In this issue, 2 fellows of the American Dietetics Association outline the need for new educational models for advanced practice in medical nutrition therapy.1 They note that entry-level qualifications provide only minimal learning in the context of practice through a short placement. Most of the contextual learning comes from experience in the work environment. Here, supervision gradually reduces, and practice becomes advanced as the dietitian moves to greater autonomy and can take greater privileges in decision making and patient care. Advanced practitioners attain positions of leadership and are innovators in the workplace. This description compares with those outlined in Australia and described in a previous issue of Nutrition Today.2 Thus, the view of an advanced practitioner in dietetics is reasonably tangible and recognizable.

The article by Annalynn Skipper and Nancy Lewis goes further, however, to discuss how the path to advanced practice may well benefit from formal educational input. This raises the question of the form in which learning might take place and the nature of the resulting qualification. The form of learning demands an understanding of the competencies demonstrated by an advanced practitioner, and this is perhaps best understood through research on practice. Skipper and Lewis3 used social research methodology to identify the components of advanced competencies that could inform practice. This approach to research has been found useful in exposing the commonalities of practice standards across a number of practitioners in a range of contexts. In Australia, for example, ethnographic research has provided a rich description of how dietitians practice in the management of type 2 diabetes mellitus.4 In this case, however, the description focused on the key elements of practice, regardless of the level. There were 6 contributors to best practice: the dietetic process, being patient-centered, working in a diabetes team, using diabetes practice guidelines, and maintaining continuing professional development and engaging in research and quality assurance. The steps in the dietetic process-assessment, education (for the patient), goal setting, and monitoring of outcomes identified by the Australian research-were found to be similar to that outlined in the American Dietetics Association Nutrition Care Process and Model.5 The outcomes of the research reflected a specialty area of diabetes management. A review of the New Zealand situation stated that these dietitians would choose practice guidelines that best fit their patients' circumstances,6 inferring a need to be able to make professional judgments. In their article in this issue of Nutrition Today, Skipper and Lewis correctly distinguish between specialty, which is focused on a particular area of practice, and advanced practice, which is associated with overall higher levels of competency. Their model was related to approach and expertise that, no doubt, comes with experience, but the model also linked in attitude, aptitude, and context.1 Achieving an advanced level of practice in these areas might well be supported through further education.

In classical terms, the higher educational award recognizing this level of competence is usually a doctorate. Both professional doctorates and doctor of philosophy programs can have courses of study contained therein. In the main, however, the knowledge and skill base of the doctor of philosophy relates to research methodology, with some including research commercialization, which is well suited to the academic environment. Although research in dietetics is essential for practice development, and undertaking research is an important component of professional development and the achievement of advanced practice, there are additional competencies to be achieved in an advanced practice model for clinical practice. Perhaps, one of the most significant scientific developments that would inform future practice comes from nutrigenomics and related areas (proteomics and metabolomics). Advanced practice in the clinical setting may well be the place to see developments in these areas emerging for patient care. This will require further developed knowledge, skills, and technology in situations of more complex clinical decision making commensurate with advanced practice. It is not surprising also that Skipper and Lewis identify nutrition pharmacology and nutrition pathophysiology as major areas of study in a professional doctorate program supporting advanced practice. It will be necessary to ensure that this learning occurs in a supportive environment with the appropriate mix of cross-disciplinary expertise on which the dietitian may draw to blend with the base knowledge of the links between food and health.

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