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 iiDedication iiiAcknowledgment ivList of Tables viiAbstract viii

CHAPTER 1 – INTRODUCTION 1Statement of the Problem 2Purpose 3Definitions in Alphabetical Order 3Research Hypothesis 4Assumptions 5Limitations 5

CHAPTER II – REVIEW OF LITERATURE 6Definition of Dietitian 7Definition of Nutritionist 9Recognition and Salary 11Snowball Survey 11Summary 13

CHAPTER III – METHODOLOGY 15Participants 15Instruments 16Statistical Analysis 17

CHAPTER IV – RESULTS 18Focus Group 18Participants 21

CHAPTER V – DISCUSSION 28Discussion of Findings 28Implications 33Research Implications 37Conclusion 38

REFERENCES 40

APPENDICESA. American Dietetic Association Nutrition and You:

Trends 2000 – Background, Objectives, and Summary 43

B. American Dietetic Association Nutrition & You:

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Trends 2002 - Final Report of Findings 49C. Feedback Form 95D. Survey Summary 96

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LIST OF TABLES

Table 1 – Focus Group Results 19

Table 2 – Socio-Demographic Data on Participants 21

Table 3 – Most Valued Sources of Nutrition Information 23

Table 4 – Professions Best Equipped to Treat Nutritional Problems 24

Table 5 – Best Qualified to Deal With Nutrition Issues 26

Table 6 – Assessed Functions of Registered Dietitian or Nutritionist 27

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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.

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Assumptions

This study was based on the following assumptions:

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 CADE-

accredited 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

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are not 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 socio-

demographics 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 Response Comments1. Is the survey question worth pursuing? 7 Yes2. Do you think the survey will elicit responses that can affect how RDs are viewed in this country?

4 Yes2 Not Sure

3. Do you think the survey can have an effect on how the ADA promotes RDs?

4 Yes3 Not Sure

4. Do you feel that an important issue has been overlooked in this survey?

1 Yes5 No1 Not Sure

“Maybe renaming our title to Registered Nutritionist-Dietitian”

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Question Response Comments5. Are questions worded in a way that is clear and unambiguous?

5 Yes1 Not Sure

“#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.”

6. Should any question be eliminated from this survey?

1 Yes3 No1 Not Sure

“Have you ever been hospitalized?”

“#6 – recommend removing ‘prepares and serves food’ since most RDs do not do this”

7. Should any question be added to this survey?

3 Yes3 No1 Not Sure

“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”

8. Comments “I really like the idea of changing our name from Registered Dietitian to Registered Nutritionist”

“Question #5 – I think you should add a column to represent equal qualification”

“Be consistent with capitalizing title of RD and Nutritionist”

28

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 N %Gender Male Female

76289

20.879.2

Age Less than 21 21-30 31-40 41-50 51-60 61-70 Greater than 70

2975395561216

10.226.213.619.221.37.42.1

29

Variables N %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

45211116211188443124141522111111111

12.357.8.34.45.8.34.92.21.11.10.8.3.51.1.31.1.31.4.5.5.3.3.3.3.3.3.3.3.3

Education Some high school High school graduate Some College Bachelor’s degree Post graduate student Post graduate degree

518118903995

1.44.932.324.710.726.0

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

3235483540174

8.89.613.29.611.047.7

30

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 185 50.7Doctor 176 48.2Nurse 37 10.1Newspapers 97 26.6Nutritionist 79 21.6TV News 104 28.5Family and friends 156 42.7Registered Dietitian (RD) 84 23Radio news 43 11.8Other non-news TV 25 6.8Internet 163 44.7Other 69 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

believed the Nutritionist, of the two, was more qualified (61.6% vs. 59.7%). Significantly

31

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 N %

Nurse 0 0Doctor 30 8.2Registered Dietitian 148 40.5Social Worker 0 0Nutritionist 120 32.9Teacher 0 0Diet Technician 4 1.1Other 3 .8Not Sure 60 16.4

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

32

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.

33

Table 5. Best Qualified to Deal With Nutrition Issues

Variables N Nutritionist %/ RD %/ Not Sure %/ (Respondents) (Respondents) (Respondents)

Use of dietary supplements 365 32 (116) 44 (162) 24 (87)Obesity/overweight condition 365 23 (83) 55 (199) 23 (83)Irradiation of foods 365 30 (110) 32 (117) 38 (138)Genetically modified foods 365 36 (132) 31 (114) 33 (119)Diabetes 365 19 (71) 54 (196) 27 (98)Hypertension 365 21 (78) 47 (171) 32 (116)Heart disease 365 23 (85) 48 (177) 28 (103)Cancer 365 21 (76) 41 (148) 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

34

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 %/ Nutr %/ Both %/ Don’t Know % (Resp*) (Resp) (Resp) (Resp)

Creates diets and menus 365 19 (68) 5 (19) 65 (237) 11 (41)Teaches nutrition 365 8 (30) 21 (76) 59 (217) 12 (42)Assesses hospitalized patients 365 49 (178) 12 (43) 24 (86) 16 (58)Provides nutrition counseling 365 9 (33) 28 (102) 52 (190) 11 (40)Prepares and serves food 365 25 (91) 12 (45) 25 (90) 38 (139)Offers psychological advice 365 19 (70) 13 (47) 24 (88) 44 (160)Must have a college degree 365 33 (122) 13 (49) 31 (113) 22 (81)Must complete an internship 365 38 (139) 9 (33) 24 (88) 29 (105)Must pass a certification exam 365 40 (145) 7 (26) 32 (117) 21 (77)

* 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.

35

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.

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

36

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

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

37

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

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

38

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

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

39

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

have a greater knowledge of the RD function, the ambiguity of these questions made it

necessary to eliminate them for this purpose.

40

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:

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

41

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

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

42

“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.

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

43

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.

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

44

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

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

45

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.

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

46

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.

47

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