Orthorexia is an obsession that drives people to restrict the kind of food they eat and to over-exercise. Sam, as she likes to be called, was a normal healthy child, but says things changed when she turned eight years old. That’s when she became deeply unhappy with her body. “To me I was like, oh my God, this is wrong. There is something wrong with me. Everyone else is slimmer than me,” she said.
At the age of 14 Sam started working out and received many compliments at school. “People would compliment me on how I was looking and I was like: ‘Oh, I must have been super disgusting before. I have to keep this up then,’” she said.
By the time Sam turned 17, she was five feet five inches tall but weighed only 89 pounds. Most of her nutrition advice came from lifestyle bloggers. “All I was eating was gross protein powder, oats, vegetables and apples. I did not feel right,” she said.
Today, Sam is 25 and is turning things around. In addition to attending therapy sessions with a specialist, she also sees a dietitian. “I want to continue getting better with my relationship with food. It is not 100 per cent and it may not ever be 100 per cent,” she says.
When Sam became obsessed with eating healthily and losing weight there was already lots of advice on nutrition out there, but since then, lifestyle blogs have become even more common. Nowadays, you can also find people giving nutrition advice through social media, Instagram and YouTube. Even some celebrities have started blogs about health and nutrition and many nutrition professionals have also created online profiles. They use their platforms to give tips and advice about what people should or should not eat, but not everyone is professionally qualified to do so.
In Canada, dietitians are the only regulated nutrition professionals. Each province has its own process, and the College of Dietitians is the regulatory body for dietitians in Ontario. To become a dietitian, the person has to earn a bachelor’s degree in food and nutrition. After four years of study at a certified university, students have to complete an accredited dietetic internship through Dietitians of Canada, the professional national association. The next step is to write a test to become eligible to register with the provincial dietitians’ organization. When you see the acronym RD, which stands for registered dietitian, that means that the person has gone through this whole process. Many dietitians also get a master’s degree in fields such as public health, eating disorders or any other related area of interest.
People called “holistic nutritionists” and “nutritionists” also work with nutrition, but in Canada neither of those professions is regulated or requires any mandatory education in order to practice.
Still, there are some voluntary standards in place. Some registered private career colleges in Canada offer online and regular courses in holistic nutrition that vary from six months to one year. After completing the coursework, students write a test in their respective schools and become registered holistic nutritionists or RHNs. Private career colleges are registered by the province in Ontario, but the government does not regulate them. There are also organizations, such as private health coach institutions, that offer nutrition courses for those who wish to become nutritionists, but the duration varies. Some courses take only two weeks, other can take six months.
Since both holistic nutritionists and nutritionists are not government regulated, there is no common standard of practice, and no official institution that can discipline practitioners if a patient is harmed.
Of the three professions, dietitians are the only ones who can also work in hospitals and treat patients with diseases such as cancer and diabetes. Nutritionists and holistic nutritionists focus on teaching healthy eating. Holistic nutritionists say that they treat not only the body, but also the mind.
There is no official record of how many people are working as holistic nutritionists or nutritionists in Ontario, but social media has made it easier for them to reach the public. The fact that anyone can call themselves a nutritionist or holistic nutritionist has been a matter of concern for dietitians. Another concern is that most Canadians seem to not be able to tell the difference between the regulated professional dietitians and the unregulated holistic nutritionists and nutritionists, and might end up getting advice that could potentially be harmful.
Justine Horne is part of an advocacy group of dietitians in Ontario that wants the term “nutritionist” protected by the province. If the term becomes protected, or regulated, dietitians would be the only professionals allowed to use it. The group started a petition last year to ask the government to regulate the word. So far, there are more than 1,600 signatures in the online document. In Ontario, there are 3,924 registered dietitians, more than 14,600 general practice doctors and approximately 141,000 registered nurses.
In Horne’s opinion, the general public does not know the difference between dietitians and nutritionists. Many clients who come into her practice have, at least once, received bad advice from a nutritionist. “I work on weight management, so the big one [advice] that I see is basically patients who have been told to go on more of a fad diet or a cleanse or detox,” she says. “They have done that so many times that, that can actually affect your metabolism long-term.”
Right after the dietitians’ petition was created online, the Canadian Association of Holistic Nutrition Professionals started its own petition to ask the government to protect the term “holistic nutritionist” in Ontario. That was a way of trying to guarantee that they would not be prohibited from using the term “nutritionist” as part of their name. That doesn’t mean holistic nutritionists want their practice to be regulated by the government. The director of the association, Lorene Sauro, says that in her opinion, it is not necessary. “A lot of people think regulation means recognition that they are validating the work, but it is not that at all. The government only regulates to protect the public from harm and within scope,” she says.
The Canadian Association of Holistic Nutrition Professionals was created eight years ago and now has almost 300 members. The association only represents registered holistic nutritionists – those who have taken a special program – and one of its goals is to become a self-regulatory body.
The nutritionist term in other provinces
Regulating the term “nutritionist” in Ontario wouldn’t be unprecedented. Three other provinces have done so. In Nova Scotia, the term was regulated in 1989. Quebec was the second province to protect the term in 1994 and more recently, in 2016, the term “nutritionist” was also regulated in Alberta.
Amanda Connor is a dietitian in Nova Scotia and the registration coordinator of the Nova Scotia Dietetic Association, which regulates dietitians in the province. According to her, the decision to regulate the term was a way of protecting the public. “If somebody going to a dietitian or nutritionist in Nova Scotia had a complaint or they felt that something about the dietitian or the nutritionist practice was unethical then they have an avenue through the NSDA to file a complaint knowing that this complaint will be taken seriously and then an investigation will be done.” In Nova Scotia, a dietitian could even lose their license to practice.
The science-based issue
The work of a dietitian is based on science and one of the main criticisms dietitians have about the work of unregulated nutritionists and holistic nutritionists is that their practice is not always science-based.
Timothy Caulfield is the Canada Research Chair in Health Law and also the director of the Policy Health Law Institute at the University of Alberta. Caulfield is the author of several books about pseudoscience and he has made public his concerns about the holistic approach. “Holistic nutritionists often try to justify their existence and a lot of alternative practitioners do this, try to justify their existence arguing that they take a more, as in their name, holistic approach, and the implication, of course, is that dieticians and other science-based groups don’t do that and that’s a false dichotomy,” he says.
According to Caulfield, holistic nutritionists have been trying to send an inaccurate message to the public when they say that they get to the root of the problem. “Again, false dichotomy that they’re trying to create the impression that dietitians and other science-based nutrition experts don’t do this, which of course isn’t the case at all,” he says.
Where the regulation stands
In an e-mail, David Jensen, the media relations coordinator of the Ministry of Health and Long-Term Care, said that “the ministry is unaware of a formal request from the College of Dietitians of Ontario to amend the Dietetics Act, 1991, to protect the title “nutritionist” and remove it from the public domain.” He also said that usually this type of request would be sent by the regulatory college and then the ministry would consider “the merits of the request with a view to ensuring that the health care needs of Ontarians are met and that patients have timely access to safe and quality health care services.”
According to the executive director of the College of Dietitians of Ontario, Melisse Willems, after Alberta regulated the term “nutritionist” the board of directors of the College in Ontario discussed the option of doing the same, but they decided not to make the request to the government. “They did not do it because they did not feel at that time that there was a good reason to,” says Willems.
Meanwhile, Justine Horne says that the advocacy group is working on a research project to study how much the public is confused about the terms dietitian and nutritionist. They are also investigating the hypothesis that the information given by unqualified nutrition professionals is potentially false, misleading, and can cause serious harm.
On the other side, the Canadian Association of Holistic Nutrition Professionals has been studying a way to become a self-regulated profession. Sauros says that the association discovered this process by talking to other professions. “Paramedics have it, blood technicians, human resources. There is a number of self-regulatory professions. It is a model. There is a process. The Ontario government has a process for it. So, we are going to try it.”
In the self-regulatory model, regulatory powers are delegated by the province to a specific body of professional members. For Sauro, the self-regulating model could even be a solution for other wellness professions. “They [government] do not really want to regulate them because it costs a lot of money. The less a profession can demonstrate harm to the public, they will not regulate you. We do not demonstrate harm, so they will never regulate us, but on the other hand at some point they are going to have an answer to these wellness professions into the model,” she says.
David Jensen explained, via e-mail, that the government may provide funding “to establish the necessary infrastructure to regulate a profession through the establishment of a new health regulatory college.” However, the organization is expected to be self-funded.
Horne disagrees that the self-regulation could be an option for holistic nutritionists in the province. “I don’t think that is going to change the way they practice. Nutrition is quite complicated; it is not as simple as people might think. There are medications, supplements, generics that it complicates nutrition. Just self-regulating, I do not think it is going to solve any problem of an eight-month or one-year certificate in nutrition,” she says.