Ed. Note: Harriet Hall was injured in a fall in Australia earlier this month. While she recovers, we are running guest posts in her regular Tuesday slot for as long as our supply of guest posts lasts. (Hint: If you ever thought of submitting a guest post and want a shot at your guest post being published on a Tuesday, now’s the time.) We wish Harriet well and hope she recovers sufficiently to resume blogging soon.
Kevin Klatt is one such contributor, a Nutritional Sciences PhD candidate and dietetics student who blogs at nutrevolve.blogspot.com. Welcome Kevin!
Registered Dietitians (RDs) are credentialed nutrition professionals who work across a broad range of clinical and public health settings to provide general nutrition recommendations and medical nutrition therapy. To become a RD, an individual must complete a set of core coursework (the Didactic Program in Dietetics) toward a Bachelor’s degree (at least), complete an accredited dietetic internship, and pass a final national examination. These standards, however, are set to change; as with many other allied health professions (e.g. Physical Therapists, Physicians Assistants, Nurse Practitioners), the dietetics profession is planning to move the RD credential to a graduate Master’s level as part of their proposed future education model. While advancing the education standards for a profession is generally seen as a smart opportunity for improving the practitioner’s entry level knowledge, the proposed education standards accompanying this shift to a Master’s degree reveal some cause for concern, for those who value science & evidence based nutrition.
The draft future standards for dietetics
In the latter half of 2016, the Accreditation Council for Education in Dietetics (ACEND), the accrediting agency for dietetic education programs, released their Draft Future Education Model Accreditation Standards for Associate, Bachelor’s and Master’s level dietetic practitioners, and their rationale for doing so. The language of the proposed standards, coupled with the proposed rationale, contain the expected education standards for a dietitian: foundational knowledge in physiology, biochemistry and genetics; fundamental knowledge regarding nutrient metabolism; understanding of pathophysiology of disease and where medical nutrition therapy might be employed; and basic counseling skills. Lumped in with these core components of dietetic practice is ‘integrative and functional nutrition’ terminology. For regular readers of the SBM website, this should raise red flags, as integrative medicine represents little more than a rebranding of complementary and alternative health.
The functional brand works its way into the curriculum
The proposed standards work the ‘integrative and functional’ language into the ‘Competencies and Performance Indicators’ section. For example, the Foundational Knowledge Competency 1.8 states that practitioners will apply ‘knowledge of pharmacology and integrative and functional nutrition to recommend, prescribe and administer medical nutrition therapy’. Another competency, under Client and Patient Services, is described as: ‘Prescribes or recommends nutrition-related pharmacotherapy and integrative and functional nutrition’. The language of ‘integrative and functional’ sticks out here, as it is not clearly defined within the standard what makes a therapy ‘integrative and functional’ (this issue of unnecessary branding is an issue for all ‘integrative medicine’). As someone familiar with the long time co-opting of nutrition therapies by alternative practitioners who themselves promote other dubious or harmful therapies, the inclusion of this wording in the dietetic education standards is a loaded association. I’m all for dietitians being aware of alternative medicine practices for safety and efficacy conversations with the whole healthcare team, but adoption of uncritical language that suggests RDs should ‘prescribe or recommend’ integrative and functional therapies is worrisome. Additionally, the use of the terminology is confusing, given that it is not used throughout the documents; some competencies just use the terminology of ‘nutrition interventions’ or provides ‘nutrition care’ – why, for a few competencies, was the ‘integrative and functional’ language chosen?
Why it was included
To understand the thinking behind the proposed education model, ACEND released a rationale document [PDF]; the rationale provided for the inclusion of integrative and functional medicine is as concerning as the actual use of this language (note: the rationale document has not been updated on the ACEND website in over a year). The document provides the details of healthcare and industry environmental scans that identified an increasing focus on ‘integrative healthcare’. Essentially, a major component of the rationale for including the ‘integrative’ language for medical nutrition therapies was to meet a market demand, not a deficit in current practices employed by RDs.
In addition to this environmental scan, ACEND released surveys to practitioners to judge their perspective on the importance of specific topics. The responses of 6,267 practitioners ranked the importance of applying ‘integrative nutrition principles to nutrition care and medical nutrition therapy, including the use of nutritional genomics, dietary supplements, and/or herbal remedies’ as 3.56 out of 4. Given this item’s wording, it’s impossible to determine how RDs feel about utilizing the integrative and functional nutrition terminology, or whether those responding have a clear understanding of the practices associated with the term. It is not surprising that this item received a high score, given that RDs have long recommended supplements when diet is unable to meet nutrient needs (e.g. b12 for vegan clients/patients), and are likely interested in learning about recent developments in areas with preclinical potential (e.g. nutrigenetics). What’s unclear in the rationale provided by ACEND is, what makes these practices ‘integrative’? I would argue that, if anything, RDs should be trying to reclaim medical nutrition therapies from their supposed ‘integrative’ counterparts (naturopaths, chiropractors) who have co-opted nutrition as somehow being outside the spectrum of evidence and science-based therapies. Instead of embracing this language, the field of dietetics might consider giving pause to further associating ourselves with integrative practitioners who do not practice evidence-based medicine.
Some problematic sources
Probably the most concerning component of the rationale document is the one page description of ‘Integrative Health Care and Integrative Medicine’. To discuss integrative medicine, ACEND cites three groups: The Institute of Medicine, the Consortium of Academic Health Centers for Integrative Medicine, and the (now defunct) Bravewell Collaborative, the latter two being notable advocates for the use of ‘integrative’ practices. The descriptions of ‘integrative medicine’ contains the typical handwaving about treating the whole person (mind, body, spirit) and focusing on prevention, as though these characteristics warrant their own brand of medicine. The ACEND document writers even rehash concerning statements from the Bravewell Collaborative, such as their emphasis on using effective interventions that are ‘natural’ whenever possible. As a profession, do RDs want to be adopting a philosophy that aligns itself with the appeals to nature fallacy? Naturalism has long invaded the popular culture perspective on nutrition (e.g. ‘Paleo diets’); acceptance of this philosophy due to a market demand is far from warranted or scientifically justifiable.
The consequences of embracing functional medicine
The consequences of using ‘integrative and functional’ language is particularly concerning when placed in the context of the field of dietetics as a whole. One of the major medical nutrition therapy textbooks, Krause’s Food and the Nutrition Care Process, often jokingly referred to as ‘The Dietitian’s Bible’, contains discussions of ‘integrative care’ which lack a critical perspective on the topic and often mixes aspects of historical practice, pseudoscience, mechanisms of action, and naturalism to produce clinically dubious recommendations. For example, in Chapter 6 on Biochemical Assessment (pages 172-173), there is a section on ‘functional nutrition assessment’ that highlights assessment of toxins entering the body, methylation and acetylation states, and antioxidants, hoping to ‘support the body’s natural mechanisms and restore balance and health’. Apart from textbook references, the Academy of Nutrition and Dietetics hosts professional interest groups, one of which is the ‘Dietitians in Integrative and Functional Medicine’, a practice group focused on ‘holistic’ and natural medicines [PDF]. As one can see from exploring these resources, critical perspectives on integrative and functional philosophies are lacking in the field, and current resources serve as a caveat for how these philosophies can lead to enthusiastic acceptance of therapies which lack validated clinical utility (e.g. assessing ‘epigenetic’ states, many supplements) or are outright scientifically implausible (e.g. spirit healing, homeopathy).
The overall lack of a critical and cautionary perspective about the inclusion of integrative and functional language in dietetics coursework should leave current RDs, students, and other allied health professionals, concerned about how these standards will be instituted by dietetic programs. The notion that a didactic education standard should become a focus for the profession based on “the popular market” rather than the scientific evidence is also of concern. If the registered dietitian is to remain “the nutrition expert” it would serve the profession best to maintain a clear identity that is grounded in food/nutrition science and evidence-based therapies.
If the inclusion of this language is concerning to individuals as dietetic practitioners, please reach out to the ACEND (they have monthly virtual town hall meetings) or relevant members in the Academy of Nutrition and Dietetics. For individuals who are not part of the field of dietetics, the impact of the inclusion of this language is something to look out for – the curriculum of an entire medical profession is currently set to adopt language associated with practitioners who promote dangerous pseudoscientific thinking about health.