Practice Paper of the Academy of Nutrition and Dietetics:
The Role of Nutrition in Health Promotion
and Chronic Disease Prevention
ABSTRACT
Food intake, lifestyle behaviors, and obesity are linked to the
development of chronic diseases such as type 2 diabetes,
certain cancers, and cardiovascular diseases. It is recognized
that physical and social environment influences individuals
behaviors, and some population subgroups such as racial/
ethnic minorities and individuals with low socioeconomic
status or limited literacy or language abilities seem to be
especially vulnerable to disparities in disease risk factors,
disease prevalence or health outcomes. Certain life cycle
phases appear to be especially important for health
promotion and disease prevention as the development of
chronic diseases can take several decades. Such complex
health issues often require system-wide, multifactorial,
and multidisciplinary solutions. Social ecological models,
with approaches spanning from individual level to macro
policy level can provide registered dietitians (RDs) and
dietetic technicians, registered (DTRs) with a comprehensive
framework to promote health and to prevent chronic
diseases. Furthermore, the Nutrition Care Process can be
utilized in carrying out the health promotion and disease
prevention efforts. RDs and DTRs have the training and
THE NEED FOR HEALTH PROMOTION AND
CHRONIC DISEASE PREVENTION
This paper supports the Position of the Academy of Nutrition
and Dietetics: The Role of Nutrition in Health Promotion
and Chronic Disease Prevention published in the July 2013
Journal of the Academy of Nutrition and Dietetics.1 Food intake
patterns, lifestyle behaviors (eg, physical activity and cigarette
smoking), and body weight status are associated with the
development of chronic diseases such as type 2 diabetes, certain
cancers, and cardiovascular diseases (CVD).2 Despite the
widespread presence of these health issues around the nation,
population subgroups such as racial/ethnic minorities and
individuals with low socioeconomic status (SES) or limited
literacy or language abilities seem to be especially vulnerable
to disparities in disease risk factors, chronic disease prevalence,
health care, and health outcomes.1,3
Certain life cycle phases appear to be especially important
for health promotion and chronic disease prevention
requisite skills to be leaders and active members of
multidisciplinary teams to promote health and prevent
chronic diseases across the lifespan. The position of the
Academy of Nutrition and Dietetics states that primary
prevention is the most effective, affordable method to
prevent chronic disease, and that dietary intervention
positively impacts health outcomes across the lifespan. RDs
and DTRs are critical members of health care teams and are
essential to delivering nutrition-focused preventive services
in clinical and community settings, advocating for policy and
programmatic initiatives, and leading research in disease
prevention and health promotion. In concordance with the
Academys position, this practice paper provides an overview
of practice examples, effective program components, and
a comprehensive range of health promotion and chronic
disease prevention strategies for RDs and DTRs. This paper
supports the Position of the Academy of Nutrition and
Dietetics: The Role of Nutrition in Health Promotion and
Chronic Disease Prevention published in the July 2013 issue
of the Academy of Nutrition and Dietetics.
(HPDP). Although the majority of the chronic diseases are
diagnosed at older ages for adults, many of these diseases
with strong ties to nutrition and lifestyle take decades
to develop and can begin during infancy or be linked to
intrauterine environment or mothers reproductive years.4
Therefore, optimal nutrition throughout all phases of
life, especially for the population groups that are at high
risk for health disparities, must be the primary focus of
health promotion and disease prevention (HPDP) efforts
of registered dietitians (RDs) and dietetic technicians,
registered (DTRs).
HPDP FRAMEWORK FOR RDs AND DTRs
HPDP can be implemented at primary (ie, targeting
the disease risk factors), secondary (ie, preventing the
onset of disease among those who have the risk factors
or are at early stages of the disease), or tertiary (ie,
preventing or managing the complications among those
1
with diagnosed disease) levels.5 Whether it is a primary,
secondary or tertiary prevention, ideal HPDP approaches
should be multifactorial,6 encompass both individual and
environmental determinants of health and disease and
should involve a diverse team of practitioners including
RDs and DTRs as pointed out in the National Diabetes
Education Program guidelines.7
Because individuals behaviors are influenced by the physical
and social environment, social ecological models8 can
provide a useful framework for HPDP. Although many
variations of social ecological models have been developed
over the years, the common characteristics of these models
are the emphasis on examining both the individual and
environmental disease risk factors and knowing that there
is a continuing interaction between these factors which can
lead to synergistic effects on the outcomes of interest.
Within a social ecological model, factors influencing
health and chronic disease risk can be organized into
intrapersonal, interpersonal, institutional, community,
and macro public policy levels (see Figure 1).9 Because of
this multidimensionality involving both individual and
environmental factors, social ecological models are readily
applicable to the multifactorial health promotion and chronic
disease prevention efforts. Effective HPDP approaches
can address multiple factors at the various socio-ecological
levels, but not all interventions require simultaneous action
at all levels. For example, some interventions may be most
effective at the macro public policy level (eg, food labeling or
food advertisement policies) for a population-wide impact
influencing various segments of a population and potentially
leading to behavior changes at multiple levels.10
Social Ecological Model and Nutrition Care Process
The Academy of Nutrition and Dietetics Nutrition Care
Process (NCP), which is aimed to help credentialed
nutrition and dietetics practitioners provide consistent, safe,
and effective nutrition care, can be a useful tool for HPDP
efforts.11 The four steps of the NCPnutrition assessment,
nutrition diagnosis, nutrition intervention, and nutrition
monitoring and evaluationcan be implemented by RDs
and DTRs in the community, institution, or clinical settings.
Although RDs and DTRs are mentioned collectively
throughout this practice paper, it is implied that DTRs work
under RD supervision in many (such as clinical) settings.
The combination of the NCP and social ecological model can
provide RDs and DTRs with a comprehensive framework
to be able to address the wide range of individual and
environmental factors that are linked to promoting health and
preventing disease (see Figure 1). For example, intrapersonal or
interpersonal level approaches may involve assessing knowledge
and behaviors (ie, nutrition assessment of NCP), determining
the behavioral issues (ie, diagnosis), delivering appropriate
educational services (ie, intervention), and evaluating and
following up on the progress (ie, monitoring and evaluation)
for individual or family-focused nutrition education services.
The community or institution level approaches may involve the
assessment of access to food outlets, community-wide surveys,
local statistics about food intake or physical activity patterns,
or inventory of related policies (eg, school wellness policies)
as a part of the nutrition assessment step. Nutrition diagnosis
may include the problems such as limited access to food in
the community or food and nutrition-related knowledge
deficit12 of the school personnel. Similar to the individual
level applications, diagnoses can be stated to indicate the
problem (eg, inadequate oral intake), possible etiology (eg,
lack of, or limited access to, healthy food choices), and the
defining characteristics (eg, local statistics for food intake,
availability and food store distribution). One of the significant
differences between using the NCP for individual versus
community or institution level statements would be the
etiology section of the diagnosis. Because of the multifactorial
nature of most community level nutrition issues, singling
out one specific etiology may not be possible or appropriate.
The nutrition intervention phase of the NCP for community
or institution level approaches would involve the designed
solutions such as nutrition education and nutrition counseling
for the food service and administrative personnel to facilitate
healthier purchasing and preparation practices and policies
to increase access to healthy food choices. Reviews of various
interventions from the Evidence Analysis Library of the
Academy of Nutrition and Dietetics13 can be a very useful tool
to select the appropriate evidence-based interventions.
Monitoring and evaluation, including the documentation
of all the processes, analyses and reporting of the outcomes
through local, state and national nutrition surveillance
systems are vital for the success of community or institution
level interventions. Active involvement of the community or
organizational members in every phase of the NCP is vital
to the success and sustainability of these approaches. Just
like the individually tailored solutions that actively engage
the patients to take action towards behavior change, active
participation serves a similarly critical purpose in community
or institution level interventions.
AN EXAMPLE OF USING THE SOCIAL ECOLOGICAL
MODEL AND NCP
Evidence-Based Breastfeeding Promotion: The Baby
Friendly Hospital Initiative and Breastfeeding Peer
Counseling
The Baby Friendly Hospital (BFH) Initiative is an effective
translational tool to promote breastfeeding in maternity
wards.14 In addition, the majority of the research evidence
2
 Figure 1. The combined social ecological model and Nutrition Care Process framework for health promotion and disease prevention.9,11 The four steps
of the Nutrition Care Process can be implemented at the five levels of the social ecological model.
indicates that breastfeeding peer counseling improves rates
of breastfeeding initiation, duration, and exclusivity.15 The
following is an example of incorporating the social ecological
framework and four steps of the NCP into breastfeeding
promotion through BFH and breastfeeding peer counseling
initiatives. The standard terminology from the International
Nutrition and Dietetics Terminology Reference Manual12
has been used where applicable.
Nutrition Assessment. Intrapersonal and interpersonal
levels: as a part of the health care team, RDs/DTRs can
assess the womens knowledge, beliefs, and intentions about
breastfeeding, and availability of support from father/family,
and perceived barriers to breastfeeding (Figure 2).
Institution and community levels: RDs/DTRs can assess
the breastfeeding rates, related cultural background and
beliefs of the target community through direct surveys and
published literature. Identifying the community agencies
that can provide breastfeeding-related support (eg, Special
Supplemental Nutrition Program for Women, Infants, and
Children [WIC] or La Leche League) should also be a part
of the community assessment. Identifying the hospitals
BFH status, its policies (including those that apply to its
employees) and practices, such as the availability of peer
counseling programs or other practices that may act as
barriers, serve as institution level assessments.
Macro public policy level: RDs/DTRs can identify and
review the national guidelines and recommendations related
to breastfeeding and BFH strategies and state or federal
regulations that may affect breastfeeding practices. If the
organization is not a BFH, state or national requirements for
the BFH qualification are reviewed.
Diagnosis. Intrapersonal and interpersonal levels: food- and
nutrition-related knowledge deficit related to lack of prior
exposure to accurate nutrition-related information or
cultural beliefs as evidenced by reported knowledge, beliefs,
and practices are determined.
Institution and community levels: low rates of breastfeeding
(ie, limited adherence to nutrition-related recommendations)
in the target community related to communitys food- and
nutrition-related knowledge deficit, lack of role models or
value for behavior change, cultural practices that affect the
ability to learn/apply information, or lack of resources/access
(such as lactation consultants, bicultural peer counselors,
3
 Figure 2. A depiction of utilizing the social ecological model and the Nutrition Care Process for the breastfeeding example.

access to a BFH) as suggested by community level survey
data are documented.* For an institution, low rates of
breastfeeding initiation (ie, undesirable food choices or
limited adherence to nutrition-related recommendations)
related to lack of resources (eg, infrastructure or staffing)
preventing changes as evidenced by reports and observations
of institutional practices and policies (eg, lack of BFH
designation, low hospital-specific breastfeeding initiation
rates, allowing marketing for baby formula to new mothers
at the hospital, lack of lactation consultants or peer
counselors) are identified.
culture- and literacy-appropriate nutrition education and
counseling to address the knowledge deficit and other
related barriers for pregnant women, nursing mothers and
their families in wellness center, clinic, or hospital settings.
Outcomes such as intentions to breastfeed, knowledge
level, perceived barriers, or breastfeeding initiation are
documented. Peer counselors can be a significant part of
this team approach by enhancing the communication and
delivery of the intervention. RDs/DTRs can refer women
to peer counseling and other programs (eg, WIC, La Leche
League) that support breastfeeding.

Macro public policy level: state level or national policies that
may be lacking adequate support for breastfeeding (despite
the evidence from research) are identified.
Intervention. Intrapersonal and interpersonal levels: as
a part of the health care team, RDs/DTRs can provide
Institution and community levels: RDs/DTRs can be critical
members of the BFH team in training the peer counselors
or other personnel about the benefits of breastfeeding,
providing community-wide nutrition education and
counseling, referring women to the peer counselors and
community programs that support breastfeeding and

* Community and organizational level problems often have multifactorial etiologies and this must be taken into account when stating diagnoses.
Diagnoses and etiologies at these levels may require the use of slightly different terminology when there are no suitable terms in the current International
Nutrition and Dietetics Terminology.
4
revising the institutional policies to promote breastfeeding.
Outcomes such as the changes in personnels knowledge or
practices, hospital- or community-wide breastfeeding rates,
new or revised educational materials, number of referrals to
breastfeeding programs, organizational policies or staffing
structure are documented.
Macro public policy level: RDs/DTRs can take active roles
in multidisciplinary networks to promote BFH and peer
counseling at the regional and state level initiatives. They can
also provide expert opinion for development or revision of
state and national level policies and guidelines.
Monitoring and Evaluation: Intrapersonal and interpersonal
levels: as a part of the health care team, RDs/DTRs can
follow up on the breastfeeding status of the new mothers
and their exposure to educational materials or sessions.
Outcomes such as breastfeeding at the time of discharge
from the hospital, during outpatient clinic visits, or through
direct patient feedback are documented, and results are
shared with the team and the organization.
Institution and community levels: RDs/DTRs can collaborate
with the hospitals and community organizations to evaluate
the program implementation (eg, nutrition education for
general public or employees), to monitor the organizational
policy and practice changes over time, breastfeeding
statistics (eg, initiation, duration, and exclusivity rates at
the community or institution levels) and to compare these
results to the national estimates. Outcomes are shared with
the overall community and relevant organizations and used
to provide further input for the future interventions.
Macro public policy level: RDs/DTRs can take active roles
in multidisciplinary teams to evaluate the implementation
of regional initiatives and to monitor the changes over time
in outcomes for regional, statewide, or national guidelines
and policies. Comparison of outcomes with state or national
standards and statistics, and sharing the information and
expertise with relevant organizations, networks, and legislative
bodies provide further input for future policy changes.
HPDP STRATEGIES AND RECOMMENDATIONS
FOR RDs AND DTRs
Intervention Components for Effective HPDP Strategies
RDs and DTRs can play a critical role in HPDP and at the
same time help reduce the health care costs through lifestyle
modification (diet and physical activity).16-18 For example,
the Diabetes Prevention Program (DPP) demonstrated that
lifestyle modification can delay or prevent the development
of type 2 diabetes,16 and RDs participated in the central
management of the DPP in several capacities including
development and delivery of the intervention.19 Lifestyle
case management interventions delivered by RDs have been
shown to help control weight and improve quality of life.17
There is growing evidence that such lifestyle interventions
are cost-effective as well.16-18 The DPP and similar programs
have been shown to be cost-effective especially when
implemented as part of routine clinical practice.16,18 There is
also evidence indicating cost-savings (ie, more effective and
less expensive than the alternative) if such interventions are
implemented at earlier adult years (<45 y).16
Behavioral counseling, interactive educational sessions,
skill and self-efficacy development (eg, cooking, self-
management), and using communication tools are some
of the characteristics of effective interventions to improve
nutrition outcomes in HPDP.13 Motivational interviewing,
goal-setting, self-monitoring, problem-solving, and
structured meal plans or meal replacement techniques have
also been reported as useful tools.20 Active participation
(including community advocacy or community-based
participatory research) and building support systems
through peers and community health workers have also been
reported as successful approaches.13 Policy and structural
changes (eg, changing cafeteria menus, vending machines,
provision of worksite physical activity opportunities, health
insurance or gym membership benefits) are among the
effective components in worksite wellness interventions.21
It must be noted that effective interventions usually employ
several of these components rather than relying on one
method to achieve success while dealing with complex issues
such as obesity or chronic disease prevention.
Having culturally and linguistically tailored interventions is
another characteristic that contributes to the effectiveness of
HPDP projects. Language is a known barrier for receiving
appropriate health-related services. Engaging culturally
competent community health workers, peer counselors and
interpretation services, and using culturally, linguistically
and literacy-appropriate materials are helpful to overcome
such barriers and to increase effectiveness of nutrition
assessment and interventions.13
Ultimately, increasing the number of RDs and DTRs
from racial/ethnic minority populations or who are
culturally competent and bilingual will most likely make
strides in overcoming cultural barriers in HPDP. There are
several cultural competency models that RDs and DTRs
can use.22 Despite the variations, these models generally
aim to improve communication skills and target eliciting
the cultural characteristics related to nutrition and health
behaviors. Although elements of cultural competence
training or culturally competent health care practices can
vary, a list of practices to enhance cultural competency
at hospitals has been compiled and made available by
the Joint Commission. In addition, RDs and DTRs can
5
benefit from the Academy of Nutrition and Dietetics
resources and publications to enhance their cultural
competency skills.23
Maintenance of changed behaviors is probably one of the
most challenging aspects of HPDP interventions. Positive
influences of interventions on lifestyle behaviors diminish
over time, suggesting that continuing support is needed
for individuals to maintain the healthy behaviors. Changes
to the environment (eg, social norms, access to healthy
foods, limitations on competitive or less healthy foods) are
necessary for lifestyle behaviors to be sustained. Through
environmental changes, even the small changes in lifestyle
behaviors can be long lasting.24
HPDP Strategies throughout the Life Cycle
Maternal and Infant Health. The intrauterine environment
is a major contributor to normal physiological growth.
As stated in a position paper of the Academy, mothers
nutritional status prior to and during pregnancy and weight
gain status during pregnancy affect infants birth weight
and health outcomes.25 Disturbances at this critical time
such as compromised nutritional status of underweight
women or obesity can result in fetal growth restriction, low
or high birth weight, preterm birth or gestational diabetes.26
Women with low SES are particularly vulnerable to dietary
deficiencies during pregnancy.27 These conditions can lead
to increased susceptibility to chronic diseases such as type 2
diabetes and CVD later in life for the mother or the baby.28
HPDP efforts during this critical time can include nutrition
counseling for optimal nutrition and weight status prior
to and between pregnancies, management of acute and
chronic health conditions, promoting breastfeeding, and
encouraging participation in federal assistance programs (eg,
WIC, SNAP) that can extend the economic and nutrition
education resources for pregnant or postpartum women and
their families.
HPDP efforts should be directed to women of reproductive
age as well as health professionals and institutions that
provide services for them. Counseling for optimal nutrition
should include but is not limited to:
an individualized, healthy diet based on age, physical
activity level, weight, pregnancy and health status that is
consistent with the Dietary Guidelines for Americans29
should be implemented prior to, during and between
pregnancies;
prevention of excessive weight gain30 based on the most
recent Institute of Medicine guidelines;31,32
appropriate level of physical activity consistent with the
national guidelines;33
appropriate use of vitamin and mineral supplements,
particularly iron, calcium, and vitamin D if not met
through dietary sources first;25
discouragement of caffeine, alcohol, and smoking;25
awareness of cultural practices that may affect diet
intake;
food safety; and
managing health conditions such as diabetes and
hypertension before, during and after pregnancy.
As outlined in an Academy position paper in 2009,
RDs/DTRs should take active roles in supporting
exclusive breastfeeding for the first 6 months of life
and breastfeeding with complementary foods from 6
months to at least 12 months of age because of the health
benefits it confers, including psychosocial, economic, and
environmental benefits.34
Because research has shown that returning to work is
associated with early discontinuation of breastfeeding, a
supportive work environment may make a difference in
whether mothers are able to continue breastfeeding.35
Despite overall improvements in breastfeeding rates,
unacceptable disparities in breastfeeding persist by race/
ethnicity, socioeconomic characteristics, and geography. For
example, breastfeeding rates for black infants are about 50%
lower than those for white infants at birth, age 6 months and
age 12 months even when controlling for family income or
education level.36
In contrast, some immigrants may be supportive of
breastfeeding as a part of their primary culture, but they
may lose this healthy behavior as they spend more years
in the United States and acculturate towards mainstream
American lifestyle.37 Identifying these groups and providing
more focused and culturally appropriate counseling is
necessary to help retain or promote the healthier behaviors
as well as to help prevent the adoption of unhealthy
behavior patterns. Coordinating these efforts with peer
counselors or peer support groups can be cost-effective
approaches especially where professional breastfeeding
support is not widely available.34
Strategies for RDs and DTRs:34
Counsel clients about the benefits of breastfeeding,
clean and safe breastfeeding practices, and appropriate
weaning foods.
6
 Work with employers to establish policies and maintain
comprehensive, high-quality lactation support programs
for their employees.
Work to overcome barriers to breastfeeding through
solutions such as: private workplace locations for
breastfeeding, breast pump rentals, lactation consultants,
peer counselors, community support groups or other
resources and child-care providers to accommodate the
needs of mothers to have direct access to their babies or
to provide adequate storage for breast milk.
Work with underserved communities to help eliminate
disparities in breastfeeding.
Use educational strategies based on informed decisions
and including the support of family and peers.
Discourage the use of educational materials supplied
by formula companies or formula marketing to
pregnant women.
Be familiar and comply with the International Code
of Marketing of Breastmilk Substitutes34,38 and keep a
current knowledge of related policies and research.
Early and Middle Childhood. Children need to be
exposed to a variety of healthy foods so they can learn to
make successful choices independently. To this end, parents
and other caregivers need to be educated on healthy food
choices and appropriate feeding practices for physical and
emotional development.39 Because children can spend
a substantial part of the day at child-care facilities and
schools, educators and administrators at these institutions
are also key figures in supporting nutrition education and
a healthy food environment as well as opportunities for
physical activities. Effective communication of nutrition
information in each of these settings should be culturally
sensitive, age-appropriate, and interactive when possible.
While increasing the exposure to healthy food options at
home, school, or child-care settings, exposure to less than
optimal food choices should be limited to help support
a food environment that is conducive to healthier eating
patterns. Therefore, media literacy among parents, caregivers,
educators, as well as policies to limit childrens media
exposure for less than optimal food choices and lifestyles
should be encouraged.
Strategies for RDs and DTRs:
Support and promote the Dietary Guidelines for
children and the use of the US Department of
Agricultures MyPlate as a guide for meeting dietary
recommendations.40
Support and promote healthy, culturally diverse dietary
intake patterns. Help immigrant families retain their
healthier food intake patterns that they might have as
a part of their primary cultural heritage, and prevent
the adoption of new and less optimal eating patterns as
they acculturate.
Provide nutrition education for parents, caregivers,
and child-care and education professionals on how to
model and encourage healthy eating practices (in home,
child-care, and school environments), regular family
mealtimes, and media literacy.
Provide expertise to food and marketing companies, media
outlets, and other organizations or legislative bodies that
determine public policies to help support a healthy eating
and physical activity environment for children.
Adolescence. Adolescent and teen years are years of rapid
growth. Considering the high rates of overweight/obesity41
as well as disordered eating patterns,42 this is a critical
phase to help teens establish and maintain healthy eating
behaviors and a physically active lifestyle. Parents need
guidance on the appropriate foods for proper growth, and
this is also the best time to help teens learn how to make
healthier nutrition decisions for themselves when eating at
home, in school or outside the home. Most importantly,
making the healthier choices the easy choices in every
environment is critical. Adolescents and teens spend 7.4
hours a day, seven days a week using media. Adolescents
and teens whose parents make an effort to limit media
usethrough the media environment they create in the
home and the rules they setspend less time with media
than their peers.43
Strategies for RDs and DTRs:
Provide parents with resources and skills for making
nutrient-dense foods readily available at home for the
entire family.
Train parents and teens in simple cooking skills.
Teach families with low SES about economical ways to
obtain and prepare healthier foods.
Educate parents and teens about how to use the
Nutrition Facts panel and other food label information
so they can select healthier food options.
Educate parents and teens about media literacy and healthy
body image to help against potentially negative media and
peer influences on eating patterns and body image.
Support parents to encourage teenagers in choosing an
activity they enjoy and to be physically active for at least
7
 30 to 60 minutes most days of the week.
Provide support and education for teens, parents,
caregivers and educators related to the use of media.
Encourage parents to model good behavior for the
entire family eating healthy and exhibiting a healthy
attitude toward eating, food and physical activity.
Encourage parents to take an active role in their schools
wellness council.
Adulthood. An essential component to keeping all adults
healthy is preventing chronic diseases and reducing
associated complications among those who are already
diagnosed. As primary prevention strategies, optimal
nutrition and an active lifestyle help promote and maintain
health throughout the adult years. Maintaining weight,
optimal nutrition, appropriate physical activity, and avoiding
other lifestyle-related risk factors (eg, cigarette smoking or
certain alcohol intake patterns) can delay or prevent chronic
diseases such as type 2 diabetes and CVD.2 Nutrition
plays a vital role in the aging process and can be critical in
preserving health, maintaining function, and reducing health
care costsespecially for older adults.44
Strategies for RDs and DTRs:
Support and promote the Dietary Guidelines for adults.
o Provide recommendations for consumption of
nutrient-dense foods and beverages including fruits,
vegetables, whole grains, low-fat dairy, lean meats,
poultry, fish, beans, eggs, and nuts and seeds.
o Provide recommendations to limit the intake of
sodium, solid fats, added sugars and refined grains
that can contribute to disease risk.
o Encourage an active lifestyle: at least 150 minutes
of moderate intensity aerobic activity (eg, brisk
walking) every week and muscle strengthening
activities on two or more days of the week that work
all major muscle groups (legs, hips, back, abdomen,
chest, shoulders and arms).
o Encourage intake of vitamins and minerals at
Dietary Reference Intake levels primarily from
dietary sources to support health and promote
disease prevention.
Support and promote the use of the US Department
of Agricultures MyPlate as a guide for meeting
dietary recommendations.
Institutional, Community, and Public Policy Level HPDP
Strategies for RDs and DTRs
Institutional.
Accelerate the translation of scientific findings into
community, worksite, and school practices and policies to
protect the health of people where they live and work.45
Provide guidance and expertise to child-care facilities
and schools to help implement the Dietary Guidelines
for Americans through nutrition education, school
meals, and school programs and policies.
o Provide training for school foodservice staff on
policies and guidelines related to school meals.
Support the availability of healthier food and
beverage options in schools through farm-to-school
and related initiatives.
Provide guidance to school wellness councils to
develop and implement healthy eating and physical
activity policies, to monitor progress and to ensure
program sustainability that will support a healthy
school environment.
Take active roles in developing and implementing
organizational nutrition and wellness policies in
places such as worksites, hospitals, senior centers,
living facilities for older adults and corporate or faith-
based organizations.
Take active roles in working with industry (eg, food
manufacturers, retail stores, marketing companies,
media) to provide nutrition education and information,
such as labeling requirements, to promote consumer
health and wellness communication.
Encourage policies for healthier menu options in
restaurants, schools and worksite cafeterias.
Take active roles in food industry, culinary and other
related (eg, food marketing) organizations through
advisory boards, panels and provision of nutrition
education and guidance to improve institutional
awareness, policies and practices including food
production, distribution and marketing to support a
healthy lifestyle.
Collaborate and build partnerships across child-
care-, health-, and education-related disciplines and
professional organizations to create and actively
participate in multi-disciplinary initiatives (eg, the State
Department of Health, Maternal and Child Health,
Department of Education, WIC, and Head Start).
8
Community.
Develop and implement culturally and literacy-
appropriate nutrition education programs and materials
that can be used in a variety of community settings (eg,
through community agencies, faith-based organizations)
to promote health and reduce the risk of chronic disease.
Collaborate with other health professionals to expand
prevention (eg, healthy eating, staying physically active,
immunizations) and early detection services especially
for older individuals, racial/ethnic minorities, and those
with low SES.
o Partner with state and local agencies to provide
health promotion programs for adults related to
common diseases such as cancer, CVD, type 2
diabetes, hypertension and osteoporosis.
Collaborate across other disciplines (eg, agriculture,
economics, urban planning, public health, social work
and medicine) to help address the health disparities
that are often experienced by racial/ethnic minorities
and individuals with low SES. Such collaborations
should create a more diverse body of partnership to
better understand and engage the target communities
and also to help form a workforce with greater capacity
to properly address the systemic issues at hand.46
Collaborate and support health promotion efforts
targeting social and environmental determinants of
health, such as increasing access to affordable healthy
food options in food deserts or other underserved
communities. Initiatives such as community gardens,
school gardens, farm-to-table (or farm-to-institution),
farmers markets, or corner store programs can be
especially useful for point-of-purchase interventions
at the institution or community levels.46 Such efforts
can help change the environment especially for racial/
ethnic minorities and individuals with low SES who
are likely to experience greater limitations in accessing
healthier foods.
Collaborate with community members, and local and
state agencies for monitoring nutrition- and health-
related issues and outcomes in the community health
surveillance efforts.
Macro public policy.
Policy, social, and environmental changes have a great
potential for improving the health of all segments of
the population. RDs and DTRs need to advocate for
evidence-based food and nutrition policies and take
leadership roles to facilitate the environmental changes
that support an active lifestyle.
Advocate for public policies and funding for nutrition,
prevention and disease management programs at the
local, state and national levels.
o Be active members of public policy teams who
participate in policy development to assist in
moving health promotion policies forward.
To guide the HPDP efforts, utilize the national
research-based policies and recommendations such
as the Dietary Guidelines for Americans, Healthy
People 2020, and National Prevention Strategy (see
Figure 3). The National Prevention Strategy46 which
focuses on health disparities and a comprehensive
health promotion and disease prevention framework
throughout all stages of life is a critical component
of the Affordable Care Act. In addition, these
guidelines should be used by RDs and DTRs in
advocating for policies such as the Farm Bill, WIC,
SNAP or school meal guidelines to promote health
and reduce chronic disease.
Advocate for policies that position breastfeeding as the
norm for infant feeding.34
Provide expertise and guidance to food and marketing
industries, and media outlets to help support a healthy
eating and physical activity environment within the
overall food system including healthier food production,
distribution, and marketing policies and practices.
Assess, evaluate, and monitor intervention outcomes
to identify and document potential solutions and
nutrition, health and economic impacts to inform the
development of future policies.
RECOMMENDATIONS FOR FUTURE PRACTICE
RDs and DTRs need to anticipate, adapt, and respond
to the changing needs of society. Two prevalent
characteristics of todays society in the United States
are the aging population and a population that is
very diverse. RDs and DTRs need to be proficient
in methods to support optimal health for an aging
population. RDs and DTRs must also engage in
planning and advocacy for equal access to healthy food,
nutrition education and quality health care thereby
reducing social inequalities and health disparities.
RDs and DTRs are well-trained in the science of food
and nutrition. Cultural competencies must also be a part
of their daily practice emphasizing quality and equity to
ensure adequate access to nutrition education and care
for a diverse population.
9
 Dietary Guidelines for Americans
http://health.gov/DietaryGuidelines

MyPlate
www.choosemyplate.gov

Healthy People 2020

www.healthypeople.gov

2008 Physical Activity Guidelines for Americans

www.health.gov/paguidelines/

National Prevention Strategy

www.surgeongeneral.gov/initiatives/prevention/strategy/report.pdf

US Preventive Services Task Force

www.uspreventiveservicestaskforce.org/

Guides to Community and Clinical Preventive Services

thecommunityguide.org

Institute of Medicine
www.iom.edu

Centers for Disease Control and Prevention: A Framework for Program Evaluation
www.cdc.gov/eval/framework/index.htm

The Surgeon Generals Call to Action to Support Breastfeeding

www.surgeongeneral.gov/library/calls/breastfeeding/index.html

CDC Breastfeeding Report Card United States 2012

www.cdc.gov/breastfeeding/data/reportcard.htm

CDC Workplace Health Promotion Nutrition Program

www.cdc.gov/workplacehealthpromotion/evaluation/topics/nutrition.html

National Action Plan to Improve Health Literacy

www.health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf

Action Plan to Reduce Racial and Ethnic Health Disparities

minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=285

The Surgeon Generals Vision for a Healthy and Fit Nation

www.surgeongeneral.gov/initiatives/healthy-fit-nation/index.html

Figure 3. Evidence-based tools and resources for registered dietitians and dietetic technicians, registered for the development, planning,
implementation, and evaluation of health promotion and disease prevention programs.

RDs and DTRs need to apply scientific approaches
to social marketing, health education, and consumer
research to inform and influence individual,
organizational, community, and public policy decisions
on health.
interdisciplinary teams in education, research and
practice as well as health reform. Collaborating with
interdisciplinary teams is critical for RDs and DTRs to
promote health and prevent chronic diseases by using
the NCP and the social ecological framework.

o Be familiar with the social determinants of health,
health equity, and life course theories and the social
ecological models and use these multifactorial
approaches to promote health.
o Utilize the NCP and the Evidence Analysis Library
to support evidence-based practices.
RDs and DTRs are integral leaders/members of
RDs and DTRs, as members of the health care
team, should translate and integrate findings from
research into their various practice settings that can
demonstrate and improve the cost-effectiveness of
lifestyle interventions.
RDs and DTRs should be in the forefront of
conducting HPDP research and stay abreast of
current and emerging scientific developments (eg,
10
 nutrigenomics, nutrigenetics) to be able to lead the
future directions.
The Academys Report on Future Practice
Recommendations47 encourages RDs and DTRs to
advance their skills and increase their professional
development.
o RDs and DTRs should develop competency in the
role that technology and social media can play in
health promotion and behavior change.
o RDs and DTRs should maintain active and
leading roles in developing and implementing
culture- and literacy-appropriate nutrition
education materials and programs to invest in
the next generation of RDs and DTRs to develop
critical thinking, communication, and cultural
competency skills as well as advancing HPDP
knowledge base, skills, and strategies for the
future RDs, DTRs, and other practitioners.
CONCLUSIONS
Although individual level determinants of health and
disease are important and have, traditionally, been the
most common way that RDs and DTRs practiced health
promotion and disease prevention in the past, it is now
widely recognized that physical and social environment
influences individuals behaviors, and for individuals to
successfully change their behaviors, environment must be
conducive to that change. Therefore, complex health issues
such as obesity or chronic diseases often require system-wide,
multifactorial, and multidisciplinary solutions. Chronic
disease prevention, to be most effective, must occur in
multiple influence layers within the social ecological context
and across individuals entire life spans. Further, HPDP
should focus on addressing the needs of those who are more
likely to experience health disparities and are at increased
risk for chronic diseases such as racial/ethnic minorities and
individuals with lower SES.
As the nutrition experts, RDs and DTRs must be active
members of multidisciplinary teams and leaders in
promoting optimal nutrition. The social ecological model
and NCP provide RDs and DTRs with a framework to
apply HPDP practices. Practice examples, effective program
components and a comprehensive range of HPDP strategies
have been included in this paper. In every HPDP effort,
employing cultural competency models will ensure that
RDs and DTRs better serve the needs of the diverse US
population and more effectively reach the population
subgroups such as minorities and immigrants who
experience health disparities. Using evidence-based programs
and an environmental approach, RDs and DTRs can assist
individuals, organizations and communities to make the
long lasting changes to promote health.
Acknowledgements
The Academy of Nutrition and Dietetics authorizes
republication of the practice paper, in its entirety, provided
full and proper credit is given. Commercial distribution is
not permitted without the permission of the Academy and
any distribution should not be used to indicate endorsement
of product or service. Requests to use portions of the paper
must be directed to the Academy headquarters at 800/877-
1600, ext. 4835, or ppapers@eatright.org. This paper will be
up for review in 2017.
Authors: Nurgul Fitzgerald, PhD, MS, RD, Rutgers-
The State University of New Jersey, New Brunswick, NJ;
Kathleen T. Morgan, DrMH, DTR, Rutgers-The State
University of New Jersey, New Brunswick, NJ; Deborah
Leachman Slawson, PhD, RD, LDN, East Tennessee State
University, Johnson City, TN.
Reviewers: Sports, Cardiovascular, and Nutrition
dietetic practice group (DPG) (Jenna A. Bell, PhD,
RD, Consultant, New York, NY); Public Health/
Clinical Nutrition DPG (Aurora Buffington, MS, RD,
Southern Nevada Health District, Office of Chronic
Disease Prevention and Health Promotion Las Vegas,
NV); Sharon Denny, MS, RD (Academy Knowledge
Center, Chicago, IL); Nutrition Education for the Public
DPG (Vivian Haley-Zitlin, PhD, RD, LD, Clemson
University, Clemson, SC); Jane E. Heetderks-Cox, MS,
RD, Consultant, Austin, TX; Mary Pat Raimondi, MS,
RD (Academy Policy Initiatives & Advocacy, Washington,
DC); Brenda Richardson, MA, RD, LD, CD, Dietary
Consultants, Inc. Richmond, KY; Nutrition Education of
Health Professionals DPG (Lona Sandon, MEd, RD, LD,
UT Southwestern Medical Center, Dallas, TX); Marsha
Schofield, MS, RD, LD (Academy Nutrition Services
Coverage, Chicago, IL); Patricia L. Simmons, MS, RD
(Missouri Department of Health and Senior Services,
Jefferson City, MO); Alison Steiber, PhD, RD (Academy
Research & Strategic Business Development, Chicago,
IL); Academy Quality Management Committee (Valaree
Williams, MS, RD, LDN, University of Pennsylvania
Health System Philadelphia, PA).
Academy Positions Committee Workgroup: Christine
A. Rosenbloom, PhD, RD, LD, CSSD (chair); Karen
P. Lacey, MS, RD, CD; Jamie Stang, PhD, MPH, RD
(content advisor).
We thank the reviewers for their many constructive
comments and suggestions. The reviewers were not asked to
endorse this practice paper.
11
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