Dietitians, who are referred to as Registered Dietitians (RD) or Registered Nutritionist Dietitians (RND) in some countries, are qualified regulated health professionals dealing with human nutrition and dietetics issues faced at any life stage. They assess, diagnose and treat dietary and nutritional problems at an individual and wider public health level (BDA Curriculum 2020) ¹⁾. They also apply the science of food and nutrition to promote health, prevent and treat disease to optimize the health of individuals, groups, communities, and populations (International Confederation of Dietetic Associations (ICDA, 2014) ²⁾. The subjects of dietitians' practice range from hospital patients, school children, elderly in long-term care facilities, or even professional athletes. Thus, dietitians have to complete an education curriculum and satisfy the requirements to prove they are capable of accomplishing the professional tasks as regulated by national authorities.
　From August 19th to 21st, 2022, young dietitians from six Asian countries (Japan, Taiwan, Thailand, Philippines, Indonesia, and Vietnam) gathered at The 8th Asian Congress of Dietetics (ACD 2022) in Yokohama, Japan. For the first time, we shared our ideas about dietitians’ education and practices in our countries. Given limited opportunities to gather and share our thoughts, everyone was eager to bring up a broad range of topics, such as the legal system related to dietitians, strategies to fight obesity, and malnutrition treatments in clinical settings. We have been meeting online twice a month from April to August, preparing the topic we wanted to share with Asian dietitians during ACD 2022. An important topic during our meetings was the education programs compulsory to be dietitians in each country. Through the online meetings and congress, we sought how Asian countries could build a mutual understanding as a foundation to develop a better education program for dietitians in the future. Here is a glance at our perspective.

Practice hours and internship

　Accreditation standards for dietetics education programs across the world, require curriculum to meet the foundational knowledge, skills and attributes needed for dietetic practice. The curriculum commonly incorporates a range of credits acquired by attending lectures, experimental/practical courses (including simulation, case studies, and role-playing) at colleges or universities, as well as taking professional practice (practical training/internships) programs in healthcare or service facilities. All countries grant pupils diplomas, bachelor's, or master's degrees by fulfillment of the education curriculum, which might be followed by additional professional practice, passing national examinations, and official administrations before they are granted their dietitian license.
　A consensus on the core concepts for the dietetics discipline and dietetic competency standards among the countries has been acknowledged. In addition to on-campus courses, professional practice in healthcare facilities, public health centers, or food service facilities is an essential part of a dietitian education program to equip prospective dietitians with comprehensive skills for their professional tasks in the future. Naturally, the number of training hours in real settings needs an extended consideration since the skills acquired from those practices are proportional to the amount of practice taken. According to International Standard for Education of Dietitians-Nutritionists by ICDA, the minimum level of education of a dietitian-nutritionist is a bachelor's degree and a period of supervised professional practice of at least 500 hours and meets the international competency standards for dietitians-nutritionists ²⁾. In western countries like the British Dietetic Association, students are expected to undertake not less than 1000 hours of practice-based learning with not less than 350 hours in the clinical setting and not more than 500 hours in one setting ¹⁾.
　Despite international standardization attempts, qualifications and education standards to become a dietitian differ in each country. We have realized that these standards may differ due to the specific conditions of the dietetic organizations in the context of the country’s education and health systems and the cultural, social, and historical experiences of the country. The varied qualifications and education standards in Asian countries are summarized in table 1.

　Among all Asian countries, the Philippines has the highest education units in their Bachelor's program in Nutrition and Dietetics as they follow the United States of America’s standard. For the Bachelor's program in the Philippines, a total of 165 units which is a combination of general education and professional courses should be completed by the student to be able to graduate in the program. This program includes 3-year didactic teaching and 1-year practical training or practicum in hospitals, food service, and the community. Schools or universities offering BSND program or equivalent is flexible when it comes to their curriculum however when it comes to professional courses, they should implement as prescribed in the program set by the Commission on Higher Education.
　In Figure 1, the practice hour is divided into on-campus training (laboratory or alternate supervised experiences such as simulation, case studies, and role-playing inside the university) and at training sites (in professional work settings such as hospitals, catering companies, community centers…). Compared to the international standard, Taiwan and Thailand have met the standard with both the practice hours on-campus and at the training sites ranging from 500 hours to 900 hours. The Philippines follows the standards of the Accreditation Council for Education in Nutrition and Dietetics (ACEND - Academy of Nutrition and Dietetics) which is 1200 hours for the practicum program ³⁾. On the contrary, Japan spends more time on on-campus training and only 180 hours practicing in hospitals or companies. Both Indonesia and Vietnam have practice hours lower than 500 hours in either category. In comparison to western countries like the US, UK, and Australia where dieticians are required to have at least 800-1000 hours of on-site training, most Asian dietetics programs seem to spend less time on it ¹⁾, ^3-4).

　Not only the duration of training but different countries also have different standards of training protocols. In Thailand, Vietnam, and Indonesia, their on-campus training may focus only on basic science laboratory training due to the limitations of university facilities. It found some difficulties to develop and set up the simulator lab like the training sites. Therefore, they mostly spent more practice hours in the real training sites. However, in Japan, Taiwan, and the Philippines, with well-established dietetic-related laboratories (e.g. food service laboratory, counseling clinics, and patient simulators), they have more opportunities to practice both on-campus and at the hospital training sites.
　With a shorter practice time, some countries like Taiwan and Indonesia require 2 years or nearly 2000 hours of after-graduation professional practice or (below mentioned as internships to contrast it with the professional practice during diplomas or undergraduate programs) in the hospital if one would like to work in the clinical setting. While the internship can help dieticians achieve competency and continue their learning, it can also affect their livelihood as some internships are unpaid. On the day of the workshop, we had the chance to discuss whether to spend more time on practice in the university or reduce the burden of practice in undergraduate training and complete the training from the internship. In 2003, the Institute of Medicine (IOM) proposed that healthcare professionals could no longer assume that they can practice effectively using the training received in their undergraduate education, as human memory could no longer continue to retain the whole knowledge-base on effective healthcare and was becoming increasingly unreliable in keeping pace with the ever-expanding healthcare research ⁵⁾. The IOM recommended that for health professionals to meet the needs of the 21st-century health setting education reform was needed, however, they recognized an “overly crowded curricula” as a challenge. Therefore with these in consideration, we would like to suggest a manageable number of practice hours around 800-900 hours in professional work settings along with a one-year internship after graduation. With this, dieticians will be able to assure the international competency standard and evolve to be adaptable, work in new emerging areas of practice, and demonstrate critical thinking skills to deal with increasing medical complexity and an aging population.

Registered Dietician (RD)/ Registered Nutritionist Dietitian (RND)

　Regardless of the difference in curricula or requirements of internships, almost every country, except Vietnam as they are still establishing its dietetics system, demands its dietitian candidates take and pass the National Board exam to be a Registered Dietician (RD)/Registered Nutritionist Dietitian (RND). The exam in most countries includes assessing the 3 main parts: basic nutrition knowledge, medical nutrition therapy, food service and management, and other supporting roles; community nutrition; and research methodology. After the board examination, the RD/RND can continue education through a Master's degree or may upskill in their chosen field of expertise (Renal Dietitian, Diabetes Dietitian, Pediatrics Dietitian, Sports Nutritionist, etc.). Registered Nutritionist-Dietitian in the Philippines may also take the Registered Dietitian examination in the US and may practice there once passed. This is from the Mutual Reciprocity of both countries.
　Renewal of license was also discussed in the workshop. Japan and Thailand have no renewal of licenses while the Philippines, Indonesia, and Taiwan have specific guidelines when it comes to the renewal of licenses (Table 1). However, since the scope of practice and work of dietitians is continuously changing, developing, and diverse, it is necessary to encourage all national RD licenses to have a process of renewal. The renewal process may help dietitians update their knowledge regularly. It can increase continuing professional development skills and lifelong learning skills in parallel with practicing competencies.

Conclusion

　Lastly, it was a great opportunity for the group of young Asian dietitians to join the workshop together in ACD 2022 to discuss each country's perspective. One of the selected topics, the dietetic legal system focusing on the eligibility to become a dietitian has been elaborated on as mentioned in this article. Although most countries have their own scopes of practice and national standards, they seem to have a similar core practice concurrent with the US, and ICDA standards. There would be more impact on our Asian countries if we could bring the collaborations to establish the standards of the dietitian system. This may go further with beneficial outcomes with the dietetic student exchange programs, working across Asian countries, and fruitful collaboration in the near future. These attempts are surely in line with the “Yokohama Declaration on Dietetics” which has been signed by the participating countries by the end of ACD 2022, declaring in points 5 and 6 as follows.

　“Education and training of dietitians as leaders in the nutritional improvement and the establishment and development of a dietetic system in line with international standards are also important.”

　“In order to achieve the above objectives, further Asian and international cooperation and collaboration will be necessary in the future.”

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AUTHOR
　Trang Thu Nguyen1*, Marita V. De Guzman², Ishak Halim Octawijaya3, Varanya Techasukthavorn⁴.

¹Nutrition and Food Culture Research Center, Jumonji University, Saitama, Japan
²Nutritionist-Dietitians’ Association of the Philippines, Makati, Philippines
³School of Nutrition and Dietetics, Faculty of Health and Social Services, Kanagawa University of Human Services, Yokosuka, Japan & Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
⁴Department of Nutrition and Dietetics, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand

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REFERENCE
1)British Dietetic Association (The Association of UK Dietitians). A Curriculum Framework for the pre-registration education and training of dietitians. 2020.
2)International Confederation of Dietetic Associations. International Standards for Dietitians-Nutritionists. 2014.
3)Accreditation Council for Education in Nutrition and Dietetics of the Academy of Nutrition and Dietetics. ACEND Accreditation Standards for Nutrition and Dietetics Coordinated Programs (CP). 2016.
4)Dietitians Association of Australia. National Competency Standards for Dietitians in Australia. 2015.
5)Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press. 2003.
＊This article was originally published in Asian Journal of Dietetics Vol. 4 No. 2-3, 2022 (http://jnl.calorie-smile.jp/).