Several weeks ago I came across a troubling article in Forbes titled “Is the American Dietetic Association Attempting to Limit Market Competition in Nutrition Counseling?” by Michael Ellsberg. It intends to put forth a case against legislation that restricts nutrition assessment and counseling (medical nutrition provisions) to practitioners licensed by the American Dietetic Association/Academy of Nutrition and Dietetics (ADA/AND) (e.g. RDs) and legislation trying to restrict the term “nutritionist,” opting instead to allow a complete freedom of choice to consumers to choose what type of professional they wish to receive nutrition counseling. But I think it shows exactly why we need such legislation precisely because of the three groups that he quotes from.
Lets start at the top of page 3 with a passage I fully agree with:
Pepin Tuma, Director of Regulatory Affairs for the Academy [of Nutrition and Dietetics], told me that the purpose of these laws is to protect the public. “When the public seeks out evidence-based, scientific nutrition information, it’s critically important that that’s what they’re actually getting. Licensure allows people to be certain that the person they’re going to has the competency to be able to help them and not hurt them. Harm from incompetent practitioners comes in a variety of forms, both physical and financial.”
Ellsberg makes his case by quoting three groups: the Alliance for Natural Health, the National Health Freedom Coalition, and Citizens for Health, as well as two nutritionists, one with a Ph.D. and one with an M.S., who apparently can’t practice nutrition in their states. What he doesn’t go into is what each of these organizations thinks is good for health. Lets go through them one by one. Ellsberg writes:
The bills do tend to include exemptions which state that they are not designed to prohibit or restrict “Any person licensed in this State under any other Act from engaging in the practice for which he or she is licensed.”
That, says Darrell Rogers, Communications Director of the Alliance for Natural Health, is the kicker. “If nutrition is within the practitioner’s recognized scope of practice within that state, then these bills would not affect them. But in many states, personal trainers, health coaches, and even Ph.D. nutritionists, either don’t have a scope of practice, or if they do have a scope of practice, nutrition might not be within it. So all those individuals would be subject to the charge that they are practicing dietetics and nutrition without a licence.”
These people are not trained in nutrition assessment unless they go through an accredited dietetics program, though. That is the point of these laws. This group even has a clever website called reallyeatright.org in which they protest against the AND’s partnerships with food companies, which I actually think is a legitimate topic to explore. But behind these less controversial positions they hide their real agenda, which is pure anti-science drivel. Perusing their website, we find that they (are):
- anti-vaccine (they think they cause autism and other diseases which is unfounded)
- pro-raw milk
- anti-radio frequency (really. they claim they are carcinogenic)
- anti-dietary supplement regulation
- pro-colloidal silver
- think vitamin D is an equal substitution to vaccination for influenza
- pro-chelation therapy (outside of legitimate uses in acute heavy metal toxicity)
- anti-lipid hypothesis/statins
- anti-pharmaceutical drugs
- believe artificial sweeteners cause cancer
- believe pesticides cause cancer at the doses we consume
- pro vitamin-C as a cancer treatment
- think x-ray machines cause cancer
Diane Miller, Legal and Public Policy Director of the National Health Freedom Coalition, told me: “The thing that a group promoting an exclusive licensure bill always says to legislators, at the state capitol, is ‘This isn’t going to hurt anyone else. This is no big deal. We just want our licensure because we want to get insurance coverage,’ etc. That’s what they say politically in their lobbying efforts. But when you read the language of the bills, it’s the exact opposite.”
From their website we see they are similarly:
- anti-vaccine (believe mercury causes autism)
- anti-dietary supplement regulation
Jim Turner, chair of the board of Citizens for Health, and a veteran of state regulatory fights against ADA-supported licensure laws, told me: “What’s fascinating about this situation is that the ADA structure actually excludes some of the most nutrition-educated people in the country from being able to provide nutrition information. You can have a master’s in nutrition or even a Ph.D. and not qualify for the ADA recognition. So you have people who are well-qualified in nutrition, who are not allowed to exchange that information with consumers, because they don’t have a legally recognized scope of practice. That’s a tragic, unfortunate result of these laws.”
Except that the laws don’t restrict information from being shared, just counseling. But look at their website and we find too that they are:
- anti-dietary supplement regulation
In the United States, regulations about the practice of psychology are determined by each state. There is no federal regulation. You must be licensed to practice psychology according to the laws and regulations in effect in each state where you provide services. These laws are regulated by state boards of psychology. Requirements for licensure are not standardized across states, but generally, candidates are assessed on their education, supervised training, and examination performance.
The doctoral degree is generally considered the entry-level degree for the independent, licensed practice of psychology as a profession in the United States. In addition to the doctoral degree, licensure for professional practice usually requires two years of supervised training: one year during the doctoral program (an internship in most cases) and an additional year after receipt of the doctoral degree (post-doctoral residency).
Title4: The current law in the overwhelming majority of states, as well as in SIOP and APA licensing policy, is that individuals who want to use the title “psychologist” must be licensed. This is not expected to change in the future. Currently I-O psychologists are not exempt from this requirement in most states and are not expected to be exempt in the future.
4 Title Law—Laws, statutes, rules, and/or regulations that refer to the public use of any title or description of services incorporating the words “psychology,” “psychological,” or “psychologist,” or claims to be trained, experienced, or an expert in the field of psychology and offers to engage or engages in the practice of psychology for any person for a fee. Title use laws vary from state to state.
Practice Activities5: Generally state practice law uses a widely adopted definition of the practice of psychology6 (used by APA, SIOP, ASPPB and many state boards) although the practice activities included vary across states. There are two groups of I-O practice activities that need to be considered:
- Organization-focused activities. These are the traditional I-O practice activities (job analysis studies, attitude surveys, selection testing, selection validation studies, designing performance appraisal systems, training, organization design) that serve the organization and typically do not involve working directly at the individual level. Although some group work might impact individuals.
- Individual-focused activities. These activities involve working with individuals using psychological principles, methods or procedures to assess and evaluate individuals on personal characteristics often for individual behavior change or for making decisions based on the interpretations that result in actions/decisions that affect people. These activities frequently involve psychological assessment and administering/interpreting psychological tests.
Most states currently have generic laws that include organization-focused activities in their description of practice. Many of those that exempt I-O practice make it clear that the exemption is only for organizationally focused activities. The revision of the Model Act attempts to differentiate these organizationally focused practice areas that have low likelihood of harm to individuals or organizations from direct services to individuals that have a greater potential for harm, and to exempt the former from licensure.
The individual-focused activities generally fall under the definition of the practice of psychology (used by APA, SIOP, and state boards). This is likely to continue to be included in the definition of practice in the future. Even jurisdictions that “exempt” I-O psychologists generally restrict this exemption to areas of practice that do not psychologically impact individuals.
Are there unlicensed but well-qualified people in nutritional counseling that are caught in these licensing changes because they didn’t need an accredited program before? Probably. But should we not raise the standard of quality for counseling because of a minority?
Ellsberg and I went back and forth a bit on twitter, and since it is difficult to reply there I wanted to add a couple thoughts here:
Putting a political label on protection from practitioners who don’t follow evidence-based information doesn’t negate what they are doing.
Sure, the system is imperfect. But arguing that because of these imperfections quacks should be allowed is a logical fallacy; there are credible pushes to move dietary guidelines away from governmental groups to limit political influence.
Perhaps there is a story to be made about higher-ed Ph.Ds and M.S./MPH’s without licenses who could provide medical nutrition counseling in some exceptions. Have there been exemptions made in some cases? I don’t know much in this area. After all, many are doing the research that generates recommendations. But I would expect that they would focus on research and not counseling anyway. There needs to be a standard of care; the accreditation through AND/ADA is standardized, forces experience in counseling settings, and discourages quackery. The counseling that individual dietitians provide is not guaranteed to be correct; being a dietitian doesn’t force one to read research (though part of licensure are continuing education programs), and there is only so much that can be crammed into a bachelor program. In addition, nutrition is a complex science and many people seem to have different definitions of sufficient evidence for various recommendations. But it would be a logical fallacy to cherry pick examples of RDs providing bad information as evidence that there should be no education standards. I’m glad that I am not a practitioner; there are so many ambiguities within many of the more focused research topics that I would not inspire much confidence in my answers to client questions. But then there are people who just make stuff up, or are misled by their cognitive bias’ so that they put peoples’ health in jeopardy. These are the ones arguing the strongest against more regulation for nutrition counseling. And this is why I support legislation to limit their practice.