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From the Association| Volume 111, ISSUE 8, P1242-1249.e37, August 2011

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)

DOI:https://doi.org/10.1016/j.jada.2011.05.021
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)
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      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 (
      American Dietetic Association Quality Management Committee
      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.
      J Am Diet Assoc. 2008; 108: 1538-1542e9
      ). 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.
      J Am Diet Assoc. 2009; 109: 1461-1467
      ) and the 2008 SOP in Nutrition Care and SOPP for RDs (
      American Dietetic Association Quality Management Committee
      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.
      J Am Diet Assoc. 2008; 108: 1538-1542e9
      ) are tools within the Scope of Dietetics Practice Framework (
      • O'Sullivan-Maillet J.
      • Skates J.
      • Pritchett E.
      Scope of dietetics practice framework.
      J Am Diet Assoc. 2005; 105: 634-640
      ) that guide the practice and performance of RDs in all settings. The concept of scope of practice is fluid (
      • Visocan B.
      • Swift J.
      Understanding and using the scope of dietetics practice framework: A step-wise approach.
      J Am Diet Assoc. 2006; 106: 459-463
      ), 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 (
      • O'Sullivan-Maillet J.
      • Skates J.
      • Pritchett E.
      Scope of dietetics practice framework.
      J Am Diet Assoc. 2005; 105: 634-640
      ), 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 (
      American Dietetic Association Quality Management Committee
      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.
      J Am Diet Assoc. 2008; 108: 1538-1542e9
      ) 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 (
      • Lacey K.
      • Pritchett E.
      Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
      J Am Diet Assoc. 2003; 103: 1061-1072
      ). 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 thumbnail gre1
      Figure 1Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 2Standards of Practice for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).
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      Figure 3Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders (DE and ED).

      Three Levels of Practice

      Competent Practitioner

      A 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 Practitioner

      A 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 Practitioner

      An expert practitioner is an RD who is recognized within the profession and has mastered the highest degree of skill in or knowledge of a certain focus or generalized area of 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 (
      American Dietetic Association Web site
      Scope of Dietetic Practice Framework definition of terms.
      http://www.eatright.org/scope
      ).
      These Standards, along with the 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.
      J Am Diet Assoc. 2009; 109: 1461-1467
      ), 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?

      Overview

      The 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 (
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision.
      American Psychiatric Publishing, Arlington, VA2000
      ). 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 (
      DSM-5: The future manual.
      http://www.psych.org/MainMenu/Research/DSMIV/DSMV.aspx
      ). 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) (
      • Miller C.A.
      • Golden N.H.
      An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.
      Nutr Clin Pract. 2010; 25: 110-115
      ). About 20% of child and adolescent inpatient psychiatric beds are occupied by those with an eating disorder, more than any other psychiatric diagnosis (
      • Klump 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: 97-103
      ). Furthermore, utilization of health care benefits for eating disorders surpasses that of any other mental health illness (
      • Klump 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: 97-103
      ). Adolescents who diet and develop disordered eating behaviors carry these unhealthy practices into young adulthood and beyond (
      • Neumark-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: 1004-1011
      ). The prevalence and incidence of eating disorders is underestimated (
      • Hoek H.W.
      • van Hoeken D.
      Review of the prevalence and incidence of eating disorders.
      Int J Eat Disord. 2003; 34: 384-396
      ) 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 (
      • van 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: 565-569
      ,
      • Herpertz-Dahlmann B.
      Adolescent eating disorders: Definitions, symptomology, epidemiology and comorbidity.
      Child Adolesc Psychiatr Clin North Am. 2008; 18: 31-47
      ,
      • Becker 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: 611-619
      ). As such, up to 90% of those with an eating disorder may go unrecognized or not receive treatment (
      • Schumann S.A.
      • Hickner J.
      Suspect an eating disorder? Suggest CBT.
      J Fam Pract. 2009; 58: 265-268
      ).
      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 (
      • Miller C.A.
      • Golden N.H.
      An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.
      Nutr Clin Pract. 2010; 25: 110-115
      ). The peak age of onset for AN is estimated to be 15 to 19 years, with BN peaking somewhat later (
      • Miller C.A.
      • Golden N.H.
      An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.
      Nutr Clin Pract. 2010; 25: 110-115
      ). The EDNOS category accounts for approximately 60% of patients treated in outpatient settings, but it is the least studied diagnostic category (
      • Miller C.A.
      • Golden N.H.
      An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.
      Nutr Clin Pract. 2010; 25: 110-115
      ). 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 (
      • Hudson 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: 348-358
      ). 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%) (
      • Hudson 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: 348-358
      ). 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%) (
      • Hudson 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: 348-358
      ).
      People with eating disorders frequently have coexisting mood, anxiety, impulse control, or substance use disorders (
      • Hudson 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: 348-358
      ). 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 (
      • Klump 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: 97-103
      ). 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 (
      • Hudson 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: 348-358
      ). Death from AN is reported to be anywhere from 5% to 16% (
      • Miller C.A.
      • Golden N.H.
      An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.
      Nutr Clin Pract. 2010; 25: 110-115
      ).
      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 (
      • Glazer J.L.
      Eating disorders among male athletes.
      Curr Sports Med Rep. 2008; 7: 332-337
      ). 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 (
      • Murray 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: 483-491
      ).
      Miller and Golden (
      • Miller C.A.
      • Golden N.H.
      An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.
      Nutr Clin Pract. 2010; 25: 110-115
      ) 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 fare better than those diagnosed later in life, with 30% to 50% of adults achieving full recovery vs 69% to 75.8% of adolescents at 10 to 15 years follow-up. A study of patients with AN and BN over the course of 7.5 years suggests that the prognosis for a full recovery from BN or an EDNOS is more optimistic overall (
      • Miller C.A.
      • Golden N.H.
      An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.
      Nutr Clin Pract. 2010; 25: 110-115
      ). Full recovery following intensive treatment for BN was reported at 74% vs 33% for patients with AN, with 99% of BN patients and 83% of those with AN achieving at least partial recovery. The relapse rate following full recovery was approximately 33% among both AN and BN subjects in this study. The prognosis for recovery or remission from EDNOS is thought to be similar to that of BN (
      • Miller C.A.
      • Golden N.H.
      An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.
      Nutr Clin Pract. 2010; 25: 110-115
      ). Interpretation of data is complicated by crossover between intake diagnosis and diagnosis at follow-up, because many patients/clients cross from one diagnosis to another (
      • Miller C.A.
      • Golden N.H.
      An introduction to eating disorders: Clinical presentation, epidemiology and prognosis.
      Nutr Clin Pract. 2010; 25: 110-115
      ). In fact, a single broad diagnostic category encompassing all eating disorders has been suggested to reflect the similarities in core features among eating disorders (
      • Crow S.
      • Peterson C.B.
      Editorial: Refining treatments for eating disorders.
      Am J Psychiatr. 2009; 166: 266-267
      ).
      Although not clinically defined, the authors of this article find that disordered eating is characterized by attitudes about food, weight, body size, and body shape that are associated with engagement in strict eating and exercise behaviors that jeopardize physical health, emotional stability, and safety. Together, DE and ED represent a significant health challenge. Ambivalence and resistance are typical among individuals with eating disorders (
      National Institute for Clinical Excellence
      Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders, (Clinical Guideline 9).
      National Collaborating Center for Medical Health, London, UK2004
      ). In addition, anxiety and fear of change (and/or fear of gaining fat) contribute to the protracted course of severe eating disorders. Eating disorders may be maintained by low core self-esteem, mood intolerance, and interpersonal difficulties that interact with the core psychopathology of the eating disorder (
      • Fairburn C.G.
      • Cooper Z.
      • Shafran R.
      Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment.
      Behav Res Ther. 2003; 41: 509-528
      ). Medical complications involve multiple systems (eg, cardiovascular, endocrine, immune, reproductive, and/or skeletal); affect growth and development; and contribute to loss of bone mineral density, cardiovascular abnormalities, gastrointestinal dysfunction, including bleeding and bowel paralysis, fluid imbalance, and electrolyte abnormalities (
      • Klump 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: 97-103
      ,
      Practice guideline for treatment of patients with eating disorders, 3rd ed, 2006.
      http://www.psychiatryonline.com/pracGuide/PracticePDFs/EatingDisorders3ePG_04-28-06.pdf
      ,
      • Carter F.A.
      • Bulik C.M.
      Childhood obesity prevention programs: How do they affect eating pathology and other psychological measures?.
      Psychosom Med. 2008; 70: 363-371
      ,
      • Neumark-Sztainer D.
      Preventing obesity and eating disorders in adolescents: What can health care providers do?.
      J Adolesc Health. 2009; 44: 206-213
      ). Males and females alike report that an eating disorder negatively impacts satisfaction with life, diminishing social, psychological, and physical domains (
      • Engel S.G.
      • Adair C.E.
      • Hayas C.L.
      • Abraham S.
      Health-related quality of life and eating disorders: A review and update.
      Int J Eat Disord. 2009; 42: 179-187
      ). Low body mass index and serum albumin are the strongest risk factors for sudden death (
      • Cockfield A.
      • Philpot U.
      Feeding size 0: The challenges of anorexia nervosa: Managing anorexia from a dietitian's perspective.
      Proc Nutr Soc. 2009; 68: 281-288
      ). Coordination of care and collaboration among professionals regarding interpretation of vital signs, anthropometric measurement, assessment of system function, evidence of self-injury, family interactions, and attitudes about food, exercise, and appearance may reduce the risk of complications (
      • Reiter C.S.
      • Graves L.
      Nutrition therapy for eating disorders.
      Nutr Clin Pract. 2010; 25: 122-136
      ).
      Providing care for those with DE and ED requires specialized knowledge and skills. The APA (
      Practice guideline for treatment of patients with eating disorders, 3rd ed, 2006.
      http://www.psychiatryonline.com/pracGuide/PracticePDFs/EatingDisorders3ePG_04-28-06.pdf
      ) and National Institute for Clinical Excellence (
      National Institute for Clinical Excellence
      Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders, (Clinical Guideline 9).
      National Collaborating Center for Medical Health, London, UK2004
      ) in the United Kingdom recommend nutrition rehabilitation for DE and ED. RDs experienced in treating DE and ED possess the expertise and skills to address issues related to food and nutrition knowledge, physiology, and behavior change as they play out in psychosociocultural realms of eating. Thus, an RD experienced in treating DE and ED is uniquely qualified as the professional to provide medical nutrition therapy across the full continuum of disordered eating and at various levels of care (
      • Reiter C.S.
      • Graves L.
      Nutrition therapy for eating disorders.
      Nutr Clin Pract. 2010; 25: 122-136
      ). Nutrition counseling is considered an integral component in the treatment of eating disorders (
      • Reiter C.S.
      • Graves L.
      Nutrition therapy for eating disorders.
      Nutr Clin Pract. 2010; 25: 122-136
      ).
      DE and ED are complex medical conditions. Basic training in dietetics, however, is generally limited relative to describing the signs and symptoms of DE and ED and documenting the type of experience needed for nutrition care of persons with DE and ED. Thus, an RD desiring to practice in DE and ED needs to obtain specialized education, training, and experience that may be obtained in mentoring situations, continuing education, and other sources. An RD specializing in DE and ED applies medical nutrition therapy to achieve nutritional rehabilitation for patients/clients with psychological disorders involving interpersonal and social issues and affecting multiple organ systems. Patients/clients with eating disorders typically present with other psychological, neuroendocrine, or substance abuse problems that further complicate treatment. Thus, an RD must be knowledgeable about the course of disease and recovery, varied approaches to the treatment of eating disorders, as well as medical monitoring, medications, and indicators of recovery relative to these populations. Recovery indicators encompass achievement and maintenance of a healthful body weight, normalization of eating patterns, normalized perception and response to hunger and satiety, and the correction of nutrition-related biological and psychological malfunction (
      • Reiter C.S.
      • Graves L.
      Nutrition therapy for eating disorders.
      Nutr Clin Pract. 2010; 25: 122-136
      ).
      As in all areas of dietetics practice, development and maintenance of a caring relationship between the patient/client and RD is central to the nutrition care process (
      • Lacey K.
      • Pritchett E.
      Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
      J Am Diet Assoc. 2003; 103: 1061-1072
      ). An RD working in the treatment of DE and ED tailors nutrition intervention and education to meet the needs of a patient/client based on learning style, culture, method of communication, access to technology, as well as practitioner competence in utilizing counseling strategies. The importance of this relationship is underscored among those with DE and ED. Patients/clients benefit from working with practitioners who fully understand and empathize with the various aspects of the struggle to eat normally and provide individualized nutritional guidance to them. Professional experience and knowledge of the current body of scientific evidence related to nutrition therapy for DE and ED populations supports development of comprehensive strategies for complex interventions. Strong counseling skills are imperative in facilitating change among patients/clients with DE and ED. Psychotherapeutic behavioral approaches allow a practitioner to develop a trusting relationship that facilitates guiding a patient/client through making changes in food selection, patterns of physical activity, and acceptance of changes in body weight, shape, or size. Ultimately, nutritional rehabilitation supports emotional and relational changes such as enhanced self-confidence and self-care (
      • Reiter C.S.
      • Graves L.
      Nutrition therapy for eating disorders.
      Nutr Clin Pract. 2010; 25: 122-136
      ).
      Nutrition care beyond nutritional rehabilitation is needed to assist in maintenance of new lifestyle habits (
      • Reiter C.S.
      • Graves L.
      Nutrition therapy for eating disorders.
      Nutr Clin Pract. 2010; 25: 122-136
      ). The goal is for a patient/client to achieve a comfortable relationship with his or her body and normalized body image, consume a varied diet that includes all food groups in appropriate amounts, and not engage in compensatory behaviors (eg, exercise motivated by negative emotional state; inappropriate eating behaviors; or use of vomiting, diuretics, laxatives, diet pills, or insulin adjustments to reduce body weight) (
      • Reiter C.S.
      • Graves L.
      Nutrition therapy for eating disorders.
      Nutr Clin Pract. 2010; 25: 122-136
      ).
      Although a physician is responsible for diagnosing eating disorders and other psychiatric conditions, treatment is most effectively carried out by a team of health professionals (
      • Cockfield A.
      • Philpot U.
      Feeding size 0: The challenges of anorexia nervosa: Managing anorexia from a dietitian's perspective.
      Proc Nutr Soc. 2009; 68: 281-288
      ). RDs work as integral members of the multidisciplinary team. The best clinical outcomes are typically achieved when care considers the treatment and medication plan and is coordinated among medical and mental health practitioners, family members as appropriate, and other professionals and persons providing support (eg, coaches, school counselors, and spiritual leaders) (
      • Cockfield A.
      • Philpot U.
      Feeding size 0: The challenges of anorexia nervosa: Managing anorexia from a dietitian's perspective.
      Proc Nutr Soc. 2009; 68: 281-288
      ). Treatment of those with DE and ED involves complicated, unpredictable, dynamic situations in which critical thinking and experience are essential. The thought process of patients/clients with BN is typically impulsive, whereas with AN, it is often black and white, perfectionistic, and comparative. Ideally, RDs consult with other health professionals when working with DE and ED treatment in the group setting because comparisons and competitiveness between patients/clients increases the risk of contagion (ie, transmission of DE and ED behaviors).
      Due to the complexities involved in counseling patients/clients with DE and ED, RDs knowledgeable and skilled in this area are needed at all levels of care, including individualized and group outpatient, partial hospitalization, inpatient hospital, and residential care. RDs working in the treatment of DE and ED engage in research that contributes to emerging evidence and therapeutic strategies. In addition, because effective prevention is desirable, RDs who work or have worked in the DE and ED field are encouraged to develop strategies and participate in programs that contribute to eating disorder prevention, awareness, and treatment. Because early intervention is critical to improving treatment outcomes, RDs who may not work directly in DE and ED can be instrumental in early identification of at risk individuals and suggesting and/or initiating referrals to appropriate health care professionals. For example, RDs who work with high-risk groups (eg, patients/clients diagnosed with diseases that include a focus on food intake or body weight, athletes in thin-build or appearance sports, and those who are otherwise in environments that emphasize appearance) can be influential in identifying disturbances in eating.

      ADA SOP and SOPP for RDs (Competent, Proficient, and Expert) in Disordered Eating and Eating Disorders (DE and ED)

      An RD may use the ADA SOP and SOPP for RDs (competent, proficient, expert) in DE and ED (see the Web site exclusive Figure 1, Figure 2, Figure 3 at www.adajournal.org) to:
      • •
        identify the competencies needed to provide DE and ED care;
      • •
        self-assess appropriate knowledge base and skills to provide safe and effective DE and ED care for their level of practice;
      • •
        identify need for additional knowledge and skills to practice at the competent, proficient, or expert level of DE and ED;
      • •
        provide a foundation for public and professional accountability in DE and ED care;
      • •
        assist management in planning of DE and ED services and resources;
      • •
        enhance professional identity and communicate the nature of DE and ED dietetics;
      • •
        guide development of DE and ED dietetics-related education and continuing education programs, job descriptions, and career pathways; and
      • •
        assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in DE and ED dietetics and the understanding of the full scope of this focus area of dietetics practice.

      Application to Practice

      The Dreyfus model (
      • Dreyfus H.L.
      • Dreyfus S.E.
      Mind over Machine: The Power of Human Intuitive Expertise in the Era of the Computer.
      Free Press, New York, NY1986
      ) identifies levels of proficiency (novice, advanced beginner, competent, proficient, and expert) (refer to Figure 1 online at www.adajournal.org) during the acquisition and development of knowledge and skills. This model is helpful in understanding the levels of practice described in the SOP and SOPP for RDs in DE and ED. In ADA focus area SOP and SOPP, the levels are represented as competent, proficient, and expert practice levels.
      All RDs, even those with significant experience in other practice areas, must begin at the competent level when practicing in a new setting. At the competent level, an RD starting to work with patients/clients with DE and ED is learning the principles that underpin this focus area and is developing skills for safe and effective DE and ED practice. Many RDs and other professionals have worked hard to help others understand we are treating patients/clients with DE and ED and not treating disordered eating and eating disorders. 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 proficient or expert knowledge/practice in another focus area. However, an RD new to the focus area of DE and ED may experience a steep learning curve.
      At the proficient level, an RD has developed a deeper understanding of DE and ED care and is better equipped to apply evidence-based guidelines and best practices than at the competent level. This RD is also able to modify practice according to unique situations. An RD at the proficient level may possess a specialist credential.
      At the expert level, an RD thinks critically about DE and ED dietetics, demonstrates a more intuitive understanding of DE and ED dietetics 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 expert level requires the application of composite dietetics knowledge, with practitioners drawing on their clinical experience and on the experience of RDs working in DE and ED in various disciplines and practice settings. Expert RDs, with their extensive experience and ability to see the significance and meaning of DE and ED dietetics within a contextual whole, are fluid and flexible and, to some degree, autonomous in practice. They not only implement DE and ED dietetics practice, they also drive and direct clinical practice, conduct, and collaborate in research, contribute to multidisciplinary teams, and lead the advancement of DE and ED dietetics practice.
      Indicators for the SOP (Figure 2, available online at www.adajournal.org) and SOPP (Figure 3, available online at www.adajournal.org) for RDs in DE and ED are measurable action statements that illustrate how each standard may be applied in practice. Within the SOP and SOPP for RDs in DE and ED, an X in the competent 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 competent RD in DE and ED could be an RD starting practice after registration or an experienced RD who has recently assumed responsibility to provide DE and ED care for patients/clients. An X in the proficient column indicates that an RD who performs at this level has a deeper understanding of DE and ED dietetics and has the ability to modify therapy to meet the needs of patients/clients in various situations. An X in the expert column indicates that an RD who performs at this level possesses a comprehensive understanding of DE and ED dietetics and a highly developed range of skills and judgments acquired through a combination of experience and education. The expert RD builds and maintains the highest level of knowledge, skills, and behaviors, including leadership, vision, and credentials.
      Standards and indicators presented in online Figure 2 and Figure 3 (available at www.adajournal.org) in boldface type originate from ADA's 2008 SOP in Nutrition Care and SOPP for RDs (
      American Dietetic Association Quality Management Committee
      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.
      J Am Diet Assoc. 2008; 108: 1538-1542e9
      ) and apply to RDs in all three levels. Several indicators developed for this focus area not in boldface type are identified as applicable to all levels of practice. Where Xs are placed in all three levels of practice, it should be understood that all RDs in the field of DE and ED 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 competent level. Several levels of practice are considered in this document; thus, taking a holistic view of the SOP and SOPP for RDs in DE and ED is warranted. It is the totality of individual practice that defines the level of practice and not any one indicator or standard.
      RDs should review the SOP and SOPP in DE and ED at regular intervals to evaluate their individual focus area nutrition 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 DE and ED to better utilize the Commission on Dietetic Registration's Professional Development Portfolio for self-assessment, planning, improvement, and commitment to lifelong learning (
      • Weddle D.O.
      The Professional Development Portfolio Process: Setting goals for credentialing.
      J Am Diet Assoc. 2002; 102: 1439-1444
      ). These Standards may be used in each of the five steps in the Professional Developmental Portfolio process (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. RDs are expected to practice only at the level at which they are competent, and this will vary depending on education, training and experience (
      • Gates G.
      Ethics opinion: Dietetics professionals are ethically obligated to maintain personal competence in practice.
      J Am Diet Assoc. 2003; 103: 633-635
      ). See Figure 5 for case examples of how RDs in different roles may use the SOP and SOPP for RDs in DE and ED.
      Figure thumbnail gr4
      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 thumbnail gr5
      Figure 5Case examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians (RDs) (Competent, Proficient, and Expert) in Disordered and Eating Disorders (DE and ED).
      In some instances, components of the SOP and SOPP for RDs in DE and ED do not specifically differentiate between proficient and expert 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 expert level, which combines dimensions of understanding, performance, and value as an integrated whole (
      • Chambers D.W.
      • Gilmore C.J.
      • Maillet J.O.
      • Mitchell B.E.
      Another look at competency-based education in dietetics.
      J Am Diet Assoc. 1996; 96: 614-617
      ). A wealth of knowledge is embedded in the experience, discernment, and practice of expert-level RD practitioners. The knowledge and skills acquired through practice will continually expand and mature. The indicators will be refined as expert level RDs systematically record and document their experience using the concept of clinical exemplars. Clinical exemplars include a brief description of the need for action and the process used to change the outcome. The experienced practitioner observes clinical events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. Clinical examples provide outstanding models of the actions of individual RDs in DE and ED in clinical settings and the professional activities that have enhanced patient/client care.

      Future Directions

      The SOP and SOPP for RDs in DE and ED are innovative and dynamic documents. Future revisions will reflect changes and advances in practice, dietetics education programs, and outcomes of practice audits. The authors acknowledge that the three practice levels require more clarity and differentiation in content and role delineation and that 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 DE and ED to better serve tomorrow's practitioners and their patients/clients).

      Conclusions

      The SOP and SOPP for RDs in DE and ED 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 treatment for persons with DE and ED. These standards also serve as a professional resource for self-evaluation and professional development for RDs specializing in DE and ED. 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 as well as advances in the treatment of persons with DE and ED 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 BHN-DPG, these standards are an application of continuous quality improvement and represent an important collaborative endeavor.
      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 Patti Steinmuller, MS, RD, CSSD, LN, for advice and counsel provided during the drafting and writing of these standards. The authors also thank Charlotte Caperton-Kilburn, MS, RD, CSSD; Pamela Kelle, RD, CDE; Leslie P. Schilling, MA, RD, CSSD; and Therese S. Waterhous, PhD, RD, who reviewed these standards.

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      Biography

      M. M. Tholking is in private practice, Greater Cincinnati/Southern Ohio.
      A. C. Mellowspring is a certified eating disorder registered dietitian, owner, Eat from the Earth Nutrition Consulting, LLC, and director of nutrition services, Oliver-Pyatt Centers, Miami, FL.
      S. G. Eberle is a board certified specialist in sports dietetics, and owner, Eat, Drink, Win!, Portland, OR.
      R. P. Lamb is a dietitian, Center for Weight Loss Surgery, Newton-Wellesley Hospital, Wellesley, MA.
      E. S. Myers is director of prevention and health management, The Little Clinic, Nashville, TN.
      C. Scribner is a faculty associate, Arizona State University, Phoenix; an adjunct faculty member, Metropolitan State College of Denver, Denver, CO; and owner, Encompass Nutrition, LLC, Littleton, CO.
      R. F. Sloan is in private practice, Nashville, TN.
      K. B. Wetherall is dietetic internship director, The University of Tennessee, Knoxville.

      Article info

      Footnotes

      Editor's note: Figure 1, Figure 2, Figure 3 that accompany this article are available online at www.adajournal.org.

      Address correspondence to: ADA Quality Management, American Dietetic Association, 120 South Riverside Plaza, Suite 2000, Chicago, IL 60606-6995. E-mail: [email protected]

      Identification

      DOI: https://doi.org/10.1016/j.jada.2011.05.021

      Copyright

      © 2011 American Dietetic Association. Published by Elsevier Inc. All rights reserved.

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