Fears about the quality of some of the advice being dished out has led to increased calls for regulation in the sector

THERE IS growing concern among trained clinical dietitians and nutritionists in Ireland over misdiagnosis and inappropriate recommended dietary changes from some people who offer nutritional advice.

The concern is that those giving advice to both adults and children may not be adequately trained in nutritional science.

While the Government is looking to regulate and license the work of dietitians, there is little preventing a person taking a short-term course in nutrition and opening up a practice, calling themselves nutritionists or nutritional therapists.

Some professionals are now urging this be changed and for trained nutritionists and nutritional therapists to be regulated in the same way as physiotherapists, dietitians and others.

Richelle Flanagan, president of the Irish Nutrition and Dietetic Institute, says members of her organisation, who are trained clinical dietitians and nutritionists, have grown increasingly concerned at some recommended courses of treatment and dietary changes that have come to light in recent months.

Flanagan says the most common examples include major changes to a person’s diet that can lead to them requiring medical treatment and, in a small number of cases, hospitalisation.

She gives the example of an eight-year-old child who presented with gross obesity at a children’s hospital recently. During a consultation with a paediatric dietitian, it was revealed the child had suffered regularly from kidney infections, and an alternative health practitioner prescribed up to 1.5 litres of cranberry juice per day. While the kidney infection went away, the child’s weight increased.

Flanagan also pointed to other examples from her members, including nutritional advice given to cut out all dairy products for sufferers of irritable bowel syndrome and Crohn’s disease, and advising on questionable supplements as replacements for key food groups.

Flanagan says she noticed examples in a leaflet in her local cafe recently, promoting a talk on coeliac disease and claiming to be able to do a simple blood test to diagnose the condition. She says the only way to diagnose the condition is with a proper TG blood test administered by a local GP and also a small bowel biopsy.

“I also saw recently, in an ‘ask the expert’ section of a leading maternity magazine, that a ‘nutritionist’ advised a mum of an 18-month-old to stop dairy as it causes ‘mucus’ and the person recommended instead rice milk. We have a reference to refute milk causing mucus, and it has been stated by Food Safety Authority of Ireland that rice milk is contraindicated in babies due to its arsenic content.”

Flanagan also has experience of questionable nutritional advice closer to home, when her sister was diagnosed with metastatic breast cancer, which she had for eight years.

“I experienced first-hand the ‘alternative’ route that she was exposed to, and saw the lack of evidence base and the resultant outcomes of weight loss due to restricted dietary advice. People with metastatic breast cancer need to maintain weight to enable them to be strong enough to receive treatment.

“People in vulnerable positions are the most targeted in relation to alternative therapies, which can, in some cases, delay valuable treatment and compromise quality of life in the long run. My sister was losing weight and on a particular recommended macrobiotic diet. In the end, her oncology team, which included a trained dietitian, changed and managed her diet properly, and she lived for four more years.”

Dr Kevina Cardiff, a consultant dietitian in Dublin, outlines the example of a 23-year-old male patient of hers who was diagnosed with ulcerative colitis, an inflammatory bowel condition. He had periods of remission, coupled with aggressive phases of the disease.

“It was important for him to have a very healthy, balanced diet. Eight months before he came to me he had been to see someone, a nutritionist who was not properly qualified, and he had been told to cut out dairy,” says Cardiff.

“There was no regard for substituting the calorie loss or no recommendation to substitute calcium from another source. In fact, a high calcium diet is a requirement for persons with ulcerative colitis, who also have a high risk of osteoporosis.

“We would never tell someone to cut out whole food groups. I gave him the correct advice and he came back a month later, and his energy, mood and weight had changed for the better.

“As a clinical dietitian, we look at the full picture and understand the background of the condition, the drugs a patient may be on and all other factors.”

Cardiff says there is often a misunderstanding among the public about the roles of a clinical dietitian and a nutritionist or nutritional therapist.

“There would be different levels of training in nutritional therapy. Generally, a properly trained therapist would require up to four years’ training. Unlike clinical dietitians and nutritionists, nutritional therapists can never work in a hospital setting as they don’t have that experience.

“We’re not trying to undermine what a properly trained nutritional therapist does, but there do need to be some clear distinctions made.”

The Health and Social Care Professionals Council at CORU – a regulatory body set up to look at professions such as physiotherapists, psychologists, clinical biochemists, occupational therapists and others – is in the process of regulating the title and work of dietitians.

Those who want to practise using that title in Ireland will be required to have certain levels of training and to register for a licence. CORU is waiting on the Minister for Health to appoint a board to complete the process. Yet, despite the fact the work of dietitians and others will be monitored and controlled, no plans are in place for the work of nutritionists to be subject to the same controls.

“Nutritionists are not in our legislation,” says Mary Griffin, head of corporate services at CORU. “There is provision for the Minister for Health to add other professions, but as of now we have 12 professions under our remit. We are aware of about 15 others that want to be added to our model, but I don’t think nutritionists are one of them.”

When dietitians are regulated, they will be subject to Garda vetting and will have to abide by an agreed code of conduct. CORU will also approve certain training qualifications.

Griffin says there could be scope to look at regulation of nutritionists at some point in the future. “The public don’t know the difference between dietitians and nutritionists. I think when we have a registration board and [statutory] body to regulate dietitians, there is scope there to work with the Minister and examine nutritionists. It’s up to the Minister, though, to appoint the board and set the process in motion in the coming months.”

Richard Burton, founding director of the Irish Institute of Nutrition and Health, which offers a variety of nutrition courses, says he would welcome better regulation of the work of nutritionists. He outlines what he sees as the main difference between the work of a trained nutritionist and a clinical dietitian/nutritionist.

“The real difference between us and dietitians is that we personalise the advice we give to each person. We’re not qualified to do a diagnosis. If two or three people went to a dietitian with irritable bowel syndrome, say, the dietitian would give them pretty much the same advice based on a sheet of protocols. If they came to us, they would leave with different recommendations, because each case is treated individually. But we also work with doctors and medical persons all the time.”

Currently, the Nutritional Therapists of Ireland (NTOI) is the professional association supporting qualified nutritional therapists in Ireland, and it is affiliated with the British Association of Nutritional Therapists. All NTOI members are trained in clinical practice.

Burton’s institute, based in Co Wicklow, offers courses to Fetac level over the course of three and four years, and he says many of his students will go on to master’s level study in the UK with Middlesex University. In relation to short-term online or weekend courses available in Ireland, Burton says it would be difficult to become a trained nutritionist in such a short space of time.

“You cannot learn to be a nutritionist in a few weeks. You have to have a very sound understanding of anatomy and physiology. In fact, it’s funny, because today I got an irate note from a student because they found an online advert for a course for a few hundred quid and running over three weeks, when ours take three years. This is mad – those coming out of these short courses are calling themselves nutritional counsellors and it is crazy.”

Burton says many in his profession would welcome regulation of the profession along the lines of dietitians, but he also feels that tensions exist between dietitians and nutritionists.

“Dietitians are concerned about safety, but they do feel threatened by nutritionists, and that is understandable. That doesn’t mean to say there is anything wrong with us or unsafe about us. Nutrition is so popular these days that there are bound to be charlatans out there. But you can’t tar everyone with the same brush.”

CLINICAL NUTRITIONIST/ DIETITIAN OR NUTRITIONIST: WHAT'S THE DIFFERENCE?

What is a clinical nutritionist/dietitian?

Clinical nutritionists and dietitians are responsible for the nutritional care of patients in a hospital setting and through private practice.

The majority of hospitals in Ireland employ clinical dietitians. In order to be employed as a dietitian in a hospital in Ireland, a BSc in human nutrition and dietetics, or a postgraduate diploma in nutrition and dietetics or dietetics, or a recognised qualification prior to 1987 is required.

There are also several food technology degree courses in universities such as University College Cork, which combine food and health, often with a focus on food nutrition. Some dietitians may choose to specialise in areas, such as paediatric nutrition.

The Irish Nutrition Dietetic Institute (INDI) is the national organisation for clinical nutritionists and dietitians in Ireland.

A regulatory body, CORU, is in the process of regulating the work of “dietitians” in Ireland and waiting on the Minister for Health to appoint a board to carry out this work.

What is a nutritionist?

A nutritionist, nutritional counsellor or nutritional therapist (as distinct from a clinical nutritionist) can offer personalised advice on diet and nutrition-related matters. Trained clinical nutritionists will be registered with the Irish Nutrition and Dietetic Institute and have degree-level qualifications.

For many others there is no onus to have any recognised qualification to offer nutritional advice or practice as a nutritionist.

The type and length of courses on offer vary from short-term weekend seminars to longer-term diploma level courses of study. It can often be difficult, though, to clearly define the role of a nutritionist.

For example, many nurses, physiotherapists and sports coaches may offer nutritional advice and have varying levels of training.

There are no plans to regulate the title of “nutritionist” at the moment.