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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2010.08.022 Byline: Becky Dorner Abstract: It is the position of the American Dietetic Association that the quality of life and nutritional status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets. The American Dietetic Association advocates for registered dietitians to assess and evaluate the need for nutrition interventions tailored to each person's medical condition, needs, desires, and rights. Dietetic technicians, registered, assist registered dietitians in the assessment and implementation of individualized nutrition care. Health care practitioners must assess risks vs benefits of therapeutic diets, especially for older adults. Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in undernutrition and related negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life. The Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities provides guidance to practitioners on implementation of individualized diets and nutrition care.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2010.04.017 Byline: Beverly J. McCabe-Sellers Abstract: It is the position of the American Dietetic Association that medical nutrition therapy (MNT), as a part of the Nutrition Care Process, should be the initial step and an integral component of medical treatment for management of specific disease states and conditions. If optimal control cannot be achieved with MNT alone and concurrent pharmacotherapy is required, the Association promotes a team approach and encourages active collaboration among registered dietitians (RDs) and other health care team members. RDs use MNT as a cost-effective means to achieve significant health benefits by preventing or altering the course of diabetes, obesity, hypertension, disorders of lipid metabolism, heart failure, osteoporosis, celiac disease, and chronic kidney disease, among other diseases. Should pharmacotherapy be needed to control these diseases, a team approach in which an RD brings expertise in food and nutrition and a pharmacist brings expertise in medications is essential. RDs and pharmacists share the goals of maintaining food and nutrient intake, nutritional status, and medication effectiveness while avoiding adverse food-medication interactions. RDs manipulate food and nutrient intake in medication regimens based on clinical significance of the interaction, medication dosage and duration, and recognition of potential adverse effects related to pharmacotherapy. RDs who provide MNT using enhanced patient education skills and pharmacotherapy knowledge are critical for successful outcomes and patient safety.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2009.12.021 Byline: Doina Kulick, Lisa Hark, Darwin Deen Abstract: Between 1998 and 2004, the total number of bariatric procedures increased almost 10-fold, from 13,386 procedures in 1998 to 121,055 in 2004. Current estimates suggest the number of bariatric operations will exceed 220,000 in 2010. Bariatric surgery encompasses several surgical techniques classified as restrictive or malabsorptive, based on the main mechanism of weight loss. Clinical studies and meta-analyses show that bariatric surgery decreases morbidity and mortality when compared with nonsurgical treatments. A successful long-term outcome of bariatric surgery is dependent on the patient's commitment to a lifetime of dietary and lifestyle changes. The registered dietitian (RD) is an important member of the bariatric team and provides critical instructions to help patients adhere to the dietary changes consistent with surgery. Referencing current literature, this article outlines the indications, contraindications, and types of bariatric surgery. The role of the RD for preoperative and postoperative nutrition assessment and medical nutrition therapy is highlighted. Management of long-term nutrition issues is also reviewed. The current recommendations include a multivitamin/mineral supplement plus vitamin B-12, calcium, vitamin D-3, iron, and folic acid. Given the increasing prevalence of obesity and bariatric surgery procedures, caring for patients who have undergone surgery will be an expanding role for the RD. Close postoperative follow-up and careful monitoring will improve the odds for successful surgical outcomes, and RDs play a very important part in this process. Article History: Accepted 3 August 2009

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2009.11.017 Byline: Jared R. Gower, Laurie J. Moyer-Mileur, Robert D. Wilkinson, Hillarie Slater, Kristine C. Jordan Abstract: Limited surveys are available to assess the nutrition knowledge of children. The goals of this study were to test the validity and reliability of a computer nutrition knowledge survey for elementary school students and to evaluate the impact of the "Fit Kids 'r' Healthy Kids" nutrition intervention via the knowledge survey. During survey development, a sample (n=12) of health educators, elementary school teachers, and registered dietitians assessed the survey. The target population consisted of first- through fourth-grade students from Salt Lake City, UT, metropolitan area schools. Participants were divided into reliability (n=68), intervention (n=74), and control groups (n=59). The reliability group took the survey twice (2 weeks apart); the intervention and control groups also took the survey twice, but at pre- and post-intervention (4 weeks later). Only students from the intervention group participated in four weekly nutrition classes. Reliability was assessed by Pearson's correlation coefficients for knowledge scores. Results demonstrated appropriate content validity, as indicated by expert peer ratings. Test-retest reliability correlations were found to be significant for the overall survey (r=0.54; P<0.001) and for all subscales: food groups, healthful foods, and food functions (r=0.51, 0.65, and 0.49, respectively; P<0.001). Nutrition knowledge was assessed upon program completion with paired samples t tests. Students from the intervention group demonstrated improvement in nutrition knowledge (12.2[+ or -]1.9 to 13.5[+ or -]1.6; P<0.001), while scores for the control group remained unchanged. The difference in total scores from pre- to post-intervention between the two groups was significant (P<0.001). These results suggest that the computerized nutrition survey demonstrated content validity and test-retest reliability for first- through fourth-grade elementary school children. Also, the study results imply that the Fit Kids 'r' Healthy Kids intervention promoted gains in nutrition knowledge. Overall, the computer survey shows promise as an appealing medium for assessing nutrition knowledge in children. Article History: Accepted 13 August 2009

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2009.10.030 Byline: Alex R. Kemper, Cheryl A. Brewer, Rani H. Singh Abstract: Adherence to highly restrictive diets is critical for women of childbearing age who have inborn errors of metabolism such as phenylketonuria. The purpose of this study was to explore attitudes about diet, barriers to and facilitators of dietary adherence, and experiences with the health care system in promoting dietary adherence among adolescent and adult women with inborn errors of metabolism to identify policy-level interventions to improve adherence. We analyzed the results of four focus groups including a total of 19 women between the ages of 12 and 52 years with phenylketonuria, methylmalonic acidemia, or maple syrup urine disease attending an educational summer camp in 2008. Themes were identified after independent analysis of transcripts. Most participants were highly knowledgeable about their dietary requirements and some could describe their own specific negative experiences of nonadherence. Many reported specific challenges, such as feelings of being different, that they experienced in elementary and middle school. Friends and family play an important role in maintaining dietary adherence. Participants identified one registered dietitian in particular who has played an important supportive role. Insurance coverage for medical foods was a common concern. Most participants identified concerns about transitioning from pediatric to adult medical services. We identified four specific strategies for future evaluation that may improve dietary adherence and health outcomes for women and their potential offspring: symptom-based dietary monitoring for some, educating school officials about medical diets, expanding the role of registered dietitians; and assisting with the transition from pediatric to adult health care providers. Article History: Accepted 13 August 2009

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2009.03.002 Byline: Shirley Y. Chao, Johanna T. Dwyer, Robert F. Houser, Sharon Tennstedt, Paul Jacques Abstract: The opinions of both national aging and health experts and practicing registered dietitians (RDs) were surveyed on which key quality indicators from the Food And Nutrition Care Indicators checklist should be regulated in assisted-living facilities (ALFs) for older adults. The extent to which the practices on which the indicators were based should be regulated, and which were in fact included in the current regulations of the 50 states was also studied. One hundred fifty-three national aging and health experts were surveyed in 2005 and 882 practicing RDs who were members of two American Dietetic Association dietetic practice groups employed in ALFs were surveyed in 2006. Both the experts and the RDs believed that the need for regulations in ALF food and nutrition services was vital for about a third of the indicators, (eg, 18 items on the 57 item checklist), particularly those involving facilities and staffing. For seven out of the 18 indicators, there was substantial consensus between experts and RDs. Only three of the seven indicators were addressed by regulations in more than half of the states. Consensus exists among experts and RDs that a small but significant number of food and nutrition service indicators need to be regulated. Article History: Accepted 24 October 2008

The objective of this cross-sectional study was to describe the level of prescriptive authority and explore barriers to obtaining prescriptive authority of registered dietitians in acute health care facilities. A sample of 1,500 clinical nutrition managers was electronically surveyed; data from 351 respondents (23% response rate) were analyzed using descriptive statistics and [chi square] tests. Many (54%) respondents reported no prescriptive authority, 36% reported dependent prescriptive authority, and 10% reported independent prescriptive authority. Most (95%) respondents with no prescriptive authority and (89%) with dependent prescriptive authority valued independent prescriptive authority. The two most commonly listed barriers to independent prescriptive authority were opposition (52% no prescriptive authority, 48% dependent prescriptive authority) and liability (40% no prescriptive authority, 48% dependent prescriptive authority). Forty-five percent of respondents with independent prescriptive authority reported the route to independent prescriptive authority was via clinical privileges. Based on the responses of this sample, the authors conclude the majority of respondents do not have, but value, independent prescriptive authority. The issue of liability as a barrier to independent prescriptive authority might need further study to determine reasons why liability is perceived as a barrier to independent prescriptive authority.

Coding, coverage, and reimbursement are vital to the clinical segment of our profession. The objective of this study was to assess understanding and use of the medical nutrition therapy (MNT) procedure codes. Its design was a targeted, cross-sectional, Internet survey. Participants were registered dietitians (RDs) preselected based on Medicare Part B provider status, randomly selected RDs from the American Dietetic Association database based on clinical practice designation, and self-selected RDs. Parameters assessed were knowledge and use of existing MNT and/or alternative procedure codes, barriers to code use/compensation, need for additional codes for existing/emerging services, and practice demographics. Results suggest that MNT is being reimbursed for a variety of diseases and conditions. Many RDs working in clinic settings are undereducated about code use of any kind, reporting that code selection frequently is determined not by the RD providing the service, but by "someone else." Self-employed RDs are less likely to rely on others to administrate paperwork required for reimbursement, including selection of procedure codes for billable nutrition services. Self-employed RDs are more likely to be reimbursed by private or commercial payers and RDs working in clinic settings are more likely to be reimbursed by Medicare; however, the proportion of Medicare providers in both groups is high. RDs must be knowledgeable and accountable for both the business and clinical side of their nutrition practices; using correct codes and following payers' claims processing policies and procedures. This survey and analysis is a first step in understanding the complex web of relationships between clinical practice, MNT code use, and reimbursement.

It is the position of the American Dietetic Association that individuals have the right to request or refuse nutrition and hydration as medical treatment. Registered dietitians (RDs) should work collaboratively to make recommendations on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as active members of institutional ethics committees. RDs have an active role in determining the nutrition and hydration requirements for individuals throughout the lifespan. When patients choose to forgo any type of nutrition and hydration (natural or artificial) or when patients lack decision-making capacity and others must decide whether or not to provide artificial nutrition and hydration, the RD has an active and responsible professional role in the ethical deliberation around that decision. Across the lifespan, there are multiple instances when providing, withdrawing, or withholding nutrition and hydration creates ethical dilemmas. There is strong clinical, ethical, and legal support both for and against administration of food and water when issues arise regarding what is or is not wanted by the patient and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision to administer or withhold nutrition and hydration requires ethical deliberation. The RD's understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provides an essential basis for ethical deliberation on issues of nutrition and hydration. The RD, as a member of the health care team, has a responsibility to promote use of advanced directives and to identify the nutritional and hydration needs of each individual patient. The RD promotes the rights of the individual patient and helps the health care team implement appropriate therapy.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2007.10.010 Byline: Susan K. Raatz, Julie K. Wimmer, Christine A. Kwong, Shalamar D. Sibley Abstract: Multiple factors influence long-term weight-loss success, as shown by the National Weight Control Registry. We evaluated the influence of two of those factors, diet instruction by a registered dietitian (RD) and frequency of weigh-in visits, on initial weight-loss success. Twenty-six overweight subjects with a baseline body mass index of 33.2[+ or -]3.7 and a mean age of 43[+ or -]12 years were enrolled in a weight-loss study. The 11-week weight loss period included 33 total visits, with weekly RD-instructed classes with a weigh-in, and 22 semiweekly related weigh-in visits without an RD present. Classes covered topics in the areas of energy restriction, dietary change, exercise, and behavior modification. Subjects were enrolled at different time points within the class topic rotation but all completed the 11-week program. The mean weight loss for all subjects was 3.8[+ or -]2.8 kg (P<0.001). Weight loss (%) was significantly correlated with attendance of RD-instructed classes (r=0.451, P=0.021) but not attendance at weigh-ins that did not include RD-instructed classes (r=0.329, P=0.101). We conclude that RD-led dietary instruction was more beneficial than frequent weigh-in visits alone in promoting weight loss.

Multiple factors influence long-term weight-loss success, as shown by the National Weight Control Registry. We evaluated the influence of two of those factors, diet instruction by a registered dietitian (RD) and frequency of weigh-in visits, on initial weight-loss success. Twenty-six overweight subjects with a baseline body mass index of 33.2 [+ or -] 3.7 and a mean age of 43 [+ or -] 12 years were enrolled in a weight-loss study. The 11-week weight loss period included 33 total visits, with weekly RD-instructed classes with a weigh-in, and 22 semiweekly related weigh-in visits without an RD present. Classes covered topics in the areas of energy restriction, dietary change, exercise, and behavior modification. Subjects were enrolled at different time points within the class topic rotation but all completed the 11-week program. The mean weight loss for all subjects was 3.8 [+ or -] 2.8 kg (P<0.001). Weight loss (%) was significantly correlated with attendance of RD-instructed classes (r=0.451, P=0.021) but not attendance at weigh-ins that did not include RD-instructed classes (r=0.329, P=0.101). We conclude that RD-led dietary instruction was more beneficial than frequent weigh-in visits alone in promoting weight loss.

Advances in the ability to study how common variations in genes affect the metabolism of drugs and foods suggest that genetic information about individuals is of increasing relevance to clinical practitioners, including registered dietitians. The acquisition, storage, and use of genetic information in nutrition counseling will pose difficult ethical and legal questions involving the maintenance of confidentiality, the right to privacy, and the risks of discrimination in decisions about insurance coverage and employment. In addition, genetic analysis of children poses new questions about the limits of parental authority. Although the field of nutritional genomics is in its infancy, it is appropriate for registered dietitians to begin now to fashion a code of conduct about the proper use of genetic information. Relevant legal topics, such as federal and state legislation and judicial decisions, are discussed.

Background/Objectives: Dietitians need to prioritise referrals in order to manage their work load. Novice dietitians may not receive training on prioritisation and could be helped with an evidence-based, effective decision-making training tool. To develop such a tool, it is necessary to understand how experts make prioritisation decisions. This study aimed to model expert decision-making policy for prioritising dietetic referrals in adult acute-care services. Methods/Subjects: Social judgement theory was used to model expert decision-making policy. Informational cues and cue levels were identified. A set of case scenarios that replicated dietetic referrals in adult acute services were developed using fractional factorial design approach. Experienced dietitians were asked to make prioritisation decisions on case scenarios. A model was derived using multiple regression analysis to elicit the weighting given to cues and cue levels by the experts when making prioritisation decisions. Results: Six cues and 21 cue levels were identified, and 60 unique case scenarios were created. Fifty experienced dietitians made decisions on these case scenarios. The 'reason for referral' and 'biochemistry picture' were the two most influential cues, and 'weight history' was the least significant. 'Nutritional status', 'presenting complaint' and 'previous food intake' had similar weightings. In all, 95.7% of the variability in the experts' average judgement (adjusted R[sup.2]=0.93) was predicted by the 6 cues. Conclusions: A model for referral prioritisation in adult acute services described experienced dietitians' decision-making policy. This can be used to develop training materials that may increase the effectiveness and quality of prioritisation judgements. European Journal of Clinical Nutrition (2017) 71, 1291-1296; doi: 10.1038/ejcn.2017.123; published online 23 August 2017, Author(s): M Hickson [1]; M Davies [2]; H Gokalp [2]; P Harries [2] Introduction Dietitians working in adult acute-care settings often receive large numbers of referrals in batches, making it [...]

It is the position of the American Dietetic Association to encourage environmentally responsible practices that conserve natural resources, minimize the quantity of waste generated, and support the ecological sustainability of the food system--the process of food production, transformation, distribution, access, and consumption. Registered dietitians and dietetic technicians, registered, play various roles in the food system and work in settings where efforts to conserve can have significant effects. Natural resources that provide the foundation for the food system include biodiversity, soil, land, energy, water, and air. A food system that degrades or depletes its resource base is not sustainable. Making wise food purchases and food management decisions entails understanding the external costs of food production and foodservice and how these external costs affect food system sustainability. This position paper provides information, specific action-oriented strategies, and resources to guide registered dietitians and dietetic technicians, registered, in food decision making and professional practice. Food and nutrition professionals also can participate in policy making at the local, state, and national levels, and can support policies that encourage the development of local sustainable food systems. Our actions today have global consequences. Conserving and protecting resources will contribute to the sustainability of the global food system now and in the future. doi: 10.1016/j.jada.2007.04.018

Objective The study was designed to identify how the beliefs and perceptions of registered dietitians (RDs) affect their decisions to propose artificial nutrition and hydration (ANH) for elderly patients as compared with nurses. Design A questionnaire consisting of demographic information, 13 belief statements, and eight patient scenarios requiring ANH was mailed to RDs (n=1,500) and nurses (n=1,500) throughout Florida. Thirteen statements, rated on a 5-point Likert scale, addressed beliefs that influence ANH decisions. Eight scenarios of patients, without an advance directive or surrogate decision maker, were created with variations in age, cognition, and emotion. For each scenario, participants selected a treatment, ANH or hydration, and responded: recommend; not recommend; undecided; or recommend a trial period; if no improvement, stop treatment. Statistical analyses performed To establish reliability and validity, the instruments were pilot-tested with a group of RDs and nurses. Cross tabulations with [chi square] tests compared the distribution of responses to the belief statements and scenarios. Statistical significance was P<0.05. Results Responses to the belief statement, "when in doubt, feed" differed significantly (P<0.001) between RDs and nurses, all other belief statements were not significantly different. In all eight scenarios, significantly more (P<0.001) RDs recommended ANH than did nurses. Conclusions RDs clearly endorsed feeding when in doubt; therefore, they recommended ANH more than nurses. Nurses, who hesitated to feed when in doubt, were more diverse with their recommendations, either recommending a trial or not recommending ANH. A philosophical difference related to feeding was apparent between RDs and nurses and may affect consistent and quality care in patients without an advance directive or surrogate decision maker.

Although numerous guidelines and standards address the management of diabetes in outpatient settings, only recently has evidence been provided to issue standards of care to guide clinicians in optimal inpatient glycemic control for hospitalized individuals with diabetes or illness-induced hyperglycemia. Both the American Diabetes Association and the American College of Endocrinology recommend critically ill patients keep their blood glucose level as close to 110 mg/dL (6.1 mmol/L) as possible. In the noncritically ill patient, the American Diabetes Association recommends to keep pre-meal blood glucose as close to 90 to 130 mg/dL (5.0 to 7.2 mmol/L) as possible, whereas the American College of Endocrinology recommends pre-meal blood glucose be kept at 110 mg/dL (6.1 mmol/L) or less. Both organizations agree that peak post-prandial blood glucose should be 180 mg/dL (10.0 mmol/L) or less. Recent evidence has also led the Joint Commission on Accreditation of Healthcare Organizations to develop standards for a voluntary certification in the management of the patient with diabetes in the in-patient setting. It is important that food and nutrition professionals familiarize themselves with these recommendations and implement nutrition interventions in collaboration with other members of the health care team to achieve these new glycemic control targets. Food and nutrition professionals have a key role in developing screening tools, and in implementing nutrition care guidelines, nutrition interventions, and medical treatment protocols needed to improve inpatient glycemic control.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2006.09.017 Byline: Laura D. Byham-Gray, Judith A. Gilbride, L. Beth Dixon, Frances King Stage Abstract: The primary aim of this study was to measure registered dietitians' (RDs') research involvement (by creating a research score) and to determine whether their perceptions, attitudes, and knowledge of evidence-based practice and key antecedent factors (eg, sociodemographic characteristics, education and training, professional experiences, and employment setting) predicted their research involvement.

A subset of registered dietitians (RDs) is known to practice at an advanced level, but a clear educational pathway supporting advanced medical nutrition therapy practice has not been identified. Thus, an electronic survey was designed to investigate interest of clinical RDs, employers, and educators in advanced practice competencies and professional doctorate degree programs in clinical nutrition. Usable responses were obtained from 440 of 978 (45%) RDs, 61 of 107 (57%) employers, and 76 of 114 (67%) educators. Mean interest (5 = very interested, 1 = very uninterested) in obtaining advanced practice education was highest among RDs (3.93 [+ or -] 1.01) and was significantly different (P<0.01) from employers (3.74 [+ or -] 1.28) and educators (2.76 [+ or -] 1.33). Interest in completing a professional doctorate in clinical nutrition was significantly (P<0.01) different among RDs (3.05 [+ or -] 1.28), employers (3.18 [+ or -] 1.30), and educators (2.3 [+ or -] 1.34). Employers' mean interest score for hiring RDs with a professional doctorate in clinical nutrition was 4.02 [+ or -] 0.93. A subset of clinical RDs appears to be interested in obtaining advanced practice competency and enrolling in professional doctorate degrees in clinical nutrition. Clinical nutrition managers in academic medical centers may be interested in hiring advanced practice clinical RDs with professional doctorate degrees. Opportunities exist for educators to develop advanced practice educational experiences and professional doctorate degree programs. J Am Diet Assoc. 2006; 106:2062-2066.

It is the position of the American Dietetic Association that nutrition intervention, including nutritional counseling, by a registered dietitian (RD) is an essential component of the team treatment of patients with anorexia nervosa, bulimia nervosa, and other eating disorders during assessment and treatment across the continuum of care. Diagnostic criteria for eating disorders provide important guidelines for identification and treatment. However, it is thought that a continuum of disordered eating may exist that ranges from persistent dieting to subthreshold conditions and then to defined eating disorders, which include anorexia nervosa, bulimia nervosa, and binge eating disorder. Understanding the complexities of eating disorders, such as influencing factors, comorbid illness, medical and psychological complications, and boundary issues, is critical in the effective treatment of eating disorders. The nature of eating disorders requires a collaborative approach by an interdisciplinary team of psychological, nutritional, and medical specialists. The RD is an integral member of the treatment team and is uniquely qualified to provide medical nutrition therapy for the normalization of eating patterns and nutritional status. RDs provide nutritional counseling, recognize clinical signs related to eating disorders, and assist with medical monitoring while cognizant of psychotherapy and pharmacotherapy that are cornerstones of eating disorder treatment. Specialized resources are available for RDs to advance their level of expertise in the field of eating disorders. Further efforts with evidenced-based research must continue for improved treatment outcomes related to eating disorders along with identification of effective primary and secondary interventions. J Am Diet Assoc. 2006;106: 2073-2082.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2006.06.009 Byline: Diane Reader, Patricia Splett, Erica P. Gunderson Abstract: Nutrition practice guidelines were developed for gestational diabetes mellitus by registered dietitians from the Diabetes Care and Education and the Women's Health and Reproductive Nutrition dietetic practice groups. To validate the guidelines, a clinical trial was designed with clinic sites randomly assigned to either nutrition practice guidelines care (12 sites) or usual nutrition care (13 sites), with diabetes, obstetric, and other clinic types represented in both groups. Volunteer dietitians served as study coordinators and recruited women diagnosed with gestational diabetes mellitus. The nutrition practice guidelines define medical nutrition therapy (MNT) for gestational diabetes and emphasize three areas -- definition of MNT clinical goals with indexes to modify or advance MNT and criteria to start insulin; use of self-monitoring tools; and provision of three nutrition visits. Usual care sites provided prenatal nutrition care according to usual practice. The effect of nutrition care (sites following the nutrition care guidelines) and type of clinic site on changes in glycated hemoglobin and infant birth weight, adjusted for other covariates, were evaluated using linear regression. Differences in insulin use and other infant outcomes between treatment groups were evaluated using logistic regression. Generalized estimating equations were used to accommodate nonindependence within randomized clusters of patients within clinic sites. Data from 215 women indicated less insulin use at diabetes clinic sites in the nutrition practice guidelines groups and improved glycated hemoglobin control during the treatment period in diabetes clinics compared with obstetric or other clinics. A higher proportion of women in the usual care group had glycated hemoglobin levels that exceeded 6% at follow-up compared with women in the nutrition practice guidelines group (13.6% vs 8.1%), although not statistically significant (P=0.26). A significant clinic type and treatment group effect was found for birth weight. Nutrition practice guidelines for gestational diabetes mellitus reflected nutrition care already being provided by registered dietitians in diabetes clinics prior to this study because outcomes at these clinics were not impacted. Use of the guidelines by dietitians at obstetric and other clinics tended to improve outcomes at these sites.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2006.04.025 Byline: Jadine Cairns, Ryna Levy Milne Abstract: The purpose of this study was to profile nutrition counseling strategies for eating disorders that English-speaking Canadian registered dietitians (RDs) use and to explore their educational needs in this area. A cross-sectional survey consisting of open- and closed-ended questions on nutrition counseling strategies was developed and administered via mail. Types of strategies included assessment, rapport-building, educational, and behavior-change strategies. Sixty-five of the 116 eligible RDs who were members of the Dietitians of Canada Eating Disorder Network responded to the survey. Descriptive statistics, I.sup.2, and Spearman correlation statistics were used. P values less than 0.05 were considered significant. Canadian RDs used strategies that were familiar and strategies they considered useful. Content-oriented or "doing" strategies were used more often than strategies that involved some process-oriented or "thinking" strategies. Reading and intuition were the most frequently reported learning routes. Seventy-one percent of respondents were dissatisfied with the educational opportunities available to RDs in this area in Canada. In Canada, both generalist RDs and specialist eating disorders RDs work with clients with eating disorders. In the absence of a formal nutrition counseling education program, there seems to be a reliance on informal learning routes such as reading or intuition, which may be suboptimal. To optimize eating disorders nutrition practice in Canada, formal coordinated programming that accounts for the educational needs of specialist RDs as well as generalist RDs is needed.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2005.12.002 Byline: Elaine Trujillo, Cindy Davis, John Milner Abstract: The human genome is estimated to encode over 30,000 genes, and to be responsible for generating more than 100,000 functionally distinct proteins. Understanding the interrelationships among genes, gene products, and dietary habits is fundamental to identifying those who will benefit most from or be placed at risk by intervention strategies. Unraveling the multitude of nutrigenomic, proteomic, and metabolomic patterns that arise from the ingestion of foods or their bioactive food components will not be simple but is likely to provide insights into a tailored approach to diet and health. The use of new and innovative technologies, such as microarrays, RNA interference, and nanotechnologies, will provide needed insights into molecular targets for specific bioactive food components and how they harmonize to influence individual phenotypes. Undeniably, to understand the interaction of food components and gene products, there is a need for additional research in the "omics" of nutrition. It is incumbent upon dietetics professionals to recognize that an individual's response to dietary intervention will depend on his or her genetic background and that this information may be used to promote human health and disease prevention. The objectives of this review are to acquaint nutritional professionals with terms relating to "omics," to convey the state of the science to date, to envision the possibilities for future research and technology, and to recognize the implications for clinical practice.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2005.12.006 Byline: Jamy D. Ard, Renee Ann Desmond, David B. Allison, Joan Marie Conway Abstract: Some psychological predictors of eating behaviors have been shown to affect usefulness of methods for dietary assessment. Therefore, this study was conducted to determine the association of dietary restraint and disinhibition with dietary recall accuracy for total energy, fat, carbohydrate, and protein. In a cross-sectional study, data were obtained from 79 male and 71 female non-Hispanic whites and African-American volunteers. Participants selected and consumed all foods for a 1-day period under observation and actual intake was determined. The following day, each participant completed a telephone 24-hour recall using the US Department of Agriculture Multiple-Pass method to obtain recalled intake. The Eating Inventory, which measures dietary restraint and disinhibition, was administered prior to eating any food in the study. Repeated measures analyses of variance were used to determine if dietary restraint or disinhibition were independent predictors of recall accuracy. The mean ([+ or -]standard deviation) age and body mass index of the participants was 43[+ or -]12 years and 29[+ or -]5.5 (calculated as kg/m.sup.2), respectively. On average, men overreported intake of energy by 265 kcal and women by 250 kcal; both groups also overreported intake of protein, carbohydrate, and fat. When controlling for body mass index, sex, and race, restraint was a significant independent predictor of energy intake (P=0.004) and negatively correlated with energy intake (r=-0.23, P<0.001). Unlike intake of carbohydrate or protein, fat intake was significantly and negatively associated with dietary restraint (P<0.001; r=-0.3). Dietary restraint did not affect accuracy of recall of intake of energy, fat, carbohydrate, or protein, but was significantly associated with intake of energy and fat. Disinhibition was not related to intake or accuracy. Dietetics professionals should consider dietary restraint a possible reason for a lower than expected estimate of energy intake when using 24-hour recalls.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2005.12.005 Byline: Chad Hetherwick, Michelle Neyman Morris, Kathryn Silliman Abstract: A convenience sample of California registered dietitians (RDs) (n=253) completed a survey investigating the perceived knowledge, attitudes, and practices of RDs who had or had not received formal training in use of dietary supplements. We also examined whether differences existed between RDs registered before or after 1997, when the American Dietetic Association began requiring that dietetics curricula include basic knowledge of dietary supplements. Statistical analysis included analysis of variance and I.sup.2 analysis. Among this sample of RDs from California, those registered before 1997 (n=194) were more likely (P<0.05) to agree that they are knowledgeable regarding supplement use, safety, interactions, and contraindications than those registered after 1997 (n=46), and were more likely (P<0.05) to assess client use. Among this sample of RDs from California, those reporting that they had received formal training in dietary supplements (n=145) were more likely (P<0.05) than those who had no formal training in supplement use (n=105) to agree that they are comfortable discussing supplements with the public; are knowledgeable regarding uses, safety, interactions, and contraindications of supplements; and assess client use. Providing RDs professional education opportunities on supplements continues to be warranted.

The purpose of this study was to identify strategies used to recall dietary intake on a food frequency questionnaire by adults in a multiethnic sample. One-on-one interviews were conducted to identify strategies used to recall intake on the Fred Hutchinson Food Frequency Questionnaire. Twenty-eight men and 26 women in San Diego, CA (average age, 41 years), were recruited from the general community with approximately equal numbers of non-Hispanic white, African-American, and English- and Spanish-speaking Hispanic participants. Recall of food intake was most commonly guided by routines. Recall strategies differed primarily by food type and not by ethnic or sex groups. Each of nine food categories on the questionnaire was associated with a distinct pattern of recall strategies. The recall strategies identified in this study may serve as cues to be included on food frequency questionnaires to aid recall and thus improve accuracy of self-reported dietary intake. J Am Diet Assoc. 2006;106:430-433.

Objective The objective of this study was to measure dietitians' perceptions, attitudes, and knowledge of evidence-based practice (PAK score), and to determine whether antecedent factors (eg, sociodemographic characteristics, education and training, professional experiences, and employment setting) predicted PAK score. Design This cross-sectional, descriptive study used the Dietitian Research Involvement Survey following the Tailored Design Method. Subjects/setting This study surveyed 500 randomly selected registered dietitians from seven dietetic practice groups of the American Dietetic Association. Statistical analyses performed Bivariate relationships were examined between antecedent factors and PAK score. Multiple linear regression analyses were conducted to test whether these factors predicted PAK score. Results Higher PAK scores were associated with registered dietitians who completed more years of education (r=0.28, P<.0005), had taken a research course (r=0.28, P<.0005), frequently read research articles (r=0.41, P<.0005), earned an advanced-level board certification (r=0.18, P=.004), worked full-time (r=0.26, P<.0005), or belonged to professional organizations (r=0.18, P=.003). The strongest predictors for PAK score were "last time read research" ([beta]=.33, P<.0005), work status ([beta]=.20, P<.0005), level of education ([beta]=.19, P=.001), and association memberships ([beta]=.14, P=.01). Conclusions Results indicated that dietitians' ability to incorporate an evidence-based approach is largely determined by their education and training, work experience, and professional association involvement. This study identified a need to integrate concepts and principles of evidence-based practice into dietetics curriculums so that practitioners are able to routinely apply research findings to clinical practice. J Am Diet Assoc. 2005;105:1574-1581.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2005.07.004 Byline: Nancy Hakel-Smith, Nancy M. Lewis, Kent M. Eskridge Abstract: To compare documentation of two groups of clinical nutrition practitioners for evidence of the nutrition care process.

This study describes Canadian dietitians' approaches to counseling adults seeking weight-management advice. Fifteen focus groups were conducted at seven sites across Canada. The participants, most of whom worked in clinical or private practice, discussed their approach to specific weight-management counseling scenarios, including women clients with and without associated risk factors (impaired glucose tolerance, hypertension, family history of cardiovascular disease) and long histories of dieting. Results indicate that participants used a lifestyle approach for weight-management counseling, where the main goal was improved client health through healthful eating and increased physical activity. In contrast to clients' perceived weight loss goals, participants rarely included weight loss as a goal for clients with no additional chronic disease risk factors. For clients with risk factors, some participants advocated moderate weight loss, while others aimed for health at any size. Participants also discussed the importance of clients' psychological well-being, particularly in relation to feelings about food and body image. Individualized approaches to setting goals, gathering information, and giving advice/educating were identified as key counseling strategies. Further research to evaluate the effectiveness of dietitians' weight-management approaches and additional counseling training for dietitians will enhance practitioners' skills and confidence in this area. J Am Diet Assoc. 2005;105:1275-1279.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2005.05.013 Byline: Dania Mercadante Green, Julie O'Sullivan Maillet, Riva Touger-Decker, Laura Byham-Gray, Pamela Matheson Abstract: The purpose of this study was to examine current professional practices of registered dietitians (RDs) in the Diabetes Care and Education dietetic practice group (DPG), analyzed by levels of practice: entry-level, specialty-practice, or advanced-level. The results of the Diabetes Care and Education DPG 2002-2003 membership survey were used for this study. The study was limited to RD members of the Diabetes Care and Education DPG who completed the membership survey in its entirety. Frequency distributions, I.sup.2, Fisher exact test, and cluster analysis were performed with a prior alpha set at .10. Sixty-one (5.0%) RDs were functioning as an entry-level practitioner, 851 (69.1%) were functioning as a specialty-practice practitioner, and 320 (25.1%) as an advanced-level practitioner. Significantly more advanced-level practitioners were performing more tasks compared with entry-level practitioners. Entry-level RDs performed a mean of 2.4 functions, specialty-practice practitioners performed 7.7, and advanced-level practitioners performed 11.6 functions. The results of this survey further delineated that RDs function at various levels of practice and that credentials for RDs increased as level of practice advanced.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2005.05.004 Byline: Gwen E. Chapman, Kari Sellaeg, Ryna Levy-Milne, Andrea Ottem, Susan I. Barr, Daniela Fierini, Gail Marchessault, Donna Nolan, Marie-Claude Paquette, Nancy Saunders, Kevin Thiele Abstract: This study describes Canadian dietitians' approaches to counseling adults seeking weight-management advice. Fifteen focus groups were conducted at seven sites across Canada. The participants, most of whom worked in clinical or private practice, discussed their approach to specific weight-management counseling scenarios, including women clients with and without associated risk factors (impaired glucose tolerance, hypertension, family history of cardiovascular disease) and long histories of dieting. Results indicate that participants used a lifestyle approach for weight-management counseling, where the main goal was improved client health through healthful eating and increased physical activity. In contrast to clients' perceived weight loss goals, participants rarely included weight loss as a goal for clients with no additional chronic disease risk factors. For clients with risk factors, some participants advocated moderate weight loss, while others aimed for health at any size. Participants also discussed the importance of clients' psychological well-being, particularly in relation to feelings about food and body image. Individualized approaches to setting goals, gathering information, and giving advice/educating were identified as key counseling strategies. Further research to evaluate the effectiveness of dietitians' weight-management approaches and additional counseling training for dietitians will enhance practitioners' skills and confidence in this area. Article Note: (footnote) * In addition to the authors of this article, the "Do It With Focus Research Group" included Eleeta Armit, Veronique Brisson, Barbara Cantwell, Charlene Chen, Margaret Coombes, Catherine Freeze, Lana Moore, Nuryt Raif, Sandy Skrzypczyk, Janet Chappell, Marielle Ledoux, Linda McCargar, Barbara Roebothan, and Judy Sheeshka.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2005.05.012 Byline: Irene E. Olsen, Douglas K. Richardson, Christopher H. Schmid, Lynne M. Ausman, Johanna T. Dwyer Abstract: Describe the level of registered dietitian (RD) involvement in neonatal intensive care units (NICUs) and associations with NICU nutrition practices.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2005.02.028 Byline: Johanna T. Dwyer, David B. Allison, Paul M. Coates Abstract: We summarize evidence on the role of dietary supplements in weight reduction, with particular attention to their safety and benefits. Dietary supplements are used for two purposes in weight reduction: (a) providing nutrients that may be inadequate in calorie-restricted diets and (b) for their potential benefits in stimulating weight loss. The goal in planning weight-reduction diets is that total intake from food and supplements should meet recommended dietary allowance/adequate intake levels without greatly exceeding them for all nutrients, except energy. If nutrient amounts from food sources in the reducing diet fall short, dietary supplements containing a single nutrient/element or a multivitamin-mineral combination may be helpful. On hypocaloric diets, the addition of dietary supplements providing nutrients at a level equal to or below recommended dietary allowance/adequate intake levels or 100% daily value, as stated in a supplement's facts box on the label, may help dieters to achieve nutrient adequacy and maintain electrolyte balance while avoiding the risk of excessive nutrient intakes. Many botanical and other types of dietary supplements are purported to be useful for stimulating or enhancing weight loss. Evidence of their efficacy in stimulating weight loss is inconclusive at present. Although there are few examples of safety concerns related to products that are legal and on the market for this purpose, there is also a paucity of evidence on safety for this intended use. Ephedra and ephedrine-containing supplements, with or without caffeine, have been singled out in recent alerts from the Food and Drug Administration because of safety concerns, and use of products containing these substances cannot be recommended. Dietitians should periodically check the Food and Drug Administration Web site (http://www.cfsan.fda.gov) for updates and warnings and alert patients/clients to safety concerns. Dietetics professionals should also consult authoritative sources for new data on efficacy as it becomes available (ods.od.nih.gov).

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2005.02.048 Byline: Judith S. Stern, Alexandra Kazaks, Morgan Downey Abstract: Obesity has been defined as a distinct disease by the World Health Organization, National Institutes of Health, Centers for Disease Control and Prevention, and the American Dietetic Association. In the United States, a major reimbursement challenge is to promote acceptance of obesity as a chronic disease and acceptance of its treatment by health management organizations, private insurers, and the government. The United States health care system is focused on treating individual obesity-related diseases, but does not treat obesity as the underlying cause. Reimbursement of obesity treatments using "condition coverage" based on the presence of other diseases does not allow obesity to be treated independently as a disease in itself. It is necessary to make major investments in research to determine the best methods and to match the treatment with the individual, to prevent obesity in vulnerable populations, and to develop more effective drugs and treatments for those already overweight or obese. There should be a more detailed analysis of the cost of obesity, costs associated with obesity and obesity-related disease treatment, and costs of inaction. The obesity epidemic is too large to be ignored. Health care professionals have a duty to be informed about the disease and to advocate for patients who need help. Registered dietitians can be key players in delivering obesity treatment.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2005.01.002 Byline: Ruth M. Debusk, Colleen P. Fogarty, Jose M. Ordovas, Kenneth S. Kornman Abstract: Nutritional genomics, which studies the genome-wide influences of nutrition, has far-reaching potential in the prevention of diet-related disease. It is highly likely that during the next decade the nutritional supplement and functional food industries will continue robust growth in response to advances in nutritional genomics research and its applications. Parallel to this growth will be impressive progress in understanding the specific influence of certain food components on metabolic pathways and on long-term risk for disease. As genetic information about individuals becomes available, such data are likely to redefine the current concept of preventive medicine. Dietetics professionals have the potential to harness this information and influence health promotion and disease prevention on a global scale. For these reasons, the dietetics profession has an exciting opportunity that, if seized and properly executed, could enhance the scientific foundation of clinical practice, improve therapeutic outcomes, and significantly expand career and economic opportunities for practitioners. The future of dietetics is unquestionably intertwined with nutritional genomics. Article Note: (footnote) Continuing Education Questionnaire, page 666. Meets Learning Need Codes 2000, 2050, 3000, and 6000

Basic educational requirements for dietitians were developed almost 80 years ago and remain largely unchanged. In the interim, other health professions have increased their academic standards. A review of the educational preparation of 16 health-diagnosing and treating professions was undertaken to better understand the standards for dietetics education within a larger context. Educational standards for each profession were obtained and reviewed for types of degrees; duration of post-secondary, college-level education; division of didactic and clinical education; and presence of accredited post-professional education. Findings reveal that at least 11 of the professions studied offer first professional degrees. Differences were noted in duration and sequencing of undergraduate education, didactic or classroom education, and especially supervised practice. Models to facilitate comparison between educational standards were developed. The current educational model in dietetics is designed to prepare entry-level practitioners and academics who comprise less than 20% of the profession. This review supports the need to investigate educational opportunities for beyond--entry-level dietitians, and to develop educational programs that amplify the existing models for educating dietitians. J Am Diet Assoc. 2005;105:420-427.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2004.08.029 Byline: Catherine H. Strohbehn, Shirley A. Gilmore, Jeannie Sneed Abstract: Assess perceptions of consultant registered dietitians (RDs) and dietary managers about food safety practices and Hazard Analysis and Critical Control Point (HACCP) implementation in assisted-living and long-term care facilities for the elderly.

Infection with the human immunodeficiency virus (HIV) and the development of acquired immunodeficiency syndrome (AIDS) have had a significant impact on domestic and global health, social, political, and economic outcomes. Prevention and treatment efforts to control HIV infection are more demanding than in previous decades. Achieving food and nutrition security, and managing nutrition-related complications of HIV infection and the multiple aspects of disease initiated by or surrounding HIV infection, referred to as HIV disease, remain challenges for patients and for those involved with HIV/AIDS prevention, care, and treatment efforts. Confounding clinical issues include medication interactions, coinfection with other infections and diseases, wasting, lipodystrophy, and others. Dietetics professionals, other health care professionals, and people infected with HIV will need to understand and address multiple complex aspects of HIV infection and treatment to improve survival, body functions, and overall quality of life. Individualized nutrition care plans will be an essential feature of the medical management of persons with HIV infection and AIDS. J Am Diet Assoc. 2004;104:1425-1441.

The Youth/Adolescent Questionnaire is a food frequency questionnaire developed for youth aged 9 to 19 years that attempts to assess diet during the past 12 months. It was developed and previously validated with white youth; however, a validation study with fourth- to seventh-grade African-American youth revealed lower validation coefficients. This study validated the Youth/Adolescent Questionnaire with 89 low-income seventh- and eighth-grade Hispanic and African-American youth. The youth completed the Youth/Adolescent Questionnaire on two occasions 3 weeks apart, and completed up to six food records in between. Most of the reliability coefficients were adequate, except for percent of energy from fat and high-fat vegetables for Hispanic students. Validity coefficients were low, even after correcting for error. The ability of seventh- and eighth-grade low-income African-American and Hispanic youth to report usual intake over a period of time appears to be limited and may not provide a valid measure of consumption. J Am Diet Assoc. 2004;104:1415-1419.

Objective The purpose of this study was to evaluate the reliability of label weights as surrogates for actual weights in commercial portion-controlled foods used in a research setting. Design Actual weights of replicate samples of 82 portion-controlled food items and 17 discrete units of food from larger packaging were determined over time. Comparison was made to the package label weights for the portion-controlled food items and the per-serving weights for the discrete units. Setting The study was conducted at the US Department of Agriculture's Beltsville Human Nutrition Research Center's Human Study Facility, which houses a metabolic kitchen and human nutrition research facility. Main Outcome Measures The primary outcome measures were the actual and label weights of 99 food items consumed by human volunteers during controlled feeding studies. Statistical Analyses Performed The difference between label and actual weights was tested by the paired t test for those data that complied with the assumptions of normality. The Wilcoxon signed rank test was used for the remainder of the data. Compliance with federal guidelines for packaged weights was also assessed. Results There was no statistical difference between actual and label weights for only 37 food items. The actual weights of 15 portion-controlled food items were 1% or more less than label weights, making them potentially out of compliance with federal guidelines. Conclusions With advance planning and continuous monitoring, well-controlled feeding studies could incorporate portion-controlled food items and discrete units, especially beverages and confectionery products. Dietetics professionals should encourage individuals with diabetes and others on strict dietary regimens to check actual weights of portion-controlled products carefully against package weights. J Am Diet Assoc. 2004;104:1420-1424.

This article (a) provides a general review of interobserver reliability (IOR) and (b) describes our method for assessing IOR for items and amounts consumed during school meals for a series of studies regarding the accuracy of fourth-grade children's dietary recalls validated with direct observation of school meals. A widely used validation method for dietary assessment is direct observation of meals. Although many studies utilize several people to conduct direct observations, few published studies indicate whether IOR was assessed. Assessment of IOR is necessary to determine that the information collected does not depend on who conducted the observation. Two strengths of our method for assessing IOR are that IOR was assessed regularly throughout the data collection period and that IOR was assessed for foods at the item and amount level instead of at the nutrient level. Adequate agreement among observers is essential to the reasoning behind using observation as a validation tool. Readers are encouraged to question the results of studies that fail to mention and/or to include the results for assessment of IOR when multiple people have conducted observations. J Am Diet Assoc. 2004;104:1385-1392.