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It sounds so “nutritionous”

Dietitians are a critical part of modern medicine. In the hospital, dieticians not only educate patients on dietary treatment of diseases such as diabetes and heart disease; they also evaluate the nutritional status of critically ill patients and develop nutrition plans that may involve tube feeding or intravenous feeding. This is complicated, and takes into account a patient’s nutritional needs, medical conditions, etc. They are highly trained professionals.

If you want to see a dietitian lose it, call them a “nutritionist”. “Dietitian” is a specific profession governed by specific educational and licensing requirements. A dietitian can call themselves a nutritionist, but so can just about anyone else. As with other health care professions, dietitians have good reason to protect their profession. Protecting their profession protects their patients. Dietary fads are among the most prolific of medical scams and good information can be hard to find. Registered dietitians explicitly strive to utilize evidence to guide their practice. And critically, they have a published Code of Ethics.*

As is not uncommon, there are those who, in the name of “health freedom” (and profit), object to the dietitian “monopoly” on nutritional therapy.   One way they have done this is to claim the title “nutritionist” and set up a certification system. Once this structure is in place, it’s easier to get states to approve them as licensed professionals.  In this second area—state licensing—they are enlisting allies that comprise many of  ”the usual suspects”.

Clinical Nutritionists

One group that is attempting to create an alternative path to nutritional therapy is the Clinical Nutrition Certification Board. Upon first learning of “clinical nutritionists” my first question was why would anyone want a second, parallel route to dietary science?  What’s wrong with the system we already have in place?

First let’s review the basic qualifications for registered dietitians (RDs):

  • Earned a bachelor’s degree with course work approved by ADA’s Commission on Accreditation for Dietetics Education. Coursework typically includes food and nutrition sciences, foodservice systems management, business, economics, computer science, sociology, biochemistry, physiology, microbiology and chemistry.
  • Completed an accredited, supervised practice program at a health-care facility, community agency or foodservice corporation.
  • Passed a national examination administered by the Commission on Dietetic Registration.
  • Completes continuing professional educational requirements to maintain registration.

The requirements for the clinical nutrition board look superficially similar.  But looking a little deeper reveals some disturbing trends.  For example, rather than the real-world training program required for an RD, they require online coursework.   And they explicitly court naturopaths, a group of doctor-wannabes who claim to be “integrative” but who actually practice magic rather than medicine, including in their practices such nonsense as homeopathy and reiki.  And as we’ve seen time and time again, once you open the door on one disproved or implausible practice, anything can (and will) walk through.

It would appear that the CNCB is not only encouraging fake doctors to apply, but also explicitly requiring “training” in fake medicine.   In the description of their examinations, they require:

Knowledge of alternative evaluation techniques (i.e., homeopathic interrogation, acupuncture meridian interrogation, kinesiology, chelation therapy, Herbology, reflexology, allergic food provocation testing electromagnetic frequency challenge) as related to nutritional assessment

Any certification process that requires a knowledge of  ”electromagnetic frequency challenge” without mentioning it as a wallet-emptying magic trick is not worthy of official recognition.

But official recognition is exactly what they want.

State Licensing

The state of Michigan is currently working on regulations for the licensing of dietitians and nutritionists.  A Michigan naturopath is rather concerned about this process and is helping campaign on behalf of the “Michigan Nutrition Association”.

Our mission is to serve the interests of the public and Michigan professionals who incorporate human nutrition in their practice and patient care. We envision a vibrant community of CNS, CCN, CNC, CN, DACBN, Pharmacists, Medical Doctors, Nurses, Chiropractors, Naturopathic Doctors and many other professionals working in the interest of public health.

What this essentially means is that they are lobbying to allow pseudo-professionals such as chiropractors and naturopaths to be “licensed dietitians and nutritionists”.  In addition to giving them a patina of legitimacy (but no more than a patina), it might allow them to order laboratory tests (and there is no shortage of profit to be found in these).

This tactic of seeking legal rather than professional legitimacy is a growing and disturbing trend.  Hopefully, the legal process will be informed more by evidence than by the lobbying of pseudo-professionals, but I’m not terribly optimistic.

_________________

*This code is much more sophisticated and transparent than that offered by the CNCB, and includes this statement:

6. The dietetics practitioner does
not engage in false or misleading
practices or communications.
a. The dietetics practitioner does
not engage in false or deceptive
advertising of his or her
services.
b. The dietetics practitioner promotes
or endorses specific goods
or products only in a manner
that is not false and misleading.
c. The dietetics practitioner provides
accurate and truthful information
in communicating
with the public.
6. The dietetics practitioner does
not engage in false or misleading
practices or communications.
a. The dietetics practitioner does
not engage in false or deceptive
advertising of his or her
services.
b. The dietetics practitioner promotes
or endorses specific goods
or products only in a manner
that is not false and misleading.
c. The dietetics practitioner provides
accurate and truthful information
in communicating
with the public.

Posted in: Science and Medicine

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24 thoughts on “It sounds so “nutritionous”

  1. ZenMonkey says:

    I feel like I’ve dodged a bullet, to some extent. I’ve seen nutritionists twice, both self-referred because I wanted to learn how to eat better. Once was in college, and the second time was about four years ago. At neither of those times was I aware the terms “nutritionist” and “dietician” were not interchangeable. Yet, luckily, both women gave me solid, sensible, basic guidance without any crazy woo or fads.

    Knowing more about the subject now, I would still see a dietician over a nutritionist for the reasons mentioned here, since lucky or not, I’d rather not roll the dice again.

  2. rastan says:

    “Dietitian is to nutritionist as dentist is to toothiologist”

    - Dara O Briain (comedian)

  3. Lapis says:

    Been reading this blog for a long time now and just wanted to finally say thank you for being such a great resource for a recovering “alt health” fanatic.

    Yes, I was once a woo fanatic (blush). I grew up around alt health in an alt health friendly city, I became a doula, did a reiki training, studied herbs, took some flower essences, got acupuncture, exclusively saw naturopaths, even went to the Institute for Integrative nutrition (a TERRIBLE place btw). It was a woo-ey life to say the least and despite having quite a lot of uncertainty about everything I was learning and the people I was meeting, it took until I met (and married) a scientist for me to finally take a good look at all the things that had been rubbing me the wrong way. Of course, I really had to swallow my pride to let go of a lot of what I “knew” and my work life has certainly suffered from it, but I am so glad to have found the other side.

  4. landanimal says:

    Wow. I really did NOT know there was a distinction between a dietitian and a nutritionist. And I am 100% sure the majority of people do not either. Thank you for this post. Things will probably start making more sense to me now cause I tend to find myself raising my eyebrow at nutritionists pretty often.

  5. qetzal says:

    Why, in their list of “alternative evaluation techniques,” do they capitalize “Herbology?” Is that some new alty technique involving somebody named Herb?

    (Yes, the capitalization is present in the original.)

  6. Wolfy says:

    Thank you for this article highlighting this important distinction.

  7. Ian says:

    I also didn’t know that there was a difference, but went in the opposite direction of the prior commenters and figured they were all bunk. So thanks, good to know that dietitians are the real deal.

    The dietitians educational requirements sound so reasonable. Makes these ‘nutritionists’ all the more frustrating!

  8. weing says:

    I’ve always dealt with dietitians, but I too, thought the terms were synonymous. It’s by sheer luck I haven’t pissed one of them off. Thanks for the info. I’ll be sure never to make that mistake again.

  9. cervantes says:

    At the community health center where I get my primary care, the nutrition counselor is called the “nutritionist.” I think this term is widely used for legitimate practitioners, so just because somebody is called a nutritionist doesn’t mean they aren’t the real deal. (I always thought a “dietician” was the person in charge of the school cafeteria.)

    So the profession really needs to start recognizing this distinction itself if it wants the public not to be confused.

  10. Joe says:

    ZenMonkey on 01 Jul 2010 at 4:22 am wrote “… I’ve seen nutritionists twice, … [L]uckily, both women gave me solid, sensible, basic guidance without any crazy woo or fads.”

    When I see something like that I wonder what basis you have for knowing the advice was good if you had to ask for it? In other words, maybe they suggested something harmless but needless (e.g., vitamins); a dietitian might have had even better advice.

  11. hatch_xanadu says:

    Sigh. You know, with all the effort quack practitioners put forth lobbying for legitimacy, you’d think they could channel some of that energy into, oh, I dunno, seeking a real education in a real specialty . . . and then make a comfortable living actually doing people some good. It’s sad that they work so hard at being lazy.

    Aw, man, did I just say “channel” and “energy”?

    And yes, thanks so much for the distinction — I’m sure most folks don’t know the distinction between “dietician” and “nutritionist”. Which, of course, is the sort of confusion dubious practitioners count on. And nice move, Michigan Nutrition Association, throwing pharmacists and medical doctors and nurses into that mix to suggest everybody in that list is one in the same. They want it both ways — to denounce the “monopoly” on real professionals but then turn around and try to pretend they’re doctors.

  12. Happy Camper says:

    @hatch_xanadu

    “You know, with all the effort quack practitioners put forth lobbying for legitimacy, you’d think they could channel some of that energy into, oh, I dunno, seeking a real education in a real specialty”

    Maybe they just didn’t have the grades.

    I agree that Alt.Med. practitioners appear to bash the very thing they covet the most.

  13. oderb says:

    Yes I remember with the great fondness what the dietician concocted at the hospital where I was a patient not long ago.

    White bread rather than whole grains, high fructose corn syrup in several dishes, canned syrupy peaches rather than fresh fruits, processed sugary cereal, and so on. Almost as nutritious as the McDonalds in the lobby.

    No nutritionist in American would have remained at such an institution.

  14. ZenMonkey says:

    @Joe — I don’t really understand this statement: “When I see something like that I wonder what basis you have for knowing the advice was good if you had to ask for it?”

    How does my asking for advice mean that it wasn’t necessarily good? That seems like an odd jump to make. Would my story have been more valid if I had been referred by another physician?

    And I wasn’t given any vitamins or supplements. I learned about proteins, fats, and carbs, and how the body metabolizes them, and why it’s better to eat less or no sugar, and that kind of thing. At this point I think I’m pretty well qualified to examine what they told me and determine that it was not woo, or useless.

  15. The Blind Watchmaker says:

    rastan mentioned it above. I thought Dara O’Brian’s bit needed to be shared.

    http://www.youtube.com/watch?v=VIaV8swc-fo

  16. Foodie says:

    In Quebec, the titles “dietitian” and “nutritionist,” as well as the abbreviations R.D. and Pt.D. are protected by the Quebec Order of Dietitians. However, this is not the case in all Canadian provinces.

  17. oderb,

    When I was hospitalized I was given choices, except for the first day I was in a new room when they’d give me their default menu. There should be healthy choices on the menu: there’s no excuse for not offering them.

    On the other hand, you can’t get nutrition out of something you don’t eat. The institutional default menu is going to be inexpensive and also as bland and familiar as they can make it in an effort to coax cheap calories into sick people. If more people in their catchment area eat white than whole wheat bread, then white bread is what will be the default.

    It’s a balancing act, and your hospital’s food service may not have gotten it right. But it’s unrealistic to expect that hospital food will be as “healthy” as dieticians prepare for themselves at home.

  18. LMA says:

    Wow. I did not know this.

    It’s funny — I’m an “ordinary citizen” — one time English major become long-long-time retail employee — with no science background beyond high school, who reads this blog all the time, and yet this post compelled me to log in and share my scientifically useless anecdote. ;D

    Over 20 years ago, after losing a great deal of weight and suffering from almost constant nausea and diahrrea, I was diagnosed by a gastroenterologist as being the “most lactose-intollerant patient he’d ever tested” (The part of the blood test where the response is supposed to go up, well, in mine, it went down. The nurse had to come into the bathroom where I was “trapped” to do the fifteen minute blood draw). That title previously belonged to my husband who had his test done only a few months earlier (if we believed in woo, we’d warn everyone away from the water in Raleigh, NC). Anyway, because of the doctor’s own recognition that he wasn’t an expert on diet, he hired onto his staff a Registered Dietician to consult with each of us.

    To date, she was/is the only person to inform us that despite popular legend, yogurt is full of lactose, and no, the fermentation *doesn’t* make it easier for truly lactose-intollerant people to digest. She had charts and lists of different cheeses with the differing amounts of lactose in each one, and cued us into all the other ingredients (“whey,” non-fat dried milk, etc) that might be in prepared foods we should avoid. She helped us come up with suitable, balanced daily meal plans that took into account our need to avoid lactose, kosher restrictions as well as my GERD. Mind you, at that time, lactase tablets and drops had only just come out on the market and I was living in the land of lard and butter, so the food scene was far more difficult to navigate than today. (To this day, I’m so intollerant that if I take one of the many drugs that uses lactose as a filler, my body reacts to it unless I down a Lactose pill with it). It sounds stupid, but when we first were diagnosed, we honestly thought we would either starve to death or die of misery, but that “nutritionist” and doctor were the greatest combination of medical experts a patient could encounter.

    My personal, entirely non-scientific lesson? There are no trivial issues in medicine. And now that I know there is a difference between a nutritionist and a dietician, I’ll be sure to make sure my acquaintances know as well. Thank you for sharing this — and all the other interesting scientific medical facts on this blog!

  19. gretemike says:

    There’s a guy names Ornish with a diet that he claims can actually reverse heart disease when it’s related to clogged vessels. Anyone know if that’s actually been scientifically demonstrated to be true?

  20. kdv says:

    My wife is a dietitian working primarily in the Intensive Care unit of a very large public hospital here in Sydney. This article resonates very strongly with her, because many of the issues in Australia match those in the USA.

    She and her colleagues really want the public to understand the differences between the scientifically educated dietitians and the “nutritionists”, but they just don’t know how to bring it about.

    I suspect that one factor is that a dietitian will rarely have a quick and easy fix for you. It usually involve modifying your eating habits more or less permanently. So, when a “nutritionist” comes along and recommends that you take 10 of these vitamin tablets daily (you can buy them from the receptionist on the way out, credit cards accepted), and all will be fine, it sounds really easy.

    Incidentally, if you enjoyed Mitchell and Webb’s portrayal of a homeopathic emergency department, this one might amuse you too:

    http://www.youtube.com/watch?v=SavsJYXWgm8

    ( sorry if everybody’s already seen it )

  21. Interesting article. I think, to the patient, the title distinction can still be a bit fuzzy. For instance, when I read the article, I thought, ‘wait, isn’t there a nutritionist on my son’s cranio-facial team?’ I had thought a dietitian worked mostly in food production services, overseeing that food for schools, hospitals and shelters is balanced nutritionally and healthy. I thought a nutritionist worked with individual patients.

    I was curious enough to look at my son’s records and the team website. The title on the craniofacial team is Nutrition Services. It seems all the staff on the Nutrition Services Team at this children’s hospital have a R.D. but one also has listed C.N.S.C. – Certified Nutrition Support Clinician

    Googling around a bit, I surmised that the C.N.S.C seems tied to training in more intense clinical nutrition such as tube feeding, IV feeding, more intense nutritional needs such as cancer or some pediatric conditions. It appears that this certification can be obtained by doctors, nurses or nurse practitioners through taking the exams (didn’t find out about specific training.)

    So I would say there does seem like there is a recognized need for a specialty in clinical nutrition. It just is not what the CNBC seems to be looking for with their C.C.N – Certified Clinical Nutritionist.

  22. Wolfy says:

    Blind Watchmaker:

    Thanks!! That Dara O’Brian bit was hysterical!!

  23. Joe says:

    ZenMonkeyon 01 Jul 2010 at 8:19 pm wrote “@Joe — I don’t really understand this statement: …

    How does my asking for advice mean that it wasn’t necessarily good? … Would my story have been more valid if I had been referred by another physician?” Only if you were referred to an RD. ‘Self-referral’ was not a problem, that is why I elided it in my comment.

    Of course, asking for information doesn’t make it bad. Asking for information from a dubious source makes it questionable, and you are not in a position to judge. Inquiring from a legitimate professional does not mean you get the best information; but the odds are increased. Does that help?

    Based on some of the comments, you may have seen an RD that you are calling a nutritionist.

  24. borealys says:

    Making it even more complicated, there *are* some jurisdictions where both “dietitian” and “nutritionist” are protected titles, referring to the same licensed, regulated profession.

    At the three different hospitals where I’ve worked (in two different Canadian provinces), the relevant department was called something like “Department of Clinical Nutrition” and employed both registered dietitians and non-professional assistants, known variably as dietary assistants, clinical nutritionists or diet techs, who were primarily responsible for managing the day-to-day menus within the constraints set out by the dietitians’ assessments and the preferences of the individual patients.

    If a patient was obese, or needed tube-feeding, or was newly diagnosed with diabetes, the dietitian was called. If a patient wanted kosher meals or didn’t like fish, the nutritionist/assistant/tech was called. It worked.

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