The Evolving Profession of the Dietitian-Nutritionist
  • ICDA is the largest world-wide body of dietetics professionals.
    It supports National Dietetic Associations (NDA) and their members, beyond national and regional boundaries, by providing:
     

    • Guidance, development and increased awareness of the standards of education and training that underpin the profession.

    • Leadership in dietetics in various contexts, with a focus on evidence based nutrition and dietetics practice.

    • An integrated communications system for members

    • Networking and professional development opportunities

    • Promotion of the role of nutrition and the dietetics professional in enhancing health, supporting human development, and reducing disease.1

     
    To achieve its mission ICDA needs an understanding of the status of dietetics and the NDA in member countries and conducts a survey of the Education and Work of Dietitian-Nutritionists every 4 years for presentation at each International Congress. A Report of the 2016 survey will be published on the ICDA website later this year.
     
    ICDA currently has 49 members in 42 countries (coloured blue on the map) representing approximately 210,000 Dietitian-Nutritionists. \
     

    Regulation of the profession
    Regulation is important primarily for protection of the public as it involves setting and monitoring of standards both in education and working practices and registration is something all NDAs have been striving for. Registration serves as a kitemark so that clients know that the Dietitian-Nutritionist is appropriately qualified and competent to practice.
     
    Since 2012 changes in legislation which will impact on dietetic practice have come into force in 7 countries. Registration bodies have been established in 5, the NDA in Italy has been legally recognised by the Ministry of Health as the representative body for dietitians and in the UK legislation has been enforced to allow suitably qualified dietitians to become supplementary prescribers under the Human Medicines Regulations.
     
    The number of countries with a professional title protected by law has steadily grown to 79% in 2016 (33 out of 42 countries), from 69% in 2008 (18 out of 26 countries), though in Denmark and Sweden the title is only protected for clinical dietitians and not for those in food service or public health.
    Registration also includes working within a recognised code of ethics, practice and/or conduct. There is an expectation that the professional will behave to a high set of standards. Codes vary but generally include the basic principles of respect, consent, confidentiality, appropriate and effective communication, maintenance of skills. In 2008 ICDA adopted an International Code of Ethics and Code of Good Practice.2 Within ICDA, countries with a recognised code has again grown steadily with 95% now having their own code or have adopted the ICDA codes. This compares very favourably with the 2004 survey when only 35% had a code and is a sign of the growing maturity of the profession and individual associations.
     
    Education
    In 2004 ICDA adopted an aspirational international standard for dietetic education. This is no longer aspirational and has been refreshed in 2016 as:
     

     
    The minimum level of education for entry into the profession is a bachelor degree in nutrition and dietetics and a period of supervised professional practice of at least 500 hours, which together meet international competency standards.

    In the 2016 survey entry level is less than a bachelor degree in only 3 countries (7%) compared to 7 countries (23%) in 2008.
     
    The supervised practice element of the international standard is also being met in the majority of countries with 92% reporting a compulsory practicum of more than 500 hours as part of the dietetic program.
     
    The third element of the ICDA education standard relates to assessment of competence. 31 countries report having competency standards students must meet, compared with 28 in 2012.
     
    Continuing competence
    Having demonstrated competence at qualification many countries now expect Dietitian-Nutritionists to demonstrate continued competence to practice. All professional practice is expected to be up to date, evidence based, safe, effective and efficient. Most Codes of Practice/Conduct include a statement about maintaining competence by being responsible for lifelong learning and engaging in self-development.

    However, ongoing study is a requirement for continuing to work as a Dietitian-Nutritionist in only 29 countries (70%) and 2 NDAs commented that it is not enforced. A further 3 NDAs recommend that their members engage in Continuing Professional Development (CPD). This is a significant increase on the 22 (59%) in 2012 and 14 (50%) in 2008.  The type of ongoing study varied, with examinations, practice assessment and CPD in different combinations quoted. In many countries credits or points for a range of activities are collected over a timespan ranging from 1 to 5 years. In some countries, the amount of CPD is not specified and Dietitian-Nutritionists are expected to self-assess, with random checks by the regulatory body.
     
    Work
    Historically Dietitian-Nutritionists have worked in hospitals in food service or clinically on the wards and in outpatient clinics. This continues to be the case with 100% of countries reporting hospitals as a location for employment but over the last 4 years there has been an increase in the number of countries reporting a more diverse range of settings.

    The greatest increase has been in public health, dietetic involvement in both health and food related Government departments, military food service, working in both Community Health Centres and Long term care and in academia and research. Many countries also reported private practice, self-employment and consultancy as growing areas of employment.
     
    In addition to location there have also been changes in the way Dietitian-Nutritionists are working, with greater involvement in:
     

    • Multi and inter-professional teams particularly in primary care locations,

    • Clinical care outside of hospitals,

    • Extending their scope to include exercise, working in sports facilities and gyms; or in clinical practice taking on tasks such as placing nasogastric tubes usually undertaken by nurses or doctors,

     
    Entrepreneurship, creating businesses and private practice.
    However, by far the biggest change reported was in the use of technology. Some of the examples include:
     

    • Online resources for many purposes including finding evidence for practice using the PEN Practice Based Evidence in Nutrition Global Resource and the Academy of Nutrition and Dietetics Evidence Analysis Library.

    • Use of standardised languages for recording the nutrition care process.

    • Webinars, web conferencing, distance learning.

    • Social media for general communication, and communication and consultation with clients.

    • Use of blogs, nutrition apps and telemedicine were also reported.

    All of these examples are designed to improve services, interactions with clients, colleagues and students, allow greater flexibility and reduce the need for time consuming and expensive travel to improve the efficiency and effectiveness of services. 
     
    Conclusion
    The dietetic profession has changed dramatically and will continue to do so as nutrition becomes embedded in the global agenda.

    The education, role and scope of the Dietitian-Nutritionist is constantly evolving to meet the needs and expectations of clients and employers, to cope with the demands on services being provided in a changing environment and to seize opportunities as they arise.
     
    The rate of evolution will vary across the world as it is influenced by the differing environments in which the profession is practised and the stage of development of the profession in each country.
    To enable promotion of the dietetic/nutrition professional in the global arena a greater understanding of what they can and are doing is required.
     
    1. International Confederation of Dietetic Associations Mission Statement. ICDA. 2014
    2. International Code of Ethics and Code of Good Practice. ICDA. 2010
     
    Carole Middleton
    Director, ICDA
    Representative, British Dietetic Association