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Medical Nutrition Therapy: A Case Based Approach

• Kathryn M. Kolasa, PhD, RDN, LDN Kathryn M. Kolasa Affiliations Brody School of Medicine at East Carolina University, 3080 Dartmouth Dr, Greenville, NC 27858 Search for articles by this author

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Inclusion of any material in this section does not imply endorsement by the Society for Nutrition Education and Behavior. Evaluative comments contained in the reviews reflect the views of the authors. Review abstracts are either prepared by the reviewer or extracted from the product literature. Prices quoted are those provided by the publishers at the time materials were submitted. They may not be current when the review is published. Reviewers receive a complimentary copy of the resource as part of the review process.

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DOI: https://doi.org/10.1016/j.jneb.2022.02.003

Dietetic and Nutrition Case Studies

Lawrence, Judy / Douglas, Pauline / Gandy, Joan

1. Edition April 2016 386 Pages, Softcover Wiley & Sons Ltd

ISBN: 978-1-118-89710-2 John Wiley & Sons

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Taking a problem-based learning approach to the subject of dietetics and nutrition, Dietetic and Nutrition Case Studies has been written to complement the internationally successful Manual of Dietetic Practice, with case studies cross-referenced accordingly. All the cases are written and peer reviewed by registered dietitians, drawing on their own experiences and specialist knowledge. Dietetic and Nutrition Case Studies is an invaluable resource for lecturers, health care students, as well as qualified dietitians and nutritionists as a tool to enhance their ongoing development.

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The ideal companion resource to 'Manual of Dietetic Practice', this book takes a problem-based learning approach to dietetics and nutrition with cases written and peer reviewed by registered dietitians, drawing on their own experiences and specialist knowledge * Each case study follows the Process for Nutrition and Dietetic Practice published by the British Dietetic Association in 2012 * Includes case studies in public health, an increasingly important area of practice

J. Lawrence, King's College London, England; P. Douglas, University of Ulster, Northern Ireland; J. Gandy, University of Hertfordshire, England

©2024 Wiley-VCH GmbH - Provider - www.wiley-vch.de - [email protected] - Data Policy - Cookie Preferences Copyright © 2000-2024 by John Wiley & Sons, Inc., or related companies. All rights reserved.

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Trends, challenges, opportunities, and future needs of the dietetic workforce: a systematic scoping review

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Merran Blair, Lana Mitchell, Claire Palermo, Simone Gibson, Trends, challenges, opportunities, and future needs of the dietetic workforce: a systematic scoping review, Nutrition Reviews , Volume 80, Issue 5, May 2022, Pages 1027–1040, https://doi.org/10.1093/nutrit/nuab071

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Issues related to nutrition and health are prominent, yet it is unclear if the dietetics workforce is being used optimally.

Trends, challenges, opportunities, and future needs of the international dietetic workforce are investigated in this review, which was registered with Open Science Framework (10.17605/OSF.IO/DXNWE).

Eight academic and 5 grey-literature databases and the Google search engine were searched from 2010 onward according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Of 2050 articles screened, 184 were eligible for inclusion.

To chart data, a directed content analysis and a constant comparison technique were used.

The following 13 themes were identified: 1) emerging or expanding areas of practice; 2) skill development; 3) economic considerations; 4) nutrition informatics; 5) diversity within the workforce; 6) specific areas of practice; 7) further education; 8) intrapersonal factors; 9) perceptions of the profession; 10) protecting the scope of practice; 11) support systems; 12) employment outcomes; and 13) registration or credentialing.

The dietetics profession is aware of the need to expand into diverse areas of employment. Comprehensive workforce data are necessary to facilitate workforce planning.

A dietitian “is a professional who applies the science of food and nutrition to promote health, prevent and treat disease to optimize the health of individuals, groups, communities and populations.” 1 To use the professional title dietitian in many countries, including the United States, Canada, Australia, New Zealand, and the United Kingdom, requires a minimum of a bachelor’s degree qualification, in addition to a minimum of 500 supervised practice hours. This is in contrast to the title of nutritionist , which is less defined in many countries, with no minimum level of education; however, professional organizations suggest undergraduate degrees in nutrition science are preferred. 2 Dietitians can register with professional bodies in their country of practice, which allows them to treat individuals under various health insurance schemes and in a range of settings. In Australia, dietitians are given the title of Accredited Practicing Dietitian, in the United Kingdom, Canada, and New Zealand, the term is registered dietitian; in the United States, a qualified and registered dietitian is referred to as registered dietitian-nutritionist. For inclusivity, the term dietitian is used in this article.

Current rates of diet-related chronic disease are high, 3 and issues related to sustainable food production 4 and food security 5 , 6 are receiving more attention and requiring strategic action. Dietitians are health professionals who are well placed to address these issues 1 ; however, it is unclear if this workforce is being used optimally. Current dietetic workforce data are limited across the world and there is no objective evidence that gives a clear indication of employment rates of graduates 7 or whether the dietetics workforce is meeting population nutrition needs. 8 In the United Kingdom, approximately two thirds of dietitians work within the publicly funded National Health Service, but employment information is lacking on the one third who do not. 9 In the United States, job growth for dietetics is predicted to be higher than for other professions 10 ; however, some dietitians report leaving the profession for higher pay in alternative fields or being unable to find work. 11 In Australia, workforce supply is perceived to be greater than demand, 12 and anecdotal evidence suggests graduates struggle to find employment.

The goal of workforce development is to ensure that workforce members are able to obtain a sustainable livelihood, in addition to using the labor to achieve organizational goals that meet the needs of society. 13 , 14 Because of the changing nature of healthcare delivery 15 , 16 and consumer needs, 17 , 18 employment opportunities for dietitians are rapidly evolving. It is important that such changes be regularly assessed 19 to ensure the profession remains effective and relevant. The dietetic profession is aware of the need for planning, and comprehensive studies have been completed in both the United States 20–22 and the United Kingdom, 9 with plans underway for similar work in Australia 23 to explore the future of the dietetics profession. Work in the United Kingdom resulted in 16 recommendations for development of a dietetic workforce strategy that included increasing the visibility of the profession and preparing dietitians for more diverse roles through strategic leadership. 9 In the United States, researchers analyzed societal-change drivers and how they might affect the growth of the dietetic profession. 20 , 21 They sketched out 4 possible scenarios of the future the profession may face, depending on how it responds to these change drivers. 22 Although these projects included a systemic review 20 and an environmental scan, 9 which informed subsequent research, no systematic reviews addressing trends within the dietetic workforce have been published.

Our purpose in conducting this systematic scoping review was to investigate trends, challenges, opportunities, and future needs of the global dietetic workforce from a diverse range of literature. This information can be used to inform future workforce development strategies and to guide training priorities for the current and future international workforce. This will help ensure that members of the dietetic workforce are well placed to find employment and effectively improve the nutritional outcomes of our population.

This systematic scoping review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist 24 and with reference to the JBI   Manual for Evidence Synthesis . 25 This review was registered with the Open Science Framework ( 10.17605/OSF.IO/DXNWE ). A scoping review was selected to be conducted in preference to synthesis approaches to capture the depth and breadth of the literature on the broad exploratory research question. 25 Grey literature was included because it has the benefit of contributing contemporary material from a broad range of stakeholders, 26 and publication delays in academic research can mean that results are indicative of past events, rather than current or future.

The following databases were searched on February 6, 2020, in in consultation with the subject specialist research librarian: Ovid MEDLINE, CINAHL Plus, Proquest Social Science Premium Collection, Scopus, and Business Source complete. Searching was also conducted in the following grey-literature databases: Open Grey, Grey Guide, MedlinePlus, Grey Literature Report, and Mednar; and thesis searching was conducted on Trove, Proquest Dissertations & Thesis Global, and Dart Europe E-Theses Portal. All searches were time restricted from January 2010 to February 2020 to capture information about the contemporary workforce from the past decade, rather than historical, outdated data. Only publications in English were included. Inclusion and exclusion criteria were predetermined on the basis of the PICOS model (ie, participants, interventions, comparisons, outcomes, and study design) ( Table 1 ). Search terms ( Table 2 ) were used with appropriate variations according to the functionality of each database. All results were uploaded to Endnote X9 and then to Covidence systematic review software. 27 Title and abstract screening, followed by full-text screening, was completed in duplicate by 2 authors (M.B. and either L.M., S.G., or C.P.). Conflicts were discussed until consensus was reached.

PICOS criteria for inclusion of studies

Abbreviation: CPD, continuing professional development.

Search terms used for the scoping review exploring trends, challenges, opportunities, and future needs of the dietetic workforce

Grey-literature searching, using the search terms listed in Table 2 , was conducted using the Google search engine in February 2020. The first 10 pages of results (ie, the first 100 hits) were screened, initially via the Google search screen, then potentially relevant sites were viewed in full. 26 Reasons for exclusion were noted, and included pages were saved in PDF format for data extraction. Screening of results from the Google search was conducted by 1 researcher (M.B.). Duplicate screening was deemed unnecessary because consensus on eligibility had been reached during database screening and conflict resolution.

Data charting of included papers was completed in a spreadsheet and included year of publication, author, country where the research was conducted or the article was published, type of article, type of study, and, if applicable, research methods, population, and number of participants. In addition, a directed content analysis 28 , 29 was conducted whereby themes were deductively generated under the formative categories of 1) trends (namely, ways the workforce was developing or changing), 2) opportunities (ie, ways to achieve further development), 3) challenges (ie, obstacles to development), and 4) future needs (ie, aspects needed to strengthen the workforce) and recorded in the spreadsheet. This structure was formulated by the researchers with reference to existing research indicating that the dietetic workforce is in a state of flux and in need ofplanning. 9 , 20–22 . For the second stage in the data charting process, we used a constant comparison method 30 whereby common recurring themes were identified, within the formative categories, and these became the results of the review. Data charting was conducted by 1 researcher (M.B) with a subset of 10% (in total) charted by another researcher (either L.M., S.G., or C.P.) and cross-checked for comparison, with no major errors or omissions identified. Critical appraisal of individual sources of evidence was not conducted, as is typical of scoping reviews. 24 The frequency of themes across studies was collated and a visual representation of the frequency of categories was developed on the basis of these data ( Figure 1 ).

Results of the scoping review exploring trends, challenges, opportunities, and future needs of the dietetic workforce, in descending order of commonality. Larger circles indicate the topic was referred to more often; however, this is a graphical representation only and circles are not to scale. Items listed in boxes are subcategories. Linking of circles indicates the path from most commonly to least commonly mentioned topic: emerging or expanding areas of practice (n=52); skill development (n=43); economic considerations (n=31); nutrition informatics (n=23); diversity within the workforce (n=20); specific areas of practice (n=20); additional education (n=17); intrapersonal factors (n=9); perceptions of the profession (n=9); support systems (n=5); protect the scope of practice (n=5); employment outcomes (n=3); registration and credentialing (n=3).

A total of 2050 articles were screened; of these, 184 were included in the scoping review ( Figure 2 ). Characteristics of the included articles are collated in Table 3 , and a comprehensive list of included articles is provided in Table S1 in the Supporting Information online. The following 13 themes were identified and are listed here in descending order of commonality: 1) emerging or expanding areas of practice; 2) skill development; 3) economic considerations; 4) nutrition informatics; 5) diversity within the workforce; 6) specific areas of practice; 7) additional education; 8) intrapersonal factors; 9) perceptions of the profession; 10) protecting the scope of practice; 11) support systems; 12) employment outcomes; and 13) registration or credentialing ( Figure 1 ). Subcategories were also identified under some themes.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of included studies in the systematic scoping review

Characteristics of articles included in the systematic scoping review

Abbreviations: JAND, Journal of the Academy of Nutrition and Dietetics; JADA, Journal of the American Dietetic Association.

Country where the research was conducted, or the article published.

Includes Australia and New Zealand; Australia and United Kingdom; Australia, United Kingdom, and United States; Ireland and United Kingdom; Sweden, Wales, and United States.

Includes China, Ghana, Israel, Italy, Malaysia, South Korea, Sudan.

Includes theses, abstracts, and 2 government reports.

Original research, excluding abstracts or theses.

Includes environmental scan, case study, Delphi survey, policy discourse analysis, nonrandomized controlled trial, prospective cohort.

Emerging or expanding areas of practice

A total of 51 different emerging or expanding areas of practice were identified ( Table S2 in the Supporting Information online). These were highlighted as employment opportunities to expand the scope of the profession 31 , 32 and ways in which dietitians can contribute valuable skills to benefit businesses and individuals. 31 , 33 , 34 Emerging areas were spoken of as a future need, because if dietitians did not fill these roles, they would be filled by other, potentially less qualified, individuals. 35

Skill development

A total of 21 different skills were identified (( Table S2 ) as both opportunities and future needs. Skill development was deemed to be a means by which dietitians would be able to “strengthen their ability to offer food and nutrition solutions in a wide range of situations.” 22 Clinical skills such as integrative and functional medicine 36 and nutritional genomics 37 were noted to be of increasing public interest. Skill development in these areas were suggested in order to meet the changing needs of consumers. 36 , 37 Social media skills were identified as a means to champion evidence-based nutrition information and to advocate for the profession. 38 Areas such as business skills, 22 collaboration, 39 client/customer focus, 40 computer literacy, 40 and financial management 41 were highlighted as skills desired by organizations. Sustainable food systems practices were identified as areas where dietitians can offer solutions to meet the needs of consumers and organizations. 42 It was also suggested that the profession encourage students to have dual degrees to strengthen skills in business and management. 22

Economic considerations

Four subcategories were identified relating to economic considerations: staffing ratios, supply and demand, compensation and benefits, and recruitment and retention.

Staffing ratios.

Inadequate staffing ratios were common 43–49 and described as a challenge because they may result in worse patient outcomes, 45 increased healthcare costs, 44 and increased staff turnover due to burnout. 47 In addition, dietitians were more commonly found in metropolitan areas, 49 which potentially results in lack of equitable access for individuals needing dietetic input. 48

Supply and demand.

Predictions of supply and demand varied between countries and over time. 19 , 20 , 50–53 The US Bureau of Labor Statistics predicted job growth to be “much faster than average” at 11% between 2018 and 2028. 10 Supply and demand were seen as dynamic, requiring ongoing assessment, and fundamental to workforce success. 21 , 22 , 54 An undersupply of dietitians was viewed as an opportunity for the existing workforce, resulting in higher pay rates. 19 Conversely, it was also seen as a challenge that could leave positions open for other professions, which would erode the potential economic advantage. 19 Attrition rates due to retirement were described as a challenge 20 that could result in a lack of qualified dietitians to fill senior positions. 19

Compensation and benefits.

Trends in compensation and benefits varied over time, sometimes keeping up with inflation 55 and sometimes not, 56 and a drop in wages was noted in the United States between 2015 and 2018 from USD 30.62/h to 30.45/h. 11 Higher wages were associated with higher education levels, as were specialty certifications, years of experience, and budgetary responsibility. 11 , 56 Direct client contact was associated with lower rates of pay, and supervisory roles were associated with higher pay rates. 11 , 56 Highest wages were reported in the “areas of food and nutrition management, consultation and business, and education and research.” 11

Some dietitians reported not working in dietetics because they found “a higher paying job outside of the field.” 11 Identified future needs included professional associations supporting members to achieve “recognition, respect and remuneration,” 56 creating job opportunities, 55 and giving members confidence in salary negotiations. 55 , 56

Recruitment and retention.

Opportunities reported to enhance staff retention included the chance for dietitians to specialize or undertake research, 57 opportunities for learning, 58 , 59 positive relationships with others (ie, staff and patients), 58 , 59 a supportive workplace culture, and recognition of the role of the dietitian from other staff members. 59 Factors reported to strengthen recruitment were enhanced job security and closeness of the position to home. 58

Nutrition informatics

Nutrition informatics was seen as a growth area 60–62 offering many opportunities for the dietetics profession. The primary benefit described was the gathering of large data sets that could be used to improve efficiency of interventions and enhance patient outcomes. 62–65 This area also was noted as a challenge because the dietetics profession was not adequately engaged in this field 66 and, at best, was moderately prepared. 63 , 66 It was reported that dietitians need to have greater input into nutritional informatics to ensure the systems developed are of benefit to the profession 62 , 64 and are in line with the Nutrition Care Process. 64 , 65 If dietitians were not involved in the development of nutrition informatics, studies suggested that another profession would fill these roles, 63 and the systems may not be fit for the purpose of dietetics. 64 To enhance dietetic involvement in nutrition informatics, future needs identified were training and professional development, 64 , 66 including certification, 64 leadership, 64 and mentoring. 63

Mobile health apps .

In the literature we reviewed, nutrition apps were seen as a valuable tool to assist in patient care 65 and, if used in conjunction with dietetic counselling, could enhance the client-dietitian relationship. 67 It was reported that dietitians want access to credible, well-designed apps that can be integrated into current practice. 67 However, mobile health apps (aka, mHealth apps) were reported to be poorly designed for collaborative treatment with a dietitian. 68 They were noted to have the potential to increase quality and efficiency of healthcare 68 by gathering real-time, noninvasive data; however, access to these data was reported to be limited. 69

Training, education, and advocacy on the part of dietetic associations were identified as future needs to ensure greater engagement with use of apps by dietitians. 70 In addition, greater collaboration among app designers, dietetic professional associations, and dietitians 67 was identified as necessary to ensure apps are optimal for use in dietetic practice. mHealth app development was identified as a growth industry and it was felt that if dietitians fail to be involved, they may leave these roles open to other, less qualified individuals. 71

Diversity within the workforce

Diversity was described as a challenge, with the dietetics profession being predominately homogenous (female and White) and not representative of the broader population. 72–74 This was reported to create a divide between the profession and the individuals they serve. 72 In addition to sex, gender 73 and race, 74 the need for diversity with reference to age, religion, socioeconomic status, 41 and disability 75 were also identified. Suggested ways to increase diversity included peer mentoring and targeted approaches to recruit more diverse students. 76 , 77

Specific areas of practice

Aspects relating to 7 different areas of practice were described. These included: high staff turnover in rural and remote practice, 78 low patient attendance rates in private practice, 79 the need for interprofessional support in primary health care, 80 the benefits of expanding food-service initiatives within the school setting, 81 and the challenges faced by academic dietetic educators 82 and sports dietitians requiring advocacy for services for college-level athletes. 83

Additional education

Advanced credentialing..

Dietitians were reported to have higher levels of advanced credentialing compared with other professions, 19 with many existing and planned advanced credentials available in the United States. 41 , 84 Opportunities associated with advanced credentialing were identified as expanding an individual dietitian’s scope of practice 84 and recognition of dietitians as leaders in food and nutrition by external stakeholders. 54 Advanced credentialing was also reported to lead to more rewarding job opportunities, 85 particularly in growth areas such as gerontology and chronic disease management. 86 Increased wages were a reported outcome of advanced credentialing, 51 and advanced credentialing was seen as beneficial to the profession because it resulted in more efficient and cost-effective interventions. 85

Challenges identified that are related to advanced credentialing included a previous lack of clearly defined pathways, 87 although many pathways were listed in a more recent article. 84 Residency programs were noted to be an effective method of delivery that incorporated practical learning 85 , 87 , 88 ; however, availability of funding for these was described as inconsistent 87 and sometimes acquired from multiple sources. 83 In addition, the general public were reported to lack understanding of the benefits of advanced credentialing 87 and employers yet to value or demand these credentials. 19

Extended scope of practice.

Extended scope of practice is the recognition of an additional skill that is outside of the defined scope of practice of a healthcare professional. 89 For dietitians, this can include activities such as blood glucose testing, adjusting insulin doses, inserting nasogastric tubes, 89 tube feeding management, 90 , 91 gastroenterologic treatment management, 92 and, depending on local legislation, prescribing of pharmaceuticals. 89 , 93 , 94

Dietitians in extended-scope-of-practice roles were noted to contribute to reduced healthcare costs resulting from streamlining of services and efficient patient-care management. 89–92 , 95 This was identified to be a result of fewer healthcare visits, 89 , 92 , 95 shorter waiting times, 91 and reduced hospital admissions. 90 Opportunities were reported to include an enhanced professional profile, with dietitians in extended-scope roles perceiving increased professional status 90 and recognition. 91 They also reported increased job satisfaction due to working to the full scope of their practice, and sharing the experience with other dietitians through a community of practice. 91 Acknowledgment and appreciation of advanced skills by the healthcare team were thought to result in enhanced working relationships. 90 , 91

The challenges associated with extended-scope roles related to the lack of strategic planning, with these roles reportedly forming out of unfilled vacancies. 90 To assist with more strategic planning, the development of a framework that incorporates the available options for extended scope of practice, 9 in addition to clearly defined learning programs and evaluation strategies, 91 was described as future needs. In 1 instance, it was reported that an extended-scope role caused conflict with nutrition nurse specialists because of the crossing of professional boundaries. 91 Supportive infrastructures were noted as essential for the creation and maintenance of these roles, such as clinical governance and stakeholder engagement. 91

Intrapersonal factors

Job satisfaction..

Trends in job satisfaction indicated that dietitians were moderately 96 or slightly 97 satisfied with their jobs, with dietitians in clinical positions reporting the lowest scores. 98 Age and experience were associated with higher levels of job satisfaction. 99 Key factors reported to enhance job satisfaction included: opportunities for promotion 96 , 97 , 99 , 100 and professional development, 100 flexibility in work hours, 100 a dynamic team environment, 100 a positive work atmosphere, 97 and higher salaries. 97–99 Other elements that were identified as increasing job satisfaction included “reward and recognition” 100 and “autonomy, meaning, recognition and respect.” 98 Issues with the physical environment and access to resources, 100 in addition to “poor perception of professional image,” 99 were reported to have a negative effect on job satisfaction.

Job satisfaction was a challenge, due to the reported costs associated with staff turnover, absenteeism, and reduced productivity 96 that occur when satisfaction levels are low. It was also seen as an opportunity, because increased job satisfaction was reported to lead to improved patient or customer satisfaction. 98

Stress and burnout.

Trends indicated that although dietitians had lower levels of burnout than other health professionals did, they still had moderate levels of emotional exhaustion. 101 In addition, their sense of personal accomplishment was only moderate, although this increased with age and years of experience. 101 The main challenge associated with stress and burnout was the potential for negative health consequences for the individual and decreased job performance, resulting in negative impacts on clients and organisations. 101

Challenges identified that increased stress and burnout were a perceived lack of respect from other healthcare professionals, due to a lack of understanding of the dietitian’s role. 102 In addition, unrealistic expectations as to what dietitians can achieve with limited time and resources and the lack of recognition associated with being a preceptor were reported as challenges. 102 Expectations that dietitians “conform to certain ideals, including thinness” were perceived to increase stress and burnout. 102 Future needs reported included additional training in “resilience, mindfulness and empathy,” as well as interprofessional approaches to combating stress. 102

Preparedness for practice.

Preparedness for practice was perceived as a challenge because of a lack of data on emerging areas of practice, 7 leading to difficulty in tailoring curricula toward employment opportunities. In addition, research specific to the workplace, involving graduates and employers, was identified as lacking. 7 Graduates reported feeling underprepared for new and emerging roles and were overwhelmed by the competition for traditional job opportunities. 103 Future needs identified included comprehensive graduate employment outcome data 7 and a realignment of course curricula to better prepare graduates for emerging roles. 103

Perceptions of the profession

Although the role of the dietitian was thought to have become less confusing to the public, 104 awareness of what a dietitian does was described as low. 105 Dietitians were reportedly seen as simply prescribers of diets, 105 , 106 and the general public had difficulty distinguishing between dietitians and other professions, such as naturopaths. 107 The level of education required to be a dietitian was reported to be poorly understood, 107 and there was an identified lack of clarity of the distinction between dietitians and nutritionists. 9 This was thought to result in a dilution of the credential and confusion regarding the dietitian’s role in healthcare. 9 As a profession, dietitians were reported to desire greater visibility and credibility and a clearer public profile that acknowledges them as experts in nutrition. 9 , 108

Dietitians also wished to be seen as a health professional who should be visited regularly, much like a dentist. 9 , 109 A transformation was reported to be occurring from the dietitian being a provider of information to being a provider of counselling-based treatment. 107 This was identified as an opportunity, because the public perceived treatments involving the transfer of information as requiring only short-term intervention, whereas they viewed a therapeutic, counselling style approach as a long-term strategy. 107 Both the dietetic profession and the public were reportedly struggling to adapt to this change from “information giver” to counsellor. 107

Strong partnerships with physicians provided opportunities, because referrals from them increased the likelihood of patients engaging in ongoing treatment. 107 In addition, physicians acknowledged that their own nutrition education is limited and they had positive opinions of the training and experience of dietitians. 107 Other opportunities identified included the work of special-interest groups with stakeholders relevant to their topic areas and incorporating a broader range of placement opportunities with a broader range of stakeholders. 9

Although dietitians felt they have much to contribute to the healthcare sector, they did not feel they had a voice that can be heard. 9 Professional associations were seen as the key to amplifying the voice of the profession and increasing visibility. 9 Some dietitians expressed concern that their professional association was not fully recognized by consumers or other healthcare practitioners. 110

Because of increasing competition in areas involving nutrition, future needs identified included “clear and compelling communication” with consumers to champion the brand of the dietitian above other potential sources of dietary advice. 105 Although consumers reported unfamiliarity with the credentials and training of dietitians, they did not have negative perceptions, so it was noted as beneficial for professional associations to continue to increase familiarity of the dietitian “brand.” 105 From the reviewed literature, we also identified that research was needed on the public perception of dietitians and nutritionists and to find ways to collaborate to provide enhanced clarity in distinguishing the 2 professions. 9

Support systems

Mentoring or professional support..

Mentoring was reported to offer opportunities in the form of enhanced confidence 111 , 112 and competence 112 , 113 and the chance for reflective practice. 111 , 113 These opportunities were noted to lead to improved productivity for both the mentor and mentee. 111 Other beneficial professional supports included working with another dietitian, peer-support networks, professional supervision, or working as part of a multidisciplinary, multicultural team. 112 Future needs identified included experienced and passionate mentors who create a trusting relationship and provide effective feedback. 113

Communities of practice.

Communities of practice were an effective method of increasing competence 114 and confidence to change practice, resulting in workforce retention 115 and development. 114

Protect the scope of practice

Protecting the scope of practice was described as “the greatest challenge” for the dietetic profession. 116 Competition in providing dietary advice and care was described as coming from other healthcare professionals, 19 , 22 whose expertise may have some nutrition overlap, as well as from individuals without academic training. 19

Opportunities within this area include the development of a workforce that adapts to the changing needs of society and whose value is acknowledged, because this type of workforce has less need to be protective of its scope of practice. 22 In addition, the creation of a more fluid scope of practice among healthcare professionals was noted as a way to enhance interdisciplinary collaboration. 21 A shared code of conduct for nutrition science professionals was suggested as a future need, because this may help define and protect the scope of practice. 117

Employment outcomes

Data related to employment outcomes had significant limitations. A comprehensive report from Australia was based on data from 2011, 118 now a decade out of date. From this report, trends indicated that less than half (45%) of individuals with a dietetic qualification worked as a dietitian, while 41% worked in unrelated occupations. 118 Another article reported on dietitians working in the public sector in a single state of Australia (namely, Victoria), 119 making this information biased toward hospital employment. Results from a study of dietitians who graduated from a single university in Canada indicated that employment may be increasingly difficult to obtain and graduates are having to work in rural or remote areas. 120

Registration or credentialing

Challenges faced in countries that were not members of the International Confederation of Dietetic Associations were distinctly different from those faced in countries where registration and credentialing are well established. In Sudan, professionalism and standards of practice were reported to be poorly defined. 121 In Ghana, an inadequate supply of dietitians in some areas and practitioners lacking formal qualifications were identified. 122 In China, a lack of educational opportunities and a poorly defined credentialing system were reported. 123

The purpose of this review was to investigate trends, challenges, opportunities, and future needs of the international dietetic workforce, from a diverse range of sources. The literature identified is predominantly focused on emerging areas of dietetic practice and skill development to meet current and future health nutrition needs of the population. This finding suggests the profession is aware of the need to adapt its skill set to successfully create jobs and have an impact on the changing food, nutrition, and health environments.

The number and scope of articles we identified demonstrate that the dietetics profession is contemplative of its position within society and how effectively it is serving communities. The profession is aware that healthcare delivery and the food and nutrition environment are changing, and is seeking information on how to adapt to these changes. There is considerable published work designed to understand and guide the future path of the profession, 9 , 20–22 with more underway. 23 Similar to the requirement that individual dietitians reflect on their own practice, 1 the profession as a whole appears to be reflective, questioning the place of dietetics within broader contexts.

The 2 most common themes identified in this scoping review were emerging or expanding areas of practice and skill development. Both of these topics have the potential to significantly enhance workforce development. Expansion of the profession into more diverse areas will lead to greater employment opportunities for dietitians, as well as increased capacity to meet the health and nutrition needs of society. Within the identified literature, emerging roles are most commonly presented as a way to expand the influence of the profession 9 and meeting the needs of society across multiple areas of healthcare and the food system. 20 , 21 The literature does not specify if emerging roles are considered important as a way to enhance employment, such as compensating for a lack of traditional roles (eg, clinical positions). Graduate employment data are lacking globally, resulting in a dearth of information regarding supply and demand for traditional roles.

The results of this review demonstrate that the topic of emerging areas of practice has been under discussion for at least a decade. 124 Despite this, dietetic education programs continue to focus on training students for clinical hospital roles, even though the majority of graduates are unlikely to work in this area. 118 Graduates are aware of the incongruence between training programs and employment opportunities, and they identify an overemphasis on clinical dietetics skills to the detriment of business and private practice skills. 103 Dietetics training programs need to reconsider their curricula to ensure training is reflective of workforce opportunities. To do this, it will be essential first to identify employment outcomes. Once these have been identified, training programs can consider implementing more diverse placement experiences to better prepare graduates for these emerging roles. Because teaching programs must meet accreditation standards, these may also need to be redefined to encourage contemporary placement settings.

Nutrition informatics was identified as an emerging area in this study, particularly relevant in light of the recent COVID-19 global pandemic. Large data sets, which can be gathered through informatics, have been identified as a valuable resource to help rapidly develop effective nutrition treatment strategies in situations such as the COVID-19 pandemic. 125 Well-designed mHealth apps can also compliment remote healthcare (eg, telehealth), as has become common during recent pandemic-associatedlockdowns. 126 Informatics will likely continue to be a rapidly expanding area for the dietetic profession as the world adapts to new healthcare models and global trends in technology.

This review has highlighted a significant lack of published workforce data. Although professional registration bodies generally gather information about their members, not all individuals with a dietetic qualification choose to become members of these organizations. Therefore, this information does not adequately capture individuals who take on nondietetic roles, nontraditional roles, those who remain unemployed. or those who choose not to be members. The US Bureau of Labor Statistics gathers workforce data on individuals who identify as working as dietitians; 10 however, as demonstrated in the Australian context, 118 almost half of individuals with a degree in dietetics work outside of the field. In addition, these data do not capture individuals who may be using the skills acquired during their dietetic degree but do not identify their primary role as “dietitian” (eg, academics teaching in dietetic programs). Comprehensive data that track graduates over time are necessary to identify if and why the profession is losing workforce members. These data are also essential to identify the most contemporary emerging areas as well as the potential impact on health and nutrition of populations. This, in turn, could guide the development of additional education priorities, and identification of specific industries in which advocacy can be targeted to enhance employment opportunities (eg, app developers 70 ).

Although graduate outcomes data will help identify current employment opportunities in the short term, ongoing research will also be needed. To remain relevant to consumer needs, more research should focus on what end users (ie, clients, patients, and the community) require from dietitians. If this area is not addressed, it is likely that other individuals will fill these gaps, as has been the case with unqualified social media “experts” providing nutrition information. 127 In addition, knowledge of the needs of the sectors and disciplines that interplay with the food system is required to identify trends, challenges, and opportunities where dietitians may play a role. It is also worth noting that none of the themes identified within this review has been “solved,” and all areas will require more exploration and development to strengthen the position of the dietetics profession. Leadership by the international dietetics community is needed, both in accreditation and training, to ensure the profession is at the forefront of contemporary developments.

Because food and nutrition have a role to play across many contexts and they affect every individual, the potential employment opportunities for dietitians are vast. Emerging employment areas include such diverse settings as policy development, agriculture, the education sector, 84 and social media. 38 By actively expanding the available fields of employment, the profession is embarking on a journey that appears to be unique to dietitians. Without precedent from other health disciplines, it is difficult to know how best to navigate these changes. What is most important is that the conversation is initiated and work begins in implementing the changes necessary to ensure the dietetic profession remains effective and relevant in the long term.

A strength of this review was that we included an international perspective; however, the restriction in publication language may have resulted in exclusion of perspectives from non–English-speaking countries, and, therefore, their perspectives remain unknown. The scoping review format and the inclusion of grey literature also meant that a broad range of opinions was included. However, this may also be a limitation, because the results were not generated solely from high-level evidence.

The global dietetic workforce is a potentially underused resource but recognizes its own need to adapt to the changing nutrition landscape. To understand this situation better, it is essential that professional bodies gather comprehensive workforce data that track graduates over time. This will assist the profession to stay abreast of emerging roles the workforce can use to expand its reach and effectiveness.

The authors express their gratitude to the unknown reviewers of this manuscript for their generous and constructive feedback.

Author contributions: All authors contributed to conceiving the study and to screening and data analysis. M.B. drafted the manuscript, and C.P., L.M., and S.G. provided critical revision. All authors read and approved the final manuscript. No individual meeting the authorship criteria has been omitted.

Funding . M.B. was supported by a scholarship from the Department of Nutrition, Dietetics and Food, Monash University, to undertake this work.

The funder had no input into the conception, design, performance, or approval of the work.

Declaration of interests. The authors have no conflicts of interest to declare.

Supporting information

The following Supporting Information is available through the online version of this article at the publisher’s website.

Table S1 . A complete list of articles, identified through database searches and the Google search engine, that were included in the systematic scoping review of trends, challenges, opportunities, and future needs of the dietetic workforce.

Table S2 . Extended results of topics identified in the systematic scoping review

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Claudia Shwide-Slavin; Case Study: A Patient With Type 1 Diabetes Who Transitions to Insulin Pump Therapy by Working With an Advanced Practice Dietitian. Diabetes Spectr 1 January 2003; 16 (1): 37–40. https://doi.org/10.2337/diaspect.16.1.37

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Registered dietitians (RDs) who have earned the Board Certified–Advanced Diabetes Manager (BC-ADM) credential hold a master’s or doctorate degree in a clinically relevant area and have at least 500 hours of recent experience helping with the clinical management of people with diabetes. 1 They work in both inpatient and outpatient settings, including diabetes or endocrine-based specialty clinics, primary care offices, hospitals, and private practices. Advanced practice dietitians provide all components of diabetes care, including advanced assessment (medical history and physical examination), diagnosis, medical management, education, counseling, and overall case management.

The role of RDs in case and disease management was explored in a recent article 2 that included interviews with three dietitians who work as case managers or disease managers. All three reported experiencing challenges in practice and noted that the meaning of “case management” varies from one health care setting to another. This is also true for RD, BC-ADMs. Advanced practice dietitians specializing in diabetes require case management expertise that stresses communication skills, knowing the limits of your own discipline, knowing how to interact with other health care professionals, and knowing when to seek the expertise of other members of the diabetes care team.

Clinical practice includes assessment and data collection, diagnosis and problem identification, planning, and intervention. In many cases, diabetes educators who are dietitians and those who are nurses are cross-trained to perform the same roles. The first one to meet with a client handles that client’s assessment, and cases are discussed and interventions planned at weekly team meetings.

For advanced practice dietitians, the first session with a client often involves a complete physical assessment, not just a nutrition history. This includes a comprehensive medical history of all body systems. The diabetes-focused physical examination, just as performed by clinicians from other disciplines, includes height and weight measurement, body mass index (BMI) calculation, examination of injection sites, assessment of injection technique, and foot assessment.

Assessment also includes reviewing which medications the client is taking, evaluating their effectiveness and side effects, and determining the need for adjustment based on lifestyle, dietary intake, and blood glucose goals.

When carbohydrate counting is added to therapy, dietitians calculate carbohydrate-to-insulin ratios and teach clients how to use carbohydrate counting instead of a sliding-scale approach to insulin. Medications are adjusted based on clients’ lifestyles until blood glucose goals are achieved.

The therapeutic problem solving, regimen management, case management, and self-management training performed by advanced practice dietitians exceeds the traditional role of most dietetics professionals. 3  

A role delineation study for clinical nurse specialists, nurse practitioners, RDs, and registered pharmacists, 4 conducted in 2000 by the American Nurses Credentialing Center, reported equal findings among all four groups for the skills used to identify pathophysiology, analyze diagnostic tests, and list problems. Assessment for medical nutrition therapy typically includes evaluation of food intake, metabolic status, lifestyle, and readiness to change. For people with diabetes, monitoring glucose and measuring hemoglobin A 1c (A1C), lipids, blood pressure, and renal status are essential to evaluating nutrition-related outcomes.

The U.S. Air Force health care system conducted a pilot test giving RDs clinical privileges and evaluating their clinical judgment in patient nutritional care. A protocol was approved, and dietitians were allowed to order and interpret selected outpatient laboratory tests independently. The higher-level clinical judgments and laboratory privileges were linked to additional certifications. 5  

The Diabetes Prevention Program (DPP) also provided a unique opportunity for dietitians to demonstrate advance practice roles. 6 Dietitians served as lifestyle coaches, contacting participants at least once a month to address intervention goals. As case managers, they interviewed potential volunteers, assessed past experience with weight loss, and scheduled quarterly outcome assessments and weekly reviews of each participant’s progress at team meetings. Within the DPP’s central management, dietitians served as program coordinators and served on national study committees related to participant recruitment and retention, quality control, the use of protocols, and lifestyle advisory groups. 7  

Dietitians now play key roles in translating DPP findings and serving as community advocates to reduce the incidence of obesity and the health care burden of type 2 diabetes. This includes serving in a consultative role to other health care team members on issues regarding weight loss and risk factor reduction.

Advanced practice RDs offer comprehensive diabetes patient care services, including identifying patient goals and expected outcomes, selecting nonpharmacological and pharmacological treatments, and developing integrated plans of care. Problems discussed with patients range from acute and chronic diabetes complications to comorbid conditions, other conditions, preventive interventions, and self-management education. Advanced practice RDs also review patients’ health care resources and order laboratory tests if information is not available from referral sources. They provide supportive counseling and referral to specialists, as needed. And, they provide a full report of their findings and any regimen changes and recommendations they make to referring clinicians after each visit.

These activities and responsibilities go beyond the scope and standards of practice for the RDs and for RD, CDEs. 8 They will be included in the scope of practice document for RD, BC-ADMs that is now being developed by the Diabetes Care and Education Practice Group of The American Dietetic Association.

The following case study illustrates the clinical role of advanced practice dietitians in the field of diabetes.

B.C. is a 51-year-old white man who was diagnosed with type 1 diabetes 21 years ago. He believes that his diabetes has been fairly well controlled during the past 20 years and that his insulin needs have increased. He was recently remarried, and his wife is now helping him care for his diabetes.

His endocrinologist referred him to the RD for an urgent visit because 4 days ago he had a hypoglycemic event requiring treatment in the emergency room (ER). He has come to see the dietitian because his doctor and his wife insisted that he do so.

B.C. has had chronic problems with asymptomatic hypoglycemia. His last doctor’s visit was 3–4 weeks ago, when areas of hypertrophy were found. His endocrinologist asked him to change his injection sites from his thigh to his abdomen after the ER incident.

He does not think he needs any diabetes education but would like help in losing 10 lb. His body mass index is 25 kg/m 2 .

His medications include pravastatin (Pravacol), 10 mg daily; NPH insulin, 34 units in the morning and 13 units at bedtime; and regular insulin at breakfast and dinner following a sliding-scale algorithm. He also takes lispro (Humalog) insulin as needed to correct high blood glucose.

Before his ER visit, B.C. monitored his blood glucose only minimally, testing fasting and sometimes before dinner but not keeping records. Since his severe hypoglycemia 4 days ago, he has begun checking his blood glucose four times a day, before meals and bedtime.

Lab Results

B.C.’s most recent laboratory testing results were as follows:

A1C: 8.3% (normal 4.2–5.9%)

Lipid panel

    • Total cholesterol: 207 mg/dl (normal: 100–200 mg/dl)

    • HDL cholesterol: 46 mg/dl (normal: 35–65 mg/dl)

    • LDL cholesterol: 132 mg/dl (normal: <100 mg/dl)

    • Triglycerides: 144 mg/dl (normal: <150 mg/dl)

Creatinine: 0.9 mg/dl (normal: 0.5–1.4 mg/dl)

Microalbumin: 4 μg (normal: 0–29 μg)

At his initial visit with the RD for crisis management of asymptomatic hypoglycemia, she examined his injection sites and asked if he had made the changes recommended by his clinician. She reviewed his injection technique, diet history, incidence of hypoglycemia, and hypoglycemia treatment methods. She discussed with B.C. ways to reduce his risks of hypoglycemia, including food choices, insulin timing, and absorption variations at different injection sites.

The RD reinforced his clinician’s instruction to avoid old injection sites and added a new recommendation to lower insulin doses because of improved absorption at the new sites.

B.C. was now checking his blood glucose and recording results in a handheld electronic device in a form that could be downloaded, e-mailed, or faxed, but he was not recording his food choices. The dietitian asked him to keep food records and started his carbohydrate-counting education. A follow-up visit was scheduled for 1 week later.

At the second visit, B.C.’s mid-afternoon blood glucose was <70 mg/dl. He did not respond to treatment with 15 g carbohydrate from 4 oz. of regular soda. His blood glucose continued to drop, measuring 47 mg/dl 15 minutes later. He drank another 8 oz. of soda, and his blood glucose increased to 63 mg/dl 1 hour later. He then drank another 8 oz. of soda and ate a sandwich before leaving the dietitian’s office. He called in 1 hour later to report that his blood glucose was finally up to 96 mg/dl.

B.C.’s records showed a pattern of mid-afternoon hypoglycemia. He was willing to add a shot of lispro at lunch to his regimen, so the RD recommended reducing his morning NPH to prevent lows later in the day.

The RD also calculated insulin and carbohydrate ratios for blood glucose correction and meal-related insulin coverage using the “1500 rule” and the “500 rule.”

The 1500 rule is a commonly accepted formula for estimating the drop in a person’s blood glucose per unit of fast-acting insulin. This value is referred to as an “insulin sensitivity factor” (ISF) or “correction factor.” To use the 1500 rule, first determine the total daily dose (TDD) of all rapid- and long-acting insulin. Then divide 1500 by the TDD to find the ISF (the number of mg/dl that 1 unit of rapid-acting insulin will lower the blood glucose level). B.C.’s average TDD was 41 units. Therefore, his estimated ISF was 37 mg/dl per 1 unit of insulin. The RD rounded this up to 40 mg/dl to be prudent, given his history of hypoglycemia.

The 500 rule is a formula for calculating the insulin-to-carbohydrate ratio. To use the 500 rule, divide 500 by the TDD. For B.C., the insulin-to-carbohydrate ratio was calculated at 1:12 (1 unit of insulin to cover every 12 g of carbohydrate), but again this was rounded up to 1:14 for safety. Later, his carbohydrate ratio was adjusted down to 1:10 based on blood glucose monitoring results before and 2 hours after meals.

The RD taught B.C. how to use the insulin-to-carbohydrate ratio instead of his sliding scale to adjust his insulin and asked him to try to follow the new recommendations. With his endocrinologist’s approval, she reduced his NPH doses to 34 units and added a shot of lispro at lunchtime, the dose to be based on the amount of carbohydrate in the meal and his before-meal blood glucose level.

The RD asked B.C. to return in 1 week for evaluation and review of his new regimen. However, 3 days later, he returned after having had another severe episode of hypoglycemia.

In the course of these early visits, a good rapport developed between B.C. and the dietitian. B.C. learned that his judgment on how hypo- and hyperglycemia felt was often inaccurate and led him to make insulin adjustments that contributed to his hypoglycemia problems. By improving B.C.’s understanding of insulin doses and blood glucose responses, the RD hoped to help him become more skilled at making insulin dose adjustments. For the time being, however, he was still at risk for asymptomatic hypoglycemia. He had recently filled a prescription for glucagon, but the RD needed to review and encourage its proper use. She also provided literature to support his wife in case she needed to administer glucagon for him.

At this third visit, the RD reduced B.C.’s morning NPH dose to 22 units because of his rapid drop in blood glucose between noon and 1:00 p.m. This reduction finally eliminated his mid-afternoon lows.

B.C. had started using carbohydrate counting to make his decisions about lunchtime insulin doses. He liked carbohydrate counting because it gave him a more viable reason for testing his blood glucose frequently. Over the years, B.C.’s glycemia had become increasingly difficult to control. He had stopped checking his blood glucose because he felt unable to improve the situation once he had the information. In the early 1990s, his endocrinologist had started him self-adjusting insulin doses using the exchange system, but he found that he was always “chasing his blood sugars.” Carbohydrate counting changed everything. He now knew what to do to improve his blood glucose levels, and that made him feel more in charge of his diabetes.

Still, although carbohydrate counting led to more frequent testing and better blood glucose control than his old sliding scale, it was not perfect. At home, he had mastered this technique, but he ate many of his meals in restaurants, where carbohydrate counting was more challenging.

B.C. found it difficult to carry different types of insulin. This and his lifestyle suggested the need to change his multiple daily injections from regular to lispro insulin. He continued checking his blood glucose before and 2 hours after meals. His insulin-to-carbohydrate ratio of 1:10 g and his ISF of 1:40 mg/dl allowed him to stay within his goal of no more than a 30-mg/dl increase in blood glucose 2 hours after meals. He continued to be asymptomatic of hypoglycemia, but lows occurred less frequently. The new goal of therapy was to recover his hypoglycemia symptoms at a more normal level of about 70 mg/dl. He was scheduled for another visit 2 weeks later.

Between visits to the RD, BC-ADM, his clinician identified problems with the timing of his long-acting insulin peak, resulting in early nocturnal lows. Based on the clinician’s clinical experience of lente demonstrating a slightly smoother peak, she changed B.C.’s long-acting insulin unit-for-unit from NPH to lente.

At B.C.’s next visit, he and the RD reviewed his insulin doses of 22 units of lente in the morning and 11 units of lente at night. His TDD including premeal lispro now averaged 49 units. His average blood glucose levels were 130 mg/dl fasting, 100 mg/dl mid-afternoon, 127 mg/dl before dinner, and 200 mg/dl at bedtime.

The bedtime levels were higher because of late meals, the fat content of restaurant meals, his meat food choices, and his inexperience at counting carbohydrates for prepared foods. The dietitian suggested mixing regular and lispro insulin to try and get the average bedtime blood glucose level to 140 mg/dl. Mixing his calculated dose to be one-third regular and two-third lispro would provide coverage lasting a little longer than that of just lispro to cover higher-fat foods that took longer to digest. At the same time, the dietitian encouraged B.C. to choose lower-fat foods to help reduce his LDL cholesterol and assist with weight loss. B.C. now had an incentive to keep accurate food records to help evaluate his accuracy at calculating insulin doses.

B.C. and the RD also reviewed his decisions for treating lows. At his first meeting, B.C. ate anything and everything when he experienced hypoglycemia, which often resulted in blood glucose levels >400 mg/dl. Now, he was appropriately using 15–30 g of quick-acting glucose—usually 4–8 oz. of orange juice. He based this amount on his blood glucose level, expecting about a 40-mg/dl rise over 30 minutes from 10 g of carbohydrate. He checked his glucose level before treating when possible and always checked 15–30 minutes after treating to evaluate the results. Once his glucose reached 80 mg/dl or above, he either ate a meal or ate 15 g of carbohydrate per hour to prevent a recurrence of hypoglycemia until his next meal.

In completing her assessment during the next few meetings with B.C., the RD identified a problem with erectile dysfunction. She notifed his clinician and referred him to a urologist. Eventually, the urologist diagnosed reduced blood flow and started B.C. on sildenafil (Viagra).

B.C. wanted to resume exercise to help his weight loss efforts. Because exercise improves insulin sensitivity and can acutely lower blood glucose, the dietitian taught B.C. how to reduce his insulin doses by 25–50% for planned physical activity to further reduce his risks of hypoglycemia. He learned to carry his blood glucose meter, fluids, and carbohydrate foods during and after exercise. His pre-exercise blood glucose goal was set at 150 mg/dl. The dietitian instructed B.C. to test his blood glucose again after exercise and to eat carbohydrate foods if it was <100 mg/dl.

She also gave instructions for unplanned exercise. He would require additional carbohydrate depending on his blood glucose level before exercise, his previous experience with similar exercise, and the timing of the exercise. Education follow-ups were scheduled with the dietitian for 1 month later and every 3 months thereafter.

At his next annual eye exam, B.C. discovered that he had background retinopathy. He also reported feeling that his daily injection regimen had become too complicated. Still feeling limited in his ability to control his diabetes and looking for an alternative to insulin injections, he wanted to discuss continuous subcutaneous insulin infusion therapy (insulin pump therapy).

He, his endocrinologist, and his dietitian discussed the pros and cons of pump therapy and how it might affect his current situation. They reviewed available insulin pumps and sets and agreed on which ones would best meet his needs. The equipment was ordered, and a training session was scheduled with the dietitian (a certified pump trainer) in 1 month.

B.C. started using an insulin pump 2 years after his first visit with the dietitian. His insulin-to-carbohydrate ratio was adjusted for his new therapy regimen, and a new ISF was calculated to help him reduce high blood glucose levels. His endocrinologist set basal insulin rates at 0.3 units/hour to start at midnight and 0.5 units/hour to start at 3:00 a.m. This more natural delivery of insulin based on B.C.’s body rhythms and lifestyle further improved his diabetes control.

One week after starting pump therapy, B.C. called the dietitian to report large urine ketones and a blood glucose level of 317 mg/dl. His endocrinologist had changed his basal rates, but he wanted to meet with the dietitian to review his sites, set insertion, troubleshooting skills, and related issues. Working together, they eventually discovered that problems with his pump sites required using a bent-needle set to resolve absorption issues.

B.C’s relationship with his endocrinologist and dietitian was seamless. He met with the dietitian when his clinician was unavailable or when he needed more time to work through problems.

B.C. has met with the RD 15 times over 3 years. Eventually, he recovered symptoms of hypoglycemia when his blood glucose levels were 70 mg/dl. After 6 months of education meetings, his lab values had reached target ranges. Most recently, his LDL cholesterol was <100 mg/dl, his A1C results were <7%, his hypoglycemia symptoms were maintained at a blood glucose level of 70 mg/dl, and his blood glucose had been stabilized using the square-wave and dual-wave features on his insulin pump.

B.C. learned how to achieve recommended goals and to self-manage his diabetes with the help of his care team: endocrinologist, cardiologist, ophthalmologist, podiatrist, urologist, and advanced practice dietitian.

Advanced practice dietitians in diabetes work in many settings and see clients referred from many different types of medical professionals. They may see clients either before or after their appointments with other members of the health care team, depending on appointment availability and their need for nutrition therapy and diabetes education. Referring clinicians rely on their evaluations and findings. When necessary, clinician approval can be obtained for immediate interventions, enhancing the timeliness of care.

Why would an RD want to obtain the skills and certification necessary to earn the BC-ADM credential? The answer, as illustrated in the case study above, lies in their routine use of two sets of skills and performance of two roles: patient education and clinical management.

Dietitians who specialize in diabetes often find that their role expands beyond provider of nutrition counseling. As part of a multidisciplinary team, they become increasingly involved with patient care. As they move patients toward self-management of their disease, they necessarily participate actively in assessment and diagnosis of patients; planning, implementation, and coordination of their diabetes care regimens; and monitoring and evaluation of their treatment options and strategies. They find that their daily professional activities go beyond diabetes education, crossing over into identifying problems, providing or coordinating clinical care, adjusting therapy, and referring to other medical professionals. They often work independently, providing consultation both to people with diabetes and to other diabetes care team members.

The BC-ADM credential acknowledges this professional autonomy while promoting team collaboration and thus improving the quality of care for people with diabetes. The new certification formally recognizes advanced practice dietitians as they move beyond their traditional roles and into clinical problem solving and case management.

Claudia Shwide-Slavin, MS, RD, BC-ADM, CDE, is a private practice dietitian in New York, N.Y.

Note of disclosure: Ms. Shwide-Slavin has received honoraria for speaking engagements from Medtronic Minimed, which manufactures insulin pumps, and Eli Lilly and Co., which manufactures insulin products for the treatment of diabetes.

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Slifka MK, Whitton JL. Clinical implications of dysregulated cytokine production. Dig J Mol Med. 2000; doi:10.1007/s801090000086.

Article within a journal supplement

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Nutrition Journal

ISSN: 1475-2891

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Parenteral Nutrition

Welcome to the Parenteral Nutrition section! Throughout this section, an inpatient case study will be used to enhance your learning and comprehension of parenteral nutrition. You will learn what information to gather for your assessment, how to interpret that data to form a nutrition care plan, how to implement your patient’s care plan, and what to look for when following-up and evaluating your plan. As you progress through the content, please keep in mind that the nutrition care process model used here is dynamic and not a linear, step-by-step process. The case study used here is an example, and not all cases will follow the same path.

Learning Outcomes

By the end of the section you will be able to:

• Identify indications, contradictions, and routes of support to determine the requirement for parenteral nutrition.
• Identify the routes, sites of delivery, and delivery methods of parenteral nutrition.
• Identify how to gather clinical, anthropometric, biochemical, and dietary data necessary to complete a parenteral nutrition assessment.
• Determine a patients energy, protein, and fluid needs using data from the initial assessment.
• Interpret biochemical values, including sodium, potassium, phosphorous, calcium, magnesium, albumin, BUN/urea, and creatinine.
• Identify the role of a total parenteral nutrition (TPN) team or the interdisciplinary team.
• Choose an appropriate parenteral nutrition formulation and plan for a patient.
• Identify a patient a risk of refeeding syndrome and implement procedures to prevent it.
• Identify the complications of parenteral nutrition and understand the appropriate management procedures.
• Understand the key factors in appropriately monitoring the parenteral nutrition care plan.
• Evaluate the nutrition care plan using assessment data relevant to the patients concerns, including malnutrition, symptom management, parenteral nutrition changes, medications, supplements, and the medical plan.

Preparation for Dietetic Practice Copyright © by Megan Omstead, RD, MPH is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.