When quackery masquerades as “free choice”: comment on nutritional counseling licensure debate in Forbes

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-homeopathy
  • anti-flouride
  • pro-raw milk
  • anti-GMO
  • 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-nanotechnology
  • anti-lipid hypothesis/statins
  • anti-pharmaceutical drugs
  • believe artificial sweeteners cause cancer
  • believe pesticides cause cancer at the doses we consume
  • anti-chemotherapy
  • pro vitamin-C as a cancer treatment
  • think x-ray machines cause cancer
  • anti-gluten
And that is just peeking at one year’s worth of their articles. All pure anti-science rhetoric. It doesn’t take but minutes of perusing peer-reviewed papers to see that research does not support these positions. Instead, these people seem to construct a conspiracy-based view of what they think is correct. And they use all sorts of logical fallacies in their arguments, most notably the naturalistic fallacy.

 

And we see these traits in the next group as well, who Ellsberg quotes from:

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-chemotherapy
  • pro-reiki
  • anti-dietary supplement regulation
  • pro-homeopathy
  • pro-naturopathy
This is also with only a quick look around their website.

 

The final group Ellsberg gives a voice to:

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-vaccine
  • anti-flouride
  • pro-homeopathy
  • anti-GMO
  • pro-accupuncture
  • pro-naturopathy
  • anti-dietary supplement regulation
etc.

 

So obviously the commonalities here are that these organizations disregard evidence-based medicine and nutrition in favor of “natural” means of treatment. This is a huge risk to public health in that they are discouraging proper treatments. Why would we want these people counseling people in how to treat disease?

 

Ellsberg complains that the ADA/AND is introducing legislation to limit competition. If the other groups providing counseling services were equal in qualifications he would have a point about fair competition. But they clearly these are not.

 

The two nutritionists that Ellsberg highlights (one with a Ph.D and one with an M.S., both from nutrition programs) complain that they cannot counsel in their home states. If their goal is to provide counseling, why is it too much to ask for them to go through an accredited program and internship? The point is to have more control over the education of nutrition counselors. Can we draw parallels to other disciplines? Ignoring the obvious like physicians, psychologists have even greater educational requirements to practice psychology, but similar in that they need to go through an accredited program, pass an exam, and do an internship:

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).

Similar to what is occurring in nutrition, psychologists are restricted more when counseling with individuals:

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:

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Putting a political label on protection from practitioners who don’t follow evidence-based information doesn’t negate what they are doing.

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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.

  • Neal W.

    Which group is bigger: the group of people who can give sound nutrition advice but can’t practice due to licensing restrictions, or the group of people who give bad advice and would practice if lower standards were implemented? I don’t know, I’m open evidence that may give us the answer. 

    You ask: “If their goal is to provide counseling, why is it too much to ask for them to go through an accredited program and internship?” Well, you’re asking for people to spend years of their life in school studying things they may already know about or could learn in a fraction of the time by themselves (simply buy the textbooks from Amazon and read them yourself), and get into 10’s of thousands of dollars in student loan debt. That’s not an insignificant barrier to entry. 

    We know for a fact that occupational licensing has costs, but you really can’t prove, empirically, that it is has benefits that outweigh those costs. The costs of occupational licensing are higher prices for nutrition counselling (because the number of practitioners is reduced, leading to higher wages for nutritionists and therefore higher prices for their counselling). Higher prices mean fewer people receive nutrition counselling, and if fewer people receive nutrition counselling then you can’t really prove that overall the level of nutritional knowledge is improved among the public by implementing licensing (unless there was a study on it but there isn’t). People who would of gotten nutrition counselling in a world with lower prices will either get no information at all, or will seek out information for themselves (“do-it-yourself”). “Do-it-yourself” nutrition counselling will be of low quality, leading some people to come to believe in all the anti-science ideas anyway.  

    One other cost of licensing is reduced labor mobility. Licensing is a barrier to entry which limits people from moving from one job to another, thus decreasing their economic opportunities in life, harming their ability to work and provide for their families. 

    So, let’s go over it again. What do we know? 

    We know that eliminating or weakening licensing will bring in more quacks. We also know that stronger licensing (relative to the no or weaker) reduces the number of people who receive professional nutrition counselling. 

    So, does the reduction in quacks outweigh the harm imposed by no nutrition counselling or “do-it-yourself” nutrition counselling? We simply don’t know how the magnitude of each will turn out in the real world. But one thing is for certain, you haven’t and can’t (at this time) prove that the benefits outweigh the costs. I think the burden of proof should probably be on you. 

    Finally, you haven’t considered the possibility that government certification, rather than licensing, could give us some the benefits of licensing requirements and reduce some of the costs, further tipping the scaled against licensing. 

    Perhaps you would be interested to read Dan Klein’s powerpoint on occupational licensing, if you have not already read it: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CFUQFjAA&url=http%3A%2F%2Feconfaculty.gmu.edu%2Fklein%2FAssets%2FOccLicensing.ppt&ei=iGO9T7uYJsnngQeW2KiPDw&usg=AFQjCNHRsqFdLtAU3NL6NGf0jxGnjJdiHA&sig2=FbECV5QEyce_7qBeJiDObw

  • Neal W.

    Here is some evidence against your position: 
    http://www.nber.org/papers/w5869 It doesn’t look at nutrition counselling, but the same logic should work for dentists if what you are saying is accurate. 

    Also, this group of experts agrees, far more than disagrees, that a range of health care occupational licensing is too strict. Who is more likely to know about occupational licensing? Experts, or you? http://www.igmchicago.org/igm-economic-experts-panel/poll-results?SurveyID=SV_9WvTDyIrJrMeTOc

  • http://twitter.com/x_ine Christine

    I see nothing wrong with requiring a health care professional to complete an accredited training program if they would like to be involved in counseling. Would you go see a doctor who was not licensed to practice? Would you want to be cared for by a nurse who did not have adequate training? Simply knowing stuff about nutrition isn’t necessarily all you need to be a good counselor in nutrition. That’s why standards exist.

    • Neal W.

      Why would I want to be cared for by people who don’t have adequate training? That’s a straw man. Please don’t argue for things that you’ve never studied. Pursue the links I posted above and educate yourself before you make arguments. 

  • Julian

    anti lipid hypothesis and statins? So is the science. These accredited dietitians are compromised by links to food industry and cannot be trusted to go unchallenged.

  • Spiralgal59

    Interesting article. I am in a difficult situation myself as I would like to get into an R.D. program, but cannot because I already have a baccalaureate degree and a Masters. I cannot get into a program because they reserve the space for first time baccalaureate students.  I am older, experienced and ready to work and am being forced to earn an M.S. in Clinical Nutrition instead of an R.D.  I would like to counsel.  I think that some of us are caught in the middle.  Also, although I believe that standardization and internships are important, I believe there are plenty of nutritionists who have earned the title CNS that are plenty qualified to counsel.  They do study the science of nutrition.  They may not have the experience in setting up dietary plans in a hospital setting nor can they set up parenteral feeding plans, but they have a lot to offer in their areas of expertise. I think there is room for both.

  • http://personalhealthfreedom.blogspot.ca/ Tracychess

    I too find it a shame that people are using the words “Health Freedom” in an unscientific manner, but for completely different reasons.  

    First, “health freedom” should be about health, not about ‘sickness’.   All of the sites you mention, and virtually all of the issues you put forth are ‘sickness issues’, not healthiness issues. 

    Second, because nobody studies ‘healthiness’ (as opposed to studying illness), we really know almost nothing about nutrition.  Actually, we have many pockets of knowledge and many knowledgeable people, but the ‘nutritionists’ are not in that group. There is no science of healthy nutrition – this is obvious to anyone who looks at the various ‘food pyramids’, ‘food plates’ and the discussions around them.  None of the many sides to nutritional issues are science based.

    These sites are (mostly) discussing ‘sickness freedom’ or perhaps ‘medical freedom’ and calling it ‘health freedom’.   Medicine is a subset of healthicine – a very small subset, although it tends to get a majority of the attention.  Healthicine is not even in most dictionaries. http://personalhealthfreedom.blogspot.ca/2012/02/healthicine-art-and-science-of.html

    If we are to learn any truths about health, and about health freedom, we need to step back, then step to the side.  We need to look at things from a ‘health perspective’, with a ‘health paradigm’, not from an ‘illness perspective’ and an ‘illness paradigm’.  Once you adopt a health paradigm, you will soon find that neither side of the many issues is very scientific. 

    Everyone has a right to life, liberty, and the pursuit of healthiness. http://personalhealthfreedom.blogspot.ca/p/subject-index.html
    to your health, tracy

  • George Henderson

    Supporting the lipid hypothesis and statins, as you appear to do here, doesn’t exactly prove your point. Many of the other views you discount have a scientific basis; whether they are always presented scientifically by their proponents is another matter, but there is often a case to answer, and appeal to authority is not that answer.
    For some people, vitamin D is superior to flu vaccine (and cold vaccine, if there was one), and gluten is an insidious toxin. Should we all live according to the mean? Because most people tolerate gluten, should I force myself to eat it, or pay for expensive and time consuming tests to prove that I have the right to avoid it?

  • Adele Hite, MPH RD

    It seems that you are suggesting that, because the groups that oppose the Academy of Nutrition and Dietetic’s monopoly on nutrition counseling is, as you put it “anti-science,” then allowing the AND’s monopoly to continue and to expand is the logical option. Otherwise we have “quackery.” I’m afraid “quackery” is in the eye of the beholder. I am a Registered Dietitian and a member of AND. I can tell you exactly how “science-based” their recommendations are, which is not very. You mention a move away from having dietary recommendations created by “government groups,” but what Willett is really recommending is a simply a transference of this responsibility from joint ownership by USDA/HHS to just HHS. And if you think that HHS is somehow immune from political influence, funding favoritism, and “cognitive bias,” I’ve got a bridge in Brooklyn I’d like you to buy. Paypal is fine.

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