practice applications
Is an Overseas Dietetics Career Opportunity for You?
This article is reprinted from the Sep-
tember 2009 issue of the Journal
(2009;109:1509-1512).
I
n her job as a nutrition therapist
for the expatriate community of
Baku, Azerbaijan, Valerie Hough-
ton, RD, travels to oil rigs to do nutri-
tion presentations and marks up pho-
tocopies of Russian-labeled foods with
English translations. Azerbaijan, an
oil-rich country on the west coast of
the Caspian Sea, has a long history of
Persian and Russian rule—influences
that still dominate the local cuisine.
Spicy beef, lamb, and poultry are of-
ten paired with saffron, spinach, and
potatoes, and vodka is the favorite
drink. Unfortunately, the country’s
health care infrastructure also dates
from the Cold War era. “Food safety is
an issue,” Houghton says. “What we
take for granted about preventative
health care doesn’t exist—there’s no
smoking cessation information, and no
information about cancers, diet, or
heart disease.” When Houghton ap-
proached the International SOS clinic
in Baku about the services she could
offer, the clinic jumped at the chance to
create a job for her. “I’m the only dieti-
tian I know in Azerbaijan who has a
pamphlet about what I do,” she laughs,
adding that she has so far met only one
other dietitian in the country.
Houghton is used to forging her
own career path— one that has in-
cluded stints in London, UK, and the
United Arab Emirates (UAE)—since
she married a partner who relocates
This article was written by Sara
Aase, a freelance writer in
Minneapolis, MN. Aase is an
award-winning journalist who
frequently writes about health,
business, and parenting. Her work
has appeared in Weekly Reader
Current Health, Minnesota
Monthly, Twin Cities Business,
Pregnancy, Parenting,
Hemispheres, and American Baby.
doi: 10.1016/j.jada.2010.03.008
© 2010 by the American Dietetic Association
every 2 to 3 years for his job with an
oil company. Working overseas hasn’t
always been ideal. In the UAE, a cos-
mopolitan federation of seven emir-
ates (like states, each administered
by a hereditary Muslim Monarch) in
the southeast part of the Arabian
Peninsula, Houghton found herself
writing dietetics articles for maga-
zines instead of practicing in a clinic
or hospital. “It’s not anything I ever
thought I would do, but was what I
needed to do at the time,” she says,
adding that the experience helped her
stay current with dietetics as well as
polish her marketing and presentation
skills. “It may take you more energy to
search out jobs overseas, but the oppor-
tunities absolutely are there.”
Why might you consider an interna-
tional career jump? Registered dieti-
tians (RDs) who live overseas—partic-
ularly in non-Western countries—say
their careers benefit from the diverse
roles they can create for themselves be-
cause of high demand. “We can create
the jobs,” says Stacia Nordin, RD, past
president of the American Overseas Di-
etetic Association (AODA), the interna-
tional affiliate of the American Dietetic
Association. For the past 12 years
Nordin has worked in the southeast-
ern African country of Malawi. She
is currently the technical advisor to
the Ministry of Education’s School
of Health and Nutrition Program,
which oversees nutrition in the pub-
lic schools. “It’s a matter of thinking
in terms of what you can do for the
world as a nutritionist.”
Paving their own road also gives RDs
a chance to be highly entrepreneurial
about their roles, says Camella Rising,
MS, RD, AODA president-elect. While
finishing an internship at the Women,
Infants, and Children (WIC) program
in San Francisco, Rising, newly mar-
ried to a Navy pilot, figured she
wouldn’t be working at their first over-
seas post in Sicily (Sigonella). “There’s
not much of a role for civilian dietitians
on a military base, since jobs in hospi-
tals go to military dietitians first.” But
then she spied a brochure for WIC
Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
BUSINESS OF DIETETICS
Get to Know the AODA
More than 700 dietitians hailing
from 70 countries make up the
membership of the American Over-
seas Dietetic Association (AODA),
the international affiliate of the
American Dietetic Association. The
AODA provides opportunities to
connect with one another, establish
professional contacts, and obtain
continuing education credits. Mem-
bers enjoy the same privileges as
other American Dietetic Association
affiliates. The AODA’s International
Dietetic Network is a resource for
country-specific nutrition and die-
tetics information, including oppor-
tunities for employment and local
food customs. It also offers a mem-
bers-only listserv and Web site,
newsletter, and access to informa-
tion about conferences and meet-
ings. The AODA holds a conference
every other year; in 2009, members
traveled to the Crowne Plaza Muti-
ara in Kuala Lumpur. See: www.
eatrightoverseas.org.
Overseas. “They didn’t have an office at
the Sicily base, so I opened one,” she
says. “Going overseas definitely re-
quires some thinking out of the box
about your career.” Rising and other
RDs say they handle more responsibil-
ities, more quickly, than they otherwise
might, which broadens their skill set
and often gives them access to a wider
variety of nutrition issues. Rising, for
example, had to order the furniture,
staff her office, coordinate with the
base grocery store and hospital, and
adapt WIC program materials for her
international clientele. The WIC out-
post, Rising notes, was her very first
dietetics job. Not only did it give her a
supervisory role early in her career, she
says, it also changed her focus from
clinical dietetics to public health.
Those RDs who stay in one place
long-term are able to see the way
their influence helps shape nutrition
health policies and dietetics educa-
tion standards. In the UAE, for exam-
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BUSINESS OF DIETETICS
ple, Ellen Edwards, RD, LD, the head
of clinical dietetics at Sheikh Khalifa
Medical City (SKMC) since 2000, has
steadily raised the bar for locally
graduating RDs. In 2000, she says,
the country didn’t have any RDs at
all. “I used to have to train the stu-
dents graduating in dietetics here for
3 to 4 years to get them to the [Amer-
ican Dietetic Association] dietetic
level,” Edwards says. “Now they are a
lot closer to the equivalent of the
4-year US program.” The UAE’s
health authority, in turn, is starting
to apply these same education stan-
dards emirate-wide. “Not to sound
grandiose,” Edwards says. “But your
influence can affect country policy.”
CAN I GET THERE FROM HERE?
COUNTRY WORK REQUIREMENTS
If you’re not being sponsored by your
employer to transfer overseas, you’ll
need to learn a particular country’s
requirements for working there, in-
cluding any reciprocity agreements,
registration requirements for RDs,
and possible job opportunities. For
example, Houghton’s first overseas
placement, in London, was also the
toughest. London requires that an
employer sponsor international work-
ers. At the time, Houghton worked for
Aramark, but the global foodservices
provider had no jobs available for her
in London and denied her request to
transfer there.
That didn’t deter Houghton. She ap-
plied for a work visa through a British
government-sponsored program for
highly skilled migrant workers, which
required her to meet a certain number
of points for degrees and published ar-
ticles. That process took 4 months.
Then she had to line up interviews or
potential interviews. “I just kept ham-
mering Aramark in all divisions,” she
says. “I knew there weren’t any dieti-
tians over there [for the company] at
all.” She persisted until she learned
that Aramark was building a London
division to promote its hospital cater-
ing services to the National Health Ser-
vice, the publicly funded health care
service of the United Kingdom. In 2002
Aramark hired her to direct its patient
services program. But Houghton faced
one last hurdle: registration. When she
first applied, the British Health Profes-
sions Council denied her dietetics reg-
istration. Houghton endured 4 more
months of paperwork and a hearing in
S34 May 2010 Suppl 1 Volume 110 Number 5
front of British examiners to finally
have her registration credentials ac-
cepted.
In the UAE, Edwards says, it can
take 3 to 6 months to hire a new RD
because of the number of verifications
the UAE requires. New hires need a
document verifying dates and job ti-
tles for every position they’ve held.
They go through security clearance.
And they must have each of their de-
grees verified and notarized by their
secretary of state in their home state
as well as in Washington, DC, and
then verified by the US embassy in
the UAE.
“You have to know
where your
boundaries are, but
be comfortable with
ambiguity. Things
aren’t always going
to be spelled out
for you.”
To inquire about country require-
ments for international dietetics work,
contact the US Department of State
or a country representative with the
AODA’s International Dietetic Net-
work, which has about 40 country rep-
resentatives, Rising says. These repre-
sentatives produce country information
sheets and act as liaisons and ambas-
sadors for new RDs working there.
“Most of the questions we field have to
do with working requirements for spe-
cific countries,” Rising says.
GETTING ACCLIMATED
Adapting to a new culture demands
flexibility, resilience, patience, open-
ness, confidence, and the willingness
to learn, RDs say. “You have to know
where your boundaries are, but be
comfortable with ambiguity,” Hough-
ton says. “Things aren’t always going
to be spelled out for you.” Reading up
on a country and talking to people
who’ve lived there can help ease your
transition. But do expect culture shock.
Bret Johnson, who works in Paris as
group senior vice president of client re-
lations with Sodexo, the global foodser-
vices company based in France, laughs
at his first bumbled attempts to buy
groceries or go to the dry cleaner in
Paris. “I assumed stores were open late
in the evening and that places would be
open on Sundays, but that’s not the
case,” he says. “The expectation is that
nothing is different here except the lan-
guage, but in reality it is quite differ-
ent.” Johnson, who hails from Iowa,
says his French is now passable enough
for him to get by in public, but early on,
he says, “I found locals who were open
and willing to be my mentors for my
personal life—people that I could say
my three words of French to and that
would come to my aid.”
That shock often extends to the
workplace. RDs starting new overseas
programs often find themselves facing
an empty shell of an office, Houghton
says, literally supplying everything
from scratch. “When I started up in
London, I had no diet manual, no noth-
ing,” she recalls. “I knew how to get all
the materials from the United States,
but it’s like walking into a bare house
and having nothing.” She also discov-
ered she would have to help change the
United Kingdom’s attitude toward the
role of dietetics in a corporate setting,
which at that time was looked down on
by RDs. “There was no private industry
operating hospitals there,” Houghton
says. “It was completely alien to them,
and the world of clinical dietetics was
completely separate from that of food-
service. I had to integrate two com-
pletely different models.”
Many Americans who are used to
being prompt also struggle with the
“looseness” that people in many other
countries have toward the concept of
time. In Paris, Johnson says, the
French tend to start meetings late
and value the art of discussion more
than the actual meeting objective. At
first, he says, this drove him crazy. “I
thought, this is pointless, we’ll never
get anywhere,” he says. Over time,
Johnson says, he softened a bit, while
his team, in turn, moved toward more
structured meetings. In many cul-
tures, “you start any meeting with
personal greetings and inquiries about
each other’s families,” says Editha He-
berlein, MS, RD, FADA (Germany),
president of AODA. “They take offense
in the American attitude of getting
right down to business.” Heberlein’s
most recent overseas job was a 7-year
stint in Stuttgart, Germany, where she
was a lieutenant colonel of the US Air
Force and the global health liaison for
the European Command.

It can feel overwhelming to realize
that you’ll face a whole new set of
social rules, from how to dress, to
whom to greet and how. In Britain
and France, for example, hierarchy is
valued and observed more formally
than in the United States. In Azerbai-
jan, Houghton says, “Men don’t ask
about women; they would never ask,
for example, how a pregnant woman
was feeling or what sex the baby
might be.” You might shake hands in
greeting, she says, but only if the
hand is extended. And you never
refuse coffee or tea when it is offered.
A simple place to start, says Heber-
lein, is to learn key phrases in the
other languages you’ll hear, such as
’hello,’ ’thank you,’ and ’how are you.’
“That you’re trying is always appreci-
ated,” she says.
PRACTICING DIETETICS ABROAD:
DIFFERENT SETTINGS, SAME GOALS
Just as in the United States, many
RDs abroad also struggle against the
rising trend in the developed world
toward a more Westernized diet and
accompanying obesity, heart disease,
and diabetes. “Across cultures you see
the same issues of identifying the bad
fats and cutting portion sizes and
empty calories,” Edwards says. “It
might be coconut oil or fried shrimp
instead of burgers, but fat is still fat,
a fruit is still fruit, and a portion is
still a portion.” As populations grow
more affluent, she says, “We have to
teach them how to spend more time
on everyday meals, eat less fast food
and soda pop.”
And just as they do in diverse
American communities, RDs overseas
try to strike a balance between sound
practice and cultural traditions. For
example, Rising says, in Sicily “it was
common to crush up biscotti and put
in a bottle with milk,” a practice that
American Academy of Pediatrics dis-
courages, as it can cause choking or
pulmonary problems and expose ba-
bies to food allergies. “Just like in
America, the biggest thing is listen-
ing, and giving them the confidence to
say they could do something differ-
ently than the way their mothers or
grandmothers did. It’s a fine balance.”
Heberlein’s challenge is to encour-
age her American clients to eat more
like the rest of the less-developed
world does, incorporating more vege-
tables, fruit, and fish, and far less
meat into their diets. “I grew up in
the Philippines, and did not realize
how healthy I was eating then,” she
says. “We ate fish for three meals a
day, and meat was only for very spe-
cial occasions.” This year in the UAE,
Edwards is starting a portion-control
program in an effort to get her clients
to take a more moderate approach to
fasting and feasting during the holy
month of Ramadan, when Muslims
fast until sundown. “We are getting
more dehydration cases and diag-
nosed diabetics because people are
gorging themselves at night,” Ed-
wards says. “There’s also a cultural
tradition, as part of Arabic hospital-
ity, to mound food on a plate.”
In Malawi, where food is often
scarce, Nordin’s work has a different
nutritional focus— one that holisti-
cally addresses the issue of creating a
sustainable food economy in a still-
developing country, where people live
directly off the land. Unlike in the
United States, there are no grocery
stores that provide access to food
whenever you like. “We realized in
Africa you cannot talk about nutrition
without talking about agriculture,
food security, the environment, and
sanitation and how they all inter-
link,” she says. “We felt the only way
to succeed is to help Malawians use
their local resources to their full po-
tential.” Over the course of her career,
Nordin has developed program mate-
rials that teach, for example, water
conservation and better food growing
techniques, along with nutrition and
complementary care for patients with
human immunodeficiency virus.
A RICHER WORLD-VIEW
When she first landed in the UAE,
Houghton says, she was surrounded
by mosques that broadcast the Mus-
lim call to prayer five times a day. “At
first it was quite annoying,” she re-
calls. “But then it just becomes part of
the day, and then after that it be-
comes quite comforting.” RDs who
live and work abroad say these subtle
transformations, where they find
themselves in sync with another cul-
ture, deepen their perspective of and
appreciation for other people, and
teach them things about themselves
they otherwise never would have
learned.
In Malawi, Nordin says, the culture
is people-focused, since they quite lit-
May 2010 ● Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
BUSINESS OF DIETETICS
erally depend on each other for daily
survival. Instead of seeing individual
farms surrounded by fields, Africans
cluster their homes together, with the
farms spread out around them. All
around her village, women rise at
4:30 AM to fetch firewood and water.
They spend their days with the neigh-
bors, pounding maize or hand-wash-
ing clothes together, and the men go
off together to work. Her life, on the
other hand, looks like that of an up-
per-class African—which is nothing
at all like a middle-class life in Bos-
ton, where she was raised. Nordin
employs maids to cook, clean house,
and run errands, and a guard for her
home. “I have four families living in-
side my walls at any one time,” she
says. “It’s the African way to support
other people—if you have an income,
you’re expected to share that with
people who can benefit from it. My
house is very alive!”
In the UAE, Edwards counts her-
self lucky to live in a melting pot for
the region. The UAE’s population
mixes native Emiratis, Arabs, Per-
sians, Asians, Indians, Phillippinos,
Egyptians, Jordanians, Pakistanis,
Somalians, Sudanese, and Bang-
ladeshis. Many, attracted to the
high level of education they can at-
tain in the UAE, go through the di-
etetics program and work with her
at SKMC, which is run by the pres-
tigious Cleveland Clinic. “Working
with each population is so differ-
ent,” Edwards says. “I never stop
learning about other people, myself
included.”
Ultimately, RDs say, rewards far
outweigh any drawbacks of interna-
tional work. “There’s so much out
there to explore, and yet the world is
so small,” Rising says. “All dietitians
have the same goal to improve the
health of each of our populations, and
it’s very exciting to see that common-
ality, and yet learn so much beyond
our own borders.”
S35