to establish rapport and regular communication will strengthen trust and support for community change to occur. Conducting a community assessment using a determinants of health lens gleans an understanding of the various contextual capacities of a community. Community engagement aids in more effectively identifying problems and positions that RDNs and community members can use to form coordinated solutions, including educational messages. This action component may include increasing community awareness on a specific nutrition or health topic using evidence-based messages that are tailored to the community. Intermediaries (eg, nurses, certified health educators, social workers, teachers, physicians, and media) are instrumental in informing, educating, and transmitting information to others (eg, patients, clients, students, community, decision-makers). Activating and empowering intermediaries and service providers to support and advance nutrition and health strategies, such as communicating consistent messages, increases opportunities for multidisciplinary cooperation and coordination across the 7 action components. Relationships are paramount to the success of addressing adaptive challenges and are a common thread throughout the Framework. Establishing greater collaboration among organizations enables them to work together for the health of the whole system rather than focusing on technical fixes to individual parts.31Senge P. Hamilton H. Kania J. The dawn of system leadership.Stanford Soc Innov Rev. 2015; 13: 26-33Google Scholar This action component encourages RDNs to build connections—informal or formal—to cultivate multidisciplinary collaborations and to apply diverse perspectives in formulating effective strategies. This can be done by engaging with existing community networks and coalitions, forming ad hoc groups to solve a specific problem, or assembling a group of committed stakeholders focused on complex problems requiring multi-prong solutions. Forming public–private partnerships whose values, policies, and practices align may also be considered.8Institute of Medicine, Committee on Accelerating Progress in Obesity PreventionAccelerating Progress in Obesity Prevention: Solving the Weight of the Nation. National Academies Press, 2012Google Scholar RDNs should examine their organization’s practices and policies and the degree to which they support healthy solutions at the operations, program/service, and workforce levels. This will likely require revising or adapting policies, regulations, and procedures within the organization to better support healthy solutions (ie, “walk the walk”). Often referred to as “little p” policies, organizational policies are more feasible to establish or modify compared with public policy. Changes in organizational policies may also lay the groundwork and build the evidence to influence public policies. The outcomes of the determinants of health assessment, in addition to the literature on behavioral design and how built and natural environments influence health, are the foundation for these strategies. The intent of this action component is to examine, modify, and design physical spaces and natural settings within organizations and public spaces that support individual, social and cultural, economic, and ecological health. RDNs can work closely with other sectors, such as planners, engineers, and developers, to evaluate and design workplaces; public spaces; and neighborhoods that ensure physical spaces support human; social; and environmental health. Public policies at local, county, state, and federal levels produce significant downstream influences on individual, household, community, and population health. Often referred to as “big P” policies, this component is focused on strategies for ensuring new and existing laws, regulations, and public policies support nutrition and health. Public policy is central to dietetics practice whether it is state licensure, federal regulations for nutrition assistance programs, or reimbu