Nutritional genomics in practice: where do we begin?

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.     

Position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior: Food and Nutrition Programs for Community-Residing Older Adults

Given the increasing number and diversity of older adults and the transformation of health care services in the United States, it is the position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior that all older adults should have access to evidence-based food and nutrition programs that ensure the availability of safe and adequate food to promote optimal nutrition, health, functionality, and quality of life. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, in partnership with other practitioners and nutrition educators, should be actively involved in programs that provide coordinated services between the community and health care systems that include regular monitoring and evaluation of programming outcomes. The rapidly growing older population, increased demand for integrated continuous support systems, and rising cost of health care underscore the need for these programs. Programs must include food assistance and meal programs, nutritional screening and assessment, nutrition education, medical nutrition therapy, monitoring, evaluation, and documentation of evidence-based outcomes. Coordination with long-term care services and support systems is necessary to allow older adults to remain in their homes; improve or maintain their health and manage chronic disease; better navigate transitions of care; and reduce avoidable hospital, acute, or long-term care facility admissions. Funding of these programs requires evidence of their effectiveness, especially regarding health, functionality, and health care–related outcomes of interest to individuals, caregivers, payers, and policy makers. Targeting of food and nutrition programs involves addressing unmet needs for services, particularly among those at high risk for poor nutrition. Registered dietitian nutritionists and nutrition and dietetics technicians, registered must increase programmatic efforts to measure outcomes to evaluate community-based food and nutrition services.Position StatementIt is the position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior that older adults should have access to evidence-based food and nutrition programs that ensure the availability of safe and adequate food to promote optimal nutrition, health, functionality, and quality of life. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, in partnership with other practitioners and nutrition educators, should be actively involved in programs that provide coordinated services between the community and health care systems that include regular monitoring and evaluation of programming outcomes. The rapidly growing older population, increased demand for integrated continuous support systems, and rising cost of health care underscore the need for these programs.     

Position of the Academy of Nutrition and Dietetics: Nutrition Informatics

It is the position of the Academy of Nutrition and Dietetics that nutrition informatics is a rapidly evolving area of practice for registered dietitian nutritionists and nutrition and dietetic technicians, registered; and that the knowledge and skills inherent to nutrition informatics permeate all areas of the dietetics profession. Further, nutrition and dietetics practitioners must continually learn and update their informatics knowledge and skills to remain at the forefront of nutrition practice. Nutrition informatics is the intersection of information, nutrition, and technology. However, informatics is not just using technology to do work. The essence of nutrition informatics is to manage nutrition data in combination with standards, processes, and technology to improve knowledge and practice that ultimately lead to improved quality of health care and work efficiency. Registered dietitian nutritionists and nutrition and dietetic technicians, registered, are already experts in using evidence to practice in all areas of nutrition and dietetics. To remain at the forefront of technological innovation, the profession must actively participate in the development of standards, processes, and technologies for providing nutrition care.     

Position of the Academy of Nutrition and Dietetics: Benchmarks for Nutrition in Child Care

It is the position of the Academy of Nutrition and Dietetics that early care and education (ECE) programs should achieve recommended benchmarks to meet children’s nutrition needs and promote children’s optimal growth in safe and healthy environments. Children’s dietary intake is influenced by a number of factors within ECE, including the nutritional quality of the foods and beverages served, the mealtime environments, and the interactions that take place between children and their care providers. Other important and related health behaviors that may influence the development of obesity include children’s physical activity, sleep, and stress within child care. Recent efforts to promote healthy eating and improve other health behaviors in ECE include national, state, and local policy changes. In addition, a number of interventions have been developed in recent years to encourage healthy eating and help prevent obesity in young children in ECE. Members of the dietetics profession, including registered dietitian nutritionists and nutrition and dietetics technicians, registered, can work in partnership with ECE providers and parents to help promote healthy eating, increase physical activity, and address other important health behaviors of children in care. Providers and parents can serve as role models to support these healthy behaviors. This Position Paper presents current evidence and recommendations for nutrition in ECE and provides guidance for registered dietitian nutritionists; nutrition and dietetics technicians, registered; and other food and nutrition practitioners working with parents and child-care providers. This Position Paper targets children ages 2 to 5 years attending ECE programs and highlights opportunities to improve and enhance children’s healthy eating while in care.     

Academy of Nutrition and Dietetics: Revised 2020 Standards of Professional Performance for Registered Dietitian Nutritionists (Competent,Proficient, and Expert) in Sustainable,Resilient, and Healthy Food and Water Systems

Current systems of food production and consumption are challenged by factors such as natural resource constraints, relative unaffordability of nutrient-dense foods, persistent social inequities, and high rates of diet-related disease. Registered dietitian nutritionists (RDNs) play a critical role in protecting the health of current and future populations by advancing sustainable, resilient, and healthy food and water systems. By definition, such systems can meet current dietary needs without jeopardizing the ability to meet the needs of future generations; can withstand or adapt to disturbances over time; and can equitably facilitate disease prevention and well-being for all individuals. This area of practice within nutrition and dietetics requires recognition of the complex interrelationships among indiviudal health and economic, environmental, and social domains of food and nutrition, and allows RDNs to bring unique expertise to diverse interprofessional teams. The Revised 2020 Standards of Professional Performance for RDNs (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems update the 2014 standards and cover the following 6 standards of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, specific indicators provide measurable action statements that illustrate how the RDN can apply the principles of sustainable food systems to a variety of practice settings. The indicators describe 3 skill levels (ie, competent, proficient, and expert) for RDNs in this focus area.     

Effect of Incorporating Genetic Testing Results into Nutrition Counseling and Care on Health Outcomes: An Evidence Analysis Center Systematic Review—Part II

In recent years, literature examining implementation of nutritional genomics into clinical practice has increased, including publication of several randomized controlled trials (RCTs). This systematic review addressed the following question: In children and adults, what is the effect of incorporating results of genetic testing into nutrition counseling and care compared with an alternative intervention or control group, on nutrition-related health outcomes? A literature search of MEDLINE, Embase, PsycINFO, CINAHL, and other databases was conducted for peer-reviewed RCTs published from January 2008 until December 2018. An international workgroup consisting of registered dietitian nutritionists, systematic review methodologists, and evidence analysts screened and reviewed articles, summarized data, conducted meta-analyses, and graded conclusion statements. The second in a two-part series, this article specifically summarizes evidence from RCTs that examined health outcomes (ie, quality of life, disease incidence and prevention of disease progression, or mortality), intermediate health outcomes (ie, anthropometric measures, body composition, or relevant laboratory measures routinely collected in practice), and adverse events as reported by study authors. Analysis of 11 articles from nine RCTs resulted in 16 graded conclusion statements. Among participants with nonalcoholic fatty liver disease, a diet tailored to genotype resulted in a greater reduction of percent body fat compared with a customary diet for nonalcoholic fatty liver disease. However, meta-analyses for the outcomes of total cholesterol, low-density lipoprotein cholesterol, body mass index, and weight yielded null results. Heterogeneity between studies and low certainty of evidence precluded development of strong conclusions about the incorporation of genetic information into nutrition practice. Although there are still relatively few well-designed RCTs to inform integration of genetic information into the Nutrition Care Process, the field of nutritional genomics is evolving rapidly, and gaps in the literature identified by this systematic review can inform future studies.     

Practice Paper of the Academy of Nutrition and Dietetics Abstract: Oral Health and Nutrition

This paper supports the “Position of the Academy of Nutrition and Dietetics: Oral Health and Nutrition” published in the May 2013 Journal of the Academy of Nutrition and Dietetics. It is the position of the Academy of Nutrition and Dietetics that nutrition is an integral component of oral health. The Academy supports integration of oral health with nutrition services, education, and research. Collaboration between registered dietitian nutritionists (RDNs); dietetic technicians, registered (DTRs); and oral health care professionals is recommended for oral health promotion and disease prevention and intervention. There is a synergistic multidirectional association between diet, nutrition, and oral health. Given that the mouth is the portal of entry into the body, it is essential that RDNs and DTRs include the oral cavity in their assessment for nutritional risk factors and deficiencies. Nutrition assessment is vital to identifying dietary intake and nutritional factors impacting oral health. Conversely, decreased salivary flow, compromised oral integrity, tooth decay, or poor periodontal health can impact an individual's ability to consume an adequate diet. A poor diet can result in limited intake of nutrients crucial to systemic health and well-being. The provision of medical nutrition therapy that incorporates total health, including oral health, is a component of the Standards of Practice for RDNs and DTRs. Inclusion of didactic and clinical practice concepts that illustrate the role of nutrition in oral health is essential in education programs for both professional groups. The multifaceted interactions between diet, nutrition, and oral health in practice, education, and research in both dietetics and dentistry merit the need for collaborative efforts to ensure comprehensive patient care.     

NUTRITION EDUCATION IN RURAL AUSTRALIA: WHY,WHO AND HOW?

ABSTRACT: Improving nutrition knowledge through nutrition education had been a major strategy used by nutritionists and health educators to improve the dietary intake of Australians. This approach continues to be supported by contemporary practice, and nutrition and health policy documents at a national and state level. In Australia, the delivery of nutrition education services to rural and remote populations is limited by a scarcity of nutrition specialists such as dietitian/nutritionists. This review highlights the importance of nutrition education in promoting the nutritional health of Australians in rural and remote areas, and describes a model for nutrition education service delivery based on generalists supported by specialists.     

Malnutrition Care During the COVID-19 Pandemic: Considerations for Registered Dietitian Nutritionists

Recent evidence examining adults infected with coronavirus disease 2019 (COVID-19) has indicated a significant impact of malnutrition on health outcomes. Individuals who have multiple comorbidities, are older adults, or who are malnourished, are at increased risk of being admitted to the intensive care unit and of mortality from COVID-19 infections. Therefore, nutrition care to identify and address malnutrition is critical in treating and preventing further adverse health outcomes from COVID-19 infection. This document provides guidance and practice considerations for registered dietitian nutritionists providing nutrition care for adults with suspected or confirmed COVID-19 infection in the hospital, outpatient, or home care settings. In addition, this document discusses and provides considerations for registered dietitian nutritionists working with individuals at risk of malnutrition secondary to food insecurity during the COVID-19 pandemic.     

Position of the Academy of Nutrition and Dietetics: Micronutrient Supplementation

It is the position of the Academy of Nutrition and Dietetics that micronutrient supplements are warranted when requirements are not being met through the diet alone. Those with increased requirements secondary to growth, chronic disease, medication use, malabsorption, pregnancy and lactation, and aging may be at particular risk for inadequate dietary intakes. However, the routine and indiscriminate use of micronutrient supplements for the prevention of chronic disease is not recommended, given the lack of available scientific evidence. A few specific age and disease states that may benefit from micronutrient supplementation are discussed. The most common dietary supplements used by both children and adults in the United States contain micronutrients. Consumers may not be well informed about the safety and use of these products, and some may have difficulty interpreting product labels. Thus, the expertise of registered dietitian nutritionists and nutrition and dietetic technicians, registered, is needed to guide the safe and appropriate selection and use of micronutrient supplements. To accomplish this, registered dietitian nutritionists and nutrition and dietetic technicians, registered, must keep up to date on efficacy, safety, and the regulatory issues influencing the use of these products. This position paper aims to increase awareness of current issues relevant to micronutrient supplementation and of the resources available to assist registered dietitian nutritionists and nutrition and dietetic technicians, registered, in evaluating their potential benefits and adverse outcomes.     

Referrals to dietitians/nutritionists: A cross‐sectional analysis of Australian GP registrars’ clinical practice

Aim

The present study aimed to describe referral patterns of general practitioner (GP) registrars to dietitians/nutritionists. There is a paucity of research regarding GP referral patterns to dietitians/nutritionists. Limited data show increasing referrals from established GPs to dietitians/nutritionists. There are no data on GP registrar (trainee) referrals.

Methods

This was a cross‐sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing, multicentre, prospective cohort study of registrars, which documents 60 consecutive consultations of each registrar in each of the three six‐month GP training terms. The outcome factor in this analysis was a problem/diagnosis resulting in dietitian/nutritionist referral (2010–2015). Independent variables were related to registrar, patient, practice and consultation.

Results

A total of 1124 registrars contributed data from 145 708 consultations. Of 227 190 problems/diagnoses, 587 (0.26% (confidence interval: 0.23–0.29)) resulted in dietitian/nutritionist referral. The most common problems/diagnoses referred related to overweight/obesity (27.1%) and type 2 diabetes (21.1%). Of referrals to a dietitian/nutritionist, 60.8% were for a chronic disease, and 38.8% were related to a Chronic Disease Management plan. Dietitian/nutritionist referral was significantly associated with a number of independent variables reflecting continuity of care, patient complexity, chronic disease, health equity and registrar engagement.

Conclusions

Established patients with chronic disease and complex care needs are more likely than other patients to be referred by registrars to dietitians/nutritionists. Nutrition behaviours are a major risk factor in chronic disease, and we have found evidence for dietitian/nutritionist referrals representing one facet of engagement by registrars with patients’ complex care needs.     

Evolving Beyond the World Foods Course: Creating Racially and Ethnically Inclusive Educational Spaces for Dietetics Students

Only 13.1% of US registered dietitian nutritionists and 27.8% of students enrolled in US dietetics education programs identify as racially/ethnically diverse individuals. National demographic trends show increasing percentages of racially/ethnically diverse individuals within the broader US and college student populations; however, these changes have not been mirrored within dietetics. Dietetics educators have an ethical and professional mandate to address diversity, equity, and inclusion within their programs. This paper reviews key terminology related to diversity, equity, and inclusion in the context of dietetics education, and describes a new framework to transform dietetics education based on the principles of cultural humility and culturally sustaining teaching. Strategies are presented to facilitate recruitment, admissions, retention, and mentorship for racially/ethnically diverse students and faculty, and to improve diversity, equity, and inclusion within curricula and classrooms. Lastly, this paper provides clear practice applications, including recommendations for program policy change and training/skill building activities for dietetics students, educators, and preceptors.     

Influence of human genetic variation on nutritional requirements

Genetic variation is known to affect food tolerances among human subpopulations and may also influence dietary requirements, giving rise to the new field of nutritional genomics and raising the possibility of individualizing nutritional intake for optimal health and disease prevention on the basis of an individual's genome. However, because gene-diet interactions are complex and poorly understood, the use of genomic knowledge to adjust population-based dietary recommendations is not without risk. Whereas current recommendations target most of the population to prevent nutritional deficiencies, inclusion of genomic criteria may indicate subpopulations that may incur differential benefit or risk from generalized recommendations and fortification policies. Current efforts to identify gene alleles that affect nutrient utilization have been enhanced by the identification of genetic variations that have expanded as a consequence of selection under extreme conditions. Identification of genetic variation that arose as a consequence of diet as a selective pressure helps to identify gene alleles that affect nutrient utilization. Understanding the molecular mechanisms underlying gene-nutrient interactions and their modification by genetic variation is expected to result in dietary recommendations and nutritional interventions that optimize individual health.     

Identifying the educational needs of aspiring sports nutritionists

Many dietetics professionals express interest in becoming sports nutritionists without full awareness of the complexity of this specialty area of dietetics—in terms of both the medical nutrition therapy involved and the business savvy required. Aspiring sports nutritionists need education in nutrition throughout the life cycle, medical nutrition therapy, nutrition therapy for management of eating disorders exercise science, business basics, and communication skills. Work experience is also important to develop confidence and skills. This is often gained while the dietitian is employed in another aspect of dietetics practice. J Am Diet Assoc. 2000;100:1522-1524.     

The genetic revolution: change and challenge for the dietetics profession

Advances in genetics are occurring at a pace that challenges our ability to understand and respond to the implications. Soon we will be able to define more precisely the molecular mechanisms underlying human health and disease; subdivide diseases and conditions (e.g., obesity) that are clinically indistinguishable into more distinct entities, thereby improving our ability to choose rational preventive and treatment measures; identify genotypic markers that predict metabolic responses to dietary interventions; stratify the population into groups at higher or lower risk for chronic diseases such as cancer, thus allowing dietary intervention to be appropriately targeted; and develop dietary recommendations that take into account genetically determined taste preferences. Dietetics leaders, teachers, practitioners, and researchers must act now to ensure that dietetics professionals are prepared for practice in this new era. In this article we introduce the Human Genome Project, review the fundamentals of molecular genetics, discuss genetics and disease risk, and define and give examples of diet-gene interactions. We also discuss issues relevant to dietary counseling of healthy people with genetic susceptibility to chronic disease. To foster the growth of knowledge regarding this new biology among dietitians, The American Dietetic Association should take the following steps: require course work on diet-gene interactions and include human genetics as a topic area on dietetic registration examinations, form a practice group on this topic, develop an Internet-based communication and information hub for dietetics professionals, sponsor a session on human genetics at annual meetings, begin a dialogue regarding a new practice specialty in diet and genetic counseling, and encourage a health care system in which personal counseling on diet-gene interactions is valued and reimbursed.     

The Impact of RDNs on Non-Communicable Diseases: Proceedings from The State of Food and Nutrition Series Forum

In the United States, nutrition-related morbidities are rising steadily at rates corresponding to increasing overweight and obesity in the population. Such morbidities take huge tolls on personal health and impose high costs on health care systems. In 2019, the Academy of Nutrition and Dietetics (Academy) and the Academy of Nutrition and Dietetics Foundation (Academy Foundation) embarked on a new project titled “The State of Food and Nutrition Series” to demonstrate the value of nutrition interventions led by registered dietitian nutritionists for individuals with the following 3 high-priority non-communicable diseases that affect many in the United States and globally: type 2 diabetes mellitus, chronic kidney disease, and hypertension. Poor nutritional status contributes to disease onset and progression in these non-communicable diseases, and appropriate medical nutrition therapy can prevent or delay worsening and ameliorate poor health outcomes. However, many people who have these conditions do not have access to an registered dietitian nutritionist, and consequently do not receive the nutrition care they need. On February 19-20, 2020 in Arlington, VA, as the first stage in The State of Food and Nutrition Series, the Academy and the Academy Foundation gathered health care policymakers, clinicians, and researchers from across the country for the State of Food and Nutrition Series Forum, where Academy leaders sought input to build a comprehensive research strategy that will quantify the impact of patient access to registered dietitian nutritionist–led nutrition interventions for type 2 diabetes mellitus, chronic kidney disease, and hypertension. This article summarizes the findings of that forum.     

Current Systems-Level Evidence on Nutrition Interventions to Prevent and Treat Cardiometabolic Risk in the Pediatric Population: An Evidence Analysis Center Scoping Review

Improving and maintaining cardiometabolic health remains a major focus of health efforts for the pediatric population. Recent research contributes understanding of the systems-level nutrition factors influencing cardiometabolic health in pediatric individuals. This scoping review examines current evidence on interventions and exposures influencing pediatric cardiometabolic health to inform registered dietitian nutritionists working at each systems level, ranging from individual counseling to public policy. A literature search of MEDLINE, CINAHL, Cochrane Databases of Systematic Reviews, and other databases was conducted to identify evidence-based practice guidelines, systematic reviews, and position statements published in English from January 2017 until April 2020. Included studies addressed nutrition interventions or longitudinal exposures for participants 2 to 17 years of age who were healthy or had cardiometabolic risk factors. Studies were categorized according level of the social-ecological framework addressed. The databases and hand searches identified 2614 individual articles, and 169 articles were included in this scoping review, including 6 evidence-based practice guidelines, 141 systematic reviews, and 22 organization position statements. The highest density of systematic reviews focused on the effects of dietary intake (n = 58) and interventions with an individual child or family through counseling or education (n = 54). The least frequently examined levels of interventions or exposures were at the policy level (n = 12). Registered dietitian nutritionists can leverage this considerable body of recent systematic reviews to inform a systems-level, collaborative approach to prevention and treatment of pediatric cardiometabolic risk factors.     

Academy of Nutrition and Dietetics: 2020 Cystic Fibrosis Evidence Analysis Center Evidence-Based Nutrition Practice Guideline

The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based practice guideline for primary nutrition issues in cystic fibrosis (CF). This guideline is designed to complement and build upon existing evidence-based CF nutrition guidelines. The objective of this guideline was to provide recommendations for registered dietitian nutritionists in the United States delivering medical nutrition therapy to individuals with CF and their families that fill gaps in current evidence-based guidelines on topics that are crucial in order to improve health and prevent disease progression. This guideline provides 28 nutrition recommendations to guide medical nutrition therapy, including nutrition screening, nutrition assessment, and dietary intake. For topics outside the scope of this guideline, practitioners are referred to external, evidence-based recommendations. The CF landscape is evolving rapidly with breakthroughs in cystic fibrosis transmembrane regulator modulators changing CF at a cellular level. Medical nutrition therapy for individuals with CF from infancy through advanced age requires novel and individualized approaches. The Academy Evidence Analysis Library CF guidelines provide a framework for expanding upon current knowledge to determine effective nutrition strategies for individuals with CF through long and healthy futures.     

Nutrition Care in Bariatric Surgery: An Academy Evidence Analysis Center Systematic Review

Obesity continues to be a major public health crisis, both nationally and globally. Metabolic and bariatric surgery has been proven to be a safe and effective treatment for this multifactorial chronic disease. However, inconsistent and varied results in bariatric nutrition literature have prevented the implementation of standardized guidelines. The purpose of this Evidence Analysis Library systematic review is to provide an evidence-based summary of nutrition-related practices in bariatric surgery. The systematic review methodology of the Academy of Nutrition and Dietetics was applied. A total of 27 research studies were included, analyzed, and assessed for risk of bias by trained evidence analysts. The literature included in the systematic review was published from 2003 to 2015. Evaluation of the literature resulted in the development of five graded conclusion statements. Limited research demonstrates that registered dietitian nutritionists play a role in improving weight loss outcomes after bariatric surgery; further research is needed to understand the role of registered dietitian nutritionists in changing behaviors after bariatric surgery. Bariatric surgery results in significant reductions in resting metabolic rate and postoperative energy intake. There is no significant relationship between macronutrient distribution and postoperative weight loss. The graded conclusion statements provide registered dietitian nutritionists who practice in the field of bariatric nutrition with more insight and evidence that can guide and support their recommendations.