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Is an Overseas Dietetics Career Opportunity for You?
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BUSINESS OF DIETETICS
Is an Overseas Dietetics Career Opportunity for You? This article is reprinted from the September 2009 issue of the Journal (2009;109:1509-1512).
I
n her job as a nutrition therapist for the expatriate community of Baku, Azerbaijan, Valerie Houghton, RD, travels to oil rigs to do nutrition presentations and marks up photocopies of Russian-labeled foods with English translations. Azerbaijan, an oil-rich country on the west coast of the Caspian Sea, has a long history of Persian and Russian rule—influences that still dominate the local cuisine. Spicy beef, lamb, and poultry are often paired with saffron, spinach, and potatoes, and vodka is the favorite drink. Unfortunately, the country’s health care infrastructure also dates from the Cold War era. “Food safety is an issue,” Houghton says. “What we take for granted about preventative health care doesn’t exist—there’s no smoking cessation information, and no information about cancers, diet, or heart disease.” When Houghton approached the International SOS clinic in Baku about the services she could offer, the clinic jumped at the chance to create a job for her. “I’m the only dietitian I know in Azerbaijan who has a pamphlet about what I do,” she laughs, adding that she has so far met only one other dietitian in the country. Houghton is used to forging her own career path— one that has included stints in London, UK, and the United Arab Emirates (UAE)—since she married a partner who relocates This article was written by Sara Aase, a freelance writer in Minneapolis, MN. Aase is an award-winning journalist who frequently writes about health, business, and parenting. Her work has appeared in Weekly Reader Current Health, Minnesota Monthly, Twin Cities Business, Pregnancy, Parenting, Hemispheres, and American Baby. doi: 10.1016/j.jada.2010.03.008
every 2 to 3 years for his job with an oil company. Working overseas hasn’t always been ideal. In the UAE, a cosmopolitan federation of seven emirates (like states, each administered by a hereditary Muslim Monarch) in the southeast part of the Arabian Peninsula, Houghton found herself writing dietetics articles for magazines instead of practicing in a clinic or hospital. “It’s not anything I ever thought I would do, but was what I needed to do at the time,” she says, adding that the experience helped her stay current with dietetics as well as polish her marketing and presentation skills. “It may take you more energy to search out jobs overseas, but the opportunities absolutely are there.” Why might you consider an international career jump? Registered dietitians (RDs) who live overseas—particularly in non-Western countries—say their careers benefit from the diverse roles they can create for themselves because of high demand. “We can create the jobs,” says Stacia Nordin, RD, past president of the American Overseas Dietetic Association (AODA), the international affiliate of the American Dietetic Association. For the past 12 years Nordin has worked in the southeastern African country of Malawi. She is currently the technical advisor to the Ministry of Education’s School of Health and Nutrition Program, which oversees nutrition in the public schools. “It’s a matter of thinking in terms of what you can do for the world as a nutritionist.” Paving their own road also gives RDs a chance to be highly entrepreneurial about their roles, says Camella Rising, MS, RD, AODA president-elect. While finishing an internship at the Women, Infants, and Children (WIC) program in San Francisco, Rising, newly married to a Navy pilot, figured she wouldn’t be working at their first overseas post in Sicily (Sigonella). “There’s not much of a role for civilian dietitians on a military base, since jobs in hospitals go to military dietitians first.” But then she spied a brochure for WIC
© 2010 by the American Dietetic Association
Get to Know the AODA More than 700 dietitians hailing from 70 countries make up the membership of the American Overseas Dietetic Association (AODA), the international affiliate of the American Dietetic Association. The AODA provides opportunities to connect with one another, establish professional contacts, and obtain continuing education credits. Members enjoy the same privileges as other American Dietetic Association affiliates. The AODA’s International Dietetic Network is a resource for country-specific nutrition and dietetics information, including opportunities for employment and local food customs. It also offers a members-only listserv and Web site, newsletter, and access to information about conferences and meetings. The AODA holds a conference every other year; in 2009, members traveled to the Crowne Plaza Mutiara in Kuala Lumpur. See: www. eatrightoverseas.org. Overseas. “They didn’t have an office at the Sicily base, so I opened one,” she says. “Going overseas definitely requires some thinking out of the box about your career.” Rising and other RDs say they handle more responsibilities, more quickly, than they otherwise might, which broadens their skill set and often gives them access to a wider variety of nutrition issues. Rising, for example, had to order the furniture, staff her office, coordinate with the base grocery store and hospital, and adapt WIC program materials for her international clientele. The WIC outpost, Rising notes, was her very first dietetics job. Not only did it give her a supervisory role early in her career, she says, it also changed her focus from clinical dietetics to public health. Those RDs who stay in one place long-term are able to see the way their influence helps shape nutrition health policies and dietetics education standards. In the UAE, for exam-
Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S33
BUSINESS OF DIETETICS ple, Ellen Edwards, RD, LD, the head of clinical dietetics at Sheikh Khalifa Medical City (SKMC) since 2000, has steadily raised the bar for locally graduating RDs. In 2000, she says, the country didn’t have any RDs at all. “I used to have to train the students graduating in dietetics here for 3 to 4 years to get them to the [American Dietetic Association] dietetic level,” Edwards says. “Now they are a lot closer to the equivalent of the 4-year US program.” The UAE’s health authority, in turn, is starting to apply these same education standards emirate-wide. “Not to sound grandiose,” Edwards says. “But your influence can affect country policy.” CAN I GET THERE FROM HERE? COUNTRY WORK REQUIREMENTS If you’re not being sponsored by your employer to transfer overseas, you’ll need to learn a particular country’s requirements for working there, including any reciprocity agreements, registration requirements for RDs, and possible job opportunities. For example, Houghton’s first overseas placement, in London, was also the toughest. London requires that an employer sponsor international workers. At the time, Houghton worked for Aramark, but the global foodservices provider had no jobs available for her in London and denied her request to transfer there. That didn’t deter Houghton. She applied for a work visa through a British government-sponsored program for highly skilled migrant workers, which required her to meet a certain number of points for degrees and published articles. That process took 4 months. Then she had to line up interviews or potential interviews. “I just kept hammering Aramark in all divisions,” she says. “I knew there weren’t any dietitians over there [for the company] at all.” She persisted until she learned that Aramark was building a London division to promote its hospital catering services to the National Health Service, the publicly funded health care service of the United Kingdom. In 2002 Aramark hired her to direct its patient services program. But Houghton faced one last hurdle: registration. When she first applied, the British Health Professions Council denied her dietetics registration. Houghton endured 4 more months of paperwork and a hearing in
S34
May 2010 Suppl 1 Volume 110 Number 5
front of British examiners to finally have her registration credentials accepted. In the UAE, Edwards says, it can take 3 to 6 months to hire a new RD because of the number of verifications the UAE requires. New hires need a document verifying dates and job titles for every position they’ve held. They go through security clearance. And they must have each of their degrees verified and notarized by their secretary of state in their home state as well as in Washington, DC, and then verified by the US embassy in the UAE.
“You have to know where your boundaries are, but be comfortable with ambiguity. Things aren’t always going to be spelled out for you.” To inquire about country requirements for international dietetics work, contact the US Department of State or a country representative with the AODA’s International Dietetic Network, which has about 40 country representatives, Rising says. These representatives produce country information sheets and act as liaisons and ambassadors for new RDs working there. “Most of the questions we field have to do with working requirements for specific countries,” Rising says. GETTING ACCLIMATED Adapting to a new culture demands flexibility, resilience, patience, openness, confidence, and the willingness to learn, RDs say. “You have to know where your boundaries are, but be comfortable with ambiguity,” Houghton says. “Things aren’t always going to be spelled out for you.” Reading up on a country and talking to people who’ve lived there can help ease your transition. But do expect culture shock. Bret Johnson, who works in Paris as group senior vice president of client relations with Sodexo, the global foodservices company based in France, laughs at his first bumbled attempts to buy
groceries or go to the dry cleaner in Paris. “I assumed stores were open late in the evening and that places would be open on Sundays, but that’s not the case,” he says. “The expectation is that nothing is different here except the language, but in reality it is quite different.” Johnson, who hails from Iowa, says his French is now passable enough for him to get by in public, but early on, he says, “I found locals who were open and willing to be my mentors for my personal life—people that I could say my three words of French to and that would come to my aid.” That shock often extends to the workplace. RDs starting new overseas programs often find themselves facing an empty shell of an office, Houghton says, literally supplying everything from scratch. “When I started up in London, I had no diet manual, no nothing,” she recalls. “I knew how to get all the materials from the United States, but it’s like walking into a bare house and having nothing.” She also discovered she would have to help change the United Kingdom’s attitude toward the role of dietetics in a corporate setting, which at that time was looked down on by RDs. “There was no private industry operating hospitals there,” Houghton says. “It was completely alien to them, and the world of clinical dietetics was completely separate from that of foodservice. I had to integrate two completely different models.” Many Americans who are used to being prompt also struggle with the “looseness” that people in many other countries have toward the concept of time. In Paris, Johnson says, the French tend to start meetings late and value the art of discussion more than the actual meeting objective. At first, he says, this drove him crazy. “I thought, this is pointless, we’ll never get anywhere,” he says. Over time, Johnson says, he softened a bit, while his team, in turn, moved toward more structured meetings. In many cultures, “you start any meeting with personal greetings and inquiries about each other’s families,” says Editha Heberlein, MS, RD, FADA (Germany), president of AODA. “They take offense in the American attitude of getting right down to business.” Heberlein’s most recent overseas job was a 7-year stint in Stuttgart, Germany, where she was a lieutenant colonel of the US Air Force and the global health liaison for the European Command.
BUSINESS OF DIETETICS It can feel overwhelming to realize that you’ll face a whole new set of social rules, from how to dress, to whom to greet and how. In Britain and France, for example, hierarchy is valued and observed more formally than in the United States. In Azerbaijan, Houghton says, “Men don’t ask about women; they would never ask, for example, how a pregnant woman was feeling or what sex the baby might be.” You might shake hands in greeting, she says, but only if the hand is extended. And you never refuse coffee or tea when it is offered. A simple place to start, says Heberlein, is to learn key phrases in the other languages you’ll hear, such as ’hello,’ ’thank you,’ and ’how are you.’ “That you’re trying is always appreciated,” she says. PRACTICING DIETETICS ABROAD: DIFFERENT SETTINGS, SAME GOALS Just as in the United States, many RDs abroad also struggle against the rising trend in the developed world toward a more Westernized diet and accompanying obesity, heart disease, and diabetes. “Across cultures you see the same issues of identifying the bad fats and cutting portion sizes and empty calories,” Edwards says. “It might be coconut oil or fried shrimp instead of burgers, but fat is still fat, a fruit is still fruit, and a portion is still a portion.” As populations grow more affluent, she says, “We have to teach them how to spend more time on everyday meals, eat less fast food and soda pop.” And just as they do in diverse American communities, RDs overseas try to strike a balance between sound practice and cultural traditions. For example, Rising says, in Sicily “it was common to crush up biscotti and put in a bottle with milk,” a practice that American Academy of Pediatrics discourages, as it can cause choking or pulmonary problems and expose babies to food allergies. “Just like in America, the biggest thing is listening, and giving them the confidence to say they could do something differently than the way their mothers or grandmothers did. It’s a fine balance.” Heberlein’s challenge is to encourage her American clients to eat more like the rest of the less-developed world does, incorporating more vegetables, fruit, and fish, and far less
meat into their diets. “I grew up in the Philippines, and did not realize how healthy I was eating then,” she says. “We ate fish for three meals a day, and meat was only for very special occasions.” This year in the UAE, Edwards is starting a portion-control program in an effort to get her clients to take a more moderate approach to fasting and feasting during the holy month of Ramadan, when Muslims fast until sundown. “We are getting more dehydration cases and diagnosed diabetics because people are gorging themselves at night,” Edwards says. “There’s also a cultural tradition, as part of Arabic hospitality, to mound food on a plate.” In Malawi, where food is often scarce, Nordin’s work has a different nutritional focus— one that holistically addresses the issue of creating a sustainable food economy in a stilldeveloping country, where people live directly off the land. Unlike in the United States, there are no grocery stores that provide access to food whenever you like. “We realized in Africa you cannot talk about nutrition without talking about agriculture, food security, the environment, and sanitation and how they all interlink,” she says. “We felt the only way to succeed is to help Malawians use their local resources to their full potential.” Over the course of her career, Nordin has developed program materials that teach, for example, water conservation and better food growing techniques, along with nutrition and complementary care for patients with human immunodeficiency virus. A RICHER WORLD-VIEW When she first landed in the UAE, Houghton says, she was surrounded by mosques that broadcast the Muslim call to prayer five times a day. “At first it was quite annoying,” she recalls. “But then it just becomes part of the day, and then after that it becomes quite comforting.” RDs who live and work abroad say these subtle transformations, where they find themselves in sync with another culture, deepen their perspective of and appreciation for other people, and teach them things about themselves they otherwise never would have learned. In Malawi, Nordin says, the culture is people-focused, since they quite lit-
erally depend on each other for daily survival. Instead of seeing individual farms surrounded by fields, Africans cluster their homes together, with the farms spread out around them. All around her village, women rise at 4:30 AM to fetch firewood and water. They spend their days with the neighbors, pounding maize or hand-washing clothes together, and the men go off together to work. Her life, on the other hand, looks like that of an upper-class African—which is nothing at all like a middle-class life in Boston, where she was raised. Nordin employs maids to cook, clean house, and run errands, and a guard for her home. “I have four families living inside my walls at any one time,” she says. “It’s the African way to support other people—if you have an income, you’re expected to share that with people who can benefit from it. My house is very alive!” In the UAE, Edwards counts herself lucky to live in a melting pot for the region. The UAE’s population mixes native Emiratis, Arabs, Persians, Asians, Indians, Phillippinos, Egyptians, Jordanians, Pakistanis, Somalians, Sudanese, and Bangladeshis. Many, attracted to the high level of education they can attain in the UAE, go through the dietetics program and work with her at SKMC, which is run by the prestigious Cleveland Clinic. “Working with each population is so different,” Edwards says. “I never stop learning about other people, myself included.” Ultimately, RDs say, rewards far outweigh any drawbacks of international work. “There’s so much out there to explore, and yet the world is so small,” Rising says. “All dietitians have the same goal to improve the health of each of our populations, and it’s very exciting to see that commonality, and yet learn so much beyond our own borders.”
May 2010 ● Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S35
BUSINESS OF DIETETICS
Is an Overseas Dietetics Career Opportunity for You? This article is reprinted from the September 2009 issue of the Journal (2009;109:1509-1512).
I
n her job as a nutrition therapist for the expatriate community of Baku, Azerbaijan, Valerie Houghton, RD, travels to oil rigs to do nutrition presentations and marks up photocopies of Russian-labeled foods with English translations. Azerbaijan, an oil-rich country on the west coast of the Caspian Sea, has a long history of Persian and Russian rule—influences that still dominate the local cuisine. Spicy beef, lamb, and poultry are often paired with saffron, spinach, and potatoes, and vodka is the favorite drink. Unfortunately, the country’s health care infrastructure also dates from the Cold War era. “Food safety is an issue,” Houghton says. “What we take for granted about preventative health care doesn’t exist—there’s no smoking cessation information, and no information about cancers, diet, or heart disease.” When Houghton approached the International SOS clinic in Baku about the services she could offer, the clinic jumped at the chance to create a job for her. “I’m the only dietitian I know in Azerbaijan who has a pamphlet about what I do,” she laughs, adding that she has so far met only one other dietitian in the country. Houghton is used to forging her own career path— one that has included stints in London, UK, and the United Arab Emirates (UAE)—since she married a partner who relocates This article was written by Sara Aase, a freelance writer in Minneapolis, MN. Aase is an award-winning journalist who frequently writes about health, business, and parenting. Her work has appeared in Weekly Reader Current Health, Minnesota Monthly, Twin Cities Business, Pregnancy, Parenting, Hemispheres, and American Baby. doi: 10.1016/j.jada.2010.03.008
every 2 to 3 years for his job with an oil company. Working overseas hasn’t always been ideal. In the UAE, a cosmopolitan federation of seven emirates (like states, each administered by a hereditary Muslim Monarch) in the southeast part of the Arabian Peninsula, Houghton found herself writing dietetics articles for magazines instead of practicing in a clinic or hospital. “It’s not anything I ever thought I would do, but was what I needed to do at the time,” she says, adding that the experience helped her stay current with dietetics as well as polish her marketing and presentation skills. “It may take you more energy to search out jobs overseas, but the opportunities absolutely are there.” Why might you consider an international career jump? Registered dietitians (RDs) who live overseas—particularly in non-Western countries—say their careers benefit from the diverse roles they can create for themselves because of high demand. “We can create the jobs,” says Stacia Nordin, RD, past president of the American Overseas Dietetic Association (AODA), the international affiliate of the American Dietetic Association. For the past 12 years Nordin has worked in the southeastern African country of Malawi. She is currently the technical advisor to the Ministry of Education’s School of Health and Nutrition Program, which oversees nutrition in the public schools. “It’s a matter of thinking in terms of what you can do for the world as a nutritionist.” Paving their own road also gives RDs a chance to be highly entrepreneurial about their roles, says Camella Rising, MS, RD, AODA president-elect. While finishing an internship at the Women, Infants, and Children (WIC) program in San Francisco, Rising, newly married to a Navy pilot, figured she wouldn’t be working at their first overseas post in Sicily (Sigonella). “There’s not much of a role for civilian dietitians on a military base, since jobs in hospitals go to military dietitians first.” But then she spied a brochure for WIC
© 2010 by the American Dietetic Association
Get to Know the AODA More than 700 dietitians hailing from 70 countries make up the membership of the American Overseas Dietetic Association (AODA), the international affiliate of the American Dietetic Association. The AODA provides opportunities to connect with one another, establish professional contacts, and obtain continuing education credits. Members enjoy the same privileges as other American Dietetic Association affiliates. The AODA’s International Dietetic Network is a resource for country-specific nutrition and dietetics information, including opportunities for employment and local food customs. It also offers a members-only listserv and Web site, newsletter, and access to information about conferences and meetings. The AODA holds a conference every other year; in 2009, members traveled to the Crowne Plaza Mutiara in Kuala Lumpur. See: www. eatrightoverseas.org. Overseas. “They didn’t have an office at the Sicily base, so I opened one,” she says. “Going overseas definitely requires some thinking out of the box about your career.” Rising and other RDs say they handle more responsibilities, more quickly, than they otherwise might, which broadens their skill set and often gives them access to a wider variety of nutrition issues. Rising, for example, had to order the furniture, staff her office, coordinate with the base grocery store and hospital, and adapt WIC program materials for her international clientele. The WIC outpost, Rising notes, was her very first dietetics job. Not only did it give her a supervisory role early in her career, she says, it also changed her focus from clinical dietetics to public health. Those RDs who stay in one place long-term are able to see the way their influence helps shape nutrition health policies and dietetics education standards. In the UAE, for exam-
Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S33
BUSINESS OF DIETETICS ple, Ellen Edwards, RD, LD, the head of clinical dietetics at Sheikh Khalifa Medical City (SKMC) since 2000, has steadily raised the bar for locally graduating RDs. In 2000, she says, the country didn’t have any RDs at all. “I used to have to train the students graduating in dietetics here for 3 to 4 years to get them to the [American Dietetic Association] dietetic level,” Edwards says. “Now they are a lot closer to the equivalent of the 4-year US program.” The UAE’s health authority, in turn, is starting to apply these same education standards emirate-wide. “Not to sound grandiose,” Edwards says. “But your influence can affect country policy.” CAN I GET THERE FROM HERE? COUNTRY WORK REQUIREMENTS If you’re not being sponsored by your employer to transfer overseas, you’ll need to learn a particular country’s requirements for working there, including any reciprocity agreements, registration requirements for RDs, and possible job opportunities. For example, Houghton’s first overseas placement, in London, was also the toughest. London requires that an employer sponsor international workers. At the time, Houghton worked for Aramark, but the global foodservices provider had no jobs available for her in London and denied her request to transfer there. That didn’t deter Houghton. She applied for a work visa through a British government-sponsored program for highly skilled migrant workers, which required her to meet a certain number of points for degrees and published articles. That process took 4 months. Then she had to line up interviews or potential interviews. “I just kept hammering Aramark in all divisions,” she says. “I knew there weren’t any dietitians over there [for the company] at all.” She persisted until she learned that Aramark was building a London division to promote its hospital catering services to the National Health Service, the publicly funded health care service of the United Kingdom. In 2002 Aramark hired her to direct its patient services program. But Houghton faced one last hurdle: registration. When she first applied, the British Health Professions Council denied her dietetics registration. Houghton endured 4 more months of paperwork and a hearing in
S34
May 2010 Suppl 1 Volume 110 Number 5
front of British examiners to finally have her registration credentials accepted. In the UAE, Edwards says, it can take 3 to 6 months to hire a new RD because of the number of verifications the UAE requires. New hires need a document verifying dates and job titles for every position they’ve held. They go through security clearance. And they must have each of their degrees verified and notarized by their secretary of state in their home state as well as in Washington, DC, and then verified by the US embassy in the UAE.
“You have to know where your boundaries are, but be comfortable with ambiguity. Things aren’t always going to be spelled out for you.” To inquire about country requirements for international dietetics work, contact the US Department of State or a country representative with the AODA’s International Dietetic Network, which has about 40 country representatives, Rising says. These representatives produce country information sheets and act as liaisons and ambassadors for new RDs working there. “Most of the questions we field have to do with working requirements for specific countries,” Rising says. GETTING ACCLIMATED Adapting to a new culture demands flexibility, resilience, patience, openness, confidence, and the willingness to learn, RDs say. “You have to know where your boundaries are, but be comfortable with ambiguity,” Houghton says. “Things aren’t always going to be spelled out for you.” Reading up on a country and talking to people who’ve lived there can help ease your transition. But do expect culture shock. Bret Johnson, who works in Paris as group senior vice president of client relations with Sodexo, the global foodservices company based in France, laughs at his first bumbled attempts to buy
groceries or go to the dry cleaner in Paris. “I assumed stores were open late in the evening and that places would be open on Sundays, but that’s not the case,” he says. “The expectation is that nothing is different here except the language, but in reality it is quite different.” Johnson, who hails from Iowa, says his French is now passable enough for him to get by in public, but early on, he says, “I found locals who were open and willing to be my mentors for my personal life—people that I could say my three words of French to and that would come to my aid.” That shock often extends to the workplace. RDs starting new overseas programs often find themselves facing an empty shell of an office, Houghton says, literally supplying everything from scratch. “When I started up in London, I had no diet manual, no nothing,” she recalls. “I knew how to get all the materials from the United States, but it’s like walking into a bare house and having nothing.” She also discovered she would have to help change the United Kingdom’s attitude toward the role of dietetics in a corporate setting, which at that time was looked down on by RDs. “There was no private industry operating hospitals there,” Houghton says. “It was completely alien to them, and the world of clinical dietetics was completely separate from that of foodservice. I had to integrate two completely different models.” Many Americans who are used to being prompt also struggle with the “looseness” that people in many other countries have toward the concept of time. In Paris, Johnson says, the French tend to start meetings late and value the art of discussion more than the actual meeting objective. At first, he says, this drove him crazy. “I thought, this is pointless, we’ll never get anywhere,” he says. Over time, Johnson says, he softened a bit, while his team, in turn, moved toward more structured meetings. In many cultures, “you start any meeting with personal greetings and inquiries about each other’s families,” says Editha Heberlein, MS, RD, FADA (Germany), president of AODA. “They take offense in the American attitude of getting right down to business.” Heberlein’s most recent overseas job was a 7-year stint in Stuttgart, Germany, where she was a lieutenant colonel of the US Air Force and the global health liaison for the European Command.
BUSINESS OF DIETETICS It can feel overwhelming to realize that you’ll face a whole new set of social rules, from how to dress, to whom to greet and how. In Britain and France, for example, hierarchy is valued and observed more formally than in the United States. In Azerbaijan, Houghton says, “Men don’t ask about women; they would never ask, for example, how a pregnant woman was feeling or what sex the baby might be.” You might shake hands in greeting, she says, but only if the hand is extended. And you never refuse coffee or tea when it is offered. A simple place to start, says Heberlein, is to learn key phrases in the other languages you’ll hear, such as ’hello,’ ’thank you,’ and ’how are you.’ “That you’re trying is always appreciated,” she says. PRACTICING DIETETICS ABROAD: DIFFERENT SETTINGS, SAME GOALS Just as in the United States, many RDs abroad also struggle against the rising trend in the developed world toward a more Westernized diet and accompanying obesity, heart disease, and diabetes. “Across cultures you see the same issues of identifying the bad fats and cutting portion sizes and empty calories,” Edwards says. “It might be coconut oil or fried shrimp instead of burgers, but fat is still fat, a fruit is still fruit, and a portion is still a portion.” As populations grow more affluent, she says, “We have to teach them how to spend more time on everyday meals, eat less fast food and soda pop.” And just as they do in diverse American communities, RDs overseas try to strike a balance between sound practice and cultural traditions. For example, Rising says, in Sicily “it was common to crush up biscotti and put in a bottle with milk,” a practice that American Academy of Pediatrics discourages, as it can cause choking or pulmonary problems and expose babies to food allergies. “Just like in America, the biggest thing is listening, and giving them the confidence to say they could do something differently than the way their mothers or grandmothers did. It’s a fine balance.” Heberlein’s challenge is to encourage her American clients to eat more like the rest of the less-developed world does, incorporating more vegetables, fruit, and fish, and far less
meat into their diets. “I grew up in the Philippines, and did not realize how healthy I was eating then,” she says. “We ate fish for three meals a day, and meat was only for very special occasions.” This year in the UAE, Edwards is starting a portion-control program in an effort to get her clients to take a more moderate approach to fasting and feasting during the holy month of Ramadan, when Muslims fast until sundown. “We are getting more dehydration cases and diagnosed diabetics because people are gorging themselves at night,” Edwards says. “There’s also a cultural tradition, as part of Arabic hospitality, to mound food on a plate.” In Malawi, where food is often scarce, Nordin’s work has a different nutritional focus— one that holistically addresses the issue of creating a sustainable food economy in a stilldeveloping country, where people live directly off the land. Unlike in the United States, there are no grocery stores that provide access to food whenever you like. “We realized in Africa you cannot talk about nutrition without talking about agriculture, food security, the environment, and sanitation and how they all interlink,” she says. “We felt the only way to succeed is to help Malawians use their local resources to their full potential.” Over the course of her career, Nordin has developed program materials that teach, for example, water conservation and better food growing techniques, along with nutrition and complementary care for patients with human immunodeficiency virus. A RICHER WORLD-VIEW When she first landed in the UAE, Houghton says, she was surrounded by mosques that broadcast the Muslim call to prayer five times a day. “At first it was quite annoying,” she recalls. “But then it just becomes part of the day, and then after that it becomes quite comforting.” RDs who live and work abroad say these subtle transformations, where they find themselves in sync with another culture, deepen their perspective of and appreciation for other people, and teach them things about themselves they otherwise never would have learned. In Malawi, Nordin says, the culture is people-focused, since they quite lit-
erally depend on each other for daily survival. Instead of seeing individual farms surrounded by fields, Africans cluster their homes together, with the farms spread out around them. All around her village, women rise at 4:30 AM to fetch firewood and water. They spend their days with the neighbors, pounding maize or hand-washing clothes together, and the men go off together to work. Her life, on the other hand, looks like that of an upper-class African—which is nothing at all like a middle-class life in Boston, where she was raised. Nordin employs maids to cook, clean house, and run errands, and a guard for her home. “I have four families living inside my walls at any one time,” she says. “It’s the African way to support other people—if you have an income, you’re expected to share that with people who can benefit from it. My house is very alive!” In the UAE, Edwards counts herself lucky to live in a melting pot for the region. The UAE’s population mixes native Emiratis, Arabs, Persians, Asians, Indians, Phillippinos, Egyptians, Jordanians, Pakistanis, Somalians, Sudanese, and Bangladeshis. Many, attracted to the high level of education they can attain in the UAE, go through the dietetics program and work with her at SKMC, which is run by the prestigious Cleveland Clinic. “Working with each population is so different,” Edwards says. “I never stop learning about other people, myself included.” Ultimately, RDs say, rewards far outweigh any drawbacks of international work. “There’s so much out there to explore, and yet the world is so small,” Rising says. “All dietitians have the same goal to improve the health of each of our populations, and it’s very exciting to see that commonality, and yet learn so much beyond our own borders.”
May 2010 ● Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S35