044 – How Dietitian Licensing Goes Wrong – My Interview with Pam Popper

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Pam Popper’s experience reveals the hidden dangers of Dietitian Licensing.

Pam PopperIt has been interesting to hear the comments of the dietitians who have commented with outrage at my interview with Diane Miller regarding Dietitian Licensing. It makes for an interesting read. I suspect this interview will engender similar outrage as well. Here Pam Popper discusses her battle with Ohio Dietitians and discusses other cases of senseless persecution from dietitians. In my dialog with Dietitians, I repeatedly ask for the evidence for their claim that nutritional advice from non dietitians was dangerous. So the dialog with dietitians is quite revealing. You can read this in the comments of my interview with Diane Miller.

It seems that the dietitians are not really prepared to make their case. This is why when challenged, such as we have done in Wisconsin, their case begins to crumble. The public wants access  to additional nutrition services and the dietitians don’t. Their claim of harm and danger to the public seems minimal or non existent. At least no evidence has surfaced here in six years of our battle in Wisconsin.

My offer to dietitians

I will do an interview with any dietitian about the merits of their case. I have offered before here in Wisconsin and had no takers. So if there is a dietitian who wants a chance to make their case with me in a recorded interview, I will put it on the podcast. I would suggest that you be better prepared than some of the dietitians who commented on the podcast. I am in favor of open discussion on this topic and let the listeners decide whose view they prefer. Any takers?

About Pam Popper

Dr. Pam Popper is a naturopath, an internationally recognized expert on nutrition, medicine and health, and the Executive Director of The Wellness Forum. Dr. Popper is the author of several books; her most recent is Solving America’s Healthcare Crisis. She is the Founder of The Wellness Forum Foundation, which offers programming in schools designed to improve children’s health through better nutrition. For more information on Pam Popper click here.

{ 24 comments… read them below or add one }

1 Jennifer December 29, 2015 at 10:05 pm

I’m an RD and the only way that I could foresee it being hazardous is that not everyone can analyze labs or nutrition-related health risks hat come with disease states. For example, telling a CHF patient to drink half their weight in ounces of water or telling an ESRD patient to follow a Paleo diet. RD’s, not excluding anyone else with some sort of nutrition background, have clinical education and practice.

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2 Steve Lankford December 30, 2015 at 10:00 am

Hello Jennifer,
We have had long and heated discussions on this topic. While we can always think of cases where certain advice is wrong, we don’t have any significant evidence that these problems need to be legislated. If some one individual is causing harm then that person should face the consequences. But to legislate against everyone who gives nutrition advice is not warranted. We also know that not all medical or dietetic advise is correct and free of harm. So consumers should have a choice with regards to their own health care advice.

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3 Paul Zimmer November 17, 2012 at 11:57 pm

If I can keep us on topic, my point is that documentation of complaints does not exist (to the best of my knowledge) and cannot be collected in the current situation for the reasons I outlined. I gather that you look at this lack of information and assume that there are no problems and everything is fine. I look at this lack of data and say that we can not assume consumers are safe. We all know of many anecdotes of harm, but there is no way to know if these are the exception or the rule without data.

Dieticians have that data being collected on a state level and there are significant penalties for violating the rules. Other nutrition advice providers are not more virtuous than dieticians, are they? So, it may be inferential on my part to assume that the same problems occur among these other providers, but we do not know how often they occur nor are there any penalties to the provider short of criminal or civil penalties. In short, dieticians are (as a group) more accountable for their nutrition advice.

Documentation of crimes and lawsuits should be possible but is far outside my area of expertise. Has anyone attempted to analyze lawsuit data (other than Pam’s anecdote about dieticians paying “bounties” in Ohio)?

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4 Steve Lankford November 18, 2012 at 3:35 am

It is my point that without some basis for your assumption I have to err on the side of liberty and free speech. You say you all have anecdotes of harm but there is no way to know if these are the exception or the rule without data. Exactly. But I also believe that if the problems that you believe exist in any significant amount the data would start to emerge. If you take the millions of consumers who are spending millions of dollars, and you look at the thousands of practitioners and other sources of nutritional information, giving millions of hours of advice and nothing rises to the top except occasional anecdotal data. You believe there is harm, where no evidence exists. I believe there is little harm because I see no evidence. The harm that exists is small and does not require elimination from consumer’s choice. Consumers like these services and they are not complaining.

No one is disputing the expertise that dietitians provide. Medical dietetics is a specialize field and others should not practice medical dietetics. But most nutritional speech does not rise to this level and is generally safe. Consumers do not feel dissatisfied with these services. The only ones dissatisfied are the dietitians.

Your last comment suggest that someone verify the problems. This is not impossible unless the problems do not exist. So prove your point then make your case, otherwise, I won’t be convinced. I would love to see them defend their assertions with case studies.

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5 Paul Zimmer November 18, 2012 at 4:19 am

Why is it that you said (about me), “You believe there is harm…”, but I don’t see where I said that at all? I wish you wouldn’t put words into my mouth if we are going to have a fruitful discussion. I said that lack of evidence is not proof of safety when we have no mechanism to collect safety data other than the legal system.

Consumer satisfaction is not a measure of safety. Consumers are very satisfied with their energy drinks (except when they are in the hospital or dead). If the FDA tries to take away energy drinks, those consumers are going to be very upset. AE data on the tens (hundreds?) of millions of energy drinks sold have been accumulating since 2006 through an in-place, well-defined reporting system. Without a reporting system, the 11 deaths would be 11 anecdotes. But, like you said, consumers love their energy drinks.

I would like to open this up to a broader group of discussants before we proceed much further. I think it will be more fruitful for everyone if we have more points of view involved.

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6 Steve Lankford November 18, 2012 at 2:00 pm

If you don’t believe there is harm, is it only an assumption, presumption or what? I say then lack of evidence is also not proof of a lack of safety. If we have no way to collect data then how can you be so sure that it exists? I think one should collect some data first and then show how it supports your point. Otherwise it is just hypothesis. Can anyone explain why it is so hard to find any case studies that could confirm this? I would think that if dietitians or doctors are encountering these problems then the data exists somewhere. Otherwise who is observing the harm? I suggest you keep looking.

As far as putting words in your mouth, I have never mentioned energy drinks, so you are equally guilty of putting words in my mouth. You could be accused of trying to cloud the issue but I won’t go there. Any problem with energy drinks is also off topic because we are talking about restrictive dietitian licensing laws. Not dietary supplements which is another debate all together.

Everyone is welcome to post their views.

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7 Paul Zimmer November 19, 2012 at 2:36 am

Thank you for your time and this exchange. Your last post was the most helpful in understanding your point of view better. To state that something is true because it hasn’t been proven false is a formal, logical fallacy called “argument from ignorance” (that is the actual name, and I am not calling you ignorant). Unless we can set aside that false premise, then we can’t have a productive, two-way conversation.

I am sorry you feel that I put words in your mouth and clouded the issue. That was not my intent. Putting words in someone’s mouth is where you claim they said something, i.e. you claiming that I said there is harm. But, I did not claim that you ever mentioned energy drinks. You did defend the safety of nutrition advice providers by saying “consumers like these services.” I provided an example of something else consumers like (i.e. energy drinks) and that liking something does not make it safe. Perhaps I could have been more clear about my point.

8 Paul Zimmer November 17, 2012 at 3:40 am

I had a question after listening to this podcast. Are you and Pam saying that misconduct among nutrition advice service providers is adequately regulated by caveat emptor and present criminal law?

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9 Steve Lankford November 17, 2012 at 2:27 pm

Based on the evidence presented so far, I would say yes. The problems that exist, do not seem to rise to the level that would require the elimination of all other nutritional services. The dietitians have not been able to make any case to support their claim. I would suspect that if there were problems occuring all around the country we would begin to have evidence of a significant amount. This lack of evidence makes it difficult to see a need for such severe restrictions.
Some states are looking a bills that would require alternative practitioners to provide transparency to their clients. This reveals their background, any degrees or certifications, they type of treatment they will receive and that they are not dietitians. This would be fully revealed to all clients. These bills would provide for legal remedy for those who caused harm. The idea is to provide access to alternative practitioners as increased accountability.
Is current criminal law sufficient? I would say yes. Son unless you can show that serious harm is occurring and no remedy exists, then where is the evidence? Where are the consumers who have been harmed? It seems to me that if significant numbers of consumers are being harmed, we would see lawsuits and media coverage. We have none of this. Without some evidence I have to think that the problems exists mostly in the minds of the dietitians or is minor at best.

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10 Paul Zimmer November 17, 2012 at 5:25 pm

There are many forms of misconduct that do not rise to the level of criminal activity yet still harm consumers. If a provider gives false advice, the consumer wastes time, money, and delays getting real help. If the provider recommends more expensive products due to financial incentives, the consumer wastes money. If the provider recommends changes that make the consumer ill (but not sick enough to require medical attention), the consumer loses out as well. Moreover, even in the unlikely chance that the consumer figures out something is wrong, there is no way to report harmful but non-criminal activity by this kind of provider. If there is no way to gather data on misconduct, it is hard to say that none exists.

As I understand it, dieticians have a binding code of ethics and standardized training. If someone feels a dietician has done something wrong, they contact the state licensing board. If the charges stack up, the dietician loses their license. In a state with a “dietician only” law, that is a career ender.

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11 Steve Lankford November 17, 2012 at 5:47 pm

It seems that all of the arguments made in favor of restrictive dietitians laws are hypothetical. If this, if that, if the other. There are ways to gather data about harm. If no one bothers to gather the data, or if the date is not so significant as to be obvious, then the question is where is the evidence that we need a restrictive regulatory scheme to protect public health. Just because you think it happens in significant ways does not make it so. This does not mean that all nutritional advice is impeccable. No one is making that case. There are millions of Americans that are spending millions of discretionary after tax dollars for these services. That indicates that consumers want these services. The lack of complaints and evidence of harm would suggest that the service as a whole is not harmful and consumers are satisfied. Consumers can always choose to see a dietitian. Nothing stops that. So this seems more about restricting consumer choice and benefiting dietitians as the only favored group. I think that is wrong. There certainly are legal remedies if a consumer is harmed. To suggest that the consumer’s who use these services are unlikely to figure it out is a slap against those consumers. If there is systemic misconduct that causes harm, there are legal methods to address those problems in current law. If you say that is not the case then give examples of cases where this has occurred. You make assertions but provide absolutely no evidence. It seems that basically you are upset because consumers are choosing other services and taking business away from dietitians. You may think that great consumer harm is occurring but you can’t seem to provide a credible example.

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12 Paul Zimmer November 17, 2012 at 6:08 pm

I would like to know what you mean by “complaints” versus “lawsuits” so that I can make sure we are talking about the same thing.

In this situation, I think that “lawsuit” means some civil law may have been violated by the provider and the consumer decided to spend thousands of dollars of their own money going after the provider.

A “complaint” is where the consumer feels wronged by the provider and wants to tell someone without having to file a lawsuit. For a dietician, it is the state licensing board. For other providers, who is it?

If no one is collecting complaints about other providers, we can’t say if harm is prevalent or not. Just because we don’t measure something, it doesn’t mean it isn’t there, e.g. lead in calcium pills many years ago.

13 Shehla Ansari November 16, 2012 at 6:22 pm

hi All,
I also don’t believe in attacking anyone but have come across the same issues that these other RDs have seen- having worked in both outpatient and gym type settings.

Here is a notation from Consumerreports.org:
The FDA gets far more reports about serious problems with prescription medication than about supplements. But there’s a big difference between the two, notes Pieter Cohen, M.D., an internist at Cambridge Health Alliance in Massachusetts with a special interest in supplements. “These powerful medications with powerful side effects are actually saving lives when used appropriately,” he says of prescription drugs. “But when healthy consumers use supplements, there’s rarely, if ever, a powerful lifesaving effect.”

The FDA suspects most supplement problems never come to its attention, says Daniel Fabricant, Ph.D., director of the agency’s Division of Dietary Supplement Programs. But those that do are still useful because they can raise red flags about a developing problem. For instance, last year the agency noted seven reports of serious health problems regarding consumers who took Soladek vitamin solution, marketed by Indo Pharma of the Dominican Republic. When the FDA learned that tested samples contained vitamins A and D at concentrations many times the recommended daily allowances, it issued a consumer warning.

Why not simply order a problem product off the market? Current laws make that so difficult for the FDA that to date it has banned only one ingredient, ephedrine alkaloids. That effort dragged on for a decade, during which ephedra weight-loss products were implicated in thousands of adverse events, including deaths.

Unfortunately I’ve seen nutritionists, exercise physiologist, personal trainers support the use of supplements which can cause harm. In the future, if I do come across a patient who was given misinformation about a product- I will be sure to report them.

I have used supplements myself and come from a homeopathic background. I’m sure some practicioners such as Dr Andrew Weil puts out excellent advice but there are some who give out poor advice. By the same token, there may be some RDs who give out poor advice, as some of my patients have told me..

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14 Al Forman November 15, 2012 at 1:48 am

ANOTHER INFORMATIVE OUTSTANDING INTERVIEW!

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15 Steve Lankford November 15, 2012 at 2:18 am

Thanks Al, I appreciate your support. For all of you, if you are so inclined, please like us and recommend us to your social networks. Your endorsement means alot.

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16 Steve Lankford November 17, 2012 at 2:16 pm

When you compare the safety record of drugs vs supplements one finds that supplements use has an exlemplary safety record. It is hard for me to believe that if the problems with supplements were so significant that we would have more reports of problems or reports to poison control centers or something.

So the FDA suspects supplement adverse effects are under reported. That might suggest that significant problems do not exist or are mostly mild and self resolving.

The FDA has full authority to remove harmful products off the market. There new regulations in place that require the reporting of adverse effects that are reported. New dietary supplements must be submitted to the FDA prior to release into the marketplace. The FDA had implemented good manufacturing practices for all supplement manufacturers which requires high standards for supplement manufacturer.

The idea that this problem is so server that we must restrict all other sources of nutritional information doesn’t seem to be supported by the reality. There seems to be a lot of claims made of harm but no solid evidence. Dietitians claim to practice science based dietetics but the science does not back up the idea that other nutrition sources are inherently dangerous.

No group is immune from bad advice, the question is: Are alternative providers causing harm as a group? The evidence is largely no.

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17 Paul Zimmer November 17, 2012 at 5:48 pm

The safety record of drugs and supplements are not comparable because of the approval process.

Clinical testing of a new chemical entity includes gathering a list of adverse events and reporting their frequency. When the drug is marketed, the physician receives a list of common and uncommon side effects to monitor and is required by law to report them (or others) to the FDA when observed.

Supplement ingredients generally do not have such extensive information on potential side effects, and it is gathered retrospectively rather than prospectively. Ingredients are given in doses ranging from subclinical to supraphysiological, and we know little about how that affects side effect profiles. Thus, physicians mostly have no idea what kinds of side effects to look for much less report to the FDA. The new FDA supplement AE reporting system is voluntary for physicians and mixes consumer-reported AEs with physician-reported ones (which aren’t very comparable in accuracy and scope).

The drug AE system is much better at detecting safety issues than the supplement AE system, but this is not proof of supplement safety.

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18 Steve Lankford November 17, 2012 at 6:13 pm

No one is suggesting that drugs and supplements are the same. Who said that? The FDA has authority over and regulates dietary supplements. Supplements have a stellar safety record when compared to almost all parameters. It does not mean there are no problems. The FDA is getting better at identifying problems and addressing them. This however is not the topic at hand. This has nothing to do with the dietitians licensing bills which restrict nutritional service providers and does not deal with supplements or supplement providers. So while this is an interesting topic it does not really pertain to this discussion. Others can comment on this if they wish. This website is mainly about exploring the safety and effectiveness on nutritional products so I think this is an important issue. It is the presumption that anything that is not controlled by the medical, pharmaceutical and dietetic industries cannot be allowed because they are so dangerous. I don’t agree and it seems millions of consumers don’t agree. And any harm that occurs is very small. There is no evidence to the contrary. At least know one has presented any evidence so far.

Why do I keep asking for evidence? Because all of the arguments are either hypothetical examples of harm or pure opinion. I have to believe that if the examples cited by all of my critics existed in any significant numbers these would be trumpeted by all as examples of the harm. But despite years of attempting to stop alternative services, the amount of significant problems uncovered seems to be zero. Nada, zilch. So if you want to make your case, prove it. Is that too much to ask? I think not, when you are trying to silence an entire movement. We deserve more than your anecdotal stories and opinions. Those are fine but they don’t prove your point.

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19 Steve Lankford November 17, 2012 at 6:29 pm

Dissatisfied consumers like to complain. Who do they complain to? Dietetic, medical, nursing and chiropractic licensing boards for one. There are state consumer safety boards. There are poison control centers. There are doctors nurses etc who can hear a complaint and move it where it can be attended. One does not have to look to far to know where to file complaints. To suggest that no venues exist for filing complaints is wrong. It is the lack of complaints that should speak loudly. If people are being harmed systematically by a particular provider then that provider can be investigated. Maybe they are practicing medicine without a license. But if these complaints do not exist, then you cannot assume that complaints abound that are not being addressed. How do you know that?

If someone has been harmed there are legal remedies. In order to do this they would have to show harm. To suggest that consumers are being harmed and are somehow not able to get legal redress is again to make an assertion that seems to lack any evidence that this is occurring. Someone should prove this is happening then you can make the case.

If no one is collecting complaints would suggest several things. 1. The numbers and significance of the complaints is very small and to be almost no existent. You say just because we don’t measure something doesn’t mean it doesn’t exist. Neither does it prove that it does exist. I think the burden of proof lies with you as you are making a case that there is harmful and dangerous nutritional advice. You are suggesting that it is so widespread and so dangerous that we must curtail all nutritional speech except for dietitians. It ain’t so just because you say so. Once again cite the evidence that supports your assertions. Otherwise all I am addressing is your opinion, experiences and stories. Recognize it for what it is. It is not enough to prove your point.

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20 Paul Zimmer November 17, 2012 at 6:51 pm

Let’s boil this down to a single example to avoid broad generalities of “To suggest that no venues exist for filing complaints is wrong.”

“If a nutrition advice service provider gives someone bad advice that costs the consumer time, money, and delays more effective treatment, no laws have been broken (to the best of my knowledge – I am not a lawyer). The consumer cannot report the provider to any state licensing or safety board (because they don’t belong to one). Nor can the consumer report this activity to the Poison Control Center or a health care practitioner.

Where would the consumer go to file a complaint?

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21 Steve Lankford November 17, 2012 at 8:47 pm

OK let me respond to your points.
Consumer spends money on ineffective treatment. Not something you can legislate.
Consumer spends time seeking ineffective treatment. Again, not something you can legislate.
Consumer delays effective treatment. This suggests there may be a pathology. Is the person practicing medicine or dietetics without a license? Are the going beyond nutritional advice and moving into medical and/or medical dietetics. There are laws against this and the licensing boards would be interested. So remedies do exist. If these remedies are not being sought by consumers or lawyers representing them then there seems to be no problem. The consumer can certainly advise licensing boards directly of abuse. I would think the boards would be particularly interested in these types of complaints. They can also call the poison control center if they feel they may have overdosed or been harmed by a supplement as someone earlier listed as a risk. If someone complained to their doctor or dietitian, the practitioner could and should report the problem. To fail to do so suggests the problems are not that severe or for some reason they don’t want to bother. The consumer could consult with a personal injury attorney who are happy to look at promising cases at no cost to the consumer. There are consumer safety commission in various states. If I had a complaint I can think of plenty of sources to make my case. So to suggest that no venues exist is wrong. They exist. It’s the complaints that don’t exist.

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22 Paul Zimmer November 17, 2012 at 10:45 pm

One actually can legislate whether a provider can give bad advice. A state can require that the provider have a license to practice. If the provider gives bad advice, the consumer complains to the licensing board who can track the complaints. These laws exist to track dieticians but they do not exist for other nutrition advice providers. This means you cannot track complaints of bad advice or unethical behavior on these other providers, but you could if licensure was legislated.

Poison control does not track down providers who suggest the wrong nutritional supplements. They are concerned with saving a life, finding the source of the poisonous material and stopping it from being used by others. Health care providers can certainly report crimes, but there is no place to call when the provider just gave bad advice that made someone temporarily sick.

The methods of recourse you list are effective for crimes. In the absence of other evidence, I suspect that these providers are no more likely to be criminals than any other profession (does anyone collate that information?). What we don’t know is the prevalence of complaints because it is not being collected.

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23 Steve Lankford November 17, 2012 at 11:15 pm

It still comes down to whether this is a problem or not. There does not seem to be a problem that can be documented so I cannot assume that there is a need. You all state hypothetical problems for which there is no evidence that these problems exist in any significant way. Without that, I do not believe that all nutritional advice should should be limited to dietitians. Potential problems are not real problems that are affecting real consumers. Without that we are still just dealing with your belief that there is harm to consumers. Unless you can demonstrate that consumers are being harmed then I don’t accept the premise.

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24 Steve Lankford November 19, 2012 at 3:33 am

Yes you did say I mentioned energy drinks. Here is the quote referring to me. ” But, like you said, consumers love their energy drinks.” Go read your posts.

After all this, you and I are the only ones involved in this spitting match, so unless someone else wants to makes some points, let’s call it a draw. We are not going to convince each other and I think others have probably gotten tired of it long before now. I know I have. So thanks for your input. Maybe someone would like to rally around your case. As for me I have to move on. We are just circling around each other. Best wishes. Maybe we’ll chat some more after some future post.

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