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2012 Lenna Frances Cooper Memorial Lecture: “When Nothing Is Sure, All Things Are Possible”
FROM THE ACADEMY Cooper Memorial Lecture
2012 Lenna Frances Cooper Memorial Lecture: “When Nothing Is Sure, All Things Are Possible” Deborah D. Canter, PhD, RD, LD Editor’s Note: This lecture was first presented on Sunday, October 7, 2012, at the Food & Nutrition Conference & Expo in Philadelphia, PA. This lecture has been edited from its original version to fit within a print format. The complete lecture can be purchased for download at: http://bit.ly/ZEehUx.
I
WANT TO EXPRESS MY GRATItude to the Kansas Dietetic Association for nominating me for this incredible honor; to my friends and colleagues; and especially past and present students, both undergraduate and graduate, who are the joy of my life and the future of our profession. As I thought about my topic for this time, my mind went in many directions. I wondered what some of YOU would expect me to talk about: perhaps dietetics education or management practice in dietetics or the phenomenon of distance education—all topics dear to my heart and the focus of much of my career—and, I WILL mention these topics. But in the end, I’ve decided to share with you my thoughts about the big picture of our profession—where we’ve been, where we are, where we’re going as October marks the 95th anniversary of the founding of the Academy of Nutrition and Dietetics.* Kansas State University is one school in an eight-university consortium providing an online Master of Science degree in dietetics, and the students in
*Formerly known as the American Dietetic Association, and will be referred to as the Academy of Nutrition and Dietetics throughout this article. Copyright © 2013 by the Academy of Nutrition and Dietetics 2212-2672/$36.00 doi: 10.1016/j.jand.2012.11.022
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this program are all practicing registered dietitians (RDs). I can’t begin to tell you how stimulating and fun it is to teach in this program. I’m privileged to teach one of the required core courses entitled, “Environmental Scanning and Analysis of Current Issues in Dietetics.” And one of the first assignments I give the students in that class is to draw a systems model of the profession of dietetics. Yes, it’s that same model you learned way back when, maybe in a science class or maybe in a foodservice management course—you know the parts: input, transformation, output, controls, memory, feedback. Stop for a minute and think how incredibly difficult it is to capture the scope of our profession in one model. I think my students would agree that it is an incredibly challenging assignment. We all want to gravitate to our own little area of practice. We’re pretty comfortable in describing the resources and tools, goals and objectives, checks and balances, the intended outcomes in our own little acre of real estate. But when we’re faced with the breadth and height and depth of what we are about as a dietetics profession, we struggle to get our heads around it. We struggle to see the big picture. The dilemma reminds me of the poem, The Blind Men and the Elephant.1 One felt the elephant’s side and thought it must look like a wall. Another grabbed the elephant’s tail and thought it must look like a snake. And so the poem goes, that all of them thought their view of the elephant was correct—and all where horribly wrong. They couldn’t see the big picture—the totality of that elephant. The temptation is great to just focus on our part of the “dietetics elephant” and operate as if that IS the profession in its entirety. Perhaps comparing our profession to an elephant is not the mental image you wish to contemplate, but the anal-
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ogy to me is on target. We are so diverse in our practice, so far-reaching in our scope, that who we are and what we do can be incredibly confusing to our broad constituencies. If we struggle to get the big picture ourselves, imagine how the lay public and the media feel. One of the students this semester wrote, “This project required me to think outside my acute care nutrition ‘box’. . . and has certainly humbled me as a member of our profession.” As we look at that proposed systems model, the part that has always intrigued me the most are the environmental factors—those elements that are unattached to the model itself and reside outside our control (see the Figure). The environments in which we live and work are dynamic and ones to which we must always be attuned. The never-ending shifts in the economic, social, ethical, political, legal, technological, and ecological environments make achievement of our goals like playing ball with a constantly moving basket. Every generation of leaders in our profession has faced an unknown future, buffeted by the winds of environmental change—and we are no different. We do indeed live in turbulent, frustrating, but also hopeful, times. Charles Dickens said it best, in his classic A Tale of Two Cities: “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us . . . .”2 Sounds like this might have been on last night’s news, rather than having been published in 1859. We all face uncertainty, but when nothing is sure, everything is possible.3 © 2013 by the Academy of Nutrition and Dietetics.
FROM THE ACADEMY Controls Federal, state and local laws and regulations Policies and procedures of employers Contracts Budgets, reimbursement rates, etc Code of Ethics; Standards of Professional Practice Accreditation standards for education programs, health care organizations (eg, Accreditation Council for Education in Nutrition and Dietetics, Joint Commission) Credentialing organizations such as the Commission on Dietetic Registration and their continuing education requirements State licensure boards Increasing call for accountability and transparency in health care
Input or Resources Dietetic technician students; Didactic Program in Dietetics students, Coordinated Program students, dietetic interns Need for food/nutrition services Money from various sources such as third-party payers, individuals, businesses, organizations, granting agencies Facilities Utilities Employers of dietetics practitioners Clients/customers/patients
The Transformation Element
Output
Education programs (community colleges, colleges, universities, internships and their affiliated sites, preceptors, teaching faculty) who transform students into practitioners Commission on Dietetic Registration who credentials entry-level and specialty practitioners Organizations that bring together clients/customer/patients with dietetics practitioners Physicians and others who prescribe medical nutrition therapy Nutrition Care Process, nutrition counseling/education for individuals/groups The media in all its forms, enabling communication between dietetics practitioners and their customers/clients/patients, collaborators Technology Research The Academy and its dietetics practice groups; state and district associations and others who provide continuing education, etc
Improved health of all Good nutrition status throughout lifespan Competent practitioners who are appropriately remunerated for their services Satisfaction of dietetics practitioners with their jobs/careers Client/customer/patient satisfaction Employer satisfaction Increased demand for dietetics services Increased collaboration with other professionals/organizations
Memory
Feedback Studies of the satisfaction of various constituencies with dietetics services Feedback of accreditation teams Pass rates on certification examinations Employment rates and related statistics Compensation and Benefits data Publications/research findings Placement rates into dietetics supervised practice Surveys/studies/chart audits/customer comments
Medical records; employee records, annual reports, historical documents, evidence analysis library; personal and organizational memory
Environmental Factors Economic, social, ethical political, legal, technological, ecological
Figure. A proposed systems model for the profession of dietetics. Adapted with permission from: Vaden AG. A Model for Evaluating the Foodservice System. Manhattan, KS: Kansas State University; 1980. You would need to be “of a certain age” to remember the old television program, “This Is Your Life” with Ralph Edwards. The show would finagle some way to bring in a well-known personality and his or her life story would be told by the show host, who often surprised them first with the voices (and presence) of people from the past who were instrumental in shaping their lives. I’d like to do a quick version of “This Is Your Life” for the profession of dietetics and the Academy. When I’ve done such reviews with my graduate student RDs, I invariably hear, “We’ve never heard this before” or “I wish this had been covered in my undergraduate program.” I believe with all my heart that if more of us had a grasp on the heritage of our profession and knowledge about where we’ve come from, that perhaps we’d be even more strongly committed to our future. I think of this as dietetics genealogy. There is a growing trend today in people wanting to know where they came from, to explore their roots. The desire February 2013 Volume 113 Number 2
to know where we came from is as old as humankind—if you’re familiar with the Bible, you remember the long list of who begat who. There’s something grounding about knowing who is in our family tree. I particularly want to acknowledge some dietetic historians including Mary Barber, who edited the History of the American Dietetic Association 1917-1959,4 and Jo Ann Cassell, who wrote Carry the Flame: The History of the American Dietetic Association,5 published in 1990. Only an amateur historian like me could fully appreciate what a labor of love these books are and what a wonderful gift they are to us and to future generations of dietetics practitioners. As we move through this lightning round of historical review, I want us to look at what was going on in the broader world, what was happening in some of those environments, and see what parallels there might be in the development of our profession and our professional organization. We typically credit the mother of the nursing profession, Florence Nightin-
gale (1820-1910), with being the first “hospital dietitian.”6 During the Crimean War in 1854, she established diet kitchens on the battlefield for critically ill soldiers. It is interesting to note that wars had a huge impact on our profession and how we grew and gained visibility and recognition because of our involvement in them. Sarah Tyson Rorer (1849-1937), who was something of the Martha Stewart of her day, is considered the first American dietitian. In 1878, right here in Philadelphia, she opened the Philadelphia Cooking School at the behest of some of the city’s leading physicians. Each year, for 33 years, she graduated 12 students who went on to become “superintendents of diet” in the leading hospitals of the day.6 In 1893 she launched a magazine that would later go on to become the Ladies Home Journal. During her long career, she wrote 54 cookbooks, more than 780 articles, and countless editorials. She was named an honorary member of the Pennsylvania Dietetic Association at their first meeting.5
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FROM THE ACADEMY The famous Lake Placid, NY, conferences in home economics, which started in 1899,7 provided the fertile ground from which our professional organization took root. Out of those conferences, the American Home Economics Association (AHEA) was founded in 1909. A subgroup of AHEA was comprised of hospital dietitians and foodservice managers from school lunchrooms, colleges, and universities and other institutional settings. I’m always proud to share with my students the role of foodservice managers in the founding of our profession. World War I began in July 1914 and ended in November 1918.8 Back in the day, when your men went off to war, you sacrificed at home. You gave up the best food and other precious commodities on the home front so that the soldiers fighting on distant fronts could have the best. We aren’t asked to do that anymore. But back in World War I, because so many of its members were involved in those food conservation efforts and other war work, the AHEA decided to cancel its regularly scheduled conference in 1917. And it was in the summer of 1917, that two women put their heads together to talk about how dietitians throughout the country could be of more service to the government’s food conservation program that was so pivotal to the war effort.5 Lulu Graves and Lenna Cooper got together while Lenna was on a business trip to Cleveland, OH, and the two of them decided to invite all the dietitians they knew to a conference in Cleveland in October. Invitations were written in longhand and people were asked to pass the word along to others that they knew. Long story short, approximately 100 people showed up from 21 states and Canada. The Academy of Nutrition and Dietetics was formally born, complete with constitution and bylaws, on October 20, 1917. The first dues were $1 per year, payable at the Annual Meeting. Lulu Graves was elected the first president. Her story might be of interest to you.5 Her first hospital job was in Chicago and she started that first position at no salary. The superintendent of the hospital promised that she would be paid when she proved she could justify the cost of her salary by money saved in good management of the food supply.5 She got paid. Those management skills 320
are no less important today—nor the ability to prove our worth.
THE ROARING TWENTIES The Roaring Twenties9—a time of economic prosperity following World War I and the era of the women’s suffrage movement, Prohibition, Al Capone, Babe Ruth, and Ernest Hemingway. One of the great medical discoveries of the era was insulin, along with a growing understanding of vitamins and minerals and successful attempts at extracting these from their food sources. The infant Academy continued to grow throughout the 1920s and by the end of the decade had a membership of around 1,300 individuals. Throughout that decade, the names and addresses of all members were included in the Journal.10 One of the major topics during the 1921 business meeting of the Academy was the presentation of a detailed report outlining a suggested 4-year degree course for dietitians. At that time, the “hospital course” (or what we would now view as the internship) was only 3 to 6 months in length. The committee who brought forth this educational proposal recommended that the hospital course be extended to 1 year and advised a year of graduate study toward a master’s degree. In 1921, the first man (Harold Walton of California) met the requirements for active membership. In 1923, the first lecture on insulin ever given at an Academy Annual Meeting was delivered.5 The first Journal of the American Dietetic Association was mailed to members in June 1925, and contained articles as varied as “Recent Developments in Vitamin Structure”11 to articles related to establishment of proper foodservice operations and menu planning, to the 1927 classic, “Standardization of Courses for Student Dietitians in Hospitals.”12 Vitamin B-1 was discovered at the close of this decade in 1929.13 I want you to recognize what a young science nutrition is!
THE THIRTIES The prosperous decade of the ’20s came to a devastating end with the Wall Street crash in October 1929, which ushered in the decade of the ’30s and the Great Depression. Clarence Birdseye sold his first frozen foods in 1930, and Ruth Wakefield invented chocolate
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chip cookies. Franklin Roosevelt was elected president in 1932, and his social welfare strategy of the “New Deal,” put in place to combat the economic and social devastation of the Great Depression, changed America in untold ways.14 As you might expect at the height of the Great Depression, dietitians struggled with food relief problems and lowcost diets. People were hungry in those days—literally!15 Dietitians in clinical practice were learning about treatment of pernicious anemia, pellagra, beriberi, and rickets. Articles in the Journal were concerned primarily with issues of nutrient deficiency. People in this country were starving. In the whole decade of the ’30s, few articles were published that addressed obesity.16 In 1934, the Nobel Prize was given to three scientists for their discoveries concerning liver therapy in cases of pernicious anemia, finding that sufferers could survive if they would eat large quantities of liver each day.17 But the Academy was ahead of the game with a 1926 Journal article outlining an incredible variety of liver recipes.18 The Nobel Prize was also awarded for the syntheses of vitamin C and vitamin E in 1937.19
THE FORTIES The end of the 1930s saw the start of the most widespread war in history. The workforce in this country changed drastically as the men went off to war and women took their places in factories and farms.20 My own mom could have been the prototype for Rosie the Riveter, as her wedding announcement indicated that the new Mrs Canter was a welder at the Chrysler plant and my dad a private in the US Army. We saw a shift in the population as farm-dwellers moved to the cities to work in defense plants. After the war, we began to move from an economy based on war to a peacetime one. War industries tried to find civilian uses for the technologies they had developed. Service men and women returned home with new skills and knowledge, and minorities and women began demanding civil rights and equality. Everything seemed to be changing.21 The Academy was 25 years old in 1942. Like other health professionals at the time, dietitians played an important role in both civilian defense proFebruary 2013 Volume 113 Number 2
FROM THE ACADEMY grams and in military service. There was a feeling of urgency because dietitians had to be trained faster both in colleges and in internships, and military status for dietitians was a growing issue. And it is interesting to note that it was the war and the shortage of dietitians to meet both civilian and military needs that began the conversation in the Academy about registration to identify qualified dietitians in each state.5 The Nobel Prize was awarded in 1943 for the discovery of vitamin K.22 The first Handbook of Diet Therapy was published in 1946.5 Dietitians were also active in lobbying for the school lunch bill, and the National School Lunch Act was passed in this year23; the use of dietetics practitioners was not mandated as a part of that legislation. I’ve always wondered if dietitians had been required to be in on the ground floor of this program, if we’d be in a different situation today and Michelle Obama and Jamie Oliver would have to find something else to focus on.
THE FIFTIES There was a lot of “booming” going on in the 1950s—the booming economy, the growing of the suburbs, and most significantly, the “baby boom.” People felt good about having babies—they were confident in the future. Middleclass people had money to spend, and spend it they did. In the realm of science, DNA was discovered in 1953.24 In 1954, the first human trials of “the pill” for women were started. In 1955, Dr Jonas Salk developed a vaccine for polio. Perhaps the most far-reaching change in communications was the huge growth in television broadcasting, which became the dominant mass media. TV began to shape what people thought and what people bought. And certainly people’s food habits were influenced as never before.25 The Academy was a large and respected organization by 1950. It was in the 1950s that the Academy worked with the US Public Health Service to produce Meal Planning with Exchange Lists, the first tool to gain universal acceptance to plan meals for persons with diabetes. In 1954, a pilot study was conducted called the “Shared Dietitian Project” to investigate the idea of whether two or more neighboring February 2013 Volume 113 Number 2
community hospitals could share the time and cost of one dietitian.5
THE SIXTIES The 1960s were, indeed, a time of change. At the beginning of the decade, with the inauguration of John Kennedy as president, we felt we were at the beginning of Camelot, our golden age. By the end of the decade, it seemed that our nation was falling apart. After the tragic assassination of John F. Kennedy, President Lyndon Johnson enacted his “Great Society” legislative reforms in hopes of bringing an end to poverty and racial injustice. Medicare and Medicaid were born, to which our progress in reimbursement seems forever tied. But while the war on poverty moved ahead on the home front, the war in Vietnam divided the nation as did the struggle for Civil Rights.26 While all of this was happening on the social front, the focus of science and technology revolved around space exploration and the space race between the United States and the Soviet Union. Those of us who were kids during that time were excited to drink Tang like the astronauts. An article in the 1960 issue of the Academy Journal concerned nutrition research for the space traveler.27 Other research began to focus on childhood obesity, how to control weight gain in adolescence, and general concerns about the diets of teenagers.28,29 Remember, by this time, televisions had been in wide use in homes for 10 to 15 years. In 1964, dietetics education changed more drastically for the first time with the approval for the first coordinated program in dietetics at The Ohio State University. But the biggest change to hit dietetics and our association in many years finally came about with the advent of registration. A system of national professional registration became a reality on June 1, 1969. The first RD exam was given in January 1970 to 56 interns. All 56 passed.5
THE SEVENTIES The 1970s continued to be a time of change and was the decade that we finally woke up to the fact that we needed to pay attention to our environment.30 The oil crisis had us waiting in line for hours to fill up our cars with gas. In 1973, the first cell phone call was
completed. We listened to our tunes on an 8-track tape, and microwave ovens became commercially available.31 Magnetic resonance imaging was first used, the insulin pump was invented, and the hemoglobin A1c test was developed. The Academy developed its first position papers as a means to communicate with members and the general public on nutrition issues. The first National Nutrition Week was celebrated in March of 1973. The Commission on Dietetic Registration was organized in 1975. Satellite technology was used for the first time to provide continuing education for dietitians in 1977. The image of the RD became a concern, and a series of regional assertiveness training programs were conducted in 1978.5
THE EIGHTIES Where were you when Mount Saint Helens erupted, John Lennon was assassinated, the space shuttle Challenger disintegrated, and the Exxon Valdez ran aground in Alaska? Ronald Reagan was elected president in 1980, and Nancy told us to “Just Say No.” The American public became aware of the AIDS epidemic in 1981.32 The first Mac computer was introduced to the public in 1984, and we saw an increasing number of articles in our Journal related to the use of computers in dietetics practice. Research on vitamin and mineral supplementation filled Journal pages, and the dietitians began to provide guidance for the vegetarian approach to eating.33 National Nutrition Week became National Nutrition Month as we attempted to reach the public in new ways. The first Academy Ambassadors, the forerunners of today’s media spokespeople, were presented to the membership in 1982. The first role delineation studies were conducted in the attempt to really identify the roles and responsibilities of RDs in their many work settings. And the first dietetic “manpower” demand study attempted to predict the future trends that would shape our profession.5
THE NINETIES The 1990s found us at war again. Our troops left for Iraq and Desert Storm in 1991.34 And it was the Gulf War that really brought CNN into our lives as we
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FROM THE ACADEMY watched that war unfold in a 24/7/365 way.35 The Information Age was upon us, and the Internet became part of our vocabulary and part of our lives. Distance education began to develop as more and more individuals entered the computer age. The Human Genome project began in 1990 and genetically engineered crops began to enter our food supply.36 During these years the Journal debated the pros and cons for low-fat and low-carb diets as the obesity epidemic continued. The Food Guide Pyramid was introduced.37 Increasing food allergies led to new research and new product development. As we waited for the dawn of the new millennium, we could look back with pride over a century of incredible advances in nutrition science and the recognition of dietetics as a legitimate profession in its own right. Outcomes research and evidence-based practice became part of our vocabulary as we sought to validate the vital role played by dietetics practitioners.38
THE NEW MILLENNIUM So here we are. The 2000s. On September 11, 2001, our lives changed forever.39 Mother Nature handed us Hurricane Katrina, tsunamis, drought, fires, and floods. The year 2007 brought the advent of “The Great Recession,” now generally acknowledged to be the most devastating global economic crisis since the Great Depression of the 1930s. The recession was officially declared “over” in 2009.40 Because of the ever increasing use of the Internet, our world is now smaller than ever before. Globalization continues to be a byword. We can interact with people all over the globe in ways that our founders would never have dreamed in a million years. I wonder what Lulu and Lenna would have thought of our social media world. Somehow I think they’d first be amazed and then we’d find them signing up for Facebook and Twitter. As in every preceding decade, our profession and our organization stand on the brink. The brink of what? We could join Dickens right now and say, “It is the best of times; it is the worst of times.”2 I don’t know where you are in your life or in your career right now. Are you just starting out, are you dreaming of retirement soon, or are you somewhere 322
in the middle? Wherever you are in your professional journey, remember, when nothing is sure, everything is possible. The Academy has shared with us a vision of the future. The Future Scan 2012-2022, which was published in the March 2012 Journal, is a must-read.41 It lays out before us the trends and statistics that will shape our world. The Academy has done the work; they’ve given us this glimpse of the future. Changes are coming. Deepak Chopra has said, “All great changes are preceded by chaos.” Does it feel chaotic right now?
Change! The aging of the US population will usher in widespread changes in our communities, our workforce, and our health care system.41 We have all heard the statistics: those 65 and over will increase by 120% by 2050. Retiring Baby Boomers are better educated and in better health, wealthier, will work or volunteer longer, and will be a more demanding clientele in their retirement. Keeping these folks well and healthy opens up incredible opportunities for dietetics practitioners in the future. However, we have to remember that a many of our own are in this Baby Boomer category. A lot of us will be leaving the workforce as we decide to retire. Some of us are creeping up on the possibility. Are we as a profession ready for . . . • • •
The increased demand for geriatric care? Older career changers who may consider careers in nutrition? Businesses who want worksite wellness programs for senior workers?
Change! Population and workforce diversity challenges our professions to change.41 Immigrant communities are springing up all across our country, changing our communities in vibrant ways. Their health needs must be met – but are we ready? Our profession is WAY too female, WAY to white. Our cultural competence often sorely lacking. The opportunities are huge. Are we ready for . . .
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• • •
The growing need for community-oriented practitioners? The possibility of new funding for preventive health care? The huge need for dietetics practitioners who are culturally competent? Dietetics practitioners who are as diverse as our country?
Change! Workforce education meets job market demands.41 Your colleagues in higher education can tell you that our dietetics student body is changing all the time. More diverse and older students are seeing dietetics in their future. How very exciting for us, because this fact meets some of the challenges we’ve already identified! I am absolutely passionate about online or distance education because it meets so many needs of this diverse and changing student body—and meets YOUR needs as practitioners. Students now take courses from multi-universities—in their internship applications, you may see courses from four, five, or six universities. The world is now our classroom, and there are so many incredible ways to engage students online. The opportunities abound. Are we ready for . . . •
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New ways of educating nontraditional working students who are into their second or third careers? Making dietetics education, undergraduate and graduate, affordable and accessible? Practice doctorates in dietetics, advanced practice residencies? Will these better prepare us for patient-centered care, interdisciplinary teams, evidence-based practice, continuous quality improvement, use of new informatics?
Change! Interdisciplinary teaming which drives innovation.41 We must learn to play well with others in the health care sandbox. We must stop circling the wagons and slapping the hands of others who are also interested in food and nutrition issues. I must admit I’ve always cringed a bit when I hear the phrase, “I’m THE nutrition expert.” If February 2013 Volume 113 Number 2
FROM THE ACADEMY you look at our dietetics career development guide, it’s a long way from novice to the top of the heap—the expert.42 While we may be the trained in the most in-depth way in food and nutrition of any health care team member, we must remember that if we draw lines in the sand around ourselves and dare anyone to cross into our territory, it’s going to be a very lonely existence. The opportunities to be a team member, and even better, a team leader are going to be required of us. Are you ready to . . . •
•
•
Remember the BIG PICTURE of dietetics practice and think beyond the world of medical nutrition therapy? Be an effective team player on interdisciplinary teams, no matter what our area of practice? Be ready to step up and be a leader?
Generalists gain an edge on specialists.41 The development of board-certified specialists within the field of dietetics has been an important element in gaining recognition for the unique expertise of some of our colleagues. Continued development of new specialty credentials is highly valued and encouraged by our members. But all that “alphabet soup” after one’s name is sometimes a two-edged sword. While those letters are impressive to those of us who know what it took to earn those letters, we often find that our health care peers in other disciplines, or the public in general, may not have a clue what those credentials mean. And having those extra credentials has unfortunately not padded our wallets in the way we might have hoped. But it is important to recognize that while we value those specialty credentials, employers are often more interested in your skills as a generalist, in your ability to swing in many directions and to be solid in the basics. Our dietetics supply and demand study reports that employers value your ability to communicate clearly, to think critically, to solve problems, to work as a team member, and to be the consummate professional. They want people who will partner with them in providing leadership in our turbulent health care, business, and educational environments. February 2013 Volume 113 Number 2
Are you ready to . . . • •
•
Showcase your innovative and creative abilities to solve tomorrow’s problems? Demonstrate flexibility and versatility on the job—to be that person who is always part of the solution, not part of the problem? Keep refreshing your professional toolkit? Remember that old saying, “If the only tool you have is a hammer, you treat everything as if it were a nail.”43 Keep adding to your toolkit.
Technology transforms nutrition counseling.41 For those of us in this audience who remember the days before e-mail and cell phones, YouTube and Facebook—we stand amazed at the tsunami of technology and how it has changed our lives forever. And given the pace of technological innovation and change, it is impossible to predict what will be possible even next year, much less 10 years down the road. The dietetics practitioner must embrace technology and all its possibilities for changing how you practice your craft in the future. The growth of informatics and the development of a comprehensive health information infrasystem in this country will catapult dietetics practitioners into a whole new world of interaction with patients, clients, and customers. Are you ready to . . . •
•
Be a developer of expert systems, the virtual nutrition coach, the builder of systems that will change the way we do business forever? Never forget the concept of “high tech— high touch”? The more technological we become, the more people long for human touch—for a real person, not a machine. There’s something intangibly real and valuable about talking with someone face to face. Don’t ever forget that!
Personalized nutrition evolves.41 The Human Genome project has expanded our horizons exponentially in being able to predict and prevent disease. Combining this new knowledge with informatics makes it possible to moni-
tor an individual’s health no matter where they are. I don’t know whether you think that sounds creepy or incredibly exciting, but it IS coming. The scientific database that can be generated blows the mind! Health monitoring technology, the evolution of genomics and its impact on dietetics, the ultimate in monitoring nutrition outcomes— we’re on the wave of some of the most incredible times for our profession. Are you ready . . . •
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With the specialized knowledge and experience required to work with these technologies? To work as a team member in conducting outcomes research that will validate the intervention of dietetics practitioners?
The food industry transforms for public priorities.41 Consumers are now in the driver’s seat more than ever before. Demands for information on their food from production to consumption have made food companies rework and reposition their products and services. Thanks to Food Network, the Cooking Channel, and the contributions of a multitude of our colleagues who are food and culinary professionals, consumers have rediscovered the joy of cooking. Who better than dietetics practitioners, with a passion for all things culinary, to help bridge the gap between the food industry and the home? Whether addressing public health issues, food safety, food labeling, or food security and sustainability, dietetics practitioners can enhance their current skills and develop new ones to meet this growing need. Are you ready to . . . • •
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Be an entrepreneur? Step forth in even more dramatic ways to share your expertise with the industry and the public? Help the public realize that our expertise reaches beyond the health care setting into their everyday lives and daily dinner tables?
At the October 2012 Food & Nutrition Conference & Expo, our House of Delegates discussed items which have the potential to change the landscape of our profession. We have not had such
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FROM THE ACADEMY sweeping recommendations to consider in 50 years. These proposals came out of the Visioning Report44 prepared by the Council on Future Practice. If you haven’t read that Visioning Report, that’s your homework assignment—it is on the Academy website. Here are the recommendations: • • •
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Require a master’s degree for entry into dietetics practice. Require that supervised practice be coordinated with the master’s degree. Create a new practice credential for baccalaureate degree graduates who have met the didactic program in dietetics degree requirements. Phase out the dietetic technician, registered credential. Require dietetics-related practice outside of the classroom as part of the undergraduate curriculum. Continue development of board-certified specialist credentials where financially feasible. Continue development of advance practice credentials as well as advanced practice educational experiences and opportunities. Conduct a well-funded, comprehensive marketing, branding, and strategic communications campaign related to these changes. Support an RD credential name change that will be reflective of the changes and in line with the name change of the Academy.
These are sweeping, dramatic, and dynamic recommendations. Read them, study the supporting material, and express your opinion to your delegates. Whether you agree with some or all of these is neither here nor there—what IS critical is that you do your homework and then stand up and be counted. Read this quote by another early leader, Beatrice Donaldson David, in 1968: “To progress in our profession and as educators and leaders, we need to accept every opportunity available for meeting the educational needs and challenges brought about by basic changes in society, to seek opportunities for using new technology, to recog324
nize and make use of resources of specialists to implement new programs, and to continue improvement through experimentation and research.”45 David’s words are as true today as in 1968. We need your leadership. What do people look for in a leader— someone who’s honest, forward-looking, competent, inspiring, credible. Do you have these characteristics? Then you have the potential for leadership. All I’m asking is that you find at least one thing that you are passionate about in your profession. Let that be the impetus that propels you to be a leader. You don’t have to be a leader all the time on every issue. But find your thing and run with it. One of the best books I’ve ever read on leadership is The Leadership Challenge46 by James Kouzes and Barry Posner. In their book, they talk about the “Five Practices of Exemplary Leadership”:
Model the Way. Know what it is that you believe and then express yourself. Authentically communicate your beliefs in a way that represents who you really are and what is near and dear to your heart. Inspire a Shared Vision. As you garner people who have heard what you said and modeled before them, help them to see your vision. Work on being able to clearly articulate your vision and help them see it. Remember Dr Martin Luther King’s “I Have a Dream” speech. I’m not expecting you to deliver that kind of oration, but that’s what I’m talking about. He took things his audience could relate to, and he helped them see his vision and where they could all go. Challenge the Process. Shake things up. Help the people you are enlisting to your cause to see new possibilities. Take small steps. Score little victories— those help you and your followers to have confidence that you’re heading in the right direction.
butions, saying “thanks” in small ways as well as in very public ways. As Kouzes and Posner say, “build the ties that bind.”
SUMMARY We stand on the shoulders of incredible women—and men. We are walking in the footsteps of giants of our profession. They were just like you. I’m sure Lulu and Lenna didn’t think of themselves as special. They saw a need and they stepped forward to meet it. And look what they birthed. Maybe you look at yourself and say, “There’s no way I could do anything like that. I’m not capable of such greatness.” But remember Mother Teresa’s famous words: “We cannot do great things on this earth, only small things with great love.” Do those small things. In conclusion, I want to leave you with the scene from the movie “The Dead Poet’s Society,” where teacher John Keating, played by Robin Williams, shows his students the faces of long-deceased former students at Welton Academy. He shares with them the concept of carpe diem, Latin for “seize the day,” and urges them to live extraordinary lives. Look at the faces of our leaders, past and present. They likewise would tell you—seize the day, live extraordinary lives, and remember, “When nothing is sure, all things are possible.” Thank you.
References 1.
Saxe JG. The Blind Men and the Elephant. http://constitution.org/col/blind_men.htm. Accessed July 25, 2012.
2.
Dickens C. A Tale of Two Cities. London, UK: Chapman and Hall; 1859.
3.
Drabble M. The Middle Ground. Raleigh, NC: Ivy Books; 1989.
4.
Barber M. History of the American Dietetic Association 1917-1959. Philadelphia, PA: Lippincott; 1959.
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Cassell J. Carry the Flame: The History of the American Dietetic Association. Chicago, IL: American Dietetic Association; 1990.
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Weigley ES. Sarah Tyson Rorer: First American dietitian? J Am Diet Assoc. 1980; 77(1):11-15.
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American Home Economics Association. Lake Placid conference proceedings. Cornell University website. http://hearth. library.cornell.edu/cgi/t/text/text-idx?c⫽ hearth;idno⫽6060826_5315_002. Accessed July 12, 2012.
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History. World War I. http://www.history. com/topics/world-war-i. Accessed August 12, 2012.
Enable Others to Act. How do we enable others to act? By building a trusting and collaborative environment. Strengthening and supporting those who’ve joined us in our effort.
Encourage the Heart. Celebrate values and victories. Acknowledge contri-
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FROM THE ACADEMY 9.
History. The Roaring Twenties. http://www. history.com/topics/roaring-twenties. Accessed August 15, 2012.
10.
American Dietetic Association. Membership list 1925. J Am Diet Assoc. 1925-1926; 1(1):37-53.
Therapeutical Application. Nobelprize.org website. http://www.nobelprize.org/nobel_ prizes/medicine/laureates/1943/dam-lecture. html. Accessed August 14, 2012.
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About the Human Genome Project. Oak Ridge National Laboratory. http://www. ornl.gov/sci/techresources/Human_Genome/ project/about.shtml. Accessed August 8, 2012.
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US Department of Agriculture, Food and Nutrition Service. The National School Lunch Program background and development. http://www.fns.usda.gov/cnd/ lunch/AboutLunch/ProgramHistory_5. htm. Accessed August 14, 2012.
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US Department of Agriculture. A brief history of USDA Food Guides. http:// www.choosemyplate.gov/food-groups/ downloads/MyPlate/ABriefHistoryOfUSDA FoodGuides.pdf. Accessed August 30, 2012.
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Fredholm L. The discovery of the molecular structure of DNA—The double helix. Nobelprize.org website. http://130.237. 143.80/educational/medicine/dna_double_ helix/readmore.html. Accessed August 16, 2012.
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Eck LH, Slawson DL, Williams R, Smith K, Harmon-Clayton K, Oliver D. A model for making outcomes research standard practice in clinical dietetics. J Am Diet Assoc.1998;98(4):451-457.
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History. 9/11 Attacks. http://www.history. com/topics/9-11-attacks. Accessed September 1, 2012.
University of Virginia. America in the 1930s. http://xroads.virginia.edu/⬃1930s/ front.html. Accessed August 14, 2012.
History. The 1950s. http://www.history. com/topics/1950s. Accessed August 17, 2012.
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Oppenheimer E. The health of children and the Depression. J Am Diet Assoc. 1934; 9(5):361-369.
History. The 1960s. http://www.history. com/topics/1960s. Accessed August 18, 2012.
Wikipedia. 2008-2012 global recession. http://en.wikipedia.org/wiki/2008%E2% 80%932012_global_recession. Accessed September 2, 2012.
27.
Finkelstein B. Nutrition research for the space traveler. J Am Diet Assoc.1960;36(4): 313-317.
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28.
Wright FH. Preventing obesity in childhood. J Am Diet Assoc.1962;40(6):516-518.
Rhea M, Bettles C. Future changes driving dietetics workforce supply and demand: Future scan 2012-2022. J Am Nutr Diet. 2012;112(3):S10-S24.
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Gallagher JR. Weight control in adolescence. J Am Diet Assoc. 1962;40(6):519520.
30.
History. The 1970s. http://www.history. com/topics/1970s. Accessed August 20, 2012.
Academy of Nutrition and Dietetics. Visioning Report: Moving Forward—A Vision for the Continuum of Dietetics Education, Credentialing and Practice. Dietetics Career Development Guide. Chicago, IL: Academy of Nutrition and Dietetics. September 5, 2012.
31.
Wikipedia. The 1970s. http://en.wikipedia. org/wiki/1970s. Accessed August 20, 2012.
43.
Maslow AH. The Psychology of Science: A Reconnaissance. Washington, DC: Regnery Publishing, Inc, Gateway Editions; 1969.
32.
History. The 1980s. http://www.history. com/topics/1980s. Accessed August 25, 2012.
44.
33.
American Dietetic Association. Position paper on the vegetarian approach to eating. J Am Diet Assoc. 1977;77(1):61-69.
Academy of Nutrition and Dietetics, Council on Future Practice. Visioning Report: Moving Forward—A Vision for the Continuum of Dietetics Education, Credentialing and Practice. http://www.eatright.org/ Members/content.aspx?id⫽6442471140. Accessed September 20, 2012.
45.
Donaldson B. Extending educational opportunities for dietitians. J Am Diet Assoc.1968;53(4):329-333.
46.
Kouzes JM, Posner BZ. The Leadership Challenge. 3rd ed. San Francisco, CA: JosseyBass; 2002.
11.
Eddy WG. Recent developments in vitamin structure. J Am Diet Assoc. 1925-1927; 1(1):17-20.
12.
Section on Education of the American Dietetic Association. Standardization of courses for student dietitians in hospitals. J Am Diet Assoc. 1926-1927;2(1):171-176.
13.
14.
15.
Christiaan Eijkman, Beriberi and Vitamin B1. Nobelprize.org website. http://www. nobelprize.org/educational/medicine/ vitamin_b1/eijkman.html. Accessed August 5, 2012.
16.
Wilder RM. The management of obesity. J Am Diet Assoc. 1930;11(2):91-100.
17.
George R. Minot—The Development of Liver Therapy in Pernicious Anemia. Nobelprize.org website. http://www. nobelprize.org/nobel_prizes/medicine/ laureates/1934/minot-lecture.html. Accessed August 10, 2012.
18.
19.
Tubbs T, Bellinger E. Preparation of calves’ liver for pernicious anemia diets. J Am Diet Assoc. 1926;2(26):163. The Nobel Prize in Chemistry 1937. Nobelprize.org website. http://www.nobelprize. org/nobel_prizes/chemistry/laureates/1937/ press.html. Accessed August 10, 2012.
20.
Farming in the 1940s: World Events. Wessels Living History Farm website. http:// www.livinghistoryfarm.org/farminginthe40s/ worldevents_01.html. Accessed 8/12/2012.
21.
Lone Star College. American cultural history 1940-1949. http://kclibrary.lonestar. edu/decade40.html. Accessed August 12, 2012.
34.
America’s Best History. U.S. Timeline 1990s. http://americasbesthistory.com/ abhtimeline1990.html. Accessed August 26, 2012.
22.
Henrik Dam—Nobel Lecture: The Discovery of Vitamin K, Its Biological Functions and
35.
Wikipedia. CNN. http://en.wikipedia.org/ wiki/CNN. Accessed August 26, 2012.
AUTHOR INFORMATION Deborah D. Canter, PhD, RD, LD, is the 50th Lenna Frances Cooper Memorial Lecturer. Canter is the director of the Didactic Program in Dietetics at Kansas State University and serves as the Academy’s chair of the Education Committee. A graduate of the University of Tennessee, Canter is a recognized speaker from Kansas to New Zealand, presenting on topics such as distance education, entrepreneurship in dietetics practice, and creating a culture for success. Canter’s publications have appeared in the Academy’s Journal, International Journal of Hospitality Management, Topics in Clinical Nutrition, School Food Service Research Review, and the Journal of Hospitality and Tourism Research. She also co-authored a book entitled, The Profession of Dietetics: A Team Approach, now in its fifth edition. For the full biography, see the Cooper Lecture announcement in the November 2012 issue of the Journal.
ACKNOWLEDGEMENTS Special thanks to Kansas State University dietetics students Thomas Lawler, Sarah Schultz, Kylie Southwick, and Nicole Specht for their assistance in the literature review of the Journal of the Academy of Nutrition and Dietetics in preparation for this presentation.
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2012 Lenna Frances Cooper Memorial Lecture: “When Nothing Is Sure, All Things Are Possible” Deborah D. Canter, PhD, RD, LD Editor’s Note: This lecture was first presented on Sunday, October 7, 2012, at the Food & Nutrition Conference & Expo in Philadelphia, PA. This lecture has been edited from its original version to fit within a print format. The complete lecture can be purchased for download at: http://bit.ly/ZEehUx.
I
WANT TO EXPRESS MY GRATItude to the Kansas Dietetic Association for nominating me for this incredible honor; to my friends and colleagues; and especially past and present students, both undergraduate and graduate, who are the joy of my life and the future of our profession. As I thought about my topic for this time, my mind went in many directions. I wondered what some of YOU would expect me to talk about: perhaps dietetics education or management practice in dietetics or the phenomenon of distance education—all topics dear to my heart and the focus of much of my career—and, I WILL mention these topics. But in the end, I’ve decided to share with you my thoughts about the big picture of our profession—where we’ve been, where we are, where we’re going as October marks the 95th anniversary of the founding of the Academy of Nutrition and Dietetics.* Kansas State University is one school in an eight-university consortium providing an online Master of Science degree in dietetics, and the students in
*Formerly known as the American Dietetic Association, and will be referred to as the Academy of Nutrition and Dietetics throughout this article. Copyright © 2013 by the Academy of Nutrition and Dietetics 2212-2672/$36.00 doi: 10.1016/j.jand.2012.11.022
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this program are all practicing registered dietitians (RDs). I can’t begin to tell you how stimulating and fun it is to teach in this program. I’m privileged to teach one of the required core courses entitled, “Environmental Scanning and Analysis of Current Issues in Dietetics.” And one of the first assignments I give the students in that class is to draw a systems model of the profession of dietetics. Yes, it’s that same model you learned way back when, maybe in a science class or maybe in a foodservice management course—you know the parts: input, transformation, output, controls, memory, feedback. Stop for a minute and think how incredibly difficult it is to capture the scope of our profession in one model. I think my students would agree that it is an incredibly challenging assignment. We all want to gravitate to our own little area of practice. We’re pretty comfortable in describing the resources and tools, goals and objectives, checks and balances, the intended outcomes in our own little acre of real estate. But when we’re faced with the breadth and height and depth of what we are about as a dietetics profession, we struggle to get our heads around it. We struggle to see the big picture. The dilemma reminds me of the poem, The Blind Men and the Elephant.1 One felt the elephant’s side and thought it must look like a wall. Another grabbed the elephant’s tail and thought it must look like a snake. And so the poem goes, that all of them thought their view of the elephant was correct—and all where horribly wrong. They couldn’t see the big picture—the totality of that elephant. The temptation is great to just focus on our part of the “dietetics elephant” and operate as if that IS the profession in its entirety. Perhaps comparing our profession to an elephant is not the mental image you wish to contemplate, but the anal-
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ogy to me is on target. We are so diverse in our practice, so far-reaching in our scope, that who we are and what we do can be incredibly confusing to our broad constituencies. If we struggle to get the big picture ourselves, imagine how the lay public and the media feel. One of the students this semester wrote, “This project required me to think outside my acute care nutrition ‘box’. . . and has certainly humbled me as a member of our profession.” As we look at that proposed systems model, the part that has always intrigued me the most are the environmental factors—those elements that are unattached to the model itself and reside outside our control (see the Figure). The environments in which we live and work are dynamic and ones to which we must always be attuned. The never-ending shifts in the economic, social, ethical, political, legal, technological, and ecological environments make achievement of our goals like playing ball with a constantly moving basket. Every generation of leaders in our profession has faced an unknown future, buffeted by the winds of environmental change—and we are no different. We do indeed live in turbulent, frustrating, but also hopeful, times. Charles Dickens said it best, in his classic A Tale of Two Cities: “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us . . . .”2 Sounds like this might have been on last night’s news, rather than having been published in 1859. We all face uncertainty, but when nothing is sure, everything is possible.3 © 2013 by the Academy of Nutrition and Dietetics.
FROM THE ACADEMY Controls Federal, state and local laws and regulations Policies and procedures of employers Contracts Budgets, reimbursement rates, etc Code of Ethics; Standards of Professional Practice Accreditation standards for education programs, health care organizations (eg, Accreditation Council for Education in Nutrition and Dietetics, Joint Commission) Credentialing organizations such as the Commission on Dietetic Registration and their continuing education requirements State licensure boards Increasing call for accountability and transparency in health care
Input or Resources Dietetic technician students; Didactic Program in Dietetics students, Coordinated Program students, dietetic interns Need for food/nutrition services Money from various sources such as third-party payers, individuals, businesses, organizations, granting agencies Facilities Utilities Employers of dietetics practitioners Clients/customers/patients
The Transformation Element
Output
Education programs (community colleges, colleges, universities, internships and their affiliated sites, preceptors, teaching faculty) who transform students into practitioners Commission on Dietetic Registration who credentials entry-level and specialty practitioners Organizations that bring together clients/customer/patients with dietetics practitioners Physicians and others who prescribe medical nutrition therapy Nutrition Care Process, nutrition counseling/education for individuals/groups The media in all its forms, enabling communication between dietetics practitioners and their customers/clients/patients, collaborators Technology Research The Academy and its dietetics practice groups; state and district associations and others who provide continuing education, etc
Improved health of all Good nutrition status throughout lifespan Competent practitioners who are appropriately remunerated for their services Satisfaction of dietetics practitioners with their jobs/careers Client/customer/patient satisfaction Employer satisfaction Increased demand for dietetics services Increased collaboration with other professionals/organizations
Memory
Feedback Studies of the satisfaction of various constituencies with dietetics services Feedback of accreditation teams Pass rates on certification examinations Employment rates and related statistics Compensation and Benefits data Publications/research findings Placement rates into dietetics supervised practice Surveys/studies/chart audits/customer comments
Medical records; employee records, annual reports, historical documents, evidence analysis library; personal and organizational memory
Environmental Factors Economic, social, ethical political, legal, technological, ecological
Figure. A proposed systems model for the profession of dietetics. Adapted with permission from: Vaden AG. A Model for Evaluating the Foodservice System. Manhattan, KS: Kansas State University; 1980. You would need to be “of a certain age” to remember the old television program, “This Is Your Life” with Ralph Edwards. The show would finagle some way to bring in a well-known personality and his or her life story would be told by the show host, who often surprised them first with the voices (and presence) of people from the past who were instrumental in shaping their lives. I’d like to do a quick version of “This Is Your Life” for the profession of dietetics and the Academy. When I’ve done such reviews with my graduate student RDs, I invariably hear, “We’ve never heard this before” or “I wish this had been covered in my undergraduate program.” I believe with all my heart that if more of us had a grasp on the heritage of our profession and knowledge about where we’ve come from, that perhaps we’d be even more strongly committed to our future. I think of this as dietetics genealogy. There is a growing trend today in people wanting to know where they came from, to explore their roots. The desire February 2013 Volume 113 Number 2
to know where we came from is as old as humankind—if you’re familiar with the Bible, you remember the long list of who begat who. There’s something grounding about knowing who is in our family tree. I particularly want to acknowledge some dietetic historians including Mary Barber, who edited the History of the American Dietetic Association 1917-1959,4 and Jo Ann Cassell, who wrote Carry the Flame: The History of the American Dietetic Association,5 published in 1990. Only an amateur historian like me could fully appreciate what a labor of love these books are and what a wonderful gift they are to us and to future generations of dietetics practitioners. As we move through this lightning round of historical review, I want us to look at what was going on in the broader world, what was happening in some of those environments, and see what parallels there might be in the development of our profession and our professional organization. We typically credit the mother of the nursing profession, Florence Nightin-
gale (1820-1910), with being the first “hospital dietitian.”6 During the Crimean War in 1854, she established diet kitchens on the battlefield for critically ill soldiers. It is interesting to note that wars had a huge impact on our profession and how we grew and gained visibility and recognition because of our involvement in them. Sarah Tyson Rorer (1849-1937), who was something of the Martha Stewart of her day, is considered the first American dietitian. In 1878, right here in Philadelphia, she opened the Philadelphia Cooking School at the behest of some of the city’s leading physicians. Each year, for 33 years, she graduated 12 students who went on to become “superintendents of diet” in the leading hospitals of the day.6 In 1893 she launched a magazine that would later go on to become the Ladies Home Journal. During her long career, she wrote 54 cookbooks, more than 780 articles, and countless editorials. She was named an honorary member of the Pennsylvania Dietetic Association at their first meeting.5
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FROM THE ACADEMY The famous Lake Placid, NY, conferences in home economics, which started in 1899,7 provided the fertile ground from which our professional organization took root. Out of those conferences, the American Home Economics Association (AHEA) was founded in 1909. A subgroup of AHEA was comprised of hospital dietitians and foodservice managers from school lunchrooms, colleges, and universities and other institutional settings. I’m always proud to share with my students the role of foodservice managers in the founding of our profession. World War I began in July 1914 and ended in November 1918.8 Back in the day, when your men went off to war, you sacrificed at home. You gave up the best food and other precious commodities on the home front so that the soldiers fighting on distant fronts could have the best. We aren’t asked to do that anymore. But back in World War I, because so many of its members were involved in those food conservation efforts and other war work, the AHEA decided to cancel its regularly scheduled conference in 1917. And it was in the summer of 1917, that two women put their heads together to talk about how dietitians throughout the country could be of more service to the government’s food conservation program that was so pivotal to the war effort.5 Lulu Graves and Lenna Cooper got together while Lenna was on a business trip to Cleveland, OH, and the two of them decided to invite all the dietitians they knew to a conference in Cleveland in October. Invitations were written in longhand and people were asked to pass the word along to others that they knew. Long story short, approximately 100 people showed up from 21 states and Canada. The Academy of Nutrition and Dietetics was formally born, complete with constitution and bylaws, on October 20, 1917. The first dues were $1 per year, payable at the Annual Meeting. Lulu Graves was elected the first president. Her story might be of interest to you.5 Her first hospital job was in Chicago and she started that first position at no salary. The superintendent of the hospital promised that she would be paid when she proved she could justify the cost of her salary by money saved in good management of the food supply.5 She got paid. Those management skills 320
are no less important today—nor the ability to prove our worth.
THE ROARING TWENTIES The Roaring Twenties9—a time of economic prosperity following World War I and the era of the women’s suffrage movement, Prohibition, Al Capone, Babe Ruth, and Ernest Hemingway. One of the great medical discoveries of the era was insulin, along with a growing understanding of vitamins and minerals and successful attempts at extracting these from their food sources. The infant Academy continued to grow throughout the 1920s and by the end of the decade had a membership of around 1,300 individuals. Throughout that decade, the names and addresses of all members were included in the Journal.10 One of the major topics during the 1921 business meeting of the Academy was the presentation of a detailed report outlining a suggested 4-year degree course for dietitians. At that time, the “hospital course” (or what we would now view as the internship) was only 3 to 6 months in length. The committee who brought forth this educational proposal recommended that the hospital course be extended to 1 year and advised a year of graduate study toward a master’s degree. In 1921, the first man (Harold Walton of California) met the requirements for active membership. In 1923, the first lecture on insulin ever given at an Academy Annual Meeting was delivered.5 The first Journal of the American Dietetic Association was mailed to members in June 1925, and contained articles as varied as “Recent Developments in Vitamin Structure”11 to articles related to establishment of proper foodservice operations and menu planning, to the 1927 classic, “Standardization of Courses for Student Dietitians in Hospitals.”12 Vitamin B-1 was discovered at the close of this decade in 1929.13 I want you to recognize what a young science nutrition is!
THE THIRTIES The prosperous decade of the ’20s came to a devastating end with the Wall Street crash in October 1929, which ushered in the decade of the ’30s and the Great Depression. Clarence Birdseye sold his first frozen foods in 1930, and Ruth Wakefield invented chocolate
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chip cookies. Franklin Roosevelt was elected president in 1932, and his social welfare strategy of the “New Deal,” put in place to combat the economic and social devastation of the Great Depression, changed America in untold ways.14 As you might expect at the height of the Great Depression, dietitians struggled with food relief problems and lowcost diets. People were hungry in those days—literally!15 Dietitians in clinical practice were learning about treatment of pernicious anemia, pellagra, beriberi, and rickets. Articles in the Journal were concerned primarily with issues of nutrient deficiency. People in this country were starving. In the whole decade of the ’30s, few articles were published that addressed obesity.16 In 1934, the Nobel Prize was given to three scientists for their discoveries concerning liver therapy in cases of pernicious anemia, finding that sufferers could survive if they would eat large quantities of liver each day.17 But the Academy was ahead of the game with a 1926 Journal article outlining an incredible variety of liver recipes.18 The Nobel Prize was also awarded for the syntheses of vitamin C and vitamin E in 1937.19
THE FORTIES The end of the 1930s saw the start of the most widespread war in history. The workforce in this country changed drastically as the men went off to war and women took their places in factories and farms.20 My own mom could have been the prototype for Rosie the Riveter, as her wedding announcement indicated that the new Mrs Canter was a welder at the Chrysler plant and my dad a private in the US Army. We saw a shift in the population as farm-dwellers moved to the cities to work in defense plants. After the war, we began to move from an economy based on war to a peacetime one. War industries tried to find civilian uses for the technologies they had developed. Service men and women returned home with new skills and knowledge, and minorities and women began demanding civil rights and equality. Everything seemed to be changing.21 The Academy was 25 years old in 1942. Like other health professionals at the time, dietitians played an important role in both civilian defense proFebruary 2013 Volume 113 Number 2
FROM THE ACADEMY grams and in military service. There was a feeling of urgency because dietitians had to be trained faster both in colleges and in internships, and military status for dietitians was a growing issue. And it is interesting to note that it was the war and the shortage of dietitians to meet both civilian and military needs that began the conversation in the Academy about registration to identify qualified dietitians in each state.5 The Nobel Prize was awarded in 1943 for the discovery of vitamin K.22 The first Handbook of Diet Therapy was published in 1946.5 Dietitians were also active in lobbying for the school lunch bill, and the National School Lunch Act was passed in this year23; the use of dietetics practitioners was not mandated as a part of that legislation. I’ve always wondered if dietitians had been required to be in on the ground floor of this program, if we’d be in a different situation today and Michelle Obama and Jamie Oliver would have to find something else to focus on.
THE FIFTIES There was a lot of “booming” going on in the 1950s—the booming economy, the growing of the suburbs, and most significantly, the “baby boom.” People felt good about having babies—they were confident in the future. Middleclass people had money to spend, and spend it they did. In the realm of science, DNA was discovered in 1953.24 In 1954, the first human trials of “the pill” for women were started. In 1955, Dr Jonas Salk developed a vaccine for polio. Perhaps the most far-reaching change in communications was the huge growth in television broadcasting, which became the dominant mass media. TV began to shape what people thought and what people bought. And certainly people’s food habits were influenced as never before.25 The Academy was a large and respected organization by 1950. It was in the 1950s that the Academy worked with the US Public Health Service to produce Meal Planning with Exchange Lists, the first tool to gain universal acceptance to plan meals for persons with diabetes. In 1954, a pilot study was conducted called the “Shared Dietitian Project” to investigate the idea of whether two or more neighboring February 2013 Volume 113 Number 2
community hospitals could share the time and cost of one dietitian.5
THE SIXTIES The 1960s were, indeed, a time of change. At the beginning of the decade, with the inauguration of John Kennedy as president, we felt we were at the beginning of Camelot, our golden age. By the end of the decade, it seemed that our nation was falling apart. After the tragic assassination of John F. Kennedy, President Lyndon Johnson enacted his “Great Society” legislative reforms in hopes of bringing an end to poverty and racial injustice. Medicare and Medicaid were born, to which our progress in reimbursement seems forever tied. But while the war on poverty moved ahead on the home front, the war in Vietnam divided the nation as did the struggle for Civil Rights.26 While all of this was happening on the social front, the focus of science and technology revolved around space exploration and the space race between the United States and the Soviet Union. Those of us who were kids during that time were excited to drink Tang like the astronauts. An article in the 1960 issue of the Academy Journal concerned nutrition research for the space traveler.27 Other research began to focus on childhood obesity, how to control weight gain in adolescence, and general concerns about the diets of teenagers.28,29 Remember, by this time, televisions had been in wide use in homes for 10 to 15 years. In 1964, dietetics education changed more drastically for the first time with the approval for the first coordinated program in dietetics at The Ohio State University. But the biggest change to hit dietetics and our association in many years finally came about with the advent of registration. A system of national professional registration became a reality on June 1, 1969. The first RD exam was given in January 1970 to 56 interns. All 56 passed.5
THE SEVENTIES The 1970s continued to be a time of change and was the decade that we finally woke up to the fact that we needed to pay attention to our environment.30 The oil crisis had us waiting in line for hours to fill up our cars with gas. In 1973, the first cell phone call was
completed. We listened to our tunes on an 8-track tape, and microwave ovens became commercially available.31 Magnetic resonance imaging was first used, the insulin pump was invented, and the hemoglobin A1c test was developed. The Academy developed its first position papers as a means to communicate with members and the general public on nutrition issues. The first National Nutrition Week was celebrated in March of 1973. The Commission on Dietetic Registration was organized in 1975. Satellite technology was used for the first time to provide continuing education for dietitians in 1977. The image of the RD became a concern, and a series of regional assertiveness training programs were conducted in 1978.5
THE EIGHTIES Where were you when Mount Saint Helens erupted, John Lennon was assassinated, the space shuttle Challenger disintegrated, and the Exxon Valdez ran aground in Alaska? Ronald Reagan was elected president in 1980, and Nancy told us to “Just Say No.” The American public became aware of the AIDS epidemic in 1981.32 The first Mac computer was introduced to the public in 1984, and we saw an increasing number of articles in our Journal related to the use of computers in dietetics practice. Research on vitamin and mineral supplementation filled Journal pages, and the dietitians began to provide guidance for the vegetarian approach to eating.33 National Nutrition Week became National Nutrition Month as we attempted to reach the public in new ways. The first Academy Ambassadors, the forerunners of today’s media spokespeople, were presented to the membership in 1982. The first role delineation studies were conducted in the attempt to really identify the roles and responsibilities of RDs in their many work settings. And the first dietetic “manpower” demand study attempted to predict the future trends that would shape our profession.5
THE NINETIES The 1990s found us at war again. Our troops left for Iraq and Desert Storm in 1991.34 And it was the Gulf War that really brought CNN into our lives as we
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FROM THE ACADEMY watched that war unfold in a 24/7/365 way.35 The Information Age was upon us, and the Internet became part of our vocabulary and part of our lives. Distance education began to develop as more and more individuals entered the computer age. The Human Genome project began in 1990 and genetically engineered crops began to enter our food supply.36 During these years the Journal debated the pros and cons for low-fat and low-carb diets as the obesity epidemic continued. The Food Guide Pyramid was introduced.37 Increasing food allergies led to new research and new product development. As we waited for the dawn of the new millennium, we could look back with pride over a century of incredible advances in nutrition science and the recognition of dietetics as a legitimate profession in its own right. Outcomes research and evidence-based practice became part of our vocabulary as we sought to validate the vital role played by dietetics practitioners.38
THE NEW MILLENNIUM So here we are. The 2000s. On September 11, 2001, our lives changed forever.39 Mother Nature handed us Hurricane Katrina, tsunamis, drought, fires, and floods. The year 2007 brought the advent of “The Great Recession,” now generally acknowledged to be the most devastating global economic crisis since the Great Depression of the 1930s. The recession was officially declared “over” in 2009.40 Because of the ever increasing use of the Internet, our world is now smaller than ever before. Globalization continues to be a byword. We can interact with people all over the globe in ways that our founders would never have dreamed in a million years. I wonder what Lulu and Lenna would have thought of our social media world. Somehow I think they’d first be amazed and then we’d find them signing up for Facebook and Twitter. As in every preceding decade, our profession and our organization stand on the brink. The brink of what? We could join Dickens right now and say, “It is the best of times; it is the worst of times.”2 I don’t know where you are in your life or in your career right now. Are you just starting out, are you dreaming of retirement soon, or are you somewhere 322
in the middle? Wherever you are in your professional journey, remember, when nothing is sure, everything is possible. The Academy has shared with us a vision of the future. The Future Scan 2012-2022, which was published in the March 2012 Journal, is a must-read.41 It lays out before us the trends and statistics that will shape our world. The Academy has done the work; they’ve given us this glimpse of the future. Changes are coming. Deepak Chopra has said, “All great changes are preceded by chaos.” Does it feel chaotic right now?
Change! The aging of the US population will usher in widespread changes in our communities, our workforce, and our health care system.41 We have all heard the statistics: those 65 and over will increase by 120% by 2050. Retiring Baby Boomers are better educated and in better health, wealthier, will work or volunteer longer, and will be a more demanding clientele in their retirement. Keeping these folks well and healthy opens up incredible opportunities for dietetics practitioners in the future. However, we have to remember that a many of our own are in this Baby Boomer category. A lot of us will be leaving the workforce as we decide to retire. Some of us are creeping up on the possibility. Are we as a profession ready for . . . • • •
The increased demand for geriatric care? Older career changers who may consider careers in nutrition? Businesses who want worksite wellness programs for senior workers?
Change! Population and workforce diversity challenges our professions to change.41 Immigrant communities are springing up all across our country, changing our communities in vibrant ways. Their health needs must be met – but are we ready? Our profession is WAY too female, WAY to white. Our cultural competence often sorely lacking. The opportunities are huge. Are we ready for . . .
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The growing need for community-oriented practitioners? The possibility of new funding for preventive health care? The huge need for dietetics practitioners who are culturally competent? Dietetics practitioners who are as diverse as our country?
Change! Workforce education meets job market demands.41 Your colleagues in higher education can tell you that our dietetics student body is changing all the time. More diverse and older students are seeing dietetics in their future. How very exciting for us, because this fact meets some of the challenges we’ve already identified! I am absolutely passionate about online or distance education because it meets so many needs of this diverse and changing student body—and meets YOUR needs as practitioners. Students now take courses from multi-universities—in their internship applications, you may see courses from four, five, or six universities. The world is now our classroom, and there are so many incredible ways to engage students online. The opportunities abound. Are we ready for . . . •
• •
New ways of educating nontraditional working students who are into their second or third careers? Making dietetics education, undergraduate and graduate, affordable and accessible? Practice doctorates in dietetics, advanced practice residencies? Will these better prepare us for patient-centered care, interdisciplinary teams, evidence-based practice, continuous quality improvement, use of new informatics?
Change! Interdisciplinary teaming which drives innovation.41 We must learn to play well with others in the health care sandbox. We must stop circling the wagons and slapping the hands of others who are also interested in food and nutrition issues. I must admit I’ve always cringed a bit when I hear the phrase, “I’m THE nutrition expert.” If February 2013 Volume 113 Number 2
FROM THE ACADEMY you look at our dietetics career development guide, it’s a long way from novice to the top of the heap—the expert.42 While we may be the trained in the most in-depth way in food and nutrition of any health care team member, we must remember that if we draw lines in the sand around ourselves and dare anyone to cross into our territory, it’s going to be a very lonely existence. The opportunities to be a team member, and even better, a team leader are going to be required of us. Are you ready to . . . •
•
•
Remember the BIG PICTURE of dietetics practice and think beyond the world of medical nutrition therapy? Be an effective team player on interdisciplinary teams, no matter what our area of practice? Be ready to step up and be a leader?
Generalists gain an edge on specialists.41 The development of board-certified specialists within the field of dietetics has been an important element in gaining recognition for the unique expertise of some of our colleagues. Continued development of new specialty credentials is highly valued and encouraged by our members. But all that “alphabet soup” after one’s name is sometimes a two-edged sword. While those letters are impressive to those of us who know what it took to earn those letters, we often find that our health care peers in other disciplines, or the public in general, may not have a clue what those credentials mean. And having those extra credentials has unfortunately not padded our wallets in the way we might have hoped. But it is important to recognize that while we value those specialty credentials, employers are often more interested in your skills as a generalist, in your ability to swing in many directions and to be solid in the basics. Our dietetics supply and demand study reports that employers value your ability to communicate clearly, to think critically, to solve problems, to work as a team member, and to be the consummate professional. They want people who will partner with them in providing leadership in our turbulent health care, business, and educational environments. February 2013 Volume 113 Number 2
Are you ready to . . . • •
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Showcase your innovative and creative abilities to solve tomorrow’s problems? Demonstrate flexibility and versatility on the job—to be that person who is always part of the solution, not part of the problem? Keep refreshing your professional toolkit? Remember that old saying, “If the only tool you have is a hammer, you treat everything as if it were a nail.”43 Keep adding to your toolkit.
Technology transforms nutrition counseling.41 For those of us in this audience who remember the days before e-mail and cell phones, YouTube and Facebook—we stand amazed at the tsunami of technology and how it has changed our lives forever. And given the pace of technological innovation and change, it is impossible to predict what will be possible even next year, much less 10 years down the road. The dietetics practitioner must embrace technology and all its possibilities for changing how you practice your craft in the future. The growth of informatics and the development of a comprehensive health information infrasystem in this country will catapult dietetics practitioners into a whole new world of interaction with patients, clients, and customers. Are you ready to . . . •
•
Be a developer of expert systems, the virtual nutrition coach, the builder of systems that will change the way we do business forever? Never forget the concept of “high tech— high touch”? The more technological we become, the more people long for human touch—for a real person, not a machine. There’s something intangibly real and valuable about talking with someone face to face. Don’t ever forget that!
Personalized nutrition evolves.41 The Human Genome project has expanded our horizons exponentially in being able to predict and prevent disease. Combining this new knowledge with informatics makes it possible to moni-
tor an individual’s health no matter where they are. I don’t know whether you think that sounds creepy or incredibly exciting, but it IS coming. The scientific database that can be generated blows the mind! Health monitoring technology, the evolution of genomics and its impact on dietetics, the ultimate in monitoring nutrition outcomes— we’re on the wave of some of the most incredible times for our profession. Are you ready . . . •
•
With the specialized knowledge and experience required to work with these technologies? To work as a team member in conducting outcomes research that will validate the intervention of dietetics practitioners?
The food industry transforms for public priorities.41 Consumers are now in the driver’s seat more than ever before. Demands for information on their food from production to consumption have made food companies rework and reposition their products and services. Thanks to Food Network, the Cooking Channel, and the contributions of a multitude of our colleagues who are food and culinary professionals, consumers have rediscovered the joy of cooking. Who better than dietetics practitioners, with a passion for all things culinary, to help bridge the gap between the food industry and the home? Whether addressing public health issues, food safety, food labeling, or food security and sustainability, dietetics practitioners can enhance their current skills and develop new ones to meet this growing need. Are you ready to . . . • •
•
Be an entrepreneur? Step forth in even more dramatic ways to share your expertise with the industry and the public? Help the public realize that our expertise reaches beyond the health care setting into their everyday lives and daily dinner tables?
At the October 2012 Food & Nutrition Conference & Expo, our House of Delegates discussed items which have the potential to change the landscape of our profession. We have not had such
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FROM THE ACADEMY sweeping recommendations to consider in 50 years. These proposals came out of the Visioning Report44 prepared by the Council on Future Practice. If you haven’t read that Visioning Report, that’s your homework assignment—it is on the Academy website. Here are the recommendations: • • •
• •
•
•
•
•
Require a master’s degree for entry into dietetics practice. Require that supervised practice be coordinated with the master’s degree. Create a new practice credential for baccalaureate degree graduates who have met the didactic program in dietetics degree requirements. Phase out the dietetic technician, registered credential. Require dietetics-related practice outside of the classroom as part of the undergraduate curriculum. Continue development of board-certified specialist credentials where financially feasible. Continue development of advance practice credentials as well as advanced practice educational experiences and opportunities. Conduct a well-funded, comprehensive marketing, branding, and strategic communications campaign related to these changes. Support an RD credential name change that will be reflective of the changes and in line with the name change of the Academy.
These are sweeping, dramatic, and dynamic recommendations. Read them, study the supporting material, and express your opinion to your delegates. Whether you agree with some or all of these is neither here nor there—what IS critical is that you do your homework and then stand up and be counted. Read this quote by another early leader, Beatrice Donaldson David, in 1968: “To progress in our profession and as educators and leaders, we need to accept every opportunity available for meeting the educational needs and challenges brought about by basic changes in society, to seek opportunities for using new technology, to recog324
nize and make use of resources of specialists to implement new programs, and to continue improvement through experimentation and research.”45 David’s words are as true today as in 1968. We need your leadership. What do people look for in a leader— someone who’s honest, forward-looking, competent, inspiring, credible. Do you have these characteristics? Then you have the potential for leadership. All I’m asking is that you find at least one thing that you are passionate about in your profession. Let that be the impetus that propels you to be a leader. You don’t have to be a leader all the time on every issue. But find your thing and run with it. One of the best books I’ve ever read on leadership is The Leadership Challenge46 by James Kouzes and Barry Posner. In their book, they talk about the “Five Practices of Exemplary Leadership”:
Model the Way. Know what it is that you believe and then express yourself. Authentically communicate your beliefs in a way that represents who you really are and what is near and dear to your heart. Inspire a Shared Vision. As you garner people who have heard what you said and modeled before them, help them to see your vision. Work on being able to clearly articulate your vision and help them see it. Remember Dr Martin Luther King’s “I Have a Dream” speech. I’m not expecting you to deliver that kind of oration, but that’s what I’m talking about. He took things his audience could relate to, and he helped them see his vision and where they could all go. Challenge the Process. Shake things up. Help the people you are enlisting to your cause to see new possibilities. Take small steps. Score little victories— those help you and your followers to have confidence that you’re heading in the right direction.
butions, saying “thanks” in small ways as well as in very public ways. As Kouzes and Posner say, “build the ties that bind.”
SUMMARY We stand on the shoulders of incredible women—and men. We are walking in the footsteps of giants of our profession. They were just like you. I’m sure Lulu and Lenna didn’t think of themselves as special. They saw a need and they stepped forward to meet it. And look what they birthed. Maybe you look at yourself and say, “There’s no way I could do anything like that. I’m not capable of such greatness.” But remember Mother Teresa’s famous words: “We cannot do great things on this earth, only small things with great love.” Do those small things. In conclusion, I want to leave you with the scene from the movie “The Dead Poet’s Society,” where teacher John Keating, played by Robin Williams, shows his students the faces of long-deceased former students at Welton Academy. He shares with them the concept of carpe diem, Latin for “seize the day,” and urges them to live extraordinary lives. Look at the faces of our leaders, past and present. They likewise would tell you—seize the day, live extraordinary lives, and remember, “When nothing is sure, all things are possible.” Thank you.
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AUTHOR INFORMATION Deborah D. Canter, PhD, RD, LD, is the 50th Lenna Frances Cooper Memorial Lecturer. Canter is the director of the Didactic Program in Dietetics at Kansas State University and serves as the Academy’s chair of the Education Committee. A graduate of the University of Tennessee, Canter is a recognized speaker from Kansas to New Zealand, presenting on topics such as distance education, entrepreneurship in dietetics practice, and creating a culture for success. Canter’s publications have appeared in the Academy’s Journal, International Journal of Hospitality Management, Topics in Clinical Nutrition, School Food Service Research Review, and the Journal of Hospitality and Tourism Research. She also co-authored a book entitled, The Profession of Dietetics: A Team Approach, now in its fifth edition. For the full biography, see the Cooper Lecture announcement in the November 2012 issue of the Journal.
ACKNOWLEDGEMENTS Special thanks to Kansas State University dietetics students Thomas Lawler, Sarah Schultz, Kylie Southwick, and Nicole Specht for their assistance in the literature review of the Journal of the Academy of Nutrition and Dietetics in preparation for this presentation.
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