The Registered Dietitian: Perceptions, Assumptions, And Reality

CALIFORNIA STATE UNIVERSITY, NORTHRIDGE

THE REGISTERED DIETITIAN: PERCEPTIONS, ASSUMPTIONS, AND REALITY

A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Family and Consumer Sciences by Arthur R. Kress

January 2007

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The thesis of Arthur R. Kress is approved:

____________________________________ Scott Plunkett, Ph.D.

___________________ Date

____________________________________ Claudia Fajardo, Ph.D.

___________________ Date

____________________________________ Terri Lisagor, Ed.D., RD, Chair

___________________ Date

California State University, Northridge

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DEDICATION

This thesis is dedicated to my mother, who during her lifetime was a constant source of support and unconditional love. She cared about, loved, and lived for her family, and was always there to support us. She was taken away much too soon, and I miss her dearly. I also dedicate this thesis to my father, who has been a significant source of love and support in so many ways, and has been instrumental in shaping who I am today. And finally, I dedicate this thesis to my brother Marc, sister Meryl, and friends who have been an inspiration to me throughout the years.

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ACKNOWLEDGMENT I would like to thank all those who supported my efforts in writing this thesis. To my chair, Dr. Terri Lisagor, your energy and support kept me constantly focused on the goal, and your wisdom helped to assure the accuracy and importance of this research. I thank you for your continuing friendship and your constant support. To Dr. Scott Plunkett, your assistance with the evaluation and interpretation of data was invaluable, as was your constant guidance in shaping the form of this thesis. To Dr. Claudia Fajardo, your support, guidance, and friendship throughout this process was greatly appreciated. To Laurel Graham, ADA Librarian, your effort and willingness to provide much of the data and reference material for this thesis was appreciated more than you could possibly know.

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TABLE OF CONTENTS Signature Page Dedication Acknowledgment List of Tables Abstract

ii iii iv vii viii

CHAPTER 1 – INTRODUCTION Statement of the Problem Purpose Definitions in Alphabetical Order Research Hypothesis Assumptions Limitations

1 2 3 3 4 5 5

CHAPTER II – REVIEW OF LITERATURE Definition of Dietitian Definition of Nutritionist Recognition and Salary Snowball Survey Summary

6 7 9 11 11 13

CHAPTER III – METHODOLOGY Participants Instruments Statistical Analysis

15 15 16 17

CHAPTER IV – RESULTS Focus Group Participants

18 18 21

CHAPTER V – DISCUSSION Discussion of Findings Implications Research Implications Conclusion

28 28 33 37 38

REFERENCES

40

APPENDICES A. American Dietetic Association Nutrition and You: Trends 2000 – Background, Objectives, and Summary

43

B. American Dietetic Association Nutrition & You:

5

Trends 2002 - Final Report of Findings C. Feedback Form D. Survey Summary

6

49 95 96

LIST OF TABLES Table 1 – Focus Group Results

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Table 2 – Socio-Demographic Data on Participants

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Table 3 – Most Valued Sources of Nutrition Information

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Table 4 – Professions Best Equipped to Treat Nutritional Problems

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Table 5 – Best Qualified to Deal With Nutrition Issues

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Table 6 – Assessed Functions of Registered Dietitian or Nutritionist

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ABSTRACT THE REGISTERED DIETITIAN: PERCEPTIONS, ASSUMPTIONS, AND REALITY by Arthur R. Kress Master of Science in Family and Consumer Sciences

The purpose of this study was to determine the public’s ability to differentiate and understand the functions of both the Registered Dietitian (RD) and the Nutritionist. Input was obtained from 418 persons, both male and female, ranging in age from 19 to 82, utilizing an online snowball survey. A Chi2 analysis of the data was performed to determine variation based on age, gender, occupation, state (location), level of education, and household income, but very few statistical variations were observed. Study results indicated a general confusion about the roles of both the RD and the Nutritionist. Even in those areas where a greater percentage of respondents correctly identified the RD function, there was a significant (>20%) “Not Sure” response that could have easily altered the results. In conclusion, the public’s inability to clearly distinguish the difference between the RD and the Nutritionist is an indication that Registered Dietitians are not being well promoted. It indicts efforts by the American Dietetic Association to effectively create public awareness of the RD function, and it may affect RD status, remuneration, and the level of nutritional support provided to the general public.

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CHAPTER 1 INTRODUCTION The formal organization of dietetic practitioners began in the late 1890’s, with a series of annual conferences to discuss the training and duties required primarily of hospital Dietitians. This fledgling organization led eventually to the creation of the American Dietetic Association (ADA) in 1917, as a way of giving women in nutrition and dietetics a way of sharing knowledge and discussing mutual problems and concerns. Only 100 Dietitians attended that first meeting in Cleveland, but over the years the organization grew rapidly to become a national, even international, voice for Dietitians, both men and women, which now numbers close to 65,000 members. Throughout its growth, the ADA has been conflicted about the definition of Dietitian, and has often used the term synonymously with Nutritionist. At the Third White House Conference on Child Health and Protection (possibly in 1930), a Dietitian was defined as “Any person who is qualified for membership in the American Dietetic Association (and) is, by virtue of uniform basic training and required experience, entitled to be designated as a Dietitian” (Cassell, 1990, p. 71). So not only do we have a term used to define itself, but this definition says nothing about function nor does it clarify the confusion between Dietitian and Nutritionist. And in 1985, when the public, as well as physicians, Dietitians, and media personnel were asked about the differences between Dietitian and Nutritionist, all four groups expressed confusion (Cassell, 1990). In a nationwide public opinion survey conducted by the ADA in 2000 (Appendix A), when the public was asked about their sources of nutritional information (being allowed to make multiple selections), 90% listed registered Dietitians (RD), and another 90% listed Nutritionists, not seeming to

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realize that there is a difference between the two. Unfortunately, this survey is no longer accessible, and only press releases describing the results can be found on ADA’s website. In a more recent survey (Appendix B), the term Nutritionist is eliminated as a choice, possibly because the ADA hoped to avoid any negative conclusions. Today, anyone can call him/herself a Nutritionist; no formal education or experience is required. A Dietitian, on the other hand, must meet educational standards, complete an internship, and then pass a qualifying national exam. Statement of the Problem It appears that the public does not recognize that RDs are the nutrition professionals, and are capable of providing the highest level of nutritional care. This lack of recognition likely translates into a poorer level of care for the public and a lower professional status for Dietitians, and may certainly affect remuneration. In a recent survey of 106 students at California State University, Northridge, while not definitive, 17% of respondents believed that RDs must have a college degree while only 6% recognized that RDs must pass a certification exam. If these results are generalizable to all demographic groups in the US, it is a terrible indictment of the ADA and its intended purpose of representing all RDs. This research attempts to survey current opinion to determine the public’s understanding of the Registered Dietitian. It’s hoped that if results show that confusion still exists in the public mind, the ADA can take steps to better promote the profession and do whatever is necessary to enhance the status of RDs and to improve their economic potential.

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Purpose The purpose of this study is to assess the public’s knowledge of the difference between Registered Dietitians and Nutritionists; to encourage the follow-up necessary to promote a positive professional image and to help assure optimal nutrition support for a population concerned with nutrition-related issues.

Definitions in Alphabetical Order 1) Dietitian

Plans and directs food service programs in hospitals, schools, restaurants, and other public or private institutions. Plans menus and diets providing required food and nutrients to feed individuals and groups. Supervises workers engaged in preparation and serving of meals. Purchases or requisitions food, equipment, and supplies. Maintains and analyzes food cost control records to determine improved methods for purchasing and utilization of food, equipment, and supplies. Inspects work areas and storage facilities to insure observance of sanitary standards. When employed in schools, hospitals, or similar organizations instructs individuals and groups in application of principles of nutrition to selection of food. May prepare educational materials on nutritional value of foods and methods of preparation (Dietitians and Nutritionists defined, 1964).

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2) Nutritionist

Organizes, plans, and conducts programs concerning nutrition to assist in promotion of health and control of disease; instructs auxiliary medical personnel and allied professional workers on food values and utilization of foods by human body. Advises health and other agencies on nutritional phases of their food programs. Conducts in-service courses pertaining to nutrition in clinics and similar institutions. Interprets and evaluates food and nutrient information designed for public acceptance and use. Studies and analyzes scientific discoveries in nutrition for adaptation and application to various food problems. May be employed by public health agency and may be designated as NUTRITIONIST, PUBLIC HEALTH (Dietitians and Nutritionists defined, 1964).

Research Hypotheses This study is guided by the following research hypotheses: 1) The public’s perception of a Nutritionist as the professional nutrition practitioner is significantly and positively greater than the perception of a registered Dietitian. 2) Knowledge of the differences between Dietitian and Nutritionist varies with socioeconomic status and gender.

Assumptions This study was based on the following assumptions:

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•

Information obtained from subject questionnaires is accurate.

•

Data entry and analysis was error free.

•

Subject numbers and diversity were sufficient to obtain desired data.

Limitations This thesis will add to the understanding of how the public perceives the Registered Dietitian. However, certain limitations to the study exist. •

This is a self-reported study, so participants’ recall may affect the results, as may a desire by participants to “say the right thing”.

•

This is a single snapshot in time and could be affected by personal and social issues beyond the scope of this study.

•

Data collected using an online snowball survey may be biased and may not accurately reflect the general population. Hence, generalizability is limited.

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CHAPTER II REVIEW OF LITERATURE Surveys of the public perception of Dietitians are rare, and they seem to be limited to those sponsored by the American Dietetic Association (ADA). When asked for copies of these surveys, the ADA claimed they no longer exist. However, the ADA did provide two sets of survey results. In Nutrition & You: Trends 2002, Final Report of Findings, October 2002 (Appendix B), the ADA concluded that television was the main source of nutritional information, with magazines and newspapers a distant second. The question did not list Dietitians or Nutritionists as an option, but did include doctors. The ADA survey further questioned the respondents’ awareness of Registered Dietitians (RDs). According to the report, around 90% of the respondents are aware of RDs. Of all the respondents, 86% saw RDs as a “credible source of information on obesity.” And on issues of dietary supplements, irradiation, and genetically modified foods, 68%, 55%, and 51% respectively, rated RDs as very credible sources of nutritional information. Generally, females were more likely to look to the RD for nutritional information, as were respondents with a lower level of education. An earlier ADA survey, Nutrition & You: Trends 2000, Background and Objectives, January 2000 (Appendix A) showed that television was the primary source for nutritional information. However, instead of asking about the main source of that information, the ADA asked about the most valued source. This makes a comparison between the two surveys difficult. The earlier survey also lists doctors, registered Dietitians, Nutritionists, magazines, and nurses, among other possibilities, and respondents were allowed multiple selections. Ninety-two percent of those respondents selected doctors, while both registered Dietitians and Nutritionists

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came in second at 90%. It appears that respondents were not able to distinguish between RDs and Nutritionists, and ascribed to both groups the same level of competency. In the 2002 survey, the ADA eliminated this question, and made no reference to Nutritionists. A recent survey conducted among California State University Northridge students (May, 2005) entitled Registered Dietitian vs. Nutritionist: Is There A Difference, showed that a majority, both male and female, lacked knowledge of Nutritionist/RD requirements, i.e. they were not aware that RDs must meet stringent criteria, while a Nutritionist may practice without adhering to any specific requirements. Most incorrectly believed that Nutritionists must meet RD qualifications, and significantly more males than females understood that Nutritionists did not need either a college degree or any type of certification. Definition of Dietitian Perhaps one major area of confusion is the definition of Dietitian. There has been much confusion within the ADA over the years, not only about what constituted a Dietitian, but how to differentiate a Dietitian from a Nutritionist. The ADA in 1930 defined a Dietitian as “Any person who is qualified for membership in the American Dietetic Association (and) is, by virtue of uniform basic training and required experience, entitled to be designated as a Dietitian” (Cassell, 1990 p. 187). Despite this earlier definition, the term Dietitian was not officially adopted until 1934. Then in 1940, an ADA committee developed the following definition: “A Nutritionist in a public health agency was a ‘qualified, professionally trained person who directs or carries on a program of activities dealing with the application of the scientific knowledge of nutrition to the prevention of disease and the promotion of positive health’” (Cassell, p.188). So

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with a seeming shift in terminology, an overlap between Dietitian and Nutritionist now existed and continued to exist for the next four years. Then, in 1944, Nell Clausen, the then President of ADA, stated that “the term Dietitian should be legally defined…, ” (Cassell, p. 141) yet this wasn’t to happen for another 20 years. In 1955, a committee established by the ADA, came up with another definition, stating that a Dietitian was a person who was “a member of the profession of dietetics, which deals with the science, the technical aspects and the art of feeding people” (Cassell, p. 188). But the ADA continued to struggle with this issue. Then in 1965, the executive board of ADA accepted the definition, which stated that a Dietitian is “a translator of the science of nutrition into the skill of furnishing optimal nourishment of people” (Cassell, 1990, p. 291). But even this was criticized, as foodservice administrators felt themselves excluded. So this lack of a legal definition was to haunt the ADA for years, preventing an actual count of practitioners, not knowing how many met ADA standards, and lacking an awareness of what Dietitians did and where they practiced. Today, the ADA definition is largely dependent on the key requirements. For example, the ADA’s website defines Registered Dietitians as “…food and nutrition experts, who have met the following criteria to earn an RD credential: Complete a minimum of a bachelor’s degree…complete a CADEaccredited supervised practice program…pass a national examination… complete continuing professional educational requirements to maintain registration” (Definition of Registered Dietitian, 2006, ¶ 1). To further confuse the schizophrenic nature of this issue, many different functions for Dietitian are listed in the revised Fourth Edition of the Dictionary of Occupational Titles (DOT) (Functions of Dietitian, 1981): Administrative Dietitian, Chief Dietitian, Clinical Dietitian, Consultant Dietitian, Research Dietitian, and

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Teaching Dietitian (Functions of Dietitian, 1971). Obviously, this was an attempt to be inclusive, but it is ultimately incomplete, since categories such as Entrepreneur and Food Science Dietitian, among others, are not included. A search for Nutritionist in the DOT, brings up Home Economist, while a search for Public Health Nutritionist, brings up Community Dietitian. And this additional overlap in terminology is definitely confusing. No wonder the public has so much difficulty with these terms. Not only can the ADA not define them well, but the government also has difficulty in doing so.

Definition of Nutritionist As discussed above, the definition of Nutritionist has often been confused with Dietitian. Most importantly, the ADA has wavered between the two terms when describing nutrition practitioners. But it is not only the ADA that has a problem. Confusion also reigns in dictionaries, government agencies, and professional organizations. For example, the U.S. Department of Labor, Bureau of Labor Statistics, lumps Nutritionist and Dietitian together in their Occupational Outlook Handbook, a source of career information for hundreds of professions (United States Bureau of Labor Statistics, 2006). The National Cancer Institute website, defines Nutritionist as “a health professional with special training in nutrition who can help with dietary choices. Also called a Dietitian" (Definition of Nutritionist recommended by the National Cancer Institute, 2006, ¶ 1). So, to the National Cancer Institute the Nutritionist is synonymous with Dietitian. The website MedicineNet.com, which is owned and operated by WebMD, defines Nutritionist as:

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“(1) In a hospital or nursing home, a person who plans and/or formulates special meals for patients. It can also simply be a euphemism for a cook who works in a medical facility but who does not have extensive training in special nutritional needs; (2) In clinical practice, a specialist in nutrition. Nutritionists can help patients with special needs, allergies, health problems, or a desire for increased energy or weight change devise healthy diets. Some Nutritionists in private practice are well trained, hold a degree and are licensed. Depending on state law, however, a person using the title may not be trained or licensed at all.” (MedicineNet.com, 2006, ¶ 1). But even this definition is suspect since it is unlikely that a Nutritionist will be found working in a hospital. It is possible, however, for Nutritionists to be certified. The American Health Science University (AHSU) awards this title to candidates who have completed six courses in nutrition and passed a six-hour comprehensive exam. This is a private certification, however. Some states also certify Nutritionists. New York, for example, requires a Bachelor’s degree in Nutrition with a minimum of six months experience, or an Associate’s degree in Nutrition with at least eight years of experience. And, all candidates must pass a state-approved licensing examination. There are also Registered Nutritionists, but a quick check of the Internet seems to indicate that this title is available primarily in the United Kingdom and Canada. Typically, however, a Nutritionist is a person who decides to practice or advise on the subject of nutrition. There are no requirements for a Nutritionist; no education, no internship, no national exam. All one needs to be classified as a Nutritionist is a desire to work in the field.

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Recognition and Salary There has been much concern among RDs that salaries in dietetics are not commensurate with the education and experiential requirements necessary for certification. In 2001, the house of delegates of the ADA indicated that salaries for members “do not always meet expectations when compared with the required scientific background for dietetics professionals” (Bonne, 2004, p. 26). And not much has changed since then. 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 a year for full-time work (United States Bureau of Labor Statistics, 2005). Certainly, there are many factors that affect salary levels, such as education, years of experience, supervisory responsibilities, nature of the job, type of employer, demand, and even location of the job, but the salary for Dietitians still pales when viewed against other professions requiring a lesser or similar background. For example, in May 2005, the median salary for Registered Nurses working in general medical and surgical hospitals was $27.80 per hour or $57,820 a year, or $11,280 more per year than for RDs (United States Bureau of Labor Statistics, 2005). It is possible that including Nutritionists with Dietitians reduces the mean average wage, yet since only hospital employment is being addressed here, that is not likely a meaningful consideration.

Snowball Survey Perhaps the easiest, quickest, and cheapest way of gathering information is via convenience sampling, which is based on easy availability or accessibility to a survey population (Definition of Convenience Sampling, 2006). The technique is not

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randomized, and the respondents may not be representative of a larger population, but the information obtained can provide significant insight and is useful in obtaining data for exploratory research. The snowball survey is a form of convenience sampling that has the capability of obtaining many respondents quickly, and with minimum cost and effort. More importantly, it allows the data collected to be automatically transferred to a database for evaluation (Braithwaite, Emery, deLusignan, & Suitton, 2003). The snowball survey has typically been used to recruit participants from hidden populations, such as intravenous drug users or HIV/AIDS patients (Thompson & Collins, 2002; Atkinson & Flint, 2001). Functionally, the researcher selects one, or a small group of subjects, possibly friends and/or relatives, often with specific criteria, to participate, and then recommend their friends and relatives who also meet the criteria. These persons, in turn, recommend their friends and relatives, and so on, such that the number of respondents expands rapidly, much as a rolling snowball increases in size. J.S. Coleman introduced the technique in 1958 as a way of identifying the network structure within a population (Snijders, 1992). However, problems with the technique became immediately apparent. It is definitely biased toward persons with a pattern of interrelationships or friendships with many other individuals (Snijders, 1992). Also, Internet users do not typically represent the general population, and the differences may be significant. According to researchers L.J. Skitka & EG Sargis, “web users are younger, wealthier, and higher in education than are nonusers,” and these differences may affect generalizability (Skitka & Sargis, 2006, p. 546). However, the Internet is uniquely positioned for conducting a snowball survey, since access to individuals is easily facilitated, is quick, can be anonymous, and is

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inexpensive. Some studies have even shown that data obtained on the Internet, can be similar to data obtained in more traditional ways (Eaton & Struthers, 2002). In addition, a number of techniques have evolved to reduce the bias of snowball surveys. One technique assures that the initial sample is randomly selected, thereby increasing the possibility for statistical inference (Goodman, 1961); another refers to adaptive sampling in which the selection of subjects “adapts to observations made during the survey (Harrison, 1997, p. 298).” When values of interest are observed, “sampling intensity may be adaptively increased for neighboring or linked units” (p. 298). But only the random selection approach lends itself to Internet implementation.

Summary Recent ADA surveys of public opinion are difficult to compare, at least with respect to differences between Registered Dietitians and Nutritionists. Some survey questions appear to be inconsistent, and even that inconsistency is difficult to verify because the actual surveys are unavailable for review. With only summary documents for evaluation, however, it does appear that respondents are aware of, and have some regard for, registered Dietitians, but at the same time they appear to have a similar regard for Nutritionists. Yet despite this, respondents to an ADA survey identified doctors, who have little nutritional training, as their most valuable source of nutritional information. Perhaps part of the public’s inability to separate RDs from Nutritionists, or even from doctors for that matter, is related to the ADA’s inability to establish a meaningful definition for Dietitians. But even then, it appears that some government agencies are also confused about this. So, no wonder RDs don’t get the recognition they deserve, and are not

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sufficiently remunerated for their efforts, at least when compared with professions that have comparable requirements. To survey current attitudes about the public’s ability to differentiate the functions of RDs and Nutritionists, an online, snowball survey was used to gather information. This approach is particularly valuable for obtaining many respondents quickly, with minimal cost and effort. In particular, the results can be used to provide insight and additional data for exploratory research. Overall, this chapter provided a review of the recent surveys conducted to determine the public’s ability to distinguish between a Registered Dietitian and a Nutritionist. It also discussed the differing definitions of the two professions, and the survey technique used to obtain the necessary data. The next chapter discusses the methodology used to conduct a new survey, and one designed to determine if the public’s perception of the two professions has changed in any way since the last ADA survey in 2002.

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CHAPTER III METHODOLOGY This study was designed to determine the public’s knowledge of differences between a Nutritionist and a Registered Dietitian. In addition, it was desired to determine if those differences were affected by location, age, gender, education, and socioeconomic status. More specifically, study objectives were to: 1) Assess the public’s ability to identify tasks that are common to both RDs and Nutritionists and separate out those tasks that can be performed more efficiently (or only legally) by RDs. 2) Determine how understanding the differences are affected by location, age, gender, education, and socioeconomic status. 3) Utilize the survey results to help the American Dietetic Association better promote RDs and assure that the general public obtains the best nutritional care.

Participants The target population for this study was anyone over 18 years of age, considered “adult” by our society and capable of making decisions about whether or not to seek professional support from a Registered Dietitian. This was a convenience, snowball survey, designed for easy accessibility and was not randomized, so generalization becomes difficult. SurveyMonkey.com was the website used to develop and conduct the survey, which was initiated on January 10, 2006 (Appendix D). Initially, California State

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University Northridge (CSUN) professors, personal friends, and relatives were asked to contact their friends and refer them to the survey site. In turn, the initial respondents were asked to refer their friends and so on, such that the total number of respondents could ultimately represent multiple states, various education levels, and a range of socioeconomic status. The survey was anonymous and the demographics of respondents were totally coincidental and dependent on referrals made to others and the desire of those contacted to participate. The survey was terminated on February 15, 2006 with a total of 417 respondents.

Instruments Focus Group Prior to initiating the study, a focus group was conducted at the Greater Los Angeles Veterans Administration (VA) Healthcare System. Seven Registered Dietitians (RDs) participated in this group for the purpose of validating the study questionnaire and obtaining opinions on the merit of this research. Each RD was asked to complete a feedback questionnaire (Appendix C) that focused on the validity and wording of the survey questions, and asked whether additional issues needed to be addressed. Also, RDs were asked if they felt that the survey might lead to changes in how the profession was promoted by the American Dietetic Association and viewed by the general public. Participation was voluntary. All suggested changes were evaluated and either incorporated in the final questionnaire or rejected if redundant or if they altered the nature of the study.

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Questionnaire The survey consisted of seventeen questions, the first eight relating to sociodemographics and a history of hospitalization (Appendix D). A question about the sources of nutrition information was taken, by permission, from an earlier ADA questionnaire. Respondents were asked to look at a variety of issues such as dietary supplements, obesity, food irradiation, genetically modified foods, diabetes, hypertension, heart disease, and cancer and indicate whether a Nutritionist or an RD was the most qualified to deal with each of these issues. Likewise, respondents were asked to address such issues as creating diets and menus, teaching nutrition, assessing hospitalized patients, providing nutrition counseling, preparing and serving food, offering psychological advice, and the requirement to have a college degree, complete an internship, and pass a certification exam. Two questions included in the survey were added to determine bias for pre-existing knowledge of the RD function: “Have you ever been hospitalized?” and “Have you ever been seen by a Registered Dietitian?”

Statistical Analysis A Chi Square analysis was performed on the demographic data to determine whether differences between a Registered Dietitian and a Nutritionist varied according to ages, genders, educational levels, and socioeconomic status. The Statistical Package for the Social Sciences (SPSS) V13.0 for Windows was used to analyze the data, with level of significance set at P < 0.05.

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CHAPTER IV RESULTS Focus Group Seven Registered Dietitians (RDs) participated in the focus group at the Veterans Administration (VA) Greater Los Angeles Healthcare System. Only a limited time was allowed for questions, however, since the focus group was conducted at the end of a monthly status meeting of RDs and Diet Technicians. The time limitation prevented much verbal discussion with the group, so issues covered were specifically related to those questions on the feedback form. The results are summarized in Table 1. All agreed that the survey was worth pursuing. Most RDs (4 of 7) thought that the survey could affect how Dietitians are viewed by the general public and could influence how the ADA promotes the profession. One RD suggested that the question, “A doctor is more qualified than a Nutritionist or a Registered Dietitian to discuss food related issues,” could be confusing. The respondent thought that it would be impossible to separately relate a medical doctor to either a Nutritionist or a Registered Dietitian. This comment clearly delineated a real problem, and the question was revised accordingly. To the question “Have you ever been hospitalized?” one RD suggested changing the words “been hospitalized” to “worked in the healthcare field.” This was rejected since (1) the questionnaire was aimed at the general public and would not likely be answered by healthcare workers and (2) the question was used primarily to determine if respondents had a bias or some pre-existing knowledge of RD functions, since they would likely be seen by an RD during hospitalization. In considering the question “Indicate whether each of the following items applies to a Registered Dietitian (RD), a Nutritionist, or both,” one

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RD suggested that the response “prepares and serves food” should be removed. This was also rejected since it was hypothesized that much of the public would see this as a primary RD function, and it was desirable to verify if that hypothesis was correct. Another RD felt that asking “Have you ever been seen by a Registered Dietitian?” was biased, since a similar question was not asked about a Nutritionist. This was also rejected since the purpose of this question was to determine respondent bias, and ascertain what they might know about RDs prior to completing the survey. To the question “Would a Nutritionist or a Registered Dietitian be most qualified to deal with the following issues: (check ONE answer for each issue),” one RD suggested adding an “Equal” column to the table, to show that both the Nutritionist and Registered Dietitian would be equally qualified. This was rejected since, in all cases, the Registered Dietitian was most qualified, and a “Not Sure” column would allow sufficiently for any confusion that might exist. Lastly, one RD suggested adding the question “Should the ADA rename the profession?” and this was also rejected since the questionnaire was not being administered to RDs. In general, the group liked the survey, and believed it to be an important medium for advancing the profession.

Table 1: Focus Group Results Question 1. Is the survey question worth pursuing? 2. Do you think the survey will elicit responses that can affect how RDs are viewed in this country? 3. Do you think the survey can have an effect on how the ADA promotes RDs? 4. Do you feel that an important issue has been overlooked in this survey?

Response 7 Yes 4 Yes 2 Not Sure 4 Yes 3 Not Sure 1 Yes 5 No 1 Not Sure

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Comments

“Maybe renaming our title to Registered NutritionistDietitian”

Question 5. Are questions worded in a way that is clear and unambiguous?

Response 5 Yes 1 Not Sure

6. Should any question be eliminated from this survey?

1 Yes 3 No 1 Not Sure

7. Should any question be added to this survey?

3 Yes 3 No 1 Not Sure

Comments “#3 – make 2 separate questions, i.e., an MD is more qualified than an RD; an MD is more qualified than a Nutritionist” “Maybe ask ‘have you ever worked in the healthcare field?’ vs. ‘occupation’ in case someone was once an RD, pharmacist, MD, etc.” “Have you ever been hospitalized?” “#6 – recommend removing ‘prepares and serves food’ since most RDs do not do this” “Should the ADA rename the profession?” “Have you ever seen a Nutritionist? – it seems biased by my asking about RD visit” “Maybe ask if there is a difference between Nutritionist and RD” “I really like the idea of changing our name from Registered Dietitian to Registered Nutritionist”

8. Comments

“Question #5 – I think you should add a column to represent equal qualification” “Be consistent with capitalizing title of RD and Nutritionist”

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Participants A total of 418 persons accessed the site during the survey period, and of these, only 365 completed more than the socio-demographic data. The results are summarized in Table 2. Of the 365 respondents that completed the survey, 76 were male and 289 were female, with ages ranging from 19 to 82. The mean age was 39.8. Respondents came from 29 different states, yet the majority of them came from only six states: California (211), Oklahoma (45), Pennsylvania (21), Massachusetts (18), Florida (16), and New York (8). Of the respondents, 174 (47.7%) had an income of $75,000 or above and 48 (13.2%) had an income between $30,000 and $44,999. Looking at the respondents educational level, 118 (32.3%) completed some college, 90 (24.7%) held a bachelor’s degree, and 95 (26%) received a post-graduate degree. Prior to taking the survey, all respondents were provided with contact information, or ways to address concerns or simply comment on the survey. No such responses were received.

Table 2. Socio-Demographic Data on Participants Variables Gender Male Female Age Less than 21 21-30 31-40 41-50 51-60 61-70 Greater than 70

N

%

76 289

20.8 79.2

29 75 39 55 61 21 6

10.2 26.2 13.6 19.2 21.3 7.4 2.1

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Variables State (location) Oklahoma California North Carolina Florida Pennsylvania Nevada Massachusetts New York Kansas Washington Connecticut Montana Ohio Texas Thailand Missouri Maryland New Jersey Arizona Illinois Indiana Louisiana Washington D.C. Utah Iowa Georgia Delaware Germany Rhode Island Education Some high school High school graduate Some College Bachelor’s degree Post graduate student Post graduate degree Household Income Less than $15,000 $15,000-$29,999 $30,000-$44,999 $45,000-$59,999 $60,000-$74,999 $75,000 or above

N

%

45 211 1 16 21 1 18 8 4 4 3 1 2 4 1 4 1 5 2 2 1 1 1 1 1 1 1 1 1

12.3 57.8 .3 4.4 5.8 .3 4.9 2.2 1.1 1.1 0.8 .3 .5 1.1 .3 1.1 .3 1.4 .5 .5 .3 .3 .3 .3 .3 .3 .3 .3 .3

5 18 118 90 39 95

1.4 4.9 32.3 24.7 10.7 26.0

32 35 48 35 40 174

8.8 9.6 13.2 9.6 11.0 47.7

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When asked about their most valued source of nutrition information, half of the respondents indicated magazines (50.7%). Doctors followed (48.2%), with Internet (44.7%), and family and friends (42.7%) as the third and fourth choices respectively. Registered Dietitian tailed behind as the seventh choice (23%), closely followed by Nutritionist (21.6%). Significantly more women than men relied on magazines (Chi2=8.824, p=.003) and significantly fewer men looked to doctors as a source of nutritional information (Chi2=3.892, p=.049). The results are summarized in Table 3.

Table 3. Most Valued Sources of Nutrition Information _______________________________________________________________________ _ Variables N % Magazines Doctor Nurse Newspapers Nutritionist TV News Family and friends Registered Dietitian (RD) Radio news Other non-news TV Internet Other

185 176 37 97 79 104 156 84 43 25 163 69

50.7 48.2 10.1 26.6 21.6 28.5 42.7 23 11.8 6.8 44.7 18.9

When asked if a Nutritionist is more qualified than a Registered Dietitian to deal with food-related issues, 78 respondents (21.4%) said yes, 114 (31.2%) said no, and almost half, or 173 (47.4%) said they were not sure who was most qualified. A majority of respondents thought that both the Nutritionist and Registered Dietitian were more qualified than a doctor to discuss food related health issues, but a higher percentage

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believed the Nutritionist, of the two, was more qualified (61.6% vs. 59.7%). Significantly more women than men were not sure whether an MD or an RD was more qualified to deal with food-related issues (28.7% vs. 15.8%), and more men than women believed that an MD had a greater qualification in this area (Chi2=12.914, p=.007). Significantly fewer respondents in the lower age range (less than 26) believed that an RD was more qualified than an MD, yet as age increased beyond 26, increasingly fewer respondents were likely to believe that an MD was the most qualified (Chi2=12.914, p=.044). When asked who is best equipped to treat nutritional (or food-related) problems, the largest percentage of respondents (40.5%) selected Registered Dietitian with Nutritionist a close second (32.9%). However, a large percentage of respondents (16.4%) were not sure who was best equipped to deal with these issues. Significantly more women selected an RD as the person best equipped to treat nutritional problems, while a larger percentage of men chose the doctor (Chi2=16.325, p=.006). Responses were also differentiated by age with significantly more respondents in the lower age ranges (less than 52) believing an RD is the most qualified. In the higher age ranges (greater than 39) more respondents tended to select Nutritionist as the nutrition expert (Chi2=26.528, p=.033). These results are summarized in Table 4. Table 4. Professions Best Equipped to Treat Nutritional Problems _______________________________________________________________________ _ Variables Nurse Doctor Registered Dietitian Social Worker Nutritionist Teacher Diet Technician Other Not Sure

N

%

0 30 148 0 120 0 4 3 60

0 8.2 40.5 0 32.9 0 1.1 .8 16.4

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When asked if a Nutritionist or a Registered Dietitian would be most qualified to deal with a variety of nutritional or disease related conditions, respondents selected Registered Dietitian for 6 of the 8 issues (i.e. use of dietary supplements, obesity/overweight, diabetes, hypertension, heart disease, and cancer). The Nutritionist was only selected as most qualified to deal with genetically modified foods. Most respondents were not sure who was most qualified to deal with food irradiation. Each condition had a large “Not Sure” vote, ranging from 23% to 39%. With increasing age, significantly fewer respondents believed that the RD was most qualified to deal with dietary supplements, while greater numbers of respondents aged 39 and above believed that a Nutritionist was best qualified here (Chi2=24.249, p=0.000). Significantly more respondents aged 26 and younger were likely to see a Nutritionist as most qualified to deal with dietary supplements, yet when the age range is extended to 39, more respondents chose the RD (Chi2=24.249, p=.000). Significantly, the “Not Sure” vote also increased with increasing age (Chi2=12.686, p=.048). With a higher education (Bachelors degree or more), significantly more respondents saw the RD as most qualified to deal with genetically modified foods, while a larger percentage (45.4%) of those with some college or less believed the Nutritionist was most qualified to deal with this issue (Chi2=8.674, p=.013). These results are summarized in Table 5.

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Table 5. Best Qualified to Deal With Nutrition Issues Variables

Use of dietary supplements Obesity/overweight condition Irradiation of foods Genetically modified foods Diabetes Hypertension Heart disease Cancer

N

365 365 365 365 365 365 365 365

Nutritionist %/ RD %/ (Respondents) (Respondents) 32 (116) 23 (83) 30 (110) 36 (132) 19 (71) 21 (78) 23 (85) 21 (76)

44 (162) 55 (199) 32 (117) 31 (114) 54 (196) 47 (171) 48 (177) 41 (148)

Not Sure %/ (Respondents) 24 (87) 23 (83) 38 (138) 33 (119) 27 (98) 32 (116) 28 (103) 39 (141)

When respondents were asked to state whether a specific task applied to a Registered Dietitian or a Nutritionist, the largest percentage indicated that both professions would create diets and menus (65%), teach nutrition-related subjects (59%), and provide nutrition counseling (52%). By selecting “Don’t Know,” respondents were not sure if RDs or Nutritionists prepare and serve food (38%) or even if they offer psychological advice (44%). The largest percentage of respondents believed that the RD would assess nutrition of hospitalized patients (49%), have a college degree (33%), complete an internship (38%), and pass a certification exam (40%). Significantly more women than men believed that both the RD and Nutritionist create diets and menus (Chi2=13.806, p=.003), that both the RD and Nutritionist teach nutrition related subjects (Chi2=9.931, p=.019), that the Nutritionist provides nutrition counseling (Chi2=8.461, p=.037), that the RD prepares and serves food (Chi2=8.906, p=.031), and that the RD offers psychological advice (Chi2=8.906, p=.031). However, significantly more males than females did not know who would create diets or menus (Chi2=13.806, p=.003), who would teach nutrition related subjects (Chi2=9.931, p=.019), who would most likely

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provide nutritional counseling (Chi2=8.461, p=.037), who would prepare and serve food (Chi2=8.906, p=.031), or who might offer psychological advice (Chi2=8.906, p=.031). With increasing age, fewer respondents knew whether an RD or a Nutritionist would provide psychological counseling (Chi2=24.894, p=.003). Younger respondents tended to believe that either an RD or both the RD and Nutritionist provided this service. The results are summarized in Table 6. Table 6. Assessed Functions of Registered Dietitian or Nutritionist Variables

N

RD %/ (Resp*)

Nutr %/ (Resp)

36 5 Teaches nutrition 36 5 Assesses hospitalized patients 36 5 Provides nutrition counseling 36 5 Prepares and serves food 36 5 Offers psychological advice 36 5 Must have a college degree 36 5 Must complete an internship 36 5 Must pass a certification exam 36 5

19 (68)

5 (19)

65 (237)

11 (41)

8 (30)

21 (76)

59 (217)

12 (42)

49 (178)

12 (43)

24 (86)

16 (58)

9 (33)

28 (102)

52 (190)

11 (40)

25 (91)

12 (45)

25 (90)

38 (139)

19 (70)

13 (47)

24 (88)

44 (160)

33 (122)

13 (49)

31 (113)

22 (81)

38 (139)

9 (33)

24 (88)

29 (105)

40 (145)

7 (26)

32 (117)

21 (77)

Creates diets and menus

Both %/ Don’t Know % (Resp) (Resp)

* Resp = Number of respondents When asked if they were ever seen by a Registered Dietitian, 292 respondents (80%) said no and 19 (5.2%) were unsure.

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CHAPTER V DISCUSSION The purpose of this study was to determine the public’s ability to differentiate between a Registered Dietitian (RD) and a Nutritionist, and understand the functions of each. As might be imagined, there are few studies on this subject, since the interest is narrowly defined and limited to RDs and the organization that represents them. Two recent studies were conducted by the American Dietetic Association (ADA) in 2000 and 2002. The focus of these studies was somewhat different from this current research, since the earlier studies also questioned the public’s attitudes, behavior, and perceptions about foods and nutrients such as vitamins and herbal supplements. Both the ADA surveys, and the current research, however, asked about the public’s most valued sources of nutrition information, the same question included (by permission) in this study. Neither of the earlier studies, however, attempted to differentiate between a Nutritionist and an RD. So this approach is somewhat unique. Overall, the current research indicates that the public has some knowledge of the RD function, but is definitely confused when trying to distinguish between the two professions.

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Discussion of Findings The original survey was not available. However, according to the ADA’s Nutrition & You: Trends 2000, Background and Objectives, January 2000 (Appendix A), results indicated that when consumers were allowed more than one answer, they rated doctors, registered Dietitians, and Nutritionists as the most valued sources of nutritional information, followed by magazines, nurses, and newspapers. Then inexplicably, ADA’s Nutrition & You: Trends 2002 survey Final Report of Findings, October 2002 (Appendix B), eliminated both RD and Nutritionist as valued sources, and now respondents rated television and magazines as most valued, with doctors falling to 8th position. There was no explanation given for why RDs and Nutritionists were eliminated as options, but the summary did comment on the doctors’ poor showing by simply stating “significantly fewer respondents currently cite doctors as a source of information…” (p. 10). Perhaps ADA sensed there would be a precipitous drop in the reliance on RDs and that is why the option was eliminated. Regardless, the oversight was corrected in this research, and the results were surprising, but not unexpected. Magazines, doctors, and Internet were the first three choices among respondents (50.7%, 48.2%, and 44.7% respectively), with Registered Dietitians and Nutritionists falling to 7th and 8th -position in the “most valued” category (at 23% and 21.6% respectively). These results were very different from the 2000 ADA survey, which showed that doctors, RDs, and Nutritionists were the most valued sources of nutritional information. So if these results are accurate, much work has to be done to reestablish the reputation of RDs. However, it is also possible that the current results are incorrect or the earlier study failed to accurately reflect consumer preferences. Perhaps only future, randomized studies will be able to resolve this issue

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completely. The 2002 ADA survey also found that reliance on magazines and newspapers was directly related to income. The current research did not confirm this. However, it did show that more women than men tend to rely on magazines as a source of nutritional information. And this may prove to be a valuable insight into how to best communicate with women about nutritional issues. Yet the reliance on magazines as the most valued source of nutritional information is somewhat nebulous, since the authors of those articles may have been RDs, Nutritionists, doctors, or even freelance journalists. There’s no way to know from this survey. And again, a similar logic applies to the selection of doctors as the #2 choice. It is highly unlikely that the doctors selected would be either RDs or Nutritionists, and they would therefore have little background in nutrition. A 2001 paper entitled “Survey of Nutrition Education in U.S. Medical Schools – An Instructor-Based Analysis” showed that on average, medical students are required to have 18 +/- 12 hours of nutrition education (Torti, Adams, Edwards, Lindell, & Zeisel, 2001), hardly enough to provide sufficient expertise in this area. So it can be inferred that to the extent patients rely on doctors, they may not be getting the latest and most appropriate nutritional advice. It is most obvious that the public is unaware of the difference between a Nutritionist and a Registered Dietitian when they are asked who is most qualified to deal with food related issues. Even though the greatest number of respondents (31.2%) believes that an RD is most qualified here, when the incorrect answers “Yes” and “Not Sure” are combined, they total 68.8%. That is more than two-thirds of all respondents who don’t recognize the expertise and capability of an RD! But respondents also seem to be somewhat mixed in their responses. For example, they believe that both the RD and Nutritionist are more qualified than a doctor to discuss food-related issues, yet

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respondents also indicate that doctors are their second most valued source of nutritional information, following magazines. RDs and Nutritionists aren’t even close. A similar situation exists with the following two questions. When respondents were asked, “Who is best equipped to treat nutritional problems,” the largest percentage chose RD (40.5%) with Nutritionist following at 32.9%. Doctors received only 8.2% of the vote. If all other options (nurse, doctor, social worker, Nutritionist, teacher, diet technician, other, or not sure) are added together, 59.5% of the respondents were incorrect in their response. That is, they didn’t select “RD.” When asked whether a Nutritionist or an RD was most qualified to deal with issues such as dietary supplements, obesity/overweight, irradiation of foods, genetically modified foods, diabetes, hypertension, heart disease, and cancer, only two options were correctly selected, and attributed to the RD: obesity/overweight and diabetes. Four of the remaining 6 options (use of dietary supplements, hypertension, heart disease, and cancer) also correctly selected the RD, but the non-RD vote again indicated significant confusion among the respondents. The last question asked respondents to indicate if certain issues applied to either an RD, a Nutritionist, or both. These were: creates diets and menus, teaches nutrition related subjects, assesses nutrition of hospitalized patients, provides nutrition counseling, prepares and serves food, offers psychological advice, must have a college degree, must complete an internship, and must pass a certification exam. Sixty-five percent of respondents thought both the RD and Nutritionist created diets and menus, but individually, RD (19%) had a greater percentage than Nutritionist (5%). So here, a large percentage of respondents accurately identified the creation of diets and menus as a significant function of both professions. Only a small percentage of respondents realized

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that the RD must have a college degree (33%), complete an internship (38%), or pass a certification exam (40%); and this may contribute to a lower status for RDs and could also be a major factor in confusing an RD with a Nutritionist, who is not required to have these qualifications. Twenty-five percent of respondents believed that RDs prepare and serve food, a percentage that’s twice as high as that for Nutritionist. So, if this truly reflects public opinion, one-quarter of the population, inaccurately believe that RDs perform this menial task, which in reality, is generally relegated to food service workers who have no special training. And only 49% recognized that RDs, and not Nutritionists, are allowed to assess the nutrition of hospitalized patients, which is a major and unique function of the clinical Dietitian. Twenty-four percent thought that both RDs and Nutritionists offer psychological advice, which neither profession is qualified to provide, further illustrating the confusion in the public’s mind about the functions of RDs and Nutritionists. Two questions were included in the survey to gauge bias, or a pre-existing knowledge of Registered Dietitians. When asked if respondents had ever been hospitalized, 65% said yes. But when asked if a Registered Dietitian had ever seen them under any circumstances, 80% said no. Strangely, more had never been seen by an RD than had been hospitalized. But perhaps that is understandable since an RD does not see all hospitalized patients, unless the severity of their illness warrants it. And even if the respondent did see an RD, he or she may not have been aware of it, or that experience may not have created a greater awareness of RD functions. So since these questions were intended to eliminate respondents who, by virtue of their interfaces with RDs, would

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have a greater knowledge of the RD function, the ambiguity of these questions made it necessary to eliminate them for this purpose.

Implications The results of this study show that the public cannot easily distinguish between the Nutritionist and the RD. Ultimately, this may mean that RDs are not seen as the nutrition professionals, and they may not receive the status or income commensurate with their education, training, and experience. For example, the mean average wage for Dietitians in a General Medical and Surgical Hospital as of May 2005, was $46,540 (United States Bureau of Labor Statistics, 2005); for Nutritionists at the same time, the mean annual wage was $57,820 (United States Bureau of Labor Statistics, 2005), a difference of $11,280! Not seeing RDs as the nutrition professionals also means that the general public is not well served when they seek nutritional advice. Most people understand the function of a medical doctor or a nurse, and believe that their advice can lead to an improved state of health. These professions 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 might also be elevated to a higher level of esteem. Since the Nutritionist is not required to have any specific training or experience, then the public, which may not understand the different competencies required, may wind up relying on advice that is not evidence-based, and which may actually harm them. This could ultimately increase the cost of healthcare and adversely affect everyone’s insurance premium. So what can be done to improve this? A number of options present themselves:

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First, RDs, to some extent, have to rely on the ADA as the organization chartered to represent them. But ADA’s track record in this arena has not been good, despite their attempts to make a difference. For example, an article appearing in the magazine Today’s Dietitian (Grieger, 2005), mentioned that in 1998-99, the ADA conducted a $1.5 million national campaign to increase the “public awareness or credibility of RDs.” But according to the article, it failed miserably. Why? The article didn’t say, and the ADA never responded to my queries about the campaign. But rather than modify their campaign, it seems that ADA took a different approach. They attempted, and still are attempting, to require RDs to have a Master’s Degree. But is that the answer? The real problem appears to be more basic than that. After all, how many hospitalized patients know, or care today, if their nurse has a Master’s Degree? Patients simply trust the nurse, believe in his/her expertise, and expect them to provide the necessary care. It is much more important that the ADA focus its efforts in developing similar expectations for RDs, possibly by helping to clarify the differences between RD and Nutritionist. And it is most important to assure that the general public, and even some doctors and nurses, understand the importance of RDs to the field of nutritional and physical health. The ADA also needs to target government documents that confuse RD and Nutritionist, as well as the web pages that confuse these terms. Next, it is important that the ADA spearheads the research that might help to highlight the contribution of Dietitians to the field of nutrition. Why is it that the Journal of the American Medical Association (JAMA) seems to publish studies that have a greater chance of getting national attention than those published in the Journal of the American Dietetic Association (JADA)? Perhaps because JAMA publishes articles such

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as “Comparison of the Atkins, Ornish, Weight Watchers and Zone Diets for Weight Loss and Heart Disease Risk Reduction: A Randomized Trial,” or “Consumption of Vegetables and Fruits and Risk of Breast Cancer,” while JADA publishes articles like “Competitive Foods Available in Public High Schools,” “Association of Ghrelin and Leptin Hormones with BMI and Waist Circumference,” or “Health Coaching as a Career.” To be sure, these articles are important to the profession, but they are incapable of achieving the visibility to ultimately elevate the status of RDs. Why? It is these special studies that seem to get promoted by the national media, and help to promote the profession of medicine. And Dietitians should expect no less. If these special studies require increased expense and expertise to implement, then perhaps the ADA should allocate their funds more wisely to sponsor such efforts. Third, since many in the public seem to perceive “Nutritionist” as the nutrition professional, why not investigate the possibility of 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. And if the public is any judge of the ADA decision, perhaps ADA made the wrong choice. It seems that many in the public domain see Dietitians as people who prepare menus, cook food, and are confined to the kitchen. And even a requirement for a PhD will not overcome that obstacle. As two focus group participants suggested, either change the name to “Registered Nutritionist” or “Registered Nutritionist-Dietitian.” This may or may not be possible, depending on the politics involved, but it should be investigated and careful consideration given to its implementation.

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Fourth, this study showed that even though 65% of respondents were hospitalized, 80% of those respondents had never seen (or did not think they saw) an RD. There seems to be a definite disconnect here that needs to be corrected. Perhaps the ADA could educate all inpatient Dietitians to actively inform patients of their status, and to reiterate that message constantly. Fifth, in addition to promoting good eating habits, why not use National Nutrition Month as a medium for promoting the RD. It is a great opportunity to use this annual event, which already has some national visibility, to help publicize RD contributions, expertise, and accomplishments. Sixth, selecting a “Registered Dietitian of the Year” could be a significant promotional event. ADA could send out national news releases showing what that person has accomplished, and highlighting how those accomplishments has led to improved health for the general public. Seventh, various national magazines could be approached about accepting articles relating to Registered Dietitians and their significant achievements. Eighth, RDs can be promoted much more effectively in elementary schools as well. 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 the various roles held by RDs. In addition, various promotional materials can be produced for children, and RDs can make a special effort to frequently visit with this population. Ninth, ADA could sponsor a weekly, or monthly, radio, television, or web broadcast, with RDs as host. This could be dedicated both to providing the latest nutritional information and helping to promote the profession.

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Tenth, the ADA has never had a male president, and this may possibly relate to how poorly the profession has been promoted. It does appear that research on male/female differences has been inconsistent in this area. But there is some agreement that women, in general, tend not to be competitive (Niederle & Vesterlund, 2006; Gneezy, Niederle, & Rustichini, 2003), are more agreeable and take fewer risks than men do (Lauriola & Levin, 2000), are less assertive (Costa, Terracciano, & McCrae, 2001), and are more focused on feelings than ideas (Costa et al.,2001). Perhaps these are not the qualities necessary to best promote the profession. Perhaps these are qualities that also make it difficult for many RDs, most of whom are women, to promote themselves. Perhaps if ADA researched this issue, they would uncover a value in developing assertiveness training programs, or they might consider actively recruiting a male president, and then analyze the results. But these are just some of the possibilities. This is not intended to be an exhaustive list, but to provide approaches that ADA and individual RDs can implement immediately to heighten an awareness of the RD function. However, it does appear to this researcher that if something significant is not done, and soon, this profession could blend in with many other nondescript professions and get lost in the flow of history.

Research Implications Since a greater percentage of survey respondents were female (79.2% vs. 20.8% male), the results could be considered biased. However, given that the Chi2 analysis indicated relatively few significant gender differences, the impact of a larger percentage

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of females seems minimal. Even so, future research may want to focus on increasing the percentage of male respondents. It is possible that the survey’s focus on diet and nutrition and asking if the respondents had ever seen an RD, may have biased the response; participants may guess that an RD is the primary focus. Hence, future studies may want to keep the subjects blind to the focus by including questions about doctor related tasks. It is also possible that some of the results could be due to the use of the term “Registered Dietitian”. It might be a good idea for future research to have some surveys use the term “Registered Dietitian” when comparing to a Nutritionist and some to simply use the term “Dietitian” to see if any differences are observed. Given that this survey targeted people with internet access, the study may have an under-representation of lower-income respondents. Hence, future studies may want to target lower-income people as well.

Conclusion The research hypotheses stated that (1) The public’s perception of a Nutritionist as the professional nutrition practitioner is significantly and positively greater than the perception of a registered Dietitian, and (2) knowledge of the differences between Dietitian and Nutritionist varies with socioeconomic status and gender. This study did not support these hypotheses, but it did illustrate the confusion that exists in the public mind when it comes to differentiating between an RD and a Nutritionist. And perhaps this is the greater issue and the one in most need of immediate attention.

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That Registered Dietitians are not given the respect they deserve is a common complaint from RDs, and one that is confirmed by public perception as described in this study. But the situation is not irreversible. By better promoting the RD, by sponsoring ground- breaking studies, and more closely working with media, the ADA and individual RDs have the power to make a difference. Research on topics of national interest would be invaluable and add to the ammunition and impetus for change. A limitation to this study is the selection bias, inherent in the use of an online snowball survey. First, persons responding to this survey had to be computer literate, so those not owning or capable of operating a computer were automatically eliminated. Second, research shows that computer users tend to be younger, wealthier, and better educated than nonusers (Skitka et al., 2006), so this may have eliminated a whole subset of possible respondents; and third, not all who received the invitation to participate, agreed to do so. Perhaps a larger, more randomized study would help to confirm these results. But until then, it is time for the ADA and individual RDs to grasp their own destiny and initiate those changes that will not only help the profession, but will also serve to benefit a population hungry for the best nutritional support.

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REFERENCES Atkinson, R., & Flint, J. (2001). Accessing hidden and hard-to-reach populations: snowball research strategies. Retrieved September 20, 2006 from http://www.soc.surrey.ac.uk/sru/SRU33.html Bonne, M. (2004, January). Dietetics salaries. Today’s Dietitian, 26-29. Braithwaite, D., Emery, J., deLusignan, S., & Suitton, S. (2003). Using the internet to conduct surveys of health professionals: a valid alternative? Family Practice, 20, 545-551. Cassell, J. (1990). Carry the flame: the history of the American Dietetic Association. Chicago, IL: American Dietetic Association. Costa, P.T., Terracciano, A., & McCrae, R.R. (2001). Gender differences in Personality traits across cultures: Robust and surprising findings. Journal of Personality and Social Psychology, 81, 322-331. Definition of convenience sampling, recommended by Ryerson University (n.d.). Retrieved on September 04, 2006 from http://www.ryerson.ca/~mjoppe/ResearchProcess/ConvenienceSample.htm Definition of Nutritionist recommended by MedicineNet.com (2006). Retrieved on August 29, 2006 at http://www.medterms.com/script/main/art.asp?articlekey=4603 Definition of Nutritionist recommended by the National Cancer Institute (2006). Retrieved on August 29,2006 from http://www.nci.nih.gov/Templates/db_alpha.aspx?CdrID=44662 Definition of Registered Dietitian recommended by the American Dietetic Association (2005). Retrieved on August 27, 2006 from http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/CADE_748_ENU_HTML.htm Dietitians and Nutritionists defined (1964). Unpublished manuscript. The American Dietetic Association, Chicago. Functions of Dietitian as recommended by the Dictionary of Occupational Titles (n.d.). Retrieved on August 27, 2006 from http://www.occupationalinfo.org/dot_d3.html Eaton, J., & Struthers, C.W. (2002). Using the internet for organizational research: a study of cynicism in the workplace. CyberPsychology & Behavior, 5, 305-313.

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Gneezy, U., Niederle, M., & Rustichini, A. (2003, August). Performance in competitive environments: Gender differences. Quarterly Journal of Economics, 118, 1049-1074. Goodman, L. (1961). Snowball sampling. The Annals of Mathematical Statistics, 32, 148-170. Grieger, L. (2005, July). To degree or not to degree. Today’s Dietitian, 31-35. Harrison, L., & Hughes, A. (1997). The validity of self-reported drug use: improving the accuracy of survey estimates. (National Institute on Drug Abuse Research Monograph No. 167). Rockville, MD: Division of Epidemiology and Prevention Research. Lauriola, M., & Levin, I.P. (2001). Personality traits and risky decision-making in a controlled experimental task: an exploratory study. Personality and Individual Differences, 31, 215-226. Niederle, M., & Vesterlund, L. (2006) Do women shy away from competition? Do men compete too much? Unpublished manuscript. Stanford University and NBER, University of Pittsburgh. Skitka, L.J., & Sargis, E.G. (2006). The internet as psychological laboratory. Annual Review of Psychology, 57, 529-55. Snijders, T.A.B. (1992). Estimation on the basis of snowball samples: how to weight? Bulletin de Methodologie Sociologique, 36, 59-70. Thompson, S.K., & Collins, L.M. (2002). Adaptive sampling in research on riskrelated behaviors. Drug and Alcohol Dependance, 68, S57-S67. Torti, F.M., Adams, K.M., Edwards, L.J., Lindell, K.C., Zeisel, S.H. (2001). Survey of nutrition education in U.S. medical schools – an instructor-based analysis (2001). Retrieved on September 2, 2006 from http://cogprints.org/2383/01/res00023.pdf United States Bureau of Labor Statistics (2005, May). Mean annual wage for registered nurses in general medical and surgical hospitals. Retrieved on 25 August, 2006 from www.bls.gov/oes/current/oes291111.htm United States Bureau of Labor Statistics (2005, May). Mean average wage for dietitians and nutritionists in general medical and surgical hospitals. Retrieved on 25 August, 2006 from www.bls.gov/oes/current/oes291031.htm

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United States Bureau of Labor Statistics (2006). Operational outlook handbook. Retrieved on 29 August, 2006 from www.bls.gov/oco/ocos077.htm

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