Saturday, November 15, 2014

The Nutrition Debate #262: Registered Dietician Nutritionists. Should you see one?

A Reuters Health Information release on my Medscape diabetes alert recently included the recommendation of a registered dietician who led a prediabetes nutritional therapy trial that “doctors should refer their prediabetic patients to a registered dietician nutritionist.” She further suggested, “These results [of the prediabetes nutrition therapy trial] further show that (medical nutrition therapy) should be considered for reimbursement in the treatment of prediabetes to reduce diabetes risk.” NOT SO FAST, I say. Let’s take a careful look at the “medical nutrition therapy” recommended.

“Patients in the intervention group [emphasis added] had been encouraged to follow diets that were calorie-restricted and balanced, so that 60-70% of the energy came from carbohydrates and monounsaturated fat, 15-20% from protein, and less than 7% from saturated fat. They also received a pedometer and diary to record the number of steps taken and minutes of physical activity completed each day,” the release said. In my opinion, you should not waste your money on this brand of medical nutrition therapy. IMHO, you would do much better to listen to your glucometer.

MY CONCLUSION: The medical nutrition therapy recommended in this prediabetes nutritional therapy trial was the same standard, one-size-fits-all, USDA's Dietary Guidelines diet that all Americans eat a balanced diet and exercise more. Ugh!

(Readers may recall that I lambasted this trial’s accomplishments in a recent post #258: “Diagnosed diabetics consumed less sugar and carbohydrates…”. The outcome was a 3% improvement in A1c in the intervention group and a >7% worsening in the “control” group. The worsening in the control group suggests to me an “out-of-control” Epicurean feast of Sybaritic dimensions… BUT it makes the small improvement in the intervention group look so much better, doesn’t it.)

Let’s face it. This RD’s pitch is just a very thinly veiled effort to 1) get doctors to send them more business and 2) for the government and insurance companies to allow Medicare and other reimbursements for “medical nutrition therapy.” You can’t expect them to do otherwise than to recommend the “nutrition therapy” that the government and the medical associations themselves recommend. Such a mutually beneficial relationship – the perfect mother and daughter symbiosis. 

But business is business, after all, and nutritional therapy service providers have to eat too. Currently, the only way that I know of that their patients/clients can get reimbursed by insurance is for them to work in a medical doctor’s office.  That is the case, anyway, for obesity counseling services, and that only since a year ago. See The Nutrition Debate #146: “Medicare to Pay for Obesity Counseling” (9/25/13) for an account of my experience with that. For my cynical take on a closely related matter, see also, #147: “AMA: Obesity is a Disease (for billing purposes)” (9/28/13).

You do have an alternative. If you do your homework, you will seek (and hopefully find) an independent nutrition counselor. My favorite is Franziska Spritzler, RD, CDE, the Low Carb Dietitian, who blogs and has a private nutrition counseling practice on the Southern California coast. She changed careers in mid-life from court reporter to registered dietitian and then discovered she was pre-diabetic. She did her own homework, and then changed her Way of Eating. Now, she says, “I'm 47, and thanks to a low-carb lifestyle and gentle exercise, I feel better than I did in my 30s.”

It’s tough, though. In her first blog post back in 2011, one commenter said, “I'd like to earn a Master's in an ADA-approved program, but am concerned my views about low-carb would create problems with faculty.” Franziska agreed, saying, “Well, I didn't have those views when I went through my didactic nutrition program, so it wasn't an issue for me. But from what I've heard most nutrition professors (and other students) are not open to LC, although there are a few exceptions.”

Kris Gunnars at Authority Nutrition has published a list of 17 Low Carb and Paleo Doctors (MDs) with blogs as well as a list of 11 Paleo and Low-Carb Registered Dietitians (including Franziska). There’s also an organization of CDEs (Certified Diabetes Educators) who reject the American Diabetes Association (ADA) balanced nutrition meme and espouse low-carb nutrition, but I can’t think of their name! Somebody please help me to promote this small band of warriors who believe that “healthy eating” does not include a diet that’s loaded with carbohydrates (both simple sugars and refined complex ones) and highly processed polyunsaturated fats from seed oils, including soy bean oil, corn oil and canola oil.

So, what a person to do? How could someone like me get certified as an RD and hope to reform such an organization from within? It’s a cabal. I’d have to keep my mouth shut and intentionally give wrong answers on every test. Fat chance of that!
Have you seen an RD?


  1. How timely. I just got sent to a dietician at Kaiser because I told my primary care doc that I'm on a low carb AND low calorie diet. She thinks it's dangerous. I told her I wouldn't talk to anyone who gave me the traditional spiel, and assured me this lady would not. True, the dietician I saw didn't push anything, but that was because she didn't really KNOW anything. She said, "If you don't eat enough calories and have a balanced diet you won't get all the nutrition you need." So I showed her in exquisite detail what I was eating and asked specifically which nutrients she was concerned about. I was hoping to find out what I needed as a supplement. She really didn't have a clue, she could only speak in general terms that came right from the food pyramid. So, on the way home I stopped at a vitamin store and told the young lady behind the counter, "This is what I eat. If you were me, what supplements would you take?" I got some very good recommendations, based on sound reasoning, not salesmanship, and went happily on my way. The nutritionist I saw was not only totally unfamiliar with a low carb diet, she wasn't interested in learning anything. I offered her references and titles of reading material and she took no notes, I think she felt her job was to just keep smiling until I left. I'll be looking at the lists above to see if I can find a better-informed advisor. Thanks for your continued efforts.

  2. So, your Kaiser guy was wrong. I wonder why he thought the RD he sent you to would be any different from virtually all the others. Or maybe he didn't. Maybe he did it for the 'good will,' or a kickback, or for the network's bottom line? Aren't they all just part of a network ('mill') that our U.S. healthcare system is becoming. Under current rules, the only way she can get paid by Medicare insurance is IF she is referred by a physician (see #146). I can definitely relate to that 'keep smiling until (you) left' sense that you had. I've sensed it as well. And THANK YOU for your continued support and readership.

  3. My primary care doctor said the other nutritionist, the one that's usually used, is really a hard-nosed high carb kind of person. I might have preferred a good argument to a vacant smile.

    1. I LOVE it, Jan. How'd you like to write a guest column some time?