Marketing Q&A

Both recommendation and endorsement involve products and services promoted to clients. They pertain to products and services that are evidence-informed 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. Although a recommendation will often be product or service specific, it is not exclusive and can be substituted.

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, but it is also Dietitian-centered. An endorsement often involves an exclusivity where other similar product or service cannot be promoted.

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.

1. 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 think of you as having specific competencies and knowledge in this type of kitchenware, when that is not the case. Therefore, products such as these should not be endorsed by Dietitians.

2. 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 necessarily or always 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.

3. 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.

For example:

• 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.

For the purposes of marketing, the line between what is considered dietetic scope and what is outside of dietetic scope is not set in stone in the Marketing Standards. Each case needs to be interpreted with the applicable context. While the CDBC can provide interpretation of its own legislation, it cannot provide legal advice to registrants about their individual business and marketing beyond the CDBC’s mandate for public protection. Registrants may seek legal advice regarding their individual business model and marketing strategies.

It is written that Dietitians may not market items that are outside of dietetic scope:

“Avoiding endorsing and marketing services and products with RD title that are outside the scope of dietetic practice (e.g., beauty products, furniture, jewelry, etc.).” is based on CDBC Bylaws’ section 77(5)(c) as per Q3. As a reminder, scope of practice is derived from the definition of “dietetics” in the Dietitians Regulation “the assessment of nutritional needs, design, implementation and evaluation of nutritional care plans and therapeutic diets, the science of food and human nutrition, and dissemination of information about food and human nutrition to attain, maintain and promote the health of individuals, groups and the community.”

The CDBC encourages registrants to think critically about their marketing and business relationships. In Q3 above, the CDBC is discouraging registrants from partnering with suppliers/companies where the partnership and selling of products would cause a power imbalance, risk of conflict of interest, and a risk of undermining the profession’s credibility. This may not be the case for Dietitians who only engage in product representation and sales (i.e., Dietitians who are not providing client counselling). Before deciding to partner with a company, you may want to ask yourself:

• How would these products fit with your practice and services as a Dietitian?
• Do you have any specific knowledge related to these products that makes you competent to market and sell them? If so, how did you acquire this knowledge and would it be considered credible and evidence-informed, if challenged?
• How do you think the members of the public would view this work considering that you are a regulated health professional with a specific scope of practice?
• Do you think there is a potential perception for conflict of interest? Or could there be feelings from your clients that they are pressured to buy these products because of your work with the company?
• Is there any potential for confusion from vulnerable groups? What impact could this marketing or business practice have on these clients?
• Would you be obligated to exclusively promote a product, thereby unable to offer alternatives? Offering alternatives for sale is actually a requirement and appears in the Marketing Standards.

Finally, you are encouraged to review the CDBC Code of Ethics and the Decision Tool on New Aspects of Dietetic Practice, both of which are available on the Quality Assurance Page of the CDBC website. These are other tools you might find helpful to make your decision.

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: cannabis@canada.ca.

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.

A Dietitian uses the Bylaws’ Code of Ethics and the CDBC Standards of Practice (SoP) to satisfy this requirement.

• 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.

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.”

It is often difficult to discern if a client intends to follow up and then doesn’t, or if the client reports an intention to follow up without actual plans to do so. It is important for you to consider the point of view of the client and in doing so, consider improving clarity of your service provision by making the terms of your contact clear in either their contract or service agreement with their client. This can help you determine how to proceed with follow-up of an existing client.

Do you have an established course of action for how you intend to follow-up and is that information accessible to the client? Consider if you had a cancellation policy or follow-up policy published on your website or in your office. It would be accessible by the client, such that they have a good understanding of what to expect from you.

If you have an established policy in your contract or service agreement, is the policy reflective of the type of clients you have? For example, clients that are being followed for diabetic control or for eating disorders may require a different follow-up policy than a client who is looking to make healthy changes to their lifestyle.

You are encouraged to review the Evidence-Informed 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-informed 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.

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).

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.

The wording of 2f includes: Avoiding implication of recommendation, endorsement, and sale of a single brand, product, or service to members of the public, unless such product or service is the only one of its kind and is evidenced as having more benefits than risks.”

You are correct that a “service” in this situation can be defined as the dietetic care you provide to a client. The clause in 2f exists for you to consider if you are the best dietitian to provide dietetic services to a client. Consider an initial consultation in your private practice with a client, who is newly diagnosed with diabetes and has no extended health care coverage. In your recommendations for follow up care, if cost is a concern for the client, the most ethical and client-centered care approach would be to discuss options for follow up that might be more affordable in addition to your services in private practice.

In this circumstance, you should not solely recommend yourself; rather, you might also suggest the option of a referral to a diabetes out-patient clinic, where the client can access publicly funded healthcare, as well as have access to dietetic and other interprofessional follow-up. Part of that discussion may also involve wait times and support the client in making the best decision for themselves.

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. 

The CDBC’s intent in making these amendments came from two sources of input: increased number of complaints received over the last 5 years on this topic, and recent public engagement and consultation with the BC Public Advisory Network (BC-PAN). In consulting on marketing of professional services and products with the BC-PAN in June 2021¹, the CDBC heard that public advisors expected health professionals to market their services clearly, accurately, in plain language, and in a way that promotes trust.

• BC Public Advisory Network (BC PAN). Practitioners Selling Products and Services. https://www.bcpan.ca/summary/practitioners-selling-products-and-services/, accessed on July 19, 2022.

The main changes to the Marketing Bylaws describe where Dietitians may use terms like “expert”, “specialist”, or “specialized”. These terms are permitted only when referring to dietetics or human nutrition generally. For example, from the BC Government Dietitians’ Day Proclamation: “dietitians are experts on the role of nutrition in whole-person care, who have a unique combination of knowledge, training and experience to translate the complex science of nutrition into practical healthy-eating solutions […] dietitians use their expertise to help individuals make positive lifestyle changes and to advance the health of British Columbians through healthy food environments […]”

In addition, adding a term to the title of “Dietitian” or “RD” that are non-medical and have no implication of being associated with a medical diagnosis, is permitted. Some examples could include: “Veggie Dietitian”, “Mindful Dietitian”, “Nourished Dietitian”, “No Nonsense Dietitian”, etc.

The marketing bylaws also outline the type of marketing with the title of “Dietitian” that is not permitted. Per CDBC Bylaw section 77(7)(c)(ii)(B): “a registrant must not use the terms [specialist, expert, specializing] to assert or imply that the registrant is an expert, specialist or specialized in an aspect of dietetic practice or a particular disease, disorder or condition that can be treated with dietetics.”

The above statement is interpreted here, with examples, that are not meant to be exhaustive, nor is any reference to an existing business name implied. Examples of titles that are not permitted, include the following categories:

1. Medical diagnosis-specific titles: “Renal dietitian”, “Mental health dietitian”, “Diabetes dietitian”, “Obesity dietitian”, etc.
2. Body system-specific titles: “GI dietitian”, “Gut health dietitian”, “Skin health dietitian”, etc.
3. Population-specific titles: “Fertility dietitian”, “Maternity dietitian”, “Pediatric dietitian”, “Sports dietitian”, etc.
4. Diet-specific titles, or titles that are specific to aspects of dietetic practice or conditions that can be treated with dietetics: “Keto dietitian”, “Low glycemic dietitian”, “Weight loss dietitian”, “Gluten free dietitian”, etc.

While the CDBC recognizes that many Dietitians focus their practice in one area, the entry-level competencies and the license allow Dietitians to work in any aspect of dietetics of their choosing, and the CDBC does not regulate any dietetic “specialties”. Qualifying the title “Dietitian” with a medical diagnosis, body system, specific population, specific diet, title related to specific aspect of practice, or title associated with conditions that can be treated with dietetics, as outlined in Bylaw 77(7)(c)(ii)(B) above, can be misleading to the public in giving the impression that these are specialties regulated by the College.

The public can be misled in thinking that a Dietitian using such qualifiers with their title has additional training regulated by the CDBC and is more qualified than another Dietitian who solely uses the title “Dietitian” or “RD”.

Section 3 of the regulation refers to the Health Professions Act’s Dietitians Regulation where the title “Dietitian” is reserved for exclusive use by CDBC registrants. The CDBC Bylaws also further specify designations related to the title, for example, in section 43(4) “Dietitian”, “Registered Dietitian” or “RD”, and in section 45(9), “Registered Dietitian – Temporary” or “RD(T)”. Avoid use of the terms “expert”, “specialist”, or “specialized” alongside protected titles.

Upon registration with the CDBC, Dietitians may choose to work in any area of practice and, over the span of a career with experience and additional education/training, Dietitians will acquire specific knowledge in their area of practice. However, the College doesn’t regulate (establish, require, oversee) this additional education and experience in order to practice safely and competently in this area. Rather, the CDBC’s involvement is limited to the CCP process, which functions to provide Dietitians with a systematic way to compare and maintain their practice to CDBC Standards of Practice, which are based on the entry level competencies associated with the Integrated Competencies for Dietetic Education and Practice (ICDEP).

When marketing services to the public, Dietitians may not refer to themselves as “Diabetes Dietitian” and instead refer to themselves as “Dietitian, Certified Diabetes Educator” or “Dietitian, Outpatient Diabetes Program”. Internally, to colleagues and other members of the healthcare team, you may be referred to informally as a “Diabetes Dietitian”, which is permitted given it is not intended to be an advertisement or marketing of your services to the public. However, this designation may not appear on business cards, email or print signatures, nor any other medium that as accessible to members of the public.

While the CDBC isn’t trying to get into the habit of policing business names, it is this type of marketing that the bylaws regulate. In this example, use of a medical diagnosis or use of a title referencing a specific body system (Bylaw section 77(7)(c)(ii)(B)), is not permitted under the Marketing Bylaws. Dietitians are permitted to use some descriptors and are restricted from using others, as outlined in Q14.

For example, marketing to the public as a “Renal” Dietitian would breach the requirements of section 77(7)(c)(iii) as it includes a term “Renal” which refers to a medical specialty in conjunction with the title “Dietitian”. Instead, you may want to consider marketing yourself as “Dietitian, practice focused on kidney (or renal) care” or if applicable, “Dietitian, BC Renal Program (or Kidney Care Services)”. The initials “RD” can also be used instead of or in combination with “Dietitian”.

If you have questions about your business name, please reach out to the CDBC anytime at practice.advisory@collegeofdietitiansbc.org.

The following examples may help you to consider your marketing and title use such that it falls into Marketing Bylaw compliance:

• Jane Doe, Dietitian focused on weight management
• John Doe, RD working in Diabetes care

Unlike the position statement, bylaws are enforced by the Ministry of Health and the CDBC is responsible to apply the bylaws as they become effective, in this case September 2, 2022. Although no grace period is available, the CDBC is supporting registrants with the bylaw changes through practice advisory and the Marketing Q&A.