September 2007

The RD: Perceptions, Assumptions, and Reality
By Art Kress, MS, RD, and Terri Lisagor, EdD, MS, RD
Today’s Dietitian
Vol. 9 No. 9 P. 96

How many of us have tried to explain what we do as RDs only to receive the quizzical response, “Isn’t that the job of a nutritionist?” Let’s face it: It often seems that we’re professionals in a field without recognition, and nothing of substance seems to be happening to change that perception. In fact, one could argue that looking at the history of the American Dietetic Association (ADA), the term registered dietitian has never been clearly defined. How did this happen and what can be done to improve matters?

History of the Dietetic Practitioner
The formal organization of dietetic practitioners convened in the late 1890s with a series of annual conferences to discuss the training and duties required primarily of hospital dietitians. This fledgling organization eventually led to the formation of the ADA in 1917, which served predominantly to give women in nutrition and dietetics a forum to share knowledge and discuss mutual problems and concerns. From only 100 female dietitians at the first meeting in Cleveland, the ADA now boasts more than 67,000 male and female members.

Throughout its history, the ADA has grappled with the definition of dietitian, often using the term synonymously with nutritionist. In 1985, when the public, physicians, dietitians, and media personnel were asked about the differences between a dietitian and a nutritionist, all expressed confusion.1

It still appears that the public fails to see RDs as the nutrition professionals. This lack of clarity may translate to a lower professional status for RDs, affect remuneration, and mean the general public misses out on higher-quality treatment.

In a recent survey of students at California State University, Northridge, only 17% of respondents recognized that RDs must have a college degree, and only 6% knew that RDs must pass a certification exam.2 Though not definitive, these results identified a need for further study and suggested that our professional organization (the ADA) and its members do more to promote RDs as the nutrition professionals.

Dietitian vs. Nutritionist
There has been much confusion within the ADA about how to define dietitian and differentiate between a dietitian and a nutritionist. In 1944, the president of the ADA stated, “…the term dietitian should be legally defined…,” yet this wasn’t to happen for another 20 years.1 In 1965, the ADA executive board defined dietitian as “a translator of the science of nutrition into the skill of furnishing optimal nourishment of people.”1 But even this was criticized, as foodservice administrators felt excluded.

This lack of a legal definition haunted the ADA for years. Even today, the ADA’s definition is largely dependent on the key requirements rather than clarifying the different terminologies. The ADA’s Web site defines RDs as “…food and nutrition experts who have met the following criteria to earn the RD credential: Complete a minimum of a bachelor’s degree … complete a CADE [Commission on Accreditation for Dietetics Education]-accredited supervised practice program … pass a national examination … complete continuing professional educational requirements to maintain registration.”3

The term nutritionist does not fare much better. A search for nutritionist in the Dictionary of Occupational Titles brings up home economist, while a search for public health nutritionist yields community dietitian. Again, the definition of nutritionist

is confused with dietitian. Confusion also reigns in dictionaries, government agencies, and professional organizations. For example, the U.S. Department of Labor’s Bureau of Labor Statistics lumps nutritionist and dietitian together in their Occupational Outlook Handbook, a career information source for hundreds of professions. The National Cancer Institute Web site defines nutritionist as “a health professional with special training in nutrition who can help with dietary choices. Also called a dietitian.” So to the National Cancer Institute, nutritionist is synonymous with dietitian.4,5

Recognition and Salary
There has been concern among RDs that dietetic salaries are not commensurate with the education and experience required for certification. In 2001, the ADA House of Delegates indicated that salaries for members “do not always meet expectations when compared with the required scientific background for dietetics professionals.”6

In May 2005, the median wage for all dietitians and nutritionists in general medical and surgical hospitals was $22.37 per hour, or $46,540 per year for full-time work.4 Certainly, there are many factors that affect salary levels (eg, education, years of experience, supervisory responsibilities, nature of the job, type of employer, demand, location), but the salary for dietitians still pales when compared with other professions requiring less or similar backgrounds. For example, in May 2005, the median salary for registered nurses working in general medical and surgical hospitals was $27.80 per hour, equaling $11,280 more per year than RDs earn.4      

According to the ADA’s survey “Nutrition and You: Trends 2002 Final Report of Findings,” respondents rated television and magazines as their most valued sources of nutrition information. These results were very different from the 2000 ADA survey, which showed doctors, RDs, and nutritionists as the most valued sources of nutrition information. If these results are accurate, much work needs to be done to reestablish RDs’ reputation.

Evidence-Based Research
In 2006, research was conducted to add quantitative data to the anecdotal information that is readily available.7 Based on the analysis of 365 respondents, 21% indicated that a nutritionist is more qualified than an RD to deal with food-related issues; nearly one half were not sure who is more qualified. A majority of respondents thought a nutritionist is more qualified than an RD to discuss food-related health issues. The nutritionist was also selected as most qualified to deal with genetically modified foods. Both professions were thought to create diets and menus, teach nutrition-related subjects, and provide nutrition counseling.

So what is the difference between a dietitian and a nutritionist, and how important is it to clarify those distinctions?

This most recent study shows that the public cannot easily distinguish between a nutritionist and an RD, demonstrating that RDs are not always seen as nutrition professionals and thus may not receive the status or income commensurate with their education, training, and experience.7 The 2000 ADA survey listed doctors as the most valued source of nutritional information, yet according to a 2001 paper, medical students were shown to average 18 +/- 12 hours of nutrition education, hardly enough time to acquire sufficient expertise.8

This misperception may also mean that the general public is not well-served when seeking nutritional advice. Most people understand the function of medical doctors and nurses and believe their advice can lead to an improved state of health. These healthcare professionals are respected partly because of this, and they are typically held in high esteem. Perhaps if the general public better understood the importance of RDs, the profession may also be elevated to a higher level of esteem.

Since a nutritionist is not required to have any specific training or experience, then the public, which may not understand the different competencies required, may rely on advice that is not evidence-based and may actually harm them. This could increase the cost of healthcare and adversely affect everyone’s insurance premium.

What Can Be Done?
First, RDs, to some extent, must rely on the ADA as the organization chartered to represent them. But the ADA’s track record in this arena has not been good, despite its attempts to make a difference. For example, a previous article in Today’s Dietitian mentioned that from 1998 to 1999, the ADA conducted a $1.5 million national campaign to increase the “public awareness or credibility of registered dietitians.”9 But according to the article, it failed. Why? The article didn’t say, and the ADA did not respond to queries about the campaign.

Rather than modify and approve its approach, it seems the ADA took a different path. The association is about to require RDs to have a master’s degree. But is that the answer? The real problem appears more basic. After all, how many hospitalized patients know or care whether their nurse has a master’s degree? Patients simply trust the nurse, believe in his or her expertise, and expect the nurse to provide the necessary care. It seems more important that the ADA focus its efforts on developing similar expectations for RDs, possibly by helping to clarify the differences between an RD and a nutritionist.

And it is most important to ensure that the general public, and even some doctors and nurses, understand the importance of RDs in the field of nutritional and physical health. The ADA also needs to target government documents and Web pages that confuse the terms RD and nutritionist.

Next, it is important that the ADA spearhead research highlighting RDs’ contributions to the nutrition field. Why is it that the Journal of the American Medical Association publishes studies that have a greater chance of getting national attention than those in the Journal of the American Dietetic Association (JADA)? Perhaps many of JADA’s articles, while important to the profession, are less able to achieve visibility that would ultimately elevate RDs’ status. If these special studies require increased expense and expertise to implement, then perhaps the ADA should allocate its funds more wisely to sponsor such efforts.

Third, since many people seem to perceive a nutritionist as the nutrition professional, why not consider changing the official designation? After all, this classification is not a fete accomplis, since the ADA, throughout its history, has been conflicted about the identity of its practitioners. It seems that many in the public domain see dietitians as people who prepare menus, cook food, and are confined to the kitchen. Even a requirement for a doctorate will not overcome that obstacle. As two focus group participants suggested, either change the name to registered nutritionist or registered nutritionist-dietitian.7

Fourth, in addition to promoting good eating habits, why not use National Nutrition Month as a medium for promoting RDs? It is a great opportunity to use this annual event, which already has some national visibility, to help publicize RDs’ contributions, expertise, and accomplishments.

Fifth, selecting an RD of the year could be a significant promotional event. The ADA could send out national news releases showing what that person has accomplished and highlighting how those accomplishments have led to improved healthcare for the general public. Also, various national magazines could be approached about accepting articles relating to RDs and their significant achievements.

RDs can also be promoted more effectively in elementary schools. It is important that young people grow up with an understanding that RDs can add value to their lives. Perhaps a comic book can be created for this age group describing RDs’ various roles. In addition, promotional materials can be produced for children, and RDs can make a special effort to frequently visit this population.

Additionally, RDs have a responsibility to respond to any misuse of the term nutritionist by the media and correct any implication that a nutritionist is the “true” professional. It’s particularly important that we be assertive if there is any hope of changing the false perception of RDs held by the public.

And finally, the ADA could sponsor a weekly or monthly radio, television, or Web broadcast with RDs as hosts. This could be dedicated to providing the latest nutrition information and helping promote the profession.

These are some possibilities, not intended as an exhaustive list but to provide approaches that the ADA and individual RDs can implement to heighten an awareness of the RD’s function. However, it does appear that if something significant, maybe even revolutionary, is not done—and done soon—this profession could go the way of other nondescript careers and be lost in the flow of history.

It is time for the ADA, our state and local dietetic associations, and individual RDs to grasp their own destiny and initiate those changes that will not only help the profession but also serve to benefit a population hungry for the best nutritional advice.

— Art Kress, MS, RD, became an RD in 2004 and shortly thereafter received his master’s degree in nutrition from California State University, Northridge. He is currently coordinating a grant project for the VA Greater Los Angeles Healthcare System to develop a diabetes prevention program for American Indian/Alaska native veterans. He is an ADA member.

— Terri Lisagor, EdD, MS, RD, is an assistant professor of nutrition and food science at California State University, Northridge, an RD in private practice, and a lecturer at the UCLA School of Dentistry. She is an ADA member.