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Academy of Nutrition and Dietetics: Revised 2020 Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems

      Abstract

      Current systems of food production and consumption are challenged by factors such as natural resource constraints, relative unaffordability of nutrient-dense foods, persistent social inequities, and high rates of diet-related disease. Registered dietitian nutritionists (RDNs) play a critical role in protecting the health of current and future populations by advancing sustainable, resilient, and healthy food and water systems. By definition, such systems can meet current dietary needs without jeopardizing the ability to meet the needs of future generations; can withstand or adapt to disturbances over time; and can equitably facilitate disease prevention and well-being for all individuals. This area of practice within nutrition and dietetics requires recognition of the complex interrelationships among indiviudal health and economic, environmental, and social domains of food and nutrition, and allows RDNs to bring unique expertise to diverse interprofessional teams. The Revised 2020 Standards of Professional Performance for RDNs (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems update the 2014 standards and cover the following 6 standards of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, specific indicators provide measurable action statements that illustrate how the RDN can apply the principles of sustainable food systems to a variety of practice settings. The indicators describe 3 skill levels (ie, competent, proficient, and expert) for RDNs in this focus area.
      Editor’s note: Figure 2 that accompanies this article is available online at www.jandonling.org.
      The Hunger and Environmental Nutrition (HEN) Dietetic Practice Group (DPG) of the Academy of Nutrition and Dietetics (Academy), under the guidance of the Academy Quality Management Committee, has revised the Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) in Sustainable, Resilient, and Healthy Food and Water Systems originally published in 2014.
      • Tagtow A.
      • Robien K.
      • Bergquist E.
      • et al.
      Academy of Nutrition and Dietetics: Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems.
      The revised document, Academy of Nutrition and Dietetics: Revised 2020 Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems (henceforth: Sustainable Food Systems) reflects advances in sustainable food systems practice during the past 6 years and replaces the 2014 Standards. This document builds on the Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice (SOP) in Nutrition Care and SOPP for RDNs.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      The Academy of Nutrition and Dietetics/Commission on Dietetic Registration’s (CDR) Code of Ethics for the Nutrition and Dietetics Profession,
      Academy of Nutrition and Dietetics, Commission on Dietetic Registration
      2018 Code of Ethics for the Nutrition and Dietetics Profession.
      along with the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      and Revised 2017 Scope of Practice for the RDN,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      guide the practice and performance of RDNs in all settings.
      Approved April 2020 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the Executive Committee of the Hunger and Environmental Nutrition Dietetic Practice Group of the Academy. Scheduled review date: December 2026. Questions regarding the Standards of Professional Performance for Registered Dietitian Nutritionists in Sustainable, Resilient, and Healthy Food and Water Systems may be addressed to Academy Quality Management Staff: Dana Buelsing, MS, manager, Quality Standards Operations; and Karen Hui, RDN, LDN, scope/standards of practice specialist, Quality Management at [email protected].
      All registered dietitians are nutritionists—but not all nutritionists are registered dietitians. The Academy's Board of Directors and Commission on Dietetic Registration have determined that those who hold the credential Registered Dietitian (RD) may optionally use “Registered Dietitian Nutritionist” (RDN). The 2 credentials have identical meanings. In this document, the authors have chosen to use the term RDN to refer to both registered dietitians and registered dietitian nutritionists.

      Overview

      Current global and domestic food production systems are placing untenable strain on both human and natural resources, delivering suboptimal benefits for population health and contributing to a changing climate that, in turn, affects human health and exacerbates inequities.
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      Agricultural practices account for an estimated 34% of global land use,
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      70% of water use withdrawn for human purposes,
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      Pathways for increasing agricultural water productivity.
      and 11% of global greenhouse gas emissions,
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      with a resulting food supply that supports neither optimal nor equitable health and nutrition outcomes. For example, 22% of all children are stunted and 39% of all adults are overweight globally; still, 41 countries face the triple burden of malnutrition via undernutrition, micronutrient deficiency, and overweight, and all countries struggle with at least one burden.
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      2018 Global Nutrition Report: Shining a Light to Spur Action on Nutrition.
      Healthy food options remain unaffordable for many, with nutrient-dense foods often more expensive than starchy staples, refined grains, and added sugars and fats
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      ; this is true in all regions, but especially in low-income countries with the highest burdens of micronutrient deficiencies.
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      The relative caloric prices of healthy and unhealthy foods differ systematically across income levels and continents.
      At the same time that the current global food supply lacks adequate amounts of nutrient-dense foods, such as horticultural crops,
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      32% of food produced globally is wasted.
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      Meanwhile, climate change poses many threats to human nutrition through increasing impacts on terrestrial and ocean temperatures, crop yields; and nutrient quality of foods, and effects on socioeconomic systems, such as income, population displacement, and conflict.
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      Climate change and global food systems: Potential impacts on food security and undernutrition.
      Furthermore, a global food sovereignty movement
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      Food sovereignty: Global rallying cry of farmer movements. Food First Institute for Food and Development Policy.
      points to the persistent struggle of farmers, fishers, including indigenous people and landless workers who produce much of the global food supply, yet often experience hunger, poverty, and lack of political power and control over their livelihoods.
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      Food sovereignty: Global rallying cry of farmer movements. Food First Institute for Food and Development Policy.
      Many of these global challenges are mirrored in the United States, and some originate in domestic food systems. Broadly speaking, the United States contributes disproportionately to global resource use and environmental degradation. Studies have estimated that if all countries were to adopt a typical US diet, the amount of global agricultural land would need to increase by 180%.
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      Evaluating the environmental impacts of dietary recommendations.
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      The impact of global dietary guidelines on climate change.
      The Western diet, characterized by low intake of whole grains, fruits, and vegetables, and high intake of foods that are processed and high in saturated fat, salt, and sugar, is both heavily reliant on resource-intensive agricultural practices and strongly associated with increased morbidity and mortality.
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      Health effects of dietary risks in 195 countries, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017.
      In the United States, vast disparities in healthy food access and diet-related diseases exist along lines of race and class, and agricultural and food industries often rely on the same marginalized populations for labor, including a high proportion of immigrants who may not receive adequate pay, health benefits, or legal protection against labor violations.
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      Food Chain Workers Alliance and Solidarity Research Cooperative. No piece of the pie: US food workers in 2016.
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      A profile of migrant health.
      The health disparities produced within the food system are often reinforced by other social determinants of health, such as access to education and health care services, exposure to violence and crime, and systemic discrimination and racism.
      HealthyPeople.gov. Social determinants of health.
      An understanding of the social determinants of health is foundational to practice within this focus area. Also important is an awareness of how nutrition outcomes are affected by other sectors; for example, the concept of “commercial determinants of health” describes conflicts between the interests of public health and those of profit-motivated industries, which influence consumer behavior and health via marketing, lobbying, and control of supply chains.
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      The commercial determinants of health.
      The challenge of equitably meeting nutritional needs without expanding agricultural land or increasing use of other natural resources intensifies with a steadily growing population. Although it is not possible for a national or global population to be supported with zero environmental footprint, improvements in agricultural practices and reduction of waste throughout food supply chains, including at the consumer level, can help to minimize the negative impacts of the food system, while promoting human nutrition and positive health outcomes.
      Producing a safe and healthy food and water supply that is accessible and affordable to all people without depletion of essential inputs, such as soil and water, or widespread exploitation of the labor force is also fundamental to meeting the United Nations Sustainable Development Goals.
      • United Nations
      The sustainable development goals report 2019.
      This challenge, which will only be amplified by the demands of a growing global population and shifting dietary patterns,
      • Tilman D.
      • Clark M.
      Global diets link environmental sustainability and human health.
      has positioned a “sustainable food system” at the forefront of institutional and governmental policies and is central to the mission of many professional organizations involved with public health and the food system.
      Food and Agriculture Organization of the United Nations
      The future of food and agriculture: Trends and challenges.
      Academy of Nutrition and Dietetics, American Nurses Association
      American Planning Association, American Public Health Association. Principles of a healthy, sustainable food system. American Planning Association.
      Council on Science and Public Health, American Medical Association
      Report 8 of The Council on Science and Public Health (A-09). American Medical Association.
      RDNs play a unique and pivotal role in promoting sustainable food systems. RDNs in all areas of nutrition and dietetics are increasingly being called upon to address issues of sustainability and resilience in their daily practice.
      • Robinson-O’Brien R.
      • Gerald B.L.
      Practice paper of the Academy of Nutrition and Dietetics: Promoting ecological sustainability within the food system.
      For example, RDNs in foodservice settings, such as school nutrition, hospital foodservice,
      • Carino S.
      • Porter J.
      • Malekpour S.
      • Collins J.
      Environmental sustainability of hospital foodservices across the food supply chain: A systematic review.
      workplace foodservice, and restaurants, are increasingly considering sustainability within food procurement, menu planning, and operational decisions
      • Peregrin T.
      Sustainability in foodservice operations: An update.
      ; clinical practitioners can incorporate food security screening and connect underserved individuals to institutional and community resources
      • Berry E.M.
      • Dernini S.
      • Burlingame B.
      • Meybeck A.
      • Conforti P.
      Food security and sustainability: Can one exist without the other?.
      ; practitioners in corporate settings can influence decisions to increase the sustainability of packaging materials or ingredient sourcing; and RDNs in all settings can champion efforts to reduce unnecessary food waste and divert unavoidable food scraps from landfills. A growing number of didactic and internship programs are incorporating sustainable food systems knowledge and skills into their training,
      • Knoblock-Hahn A.
      • Medrow L.
      Development and implementation of a sustainable, resilient, and healthy food and water systems curriculum for dietetic interns.
      ,
      • Webber C.B.
      • Sarjahani A.
      Fitting sustainable food systems into dietetic internships—A growing trend.
      and career opportunities increasingly call for RDNs to leverage their core skills in new ways, such as developing policy solutions that reflect community needs, or overseeing sustainability initiatives in foodservice, agribusiness, or food technology settings.
      Sustainability is often defined as the ability of a system to be maintained over the long term and meet the needs of the present without jeopardizing the ability to meet those of future generations.
      • Gussow J.D.
      • Clancy K.L.
      Dietary guidelines for sustainability.
      A sustainable food system is one that not only meets the needs of all individuals and communities in the present moment, but also has the capacity to adjust over time to accommodate future generations. Meeting the needs of all individuals and communities requires an emphasis on those historically marginalized and disproportionately impacted by systemic racism, sexism, classism, and other intersecting forms of oppression. These populations, which could include women, people of color, individuals living in low socioeconomic communities, communities exposed to environmental contaminants from food production practices, or communities displaced by climate change, are among those most vulnerable to the consequences of food insecurity and poor nutrition. A sustainable food system also fulfills conditions of social and economic sustainability, including fair compensation and working conditions for all people involved in growing, producing, distributing, selling, and serving foods and beverages; equitable economic opportunities and outcomes for all communities; and access to foods that are nutritious, affordable, and culturally appropriate. As frontline workers throughout the food system, RDNs frequently encounter the nutritional manifestations of unsustainable practices within the food system. These may present as disparities in diet-related disease, healthy food access, health care, and other community resources and services in client populations. This SOPP demonstrates a variety of ways RDNs can leverage their knowledge and skills to also address underlying drivers of sustainability within the food system, whether that is through their research; advocacy; or work with community coalitions, institutions, or corporations.
      It is worth noting that in addition to sustaining food systems resources and capacity over the long-term, it is also important to renew and regenerate resources. Although we use the phrasing of sustainability throughout this SOPP for brevity and consistency with previous efforts, we acknowledge that the conversation is ever-changing and we do not exclude complementary and emerging frameworks, such as regenerative or circular food systems.
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      The imperative for regenerative agriculture.
      • Jurgilevisch A.
      • Birge T.
      • Kentala-Lehtonen J.
      • et al.
      Transition towards circular economy in the food system.
      • Van Zanten H.H.E.
      • De Boer I.J.M.
      The role of farm animals in a circular food system.
      In broad terms, resilience refers to the ability of a system and the people within it to withstand or adapt to disturbances over time.
      • Tendall D.M.
      • Joerin J.
      • Kopainsky B.
      • et al.
      Food system resilience: Defining the concept.
      ,
      • Schipanski M.
      • MacDonald G.K.
      • Rosenzweig S.M.
      • et al.
      Realizing resilient food systems.
      A resilient food system continues to meet the food and nutrition needs of a population despite disturbances such as climate change, natural disasters, pandemics, political or economic crises, or rapid urbanization.
      • Biehl E.
      • Buzogany S.
      • Huang A.
      • Chodur G.
      • Neff R.A.
      Baltimore Food System Resilience Advisory Report. Johns Hopkins Center for a Livable Future.
      Similarly to sustainability, the issue of resilience applies to all areas of nutrition and dietetics practice, can be incorporated at both the program and systems levels, and is broader than any one specific practice setting or individual intervention. RDNs should consider that individuals and communities may differ in their ability to withstand and recover from disruptive events—for example, a community that was underserved before a natural disaster or political crisis may be more affected and take longer to recover—and should therefore promote equity as a central component of resilience. RDNs can support resilience in the food system by elevating the needs of vulnerable populations they work with and initiating collaborative efforts to address underlying structural issues, not only connecting food-insecure patients with resources, but also advocating for the importance of healthy food environments and fair wages. On a global scale, RDNs can lend their expertise to collaborative efforts for climate change mitigation and adaptation; for instance, ensuring that interventions to promote climate-resilient agricultural practices consider issues such as nutritional quality, food choice, food safety, gender equity, and cultural appropriateness.
      In the context of sustainable, resilient, and healthy food and water systems, the term healthy broadly refers to the ability of a food and water system to equitably facilitate well-being and disease prevention for all individuals.
      • Fanzo J.
      • Davis C.
      Can diets be healthy, sustainable, and equitable?.
      A healthy food and water system is one that makes nutrient-rich foods accessible and affordable for all individuals, including low-income and marginalized populations; adopts practices and incorporates adequate infrastructure to minimize contamination of resources, such as air and water; and ensures that people have access to resources needed for food storage (eg, refrigeration), preparation, feeding, and caregiving practices that support child and family health. RDNs are recognized leaders in promoting human health. Given the interconnectedness between sustainability, resilience, and health, RDNs are essential collaborators in interprofessional efforts to advance sustainable food systems.
      A sustainable, resilient, and healthy food system (sustainable food system, hereafter) is one in which all individuals have equitable access to a safe and secure supply of food and water that supports optimal health, both now and in the future. Sustainable food systems are at the intersection of the following 4 domains: Nutrition and Health; Social, Cultural, and Ethical Capital; Environmental Stewardship; and Economic Vitality. Principles for each domain are shown in the framework in Figure 1. The sustainable, resilient, and healthy food and water systems framework illustrates a few important concepts: sustainability is multidimensional, and the 4 domains of sustainable food systems are interconnected and overlapping. RDNs can use the framework to convey the multitude of factors that should be considered when implementing measures to promote sustainable food systems, and to identify potential co-benefits and trade-offs.
      Figure thumbnail gr1
      Figure 1Sustainable, resilient, and healthy food and water systems framework. (Adapted from Tagtow and colleagues.
      • Tagtow A.
      • Robien K.
      • Bergquist E.
      • et al.
      Academy of Nutrition and Dietetics: Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems.
      )
      RDNs have the opportunity and the responsibility to integrate sustainable food systems principles into their respective practice areas in order to strengthen food and water systems for all individuals, now and for the future. These efforts may include interactions with individual clients, or they may take the form of policy, system, and environmental changes
      • Bunnell R.
      • O’Neil D.
      • Soler R.
      • et al.
      Fifty communities putting prevention to work: Accelerating chronic disease prevention through policy, systems and environmental change.
      that address the quantity, quality, safety, and accessibility of food and water supplies and the interrelated co-benefits and impacts of environmental, economic, social, and health systems. The standards and indicators that appear in Figure 2 (available at www.jandonline.org) span all levels of practice and settings.
      RDNs in sustainable food systems frequently work with issues that exemplify complex systems. A systems thinking approach recognizes the complex interrelationships between multiple components within a larger system. Understanding nonlinear processes, recognizing feedback loops, and identifying possible trade-offs between interrelated parts of a system are all distinguishing components of this approach.
      • van Berkum S.
      • Dengerink J.
      • Ruben R.
      The Food Systems Approach: Sustainable Solutions for a Sufficient Supply of Healthy Food.
      Systems thinking benefits from an interprofessional approach, and RDNs bring a unique skill set that spans nutrition, health, and customer-focused experience to interprofessional teams. An RDN applying a systems approach to improving food and water systems would identify the root causes of a problem by utilizing information from and collaborating with colleagues in diverse fields, including but not limited to agriculture, economics, environmental health, supply chain management, urban planning, and public policy. The RDN would also consider potential implications (eg, externalities) of any one approach to resolving the problem, as well as alternative approaches, before implementing a change in policy or the environment. For example, when working with a local food policy council to increase access to healthy foods, RDNs would first consider underlying systemic factors acting as barriers to healthy food access, including current and historical public policies that may be perpetuating social and economic inequalities. In developing solutions to the problem, RDNs would also consider the ways in which programs and policies can improve nutrition and health, while generating equitable benefits for the local community, economy, and environment, and weighing potential benefits against undesired consequences or unintended outcomes. In this case, the RDN might consider working with the food policy council and community leaders to expand a federal nutrition program that allows low-income shoppers to purchase additional fruits and vegetables from local producers at the farmers market. Due to the complexity and breadth of sustainable food systems issues, working in interprofessional teams is essential to effectively address the root causes of pressing public health challenges and generate optimal benefit across multiple domains.

      Academy Quality and Practice Resources

      Scope of practice in nutrition and dietetics is composed of statutory and individual components, includes the codes of ethics (eg, Academy/CDR, other national organizations, and/or employers code of ethics), and encompasses the range of roles, activities, practice guidelines, and regulations within which RDNs perform. For credentialed practitioners, scope of practice is typically established within the practice act and interpreted and controlled by the agency or board that regulates the practice of the profession in a given state.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      An RDN’s statutory scope of practice can delineate the services an RDN is authorized to perform in a state where a practice act or certification exists (for more information, see www.eatrightpro.org/advocacy/licensure/licensure-map).
      The RDN’s individual scope of practice is determined by education, training, credentialing, experience, and demonstrating and documenting competence to practice. Individual scope of practice in nutrition and dietetics has flexible boundaries to capture the breadth of the individual’s professional practice. Professional advancement beyond the core education and supervised practice to qualify for the RDN credential provides RDNs practice opportunities, such as expanded roles within an organization based on training and certifications, if required. The Scope of Practice Decision Algorithm (www.eatrightpro.org/scope) guides an RDN through a series of questions to determine whether a particular activity is within their scope of practice.
      Academy of Nutrition and Dietetics
      Scope of Practice Decision Algorithm.
      The algorithm is designed to assist an RDN to critically evaluate their personal knowledge, skill, experience, judgment, and demonstrated competence using criteria resources.
      The Academy’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      reflect the minimum competent level of nutrition and dietetics practice and professional performance. The core standards serve as blueprints for the development of focus-area SOP and/or SOPP for RDNs in competent, proficient, and expert levels of practice. While this document addresses the SOPP only, each RDN needs to be aware of the minimum competent level of practice for the core SOP in Nutrition Care and relate its quality indicators within sustainable food systems activities by drawing upon one’s own practice experience and knowledge. The SOP in Nutrition Care is composed of 4 standards consistent with the Nutrition Care Process and clinical workflow elements as applied to the care of patients/clients/populations in all settings.
      • Swan W.I.
      • Vivanti A.
      • Hakel-Smith N.A.
      • et al.
      Nutrition Care Process and Model update: Toward realizing people-centered care and outcomes management.
      The SOPP consists of standards representing 6 domains of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. The SOP and SOPP for RDNs are designed to promote the provision of safe, effective, efficient, and quality food and nutrition care and services; facilitate evidence-based practice; and serve as a professional evaluation resource.
      These focus-area standards for RDNs in sustainable food systems provide a guide for self-evaluation and expanding practice, a means of identifying areas for professional development, and a tool for demonstrating competence in delivering sustainable food systems nutrition and dietetic services. They are used by RDNs 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 can be used to assist RDNs in transitioning their knowledge and skills to a new focus area of practice. Like the Academy’s core SOP in Nutrition Care and SOPP for RDNs,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      the indicators (ie, measurable action statements that illustrate how each standard can be applied in practice) (see Figure 2, available at www.jandonline.org) for the SOPP for RDNs in Sustainable Food Systems were revised with input and consensus of content experts representing diverse practice and geographic perspectives. The SOPP for RDNs in Sustainable Food Systems were reviewed and approved by the Executive Committee of the HEN DPG and the Academy Quality Management Committee.

      Why Were the Standards Revised?

      It is critical that RDNs working in sustainable food systems reflect current practice regarding the most recent research, evidence-based practices, and related laws and regulations in health care and other applicable practice segments. Changes in the practice environment for RDNs and nutrition and dietetics technicians, registered, can impact care and services provided by RDNs. Examples of significant changes are:
      • The Scope of Practice for the RDN
        Academy of Nutrition and Dietetics Quality Management Committee
        Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
        and the Scope of Practice for the Nutrition and Dietetics Technician, Registered
        Academy of Nutrition and Dietetics Quality Management Committee
        Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician, Registered.
        were revised and published in the Academy’s Journal in January 2018 and February 2018, respectively. The RDN Scope of Practice reflects changes impacting practice, such as the Centers for Medicare and Medicaid Services (CMS) updates to regulations; national efforts to address malnutrition; and sections on coaching, global health, and telehealth, among other updates. The Nutrition and Dietetics Technician, Registered Scope of Practice also includes revisions such as updated practice areas and a new individual scope of practice figure.
      • The CMS, Department of Health and Human Services Hospital
        US Department of Health and Human Services, Centers for Medicare and Medicaid Services
        State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders.
        and Critical Access Hospital
        US Department of Health and Human Services, Centers for Medicare and Medicaid Services
        State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); § 485.635(a)(3)(vii) Dietary Services ; § 458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds.
        Conditions of Participation now allow a hospital and its medical staff the option of including an RDN or other clinically qualified nutrition professional within the category of “non-physician practitioner” eligible for ordering privileges for therapeutic diets and nutrition-related services if consistent with state law and health care regulations.
        US Department of Health and Human Services
        Centers for Medicare and Medicaid Services. 42 CFR Parts 413, 416, 440 et al. Medicare and Medicaid Programs; Regulatory provisions to promote program efficiency, transparency, and burden reduction; Part II; Final rule (FR DOC #2014-10687; pp 27106-27157).
        For more information, review the Academy’s practice tips that outline the regulations and implementation steps at www.eatrightpro.org/dietorders. For assistance, refer questions to the Academy’s State Affiliate organization.
      • The Long-Term Care Final Rule published October 4, 2016 in the Federal Register, now “allows the attending physician to delegate to a qualified dietitian or other clinically qualified nutrition professional the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by state law” and permitted by the facility’s policies.
        US Department of Health and Human Services, Centers for Medicare and Medicaid Services
        Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final Rule (FR DOC#2016; pp 68688-68872)–Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178).
        The CMS State Operations Manual, Appendix PP-Guidance for Surveyors for Long-Term Care Facilities contains the revised regulatory language.
        US Department of Health and Human Services, Centers for Medicare and Medicaid Services
        State Operations Manual. Appendix PP Guidance to surveyors for long-term care facilities (Rev. 173, 11-22-17); § 483.30 Physician Services, § 483.60 Food and Nutrition Services.
        CMS periodically revises the State Operations Manual Conditions of Participation; obtain the current information at https://www.cms.gov/files/document/appendices-table-content.pdf.
      • The Dietary Guidelines Advisory Committee recommended that sustainability be considered as part of the 2015-2020 Dietary Guidelines for Americans. Specifically, in reviewing the scientific evidence, the Dietary Guidelines Advisory Committee indicated that not only is a diet that considers sustainability more healthful, it is also one that is better for the environment. Although the Dietary Guidelines Advisory Committee’s sustainability recommendations
        Dietary Guidelines Advisory Committee
        Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Office of Disease Prevention and Health Promotion.
        were not included in the final Dietary Guidelines for Americans,
        US Department of Health and Human Services, US Department of Agriculture
        2015-2020 Dietary Guidelines for Americans. Office of Disease Prevention and Health Promotion.
        the discussion around the topic suggests a need for credentialed nutrition and dietetics practitioners to be knowledgeable and skilled in sustainable food systems.
      • The Council on Future Practice 2017 Visioning Report, a report that discusses the future needs of the nutrition and dietetics profession, indicated that sustainable food systems is 1 of 5 high-priority areas for the future of the profession.
        • Kicklighter J.R.
        • Dorner B.
        • Hunter A.M.
        • et al.
        Visioning report 2017: A preferred path forward for the nutrition and dietetics profession.
      • The Academy’s Strategic Plan includes a focus area on “Food and Nutrition Safety and Security.” It has multiple impact goals, such as “increase equitable access to and utilization of safe and nutritious food and water; advance sustainable nutrition and resilient food systems; leverage innovations in the reduction of food waste and loss; and champion legislation and regulations that increase food and nutrition security throughout the lifecycle” (www.eatrightpro.org/leadership/governance/board-of-directors/strategic-plan).
      Other significant changes impacting nutrition and dietetics practice are highlighted in both the Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      and the Revised 2017 SOP in Nutrition Care and SOPP for NDTRs.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Nutrition and Dietetics Technicians, Registered.

      Three Levels of Practice

      The Dreyfus model
      • Dreyfus H.L.
      • Dreyfus S.E.
      Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer.
      identifies levels of proficiency (ie, novice, advanced beginner, competent, proficient, and expert) (refer to Figure 3) during the acquisition and development of knowledge and skills. The first 2 levels are components of the required didactic education (novice) and supervised practice experience (advanced beginner) that precede credentialing for nutrition and dietetics practitioners. Upon successfully attaining the RDN credential, a practitioner enters professional practice at the competent level and manages their professional development to achieve individual professional goals. This model is helpful in understanding the levels of practice described in the SOPP for RDNs in Sustainable Food Systems. In Academy focus areas, the 3 levels of practice are represented as competent, proficient, and expert.
      With safety and evidence-based practice
      Academy of Nutrition and Dietetics
      Academy definition of terms list.
      as guiding factors when working with customers/populations, the RDN identifies the level of evidence, clearly states research limitations, provides safety information from reputable sources, and describes the risk of the intervention(s), when applicable.
      The RDN is responsible for searching literature and assessing the level of evidence to select the best available evidence to inform recommendations. RDNs must evaluate and understand the best available evidence in order to converse authoritatively with the interprofessional team and adequately involve the customer/population in shared decision making.
      Figure 3Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems.
      Standards of Professional Performance (SOPP) for RDNs in Sustainable, Resilient, and Healthy Food and Water Systems (Sustainable Food Systems) are authoritative statements that describe behavior in the professional role, including activities related to Quality in Practice; Competence and Accountability; Provision of Services; Application of Research; Communication and Application of Knowledge; and Utilization and Management of Resources (6 separate standards).

      The SOPP, along with the Standards of Practice (SOP) in Nutrition Care, applicable to practitioners who provide direct patient/client nutrition care services, are complementary standards and serve as evaluation resources. All indicators may not be applicable to all RDNs’ practice or to all practice settings and situations. RDNs operate within the directives of applicable federal and state laws and regulations, as well as policies and procedures established by the organization in which they are employed. To determine whether an activity is within the scope of practice of the RDN, the practitioner compares their knowledge, skill, experience, judgment, and demonstrated competence with the criteria necessary to perform the activity safely, ethically, legally, and appropriately. The Academy’s Scope of Practice Decision Algorithm is specifically designed to assist practitioners with this process.

      The term customer is used in the SOPP as a universal term. Customer could also mean client/patient, client/patient/customer, participant, consumer, or any individual, group, or organization to which the RDN provides sustainable food systems services. These services are provided to populations, communities, and individuals of all ages across diverse settings. The SOPP apply to all practice areas, including clinical settings. In addition, it is recognized that professional colleagues, employees, organization leaders, public and private sector organizations, agencies, community members, and other stakeholders play critical roles in developing and maintaining sustainable food systems, and are important members of the interprofessional team. The term appropriate is used in the standards to mean: Selecting from a range of best practices or evidence-based possibilities, one or more of which would give an acceptable result in the circumstances.

      Each standard is equal in relevance and importance and includes a definition, a rationale statement, indicators, and examples of desired outcomes. A standard is a collection of specific outcome-focused statements against which a practitioner’s performance can be assessed. The rationale statement describes the intent of the standard and defines its purpose and importance in greater detail. Indicators are measurable action statements that illustrate how each specific standard can be applied in practice. Indicators serve to identify the level of performance of competent practitioners and to encourage and recognize professional growth.

      Standard definitions, rationale statements, core indicators, and examples of outcomes found in the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs have been adapted to reflect 3 levels of practice (competent, proficient, and expert) for RDNs in sustainable food systems (see image below). In addition, the core indicators have been expanded to reflect the unique competence expectations for the RDN providing services related to sustainable food systems.

      Competent Practitioner

      In nutrition and dietetics, a competent practitioner is an RDN who is either just starting practice after having obtained RDN registration by CDR or an experienced RDN recently transitioning their practice to a new focus area of nutrition and dietetics. A focus area of nutrition and dietetics practice is a defined area of practice that requires focused knowledge, skills, and experience that applies to all levels of practice.
      Academy of Nutrition and Dietetics
      Academy definition of terms list.
      A competent practitioner who has achieved credentialing as an RDN and is starting in professional employment consistently provides safe and reliable services by employing appropriate knowledge, skills, behavior, and values in accordance with accepted standards of the profession; acquires additional on-the-job skills; and engages in tailored continuing education to further enhance knowledge, skills, and judgment obtained in formal education.
      Academy of Nutrition and Dietetics
      Academy definition of terms list.
      A general practice RDN can include responsibilities across several areas of practice, including but not limited to community, clinical, consultation and business, research, education, and food and nutrition management.
      As shown in Figure 1, a framework for this area of practice, sustainable food systems are at the intersection of the following 4 domains: Nutrition and Health; Environmental Stewardship; Economic Vitality; and Social, Cultural, and Ethical Capital. Competent practitioners should be familiar with the basic terminology, issues, and priorities of these domains, and have an understanding of the application of the 4 domains (Figure 1) to research, policy, and practice. For more information on how to begin incorporating principles of sustainable food systems into dietetics practice, this document is a tool (including Figure 4 with resources), as well as the HEN DPG. The HEN DPG website (www.hendpg.org) has webinars, newsletters, networking opportunities, and talking points about major issues related to nutrition, sustainability, and food and water systems. In addition to these resources, the HEN DPG also allows its members free access to the Journal of Hunger and Environmental Nutrition, which is published in cooperation with HEN DPG. Other DPGs, such as the Public Health and Community Nutrition DPG and the Agriculture subgroup of the Food and Culinary Professionals DPG, may also offer relevant resources for a variety of practice settings.
      Figure 4Example Resources for Sustainable, Resilient, and Healthy Food and Water Systems (not all inclusive), listed in alphabetical order within each category. Note: the resources included in this table do not necessarily represent the views of the Academy.
      Resource (year of publication)Reference or URLDescription
      Resources from the Academy of Nutrition and Dietetics (Academy)
      Academy Hunger and Environmental Nutrition Dietetic Practice Group (HEN DPG)https://hendpg.org/The HEN DPG offers resources for registered dietitian nutritionists (RDNs) in sustainable food systems, in addition to other areas within hunger and environmental nutrition, such as an electronic mailing list, continuing professional education unit opportunities, newsletter, free access to HEN members to the Journal of Hunger and Environmental Nutrition and a Sustainable, Resilient, and Healthy Food & Water Systems Glossary.
      Cultivating Sustainable, Resilient, Healthy Food and Water Systems: A Nutrition-Focused Framework for Action (2020)Spiker and colleagues
      • Spiker M.L.
      • Knoblock-Hahn A.
      • Brown K.
      • et al.
      Cultivating sustainable, resilient, healthy food and water systems: A nutrition-focused framework for action.
      This document outlines ways that RDNs can cultivate sustainable food and water systems through 5 “entry points:” shaping and delivering dietary guidance; improving food and nutrition security and water security; aligning food production and nutrition; optimizing supply chains and food environments; and reducing waste of food, water, and other resources.
      Food Security and Sustainabilitywww.eatrightpro.org/practice/practice-resources/food-security-and-sustainabilityThis Academy website highlights efforts and resources related to food security and sustainability with links to other organizations whose work relates to this topic, such as Global Alliance for Improved Nutrition, International Food Policy Research Institute, and ReFED.
      Prioritizing Food Security Solutions Toolkit (2019)https://eatrightfoundation.org/why-it-matters/public-education/food-security-solutions/This toolkit, available from the Academy Foundation, is a 4-step food security solutions prioritization process that “identifies the best solutions to improve food security in the community, given the resources available.”
      Visioning Report 2017: A Preferred Path Forward for the Nutrition and Dietetics Profession (2017)Kicklighter and colleagues
      • Kicklighter J.R.
      • Dorner B.
      • Hunter A.M.
      • et al.
      Visioning report 2017: A preferred path forward for the nutrition and dietetics profession.
      A visioning report from the Academy’s Council on Future Practice that identifies “food and nutrition systems and sustainability” as 1 of 5 key priority areas to help meet the future needs of the profession and society.
      Resources from Other Professional Associations
      American Public Health Association: Towards a Healthy and Sustainable Food System (2007)www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/12/34/toward-a-healthy-sustainable-food-systemA policy statement from the American Public Health Association articulating how food systems affect public health.
      British Dietetics Association: One Blue Dot: Environmentally Sustainable Diet Toolkit (2019)www.bda.uk.com/professional/resources/environmentally_sustainable_diet_toolkit_-_one_blue_dotA toolkit from the British Dietetics Association with information, graphics, tools, and links to help dietitians increase their understanding of environmentally sustainable diets and discuss sustainable diets with patients or clients.
      Position of the Society for Nutrition Education and Behavior: The Importance of Including Environmental Sustainability in Dietary Guidance (2019)Rose and colleagues
      • Rose D.
      • Heller M.C.
      • Roberto C.A.
      Position of the Society for Nutrition Education and Behavior: The Importance of Including Environmental Sustainability in Dietary Guidance.
      A position paper in which the Society for Nutrition Education and Behavior states that “environmental sustainability should be inherent in dietary guidance, whether working with individuals or groups about their dietary choices or in setting national dietary guidance.”
      Resources on Sustainable Food Procurement
      Centers for Disease Control and Prevention: Food Service Guidelines for Federal Facilities (2017)www.cdc.gov/obesity/downloads/guidelines_for_federal_concessions_and_vending_operations.pdfThese guidelines have been developed to ensure that healthier foods and beverages are available and encouraged at federal facilities; environmentally responsible practices are conducted in federal foodservice venues; communities are economically supported through local food sourcing; and food safety practices are followed to minimize the risk of foodborne illnesses.
      Farm to Institution New England: Food Service Toolkit (2016)www.farmtoinstitution.org/food-service-toolkitThis toolkit, designed by a collaborative of New England states and primarily intended for use by foodservice managers, institutional sustainability directors, or supply chain facilitators, highlights the opportunities and barriers to utilizing regional food within institutional food procurement systems.
      Health Care Without Harm: Resources on Sustainable Procurement in Hospitals and Sustainable Foodhttps://noharm-global.org/Rationale and resources for sustainable procurement for health care settings, including an outline of the steps to enacting the Sustainable Health in Procurement Project—a joint initiative between the World Health Organization and Healthcare Without Harm. Another resource available in the European section is the white paper “Fresh, Healthy, and Sustainable Food: Best Practices in European Healthcare.”
      Johns Hopkins Center for a Livable Future: Instituting Change: An Overview of Institutional Food Procurement and Recommendations for Improvement (2016)https://clf.jhsph.edu/sites/default/files/2019-01/Instituting-change.pdfA report that reviews literature and key information and resources regarding institutional foodservice procurement systems, including potential benefits of shifting large-scale purchases toward local or sustainably grown food and existing barriers to adopting values-based procurement policies.
      Union of Concerned Scientists: Purchasing Power: How Institutional “Good Food” Procurement Policies Can Shape a Food System That’s Better for People and Our Planet (2017)www.ucsusa.org/sites/default/files/attach/2017/11/purchasing-power-report-ucs-2017.pdfA report that describes a comprehensive values-based institutional purchasing framework called the “Good Food Purchasing Program.” The procurement policy prioritizes 5 values in food purchasing: animal welfare, environmental sustainability, local economies, nutrition, and a valued workforce.
      Resources on the Environmental Implications of Dietary Patterns
      Food and Agricultural Organization of the United Nations (FAO): Food-Based Dietary Guidelines: Dietary Guidelines and Sustainabilitywww.fao.org/nutrition/education/food-dietary-guidelines/background/sustainable-dietary-guidelines/en/A compilation of dietary guidelines from across the world that address sustainability, developed by the FAO.
      FAO: Plates, Pyramids, Planet (2016)www.fao.org/documents/card/en/c/d8dfeaf1-f859-4191-954f-e8e1388cd0b7/An overview of developments in national healthy and sustainable dietary guidelines across the globe, developed by the FAO in 2016.
      FAO: Reports from the High Level Panel of Experts on Food Security and Nutritionwww.fao.org/cfs/cfs-hlpe/reports/en/A series of reports and position papers (1-2 per year) from FAO on global issues related to food security and food and water systems, including topics such as “Food Losses and Waste in the Context of Sustainable Food Systems (2014),” “Nutrition and Food Systems (2017),” and “Agroecological Approaches and Other Innovations for Sustainable Agriculture and Food Systems that Enhance Food Security and Nutrition (2019).”
      Scientific Report of the 2015 Dietary Guidelines Advisory Committee (Chapter 5) (2017)https://ods.od.nih.gov/pubs/2015_dgac_scientific_report.pdfChapter 5, “Food Sustainability and Safety,” addresses key research questions related to food safety and sustainability, including the relationship between population-level dietary patterns and long-term food sustainability.
      Sustainable Development Goalshttps://sustainabledevelopment.un.org/sdgsAll 17 Sustainable Development Goals are directly or indirectly related to nutrition. This website has multiple resources related to the Sustainable Development Goals, including conferences, advisory bodies, newsletters, and educational resources available through the “SDG Academy.”
      Educational and Curricular Resources
      Academy of Nutrition and Dietetics Foundation: Food Insecurity and Food Banking Curriculum for Dietetic Interns and Students (2015)http://hungerandhealth.feedingamerica.org/wp-content/uploads/legacy/mp/files/tool_and_resources/files/preceptors-guide-food-insecurity-food-banking-supervised-practice-concentration-july-2015.pdfThis curriculum, developed by the Nutrition Solutions Working Group convened by the Academy Foundation and Feeding America as part of the Academy Foundation’s Future of Food initiative, includes 12 activities to be completed within 120 practice hours. The activities are designed to help nutrition and dietetics interns develop the knowledge and skills necessary for an entry-level RDN position in a food bank, and provide the nutrition and dietetics interns and students with experiences in nutrition education, food bank management, and food systems.
      Academy of Nutrition and Dietetics Foundation: Sustainable, Resilient, Healthy Food and Water Systems Curriculum for Dietetic Interns and Students (2018)https://eatrightfoundation.org/why-it-matters/public-education/future-of-food/sfs/This curriculum, developed by subject matter experts convened by the Academy's Nutrition and Dietetic Educators and Preceptors unit as part of the Academy Foundation’s Future of Food initiative, includes 12 activities that encompass the 7 sectors of the food system, totaling 120 supervised practice hours. The curriculum is designed to provide nutrition and dietetics interns and students with strong foundational knowledge in the nutritional, social, environmental, and economic dimensions of sustainable food systems. An article discussing the curriculum is also available in the Journal of the Academy of Nutrition and Dietetics.
      • Knoblock-Hahn A.
      • Medrow L.
      Development and implementation of a sustainable, resilient, and healthy food and water systems curriculum for dietetic interns.
      Johns Hopkins Center for a Livable Future: FoodSpan curriculumwww.foodspanlearning.org/A curriculum (4 units, 17 lessons total) for high school students on critical food system issues, including an action project.
      Planetary Health Alliance: Planetary Health Educationhttps://planetaryhealthalliance.org/educationA 14-unit resource repository for primary, secondary, and university students, and health professionals on planetary health topics, including changing food systems, climate change, water scarcity, biodiversity, and nutrition.
      Other Tools
      Food Chain Workers Alliance and Solidarity Research Cooperative: No Piece of the Pie: Food Chain Workers in 2016 (2016)http://foodchainworkers.org/wp-content/uploads/2011/05/FCWA_NoPieceOfThePie_P.pdfA report that addresses the challenges faced by food system workers in the 5 key sectors of the food chain (production, processing, distribution, retail, and service), including poor working conditions, below average wages, and discriminatory and abusive practices.
      HEAL (Health Environment Agriculture and Labor): Platform for Real Foodhttps://healfoodalliance.org/platformforrealfood/This 10-point platform serves as a call to action to transform the food system to promote human, economic, and planetary health.
      Michigan State University, Center for Regional Food Systems: An Annotated Bibliography on Structural Racism Present in the U.S. Food System, Sixth Edition (2019)www.canr.msu.edu/resources/structural_racism_in_us_food_systemAn annotated bibliography that provides current research and outreach on structural racism in the US food system for food system practitioners, researchers, and educators.
      Michigan State University, Center for Regional Food Systems: Measuring Racial Equity in the Food Systems: Established and Suggested Metrics (2019)www.canr.msu.edu/foodsystems/uploads/files/measuring-racial-equity-in-the-food-system.pdfThis report identifies metrics related to racial equity in the food system that are either in use by organizations currently or have been recommended for use. The report provides metrics related to food access, food and farm business, food chain labor, and food movement.

      Proficient Practitioner

      A proficient practitioner is an RDN who is generally 3 or more years beyond credentialing and entry into the profession and who consistently provides safe and reliable service; has obtained operational job performance skills; and is successful in the RDN's chosen focus area of practice. The proficient practitioner demonstrates additional knowledge, skills, judgment, and experience in a focus area of nutrition and dietetics practice.
      Academy of Nutrition and Dietetics
      Academy definition of terms list.
      Proficient practitioners may seek opportunities for specialized training through advanced degrees, certificates of training, and specialist credentials (if available). Achieving progress in sustainable food systems requires collaboration from many disciplines and sectors. Proficient practitioners can promote linkages in the food system by deepening their understanding of other fields (such as agriculture, policy, and behavior change) so that they can improve their ability to communicate and collaborate with other food systems stakeholders.

      Expert Practitioner

      An expert practitioner is an RDN who is recognized within the profession and has mastered the highest degree of skill in, and knowledge of, nutrition and dietetics. Expert-level achievement is acquired through extensive practice and incorporating critical feedback from others. The individual at this level continues to strive for additional knowledge and experience. An expert has the ability to quickly identify what is happening and how to approach the situation. Experts easily use nutrition and dietetics skills to become successful through demonstrating quality practice and leadership, and to consider new opportunities that build upon nutrition and dietetics.
      Academy of Nutrition and Dietetics
      Academy definition of terms list.
      An expert practitioner may have advanced degree(s), extensive experience, or a leadership position (or a combination of any of these). Generally, the practice is more complex and the practitioner has a high degree of professional autonomy and responsibility.
      Sustainable food systems expert practitioners help the profession adapt to evolving food systems challenges. Expert practitioners can identify new priority areas where RDNs can leverage their skills in promoting the principles of sustainable food systems and create new pathways for practice, policy change, education and training, and research.
      • Spiker M.L.
      • Knoblock-Hahn A.
      • Brown K.
      • et al.
      Cultivating sustainable, resilient, healthy food and water systems: A nutrition-focused framework for action.
      Given that the evidence base on sustainable food systems is rapidly expanding and involves multiple scientific disciplines, expert practitioners can promote dialogue and collaboration with other disciplines in efforts to conduct and translate research that informs practice. Expert practitioners can also ensure the visibility of the profession in collaborative spaces, such as policy advisory councils, coalitions, and conferences.
      These Standards, along with the Academy/CDR Code of Ethics,
      Academy of Nutrition and Dietetics, Commission on Dietetic Registration
      2018 Code of Ethics for the Nutrition and Dietetics Profession.
      answer the following questions: Why is an RDN uniquely qualified to provide sustainable food systems nutrition and dietetics services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, and quality sustainable food and water systems at the competent, proficient, and expert levels?

      Academy Revised 2020 SOPP for RDNs (Competent, Proficient, and Expert) in Sustainable Food Systems

      An RDN can use the Academy Revised 2020 SOPP for RDNs (Competent, Proficient, and Expert) in Sustainable Food Systems (see Figure 2, available at www.jandonline.org, and Figure 3) to:
      • identify the competencies needed to provide sustainable food systems practice;
      • self-evaluate whether they have the appropriate knowledge, skills, and judgment to provide safe, adequate, effective, and quality sustainable food systems practice for their level of practice;
      • identify the areas in which additional knowledge, skills, and experience are needed to practice at the competent, proficient, or expert level of sustainable food systems practice;
      • provide a foundation for public and professional accountability in sustainable food systems practice;
      • support efforts for strategic planning, performance improvement, and outcomes reporting, and assist management in the planning and communicating of sustainable food systems practices and resources;
      • enhance professional identity and skill in communicating the nature of sustainable food systems practice;
      • guide the development of sustainable food systems education and continuing education programs, job descriptions, practice guidelines, protocols, food systems models, competence evaluation tools, and career pathways; and
      • assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in sustainable food systems, and the understanding of the full scope of this focus area of practice.

      Application to Practice

      All RDNs, even those with significant experience in other practice areas, must begin at the competent level when practicing in a new setting or new focus area of practice. At the competent level, an RDN in sustainable food systems is learning the principles that underpin this focus area and is developing knowledge, skills, judgment, and gaining experience for safe and effective sustainable food systems practice. This RDN, who may be new to the profession or may be an experienced RDN, has a breadth of knowledge in nutrition and dietetics and may have proficient or expert knowledge/practice in another focus area. However, the RDN new to the focus area of sustainable food systems must accept the challenge of becoming familiar with the body of knowledge, practice guidelines, and available resources to support and ensure quality sustainable food systems–related nutrition and dietetics practice. Competent practitioners across all areas of practice incorporate critical and systems thinking and can integrate the principles of sustainable food systems into their work. For example, practitioners may contribute to designing menus and meal plans consistent with the principles of sustainable food systems, drawing from evidence-based literature. Competent practitioners may advocate for institutional policies or procedures for purchasing, distribution, and waste management that conserve natural resources and support local communities.
      At the proficient level, an RDN has developed a more in-depth understanding of sustainable food systems practice. RDNs at this level are more skilled at adapting and applying evidence-based guidelines and best practices, incorporating critical and systems thinking into aspects of their work to draw connections between the 4 domains of sustainable food systems (Figure 1). This RDN is also able to use critical thinking skills to modify sustainable food systems practice according to unique situations, for example, tailoring interventions to take into consideration geographic variation, environmental conditions, accessibility of food and water systems services, cultural and community preferences, and readiness for change by clients, including individuals, institutions, or policymakers. Collaborating with experts outside of the profession (eg, food producers, food justice advocates, and public health practitioners) may help the RDN build skills in interprofessional communication and collaboration.
      At the expert level, the RDN thinks critically about sustainable food systems, demonstrates a more intuitive understanding of the practice area, displays a range of highly developed technical skills, and formulates judgments acquired through a combination of education and experience. Practice at the expert level requires the application of composite nutrition and dietetics knowledge, with practitioners drawing not only on their practice experience, but also on the sustainable food systems experience of RDNs across various practice settings and interprofessional collaborators from fields such as agriculture, environmental health sciences, public health, public policy, climate change science, supply chain management, and economics. Expert RDNs, with their extensive experience and ability to see the connections between sustainable food systems and nutrition within a contextual whole, are fluid and flexible, and have considerable autonomy in practice. They lead the advancement of nutrition and dietetics practice in the area of sustainable food systems by guiding interprofessional teams; collaborating in scholarly research and advocacy efforts; developing and implementing new policies, programs, and services; and accepting leadership roles within organizations and networks.
      One of the key traits of RDNs who have developed expert skills in sustainable food systems is the ability to apply a systems approach that engages interprofessional collaborators with diverse training and expertise in order to achieve goals and objectives. The nutrition-, health-, and customer-focused skill set of the RDN uniquely positions them to be a valuable member of any interprofessional team. While an RDN may not have the primary content expertise of their interprofessional collaborators, the expert-level RDN will be conversant in the broad terminology of relevant fields and will be equipped to consult a wide network of collaborators. This includes taking direction from community groups and local leaders, who should be viewed as experts in understanding how planned policies, programs, or services can affect target populations, including unintended consequences that may exacerbate existing inequities.
      Indicators for the SOPP for RDNs in Sustainable Food Systems are measurable action statements that illustrate how each standard can be applied in practice (Figure 2, available at www.jandonline.org). Within the SOPP for RDNs in Sustainable Food Systems, an “X” in the competent column indicates that an RDN who is providing services to customers is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. A competent RDN in sustainable food systems could be an RDN starting practice after registration or an experienced RDN who has recently assumed responsibility for incorporating sustainable food systems principles into recommendations and into practice.
      An “X” in the proficient column indicates that an RDN who performs at this level has a deeper understanding of sustainable food systems practice and has the ability to incorporate sustainable food systems principles into recommendations that meet the needs of patients/clients/customers in various situations.
      An “X” in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of sustainable food systems practice and a highly developed range of skills and judgments acquired through a combination of experience and education. The expert RDN builds and maintains the highest level of knowledge, skills, and behaviors, including leadership, vision, and credentials.
      Standards and indicators presented in Figure 2 (available at www.jandonline.org) in boldface type originate from the Academy’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      and should apply to RDNs in all 3 levels. Additional indicators not in boldface type developed for this focus area are identified as applicable to all levels of practice. Where an “X” is placed in all 3 levels of practice, it is understood that all RDNs in sustainable food systems are accountable for practice within each of these indicators. However, the depth with which an RDN 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 SOPP for RDNs in Sustainable Food Systems is warranted. It is the totality of individual practice that defines a practitioner’s level of practice and not any one indicator or standard.
      RDNs should review the SOPP in Sustainable Food Systems at determined intervals to evaluate their individual focus-area knowledge, skill, and competence. Consistent self-evaluation is important because it helps identify opportunities to improve and enhance practice and professional performance and set goals for professional development. This self-appraisal also enables sustainable food systems RDNs to better utilize these Standards as part of the Professional Development Portfolio recertification process,
      • Weddle D.O.
      • Himburg S.P.
      • Collins N.
      • Lewis R.
      The professional development portfolio process: Setting goals for credentialing.
      which encourages CDR-credentialed nutrition and dietetics practitioners to incorporate self-reflection and learning needs assessment for development of a learning plan for improvement and commitment to lifelong learning. CDR’s 5-year recertification cycle incorporates the use of essential practice competencies for determining professional development needs.
      • Worsfold L.
      • Grant B.L.
      • Barnhill C.
      The essential practice competencies for the Commission on Dietetic Registration’s credentialed nutrition and dietetics practitioners.
      In the 3-step process, the credentialed practitioner accesses an online Goal Wizard (step 1), which uses a decision algorithm to identify essential practice competency goals and performance indicators relevant to the RDN’s area(s) of practice (essential practice competencies and performance indicators replace the learning need codes of the previous process). The Activity Log (step 2) is used to log and document continuing professional education during the 5-year period. The Professional Development Evaluation (step 3) guides self-reflection and assessment of learning and how it is applied. The outcome is a completed evaluation of the effectiveness of the practitioner’s learning plan and continuing professional education. The self-assessment information can then be used in developing the plan for the practitioner’s next 5-year recertification cycle. For more information, see https://www.cdrnet.org/competencies-for-practitioners.
      RDNs are encouraged to pursue additional knowledge, skills, and 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. RDNs 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.R.
      • Amaya L.
      Ethics opinion: Registered dietitian nutritionists and nutrition and dietetics technicians, registered are ethically obligated to maintain personal competence in practice.
      RDNs should collaborate with other RDNs in sustainable food systems as learning opportunities and to promote consistency in practice and performance and continuous quality improvement. See Figure 5 for examples of how RDNs in different roles, at different levels of practice, can use the SOPP in Sustainable Food Systems.
      Figure 5Role Examples of Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems (Sustainable Food Systems).
      RoleExamples of use of SOPP documents by RDNs in different practice roles
      For each role, the RDN updates the professional development plan to include applicable essential practice competencies for sustainable food systems practice.
      Clinical practitioner (including acute care, ambulatory care, and long-term care)A registered dietitian nutritionist (RDN) working in a clinical setting wants to find ways to promote sustainable food systems that also align with their patient/client care goals. The RDN uses the SOPP in Sustainable Food Systems to familiarize themselves with this focus area and resources, identify areas of interest, determine ways to integrate the concepts into client education, and develop a plan for their own professional development. The RDN designs, implements, and evaluates a plan to reduce plate waste and improve oral intake by giving more attention to preferences, and addressing portion sizes to align with energy needs, supporting the twin goals of nutrition and food waste reduction.
      Communications, marketing, or corporate practitioner (eg, with a food company, food retailer, commodity group, or other business)An RDN working with a food retailer recognizes an opportunity to leverage growing consumer interest in sustainability. The RDN uses the SOPP to assess and build their knowledge in this area so that they can identify evidence-based strategies to better align company policies and practices with sustainable food systems principles. The RDN also uses the SOPP to identify topic areas for which to develop public education materials that address both nutrition and sustainability.
      Community nutrition/public health practitionerAn RDN working with clients of a nutrition assistance program is hearing from an increasing number of clients that they are unable to use their local water supply for food preparation due to contamination. The RDN uses the SOPP to identify areas for further education in order to most effectively advocate for policy changes to improve the safety of the local water supply.
      Elected official/public service RDN/member of board, committee, or councilAn RDN working at a state government agency is presented with a policy proposal that would improve community food security but could negatively impact local food producers or other stakeholders. The RDN uses the SOPP to identify other interprofessional collaborators to help with gathering stakeholder input and evaluating the policy proposal across dimensions of social, economic, and environmental sustainability and health.
      Educator (eg, faculty, administrator, or preceptor in a nutrition and dietetics education program)An RDN faculty member or preceptor reviews the SOPP to identify content areas for expanding lecture content and assigned readings for students. A dietetics program director works to strengthen the abilities of future RDNs to practice and promote knowledge of the principles of sustainable food systems so they can make dietary recommendations that not only support nutrition health but are also affordable, culturally appropriate, and steward natural resources. The program director uses the SOPP as a guide for incorporating relevant competencies into the curriculum and uses the Resource Figure (see Figure 4) as a starting point when identifying curricular resources.
      Foodservice directorAn RDN working as a foodservice director at a large urban hospital is observing a high amount of preventable food waste. The RDN confirms this by working with supervisors to collect and analyze data and develop a plan to reduce preventable food waste using a quality improvement process. The RDN uses the SOPP to identify resources to strengthen knowledge and to share with staff that would inform the improvement or creation of new procedures and training materials addressing food and other resource waste (eg, water, electricity, and paper).
      Private practitioner/ consultantAn RDN in private practice would like to focus their business on sustainable food systems-related nutrition consulting for companies, institutions, and organizations. Before accepting clients, the RDN uses the SOPP to create a benchmark of what it means to practice competently and provide quality nutrition and dietetics services in sustainable food systems. The sustainable food systems principles discussed in the SOPP guide the RDN in creating the mission and vision for their company, and Figure 2 (available at www.jandonline.org) helps the RDN to develop a career ladder and goals as a practitioner.
      ResearcherAn RDN working in a research setting is awarded a grant to evaluate the relationship between experiences of racial discrimination and participation in nutrition assistance programs. The RDN uses the SOPP and resources identified to chart a trajectory for their professional development as a researcher in sustainable food systems, including disclosing and managing conflicts of interests, convening a team of interprofessional collaborators that leverages expertise across the food system, and translating their research into evidence-based strategies that align with sustainable food systems principles.
      a For each role, the RDN updates the professional development plan to include applicable essential practice competencies for sustainable food systems practice.
      In some instances, components of the SOPP for RDNs in Sustainable Food Systems do not specifically differentiate between proficient-level and expert-level practice. In these areas, it remains 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.
      A wealth of knowledge is embedded in the experience, discernment, and practice of expert-level RDN practitioners. The experienced practitioner observes events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. The knowledge and skills acquired through practice will continually expand and mature. The SOPP indicators are refined with each review of these Standards as expert-level RDNs systematically record and document their experiences, often through the use of exemplars. Exemplary actions of individual sustainable food systems RDNs in practice settings and professional activities that enhance patient/client/population care and/or services can be used to illustrate outstanding practice models.

      Future Directions

      SOPPs are dynamic documents. Future revisions will reflect changes and advances in practice, changes to dietetics education standards, new research, regulatory changes, and outcomes of practice audits. Continued clarity and differentiation of the 3 practice levels in support of safe, adequate, effective, and quality practice in sustainable food systems remains an expectation of each revision to serve tomorrow's practitioners and their patients, clients, and customers.
      Looking forward, this SOPP can guide the development of future educational opportunities, toolkits, research, and other resources related to sustainable food systems. With the increasing urgency of environmental challenges and the continued growth of public interest in sustainability, RDNs can provide valuable clarity, evidence-based recommendations, and leadership in sustainable food systems. Achieving the vision of sustainable food systems requires that RDNs develop foundational knowledge in this area; contribute to the generation of rigorous, interprofessional research and its translation for practitioners and policymakers; and promote the principles of sustainable food systems across all practice settings. This SOPP provides a framework for the continued development of sustainable food systems practice, for individual RDNs and for the profession.

      Summary

      RDNs face complex situations every day. Addressing the unique needs of each situation and applying standards appropriately is essential to providing safe, timely, person-centered quality care and service. All RDNs are advised to conduct their practice based on the most recent edition of the Code of Ethics for the Nutrition and Dietetics Profession, the Scope of Practice for RDNs, and the SOP in Nutrition Care and SOPP for RDNs, along with applicable federal and state regulations and facility accreditation standards. The SOPP for RDNs in Sustainable Food Systems are complementary documents and are key resources for RDNs at all knowledge and performance levels. These standards can and should be used by all RDNs to consistently improve and appropriately demonstrate competence and value as providers of safe, effective, equitable, and quality nutrition and dietetics services. This applies not only to RDNs whose daily work is devoted to sustainable food systems practice, but also to RDNs across all practice settings. Given that sustainable food systems are fundamental to the practice of nutrition and dietetics, all RDNs have the opportunity, and indeed the responsibility, to align their work with the principles of sustainable food systems.
      These standards also serve as a professional resource for self-evaluation and professional development for RDNs specializing in sustainable food systems practice. 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 7 years.
      Current and future initiatives of the Academy, as well as advances in sustainable food systems practice, will provide information to use in future updates and in further clarifying and documenting the specific roles and responsibilities of RDNs at each level of practice. As a quality initiative of the Academy and HEN DPG, these standards are an application of continuous quality improvement and represent an important collaborative endeavor.
      These standards have been formulated for use by individuals in self-evaluation, practice advancement, development of practice guidelines and specialist credentials, and as indicators of quality. These standards do not constitute medical or other professional advice, and should not be taken as such. The information presented in the standards is not a substitute for the exercise of professional judgment by the credentialed nutrition and dietetics practitioner. These standards are not intended for disciplinary actions or determinations of negligence or misconduct. 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.

      Acknowledgements

      Special acknowledgement and thanks to Amanda Hege, MPH, RDN, LD; Angie Tagtow, MS, RD, LD; Barbara Hartman, MS, RD, LD; Christina Campbell, PhD, RD; Deanna Belleny, MPH, RDN; and Sarah Peterson, PhD, RD, who willingly gave their time to review these standards, and to the Hunger and Environmental Nutrition Dietetic Practice Group’s Executive Committee. The authors also extend thanks to all who were instrumental in the process for the revisions of the article. Finally, the authors thank Academy staff, in particular, Karen Hui, RDN, LDN; Dana Buelsing, MS; Carol Gilmore, MS, RDN, LD, FADA, FAND; and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, who supported and facilitated the development of these SOPPs.

      Author Contributions

      Each author contributed to drafting and editing the components of the article (eg, article text and figures) and reviewed all drafts of the manuscript.

      Supplementary Materials

      Figure 2Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Sustainable, Resilient, and Healthy Food and Water Systems. Note: The term customer is used in this evaluation resource as a universal term. Customer could also mean client/patient/customer, family, participant, consumer, or any individual, group, or organization to which the RDN provides service.
      Standards of Professional Performance for Registered Dietitian Nutritionists in Sustainable, Resilient, and Healthy Food and Water Systems (Sustainable Food Systems)

      Standard 1: Quality in Practice

      The registered dietitian nutritionist (RDN) provides quality services using a systematic process with identified ethics, leadership, accountability, and dedicated resources.

      Rationale:

      Quality practice in nutrition and dietetics is built on a solid foundation of education and supervised practice, credentialing, evidence-based practice, demonstrated competence, and adherence to established professional standards. Quality practice requires systematic measurement of outcomes, regular performance evaluations, and continuous improvement.
      Indicators for Standard 1: Quality in Practice
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Complies with applicable laws and regulations as related to their area(s) of practiceXXX
      1.1AFollows laws and regulations governing food and water systems at the consumer level (eg, safe food handling and labeling laws)XXX
      1.1BAdheres to laws and regulations regarding discrimination (eg, hiring, contractors, and customers), and provides appropriate signage and training as needed (eg, US Department of Agriculture [USDA) nondiscrimination statement)XXX
      1.1CIdentifies and complies with appropriate laws and regulations governing food and water availability at the community level (eg, agricultural production practices, hazard analysis and critical control points, zoning ordinances, and environmental regulations)XX
      1.1DProvides training and technical assistance to applicable stakeholders on local, state, and federal laws and regulations regarding Sustainable Food SystemsX
      1.2Performs within individual and statutory scope of practice and applicable laws and regulationsXXX
      1.3Adheres to sound business and ethical billing practices applicable to the role and settingXXX
      1.3AAdopts practices that are consistent with customer populations’ socioeconomic statusXXX
      1.3BDemonstrates ethical and responsible practices that consider human, environmental, social, and economic resourcesXXX
      1.3CAssures ethical and accurate reporting of services and compliance with contracts or funder requirements, when applicableXXX
      1.3DPromotes practices that support fair wages, appropriate benefits, and safe working conditions for employeesXX
      1.3EUnderstands implications of prices paid and payment terms for vendorsXX
      1.3E1Aims to procure food, beverages, and services that are produced, processed, and delivered using fair, equitable, and ethical practices (eg, prioritize companies paying fair wages; companies without labor violations; and marginalized food producers [ie, grower and farmer], and ranchers, including women and people of color)XX
      1.3E2Negotiates a fair competitive price and payment terms with vendors (eg, food producer, local food distributor, or composter)XX
      1.3E3Communicates with vendors and customers about the “true cost of food” (ie, a way of viewing food costs that includes the hidden costs or externalities of the food system, such as the costs of farm support payments, environmental degradation, or health care costs related to diet-related disease)X
      1.4Uses national quality and safety data (eg, National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division, National Quality Forum, Institute for Healthcare Improvement) to improve the quality of services provided and to enhance customer-centered servicesXXX
      1.4AComplies with production, processing, marketing, procurement, and waste management standards (eg, Good Agricultural Practices, Energy Star) and evidence-based third-party certifications (eg, Food Justice–certified, Marine Stewardship Council–certified) that support Sustainable Food Systems, when applicable or availableXXX
      1.4BPromotes production, processing, marketing, procurement, and waste management standards and evidence-based third-party certifications that support Sustainable Food SystemsXX
      1.4CDevelops or contributes to the development of production, processing, marketing, procurement, and waste management standards and evidence-based third-party certifications that support Sustainable Food SystemsX
      1.5Uses a systematic performance improvement model that is based on practice knowledge, evidence, research, and science for delivery of the highest-quality servicesXXX
      1.5AUses qualitative and quantitative Sustainable Food Systems data to analyze, monitor, and improve performanceXXX
      1.5BDevelops data collection tools to measure Sustainable Food Systems performance improvementXX
      1.6Participates in or designs an outcomes-based management system to evaluate safety, effectiveness, quality, person-centeredness, equity, timeliness, and efficiency of practiceXXX
      1.6AInvolves colleagues and others, as applicable, in systematic outcomes managementXXX
      1.6A1Solicits Sustainable Food Systems ideas from colleagues and others for feasibility of implementationXXX
      1.6A2Encourages participation in internal Sustainable Food Systems performance improvement initiatives (eg, identification of performance indicators, data collection methods, and analysis)XX
      1.6A3Provides incentives for meeting or exceeding Sustainable Food Systems performance improvement indicatorsX
      1.6A4Designs an outcomes-based management system related to Sustainable Food SystemsX
      1.6A5Communicates concerns, priorities, and actions needed to best meet target population needs and improve Sustainable Food Systems outcomesX
      1.6BDefines expected outcomesXXX
      1.6B1Collaborates with stakeholders to identify and refine outcomes, ensuring that stakeholders are diverse and reflect the communities servedXX
      1.6B2Adapts expected outcomes as needed to account for social determinants of health, health disparities, cultural competence, racial equity, and health equityXX
      1.6CUses indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)XXX
      1.6DMeasures quality of services in terms of structure, process, and outcomesXXX
      1.6D1Performs Sustainable Food Systems performance improvement auditsXX
      1.6EIncorporates electronic clinical quality measures to evaluate and improve care of patients/clients at risk for malnutrition or with malnutrition (www.eatrightpro.org/emeasures)XXX
      1.6E1Screens customers for food insecurity and takes action per protocolXXX
      1.6FDocuments outcomes and patient reported outcomes (eg, PROMIS
      PROMIS: The Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index) is a reliable, precise measure of patient-reported health status for physical, mental, and social well-being. PROMIS is a web-based resource and is publicly available.
      )
      XXX
      1.6F1Analyzes Sustainable Food Systems performance improvement outcomes (eg, reductions in pre-consumer and post-consumer food waste)XX
      1.6GParticipates in, coordinates, or leads program participation in local, regional, or national registries and data warehouses used for tracking, benchmarking, and reporting service outcomesXXX
      1.6G1Identifies relevant data sources (eg, USDA Economic Research Service Food Atlas, Loss-Adjusted Food Availability Data)XXX
      1.6G2Contributes to surveys, census, other registries maintained or administered by government agencies and/or nongovernmental organizationXX
      1.6G3Provides data that demonstrates the benefits of Sustainable Food Systems to their organizationXX
      1.7Identifies and addresses potential and actual errors and hazards in provision of services or brings to attention of supervisors and team members as appropriateXXX
      1.7ARecognizes potential environmental health issues (eg, phalates) in foods, food packaging, and preparation methodsXXX
      1.8Compares actual performance to performance goals (ie, Gap Analysis, SWOT [Strengths, Weaknesses, Opportunities, and Threats] Analysis, PDCA [Plan-Do-Check-Act] Cycle, DMAIC [Define, Measure, Analyze, Improve, Control])XXX
      1.8AReports and documents action plan to address identified gaps in care and/or service performanceXXX
      1.8BIntegrates Sustainable Food Systems goals and objectives into action plansXX
      1.9Evaluates interventions and workflow process(es) and identifies service and delivery improvementsXXX
      1.9AEnsures that services account for social determinants of health, health disparities, cultural competence, racial equity, and health equityXXX
      1.9BEstablishes procedures to ensure continuous improvement of service and delivery in alignment with Sustainable Food Systems principles (eg, resource conservation, food recovery, and waste reduction)XX
      1.10Improves or enhances patient/client/population care and/or services working with others based on measured outcomes and established goalsXXX
      1.10ACollects and analyzes customer outcomes and feedback to identify needs for Sustainable Food Systems improvementsXX
      1.10BDirects performance improvement efforts to ensure achievement of Sustainable Food Systems outcomes, standards, and best practicesX
      Examples of Outcomes for Standard 1: Quality in Practice
      • Practice decisions account for Sustainable Food Systems principles and outcomes
      • Sustainable Food Systems approaches are incorporated into food, nutrition, health, and practice
      • Practice is enhanced through interprofessional
        Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members, depending on the needs of the customer. Whereas the term may traditionally refer to other health professionals (eg, other RDNs, physicians, nurses, pharmacists, psychologists, social workers, and occupational and physical therapists),48 in the context of Sustainable Food Systems it may also include researchers, educators, and practitioners from a variety of disciplines and sectors, such as food producers, agronomists, veterinarians, environmental scientists, waste management professionals, behavioral economists, community leaders, policymakers, culinary professionals, and entrepreneurs. Interprofessional collaboration could also refer to multi-, inter-, or transdisciplinary or multi-, inter-, or trans-sectoral collaboration.
        collaborations
      • Sustainable Food Systems actions are within scope of practice and applicable laws and regulations
      • National quality standards and best practices are evident in customer-centered services
      • Use of Sustainable Food Systems practices are evident in customer-centered services
      • Performance improvement systems specific to program(s)/service(s) are established and updated as needed; are evaluated for effectiveness in providing desired outcomes data and striving for excellence in collaboration with other team members
      • Performance indicators support Sustainable Food Systems and are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)
      • Aggregate Sustainable Food Systems outcomes results meet pre-established criteria
      • Quality improvement results direct refinement and advancement of Sustainable Food Systems practice
      • Concepts of social determinants of health, health disparities, cultural competence, racial equity, and health equity are integrated into Sustainable Food Systems practices
      Standard 2: Competence and Accountability

      The registered dietitian nutritionist (RDN) demonstrates competence in and accepts accountability and responsibility for ensuring safe, quality practice and services.

      Rationale:

      Competence and accountability in practice includes continuous acquisition of knowledge, skills, experience, and judgment in the provision of safe, quality customer-centered service.
      Indicators for Standard 2: Competence and Accountability
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Adheres to the code(s) of ethics (eg, Academy/Commission on Dietetic Registration [CDR], other national organizations, and/or employer code of ethics)XXX
      2.1ADiscloses conflicts of interestXXX
      2.1A1Supports transparency within food and water systems (eg, easy access to food and water systems processes, marketing, research, funding, laws, rules)XXX
      2.1A2Evaluates potential partnerships and funding sources; and prioritizes partnerships that are in alignment with Sustainable Food Systems principlesXX
      2.2Integrates the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) into practice, self-evaluation, and professional developmentXXX
      2.2AIntegrates applicable focus area(s) SOP and/or SOPP into practice (www.eatrightpro.org/sop)XXX
      2.2BDevelops policies, procedures, and professional development strategies using the SOPP in Sustainable Food SystemsXX
      2.2CDevelops performance criteria and quality assurance measures based on SOPP in Sustainable Food Systems to evaluate and assure competent practiceX
      2.3Demonstrates and documents Sustainable Food Systems competence in practice and delivery of customer-centered service(s)XXX
      2.3AReviews and obtains guidance as needed to understand principles of Sustainable Food Systems applicable to role and responsibilitiesXXX
      2.3BMonitors program adherence to Sustainable Food Systems principles and advocates for improvements if neededXX
      2.3CCreates and updates internal processes for documenting Sustainable Food Systems competence in practice and delivery of servicesX
      2.4Assumes accountability and responsibility for actions and behaviorsXXX
      2.4AIdentifies, acknowledges, and corrects errorsXXX
      2.4BMaintains ethical and professional integrity when integrating Sustainable Food Systems principles into practice (eg, follows nutrition and dietetics credentialing and/or licensure, organizational policies, performance standards)XXX
      2.5Conducts self-evaluation at regular intervalsXXX
      2.5AIdentifies needs for professional development in Sustainable Food SystemsXXX
      2.5BEvaluates organizational culture and policies, staff diversity, and cultural competence to assess potential impact on organizational goals related to Sustainable Food Systems (eg, encourages videoconferencing to reduce air travel or to accommodate family responsibilities)XX
      2.6Designs and implements plans for professional development in Sustainable Food SystemsXXX
      2.6ADevelops plan and documents professional development activities in Sustainable Food Systems in career portfolio (eg, organizational policies and procedures, credentialing agency[ies])XXX
      2.6BEstablishes professional goals that integrate Sustainable Food Systems principles into practice (eg, identifies conferences, events, or professional organizations to strengthen knowledge and interprofessional relationships; develops community-based participatory research skills)XXX
      2.6CUses SOPP in Sustainable Food Systems to guide professional development plansXXX
      2.6DIdentifies continuing education opportunities in Sustainable Food SystemsXXX
      2.6EIntegrates Sustainable Food Systems activities into employee position descriptions and performance evaluationsXX
      2.6FProvides opportunities for staff to receive training in topics that are important for Sustainable Food Systems, including limiting food waste, cultural competency, and racial equity trainingXX
      2.7Engages in evidence-based practice and uses best practicesXXX
      2.7ACritically analyzes and incorporates Sustainable Food Systems best practices and evidence-based research from multiple disciplines into decision-makingXX
      2.7BParticipates in committees, councils, or task forces that shape evidence-based practice and/or best practices in Sustainable Food Systems with consideration to diversity, equity, and inclusionXX
      2.8Participates in peer review of others as applicable to role and responsibilitiesXXX
      2.8AParticipates in peer review activities consistent with setting and patient/client/customer population (eg, peer evaluation, peer supervision, performance evaluations)XXX
      2.8BIncorporates criteria into performance evaluations reflecting Sustainable Food Systems roles and responsibilitiesXX
      2.8CServes on advisory boards for Sustainable Food Systems organizationsX
      2.9Mentors and/or precepts nutrition and dietetics students/interns and others in Sustainable Food SystemsXXX
      2.9APursues mentoring relationships and precepting opportunities with credentialed nutrition and dietetic practitioners, and nutrition and dietetics students/interns from marginalized populationsXXX
      2.9BProvides interprofessional education and experiential learning opportunities in Sustainable Food SystemsXX
      2.9CCollaborates with colleges, universities, and other organizations in developing Sustainable Food Systems curriculaX
      2.10Pursues opportunities (education, training, credentials, certifications) to advance Sustainable Food Systems practice in accordance with laws and regulations, and requirements of practice settingXXX
      2.10AParticipates in experiential learning related to Sustainable Food Systems, such as community-based or volunteer experiencesXXX
      2.10BSeeks Sustainable Food Systems leadership opportunities at local, regional, national, and/or international levelsXX
      2.10CIntegrates Sustainable Food Systems principles into the creation of new professional development opportunitiesX
      Examples of Outcomes for Standard 2: Competence and Accountability
      • Practice reflects:
        • o
          Code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics)
        • o
          Scope of Practice, Standards of Practice and Standards of Professional Performance
        • o
          Evidence-based practice and best practices
        • o
          CDR Essential Practice Competencies and Performance Indicators
      • Practice incorporates successful strategies for interactions with individuals/groups from diverse cultures and backgrounds
      • Competence is demonstrated and documented
      • Services provided are safe and customer-centered
      • Self-evaluations are conducted regularly to reflect commitment to lifelong learning and professional development and engagement
      • Professional development needs related to Sustainable Food Systems are identified and pursued
      • Directed learning is demonstrated
      • Relevant opportunities (education, training) within Sustainable Food Systems are pursued and created to advance practice
      • CDR recertification requirements are met
      Standard 3: Provision of Services

      The registered dietitian nutritionist (RDN) provides safe, quality service based on customer expectations and needs and the mission, vision, principles, and values of the organization/business.

      Rationale:

      Quality programs and services are designed, executed, and promoted based on the RDN’s knowledge, skills, experience, judgment, and competence in addressing the needs and expectations of the organization/business and its customers.
      Indicators for Standard 3: Provision of Services
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      3.1Contributes to or leads in development and maintenance of programs/services that integrate Sustainable Food Systems principles and address needs of the customer or target population(s)XXX
      3.1AAligns Sustainable Food Systems program/service development with the mission, vision, principles, values, and service expectations and outputs of the organization/businessXXX
      3.1A1Manages programs and services to integrate Sustainable Food Systems principles (eg, stewardship of natural resources, social responsibility, community engagement, and equitable opportunities to build wealth)XX
      3.1A2Evaluates programs and services that integrate Sustainable Food Systems principles and applies quality improvement strategiesXX
      3.1BUses the needs, expectations, and desired outcomes of the customers/populations (eg, patients/clients, families, community, decision makers, administrators, client organization[s]) in program/service developmentXXX
      3.1B1Develops short- and long-term goals or objectives for Sustainable Food Systems services; seeks assistance as neededXXX
      3.1B2Determines priorities, gaps, and opportunities for integrating Sustainable Food Systems principles into servicesXX
      3.1B3Promotes practices, programs, and services that integrate Sustainable Food Systems principles to organizational stakeholders and community partnersXX
      3.1B4Identifies evidence-based resources to support programs and services that integrate Sustainable Food Systems principlesXX
      3.1B5Identifies and promotes policy, system, and environmental (built and natural) interventions that advance Sustainable Food SystemsX
      3.1B6Incorporates the social ecological model or Spectrum of Prevention
      • Jurgilevisch A.
      • Birge T.
      • Kentala-Lehtonen J.
      • et al.
      Transition towards circular economy in the food system.
      into planning programs and services that support Sustainable Food Systems principles
      X
      3.1B7Develops innovative programs that incorporate Sustainable Food Systems principlesX
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environmentXXX
      3.1C1Shapes, modifies, and adapts Sustainable Food Systems programs and service delivery in alignment with budget requirements and prioritiesXX
      3.1DProposes programs and services that are customer-centered, culturally appropriate, and minimize disparitiesXXX
      3.1D1Plans programs and services that integrate Sustainable Food System principles to respond to community needs and minimize health disparities among marginalized populationsXX
      3.2Promotes public access and referral to credentialed nutrition and dietetics practitioners for quality food and nutrition programs and servicesXXX
      3.2AContributes to or designs referral systems that promote access to qualified, credentialed nutrition and dietetics practitioners with expertise in Sustainable Food SystemsXXX
      3.2A1Joins networks (eg, food policy councils, city planning commission, and professional associations) that include diverse Sustainable Food Systems professionals (eg, food producers, planners, processors, economic developers, distributors, retailers, and commercial waste haulers)XXX
      3.2A2Establishes and/or facilitates networks that include credentialed nutrition and dietetics practitioners and other disciplines who promote Sustainable Food SystemsXX
      3.2A3Develops community strategic plans that support referrals to Sustainable Food Systems programs and servicesX
      3.2BRefers customers to appropriate providers with expertise in Sustainable Food Systems when requested services or identified needs exceed the RDN’s individual scope of practice (eg, food producers, agricultural economists, and climate scientists)XXX
      3.2B1Verifies potential referral provider’s services and practices reflects evidence-based information/research and professional standards of practiceXXX
      3.2CMonitors effectiveness of referral systems and modifies as needed to achieve desirable outcomesXXX
      3.2C1Evaluates and documents impact of referral systems as related to targeted outcomes and Sustainable Food SystemsXXX
      3.2C2Addresses gaps in meeting customer/target population referral needsXX
      3.2C3Communicates impact of referrals related to Sustainable Food Systems to decision makers and the communityXX
      3.2C4Develops and implements quality improvement processes to strengthen Sustainable Food Systems referral systemsX
      3.3Contributes to or designs customer-/target population–centered servicesXXX
      3.3AAssesses needs, beliefs/values, goals, resources of the customer, and social determinants of healthXXX
      3.3A1Identifies individual nutrition assessment indicators (eg, diet history, food frequency questionnaire) that incorporate Sustainable Food Systems principles (eg, assessing sources of food and water for quality and safety)XXX
      3.3A2Ensures community health needs assessment indicators incorporate Sustainable Food Systems principles (eg, affordability and cultural acceptability of available foods)XXX
      3.3A3Considers Sustainable Food Systems indicators when evaluating health disparities and sociodemographic determinants of customers and communitiesXX
      3.3A4Conducts comprehensive Sustainable Food Systems assessments (eg, community food assessment)X
      3.3A5Develops recommendations for strengthening services that support Sustainable Food Systems principlesX
      3.3BUses knowledge of the customer’s/target population’s health conditions, cultural beliefs, and business objectives/services to guide design and delivery of customer-centered servicesXXX
      3.3B1Identifies local and regional entities who integrate Sustainable Food Systems principles into services (eg, community-supported agriculture, permaculture design program for community and urban gardens, and youth development programs)XXX
      3.3B2Partners with community entities who integrate Sustainable Food Systems principles into servicesXX
      3.3B3Applies recommendations from Sustainable Food Systems assessmentsXX
      3.3B4Designs and delivers programs and services that incorporate Sustainable Food Systems principles (eg, prioritizing cultural needs, norms, practices, skills, and values)X
      3.3B5Designs, contributes to, and/or implements organizational, community, and public policies that integrate Sustainable Food Systems principles and support customer/target population needsX
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the customer or target populationXXX
      3.3C1Considers social determinants of health when linking messages and modes of communication to the needs of a target populationXXX
      3.3C2Educates customers/target population about Sustainable Food Systems issues relevant to disease prevention and behavioral change (eg, food safety knowledge to help with decisions about food discards)XXX
      3.3C3Develops nutrition education that integrates Sustainable Food Systems principles for customers/target populationsXX
      3.3DCollaborates with the customers to set priorities, establish goals, and create customer-centered action plans to achieve desirable outcomesXXX
      3.3EInvolves customers in decision making that supports Sustainable Food SystemsXXX
      3.4Executes programs/services that integrate Sustainable Food Systems principles in an organized, collaborative, cost-effective, and customer-centered mannerXXX
      3.4ACollaborates and coordinates with peers, colleagues, stakeholders, and within interprofessional teamsXXX
      3.4A1Manages relationships with organizations who provide Sustainable Food Systems programs/services to communitiesXX
      3.4A2Organizes a network of engaged stakeholders around Sustainable Food Systems issues within an organization or community (eg, a policy advisory council or community of practice)X
      3.4A3Identifies partnerships and opportunities that expand implementation of Sustainable Food Systems initiativesX
      3.4BUses and participates in, or leads in the selection, design, execution, and evaluation of customer programs and services that integrate Sustainable Food Systems principles (eg, nutrition screening system, medical and retail foodservice, electronic health records, interprofessional programs, community education, grant management, community food assessment, food system initiatives/campaigns, food and water systems education, and food and water systems impact analysis for customers)XXX
      3.4B1Conducts needs assessments with partners on programs and services that integrate Sustainable Food Systems principlesXX
      3.4B2Plans and implements programs and services that integrate Sustainable Food Systems principles based on community needs, assets, culture, evidence-based strategies, and available resourcesXX
      3.4B3Evaluates and reports on the health, environment, social, and economic impacts of food and water systems initiatives within a communityX
      3.4B4Establishes best practices and evidence-based guidelines for programs and services that integrate Sustainable Food Systems principlesX
      3.4CUses and develops or contributes to selection, design, and maintenance of policies, procedures (eg, discharge planning/transitions of care and emergency planning), protocols, standards of care, technology resources (eg, Health Insurance Portability and Accountability Act [HIPAA]-compliant telehealth platforms), and training materials that reflect evidence-based practice in accordance with applicable laws and regulationsXXX
      3.4C1Maintains current knowledge of local, state, and federal policies that influence food and water systems (eg Farm Bill and Child Nutrition Reauthorization)XXX
      3.4C2Maintains current knowledge of evidence-based third-party certifications (eg, Food Justice–certified) that support Sustainable Food SystemsXXX
      3.4C3Integrates Sustainable Food Systems principles into education and training materialsXX
      3.4C4Prepares evidence-based outreach, education, and advocacy tools on Sustainable Food Systems issuesXX
      3.4C5Participates in making policy, research, and program recommendations within a food policy council or similar entityXX
      3.4C6Serves as a consultant on initiatives that promote Sustainable Food Systems principlesX
      3.4DUses and participates in or develops processes for order writing and other nutrition-related privileges, in collaboration with the medical staff,
      Medical staff: Medical staff is composed of doctors of medicine or osteopathy in accordance with State law, including scope of practice laws, include other categories of physicians, and non-physician practitioners who are determined to be eligible for appointment by the governing body.49
      or medical director (eg, post-acute care settings, dialysis center, public health, community, and free-standing clinic settings), consistent with state practice acts, federal and state regulations, organization policies, and medical staff rules, regulations, and bylaws
      XXX
      3.4D1Uses and participates in or leads development of processes for privileges or other facility-specific processes related to (but not limited to) implementing physician/nonphysician practitioner
      Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.49,50 The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.51,52
      -driven delegated orders or protocols, initiating or modifying orders for therapeutic diets, medical foods/nutrition supplements, dietary supplements, enteral and parenteral nutrition, laboratory tests, medications, and adjustments to fluid therapies or electrolyte replacements
      XXX
      3.4D1iEstablishes RDN as a key stakeholder in facility processes with implications for Sustainable Food Systems principles (eg, procurement of food and materials and waste management)XX
      3.4D2Uses and participates in or leads development of processes for privileging for provision of nutrition-related services, including (but not limited to) initiating and performing bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, providing home enteral nutrition or infusion management services (eg, ordering formula and supplies), and indirect calorimetry measurementsXXX
      3.4D2iEstablishes RDN as a valued expert in integrating Sustainable Food Systems principles into nutrition-related services and materialsXX
      3.4EComplies with established billing regulations, organization policies, and grant funder guidelines, if applicable to role and setting, and adheres to ethical and transparent financial management and billing practicesXXX
      3.4FCommunicates with the interprofessional team and referring party consistent with HIPAA rules for use and disclosure of customer’s personal health informationXXX
      3.5Uses professional, technical, and support personnel appropriately in the delivery of customer-centered care or services that integrate Sustainable Food Systems principles in accordance with laws, regulations, and organization policies and proceduresXXX
      3.5AAssigns activities consistent with Sustainable Food Systems principles, including direct care to patients/clients, consistent with the qualifications, experience, and competence of professional, technical, and support personnelXXX
      3.5A1Integrates Sustainable Food Systems principles into human resource policies, practices, and trainingXX
      3.5BSupervises professional, technical, and support personnelXXX
      3.5B1Develops and implements incentives for compliance with Sustainable Food Systems practicesXX
      3.5B2Monitors and evaluates compliance to Sustainable Food Systems practices and proceduresXX
      3.6Designs and implements food delivery systems that integrate Sustainable Food Systems principles to meet the needs of customersXXX
      3.6ACollaborates in or leads the design of food delivery systems that integrate Sustainable Food Systems principles to address health care needs and outcomes (including nutrition status), ecological sustainability, and to meet the culture and related needs and preferences of target populations (eg, clients or customers of health care facilities, worksites, retail operations, schools, child and adult day-care centers, food redistribution in community feeding sites and local food banks, farmer’s markets, public drinking fountains, community gardens, and urban farms)XXX
      3.6A1Analyzes customer and community needs related to Sustainable Food SystemsXXX
      3.6A2Adopts or develops delivery systems that improve Sustainable Food Systems initiativesXX
      3.6A2iEstablishes service delivery policies to procure sustainable food, water, beverages, and service wareXX
      3.6A2iiPartners with community or regional soil- and water-conservation districtsXX
      3.6A3Promotes food and water delivery systems as a means to improve health, environments (built and natural), and profitability for both food producers and the organizationXX
      3.6A4Evaluates and continuously improves food- and water-delivery systems based on customer feedback and industry standardsX
      3.6BParticipates in, consults/collaborates with, or leads the development of menus to address health, nutritional, and cultural needs of target population(s) that integrate Sustainable Food Systems principles and are consistent with federal, state, or funding source regulations or guidelinesXXX
      3.6B1Assesses dietary needs and preferences of target population(s) in ways that build social, cultural, and ethical capital, including respect for cultural needs, norms, and valuesXXX
      3.6B2Ensures that dietary choices include options consistent with Sustainable Food Systems principlesXXX
      3.6B3Maintains menu, production, and standardized recipe practices that are based on Sustainable Food Systems principlesXX
      3.6B3iIncorporates food and beverages produced or procured using Sustainable Food Systems principles into culturally acceptable and nutrient-dense menusXX
      3.6B4Trains staff on Sustainable Food Systems principles for recipe and menu developmentXX
      3.6B5Implements procurement policies that incorporate Sustainable Food Systems principles (eg, food and equipment procurement)XX
      3.6B6Develops and/or disseminates menu policies and practices that integrate Sustainable Food Systems principles (eg, menus, recipes, cooking techniques, and plating diagrams)X
      3.6CParticipates in, consults/collaborates with, or leads interprofessional process for determining medical foods/nutritional supplements, dietary supplements, enteral and parenteral nutrition formularies, and delivery systems that integrate Sustainable Food Systems principles for target population(s)XXX
      3.7Maintains records of services provided that integrate Sustainable Food Systems principlesXXX
      3.7ADocuments according to organization policies, procedures, standards, and systems, including electronic health recordsXXX
      3.7BImplements data management systems to support interoperable data collection, maintenance, and utilizationXXX
      3.7B1Develops or collaborates with the interprofessional team to capture Sustainable Food Systems–specific data through data-collection toolsXX
      3.7CUses data to document outcomes of services (ie, staff productivity, cost/benefit, budget compliance, outcomes, quality of services, and community impact) and provide justification for maintenance or expansion of servicesXXX
      3.7C1Shares program outcomes and impact with organization, customers, or community participants (eg, pounds of food waste averted and reduction in energy costs from more efficient appliances)XXX
      3.7DUses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulationsXXX
      3.8Advocates for provision of quality food and nutrition services that integrate Sustainable Food Systems principles as part of public policyXXX
      3.8ACommunicates with policymakers regarding the benefit/cost of quality food and nutrition servicesXXX
      3.8A1Identifies policies and proposed legislation at local, state, federal, and international levels that impact Sustainable Food Systems servicesXXX
      3.8A2Collaborates with groups working on Sustainable Food Systems policies and legislation at local, state, federal, and international levelsXX
      3.8A3Uses evidence-based information to connect individual and population nutrition and health outcomes to Sustainable Food Systems practices as a means to influence policyXX
      3.8A4Works in collaboration with community organizations, including grassroots campaigns, to understand and communicate community perspectives on benefit/cost of quality Sustainable Food Systems services to policymakersXX
      3.8A5Performs Sustainable Food Systems policy analysis to identify impacts on health, economic, social, and environmental outcomes and identifies gaps and opportunities in current public policiesX
      3.8A6Develops and implements a communication plan to educate policymakers about benefit/cost of quality Sustainable Food Systems servicesX
      3.8A7Evaluates effectiveness of public policy strategies that advance Sustainable Food Systems services and adjusts strategies as neededX
      3.8A8Facilitates or participates in forums about proposed legislation, rules, or codes that impact the delivery of quality Sustainable Food Systems servicesX
      3.8A9Develops draft legislation or policies in coordination with policymakers that advance Sustainable Food Systems servicesX
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needs and chronic conditionsXXX
      3.8B1Advocates for policy, systems, and environmental (built and natural) changes that strengthen services and integrate Sustainable Food Systems principles that advance community food, nutrition, and water security, with an emphasis on marginalized populations, such as low-income groups, women, and communities of color (eg, farm to school; Child Nutrition Programs; Special Supplemental Nutrition Program for Women, Infants, and Children; Supplemental Nutrition Assistance Program; Senior Farmers Market Nutrition Program; and healthy food options in retail venues)XXX
      3.8B1iPromotes and communicates the benefits of policy changes that support local and regional food systems (eg, urban farming, community and school gardens, community-supported agriculture, value-added processing, financing for beginning food producers, food hubs, regional branding, and food cooperatives)XX
      3.8B1iiPromotes and communicates the benefits of policies and initiatives that protect ecosystem health (eg, soil, water, air, energy, and biodiversity)XX
      3.8CAdvocates for protection of the public through multiple avenues of engagement (eg, legislative action and establishing effective relationships with elected leaders and regulatory officials, participation in various Academy committees, workgroups and task forces, Dietetic Practice Groups, Member Interest Groups, and State Affiliates)XXX
      3.8C1Advocates for public policies that support Sustainable Food Systems principlesXXX
      3.8C2Serves on local, state, federal, or international committees that support policies and initiatives that improve the delivery of Sustainable Food Systems servicesXX
      3.8C3Leads advocacy on Sustainable Food Systems issues as they pertain to nutrition and healthXX
      Examples of Outcomes for Standard 3: Provision of Services
      • Program/service design and systems reflect organization/business mission, vision, principles, values, and customer needs and expectations
      • Customers evaluate their food and beverage consumption goals based on the contributions to health and sustainability
      • Customer-centered needs and preferences are met
      • Customers are satisfied with services and products
      • Customers have access to food assistance
      • Customers have access to food and nutrition services
      • Support personnel are trained in Sustainable Food System policies and goals and their compliance is routinely monitored
      • Foodservice system incorporates sustainability practices addressing energy and water use and waste management
      • Menus reflect the cultural, health, and/or nutritional needs of target population(s) and consideration of ecological sustainability
      • Evaluations reflect expected outcomes and established goals
      • Effective screening and referral services are established or implemented as designed
      • Ethical and transparent financial management and billing practices are used per role and setting
      • Culturally appropriate policies and legislation are implemented that conserve energy, water, and soil; minimize waste; enhance diversity of the food supply; and use sustainably produced food and beverages
      • Community-based food systems are vibrant and economically available
      Standard 4: Application of Research

      The registered dietitian nutritionist (RDN) applies, participates in, and/or generates research to enhance practice. Evidence-based practice incorporates the best available research/evidence and information in the delivery of nutrition and dietetics services.

      Rationale:

      Application, participation, and generation of research promote improved safety and quality of nutrition and dietetics practice and services.
      Indicators for Standard 4: Application of Research
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Reviews best available research/evidence and information for application to practiceXXX
      4.1AUnderstands basic research design and methodologyXXX
      4.1BEnsures that practice decisions are supported by peer-reviewed scientific literature or, when such data are not available, credible information from relevant sources (eg, government and national/international nongovernmental organization publications) and disciplines (eg, public health, environmental science, and agricultural economics)XXX
      4.1CIdentifies Sustainable Food Systems relevant databases (eg, Agricola, Agris, and Economic Research Service) and performs systematic reviews of the literatureXXX
      4.1DDemonstrates the experience and critical thinking skills required to evaluate strength of original research, including limitations and potential bias and evidence-based guidelines relevant to Sustainable Food SystemsXX
      4.1EIdentifies common indicators or outcome measures of Sustainable Food SystemsXX
      4.1FCritically evaluates research and research methodologies that have historically been used to justify or reinforce the subjugation of marginalized populationsX
      4.2Uses best available research/evidence and information as the foundation for evidence-based practice that supports Sustainable Food SystemsXXX
      4.2AUses validated indicators or outcome measures of Sustainable Food Systems in research and/or practiceXXX
      4.2BTranslates Sustainable Food Systems research and evidence to inform strategies in evidence-based practiceXXX
      4.2CApplies an evidence-based approach to develop and/or evaluate proposals compared to existing food and water laws and regulationsXX
      4.2DCritically analyzes current organizational practices and updates systems and processes in accordance with current evidence on Sustainable Food SystemsX
      4.3Integrates best available research/evidence and information related to Sustainable Food Systems with best practices, clinical and managerial expertise, and customer valuesXXX
      4.3AEvaluates and responds to the unintended consequences and externalities of food and water systems practicesXX
      4.3BAssesses the reciprocal/symbiotic relationship between diet and Sustainable Food SystemsX
      4.4Contributes to the development of new knowledge and research in nutrition and dietetics as it pertains to Sustainable Food SystemsXXX
      4.4AIdentifies gaps in research, evidence-based practice guidelines, and/or scientific literatureXX
      4.4BPromotes transparent process of identifying and managing biases and conflicts of interest as it relates to public and private funding of Sustainable Food Systems researchXX
      4.4CEvaluates impacts of food and water systems on environmental, economic, social, and health outcomes, with an emphasis on marginalized populations, including women and people of colorXX
      4.4DParticipates in interprofessional research teamsXX
      4.4EAssembles and leads interprofessional research teams needed to address Sustainable Food Systems issuesX
      4.4FContributes to the development of evidence-based practice guidelines and position papersX
      4.5Promotes application of research in practice through alliances or collaboration with food and nutrition and other professionals and organizationsXXX
      4.5ADisseminates the results and emphasizes the significance and value of Sustainable Food Systems research findingsXXX
      4.5BIdentifies key stakeholder groups and their Sustainable Food Systems priorities for further research collaborationXX
      4.5CAdvocates to stakeholder organizations (including government agencies, eg, the USDA National Institute of Food and Agriculture) for prioritizing and funding of Sustainable Food Systems research projectsX
      Examples of Outcomes for Standard 4: Application of Research
      • Evidence-based practice, best practices, customer values, and Sustainable Food Systems principles are integrated in the delivery of nutrition and dietetics services
      • Customers receive appropriate services based on the effective application of best available research/evidence and information
      • Best available research/evidence and information is used as the foundation of evidence-based practice
      • Evidence-based research in Sustainable Food Systems supports public policy efforts
      Standard 5: Communication and Application of Knowledge

      The registered dietitian nutritionist (RDN) effectively applies knowledge and expertise in communications.

      Rationale:

      The RDN works with others to achieve common goals by effectively sharing and applying unique knowledge, skills, and expertise in food, nutrition, dietetics, and management services.
      Indicators for Standard 5: Communication and Application of Knowledge
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      5.1Communicates and applies current knowledge and information based on evidence that supports Sustainable Food SystemsXXX
      5.1ADemonstrates critical thinking and problem-solving skills when communicating Sustainable Food Systems issues with othersXXX
      5.1A1Assesses Sustainable Food Systems research for validity and generalizability by considering soundness of methodology, assumptions, and valuesXXX
      5.1A2Models critical thinking skills and provides inclusive environments for discussionsXX
      5.1BPromotes applicability of Sustainable Food Systems principles across all areas of nutrition and dietetics practiceXX
      5.2Selects appropriate information and the most effective communication method or format when communicating Sustainable Food Systems information that considers customer-centered care and services, and the needs of the individual/group/populationXXX
      5.2AUses communication methods (ie, oral, print, one-on-one, group, visual, electronic, and social media) targeted to various audiencesXXX
      5.2A1Considers the current knowledge and viewpoints of the audience related to Sustainable Food Systems issues and responds to concerns in a respectful mannerXXX
      5.2A2Performs demographic, psychological, and contextual analysis of audience (eg, values, knowledge, and beliefs) to determine the best communication strategy for presentation of Sustainable Food Systems conceptsXX
      5.2BUses information technology to communicate, disseminate, manage knowledge, and support decision makingXXX
      5.2B1Applies technologies relevant to Sustainable Food Systems (eg, social media, apps, and software for tracking food waste)XX
      5.2B2Leads development and use of technology (eg, social media, geographic information system mapping, software applications, and infographics) to deliver Sustainable Food Systems informationX
      5.3Integrates knowledge of food and nutrition and Sustainable Food Systems with knowledge of health, culture, social sciences, communication, informatics, sustainability, and managementXXX
      5.3AIncorporates knowledge of Sustainable Food Systems principles across diverse settings (eg, community, academic institutions, business and industry, and health care)XXX
      5.3BInteracts with and educates leaders in a variety of disciplines about Sustainable Food Systems principlesXX
      5.4Shares current, evidence-based knowledge, and information of Sustainable Food Systems with various audiencesXXX
      5.4AGuides customers, families, students, and interns in the application of Sustainable Food Systems knowledge and skillsXXX
      5.4A1Integrates Sustainable Food Systems principles into existing patient and client education and professional development of RDNs; nutrition and dietetics technicians, registered; dietetics students; interns; and other professionals (eg, explaining food labels related to sustainability claims)XX
      5.4A2Expands course curricula, site-specific learning activities, and research projects to include Sustainable Food Systems principles while meeting nutrition and dietetics education competencies (ie, for students/interns)X
      5.4BAssists individuals and groups to identify and secure appropriate and available Sustainable Food Systems educational and other resources and servicesXXX
      5.4B1Promotes and supports programs, businesses, policies and resources that incorporate Sustainable Food Systems practices (eg, Special Supplemental Nutrition Program for Women, Infants, and Children Farmer’s Market Nutrition Program; local food purveyors; and commercial composters)XXX
      5.4CUses professional writing and verbal skills in all types of communications (eg, e-mails, reports, and social media)XXX
      5.4C1Delivers presentations and authors books and articles on Sustainable Food Systems for peers, consumers, health professionals, community groups, policymakers, and food systems leadersXX
      5.4C2Functions as an expert or media spokesperson on Sustainable Food Systems (eg, interviews, guest commentary, and editorials)X
      5.4DReflects knowledge of population characteristics in communication methods (eg, literacy, numeracy levels, need for translation of written materials and/or a translator, communication skills, and learning, hearing or vision disabilities)XXX
      5.5Establishes credibility and contributes as a food and nutrition resource within the interprofessional health care and management team, organization, and community promoting Sustainable Food Systems strategies that enhance health and quality of life outcomes for target populationsXXX
      5.5AAdvocates for Sustainable Food Systems principles to be integrated into health care processes and policiesXXX
      5.5BConducts activities and provides resources to educate members of the interprofessional team about Sustainable Food Systems, its applications and impacts on human, environmental, economic, and social healthXX
      5.5CServes as the Sustainable Food Systems expert on interprofessional teams (eg, facilities management, quality management, and campus dining)X
      5.6Communicates performance improvement and research results through publications and presentationsXXX
      5.6ADisseminates best practices and outcomes specific to Sustainable Food Systems (eg, institutional marketing materials, campus recruiting, annual reports, and score cards)XX
      5.6BDevelops grants and white papers, delivers presentations, and authors books and articles that incorporate and disseminate Sustainable Food Systems concepts and best practices to various stakeholders (eg, peers, consumers, health professionals, educators, community groups, policymakers, and food system leaders)X
      5.7Seeks opportunities to participate in and assume leadership roles with local, state, and national professional and community-based organizations (eg, government-appointed advisory boards, community coalitions, schools, food policy councils, and foundations or nonprofit organizations serving the food insecure) providing food and nutrition and Sustainable Food Systems expertiseXXX
      5.7AServes on local planning committees and task forces for health professionals, industry, and communityXXX
      5.7BIntroduces organizations to Sustainable Food Systems principles (eg, presentations, webinars, articles, and field trips)XX
      5.7CNominates peers for Sustainable Food Systems leadership positionsXX
      5.7DIntegrates Sustainable Food Systems principles into organization’s governance structure (eg, providing expert advice to food industry groups on corporate social responsibility metrics)X
      5.7EServes as the Sustainable Food Systems expert for organizations (eg, represents the organization’s sustainability efforts in external meetings, writes newsletters and editorials, and gives presentations)X
      5.7FOrganizes and/or presents at state, regional, national, and international meetings on Sustainable Food Systems issuesX
      5.7GLeads Sustainable Food Systems initiatives within organizations (eg, policy advisory councils, coalitions, nonprofit organizations, or primary place of employment)X
      5.7HDevelops, directs, and manages Sustainable Food Systems professional workshops, conferences, and meetings, ensuring diversity, equity, and inclusion in conference experts and attendeesX
      Examples of Outcomes for Standard 5: Communication and Application of Knowledge
      • Food and nutrition students interested in Sustainable Food Systems are guided to internships that incorporate those principles
      • Expertise in Sustainable Food Systems–related food, nutrition, dietetics, and management is demonstrated and shared
      • Sustainable Food Systems principles are supported by information technology in practice
      • Interoperable information technology is used to support practice
      • Effective and efficient communications occur through appropriate and professional use of e-mail, texting, and social media tools
      • Individuals, groups, and stakeholders:
        • o
          Receive current and appropriate Sustainable Food Systems–related information and customer-centered service
        • o
          Demonstrate understanding of Sustainable Food Systems information and behavioral strategies received
        • o
          Know how to obtain additional Sustainable Food Systems guidance from the RDN or other RDN-recommended resources
      • Leadership in Sustainable Food Systems is demonstrated through active professional and community involvement
      Standard 6: Utilization and Management of Resources

      The registered dietitian nutritionist (RDN) uses resources effectively and efficiently.

      Rationale:

      The RDN demonstrates leadership through strategic management of time, finances, facilities, supplies, technology, natural, and human resources.
      Indicators for Standard 6: Utilization and Management of Resources
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      6.1Uses a systematic approach to manage resources and improve outcomesXXX
      6.1AWorks within existing programs or policies to conserve natural resources and minimize wasteXXX
      6.1BIdentifies opportunities for programs or policies that conserve natural resources and minimize wasteXX
      6.1CAssesses the use of natural resources (eg, soil, water, biodiversity, energy, paper, and cardboard) at departmental and organizational levels to establish benchmarksXX
      6.1DImplements system-level policy and practice changes (eg, adopting new waste management systems across school districts or health care system)X
      6.2Evaluates management of resources with the use of standardized performance measures and benchmarking as applicableXXX
      6.2AUses the Standards of Excellence Metric Tool to self-assess quality in leadership, organization, practice, and outcomes for an organization (www.eatrightpro.org/excellencetool)XXX
      6.2BAssesses adequacy and pertinence of existing benchmarks and enhances Sustainable Food Systems metricsXX
      6.2CLeads in strategic planning for qualification of Sustainable Food Systems specific goals and measuresX
      6.2DDirects operational review reflecting evaluation of performance and benchmarking data to manage resources and modifications for design and delivery of Sustainable Food Systems programs and servicesX
      6.3Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and products that integrate Sustainable Food Systems principlesXXX
      6.3AIdentifies improvements to ensure maximum impact of Sustainable Food Systems services and productsXX
      6.4Participates in quality assurance and performance improvement (QAPI) and documents outcomes and best practices relative to resource managementXXX
      6.4ACollects QAPI data using designated tools and analyzes data to improve outcomes and identify best practices, collaborating with others as neededXXX
      6.4BEvaluates Sustainable Food Systems QAPI processes and communicates outcomes and best practices to leadership, stakeholders, and customersXX
      6.5Measures and tracks trends regarding internal and external customer outcomes (eg, satisfaction, key performance indicators)XXX
      6.5AAnalyzes data related to program services and customer satisfaction; communicates results and recommendations for changeXXX
      6.5BMeasures and analyzes sustainable food systems products and processes to improve outcomes and create best practices; communicates results to leadership, stakeholders, and customersXX
      Examples of Outcomes for Standard 6: Utilization and Management of Resources
      • Resources are effectively and efficiently managed
      • Documentation of resource use is consistent with operational and sustainability goals
      • Data are used to promote, improve, and validate services, organization practices, and public policy
      • Desired outcomes are achieved, documented, and disseminated
      • Identifies and tracks key Sustainable Food System indicators in alignment with organizational mission, vision, principles, and values
      • Sustainable Food Systems principles guide organization decisions and practices
      a PROMIS: The Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index) is a reliable, precise measure of patient-reported health status for physical, mental, and social well-being. PROMIS is a web-based resource and is publicly available.
      b Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members, depending on the needs of the customer. Whereas the term may traditionally refer to other health professionals (eg, other RDNs, physicians, nurses, pharmacists, psychologists, social workers, and occupational and physical therapists),
      • Stock P.
      • Burton R.J.
      Defining terms for integrated (multi-inter-trans-disciplinary) sustainability research.
      in the context of Sustainable Food Systems it may also include researchers, educators, and practitioners from a variety of disciplines and sectors, such as food producers, agronomists, veterinarians, environmental scientists, waste management professionals, behavioral economists, community leaders, policymakers, culinary professionals, and entrepreneurs. Interprofessional collaboration could also refer to multi-, inter-, or transdisciplinary or multi-, inter-, or trans-sectoral collaboration.
      c Medical staff: Medical staff is composed of doctors of medicine or osteopathy in accordance with State law, including scope of practice laws, include other categories of physicians, and non-physician practitioners who are determined to be eligible for appointment by the governing body.
      US Department of Health and Human Services, Centers for Medicare and Medicaid Services
      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders.
      d Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.
      US Department of Health and Human Services, Centers for Medicare and Medicaid Services
      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders.
      ,
      US Department of Health and Human Services, Centers for Medicare and Medicaid Services
      State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); § 485.635(a)(3)(vii) Dietary Services ; § 458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds.
      The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.
      US Department of Health and Human Services, Centers for Medicare and Medicaid Services
      Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final Rule (FR DOC#2016; pp 68688-68872)–Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178).
      ,
      US Department of Health and Human Services, Centers for Medicare and Medicaid Services
      State Operations Manual. Appendix PP Guidance to surveyors for long-term care facilities (Rev. 173, 11-22-17); § 483.30 Physician Services, § 483.60 Food and Nutrition Services.

      References

        • Tagtow A.
        • Robien K.
        • Bergquist E.
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      Biography

      M. Spiker is a healthy and sustainable food systems fellow, Academy of Nutrition and Dietetics Foundation, Chicago, IL.
      S. Reinhardt is a lead analyst, food systems and health, Union of Concerned Scientists, Washington, DC.
      M. Bruening is an associate professor, Arizona State University, Phoenix.