April 11-12 was the Virginia Academy of Nutrition and Dietetics’ 87th Annual Meeting in Fairfax, Virginia. We had the honor of hearing from Kathie Swift, Dietitian and Co-Founder of the Integrative and Functional Nutrition (IFN) Academy. She also serves on the Medical Advisory Board for Functional Formularies, LLC; is the Education Director for the Food As Medicine program at the Center for Mind Body Medicine (CMBM); and is a Nutritionist at the UltraWellness Center, Kripalu Center for Yoga & Health, and Canyon Ranch in the Berkshires. Kathy plays a leading role as an Integrative registered dietitian nutritionist (RDN), helping to bridge the gap between traditional practice and a field that has continued to grow over the past two decades. For more information about Kathie Swift and her work, visit http://www.kathieswift.com. Highlights from her presentation at the VAND Annual Meeting are found below.[i]
Introduction
More than 50% of the world lives with chronic disease and by 2020, an estimated 81 million Americans will be living with multiple chronic conditions. The specific etiology underlying chronic disease can be ambiguous, stemming from interactions between diet, genes, and lifestyle. As there are infinite combinations of diet, gene, and lifestyle factors that make each of us unique, treatment cannot be one size fits all.
So, why do we so often treat the individual using approaches developed from information learned in population-based studies?
Kathie Swift emphasizes the need for more N=1 trials, which would be trials that are specific for one person. This references an idea behind nutrigenomics that an individual’s unique genetic makeup influences response to diet and lifestyle changes. Future approaches need to be tailored, labeled by some as “P4 Medicine” – medicine that is “predictive, preventative, personalized, and participatory.”
An Individualized Approach: Integrative Medicine (IM)
In 2016, Kathie Swift and colleagues issued a survey to assess knowledge and skills in the area of IM, as well as beliefs, attitudes, and use of modalities by RDNs. Findings demonstrated that 72.5% of RDNs truly desired to learn more and felt unqualified in this growing field, necessitating a call to action for professional education on how to practice as an Integrative RDN.
The term integrative means something that serves to form, coordinate, or blend two or more separate things into a unified whole.[i] IM is a union of Complementary and Alternative Medicine (CAM) with mainstream healthcare approaches.
According to Duke Integrative Medicine,[ii]
“Integrative Medicine seeks to restore and maintain health and wellness across a person’s lifespan by understanding the patient’s unique set of circumstances and addressing the full range of physical, emotional, mental, social, spiritual, and environmental influences that affect health.”
An overarching goal is to address the whole person, rather than simply the signs and symptoms at hand. Furthermore, IM focuses on prevention and aims to nurture health behaviors and skills in self-care that patients can continue to use for years, bringing them to an even greater state of health than where they began before illness. In order to accomplish this, the patient and the practitioner are partners in a strong therapeutic relationship.
Why Should We, as RDNs, Care About the Field of IM?
- Health promotion and disease prevention are within the RDN’s scope of practice.
- Patients desire evidence-based opinions regarding trends in herbal supplements, health, and diet.
- Natural health alternatives appeal to the public, especially when traditional western approaches fail to lend desired results.
- Research in Nutritional Genomics continues to grow.
In 2006, the Future Practice and Education Taskforce declared skills and experiences necessary for future practice in 2017.[iii] Among traditional skills in MNT, nutrition support, and other areas, highlighted skills fell into complementary and alternative healthcare, nutrigenomics and genetics, and holistic healthcare, among other avenues that reflect an integrative medicine approach.
In 2011, The Bravewell Collaborative released a survey of 29 integrative medicine centers across the United States. Out of 34 integrative therapies commonly used in treatment interventions, food/nutrition was the one most consistently prescribed across a multitude of chronic conditions. Of note, only 48% of surveyed centers report employing a dietitian or nutritionist, suggesting there may not be enough qualified dietetics practitioners seeking positions in the field of IM to adequately deliver those interventions.
Putting It In Practice: How to Provide Care in the IFM Mindset
Integrative RDNs develop and provide person-centered nutrition interventions, recognizing that 1) each patient has a unique genetic make-up and 2) each patient functions in an environment with physical, social, and lifestyle factors that influence interactions between the mind, body, and spirit. Some of what they may explain to clients includes the phases of cellular metabolism, how the body naturally digests foodstuffs, the detriments of toxin burden, and how to “retune” naturally through food. They may interpret functional laboratory tests for vitamin, mineral, or nutrient deficiencies, and use these results to shape a personalized whole foods-based plan.[iv]
Other services within a treatment plan may expand beyond traditional dietetics to include safe alternative medicine practices, such as massage, homeopathy, yoga, acupuncture, qigong, herbal supplements, and more. In any area of IM, emphasis is placed on communication and collaboration with other members of the healthcare team who may be more versed in these areas of practice.
The Integrative & Functional Medical Nutrition Therapy (IFMNT) Radial[v] was created as a way to visually represent how an Integrative RDN may practice. The center of the radial represents traditional MNT as we have learned it, using the Nutrition Care Process and ADIME format. Food is still at the center of personalized care, and a determining factor in health and disease. However, the circular architecture encourages evaluation of complex interactions and interrelationships that not only may have shaped signs and symptoms but also will shape treatment outcomes. Five key areas – lifestyle, systems, biomarkers, metabolic pathways, and core imbalances – influence how food is utilized, with core clinical imbalances often exposing the root cause of disease or illness.
The Integrative RDN can use this radial to organize patient information and consider avenues for treatment. A successful treatment plan focuses on the areas where the most leverage can be found – those sections of the radial that appear to have the greatest concentration of dysfunction and that are connected to the most important presenting signs and symptoms. Remembering to focus not just on a patient’s signs and symptoms, but rather on the root cause(s), or core imbalances, is key.
Transforming the Practice of Nutrition: 5 Integrative Guidelines
Kathie Swift outlines five guidelines for RDNs outside of the Integrative and Functional Medicine sphere who wish to transform their practice in the IM model:
Honor your roots.
- Treasure your traditional dietetics education, personal experiences and endeavors, dietetic internship training, and entry-level experiences, as these are what have created your foundation.
- Continue utilizing evidence-based guidelines garnered from research, such as randomized controlled trials and systematic reviews, and utilize other existing forms of evidence, such as patient cases shared among colleagues.
Fertilize a beginner’s mind.
- Be open to alternative career paths for the RDN, such as the field of IM, and maintain an appreciation for lifelong learning.
Till your inner landscape.
- Utilize the resources available to learn about core principles in IM and discover how these principles fit into your practice.
Mulch your integrative toolkit.
- Learn about online functional laboratory testing companies.
- Explore tools and technology, such as phone apps, books, and online assessments.
- Experiment with your own body!
- Keep food, symptoms, and lifestyle journals.
- Attempt an elimination diet.
- Try out different dietary supplements.
- Experiment with functional lab testing.
- Explore alternative therapies, such as yoga, qigong, or acupuncture.
Cultivate collaborative relationships.
- Enhance your skills in motivational interviewing (MI) and person-centered therapies. Nothing can be more powerful than a patient’s story, and to gain a true story, a strong therapeutic relationship must be garnered and nurtured from the beginning. Initiate a dialogue so your patient feels open to share.
How The RD Can Gain Competencies
Think “Individual Scope of Practice”… With additional training, skills, and certifications, you can extend your own scope of practice beyond your traditional roots. The Standards of Practice and Standards of Professional Performance for Registered Dietitians in Integrative & Functional Medicine, published in 2011, outlines practice competencies for the competent, proficient, and expert practitioner.[i] The Academy has many dietetic practice groups, such as the Dietitians in Integrative and Functional Medicine, which can provide valuable resources to promote lifelong learning and gain practical competency in integrative and functional medicine. For a list of resources and tools specifically related to practice in the field of integrative medicine, you can download The Integrative and Functional Nutrition Toolkit for free at http://integrativerd.org/resources-2/.
Jacqueline Suarez is presently a dietetic intern at the University of Virginia Health System in Charlottesville. Recently, she gave a presentation on integrative medicine to internship leadership, delving into this exciting field for the first time. As an RDN one day, she hopes to learn more about integrative practice and find balance between this field and the clinical setting. Outside of the hospital, Jacqueline enjoys spending time outdoors with fellow interns and practicing yoga. Originally from New England, she obtained a BS in Nutrition & Dietetics and a BA in Psychology from Simmons College.
References:
[i] Ford D, Faj S, Batheja RK, DeBusk R, Grotto D, Noland D, Redmond E, Swift KM. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional Medicine. J Acad Nutr Diet. 2011;111(6):902-913.e23.
[i] Integrative [Def. ]. (n.d). In Merriam Webster Online, Retrieved January 20, 2016, from http://www.merriam-webster.com/dictionary/
[ii] Duke Integrative Medicine. Website. https://www.dukeintegrativemedicine.org/about/what-is-integrative-medicine/.
[iii] Phase 2 Future Practice and Education Task Force. Final Report of the Phase 2 Future Practice and Education Task Force. July 15, 2008. Academy of Nutrition and Dietetics website. www.eatright.org/futurepractice/. Accessed February 13, 2016.
[iv] Richard M. What is an Integrative RDN? Integrative RD Blog. Feb 21, 2016. http://integrativerd.org/blog.
[v] Image address: http://integrativerd.org/wp-content/uploads/2012/04/IFMNT-Radial-Guide-Copyright-2011.png
[i] Swift KM. Transforming the Practice of Nutrition: An Integrative Approach. VAND Annual Meeting 2016. Farifax, VA. 12 Apr 2016.