In India the number of overweight people has increased significantly over the last ten years. Even by conservative estimates, five per cent of the total population in the country is believed to be overweight. It is widely acknowledged that obese persons are at a greater risk of having diabetes, high blood pressure, coronary artery disease, and even arthritis (5). The problem of obesity is fast spreading in India with almost a third of middle class men and half its' women falling prey to this lifestyle anomaly according to Dr. P.S.Chatterjee, professor in the School of Tropical Medicine's Department of Nutrition and Metabolic diseases (presentation on Ideal Body Weight -- How to Achieve?' on Dec 6th 2003). Quoting recent survey findings, he said 32 per cent of Indian adults in the high socio-economic group were overweight while three per cent men and 14 per cent women above 40 years of age suffered from obesity, an anomaly that the WHO has placed in the list of the top 10 killers (6).

Over the past few years, the healthcare scene in the country has been witnessing revolutionary developments. Nutrition, fitness and health are fast becoming areas of key interests in Indian society. The recent interest in health and fitness has resulted in mushrooming of health clinics and fitness centres all over the country. Along with these, the increased life expectancy has resulted in a growing and aging population that has increased the demand for nutritional guidance and counselling in hospitals, nursing homes, community health programs, schools, and door-to-door healthcare services in villages as well as in cities. Among the top 30 occupations of 2001, half of them are health-related.
The Bureau of Labor Statistics mentioned that, employment in the private hospital industry is growing slowly. The number of health practitioners, nursing and personal care staff, nutrition and dietetics specialists is expected to grow faster than in most other occupations (7). Several job opportunities have been coming up in the fields of nutrition and dietetics, rehabilitation units, health and wellness clinics, family guidance and child-care centers and several other counseling centers.
History of Dietetics in India.

The current nutrition and dietetic education in India differs from the United States and other European countries. The field of Dietetics is very much advanced in these developed countries. However, in such a big populated country like India, the struggle for recognition of the dietary department services is still going on. The dietetics filed has not gained much momentum in India and unfortunately, it has been neglected by several health professionals for a long period of time. As the complexity of the nutrition delivery system grows, the expertise and numbers of leaders in nutrition will need to continue as well. Experts within the country and within the culture will be challenged in coming years to provide nutrition education for the growing population.

India's population is extremely diverse in language, color, religion, caste and class and . consequently, in food habits. Culture is an essential part of food behavior. India has a rich and diverse culture that represents a wide array of health practices and beliefs. The food available in India is as diverse as its culture, its racial structure, its geography and its climate. India is a county where resources are precious and very little is wasted. Extensive work has already been done in recognizing several nutritional problems related to this diversity.

In India, one of the most disturbing and least satisfactory aspects of patient care is dietary service. In the average hospital situation, its organization, administration and sanitation has left much to the desired or expected. It is a well-known fact to all that, Indian Dietaries need a great deal of change to improve their services. A few hospitals in major cities have well- maintained, organized, equipped and staffed dietary departments to provide food service to the in-patients. Their service of food includes a number of function planning menus, purchase of raw materials (as opposed to packaged) and distribution of the prepared product to the patients. The physical facilities of the dietary department have an important influence on the standard of food service, labor charges and morale of workers. But most of the Indian hospitals are lacking suitable equipment for efficient food production and service and unfortunately many of them do not have a Dietary department at all. The present dietary set up environment in Indian hospitals needs a great improvement in terms of quality as well as quantity. In India, Vellore Dietitics department is one of the oldest dietary departments in the country and now it is
Formation of Indian Dietetic Association

In 1963, a small group of nutritionists, dietitians and workers in the allied health fields resolved to form a scientific body to highlight the importance of dietetics and nutrition in the maintenance of health, and in the prevention and treatment of diseases. Thus, the Indian Dietetic Association (IDA) was founded, with Prof. Kalyan Bagchi as Secretary and Dr. C. Gopalan as President (8). The aims and objectives of IDA are to promote the cause of science by encouraging the spirit of active pursuit of knowledge and original scientific research particularly in the field of Nutrition and Dietetics; to facilitate social, scientific and cultural fellowship and cultivation of goodwill among its members; to promote close contact and interaction between persons following different branches and thus facilitate the development of a wider outlook and the integration and application of available scientific knowledge for the welfare of society and finally to safeguard the interests of scientists generally and its members in particular and work for their welfare.
The IDA was affiliated to the International congress of Dietetics in 1975. The IDA has its own registration board which became operational in Jan 1981. The board consists of the current President of IDA and five other members elected by executives. The main objective of the registration board is to ensure minimum standards of teaching and training in dietetics and to maintain a register of professional dietitians. It takes care of all the activities related to registration of dietitians. The IDA started its own scientific journal in 1963. It was named as "Journal of the Indian Dietetic Association". The inaugural issue came out in December 1963 coinciding with the first Annual Convention of the Association. It was re-christened as "Applied Nutrition" in 1973 with two issues published every year. The journal has been renamed as JIDA "Journal of the Indian Dietetic Association" in 2003.

Today there are approximately 3000 registered members in IDA all over India. All these members may not necessarily be the practicing Dietitians and Nutritionists. Due to lack of opportunities and support in the healthcare industries, many qualified nutrition people are jumping over to the other fields. Even if they are employed, their payment is less when compared to the other fields. The dietitians who are employed in the hospitals are sometimes not given much importance when compared to the doctors and their valuable services have been ignored. Here comes the question of practical knowledge of dietitians. Many dietitians complain that, they are not given the recognition that they deserve and their role is only dedicated to supervise the hospital kitchen and to passively supply the calories and proteins given by the physician. The physicians defend that attitude. Another problem is that most of the dietitians do not possess practical knowledge, which is vital in clinical nutrition applications.

The majority of the patients who visit the hospitals do not know about the Dietetics department and its significance. People give less importance to the dietary treatment when compared to medical treatment. During illness, people usually follow some diet restrictions according to their grandmas' or some other older person's advice since grandmas provide valuable, domestic, cheap and best remedies. So, many people don't feel it as a necessary to consult a dietitian when they are getting similar advices from their homes itself. That is also one of the reasons why the Dietetics field has not been recognized as an important subject. There is an old saying which is still followed by almost all Indians is that "Fasting is the greatest medicine". So many traditional Indian people do fasting for one day in a week. They feel that it is the most appropriate remedy for indigestion, constipation, fevers and several other illnesses.

It is an age-old practice that, doctors themselves counsel the patients regarding their diets and prescribe therapeutic modifications. Even today also the same situation is continued in many of the urban hospitals In India. To be frank, Indians are well accustomed to the doctors' suggestions rather than dietitians'. It is observed that, even well educated patients are also not utilizing the valuable services of dietitians.

There are only approximately 300 Registered Dietitians (RDs) in India, which really depicts the lack of importance of RDs in hospitals and healthcare industries. Only a few corporate hospitals in metropolitan cities are utilizing Registered Dietitians' services in the country. The reasons for very less number of qualified RDs may be due to several important factors. The RD qualification is not a compulsory requirement in many hospitals. Even a graduate student, with or without hospital work experience, is allowed to take part in critical clinical nutrition aspects. Those who have RD qualification are moving to western countries for better employment opportunities. The present IDA members (approx.3000) is also fewer when compared to USA figures. There are approximately 70,000 members registered with American Dietetic Association (ADA), which is the nation's largest Organization for food and nutrition professionals (9). Approximately 75 percent of ADA's members are registered dietitians (RDs).

One of the biggest challenges facing the dietetic profession in India is the development and operation of quality nutrition services in the evolving healthcare systems. The present strength of dietitians and nutritionists is not at all sufficient to the unchecked Indian population. During IDA's 13th Convention in 1978, President Dr. C.V.Ramakrishnan stressed that all the state Governments as well as private hospitals and nursing homes should develop dietetic departments as per the recommendations of the Government of India Committee on Standardized diets for hospitals. The committee had recommended that every hospital having 100 to 300 beds should have one dietitian and 300 to 600 beds two dietitians, with adequate provision for a dietary department (10). Unfortunately, this recommendation had not been fully followed in most of the Indian hospitals. Even in those places, dietitians act more or less like a store clerk or just a kitchen supervisor.
Now there are thousands of hospitals and medical centers in India. Most hospitals have large open wards with minimal staff. The number of hospitals and bed capacity in India has doubled in last ten years. There are approximately 11,174 hospitals out of which 57 percent are in the private sector. The total number of beds are expected to grow from 1500,000 (2001) to 2250,000 (2012) and the Indian Govt. is spending 17,000 Crores on Healthcare and Private Industry spends 69,000 Crores (11). Food service is very informal and bulk oriented in composition. Therapeutic diets are difficult to enforce within the hospital and almost impossible to enforce as an outpatient due to lack of specialty foods and economic issues. India does not even meet 1/3rd of Healthcare Standards set by WHO. So the available number of dietitians is not at all proportionate to the growing number of beds in Indian hospitals and there is an immediate requirement to absorb the dietitians.

India has several centers of nutrition interest. The Nutrition Foundation of India (NFI) is a non-governmental voluntary agency dedicated to the upliftment of the nutrition status of Indians. It plays a catalytic role of advocacy and education to focus attention on major nutritional problems; provides leads for practical action in overcoming these problems; and combats inadequacies in the implementation of ongoing nutrition programs.
The Nutrition Society of India (NSI), a professional organization, holds annual academic sessions to share information and research. The National Institute of Nutrition (NIN) at Hyderabad is one of the premier permanent research Institutes of the Indian Council of Medical Research (ICMR), an autonomous body under the aegis of the Ministry of Health and Family Welfare, Government of India. The history of this Institute spans over eight decades. It has published periodic editions of Nutritive Value of Indian Foods. This center also trains dietitians in India. (12)
Role of Nutritionists and Dietitians in India today.

Dietetics has yet to find its rightful place in Indian therapeutics. Nutritionists and dieticians are an integral part of the health care services. A majority of even our teaching hospitals do not have qualified dietitians. An important factor which, has probably contributed to the rather unsatisfactory position accorded to dietetics in India today, is the lack of authoritative information useful to doctors and nurses in the prescription of suitable therapeutic diets. Since no two human beings are alike, the dietician's job can be quite varied and interesting. It's always a challenge to figure out a specific diet plan based on the doctor's diagnosis and the patient's condition and lifestyle.
The major role of dietitians in India is to assist people in planning their meals depending upon their age, sickness or work routine. Dieticians scientifically evaluate diet need of a client and suggest diet modifications. The dietitian is a specialist who interprets the physician's orders in terms of daily meal patterns that have been individualized according to the patient's food habits as well as modified according to the patient's therapeutic needs. He/She is responsible for the preparation and service of food to the patient, the evaluation of patient's response to the diet and subsequent counselling of the patient and his family. The nutritionists counsel individuals and groups, organize the food service systems in hospitals, schools, hotels etc.

Dietitians specialize in education, research, administration and clinical/community dietetics. Administrative dietitians play a major role in large-scale meal planning and monitoring the food preparation process in schools, canteens etc. They take up the entire responsibility of their department and actively participate in selection, training, budgeting, equipment purchase, checking safety regulations, maintaining records etc. Clinical dietitians are associated with health care institutes, hospitals and nursing homes. Depending on the nutrition needs of the patients, they prepare their diet charts and monitor the results of dietary therapy. The other category of Dietitians belongs to Research and Development. These Research Dietitians work in the field of nutrition in healthy and therapeutic food items. They work in studying the effects of various types of diets on the body chemistry. They are also involved in conducting highly specialized research in nutritional needs of chronic disease patients and special people like astronauts.

Dieticians can guide all kinds of patients and clients regarding their healthy eating habits and draw up personalized food plans that coincide with their dietary restrictions, occupational constraints, fitness and stress levels, etc. They help them choose more appropriate foods. The diets they provide have therapeutic value and are worked out for each patient according to the illness. Other than planning meals, dieticians also look into the day-to-day functioning of the organization for which they work. The nutritionist, on the other hand, studies the effect of food (on humans) and the effect on food (when it is cooked/served). A nutritionist's work mostly consists of preventing illnesses and rehabilitating patients after an illness. But, dietary counseling and satisfaction of the nutritional needs of the patient requires the coordination of medical, nursing and dietary staff. The importance of the dietitian is well depicted in the following picture.

The common goal in feeding patients in Indian hospitals is to provide quality food that meets nutritional standards at the most economical cost. But this goal is not being achieved by many hospital dietary departments since hospital food services pose a special situation. They have captive patrons, built-in-food restrictions and a definite type of service. They cater to patients of all ages from all walks of life with different life-styles, food habits, and cultural and social preferences. Thus food service to the patients requires a lot of imagination and ingenuity in planning for a variety of foods that meet the needs of the patients. Dietitians and nutritionists, who are associated with hospitals and clinics generally, have regular work hours. In this environment, they come in direct contact with patients and advise them appropriate diet based on the illness. In commercial food service, the working hours are usually irregular.

Qualifications and Requirements to become a Dietitian or a Nutritionist in India.

Educational Qualification: A dietitian should preferably complete M.Sc (Nutrition), which is a 2year course after graduation. Preferable fields of graduation are - Microbiology, Chemistry, Home Science, Medicine, Hotel management or catering technology. Other option is to pursue a 1year PG Diploma in Nutrition and Dietetics. Fresh dietitians usually undergo training for 1 year in the Dietetics department of the hospital.

A number of universities offer a 3-yr BSc in nutrition/ dietetics / food technology. Both Delhi University and Bombay University also have a BA with nutrition and health education course. Delhi University's BA in food technology is available in five women's colleges - Aditi Mahila Mahavidyalaya, Bhagini Nivedita College, Lakshimibai College for Women, and Vivekananda College. The BA course in nutrition and health education is offered at Aditi Mahila Mahavidyalaya, Bhagini Nivedita College and Daulat Ram. Food and nutrition is offered as a specialization in MSc home science courses at over 45 universities. While some like the University of Delhi, require BSc (home science), others like the MS University of Baroda, also admit students with BSc in related subjects.

Curriculum: The curriculum is a mix of biological, social and food-based skills. It includes study of biological basis of health, food and culture, investigative skills, cell biology and metabolism, sociology, psychology, nutrition in health, therapeutic nutrition, advanced nutrition, clinical nutrition, community nutrition, food science, human physiology, microbiology and immunology and biological basis of disease.

Salary: In hospitals, trainees generally receive a starting salary of Rs 3,000 (approx.$65) per month, which may go up (after three months of service) to about Rs 5,000 to Rs 8,000. Nutritionists, quality control managers and dieticians are in great demand and the pay depends on the organization you are working for - it generally hovers in the range of Rs 12,000/- per month.

How to become a Registered Dietitian in India?

To become a Registered Dietitian, one must meet the eligibility requirements set by IDA and pass the RD exam conducted every year by the Chairperson, Vellore. The eligibility Requirements for R.D. Examinations includes: 1. Life membership in IDA. 2. Graduate in Nutrition and Dietetics / P.G. Diploma or Master's degree in Nutrition and Dietetics. 3. Six months Internship after completion of qualifying exam in a multi specialty hospital recognized by IDA for internship & supervised by an R.D. The internship should be done continuously or in two installments of 2-4 months each, with a break of not more than 6 weeks. The internship should be completed by the 31st of August every year. OR Two years of experience as a full time dietitian in a multi specialty hospital (13).

Other possible opportunities for Nutrition/Dietetics professionals:

Apart from Nutrition and Dietetic jobs, there are good career opportunities in the food industry too. Lot of food companies employs nutritionists and dietitians to check the nutritional quality of the food products, for new product development and for marketing related advice. There is teamwork involved in experimenting on flavors and preparations. This along with the booming commercial food services will ensure that these professionals continue to have ample job opportunities in the future. Research Institutions, Hospitals, Pharmaceutical Firms, Food Manufacturing Companies, Fitness Clubs and Clinics and large canteens are some of the places offering attractive openings to these professionals. With increasing health concerns amongst the population at large and a growing awareness about fitness and preventive care, writing on health and nutrition and suggesting innovative recipes with a focus on healthy and balanced eating, can be a good occupation if you have a flair for writing. All nutrition professionals can work as freelance writers for magazines, books, newspapers etc. and can share their knowledge in educating the people.

Summary

The government has to recognize the need for dietary department in all hospitals and its valuable services to the patients and must see that dietary services are mandatory along with other healthcare services. There is a definite need to understand the importance and utility of the dietary department staffed by well-trained personnel, with suitable remuneration so as to encourage, improve and uphold high standards in the preparation and services of clean, wholesome food to all types of patients in every hospital or nursing home. Educational institutes like colleges and universities need to start advanced Nutrition education courses to produce qualified Dietetics professionals. All teaching hospitals are required to provide quality internship experience to the budding professionals. The government has to provide good infrastructure facilities for planning, preparing and servicing of food items to the patients. Students must be encouraged to study Dietetics with good accommodation, stipend, certification, recognition and placements. Indian Dietetic Association must take this responsibility of producing more number of qualified dietitians and nutritionists to serve the patients and public.

References:
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9. Welcome. American Dietetic Association. (n.d). Retrieved on 19 Dec 03. http://www.eatright.org/Public/
10. Shantha and Mohan. Dietary Services in Hospitals. A Manual of Second Regional Workshop on Planning Diet for Health. March 1999.p.12-15.
11. Instromedix India Pvt.Ltd. (n.d). Retrieved on Dec 19 2003. http://www.instromedixindia.com/market.htm
12. Judith A. Beto. Beneficial Nutrition Program Through International Alliance With ADA or ICDA. 1994. Retrieved on Dec 19, 2003 http://www.eatright.org/Public/7772_17292.cfm
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Copyright Kathy Shattler 2004. This article may not be reproduced without the express permission of this editor, K.J.Shattler at kshattler@chartermi.net

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