Model for dietetics practice and research: The challenge is here, but the journey was not easy

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COMMEITARY

Model for dietetics practice and research: The challenge ishere, but the journey was not easy MARGARETA. POWERS, MS, RD;MADELYNL. WHEELER, MS, RD ietitians have a unique combination of skills and knowledge and a unique perspective on health care. As the nation is challenged to provide the best health care at a reasonable cost, dietitians should actively promote themselves as vital partners in the quest for health promotion and disease prevention. THE CHALLENGE AND THE JOURNEY The recently completed multicenter Diabetes Control and Complications Trial (DCCT) provides a model for dietetics practice and research. It defines the challenges RDs face in being integral members of both the health delivery and research teams, and being used to their full potential. Although the study results are important to us (especially as they serve as advocacy examples for dietetics practice and research), we do not intend to heap accolades (however well-deserved) on the researchers or to present their accomplishments per se. That will be done in other reports. Our intention is to explore the DCCT model and the challenge and opportunies it offers for dietetics practice and research. DIABETES CARE AS A PARADIGM Diabetes is a medical condition that encompasses all aspects of one's life; nutrition influences are entwined throughout. Those who care for persons with diabetes must always consider that person's life and not just treat the disease. The technical and medical aspects of diabetes care might, at times, receive less attention when the person with diabetes has difficulty purchasing food, has no transportation, or has no social support. Although DCCT subjects were highly motivated, these types of issues still surface and make diabetes care a model for other health programs in which it is critical to balance medical and social factors of health promotion/maintenance and disease prevention/self-management. Study Background Seventy years ago, the discovery of insulin turned diabetes management from a diet-oriented to an insulin management focus (1); some claimed it was a miracle. Persons with diabetes lived longer than before, but continued to have shorter life expectancies than persons without diabetes. Longer life spans allowed the devastating complications of diabetes - cardiovascular disease, nephropathy, retinopathy, neuropathy -to emerge. These complications often lead to death or decreased quality of life. Many health professionals, researchers, and persons with diabetes, began to ask whether these complications were inevitable. Ten years ago an international clinical trial was begun to examine this question in a systematic, conclusive manner. The hypothesis was that "tight" (in the nondiabetic range) blood glucose control would prevent or delay complications of diabetes. The benchmark was the progression of microvascular disease. The early 1980s presented the window of opportunity to conduct this research. The Results On June 13, at the Annual Meeting of the American Diabetes Association in Las Vegas, Nev, the National Institute of Diabetes M. A. Powers is with Powers and Associates, Health Promotion/CommunicationSpecialists, St Paul, MN 55116; and M. L. Wheeler is a coordinatorof researchdieteticsfor the Indiana University Medical Center's DiabetesResearch Training Center, Indianapolis,IN 46202.

and Digestive and Kidney Diseases of the National Institutes of Health (NIH) announced the results of the DCCT a year ahead of the designated ending date. For individuals with insulin-dependent diabetes mellitus, the results indicate the following. u Compared with conventional treatment, intensive diabetes therapy results in the benefit of approximately a 50% overall risk reduction for the progression of diabetic microvascular complications (retinopathy and nephropathy) and neuropathy without an increased risk of death, macrovascular disease, or changes in quality of life. * Compared with conventional treatment, intensive diabetes therapy results in a two- to threefold greater risk of severe hypoglycemia and a tendency for weight gain (about 10 lb). * Intensive diabetes therapy requires a comprehensive team approach, using the expertise of dietitians, nurses, behaviorists, and physicians, to ensure safe and effective therapy. THE DCCT MODEL FOR DIETETICS PRACTICE AND RESEARCH This research study recaptured the nutrition component of diabetes care. For many years, diet had become secondary to medication in the treatment of diabetes, often because of the difficulty in making behavioral changes related to diet. The DCCT produced a model for nutrition care when it became clear that if tight control was to be achieved, food-related issues- eg, meals, daily snacks, snacks before and after exercise, sick-day management, treating hypoglycemia, working swing shifts, traveling, eating away from home - had to be carefully monitored. To provide the guidance and support nutrition change requires, RDs clearly need adequate time and resources for nutrition education and counseling and must be involved in the total management of diabetes. Only then can we overcome the difficulties that nutrition and behavioral changes present, and nutrition can truly become an integral component of diabetes care. Because the major research focus was on controlling potentially confounding variables - blood glucose levels and weight gain with narrow limits- for the duration of the study, the DCCT dietitians' primary function became intensive diabetes nutrition therapy. As described on page 758, the initial involvement of the RDs in the DCCT was limited. Not all RDs were experts in the study topic, nor did all of them have a research background. As the study progressed, however, it became clear that RDs were invaluable in promoting adherence to factors necessary to achieve the study's goal of tight control, and they rose to the challenge. The Model The practice/research model evolved into having the RD review food intake in conjunction with blood glucose monitoring records and insulin doses. The RD, in conjunction with the patient, would then make or be involved in making management recommendations regarding blood glucose testing and adjusting insulin/food/ activity to obtain target blood glucose values. Dietitians became case managers as patients called them to discuss variations in blood tests and food and activity changes. It is imperative that RDs involved in diabetes care (insulin dependent and non-insulin dependent) become proficient in interpreting blood glucose records because these are the critical evaluation pieces that integrate food intake with other components of diabetes management. This evaluation is the guide for self-management training. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 755

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Continuum of nutrient intake control in dietetics practice/research. Self-management training involves teaching and counseling to provide the knowledge, skills, attitudes, and behaviors that promote independent living with a chronic disease. Dietitians have always used self-management training to promote independence in food selection, although we may not have called it by this name. Thus, the DCCT model shows that: (a) nutrition can now be considered the most critical and pivotal component of diabetes care in achieving target blood glucose goals for persons with insulin-dependent or non-insulin-dependent diabetes; and (b) dietitians are true partners in diabetes care and research and should make management recommendations beyond diet. This expanded role can be applied to any chronic disease.

The DCCT model shows that nutrition isnow considered the most critical component of diabetes care and that, as partners indiabetes care, RDs make management recommendations beyond diet Dietitians excel in teaching and counseling about diabetes selfmanagement because of their ability to: · allow behavioral change to proceed at a pace acceptable to the individual and sequenced to meet patient needs and abilities; * use a variety of flexible approaches to help individuals selfmanage diabetes by integrating the role of food in other aspects of diabetes care; and * successfullyintegrateinsulin and exercise with nutrition therapy. Why the Model Works Nutrition is an integrative science (2). As such, our approach to dietetics practice and research is not limited to the metabolic need for food. We draw from the work of physiologists, cell biologists, statisticians, behavioral scientists, educators, sociologists, anthropologists/culturalists, and others. This rich background gives us a unique blend of practice parameters to guide patients in making food and health choices that promote optimum health. Specifically, the DCCT model blends intensive insulin therapy with the dietitians' holistic approach to behavioral change related to food intake. Where the Model Fits The DCCT was not a controlled clinical trial in which a primary hypothesis relates to diet modification. For example, the primary hypothesis of another large multicenter trial, the Modification of Diet in Renal Disease (MDRD) study (3) is that a diet low in protein and phosphorus will retard the rate of progression of renal 756 / JULY 1993 VOLUME 93 NUMBER 7

failure in patients with chronic renal disease. Dietitians were integral to the MDRD study design and there were several fulltime dietitians at each site to provide nutrition education. The DCCT represents perhaps a more typical or conmulon situation in research studies: a controlled clinical trial in which the primary hypothesis is not dietary modification, but the interventions may affect food behavior of subjects. lUnder these circumstances diet may be a confounding variable and, if not controlled for, may make results difficult to interpret. However, to control for diet behavior, the services of skilled and knowledgeable dietitians are required, as indicated in the articles by Delahanty et al (page 758) and Anderson et al (page 768) in this issue of the JouroA dl. The DCCT model can be applied to most areas of diabetes practice and research as it fits particularly well in the middle of the continuum of nutritient intake control (Figure). At one end of the continuum, nutrient intake is strictly controlled. This is necessary when conducting metabolic nutrition research and is very well defined (4). The MDRD fits near this end of the continuutm. At t he other end of the continuum, there is little or no control of nutrient intake. The middle of the continuum covers self-management training, as was used in the DCCT. OBSTACLES TO IMPLEMENTING THE MODEL Perceptions of Others First, research investigators and other health care professionals may not have an appreciation of the level of knowledge and the types of skills dietitians are capable of providing to clinical research studies and to practice settings. · RD responsibilities for self-management training or research may still be perceived as limited to "providing a diet." Nondietitians often do not realize the time and expertise required to provide nutrition-related self-management training and the positive outcomes possible. Within the DCCTmodel, RDs were elevated to the role of partner in diabetes care and on the research teams, rather than being the ancillary support person who provided the diet. Dietitians are not typically sought as education program or study coordinators who influence and may allocate study resources. Our journey toward changing that situation will be shorter if we maintain our nutrition-related functions while expanding our responsibilities to include some not typically identified as nutrition-related. In fact, RDs were hired as study coordinators at two DCCT sites. (For tips on how RDs can become study coordinators, see the FYI article on page 749.) · Many educational programs and clinical researchstudies lo not include enough dietitian time and salary in their plans. A nutrition perspective during the conceptualizing and planning phases of health education programs and clinical/conununity research results in broader-based projects with more complete focuses. Also, adequate tihne and resources for the nutrition comprronelt (approach) ill more likely be allotted. * Within the DCCT, nutrition was originally included in the form of diet history data collection and basic diet instructio i. However, because of the pivotal role RDs played in self-mtanagenm ent trailling, (dietitiantime was refocused. Fort;ulately, because Rl)s were

part of the study structure, this change was easily incorporated. Finding dietitians for education programs and research should not be a limitingfactor in their involvement. RDs are accessible (5) and their recruitment for stimulating, rewarding work will only increase their availability. The DCCT experience justifies to administrators and researchers the need for planning appropriate time and salary for RD involvement in research studies. Perspective of the Dietitian Are the sacrifices worth it? Elevating the status of nutrition in the role of health care and expanding the dietitian's scope of practice are rewarding concepts. Nevertheless, the sacrifices that must be made to reach that point may be questioned; sacrifices may include extra time commitment with no increase in salary or deliberations with other health team members about the dietit ian's role. Each individual dietitian must examine her or his own personal situation an(d weigh it with the ultimate benefits to patient care ancd/or the research project. At some point it is unrealistic to expect a dietitian to give time and expertise gratis. How will this help me reach my career goals? Although RDs in clinical/commuity care arid in research practice to serve others. they should also manage their own careers. For example, if a dietitian is invlveed in the collection of data or provision of the intervention in a clinical trial, but is not involved in planning the research an(i drafting the resulting research manuscript, there will not be authorship credit (6). If this is unacceptable, the dietitian needs to pursue avenues to become more involved in research projects. Careful thought should be given to acquiring and marketing skills that can be applied to advanced positions. THE CHALLENGE FOR THE FUTURE How can we make use of the DCCT model for nutrition practice or research? Where do interested dietitians obtain the level of knowledge, skill, and/or experience to practice within this model, to participate in research, to help other investigators plan research, to do their own research. or to overcome obstacles such as those listed in this commentary? The answer in one word is mentoring. The DCCT dietitians developed a support and mentoring systen ito help each dietitian reach his or her potential. Mentoring in the Broad Sense Although mentoring customarily refers to a person-to-person relationship (7,8), in a broad sense it could also include influential 'paper mentors" - publications that provide "how to" information, such as those cited in references 4, 9-11, as well as in the DCCT articles on pages 758 ad 768. RDs can be inspired to accept certain challenges and make career moves by meeting mentors through a variety of situations, including: * nutrition professional organizations - eg, dietetic practice groups, district and state dietetic associations, and more broadbased health-related organizations; * noi-nutitiol-related professional organizations * community or professional workshops; * colmmitt ee work; * graduate or ge neral interest course work; and * computer networks. Mentoring in the Traditional Sense Because nutrition is an applied science, dietitians do not seem to have he advanced research training opportunities and mentoring that are so well provided in the basic science areas (12). In a survey of lmemlbers of tle Diabetes Care and Education dietetic practice group, only 28% reported that they had a mentor or a role model (1:). Thuls, wl need to expand our individual mentoring

efforts. Examples of groups who are already doing this include the Nutrition Research dietetic practice group, which has a program to link mentor and mentee (14), and the mentoring linkage project sponsored by the California Dietetic Associal ion (7). Dietitians who become involved in planning research should actively educate colleagues about the benefits of employing dietitians in clinical research (15). They should also be able to justify the inclusion of dietitians so that funding will be provided for nutrition-related research. When dietitians receive doctoral degrees in another field eg, statistics), and begin to make a name for themselves in research, they should not forsake dietetics. Such people could represent dietetics as well as their chosen advanrced-dlegree field on a national level-- at consensus conferences, at the NIH peer review level, and in te mnentoring of dietitians in research. Nlentoring does not require a lot of time. Sometimes all it takes anr the right words, in the right place, at the right time. SUMMARY If,as dietitians, we are to expand our role and illnfluence on patient care and in clinical research (as described by the DCCT model), we need to examine our strengths, obtain expertise in our areas of interest, educate nondietitians and investigators about the benefits of using our skills in the clinical and research environments, and continue to develop our mentoring system. We need to identify our own personal challenges that will make ls more effective leaders in health care. Also, we must acknowledge that the journey to reach these new goals will not always be easy, but is tremendously rewarding - personally and professionally. References 1. Powers MA. A review of recent events in the history of diabetes nutritional care. Diabetes Educ. 1993;18: 393-400. 2. Ross AC. The future direction of nutrition research: predicting the futureis problematical, butplanningforit ispossib)l.. Nt 1918:119:948949. 3. Modification of Diet in Renal Disease Study Grollp. Thie modification of diet hi renal disease study: design, methods, ailnd results from the feasibility study. Am J Kidney Dis. 1992; 18-33. 4. Ershow A, ed. Metabolic Diet Studies i Hrmans: A Practical Guide to Design and Mrn2agqeme.t. Chicago, 11:Anmeri(can Dietetic

Association; In Press. 5. Powers MA. Accessing nutrition care. In: Lebovitz HE, ed. Therapy jfrl)iaetesMellitus and Related Disorders. Alexandria, \ a: Americian

Diabetes Association; 1991: 100-102. 6. International Committee of MedicalJournal Editors. I!niforim requirements for manuscripts submittedto biomedical journals (4th ed ).NErn2,ql JMed. 1991;:324: 424-428. 7. I)arling LAW, Schatz PE: Mentoring needs of dietitians: tlle nmeItoring self-management program model. JA I)Diet Assoc. 1991:91: -154-458. 8. Lkiogi S'ategieLsfo Dietitio'ws -¥teohkiiq, Lrisco Bdildiig, aied Mentoriqg. Pojesssional Dei'e/lopplte t ,ic. , ( llumhus,

Ohio: Ross Laboratories; 1989. 9. Pastors JC, Holler H.Mea Platniig App oarhes it the Nt I -itic) tl Maonageytmeit f the Persoo with Diabetes. 2nd ed. Chicago, Ill: Armeri-

can Dietetic Association; in press. 10. Powers, MA. Handbook of diabetess Nt'itionmtl M ltloen')I.

Gaithersburg, Md: Aspen Publishers; 1987. 11. Monsen EA ed. Research - S-Sccessjl A)l)r)oth(eIrs Chicago, Ill: Americanl Dietetic Association; 1992: 38-48. 12. Wylie-Rosett .I, Wheeler M, Krueger K, Halforcl B. i)ppo)rtuniliies for research orient edl dietitians. JAm Diet Assoc. 1990;90(: 1531-15:34. 13. Powers MA, Cohen RM. The I)ietitian's Role in he C(are of Diabetic Patients. Iresenlt,d at the 1985 Anumal Meeting of the American I)ic etic Association. 14. Mcntor committee. Inaugural Report: Nut.rit.ionll Researc: h dieletic practice group. The Diqest. 1!)92;18(4):6. 15. Wheeler Ml, Fineberg N DIelahlanty L. Dietitians: vital teal moelhers in pllanning dliabet es climit al rcsearcl h.Di el)0t Sl,''('i'l o 1993; 6: 212-21.

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