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SPECIAL FEATURE: Who is best qualified to provide nutrition counseling? RDs? MDs? a CNS? You or me?

13 commentsBy Elaine WATSON , 26-Jun-2013
Last updated on 26-Jun-2013 at 14:42 GMT2013-06-26T14:42:23Z

AND: 'What the Academy opposes is unlicensed practitioners providing quack advice that harms patients'
AND: 'What the Academy opposes is unlicensed practitioners providing quack advice that harms patients'

Who is best qualified to provide nutritional counseling? A registered dietitian? A medical doctor? A nutritionist? A nutrition scientist? A sports scientist? You or me?

What most people would probably say is that ‘qualified’ is the operative word, in that in order to gain a state license to practice, you should have some kind of relevant credentials or experience before telling other people what to eat.

But what is a relevant qualification? And are laws in some states so restrictive that they give RDs a de facto monopoly when it comes to operating in this field or at least obtaining a state issued credential (and the benefits it may confer such as insurance eligibility), effectively excluding scores of other professionals that are just as qualified?

The Certification Board for Nutrition Specialists (CBNS) - the certifying body for the Certified Nutrition Specialist (CNS) credential - says this is exactly what’s happening in over a dozen US states, and it’s deeply unfair.

The Association of Nutrition and Dietetics (AND), which represents RDs, says this is nonsense, and that licensing laws protect consumers from self-appointed experts and quacks.

So who is right? And how can states address legitimate concerns about who is qualified to tell us what to eat without creating laws that the CBNS claims are written by RDs for RDs, and create only one ‘pathway’ to licensure: Dietetics?

Undercover sting operations, aggressive investigations, and prosecutions

The Alliance for Natural Health USA, which represents natural health practitioners, has been campaigning to amend or overturn what it claims are overly-restrictive nutrition counseling laws in several states, campaigns and communications director Darrell Rogers tells FoodNavigator-USA.

And while progress has been made on this score, claims Rogers, a probe by the ANH-USA recently uncovered “widespread evidence ” including “undercover sting operations, aggressive investigations, and prosecutions” that non-RD nutrition professionals are being targeted by state health departments that are “enforcing monopolistic laws sponsored by AND”.

According to Rogers, while many states recognize non-dietetics credentials such as the CNS, several states (click here for a state-by-state breakdown) make it illegal to refer to yourself as a nutritionist unless you are licensed by the state. (And to get licensed, you need RD credentials, education and experience, he says.)

Non-RD nutrition professionals are being targeted by these states’ RD monopoly laws, despite the fact that many of them have advanced degrees and a tremendous number of clinical hours to their credit. They are being prosecuted for ‘practicing dietetics without a license’ or for referring to themselves as ‘a nutritionist’ in media or marketing materials.”

The ANH-USA adamantly opposes efforts to limit consumer choice by enacting laws that benefit one particular group

He adds: “One of the AND’s key agenda items is to pass ‘scope-of-practice’ laws in each state whereby only RDs can legally offer nutrition services—even basic services like providing nutrition advice or nutrition consulting.

“In our investigation into three years of records from four state dietetics boards [Florida, Ohio, North Carolina, Georgia],  we did not find a single case of an unlicensed nutrition practitioner causing harm… and not a single case of a customer filing a complaint. Every complaint that spurred a subsequent investigation and prosecution was made at the behest of the Board itself, or from complaint forms submitted by RDs.”

While ANH-USA supports the AND’s desire to protect the term ‘Registered Dietitian’, he says, it “adamantly opposes efforts… to limit consumer choice by enacting laws that benefit one particular group.

“We believe in a competitive and open market for nutrition professionals, with consumers and employers (including hospitals) being able to decide what credentials, education, and experience they want in a nutrition provider.”

CBNS: Laws that exclude highly qualified non-RD nutrition professionals from licensure and prevent them from practicing by criminalizing their work are not in consumers’ best interests

But should anyone be able to slap the sign ‘nutritionist’ over the front door and start dishing out nutrition therapy, or gain a license to do so from the state?

Of course not, says CBNS executive director Michael Stroka, but laws that not only exclude highly qualified non-RD nutrition professionals from licensure, but prevent them from practicing altogether by criminalizing their work are not in consumers’ best interests, he argues.

For example, a PhD in Clinical Nutrition from a top regionally accredited university that has passed the CBNS exam and become a Certified Nutrition Specialist (CNS) and completed 1,000 hours of supervised experience, would be committing a crime by providing nutrition counseling in some states, he says.

“The CNS credential is only earned by masters or doctoral level health professionals from regionally accredited universities with demonstrated expertise and experience in science-based clinical nutrition, which is more sophisticated training in clinical nutrition than the undergraduate RD credential provides.”

There are important roles to play for those with a variety of levels and types of training

He adds: “There are important roles to play for those with a variety of levels and types of training.” All the CBNS is arguing is that “all nutrition practitioners be able to practice to the level of their training”.

And, ”if practitioners are defrauding the public by claiming to be something they are not, that conduct should be strictly prohibited”, he adds.

“A sensible framework would provide for top-level ‘licensure’ or ‘certification’ of highly credentialed nutrition practitioners, who have regionally accredited academic degrees or appropriate coursework in clinical health sciences and clinical nutrition, supervised experience, pass a rigorous science-based clinical nutrition examination, such as that for Certified Nutrition Specialists, and complete continuing education.”

Those without a license would not be prohibited from providing nutrition advice, but would insteadbe “required to fully and formally disclose to the public and clients that they are not licensed or certified by the state, and provide full disclosure of their training and credentials”, he suggests.

“There are many fine RDs, in fact many go on to obtain advanced degrees and then become Certified Nutrition Specialists.  The problem is not with RDs but the national leadership of the AND which is driving this monopolistic agenda.”

AND: What the Academy opposes is unlicensed practitioners providing quack advice that harms patients

AND: "Many states do require licensed dietitian-nutritionists to pass an exam focusing on dietetics practice, but that is what applicants are being licensed to do."

Not surprisingly, however, AND’s director of regulatory affairs Pepin Tuma takes a different view.

He tells us: “There is not [an RD] ‘monopoly’ on the provision of nutrition advice. Anyone can provide general, non-medical information, but states recognize health-care professionals should be licensed when they provide complex advice, such as medical nutrition therapy, tube feedings, and therapeutic diets in order to ensure the public is protected and practitioners are competent.

“Many licensed health-care and nutrition professionals—including doctors, naturopaths, nurses, physicians assistants, pharmacists, athletic trainers, and others—can provide complex nutrition advice if they’re licensed to do so. 

“What the Academy opposes is unlicensed practitioners providing quack advice that harms patients. If holistic nutritionists, homeopaths, and naturopaths want to provide nutrition advice, they should be licensed and regulated as holistic nutritionists, homeopaths, or naturopaths—not licensed dietitian-nutritionists—to ensure the public is protected.”

We strongly encourage everyone to look closely at the state statutes and regulations to see the truth

But what about someone with an advanced degree in clinical nutrition?

“Although a couple of states such as Mississippi appear to require that one is an RD to become a licensed dietitian, they are, by far, the exception”, claims Tuma

“Yes, many states do require licensed dietitian-nutritionists to pass an exam focusing on dietetics practice, but that is what applicants are being licensed to do. 

“We strongly encourage everyone to look closely at the state statutes and regulations to see the truth. Many Ph.D. clinical nutritionists can become licensed and there is usually a pathway to licensure for non-RDs.”

Stroka: AND wishes to create a scope of practice that includes nutrition and dietetics, but only allows for dietetics training as the pathway for legal practice of that dual scope

But the CBNS’s Stroka argues that clinical nutrition professionals “focus on clinical nutrition, and thus have no desire to be called dietitians…They are not becoming licensed in order to practice dietetics; they are becoming licensed in order to provide medical nutrition therapy”.

Meanwhile, while the AND is correct in pointing out that “anyone can provide general, non-medical information”, such as telling people that oranges contain vitamin C, says Stroka, if they go on to recommend that a client eats oranges to obtain more Vitamin C, they are performing nutrition assessment and/or counseling, and in many states, that means they are breaking the law if they don’t have a license.

He adds: “The crux of the problem is that the AND leadership wishes to create a scope of practice that includes both nutrition and dietetics, but only allow for dietetics training as the pathway for legal practice of that dual scope.  Their specialty is dietetics, while our group’s and other groups’ specialty is science-based clinical nutrition.”

Anyone can provide general, non-medical nutrition information, such as telling people that oranges contain vitamin C. But they go on to recommend that clients eat oranges to obtain more Vitamin C, they are crossing the line and performing nutrition assessment and/or counseling, which means they are breaking the law in many states if they don’t have a license, claims CBNS executive director Michael Stroka

While the AND says there is “usually a pathway to licensure for non-RDs”, in many states, this is a “mirage”, claims Stroka.

“The pathway the AND leadership refers to means a dietetics degree, a dietetics internship, and passing the dietetics exam. So, because clinical nutrition training is quite different from dietetics training, this pathway is a mirage. It is just another name for getting the RD credential.”

Legislators were unaware of the vast difference between dietitians and nutrition professionals

So where do things stand now across all the states?

According to Stroka, “until a few years ago… legislators were unaware of the vast difference between dietitians and nutrition professionals, and the AND was able to pass one-sided laws because opposition was dispersed.”

But in the past three years, he says, every one of the over one dozen attempts to get RD-oriented bills passed in states has been defeated.

However, there is no room for complacency says the ANH-USA’s Rogers, who argues that had an AND sponsored bill in Indiana passed earlier this year (HB 1272), anyone providing nutrition interventions (which the bill defined as "to positively change nutrition related behavior...for an individual”) would have required a state dietetic license.

Had this passed, “cooking class instructors, health coaches, PhD nutritionists and health food store employees would be breaking a law by attempting to positively change nutrition related behavior without a state license”, claims Rogers.

And new challenges are ahead, he claims, citing a federal bill (HR 2415, the Treat and Reduce Obesity Act of 2013) proposing that Medicare reimbursement be made available to RDs that offer weight loss counseling but not “most other nutrition professionals”.

Click here to see a state-by-state breakdown of laws governing the provision of nutritional counseling and therapy from the Center for Nutrition Advocacy (an initiative of the CBNS ).

Click here to read more about the educational and professional requirements to become an RD.

Click here to find out more about the Certification Board for Nutrition Specialists (CBNS).

Do you work in this field? What are your thoughts? Please tell us what you think by using the Post a comment tab below this article.

Source: Center for Nutrition Advocacy

13 comments (Comments are now closed)

Education and Credibility

It is clear that our society judges and decides on experts based on their level of education and the experience of successes and referrals they have. As a CNS with a Masters, I am about to be licensed in the state of NY. I had to go back to undergrad to get more classes that were in line with the RD program. The classes definitely broadened my nutritional knowledge as any high level educational course would do; however, I have a better and deeper understanding of the science of nutrition than my undergrad colleagues. This is surely expected. RD's were created from an association and the only requirement needed is an undergrad. States, government and insurance companies should recognize CNS's as a high level version of RD's for the simple fact that their protocol and testing exceeds the requirements of the RD. Just like IBM and Microsoft, certain leading associations should not monopolize an industry especially if they are not equipped to accommodate them. For example, the internship that the ADA requires not only requires a student to pay from 10-25000 for a 10 month work environment with no pay; it has so few participating hospitals that the likelihood of every 3.0-4.0 student to get into the program is practically impossible. Also, for the middle class; that does not get financial aid or not independently wealthy, it leaves a large gap for their eligibility to pay for this program without leaving them in debt. The salary is not great. Not like a doctor or PA, where the payoff will allow them to afford to pay back a loan. Something is broken and it is not the expertise. It is the monopoly. It reminds me of religion fighting over who is more spiritual. ADA wake up. Just 20 years ago, to become a RD was not that difficult and a lot have been grandfathered in. I recently went to a workshop sponsored by the Academy about running your own business as a nutritionist; and not only did the speakers know about what a CNS is; they repeatedly were condescending to people in the health food store giving advice all the way to non-RD's. We had to correct them and they changed their tone. Working together is the professional way to go and respect for other high level professionals in the nutrition field. The cream of the crop should be accepted on government standards which should be highly educated, good ratings on referral and reputation, and knowledge and practicing based on emerging evidence based nutritional standards; which is what the profession call for and people demand. Not on one association's acronyms that doesn't have requirements for postgraduate education.

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Posted by Jeannine Andre-Burns, MS, CNS
19 September 2013 | 03h442013-09-19T03:44:41Z

Best Qualified Nutrition Counselors

The answer to this timely and compelling question should be goal-driven. For example a famous local chef died last week and was lauded by politicians, celebrities and friends for his keen insight, knowledge and dedication to promoting one of the unhealthiest cuisines in one of the most obese states of the union. A victim of his own cooking like Dave Thomas, he died of a diet-related disease. Beloved by all who savored his deadly fare, he would not be a good choice for nutritional guidance if the survival of the customer was the goal. At the same time healthy food purveyors are often ignored into bankruptcy.

I submit that nutrition counseling is about the science of good health through diet and should never be driven by cash flow through pandering toxic food addictions, even for the sick or dying. At-your-own-risk feel good food advice should be confined to the culinary trades. Healthful dietary advice should be science based.

So there is the rub. Health is an extremely dynamic field with new knowledge accumulating every day. This means that an eminently qualified uninformed professional can easily be upstaged by a rookie who reads the literature. For example, I tested five certified professionals and an uncertified student in assessing my body composition through the common skin fold test and found that the most accurate was the student who was not steeped in years of bias of the professionals making the same measurement errors interminably.

A simple solution to verifying nutritional advice that nearly nobody follows is: Both before and after, test, don’t guess. Blood tests can determine deficiencies of almost all important nutrients and the presence of toxic substances. Submit your before test results to your counselor of choice. Reject any advice that conflicts with your test results. For example, there is no point in increasing your Vitamin C intake by eating oranges if you have enough in your system already. Then follow the advice regimen you agree on. Retest at the end and hold your counselor's feet to the fire over the results. A few iterations of this procedure will cull the frauds, incompetents and ineffectuals and optimize your nutrition based on science that is the best there is.

As to certifications, the AND upper management coterie has consistently confirmed it is little more than a pimping modality for the junk food industry. If it merely read the research reports of its constituents and implemented the most credible you would not see the pathetic pandering dog and pony show of their annual convention and its pay to play “workshops and seminars”. If their budget promoted health instead of disgusting confusion ploys like “moderation” the public health would be served (Their policy is “moderating” shooting yourself in the head with a 38 because too much might tend to be fatal) The many sincere and competent AND members are so in spite of, not because of AND. They deserve a professional organization instead of an arrogant slimeball cartel lining their pockets with their membership dues, should eject the scoundrels who've hijacked their organization and set a new course of professionalism to begin repairing badly damaged credibility or vote with their feet and form a new organization.

AND opposes unlicensed practitioners giving quack advice that harms consumers. But what about unlicensed practitioners giving quack advice that helps consumers? The record is replete with examples. MD Ignaz Semelweis is my poignant favorite. Through keen observation he deduced that infectious agents were killing pregnant females transmitted by doctors which could be totally avoided by having them disinfect their hands between patients. His colleagues were insulted, labeled him a quack, drummed him out of medicine, had him committed to an asylum where he died of injuries. No good deed goes unpunished where there is a market to protect. Today modern hospital hygiene is the direct result of Semelweis’ quack idea. Yesterday’s quack can be today’s miracle cure if exposed to testing.

http://en.wikipedia.org/wiki/Ignaz_Semmelweis

What is the downside of bad nutrition advice that AND would protect us from? Fasting experience shows up to forty days without food does not result in deficiency for average people because of nutrient stores within the body. Well before that happens the consumer will discover bad advice and move on. The downside of bad advice is non-existent so long as testing is employed to verify results.

So the answer to your question of who is the best nutritional counselor is: all of the above, and more, as long as the litmus test of testing if used to verify results. The reality of science based standards and a competitive certification market verified by testing will drive the industry to better customer service.

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Posted by Stephen Albers
19 July 2013 | 23h372013-07-19T23:37:50Z

pathway for trained health professionals to practice nutrition therapy

I have worked as an RD in Maine for the past 12 years. I consider myself a dietitian and a nutritionist. Maine has strict licensure laws for practicing medical nutrition therapy and dispensing nutrition as a form of therapy. It is a disservice to the public, in my opinion, to not have a pathway for trained health professionals with degrees (BS or advanced) in the sciences related to clinical nutrition. We need more people who have this training in the field regardless of the RD credentials. It is necessary also to protect the public from anyone calling themselves a nutritionist who has not had training (academic and practicum). There is great benefit for the public to have additional pathways for qualified individuals to provide nutritional services (and be able to get re-imbursed).

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Posted by Marybeth Judy MS, RD, LD
11 July 2013 | 20h332013-07-11T20:33:55Z

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