Our switch from holding in-person appointments to telehealth has yielded many benefits, one of which is that now nobody can see the various diplomas and certificates that are mounted on my office wall. Having these documents on display makes me somewhat uncomfortable, as it feels a bit like bragging, which is why I only put them up after some patients suggested I should. Looking at them recently, I began to wonder what these framed pieces of paper mean to the people who wanted to see them. In essence, they are just souvenirs from my education, so perhaps interest in them is really just indirect curiosity about my training. So, what exactly do future dietitians learn in nutrition school? The specifics depend on where and when they study, but if my experience is any indication, it probably looks something like this.
The Basics
As an undergrad at Tufts University double majoring in mathematics and English, I had little room in my coursework for science classes. Given that, before I could begin to directly study nutrition at the University of Massachusetts Amherst (UMass), the department required that I take some prerequisites. Therefore, my nutrition schooling started from the very beginning with the most basic biology, chemistry, and physiology courses.
Of these three disciplines, the greatest focus was on chemistry. We had two semesters of general chemistry followed by two semesters of organic chemistry and one biochemistry course, all of which had lab components. When I last studied chemistry in high school, I found it difficult to understand and I consequently struggled. With that being my history, the prospect of having to take these relatively advanced chemistry courses was so intimidating that I nearly backed out of the program on the eve of my first day of classes because I was doubtful that I could succeed. Instead, I plunged myself into the subject. Motivated by intense fear and intimidation, I did everything I could to survive. No matter how well I did, I figured failure was just around the corner, so I had better keep the pedal to the metal. In addition to regularly attending office hours, I went to the on-campus tutoring department for extra review. In my free time, I answered every question in the textbooks, including ones that were not assigned. At the peak of my anxiety, I even sat in on chemistry classes I was not enrolled in just so I could hear the material discussed again and again and again.
In the end, the university gave me a merit scholarship for being one of the top three organic chemistry students out of approximately 600. Given my history with the subject and how hard I worked, receiving this award was one of the proudest achievements in my life. However, all that knowledge has played virtually no role in my work as a dietitian. Sure, I can explain the chemical structures of sugar alcohols and omega-3 fatty acids, why some fats are solids at room temperature while others are liquids, and how a bomb calorimeter works, but these skills make me no better of a clinician than a colleague who cannot do these things. Hopefully, chemistry requirements have scaled down in the years since I was a student, as my curriculum could have easily included less chemistry without negatively affecting my abilities as a practitioner.
Food Service
If you had no idea that many dietitians end up working in food service management, then you are in good company, as I had no idea about that either before I started nutrition school. To prepare us for this possible career track, the department had us take two courses in the hotel, restaurant, and travel administration (HRTA) program and two more in the management school.
Sometimes I contrast the difference between the random bits of information that have stuck with me from a course versus what I imagine those in charge of my education hoped I would retain. From the first HRTA course, I recall learning what a physical hazard is, how baby carrots are made, and that a successful coastal New England restaurant was thriving because of their choice of oven. All I remember from my human resource management course is working my ass off to show our professor – who warned us at the beginning of the semester that she does not give out As – that, actually, she does.
My second HRTA class made more of an impression, as it was a hands-on course that had us working in a semi-mock restaurant. We prepared and served real food to real customers, but no money changed hands because free food was their reward for being our guinea pigs. Joanne could tell you that whenever we meet someone who works in a restaurant, I pepper them with earnest questions that reflect my curiosity, such as how many eggs their diner goes through in a day. Given that, I thought this course was fascinating. We devised menus, planned theme meals, and rotated between all jobs in both the front and back of the house. Never having worked in a restaurant before, this was my first time being the target of the rudeness that some customers – even those who were eating for free and knew students were running the show – inflict upon those who wait on them.
Nutrition
And finally, the nutrition coursework itself began. The most basic class, Nutrition 101, was a survey class about the profession. This is where I learned that the term “nutritionist” has no legal definition, and anybody can call themselves one. The professor told us a story about someone who took an online test and received a nutritionist certificate – for their dog. One of my classmates announced to everybody that she was studying nutrition because she wanted to become a millionaire by inventing a fad diet.
Meal management and scientific principles, otherwise known as Nutrition 210, was an interesting course in that it included a lab component. Our experiments involved making several versions of a recipe and tweaking a variable, such as an ingredient or a preparation technique, to see how the changes affected the finished products. For example, we broiled, poached, and microwaved flounder fillets and then compared the texture and flavor of the cooked fish. We counted how many chews it took to sufficiently masticate pieces of top round sirloin prepared with a variety of tenderizers. My friend and I gave a group presentation on artificial sweeteners in which we compared popular myths versus what actual scientific research had found.
Nutrition 230 was a basic nutrition course in which we discussed the chemical structures, functions, and metabolism of various nutrients. Our professor told us that one of the reasons she chose a career in nutrition is because whenever she meets people, such as at a party, they are always interested in what she does. In contrast, many of our colleagues (including myself) try to conceal what we do for work because the follow-up questions – which are almost always based on myths and incorrect assumptions about our profession – can be frustrating and exhausting to answer.
A few years ago, I emailed my former Nutrition 352 professor, who has since been promoted to an associate dean, and let her know that my greatest regret from nutrition school is having sold my textbook soon after completing her life cycle nutrition course. Despite my two part-time jobs as a personal trainer and an assistant to the university’s food service dietitian, money was tight, and I felt I could use the cash more than a leftover textbook. Besides, I did not imagine that all these years later I would still be having occasions in which I want to refer back to it, yet that has turned out to be my reality. Fortunately, the Academy of Nutrition and Dietetics’ online Nutrition Care Manual contains a section on pediatric nutrition, which has somewhat filled the void, but I still wish I had that textbook.
Nutrition 572, community nutrition, is where I began to understand that food scarcity is not some abstract notion or one that only afflicted our ancestors and people in faraway lands, but rather one that is still a reality for many of our neighbors. One of our assignments was to go to the grocery store and design a diet that would nutritionally satisfy the Dietary Approaches to Stop Hypertension (DASH) diet while also financially satisfying the Thrifty Food Plan’s allowance of $4.37 per day. Even with my math background and nutrition knowledge, I could not do it, as the closest I could come was $4.77 per day, still $0.40 over budget. This course helped me to appreciate the impacts that financial limitations and food availability can have on health. The simple truth that people can only buy what they can afford and is accessible to them sounds so obvious now, but it took studying community nutrition for me to really get it. When I rode my bicycle from Seattle to Boston that summer, I made a point to visit the grocery stores on the Native American reservations that I passed through, as I wanted to understand the options available to the residents of these relatively isolated communities. Had I not taken community nutrition, I am not so sure I would have had the same level of curiosity.
In Nutrition 577, aptly titled nutritional problems in the United States, we studied the impact of nutrition on some of this country’s most common health concerns, such as cancer, diabetes, cardiovascular disease, and osteoporosis. Our professor was excellent, perhaps the best I ever had in nutrition school. She expected a lot from us, and she held herself to the same standard. She was also fat. While I did not judge her for her size, I remember perceiving that it was awkward for her – a nutrition expert in a bigger body – to teach us about “obesity.” Whether it was her or one of the other faculty of a similar build in our department, I cannot recall, but I do remember one of them explaining how difficult it was for them to be taken seriously because of their size. Many years later, this seed grew into a conference presentation I gave entitled “‘Looking the Part’: Patients’ Size-Based Biases Towards Their Practitioners and How to Handle Them.”
Medical nutrition therapy, Nutrition 580, was where the rubber met the road. We learned how to utilize the nutrition knowledge we had thus far accumulated and apply it to treating a wide variety of medical conditions. What stands out to me though are not the disease states we learned about, but rather some key ones that were omitted, namely eating disorders. Each of us had to research a disease (Mine was chronic pancreatitis.) and present to the class about it, and if not for another student’s brief presentation on anorexia nervosa, I would have gone the entire way through nutrition school having learned literally nothing about eating disorders. Maybe I am just biased because I now specialize in treating eating disorders, but it is hard for me to fathom that such an important group of illnesses that affect so many people was barely even mentioned.
Speaking of missing curriculum, the only counseling course we had was Nutrition 585. Of course, learning about the hard science of nutrition is important, but if dietitians are unable to effectively convey their knowledge to patients, then the information is moot. Before finishing nutrition school, I was already of the opinion that students (and therefore their future patients) would be better off if the required coursework focused less on the hard sciences, particularly chemistry, and more on counseling skills. My professional experience has only strengthened this stance.
My final course in the department was Nutrition 731, nutritional assessment. During my presentation on anthropometric predictors of cardiovascular disease, I demonstrated how hydration status introduces a source of error into bioelectrical impedance device readings that estimate body fat percentage by using such a device on myself at the beginning of my talk, then putting on a bunch of extra layers of clothes and giving the bulk of my presentation while riding an exercise bike, and then using the device again after having worked up a sweat.
Outside the Department
While taking the aforementioned nutrition courses, I also took classes in other departments, such as energy metabolism in the exercise science department. One of my takeaways from this class is just how difficult it is to design research studies that yield definitive answers. For example, our professor was confident that walking a mile and running a mile require the same caloric expenditures, but he could neither confirm nor reject this hypothesis because he could not design a study that would adequately control for all the confounding variables. He was also the first person to introduce me to the “fat-but-fit” concept, which is that someone can be both healthy and live in a bigger body.
The microbiology course I took in the food science department centered on foodborne illnesses. We learned about salmonella, staph, spores that survive cooking and freezing, and other scary things that to this day continue to make me think twice about some potential eating decisions. All these years later, I am still not brave enough to roll the dice with fried rice.
My psychology course was an introduction to the field’s basics with a focus on the nervous system’s structures and physiology. One of my takeaways was how important dietary fat is for maintaining the myelin sheaths that insulate our neurons and enable rapid transmission of electric impulses.
The nutrition program required some other courses that I was able to place out of due to my previous studies. For example, my English degree got me out of their nutrition and writing course, and my math degree similarly meant that I need not bother taking statistics. The child development course I took at Tufts enabled me to skip the same class at UMass.
Although I was fairly certain that I wanted to be a dietitian, I toyed with the idea of becoming a physical therapist, so I took some additional physics and anatomy courses that were prerequisites for physical therapy programs just to cover all my bases. Learning about anatomy was interesting, not so much because of the subject matter itself, but because it taught me the importance of speaking a patient’s figurative language. With my personal training clients most comfortable with colloquial terms like “chest” and “quads,” knowing the scientific names of hundreds of body parts proved fairly useless, and the knowledge soon escaped me.
Internship
Now you know what it took to earn the nutrition degree on my wall. One of the other significant documents that hangs near it is from my dietetic internship, which is somewhat like a future doctor’s residency and must be completed before dietitians-to-be can sit for their registration and licensing exam. Because this blog is already so lengthy that pretty much everybody has stopped reading by now (Hi, mom!), I will save discussing my internship until another time.