Many years ago — seems like a lifetime ago now — my daughter was born with a low birth weight. Although at 38 weeks and otherwise healthy, she entered this world a scrawny 4 lbs 14 oz, and the first months of her life were spent hovering around the 3rd percentile of the weight charts. Eventually she climbed a little, but then she fell back, at which point our paediatrician referred us to a nutritionist to help us develop strategies to ensure her relative weight did not drop further.
Like many new parents, I didn’t question much of what our paediatrician said. She said go to a nutritionist and off we went, unaware of just how much peril we might be facing with that one simple decision. In the end we were lucky — she referred us directly to an excellent Registered Dietitian in the family care unit of St. Joseph’s Hospital in Toronto. But it could have gone another way.
That’s because, as we’ve seen in the first two parts of this series, there are many kinds of “nutritionist” in Canada. All have letters and certifying bodies, and all sound very official, but they’re not created equal. When all is said and done, only one designation assures you of science-based care — the Dietitian.
Dietitians are to nutrition what pharmacists are to drugs — specialists that work alongside physicians and other conventional health care practitioners to provide deep knowledge in their area of expertise. The term itself is protected under the provincial health legislation in each province (e.g. Ontario’s Regulated Health Professions Act), and that protection is enforced by the appropriate College of Dietitians, the respective provincial regulatory body. That protection extends to common variants such as RD or RDt (“Registered Dietitian”), PDt (“Professional Dietitian”) and their French equivalents (e.g. DtP – Diététiste Professionnel). Though it differs province by province which of these terms are explicitly called out in the legislation, basically any term with “Dietitian” in it will be protected in any province.
Somewhat confusingly, Québec and Nova Scotia also protect the term “Nutritionist” as a designation for Dietitians, and accordingly, many of the unregulated designations we looked at in the past two articles cannot be used in those provinces. Two other provinces protect specific uses of “Nutritionist”, as summarized in the table below.
Whatever they’re called, Dietitians are a fundamentally different beast than the unregulated nutritionists we encountered in the first two parts of this series, and in this third and final instalment, we’re going to explore why. Specifically, we’re going to contrast the two camps on four key criteria:
- Eligibility Requirements — what it takes to become accredited
- Knowledge Base — what practitioners learn in school prior to accreditation
- Professional Standards — how ethics and professional conduct are enforced
- Governance — what support practitioners receive from their organizing bodies
We saw in the first two instalments that eligibility for the various unregulated nutritionist designations is typically automatic upon graduation from an approved program. Indeed, the most established associations pride themselves on their selectiveness. But how rigorous are the programs themselves? As it turns out, not very.
The Registered Holistic Nutritionist program from the Canadian School of Natural Nutrition (CSNN) is only 1 year, as are the diploma in Applied Holistic Nutrition from the Institute of Holistic Nutrition (IHN) and the Practitioner Diploma in Holistic Nutrition from the Edison Institute. Those are the three top programs in Canada, with the broadest recognition by the accrediting bodies we’ve looked at.
By contrast, becoming a Dietitian is a five year commitment — four years of undergraduate study in a recognized university dietitian program followed by a clinical internship year that’s either integrated with the degree or offered via an approved hospital or health centre.
In other words, Dietitians are required to have five times the schooling of unregulated nutritionists — a monumental difference that speaks directly to the expanse of their knowledge base.
But the difference isn’t just quantitative — there are significant qualitative differences as well. Dietitians follow a science-based curriculum grounded in chemistry, biology, and physiology — see, for example, the course lists at UBC, University of Alberta, and University of Saskatchewan.
By contrast, the CSNN offers courses in aromatherapy, detoxification, and homeopathy. The IHN offers a holistic food preparation course that promises “hands-on experience in preparation of breakfast ‘power-drink’”. Or if Smoothie 101 isn’t your thing, there’s always the course in Ayurvedic mind-body healing.
Admittedly, I’m cherry-picking the worst offenders, and I’m sure that alongside this nonsense is lots of reasonable, science-based information . But when it’s all given equal weight, how are these future practitioners supposed to know the difference? I personally prefer my health care providers to be able to tell fact from fiction.
A consistent refrain we saw from the certifying associations of unregulated nutritionists is their lack of any sort of enforcement regime for their professional standards. The common, and disappointing, two part answer was that (1) it was a liability insurance issue, and that anyway, (2) there’s no way for nutritionists’ protocols to do any harm.
Dietitians don’t take such things quite so lightly, and part of the mandate of the provincial colleges is to directly address concerns about their members. The Ontario college provides detailed instructions for filing a complaint on their website, and the the BC college even publishes complaint outcomes. There’s no self-denial about their potential to cause harm — if they’re medical practitioners (and they are) then their mistakes have the potential to hurt patients. It’s a credit to the profession that they take that responsibility seriously.
As we saw in the first two instalments, the certifying bodies for unregulated nutritionists are riddled with infighting and cross purposes, sometimes fighting over substantial issues like lobbying goals, but mostly fighting over less noble ones like membership revenues and trademark ownership. Significant conflicts are created by the cross-incentives between the schools and the organizations, and in some cases maybe even between the organizations and their own executive.
For Dietitians, governance is a lot clearer. Each province has one body (the College) that regulates Dietitians in their jurisdiction — conferring registration, investigating complaints, and working with government. Nationally, Dietitians of Canada is the sole professional association, acting to develop and promote the profession, accredit educational programs, and mediate between Dietitians and the respective colleges. In my discussions with contacts at both DC and the Ontario College, it was clear that the working relationship was in place and that each knew where their jurisdiction ended and the other’s started.
Beyond that, I found one other big difference from the unregulated associations — financial transparency. The Dietitian organizations state openly what they do with the money they collect. For example, the Ontario College makes their financial statement public as part of their annual report. Ditto for BC. Dietitians of Canada’s annual report is also public, with financial statements online for members.
If you’ve gotten this far in the series, it should be clear that “nutritionist” is one of the most misleading terms in healthcare — referring variably to a science-based practitioner with 5+ years of training, or an individual with a year or less that hasn’t been taught to distinguish science from magical thinking. The proper term for the former is Dietitian, but most of us are careless with the distinction — possibly because we’re not fully aware of just how great a distinction it is.
The unregulated associations and schools play to that wooliness, introducing a vast array of designations designed to manufacture legitimacy where little exists. To make RD ‘s and their equivalents in other provinces seem like just another option alongside CNP’s, RNCP’s, ROHP’s, RHN’s, NNCP’s, RHP’s, and the myriad other designations they offer. To make being “board certified” by one of these squabbling diploma factories look just like being the member of a regulated health profession that works hand in glove with physicians in hospitals and other clinical settings.
Their professional body, Dietitians of Canada, has their work cut out for them to educate the public of this distinction, against those forces trying intentionally to blur it. As skeptics committed to science-based healthcare, I think we need to help them by using the term properly, and by educating those around us — especially those seeking nutrition counseling or treatment — that the small difference of a few letters means a big difference to their health. [Read the Post Script]