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The making of a nutrition professional: the Association for Nutrition register

Published online by Cambridge University Press:  02 April 2012

JE Cade*
Affiliation:
Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds LS2 9JT, UK
E Eccles
Affiliation:
Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds LS2 9JT, UK
H Hartwell
Affiliation:
Centre for Wellbeing and Quality of Life, School of Tourism, Bournemouth University, Bournemouth, UK
S Radford
Affiliation:
Association for Nutrition, London, UK
A Douglas
Affiliation:
Association for Nutrition, London, UK
L Milliner
Affiliation:
Association for Nutrition, London, UK
*
*Corresponding author: Email j.e.cade@leeds.ac.uk
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Abstract

Objective

Nutritionists in the UK are at the start of an exciting time of professional development. The establishment of the Association for Nutrition in 2010 has presented an opportunity to review, revitalize and expand the UK Voluntary Register of Nutritionists. In the UK and elsewhere, there is a need for a specialist register of nutritionists with title protection as a public safeguard.

Design

The new structure will base professional registration on demonstration of knowledge and application in five core competencies. Initially, there will be five specialist areas: animal; public health; nutritional scientist; food; sports and exercise. The wording and requirements linking the specialist areas to the competencies have been carefully defined by leading individuals currently on the existing register in these specialist areas. These have been evaluated by a random sample of existing registrants to check for accuracy of definitions and examples. Other work aims to establish a clear quality assurance framework in nutrition for workers in the health and social care sectors (UK Public Health Skills and Career Framework Levels 1–4) who contribute to nutrition activity, such as community food workers, nutrition assistants and pharmacists. Students, co-professional affiliates and senior fellows will also find a place in the new Association. The title ‘nutritionist’ is not currently legally protected in the UK and it is used freely to cover a range of unregulated practice.

Conclusions

The establishment of a professional register to protect the public and to provide a clear identity for nutritionists is a vital step forward.

Type
Hot Topic – Workforce development
Copyright
Copyright © The Authors 2012

Nutritionists in the UK are at the start of an exciting time of professional development following the establishment of the Association for Nutrition in 2010(1). The UK Voluntary Register of Nutritionists, which formed in 1997, regulates professionals in the field of nutrition(Reference Landman, Buttriss and Margetts2). It was originally hosted by the Nutrition Society and developed in rather a piecemeal fashion, with additional sections added to the register as need arose. With the transfer of the Register to the Association for Nutrition there is an opportunity to review, revitalize and expand the Register, its constitution, structure and standard operating procedures.

Why do we need a register of nutritionists?

Government priorities both nationally and internationally include promoting appropriate nutrition for health and well-being(3, 4). Nutrition is big business, and rising food prices could be a major risk to the UK's economy(5). Over recent years there has been a proliferation of people offering nutrition advice or dietary supplements. As consumers have become more aware of the links between nutrition and health, food and nutrition misinformation in the media has flourished(Reference Wansink6). News stories are often judged by the instant appeal of the headline or sound bite(Reference Rowe7). High-profile individuals are claiming nutrition credentials without any relevant training or qualifications. Therefore, professional bodies of nutritionists and dietitians have a responsibility to promote evidence-based nutrition information to reverse the tide of nutrition ‘quackery’. In the UK and elsewhere, there is a need for a specialist register of nutritionists with title protection(8) and it is important so that qualified and experienced nutritionists from specialist areas can be centrally recognized and regulated(Reference Stockley and Scott9). It is also essential for public safeguard as the public needs access to a regulated register to avoid sham nutritionists who give advice without having the correct knowledge, competency, skills or experience required(Reference Stockley and Scott9, Reference Hughes10). Notwithstanding, nutritionists can also be regulated elsewhere through publicly available registers(11); however, a unified, single regulated source is clearly required.

Theoretical models of professional practice

Nutritionists work in a diverse range of settings creating a range of educational needs. Not all nutritionists have had formal training in terms of a first degree in nutrition. The definition of a professional nutritionist must be broad enough to capture the relevant scopes of practice and provide benchmarking against which standards can be assessed. The approach taken by the Association for Nutrition is one of competency-based learning and experience. Competencies relate to nutrition education through making explicit expected outcomes. To achieve competency in a particular skill is defined as ‘the ability to perform and sequence actions to attain a specific goal’(Reference Koo and Miner12). Competencies are a useful foundation for a professional body since they can be used to define the profession for practitioners at different levels of experience and should be part of continuing professional development. This approach is demonstrated in other professions including public health, where the Dreyfus model of skills acquisition has been used to define seven levels of professional behaviour from entry-level practitioner through to capable, competent, proficient, expert, advanced expert and luminary(Reference Koo and Miner12). These can be used to benchmark expected competencies at different points of the professional's career development. Others have suggested a cube model with three axes representing competency development for the professional, the three axes being foundational competencies, functional competencies and developmental progression(Reference Hanson and Kerkhoff13).

The current position in the UK

The voluntary register of nutritionists developed by the Nutrition Society in the UK and now held by the Association for Nutrition has four categories of nutritionist: two at a junior level, i.e. Associate Nutritionist and Associate Public Health Nutritionist; and two at fully registered nutritionist level, i.e. Registered Nutritionist and Registered Public Health Nutritionist. Before individuals are admitted to the register they must affirm that they accept the Code of Ethics and Professional Conduct and meet the minimum competencies. The ethical code requires registrants to remain professional at all times through maintaining and enhancing competencies(14). Additionally, there are also Standards of Proficiency that each member has to uphold, which outline expectations in terms of autonomy, teamwork, skills for assessment and delivery of health plans and strategies, communication, education, implications of knowledge and understanding(15).

Applicants who are eligible for full registration have an approved qualification or equivalent in nutrition and significant contemporary relevant professional experience, normally lasting three years in the past five. In addition, a portfolio of evidence of working as a nutritionist must be submitted and a Self-assessment of Professional Competency form completed. There are differences in training and experience required for the two groups of Full Registrants (Nutritionists and Public Health Nutritionists), and this is potentially confusing for both applicants and the public.

Associate Registration is for graduates with a BSc Honours in nutrition or a postgraduate degree in nutrition, who have knowledge but little practical experience or training that is required for Full Registration. There is some inconsistency here, in that for Associate Nutritionists (but not Associate Public Health Nutritionists) inclusion on the register is possible at this level on submission of an appropriate portfolio of evidence and completion of a self-assessment form.

To appear on the register a nutritionist has to complete and provide evidence of professional competency, which covers three areas: (i) underpinning scientific knowledge; (ii) general professional skills and practice; and (iii) professional skills and practice with individuals. Sections 2 and 3 relate to nutritionists who have work experience in these areas, while individuals who can currently only provide evidence for section 1 can apply to become Associate Nutritionists(16). There is a separate ‘self-assessment form’ for applying to the Public Health Nutrition category(17).

New structure of the register

In order to simplify and streamline the application procedure the new Association for Nutrition is improving the register structure while retaining standards for nutritionists. There will be one single registered status, i.e. Registered Nutritionist (RNutr), and a single junior title, i.e. Associate Nutritionist (ANutr). Nutritionists will have to demonstrate knowledge and application (for full registrants) in five core competencies and registrants and associates may choose to be in one or more of five specialist areas, currently these are animal; public health; food; nutrition scientist; sports and exercise.

Core competencies

The areas of core competency identified for all nutritionists in summary form are:

  • scientific background;

  • impact of dietary intake on food choice;

  • food in a social or behavioural context;

  • nutrition in health promotion; and

  • professional conduct and the nutritionist's code of ethics.

These competencies have already been specified as part of the new system to demonstrate what is expected in terms of knowledge, application and the evidence of experience needed by registrants and associate members. Specific definitions will help dispel confusion surrounding the title and expertise of nutritionists. Competencies have been set for nutritionists in other countries. For example, in Australia nutritionists must demonstrate experience, application and knowledge of eleven different core competencies(11). In the USA, fifty competencies were identified by primary care physicians as a basis for nutrition education of medical students(Reference Young, Weser and McBride18). An Italian review paper found that the role of a nutritionist should be defined in terms of specialist competencies to deal with population nutritional advice(Reference Cena, Roggi and Lucchin19), where it identified four areas of nutritional science: applied, public health, clinical and behavioural. Hughes(Reference Hughes20) used both quantitative and qualitative methods for evaluation of nutrition competencies. A ‘Delphi’ method using an international panel of twenty-four public health nutrition experts from nine countries resulted in seven different competency areas. Although this research was carried out for the Australian population, the international panel suggests the results could be more generally applied to other populations. Competencies for professional nutritionists will act as a step in eliminating erroneous advice to the public and therefore fulfil the Nutrition Society's aim of ‘restoring credibility to nutrition’(Reference Landman and Wootton21).

Specialist areas

The new structure of the Association for Nutrition register, to be introduced in 2012, will have a number of specialist areas for nutritionists. Currently these are:

  • animal, which covers nutritionists who specialize in animal nutrition;

  • nutritional scientist, which covers nutritionists who investigate the metabolic and physiological responses of the body to foods and nutrients;

  • food, which covers nutritionists who specialize in hospitality and the food industry;

  • public health, which covers nutritionists who work in the community or with population-level data; and

  • sports and exercise, which covers nutritionists who advise teams and individuals.

The wording and requirements linking the specialist areas to the competencies have been developed by leading individuals currently on the register in the specialist areas. These needed to be carefully defined to avoid public confusion and to provide a platform for professional practice(Reference Stockley and Scott9).

An example is shown in Table 1 of the core competencies which are common to all specialty areas. In addition, Table 1 includes definitions in terms of knowledge/skills, applications with examples and evidence required to demonstrate competency in each area for the Public Health Nutrition specialty as defined by the relevant working group. Similar definitions with examples have been developed for the other areas of specialism. This was done to allow each specialty group to emphasize skills and workplace examples of direct relevance to each area.

Table 1 Example of mapping knowledge and application against competencies for the nutrition specialty, Public Health Nutrition

Evaluation of core competencies and specialist areas

The definitions and identification of the specialities with knowledge and application of the five core competencies have been evaluated using nutritionists currently on the register. An online survey was sent to a randomly selected representative sample of 256 members of the existing UK Voluntary Register of Nutritionists in June 2011. This random sample had forty-five registrants in each category of the existing register (RNutr, ANutr, PHNutr, APHNutr) plus accredited nutrition degree course leaders. The survey was completed by fifty-nine respondents (23 % of the original sample). The majority of respondents agreed that the new specialist category definitions and competencies – knowledge, application and evidence examples – were accurate. The more experienced or qualified nutritionists were, the more likely they were to agree with the definitions and examples. Minor tweaks and additions to the definitions were recommended.

Other literature reinforces the need for specialist categories of nutritionists within different settings. This is demonstrated by Pérez-Rodrigo and Aranceta(Reference Pérez-Rodrigo and Aranceta22), whose review identifies the need for public health and food nutritionists to lead other parts of society in good nutrition practice. Similar requirements have been identified for distinguishing ‘care/clinical’ nutritionists who can be regulated to deal with individuals and diseases(Reference Eaton, McBride and Gans23, Reference Ettinger24), clearly an area of nutrition where professional scrutiny is paramount. This clinical area may be a future development of the specialty area of the register.

Nutritionists develop, implement and evaluate nutrition policies and programmes, generating the evidence base and applying scientific knowledge to ensure understanding of the impact of food and diet on the health and well-being of people and communities. They can operate in a range of settings including as independent practitioners in relation to nutrition and health both for individual clients and for groups of people or populations. They may contribute to the management of people with medical conditions as part of a multidisciplinary team under the supervision of a suitably qualified health professional. However, clinical management is not part of their remit and registration as a nutritionist does not entitle a registrant to represent him/herself as a dietitian. There is a difference in the skills and responsibilities required for those in clinical dietetics and other nutritionists, where the latter tend to focus on the promotion of good health through nutrition and the primary/secondary prevention of nutrition-related illness in the population(Reference Eggers and Kennedy25). Nevertheless, professional boundaries have been flexed and although some nutritionists work at the population level, all communities and groups comprise individuals. Thus, nutritionists may work with individuals within the scope of their competence to practice(Reference Landman and Wootton21). Interestingly, in the USA, doctors, dietitians and other health-care professionals with a suitable background are eligible to take the examination to become a certified clinical nutritionist through the Clinical Nutrition Certification board. However, the requirements to become a certified nutritionist/dietitian vary from State to State.

Specialist sports and exercise nutritionists are needed to augment the nutritional education that athletes already receive(Reference Jessri, RashidKhani and Zinn26, Reference Smith-Rockwell, Nickols-Richardson and Thye27), albeit this is a limited remit for their skills. Both papers report on studies of student athletes, but do not recognize the need for reliable and competent support for the many in society who need advice and guidance to improve their own programme of activity and exercise. The American Dietetic Association, Dietitians of Canada and the American College of Sports Medicine emphasize the importance of optimal nutrition in physical activity and athletic performance. They state that nutrition advice should only be provided by a qualified nutrition expert, after carefully reviewing the athlete's health, diet, supplement and drug use, and energy requirements(28). It is our intention to provide a professional framework within which those with a broad general interest in improving lifestyle and protecting health can demonstrate that their practice is assured with confidence.

The need for animal nutritionists has been highlighted by the American College of Veterinary Nutrition. It has established requirements for certification in veterinary nutrition, encouraging continuing professional education, promoting research, and enhancing the dissemination of new knowledge of veterinary nutrition through didactic teaching and postgraduate programmes. There is no such equivalent organization in the UK. Food scientists also do not have a regulatory body, although they can apply for chartered scientist status through the Institute of Food Science and Technology (http://www.ifst.org/chartered_scientist_2/chartered_scientist_competences/).

Further developments

Other development work is in progress, spearheaded by a UK Department of Health-funded project, ‘Improving Capacity, Confidence and Competence in Nutrition across the Workforce’, which aims to establish mechanisms to ensure that all those involved in communicating nutrition messages can demonstrate competence in the subject. This will help to guarantee that the advice they provide to the public is safe, evidence based and effective. The ultimate objective will be to enable such workers to make a significant contribution to addressing nutrition-related inequalities, while making it possible to establish a clear quality assurance framework in nutrition(Reference Radford and Hall29). The focus of the project is on those with lower levels of nutritional knowledge and skill than is possessed by registered nutritionists. This includes individuals and groups of workers within the health and social care sectors (UK Public Health Skills and Career Framework Levels 1–4) who may not focus directly on food and nutrition in their work, but who may contribute to it, such as community food workers, nutrition assistants and pharmacists.

Plans are also underway to introduce an Association for Nutrition student membership scheme and for more senior members a Fellow scheme. A new Co-professional Affiliate of the Association for Nutrition will allow those with expertise and interest in nutrition from other professions to be linked to the Association. Examples of people who might find this relevant for their career would be nurses, veterinary nurses, other health professionals and food managers. Co-professional Affiliates must have a commitment to the improvement of nutrition or food quality in individuals or populations using evidence-based practice. Co-professional Affiliates can therefore come from any background, experience or training. Degree-level attainment in nutrition is not required but applicants must have reached degree-level standard in some area of study or have a combination of experience/qualifications deemed to be equivalent. Co-professional Affiliates will not be Registered Nutritionists (and will therefore not form part of the UK Voluntary Register of Nutritionists); they will not have letters to use after their name and will not be required to specify any category of specialism, but will be able to show an allegiance to nutrition. The overall structure of the proposed new membership of the Association is shown in Fig. 1. The categories of membership included on the register will be the Associate Nutritionist and the Registered Nutritionist. There will be a variable fee structure depending upon category of membership. This will be in line with other similar professional organizations.

Fig. 1 Proposed new structure of membership of the Association for Nutrition

Benefits of a new structure

There are considerable opportunities provided by the transfer of the Register to the new Association. Processes can be streamlined, providing clarity for applicants. Externally the new organization can provide better understanding of what makes a professional nutritionist. The scope of the Register and linked membership areas can be expanded. It is important that the Register is relevant to today's nutritionists and reflects current training and new areas of expertise. In addition, the revised structure will provide a framework for progression through the new levels of the Register. Longer-term plans would be to work towards chartered status for the title ‘nutritionist’. This can only be achieved with at least 5000 registrants, at present there are just over 1000 on the voluntary register.

The title nutritionist is not currently legally protected in the UK. The term is used freely to cover a range of unregulated practice and within common parlance nutritional therapist, nutrition consultant and nutrition advisor are all evident. There is a multitude of titles, qualifications and awarding bodies with an array of impressive credentials. However the robustness of the underpinning science which is offered to justify some of these practices does not appear to be secure and may be questioned(Reference Buttriss30). Hence the establishment of a professional register both to protect the public and to provide a platform of identity for nutritionists while also improving the understanding and practice of fellow health practitioners is a vital step forward.

Conclusions

A new structure for the voluntary register of nutritionists held by the Association for Nutrition in the UK has been described. This is competency based, with one unified title, Registered Nutritionist. However, the new structure will be flexible to allow nutritionists to identify themselves in one or more of five specialist areas. The success of the register will need to be measured in terms of its use by registrants, employers, the public and industry to ensure high standards of nutritional practice throughout the UK.

Acknowledgements

S.R. is funded through a project supported by the UK Department of Health. S.R., A.D. and L.M. are employed by the Association for Nutrition. J.E.C. is chair and H.H. deputy chair of the Registration Committee of the Association for Nutrition – these are voluntary positions. All authors contributed to the writing of this paper.

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Figure 0

Table 1 Example of mapping knowledge and application against competencies for the nutrition specialty, Public Health Nutrition

Figure 1

Fig. 1 Proposed new structure of membership of the Association for Nutrition