Almost anyone can get "schnookered," says Dr. John Renner. But for some reason, the public is better at spotting a phony car dealer than it is at recognizing nutritional nonsense from an unqualified practitioner, says Renner, a Kansas City physician who has been studying nutrition fraud.
Controversy over the value of various nutritional programs is nothing new. Yet some observers say that the situation is only getting worse as awareness of the connection between diet and health and the confusing array of information on how to connect the two increases.
From magical diets to miracle food and megadose vitamin cures for cancer or diabetes, advice is continuously dispensed to a vulnerable public by those claiming to be nutrition "experts."
What is new about this phenomenon is that in practically every state across the nation, dietitians and nutritionists with degrees from accredited universities are fighting back. They want to license their profession, they want the scope of their jobs legally defined. And they want to make it illegal for individuals to offer nutrition advice without proper credentials.
Of course, formal credentials do not guarantee competence. On the other hand, the fact that a person lacks such credentials is not necessarily an indication that the services or programs he offers are inadequate.
However, Renner, director of the Sisters of St. Mary's Hospital Family Residency Program and a patient education advocate who teaches nutrition to doctors, believes that licensing would give consumers a better idea of what they're getting if the entry in the yellow pages was followed by a line that said, "licensed dietitian."
According to Catherine Babington, director of government affairs of the American Dietetic Association, dietitians in 36 states are pursuing mandatory licensure, although details of the proposed laws vary from state to state. A bill awaits the governor's signature in Maryland, while dietetic associations in Virginia and the District of Columbia are in the beginning stages of drafting such bills.
Puerto Rico and Oklahoma have mandatory licensing laws. Dietitians in four other states are working on voluntary licensure, while Georgia and Texas already have passed such bills. North Dakota has mandatory licensure for dietitians and voluntary licensure for nutritionists.
And four states -- California, Louisiana, Alabama and Montana -- have entitlement, which spells out certain educational requirements that someone must have to use the title "dietitian" (but does not define scope of practice as licensure does), while five others are working for entitlement. James Kenney of the National Council Against Health Fraud in California, says that in that state the entitlement law has just "prevented the quack nutritionists from calling themselves dietitians and they weren't calling themselves dietitians anyway."
Licensing is a complicated issue of pros and cons that has pitted registered dietitians -- who have a bachelors or masters degree from accredited schools in a nutrition or related field and have passed an exam administered by the American Dietetic Association -- against others who may lack these credentials. Some of the latter have received correspondence course degrees from Donsbach University, an unaccredited California school founded by Kurt Donsbach. According to Bruce Brown of the FDA, the agency is presently investigating whether nutritional supplements bearing Donsbach's name are being sold for medical purposes in interstate commerce.
Donsbach, reached at his school in Huntingdon Beach, Calif., said he "hasn't the faintest idea" of what the FDA investigation is about, and that he does not own any nutrition supplement companies, but lends his name to them under a license agreement.
Further confusing the licensure issue is uncertainty about just what the difference is between a dietitian and a nutritionist. The ADA holds that the titles are interchangeable, but others, such as Clinton Ray Miller of the National Health Federation, a health-food lobby, stereotype dietitians as the white bread and Jell-O distributors in hospitals and cafeterias and think of nutritionists as having a broader, more liberal viewpoint.
Proponents of licensing argue that its purpose is to protect the public from practitioners who lack necessary training, that it would define minimum quality standards for the profession and improve professional prestige.
Opponents such as the National Health Federation, chaired by Donsbach, and the National Nutritional Foods Association, which represents more than 3,500 health food stores, contend that highly restrictive bills could create a monopoly for one school of traditional nutrition thought, limiting the free market and consumer choice, and that their primary intent is not to protect the public, but to give clout and recognition to a single segment of dietitians, increasing their chances of obtaining reimbursement from insurance companies.
Doubts about licensing have been voiced by other segments of the nutrition community. Nutritionists with masters degrees or PhD's in nutrition or related fields from accredited universities -- who may work in public health, academia or research -- fear that licenses restricted to registered dietitians may exclude them from practicing as well.
Babington of the ADA said that laws are being drafted to include more than just ADA members. Licensure is not intended to exclude people who are qualified; its intent is to exclude people who aren't, Babington said. Bills are providing exemptions for such professionals as the nutritionists mentioned above, physicians who practice nutrition, county extention agents and lecturers at weight-loss programs such as Weight Watchers.
In fact, licensure would not effect personnel in health-food stores, as many in the health-food business fear, said Babington. Although there is a fine line between the two, federal law already prohibits health-food store operators from giving out nutrition or medical advice to sell a product, although they may dispense information. (Claims, however, often appear elsewhere in the store in posters or aisle displays, since non-drug products themselves cannot legally bear such labels.)
In addition, in a climate where professionals from florists to travel agents are seeking licensure, bills that favor deregulation of professionals in general are being resisted by state legislatures, says Babington.
And although some hospital associations oppose licensure because they fear dietitians could command higher salaries and create more red tape, some dietitians say this is not a necessary repercussion.
"It's a female-dominated field," said Katherine Tallmadge, a registered dietitian in the District spearheading the movement here, who added that nurses, who are licensed, "certainly" don't command high salaries.
Other opponents argue that licensure doesn't guarantee public protection from incompetence, and that license revocation in already licensed professions is ineffective. The American Medical Association's licensing boards are "at best innocuous, at worst invisible," says Michael Rooney, director of the People's Medical Society, a consumer organization founded by Robert Rodale, which supports deregulation of health professionals. "The fact that the medical profession has botched licensure doesn't mean that the dietetic association will," says Kenney of the National Council Against Health Fraud.
Supporters of licensure for dietitians and nutritionists admit that it is a imperfect solution to totally eliminate nutrition fraud, but that it is a step in the right direction. "It's just like what a mandatory handgun law would do. It's not 100 percent protection, but if it can protect 50 percent more of the people than it is now, it's worth it," said Tallmadge.
Mandatory licensure only has "positive ramifications," says Kenney, especially if it leads to third-party reimbursement. Preventative treatment is cheaper, he contends. It makes more sense for an insurance company to shell out a few hundred dollars to a dietitian so a person can learn how to lower his cholesterol level than it is to have to pay a hospital $25,000 for coronary bypass surgery, Kenney said.
Part of the dietitians' case for licensing is to prove that actual harm has resulted because the profession is not regulated. There are documented cases, such as one cited to the Washington State Health Coordinating Council by a proponent of licensing, of a child who was taken off asthma medication prescribed by a medical doctor, given verbally recommended megadoses of Vitamin A and ended up in the hospital. But cases of harm are difficult to prove, says Tallmadge of the District dietetic association. Tallmadge, who says she sees clients who have been unsuccessfully treated by nonprofessionals, said frequently people are afraid to admit they've been duped, or they wrongfully blame themselves -- and not the nutritionist -- for failing to lose weight on a bogus diet program, for example.
According to Bill Jarvis, director of the National Council Against Health Fraud, nutritional remedies can hit hard on people's pocketbooks, especially the elderly's. And according to the May issue of Consumer Reports -- which details a myriad of nutritional supplements whose claims, it concludes, are unproven -- many products sold in health food stores are hazardous, not in themselves, but because users may forgo treatments that actually work.
Whatever the educational background, no dietitian or nutritionist is permitted to give medical treatment, and that's what worries people like Jarvis. Alfafa tablets to cure arthritis or megadoses of vitamins to cure diabetes are examples that some would construe as medical treatment. "When they start treating diseases, that's where the line needs to be drawn," agrees Mary Goodwin, chief nutritionist of the Montgomery County Health Department, who was active in rewriting the Maryland bill to include licensees other than ADA members.
Miller of the National Health Federation says that by definition a "quack" is someone who "pretends medical skill," and that the association's members do not do so. The federation represents people who are "sincere, highly qualified, brilliant, gifted healers," said Miller. "Ecletics in the true sense of the word."
Miller also said that correspondence schools offering courses in nutrition are "the answer America has been looking for" and that they teach "the truth," while "others are teaching falsehoods." Graduates of formal medical schools and nutrition programs are "flat worlders, whose primary thought is that any lay person cannot self diagnose with nutrition," Miller said.
Among the "nutrition advice" that Miller said he "defends," but does not "promote," is unpasteurized milk and its "immediate miraculous effect" on improving asthma. The FDA has concluded that raw milk consumption presents a public health problem and is strongly associated with disease outbreaks, according to spokesman Jim Greene. The agency has not banned raw milk sales because it believes it is an issue best handled by the states, Greene said.
Richard Power, who offers hair analysis for mineral assessment and diet planning and is one of approximately 30 graduates of Donsbach University who provide nutritional services in Maryland, says that the Maryland bill will not affect his business.
The bill states that individuals are permitted to "conduct classes or provide services and information related to non-medical nutrition." Powers says he doesn't "do medical nutrition" and that the advice and analysis he gives are a "service."
James Temple, assistant coordinator for Boards and Commissions of the Department of Health and Mental Hygiene for the state of Maryland, said there is often "a fine line" in the health professions of what constitutes the scope of practice, and that with all cases, information or complaints about any practitioner operating outside of the boundaries of the law will be referred to the attorney general's office for investigation.