[Whole] Food For Thought
BY EMILY BEERS
From: CrossFit Journal
Amanda Petroccione thought she wanted to be a registered dietitian.
In some states, only registered dietitians (RDs) can provide individualized nutrition plans, and RDs generally have more rights than any other nutrition practitioner in the United States. But Petroccione was disheartened when her studies highlighted flaws in a program designed to produce food-and-nutrition experts who lead the industry.
Petroccione enrolled in college to complete a bachelor’s degree in community health and nutrition at the State University of New York (SUNY) at Potsdam. During her time at Potsdam, she had the opportunity to work with an RD in a hospital and was surprised by the lack of individual patient care.
“I would see a lot of patients in one day, and I think there were six different generic diets we would prescribe to them. A cardiac patient would get the prescribed low-salt diet. And someone else might be put on the generic high-calorie diet,” Petroccione said of her five-month internship at Canton-Potsdam Hospital in 2004.
“We just had to follow the rigid procedure and didn’t actually talk to the patients.”
Instead of spending time with patients and drafting nutrition plans according to individual needs, Petroccione gave them simplified handouts that explained the details of their diet.
The clinical environment was largely based on what Petroccione described as a blanket approach to nutrition, meaning it followed broad public-nutrition guidelines, such as the United States Department of Agriculture (USDA) MyPlate program, formerly the Food Guide Pyramid. MyPlate essentially promotes a high-carbohydrate, low-fat diet and is criticized by many as being outdated and ineffective for optimal health.
Blanket prescriptions aside, Petroccione said she also thought the food served to patients was inadequate.
“I remember feeding everyone Ensure, and I remember thinking, ‘This is garbage.’ Straight-up garbage,” she said.
Although Ensure is marketed as a nutrition drink with essential vitamins and minerals, an 8-oz. serving contains between 18 and 23 g of added sugar, depending on the flavor, meaning patients were consuming more than 5 tsp. of sugar with each serving. In contrast, the American Heart Association recommends a daily limit of 9 tsp. of added sugar for men and 6 tsp. for women.
“I thought, ‘This is what we’re feeding a sick, elderly patient? There must be something better than this,’” Petroccione said. “It was so disappointing—disappointing that this was the direction our country was going in in the field of nutrition.”
Becoming an RD
Becoming an RD is only one way into the nutrition field.
RDs—also called registered dietitian nutritionists (RDNs)—are regulated by the Academy of Nutrition and Dietetics (AND), formerly the American Dietetic Association (ADA). Individuals who hold the credential can choose to call themselves an RD, the traditional name, or an RDN, the newer title.
Becoming an RD involves completing a bachelor’s degree at a college that offers AND-approved course work and a 900-1,200-hour unpaid internship at AND-approved facilities. The next step is passing the AND’s national exam, which costs applicants US$200.
The national exam is broken into four domains:
Principles of dietetics (includes topics such as food science and nutrient composition of foods).
Nutrition care for individuals and groups (clinical nutrition).
Management of food and nutrition programs and services.
RDs also pay an annual $60 renewal fee to the AND, as well as yearly membership dues, which vary depending on whether the member is a student, an RD or part of the military. The average rate for these membership dues is $175 a year, explained Sarah Krieger, an RD and spokeswoman with the AND, which has more than 75,000 members today.
When the ADA was founded in 1917, its aim was to help the government feed the population during a time when World War I was affecting many of the country’s resources. Since inception, the AND has been focused on a broad, public approach to nutrition. In a 2013 position paper, the AND explained how it promotes what it calls a “total diet approach to healthy eating.”
“All foods can fit within this pattern if consumed in moderation with appropriate portion size and combined with physical activity,” the paper stated.
The paper listed MyPlate as well as the “2010 Dietary Guidelines for Americans” as two of several approaches that support the total diet approach. Like MyPlate, “Dietary Guidelines for Americans” is a public-nutrition guide that promotes a low-fat, high-carb diet. It is updated every five years by the USDA in conjunction with the U.S. Department of Health and Human Services.
“The dietary guidelines are very general … and may not apply to everyone. But for normal, healthy individuals, these are our recommendations,” Krieger said.
During Petroccione’s time at SUNY Potsdam, the nutrition courses she took—ranging from nutrition science to foodservice-systems management to culinary arts—were taught by RDs. The curriculum was largely based on AND recommendations, Petroccione explained.
Krieger said the RD education reflected in AND-approved coursework is “the gold standard” in nutrition education.
“It’s the level of education RDs obtain to gain credibility (that makes it the gold standard),” she explained.
The AND’s prescriptions are evidence based and updated every five years, she added.
“We put out position papers that are extensively researched on all aspects of nutrition,” Krieger said.
Petroccione, though, said she didn’t feel she was receiving a gold-standard education, so she chose to abandon her RD studies. Instead, she did a master’s degree in business at Clarkson University in Potsdam and went on to acquire a holistic-nutritionist credential in 2011 via a one-year program offered by the Institute for Integrative Nutrition.
“The RD’s generalized, public approach to nutrition was outdated and only looks at one way of doing things,” Petroccione said. “RD education is based on one perspective, based on crunching numbers of macronutrients, based on broad guidelines.” The holistic-nutrition credential provided her with a much more diverse education, she said.
“I learned more than 100 different theories about nutrition,” she said. This was refreshing after spending her university days challenging many of the prescriptions her professors preached, Petroccione said.
“(There were) things I disagreed with, like the standard 2,000-calorie diet and that we should be eating 60 percent carbohydrates,” she said. “And (my professors) were just like, ‘This is just the way it is. These are the prescriptions.’”
When it comes to accepting newer diet beliefs—such as Zone, Paleo, gluten-free or low-carb prescriptions—the AND is often reluctant. A 2015 article published by the AND criticized the Paleo Diet, suggesting it falls short on traditional beliefs about appropriate carbohydrate recommendations.
Krieger said the AND doesn’t support diets such as the Zone or Paleo plans because they’re “temporary diets.” The AND looks to provide lifelong dietary advice to the public, she added.
But Petroccione said she suspects one of the reasons the AND promotes what she considers ineffective nutrition guidelines is to protect the companies who fund the AND. Some of the AND’s sponsors over the years have included the National Dairy Council, beverage companies such as Coca-Cola and PepsiCo, and food companies such as Kellogg’s, Hershey’s, General Mills and Kraft. Petroccione’s suspicions are shared by others, including Marion Nestle, professor of nutrition, food studies and public health at New York University. Nestle is author of “Food Politics: How the Food Industry Influences Nutrition and Health” and many other books.
While Krieger and the AND deny sponsorship influences the AND’s position on health and nutrition, an July 2013 International Business Times article by Christopher Zara argued that “anyone with a digestive system” has the right to be suspicious.
“The nation’s nutrition industry has been hijacked by the very companies whose products most contribute to our obesity and health problems,” Zara wrote.
Petroccione said the fact that Coca-Cola funds the AND made her wary of some of the concepts she was learning, such as the total-diet approach in which all foods can be good foods with moderation.
“That tells the public it’s OK to drink Coke. And Ensure,” she said. “I just don’t trust the AND.”
A Longstanding Monopoly
Michael Stroka is the executive director of the Board for Certification of Nutrition Specialists (BCNS), the body that governs certified nutrition specialists. Stroka called the BCNS credential the RD’s “primary competitor,” though its approach to nutrition is much different.
“(The AND’s) focus has traditionally been around food-service management … making sure the population gets good nutrition according to U.S. dietary guidelines,” Stroka said. “The certified nutrition specialist (CNS) is based on managing and reversing (an individual’s) ailments through targeted nutrition therapy.”
The CNS credential—accredited through the National Commission for Certifying Agencies—requires candidates to complete a master’s degree or doctorate, 1,000 hours of practical experience and a rigorous certifying exam. Continuing education is required for maintenance of the credential.
Despite the presence of the CNS and other credentials—including the holistic-nutritionist credential—the AND has essentially had a monopoly on nutrition practitioners in the U.S. for more than 30 years, Stroka explained.
During the 1980s and 1990s, states began introducing nutrition regulation. Today, 46 states regulate nutrition practitioners. The type and severity of regulation varies from state to state, but essentially RDs have more rights than any other nutrition practitioner across the country, Stroka said.
The term “dietitian” is regulated and protected in the United States and other countries, meaning only RDs can refer to themselves as dietitians, while other nutrition practitioners must refer to themselves as “nutritionists.”
In the more tightly regulated states, RDs are the only nutrition practitioners who are legally allowed to provide individual nutrition advice or counseling, and they’re the only practitioners allowed to use nutrition to treat and prevent disease, a practice referred to as “medical nutrition therapy (MNT),” Krieger explained.
Unlike “dietitian,” “nutritionist” is not a regulated term in the United States. A nutritionist without an RD credential falls under the freedom-of-speech aspects of the First Amendment, Krieger said.
“This means (nutritionists) can give general advice to the masses but no individual meal plans, especially if there is a medical condition,” she said. Nutritionists are not allowed to diagnose or treat any diet-related medical conditions, she added.
Further, some states require nutrition practitioners to be licensed.
In 16 states, including North Carolina and Georgia, only RDs are eligible for licensure. In these states, it is a criminal offense for anyone other than an RD to perform nutrition counseling. Other states, such as Minnesota and Illinois, are also regulated through licensure; however, credentials such as the CNS are also accepted. In the most unregulated states, such as California, Pennsylvania, New York and Michigan, licensure is not required and it is legal to provide nutrition care without an RD credential. However, even in these states, some insurance providers choose to cover RDs only.
In short, those without an RD credential in much of the U.S. need to proceed with caution or they could end up in court facing penalties from fines to jail time. This was the case for Steve Cooksey from North Carolina, who found himself embroiled in a legal battle in 2012 when the North Carolina Board of Dietetics/Nutrition told him he could not offer diet advice. Cooksey, who had blogged about how the Paleo Diet helped his diabetes and advised others on the benefits of eating this way, filed a free-speech lawsuit in federal court, but it was ultimately dismissed.
Protection or Policy Disaster?
The AND’s publicly stated reason for promoting nutrition regulation is to protect the public from working with unqualified individuals.
“Someone can take a six-week class about nutrition online and get a certificate in the mail and call themselves a nutritionist,” Krieger explained. Regulation protects the public because it assures the consumer the RD is well trained, she added.
“Licensing dietitians and nutritionists assures the public that individuals disseminating nutrition advice have the appropriate education and experience,” the AND website states.
The type of education that’s “appropriate” is very much up for debate. “The (AND) has convinced RDs they’re the experts in nutrition, but nobody else is convinced,” Stroka said. “They don’t have the expertise to do serious one-on-one individualized work to optimize your body.”
Stroka said he believes there are many other high-quality certifications available, and the very concept of regulating the nutrition practitioner is flawed.
“It’s terrible public policy,” he said. “It artificially constrains the supply of nutrition information and artificially restricts who can legally do the work.”
Stroka said by limiting consumer choice and restricting qualified individuals from working in the field in certain states, current regulation provides zero benefit to anyone—except the AND.
“It’s extremely beneficial to the academy (AND). People need to go through their certification and pay for their certification,” Stroka said. “It’s all about power and money.”
Stroka is working to get this point across to the public through The Center for Nutrition Advocacy (CNA). Stroka explained the CNA is nonprofit initiated by the BCNS that strives to put a stop to the AND’s monopoly for the sake of consumer choice and practitioner freedom.
The CNA’s philosophy is to give various nutrition practitioners—who hold diverse views on nutrition and nutrition therapy—the freedom to legally provide individual nutrition advice to their clients, Stroka added.
“We believe all nutrition practitioners should be able to practice according to the level of their training,” he said.
This means RDs, CNSs, holistic nutritionists, athletic therapists, health coaches, personal trainers and those with doctoral degrees in dietetics, among others, should be able to use nutrition to help their clients, he added.
“Each of them has an important role in combating the chronic diseases associated with poor nutrition today,” Stroka said.
Stroka said he believes the best way to ensure various practitioners are able to practice to the level of their training is through title protection. This would mean the state would regulate the titles of the various credentials. For example, you can’t call yourself an RD unless you have an RD credential, nor can you call yourself a CNS unless you’ve acquired a CNS credential, Stroka explained. He said it would then be up to the various practitioners to accurately inform the public as to their training and qualifications, and the free market would essentially decide which practitioners are best.
Apart from consumer choice and practitioner freedom, another factor to consider when looking at regulation is quality of care. Stroka said current regulation has not helped increase quality. He’s not alone.
A 2007 policy study published by The Reason Foundation—a public-policy think tank—looked at various academic studies and presented a similar viewpoint.
“Oftentimes, licensing laws actually reduce service quality and public safety,” wrote author Adam B. Summers. One of the reasons for this is because regulation reduces quality competition, he argued.
“The real motivation behind most occupational licensing regulations is one of special interests, not the public interest,” Summers wrote.
A 2011 policy paper published by the W.E. Upjohn Institute noted that several studies showed increased licensure doesn’t lead to quality improvements but results in a decrease in employment opportunities.
Government-mandated licensure has hurt various professions, including hair braiders, interior designers and florists. Practitioners in each field have suggested there’s simply no need for regulation.
“It doesn’t make sense to regulate (nutrition) like dentistry. Everyone agrees on one standard in dentistry, and nobody but a dentist would be able to practice dentistry,” Stroka said.
“Nutrition isn’t like that. It’s a tool that is used by a wide variety of individuals and professionals in different settings, so to regulate it … like dentistry just doesn’t work.”
Not on MyPlate
Beth Miller is an RD with the University of California Los Angeles (UCLA), where she works with various varsity athletic teams.
Without her RD credential, she likely wouldn’t have been hired by UCLA. However, Miller explained much of what she learned while becoming an RD isn’t information she uses with her clients today. This includes the MyPlate guidelines, which she said formed the basis of many of her nutrition textbooks in school.
“For athletes, we typically make our nutrition prescriptions using grams per kilogram of body weight for each macronutrient, depending on the sport and athlete’s needs,” she said. “It’s tough to be so general with nutrition because it’s very individual, and (MyPlate) tries to reach a large scale of people.”
In many public environments, however, such as nursing homes and hospitals, patients tend to receive more general information from RDs, Miller added.
Amanda Montalvo, an RD from Farmington, Connecticut, explained the AND doesn’t monitor or restrict what types of nutrition guidelines she promotes to her clients. Because of this, Montalvo has abandoned all things MyPlate, both in her private practice, Naturally Evolving Wellness, and with her nursing-home patients.
“There are things I don’t like about (MyPlate). For one, there’s no movement or exercise component,” she said. “And it’s just so basic. Everyone is so different. I like to work with people and try to find specific things that work for them.”
She has also abandoned what the AND taught her about a low-fat diet.
“There are tons of studies and data that talk about healthy fats these days, but the AND still promotes a low-fat diet,” Montalvo said.
Luke Corey, an RD at EXOS, an athletic-performance training company run out of the Mayo Clinic Sports Medicine Center in Rochester, Minnesota, said most RDs he knows stay away from many of the AND’s prescriptions.
“The majority of dietitians know that (MyPlate) recommendations aren’t appropriate and they don’t use it,” he said.
Corey said he believes regulation throughout the United States might play a role in preventing the AND—and the college curriculum that leads directly to the RD credential—from quickly adopting new science.
“Textbooks are written based on large, long-term sample sizes. (When science evolves) there’s a lot of hesitation toward embracing new research, so they fall back on what they feel comfortable with, and what the long-term studies say,” Corey said.
Instead, Corey said much of the nutrition information he uses today he learned not through textbooks but through internships, through working with athletes and through self-education.
“I have learned most by taking initiative and staying up to date with the latest research available,” he said.
Letting the Free Market Decide
Considering the diet-related health crisis in the United States today—evidenced by the rise in diabetes, heart disease and obesity-related illnesses—skilled nutrition practitioners are needed. The AND is the most powerful gatekeeper in the industry, but comments from Stroka, Petroccione, Miller, Montalvo and Corey suggest it’s far from the most forward thinking.
“Effectively, (the AND’s) stance is ‘if you’re not an RD, it’s not possible to provide any effective nutrition advice,’” Stroka said. “A lot of people are practicing nutrition in different ways, so saying only a narrow subset of people can do nutrition doesn’t make sense.”
Instead, Stroka wants the public—and nutrition practitioners—to have a chance to learn diverse ways of thinking about nutrition.
“Then the public, not the AND, can decide which title and which practitioners they think are best,” he said.
About the Author: Emily Beers is a CrossFit Journal contributor and coach at CrossFit Vancouver. She finished 37th at the 2014 Reebok CrossFit Games.
Cover image: Dave Re/CrossFit Journal