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Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders

      Abstract

      Eating disorders (ED) are complex mental illnesses and are not a result of personal choice. Full recovery from an ED is possible. The severity and inherent lethality of an ED is undisputed, and the role of the registered dietitian nutritionist (RDN) is essential. Clinical symptomology presents at varying developmental milestones and is perpetuated through a sociocultural evaluation of beauty and drive for ascetic idealism. ED are globally prevalent in 4.4% of the population aged 5 to 17 years, yet affect individuals across the entire lifespan, including all cultures and genders. The Behavioral Health Nutrition Dietetic Practice Group, along with the Academy of Nutrition and Dietetics Quality Management Committee, revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs in Eating Disorders. Including the RDN in ED treatment is vital for all levels of care. The RDN must be perceptive to negative symptoms indicative of psychological triggers when exploring food belief systems, patterns of disinhibition, and nutrition misinformation with clients. Through a conscious awareness of medical, psychological, and behavioral strategies, the implementation of the SOP and SOPP supports a dynamic and holistic view of ED treatment by the RDN. The SOP and SOPP are complementary resources for RDNs and are intended to be used as self-evaluation tools for assuring competent practice in ED and for determining potential education, training, supervision, and mentorship needs for advancement to a higher practice level in a variety of settings.
      Editor’s note: Figures 1 and 2 that accompany this article are available online at www.jandonling.org.
      The Behavioral Health Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics (Academy), under the guidance of the Academy Quality Management Committee, has revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians in Disordered Eating and Eating Disorders originally published in 2011.
      • Tholking M.M.
      • Mellowspring A.C.
      • Eberle S.G.
      • et al.
      American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Disordered Eating and Eating Disorders (DE and ED).
      The revised document, Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders, reflects advances in practice during the past 9 years and replaces the 2011 Standards. This document builds on 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.
      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 (Academy)/Commission on Dietetic Registration (CDR). 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.
      Scope of practice in nutrition and dietetics is composed of statutory and individual components, includes the code(s) 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, or additional credentials (eg, Certified Eating Disorders Registered Dietitian [CEDRD] or CEDRD-supervisor [CEDRD-S], Certified Nutrition Support Clinician [CNSC], or focus area CDR specialist certification, eg, Certified Specialist in Sports Dietetics [CSSD] or Certified Specialist in Pediatric Nutrition [CSP]). 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. The algorithm is designed to assist an RDN to critically evaluate their personal knowledge, skill, experience, judgment, and demonstrated competence using criteria resources.
      Scope of Practice Decision Algorithm
      Academy of Nutrition and Dietetics.
      Approved June 2020 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the Executive Committee of the Behavioral Health Nutrition Dietetic Practice Group of the Academy. Scheduled review date: June 2026. Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Eating Disorders may be addressed to Academy Quality Management Staff: Dana Buelsing, MS, manager, Quality Standards Operations; and Carol J Gilmore, MS, RDN, LD, FADA, FAND 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 two 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.
      The Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services, Hospital
      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.
      and Critical Access Hospital
      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. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      Conditions of Participation now allow a hospital and its medical staff the option of including RDNs or other clinically qualified nutrition professionals within the category of “non-physician practitioners” eligible for ordering privileges for therapeutic diets and nutrition-related services if consistent with state law and health care regulations. RDNs in hospital settings interested in obtaining ordering privileges must review state laws (eg, licensure, certification, and title protection), if applicable, and health care regulations to determine whether there are any barriers or state-specific processes that must be addressed. For more information, review the Academy’s practice tips that outline the regulations and implementation steps for obtaining ordering privileges (www.eatrightpro.org/dietorders/). For assistance, refer questions to the Academy’s State Affiliate organization.
      Medical staff oversight of an RDN(s) occurs in one of two ways. A hospital has the regulatory flexibility to appoint an RDN(s) to the medical staff and grant the RDN(s) specific nutrition ordering privileges or can authorize the ordering privileges without appointment to the medical staff. To comply with regulatory requirements, an RDN’s eligibility to be considered for ordering privileges must be through the hospital’s medical staff rules, regulations, and bylaws, or other facility-specific process.
      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). US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      The actual privileges granted will be based on the RDN’s knowledge, skills, experience, and specialist certification, if required, and demonstrated and documented competence.
      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. 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 qualified professional must be acting within the scope of practice as defined by state law; and is under the supervision of the physician that may include, for example, countersigning the orders written by the qualified dietitian or clinically qualified nutrition professional. RDNs in eating disorders (ED) who work or consult in long-term care settings may have a policy in place that allows a resident’s attending physician to delegate to the RDN writing orders for the diet/meal plan and other nutrition-related services. Whether ordering or recommending a meal plan, this would facilitate the RDN addressing the resident’s ED-related needs and preferences consistent with any advanced directives that may be in place. Monitor the Academy’s updates for any CMS changes to §483.60 Food and Nutrition Services (www.eatrightpro.org/practice/quality-management/national-quality-accreditation-and-regulations/centers-for-medicare-and-medicaid-services). Review the state’s long-term care regulations to identify potential barriers to implementation; and identify considerations for developing the facility’s processes with the medical director and for orientation of attending physicians. The CMS State Operations Manual, Appendix PP-Guidance for Surveyors for Long-Term Care Facilities contains the revised regulatory language (new revisions are italicized and in red color).
      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. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      CMS periodically revises the State Operations Manual Conditions of Participation; obtain the current information at www.cms.gov/files/document/appendices-table-content.pdf.

      Academy Quality and Practice 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 SOPP for RDNs in competent, proficient, and expert levels of practice. 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/residents/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 consist 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 equitable 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 ED 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 ED nutrition and dietetics 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 general clinical practice with maintaining minimum competence in the focus area and by RDNs 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 Figures 1 and 2, available at www.jandonline.org) for the SOP and SOPP for RDNs in Eating Disorders were revised with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDNs in Eating Disorders were reviewed and approved by the Executive Committee of the Behavioral Health Nutrition Dietetic Practice Group and the Academy Quality Management Committee.

      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 (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 SOP and SOPP for RDNs in Eating Disorders. In Academy focus areas, the 3 levels of practice are represented as competent, proficient, and expert.
      Figure 3Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Eating Disorders.
      Standards of Practice (SOP) are authoritative statements that describe practice demonstrated through nutrition assessment, nutrition diagnosis (problem identification), nutrition intervention (planning, implementation), and outcomes monitoring and evaluation (4 separate standards) and the responsibilities for which registered dietitian nutritionists (RDNs) are accountable. The SOP for RDNs in Eating Disorders presuppose that the RDN uses critical thinking skills; analytical abilities; theories; best available research findings; current accepted nutrition, dietetics, and medical knowledge; and the systematic holistic approach of the nutrition care process as they relate to the application of the standards. Standards of Professional Performance (SOPP) for RDNs in Eating Disorders 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).

      SOP and SOPP 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 client is used in the SOP as a universal term as these Standards relate to direct provision of nutrition care and services. Client could also mean patient, resident, participant, consumer, or any individual, group, or population who receives eating disorder treatment, care and services. 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 or those in the client’s support system to which the RDN provides services. These services are provided to individuals throughout the lifespan. The SOP and SOPP are not limited to the clinical setting. In addition, it is recognized that the family and caregiver(s) or advocate of these clients, including individuals with special health care needs, play critical roles in overall health and are important members of the team throughout the assessment and intervention process. The term appropriate is used in the standards to mean selecting from a range of best practice 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 eating disorders (see image below). In addition, the core indicators have been expanded to reflect the unique competence expectations for the RDN in eating disorders treatment.

      Standards described as proficient level of practice in this document are not equivalent to the International Association of Eating Disorders Professionals (iaedp) certification as a Certified Eating Disorder Registered Dietitian (CEDRD). Rather, the CEDRD designation recognizes the skill level of a RDN who has developed and demonstrated, through successful completion of the certification examination and its qualifications, advanced knowledge and application beyond the competent practitioner and establishes, at a minimum, proficient-level skills.

      Standards described as expert level of practice in this document are not equivalent to the iaedp certification as a CEDRD-supervisor (CEDRD-S). Rather, the CEDRD-S designation recognizes the skill level of an RDN who has developed and demonstrated through successful completion of the certification examination and its qualifications, advanced knowledge and application beyond the proficient practitioner and establishes, at minimum, expert-level skills.

      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 apply to all levels of practice. 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. A general practice RDN may have responsibilities across several areas of practice, including community, clinical, consultation and business, research, education, and food and nutrition management.
      With safety and evidence-based practice as guiding factors when working with patients/clients/customers/residents/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 Academy offers a webinar, Evidence-Based Nutrition Using Scientific Evidence to Inform Clinical Practice (www.eatrightstore.org/cpe-opportunities/recorded-webinars) that presents the 5-step evidence-based process as a mechanism to acquire and critique evidence for practicing evidence-based nutrition care. 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 patient/client/customer/population in shared-decision making.
      Patients/clients with ED will present in a variety of practice areas, therefore, an RDN’s familiarity with resources and clinical guidelines for this population is recommended. Early recognition of nonverbal cues of ED pathology, sensitivity to body shape variances among ED clients, and clinician bias to this population are vital. Most critically, rapid referral to an experienced ED RDN (eg, CEDRD/-S) is necessary when treatment needs are beyond the RDN’s individual scope of practice.
      The CEDRD credential requires advanced education through the International Association of Eating Disorders Professionals (iaedp) (http://www.iaedp.com/certification-overview/) and skill development in the diagnosis, assessment, treatment, and prevention of ED. To obtain the CEDRD credential, more than 2,500 clinical hours treating clients with ED under the supervision of an expert CEDRD-S, a minimum of 2 years practicing specifically within ED, and a passing score on an interdisciplinary comprehensive examination are required to qualify for the CEDRD credential. The CDR recognized the CEDRD in June of 2015 as the specialized certification for RDNs practicing in ED.
      A CEDRD-S is an RDN who has obtained the CEDRD credential, worked 6,000 or more hours in the field of ED as an integral part of the interdisciplinary treatment team, and is trained and skilled in providing clinical supervision to RDNs and nutrition and dietetics students/interns specific to the treatment of and competency in ED.
      Working with an experienced ED mentor (ie, supervisor [CEDRD-S]) is essential to RDNs new to the treatment of ED to increase exposure to experiences that facilitate professional excellence and mastery of underlying ED psychopathology. It is necessary to gain practical skills for recognizing and maintaining therapeutic boundaries with interprofessional team members and client(s). If planning to pursue the CEDRD certification through iaedp, seek out a qualified RDN (eg, CEDRD-S) in ED who can provide the required professional clinical supervision as the ED-specific practice hours are obtained. Furthermore, obtaining ED-related continuing education and shadowing experiences with ED interprofessional team members will build knowledge and skills in this area.

      Proficient Practitioner

      A proficient practitioner is an RDN who is generally 3 or more years beyond credentialing and entry into the profession and 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. An RDN may acquire specialist credentials, if available, to demonstrate proficiency in a focus area of practice.
      An RDN who has chosen ED as their area of clinical practice is strongly encouraged to establish a professional clinical supervisory relationship with an expert RDN in ED to gain knowledge, skills, and insight into this area of practice. Supervision is an essential self-care tool for all professionals and provides opportunities for concept discussion, case review, and advanced learning. Because the CEDRD requires supervision with an expert RDN, this certification is recommended for practice in ED. Additional continuing education toward and understanding of interprofessional use of therapeutic modalities (eg, Dialectical Behavioral Therapy, Cognitive Behavioral Therapy, Acceptance Commitment Therapy, Exposure Response Prevention), principles of psychopathology, culinary medicine, research methods, administrative management, and business administration is also recommended. At this level, an RDN may have achieved the coursework, experience, professional supervision, and successfully completed the examination for the CEDRD certification.

      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 ongoing critical evaluation of practice and feedback from others. The individual at this level strives for additional knowledge, experience, and training. 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. An expert practitioner may have an expanded or specialist role or both, and may possess an advanced credential(s), such as the CDR Advanced Practitioner Certification in Clinical Nutrition or focus area credential, such as the CEDRD-S. Generally, the practice is more complex and has a high degree of professional autonomy and responsibility, while maintaining peer professional clinical supervision to assist with processing complex relational issues. The expert practitioner demonstrates the ability to independently manage the complexity of nutritional recovery for ED, including case management across all levels of care and supervision/professional development of competent- and proficient-level RDN practitioners. This RDN develops a perception and clarity to address countertransference or transference issues as they arise throughout the course of treatment.
      These Standards, along with the Academy/CDR Code of Ethics,
      Academy of Nutrition and Dietetics (Academy)/Commission on Dietetic Registration (CDR). 2018 Code of Ethics for the Nutrition and Dietetics Profession.
      answer the questions: Why is an RDN uniquely qualified to provide ED nutrition and dietetics care and services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, efficient, equitable, and quality ED nutrition care and service at the competent, proficient, and expert levels?

      Overview

      The severity and inherent lethality of an ED is undisputed.
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      Addressing critical gaps in the treatment of eating disorders.
      The global prevalence rate for ED in individuals aged 5 to 17 years is 4.4% of the population
      • Erskine H.E.
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      • Patton G.
      • et al.
      The global coverage of prevalence data for mental disorders in children and adolescents.
      ; however, the rates of subclinical ED within broader populations are significant. Refer to Figure 4 for further explanation of a subclinical ED. Approximately 25% of female college athletes present with subclinical ED,
      • Greenleaf C.
      • Petrie T.A.
      • Carter J.
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      Female collegiate athletes: Prevalence of eating disorders and disordered eating behaviors.
      and over 70% of individuals with anorexia nervosa (AN) or bulimia nervosa report at least 1 diagnosis of anxiety disorder within their lifetime.
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      Anxiety disorders in anorexia nervosa and bulimia nervosa: Co-morbidity and chronology of appearance.
      Within a survey group of more than 4,000 women aged 25 to 45 years, 31% of women with no history of AN or binge eating disorder (BED) purged for weight control, and almost 75% report that body shape and weight concerns interfere with quality of life.
      • Reba-Harrelson L.
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      Patterns and prevalence of disordered eating and weight control behaviors in women ages 25-45.
      Figure thumbnail gr2
      Figure 4Overview of eating disorders and multifactorial contributors.
      Clinical symptomology presents at varying developmental and sociocultural milestones (eg, biological maturation, onset of adulthood, parenthood, and interpersonal transitions), throughout the lifespan,
      • Kazdin A.E.
      • Fitzsimmons-Craft E.E.
      • Wilfley D.E.
      Addressing critical gaps in the treatment of eating disorders.
      ,
      • Brandsma L.
      Eating disorders across the life span.
      and with a myriad of symptoms.
      Eating Disorders. National Institute of Mental Health.
      ED are globally inclusive
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      of all cultures and genders.
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      • et al.
      Gender difference in the prevalence of eating disorder symptoms.
      It is critical to acknowledge and advocate for vulnerable populations including lesbian, gay, bisexual, transgender and queer (or questioning) and others
      • Diemer E.W.
      • White Hughto J.M.
      • Gordon A.R.
      • et al.
      Beyond the binary: Differences in eating disorder prevalence by gender identity in a transgender sample.
      and those with all forms of disabilities who require and desire support and access to specialized, adequate ED support. Diet culture ideals and marketing are deeply rooted and entangled within systemic racism, fear, and discrimination against the Black body and other people of color.
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      Our eating disorders blind spot: Sex and ethnic/racial disparities in help-seeking for eating disorders.
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      As a psychiatric condition with biopsychosocial mediators, each variant of an ED will be impacted by 4 primary variables: temperament,
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      environment,

      Harrop E, Collins L, Clark D, Dios E. Weight stigma is a social justice issue. Oral presentation at: Pre-conference workshop at the meeting of the Association for Size Diversity and Health; August 2018; Portland, OR.

      • Alberga A.S.
      • Russell-Mayhew S.
      • von Ranson K.M.
      • McLauren L.
      Weight bias: A call to action.
      • Araiza A.M.
      • Wellman J.D.
      Weight stigma predicts inhibitory control and food selection in response to the salience of weight discrimination.
      • Ulian M.D.
      • Aburad L.
      • da Silva Oliveira M.S.
      • et al.
      Effects of health at every size interventions on health-related outcomes of people with overweight and obesity: A systematic review.
      • Bratman S.
      Orthorexia vs. theories of healthy eating.
      • Dunn T.M.
      • Bratman S.
      On orthorexia nervosa: A review of the literature and proposed diagnostic criteria.
      The Health at Every Size approach. Association for Size Diversity and Health.
      and malnutrition.
      • Keys A.
      • Brozek J.
      • Henshel A.
      • Mickelson O.
      • Taylor H.L.
      • Galmiche M.
      • Dechelotte P.
      • Lambert G.
      • Tavolacci M.P.
      Prevalence of eating disorders over the 2000-2018 period: A systematic literature review.
      • Norris M.L.
      • Robinson A.
      • Obeid N.
      • et al.
      Exploring avoidant/restrictive food intake disorder in eating disordered patients: A descriptive study.
      • Izquierdo A.
      • Plessow F.
      • Becker K.
      • et al.
      Implicit attitudes toward dieting and thinness distinguish fat-phobic and non-fat-phobic anorexia nervosa from avoidant/restrictive food intake disorder in adolescents.
      • Mascolo M.
      • Geer B.
      • Feuerstein J.
      • Mehler P.S.
      Gastrointestinal comorbidities which complicate the treatment of anorexia nervosa.
      • Garber A.K.
      Moving beyond "skinniness": Presentation weight is not sufficient to assess malnutrition in patients with restrictive eating disorders across a range of body weights.
      • Mountjoy M.
      • Sundgot-Borgen J.
      • Burke L.
      • et al.
      The IOC consensus statement: Beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S).
      Figure 4 offers a graphical illustration of clinical diagnoses inclusive of the phrase eating disorder.
      • Dobinson A.
      • Cooper M.
      • Quesnel D.
      Safe Exercise at Every Stage (SEES) guideline—A clinical tool for treating and managing dysfunctional exercise in eating disorders. Safe Exercise at Every Stage.
      • Dalle Grave R.
      • Calugi S.
      • Marchesini G.
      Compulsive exercise to control shape or weight in eating disorders: Prevalence, associated features, and treatment outcome.
      • Moola F.
      • Gairdner S.
      • Amara C.
      Exercise in the care of patients with anorexia: A systematic review of the literature.
      • Shroff H.
      • Reba L.
      • Thornton L.M.
      • et al.
      Features associated with excessive exercise in women with eating disorders.
      Each manifestation of an ED is diagnosed by a licensed clinician using clinical symptoms as noted by the Diagnostic and Statistical Manual of Mental Disorder, 5th edition.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorder.
      • Stein K.
      The politics and process of revising the DSM-V and the impact of changes on dietetics.
      • Hay P.
      • Girosi F.
      • Mond J.
      Prevalence and sociodemographic correlates of DSM-5 eating disorders in the Australian population.
      The RDN does not provide an ED diagnosis. Every ED presents with a unique clinical manifestation
      • Allen K.L.
      • Byrne S.M.
      • Oddy W.H.
      • Crosby R.D.
      DSM-IV-TR and DSM-5 eating disorders in adolescents: Prevalence, stability, and psychosocial correlates in a population-based sample of male and female adolescents.
      that is subjectively significant to the client being impacted by the condition.
      • Ágh T.
      • Kovács G.
      • Supina D.
      • et al.
      A systematic review of the health-related quality of life and economic burdens of anorexia nervosa, bulimia nervosa, and binge eating disorder.
      Due to the individualization of an ED’s clinical severity and symptom presentation, the subjective nature of these illnesses offers additional rationale for the RDN to have ongoing education and professional clinical supervision.
      The biological understanding of malnutrition and subsequent development of an ED was founded on the Minnesota Starvation Experiment published in 1950.
      • Keys A.
      • Brozek J.
      • Henshel A.
      • Mickelson O.
      • Taylor H.L.
      ,
      • Kalm L.M.
      • Semba R.D.
      They starved so that others be better fed: Remembering Ancel Keys and the Minnesota experiment.
      Thirty-two men voluntarily participated in a laboratory simulation of severe famine to create scientific guidance for assisting famine victims after World War II. Their behavior and sleep patterns, cognitive status, and physiological parameters of health were evaluated. Results of this study offer the scientific framework demonstrating how malnutrition can create physiological, personality, and behavioral changes that lead to an ED independent of medical and psychiatric predisposition.
      ED may be prompted through environmental insults and societal prejudice of body size.
      • Magallares A.
      Well-being and prejudice towards obese people in women at risk to develop eating disorders.
      The comparative attitudes alongside a sociocultural evaluation of beauty,
      • Becker A.
      • Burwell R.A.
      • Hezog D.B.
      • et al.
      Eating behaviours and attitudes following prolonged exposure to television among ethnic Fijian adolescent girls.
      ,
      • Sidani J.E.
      • Shensa A.
      • Hoffman B.
      • Hanmer J.
      • Primack B.A.
      The association between social media use and eating concerns among US young adults.
      and drive for thinness perpetuate the biological manifestation of an ED.
      • Frank G.K.W.
      • Shott M.E.
      • DeGuzman M.C.
      The neurobiology of eating disorders.
      Societal reinforcement of “diet culture” ideals,
      • Hibbeln J.R.
      • Northstone K.
      • Evans J.
      • Golding J.
      Vegetarian diets and depressive symptoms among men.
      including a metamorphosis of physical shape

      Beasley T, Cook B. Exercise in Eating Disorder Treatment: Misconceptions, Evidence and Future Directions. Oral presentation at: Academy of Nutrition and Dietetics Food & Nutrition Conference & Expo; October 2019; Philadelphia, PA.

      or psychological grit to achieve deprivation
      • Lee J.E.
      • Namkoong K.
      • Jung Y.C.
      Impaired prefrontal cognitive control over interference by food images in binge-eating disorder and bulimia nervosa.
      reinforces the intrinsic reward mechanism for maintaining a state of malnutrition.
      • Healy-Stoffel M.
      • Levant B.
      N-3 (Omega-3) fatty acids: Effects on brain dopamine systems and potential role in the etiology and treatment of neuropsychiatric disorders.
      ,
      • Ma R.
      • Mikhail M.E.
      • Culbert K.M.
      • et al.
      Ovarian hormones and reward processes in palatable food intake and binge eating.
      Further investigation into dopamine receptor activation,
      • Dalenberg J.R.
      • Patel B.P.
      • Denis R.
      • et al.
      Short-term consumption of sucralose with, but not without, carbohydrate impairs neural and metabolic sensitivity to sugar in humans.
      behavioral strategies to support amygdala inhibition,
      • Donnelly B.
      • Touyz S.
      • Hay P.
      • Burton A.
      • Russell J.
      • Caterson I.
      Neuroimaging in bulimia nervosa and binge eating disorder: A systematic review.
      regulation of default mode networks,
      • Hibbeln J.R.
      • Northstone K.
      • Evans J.
      • Golding J.
      Vegetarian diets and depressive symptoms among men.
      and polyvagal theory
      • Porges S.W.
      The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation.
      supports best practices for theoretical and clinical treatment of ED.
      • Hilbert A.
      • Hoek H.W.
      • Schmidt R.
      Evidence-based clinical guidelines for eating disorders: International comparison.
      Full recovery from an ED is possible. The global burden of ED is 4½ times higher for females than males.
      • Erskine H.E.
      • Whiteford H.
      • Pike K.
      The global burden of eating disorders.
      ,
      • Ulfvebrand S.
      • Birgegård A.
      • Norring C.
      • et al.
      Psychiatric comorbidity in women and men with eating disorders: Results from a large clinical database.
      Treatment of an ED requires an interprofessional team that must include an RDN.
      American Dietetic Association
      Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and other eating disorders.
      • Yager J.
      • Devlin M.J.
      • Halmi K.A.
      • et al.
      Guideline Watch (2012): Practice Guideline for the Treatment of Patients with Eating Disorders. 3rd ed. American Psychiatric Association.
      • Yager J.
      • Devlin M.J.
      • Halmi K.A.
      • et al.
      Practice Guideline for the Treatment of Patients with Eating Disorders, 3rd ed. American Psychiatric Association.
      ED recovery encompasses all dimensions of health. Best practices include a treatment framework that embraces the whole person and includes nutrition, psychotherapy, medicine, movement, spirituality, and relational aspects of self. Early detection alongside consistent and comprehensive treatment aiming to reverse malnutrition is paramount. Addressing psychological schemas and nutrition-related educational deficits are also critical to the overall framework for recovery.
      As a holistic view of ED treatment becomes best practice, the evaluation of religious, spiritual and relational dimensions of recovery support are necessary. The development of self-compassion, forgiveness, and an acceptance of personal behavioral patterns entangled within ED pathology are essential for lasting recovery.
      • Akrawi D.
      • Bartrop R.
      • Potter U.
      • Touyz S.
      Religiosity, spirituality in relation to disordered eating and body image concerns: A systematic review.
      ,
      • Berrett M.E.
      • Hardman R.K.
      • O'Grady K.A.
      • Richards P.S.
      The role of spirituality in the treatment of trauma and eating disorders: Recommendations for clinical practice.
      A recent study revealed 16.8% of adolescents who fasted for religious purposes scored in the ED pathological range on the Eating Attitudes Test-26.
      • Düzçeker Y.
      • Akgul S.
      • Durmaz Y.
      • et al.
      Is Ramadan fasting correlated with disordered eating behaviours in adolescents?.
      Exploring underlying spiritual belief systems allows for the development of a purpose for engaging treatment beyond being a requirement. The spiritual aspect of treatment is not about religion, but rather a unification of self across all cultures and ethnicities for the common purpose of ED recovery.
      • King L.H.
      • Abernethy A.D.
      • Keiper C.
      • Craycraft A.
      Spirituality and eating disorder risk factors in African American women.
      Physical activity/movement is supportive of the ED recovery process. Figure 5

      Beasley T, Cook B. Exercise in Eating Disorder Treatment: Misconceptions, Evidence and Future Directions. Oral presentation at: Academy of Nutrition and Dietetics Food & Nutrition Conference & Expo; October 2019; Philadelphia, PA.

      presents an integrative framework for the inclusion of exercise in the treatment of ED.
      • Quesnel D.A.
      • Libben M.
      • Oelke N.D.
      • et al.
      Is abstinence really the best option? Exploring the role of exercise in the treatment and management of eating disorders.
      Transforming physical activity/movement from being used as a tool of self-destruction into a source of interpersonal restoration is beneficial for all clients. Exploring both medical and psychological motivations for movement offers the RDN opportunities to provide appropriate corrective nutrition education. There is great benefit to be gained from integrating physical activity/movement into the ED recovery process as clinically indicated.
      Figure thumbnail gr3
      Figure 5Unified Model of Exercise in Eating Disorders. (Adapted from Beasley T, Cook B; 2019,74 with permission. No part of this content may be reproduced or transmitted in any form or by any means without the express written consent of the authors, except as permitted by applicable law.)
      Performance athletes with symptoms consistent with an ED
      • Stanbert M.
      • Slager E.
      • Spital D.
      • Coia C.
      • Quatromoni P.A.
      Athlete-specific treatment for eating disorders: Initial findings from Walden GOALS Program.
      warrant further evaluation by a proficient-/expert-level ED RDN practitioner to create an integrative treatment plan
      • Quatromoni P.
      A tale of two runners: A case report of athletes’ experiences with eating disorders in college.
      in collaboration with a sports RDN
      • Valiant M.
      • Daigle K.
      • Subach J.
      Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sports and Human Performance Nutrition.
      and other members of the athlete’s performance team given an athlete’s unique physiological demands.
      • Thomas D.T.
      • Erdman K.A.
      • Burke L.M.
      Position of the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and athletic performance.
      The RDN’s aim is to promote an inclusive lens of treatment in conjunction with an increase in self-efficacy to treat individuals with ED using the available practice standards
      • Anderson Girard T.
      • Russell K.
      • Leyse-Wallace R.
      Academy of Nutrition and Dietetics: Revised 2018 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Mental Health and Addictions.
      • Davidson P.
      • Ross T.
      • Castor C.
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Diabetes Care.
      • Robinson G.E.
      • Cryst S.
      Academy of Nutrition and Dietetics: Revised 2018 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Post-Acute and Long-Term Care Nutrition.
      • Noland D.
      • Raj S.
      Academy of Nutrition and Dietetics: Revised 2019 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition in Integrative and Functional Medicine.
      and guidelines for the use of exercise in ED treatment.
      Each level of care (eg, inpatient, residential, partial hospitalization program, intensive outpatient program, and outpatient) for treatment of ED is designed to offer the appropriate intensity of nutrition, medical, and psychological support required to address underlying issues related to the manifestation of the ED. Assessment of standards of practice from international authorities and medical indices (eg, orthostatic blood pressure, bradycardia, tachycardia, laboratory values, and urine-specific gravity) that support evaluation of ED severity is a core responsibility of an RDN choosing to work with ED. Recognition of clinical symptoms, attitudes/food beliefs, and changes in personality features as a result of malnutrition offers support for early detection of ED.
      In 2013, the addition of BED and avoidant/restrictive food intake disorder (ARFID) to the Diagnostic and Statistical Manual of Mental Disorder, 5th edition,
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorder.
      expanded the scope of ED beyond the assumption that body mass or physical appearance was the primary indicator of an ED. The inaugural addition of BED and ARFID illustrates the diversity of clinical manifestation for the ED.
      • Bourne L.
      • Bryant-Waugh R.
      • Cook J.
      • Mandy W.
      Avoidant/restrictive food intake disorder: A systematic scoping review of the current literature.
      ,
      • Hay P.
      • Mitchison D.
      • Collado A.E.L.
      • et al.
      Burden and health-related quality of life of eating disorders, including Avoidant/Restrictive Food Intake Disorder (ARFID), in the Australian population.
      Lifetime prevalence of BED in the United States is 2.6%.
      • Guerdjikova A.I.
      • Mori N.
      • Casuto L.S.
      • McElroy S.L.
      Update on binge eating disorder.
      In contrast to other ED, the female to male ratio in BED is more balanced. However, symptoms of BED can be overlooked and dismissed due to gender bias.
      • Murakami J.M.
      • Essayli J.H.
      • Latner J.D.
      The relative stigmatization of eating disorders and obesity in males and females.
      In comparison, ARFID
      • Hay P.
      • Mitchison D.
      • Collado A.E.L.
      • et al.
      Burden and health-related quality of life of eating disorders, including Avoidant/Restrictive Food Intake Disorder (ARFID), in the Australian population.
      ,
      • Kohn J.B.
      What is ARFID?.
      was more commonly diagnosed in early-onset eating disorder (EOED) and had a longer duration of stay compared with patients with AN. ARFID can be overlooked and dismissed due to the absence of body dissatisfaction or desire to alter one’s body shape.
      Early recognition of ED symptomology supports long-term recovery. A behavioral exploration of each human’s relationship with food and body is the core of ED treatment. Exploring food belief systems, patterns of disinhibition, and nutrition misinformation are core topics of discussion by the RDN and client.
      • Linardon J.
      • Mitchell S.
      Rigid dietary control, flexible dietary control, and intuitive eating: Evidence for their differential relationship to disordered eating and body image concerns.
      The overlap between adverse childhood experiences
      • Guillaume S.
      • Jaussent I.
      • Maimou L.
      • et al.
      Associations between adverse childhood experiences and clinical characteristics of eating disorders.
      and ED demands developmental and pediatric feeding strategies
      • Lowe C.J.
      • Morton J.B.
      • Reichelt A.C.
      Adolescent obesity and dietary decision making-a brain-health perspective.
      to overcome somatically engrained traumatic experiences
      • Tasca G.A.
      Attachment and eating disorders: A research update.
      that interfere with adequate nutrition consumption. A recent study revealed the mean age of ED presentation was 13.9 years; the most common form presenting in children was AN followed by atypical AN.

      Chew CSE, Kelly S, Baeg A, Oh JY, Rajasegaran K, Davis C. First presentation of restrictive early onset eating disorders in Asian children. Int J Eat Disord. Published online August 26, 2020. https://doi.org/10.1002/eat.23274.

      Therefore, familiarity with and use of adult
      • Skipper A.
      • Coltman A.
      • Tomesko J.
      • et al.
      Position of the Academy of Nutrition and Dietetics: Malnutrition (Undernutrition) Screening Tools for All Adults.
      and pediatric malnutrition screening tools are critical for treatment of ED. It is the clinical responsibility of the RDN to judicially choose assessment measures to complete a comprehensive nutrition assessment, meanwhile, being mindful for the onset of negative symptoms indicative of psychological triggers.
      Trigger is a key term that must be understood to practice competently as an ED RDN.
      • Yaribeygi H.
      • Panahi Y.
      • Sahraei H.
      • Johnston T.P.
      • Sahebkar A.
      The impact of stress on body function: A review.
      A trigger is an antecedent that generates or provokes an ED behavior as a coping mechanism. Each ED client will have unique triggers that are specific to their underlying psychopathology. The nutrient composition of food, environmental variables such as location and smell, and dysfunctional relationships with people are common triggers. The ED RDN needs to explore and recognize these variables and refer the client to the appropriate interprofessional team member for resolution.
      Every RDN can benefit from understanding available treatment modalities for ED. Role Examples of how RDNs in various practice areas would use the SOP and SOPP in Eating Disorders to assess their competence and identify resources in ED is in Figure 6. As the emergent field of nutritional psychiatry continues to unfold,
      • Sarris J.
      • Logan A.C.
      • Akbaraly T.N.
      • et al.
      International Society for Nutritional Psychiatry Research consensus position statement: Nutritional medicine in modern psychiatry.
      the role of the RDN in ED treatment must also evolve. Understanding the differences within each level of competence is essential to develop a plan for continued professional growth. Ongoing education and clinical exploration of nutrition interventions for the management of psychiatric conditions is critical. Additional resources and references for ongoing learning are available in Figure 7.
      Figure 6Role Examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Eating Disorders.
      RoleExamples of use of SOP and 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 eating disorders nutrition care and services.
      For presentation examples and common signs and symptoms of eating disorders, refer to indicators in Standard 1 of Figure 1 and the article overview.
      Clinical practitioner (acute care or psychiatric hospital)A hospital-based RDN responsible for the medical and locked psychiatric units recognizes that some patients have symptoms of an eating disorder (ED). The medical and nutrition history provided insight into a patient’s eating-related behaviors and the duration of the psychopathology. The RDN reviews the SOP and SOPP in Eating Disorders to identify needed competence for recognizing the symptoms that suggest an eating disorder and to best support interprofessional collaboration for development of an appropriate plan of care.
      Clinical practitioner–ED residential treatment center (RTC)An RDN with the Certified Eating Disorders Registered Dietitian (CEDRD) certification employed by an RTC provides nutrition care to individuals with an ED who have chronically compromised medical and psychiatric status. The RDN recognizes the benefit of having an ongoing professional supervision relationship with a CEDRD-supervisor (CEDRD-S) for guidance and self-care. Review of the SOP and SOPP in Eating Disorders has helped identify areas for continuing education and for increased knowledge to benefit public policy advocacy. A career goal of this RDN is to pursue the distinction of qualifying for the CEDRD-S certification after practicing as a CEDRD for 7 years.
      Clinical practitioner–ED partial hospitalization program (PHP) or Intensive outpatient program (IOP)An experienced RDN employed by a PHP provides nutrition care to individuals diagnosed with an ED who require intensive behavioral and nutrition support in a structured and supervised setting. The RDN periodically reviews the SOP and SOPP in Eating Disorders and the identified resources with the goal of achieving the proficient-level performance indicators for quality and safe ED practice. A professional development goal of this RDN is to advance career and practitioner opportunities to ultimately qualify for the CEDRD certification.
      Private practice practitionerAn RDN in private practice, who provides services to children, teens, and/or adults, has learned that some clients are exhibiting ED behaviors and motivations. The RDN uses the SOP and SOPP in Eating Disorders and other resources for appropriate screening indicators and maintains a network of expert ED RDNs (eg, CEDRD/-S) for collaborating with physicians to facilitate referrals.
      Diabetes educator–inpatient or outpatient settingAn RDN diabetes educator refers to the SOP and SOPP in Eating Disorders and the SOP and SOPP in Diabetes Care for identifying and coordinating support for patients/clients with diabetes presenting with signs/symptoms of disordered eating. The RDN consults with the patient’s/client’s physician to develop a nutrition care plan, collaborates with consulting ED or mental health professional, and/or assists with referral to an ED professional or program experienced with treating individuals with diabetes.
      Fitness, health club, collegiate athletic departmentAn RDN, employed by a collegiate athletic department, encounters individuals with ED behaviors. The RDN refers to the SOP and SOPP in Eating Disorders and SOP and SOPP in Sports and Human Performance Nutrition (forthcoming 2021) for information and resources to inform screening questions for disordered eating and signs/symptoms of malnutrition related to inconsistent nutrition intake. The RDN follows department protocol for making a referral to the student health services’ RDN with ED experience or to an RDN, CEDRD as appropriate.
      ED nutrition program directorAn RDN, CEDRD nutrition program director refers to the SOP and SOPP in Eating Disorders for support tools when developing position descriptions, performance competencies, and expectations, and for RDN staff and interprofessional team training. The director also uses the SOP and SOPP in Eating Disorders and other focus areas as resources with RDN staff to coordinate supervision needs, guide self-evaluation, and plan professional development activities.
      Nutrition and dietetics faculty, preceptor, or researcherAn RDN faculty member preparing lecture materials and their own research uses the SOP and SOPP in Eating Disorders to integrate practical knowledge and skills to incorporate the required competencies for ED prevention and treatment in course syllabus, supervised practice activities, and research guidelines.
      a For each role, the RDN updates the professional development plan to include applicable essential practice competencies for eating disorders nutrition care and services.
      Figure 7Eating disorder resources (not all inclusive).
      ResourceAddressDescription
      Academy of Nutrition and Dietetics (Academy) Behavioral Health Nutrition Dietetic Practice Group (BHN DPG)https://www.bhndpg.org/This dietetic practice group encompasses more than 2,000 credentialed nutrition and dietetics practitioners, students, and interns who are passionate about 4 key areas of behavioral health nutrition practice: substance use disorders, eating disorders, intellectual and developmental disabilities, and mental health conditions. Members of BHN DPG receive no-cost training by global experts and access to both print and digital resources, such as the bi-annual newsletter, monthly updates, electronic mailing list, member forums, supervision/mentoring, webinars, and case studies.
      Academy’s Chronic Disease, Sports, Wellness and Behavioral Health websitehttps://www.eatrightpro.org/practice/practice-resources/chronic-disease-and-wellnessThis website offers resources related to chronic disease prevention, behavioral health, eating disorders, and sports nutrition.
      Academy’s Pocket Guide to Eating Disorders, 2nd editionhttps://www.eatrightstore.org/product-type/pocket-guides/academy-of-nutrition-and-dietetics-pocket-guide-to-eating-disorders-second-editionThis book, organized according to the nutrition care process, is a comprehensive guide that includes what the registered dietitian nutritionist (RDN) will need for nutrition assessment and intervention with an individual with an eating disorder. It includes sample PES
      PES = problem, etiology, and signs and symptoms.
      statements, the role of the RDN within the interprofessional team, Diagnostic and Statistical Manual of Mental Disorders, 5th edition
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorder.
      diagnostic criteria, guidelines for providing nutrition education, communication in difficult situations, and more.
      Academy’s Recognition and Treatment of Deficient Energy Intake Among Athleteshttps://www.eatrightstore.org/dpg-products/scan/scan-fact-sheets/recognition-treatment-of-deficient-energy-intake-among-athletesThis fact sheet is for RDNs who work with athletes with an eating disorder or relative energy deficiency in sport (RED-S). This fact sheet highlights RED-S resources, such as a diagram that uses a stoplight to represent athletes who are high risk, moderate risk, or low risk.
      Academy for Eating Disorders (AED)https://www.aedweb.org/homeThe AED is an organization dedicated to eating disorders research, education, treatment, and prevention. Their goal is to provide access to knowledge, research, and best practices for eating disorders. They provide key resources, such as A Guide to Medical Care, and the Nutrition Care Standards on the Treatment of Eating Disorders (forthcoming 2020) They also provide newsletters, journals, and fact sheets.
      Alliance for Eating Disorders Awarenesshttps://www.allianceforeatingdisorders.com/“The Alliance for Eating Disorders Awareness is a national non-profit organization dedicated to providing programs and activities aimed at outreach, education, early intervention, and advocacy for all eating disorders.”
      American Psychiatric Associationhttps://www.psychiatry.org/The American Psychiatric Association is an organization of psychiatrists who work to promote quality care for individuals with mental illness and promote psychiatric education and research. The American Psychiatric Association also provides information and resources on various disorders (eg, eating disorders). A key resource for eating disorders is the Diagnostic and Statistical Manual of Mental Disorder, 5th edition.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorder.
      American Psychological Associationwww.apa.orgThe American Psychological Association’s mission is to “advance the creation, communication and application of psychological knowledge to benefit society and improve people’s lives.” The American Psychological Association meets their mission by encouraging the development of psychology; promoting research and application of findings; and establishing standards of ethics, conduct, education and achievement.
      Australia & New Zealand Academy for Eating Disorders (ANZAED)https://www.anzaed.org.au/ANZAED is an organization that supports professionals in the field of eating disorders on issues related to prevention, treatment, and research. They provide access to guidelines such as Inpatient Services for Eating Disorders, Outpatient Services for Eating Disorders, The Role of Nutritional Management in Eating Disorders, and other member accessible resources.
      Eating Disorder Registered Dietitians and Professionals (EDRDpro)https://edrdpro.com/EDRDpro is an organization composed of a community of RDNs and other professionals in eating disorders. Member resources include articles, research, handouts, books, podcasts, and webinars in topics ranging from health at every size, family-based therapy, and the various eating disorders.
      International Association of Eating Disorders Professionals (iaedp) Foundationhttp://www.iaedp.com/The iaedp is an organization recognized for its education and training resources (eg, Eating Disorders Review) for health care practitioners who treat eating disorders. It established the certification process to promote standards within the field of eating disorders and offers the credentials Certified Eating Disorders Registered Dietitian (CEDRD) and the CEDRD-S (Supervision).
      International Federation of Eating Disorder Dietitians (IFEDD)http://www.eddietitians.com/IFEDD is an organization of RDNs and other professionals and IFEDD’s purpose is to support those who work with individuals with eating disorders. The IFEDD conducts eating disorder research, educates professionals and the public on eating disorders, and consults with eating disorder treatment facilities. IFEDD’s purpose is to improve quality of care of individuals with eating disorders by improving their access to eating disorder RDNs.
      Intuitive Eating: An Anti-Diet Revolutionary Approach, 4th editionTribole E, Resch E. Intuitive Eating: An Anti-Diet Revolutionary Approach. 4th ed. New York, NY: St. Martin’s Press; 2020.This book has information on rebuilding a healthy body image and making peace with food. It helps teach readers how to honor hunger and feel fullness, how to achieve a safe relationship with food, and how to follow the principles of intuitive eating among others.
      Journal of the Academy of Nutrition and Dietetics Eating Disorders Collectionhttps://jandonline.org/content/eatingdisordersThe Journal collection has various articles dedicated to eating disorder topics, such as orthorexia, athletes and eating disorders, adolescents and eating disorders, in addition to ethical considerations when nutrition and dietetics students have an active eating disorder.
      National Association of Anorexia Nervosa and Associated Disorders (ANAD)https://anad.org/ANAD is a nonprofit organization working to raise support, awareness, advocacy, and increase education and prevention of eating disorders. They provide resources, such as an ANAD Approach Guide, blog, online forums and support groups, and other resources in various eating disorders areas, such as body image and athletes.
      National Eating Disorders Association (NEDA)https://www.nationaleatingdisorders.org/NEDA is a nonprofit organization that supports individuals and families affected by eating disorders. NEDA has various programs and services such as an eating disorder screening tool, helpline, support groups, and research studies. They also host the National Eating Disorders Awareness week.
      Nutrition Counseling in the Treatment of Eating Disorders, 2nd editionHerrin M, Larkin M. Nutrition Counseling in the Treatment of Eating Disorders. 2nd ed. New York, NY: Routledge; 2013.This book highlights research-based approaches and clinically refined tools for managing food- and weight-related issues. It includes sections such as nutrition assessment guidelines, nutrition counseling interventions, and techniques for managing bingeing, purging, excessive exercise, and weight restoration.
      a PES = problem, etiology, and signs and symptoms.
      ED treatment must include the RDN at all phases of recovery. Throughout the treatment process, an RDN serves as a clinical advocate for the nutritional needs of clients. Developing clinical sustainability as an ED RDN demands maintenance of professional best practices (eg, professional clinical supervision, advanced training/certification, and daily self-care). Given the commonality of RDNs and nutrition and dietetics students to present with disordered eating patterns or ED
      • Houston C.A.
      • Bassler E.
      • St. Germain A.
      Ethical considerations when students experience an active eating disorder during their dietetics training.
      ,
      • Tremelling K.
      • Sandon L.
      • Vega G.L.
      • McAdams C.J.
      Orthorexia nervosa and eating disorder symptoms in registered dietitian nutritionists in the United States.
      during their career, introspective evaluation of the personal motivation to work with this population is recommended. An evaluation of transference and countertransference that arise during clinical treatment is essential for every RDN treating ED and limits the development of compassion fatigue.
      • Tehrani N.
      Compassion fatigue: Experiences in occupational health, human resources, counselling and police.
      As science advances, continued exploration into the role of nutrition on mental health,
      • Holscher H.D.
      Diet affects the gastrointestinal microbiota and health.
      ,
      • Adan R.A.H.
      • van der Beek E.M.
      • Buitelaar J.K.
      • et al.
      Nutritional psychiatry: Towards improving mental health by what you eat.
      psychobiotic neuroregulators,
      • Anderson S.C.
      • Cryan J.F.
      • Dinan T.G.
      The Psychobiotic Revolution: Mood, Food, and the New Science of the Gut-Brain Connection.
      and the gut microbiome
      • Dinan T.G.
      • Cryan J.F.
      Brain-gut-microbiota axis and mental health.
      • Glenny E.M.
      • Bulik-Sullivan E.C.
      • Tang Q.
      • Bulik C.M.
      • Carroll I.M.
      Eating disorders and the intestinal microbiota: Mechanisms of energy homeostasis and behavioral influence.
      • Kleiman S.C.
      • Watson H.J.
      • Bulik-Sullivan E.C.
      • et al.
      The intestinal microbiota in acute anorexia nervosa and during renourishment: Relationship to depression, anxiety, and eating disorder psychopathology.
      will offer the RDN new educational frameworks to provide medical nutrition therapy for treating ED through the lifespan.
      • Elran-Barak R.
      • Fitzsimmons-Craft E.E.
      • Benyamini Y.
      • et al.
      Anorexia nervosa, bulimia nervosa, and binge eating disorder in midlife and beyond.
      Best practices for ED include a culturally inclusive view of treatment, inclusion of physical activity/movement, and development of a personal spirituality. The call to action for every RDN is to use an assertive, evidence-based, and clinically relevant
      • Mitchell J.E.
      • Peterson C.B.
      Anorexia nervosa.
      approach to treatment for ED.

      Academy Revised 2020 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Eating Disorders

      An RDN can use the Academy Revised 2020 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Eating Disorders (see Figures 1 and 2, available at www.jandonline.org, and Figure 3) to:
      • identify the competencies needed to provide ED nutrition and dietetics care and services;
      • self-evaluate whether they have the appropriate knowledge, skills, and judgment to provide safe, effective, efficient, equitable, and quality ED care and services 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 ED nutrition and dietetics practice;
      • provide a foundation for public and professional accountability in ED nutrition and dietetics care and services;
      • support efforts for strategic planning, performance improvement, outcomes reporting, and assist management in the planning and communicating of ED nutrition and dietetics services and resources;
      • enhance professional identity and skill in communicating the nature of ED nutrition and dietetics care and services;
      • guide the development of ED nutrition and dietetics-related education and continuing education programs, job descriptions, practice guidelines, protocols, clinical 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 ED nutrition and dietetics, 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 ED is learning the principles that underpin this focus area and is developing knowledge, skills, judgment, and gaining experience for safe and effective ED 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 ED must accept the challenge of becoming familiar with the body of knowledge, required clinical judgment skills, practice guidelines, and available resources to support and ensure quality ED-related nutrition and dietetics practice.
      At the proficient level, an RDN has developed a more in-depth understanding of ED practice and is more skilled at adapting and applying evidence-based guidelines and best practices than at the competent level. This RDN is able to modify practice according to unique situations (eg, refusal of food by mouth, splitting between interprofessional team members by client, and management of safety concerns for client as a result of malnutrition). A proficient-level RDN in ED can actively engage with the interprofessional team (eg, physicians, psychologists, iaedp-Certified Eating Disorders Registered Nurse, iaedp-Certified Eating Disorders Creative Arts Therapist), work with complex diagnoses and comorbidities, conduct research, and mentor competent-level RDNs or students/interns.
      At the expert level, the RDN thinks critically about ED nutrition and dietetics, demonstrates a more intuitive understanding of the practice area, displays a range of highly developed clinical and technical skills, and formulates judgments acquired through a combination of education, experience, professional clinical supervision, and critical thinking. 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 experience of the ED RDNs in various disciplines and practice settings. Expert RDNs, with their extensive experience and ability to see the significance and meaning of ED nutrition and dietetics within a contextual whole, are fluid and flexible, and have considerable autonomy in practice. They not only develop and implement ED nutrition and dietetics services, they also manage, drive and direct clinical care; conduct and collaborate in research and advocacy; accept organization leadership roles; engage in scholarly work; guide interprofessional teams; and lead the advancement of ED nutrition and dietetics practice. Expert RDNs in ED also provide leadership to credentialed nutrition and dietetics practitioners through education, mentoring, research, and public policy advocacy. An expanded role reflective of an expert RDN in ED with the CEDRD is to pursue the next level of certification as an approved supervisor (CEDRD-S) through iaedp. This certification enables the RDN to provide professional supervision to RDNs working to qualify for the CEDRD.
      Indicators for the SOP and SOPP for RDNs in Eating Disorders are measurable action statements that illustrate how each standard can be applied in practice (Figures 1 SOP and 2 SOPP, available at www.jandonline.org). Within the SOP and SOPP for RDNs in Eating Disorders, an “X" in the competent column indicates that an RDN who is caring for patients/clients is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. A competent RDN in ED could be an RDN starting practice after registration or an experienced RDN who has recently assumed responsibility to provide ED nutrition care for clients.
      An “X" in the proficient column indicates that an RDN who performs at this level has a deeper understanding of ED care and services and has the ability to modify or guide therapy to meet the needs of patients/clients in various situations (eg, assessment of need for a higher level of care; and evaluation of the impact of malnutrition on psychopathology and client social eating experiences that create psychiatric distress).
      An “X" in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of ED and a highly developed range of skills and judgments acquired through a combination of experience, education, and professional clinical supervision. The expert RDN builds and maintains the highest level of knowledge, skills, and behaviors, including leadership, clinical supervision and mentorship, vision, and credentials.
      Standards and indicators presented in Figure 1 and 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 ED 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 SOP and SOPP for RDNs in Eating Disorders 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 SOP and SOPP in Eating Disorders 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, including guidance from professional clinical supervision, also enables RDNs in ED 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 ED as learning opportunities and to promote consistency in practice and performance and continuous quality improvement.
      In some instances, components of the SOP and SOPP for RDNs in Eating Disorders 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 SOP and SOPP indicators are refined with each review of these Standards as expert-level RDNs systematically record and document their experiences, often through use of exemplars. Exemplary actions of individual ED 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

      The SOP and SOPP for RDNs in Eating Disorders are innovative and dynamic documents. Future revisions will reflect changes and advances in practice, changes to dietetics education standards, regulatory changes, and outcomes of practice audits. Continued clarity and differentiation of the 3 practice levels in support of safe, effective, efficient, equitable, and quality practice in ED remains an expectation of each revision to serve tomorrow's practitioners and their patients, clients, and customers.
      Future revisions of ED standards will require ongoing integration of a multidimensional and interprofessional approach to treatment. Exploration of the interplay between the gut microbiome and neurochemical modulators of behavior,
      • Anderson S.C.
      • Cryan J.F.
      • Dinan T.G.
      The Psychobiotic Revolution: Mood, Food, and the New Science of the Gut-Brain Connection.
      investigation of chemical substrates being consumed through the food supply that modulate perception/expression of human behavior and an understanding of the biopsychosocial model used for the treatment of ED, which allows for inclusion of all people seeking recovery, are needed. RDNs at each level of competence are responsible for contributing to the advancement of the field of ED.

      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 SOP and SOPP for RDNs in Eating Disorders are complementary documents and are key resources for RDNs at all knowledge and performance levels. These standards can and should be used by RDNs in daily practice who provide care to individuals with ED to consistently improve and appropriately demonstrate competence and value as providers of safe, effective, efficient, equitable, and quality nutrition and dietetics care and services. These standards also serve as a professional resource for self-evaluation and professional development for RDNs specializing in ED 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 ED care and services, 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 the Behavioral Health Nutrition Dietetic Practice Group, 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 Jaimie Winkler, RD, LDN; Beth Harrell, MS, RD, LD, CEDRD-S; and Jillian Lampert, PhD, RD, LD, MPH, FAED, who willingly gave their time to review these standards, and to the Behavioral Health 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, Carol Gilmore, MS, RDN, LD, FADA, FAND; Dana Buelsing, MS, CAPM; Karen Hui, RDN, LDN; and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, who supported and facilitated the development of these SOP and SOPP.

      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 1Standards of Practice for Registered Dietitian Nutritionists (RDNs) in Eating Disorders. Note: The terms patient, client, customer, resident, individual, person, group, or population are used interchangeably with the actual term used in a given situation depending on the setting and the individual/population receiving care or services.
      Standards of Practice for Registered Dietitian Nutritionists in Eating Disorders

      Standard 1: Nutrition Assessment

      The registered dietitian nutritionist (RDN) uses accurate and relevant data and information to identify nutrition-related problems.

      Rationale:

      Nutrition screening is the preliminary step to identify individuals who require a nutrition assessment performed by an RDN. Nutrition assessment is a systematic process of obtaining and interpreting data in order to make decisions about the nature and cause of nutrition-related problems and provides the foundation for nutrition diagnosis. It is an ongoing, dynamic process that involves not only initial data collection, but also reassessment and analysis of patient/client or community needs. Nutrition assessment is conducted using validated tools based in evidence, the 5 domains of nutrition assessment, and comparative standards. Nutrition assessment may be performed via in-person or facility/practitioner assessment application or Health Insurance Portability and Accountability Act (HIPAA)–compliant video conferencing telehealth platform.
      Indicators for Standard 1: Nutrition Assessment
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Patient/client history: Assesses current and past information related to personal, medical, family, and psychosocial/social historyXXX
      1.1AEvaluates nutrition screening documentation and determines risk for malnutrition (eg, diet history, physical assessment data, belief systems around eating, and environmental barriers to adequate nutrition, including food security) using evidence-based screening tools for the setting and/or population (adult or pediatric)XXX
      1.1BAssesses development, onset, and history of eating disorder(s) (ED) and related factors (eg, food issues, weight history, physical activity, sport-specific activities, previous dieting methods)XXX
      1.1CAssesses developmental history (eg, birth weight, early feeding history, growth pattern, menstrual history in females, onset of puberty)XX
      1.1DAssesses medical and disease conditions common in individuals with an ED:
      • cardiovascular (eg, orthostasis, electrolyte imbalance, bradycardia)
      • gastrointestinal (GI) (eg, delayed gastric emptying, esophagitis, gastric dilation, irritable bowel syndrome, constipation)
      • renal (eg, dehydration, hypokalemia, refeeding syndrome)
      • pulmonary (eg, sleep apnea)
      • endocrine and related abnormalities (eg, osteopenia, hypoglycemia, diabetes, hypothyroidism, obesity, thermoregulation)
      • reproductive (eg, no/delayed menses, low testosterone)
      • immune (eg, slowed healing time)
      • oral pathology (eg, dental caries)
      • hematological (eg, anemia, pancytopenia)
      XX
      1.1EAssesses behavioral health and physical activity-related comorbidities commonly associated with ED:
      • for presence of mental illness (eg, depression, anxiety disorder, personality disorder), substance use disorder, and other addictions
      • relationship with physical activity (eg, including frequency, duration, compulsive behaviors and patterns, avoidance, compensatory motivations)
      XX
      1.1FAssesses family history in relation to disordered eating:
      • medical conditions (eg, including mental health conditions and substance use disorders)
      • eating and food history, including methods (eg, family meals, eating out)
      • body size and/or shape concerns, including genetic predispositions of body size and shape
      • other relevant health-related beliefs or practices, (eg, spirituality, religious fasting, fad diets, ethical or cultural dietary preferences)
      • access to and priority of health care, attitudes about mental health care
      XX
      1.2Anthropometric assessment: Assesses anthropometric indicators (eg, stature, body size, physical composition), comparison to age-specific reference data, individual patterns, and history completed at a time appropriate to patient’s/client’s physical and/or mental readinessXXX
      1.2AIdentifies and interprets trends in anthropometric indices taking into consideration cultural diversityXXX
      1.3Biochemical data, medical tests, and procedure assessment: Assesses laboratory profiles (eg, acid–base balance, renal function, endocrine function, inflammatory response, vitamin/mineral profile, lipid profile, hepatic enzymes), and diagnostic medical tests and proceduresXXX
      1.3AReviews consultation reports (eg, behavioral, psychosocial, dental, physical therapy/occupational therapy, physician) and applicable diagnostic surveys (eg, Eating Disorder Examination Questionnaire [EDE-Q], Binge Eating Scale [BES], Eating Disorder Diagnostic Scale [EDDS], Eating Attitudes Test [EAT], Body Shape Questionnaire [BSQ], Generalized Anxiety Disorder 7 [GAD-7])XX
      1.3BReviews relevant biochemical and physiological measures, including micronutrient imbalances, hydration status, neuroendocrine status, endocrine markers, genetic mutations, and other tests to determine stage of illness (eg, complex metabolic profile, thyroid function, urinalysis, blood urea nitrogen to creatinine ratio, hepatic and reproductive function)XX
      1.3CAssesses implications of the results of diagnostic tests on the therapeutic process (eg, indirect calorimetry measurements or energy needs estimated from appropriate calculation [resting metabolic rate], GI diagnostic tests, cardiac electrocardiogram, electroencephalogram, functional magnetic resonance imaging, and bone health [dual-energy x-ray absorptiometry (DEXA) scan] evaluations) in relation to EDXX
      1.3DAssesses need for additional tests (eg, food intolerance, food allergy, or malabsorption studies) or periodic diagnostic measurements (eg, electrolytes, orthostatic blood pressure, valid body weight [actual and accurate])XX
      1.4Nutrition-focused physical examination (NFPE) may include visual and physical examination: Obtains and assesses findings from NFPE (eg, indicators of vitamin/mineral deficiency/toxicity, edema, muscle wasting, subcutaneous fat loss, altered body composition, oral health, feeding ability [suck/swallow/breathe], appetite, and affect)XXX
      1.4APerforms NFPE (or selective components) at appropriate stage for the client’s physical and/or mental readiness consistent with training and experience with the ED population; seeks assistance from more experienced RDN if neededXXX
      1.4A1Conducts NFPE that includes, but is not limited to:
      • evaluate for evidence of oral, perioral, and skin-related abnormalities; notes client reports of alterations in taste, smell, and dentition/chewing ability; considers vital signs (blood pressure, temperature, and rate of respirations) as reported by others
      • clinical signs of malnutrition (undernutrition) (eg, dry, brittle, or thinning hair and nails, irritability, inability to concentrate)
      XXX
      1.4BEvaluates nutrition-related findings specific to eating disorders (eg, signs and symptoms of dehydration, lightheadedness, cold tolerance, fatigue, loss of concentration, acrocyanosis, insomnia, hair loss, dry skin)XX
      1.4CEvaluates more complex findings impacting nutrition status (eg, acrocyanosis, Russell’s signs, orthostatic changes, temperature shifts [as indicative of starvation-induced hyperactivity vs compulsive exercise], sialadenitis; and, when indicated, includes the “walk across the room” test
      • Guadiani J.L.
      Sick Enough: A Guide to the Medical Complications of Eating Disorders.
      used for determining difference in “athletic heart” vs “starved heart”)
      X
      1.5Food and nutrition-related history assessment (ie, dietary assessment)—

      Evaluates the following components:
      1.5AFood and nutrient intake, including composition and adequacy, meal and snack patterns, and appropriateness related to food allergies and intolerancesXXX
      1.5A1Evaluates pattern of food, beverage, energy, and nutrient intake, including timing, location, and frequency of meals and snacksXXX
      1.5A2Evaluates current and historical efforts to use specialized and structured diets (eg, low fat, low sodium, low carbohydrate/high protein, liquids only, vegan/vegetarian, macrobiotic, food category restriction)XXX
      1.5A3Integrates evaluation of food allergies and intolerances (clinical and/or self-diagnosed), clinical presentation, previous symptomologyXX
      1.5A4Evaluates nutrient imbalances related to avoidance, or excessive intake of certain foods or food groups as a means of manipulating or controlling weightXX
      1.5BFood and nutrient administration, including current and previous diets and diet prescriptions and food modifications, eating environment, and enteral and parenteral nutrition administrationXXX
      1.5B1Assesses compliance to previous nutrition prescription/intervention(s) (eg, previous type, frequency, and duration of ED treatment)XXX
      1.5B2Assesses physiological and biological needs and processes related to stage of nutrition rehabilitation or weight restoration (eg, hypermetabolism, hypometabolism, dehydration)XXX
      1.5B3Assesses nutritional philosophy, attitudes, and/or maladaptive feeding patternsXX
      1.5CMedication and dietary supplement use, including prescription and over-the-counter medications, and integrative and functional medicine productsXXX
      1.5C1Evaluates potential interactions between nutrients/nutritional status and prescribed and over-the-counter medications, illicit drugs, and caffeineXXX
      1.5C2Evaluates drug/nutrient/food and dietary supplement/herbal/food interactions (eg, St John’s wort, valerian root, kava kava, grapefruit juice); refer to database resources (eg, Natural Medicine Database: https://naturalmedicines.therapeuticresearch.com/)XXX
      1.5C3Evaluates current and past use of medications/dietary supplements/herbals for appropriate use or misuse including, but not limited to:
      • appropriate use and adherence (eg, calcium, digestive aides)
      • excessive use of fiber, caffeine, guarana, energy drinks, and/or green tea extract
      • used or needed for psychiatric or comorbid conditions (eg, depression, anxiety, diabetes, GI concerns)
      • misuse of laxatives, diuretics, insulin, ipecac
      • use relative to potential interactions and potential relationship to compensatory behaviors
      XX
      1.5C4Evaluates nutrition-related side effects of common behavioral health medications (eg, weight gain, fluid retention, dry mouth, excessive thirst, constipation, altered glucose and/or lipid metabolism, GI discomfort, anorexia, increased appetite)XX
      1.5DKnowledge, beliefs, and attitudes (eg, understanding of nutrition-related concepts, emotions about food/nutrition/health, body image, preoccupation with food and/or weight, readiness to change nutrition- or health-related behaviors, and activities and actions influencing achievement of nutrition-related goals, including the genesis of food and nutrition belief systems)XXX
      1.5D1Assesses client perceptions of previous nutrition interventionsXXX
      1.5D1iAssesses reported effectiveness of previous nutrition therapyXXX
      1.5D1iiAssesses readiness for change (eg, stages of change)XXX
      1.5D1iiiAssesses knowledge of nutrition and EDXX
      1.5D1ivAssesses knowledge of the long-term recovery process and impact of treatmentX
      1.5D2Evaluates food beliefs for impact on nutrition status and implications for the nutrition intervention for ED
      • distorted beliefs about food, nutrients or eating behavior (eg, exaggerated risk or value)
      • associations of foods, diet, or eating behaviors with self-judgment (eg, labeling food choices or self as “right,” “wrong,” “good,” or “bad”; superior self-control implies better “willpower”)
      • disgust or distrust related to food (eg, fear that foods are contaminated either intentionally or unintentionally)
      XX
      1.5EFood security defined as factors affecting access to a sufficient quantity of safe, healthful food and water, as well as food-/nutrition-related suppliesXXX
      1.5E1Assesses barriers to adequate food access (eg, economic, transportation, living situation, limited cooking proficiency combined with rigid food rules); reviews observations of health care professionals and family and social service reportsXXX
      1.5FPhysical activity, cognitive and physical ability to engage in developmentally appropriate nutrition-related tasks (eg, self-feeding and other activities of daily living [ADLs]), instrumental ADLs (eg, shopping, food preparation), and breastfeedingXXX
      1.5F1Assesses limitations based on comorbid psychiatric diagnosis(es) (eg, attention deficits, executive functioning, ability to plan, impulse control)XX
      1.5GOther factors affecting intake and nutrition and health status (eg, cultural, ethnic, religious, lifestyle influencers, psychosocial, and social determinants of health)XXX
      1.5G1Assesses developmental, functional, and mental status, and cultural, ethnic, and lifestyle factors using validated tools and observations of other interprofessional
      Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, psychiatrists, nurses, nurse practitioners, dietitian nutritionists, pharmacists, physician assistants, psychologists, licensed professional counselors, licensed marriage and family therapists, social workers, dentists, and occupational and physical therapists), depending on the needs of the client. Interprofessional could also mean interdisciplinary or multidisciplinary.
      team members
      XXX
      1.5G2Assesses access to medical care and interprofessional teamXXX
      1.5G3Assesses barriers (eg, co-existing conditions, learning style, lack of support, availability of treatment resources)XXX
      1.5G4Assesses for food- or eating-related ED behavior triggers (eg, specific foods or food situations, social eating)XX
      1.5G5Assesses for significant subjective emotional/physical stressors or traumatic experiences that impact ED behaviorsXX
      1.5G6Assesses for psychological or physiological triggers for ED behaviors; evaluates:
      • psychiatric and addiction history
      • trauma history (eg, self-injury, accident/injury)
      • personality traits (eg, impulsivity, perfectionism, anxiety, level of distress tolerance)
      • interoceptive (stimuli arising within the body, especially the viscera) awareness: ability to recognize and discriminate between physiological states (eg, hunger, fatigue) and emotions, and appropriately self-regulate
      • body image dissatisfaction/distortion
      • self-esteem (eg, negative self-talk, self-criticism)
      • stress management/coping skills
      • maturity fears (eg, issues related to breast development, sexual attractiveness)
      • sense of personal effectiveness or adequacy
      X
      1.5G7Identifies client’s interpersonal boundaries and psychological defense mechanisms manifested through food behaviors that are preventing progress and collaborates with interprofessional treatment team for additional support as neededX
      1.5HAssesses resources for affecting change (eg, financial, emotional, coping skills) over course of treatmentXX
      1.5IEvaluates interpersonal social precipitants and stressorsXX
      1.5I1Evaluates:
      • social eating insecurity
      • social support system (eg, family, friends, school, or workplace)
      XX
      1.5I2Evaluates:
      • sense of social inadequacy
      • interpersonal distrust of others (eg, belief that family members sabotage attempts to self-regulate food and weight)
      • trauma (eg, sexual, psychological, or physical abuse; divorce, loss, or change in relationship)
      • interpersonal sensitivity (eg, accurate and/or appropriate perception, evaluation, and response to others, anxiety about being understood)
      X
      1.5JEvaluates food and body-related rituals before, during, and after mealsXX
      1.5J1Systematic eating patterns that may be associated with ED or a comorbid condition, including but not limited to:
      • behaviors to manipulate energy intake (eg, spreading out fat/sauces/cheese to appear if they had been eaten, hiding food, chewing and spitting)
      • behaviors to dilute/suppress appetite (eg, excessive intake of fluids with meals, excessive intake of water/caffeinated beverages, and artificial sweeteners)
      • behaviors indicative of aversions (eg, limiting foods based on color, temperature, food group, or characteristics)
      • behaviors that make socializing difficult (eg, excessive cutting, mixing, or separating foods; comparing intake with others; eating in solitude)
      • behaviors indicative of obsessive-compulsive thinking (eg, eating with rigid order, timing, or counting)
      XX
      1.5J2Obsessive tracking of food intake and/or physical activityXX
      1.5J3Systematic purging system and/or efforts to conceal purgingXX
      1.5J4Body checking (eg, reflection/mirror checking, body pinching, compulsively checking body weight or fit of clothing)XX
      1.5KEvaluates use of compensatory behaviors, including exercise, vomiting, colonic cleanses, diuretic use, laxative use, diet pills use, and/or insulin adjustmentsXX
      1.6Comparative standards: Uses reference data and standards to estimate nutrient needs and recommended body weight, body mass index (BMI), and desired growth patternsXXX
      1.6AIdentifies the most appropriate reference data and/or standards (eg, international, national, state, institutional, and regulatory) based on practice setting and patient-/client-specific factors (eg, age and disease state)XXX
      1.6BUses anthropometric measurement standards (eg, BMI, growth charts)XXX
      1.6CUses data from client health history (eg, healthy weight history before ED, family health history, weight at menses)XXX
      1.6DUses evidence-based sources and scientific reports for ongoing refinement of “best practice” treatment guidelinesXXX
      1.6EEvaluates epidemiological studies, identifying prevalence of ED as it applies to health and disease conditions for nutrition-related consequencesXXX
      1.6FCompares laboratory findings (eg, heart rate, blood pressure, hydration status, electrolytes) to clinical standards in relation to current diagnosisXX
      1.6GReferences emerging data from clinical observations and research specific to ED that supports incorporating nutrition assessment throughout treatmentXX
      1.6HIdentifies limitations of evidence-based guidelines in personalizing the nutrition assessment to an individual with ED’s needsX
      1.7Physical activity habits and restrictions: Assesses physical activity, history of physical activity, and physical activity trainingXXX
      1.7AEvaluates energy expenditure from conscious movement patterns and physical activity (past and current), including length of time, intensity, compulsivity, sleep patterns, ADLs, and starvation-induced hyperactivity, such as fidgetingXXX
      1.7BAssesses use of self-monitoring behaviors—benefits vs risks (eg, health app, energy expenditure)XXX
      1.7CEvaluates history of physical activity or exercise dependence and adherence to interprofessional team recommendationsXX
      1.7DEvaluates resistance to engaging in physical activity, including physical and emotional barriersXX
      1.8Collects data and reviews data collected and/or documented by the nutrition and dietetics technician, registered (NDTR), other health care practitioner(s), patient/client, or staff for factors that affect nutrition and health statusXXX
      1.8AObtains and integrates data from members of the interprofessional treatment teamXXX
      1.9Uses collected data to identify possible problem areas for determining nutrition diagnosesXXX
      1.9ARecognizes role of client’s ability and perception to grasp magnitude and severity of their conditionXXX
      1.9A1Understands limitations (eg, under- or over-reporting by client of thoughts, feelings, and behaviors)XX
      1.9A2Understands that interrelatedness of eating behaviors, cognitions, and psychopathology contribute to changing nutritional statusXX
      1.9BEvaluates actual or risk of developing acute complications of ED (eg, refeeding syndrome, metabolic, cardiovascular, renal, hormonal, GI, neurologic, or psychiatric)XX
      1.9CEvaluates actual or risk of developing chronic complications of ED (eg, cardiovascular, dental, endocrine, stress fractures/poor bone health, growth retardation and delayed puberty, menstrual dysfunction, infertility, sleep apnea, or metabolic syndrome)XX
      1.9DEvaluates actual or risk of complications related to co-existing biopsychosocial factors (eg, psychiatric condition, intellectual/ developmental disability, status post bariatric surgery, pregnancy, lactation, disease states, exercise dependence, involvement in athletics, or career with implicit expectations regarding body size or shape)X
      1.10Documents and communicates:XXX
      1.10ADate and time of assessmentXXX
      1.10BPertinent data (eg, medical, social, behavioral)XXX
      1.10CComparison to appropriate standardsXXX
      1.10DPatient/client/population perceptions, values, and motivation related to presenting problemsXXX
      1.10EChanges in patient/client/population perceptions, values, and motivation related to presenting problemsXXX
      1.10FReason for discharge/discontinuation or referral, if appropriateXXX
      Examples of Outcomes for Standard 1: Nutrition Assessment
      • Appropriate screening and assessment tools and procedures are used in valid and reliable ways
      • Appropriate and pertinent data are collected
      • Effective interviewing methods are used
      • Data are organized and in a meaningful framework that relates to nutrition problems
      • Use of assessment data leads to the determination that a nutrition diagnosis/problem does or does not exist
      • Problems that require consultation with, or referral to, another provider are recognized
      • Documentation and communication of assessment are complete, relevant, accurate, and timely
      Standard 2: Nutrition Diagnosis

      The registered dietitian nutritionist (RDN) identifies and labels specific nutrition problem(s)/diagnosis(es) that the RDN is responsible for treating.

      Rationale:

      Analysis of the assessment data leads to identification of nutrition problems and a nutrition diagnosis(es), if present. The nutrition diagnosis(es) is the basis for determining outcome goals, selecting appropriate interventions, and monitoring progress. Diagnosing nutrition problems is the responsibility of the RDN.
      Indicators for Standard 2: Nutrition Diagnosis
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Diagnoses nutrition problems based on evaluation of assessment data and identifies supporting concepts (ie, etiology, signs, and symptoms)XXX
      2.1AOrganizes and groups data consisting of physical, clinical, psychosocial, behavioral-environmental, and nutrition assessment findings to determine nutrition diagnosis(es) (eg, significant and adequate information for drawing conclusions)XXX
      2.1BEvaluates findings systematically using critical thinking, and experience with the population when formulating the nutrition diagnosis; consults with interprofessional team as neededXXX
      2.1CDemonstrates understanding of psychiatric (ie, Diagnostic and Statistical Manual of Mental Disorders, 5th edition for ED) and medical diagnostic criteria (eg, amenorrhea, orthostatic hypotension, tachycardia, mania, and acute psychosis)XX
      2.1DIntegrates complex information related to food intake, biochemical data, diagnostic tests, clinical complications, and their management within an interprofessional environment or need for consultation with other providers when formulating a nutrition diagnosis(es)X
      2.2Prioritizes the nutrition problem(s)/diagnosis(es) based on severity, safety, patient/client needs and preferences, ethical considerations, likelihood that nutrition intervention/plan of care will influence the problem, discharge/transitions of care needs, and patient/client/advocate
      Advocate: An advocate is a person who provides support and/or represents the rights and interests at the request of the patient/client. The person may be a family member or an individual not related to the patient/client who is asked to support the patient/client with activities of daily living or is legally designated to act on behalf of the patient/client, particularly when the patient/client has lost decision making capacity. (Adapted with permission The Joint Commission’s Glossary of Terms13 and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation6,7).
      perception of importance
      XXX
      2.2AEvaluates assessment data to prioritize nutrition problems/diagnosis(es) considering:
      • impact/urgency of the identified problems (eg, risk for refeeding syndrome with hypoglycemia, hypokalemia, and hypophosphatemia; orthostatic blood pressure changes; and/or excessive and pitting edema)
      • presence of beliefs or behaviors that will hamper developing or following through with agreed upon nutrition plan of care
      Seeks assistance if needed from team members or a more experienced RDN
      XXX
      2.2BRecognizes limitations affecting best practices among ED professionalsXX
      2.2B1Recognizes lack of consensus among ED professionals (eg, philosophies around treatment approaches and interventions)XX
      2.2B2Recognizes that working within an interprofessional team and setting priorities for treatment requires the ability to communicate relevant concerns using ED-specific terminologyXX
      2.2CConsults with family/support system and interprofessional treatment team when evaluating nutrition diagnoses for recovery care planXX
      2.2DUses critical thinking, experience, and judgment when considering the complex nature of ED behaviors and possibility of comorbid conditions when ranking diagnoses in order of importance and urgency for the clientX
      2.2EUses advanced reasoning and judgment that reflects recognizing the broad array of co-existing neuroendocrine and/or personality disorders seen in ED behaviors when ranking nutrition diagnoses in order of importanceX
      2.3Communicates the nutrition diagnosis(es) to patients/clients/advocates, community, family members, or other health care professionals when possible and appropriateXXX
      2.3AUses the most appropriate communication method (eg, written, oral, low literacy) to share informationXXX
      2.3BEngages in ongoing communication and education with members of the interprofessional team and any other health care professionals involved in client assessment for ED and physical activity behaviorsXXX
      2.3CExplains identified nutrition diagnosis(es) to the client/family/caregiver using appropriate communication methods, timing, and techniquesXXX
      2.4Documents the nutrition diagnosis(es) using standardized terminology and clear, concise written statement(s) (eg, using Problem [P], Etiology [E], and Signs and Symptoms [S] [PES statements] or Assessment [A], Diagnosis [D], Intervention [I], Monitoring [M], and Evaluation [E] [ADIME statements])XXX
      2.5Re-evaluates and revises nutrition diagnosis(es) when additional assessment data become availableXXX
      2.5AUses most current information that may impact nutrition diagnosis(s), revises if needed, and communicates change to interprofessional team, client/family/caregiver as appropriate in a timely mannerXXX
      Examples of Outcomes for Standard 2: Nutrition Diagnosis
      • Nutrition diagnostic statements that accurately describe the nutrition problem of the client and/or community in a clear and concise way
      • Documentation of nutrition diagnosis(es) is relevant, accurate, and timely
      • Documentation of nutrition diagnosis(es) is revised as additional assessment data become available
      Standard 3: Nutrition Intervention/Plan of Care

      The registered dietitian nutritionist (RDN) identifies and implements appropriate, person-centered interventions designed to address nutrition-related problems, behaviors, risk factors, environmental conditions, or aspects of health status for an individual, target group, or the community at large.

      Rationale:

      Nutrition intervention consists of 2 interrelated components—planning and implementation.
      • Planning involves prioritizing the nutrition diagnoses; conferring with the patient/client and others; reviewing practice guidelines, protocols, and policies; setting goals; and defining the specific nutrition intervention strategy.
      • Implementation is the action phase that includes carrying out and communicating the intervention/plan of care, continuing data collection, and revising the nutrition intervention/plan of care strategy, as warranted based on change in condition and/or the patient/client/population response.
      An RDN implements the interventions or assigns components of the nutrition intervention/plan of care to professional, technical, and support staff in accordance with knowledge/skills/judgment, applicable laws and regulations, and organization policies. The RDN collaborates with or refers to other health care professionals and resources. The nutrition intervention/plan of care is ultimately the responsibility of the RDN.
      Indicators for Standard 3: Nutrition Intervention/Plan of Care
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      Plans the nutrition intervention/plan of care:
      3.1Addresses the nutrition diagnosis(es) by determining and prioritizing appropriate interventions for the plan of careXXX
      3.1AEvaluates readiness for change upon initiation of treatment and throughout processXXX
      3.1BIdentifies available resources and clinical support team for recovery processXX
      3.1CRecognizes mental health concerns (eg, safety and psychiatric status) and co-occurring maladaptive behaviorsXX
      3.1DPrioritizes assessment measures and hierarchy of interventions for medical conditions based upon severity of condition at initiation of treatmentX
      3.1EIdentifies the impact of personality traits (eg, obsessive compulsive tendencies, perfectionism, borderline personality traits) throughout the treatment processX
      3.2Bases intervention/plan of care on best available research/evidence and information, evidence-based guidelines, and best practicesXXX
      3.2AConsults nationally developed adult and pediatric evidence-based practice guidelines and position papers (eg, Academy of Nutrition and Dietetics [Academy] position and practice papers, Academy Evidence Analysis Library, and Adult and Pediatric Nutrition Care Manuals) for guidelines for control or improvement of the disease or conditions as defined and supported in the literatureXXX
      3.2BContributes to the development of clinical guidelines and up-to-date intervention toolsXX
      3.2CMonitors and critically evaluates progress of intervention and recognizes when it is appropriate to deviate from established guidelinesXX
      3.3Refers to policies and procedures, protocols, and program standardsXXX
      3.3AAdheres to departmental/organizational program policies, procedures, guidelines, and protocols related to behavioral health and nutritionXXX
      3.4Collaborates with patient/client/advocate/population, caregivers, interprofessional team, and other health care professionalsXXX
      3.4ACommunicates with support team while maintaining appropriate confidentiality and HIPAA guidelinesXXX
      3.4BIdentifies essential and relevant interprofessional team membersXX
      3.4CEngages and educates support team to optimize the maximum positive influence towards recovery of clientX
      3.5Determines motivation and commitment to change throughout the course of treatmentXXX
      3.5AAsks open-ended questions and listens to responsesXXX
      3.5BExpresses empathy, develops clarity between personal and professional boundaries, acknowledges resistance, and supports self-efficacyXXX
      3.5CAffirms, reflects, and elicits discussion of recovery-oriented changeXX
      3.5DSupports motivation to change elicited from the client when motivation is recovery-oriented (eg, weight-neutral goals vs weight suppression or weight loss goals)XX
      3.5EProvides the client with information regarding the course of illness and recovery reflecting the complex nature of EDX
      3.6Works with patient/client/advocate/population and caregivers to identify goals, preferences, discharge/transitions of care needs, plan of care, and expected outcomesXXX
      3.6AAddresses client concerns related to physical change, food selection, and body shape using an appropriate, recovery-oriented framework (eg, general healthy eating principles, liberalizing food selections, weight-neutral, or health at every size approaches)XXX
      3.6BEstablishes measurable and realistic behavior goals and expected outcomesXXX
      3.6CIdentifies potential barriers to successful implementation of plan (eg, continued focus on weight loss or weight suppression, client compliance, food availability and preparation issues, social support, readiness to change)XX
      3.6DDevelops and uses nonverbal attending skills, verbal leading skills, active listening, and appropriate use of self-disclosure and/or self-involvement in counselingXX
      3.6EReviews philosophical approaches and treatment in relation to individual goals, resources, knowledge, skills, ability to change or take risks; prioritizes optionsX
      3.6FAnticipates and addresses possible lapses in recovery, and identifies strategies to prevent lapses and/or re-establish recovery-oriented behaviors following lapsesX
      3.7Develops the nutrition prescription and establishes measurable patient-/client-focused goals to be accomplishedXXX
      3.7ATailors nutrition prescription by taking into consideration factors affecting nutrition status (eg, health risks associated with overweight and obesity, addictions, and comorbidities, such as intellectual and developmental disabilities and living situation)XXX
      3.7BConsiders the following when developing a nutrition prescription:
      • physiological consequences of ED (eg, dental erosion, osteoporosis, esophageal erosion/tears/bleeding, delayed growth and sexual development, hair loss, muscle atrophy, dermatitis, mental confusion, reduced hormone production, bradycardia, cardiac arrest, dehydration, hypotension, weakness, and hypothermia)
      • need for alternative feeding methods or dining setting; rehabilitation evaluation/treatment to ensure adequate social support
      XXX
      3.7CIdentifies interventions based on individual needs, goals, and resources; selects appropriate education and behavior change toolsXXX
      3.7D
      • Considers the following when developing a nutrition prescription:
      • realistic weight goals considering the impact of any skeletal abnormalities, psychiatric medications, actual or potential for physical activity, behaviors unique to the client
      • psychological consequences of ED (eg, depression, substance use disorder, self-harm)
      • environmental/cultural/media literacy factors influencing ED
      XX
      3.7EConsiders severity of nutritional issues, and/or pending medical and/or behavioral/psychiatric interventions that are influenced by or may influence nutrition statusXX
      3.7FUses critical thinking and synthesis skills to guide decision-making in complicated, unpredictable, and dynamic situationsXX
      3.7GConsiders emerging/alternative treatment strategies (eg, for severe and enduring eating disorders) that are supported by scientific evidence (evidence-based research, guidelines, and information)X
      3.8Defines time and frequency of care, including intensity, duration, and follow-upXXX
      3.9Uses standardized terminology for describing interventionsXXX
      3.10Identifies resources and referrals neededXXX
      3.10AEstablishes and maintains a directory of various resources based on client population intervention needsXXX
      3.10BCoordinates referral(s) for other services and uses interprofessional networksXX
      3.10CResearches, recommends, and coordinates, as appropriate, referral to appropriate or best available higher level of care (eg, treatment program/facility)XX
      Implements the Nutrition Intervention/Plan of Care:
      3.11Collaborates with colleagues, interprofessional team, and other health care professionalsXXX
      3.11AParticipates in communications within the interprofessional teamXXX
      3.11BCollaborates for guidance or assistance or refers to other members of the interprofessional team when need is outside scope of practice or experience of RDN (eg, psychiatrist, social worker, occupational therapist, speech therapist, RDN with expertise in ED)XXX
      3.11CFacilitates and fosters active communication, learning, partnerships, and collaboration within the interprofessional team and other providers as appropriateXX
      3.11DLeads or directs the interprofessional team and others as appropriateX
      3.11EIdentifies and seeks out opportunities for interprofessional and interagency collaboration, specific to the client’s needsX
      3.12Communicates and coordinates the nutrition intervention/plan of careXXX
      3.12ADocuments ongoing care and progress for short- and long-term interventions and communicates to team and others as appropriateXXX
      3.12BEnsures communication of nutrition plan of care with team members and others as appropriate; and transfer of nutrition-related data between care settings as neededXXX
      3.12CInitiates behavioral contract between client and team members to support nutrition-related treatment goalsXX
      3.12DCoordinates care for the client with multiple diagnoses or repeat admissions with other members of the interprofessional team (eg, physician, psychiatrist, psychologist, social workers, behavioral therapist)X
      3.13Initiates the nutrition intervention/plan of careXXX
      3.13AUses approved clinical privileges, 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.6,7 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.9,10
      –driven orders (ie, delegated orders), protocols, or other facility-specific processes for order writing or for provision of nutrition-related services consistent with applicable specialized training, competence, medical staff, and/or organizational policy
      XXX
      3.13A1Implements, initiates, or modifies orders for therapeutic diet/meal plan orders as authorized by institution/treatment facility, nutrition-related pharmacotherapy management, or nutrition-related services (eg, medical foods/nutrition/dietary supplements, food texture modifications, enteral and parenteral nutrition, intravenous fluid infusions, laboratory tests, medications, and education and counseling)XXX
      3.13A1iProvides education and counseling on the use of prescribed or recommended over-the-counter medications or dietary supplements for safety, to minimize interactions with prescribed medications and treatmentsXX
      3.13A2Manages nutrition support therapies (eg, formula selection, rate adjustments, addition of designated medications and vitamin/mineral supplements to parenteral nutrition solutions or supplemental water for enteral nutrition)XXX
      3.13A2iConsistent with privileging or physician delegated orders, if applicable, or organization/program guidelines and regulations; manages or oversees care for clients receiving enteral or parenteral nutrition in collaboration with physician or interprofessional team; seeks assistance, if neededXXX
      3.13A3Initiates and performs nutrition-related services (eg, bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, and indirect calorimetry measurements, or other permitted services)XXX
      3.13BConsiders client learning style, culture, and method of communication when selecting or combining intervention approaches and adapting general nutrition education toolsXXX
      3.13CUses appropriate therapeutic and behavior change theories (eg, states of change, motivational interviewing, behavior modification, modeling) to prioritize health, safety, and appropriate level of care to support client success using a treatment team approachXXX
      3.13DTailors nutrition intervention to developmental life stage of the client and makes changes to the intervention as appropriate (eg, during puberty, pregnancy, aging)XXX
      3.13EUses tools for nutrition education that are appropriate to the client’s (and/or family’s) educational needs, learning style, culture, and method of communication; uses interpersonal teaching, training, coaching, counseling, or technological approaches as appropriateXXX
      3.13FUses higher level of therapeutic modalities (eg, psychoeducation, advanced interviewing skills, cognitive behavior therapy, acceptance commitment therapy, modeling) to promote behavior change and empower the client to make necessary/required progress in an appropriate/reasonable time frameXX
      3.13GAnticipates, identifies, and effectively addresses client’s psychological barriers to making progress (eg, ambivalence, resistance, and defiance)XX
      3.13GiAnticipates and recognizes psychological issues and works with the treatment team to make changes to the intervention as appropriateX
      3.13HAnticipates risks related to the influence of ED behaviors on others, competition, self-disclosure, and establishes professional boundaries accordinglyXX
      3.13IUses synthesis skills for combining multiple intervention approaches as appropriateX
      3.13JDraws on professional experiential knowledge and current body of scientific evidence about the client population to individualize the strategy for complex interventionsX
      3.14Assigns activities to NDTR and other professional, technical, and support personnel in accordance with qualifications, organizational policies/protocols, and applicable laws and regulationsXXX
      3.14ASupervises professional, technical, and support personnelXXX
      3.14BProvides professional, technical, and support personnel with information and guidance needed to complete assigned activitiesXXX
      3.15Continues data collectionXXX
      3.15ACollaborates with interprofessional team in the collection of pertinent data, including changes in food and fluid intakes, laboratory values, skin conditions, body weight, and advanced directivesXXX
      3.15BReassesses client nutrition intake and eating behaviors in relation to current physiological needs and requirementsXXX
      3.15CUses measurable, standardized indicators based on goals and outcomes and documents using prescribed/standardized format for recording dataXXX
      3.15DReassesses client’s nutritional intake, eating behaviors, and exercise dependence (eg, flexibility, anxiety level, recognition, and response to hunger and satiety cues) in relation to current and future physiological needs/requirementsXX
      3.15ELeads and directs in collecting empirical evidence toward further understanding and promotion of recovery, including effectiveness and acceptance of treatment(s)X
      3.16Documents:
      3.16ADate and timeXXX
      3.16BSpecific and measurable treatment goals and expected outcomesXXX
      3.16CRecommended interventionsXXX
      3.16DPatient/client/advocate/caregiver/community receptivenessXXX
      3.16EReferrals made and resources usedXXX
      3.16FPatient/client/advocate/caregiver/community comprehensionXXX
      3.16GBarriers to changeXXX
      3.16G1Influencing factors or barriers affecting ability and/or willingness to implement and adhere to nutrition care plan (eg, living environment, psychosocial factors, emotional intelligence, cognitive impairment, change in mental or physical ability, financial status)XXX
      3.16HOther information relevant to providing care and monitoring progress over timeXXX
      3.16IPlans for follow-up and frequency of careXXX
      3.16JRationale for discharge or referral if applicableXXX
      Examples of Outcomes for Standard 3: Nutrition Intervention/Plan of Care
      • Goals and expected outcomes are appropriate and prioritized
      • Client/advocate/population, caregivers, and interprofessional team collaborate and are involved in developing nutrition intervention/plan of care
      • Appropriate individualized client-centered nutrition intervention/plan of care, including nutrition prescription and individualized education and recommendations regarding weight, is developed
      • Nutrition intervention/plan of care is delivered, and actions are carried out as intended
      • Discharge planning/transitions of care needs are identified and addressed
      • Documentation of nutrition intervention/plan of care is:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and timed
      Standard 4: Nutrition Monitoring and Evaluation

      The registered dietitian nutritionist (RDN) monitors and evaluates indicators and outcomes data directly related to the nutrition diagnosis, goals, preferences, and intervention strategies to determine the progress made in achieving desired results of nutrition care and whether planned interventions should be continued or revised.

      Rationale:

      Nutrition monitoring and evaluation are essential components of an outcomes management system in order to assure quality, patient-/client-/population-centered care and to promote uniformity within the profession in evaluating the efficacy of nutrition interventions. Through monitoring and evaluation, the RDN identifies important measures of change or patient/client/population outcomes relevant to the nutrition diagnosis and nutrition intervention/plan of care; describes how best to measure these outcomes; and intervenes when intervention/plan of care requires revision.
      Indicators for Standard 4: Nutrition Monitoring and Evaluation
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Monitors progress:XXX
      4.1AAssesses patient/client/advocate/population understanding and compliance with nutrition intervention/plan of careXXX
      4.1A1Documents progress in meeting energy, fluid, and nutrient intake needsXXX
      4.1A2Verifies client’s understanding of nutrition intervention by having the client/family/caregiver verbalize and/or demonstrate understandingXXX
      4.1A3Assesses compliance considering stage of recovery and client’s goals and objectivesXXX
      4.1A4Determines whether barriers to understanding are present and impacting the client’s/family’s/caregiver’s compliance with the nutrition intervention/plan of careXX
      4.1A5Reassesses client’s stage of behavior change and learning style to evaluate need to revise nutrition interventionXX
      4.1BDetermines whether the nutrition intervention/plan of care is being implemented as prescribedXXX
      4.1B1Assesses GI toleranceXXX
      4.1B2Communicates and collaborates with members of the interprofessional team and/or others to verify progress and share observations and concernsXXX
      4.1B3Evaluates intervention plan implementation in conjunction with team members, including family, if applicable, regarding client’s prescribed goals and objectives (eg, parents’ or support systems’ report whether food intake improves)XXX
      4.1B4Evaluates intervention plan implementation considering special situations (eg, holidays, moving, relationship change)XXX
      4.1B5Assesses progress in adjusting beliefs related to food to support recoveryXXX
      4.1B6Assesses progress in adjusting beliefs related to body image/body experienceXX
      4.1B7Assesses advancement in social and interpersonal skills through observation and interactionsXX
      4.1B8Facilitates interprofessional team communication of nutrition status, current barriers to treatment, and behavioral strategies that enhance compliance with meal planXX
      4.1B9Collaborates with the interprofessional team to tailor tools and methods based on emerging information/client response to ensure desired outcomesXX
      4.1B10Uses advanced expertise to identify additional resources and/or avenues of therapy to enhance effectiveness of interventionX
      4.2Measures outcomes:XXX
      4.2ASelects the standardized nutrition care measurable outcome indicator(s)XXX
      Considers:
      4.2A1Anthropometric measures (eg, weight, body mass/BMI, body composition, rate of weight change, bone density)XXX
      4.2A2Laboratory measures (eg, electrolytes, ferritin)XXX
      4.2A3Behavioral measures (eg, activity level, cognitive functioning, food selection/choice, purging, food rituals)XXX
      4.2A4Quality of life measures (eg, social eating, level of obsessiveness)XX
      4.2A5Treatment outcomes (eg, possible barriers, mood and cognitive function changes, treatment delays, signs of relapse) and need for more advanced/involved treatment optionsX
      4.2BIdentifies positive or negative outcomes, including impact on potential needs for discharge/transitions of careXXX
      4.2B1Collaborates with treatment team to assess impact of treatment history specifically related to frequency and effectiveness of prior admissions to higher level of careXXX
      4.2B2Identifies unintended consequences (eg, continued weight loss, blood glucose variability), or the use of inappropriate methods of achieving goals (eg, medication or dietary supplement erratic use/noncompliance, self-imposed dietary restrictions, personal beliefs)XX
      4.2B3Leads the development or revision of protocols for timely review and documentation of client’s clinical, metabolic, and nutrition status (including growth and development)X
      4.3Evaluates outcomes:XXX
      4.3ACompares monitoring data with nutrition prescription and established goals or reference standardXXX
      4.3A1Monitors and analyzes clinical data relative to achieving client outcomes; seeks assistance as neededXXX
      4.3A2Compares and analyzes the data for each problem area to nutrition prescription/goal using experience and clinical judgment skills, and incorporates additional consideration of progress with ED treatment plan, the client’s learning style, readiness, and willingness to changeXX
      4.3A3Analyzes data considering the complexity of problems and correlates one problem to another (eg, using expert clinical judgment skills reflecting on the holistic focus of ED as a complex disorder)X
      4.3A4Conducts comprehensive data analysis to identify trends in collaboration with interprofessional teamX
      4.3BEvaluates impact of the sum of all interventions on overall patient/client/population health outcomes and goalsXXX
      4.3B1Evaluates positive and negative outcomes in context of overall treatment plan, including impact on potential needs for discharge/transitions of careXXX
      4.3CEvaluates progress or reasons for lack of progress related to problems and interventionsXXX
      4.3C1Uses most appropriate measures for evaluation of goal attainment (eg, changes in food intake, anthropometrics, biochemical data)XXX
      4.3C2Elicits feedback from client/advocate about success with behavior change (eg, food, physical activity, and health outcome goals)XXX
      4.3C3Reviews progress with meeting nutrition goals with interprofessional team to determine if any revisions are indicatedXXX
      4.3C4
      • Uses multiple data sources to assess progress:
      • Examples may include:
      • NFPE (including, but not limited to signs of fluid, energy, and/or nutrition depletion or excess)
      • adequacy of nutrient intake from all sources
      • changes in body weight, body composition
      • laboratory and other clinical data
      • fluid and electrolyte balance
      • pertinent medications and dietary supplements relative to effectiveness of care plan
      • change in purging behaviors, such as overexercising, vomiting, and laxatives
      XX
      4.3C5Identifies complex underlying problems beyond the scope of nutrition that are interfering with the intervention and suggests possible adjustments to interprofessional team membersX
      4.3DEvaluates evidence that the nutrition intervention/plan of care is maintaining or influencing a desirable change in the patient/client/population behavior or statusXXX
      4.3D1Uses direct observation, interviews, and/or other factors specific to the client (eg, social, cognitive, environmental) to evaluate progress; and, when there is lack of response, identifies contributors influencing response to nutrition interventionsXXX
      4.3D2Communicates with interprofessional team members regarding clinical findings related to client behavior or nutritional statusXXX
      4.3D3Monitors emotional, social, cognitive, environmental factors that may influence response to nutrition interventionXX
      4.3D4Assesses motivators and incentives to change and/or consequences of changeXX
      4.3D5Evaluates the client’s variance from planned outcomes and incorporates findings into future individualized treatment recommendationsXX
      4.3D6Evaluates client outcomes in relationship to goals of program or facilityXX
      4.3ESupports conclusions with evidence (Examples in 4.2A1 to 4.2A4)XXX
      4.3E1Demonstrates that prescribed nutrition intervention is successful/unsuccessful through documentation of clinical, cognitive, and psychosocial indicatorsXXX
      4.4Adjusts nutrition intervention/plan of care strategies, if needed, in collaboration with patient/client/population/advocate/caregiver and interprofessional teamXXX
      4.4AImproves or adjusts intervention/plan of care strategies based upon outcomes data, trends, best practices, and comparative standardsXXX
      4.4A1Collaborates with interprofessional team for additional resources to modify nutrition prescription(s) for consistent achievement of therapeutic goalsXXX
      4.4A2Provides client-centered evidence-based education, while supporting the client to review and emotionally process the risks, benefits, and consequences of engagement in ED recoveryXXX
      4.4A3Develops and executes innovative strategies in collaboration with interprofessional team members to support ED recoveryXX
      4.4A4Consults with other expert RDNs to make adjustments in unpredictable and dynamic situations (eg, family dysfunction, past or current substance abuse, presence of a primary psychiatric diagnosis)X
      4.4BSeeks professional supervision for adjusting behavioral intervention strategies in complex ED cases and engages necessary introspective evaluation of transference and countertransference (ie, therapeutic interference due to the projection of positive or negative thoughts, emotions, or behaviors) due to complexity of client populationXXX
      4.5Documents:XXX
      4.5ADate and timeXXX
      4.5BIndicators measured, results, and the method for obtaining measurementXXX
      4.5CCriteria to which the indicator is compared (eg, nutrition prescription/goal or a reference standard)XXX
      4.5DFactors facilitating or hampering progressXXX
      4.5EOther positive or negative outcomesXXX
      4.5E1Changes in client level of understanding and food-related behaviorsXXX
      4.5FChanges in clinical or psychological statusXXX
      4.5GAdjustments to the nutrition intervention/plan of care, if indicated; and communications with interprofessional team as neededXXX
      4.5HFuture plans for nutrition care, nutrition monitoring and evaluation, follow-up, referral, transfer to another setting or level of care, or dischargeXXX
      Examples of Outcomes for Standard 4: Nutrition Monitoring and Evaluation
      • The client/community outcome(s) directly relate to the nutrition diagnosis and the goals established in the nutrition intervention/plan of care. Examples include, but are not limited to:
        • Nutrition outcomes (eg, change in knowledge, behavior, food, or nutrient intake)
        • Clinical and health status outcomes (eg, change in laboratory values, body weight, blood pressure, risk factors, signs and symptoms, clinical status, infections, complications, morbidity, and mortality)
        • Client/population-centered outcomes (eg, quality of life, satisfaction, self-efficacy, self-management, functional ability)
        • Health care utilization and cost-effectiveness outcomes (eg, change in medication, special procedures, planned/unplanned clinic visits, preventable hospital admissions, length of hospitalizations, morbidity, and mortality)
      • Nutrition intervention/plan of care and documentation is revised, if indicated
      • Documentation of nutrition monitoring and evaluation is:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and timed
      a Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, psychiatrists, nurses, nurse practitioners, dietitian nutritionists, pharmacists, physician assistants, psychologists, licensed professional counselors, licensed marriage and family therapists, social workers, dentists, and occupational and physical therapists), depending on the needs of the client. Interprofessional could also mean interdisciplinary or multidisciplinary.
      b Advocate: An advocate is a person who provides support and/or represents the rights and interests at the request of the patient/client. The person may be a family member or an individual not related to the patient/client who is asked to support the patient/client with activities of daily living or is legally designated to act on behalf of the patient/client, particularly when the patient/client has lost decision making capacity. (Adapted with permission The Joint Commission’s Glossary of Terms
      The Joint Commission
      Glossary.
      and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation
      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.
      ,
      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. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      ).
      c 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.
      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.
      ,
      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. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      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. 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).
      ,
      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. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      Figure 2Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Eating Disorders. Note: The term customer is used in this evaluation resource as a universal term. Customer could also mean client/patient/customer, family, resident, participant, consumer, or any individual, group, or organization to which the RDN provides service.
      Standards of Professional Performance for Registered Dietitian Nutritionists in Eating Disorders

      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 practice (eg, Health Insurance Portability and Accountability Act [HIPAA])XXX
      1.1A
      • Complies with:
      • state licensure or certification laws and regulations, including telehealth and continuing education requirements
      • federal, state, and local laws and regulation related to care of clients with behavioral health and substance use disorders
      XXX
      1.2Performs within individual and statutory scope of practice and applicable laws and regulations, including requirements of additional credentialing (eg, Certified Eating Disorders Registered Dietitian [CEDRD], Certified Specialist in Pediatrics [CSP])XXX
      1.2AAdheres to the practice boundaries related to nutrition vs behavioral health counseling unless qualified through additional credentials and state-specific regulationsXXX
      1.3Adheres to sound business and ethical billing practices applicable to the role and setting (eg, payer billing codes, type of nutrition visit)XXX
      1.4Uses national quality and safety data (eg, National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division, National Quality Forum (NQF), Institute for Healthcare Improvement) to improve the quality of services provided and to enhance customer-centered servicesXXX
      1.4AUses nationally standardized and consensus-based behavioral health performance measures (eg, American Psychological Association [APA] Clinical Practice Guidelines) in design and evaluation of nutrition care and servicesXXX
      1.4BContributes to or leads efforts to maximize eating disorders (ED) nutrition services using national quality and safety dataXX
      1.4CLeads program’s interprofessional
      Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, psychotherapists, certified counselor, clinical social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
      team meetings and promotes use of national consensus-based standards and measures in performance monitoring processes
      X
      1.5Uses a systematic performance improvement (PI) model that is based on practice knowledge, evidence, research, and science for delivery of the highest-quality servicesXXX
      1.5AIdentifies and participates in using an appropriate organization-approved PI model(s)/process(es)XXX
      1.5BLeads or contributes to the design of PI activities, collaborating with other health care practitioners to address process and outcome goals for the ED programXX
      1.5CTrains and guides interprofessional PI activities across programX
      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
      1.6A1Participates in outcomes management activities and advocates for existing or improved coordination of interprofessional ED careXXX
      1.6A2Participates in and coordinates interprofessional efforts to evaluate and improve ED client population outcomesXX
      1.6A3Leads interprofessional efforts to create and evaluate systems, processes, and programs that promote and support the program’s ED and nutrition-related objectivesX
      1.6BDefines expected outcomesXXX
      1.6B1Identifies quality outcomes to measure (eg, standardized measures of mood states, level of psychological distress, biological markers, or program-specific measures)XX
      1.6B2Determines desired nutrition-specific outcomes for the client population through direct evaluation, benchmarking (eg, national programs, standards, recognized practice guidelines), and evaluation of environmental trendsX
      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
      1.6D1Uses and/or develops systematic quality improvement approach to collect and organize data to measure quality of care and services against desired outcomes using data from multiple sourcesXXX
      1.6D2Selects criteria for data collection, and advocates for and participates in developing data collection tools (eg, clinical, operational, and financial)XX
      1.6D3Uses and/or adapts existing systems for evaluating nutrition and food/dining service specific to the population and settingXX
      1.6D4Leads clinical or operational PI activities (eg, designs and implements evaluative protocols) and data analysisX
      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
      1.6E1Ensures that screening for nutrition risk is a component of program admission process or nutrition assessment using evidence-based screening tools for the setting and/or populationXXX
      1.6E2Collects data using clinical quality measures applicable to population and setting (eg, screening time frames, severity of malnutrition, and services provided [eg, nutrition assessment, nutrition counseling])XXX
      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
      1.6F1Participates in collecting and evaluating outcomes data specific to client population needs and treatment goalsXXX
      1.6F2Evaluates client and service outcomes data against client population needs, treatment and program goals, and community impactXX
      1.6F3Leads or collaborates in program/organization-approved efforts to reinforce current practices or implement changes in practice(s) and to share outcomes data with the ED communityX
      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
      1.6G1Promotes the inclusion of RDN-provided medical nutrition therapy and ED nutrition services data in local, regional, state, and/or national data registriesXXX
      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
      1.7ACollaborates with medical provider and/or other members of ED team (eg, pharmacist) to:
      • contribute to awareness of potential drug–food/nutrient and drug–dietary supplement (eg, vitamin, mineral, herbal) interactions; and to education of clients/families and interprofessional team
      • identify, address, and prevent errors (eg, food allergy/intolerances vs food aversion)
      XXX
      1.7BAnticipates the potential for errors (eg, medical errors, miscommunications, foodservice errors, signs of refeeding syndrome, gastrointestinal distress), addresses and/or alerts supervisors/administrators, as appropriateXX
      1.7CDevelops safety alert systems to monitor key indicators of ED clients’ comorbid medical conditionsXX
      1.7DRecognizes possible drug–nutrient interactions and potential interactions between prescribed treatments and integrative and functional medicine therapiesXX
      1.7EDevelops policies and procedures, and/or best practices to identify, address, and prevent errors and hazards in the delivery of nutrition care and servicesX
      1.8Compares actual performance to performance goals (ie, Gap Analysis, SWOT Analysis [Strengths, Weaknesses, Opportunities, and Threats], PDCA Cycle [Plan-Do-Check-Act], DMAIC [Define, Measure, Analyze, Improve, Control])XXX
      1.8AReports and documents action plan to address identified gaps in care and/or service performanceXXX
      1.8BCompares program/service performance to established goals and outcomes; and to national programs and standardsXX
      1.8CMonitors clinical measures (eg, weight range, menstrual health, testosterone levels, bone health) to program/organization goalsX
      1.9Evaluates interventions and workflow process(es) and identifies service and delivery improvementsXXX
      1.9AUses evaluation data and/or collaborates with interprofessional team to identify program/service improvementsXX
      1.9BLeads the development, testing, and redesign of program/service evaluation systemsX
      1.10Improves or enhances patient/client/population care and/or services working with others based on measured outcomes and established goalsXXX
      Examples of Outcomes for Standard 1: Quality in Practice
      • Actions are within scope of practice and applicable laws and regulations
      • National quality standards and best practices are evident in customer-centered services
      • PI 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 are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)
      • Aggregate outcomes results meet pre-established criteria
      • Quality improvement results direct refinement and advancement of practice
      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], APA, other national organizations, and/or employer code of ethics)XXX
      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) (eg, Mental Health and Addictions)XXX
      2.2BUses the SOP and SOPP for RDNs in ED to assess performance at the appropriate level of practice; develops and implements a professional development plan to improve quality of practice and performance; and advance practiceXXX
      2.2CDevelops program policies, guidelines, human resource materials (eg, job descriptions, career ladders, care and service activities for each performance level) using the SOP and SOPP for RDNs in EDXX
      2.2DDefines roles, actions, and guidelines for each level of practice based on advanced practice knowledge and experience; and consistent with the SOP and SOPP for RDNs in EDX
      2.3Demonstrates and documents competence in practice and delivery of customer-centered service(s)XXX
      2.3ADocuments examples of expanded professional responsibility (eg, quality assurance and PI, leadership responsibilities, corporate-/system-level role(s), state and/or national advisory board participation)XX
      2.4Assumes accountability and responsibility for actions and behaviorsXXX
      2.4AIdentifies, acknowledges, and corrects errorsXXX
      2.4BDisplays professionalism and integrity in ED nutrition and strives for improvement in practice (eg, manages change effectively; demonstrates assertiveness and conflict resolution skills; demonstrates ability to network and build coalitions); seeks assistance if neededXXX
      2.4CDemonstrates responsible behavior regarding scope of practice, supervision, referrals, collaboration, and self-disclosureXXX
      2.4DDevelops and implements policies and procedures that ensure staff accountability and responsibilityXX
      2.5Conducts self-evaluation at regular intervalsXXX
      2.5AIdentifies needs for professional developmentXXX
      2.5A1Evaluates current level of practice to identify areas for professional development:
      • compares individual performance to self-directed goals and for consistency with evidence-based guidelines, best practices, and research in ED
      • seeks formal/informal feedback from colleagues, members of the interprofessional team, and ED-experienced supervisors
      • explores increased responsibilities for advancing practice
      XXX
      2.5A2Seeks to learn and use advanced psychoeducational knowledge and skills in areas such as:
      • Acceptance and Commitment Therapy (ACT)
      • Cognitive Behavioral Therapy (CBT)
      • Cognitive Processing Therapy (CPT)
      • Dialectical Behavioral Therapy (DBT)
      • Exposure Response Prevention (ERP)
      • Health At Every Size (HAES)
      • Intuitive Eating (IE)
      • Motivational Interviewing (MI)
      XXX
      2.6Designs and implements plans for professional developmentXXX
      2.6ADevelops plans and documents professional development activities in career portfolio (eg, organizational policies and procedures, credentialing agency[ies]) to maintain and advance practiceXXX
      2.6A1Includes professional goals around key dimensions of ED, PI, research, service, and leadershipXXX
      2.6A2Includes a plan for achieving the knowledge, skills, and experience needed to qualify for or maintain certification(s) (eg, CEDRD) to support role(s) and responsibilitiesXX
      2.7Engages in evidence-based practice and uses best practicesXXX
      2.7AInterprets current research, trends, and best practices in the prevention and treatment of ED, co-occurring mental health and/or substance use disordersXX
      2.7BContributes as a reviewer of original research and/or evidence-based guidelines relevant to ED nutrition practiceX
      2.8Participates in peer review of others as applicable to role and responsibilitiesXXX
      2.8AEngages in peer-review activities consistent with setting, responsibilities, and client population (eg, peer evaluation, peer supervision, clinical chart review, performance evaluations); seeks assistance if neededXXX
      2.8BParticipates in scholarly review (eg, educational materials, professional articles, and resource materials)XXX
      2.8CDemonstrates knowledge and skills to train, mentor, and guide credentialed nutrition and dietetics practitioners and other support staffXX
      2.8DLeads/serves on editorial board for review of professional articles, chapters, and booksX
      2.9Mentors and/or precepts othersXXX
      2.9AParticipates in mentoring and/or precepting students/interns, entry-level RDNs in ED and credentialed nutrition and dietetics practitioners; seeks to be inclusive of marginalized or diverse individualsXXX
      2.9BObtains knowledge and experience to mentor RDNs interested in gaining further ED treatment experience and to recognize when to obtain the expertise of other disciplinesXX
      2.9CProvides leadership, mentoring, and professional guidance to RDNs and other health care professionals (eg, behavioral care team, family therapists, performance advisor, ie, coach, trainer) for the continued advancement of ED recognition and treatmentX
      2.9DProvides case consultation and/or formal supervision to other RDNs in the treatment of EDX
      2.10Pursues opportunities (education, training, credentials, certifications) to advance practice in accordance with laws and regulations, and requirements of practice settingXXX
      2.10AActively participates in case consultation and/or professional supervision related to the treatment of ED to learn from interactive and collegial sharing/guidanceXXX
      2.10BDevelops programs, tools, and resources in support of assisting RDNs to obtain specialty certification in ED (eg, CEDRD)XX
      2.10CLeads effort to develop, establish, or advance education, training, and credentialing opportunities for ED specialization for RDNsX
      2.10DSeeks advanced fellowships, training, and certifications to support application for the International Association of Eating Disorders Professionals (iaedp)–approved CEDRD supervisor designation (CEDRD-S) or to support applications for other advanced certifications (eg, Academy for Eating Disorders [AED] Fellow)X
      Examples of Outcomes for Standard 2: Competence and Accountability
      • Standards of practice are safe, customer-centered, and ethical; and practice reflects:
        • Code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics)
        • Scope of Practice, Standards of Practice, and Standards of Professional Performance
        • Evidence-based practice and best practices
        • CDR Essential Practice Competencies and Performance Indicators
      • Practice embraces diversity in culture, race, age, gender, socioeconomic status, and body size in all interactions with individuals and groups
      • Self-evaluations are conducted regularly to identify and pursue professional growth reflecting a commitment to lifelong learning and professional development
      • Relevant opportunities (education, training, credentials, certifications) are pursued to meet CDR recertification requirements and advance practice
      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 address needs of the customer or target population(s)XXX
      3.1AAligns program/service development with the mission, vison, principles, values, and service expectations and outputs of the organization/businessXXX
      3.1A1Participates in strategic planning for internal and external resources for ED nutrition programs (ie, staff, budget)XX
      3.1A2Develops and manages nutrition services tailored to the mission and needs of the ED program and client populationXX
      3.1A3Leads efforts to identify and provide program/facility-specific outcomes data to support current and new ED nutrition-related servicesX
      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
      3.1B1Routinely assesses needs, expectations, and desired outcomes of clients, families, organization leaders, and community stakeholders; seeking assistance as neededXXX
      3.1B2Develops and participates in community education programs that promote safe and effective nutrition services for ED treatmentXX
      3.1B3Advocates for and leads the development of resources and nutrition services to meet under-served population needs at the systems levelX
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environmentXXX
      3.1C1Shapes and adapts program and service delivery to align with budget (eg, staffing reflective of the time intensive nature of ED population)XX
      3.1DProposes programs and services that are customer-centered, culturally appropriate, and minimize disparitiesXXX
      3.1D1Adapts practice(s) to minimize or eliminate health disparities associated with culture, race, gender, socioeconomic status, age, and other factorsXXX
      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 practitionersXXX
      3.2A1Participates in or designs the referral process between practitioners based on client population needs (eg, social worker, psychologist, psychiatrist, pharmacist, physician, or case manager)XX
      3.2A2Designs and manages referral systemsX
      3.2BRefers customers to appropriate providers when requested services or identified needs exceed the RDN’s individual scope of practice (eg, physician, therapist, social worker, psychiatrist, or occupational/speech-language pathologist)XXX
      3.2B1Builds relationships with other health care practitioners to facilitate collaborative referrals within the interprofessional teamXXX
      3.2B2Verifies potential referral practitioner’s care reflects evidence-based information and professional standards of practiceXXX
      3.2B3Establishes and maintains networks to support the continual recovery of clients transitioning to home or another care settingXX
      3.2B4Supports referral resources with curriculum and training regarding complex nutrition needs of clients with an EDX
      3.2CMonitors effectiveness of referral systems and modifies as needed to achieve desirable outcomesXXX
      3.2C1Tracks data to evaluate efficiency and effectiveness of the nutrition referral processesXXX
      3.2C2Manages and/or leads data review and revision of the nutrition referral process and collaborative tools within the interprofessional teamXX
      3.3Contributes to or designs customer-centered servicesXXX
      3.3AAssesses needs, beliefs/values, goals, resources of the customer, and social determinants of healthXXX
      3.3A1Recognizes the influences that culture, health literacy, and socioeconomic status have on clients’ health/illness experiences and access to health care servicesXXX
      3.3A2Applies goal-setting and behavior-change strategies and techniques (eg, stages of change, transtheoretical model [TTM], or MI) to design client-centered servicesXXX
      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
      3.3B1Adapts practice to meet the needs of an ethnically and culturally diverse populationXXX
      3.3B2Connects clients/families with established resources and services within the specific ethnic/cultural communityXXX
      3.3B3Secures additional resources to enhance health-related decision-making within the clients’ immediate support networkXX
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the customer or target populationXXX
      3.3C1Advises on and uses systems or tools to communicate disease prevention and behavioral change approaches for individuals with an ED within specific populations considering age and needsXX
      3.3C2Develops and implements treatment guidelines to address clients with complex needs for other nutrition and health care practitionersX
      3.3DCollaborates with the customers to set priorities, establish goals, and create customer-centered action plans to achieve desirable outcomesXXX
      3.3D1Collaborates with clients/caregivers, health care practitioners, and other support resources to create person-centered action plans that reflect clients’ needs, desired outcomes, and program/service objectivesXXX
      3.3D2Adapts practice to address barriers to change and/or barriers to the use of health care services to meet clients’ needXX
      3.3D3Participates in or initiates development of tools to guide shared decision making and goal setting to maximize outcomes for clients and/or their support networksXX
      3.3D4Demonstrates willingness and ability to initiate and/or sustain effective long-term communication with interprofessional team and clients’ support team (eg, family, friends, performance advisor)XX
      3.3D5Leads in the research and development of prevention and treatment protocols to address multiple levels (eg, intensity of treatment, approach when using telehealth, during a disaster) of careX
      3.3EInvolves customers in decision makingXXX
      3.3E1Follows and participates in organization/program discussions with interprofessional team to ensure person-centered care and servicesXXX
      3.3E2Reviews information shared by client/family/caregiver with interprofessional team for planning and problem solving to support consistency in treatment plans to assure person-centered careXX
      3.4Executes programs/services in an organized, collaborative, cost-effective, and customer-centered mannerXXX
      3.4ACollaborates and coordinates with peers, colleagues, stakeholders, and within interprofessional teams for safe quality careXXX
      3.4A1Interacts with interprofessional team to:
      • educate and develop skills
      • demonstrate role of RDN and nutrition in treatment of ED
      • contribute formally and informally to the client care team (eg, share relevant articles and investigate queries)
      • communicate nutrition strategies guided by evidence-based guidelines/best practices
      XXX
      3.4A2Facilitates and fosters active communication, learning partnerships, and collaboration within an interprofessional ED team and with other practitioners as neededXX
      3.4A3Contributes to improving collaboration between clients and health care practitionersXX
      3.4BUses and participates in, or leads in the selection, design, execution, and evaluation of customer programs and services (eg, nutrition screening system, medical and retail foodservice, electronic health records, interprofessional programs, community education, grant management)XXX
      3.4B1Evaluates evidence-based practices for application to services provided (eg, meal, snack and supplement guidelines, sustainability practices, use of social media for consumer outreach)XXX
      3.4B2Identifies and uses population- and setting-specific nutrition and ED screening tools based on level of careXX
      3.4B3Establishes nutrition screening guidelines, indicators, and care recommendations for individuals with EDX
      3.4B4Directs and serves as primary consultant regarding the planning, development, and implementation of comprehensive nutrition services program within an interprofessional system of careX
      3.4CUses and develops or contributes to selection, design and maintenance of policies, procedures (eg, discharge planning, transitions of care, emergency planning), protocols, standards of care, technology resources (eg, HIPAA-compliant telehealth platforms), and training materials that reflect evidence-based practice in accordance with applicable laws and regulationsXXX
      3.4C1Uses and collaborates with interprofessional team to develop and maintain program and nutrition policies, procedures, practice tools, and services to meet needs of client population (eg, nutrition and other screenings, treatment team meetings, educational needs, and family observations)XXX
      3.4C2Develops and/or maintains ED nutrition programs, policies, and protocols based on research, evidence-based guidelines, best practices, trends, and national and international guidelines for practice setting, such as:
      • AED Nutrition Care Standards on the Treatment of Eating Disorders (forthcoming)
      • American Academy of Child and Adolescent Psychiatry Practice Parameters for the Assessment and Treatment of Children and Adolescents with Eating Disorders
      • APA Eating Disorder Clinical Practice Guidelines
      • Australia & New Zealand Academy for Eating Disorders Guidelines
      • British National Institute for Clinical Excellence (NICE) Guidelines
      XX
      3.4C3Leads department and interprofessional process of developing, monitoring, evaluating, and improving the protocols, guidelines, and practice tools/process as neededX
      3.4C4Negotiates and/or updates policies and procedures at a systems level for new advances in treatment of EDX
      3.4DUses and participates in or develops processes for order writing and other nutrition-related privileges, in collaboration with the medical staff
      Medical staff: A medical staff is composed of doctors of medicine and osteopathy and may in accordance with state law, including scope of practice laws, include other categories of physicians, and nonphysician practitioners who are determined to be eligible for appointment by the governing body.6
      or medical director (eg, post-acute care settings, public health, community, 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.6,7 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.9,10
      –driven delegated orders or protocols, initiating or modifying medical foods/nutrition supplements, dietary supplements, enteral and parenteral nutrition, laboratory tests, medications, and adjustments to fluid therapies or electrolyte replacements
      XXX
      3.4D1iAdheres to setting-specific approved medical provider protocols/delegated orders for including in scope of work: ordering or revising meal plan (preferred terminology in ED settings rather than diet orders), medical food and dietary supplementsXXX
      3.4D1iiContributes to organization or program medical staff/medical director process for identifying RDN privileges to support ED care and services (eg, meal plan orders, medical food and dietary supplements)XX
      3.4D1iiiObtains privileges or develops medical director-approved protocol for ordering and monitoring laboratory and diagnostic testing as part of ED treatment planX
      3.4D2Uses and participates in or leads development of processes for privileging for provision of nutrition-related services, including (but not limited to) inserting and/or monitoring nasoenteric feeding tubes, providing home enteral nutrition or infusion management services (eg, ordering formula and supplies), and indirect calorimetry measurementsXXX
      3.4D2iEstablishes collaborative practice with other health care practitioners at organization or systems level (eg, participate in treatment team meetings, and/or a disease management program, case management)XX
      3.4EComplies with established billing regulations, organization policies, 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 the HIPAA rules for use, disclosure, and storage of customer’s personal health informationXXX
      3.5Uses professional, technical, and support personnel appropriately in the delivery of customer-centered care or services in accordance with laws, regulations, and organization policies and proceduresXXX
      3.5AAssigns activities, including direct care to patients/clients, consistent with the qualifications, experience, and competence of professional, technical, and support personnelXXX
      3.5A1Identifies capabilities/expertise of support staff to delegate client population tasks as neededXX
      3.5BSupervises professional, technical, and support personnelXXX
      3.5B1Trains professional, technical, and support personnel and evaluates their competence/skillsXX
      3.6Designs and implements food delivery systems to meet the needs of customersXXX
      3.6ACollaborates in or leads the design of food delivery systems 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 (ie, health care patients/clients, employee groups, schools, child and adult daycare centers)XXX
      3.6A1Participates in foodservice planning and delivery for health care and community settings that provide ED servicesXXX
      3.6A2Develops ED nutrition-related guidelines for foodservice system planning and deliveryXX
      3.6A3Serves as consultant to organization/program leadership in determining foodservices to be providedX
      3.6A4Develops nutrition and ED-related guidelines reflecting global standards (eg, AED, iaedp, Eating Disorders Coalition, and International Federation of Eating Disorder Dietitians), and applicable federal or state regulations (eg, menu-related regulations, food safety standards, and food assistance programs) to guide food delivery system according to the population servedX
      3.6BParticipates in, consults/collaborates with, or leads the development of menus to address health, nutritional, and cultural needs of target population(s) consistent with federal, state, or funding source regulations or guidelinesXXX
      3.6B1Reviews or participates in the development of master menus and snack options with modifications to address health and nutrition needs of ED population across the lifespans; refers to Adult and Pediatric Nutrition Care Manuals for guidanceXXX
      3.6B2Designs or provides consultation on menus and snack options that reflect and encourage normalized eating (ie, attention to satiety and hunger, somatic and hedonic preferences, biological and psychological autoimmune responses to food, as well as food rituals and behaviors)XX
      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 for target population(s)XXX
      3.6C1Provides guidance regarding products and formulas in accordance with best practices (eg, American Society for Parenteral and Enteral Nutrition guidelines)XXX
      3.6C2Provides expertise in addressing drug-dietary supplement-food interactions with medications.XX
      3.6C3Designs or consults on organization/program protocols for nutrition support best practices for individuals with EDX
      3.7Maintains records of services providedXXX
      3.7ADocuments according to organization policies, procedures, standards, and systems, including electronic health recordsXXX
      3.7A1Maintains documentation as mandated by regulatory agencies, accrediting/credentialing bodies, local, state, and federal regulations and/or laws, and consistent with the Nutrition Care Process (see: electronic Nutrition Care Process Terminology related to the Behavioral Domain; https://www.ncpro.org/pubs/encpt-en/page-044), where appropriateXXX
      3.7A2Uses and participates in the development and/or revision of electronic health records as appropriateXXX
      3.7BImplements data management systems to support interoperable data collection, maintenance, and utilizationXXX
      3.7CUses data to document outcomes of services (ie, staff productivity, cost/benefit, budget compliance, recovery outcomes, remission rates, quality of services) and provide justification to maintain or expand services (eg, staffing)XXX
      3.7C1Advocates for and participates in developing clinical, operational, and financial databases to support data collection, analysis, and use of data to communicate value of nutrition services to client population and program outcomes/goalsXX
      3.7C2Uses data to pursue expanded services (eg, community outreach programs, research program), and to obtain the necessary resources (eg, additional support and specialized clinical staff, research associates, and public policy/clinical translation experts)X
      3.7DUses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulationsXXX
      3.7D1Communicates clinical and quality improvement outcomes to interprofessional stakeholders to support improvement of clinical care and servicesXX
      3.7D2Prepares and presents analysis of nutrition care services and outcomes data for organization and accrediting bodiesXX
      3.8Advocates for provision of quality food and nutrition services as part of public policyXXX
      3.8ACommunicates with policy-makers regarding the benefit/cost of quality food and nutrition servicesXXX
      3.8A1Networks and participates in development of policies/regulations related to ED food and nutrition services at the local and/or state levelXXX
      3.8A2
      • Interacts with policy-makers and stakeholders to:
      • contribute nutrition information and influence ED nutrition and behavioral health issues
      • advocate for ED recognition and expansion of reimbursement for nutrition services
      • participate in legal, legislative, and reimbursement efforts (eg, contacts legislators, testifies in court or during legislative sessions, assists with health insurance issues)
      • advocates for the advancement of ED nutrition practice to stakeholders (eg, Centers for Medicare and Medicaid Services [CMS], accreditation organizations, state licensure boards, the Academy’s Policy Initiative and Advocacy Office)
      XX
      3.8A3Provides leadership regarding advocacy activities/issues (eg, authors peer-reviewed articles, serves on state/national/international boards)X
      3.8A4Serves as an expert to legislative and policy-makers, and payers on nutrition-related issues; proposes policies and supports legislative efforts to benefit the population with EDX
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needs and chronic conditionsXXX
      3.8B1Initiates and coordinates advocacy activities/issues (eg, authors article[s], delivers presentation on topics, networks)XX
      3.8CAdvocates for protection of the public through multiple avenues of engagement (eg, legislative action, 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
      3.8C1Participates in advocacy activities (eg, responds to Academy Action Alerts, other calls to action via Action Center, letters, e-mails, and/or phone calls)XXX
      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 collaborate with RDN to establish goals, create customer-focused action plans, and coordinate nutrition interventions (eg, in-person or via telehealth)
      • Customers are satisfied with clinical program and services and evaluations reflect expected outcomes.
      • Customers have access to food and nutrition services, including food assistance.
      • Menus reflect the cultural, health, and/or nutritional needs of target population(s) and foodservice system supports ecological sustainability
      • Professional, technical, and support personnel are supervised when providing nutrition care to customers
      • Ethical and transparent financial management and billing practices are used per role and setting
      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 methodology and application of research findingsXXX
      4.1BMaintains awareness of peer-reviewed publications, evidence-based guidelines, clinical consensus standards (eg, APA), and practice guidelines in the fields of nutrition and EDXXX
      4.1CDemonstrates the experience and critical thinking skills required to evaluate strength of original research, including limitations and potential bias, and evidence-based guidelines relevant to EDXX
      4.1DApplies evidence-based tools/resources (eg, Academy Evidence Analysis Library [EAL], practice guidelines) to stimulate awareness and integration of current evidence into clinical practiceXX
      4.1EFunctions as a primary or senior author of research, academic, and/or organization position and scholarly practice papersX
      4.2Uses best available research/evidence and information as the foundation for evidence-based practiceXXX
      4.2ADemonstrates use and adherence to evidence-based practice guidelines and clinical consensus standards to:
      • provide consistent, safe, effective, efficient, equitable quality care for individuals with ED
      • reduce compensatory behaviors/relapse risk, stabilize medical parameters, and support attitudes towards relationship with food and the body
      XXX
      4.2BEvaluates and recognizes the gap in available scientific literature where evidence-based guidelines for ED are not yet establishedXX
      4.2CCritically evaluates and applies available scientific literature in situations where evidence-based guidelines for ED are not yet established (eg, multisystem disease processes)X
      4.3Integrates best available research/evidence and information with best practices, clinical and managerial expertise, and customer valuesXXX
      4.3AIdentifies and uses evidence-based guidelines, clinical consensus standards, and cultural contributors (ie, goals, family heritage, spiritual orientation or practices, and/or geographical influences) to incorporate client values in the development of treatment plansXXX
      4.3BDevelops familiarity with and accesses commonly used sources of evidence in identifying applicable courses of action for client care and services (eg, NQF; ED, mental health and other resources; Substance Abuse Mental Health Services Administration [SAMHSA])XXX
      4.3CManages integration of evidence-based guidelines into policies, procedures, and protocols for ED care processes and educationXX
      4.3DIntegrates ED guidelines, policies, and procedures with information from consultation with national and international stakeholders for development and oversight of treatment approachX
      4.4Contributes to the development of new knowledge and research in nutrition and dieteticsXXX
      4.4AParticipates in efforts to extend research to practice (eg, journal clubs, collection of client baseline/outcomes data, listserv participation, group supervision)XXX
      4.4BParticipates in practice-based research networks (ie, Academy’s Nutrition Research Network or EAL workgroup) and the development and/or implementation of practice-based research, national research databases, and adheres to Institutional Review Board protocols and confidentiality guidelinesXX
      4.4CContributes to the body of knowledge for the profession (eg, presentations, publications, research)XX
      4.4DIdentifies and initiates research relevant to ED practice; acts as principal or co-investigator as part of collaborative research or with health care teams examining nutrition and ED careX
      4.4EMentors others in developing skills to critically assess and analyze research for application to practiceX
      4.4FServes as advisor, preceptor, and/or committee member for graduate and doctoral level researchX
      4.4GDevelops research grant proposals and professional conference request for proposals to support continuing education of scientific community about EDX
      4.5Promotes application of research in practice through alliances or collaboration with food and nutrition and other professionals and organizationsXXX
      4.5AIdentifies research issues/questions and participates in studies related to ED nutrition care and servicesXXX
      4.5BCollaborates with interprofessional and/or interorganizational teams to perform and disseminate nutrition research on EDXXX
      4.5CAdvocates to stakeholder organizations, groups, and/or agencies to prioritize and fund ED research projectsXX
      4.5DLeads interprofessional and/or multi-organizational collaborative research activitiesX
      Examples of Outcomes for Standard 4: Application of Research
      • Evidence-based practice, best practices, clinical and managerial expertise, and customer values 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
      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 evidenceXXX
      5.1ADemonstrates critical thinking and problem-solving skills (ie, educational sensitivity of audience, dynamic adjustment to audience’s needs, and language reflective of technical understanding of intended audience) when communicating with othersXXX
      5.1A1Integrates learned clinical wisdom along with scientific evidence to provide effective educational environments (eg, online, academic, community, treatment team collaborations) for clients, colleagues, health care practitioners, and other interested partiesXX
      5.1A2Demonstrates the ability to convey comprehension of foundational and dynamic ED concepts (eg, Minnesota Starvation Experiment, “set point theory,” gut–brain axis, biopsychosocial triggers, and nutritional epigenetics) to other health care practitioners, clients, and the publicXX
      5.1BInterprets regulatory, accreditation, and reimbursement programs and standards for programs/settings and providers that are specific to ED care and education (eg, CMS, state regulations, Joint Commission, or applicable accrediting organization); seeks assistance if neededXXX
      5.1CEvaluates public health trends and epidemiological reports related to ED prevalence, prevention, and treatment, and applies data in clinical practice, professional activities, and work settingsXX
      5.1DConsults on complex ED service issues with other health care practitioners, organizations, and the communityX
      5.2Selects appropriate information and the most effective communication method or format that considers customer-centered care 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
      5.2BUses information technology to communicate, disseminate, manage knowledge, and support decision makingXXX
      5.2B1Recognizes advantages and disadvantages of technology related to privacy, confidentiality, effectiveness, and safety for clientsXXX
      5.2B2Creates nutrition education materials and intervention strategies through technologyXX
      5.2B3Leads the development of client- and system-specific technology that effectively conveys nutrition information on ED-related issues to diverse audiencesX
      5.2CInvestigates and uses a wide array of technology platforms to establish a stronger voice of scientific expertise (eg, blogs, podcasts, and social media)XXX
      5.3Integrates knowledge of food and nutrition with knowledge of health, culture, social sciences, communication, informatics, sustainability, and managementXXX
      5.3AApplies current and emerging scientific knowledge of ED when considering population’s health status, behavior barriers, communication skills, and interprofessional team involvement; seeks assistance if neededXXX
      5.3BParticipates in and/or leads the integration of evidence-based knowledge, knowledge from professional supervision, and experience in ED nutrition in management of complex problemsXX
      5.4Shares current, evidence-based knowledge, and information with various audiencesXXX
      5.4AGuides customers, families, students, and interns in the application of knowledge and skillsXXX
      5.4A1Contributes to the education and professional development of RDNs, Nutrition and Dietetics Technicians, Registered, students/interns, performance advisors, and health care practitioners in all disciplines related to ED through formal and informal teaching and mentoring; seeks assistance if neededXXX
      5.4A2Participates and leads target populations through experiential food and culinary activities (eg, personalized menu creation, food safety principles, budgeting, individual and group food exposures, farmers market and grocery store tours, customer service principles, and somatic awareness during eating experiences)XXX
      5.4A3Develops educational programs or experiential opportunities using evidence-based science and clinical consensus in the treatment of EDXX
      5.4A4Develops and provides educational opportunities for health care practitioners in ED on current and emerging ED nutrition treatment modalities and challengesX
      5.4A5Designs training curriculum (eg, experientials, didactic simulation, case studies, and peer-to-peer evaluation) to advance skills in the treatment of EDX
      5.4BAssists individuals and groups to identify and secure appropriate and available educational and other resources and services (eg educational, financial, and technological)XXX
      5.4B1Identifies and recommends current, evidence-based ED educational resources to specific client populations to positively influence careXXX
      5.4B2Develops/manages systematic process to identify, track, and update resources available to clients, their support team, and health care practitionersXX
      5.4CUses professional writing and verbal skills in all types of communicationsXXX
      5.4C1Demonstrates professional writing and oral communication skills with the ability to translate complex scientific and policy information to the publicXXX
      5.4C2Develops sensitivity to methods of communication that encourage and support recovery (eg, client-centered words/pronouns, tone, and body language)XXX
      5.4C3Practices sensitive word selection, tone, and body language for the purpose of confronting and correcting inappropriate behaviors and language that impair recoveryXX
      5.4C4Develops, trains, and implements organizational protocols to ensure sensitive word selection, tone and body language are practiced; participates in corrective action as neededX
      5.4DReflects knowledge of population characteristics in communication methods (eg, literacy and numeracy levels, need for translation of written materials and/or a translator, communication skills, and learning, hearing or vision disabilities)XXX
      5.4D1Considers culture, literacy, and communication styles in dialogue, written communications, and educational activities for all audiences (eg, clients, program staff/leaders, community stakeholders); seeks assistance if neededXXX
      5.5Establishes credibility and contributes as a food and nutrition resource within the interprofessional health care and management team, organization, and communityXXX
      5.5APromotes the use of evidence-based guidelines and the Academy’s EAL with the interprofessional team and others to integrate food, nutrition, and lifestyle behaviors with ED treatmentXXX
      5.5BCommunicates effectively with members of the treatment team (eg, physicians, therapists, nurses), client, and support team (eg, family, loved ones, friends)XXX
      5.5CEducates other significant individuals (eg, family members, friends, teachers, school counselors, performance advisors) about health-related consequences of ED within HIPAA boundariesXX
      5.6Communicates performance improvement and research results through publications and presentationsXXX
      5.6APresents information on evidence-based ED guidelines and research at the local level (eg, community groups and colleagues)XXX
      5.6BPresents evidence-based ED nutrition research, guidelines, and information at professional meetings and conferences (eg, local, regional, national, international)XX
      5.6CAuthors peer-reviewed ED publications and authoritative articles for consumers, credentialed nutrition and dietetics practitioners, and other health care practitionersXX
      5.6DServes in leadership roles for local, national, and international program/conference planning or to the media (eg, invited reviewer, presenter)XX
      5.6EDirects collation of research data into publications (eg, systematic reviews and position/practice papers), as well as national/international presentationsX
      5.7Seeks opportunities to participate in and assume leadership roles with local, state, national, and international professional and community-based organizations (eg, government-appointed advisory boards, community coalitions, schools, foundations or nonprofit organizations serving the food insecure) providing food and nutrition expertiseXXX
      5.7AParticipates in professional and work-related leadership activitiesXXX
      5.7BServes on ED prevention, awareness, and treatment task forces or committeesXXX
      5.7CLeads and supports the development of population-based and specialty-focused health promotion/prevention programs and education materials based on client population needs, culture, evidence-based strategies, and available resourcesXX
      5.7DIdentifies new opportunities for leadership and cross discipline dialogue to promote nutrition and dietetics in a broader contextXX
      5.7EInitiates and proactively develops professional alliances for the benefit of care and advancement of ED prevention and educationX
      5.7FRepresents nutrition and dietetics at the national and international level and serves as lead collaborator for national projects and professional organizations (eg, Academy dietetic practice groups, APA, AED, NQF)X
      5.7GServes as a consultant/content expert to organizations, health care practitioners, and other professionals interacting with individuals with an ED to provide education on ED risks/screening/treatment, and highlight the contribution of RDNs in EDX
      Examples of Outcomes for Standard 5: Communication and Application of Knowledge
      • Expertise in food, nutrition, dietetics, and management is demonstrated
      • 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:
        • Receive current and appropriate information and customer-centered service
        • Demonstrate understanding of information and behavioral strategies
        • Know how to obtain additional guidance from the RDN or other RDN-recommended resources
      • Leadership 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
      6.1AParticipates in operational planning and program development of ED nutrition programs and servicesXXX
      6.1BRecognizes and uses existing resources (eg, educational/training tools and materials, and staff time) as needed in the provision of ED nutrition servicesXXX
      6.1CManages and ensures effective delivery of programs and services (eg, business planning, budget, program administration, foodservice management and food safety, emergency management) and collaborates with administrative, medical, and foodservice staff, if applicableXX
      6.1DDirects or manages the design and delivery of ED nutrition services, and holds responsibility for accurate management of grants when applicableX
      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
      6.2BCollects or contributes data and participates in analyzing program resources/service participation and expense data to evaluate and adjust programs and servicesXXX
      6.2CMonitors, documents, and evaluates program and service resource use against budget or other metrics (eg, staff hours, staff to client ratio, referral requests, program participation rate, reimbursement data, supplies, training and professional development, technology, and food cost, if applicable)XX
      6.2DLeads operational review reflecting evaluation of performance and benchmarking data to manage resources and modifications to design and delivery of ED nutrition programs and servicesX
      6.3Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and productsXXX
      6.3AAssures nutrition services and foodservice comply with regulations (eg, food safety, CMS or state regulations), and accreditation standards (eg, The Joint Commission) when applicableXXX
      6.3BParticipates in the evaluation and selection of equipment, tools, and products (eg, enteral nutrition, specialty food items, medical foods/nutrition supplements, web-based programs, monitoring systems) to assure safe, optimal, and cost-effective delivery of care and servicesXXX
      6.3CEvaluates and selects new products (eg enteral nutrition formulas, food/meals, medical foods/nutrition supplements) that are specific to the nutrition needs of ED clientsXX
      6.3DEvaluates safety, effectiveness, productivity, sustainability practices, and value of services at the systems levelX
      6.4Participates in quality assurance and performance improvement (QAPI) and documents outcomes and best practices relative to resource managementXXX
      6.4AParticipates in QAPI activities or data collection and analyzes to improve outcomes and identify best practicesXXX
      6.4BUses data to proactively recognize needs, anticipate outcomes, and make necessary modifications to achieve desired client-related and program/service resource allocation outcomesXX
      6.4CIntegrates quality measures and PI processes into management of human and financial resources and information technologyX
      6.5Measures and tracks trends regarding internal and external customer outcomes (eg, satisfaction, key performance indicators)XXX
      6.5AParticipates in conducting regular surveys with clients/families/advocates, interprofessional team members, community participants and stakeholders to assess satisfaction; and in communicating results and recommendations for change(s)XXX
      6.5BResolves internal and external problems that may affect the delivery of ED nutrition servicesXX
      6.5CImplements, monitors, and evaluates changes based on data collection and analysisX
      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
      • Key performance indicators are identified and tracked in alignment with organization mission, vision, principles, and values
      a Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, psychotherapists, certified counselor, clinical social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
      b 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.
      c Medical staff: A medical staff is composed of doctors of medicine and osteopathy and may in accordance with state law, including scope of practice laws, include other categories of physicians, and nonphysician practitioners who are determined to be eligible for appointment by the governing body.
      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.
      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.
      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.
      ,
      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. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      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. 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).
      ,
      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. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.

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