American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional

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from the association
American Dietetic Association: Standards of Practice
and Standards of Professional Performance forRegistered Dietitians (Competent, Proficient, and

Expert) in Integrative and Functional MedicineDeborah Ford, MS, RD; Sudha Raj, PhD, RD, CDN; Rita Kashi Batheja, MS, RD, CDN;

Ruth DeBusk, PhD, RD, LDN; Dave Grotto, RD, LDN; Diana Noland, MPH, RD;
Elizabeth Redmond, PhD, MMSc, RD, LD; Kathie Madonna Swift, MS, RD, LDN
Editor’s note: Figures 1, 2 and 3 thataccompany this article are availableonline at www.adajournal.org.

The Dietitians in Integrative andFunctional Medicine (DIFM) Di-etetic Practice Group (DPG) of

he American Dietetic AssociationADA), under the guidance of the

D. Ford is owner, Good EarthHealth Nutrition & Fitness, VanWert, OH. S. Raj is a senior part-time instructor, Department ofNutrition Science and Dietetics,College of Human Ecology, Syra-cuse University, Syracuse, NY.R. K. Batheja is in private prac-tice, Baldwin Harbor, NY. R. De-Busk is in private practice, Talla-hassee, FL. D. Grotto is presidentand founder, Nutrition Housecall,LLC, Elmhurst, IL. D. Noland isfaculty/nutrition coordinator, In-stitute for Functional Medicine,Gig Harbor, WA, and in privatepractice, Northridge, CA. E. Red-mond is a technical specialist,Metametrix Clinical Laboratory,Duluth, GA. K. M. Swift is seniornutrition advisor, Optimal Healthand Prevention Research Founda-tion, Pittsfield, MA.

Address correspondence to: ADAQuality Management, AmericanDietetic Association, 120 SouthRiverside Plaza, Suite 2000, Chi-cago, IL 60606-6995. E-mail:[email protected]/$36.00
doi: 10.1016/j.jada.2011.04.017
902 Journal of the AMERICAN DIETETIC ASSOCIATIO

ADA Quality Management Commit-tee and its Scope of Dietetics PracticeFramework Sub-Committee, has de-veloped Standards of Practice (SOP)and Standards of Professional Perfor-mance (SOPP) for Registered Dieti-tians (RDs) in Integrative and Func-tional Medicine (see the Web siteexclusive Figures 1, 2, and 3 atwww.adajournal.org). These documentsbuild on the ADA Revised 2008 SOP forRDs in Nutrition Care and SOPP forRDs (1). ADA’s Code of Ethics (2) andthe 2008 SOP in Nutrition Care andSOPP for RDs are decision toolswithin the Scope of Dietetics PracticeFramework (3) that guide the practiceand performance of RDs in all set-tings. The concept of scope of practiceis fluid (4), changing in response tothe expansion of knowledge, thehealth care environment, and tech-nology. An RD’s legal scope of practiceis defined by state legislation (eg,state licensure law) and differs fromstate to state. An RD may determinehis or her own individual scope ofpractice using the Scope of DieteticsPractice Framework, which takesinto account federal regulations; state

Approved February 2011 by the Qualiican Dietetic Association (ADA) Housmittee of the Dietitians in Integrativetice Group of the ADA. Scheduledregarding the Standards of Practicemance for RDs in Integrative and FuADA quality management staff: ShFADA, director, Quality Management

laws; institutional policies and proce-

N © 2011

dures; and individual competence, ac-countability, and responsibility forhis or her own actions.

ADA’s Revised 2008 SOP in Nutri-tion Care and SOPP reflect the mini-mum competent level of dietetics prac-tice and professional performance forRDs. These standards serve as blue-prints for the development of focusarea SOP and SOPP for RDs in com-petent, proficient, and expert levels ofpractice.

The SOP in Nutrition Care addressthe four steps of the Nutrition CareProcess (NCP) and activities relatedto person-centered care (5). They aredesigned to promote the provision ofsafe, effective, and efficient food andnutrition services, facilitate evidence-based practice, and serve as a profes-sional evaluation resource. The SOPPare authoritative statements that de-scribe a competent level of behavior inthe professional role. Categorized be-haviors that correlate with profes-sional performance are divided intosix separate standards.

These focus area standards are aguide for self-evaluation and expand-ing practice; that is, a means of iden-

anagement Committee of the Amer-f Delegates and the Executive Com-d Functional Medicine Dietetic Prac-view date: June 2016. Questionsd Standards of Professional Perfor-ional Medicine may be addressed ton McCauley, MS, MBA, RD, LDN,[email protected].

ty Me oanreannctaro

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tifying areas for professional develop-

by the American Dietetic Association

http://www.adajournal.org


mailto:[email protected]

mailto:[email protected]

ment. These standards provide a toolfor demonstrating competency in de-livering integrative and functionalmedical nutrition therapy (IFMNT), aterm used by DIFM to identify a typeof medical nutrition therapy incorpo-rating both integrative and functionalmedicine practices for chronic diseaseconditions. They are used by RDs toassess their current level of practiceand to determine the education andtraining required to maintain cur-rency in this focus area and advance-ment to a higher level of practice. Inaddition, the Standards may be usedto assist RDs in transitioning theirknowledge and skills to a new focusarea of practice. Like the SOP in Nu-trition Care and SOPP for RDs, theindicators (measurable action state-ments that illustrate how each stan-dard can be applied in practice; seeFigures 2 and 3, available online atwww.adajournal.org) for the SOP andSOPP for RDs in Integrative andFunctional Medicine were developedwith input and consensus of contentexperts representing diverse practiceand geographic perspectives. TheSOP and SOPP for RDs in Integrativeand Functional Medicine were re-viewed and approved by the Execu-tive Committee of the DIFM DPG, theScope of Dietetics Practice Frame-work Sub-Committee, and ADA’sQuality Management Committee.

THREE LEVELS OF PRACTICECompetent PractitionerIn dietetics, a competent practitioneris an RD who is starting in practiceafter having obtained RD registrationby the Commission on Dietetic Regis-tration or an experienced RD who hasnewly assumed responsibility to pro-vide nutrition care in a new focusarea. A focus area is defined as anarea of dietetics practice that requiresfocused knowledge, skills, and experi-ence. A competent practitioner whohas obtained RD status and is start-ing in professional employment re-quires on-the-job skills as well asengaging in tailored continuing edu-cation to enhance knowledge andskills. This RD starts with techni-cal training and interaction for ad-vancement and expanding breadth ofcompetence. The practice of a compe-tent RD may include responsibilitiesacross several areas of practice, in-
cluding, but not limited to, more than
one of the following: community, clin-ical, consultation and business, re-search, education, and food and nutri-tion management.

Proficient PractitionerA proficient practitioner is an RD whois generally 3 years or more beyondentry level into the profession, whohas obtained operational job perfor-mance skills, and is successful in thechosen focus area of practice. Thisproficient practitioner demonstratesadditional knowledge, skills, and ex-perience in a focus area of dieteticspractice. This RD may acquire spe-cialist credentials, if available, todemonstrate proficiency in a focusarea of practice.

Expert PractitionerAn expert practitioner is an RD whois recognized within the professionand has mastered the highest degreeof skill in or knowledge of a certainfocus or generalized area of dieteticsthrough additional knowledge, expe-rience, and/or training. An expertpractitioner exhibits a set of charac-teristics that include leadership andvision, and demonstrates effective-ness in planning, achieving, evaluat-ing, and communicating targeted out-comes. An expert practitioner mayhave expanded or specialist roles orboth, and may possess an advancedcredential, if available, in a focus areaof practice. The practice often is morecomplex and the practitioner has ahigh degree of professional autonomyand responsibility (6).

These standards, along with theADA’s Code of Ethics (2), answer thequestions: Why is an RD uniquelyqualified to provide IFMNT? Whatknowledge, skills, and competenciesdoes an RD need to demonstrate forthe provision of safe, effective, andquality IFMNT care at the compe-tent, proficient, and expert levels?

OVERVIEWDIFM DPG of ADA represents a focusarea of more than 2,550 memberswho apply their knowledge of integra-tive medicine and functional medi-cine to personalize client care. RDswho practice IFMNT develop and pro-vide person-centered nutrition inter-
ventions in health and chronic dis-
June 2011 ● Journ

ease using two principles. First, theyrecognize that each client has aunique genetic make-up. Second,each client functions in an environ-ment with internal and external fac-tors that influence interactions (7) be-tween the mind, body, and spirit suchas physical, social, and lifestyle fac-tors (8). An IFMNT RD employs asystems assessment of a person’s bio-chemical individuality (9) to develop aplan using the NCP (5). The assess-ment includes information from emerg-ing sciences such as nutritional genom-ics (10) and environmental toxicology.An RD practicing IFMNT may act in-dependently in private practice or aspart of an integrative medicine orfunctional medicine health care team.

Both integrative medicine and fun-ctional medicine are central to thepractice of dietetics practitioners inDIFM. They represent a broader par-adigm of medicine that is person-cen-tered, oriented to healing, and the useof both conventional and complemen-tary therapies. Many practitionersare currently using either an inte-grative or functional medicine ap-proach that is complementary to con-ventional medicine practices, andinclude the major tenets that DIFMRDs embrace (11-13). In addition,they may include safe “alternativemedicine” traditions (eg, use of prod-ucts and practices that are not part ofstandard care such as massage or ho-meopathy). DIFM RDs appreciatethat all individuals have unique met-abolic patterns often based on genet-ics that affect health needs. Thus, theconcept of individuality is central toevery aspect of both integrative andfunctional medicine, from clinical as-sessment and diagnosis to the broadspectrum of prevention and diseasemanagement (14). Client uniquenessencompasses both voluntary activi-ties, such as decision making andemotional responses, and the involun-tary activities of nutrient metabo-lism, cellular processing of informa-tion, and communication betweenorgan systems.

A unique central theme of func-tional medicine used by DIFM RDs inclinical practice is to hear the pa-tient’s story (15) to support clientwell-being and consider the beliefs,attitudes, and motivations, as well asthe physical, mental, and emotionalaspects of the individual. Indeed, the
focus on addressing the root cause of
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disease and focus on preventive careare central tenets of IFMNT. In theintegrative and functional medicineparadigm, optimal health is describedas “something other than the absenceof disease; conceived as an integratedfunction of biology, environment, andbehavior; and measured as a productof physical, mental, social, and spiri-tual variables” (15).

The functional medicine model wasfirst proposed in the early 1980s byJeffrey Bland, PhD (16). This dy-namic, science-based (17) approachconsiders the complex interactionsamong a person’s genetic predisposi-tions, environmental inputs, and life-style to assess, prevent, and treatchronic disease. Internal and external

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904 June 2011 Volume 111 Number 6

core physiological imbalances anddysfunction in physiological systems,including the significant influencethat “long-latency nutritional insuffi-ciencies” (18,19) have on the develop-ment of chronic disease (20). Both in-tegrative medicine and functionalmedicine focus on the biochemicalpathways that are the basis of exten-sive metabolic networks and thegenes that underlie these pathways(21). Nutrients play essential roles inthe cellular metabolism of these net-works that are influenced by a per-son’s unique diet–gene–environmentinteractions throughout the lifetime(22).

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duce a cascade of biological triggerscommonly termed a “snowball effect,”with long-latency effects that can even-tually lead to poor health and chronicillness (18,19,23). To address such sit-uations, IFMNT practitioners use arange of assessment tools in practice.These include a nutrition-focused phys-ical exam (24) and conventional labo-ratory data along with functionaltests (25) to assess the integrity of themetabolic networks and core imbal-ances that may be present. Early in-tervention to address core imbalancesis thought to impede or prevent thesnowball effect. For this reason thetwo types of medicine focus on restor-ing optimal function as well as man-aging symptoms and promoting over-

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The integrative and functionalmedicine approaches were driven ini-tially by consumer demand (26) andare now increasingly accepted byhealth care providers and institutions(15,27). They reaffirm the importanceof the therapeutic relationship, a fo-cus on the whole person and lifestyle,a renewed attention to healing, and awillingness to use all appropriatetherapeutic approaches whether theyoriginate in conventional or alterna-tive medicine (27). IFMNT incorpo-rates varied modalities such as ther-apeutic food elimination diets (28);dietary supplements, including vita-mins, minerals, and botanicals (29,30);gastrointestinal interventions (21,22,30); and detoxification programs (31-

Figure 5. Integrative and Functional Medical NDiana Noland, MPH, RD; and Elizabeth Redmo

33). IFMNT also appreciates the value e

of therapeutic interventions such asyoga, movement, imagery, and medita-tion in holistic health care (34).Through changes in lifestyle, environ-ment, and nutrition, integrative andfunctional medicine nutrition practitio-ners rely on their knowledge of the dy-namic interplay of genetics, biochemi-cal processes, and biological systemsand networks for establishing an inno-vative, holistic nutrition care process(27,35).

The theories and practice of inte-rative and functional medicine haveeveloped over time and are increas-ngly being incorporated into practicey diverse health care professionals27). During the past 30 years, twonstitutions have been leaders in the

ion Therapy (IFMNT) Radial. Reprinted with perPhD, MMSc, RD, LD.

ducation of health care professionals f

June 2011 ● Journ

n these two areas of medicine with aocus on the importance of nutrition.he Arizona Center for Integrativeedicine (34) provides online courses,

onferences, and publications, and of-ers the largest integrative medicalellowship in the United States,hereas The Institute for Functionaledicine (35) offers educational pro-

rams and publications in functionaledicine.The Institute for Functional Medi-

ine proposed the Functional Medi-ine Matrix (Figure 4) (33), as a use-ul tool for practitioners to use inheir assessment and interactionsith clients. The Matrix serves as aractical tool for capturing a patient’story as well as an organized system

sion from Kathie Madonna Swift, MS, RD, LDN;
utrit mis
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terns within the complex symptomscharacteristic of chronic disorders.The Matrix provides a frameworkthat allows practitioners to probe themultiple dimensions involved in pro-moting health and preventing dis-ease. This framework captures infor-mation in three sectors that areimportant to patient health: the pa-tient’s story and an assessment of theantecedents (preceding events), trig-gers (precipitates an event), and me-diators (a substance that promotes areaction) that contributed to a pa-tient’s health status (15); an assess-ment of parameters that supporthealth, such as food and nutrition,exercise and movement, sleep andrest, relationships, meaning, and lifepurpose (27); and an assessment ofparameters such as inflammation bio-markers and body composition typi-cally associated with core physiologi-cal imbalances and chronic diseasedevelopment and perpetuation. Inte-grated throughout this framework isthe honoring of the mind–body–spirit(36) uniqueness of an individual pa-tient.

The IFMNT Radial (Figure 5) (37)has been established by three ad-vanced practice DIFM members as aconceptual framework to assist di-etetics practitioners implementingIFMNT in practice. It is a model forcritical thinking that embraces boththe science and art of personalizednutrition care with consideration ofmultiple conventional or alternativemedicine disciplines. The circular ar-chitecture of the IFMNT Radial al-lows for the evaluation of complexinteractions and interrelationshipsamongst the five key areas of IFMNT(38). The individual is the central fig-ure in a person-centered processbased on the NCP principles of as-sessment, diagnosis, intervention,monitoring, and evaluation. The Ra-dial depicts food as a determining fac-tor in health and disease. Food con-tains the messages of biologicalinformation that influence the fivekey areas of IFMNT: lifestyle, sys-tems (signs and symptoms), core im-balances, metabolic pathways, andbiomarkers. All areas are intercon-nected and influenced by a person’sbiochemical and genetic uniqueness,illustrated by the DNA strands link-ing the five key areas.

The lifestyle circle takes into ac-
count the many factors that an RD

must consider in personalizing nutri-tion care, including access and avail-ability to food, culture and traditions,environment, extent of movement orexercise, stress, and other critical fac-tors. The systems circle representseach of the body systems; a full as-sessment of body systems is donewith a hands-on nutrition-focusedphysical exam (24). Biomarkers canhelp to further evaluate abnormali-ties found in the nutrition physicalexam or any of the systems (39). Be-sides establishing the status of a sin-gle nutrient, reviewing biochemicalassessments can give information onthe functions of metabolic pathwaysor networks when interpreted withinthe clinical context in either health ordisease. Metabolic pathways aredriven by enzymes, the majority de-pendent on micronutrient cofactorsthat can be evaluated with biomarkerassessments (25,39).

In addition, a person’s micronutri-ent status can affect metabolic func-tion because the body prioritizesavailable micronutrients for the mostimportant functions (18,40). Al-though the effects of this prioritiza-tion may be insignificant in the timeframe of days or months, such rank-ing may contribute to chronic condi-tions, antioxidant stress, and prema-ture aging (40) over years andthroughout the life cycle. Cliniciansinvolved in IFMNT must become wellversed in nutritional biochemistry tofully understand these long latencyeffects.

The core clinical imbalances con-centrate and summarize the findingsfrom each of the other circles, identi-fying their relationships to health.Imbalances in these core regions canhave far-reaching effects and are acentral foundation in IFMNT. Sur-rounding the Radial are precipitatingfactors such as food allergens and in-tolerances (21), negative thoughtsand beliefs (41,42), pathogens, andenvironmental exposures (43). Thesefactors can adversely affect an indi-vidual and may result in specific mea-surable biomarkers indicating imbal-ance in body systems, pathways, andnetworks. The metabolic impact var-ies, depending on genetic uniquenessand cellular integrity. An individual’sability to respond to external antago-nists is also dependent on lifestyle
factors (eg, food, culture, environ-
ment, movement, sleep, and stress)that determine resiliency.

BACKGROUND OF DIFM DPGThis group, previously known as theNutrition in Complementary CareDPG, was originally established in1998 by a group of RDs interested inbroadening their skill sets in topicssuch as nutritional genomics, func-tional foods, dietary supplements(44), and ancient traditions (33) suchas Chinese dietary therapy andAyurveda. These topics were re-searched and discussed at profes-sional meetings and in DPG newslet-ters. The DPG changed its name toDIFM in September 2009 to more de-finitively reflect the expertise of RDsin integrative and functional medicalnutrition therapy. The vision of theDIFM DPG is to optimize health andhealing through integrative and func-tional medicine nutrition practices;the long-range mission is to empowermembers to be leaders in personal-ized genomics, holistic care, and inte-grative and functional nutrition ther-apies (the DIFM DPG strategic planis available at www.IntegrativeRD.org). Strategies to achieve this mis-sion include:

● Disseminating information aboutnew and emerging technologiessuch as nutritional genomics;

● Incorporating recent research intoenvironmental toxins’ affect onhealth (43); and

● Building collaborative partnershipswithin the integrative and func-tional medicine communities.

Examples of partnerships includethe Institute for Functional Medicine,Arizona Center for Integrative Medi-cine, American Botanical Council,Omega 3 Learning Institute, andthe Center for Mind-Body Medicine.These partnerships allow for access tovaluable educational opportunitiesand often include substantial dis-counts on professional conferences,webinars, newsletters, and onlinecourses for members of the DPG. Inaddition, DIFM encourages collabora-tive work with these partnershipsand others for further research anddevelopment of evidence-based proto-cols and practice guidelines for inte-grative and functional medicine. Formore information on collaborative part-
nerships, visit www.IntegrativeRD.org.
http://www.IntegrativeRD.org



as Pro

FUTURE DIRECTIONSThe SOP and SOPP for RDs in Inte-grative and Functional Medicine areinnovative and dynamic documents.Future revisions will reflect changesin practice, dietetics education pro-grams, and outcomes of practice au-dits. This focus area will continue toevolve with new and expanded roles,pushing the envelope to incorporatenew scientific and technological ad-vances. Educational and credential-ing opportunities are significant be-cause the foundational knowledgeand necessary skills are growing atan exponential rate. The three prac-tice levels require more clarity anddifferentiation in content, context,and role delineation and competencystatements that better characterizedifferences among the practice levelsare needed. Creation of this clarity,differentiation, and definition are to-day’s challenges to better serve to-morrow’s practitioners and their pa-tients, clients, and customers.

DIFM DPG anticipates the develop-ment of a specialist certification forRDs in integrative and functional med-icine in collaboration with the Councilon Future Practice and the Commis-sion on Dietetic Registration, which

How to Use the Standards of Practice and SExpert) in Integrative and Functional Medicin

1. Reflect

2. Conduct learning needs assessment

3. Develop learning plan

4. Implement learning plan

5. Evaluate learning plan process

aThe Commission on Dietetic Registration Professional De5-year recertification cycle and succeeding cycles.

Figure 6. How to Use the Standards of PractiExpert) in Integrative and Functional Medicine

would enhance the role of the RD in

health care and empower members tobe leaders in the field of IFMNT.

ADA SOP AND SOPP FOR RDs(COMPETENT, PROFICIENT, EXPERT) ININTEGRATIVE AND FUNCTIONAL MEDICINEAn RD may use the SOP and SOPP(competent, proficient, expert) for RDsin Integrative and Functional Medicine(see the Web site exclusive Figures 1, 2,and 3 at www.adajournal.org) to:

● identify the competencies needed toprovide IFMNT;

● self-assess if he/she has the appro-priate knowledge base and skills toprovide safe and effective IFMNTfor their level of practice;

● identify the areas in which addi-tional knowledge and skills areneeded to practice at the compe-tent, proficient, or expert level ofIFMNT;

● provide a foundation for publicand professional accountability inIFMNT;

● assist in the planning of IFMNTand resources;

● enhance professional identity andcommunicate the nature of IFMNT;

● guide the development of IFMNT-

ards of Professional Performance for Registers part of the Professional Development Portfol

Assess your current level of practice and whor maintain your current level of practice.Standards of Professional Performance dofuture practice to be, and assess your stredocuments can help you set short- and lo

Once you have identified your future practicePractice and Standards of Professional Perknowledge, skills, behaviors, and define wrequired to achieve the desired level of pr

Based on your review of the Standards of PrPerformance, you can develop a plan to ayour desired level of practice. Your learninspecialist credential.

As you implement your learning plan, keep rStandards of Professional Performance dobehaviors and your desired level of practic

Once you achieve your goals and reach or mimportant to continue to review the StandaPerformance document to re-assess knowof practice.

ment Portfolio process is divided into five interdependent ste

nd Standards of Professional Performance forpart of the Professional Development Portfolio

related education and continuing

June 2011 ● Journ

education programs, job descrip-tions, and career pathways; and

● assist educators and preceptors inteaching dietetic students and in-terns the knowledge, skills, andcompetencies needed to work inIFMNT and the understanding ofthe full scope of this focus area ofdietetics (13,45,46).

APPLICATIONS TO PRACTICEThe Dreyfus model identifies levels ofproficiency (ie, novice, advanced be-ginner, competent, proficient, and ex-pert) (refer to Figure 1, available on-line at www.adajournal.org) duringthe acquisition and development ofknowledge and skills (47). This modelis helpful in understanding the levelsof practice described in the SOP andSOP for RDs in Integrative and Func-tional Medicine. In the SOP andSOPP for RDs in Integrative andFunctional Medicine, the levels arerepresented as competent, proficient,and expert practice levels.

All RDs, even those with significantexperience in other practice areas,must begin at the competent levelwhen practicing in a new setting. Atthe competent level, an RD in integra-

Dietitians (Competent, Proficient, androcessa

r your goals are to expand your practiceiew the Standards of Practice andent to determine what you want yourhs and areas for improvement. Theseterm professional goals.als, you can review the Standards of

ance document to assess your currentcontinuing professional education is

ce.ce and Standards of Professionalss your learning needs as they relate to

lan may include a goal to obtain a

wing the Standards of Practice andent to re-assess knowledge, skills, and

tain your desired level of practice, it isof Practice and Standards of Professionale, skills, behaviors, and your desired level

hat build sequentially upon the previous step during each

gistered Dietitians (Competent, Proficient, andcess.

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ing the principles that underpin thisfocus area and is developing skills forsafe and effective IFMNT. This RD,who may be an experienced RD ormay be new to the profession, has abreadth of knowledge in nutritionoverall and may have proficient or ex-pert knowledge/practice in anotherfocus area. However, an RD new tothe focus area of IFMNT may experi-ence a steep learning curve.

At the proficient level, an RD hasdeveloped a deeper understandingof IFMNT and is better equipped toapply evidence-based guidelines andbest practices than at the competentlevel. This RD is also able to modifypractice according to unique situa-tions. An RD at the proficient levelmay possess a specialist credential.

At the expert level, an RD thinkscritically about IFMNT, demonstratesa more intuitive understanding of

Figure 7. Case examples of Standards of P(Competent, Proficient, and Expert) in Integrati

IFMNT, displays a range of highly de-


veloped clinical and technical skills,and formulates judgments acquiredthrough a combination of experienceand education. An RD at the expertlevel may possess an advanced cre-dential, if applicable. Essentially,practice at the expert level requiresthe application of composite dieteticsknowledge, with practitioners draw-ing not only on their clinical experi-ence, but also on the experience of theDIFM RDs in various disciplines andpractice settings. Experts, with theirextensive experience and ability tosee the significance and meaning ofIFMNT within a contextual whole arefluid and flexible and, to some degree,autonomous in practice. They notonly implement IFMNT, they alsodrive and direct clinical practice, con-duct and collaborate in research, con-tribute to multidisciplinary teams,and lead the advancement of IFMNT.

ice (SOP) and Standards of Professional Perand Functional Medicine.

Indicators for the SOP (Figure 2,

available online at www.adajournal.org)and SOPP (Figure 3, available onlineat www.adajournal.org) for RDs in In-tegrative and Functional Medicineare measurable action statementsthat illustrate how each standardmay be applied in practice. Withinthe SOP and SOPP for RDs in Inte-grative and Functional Medicine, anX in the competent column indicatesthat an RD who is working with cli-ents is expected to complete this ac-tivity and/or seek assistance to learnhow to perform at the level of thestandard. A competent RD in IFMNTcould be an RD starting practice afterregistration or an experienced RDwho has recently assumed responsi-bility to provide IFMNT care to cli-ents. An X in the proficient columnindicates that an RD who performs atthis level has a deeper understandingof IFMNT and has the ability to mod-

ance (SOPP) for Registered Dietitians (RDs)
ract form
ify the specifics of the NCP to meet



the needs of clients in various situa-tions (eg, assessment tools, diagnosticanalysis, therapeutic interventions,and monitoring and evaluation ap-proaches). A proficient RD may hold aspecialist credential (46,48). An X inthe expert column indicates that anRD who performs at this level pos-sesses a comprehensive understand-ing of IFMNT and a highly developedrange of skills and judgments ac-quired through a combination of ex-perience and education in IFMNT,genomics, nutritional biochemistry,functional laboratory testing, theo-ries of long latency nutritional insuf-ficiencies and nutritional systemsbiology, nutrition modulated detoxifi-cation, and other integrative andfunctional medicine areas (48,49). Anexpert RD builds and maintains thehighest level of knowledge, skills, andbehaviors, including leadership, vi-sion, and credentials.

Standards and indicators pre-sented in Figure 2 and Figure 3 inboldface type originate from ADA’s2008 SOP in Nutrition Care andSOPP for RDs (1) and should apply toRDs in all three levels. Several indi-cators developed for this focus areanot in boldface type are identified asapplicable to all levels of practice.Where Xs are placed in all three lev-els of practice, it is understood thatall RDs in DIFM are accountable forpractice within each of these indica-tors. However, the depth with whichan RD performs each activity will in-crease as the individual moves be-yond the competent level. Several lev-els of practice are considered in thisdocument, thus taking a holistic viewof the SOP and SOPP for RDs in In-tegrative and Functional Medicine, iswarranted. It is the totality of individ-ual practice that defines the level ofpractice and not any one indicator orstandard.

RDs should review the SOP andSOPP for RDs in Integrative andFunctional Medicine at regular inter-vals to evaluate individual knowledgeof IFMNT, skill, and competence.Regular self-evaluation is importantbecause it helps identify opportuni-ties to improve and/or enhance practiceand professional performance. Thisself-appraisal also enables DIFM dieti-tians to better utilize the Commissionon Dietetic Registration’s ProfessionalDevelopment Portfolio (50) for self-as-
sessment, planning, improvement,
and commitment to lifelong learning.These Standards may be used in eachof the five steps in the ProfessionalDevelopmental Portfolio process (Fig-ure 6). RDs are encouraged to pursueadditional training, regardless ofpractice setting, to maintain currencyand to expand individual scope ofpractice within the limitations of thelegal scope of practice, as defined bystate law. RDs are expected to prac-tice only at the level at which they arecompetent, and this will vary depend-ing on education, training, and expe-rience (51). RDs are encouraged topursue additional knowledge andskill training regardless of practicesetting to promote consistency inpractice and performance and contin-uous quality improvement. See Fig-ure 7 for case examples of how RDs indifferent roles, at different levels ofpractice, may use the SOP and SOPPfor RDs in Integrative and FunctionalMedicine.

In some instances, components ofthe SOP and SOPP for RDs in Inte-grative and Functional Medicine donot specifically differentiate betweenproficient and expert levels of prac-tice. In these areas, it was the consen-sus of the content experts that thedistinctions are subtle, captured inthe knowledge, experience, and intu-ition demonstrated in the context ofpractice at the expert level, whichcombines dimensions of understand-ing, performance, and value as an in-tegrated whole (52). A wealth ofknowledge is embedded in the experi-ence, discernment, and practice of ex-pert-level RDs. The knowledge andskills acquired through practice willcontinually expand and mature. Theindicators will be refined as expert-level RDs systematically record anddocument their experience using theconcept of clinical exemplars. Clinicalexemplars include a brief descriptionof the need for action and the processused to change the outcome. An expe-rienced practitioner observes clinicalevents, analyzes them to make newconnections between events and ideas,and produces a synthesized whole.Clinical exemplars (48,53,54) provideoutstanding models of the actions ofRDs in integrative and functionalmedicine in a clinical setting and theprofessional activities that have en-
hanced person-centered care.
June 2011 ● Journ

CONCLUSIONSThe SOP and SOPP for RDs in Inte-grative and Functional Medicine arecomplementary, dynamic documentsand are key resources for RDs at allknowledge and performance levels.These standards can and should beused by RDs in daily practice to con-sistently improve and appropriatelydemonstrate competency and valueas providers of safe and effective nu-trition care. These standards alsoserve as a professional resource forself-evaluation and professional de-velopment for RDs specializing inIFMNT practice. Just as a profession-al’s self-evaluation and continuingeducation process is an ongoing cycle,these standards are also a work inprogress and will be reviewed and up-dated every 5 years. Current and fu-ture initiatives of ADA, along withpractice changes in conventional andalternative medicine and IFMNT,will further clarify and document thespecific roles and responsibilities ofRDs at each level of practice. As aquality initiative of ADA and theDIFM DPG, these standards are anapplication of continuous quality im-provement and represent an impor-tant collaborative endeavor.

The authors thank Sylvia Escott-Stump, MA, RD, LDN, for her reviewof the documents; Tatyana El-Kour,MS, RD, CNSC, and Rick Hall, PhD,

These standards have been formu-lated to be used for individual self-evaluation and the development ofpractice guidelines, but not for in-stitutional credentialing or for ad-verse or exclusionary decisions re-garding privileging, employmentopportunities or benefits, disciplin-ary actions, or determinations ofnegligence or misconduct. Thesestandards do not constitute medi-cal or other professional advice,and should not be taken as such.The information presented inthese standards is not a substitutefor the exercise of professionaljudgment by a health care profes-sional. The use of the standards forany other purpose than that forwhich they were formulated mustbe undertaken within the sole au-thority and discretion of the user.

RD, for their initial involvement in


.

the Work group; and Patricia Stein-muller, MS, RD, CSSD, LN, memberof the Scope of Dietetics PracticeFramework Sub-Committee of theQuality Management Committee, whoserved as advisor to DIFM and pro-vided valuable input.

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GLOSSARY OF TERMS

Ayurvedic: A system of traditional medicine from India that aims for the knowledge for a long life. Ayurveda promotes abalance of the three bodily humors or doshas called vata, pita, and kapha. It is generally practiced as complementary toconventional medicine. Ayurveda emphasizes good health and prevention and treatment of illness through lifestyle practices(such as massage, meditation, yoga, and dietary changes) and the use of herbal remedies.

Biomarkers: A biological marker, usually a substance or behavioral or phenotypic indicator of a person’s biological ormetabolic state (33).

Biotransformation: Chemical alteration of a compound (eg, drug, food, or toxin) occurring within the body, as by catalyticaction of enzyme activity. Often referring to the conversion of toxic substances into non-toxic metabolites (and subsequentexcretion), which primarily takes place in the liver and intestinal mucosal wall (33).

Core Clinical Imbalances: Imbalances that arise from malfunctions within the body as a result of multiple influencingfactors including genetics, diet, toxicants, pathogens, allergens, stress, trauma. They include:

● Cellular integrity● Digestion● Detoxification● Energy metabolism● Inflammation/oxidative stress● Neuro-endocrine-immune● Nutritional status (33,35,37)

Detoxification: A practice to help increase excretion of toxins, and can include saunas, exercise, targeted supplements,massages, and dietary inclusions and restrictions. Limited research has evaluated specific protocols (55). A complete detoxifi-cation program focuses on three targets: restore gut functioning, reduce toxins like heavy metals and organic chemicals storedin fat tissue, and assisting the body’s natural detoxification systems (56).

Dietary Supplements: Nutritional and botanical products that supplement the diet, containing either alone, or in combi-nation, one of the following components: vitamins, minerals, herbs, amino acids, or any concentrates or extracts of thesesubstances. Additional substances can include herbs or other botanicals, enzymes, probiotics, glandulars, fatty acids, etc. Theycan be extracts or concentrates, and may be found in many forms such as tablets, capsules, softgels, gelcaps, liquids, powdersand topical creams (57). When working with licensed practitioners, prescription intramuscular and/or intravenous solutions canalso be used (eg, intramuscular B-12 injections, intravenous vitamin C) (58).

Evidence-based/practice guidelines: Determined by scientific evidence. Practice guidelines are systematically developedstatements to assist practitioner and patient decisions about appropriate health care (17,59,60).

Eicosanoid series: Signaling molecules derived from either n-3 (�-3) or n-6 (�-6) essential fatty acids (EFAs). They act ininflammation, immunity, or as messengers in the central nervous system (61-63).

Fasting: A detoxification practice that is based on food elimination for a designated period of time and may include the useof dietary supplements and/or medical foods. Supervised fasting programs may have benefits on liver, cognitive function, andimmune function (56).

Functional laboratory testing: Tests that are used to evaluate impaired physiological processes or functions. These testsmay include but are not limited to: organic acids, red blood cell minerals, amino acids, oxidative stress and antioxidant status(8-hydroxy-2deoxygaunosine, lipid peroxides), stool analysis (intestinal bacteria, parasites, elastase 1), genomic biomarkers(SNPs), inflammatory markers (hsCRP, lactoferrin), urine toxic elements, etc (25,33).

Functional food: The American Dietetic Association defines functional foods as those that “move beyond necessity to provideadditional health benefits that may reduce disease risk and/or promote optimal health. Functional foods include conventionalfoods, modified foods (fortified, enriched or enhanced), medical foods and foods for special dietary uses” (64).

Functional medicine: A systems-biology based approach to individualized medicine that focuses on underlying causes ofdisease; the clinical application of systems and lifestyle medicine to chronic disease that is grounded in the following principles:

● Biochemical individuality describes the importance of individual variations in metabolic function that derive from geneticand environmental differences among individuals.

● Patient-centered medicine emphasizes “patient care” rather than “disease care,” following Sir William Osler’s admonitionthat “It is more important to know what patient has the disease than to know what disease the patient has.”

● Dynamic balance of internal and external factors.● Web-like interconnections of physiological factors—an abundance of research now supports the view that the human body

functions as an orchestrated network of interconnected systems, rather than individual systems functioning autonomouslyand without affect on each other. For example, immunological dysfunctions impacting cardiovascular disease, dietaryimbalances affecting hormonal disturbances, and environmental exposures precipitating neurologic conditions such asParkinson’s disease.

● Health as a positive vitality—not merely the absence of disease.● Promotion of organ reserve as the means to enhance health span, not just the life span, of each patient (33,35,37).

Genomics: Genomics refers to the study of the entire genome of an organism whereas genetics refers to the study of aparticular gene (65,66). Note: gene–environment interactions are only a part of genomics.

Genetic testing: The use of genetic information to identify genes associated with various diseases and metabolic impair-ments. Genetic tests can be done to confirm a suspected diagnosis, to predict the possibility of future illness, to detect thepresence of a carrier state in unaffected individuals (whose children may be at risk), and to predict response to therapy (66).

Note: Genomic testing is to test the whole genome; the testing currently used looks only at specific genes.


Holistic: Practices that focus on interventions encompassing the “whole” individual with consideration of the person’semotions, beliefs, values, diet, environment, relationships, and lifestyle as well as his or her physical symptoms (67,68).

Integrative medicine: Patient-centered, healing-oriented medicine that embraces conventional and complementary thera-pies. Integrative medicine reaffirms the importance of the therapeutic relationship, a focus on the whole person and lifestyle, arenewed attention to healing, and a willingness to use all appropriate therapeutic approaches whether they originate inconventional or alternative medicine (34,69).

Integrative and functional medicine: Sharing a systems biology (70,71) approach to health care, both types of medicineencompass patient-centered, healing-oriented medicine that embraces conventional and complementary therapies. They repre-sent a broader paradigm of medicine than the current dominant biomedical model. They were driven initially by consumerdemand and are now increasingly accepted by health care providers and institutions. There are other terms describing thisparadigm: personalized medicine, anti-aging, nutritional medicine, biological medicine, and a growing list of others (27).

Lifestyle: A person’s way of life encompassing diet, physical activity, beliefs, relationships, food security, lifetime toxicexposure, environment, and social attitudes. There is increasing evidence in public health statistics that lifestyle is stronglyassociated with the risk of chronic diseases (27).

Long latency nutritional insufficiencies: A theory that postulates long-term nutrient inadequacies or micronutrientdeficiencies can accelerate molecular aging, including DNA damage, and mitochondrial decay, which may contribute to thedevelopment of major chronic diseases (18,19).

Medical Symptom Questionnaire (MSQ): A nonvalidated questionnaire used to assess and monitor a patient’s level ofsymptoms (72).

Methylation: Denotes the addition of a methyl group (CH3). In biological systems, methylation is a critical process ofmetabolism. It is also involved in gene expression, as well as modification of heavy metals and RNA metabolism (25,70).

Metabolic pathways and networks: Each cell of any living organism involves biochemical metabolic pathways that are aseries of chemical reactions. Essential and nonessential nutrients are indispensable for the function of these pathways andnetworks. The study of these pathways can produce focused and effective intervention strategies in restoring optimum cellularfunction (25,73).

Nutritional genomics: The study of how foods affect the expression of genetic information in an individual and how anindividual’s genetic makeup metabolizes and responds to nutrients and bioactives (74).

Nutritional Systems Biology: The concept of describing the complete molecular physiological processes linking genetics,environment, and nutrition. Nutritional systems biology aims to exploit complete datasets on transcriptome, proteome, andmetabolome levels, targeting a new concept of biomarker in disease prevention (66,75,76).

Organic Acids: Products of metabolism that can sensitively identify nutrient deficiencies and core clinical imbalances thatlead to metabolic roadblocks. Traditionally they were used for detection of neonatal inborn errors of metabolism, includingmitochondrial disorders (eg, a deficiency of vitamin B-12 produces high levels of a urinary organic acid called methylmalonicacid). Other organic acids can show deficiencies of vitamin B-1, vitamin B-6, folic acid, and many other metabolic networks(25,77,78).

Phthalates: Industrial chemicals that are added to plastics to impart flexibility and resilience. Health effects from phthalatesat low environmental doses or at biomonitored levels from low environmental exposures are unknown. Dietary sources have beenconsidered as the major exposure route (79).

Psychoneuroendoimmunology (PNI): Psychological, neurological, endocrine, and immunological relationships and net-works in the pathophysiology of health and disease (80).

Resilience: Able to ’spring back’ into shape after being deformed. To be emotionally resilient means to be able to spring backemotionally and physically after suffering through difficult and stressful times in one’s life (27).

Science-based: Based on peer-reviewed science and evidence based research (see Evidence-based/practice guidelines)(17,27,59,60,69).

Single Nucleotide Polymorphism (SNPs): DNA sequence variations that occur when a single nucleotide (A, T, C, or G) inthe genome sequence is altered. SNPs are actively being investigated to find ways to personalize drug and dietary recommen-dations (81).

Systems: Complex biological metabolic systems of the body continually are invoked to establish and maintain homeostasisand function (71). The process of healing is defined as the process of recovery, repair, and reintegration resulting from all thesystems of the whole body progressing toward wellness and maintenance of well-being (69,82). Systems approach is the basis ofthe paradigms of systems biology medicine used in clinical practice without “claiming specific or direct casual links to disease,because they target inherent adaptogenic responses and assume that redundancy and multiple pathways are an inherentcharacteristic of every system” (27).

June 2011 ● Journal of the AMERICAN DIETETIC ASSOCIATION 913

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Figure 1. Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in ntegrative and Functional Medicine.
June 2011 ● Journal of the AMERICAN DIETETIC ASSOCIATION 913.e1

Figure 2. Standards of Practice for Registered Dietitians in Integrative and Functional Medicine.

913.e2 June 2011 Volume 111 Number 6

Figure 2. Standards of Practice for Registered Dietitians in Integrative and Functional Medicine. (Continued)




















Figure 3. Standards of Professional Performance for Registered Dietitians in Integrative and Functional Medicine.


Figure 3. Standards of Professional Performance for Registered Dietitians in Integrative and Functional Medicine. (Continued)




















Documents

American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional