If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
American Dietetic Association Revised Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care
Approved September 2010 by the Quality Management Committee of the American Dietetic Association House of Delegates and the Executive Committee of the Diabetes Care and Education Dietetic Practice Group of the American Dietetic Association. Scheduled review date: January 2016. Questions regarding the revised Standards of Practice and Standards of Professional Performance for registered dietitians in diabetes care may be addressed to ADA Quality Management staff at [email protected]; Sharon McCauley, MS, MBA, RD, LDN, FADA, director of Quality Management, or Cecily Byrne, MS, RD, LDN, manager of Quality Management.
The Diabetes Care and Education Dietetic Practice Group (DCE 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 revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for registered dietitians (RDs) in diabetes care (see the Web site exclusive Figure 1, Figure 2, Figure 3 at www.adajournal.org). The SOP and SOPP for RDs in diabetes care were originally published in 2005 (
American Dietetic Association Standards of Practice and Standards of Professional Performance for registered dietitians (generalist, specialty, and advanced) in diabetes Care.
) and were scheduled for periodic review and revision. The revised documents reflect advances in diabetes nutrition practice during the past 5 years and replace the 2005 standards. These documents build on the ADA revised 2008 SOP for RDs in nutrition care and SOPP for RDs (
American 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.
). 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.
In October and November 2010, the House Leadership Team of the American Dietetic Association House of Delegates approved the Council on Future Practice's Dietetics Career Development Guide, as well as definitions for focus area of dietetics practice, specialist, and advanced practice, respectively. The Dietetics Career Development Guide is based on the Dreyfus Model of Skill Acquisition
Dreyfus HL, Dreyfus SE. Mind Over Machine. New York, NY: The Free Press; 1986.
Dreyfus HL, Dreyfus SE. Mind Over Machine. New York, NY: The Free Press; 1986.
which suggests that as a person acquires and develops a skill, s/he “… usually passes through at least five stages of qualitatively different perceptions of his task and/or mode of decision-making as his skill improves.” The stages are: novice, advanced beginner, competent, proficient, and expert.
At the competent stage, a dietetics practitioner has just obtained the RD or DTR credential, starting in an employment situation, and gains on the job skills as well as tailored continuing education to enhance skills and knowledge. The RD or DTR as a beginner starts the technical training and interaction for advancement and breadth of competence. At the proficient stage, the RD or DTR is three plus years beyond entry into the profession, has obtained operational job performance skills and is successful in the chosen focus area of practice. The RD or DTR may begin to acquire specialist credentials, if available, to demonstrate proficiency in a focus area of practice. At the expert stage, the RD or DTR 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, or training.
The Council on Future Practice has recommended with approval by the Quality Management Committee and Scope of Dietetics Practice Framework Sub-committee that all future practice-specific Standards of Practice (SOP) and Standards of Professional Performance (SOPP) use the terms competent, proficient, and expert to describe the levels of dietetics practice, versus the terminology generalist, specialty, and advanced. In addition, these documents will be referred to as focus area SOP and SOPP.
At press time, the Revised SOP and SOPP for RDs in Diabetes Care contains the verbiage generalist, specialty, and advanced to describe the levels of dietetics practice. Because the Revised SOP and SOPP for RDs in Diabetes Care was approved for publication in September 2010, it was not feasible to incorporate the changes in terminology. In future focus area SOP and SOPP publications, the levels of practice will be referred to as competent, proficient, and expert.
American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics and Process for Consideration of Ethics Issues.
American 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.
), 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 will differ from state to state. An RD may determine his or her own individual scope of practice using the Scope of Dietetics Practice Framework (
), 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 in nutrition care and SOPP (
American 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.
) reflect the minimum competent level of dietetics practice and professional performance for RDs. ADA's SOP in nutrition care and SOPP serve as blueprints for the development of practice-specific SOP and SOPP for RDs in generalist, specialty, and advanced levels of practice.
The standards 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 diabetes care and education. 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 practice 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 practice area. Like the revised 2008 SOP in nutrition care and SOPP for RDs, the revised SOP and SOPP for RDs in diabetes care were developed with input and consensus of content experts representing diverse practice and geographic perspectives and were reviewed and approved by the Executive Committee of the DCE DPG, the Scope of Dietetics Practice Framework Sub-Committee, and ADA's Quality Management Committee.
Three levels of practice in diabetes care—generalist, specialty, and advanced—are defined (
). A general practitioner (or generalist) is an individual whose practice includes 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. The generalist level also includes entry-level practitioners. An entry-level practitioner, as defined by the Commission on Dietetic Registration, has <3 years of registered practice experience and demonstrates a competent level of dietetics practice and professional performance. A specialty practitioner is an individual who primarily concentrates on one aspect of the profession of dietetics. This specialty may or may not have a credential and additional certification, but often includes expanded roles beyond entry level practice. An advanced practitioner has acquired the expert knowledge base, complex decision-making skills, and competencies for expanded practice, the characteristics of which are shaped by the context in which he or she practices. Advanced practitioners may have expanded or specialty roles or both. Advanced practice may or may not include additional certification. Generally the practice is more complex, and the practitioner has a higher degree of professional autonomy and responsibility.
These standards, along with ADA's Code of Ethics (
American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics and Process for Consideration of Ethics Issues.
), answer the questions: “What uniquely qualifies an RD to provide diabetes nutrition services?” and, “What knowledge, skills, and competencies does an RD need to demonstrate for the provision of safe, effective, and quality diabetes care at the generalist, specialty, and advanced levels?”
Overview
Diabetes is a significant health challenge. In 2007 in the United States, estimates suggested that nearly 24 million individuals had diabetes and another 57 million were at increased clinical risk of developing this chronic disease (ie, prediabetes) (
). Diabetes has consistently been among the top causes of morbidity and mortality among patients with chronic disease, and the costs associated with diabetes care place a significant financial burden on the country's health care system. It is well-documented that keeping blood glucose and blood pressure at near-normal levels significantly reduces diabetes complications (
The Diabetes Control and Complications Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
UK Prospective Diabetes Study Group Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).
). Yet despite this widely known information, the National Health and Nutrition Examination Survey data have observed that the age-adjusted percentage of people achieving glycemic, blood pressure, and cholesterol targets (ie, all three targets) increased only from 7.0% in the period 1999-2002 to 12.2% in the period between 2003 and 2006 (
). Although the proportion of those achieving these three targets appears to be increasing, there remains a significant proportion of individuals with diabetes who fail to achieve recommended hemoglobin A1c (HbA1c), blood pressure, and cholesterol levels.
Given the rapid rise of diabetes over the past several decades and the immense opportunity to improve diabetes-related measures, the need for RDs with diabetes expertise is critical to improve the health of individuals both at risk for diabetes and with diabetes. Nutrition has been recognized as one of the three cornerstones of diabetes management, along with medication therapy and exercise. Studies implementing a variety of nutrition interventions report a reduction in HbA1c levels (
DAFNE Study Group Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes; dose adjustment for normal eating (DAFNE) randomized controlled trial.
DAFNE Study Group Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes; dose adjustment for normal eating (DAFNE) randomized controlled trial.
). In addition, some studies also report improvements in lipid profiles, improved weight management, adjustments in medications, and a reduction in the risk for onset and progression of comorbidities with nutrition intervention (
). Diabetes medical nutrition therapy (MNT) provided by RDs can effectively decrease HbA1c by approximately 1% to 2% (range −0.5% to −2.6%), depending on the type and duration of diabetes (
). MNT has the greatest effect following the initial diagnosis and continues to be effective throughout the disease process. Outcomes of nutrition interventions are generally measureable in 6 weeks to 3 months and evaluations by an HbA1c test should be done at this time. If a patient's/client's glycemic control has not clinically improved at 3 months, the RD should contact the referral source and recommend the need for initiation or a change in diabetes medication.
Nutrition therapy provided by an RD can also help individuals prevent or delay the development of diabetes. Intensive lifestyle changes (ie, at least 150 minutes/week of physical activity and reduced energy intake) and weight loss (ie, 7% of initial body weight) have been demonstrated to reduce diabetes risk (
), diabetes incidence in high-risk adults was reduced by 58% as a result of these intensive lifestyle interventions and 31% by metformin only compared with placebo. Ten years later at follow-up, the DPP participants who had received the original intensive lifestyle intervention had maintained their lower rate of diabetes onset (
RDs providing diabetes care recognize that effectively addressing the challenges of managing and preventing diabetes requires specialized knowledge and skills. The Diabetes Control and Complications Trial (DCCT) documented the expanded role of RDs in the care of type 1 diabetes; the DCCT established RDs as more active team participants focused not only on nutrition, but on assisting with medication therapy, weight management, and exercise strategies to improve glycemic control (
). The United Kingdom Prospective Diabetes Study documented the role of dietitians as research interventionists and demonstrated the influence of diet in the treatment of type 2 diabetes (
U.K. Prospective Diabetes Study Group UKPDS 18: Estimated dietary intake in type 2 diabetic patients randomly allocated to diet, sulphonylurea or insulin therapy.
United Kingdom Prospective Diabetes Study Group Effects of three months' diet after diagnosis of type 2 diabetes on plasma lipids and lipoproteins (UKPDS 45).
). The DPP documented the expanded RD role in preventing type 2 diabetes. RDs served as case managers, and in some centers, the RDs served as program coordinators and participated on national study committees (
). In both the DCCT and DPP, RDs designed and conducted ancillary substudies and participated in writing groups for the primary results articles. Beyond these large trials, the RD role has also expanded to include teaching self-management skills that include proper administration of injectable medications, self-blood glucose monitoring, insulin pump therapy, and teaching individuals how to treat hypoglycemia and hyperglycemia (
Statement from the Diabetes Care and Education Dietetic Practice Group of the American Dietetic Association The role of the registered dietitian in teaching and in administration of injectable medications used in diabetes management.
). In some clinical settings an RD's role has evolved to include a role in managing dyslipidemia and blood pressure through use of stepwise protocols to initiate and titrate medications (
Delivery of multifactorial interventions by nurse and dietitian teams in a community setting to prevent diabetic complications: A quality improvement report.
RDs in diabetes care work as members of multidisciplinary health care teams in a variety of work environments (eg, clinics, education centers, hospitals, community health settings, health plans, industry, or private practice). Nutrition education and counseling are integral components of high quality diabetes care. MNT pertains to clinical management and, as such, is conducted by RDs. The differences between the provision of nutrition education and counseling in diabetes care were defined and described in a Diabetes White Paper (
). Diabetes self-management training and community programs include nutrition education (ie, instructional methods) that promote healthful behaviors by imparting information that individuals and groups can use to make informed decisions about food, eating habits, and health (
). MNT “is an evidence-based application of the Nutrition Care Process focused on prevention, delay or management of diseases and conditions, and involves an in-depth assessment, periodic re-assessment and intervention.” (
) MNT services are defined in Medicare statutes as “nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by an RD” (
ADA Revised Standards of Practice and Standards of Professional Performance for RDs (Generalist, Specialty, and Advanced) in Diabetes Care
An RD may use the Revised SOP and SOPP (generalist, specialty, and advanced) for RDs in diabetes care (see the Web site exclusive Figure 1, Figure 2, Figure 3 at www.adajournal.org) to:
•
identify the competencies needed to provide diabetes care inclusive of diabetes self-management training and MNT;
•
self-assess whether he or she has the appropriate knowledge base and skills to provide safe and effective diabetes care for their individual level of practice;
•
identify the areas in which additional knowledge and skills are needed to perform at the generalist, specialty, or advanced level of diabetes care practice;
•
provide a foundation for public and professional accountability in diabetes care;
•
assist management in the planning of diabetes care services and resources;
•
enhance professional identity and communicate the nature of diabetes care;
•
guide the development of diabetes care-related education and continuing education programs, job descriptions, and career pathways; and
•
assist preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in diabetes care and the understanding of the full scope of this profession.
This approach to professional standards allows for recognition of the independent provider status for RDs resulting from the Medicare MNT statute that became effective January 1, 2001. Independent provider status recognizes the RD credential as indicating that an individual is qualified to provide and be reimbursed directly for MNT services (
). The standards are also reflective of the knowledge and skills required for additional certifications. Current certifications available to an RD in diabetes care are certified diabetes educator (CDE), a specialty certification, and the Board certified–advanced diabetes management (BC-ADM), an advanced practice certification. RDs with the demonstrated level of competence (ie, who meet the revised Standards of Practice and Standards of Professional Performance for RDs in diabetes care), along with the appropriate hours of practice and who meet any additional requirement of the credentialing boards for the CDE or the BC-ADM certifications, can also choose to obtain the CDE or BC-ADM credentials. More information on obtaining the CDE credential is available from the National Certification Board for Diabetes Educators (www.ncbde.org) (
2010 Candidate Handbook, National Certification Board for Diabetes Educators. National Certification Board for Diabetes Educators,
Arlington Heights, IL2009
) identifies levels of proficiency (novice, proficiency, expert) during the acquisition and development of knowledge and skills. This model is helpful in understanding the levels of practice described in the revised SOP and SOPP for RDs in diabetes care. In the ADA practice-specific SOP and SOPP for RDs, the stages are represented as generalist, specialty, and advanced practice levels.
All RDs, even those with significant experience in other practice areas, begin at the novice level (generalist level) when practicing in a new setting. At the novice level (generalist level), an RD in diabetes care is learning the principles that underpin the practice and is developing skills for effective diabetes care. This RD, who may be an experienced RD or may be new to the profession, has a breadth of knowledge in nutrition overall and may have specialty or advanced knowledge/practice in another area. However, an RD new to the specialty of diabetes care may experience a steep learning curve.
At the proficiency stage (specialty level), an RD has developed a deeper understanding of diabetes care and is better equipped to apply evidence-based guidelines and best practices. This RD is also able to modify practice according to unique situations (eg, an RD assesses blood glucose monitoring results and needs for MNT and medication adjustments, calculates insulin-to-carbohydrate ratios and insulin sensitivity factors, and assesses other metabolic outcomes).
At the expert stage (advanced practice level), an RD thinks critically about diabetes care, demonstrates a more intuitive understanding of diabetes care and practice, displays a range of highly developed clinical and technical skills, and formulates judgments acquired through a combination of experience and education. Essentially, practice at the advanced level requires the application of composite dietetics knowledge, with practitioners drawing not only on their clinical experience, but also on the experience of diabetes practitioners in various disciplines and practice settings. Experts, with their extensive experience and ability to see the significance and meaning of diabetes care within a contextual whole, are fluid and flexible and, to some degree, autonomous in practice. They not only implement diabetes care, they also drive and direct clinical practice, conduct and collaborate in research, contribute to multidisciplinary teams, and lead the advancement of diabetes care.
Indicators for the revised SOP (Figure 2, available online at www.adajournal.org) and SOPP (Figure 3, available online at www.adajournal.org) for RDs in diabetes care are measurable action statements that illustrate how each standard may be applied in practice. Within the revised SOP and SOPP for RDs in diabetes care, an X in the generalist column indicates that an RD who is caring for patients/clients is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. A generalist in diabetes care could be an entry-level RD or an experienced RD who has newly assumed responsibility to provide diabetes care to patients/clients. An X in the specialty column indicates that an RD who performs at this level has a deeper understanding of diabetes care and has the ability to modify therapy to meet the needs of patients/clients in various situations (eg, instruct patient/client how to self-monitor blood glucose in addition to the carbohydrate counting meal planning approach for the patient/client to determine how their food choices affect their glycemic control, and recommends medication adjustments, if needed). An X in the advanced column indicates an RD who performs at this level possesses a comprehensive understanding of diabetes care and a highly developed range of skills and judgments acquired through a combination of experience and education (eg, an RD who instructs patients referred for MNT on use of an insulin pump to deliver mealtime insulin and on use of a continuous glucose monitor to monitor glucose in an effort to optimize glycemic control). An RD, drawing on experiential and advanced knowledge, uses downloaded insulin pump and continuous glucose monitor data to evaluate insulin-to-carbohydrate ratios and insulin sensitivity factors and make dose adjustment recommendations as indicated).
Bolded type standards and indicators originate from ADA's revised 2008 SOP in nutrition care and SOPP for RDs (
American 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.
) and should apply to RDs in all three categories. Several indicators not in boldface type are identified as applicable to all levels of practice. Where Xs are placed in all three categories of practice, it is understood that all RDs in diabetes care are accountable for practice within each of these indicators. However, the depth with which an RD performs each activity will increase as the individual moves beyond the generalist level. Level of practice considerations warrant that a holistic view of the revised SOP and SOPP for RDs in diabetes care be taken. It is the totality of individual practice that defines the level of practice and not any one indicator or standard.
RDs should review the revised SOP and SOPP for RDs in diabetes care at regular intervals to evaluate individual nutrition and diabetes care knowledge, skill, and competence. Regular self-evaluation is important because it helps identify opportunities to improve and/or enhance practice and professional performance. This self-appraisal also enables RDs in diabetes care to better utilize the Commission on Dietetic Registration's Professional Development Portfolio (
) for self-assessment, planning, improvement, and commitment to lifelong learning. These Standards may be used in each of the five steps in the Professional Developmental Portfolio process (see Figure 4). RDs are encouraged to pursue additional training, regardless of practice setting, to maintain currency and to expand individual scope of practice within the limitations of the legal scope of practice, as defined by state law. Individuals are expected to practice only at the level at which they are competent, and this will vary depending on education, training, and experience (
). RDs are encouraged to pursue additional diabetes knowledge, skills training, and competence regardless of practice setting to promote consistency in practice and performance and continuous quality improvement. See Figure 5 for case examples of how RDs in different roles and at different levels of practice may use the revised SOP and SOPP for RDs in diabetes care.
Figure 4Application of the Commission on Dietetic Registration Professional Development Portfolio Process.aThe Commission on Dietetic Registration Professional Development Portfolio process is divided into five interdependent steps that build sequentially upon the previous step during each 5-year recertification cycle and succeeding cycles.
Figure 5Case Examples of how the registered dietitian (RD) utilizes the Revised Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians (RDs) (Generalist, Specialty, and Advanced) in Diabetes Care to assess competencies and set goals as part of the professional development portfolio plan.
Figure 5Case Examples of how the registered dietitian (RD) utilizes the Revised Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians (RDs) (Generalist, Specialty, and Advanced) in Diabetes Care to assess competencies and set goals as part of the professional development portfolio plan.
Figure 5Case Examples of how the registered dietitian (RD) utilizes the Revised Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians (RDs) (Generalist, Specialty, and Advanced) in Diabetes Care to assess competencies and set goals as part of the professional development portfolio plan.
In some instances, components of the revised SOP and SOPP for RDs in diabetes care do not specifically differentiate between specialty and advanced level practice. In these areas, it was the consensus of the content experts that the distinctions are subtle, captured in the knowledge, experience, and intuition demonstrated in the context of practice at the advanced level, which combines dimensions of understanding, performance, and value as an integrated whole (
). A wealth of knowledge is embedded in the experience, discernment, and practice of advanced-level RD practitioners. The knowledge and skills acquired through practice will continually expand and mature. The indicators will be refined as advanced-level RDs systematically record and document their experience using the concept of clinical exemplars. An experienced practitioner observes clinical events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. Clinical exemplars provide outstanding models of the actions of individual RDs in diabetes care in clinical settings and the professional activities that have enhanced patient/client care. Clinical exemplars include a brief description of the need for action and the process used to change the outcome.
Future Directions
The revised SOP and SOPP for RDs in diabetes care are innovative and dynamic documents. Future revisions will reflect changes in practice, dietetics education programs, and outcomes of practice audits. The three practice levels require more clarity and differentiation in content and role delineation and competency statements that better characterize differences among the practice levels are needed. Creation of this clarity, differentiation, and definition are the challenges of today's RDs in diabetes care to better serve tomorrow's practitioners and their patients, clients, and customers.
Conclusions
The revised SOP and SOPP for RDs in diabetes care are complementary documents and are key resources for RDs at all knowledge and performance levels. These standards can and should be used by RDs in daily practice to consistently improve and appropriately demonstrate competency and value as providers of safe and effective diabetes care. These standards also serve as a professional resource for self-evaluation and professional development for RDs specializing in diabetes care. The development and evaluation process is dynamic. Just as a professional's self-evaluation and continuing education process is an ongoing cycle, these standards are also a work in progress and will be reviewed and updated every 5 years. Current and future initiatives of ADA will provide information to use in these updates and in further clarifying and documenting the specific roles and responsibilities of RDs at each level of practice. As a quality initiative of ADA and the DCE DPG, these standards are an application of continuous quality improvement and represent an important collaborative endeavor.
Glossary of Terms for the Revised SOP and SOPP for RDs in Diabetes Care
AADE7: The American Association of Diabetes Educators (AADE) has defined the AADE7 Self-Care Behaviors as a framework for patient-centered diabetes education and care. The seven self-care behaviors essential for successful and effective diabetes self-management are healthy eating, being active, monitoring, taking medication, problem solving, healthy coping, and reducing risks. The AADE7 Self-Care Behaviors provide an evidence-based framework for assessment, intervention, and outcome (evaluation) measurement of the diabetes patient, program, and population (
Competence: The “ability to demonstrate appropriate professional behaviors with desirable outcomes. Professionals who are competent use up-to-date knowledge and skills; make sound decisions based on appropriate data; communicate effectively with patients, customers, and other professionals; critically evaluate their own practice; and improve performance based on self-awareness, applied practice, and feedback from others” (
Diabetes Control and Complications Trial (DCCT): A study by the National Institute of Diabetes and Digestive and Kidney Diseases, conducted from 1983 to 1993 in people with type 1 diabetes. The study showed that intensive therapy compared to conventional therapy significantly helped prevent or delay diabetes complications. Intensive therapy included multiple daily insulin injections or the use of an insulin pump with multiple blood glucose readings each day. Complications followed in the study included diabetic retinopathy, neuropathy, and nephropathy (
Diabetes Control and Complications Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
Diabetes Prevention Program (DPP): A study by the National Institute of Diabetes and Digestive and Kidney Diseases conducted from 1998 to 2001 in people at high risk for type 2 diabetes. All study participants had impaired glucose tolerance, also called pre-diabetes, and were overweight. The study showed that people who lost 5% to 7% of their body weight through a low-fat, low-calorie diet and moderate exercise (usually walking for 30 minutes 5 days a week) reduced their risk of getting type 2 diabetes by 58%. Participants who received treatment with the oral diabetes drug metformin reduced their risk of getting type 2 diabetes by 31% (
Diabetes self-management training (DSMT): Under Medicare Part B, “diabetes outpatient self-management training services means educational and training services furnished … to an individual with diabetes by a certified provider … in an outpatient setting by an individual or entity who meets the quality standards … , but only if the physician who is managing the individual's diabetic condition certifies that such services are needed under a comprehensive plan of care related to the individual's diabetic condition to ensure therapy compliance or to provide the individual with necessary skills and knowledge (including skills related to the self-administration of injectable drugs) to participate in the management of the individual's condition.” (
) “The program includes instructions in self- monitoring of blood glucose; education about diet and exercise; an insulin treatment plan developed specifically for the patient who is insulin-dependent; and motivation for patients to use the skills for self-management. (
) Under Medicare Part B, all DSMT programs must be accredited as meeting quality standards by a Centers for Medicare & Medicaid Services–approved national accreditation organization. Currently, the Centers for Medicare & Medicaid Services recognize the American Diabetes Association Education Recognition Program and the American Association of Diabetes Educators Diabetes Education Accreditation Program as approved national accreditation organizations (
Diabetes Self-Management Education (DSME): “Diabetes education, also referred to as diabetes self-management education or diabetes self-management training, is performed by health care professionals who have appropriate credentials and experience consistent with the particular profession's scope of practice.”
“DSME involves the person with pre-diabetes or diabetes and/or the caregivers and the educator(s) and is defined as the ongoing process of facilitating the knowledge, skill, and ability necessary for self-care. It is a component of a comprehensive plan of diabetes care. The process incorporates the needs, goals and life experiences of the person with pre-diabetes or diabetes and is guided by evidence-based standards. The overall objectives of DSME are to support informed decision-making, self-care behaviors, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life. The process includes:
•
An individual assessment and education plan developed collaboratively by the individual and educator(s) to direct the selection of appropriate educational interventions and self-management support strategies.
•
Educational interventions directed toward helping the individual achieve self-management goals.
•
Periodic evaluations to determine attainment of educational objectives or need for additional interventions and future reassessments.
•
A personalized follow-up plan developed collaboratively by the individual and educator(s) for ongoing self-management support.
•
Documentation in the education record of the assessment and education plan and the intervention and outcomes.”
Differential nutrition diagnosis: A systematic process of considering various possible nutrition diagnoses, considering the characteristics of each diagnosis in comparison to an individual's presentation, and arriving at a specific nutrition diagnosis. Nutrition diagnoses are well defined in the International Dietetics and Nutrition Terminology Reference Manual, 3rd edition (
Evidence-based dietetics practice: The use of systematically reviewed scientific evidence in making food and nutrition practice decisions by integrating best available evidence with professional expertise and client values to improve outcomes (
Health numeracy: The degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health information needed to make effective health decisions (
Intensive therapy: “A treatment for diabetes in which blood glucose is kept as close to normal as possible through frequent injections or use of an insulin pump; meal planning; adjustment of medicines; and exercise based on blood glucose test results and frequent contact with a person's health care team” (
Medical nutrition therapy (MNT): “Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process focused on prevention, delay or management of diseases and conditions, and involves an in-depth assessment, periodic re-assessment and intervention” (
MNT services are defined in federal (Medicare Part B) statute as “nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by a registered dietitian or nutrition professional … pursuant to a referral by a physician.” MNT is provided by licensed/certified (as applicable) registered dietitians and nutrition professionals (
Nutrition Care Process and Model: A systematic problem-solving method that food and nutrition professionals use to think critically and make decisions that address practice-related problems (
Nutrition diagnosis: A critical step in the Nutrition Care Process (NCP) in which the practitioner identifies a nutrition problem that can be addressed with nutrition intervention (
Nutrition focused physical findings: Part of the assessment phase of the NCP. A skilled practitioner evaluates several aspects of the client's appearance, including hair, skin, eyes, oral cavity, nails, gastrointestinal symptoms (such as appetite, bowel function, nausea, altered taste), neurological findings (confusion, for example), and vital signs (
United Kingdom Prospective Diabetes Study: (UKPDS) – A study in the United Kingdom, conducted from 1977 to 1997 in people with Type 2 diabetes. “The study showed that if people lowered their blood glucose, they lowered their risk of eye disease and kidney damage. In addition, those with Type 2 diabetes and hypertension who lowered their blood pressure also reduced their risk of stroke, eye damage, and death from long-term complications” (
UK Prospective Diabetes Study Group UKPDS 18: Estimated dietary intake in type 2 diabetic patients randomly allocated to diet, sulphonylurea or insulin or insulin therapy.
These standards have been formulated to be used for individual self-evaluation and the development of practice guidelines, but not for institutional credentialing or for adverse or exclusionary decisions regarding privileging, employment opportunities or benefits, disciplinary actions, or determinations of negligence or misconduct. These standards do not constitute medical or other professional advice, and should not be taken as such. The information presented in these standards is not a substitute for the exercise of professional judgment by a health care professional. The use of the standards for any other purpose than that for which they were formulated must be undertaken within the sole authority and discretion of the user.
The authors thank Marion Franz, MS, RD, LD, CDE; Gretchen Benson, RD, LD, CDE; and Molly Hyland for their review and assistance with manuscript preparation. The authors also thank all who participated in the process of revising this document.
Appendix
Figure 1Revised Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
Figure 3American Dietetic Association Revised Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care.
American 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.
American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics and Process for Consideration of Ethics Issues.
Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).
Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes; dose adjustment for normal eating (DAFNE) randomized controlled trial.
Delivery of multifactorial interventions by nurse and dietitian teams in a community setting to prevent diabetic complications: A quality improvement report.
2010 Candidate Handbook, National Certification Board for Diabetes Educators. National Certification Board for Diabetes Educators,
Arlington Heights, IL2009
J. L. Boucher is vice-president of education and a certified diabetes educator, Minneapolis Heart Institute Foundation, Minneapolis, MN
A. Evert is diabetes nutrition educator/coordinator of diabetes education programs and a certified diabetes educator, University of Washington Medical Center, Diabetes Care Center, Seattle
A. Daly is director of nutrition and diabetes education, board-certified in advanced diabetes management, and a certified diabetes educator, Springfield Diabetes and Endocrine Center, Springfield, IL
K. Kulkarni is director, scientific affairs, board-certified in advanced diabetes management, and a certified diabetes educator, Abbott Diabetes Care, Salt Lake City, UT
J. Rizzotto is director of educational services and a certified diabetes educator, Joslin Diabetes Center, Boston, MA
K. Burton is a junior research associate and a certified diabetes educator, University of Cincinnati, Cincinnati, OH
B. G. Bradshaw is adjunct assistant professor, Division of Nutrition, University of Utah, Salt Lake City
Article info
Footnotes
Address correspondence to: Cecily Byrne, MS, RD, LDN, Manager, Quality Management, American Dietetic Association, 120 South Riverside Plaza, Suite 2000, Chicago, IL 60606-6995. E-mail: [email protected]
Dreyfus HL, Dreyfus SE. Mind Over Machine. New York, NY: The Free Press; 1986. which suggests that as a person acquires and develops a skill, s/he “… usually passes through at least five stages of qualitatively different perceptions of his task and/or mode of decision-making as his skill improves.” The stages are: novice, advanced beginner, competent, proficient, and expert.
01834-1&id=gr4.jpg){kind=link}
01834-1&id=gr5a.jpg){kind=link}
01834-1&id=gr5b.jpg){kind=link}
01834-1&id=gr5c.jpg){kind=link}
01834-1&id=gr1.jpg){kind=link}
01834-1&id=gr2a.jpg){kind=link}
01834-1&id=gr2b.jpg){kind=link}
01834-1&id=gr2c.jpg){kind=link}
01834-1&id=gr2d.jpg){kind=link}
01834-1&id=gr2e.jpg){kind=link}
01834-1&id=gr2f.jpg){kind=link}
01834-1&id=gr2g.jpg){kind=link}
01834-1&id=gr2h.jpg){kind=link}
01834-1&id=gr2i.jpg){kind=link}
01834-1&id=gr2j.jpg){kind=link}
01834-1&id=gr2k.jpg){kind=link}
01834-1&id=gr3a.jpg){kind=link}
01834-1&id=gr3b.jpg){kind=link}
01834-1&id=gr3c.jpg){kind=link}
01834-1&id=gr3d.jpg){kind=link}
01834-1&id=gr3e.jpg){kind=link}
01834-1&id=gr3f.jpg){kind=link}
01834-1&id=gr3g.jpg){kind=link}
01834-1&id=gr3h.jpg){kind=link}
01834-1&id=gr3i.jpg){kind=link}
01834-1&id=gr3j.jpg){kind=link}
01834-1&id=gr3k.jpg){kind=link}
01834-1&id=gr3l.jpg){kind=link}
01834-1&id=gr3m.jpg){kind=link}
01834-1&id=gr3n.jpg){kind=link}
01834-1&id=gr3o.jpg){kind=link}