Next-Generation Solutions to Address Adaptive Challenges in Dietetics Practice: The I+PSE Conceptual Framework for Action

Abstract

Obesity, diabetes, and heart disease; health care expenditures; food insecurity and hunger; climate change; food waste; reimbursement rates for dietetics services; nutrition research funding; and, most recently, the unprecedented coronavirus disease 2019 (COVID-19) pandemic. These complex problems or “adaptive challenges” are commonplace for registered dietitian nutritionists (RDNs). An adaptive challenge is a complex situation without known solutions to the problem or too many solutions without clear choices.1Heifetz R. Grashow A. Linsky M. The Practice of Adaptive Leadership. Tools and Tactics for Changing Your Organization and the World. Cambridge Leadership Associates, 2009Google Scholar The COVID-19 pandemic has introduced unprecedented tribulations to public health, health care, and food-supply chains, and has disrupted dietetics practice, settings in which RDNs work, and the individuals and populations RDNs serve. In the face of adversity, RDNs need to reflect and ask, “Is what I am doing making a difference?” “Are there other evidence-based tools I should use?” “Who can I partner with to advance my work?” and “What can I do differently to help achieve the goals for the individuals and communities I serve?” Although many of these issues are not new, the approaches to addressing these issues are perhaps new territory for RDNs. Adaptive challenges require new learning and new behaviors for RDNs to be better prepared and to more effectively respond to emergent, complex problems. It also requires RDNs to embrace systems thinking, that is, to dig deep and uncover the root causes of the adaptive challenge, to partner with others, to be innovative and design coordinated actions, take calculated risks, and invest the time needed to shift the trajectory of complex problems.1Heifetz R. Grashow A. Linsky M. The Practice of Adaptive Leadership. Tools and Tactics for Changing Your Organization and the World. Cambridge Leadership Associates, 2009Google Scholar This article describes the Individual plus Policy, System, and Environmental (I+PSE) Conceptual Framework for Action (known as the “Framework”) as a roadmap for RDNs across all areas of practice (eg, research, education, clinical, community, and management) to better address adaptive challenges and to formulate multidimensional strategies for optimal impact. The Framework has cross-cutting practice implications for all areas of dietetics practice and can lead to the next generation of solutions to tackle adaptive challenges that better support nutrition and health. The I+PSE Conceptual Framework for Action in Figure 1 is a blueprint for RDNs and their partners to develop and implement multidimensional strategies using a systems orientation to achieve greater responsiveness to adaptive challenges and realize greater impacts.1Heifetz R. Grashow A. Linsky M. The Practice of Adaptive Leadership. Tools and Tactics for Changing Your Organization and the World. Cambridge Leadership Associates, 2009Google Scholar, 2Carey G. Malbon E. Carey N. et al.Systems science and systems thinking for public health: A systematic review of the field.BMJ Open. 2015; 5 (12)e009002Google Scholar, 3Honeycutt S. Leeman J. McCarthy W.J. et al.Evaluating policy, systems, and environmental change interventions: Lessons learned from CDC's Prevention Research Centers.Prev Chronic Dis. 2015; 12: E174Crossref PubMed Scopus (45) Google Scholar, 4Leeman J. Meyers A.E. Ribisl K.M. Ammerman A.S. Disseminating policy and environmental change interventions: Insights from obesity prevention and tobacco control.Int J Behav Med. 2015; 22: 301-311Crossref PubMed Scopus (24) Google Scholar, 5Stroh D.P. Systems Thinking for Social Change. A Practical Guide to Solving Complex Problems, Avoiding Unintended Consequences, and Achieving Lasting Results. Chelsea Green Publishing, 2015Google Scholar, 6Glanz K. Bishop D.B. The role of behavioral science theory in development and implementation of public health interventions.Annu Rev Public Health. 2010; 31: 399-418Crossref PubMed Scopus (1122) Google Scholar, 7O’Connor J. Chronic disease prevention as an adaptive leadership problem.J Ga Public Health Assoc. 2017; 6: 398-400Google Scholar Once an adaptive challenge is identified, RDNs can apply a determinants of health lens (Figure 1, phase 1) to closely examine nutrition and health problems and better identify why problems are worsening despite best efforts to solve them. The result of this focused assessment is a stronger diagnosis of the root causes that supports strategic decision-making1Heifetz R. Grashow A. Linsky M. The Practice of Adaptive Leadership. Tools and Tactics for Changing Your Organization and the World. Cambridge Leadership Associates, 2009Google Scholar,2Carey G. Malbon E. Carey N. et al.Systems science and systems thinking for public health: A systematic review of the field.BMJ Open. 2015; 5 (12)e009002Google Scholar in phase 2. Phase 2 is the formation of coordinated multidimensional strategies that produce a sustainable and synergistic effect. Phase 3 is the evaluation of outcomes and impacts of the suite of strategies and the degree to which change has occurred at the individual, practice, program, organizational, policy, and population levels.3Honeycutt S. Leeman J. McCarthy W.J. et al.Evaluating policy, systems, and environmental change interventions: Lessons learned from CDC's Prevention Research Centers.Prev Chronic Dis. 2015; 12: E174Crossref PubMed Scopus (45) Google Scholar, 4Leeman J. Meyers A.E. Ribisl K.M. Ammerman A.S. Disseminating policy and environmental change interventions: Insights from obesity prevention and tobacco control.Int J Behav Med. 2015; 22: 301-311Crossref PubMed Scopus (24) Google Scholar, 5Stroh D.P. Systems Thinking for Social Change. A Practical Guide to Solving Complex Problems, Avoiding Unintended Consequences, and Achieving Lasting Results. Chelsea Green Publishing, 2015Google Scholar Encircling the Framework is systems thinking and reflection to support an iterative cycle of robust assessment, planning, implementation, and impact evaluation. The Framework is versatile and can be adapted to a wide range of nutrition issues, areas of dietetics practice, and diverse partnerships. The first step in addressing an adaptive challenge is to assemble all relevant qualitative and quantitative information and answer the questions “What does the evidence tell us?” “Where are the gaps?” and “How does this impact the nutrition and health of the individuals or communities we serve?” To inspire a broad examination of contextual influences on health and support root cause analyses,1Heifetz R. Grashow A. Linsky M. The Practice of Adaptive Leadership. Tools and Tactics for Changing Your Organization and the World. Cambridge Leadership Associates, 2009Google Scholar RDNs and their partners are encouraged to use a determinants of health lens (Figure 1, phase 1). This phase includes 3 categories of information—social, commercial, and political—that have demonstrated influence on the nutritional health of individuals and populations. Strong evidence supports that where individuals live, work, learn, and play is associated with health risks, well-being, and lifespan.8Institute of Medicine, Committee on Accelerating Progress in Obesity PreventionAccelerating Progress in Obesity Prevention: Solving the Weight of the Nation. National Academies Press, 2012Google Scholar Social Determinants of Health (SDOHs) are the interconnections between social, physical, and economic characteristics and how they influence health status at a community or population level.9Sims J. Aboelata M.J. A system of prevention: Applying a systems approach to public health.Health Promot Pract. 2019; 20: 476-482Crossref PubMed Scopus (13) Google Scholar,10Centers for Disease Control and Prevention, Division of Community HealthA Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease. US Department of Health and Human Services, 2013Google Scholar An SDOH approach examines disparities and serves as the catalyst for a root cause matrix to identify nutrition and health inequities.10Centers for Disease Control and Prevention, Division of Community HealthA Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease. US Department of Health and Human Services, 2013Google Scholar The SDOH assessment includes economic, education, social and cultural, health, neighborhood, and built environment information.11Healthy People 2020. Social Determinants of Health. Office of Disease Prevention and Health Promotion, US Health and Human Services.https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-healthGoogle Scholar However, in the context of nutrition and health, the dimensions of food systems, natural environments and ecosystems, and public health capacity need to be considered. Greater awareness of these linkages within a nutrition context drives informed solutions that advance healthy choices as the default choices.12Ten essential public health services and how they can include addressing social determinants of health inequities. Social Determinants of Health: Know What Affects Health. Centers for Disease Control and Prevention.https://www.cdc.gov/publichealthgateway/publichealthservices/pdf/ten_essential_services_and_sdoh.pdfGoogle Scholar The rise of diet-related chronic diseases as an adaptive challenge is regarded as a symptom of a global culture in which profits are prioritized over health.13Kickbusch I. Allen L. Franz C. The commercial determinants of health.Lancet. 2016; 4: e895-e896PubMed Scopus (228) Google Scholar, 14Millar J.S. The corporate determinants of health: How big business affects health, and the need for J Public Health. PubMed Scopus Google Scholar, R. C. G. et determinants of health: of and at Health 2019; PubMed Scopus Google Scholar determinants of health are as the to and services that that can impact their J.S. The corporate determinants of health: How big business affects health, and the need for J Public Health. PubMed Scopus Google Scholar, R. C. G. et determinants of health: of and at Health 2019; PubMed Scopus Google Scholar, M. the corporate and commercial determinants of J Public Health. PubMed Scopus Google Scholar M. the corporate and commercial determinants of J Public Health. PubMed Scopus Google Scholar influence and and using strategic of and R. C. G. et determinants of health: of and at Health 2019; PubMed Scopus Google M. the corporate and commercial determinants of J Public Health. PubMed Scopus Google Scholar and are an influence on public R. C. G. et determinants of health: of and at Health 2019; PubMed Scopus Google M. the corporate and commercial determinants of J Public Health. PubMed Scopus Google Scholar global chains, which and they can using and social health and environmental J.S. The corporate determinants of health: How big business affects health, and the need for J Public Health. PubMed Scopus Google Scholar, R. C. G. et determinants of health: of and at Health 2019; PubMed Scopus Google Scholar, M. the corporate and commercial determinants of J Public Health. PubMed Scopus Google Scholar these strategies social and that are to healthy Guide to for Research and A. 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