Dietitians vs. Nutritionists: Licensure Battles Underscore Growth of the Field

Surrounded by a food environment that is arguably more bountiful and less nutritious than ever before, many Americans have a pressing need for access to high-quality nutrition information and nutrition-focused health care practitioners.

But like so many other aspects of health care in this country, meeting this seemingly simple need is fraught with complications.

Almost as extensive as the assortment of foodstuffs available to American consumers is the variety of nutrition service providers. Diverse professionals with varying titles and credentials now vie with each other to offer some form of nutrition counseling or food-based therapy to the health-conscious public.

As the nutrition service professions continue to grow and diversify, it is imperative that those in search of diet-related guidance understand how to navigate the broad and varied network of nutrition providers.

This can be a challenge not only for patients but for physicians as well: How do you find well-qualified, credible nutrition professionals to whom you can confidently refer patients when their specific needs exceed your own nutritional knowledge?

A Spectrum of Services

On one end of the nutrition services spectrum is the profession of dietetics. The Academy of Nutrition and Dietetics, formerly known as the American Dietetic Association, defines the profession as the "integration, application and communication of principles derived from food, nutrition, social, business and basic sciences, to achieve and maintain optimal nutrition status of individuals through the development, provision and management of effective food and nutrition services in a variety of settings."

AND presents dietetics and its practitioners--Registered Dietitians (RDs)--as the gold standard inandlogo modern nutritional medicine. The group claims that RDs are "the food and nutrition experts." Upon completion of either a BS or MS degree program in dietetics and an approved dietetic internship, dietitians must pass a national registration examination administered by the AND's credentialing arm, the Commission on Dietetic Registration, in order to receive the RD credential.

One key trait that distinguishes RDs from other types of nutrition professionals is their ability to administer medical nutrition therapy (MNT). Federal statutes designate RDs as the sole providers of MNT, and many RDs work in hospitals or other healthcare facilities as part of larger medical teams, giving MNT as well as nutritional counseling on the treatment and prevention of disease.

RDs, however, are only one segment of today's diverse field of nutrition professionals.
Another branch of nutritional medicine that has emerged in recent years is the field of Clinical Nutrition. Similar to RDs, Certified Clinical Nutritionists (CCNs) also, at a minimum, hold a BS degree, have completed a supervised internship, and passed a national board certification examination.

Prospective CCNs who do not hold graduate-level degrees are required to complete post-grad coursework in clinical nutrition, in order to ensure an advanced skill set and knowledge of the clinical and research applications of nutrition in food planning and dietary supplementation. Based on the concepts of biochemical individuality and person-centered care, Clinical nutrition is part of a larger nutrition specialty that may be broadly defined as holistic nutrition.

In addition to CCNs, a wide variety of non-RDs identify as providers of holistic nutrition services. Practitioners of ancient healing disciplines such as Traditional Chinese Medicine and Ayurveda view diet and digestion as key determinants of overall physical, emotional, and spiritual health and wellbeing (read, Ayurveda in America: How India's Ancient Health Sciences Can Heal American Medicine). Given the importance these systems place on food and nutrition, TCM and Ayurvedic practitioners are, de facto, practitioners of nutrition counseling.

Contemporary applications of the ancient concept of food-as-medicine are evident in the growing fields of holistic nutrition counseling and nutrition coaching. Regardless of their specific titles, holistic nutrition providers across all disciplines share the common goal of offering individualized, whole-person care that addresses the complete and unique nutritional needs of their patients. They tend to encourage diets based on whole foods and emphasize elements of food quality, seasonality, and sustainability--aspects that are often missing from the more institutional practice of dietetics.

Credentialing Conundrums

With the upsurge of public interest in nutrition and health, questions regarding the regulation, credentialing, and scope of practice for nutrition service providers have become the subject of great controversy in many parts of the country.

Today, myriad schools and institutions, including ones not historically focused on nutrition studies, now offer coursework and degree programs in holistic nutrition. As a result, practitioners with varying credentials, qualifications and educational experiences present themselves as nutrition service providers, though their specific titles and credentials may not be widely recognized by the larger medical community. This flourish of certifications and titles can create confusion not only among consumers, but also among other healthcare professionals wishing to provide nutrition referrals to their patients.

GerbstadtChristine Gerbstadt, MD, RD, and spokesperson for the Academy of Nutrition and Dietetics, warns consumers against the "plethora of 'credentials' offered to bolster the credibility of individuals who claim, with various levels of training, to be "nutritionists.'" She notes that some nutrition credentials "have no requirements behind them other than to pay a fee," and that "these and other 'credentials' can often be attained by the completion of as little as 48-hours of weekend education or online programs."

In order to identify qualified, credible nutrition providers, she advises healthcare consumers to "always look for the RD credential."

While the certifications required for some non-RD nutrition credentials may seem scant, there is nonetheless a growing community of highly educated, holistic nutrition professionals with advanced degrees in nutritional medicine as well as extensive experience providing clinical nutrition services. However, because the "nutritionist" title is largely unregulated, it can be challenging at first glance to distinguish practitioners with extensive training from their potentially less-qualified nutrition colleagues.

Nicole Hodson, NC, Executive Director of the National Association of Nutrition Professionals nanplogo(NANP), suggests that when seeking a nutrition services provider, it is important for consumers and healthcare providers alike to do their homework. The NANP, a national coalition of nutrition service providers, is focused on the advancement of the holistic nutrition community and seeks to give voice and credibility to non-RD holistic nutrition professionals.

Hodson advises patients and practitioners to find a legitimate "credentialing organization or certificate-granting or board certification organization that resonates with their beliefs and practices" regarding nutrition. She notes that one distinguishing factor among credentialing bodies is the extent to which they emphasize a clinical or allopathic approach to nutritional medicine. To those in search of holistic nutrition providers, Hodson encourages care seekers to look specifically for advanced practitioners who are board certified in holistic nutrition.

HodsonThe NANP's Holistic Nutrition Credentialing Board (HNCB) administers the Board Exam in Holistic Nutrition. Eligibility to sit for the examination requires the completion of studies in a NANP-approved holistic nutrition program  and extensive professional experience in holistic nutrition.

Several other credentialing bodies currently recognize and certify highly trained non-RD practitioners. Created specifically for highly trained nutritionists, the Certification Board for Nutrition Specialists (CBNS) offers an examination which, in some states, qualifies practitioners to apply for licensure as nutritionists. The CBNS confers the Certified Nutrition Specialist (CNS) credential, obtainment of which requires the completion of an advanced degree (masters or doctoral level), significant experience and continuing education in the nutrition field, passing of the CBNS certifying examination, and commitment to re-certification every five years.

A similar certification for clinical nutritionists is offered by the Clinical Nutrition Certification Board (CNBS). Clinical nutritionists must pass the CNBS' Certified Clinical Nutritionist (CCN) Examination in order to earn the CCN credential. The International & American Association of Clinical Nutritionists (IAACN) notes that the "CCN Examination and re-certification process has become the National Standard for professional clinical nutrition competency."

Physicians looking to refer patients for comprehensive holistic nutrition services might look for providers who have obtained any of the aforementioned certifications, which can help to distinguish practitioners with extensive education and experience in the nutrition sciences.

Dietitians Determined to Dominate

Considering the state of our nation's health, there is no shortage of people who might benefit from a bit of advice or counseling from a nutritionist. In spite of this great need, the AND and various state-level dietetics organizations are attempting to limit the licensure and scope of practice of non-RD nutrition professionals.

According to internal AND documents, one of AND's ongoing goals is to promote RDs as the "preferred and qualified provider of nutrition services." To this end, the organization has sought counsel from external groups on both the national and federal levels to assist in legislative efforts to limit the licensure of dietitians/nutritionists to RDs alone.

At present, laws in 44 states mandate the certification, title protection, scope of practice, and licensure of RDs. Although the AND contends that "licensure is not an attempt to control any market," the reality is that many statewide dietetics associations have become actively involved in legislative efforts to define and limit the types of providers who may legally call themselves nutritionists. They hold that this privilege belongs to RDs, and RDs only.

Under the guise of protecting the public, RD organizations have strengthened the dietitians' stronghold over the nutrition profession, while simultaneously threatening and ostracizing the practices and livelihoods of thousands of holistic nutrition practitioners.

According to the Alliance for Natural Health, a natural healthcare consumer advocacy group, the AND played a key role in the introduction of pivotal bills in 9 states at the beginning of this year alone. Currently pending in New Jersey is S833, the "Dietitian/Nutritionist Licensing Act," which seeks to establish a clear licensing process for "dietitians/nutritionists." Effectively conjoining the professions of nutrition and dietetics under one shared name, the bill disregards the distinctions between the two fields and requires that all practitioners meet AND credentialing standards in order to obtain licensure as a nutritionist/dietitian.

The New Jersey bill states that "no person, business entity or its employees, agents or representatives shall use the titles, 'dietitian/nutritionist,' 'nutritionist,' 'dietitian,' 'dietician,' 'nutrition counselor,' 'nutrition consultant,' 'nutrition specialist,' 'LDN,' 'LD,' 'LN,' or any other title, designation, words, letters, abbreviations or insignia indicating the practice of dietetics/nutrition unless licensed to practice dietetics/nutrition."

Similar efforts in New York (bills A5666 and S3556), also seek to combine the dietitian and nutrition professions under the common title of "Licensed Dietitian/Nutritionist" (LDN). The bills would also establish a supervisory board comprised predominantly of AND members, whose role would be the selection and oversight of the examination required for conferment of the LDN title.

Holistic nutrition advocates are concerned that, should this bill pass, it is highly likely that the oversight board will designate the AND examination as the only acceptable exam for qualification for LDN licensure. Because the AND-administered exam is only accessible to AND-approved nutrition professionals, the bill would effectively prevent all non-RDs from earning licensure as dietitian/nutritionists.

In Illinois, SB2936, the pending and prohibitive "Dietitian Nutritionist Practice Act," delineates licensing requirements that would allow dietitians alone to qualify as practitioners of nutrition services. The bill would establish strict penalties against "any person who practices, offers to practice, attempts to practice, or holds oneself out as being able to provide dietetics and nutrition services without being licensed" by the state. As the Alliance for Natural Health notes, this bill would effectively "create a monopoly on nutrition services exclusively for dietitians, denying consumers access to expert advice from...some of the most highly educated and well-respected professionals in the field of nutrition."

These are just a few examples of the ways in which RD-backed groups are attempting to put up enormous obstacles against the licensure of holistic nutrition professionals. Their highly restrictive legislation, which favors the RD profession, drastically undermines the tremendous value and competency of highly trained non-RD holistic nutrition professionals. Consequently, the struggle to practice safely and without persecution is one that many holistic nutritionists still fight on a daily basis.

Nicole Hodson notes that despite their strong educational backgrounds and extensive training, some nutritionist members of the NANP have received cease and desist letters from their local Nutrition/Dietetics Boards for violations with allegations as serious as practicing without a license.

In addition to limiting or eliminating holistic nutritionists' right to practice, legislation that favors RDs also inhibits consumers' right to choose their desired healthcare practitioners. At the expense of highly competent holistic nutritionists who hold masters level and doctoral degrees, the nutrition profession is in danger of becoming relegated largely to RDs, many of whom are trained in the ADA-supported conventional approach to nutritional medicine. This approach tends to focus primarily on the treatment of acute health conditions, unlike holistic practitioners' integrative orientation towards the underlying causes and prevention of disease.

ADA convention has informed the USDA's Food Pyramid dietary guidelines, as well as national food standards in institutional settings including schools, hospitals, and nursing homes.

Also questionable is the ADA's long history of collusion with big business. Historically, the ADA has received tremendous financial support from pharmaceutical and medical device companies. It has also allowed behemoth drug producers and food corporations such as PepsiCo, Hershey's, Taco Bell, Crisco, and McDonald's, to advertise their products at its annual Food & Nutrition Conference & Expo. Given the organization's apparent collaboration with junk food and pharmaceutical companies, consumers are left to wonder whether their health and wellness or the prosperity of large companies are of greater interest to the ADA.

In order to truly support the best interests of the public, we must look for ways in which to widen rather than tighten the credentialing and licensure of qualified, credible holistic nutrition providers. Otherwise, we risk allowing the future direction of the nutrition profession to be dictated by industry interest and commercial gain over consumer choice, freedom, and wellbeing.

Non-RDs Push Back

As RDs seek to protect their territory and boost their reputation as the preeminent providers of nutrition services, organizations of holistic nutritionists and activist groups throughout the nation have begun to publicly question the discriminatory notion that dietitians alone should have sole reign over the field of nutritional medicine.

Some have taken the stance that the health of the public would be better served by allowing greater latitude for a wider range of nutritionist professionals to practice safely and legally.

Pushback from the holistic nutrition community has ignited glimmers of hope in some parts of the country. For example, per the recommendations of the Michigan Nutrition Association, legislators in the state of Michigan are now, after several years of opposition, proposing the deregulation of the dietetic and nutrition professions, having identified no significant value in devoting time and financial resources to the regulation of an industry that presents no apparent threat to public health.

Advocates are hopeful that the Michigan decision will set precedence in other states considering legislation that would restrict the field.

As various groups attempt to define and regulate the nutrition profession, what must remain sacrosanct is the right of consumers to choose practitioners whose services best fit their personal nutrition needs. Given the massive burden of disorders caused by poor diet and unhealthy lifestyle, the ultimate goals of public health would be best served if we recognize and honor an assortment of nutrition practitioners who can provide a range of services that are as diverse as our individual biochemical compositions.

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