Q1: When I reviewed the definitions of ‘marketing’ and ‘advertisement’ in the Marketing Standards I thought they were inflexible. Could these limit the actions of a dietitian in private practice, particularly in a social media context?
The terms ‘marketing’ and ‘advertisement’ are in bylaw and are not new. These terms are not flexible in their definition without requiring consultation with the Ministry of Health and a change in bylaw. The definitions apply to marketing of dietetic services and products, and not other types of publications (such as scientific reviews, educational articles, provision of factual, common nutrition information, general social media content) that are otherwise unrelated to communications and publications “…by which professional services are promoted.” (CDBC bylaws, section 74, Marketing)
Q2: What is the difference between “recommendation” and “endorsement”?
Both recommendation and endorsement involve products and services promoted to clients. They pertain to products and services that are evidence-based and assessed to be beneficial to a client after completion of a nutrition assessment and care plan.
A recommendation has no personal or financial gain for the dietitian. It is client-centered.
An endorsement can go on to provide the dietitian with financial gain and/or personal gain (advancing of career, public recognition, and/or discounted/gifted products/services). It may be client-centered, and is also dietitian-centered.
Q3: What are some examples of products that I can promote in my practice? What are examples of products that I cannot promote in my practice?
It would be impossible to include an exhaustive list of products and services in this answer. Below are some examples. Please contact the CDBC if you have specific questions on this topic.
- Consider dietetic scope:
Per CDBC Bylaw section 74(5)c: “A dietitian may not endorse or lend…” [themselves] “… as a registrant to the advertisement of any property, investment or service for sale to the public unless such property, investment or service relates directly to dietetics”. This is also reiterated in Marketing Standard 2(c). Here are some considerations:
- Products and services that are involve food, nutrition supplements, vitamins, minerals, probiotics are considered within dietetic scope.
- Lifestyle products (soaps, shampoos, housewares etc.) are not within dietetic scope because they are unrelated to dietetic scope.
- What about items such as blenders and cookware as they can arguably be seen as related to nutrition? It is important to note that, as a dietitian, you will have an innate power imbalance over your clients and prospective clients. If you endorse certain brands of pots and pans, for example, your clients may see you as an expert in this type of kitchenware, when that is not the case. Therefore, products such as these should not be endorsed by dietitians.
- Consider individual scope:
It is important to dissociate dietetic scope vs individual scope. Using the example above, probiotics are within dietetic scope. However, perhaps you don’t have as much knowledge as others who focus their practice on this type of supplement. It is thereby not in your individual scope and you could use a document such as the Decision Tool for New Aspects of Dietetic Care to help you come to this conclusion. You could then refer your client to another dietitian who includes probiotics in their scope of practice.
- Consider relevant legislation, standards, and guidelines that exist outside of the CDBC which may pertain to dietitians. Consider any provincial or national legislation that restricts the endorsement or recommendation of products, even when they appear to be related to dietetics.
- Cannabis, which has clinical evidence for use in certain disease processes (appetite stimulant, which is nutrition-related). For therapeutic purposes, cannabis is a scheduled drug and dietitians have a limited role when it comes to recommendations for both therapeutic and recreational use. The Cannabis Actsets out rules and exceptions for the promotion of Cannabis in Canada. The Cannabis Act prohibits Canadians from advertising, promoting, or selling cannabis to minors (under the age of 19 in BC).
- The International Code of Marketing has published recommendations on marketing for infant feeding breast milk alternatives.
Q4: Can I advertise or write about medical or recreational cannabis (ex: Instagram, blog, newspaper article, research paper)?
First, you should define the purpose and scope of what you will write about. As mentioned in Q3, cannabis is scheduled drug and dietitians have a limited role when it comes to both therapeutic and recreational use. The next step is to consider the relevant legislation, standards, and guidelines applicable to dietitians.
The Cannabis Act sets out rules and exception for the promotion of Cannabis in Canada. For example, the Cannabis Act prohibits Canadians from advertising, promoting, or selling cannabis to minors (under the age of 19 in BC). Any questions, comments, or complaints about the Cannabis Act should be directed to Health Canada at: email@example.com.
You may also choose to seek legal advice on the interpretation of this Act for your practice. The College’s Marketing Standards provide direction on the type of information that dietitians may not include in advertisement such as misleading information, endorsement of products not related to dietetic scope of practice, or recommendation of exclusive use of a product. Additionally, identification and management of conflict of interest should be documented.
Q5: In Marketing Standard 1(d), a registrant ensures “publishing clear and legally sound information”. How do I ensure this?
- SoP #1 (provincial and federal law implications),
- SoP #2 (legal scope of dietetic practice),
- SoP #4 (practice ethically and accurately representing self, experience and knowledge),
- SoP #9 (professional integrity in communication)
- SoP #13 (communicate evidence-informed information)
- SoP #17 (all three indicators are relevant to marketing)
Any registrant who isn’t clear on whether published material is legally sound is encouraged to access CDBC for support, as well as seek legal counsel through their Liability Insurer.
Q6: How am I expected to keep all marketing materials for one year when I am posting on social media platforms such as Instagram stories or SnapChat, which are inherently temporary?
For marketing materials that are temporary, such as those mentioned in certain social media platforms, it is expected that you take a screen capture of the marketing document, including where and when it was used, and archive it for one year.
Per CDBC Bylaws section 74(3d): “Any marketing undertaken or authorized by a registrant in respect of [their] professional services must not be:…unverifiable.”
In addition, section 74(8): “A registrant must retain for one year after the date of publication or broadcast of any advertisement or brochure, and must provide to the registrar, the inquiry committee, the discipline committee or the board upon request:
(a) a copy of any such publication;
(b) a recording of any such broadcast made by any electronic media or information communication technology; and
(c) a written record of when and where the publication or broadcast was made.”
Q7: Marketing Standard 2(a) is specific to evidence-based practice. On occasion, I see content on another dietitian’s social media that includes certain “diet” counselling offered that is not backed in good science.
You are encouraged to review the Evidence-Based Practice Q&A.
The wording in this specific standard includes: “…advertisement is true, accurate, honest, verifiable, and ethical.” The Standard lists the CDBC Code of Ethics and Standard of Practice 8 as its basis. It is also important to consider Standard of Practice 13.5, which includes communication of evidence-based and best practice information to clients. The Health Professions Act requires a registrant to report to the CDBC, a dietitian that may be putting the public at risk with false statements or if not upholding the CDBC Standards of Practice.
Q8: Given the wording of Marketing Standard 2(f), am I restricted in my ability to refer to a preferred colleague?
It is within scope, and within Standards of Practice (2, 11) to refer to another professional as needed. Note that 2(f) delineates between recommendation and endorsement. It is appropriate to recommend (no financial gain) a colleague who focuses their practice in the area you are looking to refer for, and inappropriate to endorse one (where you may receive financial or professional gain).
Q9: Why can I not endorse or sell an exclusive product or brand?
Dietitians may find that this is a particularly difficult standard for any of the following reasons:
- I have a contractual obligation that prohibits me from discussing alternative products outside of the brand I am being paid to endorse,
- I am worried about my bottom line,
- I am a [insert brand here] representative for enteral or parenteral nutrition products,
- I want to be a brand ambassador for a product I believe in.
Per CDBC Standard of Practice 8, indicator 3: “A dietitian identifies and manages any real, perceived, or potential conflict of interest… [by] provid[ing] options for the sale of dietetic products.”, a dietitian may not offer only one option to members of the public.
This wording excludes dietitians who work in roles such as pharmaceutical representatives, since they are communicating with other healthcare professionals in their roles. Dietitians who provide counseling to clients are deemed to be involved in a therapeutic relationship. As part of that relationship, clients can expect to receive evidence-informed options that are tailored to their individual nutritional needs (Standards of Practice 12-14). Consider how client needs vary (nutritionally, budget-wise) and how similar products are often available, while differing in cost. It would be unethical to provide a client in this scenario with only one expensive option, simply because the dietitian is a brand ambassador or paid to endorse an exclusive product.
Dietitians can endorse products (think gain, not advisable within therapeutic relationships due to conflict of interest), but they must also be able to recommend products (think no gain) while preserving professional boundaries and client-centered care. In a non-therapeutic relationship, or when not practicing dietetics to promote certain products, registrants must not use their RD titles, and should separate out their RD practice from their non-RD practice (refer to Conflict of Interest and Sales Policy 4(b)). Concerns related to legal requirements to promote a certain product should be met with the knowledge that a company’s legal requirement for a dietitian to avoid speaking of alternatives does not supersede College requirements and protection of the public.
Q10: Am I permitted to use the CDBC logo on my private practice website?
No. The CDBC bylaws (section 74(5)) prohibit registrants from using the CDBC logo. “A registrant must not: (a) use the College of Dietitians of British Columbia’s name, logo, or other identifying marks in any marketing, materials or activities…”
The public can verify dietitians are CDBC registrants, in good standing, by visiting the CDBC Public Register of Dietitians.
Q11: The Marketing Standards (2i) prohibit me from using the word “specialist” when describing myself or my practice. This seems unnecessarily restrictive.
The avoidance of the use of “specialist” is in CDBC Bylaw (74(7a)) and is not new. Bylaws also state that education received, expertise gained, and focused practice can be used as descriptors for a practicing registrant, without the use of the word “specialist”.
Q12: I noticed that Marketing Standard 2(g) includes a ban on testimonials, including before and after photos. What is the rationale for this?
Use of testimonials in practice goes against the Code of Ethics, as it prioritizes the interest of the dietitian over the client’s and creates the following risks:
- selection bias: testimonials are not representative of all clients’ experience and opinion of services received. Dietitians can select which testimonials to publish, which may focus on positive testimonials and leave out less flattering ones.
- professional boundaries not being maintained: clients may feel pressured to agree to leave a positive review to maintain a good therapeutic relationship with the dietitian. Similarly, for before and after photos, clients may feel pressured to give consent to participate to this activity.
- misleading the public: both testimonials and before and after photos can give the false impression that members of the public could achieve the same results as the ones shared in testimonials and before and after pictures.
- breaching client privacy: depending on the amount of information in the testimonial, it could make the client recognizable to others. This is also applicable in the example of before and after photos.
The CDBC has developed a Position Statement on Testimonials. You are encouraged to review it.
Q13: Isn’t banning testimonials giving unregulated nutrition related practitioners an unfair advantage? They can promote each other and accept promotion from the public.
See the rationale in Q12 for background.
Dietitians in BC are regulated health professionals and are held to the same high standards as other health professions governed by the Health Professions Act. There are no standards for unregulated professions with respect to marketing, advertising, standards of care and ethical practice. Therefore, in BC, nutritionists (RHN etc.) and Registered Dietitians cannot be compared equally.
CDBC consulted with the BC Public Advisory Network (BC PAN) on the Testimonial Position Statement and the Social Media Guidelines. The BC PAN advisors are members of the public who have varying levels of experience with the health care system. They represent different demographics in the population, such as gender, age, ethnicity, and geographic location within the province.
The response to the Testimonial Position Statement and Social Media Guidelines was overwhelmingly positive. The group cited a feeling of vulnerability when accessing healthcare, including the sense that they could easily be taken advantage of. This is especially apparent when discussing the imbalance of power in the therapeutic relationship and the fact that testimonials can be seen as inauthentic and one-sided.
Testimonials have historically been discouraged by the CDBC. However, given the move of many regulatory colleges in BC and Canada to prohibit testimonials among regulated health care professions, the CDBC is taking the same stance.
The Board approved the Testimonial Position Statement and the Social Media Guidelines after the public consultation process and the professional consultation process. In short, as a dietitian, you have a responsibility to look out for the best interest of your clients, over your own. Testimonials benefit the practitioner and not the client.
Q14: I currently use testimonials in my dietetic practice. Now that they are suddenly banned, it will take me some time to remove the testimonials from my online presence.
The CDBC recognizes that this represents a significant change for dietitians who currently use testimonials. There will be transition time effective to March 31, 2022 to allow for registrants to adjust to these changes, without inquiry actions.
Q15: What should I do with any reviews or testimonials I receive that are unsolicited. If I can’t publish them, how are they of value to me?
It is always great to receive positive feedback or a good review. You are encouraged to save them in your professional portfolio. You may even choose to use them when listing your Learning Activities for CCP goals if they are applicable and have demonstrated a level of interaction (such as in a communication goal) where they demonstrate a new skill or improvement of practice.