Practice Consideration
The Academy of Nutrition and Dietetics: Revised 2018 Standards of Practice and Standard of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Mental Health and Addictions describe the roles and activities for three levels of dietetics practice: Competent, Proficient and Expert. (1)
In order to demonstrate Competency, RDNs who are just starting practice or who do not routinely practice in this area need to build their knowledge in the following fields:
- Types of mental illness and addictions, and their characteristics
- Behavior of individuals experiencing these conditions
- Side effects of prescribed medications or illicit drug use
- Potential impact on nutritional needs
- Nutrient deficiencies and excesses that cause an altered mental state
- Dietary habits and medications that lead to deficiencies or excess of nutrients
The Standard of Professional Performance (SOPP) also identifies specific activities related to alcohol addiction that competent dietitians perform.a When developing the nutrition prescription and medical nutrition therapy goals for a patient with alcohol misuse, the competent dietitian considers:
- Contraindications for alcohol consumption such as; medication interaction, commitment to abstinence, history of substance use disorder, peri-conception, pregnancy and lactation, children and adolescents, specific medical conditions
- Nutrition in the prevention of developmental disabilities; maternal nutrition, abstaining from alcohol and drugs, pica
- Effects of chemical dependency on physical health including: ascites, osteoporosis, peptic ulcer disease, esophageal reflux disease; cancers of the mouth, esophagus, stomach, bowel; heart disease, pancreatitis, altered glucose regulation, liver cirrhosis/necrosis, dyslipidemia, lactose intolerance, malnutrition
When selecting and conducting the nutrition intervention the competent dietitiana:
- Identifies tools to assist patient/client with self-management of nutrition status
- Identifies resources to support patient/client/family/caregiver with behavior change goals. For example, support groups, health care services, meal programs, community outreach programs
- Identifies and facilitates referrals for physical assistance, including adaptive equipment, speech therapy, occupational therapy, physical therapy, dental services, home care
- Identifies and facilitates referrals for:
- Behavioral services such as psychotherapist, pastoral counseling, community-based support groups including 12-step groups, The National Alliance on Mental Illness
- Educational adjuncts such as Cooperative Extension nutrition program, community education programs
- Financial resources such as state or federal food assistance programs, for example SNAP {Supplemental Nutrition Assistance Program} or WIC {Special Supplemental Nutrition Assistance Program for Women, Infants, and Children}, community meal programs, food pantries
- Collaborates with physician and interprofessional team to use approved protocols or similar documents consistent with facility/program policies
- Collaborates for guidance or assistance or refer to other members of the interprofessional team when need is outside scope of practice of RDN (psychiatrist, psychologist, social worker, occupational therapist, speech therapist, RDN with expertise
RDNs do not have responsibility for treating alcohol abuse. The dietitian may have more detailed information than the rest of the healthcare team regarding the extent of alcohol consumption since the diet history elaborates quantity and frequency of consumption in clients who choose to share. Sharing this information with the rest of the healthcare team must be conducted in an ethical, sensitive and professional way.
There is standardized language terms in the Nutrition Assessment terms for recording information about alcohol intake. There are also terms for reflecting, knowledge, attitudes and beliefs related to alcohol consumption, changes in activities of daily living, etc. In intervention the most appropriate terms relate to coordination of care with other healthcare team members to reinforce encouragement for the client to seek help from qualified substance-abuse healthcare professionals or support/treatment organizations.
a "A competent practitioner who has achieved credentialing as an RDN and is starting in professional employment consistently provides safe and reliable services by employing appropriate knowledge, skills, behavior, and values in accordance with accepted standards of the profession; acquires additional on-the-job skills; and engages in tailored continuing education to further enhance knowledge, skills, and judgment obtained in formal education.
Dietitians Australia (DA) Mental Health Role Statement2
This role statement was created by Accredited Practising Dietitians (APDs) working in mental health. It details the role of a dietitian working in the area of mental health.
Importance of APDs in mental health
Dietitians are increasingly recognised as key members of the mental health care team to assist in improving both mental and physical health.
Diet plays an important role for overall mental wellbeing. Healthy diets are linked with good mental health; poor diets are linked with poor mental health. Dietary support should form part of the core treatment of mental illness. When used in ongoing treatment for mental illnesses like depressive disorders, dietary support can help to prevent, treat or manage symptoms.
Mental illness and substance use often negatively impact both dietary intake and physical health. Food intake and overall health are also affected by medication side-effects (such as increased appetite), symptoms of mental illness (like low motivation and low energy) and social determinants of health. If these concerns are not addressed, they can lead to physical illnesses like cardiovascular disease and diabetes. The life expectancy of people experiencing mental illness and substance use disorders in Australia is 10-to-16 years shorter than the rest of the population, mainly due to poor physical health. Diet improvement is critical for both prevention and management of physical illness.
What all APDs in mental health can do
Entry level competencies ensure all APDs can conduct assessments, diagnose nutrition issues, and develop, monitor and evaluate interventions. This applies to individuals, groups, communities, organisations, and population and systems levels. Dietitians in mental health have specific skills to:
- Provide holistic nutrition care, taking into account key issues in mental illness, including:
psychotropic medication side effects and nutrient interactions- risk of co-existing physical health conditions, and relevant biochemical measures (including lipids, glucose, Liver Function Tests, folate, vitamin B12, vitamin D)
- behavioural, motivational, social, and financial challenges
- concurrent addictions and substance use, disability, or cognitive impairment
- risk of malnutrition, disordered food/eating patterns or food insecurity
- Support lifestyle change using individualised nutrition advice and counselling, including practical strategies such as cooking groups, label reading, food budgeting, meal planning, and using visual aids and demonstrations (such as food or meal portions).
- Collaborate with clients, carers, families, GPs and all members of the multidisciplinary team to develop a realistic nutrition care plan.
- Act as a resource to other health professionals, providing information about nutrition and mental health and why dietitians are important in mental health care.
What APDs with greater experience in mental health can do
As APDs gain experience and expertise in their area of practice, they can take on more complex tasks. Dietitians experienced in mental health may:
- Provide nutrition intervention using advanced counselling techniques, such as cognitive behavioural therapy and coaching skills, to enhance lifestyle change and client outcomes.
- Use their knowledge of the side effects of prescribed medications or illicit drugs and their potential impacts on nutritional needs and food behaviours.
- Identify a decline in mental state and inform an appropriate mental health clinician.
- Understand and apply the principles of recovery oriented, strengths focused and trauma informed care to all aspects of nutrition care.
- Apply understanding of the unique and varied food service needs and specific food service guidelines for mental health populations, catering to both under and over nutrition.
- Advocate for the role of nutrition in mental health, inform policy and service development, provide training and education to other health professionals and advice on nutrition screening, assessment and discharge planning for mental health services.
- Engage in research and quality improvement projects, contributing to the emerging evidence base in nutrition and mental health, as well as policy and service development.
What APDs in mental health and addiction don’t usually do
Dietitians work closely with other professionals to ensure the best outcomes for the people they work with. However, dietitians don’t always provide the same services as non-dietitian colleagues. Unless they have further training and an extended scope of practice, dietitians in mental health and addiction don’t usually:
- Diagnose mental illness – refer to a GP or psychiatrist.
- Conduct mental health risk assessment – refer to a psychologist, social worker or doctor.
- Assess safety and functioning while cooking – refer to an occupational therapist.
- Assess physical activity capacity – refer to an exercise physiologist or physiotherapist.
- Assess swallowing difficulties – refer to a speech pathologist.
For more, download the full role statement.
References
1. Girard TA, Russell R, Leyse-Wallace R. Academy of Nutrition and Dietetics: Revised 2018 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Mental Health and Addictions. Journal of Academy and Nutrition Dietetics. 2018:118(10):1975-1986 e.53. DOI: https://doi.org/10.1016/j.jand.2018.07.013\
2. Mental Health Role Statement. Dietitiansaustralia.org.au. September 8, 2022. Accessed October 31, 2024. https://dietitiansaustralia.org.au/working-dietetics/standards-and-scope/role-statements/mental-health-role-statement