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Scientific Underpinnings for the Profession

1997; Elsevier BV; Volume: 97; Issue: 6 Linguagem: Inglês

10.1016/s0002-8223(97)00153-3

1878-3570

Johanna Dwyer,

Food Security and Health in Diverse Populations

In examining ways in which research competencies might be incorporated into dietetics practice, particularly focusing on the science and clinical components of the profession, it is necessary to consider barriers and opportunities that exist both in dietetics training and within job situations. However, definitions of several terms are needed first. In this article, research is defined as the organized study of a phenomenon—at both the basic and more applied levels—with the specific topics of the endeavor varying between investigators and over time. Science is defined broadly, to include both the biologic and social sciences. Similarly, clinical components will include references to inpatient and outpatient settings as well as those in the community. Dietetics is defined differently from what is presented in the National Academy of Sciences’ Opportunities in the Nutrition and Food Sciences((1)Committee on Opportunities in the Nutrition and Food Sciences, Food and Nutrition Board, Institute of Medicine; Thomas PR, Earl R, eds. Opportunities in the Nutrition and Food Sciences: Research Challenges and the Next Generation of Investigators. Washington, DC: National Academy Press; 1994.Google Scholar), which defines dietetics as “the practice of nutrition vis a vis nutritional science.” Rather, the Oxford English Dictionary ((2)Compact Edition of the Oxford English Dictionary. Oxford University Press, Oxford, England1971Google Scholar) definition of dietetics might be used: “the regulation of the kind and quality of food to be eaten, especially as a branch of medical science; a dietitian is one who is skilled in diet and who treats disease by a systematic course of diet.” More precisely, dietetics is “the translation of the science of nutrition into the provision of optimal nutrition to people,” as it was defined by The American Dietetic Association (ADA) in 1972 ((3)The Profession of Dietetics. American Dietetic Association, Chicago, Ill1972Google Scholar). The food and nutrition sciences themselves are integrating fields that involve many disciplines. They aim not only at developing new knowledge, but also at applying it for solving human problems. Dietetics emphasizes the applications to a greater extent than the development of new knowledge, whereas the nutrition sciences concentrate more on the latter. When dietitians approach research, they often do so to understand or solve some difficulty observed in practice, rather than from a theoretical basis. The advantage of this deductive approach, which starts with the patient or physical reality situations, is that the problem addressed has some practical importance. The disadvantage is that without recourse to theory or organizing principles, solutions may not be found—and with greater exposure to basic theory, observations might be better informed. The modern scientific outlook includes the following characteristics ((4)American Board of Nutrition Candidates Manual. American Board of Nutrition, Bethesda, Md1994Google Scholar), all of which have direct relevance to translating basic and applied biology into food and nutrition realities: ■ Objective methods by which to test reliable knowledge; ■ Formulation of theories and testing theories by reference to evidence, rational coherence, and predicted experimental consequences; ■ Quantification to establish theories and estimate effect sizes; ■ Discovery of causal regularities and associations in interactions with nature; ■ Scientific knowledge that goes beyond the subjective and culturally relative to broader intercultural levels; ■ Tentative, probabilistic, open to alternative explanations; ■ Knowledge of probable causes discovered in scientific research that can be applied. Dietetics must continually be invigorated with new findings in biology while we apply what we already know. Involving dietitians actively in clinical and scientific research helps to reduce the considerable time lag that often exists in applying new and existing knowledge rapidly. Evidence of the efficacy of treatments is just the beginning of the application process. A great deal of time and effort are needed in most fields to induce practitioners to use the findings and to overcome various barriers to acceptance ((5)Committee on Annual Practice. Report to the American Society of Clinical Nutrition Council. The Role of the Physician Nutrition Specialist in Medical School Affiliated Hospitals. American Society of Clinical Nutrition. Unpublished manuscript; 1994.Google Scholar). Participation of dietitians in randomized clinical trials and other studies that provide practical evidence of effectiveness speeds this acceptance. One reason scientific and clinical research competence are necessary is to ensure that new developments improving human food and nutritional health are incorporated into dietetics practice. However, because it is not necessary for a person to do research for his or her dietetics practice to be up-to-date, there must be other reasons as well for insisting on scientific and clinical research competence. Another reason for this emphasis is that if dietitians are to be leaders as well as followers, they must do research themselves. Nutrition is an experimental and analytic science, not simply a descriptive one. Scientific and clinical research must be performed for it to advance. The rewards in scientific professional and academic life are awarded largely on the basis of the new contributions and accomplishments in scientific research. Third, research competence to develop new knowledge must be included in dietetics practice because dietetics is a field that focuses on speedily applying the best of food and nutrition knowledge to solve human needs. A fourth reason is more pragmatic, but in the end perhaps equally as important as the others. Career advancement in academic life is very tightly linked to scientific productivity. In addition, scientific productivity is linked to the ability to raise money by writing and successfully competing for research grants. As universities become increasingly constrained with respect to money and positions available, pressure is likely to increase on all faculty members, including those whose responsibilities have been primarily didactic, to generate research dollars. Similarly, as hospitals become increasingly cost-oriented, cross subsidies from other cost centers to fund research may become increasingly rare. When planning research, one looks for persons who can complement each other and bring needed skills to the enterprise. The question then arises: What do dietitians bring to the research enterprise today, and what might they bring in the future? First, good dietitians usually have extensive knowledge of the foods commonly used; the practicalities of getting people to eat; and the specific medical, economic, preference, and logistical problems involved in getting food that is prepared in a hygienic and tasty manner to different groups of people to eat. Thus, they provide useful reality checks in research groups, especially when experimental variables include diet. Second, because of the increased number of clinical trials involving diet over the past 20 years sponsored by the National Institutes of Health (NIH) and private drug companies, more dietitians are comfortable in the role of coinvestigator and sometimes even investigator in clinical trials. They are aware of the general process of conducting clinical trials, why these trials are important, and how the findings would be incorporated into daily practice. Third, dietitians generally are comfortable with studies involving social and management sciences, such as health education, cost accounting, development of systems of care, practice guidelines, implementation, and outcomes evaluation. Dietitians have increasingly striven for greater knowledge. Nearly half of all dietitians today have master's degrees, and the proportion of doctoral degrees awarded to dietitians is also rising. In the next two decades, if the incentives are appropriate, larger numbers of dietitians are likely to seek doctoral degrees in the basic and applied sciences—and will bring this expertise to bear on practical problems. Major sources of funding for basic research projects include the NIH, the National Science Foundation, and the US Department of Agriculture's (USDA) competitive grants program. The mark of a good clinical dietitian is providing patient care that is an end—rather than a means—to obtaining more information to achieve some other end. This focus on the patient provides a unique basis for both research and care for the dietitian who wishes to specialize in research. Clinical research and training involving hospitalized or ambulatory patients with highly complex and involved problems has traditionally involved a rather small number of hospitals in the country—probably a core of about 500 hospitals that provide subspecialty training in several different medical specialties. Several hundred other hospitals have residencies in only one or two subspecialties. The vast majority of future medical researchers and chairs of departments in medical schools will come from the former facilities. If dietitians wish to train and work with these persons and be regarded as their colleagues in the future, it is critical that dietetic internships and more advanced training opportunities continue in these teaching hospitals. Entry-level dietetics training currently includes some, but not all, of these teaching hospitals. Whether dietetic internships or other training opportunities will survive in these teaching hospitals in the future will depend on whether special levels of reimbursement are provided to them for their teaching function. Even the best and the brightest graduates of the top undergraduate and graduate universities will not be hired in the health care facilities where the most exciting clinical research is taking place if they are lacking in sophisticated clinical skills. Therefore, it is critical that such persons receive the best clinical training available. Educators in universities need to distinguish between two types of students interested in dietetics. Some have rather limited career perspectives and are adequately served by the “terminal” bachelor's degree program coupled with a plan IV internship in a community setting that will equip them for an entry-level position. However, a second group deserves particular attention: the extremely strong students interested in both dietetics and research. These students should be encouraged to take deeper, more challenging undergraduate programs and apply for postbaccalaureate training at a teaching hospital, where they will be trained in conjunction with physicians and other health professionals in training who will become the research leaders of tomorrow. These dietetics internship programs tend to expose young dietitians to clinical nutrition research early in their graduate training. At the same time that these internships provide the gateway to clinical research training of a practical nature, they also provide socialization to the ways of teaching hospitals. These same hospitals and health care facility networks have the highest probability of participating in clinical trials and other intervention research programs. Thus, dietetics researchers who wish to be involved in these endeavors need to be trained at or otherwise develop ties with these institutions. Because the dual missions of patient care and biomedical student teaching put these institutions at a disadvantage in a growing cost-conscious environment, means must be found to support dietetics training both at the basic and more advanced levels in these institutions. Currently, these institutions receive support only for medical student and primary care/family medicine training; no specific subsidy is provided for dietitian training, and it is unlikely that such subsidies will be available in the future. Ever-increasing cost pressures on departments of dietetics will likely make existing stipends for dietetics interns increasingly difficult to obtain. “On-the-job” training of persons who are not competent to perform adequately in clinical settings involving research is unlikely, since job mobility (especially among the young, bright, single women who are often most interested in research) is too high to justify the costs in most cases. One possibility is for universities with both medical schools and strong nutrition programs to pay hospitals directly for training dietetic interns or those at more advanced levels of practice in biomedical research and clinical areas. Great potential exists in some of the new food processing methods that may be amenable to clinical and other applications, particularly in military settings. Also relevant are some of the advances made in the development of special supplements and modular formulas for specific purposes. These, too, require a good deal of research that can be recommended for clinical purposes. Dietitians are in a good position to carry out such research studies. This area needs exploration. New directions in health policy and management may also provide research opportunities for dietitians. There is a major need to rationalize care in clinical settings involving personal health services through studies of clinical practice guidelines, with outcomes research and cost-effectiveness/cost-benefit analysis of procedures. The resulting algorithms are likely to furnish the basis for managed care plans in the future. Dietitians have been actively advocating nutrition services, especially for vulnerable groups such as the elderly and persons with disabilities. Now it is time to research the effects, costs, and benefits of such services. Many professional and private agencies have developed clinical practice guidelines, which are systematically developed statements to help practitioners and patients make decisions about appropriate health care for specific clinical circumstances, according to the Institute of Medicine's 1990 report ((6)Institute of Medicine.Clinical Practice Guidelines. National Academy Press, Washington, DC1990Google Scholar). They are currently used for several purposes, including clinical decision making, education, assessment and assurance of the quality of care, allocation of resources for health care, and reducing risk of legal liability for negligent care. Health care policy makers are now interested in guidelines because of the issue of costs; they are also motivated by unexplained variations in practice patterns and use of health services, inappropriate use of many services and inappropriate care, and uncertain outcomes from the use or nonuse of various services or procedures. Certainly many nutrition and dietetics services are poorly documented with respect to unexplained variation in their use, sometimes inappropriate or inadequate care, and uncertain outcomes. Practice guidelines for these services must be developed, and outcomes and effectiveness research must be conducted to revise, reformulate, and improve the cost-effectiveness of health care. Although it is commonly assumed that practice guidelines can lead to better health outcomes and lower health care costs, this is at present an unproven assumption that outstrips current knowledge. However, there is every reason for dietitians to become involved in learning how guidelines and other efforts to improve the quality and efficiency of nutrition services in health care can be brought to bear to support, supplement, and complement each other. High-quality, sound methods and procedures to develop guidelines are essential. A 1992 report ((7)Field MJ, Lohr KN, eds. Guidelines for Clinical Practice: From Development to Use. Washington, DC: National Academy Press; 1992.Google Scholar) specifies desirable attributes of clinical practice guidelines and medical review criteria to ensure that they will be usable and reasonable and will provide desirable health outcomes. Guidelines should be accompanied by a statement indicating how strong the evidence is and what expert judgment is behind the guidelines. Projection of relevant health and cost outcomes of alternative courses of care are helpful, and must consider patient perceptions and preferences. They should also include information on how compelling the case is for particular services or courses of care under different and particular clinical circumstances. When knowledgeable dietitians are not involved in such a process, the dietetics aspects of treatment are apt to be neglected. The prerequisites for substantive content of guidelines are that they be valid, reliable, clinically applicable, and clinically flexible. The process of guidelines development must be clear and must involve a multidisciplinary process, scheduled reviews, and documentation. If guidelines are also to be used for review, they must include attributes such as sensitivity, specificity, patient responsiveness, readability, computer compatibility, and appeals criteria. ADA recently funded work on type II diabetes guidelines for practice. The US Preventive Services Task Force has also developed, and is now revising, recommendations for clinicians on the appropriate use of preventive interventions, based on systematic review of the evidence on clinical effectiveness of various services, including nutrition service ((8)US Preventive Services Task Force.Guide to Clinical Preventive Services. Williams and Wilkins, Baltimore, Md1989Google Scholar). In the current as well as revised edition, the coverage given to nutrition in preventive services is scant and in great need of buttressing and constructive criticism. Those interested in dietetics research should review and comment on these and similar guidelines. I believe there is a pressing need for dietitians to become actively involved in the dialogue identifying: care for which there is good scientific evidence, care for which there is good consensus but limited or no evidence, and care for which there is neither evidence nor consensus. Because few studies of dietary therapies in comparison to drug or other therapies have been conducted in a rigorous fashion, dietetics will likely be at a disadvantage, because conclusions based on scientific evidence are the most compelling. Among the pressing research priorities are priority topics from the standpoint of dietetics for guidelines development, how best to obtain expert judgments, how best to analyze and rate the scientific evidence developed, how to improve knowledge of health outcomes and patient preferences, how to identify and project the alternative costs of care, and how to make comparisons of cost-effectiveness. This is a fertile area for research in dietetics. Strengthening the links between nutrition and function is an attractive area for basic as well as applied research. To the extent that intervention on nutrition-related variables can be linked to function, there is the basis for a strong argument justifying inclusion of nutrition services in the treatment of certain conditions. The materials prepared by the Nutrition Screening Initiative and related research efforts have been helpful in clarifying what some of these factors might be for older persons ((9)Galanos A.N. Pieper C.F. Cornoni-Huntley J.C. Bales C.W. Fillenbaum G. Nutrition and function is there a relationship between body mass index and the functional capabilities of community dwelling elderly?.J Am Geriatr Soc. 1994; 42: 368-373Google Scholar). The Agency for Health Care Policy Research's Medical Treatment Effectiveness Program has recently sponsored several studies conducted by Patient Outcome Research Teams to investigate the effectiveness of reasonable approaches to caring for patients with specific clinical conditions that vary greatly in clinical practices and outcomes (program note, Medical Treatment Effectiveness Research, Agency for Health Care Policy and Research, Rockville, Md, March 1990). The data analyze variations in medical practices and outcomes. Some of the conditions studied to date involve dietetics aspects, but it is not clear if these have been included. The problem is that if nutrition services are not included in the guidelines, practices may change—and without being subjected to a true test, nutrition services may be ignored when they might do some good, and, in fact, might be more cost-effective than the alternatives proposed. The issue of appropriate medical care has been studied by the RAND Corporation and groups spawned by its Health Services Utilization Study to develop appropriateness criteria and practice guidelines ((10)Winslow C.M. The role of guidelines in achieving rational health care management.Internist. 1990; 31: 14-16Google Scholar). A report on the findings of the Medical Outcome Study ((11)Tarlov A.R. Ware J.E. Greenfield S. Nelson E.D. Perrin E. Zubkoff M. The medical outcomes study.JAMA. 1989; 262: 925-930Google Scholar) emphasizes functional outcomes research. Patient-based outcome measures need to be built into all research, especially in dietetics research. Dietitians should be trained to incorporate such measures into their clinical services. Such training is now available at some teaching hospitals. An example of a “home-grown” outcomes research project is the recent collaborative study of outcomes from dietary counseling for coronary artery disease risk completed by several dozen departments of dietetics in Massachusetts as part of a campaign to obtain funding for dietetics services from the state legislature. With minimal financial resources but with several expert advisers, a state dietetic association was able to develop and publicize this sound effectiveness research. Because it is likely that struggles for funding will continue, however, it is important that at least some dietitians become expert in these techniques. Finally, cost-effectiveness studies are critical for medical nutrition therapies (eg, dietetic therapies) if they are going to survive as unique services in health care reform legislation. ■ Urge research-oriented dietitians with advanced degrees to join relevant nutrition research societies. Sister organizations with a strong focus on research (eg, the American Society for Nutrition Sciences [ASNS] and the American Society of Clinical Nutrition [ASCN]) now have research interest groups that provide the dialogue, networking, and collaboration needed to advance nutrition science and communicate findings quickly. Joint membership in The American Dietetic Association (ADA) and in ASNS/ASCN fosters incorporation of research into practice, and encourages the organizations to mount joint efforts for addressing science policy issues. ■ Develop more proactive programs for support of dietetics training—in particular, excellent clinical nutrition and dietetics research and training programs. The strategy here is to build strong dietetics programs in centers of biomedical excellence. The 500 leading teaching hospitals—including federally supported hospitals such as the Clinical Center at the National Institutes of Health, the Veterans’ Administration, and the large military hospitals where training programs are now strong—should be singled out for particular attention, as it is primarily from these institutions that the medical researchers of the 21st century will emerge. Advocacy on the importance of the research training function of these hospitals in medical and other fields must proceed. Educational efforts should include members of Congress as well as relevant academic medicine groups and hospital organizations, such as the Council of Teaching Hospitals and the American Association of Medical Colleges. Also, the requests for proposals and requests for applications issued by NIH could stress the dietetics training component to a greater extent in their proposals involving clinical nutrition research units and other similar facilities. ■ Advocate with hospital associations, accrediting bodies, federal agencies, and others to include dietitians in practice patterns initiatives, clinical guidelines development, and research outcomes. Dietitians should advocate with hospital associations such as the American Hospital Association, accrediting bodies such as the Joint Commission on Accreditation of Healthcare Organizations, federal bodies, and others to include dietitians in practice pattern initiatives and in the process of clinical guidelines development, as well as on panels for planning outcomes research on conditions that they often contain dietetic elements of care. These studies will be critical in restructuring and refining procedures as health care reform proceeds. Guidelines, practice pattern profiles, and outcomes reviews and research based on clinical guidelines are already transforming the practice of medicine. They should involve practitioners and researchers in dietetics practice and in clinical nutrition, and should not be designed primarily or solely by physicians, as is common today. ■ Lobby for establishing dietetics research traineeships at federally funded centers. Congress should be lobbied to include dietetics research traineeships at federally funded centers; the USD A, the Department of Veterans Affairs, the Geriatric Research and Education Centers, the clinical nutrition research units funded by NIH, various cancer centers, and other centers funded by the Department of Health and Human Services, such as the Centers of Excellence in Research on maternal and child health proposed by the Maternal and Child Health Service. Training at these centers can increase technology transfer and research expertise competence. For example, training at centers specializing in pediatrics could provide relevant research training for those conducting research on the Special Supplemental Nutrition Program for Women, Infants, and Children or other child food programs; centers specializing in aging could do the same for those participating in programs for the elderly; and training at clinical nutrition research centers and cancer centers could provide specialized research training in specific disease states. ■ Begin a frank dialogue with universities about what is feasible regarding “on-the-job” clinical training for research careers of those not so trained at universities, given the exigencies and economic stresses engendered by health care reform. Line items in hospital budgets for dietetic internship stipends are increasingly questioned. In spite of the direct economic benefits associated with dietetic internships in some settings, they may not survive through the end of the century ((12)Conklin M.T. Simpko M.D. Direct economic benefits associated with dietetic internships.J Am Diet Assoc. 1994; 94: 174-178Google Scholar). Clinical instructors are no longer likely to be available gratis, and new relationships between universities and hospitals may be necessary. Some hospitals may need to establish clinical training fees to cover the cost of clinical training, particularly advanced clinical training with little paid back in staff relief. In the future, persons who want clinical research training will likely have to pay more to get it than in the past. ■ Work with universities to develop doctorate-level tracks for clinical research and community service needs, and foster collaboration between universities and teaching hospitals. Work with universities to develop more appropriate and realistic tracks for clinical research and community service needs at the doctorate level. Tracks different from those outlined by the Institute of Medicine ((1)Committee on Opportunities in the Nutrition and Food Sciences, Food and Nutrition Board, Institute of Medicine; Thomas PR, Earl R, eds. Opportunities in the Nutrition and Food Sciences: Research Challenges and the Next Generation of Investigators. Washington, DC: National Academy Press; 1994.Google Scholar) are probably needed for doctorate-level dietitians. Universities and teaching hospitals need to collaborate in mutually supportive joint ventures that are fiscally neutral to establish more rigorous clinical training situations for undergraduate and particularly for graduate students interested in dietetics, while maintaining more traditional entry-level training for those not pursuing clinical research. Finally, the two institutions must develop mutually beneficial and fiscally neutral (for health care facilities) beyond entry-level research training opportunities for dietetics professionals. ■ Advocate and perpetuate the view that clinical nutrition involves several disciplines. Clinical nutrition involves professionals from a variety of disciplines: physicians with special human nutrition expertise, dietitians with clinical expertise and doctorates or other advanced degrees, and pharmacists and nurses with human nutrition training. Nonphysician disciplines are collaborative with, and not subordinate to, physician specialists in clinical nutrition. Currently, there is competition in the health care environment for positions, span of control, economic resources, and influence. The enhancement of clinical nutrition as a medical specialty should not be at the expense of clinical dietetics or of dietetics departments in hospitals. Current efforts to establish clinical nutrition as a medical specialty are curiously myopic with respect to speaking to these issues. It is time to address them forthrightly and to begin a dialogue with dietitians and other allied health professionals involved in the provision of clinical and other nutrition services to patients on how “win-win” solutions can be developed. As a start, the several professional associations involved (in the areas of medicine, dietetics, and clinical nutrition) might work with all of the professional schools involved to develop clearer role delineations, as was suggested in the Pew Health Professions Commission report ((13)Pew Health Professions Commission.Health AmericaPractitioners for 2005. Pew Health Professions Commission, San Francisco, Calif1991Google Scholar). ■ Develop bridging schemes for enhancing research training. Dietitians bridging the gap between practical problems and the more basic supporting disciplines may require new or special programs similar to those suggested in the opportunities report ((1)Committee on Opportunities in the Nutrition and Food Sciences, Food and Nutrition Board, Institute of Medicine; Thomas PR, Earl R, eds. Opportunities in the Nutrition and Food Sciences: Research Challenges and the Next Generation of Investigators. Washington, DC: National Academy Press; 1994.Google Scholar) of the Institute of Medicine. This might involve training or collaboration with more basic research groups in teaching hospitals or universities. ■ Start examining the barriers currently perceived to impede dietitians whose practice focuses on scientific and clinical research aspects. Begin to examine the perceived barriers—financial, career mobility, status, career ladders, and others—that currently exist for dietitians whose practice emphasizes scientific and clinical research aspects of the profession, and explore how best to overcome them. If today's role model researchers in dietetics do not have rewarding and satisfying careers, this reality will not likely change in the increasingly resource-constrained health care environments of the 1990s unless conditions are changed. ■ Survey alleged inequities regarding rank, salary, course and student loads, research funding, and other problems faced by the dietetics faculty. Conduct a survey of university department heads and relevant dietetics and nondietetics staff to explore and address reasons for actual or claimed inequities in rank, salary, course and student loads, research funding, and other problems confronting the dietetics faculty. Conduct a similar survey of research-oriented dietitians in teaching hospitals to determine their present level of involvement with students; their faculty status, rank, teaching salary, and student loads; difficulties with research funding; and other impediments they see in incorporating research into clinical practice as well as incorporating the more basic science components into the profession. Also of interest are broader issues of salary, job security, and opportunities for advancement. ■ Include nutrition scientists with dietetics credentials on study sections and grant reviews of relevant nutrition and food research. In the nutrition research community, frequent complaints are heard about nutrition research grant proposals being evaluated by scientists who lack interest or expertise in the nutrition sciences or nutrition-related questions. A similar problem may exist in the evaluation of dietetics research by groups that do not include dietitians. Currently, those in other disciplines regard dietetics scientific and clinical research as basically derivative rather than unique. Therefore, other disciplines believe they are better positioned than dietitians to judge its research merit. It is important to determine if there are, in fact, aspects of dietetics research that are unique, and that are unlikely to be judged satisfactorily and rigorously by nondietitians. If so, these need to be documented, so that dietitians or nondietitians with such expertise be asked to participate in grant review and funding decisions. Some NIH- and USDA-sponsored program reviews currently lack relevant dietetics research expertise, although such expertise is critical in meeting their missions. The expertise includes relevant aspects of food and nutrition service management as well as clinical and basic science components. Review teams for projects, centers, and research units involving such issues should also include dietetic expertise. If this proves unfeasible, an alternative strategy is to pursue the development of a separate study section or institute for nutrition research (which would include dietetic topics), along the lines of the Nursing Institute at NIH or the recently constituted study section and program on alternative therapies. These strategies are less desirable because nutrition research of most types is probably sounder if it is judged by multiple experts. But politically they may be necessary. ■ Recognize that “turf” problems exist and work to resolve them. The Institute of Medicine's report on allied health ((14)Institute of Medicine.Allied Health Services. National Academy Press, Washington, DC1989Google Scholar) and other reports suggest that many dietitian duties could be eliminated or performed by other personnel. At the same time, other health professionals increasingly see their roles as including functions dietitians regard as their particular area of expertise. Power struggles and “turf” problems, especially with respect to nutrition research and clinical nutrition, are becoming more acute, given the constrained fiscal climate and capping of other medical spending options in teaching and research hospitals. Until these are resolved, research careers in dietetics are likely to lack career ladders and rewards. ■ Develop clinical research fellow ships for dietitians with advanced degrees that go beyond dietetic internship experiences, and develop appropriate funding for them. Develop career ladders for graduates of such fellowships. ■ Ensure that investigators design sound research, avoid conflicts of interest, and are not intimidated by special interest groups (15).■ The author thanks the following persons who kindly contributed their critiques and suggestions: Donna Porter, PhD, RD; Mary Carey, PhD, RD; Mary Ellen Collins, MEd, RD; Alice McCarley, MS, RD; Helen Doherty, RD; and Ann Coulston, MS, RD. This project has been funded at least in part with federal funds from the US Department of Agriculture (USDA), Agricultural Research Service, contract No. 53-3K06-01. The contents of this paper do not necessarily reflect the views or policies of USDA, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.