The food we eat significantly impacts our health. Registered Dietitian Nutritionists (RDNs) are experts in nutrition and its impact on health. Dietitians are essential healthcare workers equipped to ensure individuals are well-informed about the importance of a healthy diet. Their expertise is crucial in preventing and treating chronic diseases. Regulations at both state and federal levels mandate that nursing facilities (NFs) must have either a full-time employed or contracted Registered Dietitian (RD) on staff. In NFs, RDs have an essential role in maintaining the health and overall well-being of the people living in the facility.
What Dietitians Do
Dietitians and nutritionists are experts in the use of food and nutrition to promote health and manage disease. They held about 90,900 jobs in 2024. Many of those openings are expected to result from the need to replace workers who transfer to different occupations or exit the labor force, such as to retire.
Core Responsibilities
Dietitians and nutritionists counsel clients on nutrition issues and healthy eating habits. They develop meal and nutrition plans to meet the health needs of clients. They evaluate the health of their clients through nutrition assessment and diagnostic laboratory testing. A dietitian determines your needs and figures out how you need to get nutrients, either by mouth, by tube or through an IV.
Specializations
Although many dietitians and nutritionists do similar tasks, there are several specialties within the occupations:
- Clinical dietitians and clinical nutritionists: Provide medical nutrition therapy, creating customized nutritional programs based on the health needs of clients and counseling clients on how to improve their health through nutrition. They may further specialize, working only with people who have kidney disease, diabetes, digestive disorders, or other specific conditions.
- Community dietitians and community nutritionists: Develop programs and counsel the public on topics related to food, health, and nutrition, often working with specific groups of people, such as adolescents or the elderly.
- Management dietitians: Plan food programs, responsible for buying food and carrying out other business-related tasks, such as budgeting. They may oversee kitchen staff or other dietitians.
- Consultant dietitians: Consultant RDs work in private practice. They help their clients design eating plans for their specific needs and goals.
- Research dietitians: Some dietitians work as researchers. They study how food affects certain groups of people. Some might specialize in one topic, like food allergies.
A registered dietitian can specialize in certain areas like:
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- Geriatric nutrition: Specializing in the nutrition needs of older adults, they create nutrition plans to help prevent and treat some of the common conditions that can affect this population, like osteoporosis.
- Pediatric nutrition: They design nutrition plans to meet children’s general growth and development needs.
- Pediatric critical care nutrition: This type of dietitian works with a team of healthcare providers caring for children in intensive care.
- Obesity and weight management: They offer support for people trying to manage their weight to prevent or treat obesity.
- Sports nutrition: An expert in nutrition for athletes and highly active professionals, like police, military and rescue forces.
- Renal nutrition: A dietitian who creates renal diets for people with chronic kidney disease (CKD) and kidney failure.
- Oncology nutrition: A dietitian who specializes in the nutrition needs of people in treatment for or recovering from cancer.
- Eating disorders: A dietitian who focuses on nutritional rehabilitation for people with eating disorders.
- Diabetes nutrition and care.
Skills and Qualities
The following are examples of qualities that are important for these workers to perform their duties:
- Analytical skills: Dietitians and nutritionists must keep up with food and nutrition research.
- Compassion.
- Listening skills: Dietitians and nutritionists must listen carefully to understand clients’ goals and concerns.
- Organizational skills: Dietitians and nutritionists must prepare and maintain many types of records for multiple clients.
- Problem-solving skills.
- Speaking skills: Dietitians and nutritionists must explain complicated topics in a way that people can understand.
Education and Training
To enter the occupation, dietitians and nutritionists typically need a bachelor's or master’s degree in dietetics, food and nutrition, or a related field to enter the occupation. A graduate degree is required for some credentials. They also typically are required to have supervised training through an internship. Dietitians and nutritionists typically receive supervised training, usually in the form of an internship following graduation from college.
Licensing and Certification
Many states require dietitians and nutritionists to be licensed in order to practice. Other states require only state registration or certification to use certain titles, and a few states have no regulations for this occupation. Check with your state board for specific requirements. Employers may prefer to hire candidates who have a professional credential, such as the Registered Dietitian (RD)/Registered Dietitian Nutritionist (RDN) or the Certified Nutrition Specialist (CNS) designation. The RD/RDN designation requires completion of a minimum of a master’s degree and a Dietetic Internship (DI), which includes supervised experience. Students may complete both criteria at once through a coordinated program, or they may finish their degree before applying for an internship. Many states accept the Certified Nutrition Specialist (CNS) credential or exam for licensure purposes. To qualify for the credential, applicants must have a master’s or doctoral degree, complete supervised experience, and pass an exam.
The Role of Dietitians in Long-Term Care Facilities
One of the many options you have in the field of dietetics is to work as a registered dietitian in long-term care. Now, the terms “long-term care” or “nursing and rehab center” are used more universally to include a broader spectrum of care.
Importance of Dietitians in Nursing Homes
The RD is a key member of the interdisciplinary team (IDT), working collaboratively with other team members to ensure high-quality care is provided to each person living in the NF. The RD assesses each individual’s nutritional status, taking into consideration their medical history, medications, and other factors that may impact their dietary needs.
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Specific Duties in Nursing Homes
Depending on the size of the facility, it is not uncommon to serve as a single-site dietitian. The duties of the dietitian vary from clinical care documentation to assisting with tray service and meal operations to completion of MDS records. Most dietitian offices in long-term care are inside the kitchen or close by.
*RD Nutrition Consultants (RDNC) provide comprehensive medical nutrition therapy care to residents living in these nursing facilities. RDNC can ensure that you are meeting CMS (Centers for Medicare & Medicaid Services) and State regulations for Dietitians.
Daily Morning Meetings
Typically, a daily morning meeting will be held with all the department heads and administration. This meeting provides an opportunity to go over things that happened over the last 24 hours. For example, as the dietitian, you may notify the team of a significant weight change, request a re-weight on a resident, explain a diet change, or share information obtained from a family member pertaining to the plan of care. The meeting serves to follow up on things discussed the day prior and prevent a delay in care.
Collaboration with Other Healthcare Professionals
With all your coworkers and peers, learn how they like to be contacted and provide them with your preferred way as well. The DON and ADON are the heads of the entire nursing department including nurse managers, floor nurses, and nursing assistants. They are the ones assigning staff to obtain weekly/monthly weights, tracking facility wounds, feeding, and recording meal percentages, just to name a few. To the dietitian, the nursing staff are your lifeline. The MDS coordinator can assist you with anything MDS-related. They are well-educated on MDS regulations and can direct you to a reference if you have a question regarding Section K. The director of social services is typically in charge of scheduling care plan meetings with resident and their responsible parties. The activities department may assist in menu distribution if the facility has a select menu. The speech therapist communicates diet consistency changes, and their documentation helps you complete the MDS.
MDS and Section K
MDS in long-term care stands for Minimum Data Set. It is a tool used to determine the overall health status for all residents in long-term care facilities certified to participate in Medicare or Medicaid. Each discipline is assigned a section(s) that they must complete timely and accurately as part of the larger picture. Section K in the MDS is typically the registered dietitian’s responsibility. This section focuses on assessing the resident’s nutritional status as well as their swallowing ability. For this section to be completed properly, an assessment of the resident must be completed to determine the following: height, weight, BMI, if there is a swallowing disorder present, and the need for a therapeutic or modified consistency diet. This section can also indicate whether the resident has received IV hydration, TPN, and/or tube feeding and how much.
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Care Area Assessment (CAA)
CAA stands for Care Area Assessment and is found in Section V. The CAA process puts focus on problems identified in the MDS. A significant change in condition prompts an additional (unplanned) resident assessment/evaluation and requires completion of Section K and a CAA, if indicated.
Diet Liberalization
Making the choice between ordering a therapeutic diet and liberalizing a resident’s diet in long-term care is an important one. In the case of a true long-term care resident of the facility who has no plans to discharge, often liberalizing their diet is the best approach. It is the dietitian’s job to explain the diet recommendations as they pertain to the resident’s health conditions and how dietary changes can impact health and quality of life. An open discussion allows you to take all things into consideration and base your decision on more than just your opinion. Towards the end of life, quality of life becomes a priority for most residents.
Monitoring and Addressing Weight Changes
As a dietitian in long-term care, one of the main areas of focus is tracking and evaluating weight changes. Beginning with your initial assessment, you should obtain a weight history from the resident. If a resident’s weight changes +/-3% in a week, begin to investigate and document accordingly. If the resident is at risk for continued loss, initiate an intervention by adding fortified foods, between-meal snacks, or nutritional supplementation. Notifying the resident’s responsible party and their physician is a necessary part of your documentation. Addressing weight changes is a team effort that is orchestrated by the dietitian.
Care Plans
Each resident in a long-term care facility has a set of care plans that act as a guide for taking the best care of each person. The care plan is established on admission to the facility and reviewed during each assessment. A care plan should be updated any time a change to the resident’s plan of care occurs. A care plan meeting is held on a quarterly basis and whenever there is a significant change in the resident’s condition that could result in a change to their care. The interdisciplinary team is present as well as the resident’s family or responsible party. The resident is invited to the meeting and is welcome to attend if they wish to participate. A care plan meeting can be held in person or via telephone.
Impact of PDPM
Since 2019, the PDPM replaced the way long-term care facilities are reimbursed by Medicare and Medicaid. This change in reimbursement gives credit to facilities for the services that dietitians provide. Under PDPM, case-mix components refer to the care the resident receives while residing in a nursing facility. As dietitians, we play a role in two of the five categories-speech therapy and non-therapy ancillary.
Preparing for Long-Term Care Surveys
Preparing for the annual long-term care survey should be on your radar all year long. Keep a log of your high-risk residents and the date of your last note. Check-in with the food service manager and staff. You will have already reviewed the menu cycle and signed it, as well as the menu extensions. Assist the manager and supervisor with kitchen audits on a monthly basis to prepare for survey time. When approached by the survey team, stay calm and answer the questions asked. There is no need to share additional information and do not argue. Rather, provide what is requested and be open to their comments and suggestions.
Specific Contributions of Dietitians to Resident Health
Developing Personalized Care Plans
Based on this assessment, the RD develops person-centered care plans that include specific dietary recommendations, such as:
- The type of foods the person prefers
- Portion sizes
- Frequency of meals
- Fortified meal plans, and nutritional supplements
For those who require enteral nutrition, the RD determines the type of formula and feeding method that is most appropriate for each person based on their medical history, nutritional needs, and digestive capabilities. Dietitians select appropriate enteral feeding formulas that meet the patient’s nutritional needs. Continuous monitoring of the patient’s tolerance to the feeding regimen is essential. Dietitians track weight, biochemical markers, and clinical symptoms to ensure the patient is receiving adequate nutrition. For patients who cannot use their gastrointestinal tract, dietitians work closely with a multidisciplinary team to formulate parenteral nutrition solutions that are administered intravenously.
Menu Planning and Modification
The RD collaborates with food service personnel to develop menus that are nutritionally balanced, appealing, and culturally appropriate. The RD also reviews and approves the menus to ensure that they meet the dietary needs and preferences of the people living in the NF.
Kitchen Rounds and Food Safety
The RD also conducts kitchen rounds as part of their role to ensure food is being prepared and served according to the dietary department’s policies and procedures. This includes:
- Checking food temperatures
- Observing food preparation techniques
- Observing the meal service process
- Monitoring portion sizes
- Monitoring any specialized diets, such as pureed or fortified meal plans, to ensure they are prepared and served appropriately
- Identifying areas of improvement in food quality and/or service
Addressing Malnutrition
Many older adults experience malnutrition due to various factors, such as decreased appetite, difficulty swallowing, or chronic conditions.
Managing Chronic Conditions
Dietitians play a critical role in helping patients manage chronic conditions such as diabetes, heart disease, and arthritis through dietary interventions. Reduce the risk of heart disease by advising patients to consume a heart-healthy diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats while limiting saturated and trans fats, sodium, and cholesterol. Manage arthritis symptoms by promoting a balanced diet that includes anti-inflammatory foods, such as omega-3 fatty acids found in fatty fish, nuts, and seeds, as well as antioxidants found in fruits and vegetables.
Promoting Independence
Dietitians can empower patients to develop sustainable strategies for maintaining a healthy diet independently, enabling them to live more fulfilling and independent lives. This involves teaching patients practical skills, such as meal planning, grocery shopping, and food preparation, as well as providing guidance on how to navigate challenges like limited mobility, cognitive impairments, or financial constraints.
Psychosocial Support
Dietitians also offer support to help patients cope with the psychological and social impacts of using alternative feeding methods.