.What does it take to be self-employed and How can you make sure that you're successful?

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THE ENTREPRENEURIAL

NUTRITIONIST Fourth Edition

■ KATHY KING, RD, LD Owner, Helm Publishing

Lake Dallas, Texas

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Acquisitions Editor: David Troy Product Manager: Linda G. Francis Design Coordinator: Teresa Mallon Production Service: Maryland Composition Inc.

351 West Camden Street 530 Walnut Street Baltimore, MD 21201 Philadelphia, PA 19106

All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner.

The publisher is not responsible (as a matter of product liability, negligence, or other- wise) for any injury resulting from any material contained herein. This publication contains information relating to general principles of medical care that should not be construed as specific instructions for individual patients. Manufacturers’ product in- formation and package inserts should be reviewed for current information, including contraindications, dosages, and precautions.

Printed in China

Library of Congress Cataloging-in-Publication Data

King, Kathy, RD. The entreprenuerial nutritionist / Kathy King. — 4th ed.

p. ; cm. Includes bibliographical references and index. ISBN 978-0-7817-9369-8

1. Dietetics—Practice. I. Title. [DNLM: 1. Dietetics—organization & administration. 2. Dietary Services—organiza-

tion & administration. 3. Entrepreneurship. 4. Professional Practice—organization & administration. WB 400 K53e 2009]

RM218.5.K56 2009 613.2068—dc22

2009007496

The information in this book is for general use only; it is a starting point; it should not be considered legal or medical advice. Readers are referred to the appropriate professionals for more individualized information.

No part of this book may be used or reproduced in any manner whatsoever without written permission, except in the case of brief quotations embodied in articles and reviews.

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This book is dedicated to the dietitians and diet techs who have shared their

wisdom and life’s lessons; also, to Savannah, Cherokee, Laura, Chris, and

Kate, grandkids, Grace and Grant, and my husband, Dr. Larry Gilbert, the

flowers in my garden, for their never-ending love and support.

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Becky Dorner, RD Owner, Becky Dorner & Associates, Inc. Nutrition Consulting Services, Inc. Akron, Ohio

Mary Abbott Hess, LHD, MS, RD, LD, FADA Partner, Culinary Nutrition

Associates, LLC Past President, The American Dietetic

Association Chicago, Illinois

Mary Ann Hodorowicz, RD, LDN, MBA, CDE, CEC Owner, Mary Ann Hodorowicz

Consulting, LLC Palos Heights, Illinois

Susan Magrann, MS, RD Nutrition Education Consultant California Department of Public Health

Program Sacramento, California

Teresa Pangan, RD, PhD Owner, Webnoxious Co-owner, Feed Your Career Flower Mound, Texas

Jane Grant Tougas Owner, JGT Ideas Cincinnati, Ohio

CONTRIBUTORS

CASE STUDY CONTRIBUTORS

Chere Bork Grace Cadayona Amanda Clark Mitzi Dulan Karen Fynan Donna Israel Jill Jayne Sheela Krishnaswamy

Linda McDonald Diana Noland Teresa Pangan Elyse Resch Mia Sadler Bonnie Taub-Dix Mandi Wong

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ACKNOWLEDGMENTS

vii

I want to thank the dietitians and other professionals who contributed chapters to the first or second editions of this book: Alanna Dittoe, Karen Dolins, Marianne Franz, Cecilia Helton, Paulette Lambert, Susan Tornetta Magrann, Becky McCully- Varner, Wendy Perkins, Olga Satterwhite, Marilyn Schorin, and Jan Thayer. And a big note of appreciation goes to the new authors of chapters in this edition and the

last: Mary Abbott Hess, Jane Tougas, Becky Dorner, and Mary Ann Hodorowitz. My special gratitude goes to Teresa Pangan for her three wise and detailed chapters on the Web. Also, to Dollie Parsons and Savannah Helm for their editing and suggestions.

At Lippincott Williams & Wilkins, I want to thank David Troy for his enthusiasm and support, and my editor, Linda Francis, for her cheerleading.

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TABLE OF CONTENTS

Contributors v Acknowledgments vii Preface xi Introduction xiii

PART I The Beginning 1 1 The Entrepreneurial Spirit 3 2 Is Self-Employment for You? 13

PART II Building a Strong Foundation 27 3 Business Strategies and Management 29 4 What Can We Learn from the “Masters”? 44 5 Nurturing Creativity 49 6 Building Your Credibility 54 7 Ethics and Malpractice 59 8 Creating a Good Business Image 67 9 Counseling Expertise 73

PART III Managing Your Business 91 10 Business Plan 93 11 Marketing Decisions 100 12 Legal Forms of Business Ownership 113 13 Protecting Your Ideas and Interests 124 14 Choosing Your Business Advisors 133 15 Money and Finance 138 16 Start-Up Decisions and Costs 155 17 Prices and Fees 166 18 Reimbursement 177 19 Negotiation, Selling, and Contracts 190 20 Office Policy and Dealing with Clients 200

PART IV Taking Your Ideas to Market 207 21 Promoting Your Venture 209 22 Using the Internet in Your Business 227

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x CONTENTS

23 Website Basics 235 24 Promoting Your Website 259

PART V Developing Your Professional Practice 273 25 Consulting in Long-Term Care 275 26 Tapping the Food and Culinary Markets 281 27 The “Write” Way to Get Published 299 28 Media Savvy 312 29 Sports and Cardiovascular Nutrition 322 30 The Wellness Movement 330 31 Continued Competency 338

Index 341

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what kind of time investment is involved? We have the results!

This fourth edition is totally updated with new chapters on Reimbursement by Mary Ann Hodorowitz, MBA, RD, and What Can We Learn from the “Masters”? (those making more than $100,000 net in their own business). We have new information about marketing on the Internet, uses of the Web, tapping food and culinary markets, and consulting in long-term care. We have numerous practical examples to illustrate points, and answers to questions commonly asked by new and seasoned entrepreneurs. The term “entrepreneur” will be used to identify both self-employed people and em- ployed intrapreneurs who try things in new ways. The opinions are obviously those of the authors. They should provide you with a starting point for your own research and personal growth.

Hundreds of dietitians have told me that the first three editions of this book helped them start and maintain successful businesses. For thousands of others, it taught skills and strategies that were used daily in their employment setting. Many say they referred to this book many times over the years as new decisions and hassles arose. I hope you find this book helpful and interesting!

Wow! It has taken over 30 years but we have many wonderfully successful entre- preneurial nutritionists in the U.S. and around the world. In my 2008 World-wide Entrepreneurial Dietitian Survey, 30 dieti- tians were netting over $200,000 per year and 60 were netting $100,000 to $200,000 per year. Do you want to know how they did it? Read our new fourth edition of The Entrepreneurial Nutritionist!

This book is written for nutrition profes- sionals who want to start their own busi- ness. It offers them practical successful guidelines and business knowledge, skills, and insider tips. I have included interviews and case studies from successful practition- ers who may act as role models for you while others will show you what you don’t want to do.

Our most exciting newcomer to this edi- tion is the results of the first and largest worldwide entrepreneurial survey ever con- ducted, with over 1335 dietitians who com- pleted the 88 survey questions. Do you want to know how much dietitians charge or what products sell the best? How much it costs to start a business, or how many years it takes most dietitians to break even on their initial investment? What market- ing ideas work best and which ones don’t work at all? Do you really want to hear

PREFACE

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INTRODUCTION TO ENTREPRENEURSHIP

Entrepreneurship can be one of the most challenging, difficult projects you ever un- dertake. It may also be one of the most satisfying and exciting. Trial and error, ad- justing to market changes, and trusting your gut instincts are part of every new venture. Passion for your projects is a must. Becom- ing skilled requires study, action, money, assessment, more action, more time, and more money.

The mere idea of starting a business ven- ture of some sort was embraced by only a few maverick dietitians in the 1960s and 1970s. Self-employment became more pop- ular in the 1980s and 1990s. Today, entre- preneurship is in the mainstream of dietetics and world-wide business. Dieti- tians are choosing self-employment to make more money per hour, to have more flexible hours, to try new ideas, and to work with new client populations or food in a different way.

EARLY ENTREPRENEURS

The dietitians who founded our profession were innovative, risk taking individuals. Many were consultants, authors, or inno- vators who created their hospitals’ and uni- versities’ first dietary departments.

Eloise Treasher began the earliest known clinical private practice in 1949 in Balti- more, Maryland. As Eloise retired from work at The Johns Hopkins Hospital, many physicians wanted to continue sending their patients to her, and her consulting business began. Treasher stated, “Private

practice is not for everyone, and not every- one will be good at it. But, if you offer qual- ity counseling and service, you will be in demand.”

In 1953, Norma MacRae began her coun- seling business in Seattle, Washington. Her practice included writing cookbooks. When asked about her success, MacRae stated, “I knew I had ‘arrived’ when physi- cians started coming to see me as patients.”

Other pioneers include Virginia Bayles, RD, a consulting nutritionist in Houston, Texas, and author, Dorothy Revel, RD, from Fargo, North Dakota. Carol Hunerlach, RD, of Maryland, is credited with spearheading the movement to organize the Nutrition Entrepreneurs (formerly Consulting Nutri- tionists) Dietetic Practice Group of The American Dietetic Association.

Today, there are creative, extremely suc- cessful dietitians who are best-selling au- thors; others own multimillion dollar companies, restaurants, health food stores, vineyards, publishing houses, home health agencies, large long-term care consulting firms, and computer companies. Others offer services on a smaller scale where they consult to cruise lines, act as a chef or per- sonal trainer, or counsel private clients. A growing number of highly skilled clinical practitioners are practicing biochemical- based functional nutrition therapy, which will become the practice of the future as medicine turns to functional medicine practice for chronic care therapy. Entrepre- neurial nutritionists also write newspaper columns, host television and radio pro- grams, author books, invent products, de- velop websites, consult to top athletes, speak professionally, and act as media spokespersons for food companies.

INTRODUCTION

xiii

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perwork, marketing, or other nutrition projects with no guarantee of income.

Before one year was up, I knew the con- cept worked. I decided to borrow $1000 from my grandparents and open a 10- by 13-foot office in the new medical complex being built next to the suburban hospital where I had last worked. I loved it. Patients came to me and I didn’t have to counsel them over the stirrups on an exam table. I furnished my office with antiques and plants. I raised my fees slightly ($10 for the initial and $3 for revisits) to cover the in- creased overhead, and I looked like a legit- imate business.

During my third year, I decided to sub- lease the office 2 days per week to a speech therapist. That freed me to take consultant positions at Head Start and retirement homes, and start a Master of Science course in exercise physiology to broaden my ex- pertise. It also gave me a change of pace from full time counseling.

To promote my business, I gave several free speeches each week. I appeared weekly on NBC TV’s “NoonDay” and monthly on KMGH TV’s “Blinky’s Fun Club,” for a total of 8 years. I volunteered for the Col- orado Dietetic Association so that other di- etitians would get to know me and I them. After 3 years, over half of my new consul- tant accounts were from referrals from other dietitians.

I learned more about sports nutrition by volunteering for 3 years for the exercise physiology staff at the University of Den- ver. I was their “on call” nutritionist for speaking at sports conferences and counsel- ing athletes. I invented a natural sports drink with the aid of the Herty-Peck Com- pany in Indianapolis which 7–11 Stores wanted to buy, but that is another book.

Sports consulting with the Denver Bronco Football Team, Denver Avalanche Soccer Team, paid media work, media spokesperson jobs, lecturing, and writing started to come my way as my expertise and reputation grew. My approach to nutrition was from a wellness point of view, so when the trend finally hit Denver, I was ready to grow with it. I taught wellness nutrition to

MY STORY

I graduated in Food Science and Nutrition from Colorado State University, which gave me a good, solid academic back- ground. My internship was at Beth Israel Hospital in Boston, a Harvard teaching hos- pital, where I discovered my love for clini- cal nutrition intervention and outpatient counseling.

After practicing 2 years as a hospital clinical dietitian, I began my business in 1972 in Denver, Colorado. The lack of pre- vention and outpatient counseling in the hospital setting frustrated me. I decided to go into the outpatient setting and start my private practice. I wanted to see if I could make a difference by keeping clients healthier when their symptoms or abnor- mal clinical values first appeared instead of waiting until they progressed and hos- pitalization was necessary.

My business strategy was easy: Keep my overhead low, work day and night for a year, and then reevaluate. This decision was not hard to make, since I was single and had nothing of value to borrow against—but I had the time and dedication.

My business started at one physician’s of- fice 2 days per week for $5 per hour. I lived on that income while I developed my busi- ness, working out of six other physicians’ of- fices. I spent a lot of time in transit, waiting for patients to arrive, and marketing to physicians so they would remember to refer clients. After expenses were paid, I lived on $8 a week for food.

I went to a lawyer friend of mine in order to pursue incorporation. He said, “I won’t do it.” I wanted to know why. He said, “Because you aren’t worth suing. Why waste your money?” I have never forgotten that philosophy: Weigh costs against the benefits or risks before investing.

The first year I charged $7 for the initial visit and $2 for revisits—and some people still complained about my fees! I supported myself from the start, supplementing my income with cleaning houses and sewing. For every hour I generated income in the business, I usually worked 3 hours on pa-

xiv INTRODUCTION

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INTRODUCTION xv

online testing (see our website at http:// www.helmpublishing.com).

In 1997, after looking for an asset to in- vest in, I purchased a rundown feed store to hold my publishing company and a “healthy” gift store less than a mile from my home on Main Street in Lake Dallas, Texas. I had it renovated into a beautiful peach-colored store with a white front porch, surrounded by an herb garden. As the publishing company grew, it made it very difficult to run two businesses, and we had to close the store or hire another per- son—it was a financial decision that had to be made. Retail antiques were great fun, but not especially profitable in a small town after 9/11.

From my 37 years of experience, I have learned that when the tough decisions have to be made, no one can do it better than I. I have stopped looking for that ex- pert on a white horse. I try to learn from each experience and person I meet who knows something I don’t. I have learned skills I never wanted to know. I find it still takes time and patience to break into new business arenas where I am unknown. I, and other entrepreneurs I know, continue in business because we love the chance to be creative, to create high-quality output, to work with people, and the freedom. The difficulty of the challenge makes us appre- ciate the rewards even more.

Innovative practitioners will continue to lead our profession into new, nontradi- tional job markets. We, as a profession, need to identify these trailblazers and let them teach us how to find these new career avenues. We should be willing to learn about new areas of practice and then act as mentors to our younger members. Or, rec- ognize when someone is willing to take the risk and support that individual with our goodwill and enthusiasm—not the Tall Poppy Syndrome where an innovator is punished by their peers. We need this type of growth and experimentation to take place worldwide in dietetics.

Kathy King, RD, LD Owner, Helm Publishing

Lake Dallas, Texas

physicians, nurses, and hospital administra- tors, as well as the public. I was always curi- ous and open-minded about alternative therapies. Being involved with media meant that I had to explore things the Denver pub- lic was interested in knowing.

My commitment to the profession grew as I was elected President of the Colorado Dietetic Association, and spent 5 years in the leadership of the Council on Practice, and 2 years on the American Dietetic Asso- ciation’s Board of Directors and House of Delegates.

When I married and moved to Texas in 1983, I didn’t want to start over again by building a group of clinical offices. Instead, I helped develop a hospital-based wellness program, consulted at The Greenhouse Spa, wrote or edited several books, acted as a media spokesperson, hosted my own na- tionally syndicated radio talk show for a year, and traveled giving lectures and semi- nars. When I wasn’t traveling, I worked from a home office so I could be home with my two daughters. Through meeting inno- vative dietitians from around the world, I have been fortunate to speak in six foreign countries. Individual patient counseling was a special high for me and I have counseled over 6,000 people, including three who lost over 125 pounds through diet, exercise, and cognitive-behavioral counseling.

This book has been translated into Japa- nese by Reiko Hashimoto, an outstanding private practitioner in Tokyo who also counsels sumo wrestlers. I self-published the second and third editions of this book when the publisher let it go out of print, and I asked for the copyright. That experi- ence opened doors to more writing and publishing other dietitians’ material. Helm Publishing is now a publisher of continuing education for Registered Dietitians (RD), Di- etetic Technicians (DTR), Registered Nurses (RN), Certified Diabetes Educators (CDE), and Certified Dietary Managers (CDM). We are a mail-order and online cataloger with over 75 products that are more outpatient, nontraditional, functional medicine, and prevention oriented. We adopted marketing on the Web over 12 years ago for sales and

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WORDS OF WISDOM

Do not follow where the path may lead. Go, instead, where there is no path and leave a trail.

Ralph Waldo Emerson

Many of life’s failures are men who did not realize how close they were to success when they gave up.

Thomas Edison

It’s choice—not chance—that determines your destiny. Jean Nidetch

THE BEGINNING

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Individual dietitians, worldwide, have be- come very successful, self-employed busi- ness owners over the past 25 years. Their ingenuity, creative verve, aggressiveness, and willingness to handle fear of failure are leading them and the dietetic profession around the world into new markets and fields of experience.

Starting a business is a lot of work. It can take over your life. But for 97.3% of the 1581 dietitians who answered this question on the 2008 World-wide Entrepreneurial Dietitian Survey, they said they would choose entre- preneurship again if they had their lives to live over (1). There aren’t many jobs that can boast that high of a satisfaction rate.

Many new graduates see nutrition’s po- tential in the marketplace and want to try something different. They eagerly watch and listen to the role models who are blaz- ing new trails, or they see markets that no one has tapped. This wonderful enthusi- asm must be tempered with reality—their business skills may be limited, networking contacts take time to establish, and start-up funds have to be available. Will waiting 5 to 10 years before starting a business guar- antee success? Of course not; it depends on your personality, your decisions, and what you do while you wait. While employed, you should try new ideas, save money, and meet people.

How much experience did our most suc- cessful entrepreneurs have before they started their businesses? Of the 90 surveyed dietitians who made over $100,000 net (profit), it is very interesting to note that 13.6% had no employed dietetic experience before becoming self-employed, 38.6% had 1–5 years experience, and 26.1% had 6–10

years experience (1). In the full survey, of the 1589 respondents who answered this question, 75% had, at most, 10 years of ex- perience (Fig. 1.1) (1).

EXPERIENCED PRACTITIONERS

As many dietitians and dietetic technicians reach the top of their professional career lad- ders, they look for new ways to grow. They want to be successful, recognized, and well paid for their expertise. Jean Yancey, a for- mer small business consultant from Denver, called this their “X-Point,” or crossroads. At this X-point, they arrive at a decisive point where they feel they must do something dif- ferent. These successful practitioners feel like so many things they used to do need to be left behind (a case of “been there, done that”). It feels similar to starting over again to pursue new career avenues, but this time, it is on a much higher level of expertise.

For some, the answer is entrepreneurship. This is the chance to be their own boss, schedule their own time, and create new services or products to make a personal profit. It streamlines decision-making, mak- ing it more effective. Entrepreneurship stim- ulates productivity and relieves boredom. It capitalizes on the personal and professional relationships the person has nurtured over the years.

THE ENTREPRENEURIAL EXPLOSION

Entrepreneurism is thriving in America. Being an entrepreneur has moved from cult status in the early 1980s to become de

THE ENTREPRENEURIAL SPIRIT

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4 THE ENTREPRENEURIAL NUTRITIONIST

businesses in the U.S. returned the follow- ing impressive statistics (6):

■ There were an estimated 10.4 million privately-held firms.

■ This accounted for every two out of five (40.2%) businesses in the country.

■ These firms generated $1.9 trillion in annual sales and employed 12.8 mil- lion people nationwide.

In a survey of influential Americans com- pleted for Ernst & Young, results showed 78% believed entrepreneurship would be the defining trend of the 21st century (8). People who completed the survey felt the major factors that would contribute to this rise in entrepreneurship were (8):

■ New technology (helps small busi- nesses compete), 76%

■ Economic conditions (low inflation), 53%

■ Social conditions (two incomes, return to family), 45%

■ Global economy, 33%

THE ENTREPRENEURIAL MINDSET

Thomas Petzinger, a Wall Street Journal columnist and author of The New Pioneers, believes, “Everyone will have to be an

rigueur at the turn of the century. In 2006, there were more than 26.8 million small businesses in the U.S., and more than 12.3 million Americans were self-employed (2). In 2004, there were approximately 17,000 large businesses in the U.S. (3). According to the Small Business Administration (SBA), small businesses represent (4):

■ 99.7% of all employers ■ 60%–80% of the new net jobs ■ 50% of the private sector output ■ 97% of all exported goods

According to Dun and Bradstreet, the aver- age small business owner has three employ- ees, 1.3 locations of business, and is not a part of a franchise organization. They found owners typically work about 50 hours a week at businesses that generate average revenues of $50,000 to $200,000 (5).

Between 1997 and 2006, businesses that were fully women-owned, or majority- owned by women, grew at nearly twice the rate of all U.S. firms (42.3% vs. 23.3%) (6). During this same time period, employment among women-owned firms grew 0.4%, and annual sales grew 4.4% (6). Women start their own businesses at twice the rate of men (7). In 2006, reports on women- owned (or majority owned by women)

FIGURE 1.1 ■ Number of years of dietetic employment before begin- ning self-employment (1589 respon- dents) (1).

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CHAPTER 1 ■ The Entrepreneurial Spirit 5

entrepreneur in the future” (9). This state- ment comes from the awareness that jobs have changed drastically in the past two decades and entrepreneurship is more mainstream. “Entrepreneurship was really an immigrant activity for many genera- tions” (9). Business life helped immigrants learn English and slowly assimilate into so- ciety. Petzinger sees people of all ages be- coming entrepreneurs and bringing new ideas on social goodwill, creative solutions, and more holistic views on merging their home and business lives (9).

In his classic book, Innovation and Entre- preneurship, Peter Drucker, veteran business consultant and management philosopher, says “the entrepreneurial spirit is based on the premise that change is normal, healthy, and desirable, that it sees the major task in society, and especially in the economy, as doing something different rather than doing better what is already being done” (10). Entrepreneurship is a way of thinking where you see the possibilities of an idea before you dwell on its limitations.

Rosabeth Moss Kanter, former editor of the Harvard Business Review and author of Change Masters, a book based on her study of 50 corporations, concluded that those companies on a downward slope were there because of “the quiet suffocation of the entrepreneurial spirit” (11). There is a close relationship between entrepreneur- ship and innovation in meeting new cus- tomers’ needs, increasing job satisfaction, devising new work methods, and improv- ing quality (12). New ideas are essential.

In The Atlantic Monthly, authors Stephen Pollan and Mark Levine made observations about small business (13):

■ The current tax situation makes it clear to Americans that owning one’s own business is one of the few oppor- tunities people have to create wealth.

■ Government at all levels realizes that small businesses are the primary cre- ators of jobs and is offering incentives encouraging entrepreneurs into their communities.

■ Technology—in particular computeri- zation and information processing—is lowering the start-up costs associated with small businesses and helping them seize chances.

■ Small businesses have been so suc- cessful that large, hungry corpora- tions have been moving into areas traditionally left to entrepreneurs, like childcare. As big businesses move, entrepreneurs are moving into areas that once were thought beyond their scope, like manufacturing for global markets.

■ Creativity and innovation remain the province of the entrepreneur. More than half the major inventions since World War II have come from small businesspeople.

CHANGES IN THE EMPLOYMENT ENVIRONMENT

Jobs are changing. Job loyalty is changing. As more companies cut costs, merge, and consolidate, an increasing number of highly educated or experienced people will be let go (14). Business experts see a trend toward replacing many employees with a staff of subcontractors and consultants who will only be used on an on-call or per- project basis—they will get no fringe ben- efits or regular paychecks, but may be able to make more pay per hour. This will hit the Baby Boomers especially hard, since so many will be vying for the few good top- level positions their years of experience and expertise warrant.

Former President of the American Di- etetic Association (ADA), Judith Dodd, agreed when she wrote, “A starting point is recognizing there is no safe place in any healthcare-related field. It is difficult to identify a position or a site that remains unaffected by technology, cost contain- ment, takeovers, or mergers” (15).

The average American changes jobs about every 4 years due to better job opportunity, boredom, cutbacks, spouse

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6 THE ENTREPRENEURIAL NUTRITIONIST

lower cost. To compete in any marketplace, we must continually market ourselves, im- prove the level of our skills, upgrade the uniqueness of our products, and offer serv- ices that are not easily duplicated. Our cus- tomer service must be helpful, timely, and better than the closest competitor’s.

WHERE DO YOU FIND NONTRADITIONAL JOBS?

In the nontraditional job arena, communi- cation links are less formal and structured, so self-promotion is a must. People learn about qualified practitioners through per- sonal interviews, mutual friends, speaking, writing, networking, and through member- ships in organizations and on committees. Most self-employed people will tell you that their good jobs come upon referral. In fact, career experts estimate that 70% to 80% of employment opportunities actually come from referrals (18).

Consultant and writer Howard Shenson found the type of marketing strategies used by consultants who make over $110,000 per year are different than those who make less than $55,000 per year (18). Top earners promoted themselves through:

■ Calling on prospects referred by satis- fied clients

■ Lectures to civic, trade, or professional audiences

■ Writing articles, books, and newsletters

The consultants who earned less marketed themselves primarily through:

■ Cold calling new accounts who had not heard of them before

■ Direct mail brochures and sales letters ■ No-charge consultations to prequali-

fied leads

These last methods are time-consuming, expensive, and not as effective. By looking at the top-earner list, you can see that peo- ple seek consultants with established iden- tities, ones who are accepted and promoted by others. So, it boils down to getting to know people, becoming known for your

transfers, or other reasons (12). Some ex- perts believe people will also change the focus of their careers multiple times. For some, change is unsettling, but others see it as an opportunity to grow, meet new people, and try new ideas.

Spencer Johnson, author of Who Moved My Cheese?, stated in an interview, “What’s changing is the speed of change; it’s accel- erating. I think the major challenge will be not only to adapt to change but to enjoy change and view it in such a way that it works to your advantage. The other half of that coin is to keep things in balance, and slow down a bit, and ask ourselves, ‘Is this change really necessary?’ Knowing when to change and when not to will call for good judgment and those who have it will win in the 21st century” (16).

WORKING FROM HOME

Four and a half million Americans work in home-based businesses either full- or part- time, and another 3.5 million work at home for an employer (17). Working at home is a growing option, especially for people who consult, write, publish, speak, make client home visits, or use the com- puter for the bulk of their work. A home of- fice keeps the overhead low, reduces travel time, allows more time with your family, and offers scheduling flexibility. However, unless you are careful, it can overwhelm your personal and family life. Any negative stigma associated with working at home is quickly disappearing.

GLOBAL MARKETS

Global markets will change the competitive environment worldwide. Our business boundaries can expand overseas. Some jobs will continue to be lost to overseas compa- nies if those companies produce products or services more economically and similar in quality. Products sell well when they are new, innovative, and ahead of the market curve. They often own the market until a competitor reproduces them at a much

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CHAPTER 1 ■ The Entrepreneurial Spirit 7

knowledge and talents, and investing in your future while bringing home enough income to live on.

SURVEY RESULTS

There were 1638 respondents who began the 2008 World-wide Entrepreneurial Dietitian Survey, and 1337 who completed all 88 ques- tions (1). Ninety-seven percent were women and 3% were men, which are the same gen- der ratios as in the ADA membership (19).

HOW MANY YEARS IN SELF-EMPLOYMENT?

According to the 2008 survey, of the 1638 respondents who answered this question, it is interesting to see how many practition- ers had recently chosen to become entre- preneurs (1):

■ 31.3% (512 RDs or DTRs) self- employed 1–3 years

■ 33.4% (548 RDs or DTRs) self- employed 4–10 years

■ 21.9% (360 RDs or DTRs) self- employed 11–20 years

■ 10.7% (175 RDs or DTRs) self- employed 21–30 years

■ 3% (50 RDs or DTRs) had been in their own business for 31 or more years

Wow! Two hundred twenty-five nutrition professionals have been entrepreneurs for over 21 years! It’s hoped that the informa- tion in this book will help those just start- ing out to find pearls of wisdom that will make them as successful as these veterans. See Chapter 2 for guidelines on who might best succeed at self-employment.

HOW OLD WERE THE RESPONDENTS?

Are the newest entrepreneurs just out of school? No, almost 60% were 41–59 years old, and we have at least two (0.1%) entre- preneurs in our profession who are 80 years old or older (Fig. 1.2) (1)!

HOW EDUCATED ARE SELF-EMPLOYED RDs AND DTRs?

Of the 1634 respondents answering this question, there were (1):

■ 0.4% (6) DTRs ■ 43.5% (711) RDs ■ 51.5% (841) RDs with Master of Science ■ 4.7% (76) with Doctorates

FIGURE 1.2 ■ Ages of 2008 World- wide Entrepreneurial Dietitian Survey (1644 respondents) (1).

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8 THE ENTREPRENEURIAL NUTRITIONIST

The important number to know is how much you net in a business—this is the amount of money you keep after expenses are removed. When you start a business, you can find lots of things to spend your money on that can be used as deductions, so your income doesn’t look very prosper- ous, but your deductions are greater and your tax burden is less. In ADA’s 2007 Com- pensation Survey, the average dietitian took home $53,300 each year (19). See Figure 1.3 on the net income from the 2008 World- wide Entrepreneurial Dietitian Survey respon- dents’ best year in business (1).

HOW MUCH DID IT COST TO START THE BUSINESS?

We will talk about what it costs to finance a business in later chapters, but suffice it to say that 85.2% of survey respondents spent $5,000 or less to start their businesses, and of all respondents, 72.2% broke even in the first year, and 90.8% had broken even in 2 years (1).

WHAT SERVICES AND PRODUCTS GENERATED THE MOST REVENUE?

What services or products generated the largest amounts of income for the 1359 re- spondents that answered this question?

Self-employed practitioners are more highly educated than the general ADA membership, which, according to the 2007 Compensation Survey, had 45% of RDs with Master of Science degrees and 3% with doctoral degrees (19). Just as interesting is that there were eleven dietitians who were also MDs (Physicians), six RD/RNs (Nurses), two dentist/RDs, two RD/physical therapists, and one RD/ Naturopath.

HOW MUCH DID SELF-EMPLOYED PRACTITIONERS MAKE IN THEIR BEST YEAR?

There were 11.5% (180) who grossed (total income generated) $100,001 to �$500,000, which is fantastic! It is more representative of the full group that there were (1):

■ 19.8% (311) who grossed less than $10,000 per year (presumably working part time)

■ 3% (361) who grossed $10,001– $30,000

■ 31.2% (489) who grossed $30,000– $70,000

■ 14.4% (226) who grossed $70,001– $100,000

■ 11.5% (180) who grossed $100,001 to �$500,000

25.6% 29.2%

32.2%

7.3% 3.8% 1.9%

0% 5%

10% 15% 20% 25% 30% 35%

un de

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,00 0

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FIGURE 1.3 ■ Net income from survey respondents’ best year in busi- ness (1560 respondents) (1).

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CHAPTER 1 ■ The Entrepreneurial Spirit 9

Keep in mind that although these are the most common and popular, there are niche jobs and markets that may be very lucrative because not many practitioners are pursu- ing them at this time. Be sure to read Chap- ter 4 on what the top income-producing practitioners are selling. In descending order the answers were (1):

■ Medical nutrition therapy (MNT) 35.3% (850 respondents)

■ Wellness consulting/presenting (555) ■ Speaking (539) ■ Long-term care (408) ■ Menu or recipe development (334) ■ Writing articles and brochures (260) ■ Business consulting (92 respondents

ranked this option as their first choice) ■ Counseling in functional nutrition

therapy or nutrition genomics (159) ■ Sports counseling (158) ■ Writing books (129) ■ Media spokesperson (90) ■ Marketing products (80) ■ Selling supplements (83) ■ Supermarket personal shopper/tour

guide (74) ■ Complementary and alternative med-

icine (CAM) (74) ■ Fitness teacher (70)

Of the 546 respondents who work in long- term care, 470 identified the geriatric mar- ket as their largest market; second was the care of the disabled with 167; third was home healthcare with 111; fourth was hos- pice with 104; and fifth was drug and alco- hol rehabilitation with 69 ranking it in their top five (1).

WHAT WERE THEIR GREATEST JOYS AND BIGGEST DISAPPOINTMENTS?

These were open-ended questions so peo- ple could be honest and creative in answer- ing them. Of the 1289 respondents who answered the question on their greatest joy or satisfaction, the highest number identi- fied helping patients or clients as the most satisfying; followed by self-satisfaction for their personal achievement; third was

being their own boss; and in fourth place was better quality of life for the practitioner and his or her family.

The biggest disappointments tied for first place were “none” and “long hours/stress.” Tied for third and fourth were “slow business/no shows” and “worry about funds/economy.” A distant tie for fifth and sixth were “working with the medical profession” and “outside competition.”

WHAT WOULD YOU DO OVER? WHAT WERE YOUR LARGEST BARRIERS TO SUCCESS?

Of the 1117 respondents that answered what they would do over, the majority said “plan better,” followed by “better marketing,” then “stronger belief in my- self and my abilities” and “better staff support.”

Of the 1155 respondents, the number one barrier was “lack of business experi- ence”; second was “too much time com- mitment”; third was “lack of or improper marketing”; fourth was “inadequate busi- ness planning”; fifth was “difficulty obtain- ing insurance reimbursement”; sixth was “unfamiliar with networking and using contacts well”; and seventh was “inade- quate funding.”

WHAT SHOULD BE EMPHASIZED MORE IN DIETETIC EDUCATION? HOW CAN ADA HELP MORE?

Of the 1253 respondents that answered the question on the top five ideas for improv- ing dietetic education (1):

■ The top answer was “more marketing skills,” voted by 863.

■ Second was “business management in order to generate a profit,” with 791 votes.

■ Third, with 681 votes, was “negotia- tion skills.”

■ Fourth, with 394 votes was, “arriving at appropriate prices.”

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10 THE ENTREPRENEURIAL NUTRITIONIST

segmented and there will be other health professionals ready and willing to answer the needs of those new markets with skills and information dietitians have not yet learned or rejected as unnecessary.

Nonetheless, there will always be an on- going need for good nutritional informa- tion as each new generation participates in sports, has babies, fights obesity, prevents or recovers from illness, and wants to stay healthy as it grows older.

Career avenues for dietitians who distin- guish themselves will abound. Competing successfully in the markets of the future may require experience and education out- side the required nutrition curriculum and traditional career settings. Today, dietitians are learning about integrative medicine, functional nutrition therapy, medicine, psychotherapeutic counseling skills, media broadcasting, business management, culi- nary, pharmaceuticals, exercise physiology, law, marketing and sales, product manufac- turing, writing, and public speaking. As is often said when faced with so much oppor- tunity, only the person’s imagination and energy will limit what she or he can do.

Dietitians are best selling authors, per- sonal chefs, media spokespersons, media personalities, and sports nutritionists. They own public relations firms, publishing houses, and nursing homes. A few are in- ventors of products like fruit-sweetened cookies, diet card games, educational videos, and multimillion dollar computer data companies. Dietitians are culinary and nutrition consultants to movie stars, spas, restaurants, and fast food chains. Others offer consultant management expertise in inventory control and reducing the inci- dence of malnutrition. A growing number of Nutrition Therapists are pursuing new areas of clinical practice like integrative medicine, nutritional genomics, and func- tional nutrition therapy.

Becoming an entrepreneur fulfills for many people the desire to create their own destinies. Some people say they are more satisfied—financially and personally—than ever before.

■ Fifth, with 376 votes, was “bookkeep- ing and accounting.”

■ Sixth, with 363 votes, was “product or service development.”

■ In seventh place, with 317 votes, was “building self-esteem or self- confidence.”

To the open-ended question, “What could our profession do to help support entrepre- neurs better?,” there were 1771 responses. The responses were all over the board, but the most repeated ones were:

■ More practical, entrepreneurial busi- ness skills in our education

■ Better support for ideas and practice outside of acute clinical care

■ Raise the level of counseling skills being taught

■ Better marketing of our profession ■ Encourage our members to work with

other professions ■ More support for RDs and DTRs in

“nontraditional” practice areas ■ Lower prices for ADA members for its

marketing opportunities ■ Encourage members to mentor and

support each other better

OTHER SURVEY RESULTS WILL BE SHARED

More survey results on what works best in marketing, the best advisors for entrepre- neurs, what dietitians charge for their serv- ices, and which forms of business most entrepreneurs use will be discussed in the upcoming chapters.

SUMMARY

Presently, the marketing window of oppor- tunity for nutrition is wide open. Nutrition has never been a “hotter” topic, and it will remain so for some years to come. How- ever, as with all great ideas and trends, it too will fade as our very large target mar- kets become saturated with nutrition infor- mation and products. Markets will become

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CHAPTER 1 ■ The Entrepreneurial Spirit 11

In a speech to undergraduates at Cornell University, business expert Tom Peters gave sage advice that fits this topic well. He said (20):

■ Don’t think, do. You only really know if something works after you try it, so don’t spend all your time and energy plan- ning. You will never make all of the right decisions before you start something. Things get better as you apply what you learn.

■ Fail with flair. Quoting novelist Tom Robbins: “If you’ve any sense at all, you must have learned by now that we pay just as dearly for our triumphs as we do for our defeats. Go ahead and fail with wit, fail with grace, fail with style.” Sadly, all too many newly minted college grads, and forty-year olds, fear failure—that, in the end, is to fear living itself.

■ Listen naively. Don’t just listen, but also “hear.” Hearing is about empathy and taking the time to respect others. If you are not empathetic (by this point), I don’t know what to tell you— except, don’t be the boss.

■ Ask dumb questions. You couldn’t possi- bly know all the answers, so ask and im- prove your ability to solve problems.

■ Get others involved. It takes time to lis- ten, hear, trust, and gain commitment but it is time well spent. Others come to us with motivation and then we go about destroying it with demeaning attitudes and humiliating rules instead of enthusi- asm for new ideas.

■ Go where the action is. The best, most successful chiefs and generals spend most of their time at the firing line, and the least in the office.

■ Make it fun. All human endeavors are about emotion—zest, joy, pride, fun, and even crying are near the heart of any successful enterprise.

■ Be interesting! Life’s too short to waste time suppressing emotions, trying to be like the others, fearing rebuffs, or being fired. You will never please everyone.

So go nurture some very interesting failures and even better successes!

REFERENCES 1. King K. 2008 World-wide Entrepreneurial Dietitian

1998–2004. Washington, DC: U.S. Small Busi- ness Administration, 2007. Available at: http:// www.sba.gov/advo/research/rs299tot.pdf. Accessed January 1, 2009.

3. Thompson R. Harvard Business School Dis- cusses Future of the MBA. HBS Bulletin, Novem- ber 24, 2008.

4. CHI Research, Inc. Small Serial Innovators: The Small Firm Contribution To Technical Change, DC: U.S. Small Business Administra- tion, 2003. Available at: http://www.sba.gov/ advo/research/rs225tot.pdf. Accessed January 9, 2009.

5. Dun and Bradstreet Report on Entrepreneurs. In: Williams G. 2001: An Entrepreneurial Odyssey. Entrepreneur, April, 1999.

6. Wolfe L. Trends and Statistics for Women in Business: Using Industry Trends and Business Growth Statistics to Grow Your Own Business. Available at: http://womeninbusiness.about. com/od/wibtrendsandstatistics/a/wibtrend- snstats.htm. Accessed January 9, 2009.

7. Special Report: A Quick Guide for Women & Minority Entrepreneurs. Entrepreneur, January, 1998.

8. Roper Starch Worldwide Survey of Influential Americans for Ernst & Young. In: Williams G. 2001: An Entrepreneurial Odyssey. Entrepre- neur, April, 1999.

9. Petzinger T. The New Pioneers: The Men and Women Who Are Transforming the Workplace and Marketplace. New York: Simon & Schuster, 2000.

10. Drucker P. Innovations and Entrepreneurship. Burlington, MA: Elsevier, 2007.

11. Kanter R. Change Masters: Innovation for Produc- tivity in the American Corporation. New York: Simon & Schuster, 1983.

12. Bolles RN. What Color is Your Parachute? 2009: A Practical Manual for Job-Hunters and Career- Changers. Berkeley, CA: Ten Speed Press, 2008.

13. Pollan S, Levine M. Playing to Win. The Atlantic Monthly, Fall, 1988.

14. Kunde D. Striking Out on Their Own. The Dallas Morning News, February 19, 1991.

15. Dodd J. Look before you leap—but do leap! J Am Diet Assoc 1999;99(4):422.

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http://www.sba.gov/advo/research/rs225tot.pdf

http://womeninbusiness.about.com/od/wibtrendsandstatistics/a/wibtrendsnstats.htm

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12 THE ENTREPRENEURIAL NUTRITIONIST

19. American Dietetic Association Commission on Dietetic Registration. Compensation & Ben- efits Survey of the Dietetics Profession 2007. Chicago, IL: American Dietetic Association, 2008.

20. Peters T. Some Advice: Do. Fail. Laugh. Weep. And be Interesting. Dallas Business Journal, Feb- ruary 12, 1990.

16. Johnson S. Who Moved My Cheese?: An Amazing Way to Deal with Change in Your Work and in Your Life. New York: Putnam, 1998.

17. U. S. Small Business Administration. Frequently Asked Questions. Available at: http://web.sba. gov/faqs/. Accessed January 9, 2009.

18. Shenson H. Surefire Strategies for Making it as a Consultant. Home Office Computing, April, 1991.

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Self-employment is not a decision that should be taken lightly. It’s a calculated risk that requires forethought and continuous critical thinking to evaluate the options and pitfalls as a project grows. Because it’s challenging, succeeding as an entrepreneur can be one of the most satisfying accom- plishments you will ever have.

What makes some individuals want to do such a thing in the first place? What drives some to do it, while others only talk about it? How do you tell if you’re one of them?

According to Jerry White, author of The Entrepreneur’s Master Planning Guide and di- rector of the Caruth Institute of Owner Managed Business at Southern Methodist University, there are a few universal criteria that are common to most successful entre- preneurs (1). He says it’s the person who gets a little angry and then galvanizes for action when let go in a downsizing—he or she gets a gleam in the eye and plans the future. He states that there are key person- ality traits that describe the successful en- trepreneurs he sees (1):

■ Stamina ■ Realism ■ Self-motivation ■ Self-confidence ■ Calculated risk-taking

If these characteristics don’t describe you, then you might want to think long and hard before going into your own business.

The personal qualities, experience, luck, or financial resources necessary for an en- trepreneur’s success may be less important for another. Encouraging potential nutri- tion entrepreneurs to merely have years of experience in dietetics without regard to

the type and quality of experience is not well founded. Dietitians and dietetic tech- nicians have the basic clinical knowledge and skills upon entry into the profession. It’s the other personal qualities and skills that help set people apart from their peers.

Venture capitalist Arthur Rock states, “Good ideas and good products are a dime a dozen. Good execution and good management—in a word, good people—are rare. A conventional manager isn’t risk- oriented enough to succeed with a new venture, while an entrepreneur without managerial savvy is just another promoter. Good managers, on the other hand, can’t lose. If their strategy doesn’t work, they can develop another one. Great people make great companies, and that’s the kind of company I want to be a part of” (2).

WHAT DOES IT TAKE?

Sixty-four percent of the 1581 dietetic en- trepreneurs who answered the question feel they have “always had an entrepreneurial personality” (3). Of the three dominant personality types that some businesspeople feel entrepreneurs have, 44% of survey re- spondents chose “creative, inventor, idea- person,” 24.7% chose “manager, leader, financial-person,” and 31.4% chose “tech- nician, detail-oriented, task person” (3). It is interesting to note that the most finan- cially successful dietitian “masters” (those making over $100,000 net income per year) who had been in business many more years chose very differently (3):

■ 51.7% said they were a “creative, in- ventor, idea-person”

IS SELF-EMPLOYMENT FOR YOU?

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14 THE ENTREPRENEURIAL NUTRITIONIST

4. Ability to network and build rela- tionships

5. Knowledgeable and keep up with trends

6. Good communicator

“Successful entrepreneurs know (or learn) how to be tough, how to accept criticism, and how to make quick decisions. Personal integrity is crucial for continued growth of the business. The most successful strive for short-term excellence on every project or they do not agree to do it. They must be able to accept responsibility and stick by commitments” (4).

As a nutrition counselor, it is important to be people-oriented, empathetic, and be exceptionally good in communicating with others. Advanced counseling skills learned through additional education or training in psychotherapeutic counseling with profes- sional supervision will be necessary for a long career in counseling. As medicine changes, especially in chronic care, to func- tional medicine, dietitians will need to know the body’s biochemical functions and pathways that use nutrition as their cornerstone.

As media spokespersons, public speakers, and consultants, dietitians must develop their verbal communication skills and the powers to reason, organize, and think quickly on their feet. As you can see, formal dietetic education is just the beginning.

There is no guarantee that a new busi- ness will show an immediate profit. Indi- viduals who start their own businesses cannot be prone to discouragement or boredom. A successful entrepreneur is a re- alist as well as a dreamer—reaching for the stars while maintaining a firm, earthly foot- ing. Financially, entrepreneurs learn where to cut corners to save money and where to spend their limited resources to make the best impression or serve their clients better. Entrepreneurs must learn to be brutal when it comes to cutting “bad” ideas that drain resources, but generate fun diversion.

Entrepreneurs must learn from others be- cause so many new skills are unfamiliar and because most new ventures are solo projects.

■ 33.7% said they were a “manager, leader, financial-person”

■ 14.6% said they were a “technician, detail-oriented, task person”

These figures beg the questions: does the job change the person into someone who is more creative and a financial manager, or will the process of starting and managing a business naturally weed out the people who are more technical and detail-oriented?

The majority of dietitians who become entrepreneurs come from clinical back- grounds, followed in descending order by community nutrition, education, food management, business or communication, and, finally, research (3).

A successful entrepreneur has many areas of expertise that should be developed, including:

■ A desire and an ability to network with other people

■ A thorough working knowledge of how a business operates (often learned or observed on a former job)

■ A willingness to promote self and the business

■ The ability to develop a quality prod- uct or service

■ Financial management skills and abil- ity to generate capital to finance the business

The strengths of the business should be based upon the owner’s unique personality, knowledge, and experience. This means that you must know about yourself. You may not need specialized training beyond the di- etetic education and internship, or you may go for graduate degrees and certifications. Of the masters making over $200,000 net per year, an equal number had the RD cre- dential or their Master of Science degree and 17% had their doctoral degree (3).

Survey masters identified their personal characteristics they felt were most responsi- ble for their success, listed below in de- scending order (3):

1. Hard work and persistence 2. Personality traits 3. Caring and passion

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CHAPTER 2 ■ Is Self-Employment for You? 15

Many will set up informal mentor relation- ships with highly respected authorities who have experience and insight beyond that of the entrepreneur. At other times, they will network in dietetic practice groups and local business groups where they share ideas and problems with other entrepreneurs.

WHY CHOOSE SELF-EMPLOYMENT?

Dietitians on the verge of leaving employee status for that of self-employment find that being an employee no longer gives them what they need. It’s as if they have come to the end of a certain passage. They can no longer grow in the present environment. Venturing into the unknown becomes nec- essary in order to continue personal and ca- reer growth.

Other reasons for becoming self-em- ployed are to gain flexibility of time, to be your own boss, or to be home with small children. Some do it to follow patient care in a wellness setting, to create and imple- ment programs, to do a greater variety of

work, or to make more income or have greater recognition for their work.

In the 2008 World-wide Entrepreneurial Dietitian Survey, the 1335 respondents ranked the reasons why they chose to be entrepreneurs with “flexible schedule” coming in first (3):

1. To have a more flexible schedule 2. To do a variety of work 3. To be my own boss 4. To be challenged 5. To earn more money 6. To have more freedom to use my

creativity

The potential exists to make it in a big way. If entrepreneurs are successful, they can make much more money than they ever could as an employee in a traditional job because they collect both the owner’s and employee’s shares. However, they also pay for all the overhead and fringe benefits—both the owner’s and employee’s shares.

There is a tremendous swelling of pride in their work and in themselves as they

One of the many decisions a home-based businessperson has to make!

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16 THE ENTREPRENEURIAL NUTRITIONIST

the business. Does it help to involve the spouse in business activities? It helps some marriages because they see the work as a labor of love, sharing the workload and reducing the time needed to conduct the business. For others, it is the beginning of the end. Too many hours together may worsen tempers instead of soothe them.

Of the 1305 survey respondents that an- swered the question about their marital and family status when starting into self- employment, about 50% were married with children (see Fig. 2.1) (3). In response to the question about whether the spouse’s or significant other’s support was helpful, 91.1% of 1132 people said their support was neutral up to very supportive.

NOT FOR EVERYONE

As you can tell from what has been shared, entrepreneurship does intimately affect an individual. Also, the point needs to be made that you can’t assume that since you have good ideas, money, lots of energy, and the right credentials you should start your own business. You might also think about work- ing as an employee in business and indus- try, or for a spa, caterer, cruise line, large medical clinic, or another nontraditional employment setting. Good, progressive cor- porations are starting to recognize the value of hiring more creative individuals who are looking for career alternatives with regular paychecks and fringe benefits.

The negative aspects of starting a busi- ness are very real but certainly not insur- mountable when a person does careful research and develops well thought out solutions. The fear of the unknown is often more paralyzing than what really happens.

MYTHS ABOUT ENTREPRENEURSHIP

MYTH: YOU WILL GET RICH QUICK!

You hear about the “miracle” franchises that make tons of money overnight or the skateboarding college dropouts who built

bring to fruition projects they originate. In society as a whole, entrepreneurs receive the approval and respect of many people who realize the enormity of the commit- ment and effort.

WHAT PRICE IS PAID?

Many of the benefits granted the employee, for example, regular paychecks, paid sick leave, pension plans, health insurance, reg- ular working hours, and paid vacation time, are no longer givens when you are your own boss. It may dawn on the new entrepreneur that if he doesn’t work a day, he doesn’t get paid. There are no benefits when self-employed, except what you pro- vide for yourself.

In logical and practical terms, the possible risks of being an entrepreneur can include:

■ Financial and emotional insecurity (at times)

■ A large time and effort commitment ■ Family stress due to long hours and fi-

nancial insecurity ■ No paid benefits, especially healthcare

insurance

Family needs, emotional support, and oth- ers’ schedules must be considered before becoming an entrepreneur, especially for a person with children or with a partner without stable work. The stress can be high when children are young, ill, or very active in sports or other activities that require a parent to be available. Although an entre- preneur’s schedule can be more flexible, once appointments and regular office hours are set, an entrepreneur’s image can be damaged by frequently changing ap- pointments or closing the office during office hours. When a spouse’s work is spo- radic or money is tight, the stress can be high for an entrepreneur trying to make the best long-term decisions for the grow- ing business instead of taking jobs that pro- duce immediate income.

Even formerly supportive spouses can become antagonistic and jealous about the time and effort an entrepreneur invests in

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CHAPTER 2 ■ Is Self-Employment for You? 17

skateboards and are now millionaires. But those are flukes, according to most entre- preneurs’ experience. The majority of en- trepreneurs find that growing a business takes time and patience. There are false starts along the way and growing pains when things catch on (5).

MYTH: IT IS ALL ABOUT MAKING MONEY

Surveys and interviews don’t support the conclusion that it’s all about making money. More entrepreneurs say they’re in business for the other reasons that have been mentioned. Satisfaction comes from the thrill of the challenge, and the money helps make ends meet and covers the bills. After needs and wants are met, having more money doesn’t make everything ex- ponentially better, but it does feel great and the accomplishment is satisfying.

MYTH: WHEN YOU FINALLY MAKE IT, IT GETS EASIER

After working day and night to get the busi- ness past start-up, there are all new chal- lenges to preoccupy the owner’s time and

resources. As the business gets larger and more successful, there can be employee problems, increased consumer expecta- tions, new products or services to invent and maintain, increased costs to improve the business image, more equipment to purchase, increased overhead, larger space needs, and more tax commitments (5).

MYTH: IF YOU BUILD IT, THEY WILL COME

Too many new entrepreneurs plan for the huge surge of patients or customers when they open their doors or throw a Grand Opening. However, many experience frus- tration because they never realized how much of their previous success at work was due to customers being attracted or loyal to their earlier employers (6). Before starting a business, Rebecca Hart, market- ing consultant, suggests, “I’d say you need at least 250 names in your Rolodex. They don’t all have to be potential clients or re- ferral agents, but you at least need a base of people who know you and who you can count on for information” (6). Televi- sion book promoter Matthew Lesko stated in a seminar for dietitians, “I had a new

FIGURE 2.1 ■ Marital and family status when starting into self-em- ployment (1305 respondents) (4).

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18 THE ENTREPRENEURIAL NUTRITIONIST

Smart people learn how to minimize their risks. In his article, Risky Business, Bob Winston points out the difference between “dumb” and “smart” risks (11).

Dumb risks:

1. When the odds are staggeringly against you.

2. You’ve done little or no research. 3. It was an emotional decision without

great merit. 4. You are about to change your life all

at once. 5. You’ll make a big effort for a small re-

turn on investment.

Smart risks:

1. You’ve researched it for months. 2. The timing is right. 3. You’ve given it your undivided

attention. 4. Experts support you. 5. It blends well with the rest of your life. 6. Your gut instinct tells you to go for it.

SIX STEPS TO SUCCESS (11,12):

1. Careful planning—but don’t wait too long before acting. Which venture and when are extremely important concerns. Markets change and trends come and go. Competitors’ plans can open new doors for you or destroy your plans. However, for most services, the primary competitor is apathy on the part of the patient or client, not another competitor.

2. Control the size of the risks. Consider starting slow and building your business as revenues grow. First, contact clients who already know you and like your services instead of going after all new markets. Consider work- ing part-time on a job while waiting for your entrepreneurial venture to grow. Start with services or products that are familiar to you, and try pro- moting them to new markets instead of inventing something totally new. Try offering more than one service or

MBA degree, a fancy office, and new fur- niture, and do you know what? NO ONE CARED! I needed something to sell that people wanted to buy” (7).

MAJOR REASONS WHY BUSINESSES FAIL

1. Not advertising or promoting enough. Many businesses have gone under before adequate money started coming in (8).

2. The product and service are not unique enough, and there is either little demand for what you are sell- ing, or the competition is strong so you decide to compete on price. That strategy often fails.

3. You have not borrowed or saved enough money to run the business and pay living expenses. Or, you let your overhead get out of hand by having an expensive office, staff, and equipment before you could afford them (8).

4. Joining forces with the wrong partner(s) has destroyed many busi- ness ventures—partnerships usually last less than 18 months.

5. You are not willing to put in the time and effort necessary to nur- ture the start-up process. “What sepa- rates success from failure: You have to be willing to do anything and everything to get the business off the ground” (9).

6. Starting a business is a major lifestyle decision. The business owner and her or his family must be committed to making the business succeed (9).

RISK-TAKING IS NOT RISKY LIKE IT USED TO BE

Risk-taking has always involved fear of the unknown. In today’s dietetic market, the status quo involves fear of the unknown. Change is happening at an alarming rate. Dietitians must grow just to stay even (10).

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CHAPTER 2 ■ Is Self-Employment for You? 19

product to each client—bundle com- plementary items to increase the size of the sale.

3. Time your risk. Learn more about the importance of the Product Life Cycle described in Chapter 3. You will be able to time the introduction of new items for more success than when you allow them to “happen” when it is most convenient for your schedule.

4. Build a support system. To get through tough times, surround your- self with people who support you in your risk-taking. Look for role models, and join groups where successful peo- ple meet and get to know one an- other. No one expects a person who is new to business not to make any mis- takes. However, there is no excuse for repeated blunders when there are so many people and resources available to help businesspersons.

5. Keep cool under stress. Learn to identify the amount of change and stress you can handle comfortably. Look for signs of having too much stress, such as irritability, hyperactiv- ity, shakiness, excessive smoking, overeating, drinking alcohol, depres- sion, and forgetfulness. If these signs appear, consider delegating some of your tasks and unnecessary busy work, take some time to relax, and get away from the office.

6. Save a percent of your income and invest it in assets. Don’t spend every cent you make. Save for pur- chases instead of going into more debt each time. Use income from your busi- ness to create savings and buy assets that will appreciate in value, as well as provide retirement income.

COMMONALITIES IN PRIVATE PRACTICE

Although there is wide diversity in dieti- tians’ businesses, the majority support themselves, especially initially, with one- to-one counseling. More experienced prac-

titioners begin with business consulting to established business contacts (4).

■ In clinical private practices, there is a shift in the type of nutrition information that is used most— from acute medical diets used in the hospitals to “chronic,” or preventive, nutrition with a disproportionate em- phasis on weight control. Most practi- tioners report that at least 70% of their clients have weight loss as a primary or secondary diagnosis. Diets for heart dis- ease, diabetes, eating disorders, sports, and allergy diets are common.

■ Practitioners find that this busi- ness is seasonal, with slack times oc- curring usually over the holidays and in July and August. It is important to remember these times do exist. They are great times to do busy work and plan your own vacations. They should be avoided when planning group classes, mail-outs, and grand open- ings. In the weight control business, there are two times of the year when major marketing efforts are most effec- tive: early fall and after the New Year.

■ Private practitioners’ relation- ships with other heath profes- sionals begin to mature to true members of the healthcare team. The major reason interrelationships are more cooperative is because pa- tients are treated for chronic problems instead of acute, life-threatening ones. As an entrepreneur, more time is given to patient instruction and follow-up than is traditionally available in a hos- pital setting. As a result, nutrition in- tervention often produces impressive outcomes. Referring physicians and nurses become very supportive of ef- fective nutrition therapists.

■ Money takes on new meaning to new business owners. To survive, you must generate more income than expenses. It doesn’t take long before new business owners learn how to call or delegate the duty to contact their

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20 THE ENTREPRENEURIAL NUTRITIONIST

up with the market, you must develop some solutions. First, see if you can start an informal journal club with other dietitian business owners or at-home moms. Start subscribing to nutrition newsletters and use your computer to access databases or get updates online from the American Di- etetic Association (ADA) or health services. Read the newspaper and business-related magazines regularly. Join dietetic practice groups that relate to your areas of interest. Many of their newsletters offer a wealth of information and so do their meetings. Look for self-study continuing education pro- grams on timely topics that put you ahead of the curve for what your target markets presently know.

Q: I’ve always had difficulty getting organized, any suggestions? A: This concern is extremely important. If you want to stay in business, you will ei- ther learn to organize out of necessity, or you will have to hire someone to either do it for you or teach you how. You alone are responsible for the timeliness and quality of your output. There isn’t an employer or supervisor to look over your shoulder telling you what to do and when.

If you work out of your home, you will want to maintain “business hours” and avoid watching daytime television and doing chores instead of business projects during that time. Good time management is essential. Start a notebook and list your daily “things to do.” Be sure to prioritize them—all things are not equally impor- tant. Start with the most dreaded task first and get it out of the way. Many people make lists, but end up doing the low-risk, fun projects first.

Q: I have wanted to start a consulting practice for years. I have some money from the sale of our house, and I also have some income from two consultant jobs for food companies in the area. I will need a steady income to support us. How do I get started? A: You have already started your business, since you have two consulting positions. Before you go any further, I suggest you do as my mentor, Jean Yancey, suggested,

“accounts receivable” to ask for a prompt payment, or to establish a pol- icy where payment is due at the time of the visit. In the beginning, the fun, creative work with great future finan- cial potential may have to take a back- seat to less exciting projects that make money now and pay the bills.

■ Practitioners realize the begin- ning pace of a small business can’t be kept up forever. The need arises to develop projects that produce “passive” income. This is some product or service that brings in revenue with- out the consultant’s constant input. Ex- amples are selling products, earning book royalties, selling copyrighted teaching materials or computer pro- grams, inventing a product, or hiring other dietitians to cover some of your client contracts. The business strategy to create passive income is responsible for some of the most financially suc- cessful businesses owned by dietitians.

■ As the business and its owner mature, it’s common to narrow the kinds of products and serv- ices the business offers. The dead weight—fun but not profitable or prof- itable but no longer fun projects— should be let go. The owner learns over the years who to trust and who has to pay up front and sign in front of a no- tary. Entry-level projects that used to be loads of fun and tons of work are usually left to the newcomers.

■ Business maturity leads entre- preneurs into working in other settings, such as on decision-making committees, as a state or national di- etetic officer, and as Board of Directors of businesses and organizations out- side of dietetics.

COMMON QUESTIONS

Q: I’m afraid I won’t keep current without the input of other professionals around me, like in the hospital. A: This can be a problem. However, since your livelihood will depend upon staying

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CHAPTER 2 ■ Is Self-Employment for You? 21

“Weed out the garden of your life.” Sit down and take a good, hard look at your life and see what is draining you emotion- ally and all other ways. Do you take on too much responsibility at home, church, or school, and leave too little time for your- self? Do you have too much debt? Are there people who use you or abuse boundaries you set? Those are just a few of the weeds that must be considered and better con- trolled before starting your own business.

Next, go and talk to your two present ac- counts and tell them about your plans to expand, and ask if there is additional work you could do for them. Ask if they know of other companies that might use your services.

Now, call and meet with as many other business contacts as you can to discuss what services you can offer. Many times, new services or ideas will emerge from these dis- cussions that you never considered before. Join and become active in the ADA referral network and Dietetic Practice Groups. Use their online discussion groups and attend meetings of local industry groups. Volunteer to be on highly visible committees where you will meet potential clients, like charity golf tournaments, gala fundraisers, or when soliciting sponsorships for large events so you can meet company owners.

Stay visible, become current with the newest controversies and products, agree to speak for groups of potential clients, and begin to research and write articles that es- tablish your credibility in the consulting areas you want to pursue. Good luck!

EVALUATING YOUR STRENGTHS AND WEAKNESSES

It is important that you look at your strengths and weaknesses objectively. You need to know what your strengths are be- cause you will want to capitalize on them and base a lot of your business strengths on them. Knowing your weaknesses will show you where you could be vulnerable. You can seek help to supplement your weaker areas, such as public speaking, writ-

ing, bookkeeping, marketing, computer work, etc. The less you are able to do for yourself, the more it will cost to operate a business. The cost of delegating responsi- bilities and training office staff must be weighed against the value of your time in generating income. A good manager will manage resources and time so he or she is not forced to do $12-per-hour office work instead of $125-per-hour client-contact work.

EDUCATION

The challenges of entrepreneurship can ac- cess every brain cell and frame of reference you have. People often enter a small busi- ness totally unprepared for the scope of skills that are needed. It’s unreasonable to assume a new entrepreneur would know how to do everything. For that reason, en- trepreneurs must accept that education will be ongoing both formally in continuing education or schooling and informally from life or work experience.

A dietetic technician is only limited in the clinical area of nutrition practice, where supervision by a dietitian is neces- sary. He or she is certainly more qualified than most of the lay counselors who work with the public in weight loss and fitness centers. By working in catering, food devel- opment, management, or with “normal” nutrition, a dietetic technician can be suc- cessfully self-employed.

In a survey of successful private practi- tioners, Rodney Leonard, former writer for Community Nutritionist, found that, “If they had to do their schooling over again, they would choose a curriculum heavily weighted toward building communication skills and acquiring a basic knowledge of business practices. They would take public speaking, journalism, marketing, public re- lations, bookkeeping or accounting, and economics” (4). In interviews conducted re- cently, entrepreneurs agreed with this list and added more advanced counseling skills.

Graduate Education or Specialty Certifications should open various doors

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22 THE ENTREPRENEURIAL NUTRITIONIST

Dietetic experience past the internship level is all but mandatory to gain compo- sure, practical clinical knowledge, save money, build a network, and to learn those things not taught in school. People cur- rently in practice have recommended 2 to 5 years of experience in a variety of posi- tions before starting out on your own.

There are, of course, exceptions to every guideline, and, as disclosed in Chapter 1, there are dietitians who have started suc- cessful businesses directly out of school. But for the majority of entrepreneurs, the added years can be beneficial in learning new ways of doing things, trying out programs in in- stitutions where resources are more readily available, establishing good credit, and sav- ing seed money for a new venture.

COMMITMENT LIMITS

You will need to decide the amount of per- sonal commitment you want to devote to your business. There are some important questions to ask yourself and decisions that need to be made.

■ Will you work at private practice full- or part-time?

■ Will you try to keep your other job? ■ Will you have a medical, commercial,

or home office? ■ How much debt can you handle? ■ Where can you get funding for the

venture? ■ If you have a family, how will you jug-

gle the multiple facets of your life?

When determining your limits, recognize that having support for your venture from your family and friends can be very helpful on your road to success. Involving other people in your decision-making may help solicit their support for your projects.

LEAVING YOUR OTHER JOB

How you leave your present job or how you handle your job while you start a new busi- ness on the side can be very important

in business and improve an entrepreneur’s marketability. Besides nutrition, dietitians are taking advanced degrees or training in law, medicine, culinary, chiropractic, exer- cise physiology, communications, health promotion, food technology, business management, psychology, functional med- icine, Chinese medicine, and marketing, to name a few. Certification can be in dia- betes, renal, pediatric, nutrition support, sports nutrition, lactation, weight counsel- ing, Certified Clinical Nutritionist, and many others.

Practitioners do not agree on the exact role that an advanced degree will play in an entrepreneur’s career. Some feel it is an ab- solute necessity that provides an edge in today’s professional world and competitive markets. Others feel advanced degrees are perhaps only important in clinical set- tings, academia, and government posi- tions. Everyone agrees that a Master of Science degree or PhD will not compensate for a lack of ability, skill, or personality traits needed to succeed in business as an entrepreneur.

Re-education is important when a die- titian hasn’t remained current in the areas of nutrition that will be used in practice. Due to the growing nutrition awareness of the public and the sophistication of the competition, new business owners can’t af- ford to be outdated.

For dietitians who have not practiced for some time, don’t underestimate what you know. However, you should consider tak- ing dietetic courses, self-study continuing education courses, qualifying for dietetic registration (if you aren’t registered), and perhaps working in a teaching or clinical setting for a while to refresh your knowl- edge and improve your skills.

Experience/Expertise can be gained in a variety of ways—from working in a family-owned business, working as an em- ployee or volunteer, or creating a business of your own. The quality of the experience and the degree of involvement are usually as important as the number of years, but ad- equate time and exposure are necessary.

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signed a noncompete contract, and even then it must be reasonable. An agreement may state that you can’t solicit business from your employer’s client accounts or disclose the employer’s proprietary infor- mation. You should be able to contact physicians on staff at the hospital, but on your day off, not during paid working hours.

One practitioner reported a food service company asked her to sign a contract when she first started. It stated that upon termi- nation, or if she quit, she could not work as a dietitian for anyone for one year within a 100-mile radius of the large metropolitan area where she lived. Don’t sign something like that! It’s doubtful the agreement would stand up in court, but who wants the ex- pense and bother of a court case? Talk to a good lawyer about some compromise.

C A S E S T U D Y 2 . 1

T H E N U T R I - S E R V E S T O R Y

On March 31, 1987, I incorporated Nutri- Serve Food Management in the State of New Jersey. Nutri-Serve Food Management con- tracts with school districts in the state to pro- vide school food management services.

I had worked for a small food service man- agement company in New Jersey for 10 years. It was my plan to be the owner of my own food service management company by the time I was 40 years old. When pencil came to paper, working for that company no longer contributed to my career growth, so I decided to start out on my own at age 33. The com- pany I left had 17 clients, so I set a goal to have 17 clients by the time I was 40. At Nutri- Serve’s 5 year anniversary, I had exceeded my goal of 17 clients.

I started my business in the second bed- room of my townhouse. I was single at the time, and lived off of my savings. I taught a class once a week to pay for groceries, bought anything I needed from a second hand store, and worked and worked. I decided to call my business Nutri-Serve Food Management

CHAPTER 2 ■ Is Self-Employment for You? 23

professionally. Your reputation either will precede or follow you into your new ven- ture, so the past is never really gone. Try to leave as amicably and cordially as you can. After giving notice, use the next few weeks to let people know about your plans and generate goodwill. Hopefully, your present colleagues will become good referral agents if you have chosen to conduct a noncom- peting business.

If you are starting a business on the side, keep it on the side. Don’t get fired because you used the photocopier to print all of your diets or solicited patients on the floors of the hospital. Also, be aware many em- ployers consider starting a private practice after hours as a conflict of interest, and it may jeopardize your job.

Several clinic dietitians have found their employers were less than understanding when they established part-time private practices in the same community and of- fered services that competed with the em- ployers’ outpatient clinic services. That wasn’t a smart move. Put yourself in the em- ployer’s spot—wouldn’t you make the dieti- tian decide which job she or he wanted more? Work in a different community or offer excellent, but noncompetitive services, such as group weight loss classes with an ex- ercise specialist or diabetic cooking classes.

Your reputation and goodwill toward you will grow as you become known for your services. Your identity will grow sepa- rate from your employer’s.

A common question dietitians ask is: “What is mine when I quit?” Generally, the rule of thumb is: Intangibles are probably yours (including the names of your con- tacts), and tangibles (patient records, the Rolodex or palm computer provided by the employer, etc.) are probably not. If you in- vented or created something on your salaried time, usually it belongs to your em- ployer unless you had another agreement. If you wrote materials that you want to use later in your business, plan to write differ- ent ones with newer information.

A former employer can’t keep you from practicing your profession—unless you

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24 THE ENTREPRENEURIAL NUTRITIONIST

After the class was over, I became a teaching assistant for two more classes so I could con- tinue to learn without having to pay for it.

The excellent book, Think and Grow Rich by Napoleon Hill, was essential in my personal and business growth. Reading, studying, and implementing this plan was a turning point in my life. Napoleon Hill was contracted by wealthy businessperson Andrew Carnegie to interview, over a 20-year period, hundreds of well-known successful businesspeople. He took this information and consolidated it into 13 common points that are described in the book.

My Christian faith is my keystone. I am a spiritual person. When I would get down to my last $1000, my path would take a bend in the road. Something positive would work out that I never dreamed would happen and I would be back on track.

The Creative Side of Work Clients like to buy into a creative idea. I created the “Balloons for a Balanced Lunch” clown unique to Nutri-Serve Food Management to represent the mission of nutrition. When stu- dents take a food of each color they have a bal- anced meal. The USDA Nutrition Pyramid also enhances our message. This year, Nutri-Serve added flags for each food group over our serv- ing lines, adding color to the line and reinforc- ing our nutrition message to students.

Use the talents of friends and family when- ever you can. I developed Nutri-Serve’s signa- ture clown and flags, and my mother drew all of the artwork. All the brain power you can get for free is great. Napoleon Hill calls this the Master Mind Group. It is very important to surround yourself with positive people and positive thoughts.

I had a booth at the New Jersey School Board’s Convention the very first year I was in business. My father went with me to work the floor. When prospects walked by the booth and asked what clients Nutri-Serve had, I would mention two clients and then let my voice linger (as if I had others but just didn’t mention them) and moved onto something specific about our service to benefit them.

because I wanted to include Nutrition in the name and because Service is key to the suc- cess of any business, especially food service.

It is very humbling when you are a cog in a larger wheel because you have to do EVERY- THING yourself. I was shaking to the bottom of my socks at times. After you do something for the third or fourth time it gets a lot easier! I would highly recommend to anyone starting their own business that they find an excellent attorney, CPA accountant, and insurance agent. These three people will be of great help.

I researched the competition, wrote a pro- posal book, sent out letters to the school dis- tricts in nearby counties, and started to cold call. I got my first client in September, 1987, when the new school year started, and I am pleased to say we still have that client. I hired my first employee part-time in January, 1988. When asked what it takes to start and succeed in your own business, I think it is having per- severance beyond your wildest imagination! Integrity is also extremely important to me and was one of the ma`jor reasons I started my own business.

What Helped Most? Rejection can be hard in the beginning. I lis- tened to positive-thinking tapes, read positive- thinking books, and watched positive-thinking ministers on television. I had several mantras to keep in my brain. My favorites include:

■ “Don’t give up. . .we know you can do it!” Written in a card from my parents

■ “Do what you fear most.” Dale Carnegie ■ “Most of us have far more courage than we

ever dreamed we possessed.” Dale Carnegie

In addition, I have some anonymous sayings:

■ “Ready, shoot, aim.” ■ “The universe rewards action.” ■ “The universe will provide.” ■ “Fall forward—When you pick yourself up

you will be one step ahead.”

I listened to Jack Canfield’s Self Esteem and Peak Performance by Career Track until I wore out the tape. I took the Dale Carnegie Sales Course to increase my confidence in selling.

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CHAPTER 2 ■ Is Self-Employment for You? 25

Growing a Business I think it is important to be progressive, always learning, and to take reasonable risks. Trust your gut! It is usually right. One of the first things I did in 1987 was to invest a good part of my life savings into having a software pro- gram written for the accounting portion of the school food service business. Personal com- puters were relatively new and fax machines were not invented yet. This program has served us well. It has been rewritten and updated over the years and it is still in use. Implementing sys- tems that can be used year after year is impor- tant to the stability of the company and makes it much easier to train employees.

I got into the habit of collecting good in- terviewing questions as the company grew be- cause I needed them to hire people to partner with me on my team. I wanted to hire people who would believe in my dream. Asking the right questions was essential. I am very proud to say I work with an absolutely excellent team of people who are very dedicated, hard work- ing, honest, and understand the goals of Nutri-Serve Food Management. No job is too big or too small. We all work together to ac- complish the goal.

In August 2002, I purchased a building for our corporate headquarters. This is now my office. As of September 2008, Nutri-Serve Food Management was serving 76 school dis- tricts in central and southern New Jersey with 200 schools. We serve about 78,000 total meals a day and have 900 employees.

I never take anything for granted. You will make mistakes. It’s part of being human. Learn from them. I learn and grow every day. If you are faced with a new problem or, as I like to call them, “challenges” or “character builders,” re- member there is a solution, you just haven’t thought of it yet! —Karen B. Fynan, MS, RD

SUMMARY

If you are going to succeed as an entrep- reneur, you must have a burning desire to develop your idea, and you must believe so firmly in the idea that everything else pales in comparison (2). By now you can tell the commitment to become a full-time entre- preneur should not be taken lightly. In the next chapters, you will learn the impor- tance of timing, customer service, and mar- keting to making a venture a success.

REFERENCES 1. White J, Welch JA. The Entrepreneur’s Master

Planning Guide: How to Launch a Successful Busi- ness. NY: Prentice Hall, 1983.

2. Rock A. Strategy vs. Tactics from a Venture Capitalist. Harvard Business Review on Entrepre- neurship. Boston, MA: Harvard Business School Press, 1999.

4. Leonard R. Private Practice. On Our Own. Com- munity Nutritionist, 1982.

5. Chun J. To Tell the Truth. Entrepreneur, April, 1998.

6. McCafferty D. Are you ready to become self- employed? CareerBuilder on MSN.com, 2000.

7. Lesko M. Speech in Washington, DC, at How to Make Money in Dietetics, 1992.

8. Mancuso J. How to Start, Finance, and Manage Your Own Small Business. New Jersey: Prentice Hall, 1990.

9. Ciabattari J. When You Start Your Own Busi- ness. Parade, August 21, 1988.

10. Helm KK. Risk taking isn’t risky like it used to be. J Am Diet Assoc 1989;89(4):488–489.

11. Weinstein B. Risky Business. Entrepreneurial Woman, May/June, 1990.

12. Beckwith H. Selling the Invisible: A Field Guide to Modern Marketing. New York: Warner Books, 1997.

Nutri-Serve’s booth at the 2008 New Jersey School Board’s Convention.

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WORDS OF WISDOM

We cannot direct the wind. . .But we can adjust the sails. Bertha Calloway

Do not let what you cannot do interfere with what you can do. John Wooden

BUILDING A STRONG FOUNDATION

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Most people believe customers can tell excellence when they see it, that cus- tomers seek the superior choice when buy- ing as long as the price is lower, and that they want healthy food and quality pro- gramming on television. However, ac- cording to marketing consultant, Harry Beckwith (1):

■ People buy what they hear about most or what seems most familiar and tastes good.

■ They want to avoid making a bad choice; they seldom seek the superior choice.

■ They buy from people with whom they have a relationship.

■ They will pay more if the “perceived value” or image is higher than the price.

■ They aren’t truthful on surveys—they say what they think surveyors want to hear and what makes the customer look good.

There is so much advice for new busi- nesses on strategies for success—much of it conflicting—because “the range of options and problems is vast and most decisions are ‘up for grabs.’ Many new business ventures simultaneously lack coherent strategies, competitive strengths, and talented em- ployees” (2). Successful entrepreneurs en- courage newcomers to:

■ Create a focused, timely business strategy

■ Execute it well ■ Exceed customers’ expectations ■ Keep the overhead a modest percent-

age of the income

RELATIONSHIPS ARE THE KEY

Your marketing, talent, professional knowledge, and expertise will get cus- tomers to your door, but your service busi- ness will not flourish unless you have relationships with your customers (1). This helps explain why some well-financed businesses run by highly educated people fail or make only marginal income. Cus- tomers don’t return and they don’t refer their friends and colleagues when your service is an “encounter” (like ordering on- line or buying from a vending machine), instead of a relationship (3). As more and more businesses turn to offering services and products online with no human con- tact, it will be interesting to see how they try to maintain the loyalty factor with en- counter services instead of relationships. Using a person’s name in direct mail or re- calling their past purchases haven’t proved to be very effective marketing and aren’t really relationships.

Customer service skills for front line em- ployees and yourself are imperative in today’s competitive marketplaces. For a small business with limited resources, es- tablishing relationships with physicians is often the difference as to why patients are referred to you instead of the outpatient de- partment of the local hospital. Addition- ally, relationships are why a food company returns to you when they need a media spokesperson, even though there are other dietitians who can speak as well or are will- ing to work for less.

There are noteworthy, changing trends in some services that seem to be catching

BUSINESS STRATEGIES AND MANAGEMENT

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30 THE ENTREPRENEURIAL NUTRITIONIST

neurs pursue such ventures as one-on-one counseling, consulting to businesses on smaller projects, speaking, media opportu- nities, book writing, and being a personal chef or trainer.

Sustainable nutrition business owners who want to grow a venture to sell for a large amount, eventually take public, or just enjoy on a larger scale, pursue more high-dollar markets like computer pro- gramming for institutions, product manu- facturing, building a retail business, weight loss programs for the masses, or creating a consultant firm with employees and nu- merous client accounts. The company name and image are promoted, not neces- sarily the owner’s. The entrepreneur’s day is spent more on management of employ- ees, overseeing projects, negotiation, prod- uct development, or financial issues. The most common drawbacks or stresses for these entrepreneurs are:

■ Missing the day-to-day closeness with customers

■ Employee hassles ■ Large debt and tax issues ■ Uncertainties or feelings of loss when

delegating their favorite tasks to others

THE BIG IDEA

At one time or another, we all have a “big” idea we know will make us a million dol- lars if we would just pursue it. Truth is, not many people actually try to pursue their ideas. The patent office reports that out of the 1400 new patents issued per week, only about 5% are ever manufactured.

In his book, The Rejects, Nathan Aaseng explores the difficulties and negative feed- back that inventors of well-known, highly successful products or services had to en- dure in order to make their ideas suc- cessful (4). His examples included: Orville Redenbacher and his high-priced but high-quality popcorn, Frederick Smith and his idea for overnight delivery (Federal Express), and Clarence Birdseye, who drew upon his adventures in the Arctic

on: one hour eyeglasses, buying stocks on- line, and laundry services with 24/7 service and online reports when clothes are ready (3). The keys are to keep the services fast, effective, efficient, friendly, and with min- imal hassle.

LIFESTYLE OR SUSTAINABLE ENTREPRENEUR?

When choosing strategies for your busi- ness, an important decision to make up front is whether you want to be a lifestyle entrepreneur (you enjoy working and keep- ing the business the size you can manage), or you want to build a sustainable business (survives without the founder and may eventually sell out to the highest bidder). Your goal for the business is important be- cause each type is run differently and usu- ally seeks different markets. It also may be that entrepreneurs must remain “lifestyle” until they finally create the sustainable concept that is lucrative enough to attract outside financing, crack employees, and an eventual buyer.

“Lifestyle entrepreneurs are interested in generating enough cash flow to maintain a certain way of life, so they don’t need to grow very large. In fact, a business that be- comes too big might prevent the founder from enjoying life or remaining personally involved in all aspects of the work”(2). Their problems include:

■ Limited ability to attract good employ- ees or financial backing

■ Long hours ■ The owner is so closely associated with

the business, selling it is difficult ■ Burnout or illness can threaten its

stability

“With no ways to leverage their skills (ex- cept subcontracting or hiring employees), they can eat only what they kill. Factors that make it easy for entrepreneurs to launch such businesses often make it easy for competitors or employees to do what founders do” (2). These nutrition entrepre-

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CHAPTER 3 ■ Business Strategies and Management 31

to invent a process to freeze vegetables successfully.

The small book is inspirational because it does not highlight the “overnight” success stories. Instead, it looks at the ded- ication and perseverance required when you believe in your idea and it is not an instant hit. The reader sees that the thrill and satisfaction from an idea is in the in- tellectual challenge, creativity, cama- raderie with the others involved, and the emotional highs along the way. Money is a good reward too, but for most entrepre- neurs, it is the thrill of the challenge that makes us happiest.

WHAT IS IT ABOUT AN IDEA THAT MAKES IT UNIQUE?

It could be you and your association with the idea. It could be how you market it or its message. Usually, it is the fact it was the first on the market, or if not first, then how it was different and better. There are many ideas that hit when the timing was right; they weren’t first, but the public responded like they were first. Miller Lite beer was ac- tually the third or fourth lower-calorie beer to hit the market, but when it hit, the tim- ing was right and so was its message, “lighter and less filling,” not “diet.”

Sometimes, a “new” idea is not always better. When McDonald’s fast food con- cept was first invented, it streamlined food production. The menu was made as sim- ple as possible (nonmessy foods that can be eaten while driving); the production line was broken into repetitious steps so that each product tasted, looked, and was the same; labor was trained and treated as interchangeable robots (no waitresses or relationships were needed). Unfortu- nately, we have been experiencing a time in medicine where the Health Mainte- nance Organization (HMO) creators tried to instill that same concept in the provi- sion of healthcare in the U.S. and the pub- lic responded by pulling away from HMOs. Relationships in healthcare are ex- pected by consumers.

CRAFTING STRATEGIES THAT WORK

Most new start-ups have to start with tried and true strategies that have worked for others because of the lack of funding and the need to gain business experience. As discussed by Amar Bhide in Harvard Busi- ness Review on Entrepreneurship, “A new company based on hustle, like consulting or sales, can provide good income and a dy- namic and competitive market. Capital re- quirements are low and overhead is often lower. Surprisingly, small endeavors often hold more financial promise than large ones. Often, the founders can keep a larger share of the profits because the company grew on its own profits instead of borrowed money. However, niche enterprises can also enter the ‘land of the living dead,’ be- cause their market is too small for the busi- ness to thrive, but the entrepreneur has too much invested to walk away” (5). In this case, the venture needs to be redesigned or diversified.

It is okay not to be the leader in the mar- ket—you can be a follower and still find your niche and make a decent living (6). When you are the leader, competitors seek to dethrone you and continually point out your faults to customers. Leaders often spend more money and time trying to maintain the status of that role. At their own expense, leaders often help create new awareness in the marketplace for a new kind of product or service that an entrepre- neur can also deliver. Then, an entrepre- neur comes along and capitalizes on that awareness in a smaller segment of the mar- ket. For example, the leader may be going for all households over $50,000 in income, and an entrepreneur markets to teens or to single-parent families with a similar prod- uct or service.

A National Federation of Independent Businesses survey of almost 3000 start-ups found that entrepreneurs who spent a large amount of initial study, reflection, and planning were no more likely to survive for 3 years in business than people who seized

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32 THE ENTREPRENEURIAL NUTRITIONIST

As illustrated in Stage 1 of the chart, Infancy describes the period when a new trend is just emerging or when a new idea is at the cutting edge, as was wellness in the 1970s. A few people were talking about the idea, but it didn’t have mass appeal. The di- etitian who wanted to become established as an expert at this stage did so at her or his own expense. However, at this stage it often doesn’t take much money to become estab- lished. True entrepreneurs love this stage. They thrive on the untapped potential of the emerging trend and creative brain- storming. They often develop close profes- sional ties with people they meet while actively pursuing the trend at this stage (8).

Stage 2, Growth, begins when the idea be- comes more popular and demand grows for the best services, products, and providers from Stage 1. Profits rise, and the new idea starts to attract the attention of other possi- ble providers (your competitors). Competi- tors copy or improve on the best ideas and add lots of marketing dollars. As the market matures, it becomes expensive to enter with a new product or service. Businesses experi- ment less at this stage. Ineffective or mar- ginal services, products, staff, and marketing efforts are let go. The venture is honed to a lean, well-functioning, revenue-generating business (8).

Saturation becomes a problem in the Ma- ture stage, Stage 3, as too many competitors vie for a piece of the market. Sales are at the highest level since the product or service was introduced but growth begins to de- cline. As James Rose, RD, stated, “During Stage 3, the business becomes fairly routine so many entrepreneurs lose interest. A per- son with good management skills is needed at this stage to keep the product or service consistent in quality and efficiently pro- duced” (9). Marketing is especially compet- itive at this stage with each competitor trying to attract the same shrinking target markets. If this chart represents your career, it means that what you are doing has reached its peak of popularity and you need to be investing in several new ideas in ear- lier stages with future revenue potential.

opportunities as they presented themselves without much preplanning (7). Successful entrepreneurs adopt practical approaches that are quick, inexpensive, and timely.

Bhide, a venture capitalist and Harvard University visiting professor, gives four help- ful guidelines for aspiring founders (5):

1. Screen out unpromising ideas as early as possible through judgment and re- flection, not gathering loads of data.

2. Realistically assess your financial sit- uation, personal preferences, and goals—they will gauge your passion for the idea.

3. A niche venture can’t justify too much advertising (but it must advertise); it must work within its budget and avail- able distributors and referral agents because it can’t support huge invest- ments. In other words, you work smart—use local printers to save on shipping and network with people you know, as well as referred colleagues.

4. Integrate action and analysis. Don’t wait for all the answers, and remain flexible and ready to change course.

PRODUCT LIFE CYCLE

The product life cycle concept can be ap- plied to products, services, market trends, and even careers and professions. Just as trends come and go, so does market poten- tial. By understanding the graph (see Fig. 3.1), an entrepreneurial dietitian can better anticipate the levels of consumer demand and competition and better estimate the amount of capital needed to enter a market. The more established the competition (ma- ture market), the more it will cost to create an identity for a new service or product.

I II III IV

FIGURE 3.1 ■ Product life cycle.

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CHAPTER 3 ■ Business Strategies and Management 33

Finally, Stage 4, Decline, arrives. The trend and its attractiveness to its present target markets are declining. There are fewer new buyers because everyone who wanted the product or service has pur- chased it. Sales drop and the product, serv- ice, practitioner, profession, or trend in its original form is no longer competitive. There are three options at this stage. The first is to continue offering the product or service for as long as it is profitable. The second is to reformulate or repackage the concept and reintroduce it as “new and improved.” The third option is a mixture. While either of those two options takes place, you invest a percentage of your re- sources into a new, cutting-edge concept in Stage 1 or early Stage 2. Smart busi- nesses offer several products or services, each fitting into a different stage of the life cycle.

Although many trends may take years for Stage 4 to evolve, when something dra- matic happens like a new breakthrough product or widespread negative publicity, change can happen overnight. For exam- ple, when Oprah Winfrey announced she had lost weight on a liquid protein diet, it gave credibility and heaven-made expo- sure to that industry. Other weight loss programs based on more gradual diets couldn’t attract enough participants to hold class for several years. Stage 4 hap- pened in a matter of weeks. However, as often happens with fads, when news hit of the women suing a diet franchise because of gallbladder problems, liquid diet pro- grams went into Stage 4 and began to fold within weeks.

THE PROCESSES OF MANAGEMENT

Managers decide what is to be done and how it will be accomplished. The majority of self-employed entrepreneurs will work solo, but there will be advisors, printers, re- pair people, and numerous others to over- see. So, the success of their business is still based on how well they manage.

Entrepreneurs must be self-motivated and have coordination in seven critical areas, as outlined by Tom Gorman (10) and others (5,9,11,12):

1. Planning: determines what is to be done—it can be strategic plans, fi- nancial plans, marketing plans, and production. The business plan will cover all of these plans and should be in enough detail to steer the business.

2. Goal-Setting: Goals should be big enough to inspire people and small enough to be achieved. There should be business, financial, marketing, and personal goals. Goals also must have the following three characteristics: ■ Specific—goals must be specific,

i.e., “breakeven by 6 months in business.”

■ Measurable—so you know whether or not you reached it, i.e., “contact three new accounts each week.”

■ Time-limited—It has a deadline and is not open-ended, i.e., “com- pleted by June 10, 2010.”

3. Decision-maker: A good manager is a decision-maker. Some people hate to make decisions because they hate being “wrong.” Actually, the business will suffer if timely decisions are not made. The following is a six-step process for making decisions: ■ Define the problem. Identify

what you must work with or solve. ■ Gather information. Dig deep to

find all the facts: talk to people, re- search trends and market econom- ics, study competitors, and so on.

■ Analyze the information. You may use the personnel policy man- ual, legal counsel, mathematical equations, or a computer decision- support system to help with the analysis. This step helps you un- derstand the full ramifications of the issue.

■ Develop options. Options give you choices, which you need to ar- rive at logical, rational, legal, and practical decisions.

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34 THE ENTREPRENEURIAL NUTRITIONIST

7. Controlling to Plan: This means controlling all the elements—people, resources, time, money—to follow the plan to reach the goals that were set out in the beginning.

MORE ON DELEGATION

Because entrepreneurs are so self-reliant and independent, many have trouble dele- gating to anyone else. They fear loss of con- trol or loss of quality output. This hesitancy may cause problems like:

■ Owner burnout ■ Frustration for anyone who has to

work or live around the owner ■ Red flags of warning for possible

investors ■ Stifling of growth, if the business is

ready for expansion

This situation is remedied by hiring or subcontracting to very qualified people, which will take the entrepreneur some re- search time to find. It may take several tries, but if the person is right for the job, it should become apparent.

STRATEGIC THINKING

Strategic thinking was originally a wartime concept, but it has come to mean the “process of reasoning that during the deci- sion-making process is used to find the ideal route to achieving a goal or competi- tive advantage. People who are good at strategic thinking have developed the ca- pacity to craft unique ideas that are practi- cal and applicable to specific business situations and, most importantly, to bring them to fruition” (13). Robert Jonas, Presi- dent of Strategy International, Inc., sug- gests specific tools that may be used to develop this skill (13):

■ Get training to overcome the status quo and learn strategies, like in chess.

■ Seek environmental stimulation while walking around and seeing new things in order to break the monotony of mental stagnation.

■ Choose and use the best option. Now you act because you have all the information you need to make the best choice that anyone could make, given the same knowledge. Don’t be paralyzed by dwelling on the need for more analysis.

■ Monitor the outcome. You need to know if your decision solved the problem, so you have to monitor and make another decision if the problem remains or it mutates.

4. Delegation: Assign tasks and re- sponsibilities to others. This is how managers get work done through em- ployees, and how lone rangers get more work done—by letting tempo- rary help, subcontractors, graphic artists, and others do what they do best, while the owner gets “high-level stuff” done. Others may do the work but the manager is still responsible for approving the quality of work and its completion schedule. Everyone should have clear responsibilities, and enough authority to carry them out. Everyone should have only one per- son to report to.

5. Support: Employees and others who are assigned delegated work will meet with barriers or problems—some an- ticipated, some not. The manager can’t just walk away and say, “Not my problem, you take care of it.” The manager needs to be there initially to help problem-solve, establish guide- lines, listen to complaints as they come in, and correct problems. Man- agers also need to hand out humor, encouragement, pointers, and praise.

6. Communication: This is one of the most important skills of a manager, and one that often determines suc- cess. First, listen to what is being said. Respond in direct, precise, clear lan- guage, and then ask the person to tell you, in his or her own words, what you said. People like to feel needed and important; this means that oth- ers need to feel “in the loop,” so share important information.

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CHAPTER 3 ■ Business Strategies and Management 35

nities present themselves, the plans may be informally reviewed or revised more or less frequently.

Small business owners, especially, need to write down their plans for three impor- tant reasons (12):

■ Continuity and succession plan- ning—If the owner becomes ill, in- jured, or dies, the mental plans go with him or her if they aren’t written down.

■ Quality of decisions improves— The owner is forced to assess the pros and cons of ideas, which can help the best ideas come to the top.

■ Commitment—The plan acts as a psychological tool or contract to reaf- firm the owner’s implicit commitment to his or her business.

Business consultants suggest that good managers know when to micromanage a project and when to only set up check- points along the way. They know they will never be able to guess all the right answers before a project begins, so they develop ac- tion plans based on their best research, and then begin. They make corrective

■ Seek generalists who more often see the whole picture instead of “experts” who may be locked into their narrow vision of what works.

■ Benchmarking has helped businesses learn from others, but not all competi- tors will share their secrets (nor should they). This practice may also mean everyone is mediocre.

■ Elaboration in the forms of proto- types, models, tests, what-ifs, and risk analysis must be conducted during the discovery stage.

■ Role playing to gain perspective from another’s view point.

■ Create an environment that accepts and fosters learning from failures.

STRATEGIC PLANNING

Strategic planning is concerned with iden- tification and actualization of long-term organizational objectives (that cover 5 or more years) (12). Short-range forecasts are revised on a quarterly basis, and medium- range plans are reviewed annually. When a venture is first planned, these stages are identified and explored. As new opportu-

A Few Terms to KnowBOX 3.1

1. Balanced scorecard: As the fiasco over World- Com and others proved, we expect more from a company than just financial success.

2. Benchmarking: Assess the best in your field and apply the lessons and strategies to help your business.

3. Continuous improvement: This can have power- ful results—getting a little better over a long pe- riod of time.

4. Core competencies: These are the things you and your business are best at doing; focus on them, especially as a small business.

5. Customer relationship management: Your rela- tionship to your customers is what it’s all about.

6. Learning organizations: Knowledge is increas- ingly the most important asset and with so much information coming out in nutrition, ef- fort must be taken to keep up.

7. Mass customization: Information and services meet in an effort to give customers what they want.

8. Mission and vision statements: Although many discount these, they’re among the most popular and long-lived management tools around.

9. Reengineering: The 1990s were the reengineer- ing decade, but the U.S. will benefit from im- proving business processes for years to come.

10. Total quality management (TQM): The systems era of business management began in 1980 and is almost synonymous with TQM—striving toward constant and ongoing improvement through empowering employees, setting long-term objectives, using the team approach, and to “do it right the first time” (11,13).

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36 THE ENTREPRENEURIAL NUTRITIONIST

Inc., a supplier of food cost management and nutrition analysis software and com- puterized cookbooks. In total, it has over 50 different products for the food service and dietetic industries. Through aggressive marketing, Computrition’s products have become known as state-of-the-art in the food service arena. Luros-Elson says, “It takes about 18 months for a product to be developed, tested, refined, and packaged for the market. It takes an additional 27 months for it to breakeven, and for us to recover our investment. Our company has over $10 million invested in product de- velopment. But even with the high costs, having products to sell is the only way I know to make a lot of money in dietetics. Service-based businesses soon realize there are only so many hours in the day to sell. After the start-up investment, products can sell and generate revenue without your heavy input of time like with service businesses.”

Randye Worth, RD, developed the fruit sweetened cookies you see in your grocery called R.W. Frookies and Animal Frackers. She and her husband wanted an all-natural cookie that was good for you. Two and a half years in development, and with her husband’s aggressive, creative marketing and product experience, they started with four flavors and a concept for a free stand- ing display (15).

In an interview, product experts John Luther and Jim McManus of the Marketing Corporation of America in Westport, Con- necticut, gave advice to people with prod- uct-based businesses (16):

■ Don’t introduce a new product unless it has proprietary competitive advantages. If it’s not unique, don’t spend your time and money on it. If there is no barrier to a competitor entering the market with a product that is just as good, or better than yours, you’ll quickly be competing on price. You could have a marketing success, but you’ll have a business failure if you can’t sell it at a profit.

decisions along the way in order to stay on target to their goals. Entrepreneurs take risks, but they are calculated, well researched, and closely managed.

DESIGNING SERVICES THAT DELIVER

Even though they are intangible, services can be subjected to the same rigorous analysis as other management operations, according to Lynn Shostack, a senior vice president at Bankers Trust, in an article in the Harvard Business Review (14). She uses a blueprint concept to develop new services, to decide the steps and stages of delivery, and to identify problems and the potential for other market opportunities.

The development of new services is usu- ally characterized by trial and error. How- ever, there is no way to ensure quality or uniformity without a detailed design (14). By adapting a work flow design, you can devise a blueprint that is nonsubjective and quantifiable, one that will allow you to work out details ahead of time (14). Simply identify all the steps of a service, adding time and costs, including any preparation time. By illustrating what you do, or plan to do, you can find possible weak points where quality may be com- promised. Or, you can use the example to train a subcontractor on the finer points of a service you provide that you want duplicated.

GROWING A PRODUCT-BASED BUSINESS

The profession of dietetics can point to some very successful members when it dis- cusses people with product-based busi- nesses. Merilyn Cummings, MS, RD, invented The Diet to Lose & Win, a card- wallet system to control food intake, using the diabetic exchanges.

Ellyn Luros-Elson, RD, was former pres- ident and cofounder of Computrition,

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CHAPTER 3 ■ Business Strategies and Management 37

■ Be simple and candid in your packaging and in your description to the trade. If you can’t be, the product probably isn’t very good.

■ Don’t bet the ranch. Always hold some assets in reserve.

■ You test market by getting into the busi- ness. There is nothing theoretical about it. Just do focus groups in at least two geographic regions to get a reality check that you are on target with col- ors, flavors, attributes, marketing mes- sages, and so on. The old thinking was that you test marketed a product in a representative city and if the con- sumers liked it, it would sell nation- wide. That did not prove to be true.

Two very interesting books on product development are How to Create Your Own Fad and Make a Million Dollars by Ken Hakuta (17) and Toyland: The High-Stakes Game of the Toy Industry by Sydney Stem and Ted Schoenhaus (18). Although these two books talk about the toy industry, the manufacturing trials, competition, retail problems, and so on are often similar to those in other markets. (Look on Ama- zon.com by topic or title to find used copies of these and other books on this ex- citing topic.)

There are several universities in the U.S. that have departments that will analyze your product and its marketing plan for a fee of about $500 or so to determine whether they feel it has a chance for suc- cess. Products can be extremely successful; they can also be very time consuming and expensive pastimes.

Your ideas for your business may change many times as you conduct market re- search and talk to people. The most impor- tant point is to remain open-minded but analytical and thorough in your quest.

BUILDING A MATURE BUSINESS

What do you do differently when your business matures? Your reputation is es- tablished, you have a stable relationship

with clients, and your days are filled more with income-producing projects than get- your-foot-in-the-door freebies. This is the time to establish stability and savor what you have created. Read the books, Rich Dad, Poor Dad (19) and The Millionaire Next Door (20), and see that it’s common folks who save the money and invest in assets that end up having financial security and fewer sleepless nights. Spending every cent that comes in is a common practice and tempting, but foolish. Even if it’s for the newest technology, if you really don’t need it to increase business revenue, don’t get it.

The keys to prosperity are:

■ Save a percentage of your income that you can afford every month— pay yourself first before you pay the bills (19).

■ Invest in assets first (real estate, small apartment building, stocks, bonds, etc.) that grow in value, instead of lia- bilities that eat your cash flow and de- preciate (fancy home, expensive car, the most expensive technology, and toys) (19).

■ Watch out—don’t live on credit cards and leveraged assets where your in- come is spent on big interest payments.

■ Don’t buy new assets or liabilities until you can afford them—learn to delay gratification and live within your means (19,20).

Maturing businesses also can mean a lot more of the same work the entrepreneur has been doing for years. All of a sudden, the physicians are referring, more food companies need menus analyzed, the media want more interviews, and some- where in there your family wants to see you too. What can you do? Don’t quit and walk away! This is what you worked for all these years. Try these ideas instead:

1. Get rid of the most time-consuming jobs that pay the least—or hire some- one to cover them, as long as you still make a decent profit as manager.

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38 THE ENTREPRENEURIAL NUTRITIONIST

2. Say “no” to volunteer or lower pay- ing jobs that don’t really need your skills, unless you love them—then do fewer.

3. Do the work and then find interest- ing activities to do outside of work— with your family and friends or by yourself—this changes the pace, while improving your attitude and you still reap the benefits of your years of labor. Sometimes surges in workload are just temporary and don’t warrant any major changes.

4. Cut back on your workload since it is more lucrative now and refocus your career to include activities you have always wanted to do, like speaking, writing, becoming a chef, or mentor- ing young entrepreneurs.

5. Create a parallel career in something you enjoy that doesn’t involve nutri- tion, like music, art, sewing, fishing, or managing your apartment complex.

Interview with Becky Dorner, RD Owner of Becky Dorner & Associates, Akron, OH

BOX 3.2

Q: What kind of business do you have? A: I have about 20 employees and two subcon-

tractors and together we cover over 130 accounts, plus temporary staffing for vaca- tions, etc. We consult to skilled nursing facili- ties, assisted living, retirement villages, acute care facilities, and MRDD group homes.

Q: What did you feel when you were no longer satisfied with just growing the business larger?

A: Obviously, my family is most important to me. However, my business and career are a huge part of my life. I derive a great deal of my self- value and satisfaction from working. In one year, I doubled the business income, which meant I worked day and night. I made major changes in systems, developed new policies and procedures, hired and trained a lot of staff, and increased staff benefits. And with all the hard work and success, I found I was mis- erable. I was not happy with how I was spend- ing my time—it was no longer fulfilling.

Q: What did you do to restore your enthusiasm? A: I spent a lot of time soul searching and

worked with a business/career coach. I dis- covered what I truly love to do—what I am passionate about—and started spending more of my time on that (speaking, writing, marketing, and product development). I del- egated what I did not enjoy—it took years to train other people to take over those jobs, but I am much happier now! I use the tal- ents and skills of others to do what they do best. The business is a great success and everyone wins!

Q: Why did you buy your office space? A: I bought and renovated a Cape Cod-style

house in a commercial area and converted it into offices. I felt it was a good investment. I can potentially earn income down the road when I choose to sell it, rather than just throwing my money away on rent. And best of all, it is very comfortable for my staff.

SUBCONTRACTOR OR EMPLOYEE?

Expansion is not to be taken lightly. It must be well planned, adequately financed, and you must be willing to accept new ad- ditional responsibilities, especially manage- ment and leadership. Your accountant, lawyer, and business advisor(s) need to be consulted before any steps are taken in this direction.

Don’t bring on a subcontractor to help you if only your needs are presently being met. Don’t jump prematurely. Many busi- ness advisors suggest having enough work for one-and-a-half full time dietitians be- fore a part-time associate is added. The other option is to have a consultant work as needed to cover new projects, client ac- counts, or office patients in order to free your time to pursue new client accounts. First, grow your business and work out the bugs, then subcontract or hire an em- ployee—in that order—usually.

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CHAPTER 3 ■ Business Strategies and Management 39

Olga Dominguez Satterwhite, RD, my seminar copresenter in 64 programs on how to start a private practice, used to tell how she contacted over 200 Spanish- surnamed physicians in the Houston area to introduce herself before she opened her business doors and quit her job. She hired an office receptionist and help at home before she began business so that her time could be better spent on business manage- ment, program development, and client counseling. If you carefully look at what she did, she worked smart and did things in the correct order for her—she marketed her new business while remaining gain- fully employed, so her decision to quit, hire employees, and start into business were not high-risk decisions. I comple- mented her style at the seminars with more of a bootstrap approach because I had very little money, no assets except a paid-off Volkswagen, no family to sup- port, and lots of time and energy when I quit my job (after 2 months of marketing to physicians).

Dietitians who own businesses that sub- contract to or hire other dietitians or any employees report it can be a big challenge. You can’t expect that other practitioners will have the same dedication as you do to your business. You must take the time and spend the money to interview, hire, and train good people to act as subcontractors or employees. Then you work with your client accounts to accept and trust a substi- tute for yourself.

Your job changes from a virtual consult- ant to overseeing accounts and personnel. Unless there is sufficient profit coming in, you personally may have a resultant short term loss of income when the overhead expenses increase for local travel, added secretarial services, telephone, insurance, printed materials, bookkeeping, legal fees to write agreements, and so on.

If you split the revenue generated by your subcontractor, for example 50%–50% or 60%–40%, after you deduct the added overhead, you may make less than 10% of

the money generated by a subcontractor. When you consider your earlier loss of in- come and time spent managing, that could be breakeven. According to these same practitioners, unless you can bill three times the hourly wage you pay the subcontractor, it is probably better to bring people on as employees. In some in- dustries, like public relations, media work, and consulting to business and industry, fees are high enough to more easily sub- contract.

The IRS is very particular about who can be called contract labor and who is an em- ployee, working under the titles “consult- ant” or “subcontractor.” If you set the person’s hours and days of work, offer training on how to do the job, pay by the hour, and the other person only works for you and does not have other clients, he or she meets the IRS criteria for an employee. When a person is an employee there are federal and state taxes, workman’s com- pensation, and unemployment taxes to pay. If the person has worked several years for you as an independent contractor and then the IRS rules the person has always been an employee, there may be back taxes and penalties to pay. Check with your ac- countant and see Chapter 15 to avoid get- ting into trouble.

In his book on entrepreneurship, Joseph Mancuso discusses how to choose the team members that work best with an entrepreneur (21). The best choice is not an energetic, go-getter like the owner. That person may become frustrated and refuse to take orders, or become an in- house competitor instead of an aide. You want to choose a bright, but otherwise committed (family, small children, not a leader, etc.), person who benefits your company through good ideas, loyalty, and team spirit. Dietitians have had luck with subcontractors who complement their own personality traits. If the owner loves to market or sell, the subcontractor may enjoy counseling patients in a well-run office.

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40 THE ENTREPRENEURIAL NUTRITIONIST

C A S E S T U D Y 3 . 1

P R O D U C T I N V E N T I O N I N A U S T R A L I A

In the early 2000s, I developed the concept for a dinner plate (Fig. 3.2) that presented three nutrition messages in a visual and useable for- mat. I had the distribution channel estab- lished via my Great Ideas in Nutrition online bookshop for dietitians, but I was a little stumped at how to get my ideas into produc- tion, particularly while running a busy private practice.

By 2005, other products had popped up overseas, but I had my plate in production and Australian dietitians loved it. I then could see that I needed to attract more attention from the general public so that it could be used for dinner rather than just as an educa- tional model. I wanted to get the plate into stores, but what kind of stores would you ex- pect to find such an item—pharmacies? kitchen shops? health food stores? And, how does one get a product into such stores? I sent out a few letters and tried talking to a few people, but really didn’t get anywhere.

I also felt the plate needed another prod- uct that made the package more comprehen- sive. The plate would only be used for one or two main meals in the day—but what was my guidance for the snacks or the other meals? I decided I should write a comprehensive book- let to sell with the plate and package it all up to sell through an outlet of some kind. In fact, I felt I should add photographs to the book- let so that it continued with the theme of a vi- sual tool for weight control. I wanted to show people how much and what to eat for break- fast and snacks and other meals that didn’t fit on the plate. This project then sat on my list of “things to do” for a while.

Being a retail bookshop, I get all the prere- lease catalogues from the publishers. I often spot business books which make interesting reading and buy a copy for my own interest. In early 2007, I placed one such order for a book entitled Maverick Marketing, by Lisa Mes- senger. Her concept was to publish a book to

help raise the profile of your business. She suggested that you could actually try and sell copies before it was even written by develop- ing a prerelease brochure and setting the re- lease date several months ahead. Her ideas suggest that the book should be like a busi- ness card—reflecting the style of your organi- zation and showcasing your products.

The book went on to suggest that you partner with like-minded businesses who may like to bulk buy copies of your book to give to their customers or staff and that this way you could fund the printing of your book, not to mention only finish writing it when you knew you had a market. In fact, this is what Messenger had done with me. She was able to show her book in the prere- lease catalogue of her distributor several months in advance and find out how many bookstores had placed orders for it before it went to print.

I realized that while I knew nothing about getting a product into pharmacies or kitchen stores, I knew a lot about how the book in- dustry worked. I decided that rather than write a booklet to go with the plate, I’d write a book that would help sell it in bookstores and box it up with a plate!

Lisa had showcased her own business very well in her own book, so I knew that she of- fered services in assisting people to self pub- lish. I set up a meeting immediately. I knew what I wanted my book to do but I couldn’t exactly see what should be on each page. Dur- ing a consult, I started thinking about what I would show clients if I had unlimited access to foods, and it all began to fall into place. I wanted to assess all the brand-named prod- ucts on the market, choose the ones with ap- propriate calorie contents for either weight loss or weight maintenance and show photos so they were recognizable and easy to find in the supermarket.

A year of cooking, shopping, photography and design, and a lot of spending, and it was done! The finished product was released on October 1, 2008, and it’s selling really well with significant media interest.

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CHAPTER 3 ■ Business Strategies and Management 41

over your calorie target, the plate smashes and you get to try again.

It’s fun, has some educational value, and is a method of driving people to our site to purchase the products.

I have really loved the freedom that private dietetic practice gives me to apply my knowl- edge in any way that I see fit. I encourage di- etitians to pursue their own interests within the field and to look for ways to make their ideas come to fruition.

Check out our websites: www.portionper- fection.com.au for the game and information about the book or www.greatideas.net.au to see our online bookshop. —Amanda Clark

About the Author Amanda Clark, dietitian, Advanced APD, au- thor of Portion Perfection and director of Great Ideas in Nutrition, was the winner of the 2006 President’s Award for Innovation from the Dietitian’s Association of Australia.

FIGURE 3.2 ■ Dinner plate developed by Amanda Clark (see Case Study 3.1).

I have wanted to do more than that. I re- ally feel that portion control is the way to go for most people, and that many have lost touch with what is a suitable-sized meal or snack. I want to ensure that this product has its best chance of making a difference, and for that to happen, people need to have a copy.

I have decided to take advantage of the Web email network women have, forwarding interesting, amusing, and sometimes contro- versial snippets around the globe to their whole address books. I wanted to test out “viral marketing.” We are currently working on our online game, where players will be able to select a profile, such as “Women aim- ing to lose weight,” which will set their calo- rie target for the lunch meal. They will have a selection of foods from the book to drag and drop via the “portion perfection fairy” char- acter onto the plate and each food will give a little message and a calorie count. If you go

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42 THE ENTREPRENEURIAL NUTRITIONIST

■ Provide good management to keep services consistent and on budget.

■ Keep an open mind and be flexible to make changes when needed.

■ Have credibility and shared loyalty with customers.

■ Invest hard work and have perse- verance.

REFERENCES 1. Beckwith H. Selling the Invisible: A Field Guide

to Modern Marketing. New York: Warner Books, 1997.

2. Bhide A. The Questions Every Entrepreneur Must Answer. Harvard Business Review on Entre- preneurship. Boston, MA: Harvard Business School Press, 2004.

3. Gutek B, Welsh T. The Brave New Service Strat- egy: Aligning Customer Relationships, Market Strategies, and Business Structures. New York: AMACOM, 2000.

4. Aaseng N. The Rejects. Minneapolis, MN: Lerner Publications, 1989.

5. Bhide A. How Entrepreneurs Craft Strategies That Work. Harvard Business Review on Entrepre- neurship. Boston, MA: Harvard Business School Press, 2004.

6. McGarvey R. We’re Not #1: Why Playing Sec- ond Fiddle to an Industry Leader May be Music to Your Ears. Entrepreneur, January, 2001.

7. 1990 Survey of Business Start-ups. National Federation of Independent Business, 1991. Available at: http://www.businessweek.com/ smallbiz/news/coladvice/ask/sa990930.htm. Accessed April 4, 2009.

8. Helm KK. Becoming an Entrepreneur in Your Own Setting. Chicago, IL: The American Dietetic As- sociation, 1991.

9. Rose J. Cooper Memorial Lecture. Presentation at ADA Annual Meeting, 1987.

10. Gorman T. The Complete Idiot’s Guide to MBA Basics. New York: Alpha Books, 2003.

11. Henricks M. Management. Entrepreneur, Janu- ary, 2001.

12. Sobel M. The 12-Hour MBA Program. New Jer- sey: Prentice Hall, 1993.

13. Jonas R. Strategic Thinking: A Vital Skill Set for 21st Century Survival. National Business News, May/June, 1999. Available at: http://www.strat- egyinc.com/pdfs/Business%20strategy.pdf. Accessed April 4, 2009.

14. Shostack GL. Designing Services That Deliver. Harvard Business Review, January/February, 1984.

A contract or letter of agreement should be signed and reviewed by your lawyer. If a subcontractor or employee is placed with a client’s account, have the client agree to it in writing, and visit the client every 4 to 6 weeks. Replace the person if the client is unhappy instead of losing the account. Keep business as business.

YOU KNOW IT IS TIME TO CLOSE WHEN. . .

After all you have invested, you know it is time to close the business when (22):

■ You become emotionally detached from the business and dread going to work.

■ You struggle to pay the bills month after month, taxes go unpaid, and you start paying bills with credit cards.

■ There is a marked increase in customer complaints, or established customers are coming less often or not coming back—and you have been trying to correct things for some time.

■ You are in strong denial about how bad things are really getting—or have been for some time. You realize you haven’t been listening to your banker, account- ant, or family when they tried to tell you what was happening.

Some other signs of trouble may be ex- cessive employee turnover (often a sign of a failing business) and excessive price cuts to move inventory or attract business (re- duces profits and cash flow causing an even worse downward spiral). These signs can also be a call to action to do something to correct them.

SUMMARY

The keys to a successful business are:

■ Work on having a relationship or quality encounter with clients.

■ Have good products or services and great customer service.

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CHAPTER 3 ■ Business Strategies and Management 43

15. Dietitian and Product Development. Courier. Chicago, IL: The American Dietetic Associa- tion, 1990.

16. Richman T. How to Grow a Product-Based Business: Advice on How to Develop a Business Around a Product Idea. INC., April, 1990.

17. Hakuta K. How To Create Your Own Fad and Make a Million Dollars. New York: Avon Books, 1989.

18. Stem S, Schoenhaus T. ToyLand: The High- Stakes Game of the Toy Industry. Chicago: Con- temporary Books, 1990.

19. Kiyosaki R, Lechter S. Rich Dad, Poor Dad: What the Rich Teach Their Kids About Money—That the Poor and Middle Class Do Not! New York: Warner Books, 2002.

20. Stanley TJ, Danko WD. The Millionaire Next Door. New York: Pocket Books, 1998.

21. Mancuso J. How to Start, Finance, and Manage Your Own Small Business. New Jersey: Prentice Hall, 1990.

22. Wuorio J. Know When It’s Time to Close Up Shop. Home Office. MSN.com Accessed July 15, 2002.

RESOURCES ON ENTREPRENEURSHIP AND BUSINESS SKILLS Allen D. Getting Things Done: The Art of Stress-Free

Productivity. New York: Penguin Books, 2002.

Barringer B, Ireland D. What’s Stopping You? Shatter the 9 Most Common Myths Keeping You from Starting Your Own Business. Upper Saddle River, NJ: FT Press, 2008.

Gitomer J. Little Platinum Book of Cha-Ching!: 32.5 Strategies to Ring Your Own (Cash) Register in Business and Personal Success. Austin, TX: FT Press, 2007.

Gitomer J. Little Red Book of Selling: 12.5 Princi- ples of Sales Greatness. Austin, TX: Bard Press, 2004.

Gold SK. Entrepreneur’s Notebook: Practical Advice for Starting a New Business Venture. Stanford, CA: Learning Ventures Press, 2006.

Heyman J. All You Need is a Good Idea!: How to Create Marketing Messages that Actually Get Results. Hoboken, NJ: John Wiley & Sons, 2008.

Kawasaki G. The Art of the Start: The Time-Tested, Battle-Hardened Guide for Anyone Starting Any- thing. New York: Penguin Books, 2004.

Sweet M. A Fearless Guide to Starting a Profitable 5K Business: Create Immediate Income by Investing $5,000 or Less. Boulder, CO: Cherry Creek Press, 2007.

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4 WHAT CAN WE LEARN FROM THE “MASTERS”?

In the 2008 World-wide Entrepreneurial Dietitian Survey that I conducted on Survey- Monkey.com, 1638 dietitians and dietetic technicians answered questions on the sur- vey (1). Out of that number of practition- ers, 60 indicated that they make $100,000 to $200,000 net income per year, and 30 made more than $200,000 net income in their best year (1). There are salaried dieti- tians who make more than $100,000 per year, especially those who are in business sales or executive positions, food service management, education, and research, but the median compensation for Registered Dietitians (RD) in the U.S. in 2007 was $53,300 and $36,400 for Dietetic Techni- cians, Registered (DTR) (2).

Since it appears that these 90 RDs are doing some things better than the rest of us, why don’t we study these “masters” to learn what they do?

DEMOGRAPHICS

Let’s get to know more about who these people are. Eighty-three of them said they were women and six were men. Their ages varied with the majority being in their 40s and 50s (see Fig. 4.1) (1).

How long had these practitioners been self-employed? Out of the 90 respon- dents (1):

■ 27 were self-employed for 10 years or less

■ 27 were self-employed for 11 to 20 years ■ 32 were self-employed for 21 to 30 years ■ 4 were self-employed for 31 or more

years

It is interesting to see that 30% of this suc- cessful group had been self-employed for 10 years or less—and 60% had been entre- preneurs for 20 years or less (1). This leads me to believe that when the right formula comes together—the person and her or his personal abilities with the right idea—pros- perity can happen sooner rather than later, and there is longevity. Although there are ups and downs in any business, entrepre- neurs learn how to sustain their businesses once the tremendous amount of initial ef- fort begins to pay off.

How educated are these individuals? As mentioned earlier, of the masters making more than $200,000 net income per year, 12 were RDs, 13 had Master of Science de- grees, and 5 had Doctorates (1). Of the mas- ters making $100,000 to $200,000, 12 were RDs, 39 had Master of Science degrees, and 9 had Doctorates (1). Although the masters group as a whole was more highly educated percentage-wise than the members of the American Dietetic Association, 27% had just the RD credential, which shows that being successful as an entrepreneur re- quires unique personal qualities but does not demand an advanced degree. It can’t be overlooked however, that three-fourths of these individuals have advanced degrees which surely helped bring more credibility and a higher level of image or prestige into some work venues, and it surely helped them land consultant positions or open doors.

When asked if they had always had an entrepreneurial personality, 93% of the masters said “yes,” but only 64% of those in the full survey had said “yes” to this

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CHAPTER 4 ■ What Can We Learn From the “Masters”? 45

week, 51% worked 26–60 hours per week, and 13% worked 61 to more than 70 hours per week. Now that their businesses are suc- cessful, how many hours per week does it take to maintain their income? This is in- teresting; they reported (1):

■ 6.6% work less than 26 hours per week

■ 26.7% work 26–40 hours per week ■ 50.7% work 41–60 hours per week ■ 13.3% work 61 to more than 70 hours

per week

So, some of the masters have figured out how to maintain their level of income while cutting back on work hours. This can be accomplished by working in the highest paying media jobs or by creating products (such as best selling books, soft- ware programs, licensing inventions, and so on) that sell without the person’s phys- ical body being there to make the sale or deliver the service. As you can see, to make this level of income requires 64% of the re- spondents to work 41 to more than 70 hours per work week. Their commitment to their ventures would be overwhelming to many.

Initially, most of their planning time before opening their businesses was spent on (a) creating the product or serv- ice; (b) establishing a referral network; (c) writing handouts, forms, materials, and client contact; (d) paperwork and bookkeeping; (e) marketing planning and meeting to discuss strategies; (f) creating a business plan; (g) securing the right lo- cation; and (h) meeting with professional advisors (1).

When asked how much of their own money they invested to get their businesses started, the responses were (1):

■ 36.3% invested up to $1000 ■ 26.35% invested $1000 to $5000 ■ 12.5% invested $5001 to $30,000 ■ 11.3% invested $30,001 to $60,000 ■ 6.3% invested more than $80,000

question. Members of this well-paid group identified their top reasons for starting into their own businesses (1):

1. To be their own boss 2. A more flexible schedule 3. To make more money 4. To do a variety of work 5. To be challenged and to use their

creativity more

These individuals were willing to trade an 8-hour per day position for one requiring 12 hours or more in order to be their own boss and make more of the decisions governing their professional and private lives.

The time and effort invested in their en- trepreneurial ventures may be hefty, but it should also be pointed out that these in- dividuals volunteer a lot of their time and expertise to their dietetic practice groups, churches, community needy programs, and school or community groups like scouts or Boys and Girls Clubs (1).

WHAT DID IT TAKE?

Initially, 58% of the masters said they started into business while working part- time. During their first year in business, 36% worked less than 10–25 hours per

FIGURE 4.1 ■ 2008 World-wide Entrepreneurial Dietitian Survey: Ages of “Masters” making $100,000 or more (1).

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46 THE ENTREPRENEURIAL NUTRITIONIST

BOX 4.1

An interview with Mia Sadler, Accredited Practicing Dietitian (APD), Managing Director, The Food Group International (aka The Food Group Australia or just “The Food Group”), Sydney, Australia

Q: You started with a one dietitian consulting service in one local food company. You now have a team of dieti- tians servicing global food clients in 38 countries. How did you get there? A: It began with the exit strategy. The plan was to establish a global nutrition consulting agency, but I wanted the agency to one day op- erate without me. So right from the start, I worked under a company name that is not mine. I wore many hats—principal dietitian, re- ceptionist, accounts payable, accounts receiv- able, and the rest. Whatever the task, it was recorded. All processes, procedures, tools, best practices, learnings (good and bad), and client details were documented. That way, as the business grew, I could recruit people to con- tinue with consistent service delivery, while I focused on the future business.

Q: How do you maintain such long-term relationships with your clients? A: First, we ensure that our work ethics are well matched. We have a set of company values at The Food Group, and we select and partner with clients on the basis of value compatibility. Our values (integrity, excellence, superior serv- ice, accountability, teamwork, and wisdom) are not the kind of values listed on a plaque on the wall, gathering dust. We work by them, recruit by them, and base our processes and proce- dures on them; so, we need our clients to value them as we do. All our value discussions take place before we commit to working with a client. This up-front investment has allowed us to sustain and grow our working relationships for the 11 years that we have been in business. At the same time, we have never had to com- promise our values, our credibility, and there- fore our future business.

Second, the more we know about our clients’ businesses, the more value we can offer, and the more strength we add to our ongoing business relationships. Our clients and our company both invest significant time and resources to ensure that our nutrition service team understands their business. Our clients all have different focuses and competencies in nutrition, but they all share the common value of pursuing excellence. Whether they are pri- mary producers, food manufacturers, or the leading quick service restaurant—McDonald’s— as long as they maintain their commitment to create better-for-you choices, we will join them on their journey, hopefully for many years to come!

Q: What advice do you have for dietitians who want to start a consulting business like yours? A: Define what success means to you and plan for it. By success, I mean not just in terms of your business but also your life. For example, success for you may include being fit and healthy, being a good parent, or giving back to your community. Once you have defined suc- cess, you can focus on those things that are most critical in achieving it.

For me, achieving business success depends on our people. This begins with clearly articulat- ing the competencies I want in my people and re- cruiting talent that matches. Behavioral interviewing, validated psychometric or cognitive testing, and guidance from an occupational psychologist have helped me make the right and often difficult people choices. Once on board, I work in partnership with each team member to plan for their ongoing competency, develop- ment, and life success. This starts at orientation and never stops. To date, it’s included in plan- ning for work, overseas experience, maternity or paternity leave, career moves, and returning back to work at The Food Group. Whatever it is, the aim is always to enjoy the journey, because success for me is loving what I do! And even though I will exit one day, right now, I’m loving it too much.

For more information, contact Mia at mia.sadler@ thefoodgroup.com.au.

Once You’ve Built a Successful Business, How Do You Stay There?

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Very few people borrowed money to cover this investment, but when they did bor- row, they usually got the added money from (a) a financial institution loan, (b) credit cards, or (c) family (1). These frugal people kept their overhead low, and 74% broke even on their initial investment within 1 year or less (1). One hundred per- cent of them had recovered their initial in- vestment within 4 years or less (1).

WHAT DO THEY SELL?

Below is the listing in descending order of what the masters sell to make their in- come (1):

1. Medical nutrition therapy (MNT) 2. Speaking 3. Business consulting 4. Writing articles and brochures 5. Wellness consulting or presenting 6. Writing books 7. Media spokesperson

The list changes, however, when you look at what the “ultra-masters” (people making over $200,000 per year) sell to generate their income (1):

1. Business consulting 2. Speaking 3. Writing books 4. MNT 5. Writing articles and brochures 6. Long-term care 7. Media spokesperson

The top clients change in this second list- ing from working with individual clients to working more with business clients. There were also random individuals who made most of their money in web designing, as supermarket consultants, as CAM (comple- mentary and alternative medicine) or func- tional medicine consultants, as menu or recipe developers, as fitness teachers, or in self-publishing (1).

HOW IS THE LESS THAN $30,000 PER YEAR GROUP DIFFERENT FROM THE MASTERS?

Comparisons need to be made here about the differences between survey respon- dents who make less than $30,000 per year and these masters. Of the lower in- come group, 64% see less than 50 new clients per year, while the masters have 34% who see less than 50 clients but 47% who see 51–500 new clients per year (1). The fees charged for an initial patient consultation points out another reason for the large gap in income: 70% of the lower income group charge less than $50 up to $100 per initial consultation while only 26% of the masters charge in that range (1). Yet, both groups spend the same amount of time in the consultation (46–90 minutes) (1). Seventy-four percent of the masters charge $100 or more for initial consultations with patients, and only 30% of the lower income group charge over $100 for the initial patient visit (1).

Seven percent of the lower income group works more than 41 hours per week as com- pared with 64% of the masters (1). Sixty-six percent of the less than $30,000 per year group have 15 or fewer billable hours per week that generate income, while only 6% of the masters have so few hours per week that produce income (1). Fifty-eight percent of masters have more than 26 billable hours per week, and the lower income group had 8% with more than 26 billable hours per week.

We don’t know the actual situations, but by looking at the numbers, we can see that the masters work longer hours, see more clients, and charge more for each visit.

SUMMARY

If an entrepreneur is earning less than $30,000 per year and wants to generate

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48 THE ENTREPRENEURIAL NUTRITIONIST

more income, there are at least five things to do:

1. Improve what you sell so that its per- ceived value is as good, or better, than your local competition.

2. Raise your prices to complement the new value of the improved services or products.

3. Contact two new potential referral agents each week and cultivate a relationship with them, so that you will have more patients or clients to see.

4. Schedule these new clients; offer excellent customer service; and thus, generate more billable hours of revenue.

5. Work smart and make good deci- sions—make a list of five things you could change to improve your busi- ness and start working on the list to- morrow.

REFERENCE 1. King K. 2008 World-wide Entrepreneurial Dietitian

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Creativity remains the lifeblood of con- tinued growth in a career. Creativity can mean a new invention or insight, or the ability to overcome obstacles by approach- ing them in novel ways.

Psychologists now believe that we are born with creativity but we allow it to at- rophy as we grow older (1). They believe it’s our social conditioning that teaches us to squelch curiosity, fear failure, and inhibit any new, nontraditional ideas. Eventually, we become so used to conforming that cre- ative thought becomes uncomfortable. Ashley Montague once said that all men want today is “a womb with a view” (2).

Many businesses are just beginning to recognize the importance of having new, exciting ideas. They are developing inno- vation committees and creative think- tanks, and rewarding new ideas. Some companies have been doing it for years. The 3M Company has allowed its re- searchers to spend 15% of their time on whatever project interests them, since the 1920s (3). Corporations are sending their employees to training programs run by “creative consultants.” Some business schools now teach creativity along with other basic courses.

As Teresa Amabile, senior associate dean for research at the Harvard Business School, found in her research, “In many compa- nies, new ideas are met not with open minds but with time-consuming layers of evaluation” (4). She found managers in successful, creative organizations rarely offer financial rewards but instead freely and generously recognize creative work,

whereas managers who kill creativity do so by failing to acknowledge innovative ef- forts or greet them with skepticism (4).

INTELLIGENCE AND EDUCATION

As nutrition professionals with scientific training, we often discount the importance of creativity. Creative ideas may be seen as nonscientifically based. Could our en- trenchment in this way of thinking be the reason why so often we are hired to carry out a layman’s or other health profes- sional’s nutrition ideas? Why aren’t more of us at the forefront of the nutrition trends?

Nobel laureate, Jonas Salk, inventor of the polio vaccine, once said, “When I be- came a scientist, I would picture myself as a virus, or a cancer cell, and try to sense what it would be like to be either” (5). He often referred to himself as both a scientist and an artist. Intelligence is creative by na- ture. Creativity helps develop ways to bet- ter use our intellectual capabilities (5).

By teaching and only using today’s gen- erally accepted nutrition ideas and strate- gies, we are doomed to follow, instead of lead in our nutrition arena. Trying to make dietitians or dietetic technicians think just the same is a grave mistake. Yet, so often we are hesitant to try new ideas ourselves or to support our peers when they try something new like nutrition in comple- mentary medicine or higher-level business skills in sales, marketing, product develop- ment, etc.

NURTURING CREATIVITY

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50 THE ENTREPRENEURIAL NUTRITIONIST

“STUCK”

The opposite of creativity is being “stuck,” or habitual thinking. When a quick answer will not come for a problem, many people doggedly stick to the same problem-solving processes they have used all their lives (7).

When people are stuck, they often jump to conclusions before they have full under- standing of the situation. On the other hand, creativity allows a good problem solver to look on all sides before commit- ting to a solution (5).

MYTHS ABOUT CREATIVE GENIUS

In an article, Strokes of Genius, psychologist Perry Buffington explores the myths around the idea that very creative people are differ- ent from the rest of us. He suggests that “genius may be nothing more than a cer- tain style of thinking” (7).

Because most people do not feel that they are capable of advanced thinking, they often fail to live up to their full potential. However, genius may be the result of using the creative potential of the brain, instead of being born with a “special” brain (8).

When Albert Einstein’s brain was do- nated to science, it was found that it did have more glial brain cells. It is thought that these cells contribute to amalgamation of information from other areas of the brain. In fact, the extra brain development in Einstein may have been the result of his genius ways of working and thinking rather than the cause of it (8).

Myths about creative genius need to be explored to negate the powerful hold they have on our perceived ability to grow and be creative. Buffington identified the fol- lowing five myths (7).

MYTH: A GENIUS CREATES MASTERPIECES OR INVENTS REVOLUTIONARY THEORIES OVERNIGHT

This is not true. Much like the average per- son, a genius develops ideas via incremen- tal critical thinking and a special type of

PERSONALITY

Creativity is not just a matter of intellect; it is a factor of personality. Experts describe a highly creative person as one willing to live with ambiguity. He does not need problems solved immediately and can af- ford waiting for the right idea. Creative people are often unconventional, curious, and highly motivated but easily bored (5).

Creative people are often depicted as leading chaotic lives. The truth is that busi- ness executives could learn a lot about organization from artists. According to Stephanie Winston, author of The Orga- nized Executive, “Creative people are ex- tremely disciplined in their use of time, control their environment, and are capable of focusing their attention like a laser. They are essentially not distractible, whereas many of my business clients can be dis- tracted by the drop of a pin” (6).

Other people sometimes perceive creative people as being “different” or so ingenious as to be a “threat” to the comfortable status quo on a job. For a self-assured supervisor, these people won’t pose a threat but, in- stead, an opportunity to have wonderful en- ergy and new ideas coming into the system.

In Australia, they have a concept called the Tall Poppy Syndrome, which describes the event when a person becomes espe- cially recognized or successful and he raises his (poppy) head above the status quo (where all poppies are the same height)—his peers or colleagues bring him back down (through various means like gossip, discrediting, withholding recogni- tion, peer pressure, etc.). This lack of sup- port for successful colleagues is not unique to Australia.

Often, creative people work best while alone. They can also be productive in a sup- portive environment where other people with greater skills in management or tech- nical expertise refine and carry out their ideas. By complementing each other’s areas of specialty, each person’s capability for creativity can blossom. Work output is sometimes brilliant.

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CHAPTER 5 ■ Nurturing Creativity 51

worry. For example, there is no doubt that Ludwig von Beethoven was a genius. Yet, inspection of his sketchbooks with over 5000 pages of preliminary musical scores makes it clear that Beethoven worked hard to perfect his work (7).

Inherent in this myth is the idea that creative ideas all of a sudden appear with- out any previous thought. According to Buffington, “It appears that efficient prob- lem-solvers ‘creatively worry’ and carry a problem around with them mentally even while doing other tasks. Brief episodes of mulling over a problem are precursors to insight. What appears to be a sudden solu- tion is actually the result of days or weeks of detailed thoughts, incremental changes, and critical evaluations, eventually allow- ing the solution to arrive” (7).

MYTH: GENIUSES ARE BORN

Although slightly true, there is evidence to suggest that a genius’s abilities are because of practice. Ten years of practice seems to be the amount required (7,8). A period of time is needed to learn the rules of the trade or field of study. Even a would-be genius must study and learn the necessary building blocks. For instance, a master chess player must develop at least 50,000 patterns with four or five pieces in each pattern. These building blocks are developed over time: 10 years and 25,000 to 30,000 hours of creative worrying and actively studying chess (7).

Motivation and commitment are key variables in the definition of genius. Dr. John Ketteringham, coauthor of the book, Breakthroughs!, states that originators of great ideas “come from all strata of society and can be anyone from distinguished research scientists to high school dropouts” (9).

MYTH: AN INDIVIDUAL GENIUS IS CONSISTENTLY CREATIVE THROUGHOUT HIS OR HER LIFE

This is not true. For example, Einstein rejected the statistical laws of quantum mechanics as an explanation of how our

universe works and as a result removed himself from the forefront of new thought in this area. In later years, Einstein himself stated that this inability to see far enough into the future made him and his views a “genuine old museum piece” (10).

Until recently, dietitians have had the image of being slow to accept or apply new ideas in nutrition. This slowness often has made our programs and business ideas also-rans, instead of on the leading edge of nutrition innovation. It’s encour- aging to see support for programming on herbs and alternative therapies, functional medicine, nutrition genomics, and mem- bers’ enthusiasm for the Nutrition in Complementary Care (NCC) Dietetic Prac- tice Group.

MYTH: TO BE A GENIUS, ONE MUST CREATE ORIGINAL WORKS

Often the creative genius lies in the ability to do a common thing “different or better.” It’s not necessary to create a breakthrough idea to be considered immensely successful in life.

A breakthrough is defined as a product or service that proves to be much more than a fad or trend. It can change the way people live and can create huge new markets where none existed before, like gourmet bottled water or the microwave (9).

Copying others’ work is certainly not suggested, because it shows lack of creative thought and respect of ownership. Learn- ing from another is the way most ideas are developed.

MYTH: GENIUS IS ALWAYS RESPECTED AND ACKNOWLEDGED

Not so. The true worth of a person’s ideas may be seen after the person’s death or fall from popularity. What is genius in one set of circumstances may be simple medioc- rity in another. In other words, the ac- knowledgment of creative genius is an interaction between the artistic work or

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52 THE ENTREPRENEURIAL NUTRITIONIST

BRAINSTORMING VERSUS CREATIVE THINKING

In the early 1950s, Alex Osborn developed the notion of brainstorming, initially de- signed to increase the creativity of Ameri- can scientists and engineers. The technique allows any idea to be put on the table. Crit- icism is not allowed; bizarre ideas are wel- come; quantity is encouraged; and no critiquing takes place until the ideas are generated (7).

Recent studies have compared brain- storming groups and critical thinking groups (creative worrying practiced by most geniuses). The result supports the ge- nius way of thinking. Two groups of under- graduates were chosen as participants. Both groups were asked to invent brand names for a deodorant and an automobile. One group was allowed to use the brainstorm- ing technique with no instructions. The other group, critical thinkers, was offered instructions that placed more emphasis on analyzing the ideas as they were produced. The names generated were then rated on a quality scale by a third group of students. As expected, the brainstorming group gen- erated more ideas than the other group. However, on closer inspection, they did not create as many “great ideas.” In other words, critical evaluation, or creative wor- rying, increases the quality of ideas. Critical judgment is essential from the moment the idea is conceived and it is what separates average ideas from genius-type ones (7).

HOW CAN BUSINESSES FOSTER CREATIVITY?

There is no set formula for fostering creativ- ity. The company that designs a “creative workplace” has no more chance than any other company of engendering a break- through idea, according to Ketteringham. He states, “We found that breakthrough ideas grew in rich soil, poor soil, and no soil at all” (9).

scientific theory and the current needs of the audience (10).

Ketteringham states, “The popular myth is that inventors see a need in the market- place and try to satisfy it. In most cases, we found that they were driven by their own intellectual curiosities and personal needs to solve a problem” (9).

CREATIVITY TRAINING

The purpose of creativity training is to help people avoid becoming stuck or escape from it to find better solutions. For years, experts have been trying to find out how people come up with creative ideas.

The moment of creative insight often does not come when a person tries the hardest but when he or she least expects it. In most cases, creative people had been grappling with the problem consciously and subconsciously for a long time before their sudden insight (2).

The major contributors to the deve- lopment of creative thought are the com- mitment of adequate time, energy, and free-flowing thoughts. Old barriers (time, money, resources, etc.) and old ways of doing things should not be allowed to in- fluence the flow of ideas. Reality can be dealt with later, after the full potential of the idea has come forth. Another idea to help stimulate creativity includes associat- ing with other creative people who en- courage new ideas to flow. Whenever a person is stuck, he or she should alter the pace, change rooms, or go for a walk. Let the subconscious mind work with the problem while the person does something else (5).

TECHNIQUES

Faced with the job of fostering new ideas on a daily basis, businesspeople soon de- velop their own style. Some common tech- niques follow.

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CHAPTER 5 ■ Nurturing Creativity 53

Management can help by allowing team- work and exchange of new ideas to take place. It also can help by not overmanag- ing a new idea. New ideas need to be given time and room to develop to the full poten- tial in a supportive atmosphere.

At 3M, they use the “lead user” ap- proach, which means they collect informa- tion from the early users of new ideas, not from the people who follow the crowd once the idea is a hit. When 3M team members have the beginning of a good idea, they know there are probably lead users in the public who are many stages ahead on the development. Through net- working and following leads to authors of articles, speakers, government researchers, and amateur inventors, they track down the people who are on the leading edge of a new concept. These experts help the 3M people understand the breakthrough idea they are seeking and save untold amounts of trial and error as well as years of invested time to assess the idea’s potential and whether it should be developed (11).

SUMMARY

The creative dietitian will read this informa- tion and start to relax while she or he plots the course for change. Sarah and Paul Ed- wards, authors of Making It on Your Own, a book on how to start a business from home, give the following suggestions on “what to do when you don’t know what to do” (12):

1. Don’t worry. Decide instead that you need to solve the problem and then go after it.

2. Trust your gut. One way to make sure you do something right is to do it wrong first, but not for long. How- ever, intuition can often be accurate and a very dependable barometer for how you really feel about something.

3. Focus on the desired outcome. If you’re caught up in the problem, the solutions aren’t readily apparent. Look at it objectively.

4. Think of several solutions. Gen- erate as many options as possible be- fore you decide which is best.

5. Talk with an outsider. Talk it through with someone and look or listen for new ideas or perspectives. Seek out people you respect who lis- ten well and don’t always agree with you. This may be a good time to con- sider talking to mentors, peer confi- dants, or professional advisors.

6. Don’t just stand there, do some- thing. Often, lack of action sets you back as much as taking the wrong ac- tion. Try out an option in a small way if you can, to see if it works.

Every business venture has problems and every businessperson has times of indeci- sion. The successful businessperson is the one who learns to solve problems, comes up with new options, or reacts to situations that need feedback quickly and efficiently.

REFERENCES 1. Seabrook J. Flash of Genius: And Other True Stories

of Invention. New York: St. Martin’s Press, 2008. 2. Ingber D. Inside the Creative Mind. New York:

Success, 1985. 3. Hoffer W. Innovators at Work. New York: Suc-

cess, 1985. 4. Amabile T. How to kill creativity. Harv Bus Rev.

1998;76(5):76–87. 5. Neimark J. Intelligence vs. Creativity. New

York: Success, 1985. 6. Feinberg A. Artists of Organization. New York:

Success, October, 1987. 7. Buffington P. Strokes of Genius. Dallas, TX:

Sky, February, 1987. 8. Weisberg RW. Genius and Other Myths. New

York: W.H. Freeman and Co, 1986. 9. For Members Only. American Express. Interview

with John Ketteringham, coauthor of Break- throughs!, 1990.

10. Yulsman T. Einstein Update: The Better Brain. Science Digest, July, 1985.

11. von Hippel E, Thomke S, Sonnack M. Creating breakthroughs at 3M. Harv Bus Rev 1999;77 (5):47–57.

12. Edwards P, Edwards S. Making It on Your Own. Los Angeles, CA: JP Tarcher, 1990.

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6 BUILDING YOUR CREDIBILITY

Not being taken seriously is a common complaint of new entrepreneurs. It’s a prob- lem if you work out of your home, or if you look or sound very young. Institutions still discriminate against self-employed people. Banks, for example, categorically used to refuse credit card merchant accounts of home-based businesses, and some tempo- rary employment agencies won’t send per- sonnel to a home office (1). These problems are improving, but for individuals who look young or inexperienced, they are very real. The longer a person stays in business and gains more credibility, the more these barriers diminish.

THREE SOURCES OF POWER

Self-employed people need power in order to attract clients, business financing, and support from others. In his book, Games People Play, Dr. Eric Berne describes the three sources of power, which he feels lead to credibility (2):

1. Position power is the authority and respect you command because of the position you hold within an established organization. Ways to capitalize on position power are the following:

■ Refer to yourself as “President,” “Owner,” “Senior Partner,” or some- thing similar.

■ Highlight former positions: “For- mer director of. . .” or “Former consultant to. . .”

■ Take a part-time teaching position that will show authority: “Instructor at. . .”

■ Become active in trade and profes- sional organizations where you work to be elected to positions of authority and visibility.

■ Land a position on the media or as a columnist in a newspaper or magazine.

2. Cultural power arises from the values of the culture within which you work. The academic degrees you hold, the schools you attended, the people you know, the clients you’ve served, the way you dress—each field and each community has its own set of expected credentials.

■ Look the part. Successful people look and act a certain way. How you look and act is your affair, but if you want the approval of others in power, it helps to look successful.

■ Become involved in business and business organizations so that you will know the un- written way to do things. It will give you more power, more clout, and will probably save you money.

3. Personal power is the authority you command by the force of your own personality and the results you produce. The other powers may get you in the door, but only if you pro- duce results will your credibility grow.

CREDIBILITY IS THE GOAL

The remainder of this chapter is adapted from material developed by Orlando Barone, used with his permission. Educator, lecturer, trainer,

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CHAPTER 6 ■ Building Your Credibility 55

be tarnished whether or not you knowingly tell an untruth.

Honesty generates confidence. If people think you are telling the truth, they will tend to have confidence in what you say. If people (patients, clients, peers, employers, etc.) have confidence in what you say, they do not need further verification beyond your word.

Confidence means people do not second- guess you. You say it, and the matter is put to rest. There is no endless debate about what you really meant. When confidence does not exist, your statement is the begin- ning of the matter, not the end of it.

The perception of honesty means people believe you. Communication is clean, clear, and efficient. Messages are taken at face value, not analyzed and reprocessed. Peo- ple listen for your content rather than for your motive.

Responsiveness Responsiveness occurs when others believe you will come through for them. They feel that you have access to the resources needed, and that you have the intelligence, energy, and ability to make things happen.

Promises must be kept. Responsiveness is built on honesty, but it goes beyond hon- esty. When your weight loss proposal ar- rives at your client’s office on Tuesday as promised, or when you call back your clients in a timely manner, your credibility is established. When you have to state honestly that the proposal was mailed on time and you don’t know what delayed it, credibility tends to deteriorate.

The perception of unresponsiveness, sometimes seen as irresponsibility, is deadly to credibility. Others often perceive you as being half-hearted or only giving “lip service.”

On the positive side, responsiveness gen- erates loyalty. If others think you will “come through” for them, they will do so for you. Responsiveness is actually a form of loyalty, the best form. If people perceive that you have that kind of loyalty, they will return it.

and author of Your Voice Is Your Business, Barone has for 30 years designed, developed, and delivered internationally acclaimed training in self-presentation and interper- sonal effectiveness. He has instructed at the graduate level in training and development and is on the adjunct faculty of Villanova University and Harvard University (3).

Credibility is a perception others can have about you; it means they believe and trust you. Having credibility with others gives you freedom to act because others trust you will do it well.

Studies of the most important qualities in scientists, managers, leaders, and sales- people always put credibility at or near the top. Most healthcare providers believe that credibility is essential to their effectiveness.

Strong credibility can sustain a profes- sional relationship even in severe adversity. Credibility is the basis of all lasting and fruitful human relationships. It forms the basis for open communication, teamwork, and mutual respect.

Strong credibility is difficult to build, but once established, it’s very resistant to ero- sion. However, once destroyed, credibility possibly will never be reestablished. It’s curious how so many politicians have been reelected after they have been convicted of crimes. Of course, some have been re- elected after they died!

COMPONENTS OF CREDIBILITY

Four basic terms act as building blocks that help develop credibility. These terms are honesty, responsiveness, consistency or reli- ability, and forethought. Since having cred- ibility is so important to a career, these four terms will be described in more detail (3).

Honesty The primary building block of credibility is honesty or truthfulness. People must feel that you are being honest with them. Cred- ibility will never be built if others think or even suspect you are lying. Credibility can

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This is not a loyalty born of obligation. This is a reasoned loyalty, earned loyalty, and loyalty rooted in legitimate self-interest. If credibility is strong, this loyalty will endure. Others will stay with you in a crisis; in other words, you have a right to ask for their loy- alty when times become rough for you.

A dietitian who offers extra time or en- ergy to a consultant account or client shows responsiveness and, of course, expects loy- alty in return. If loyalty is not forthcoming, the client’s credibility may be lost, and the dietitian may not choose to be responsive in the future.

The following is a good example of how responsiveness works in brief encounters: if a patient requests an appointment for a diet consultation at 7:00 AM (before nor- mal working hours), but then the patient fails to show up, it is doubtful that the dietitian will agree to reschedule at the pa- tient’s convenience again. Loyalty was not returned and therefore, the patient’s credi- bility was compromised.

Consistency or Reliability When you are consistent and reliable, oth- ers believe they can depend on you. They believe you will not give your support one day and retract it the next day. You do not change your personality or behave errati- cally as far as other people are concerned.

Your credibility will suffer if you cons- tantly change career courses or if you begin a new job before adequately finishing the last. It will suffer if you switch loyalties too often. As someone who is given a task, you should not have to be concerned whether to change course and leave him or her with many hours of wasted energy.

Sometimes reliability simply means that you are available and present. Reliability adds depth to responsiveness over time. There is a quality of constancy about your working relationship. Others have access to you; they can find you. You will not scare them off with mood changes or messages that you are too busy for them.

Credibility not only means that others believe what you say. They also believe that

what you say today, you will say tomorrow. This quality is really stability, a decision- making process that reaches conclusions sound enough that frequent changes of mind do not happen.

Forethought Forethought means what you say makes sense to other people. The things you say seem to be based on sound suppositions, on researched information, and logic. You show a command of the topic or situation. You seem to understand the way things really are. This aspect of credibility is often overlooked, yet its absence erodes credibil- ity. It appears a person does not use fore- thought when he uses inappropriate, quick, off-the-cuff remarks. Comments also may be poor due to the speaker’s lack of ex- pertise, knowledge, or intelligence.

Forethought generates respect. Respect is really a sense of security. Others feel secure when you know what you are doing.

Respect also means that other people feel you understand enough about a situa- tion to make intelligent statements on it. Dietitians who do not know enough about sports nutrition and the requirements of training or competition lose credibility with athletes by making statements that seem irrelevant and uninformed.

Being knowledgeable is essential in building credibility. Using your knowledge to say things that make good sense is a critical part of the perception of credibility.

CREDIBILITY SHOULD NOT BE CONFUSED

Since having credibility engenders many deep emotions, it is often confused with other feelings that people have for one an- other (3).

CREDIBILITY IS NOT RAPPORT

Many people confuse credibility with being personable, well liked, or sociable. It’s possible to have excellent rapport with someone and yet fail to have any credibility with him or her at all.

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CHAPTER 6 ■ Building Your Credibility 57

ship between the two people. They believe in certain things about your character, competence, experience, and knowledge. They learn these things about you as you relate to one another. Your authority is not something they learn; it goes with your position within that organization.

You may be obeyed because you have authority. Others may show you respect be- cause you have authority. But you will never have credibility with them simply be- cause you have authority.

Interestingly, credibility can give you a kind of authority. If you are credible on an issue, you are perceived as “authoritative,” having sound knowledge and competence in that area. This quality can cause people to follow you even when you have no for- mal authority at all. On the other hand, subordinates have been known to abandon ship on a manager with all the authority in the world—because the manager lost credibility!

CREDIBILITY IS NOT FEAR

You may have power over other people, either organizational or brute power. Others may do your bidding, but you will not necessarily have a shred of credibility with them. In fact, people who use intimida- tion frequently damage their credibility when they intimidate.

CREDIBILITY IS NOT SUBMISSIVENESS

All three of the above, rapport, authority, and intimidation, can bring about submis- siveness even if they do not engender credibility. Because you are personable and popular, you may cause some to fol- low your wishes, perhaps because the per- son does not perceive himself or herself to be very popular.

If you are submissive, there is an under- tone of coercion. You are acting against your will. If you go in someone’s direction because of his credibility, there is never co- ercion, or the feeling of coercion. You go because you believe in him or her.

Credibility never covers all areas, issues, and topics. You may have credibility as a clinical renal dietitian, but totally lack cred- ibility as a wellness dietitian. If you have no wish to establish your credibility as a well- ness dietitian, there is no problem.

The credibility issue arises only in those areas in which you want to build or main- tain credibility. If you want to be credible as a renal dietitian, and you are not, you have a problem. Others may think you are a wonderful person, but you may still lack credibility as a renal dietitian. The rapport is no substitute.

In addition, the credibility issue arises only with those persons with whom you want to establish credibility. You may want credibility with your clients as a culinary expert, but have no wish to estab- lish your credibility as a dietitian with your preacher. You may want to establish credibility with your preacher as a choir leader.

So, you may have rapport with someone at all times, but you can’t possibly have credibility with someone in all areas, or with all people in any one area.

While rapport is useful and positive in a relationship, it’s not essential to credibility. You can have very strong credibility with someone who would not spend one more minute than necessary with you.

Confusing credibility with rapport can cause anxiety and hurt feelings. For exam- ple, as a consultant, you may fail to sell yourself to a potential client who is also your friend. The client may not believe your argument that you are best qualified for the job if he has never known you as an expert in that field.

CREDIBILITY IS NOT AUTHORITY

Managers often confuse their organiza- tional power or authority with credibility. The manager is wearing the badge and giv- ing the orders, so he or she feels he or she has credibility with his people.

Credibility is built between one person and another. It is intrinsic to the relation-

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CREDIBILITY IS NOT AWE

Finally, someone may be awestruck, enrap- tured by you and your charisma, but you may fail to have a shred of credibility with him. If you perform some spectacular stunt or feat, you might well engender the feel- ing of awe, but you will have no more credibility than a waterfall. You will have credibility as someone who can engender awe in others.

Credibility is always built over time, as a result of sustained contact between two peo- ple. Awe comes in a sudden flash and can leave just as suddenly. Credibility, once built, never leaves suddenly, except through some calamitous event.

Remember that credibility always has a basis in reason and logic. It is always built over time, and it brings about a feeling often different from awe.

PROXY CREDIBILITY

Proxy credibility is any perception that eases or shortens the process of building credibility with you. Examples are reputa- tion, rumor, rapport, and several other personal promotional tools (3).

REPUTATION

If you are well regarded, well credentialed, or have a good record of performance, your reputation is enhanced, which creates

a favorable climate and builds credibility for yourself, your company, and your profession.

RAPPORT

If someone likes you, enjoys your company, shares common interests, and feels comfort- able with you, the path to credibility is smoothed.

SUMMARY

Credibility is essential for a long, sustained career in any field. It makes day-to-day dealings with people more productive and pleasant. Credibility opens doors of oppor- tunity and lowers resistance to ideas one wants to develop. Credibility is built day by day as you work and interrelate with other people. High achievers place attaining cred- ibility as a top priority.

REFERENCES 1. Edwards P, Edwards S. How to Win Credibility

and Respect. Home Office Computing, May, 1991.

2. Berne E. Games People Play. New York: Ballentine Books, 1996.

3. Adapted from a presentation by Orlando Barone. Credibility. Used by permission; Copy- right 1986. In: King Helm, K. The Entrepreneur- ial Nutritionist. 1st ed. New York: Harper & Row, 1987.

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The ethical manner in which people con- duct their businesses determines to a large extent the loyalty of clients and the support of peers. Clients want to feel they are being honestly served for a fair price. Our peers expect us to conduct ourselves profession- ally, honestly, and within the law. They expect us to give accurate information and not to engage in questionable dealings. It is also important to understand and interpret ethics from a multicultural perspective, and to understand that a person from another culture may interpret statements and ac- tions differently than we do (1).

Commonly, professional people who get into trouble ethically, legally, or be- cause of malpractice, go out of business. Occasionally, however, there is that rare instance where a person benefits from all of the publicity and ends up with a boom- ing business. If the breach is bad enough, a lawsuit, or loss of license or professional membership may occur.

All too often in the past, health profes- sionals were ridiculed or ousted from their professional groups because they had tried or believed in something new and differ- ent, but completely ethical and legal. For a profession and its members to lead in their areas of expertise, exploration of new ideas is mandatory. When judging the merit or ethical nature of a new idea, peers and or- ganizations must show some tolerance.

WHO JUDGES ETHICS?

Ethics in private practice may be “judged” by our professional and business peers, by government agencies, such as the judicial

system, the Internal Revenue Service, the Public Health Department, and by busi- ness organizations, such as the Better Business Bureau and the local Chamber of Commerce. As long as no one complains, probably no one will ever be concerned about you or your business. That is one good reason to take complaints seriously and follow them to resolution. However, fear of ethical breaches should not para- lyze you or make you compromise on all matters that you feel very strongly are right.

PROFESSIONAL PROCESS

If the person is an employee or contractual consultant, an ethical matter could simply be addressed in-house. If the person is in pri- vate practice, more than likely it is the local or state dietetic organization or state licens- ing board that will question a professional ethics problem. If the matter is serious enough, the Ethics Committee of the Amer- ican Dietetic Association (ADA) will review the case in terms of considering censoring or revocation of membership.

Peers have the obligation to handle an ethical review in a professional manner, and not to commit slander, libel, and character assassination. The accused indi- vidual has the basic right to be considered in the clear until proven otherwise.

THE INDIVIDUAL

Ultimately, it is the individual practitioner who must live with his or her own deci- sions. We all have varying degrees of restric- tions that we have placed on our actions,

ETHICS AND MALPRACTICE

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60 THE ENTREPRENEURIAL NUTRITIONIST

and values of individuals, and do not discriminate

■ That professional qualifications are presented accurately

■ That sufficient information is pro- vided for patients to make informed decisions

■ That conflicts of interest and the appearance of conflicts are avoided

■ That competency of practice is main- tained

■ That the professional does not engage in sexual harassment

■ That confidentiality of information is respected

■ That controversial material is substan- tiated and the interpretation is based on scientific principles

■ That advertising statements and product representation are truthful and do not misrepresent the product nor mislead the consumers

UP-TO-DATE KNOWLEDGE

As professional dietitians and dietetic tech- nicians, we are expected to give the best quality work we are capable of doing. To do that, we have an obligation to remain current and up-to-date in our field of knowledge. Our knowledge is what we have to market. Therefore, every effort should be made to have our knowledge timely, unbi- ased, well thought out, and of such quality that it is ahead of the competition.

SELF-REFERRALS

Established private practitioners normally consider it ethical to accept new patients who refer themselves as long as the service being asked for is within the professional’s scope of practice. The professional relation- ship between the patient and the practi- tioner is similar to when a patient goes to see a family guidance or a stop-smoking counselor—no referral is needed unless the patient wants insurance coverage to help pay for the visit. Why would eating be con- trolled by a medical referral? The dietitian is

according to our value systems. We tempt our ethical boundaries every time we don’t refuse a physician who wants a kickback, or when we give less than our best care because we run short of time, or when we discuss our fees at the local dietetic meeting (could be interpreted as price-fixing).

HONESTY IN BUSINESS

In their article, Why Be Honest If Honesty Doesn’t Pay?, authors Bhide and Stevenson have found in extensive interviews that treachery can pay (2). There is no com- pelling economic reason to tell the truth or to keep one’s word. In the real world, punishment for the treacherous is neither swift nor sure, even when wrongdoing has clearly been shown. Conscience, rather than calculation, explains why most busi- nesspeople keep their words and deal fairly with one another. It is the absence of pre- dictable financial rewards that makes hon- esty a moral quality to be cherished (2).

Because of Enron, WorldCom, and other corporate fraud instances, laws are being changed to help protect investors and in- sure the reliability of a corporation’s finan- cial books. But the line has been crossed, and it will be hard to have businesses re- turn to valuing honesty and credibility, when the financial reward is so great and the punishment is so small.

WHAT THEN IS ETHICAL?

The ADA and its credentialing agency, the Commission on Dietetic Registration have written a Code of Ethics for the Profession of Dietetics. A copy of the full list can be obtained from the ADA at 800-877-1600, or online at http://www.eatright.org. The main components of the standards include the following (3):

■ That a member practices honesty, integrity, and fairness

■ That members provide professional services with objectivity and sensitiv- ity with respect for the unique needs

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CHAPTER 7 ■ Ethics and Malpractice 61

the trained expert in the nutrition field, and nutrition is the area of service. Nutrition practitioners do not make medical diag- noses from symptoms. They make nutri- tional assessments, nutritional diagnoses, and provide nutritional care plans. Patients who need medical care are given several names of competent medical professionals or are referred to the local medical society.

COMPUTING DIETS

Computing diet limits for all patients is commonplace in private practice. Most private practitioners find that diet orders change from specific limits or chemical scores to just the medical diagnosis as refer- ring physicians gain confidence in them. It seems that we have all come to realize that it is premature for them to guess a calorie level or nutrient needs before we make a diet history and assessment.

CONFIDENTIALITY OF PATIENT RECORDS

Your patients’ records need to be kept con- fidential. A patient has the right to see his or her own chart; therefore, care should be taken when you make or even repeat com- ments in the chart that are not related to the patient’s nutritional care. If a patient requests that his or her records be sent to his or her physician, clinic, or other die- titian, get it in writing and photocopy the materials—keep the original copy and send the other. It is recommended that you keep the old patient charts for as long as you are in business. If the office storage space becomes a problem, box the charts that have not been used for many years, label the box, and store it in the attic.

REFERRALS TO OTHER PROFESSIONALS

It is considered good patient care to refer patients to other professionals whom you feel could help the patients with their prob- lems. This is often done in the case of

anorexia nervosa, when suicidal statements are made, when the patient needs medical care, or when more testing is needed. If the patient has a referring physician, you should try to work through that physician to help the patient.

Referral of patients to other professionals does put you at some risk, especially if you only give one or two names. You may be held responsible if patients are very un- happy with the care they receive from the other professional—you and the other professional may be sued. Therefore, give several names of specialists you highly re- spect, also suggest that the patient seek help from the local medical society or the county health department, or look in the Yellow Pages.

It is ethical to suggest that patients seek a second opinion in matters of health. Care should be taken not to alarm patients unnecessarily or to condemn their medical care. Consulting nutritionists state that seeing questionable medical care is not an uncommon occurrence.

QUESTIONING DIET ORDERS

For a nutritionist to question a diet order that is not clear, unreasonable, or incorrect is ethical, if not mandatory. Part of what the patient and the public expect from a professionally trained nutritionist is that decisions are made in the best interest of the patient.

“ORDERING” LABORATORY TESTS

According to Sue Rodwell Williams, PhD, RD, from California, some private practi- tioners “order” appropriate laboratory tests for their patients through arrange- ments made with a local physician. To do this, at least two major criteria must be met. First, the dietitian must be a clinical nutrition specialist and be recognized by the medical community as such; and sec- ond, sound protocols must be written jointly by the practitioner and a physi- cian, and be filed with a nearby reputable

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62 THE ENTREPRENEURIAL NUTRITIONIST

■ Tell patients they are free to buy the products wherever they like, but stress the minimum quality standards or rec- ommended brands.

■ If possible, offer several products with a range of prices.

■ Do not recruit patients in any manner for multilevel marketing programs or buying clubs.

WHAT IS UNETHICAL?

Other than failing to follow the previously mentioned ethical practices, it is also uneth- ical to commit theft, fraud, and other illegal acts. Many activities are open to interpreta- tion, while others are very clearly defined by the local and federal government.

ADVERTISING

Regardless of its intent, an advertisement is unethical if it is deceptive (6). Although enforcement may be a problem, the law supports this position.

BRIBERY OR KICKBACK

Bribery is an action on the part of an em- ployee or consultant that permits a third party to gain unfair advantage in dealings with the employer or client account in re- turn for being enriched (e.g., kickbacks). This is both unethical and illegal (6). Gifts can also be a form of bribery and many companies and government agencies set stringent limits on the value of accepted items (usually under $25) (6).

As it relates to our profession, a “kick- back” is a payment that comes from a noncontractual favoritism, which usually involves restraint of trade. For example, a referring physician or clinic wants to charge a percentage of your fee merely for the referral of a patient, and if you refuse, the referral would be made to a competitor instead. It can also occur when a consult- ant dietitian awards a contract for a client account to a food service company in

clinical laboratory. The protocols should be reviewed and updated periodically by the dietitian and physician. Additionally, you should not hesitate to recommend to a physician that certain tests would be appropriate for nutritional assessment. Mutual respect and good working rela- tionships are prerequisites for this kind of trust to take place. See “Finger-Stick Blood Screening” under the “Malpractice” heading.

SELLING SUPPLEMENTS AND OTHER PRODUCTS

In consideration of the competitive nature of healthcare today, some practitioners increase their income and the conve- nience of their patients by selling products like recommended cookbooks, herb books, kitchen gadgets, and nutritional or herbal supplements (4). Many health profession- als have been doing this for years with pre- scriptions, eyeglasses, prostheses, braces, crutches, and so on. The products are legal, and selling them is ethical and legal—but care must be taken to allow the patient the option of buying those products some- where else.

The fear is that the health professional may unfairly influence the patient to buy a recommended product from the healthcare provider without comparing prices from elsewhere and without having the ade- quate time to determine whether the prod- uct is wanted. On the flip side, some high-quality products are hard to find and it will save the patient’s time and money to have those products available and not have to pay for the shipping.

Guidelines for selling products by health professionals have been published for years and are summarized below (5):

■ Provide patients with enough infor- mation so they know what they are being asked to buy and what to ask for if they go to another retailer.

■ Disclose that you are making a profit from the sale of the products.

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CHAPTER 7 ■ Ethics and Malpractice 63

return for receiving remuneration “under the table.”

The government believes that patients should not have to pay to be referred for proper care (fees would undoubtedly be raised to cover the cost of kickbacks). Client accounts should be able to have fair, honest contracts without the negotiator making a profit, unless the profit is part of the hiring agreement.

A point of clarification should be made here, which concerns office sharing and paying a percentage of your income for it. If office space or services are being exchanged in return for seeing patients, it is, therefore, not considered a kickback to pay for the space.

CONFLICT OF INTEREST

The rule of thumb on conflict of interest centers on concealment and whether all parties are aware that a professional is “wearing more than one hat” (6). For ex- ample, it is very common for sponsoring organizations to ask their speakers if they work for a food or pharmaceutical com- pany, and whether their products will be mentioned in the speech. The concern is, whether the audience is getting unbiased information or commercial announce- ments. Conflict of interest also happens when a contract is awarded to a relative or a close friend and the client account is un- aware of the relationship. If the client knows the relationship and agrees with the decision, it is not a conflict.

FIRING EMPLOYEES

From legal and ethical standpoints, em- ployees do not want to be fired “at the whim” of a supervisor or employer. They want a due process where they can state their case and be judged fairly (6). The em- ployer must justify why the employee should be terminated. It helps to have doc- umentation and to show that attempts to work with the employee or employer have been made.

IGNORANCE OF THE LAW

Ignorance of the law does not constitute a defense or justification from a legal or ethical standpoint (6).

INFORMED CONSENT

Simply put, if someone is potentially at risk for using a product or diet (e.g., be- cause of side effects or possible allergic reaction to an herbal supplement), the consumer should know about it ahead of time. The information can be written on a patient information sheet, on a label, or accompanying pamphlet. If the consumer knowingly buys the product, consent is implied. Failure to obtain informed con- sent is unethical and may subject the offender to damages under civil law (6).

MOONLIGHTING

Moonlighting (holding a second job) is nei- ther unethical nor illegal. There may be a problem, however, if you work “on the side” for a competitor or customer of your major client account or employer (it may be seen as a conflict of interest).

PRICE-FIXING

Price-fixing is the conspiracy by “competi- tors” in the same market to set prices, and is both unethical and illegal. This is when professionals discuss in writing or verbally what to charge for services in a local area, or when they encourage a new practitioner to call around to check the “going prices” of allied health professionals in the local area. The concern is that the buying public is not getting the best deal because every- one who provides a certain service is influ- enced to charge a certain fee—instead of allowing competition to prevail.

That being said, physicians and clinics have reported that managed care and insur- ance agencies have been practicing price- fixing for some time. When physicians want to charge a lower or higher price than

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64 THE ENTREPRENEURIAL NUTRITIONIST

and adopt what we think will work for our business.

Ethically, the important point to re- member is that we should respect the legal protection offered by the copyright, patent, or trademark. Also, there may be a unique business concept closely associated with a competitor in your market. If you copy the idea, do not be surprised if the person feels you have infringed upon her or his busi- ness. Although you have not broken any laws, you may have generated unnecessary bad will for your business and may have risked an ethics charge in the profession for lack of fairness or integrity.

Given the opportunity, many people are happy to give a copyright release or negoti- ate some equitable agreement. All too often, it seems that the very people, who become upset when their own work is used without permission, do not give second thoughts about photocopying someone else’s chart, teaching materials, or book chapter.

Certainly, not all ethical and legal issues have been discussed, just some of the major rea- sons for concern for self-employed practitioners. For answers to other questions, call the appro- priate legal or business advisor or the ADA.

MALPRACTICE

Nutritional malpractice occurs when a die- titian fails to meet the accepted standard of care and the action results in harm to the patient. Although there have been cases where dietitians have been sued for mal- practice, the possibility of having more cases in the future is very real. As dietitians become more professionally visible, as we take the initiative to prescribe diets, as mal- nutrition is diagnosed in institutions more often, and as more attorneys use “blind pleading” in suits for their clients, wherein more professionals other than just physi- cians are implicated, the risk of a suit is more likely (7).

Life and business are not risk free; how- ever, to have a basic understanding of the

the area’s “going rate,” they often are either penalized until the price is changed or they are reimbursed at a smaller percentage.

PRACTICING MEDICINE

State medical licensing boards and medical societies are very concerned when they feel people overstep their professional scopes of practice into practicing medicine. The line is not always clearly defined, but it usually involves making diagnoses from the patient’s symptoms and tests (radiographs, CAT scans, blood tests, etc.), and representing oneself as “curing” a patient.

Screening for glucose or cholesterol prob- lems is now so common in grocery stores and wellness health screens that by itself, without diagnosing, is not considered prac- ticing medicine. Laboratory results must be reported in comparison to their “normal” ranges. When the results are out of the norm, people are referred back to their physicians.

Several physicians or medical societies have accused private practitioners of prac- ticing medicine. The known instances re- volved around allergy testing, making a medical diet based upon symptoms, and poor word choice in an advertisement. The problems were resolved but only after much trouble and embarrassment. Care must be taken not to insinuate that med- ical diagnoses are being made.

MISREPRESENTATION OF OWNERSHIP OF IDEAS

Ideas have value. To protect the ownership of new ideas, the government created copy- rights, patents, and trademarks. Most ideas are evolutions or conglomerations of thoughts from many sources. “New” ideas are often better ways of stating or doing an old concept.

As we progress in business, we evaluate our ideas and keep the ones that work and then discard the rest. We also evaluate ideas, programs, materials, speeches, and business techniques that we see around us

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CHAPTER 7 ■ Ethics and Malpractice 65

legal system as it applies to malpractice may help minimize the risk and its accom- panying expense and embarrassment.

LEGAL PRINCIPLES

In their article, “Malpractice Law and the Dietitian,” Elizabeth and Daniel Reidy have stated, “Each person is required by the law to exercise a certain standard of care to avoid causing injury to the person or property of others. If a person fails to meet that standard and that failure causes harm to another person or another’s prop- erty, then that person is liable for the damage. This is the basic law of negli- gence. Dietitians—like physicians, lawyers, accountants, and other professionals— must exercise the skill and knowledge normally possessed by members in good standing of their profession” (8).

There is no theoretical minimum harm a patient has to prove. Simply demon- strating that negligence of proper care on the part of the dietitian that caused dis- comfort to the patient or delayed the pa- tient’s recovery process constitutes the basis for a lawsuit. However, if the patient cannot prove that the dietitian’s care caused some injury to him or her, there cannot be a finding of liability against the dietitian (8).

POSSIBLE LIABILITY SITUATIONS

Whenever dietitians practice their profes- sion, whether or not they are paid for it, they are potentially at risk for liability and must meet the professional standards of practice. Other instances where liability may be tested are in situations where food from a kitchen causes food poisoning, where a nursing home patient dies because of or is diagnosed with malnutrition, and where there are miscalculations on diet in- structions, such as the amount of protein or potassium in a renal diet (7). Dietitians who violate the accepted management principles run the risk of being charged with administrative malpractice.

PROTECTING YOURSELF FROM MALPRACTICE

Along with giving good care, a dietitian should stay current with new advances or practices in the field of nutrition. In a court of law, documentation of proper care and communication about the patient’s poor eating habits to the proper channels are extremely important. Records should show that the proper information was given to the patient, his or her progress was ade- quately followed, or if he or she did not return or follow it, it should be stated so, and the referring physician should be ad- vised of the patient’s progress in writing.

FINGER-STICK BLOOD SCREENING

According to an announcement in the ADA Courier, “Members covered by ADA-spon- sored liability insurance are protected against malpractice suits when performing finger-stick blood screening, a procedure many dietetic professionals include in their practice as a client service. This simple screening technique can identify possible health problems related to blood sugar and cholesterol. When questionable results are obtained, the client is referred to his or her physician for further laboratory analysis. Diet modifications are made only after the client’s condition has been assessed. Mal- practice insurance coverage for eligible members is effective, provided that the RD practitioner has received training on the finger-stick blood screening techniques” (9).

WHAT IS LIBEL AND HOW IS IT DIFFERENT?

Legally, libel is any statement or representa- tion published without just cause or excuse, or by pictures, effigies, or other signs tend- ing to expose another person, corporation, or product to public hatred, contempt, or ridicule (7). Calling someone a “quack” or “incompetent” could cause defamation.

You should not, however, be discour- aged from stating the facts as you know

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66 THE ENTREPRENEURIAL NUTRITIONIST

SUMMARY

The dietitian’s main concern should always be the welfare of his or her patient or client. Excessive measures need not be practiced just out of fear of liability. By offering qual- ity, humanistic care, and good manage- ment practices, and by taking the steps to document their services, practitioners should be able to conduct business with a minimum fear of risk.

REFERENCES 1. Cooper DE. Ethics for Professionals in a Multi-

cultural World. New York: John Wiley & Sons, 2007.

2. Bhide AV, Stevenson HH. Why be honest if honesty doesn’t pay? Harvard Business Review September–October, 1990.

3. The American Dietetic Association (ADA). Code of ethics for the profession of dietetics 1999. J Am Diet Assoc 1999;99:109–113.

4. Fieber LK. Practic1e points: ethical considera- tions in dietetic practice. J Am Diet Assoc 2000; 100:454.

5. American Nutraceutical Association. Guide- lines for selling supplements to patients. American Nutraceutical Association, 1997.

6. Sobel M. The 12-Hour MBA Program. Paramus, NJ: Prentice Hall, 1993.

7. Baird PM, Jacobs B. Malpractice: your day in court. Food Management Magazine February, 1981.

8. Reidy EG, Reidy DE. Malpractice law and the dietitian. J Am Diet Assoc 1975;67:335–338.

9. News Notes. Courier. The American Dietetic Association, May, 1990.

10. King K. Starting a Private Practice. Study Kit #3. The American Dietetic Association, 1982.

ORGANIZATIONS AND RESOURCES American Dietetic Association. Check this ADA

website to read the more recent information on ethics as it relates to dietetic practitioners: http://eatright.org/cps/rde/xchg/ada/hs.xsl/ education_779_ENU_HTML.htm.

Ethics Resource Center, 2345 Crystal Drive, #201, Arlington, VA 22202. http://www.ethics.org.

Strom-Gottfried K. Straight Talk About Professional Ethics. Chicago, IL: Lyceum Books, 2007.

them, backed up with scientific evidence. Such subjects as the danger of a severely low-calorie diet regime and the nutritional inadequacy of some foods are important to the public, and it is the responsibility of our profession to warn the public.

Don Reuben, an attorney for Reuben and Proctor in Chicago, Illinois, has stated that in cases where a dietitian makes a public statement about an issue, “A dietit- ian’s key defense against a public person (corporation) or government official who sues for libel is that the suing party must prove the dietitian knew it was libelous at the time of the statement. A dietitian is an expert and a professionally trained author- ity who has the right to express nutrition facts as he or she sees them under fair comment protection” (7).

Victor Herbert, trained as both a physi- cian and a lawyer, has stated, “If a private individual or company sues you for speak- ing the truth as you see it, without malice, countersue on the grounds of malicious harassment and abuse of process. Ask the court to order the plaintiff to pay your legal fees, as suggested by Federal Judge A. Sofaer in NNFA (National Nutritional Foods Associ- ation) v Whelan and Stare (78 Civ. 6276 [ADS], U.S. District Court, Southern District of New York) (1980)” (7).

Betty Wedman, who was threatened with a libel suit by a food company for a statement she made, has stated, “From personal experience let me emphasize the need for daily, detailed logs of conversa- tions that could be used in a court of law, if litigation were pursued. Keep records and widely read them, check out your facts with reference books and other profession- als, and you need not be intimidated by the food industry, drug manufacturers, physi- cians, or patients” (7).

Malpractice insurance coverage will usually cover your court costs and up to a maximum amount for a settlement for nutrition-related libel suits. Check with your insurance agent or policy concerning all items covered.

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Every new business and its owner will eventually develop an image in the mind of the public. The important thing is for that image to be a good one. Having a positive, successful image is what many large corpo- rations, politicians, and movie stars spend untold amounts of money to achieve. They know their image will usually decide their success—whether their products sell, they get a vote, or remain a star (1).

Consultant nutritionists report that as their professional images look more successful, their businesses attract new clientele with a minimum of effort. Good images make patients, physicians, and busi- nesspeople want to use their services. Everyone likes to feel that their nutritionist (or physician or dentist) is the best, the most sought after, the most qualified, and the most successful.

According to business experts, Paul and Sarah Edwards, authors of Working from Home, “Until you’ve bought from a busi- ness and tested it, all you have to go on is image. Image is where many small busi- nesses fall down, however. Started on too tight a budget or operated too casually, a home or small business can look like an amateur effort” (2).

YOUR OWN STYLE

When creating an image, the first thing that comes to mind is physical appearance; however, what is most important is who we are, what we stand for, our “message,” our tactfulness, our stability, our credibility, and the appearance of our success.

Successful entrepreneurs have various professional approaches. Some are very conservative in dress and manner, and tra- ditional in instructing patients or in con- sulting to business accounts. Others have flashy appearances and seek out unconven- tional nutrition information. As long as the person’s practice is ethical and meets clients’ needs, it’s not necessary for every- one’s approach to be the same.

Creativity and uniqueness in the devel- opment of a business will help create an image that is distinctive from its competi- tion. One image is only better than another if the practitioner feels more comfortable with it, or if it’s more successful in reach- ing people and producing better outcomes and more income. It doesn’t matter if the practitioner’s peers like it.

WHO WE ARE AND WHAT WE STAND FOR

Choose battles carefully. Others’ opinions about us are greatly influenced by what we choose to defend, our honesty, and how we fight our battles. It’s important that we have opinions and that they are well thought out and evidence-based. Do not be a person who lacks loyalty and changes his or her opinions to please whoever is ahead. Defend your arguments with facts and fairly listen to others’ points of view. Also, be willing to accept a majority vote or new evidence that sub- stantiates another point of view. Become known for your honesty, integrity, and fairness.

CREATING A GOOD BUSINESS IMAGE

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68 THE ENTREPRENEURIAL NUTRITIONIST

in a three-piece suit. The difference in the amount of money he collected was astound- ing—about $19 on the first day and more than $300 on the second day! The public re- sponded to how he took care of himself, his dress, the status or power his appearance implied, and whether he was telling a lie (begging) or not (really lost his wallet).

To show examples of how dress and appearance influence feelings about some- one, think how you would feel when:

1. A very close relative of yours is in the hospital, and during your visit, a young medical person comes into the room. The fellow is wearing a white jacket with a stethoscope around his neck. He is also wearing a loud-colored paisley tie. Do you wonder whether he is really the physician in charge, a student, or a nurse? Do you question his seriousness?

2. You are down to the final two candi- dates for the head dietitian for a cor- porate wellness fundraising campaign. You must hire the best one for the job. Both women speak equally well and have similar grooming. One candidate has worn shirtwaist dresses on both interviews and the other has worn a linen suit on her first interview and a black suit on her second interview. Do you feel the tendency to hire the can- didate who dressed more like a corpo- rate executive?

A dietitian should strive to be a good example of the nutrition and health profes- sions, and should “practice what he or she preaches.” That means he or she should have near normal weight, eat well, and have a healthy appearance. Carolyn Worthing- ton, a registered dietitian who specializes in recruiting dietitians, states that, “Nothing diminishes a candidate’s job prospects more than being very overweight. The overweight dietitian destroys her or his credibility with clients and medical staffs.” Just like a cardiologist who smokes or a preacher who lies loses credibility in the eyes of some of his or her clients, extreme obesity and poor

The public’s opinion of health organiza- tions is also influenced by the alliances they make with commercial companies. One day, will we look back on our national orga- nization’s alliances with wealthy food com- panies that offered food products that evidence-based research cannot defend, and shake our heads? While attending a med- ical convention recently, I heard very dis- appointed physicians state how they felt they were trained to be “pill pushers” for pharmaceutical companies instead of bio- chemical diagnosticians. The public de- serves better from healthcare professionals.

APPEARANCE AND FIRST IMPRESSIONS

Because of stiff competition and the fast- paced nature of this society, a person sel- dom has the opportunity to make up for a poor first impression. A well-qualified dieti- tian may never get the chance to show what he or she knows because he or she did not “first get her foot in the door.”

Having a good appearance increases the chances that a consultant’s creative ideas will be heard. A counselor’s effectiveness on the job is also influenced by his or her appearance. Part of whether a patient or his family responds to counseling is dependent on their first impression of the counselor, and whether credibility and a relationship have been established.

Although it may seem vain and foolish to put too much emphasis on outward appearance, it is equally foolhardy to put too little value on it. A story about an East Coast student illustrates the importance the public gives on overall appearance and clothing. A student dressed in two different ways, on two different days, and then went to ask people for money in a New York City subway. He used the same words on both days, “I’ve lost my wallet; can I borrow 30 cents to get home?” On the first day, the student had a day’s growth of beard and was dressed slovenly in old clothes. On the sec- ond day, he was clean-shaven and dressed

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CHAPTER 8 ■ Creating a Good Business Image 69

health habits can also create a credibility problem for a dietitian.

Other aspects of a good physical image and appearance are posture, direct eye contact while speaking, a firm handshake, and a body language that is confident, pos- itive, and not filled with nervous movement. Speaking in a clear, bold man- ner and making sure that statements are well thought out also contribute to good image.

TACTFULNESS AND MANNER

Along with physical appearance, people notice and respond to a professional’s tact- fulness and manner. The old adage holds true, “He was right, but he lost the argu- ment because of the way he handled it.” People in business find that they are not only selling a commodity or service, but also themselves to the client, their families, and professional peers.

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70 THE ENTREPRENEURIAL NUTRITIONIST

Secondhand messages have a way of being misinterpreted.

3. When people ask, “Are you worth that much money?” consultants can answer by saying, “I certainly am; let me explain what I can do for you.”

4. If a physician states that he or she only charges $65 for a visit, and asks you why you charge $125, a good answer is, “That is true, but the differ- ence may be in how long we spend with each patient. I spend 1.5 hours with a patient for that fee.”

5. If a patient does not respond to the counseling and appears to have no in- tention of doing so, it is not out of line to suggest that, “We evidently do not respond well to each other, and I feel that perhaps another counselor could help you more. Would you like me to refer you to someone else?”

6. If a professional advisor (lawyer, accountant, etc.) has not performed their work well, talk directly to the individual and state, “Your work is not the quality I expected and I am disappointed. Some of it is not what we discussed. I would like you to re- evaluate the charges on the bill you sent me.”

STABILITY AND CREDIBILITY

In his book, Winning Images, Robert Shook states, “People need to know that their re- lationships with you are durable. Everyone realizes that flash-in-the-pan types cannot be counted on, and such an image scares people away” (1).

A service type of business, such as nutri- tion counseling, is intangible; therefore, its need to look stable and credible is even greater. Most beginning practitioners will not be in a financial position to afford an expensive office in the best location, so other means to look stable and prosperous must be found.

The use of high-quality business cards and brochures, as well as handout

Businesspeople have the task of finding the happy medium between being aggres- sive and knowing when to be passive and pull back. They must learn when to make a point, and when to let another’s point of view dictate. Novices tend to experience greater swings and to react in one extreme manner or the other. Experience and self- confidence help develop a more self- assured, moderate attitude and approach. This transition is difficult for most. Until the last 30 years, women have never been encouraged to be assertive. Consultant nu- tritionists, coming from meeker hospital roles into trying to distinguish themselves as businesspersons, have definitely experi- enced this confusion. Time and experience in the field prove to be the best teachers.

The “Rule of 250,” developed by a sales trainer, briefly states that every person we meet has a sphere of influence with other people, such as employer, family, neigh- bors, and so on, that may affect as many as 250 more people. That means, a tactless comment, a bad encounter, or a very posi- tive experience can have influence on a po- tentially large number of people. The image of a businessperson in the eyes of the pub- lic is greatly affected by his or her small day-to-day dealings and the manner in which he or she handled them.

Some suggestions that could improve tact- fulness with your patients, clients, referring physicians, leasing agents, professional coun- selors, etc., include:

1. Be very cautious about what you are going to say when you feel you have been attacked. Becoming defensive and “striking back” is not the best response. Instead, try to relax and state something like, “I am sorry you feel that way,” or “I don’t feel that was necessary to say.”

2. Be brief and direct in your word choices and speak in a slow, none- motional tone. Conduct your busi- ness directly with the individuals involved and do not leave long mes- sages with their spouses or secretaries.

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CHAPTER 8 ■ Creating a Good Business Image 71

materials, gives the appearance of profes- sionalism and can engender a sense of trust in others. Offering a personalized in- struction and developing high-quality pro- grams give credibility to a business and its owner. Completion of projects by the deadline and within the proposed budget builds a good reputation. Doing something when you say, you will sounds simple, but an individual or a company that actually follows this principle is rare.

Keeping appointments and arriving on time are important and appreciated. Clients and patients are also expected to come and meet with a consultant nutri- tionist at or near the appointment time. Physicians, who are notoriously late in seeing their patients, will find that their patients will not accept this discourtesy anymore, as they used to.

Second chances are seldom given today to professionals who do not perform as they have promised. Many people, whose talents border on genius, achieve only mediocre results from their careers because they lack the necessary follow-through and persistence to perform well. In busi- ness, less-gifted people continually outper- form highly educated and gifted persons because they provide consistently good service (1).

To enjoy a long and rewarding career, an entrepreneur should provide outstanding work and good and timely information. The clients should feel that they receive the full value of services rendered.

SUCCESS BREEDS SUCCESS

People like to deal with successful people because being successful may mean that they are good at what they do. When given a choice, people want to deal with the best. To create an image of success, do outstanding work, and become success- ful. The performance and reputation of a professional will attract the public and will bring in business referrals as time passes.

When starting a new business, there are some lessons that can be incorporated to reduce the amount of time needed to appear as a winner.

1. First, appear busy to the client. Pa- tients question how good a profes- sional is if they can make an appointment at any time on any day they call. It is not misrepresentation to state several available appoint- ment times during the week instead of saying, “Any time you want, Tues- day or Wednesday—I’m open.” One practitioner has found that as she traveled on business and became less available in her office, the demand for her services has increased because her professional image has become more successful.

One practitioner in California, after being in business for 3 years, had an actual 8-month waiting period for nonemergency patients to make an appointment. Patients must have felt privileged to see such a successful nutritionist. Why else would they have agreed to wait so long?

When working in a medical com- plex or clinic area, professionals are discouraged from taking extended breaks in the public areas. Prospective clients and referring physicians take notice of others who don’t appear to be busy.

2. Framed diplomas, degrees, or awards displayed on office walls are also a graphic way to show success and accomplishment. Desk sets and tro- phies have adorned offices of busi- nesspeople for years, so there is no reason for plastic food models and free calorie charts to be the only high- lights of a nutritionist’s office!

The image of success is undoubt- edly the most significant reason many people are able to demand such high prices for their work. Ar- tists, for example, who establish their reputation of being distinctive and

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72 THE ENTREPRENEURIAL NUTRITIONIST

them on the issues. Referrals of new clients and jobs are received with minimum effort, as compared to that needed to start the business. Fees go up to improve the profit margin. More importantly, job satisfaction increases because more options open in the nutritionist’s life.

REFERENCES 1. Shook R. Winning Images. New York: Macmillan

Publishers, 1977. 2. Edwards P, Edwards S. Working From Home. 5th

ed. New York: Penguin Putnam, 1999.

expensive, may soon get more for their work than many unknown artists, who have as much or more talent. The secret is in their ability to build a winning image, not in their talent to paint on canvas (1).

SUMMARY

When entrepreneurs become successful in their businesses, they usually find that other people, who could not be bothered before now, seek advice and agree with

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Counseling in the outpatient setting has continued to evolve into the long-term, relationship-based psychotherapeutic style of counseling identified in this chapter, 23 years ago in the first edition. Counselors in private practice found that what they had been taught about counseling in the medical model of therapy (short-term in- tervention with loads of information for the patient) often didn’t change behaviors nor produce the outcomes patients needed to be healthier (1). Change is difficult and more information won’t necessarily make it happen—there are other barriers and variables with which to work. Nutrition counselors needed more therapy options, and more training and supervision by other more qualified counselors.

NUTRITION THERAPISTS

A definition offered by the Nutrition Ther- apists’ subgroup states, “Nutrition Ther- apists integrate theories and techniques of counseling psychology into nutrition practice to facilitate changes in clients’ be- liefs and choices related to food, health, and weight. Ideally, they have training and education in counseling and psychol- ogy, and practice in a multidisciplinary framework” (2).

Our success as nutrition therapists de- pends on our ability to help clients iden- tify their barriers and level of motivation, learn and apply new information, and practice new skills. Dietitians who become counselors need to realize that their em- pathy, ability to establish relationships,

and counseling expertise determine the quality of their output. When nutrition therapists have problems getting their busi- nesses established, it may be for several rea- sons, including their lack of relationship- building and counseling skills.

Developing high-quality counseling skills is a time-consuming, complex task. It often means changing old, familiar, but unsuccessful, counseling habits. Do not ex- pect to achieve perfect skills within a few weeks or months. It takes time to practice the new techniques learned through course work, seminars, self-study, and supervision. Every new client walks in the door with an interesting, challenging mix of expecta- tions, preconceived ideas, and food prefer- ences. What works for one client won’t necessarily apply to another.

The day-to-day job of counseling clients can be extremely stressful and draining. You need the ability to “turn off” your business mind when you’re not working, to better protect yourself from being emotion- ally drained and burned out.

This chapter and others intend to share some basic insights and ideas for produc- ing successful counseling sessions and busi- ness practices. Advanced counseling skills are beyond the scope of this book. Please refer to the resources at the back of this chapter for more in-depth information.

Successful practitioners have their own style of patient counseling. The amount of information, number of sessions, and em- phasis on wellness, nondiet therapies, in- tuitive eating skills, behavior modification, or psychology are the counselor’s decision and vary with each patient.

COUNSELING EXPERTISE

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74 THE ENTREPRENEURIAL NUTRITIONIST

■ Ability to assess and teach develop- mental skills

Goals of counseling are the following (1):

■ Increase clients’ self-awareness, de- crease denial of problems that affect their nutrition or weight, and give en- couragement these problems can be resolved.

■ Help client become aware of inner strengths in order to function inde- pendently and challenge old beliefs.

■ Help client feel responsible for his or her own feelings, thoughts, behaviors, and relationships instead of holding onto the “victim” role.

■ Help client take more risks like being more flexible or tolerating more incongruities.

■ Help client trust more and give new behaviors and thoughts a chance.

■ Help client become more conscious of alternative choices when responding to stress and to not always turn to food.

■ Help client achieve self-acceptance.

QUALIFICATIONS OF A COUNSELOR

Not everyone has the personality and pa- tience to be a good counselor. The personal attributes usually associated with a success- ful counselor include empathy, optimism, good communication skills, sensitivity, patience, creativity, teaching ability, and enthusiasm.

CLINICAL JUDGMENT IS IMPERATIVE TO GOOD NUTRITION COUNSELING

Everyone recognizes that a practitioner’s counseling skills and clinical judgment mature with years of experience. Without this practical experience, it is difficult but not impossible for a nutrition therapist to be proficient at counseling or to have de- veloped sound clinical judgment. A con- sultant must be aware of common drugs and their side effects, know how to do as- sessment tests, and be aware of the labora-

NUTRITION EDUCATION OR PSYCHOTHERAPEUTIC COUNSELING?

For too long, dietitians used nutrition edu- cation as counseling. Experience has shown us handing out lists of foods and calculat- ing diets, and explaining the physiology of the disease will not necessarily create com- pliance nor motivate patients to change their behaviors. We know what’s best for them; they just need to do it! This approach works when the client makes the effort to read, learn, and apply the content (3). What then is the difference between nutrition education and more advanced counseling skills (Table 9.1)? Advanced counseling skills include (1):

■ Relationship-building skills: empathy, warmth, and genuineness

■ Helping skills: attending, helping a client explore, and active listening

■ Ability to gain collaboration and to empower the client

■ Ability to match each client’s needs with the appropriate cognitive–behav- ioral strategies

■ Sensitivity to multicultural and other client-specific uniqueness

■ Ability to sustain a long-term counsel- ing relationship

Psychotherapeutic Content-Based Education Counseling

Short term Open-ended (based on client’s needs)

Content-based (learning Relationship-oriented; assumed) counselor is trainer

Improve knowledge and Resolution of issues and skills barriers

Work on behaviors Work on thoughts, feelings, and behaviors

Address cognitive deficits Address motivation denial, and resistance

Success measured objectively Success is measured (e.g., knowledge, behavior subjectively (e.g., happiness, change) mood shifts, relationships)

TABLE 9.1 NUTRITION EDUCATION VS. CLIENT-CENTERED COUNSELING (4,5)

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CHAPTER 9 ■ Counseling Expertise 75

tory chemical values as they relate to nutrition.

RELATIONSHIP-BUILDING SKILLS ARE NECESSARY FOR EFFECTIVE COUNSELING

Before counselors can develop plans for a client’s behavior change, the counselor must understand the client’s needs (3). The development of a “helping relationship” that projects empathy, understanding, and trust needs to precede any development of plans and strategies.

The nutrition therapist encourages clients to talk about themselves and their feelings. A client needs to feel safe in reporting fail- ures as he or she practices new thoughts and behaviors, so adjustments can be made to the care plan.

Being a good nutrition counselor in- volves possessing interpersonal skills that promote positive outcomes in counseling. A successful counselor is one who gen- uinely cares about and is committed to patients. Although a counselor wants to be warm, caring, empathetic, and so on, it is important that the counselor remain pro- fessional. Exercise caution. There is a point in counseling where becoming too close and familiar with patients may jeopardize your ability to act as a counselor to them.

Several other traits are helpful. A positive attitude keeps the client and you interested in continuing to work together. One needs to be positive and even-tempered to deal with counseling on a day-to-day basis. Being assertive in a caring way and not being afraid of dealing with issues that inhibit progress is important. Nutrition counseling is not passive but is a very ac- tive procedure.

COGNITIVE–BEHAVIORAL THERAPY SKILLS ARE IMPORTANT TO COUNSELORS

Along with the ability to dispense infor- mation, a practitioner needs to be able to promote behavior changes in clients. Be- havioral therapy skills include being able to

define a problem, design plans and strate- gies to treat a problem, and to evaluate and make necessary changes. Behavioral ther- apy uses various techniques, such as behav- ior modification, stimulus control, and cognitive restructuring to help the client change his behavior.

For example, if your client admits hav- ing many failed attempts at weight control, find one eating behavior that has caused problems and work with the client to come up with a solution. Start with one incre- mental step. For many clients, it may be merely reducing fat intake at dinner or avoiding the morning donut.

AN UNDERSTANDING OF PSYCHOLOGY AND MOTIVATIONAL INTERVIEWING ARE IMPORTANT

By understanding clients’ level of motiva- tion or other barriers to change, a good counselor can then facilitate finding ways to satisfy their needs in non–self-defeating or food-oriented ways. An appreciation for psychology also helps in perspective—the counselor is part of the solution, not part of the problem. As an example, if the counselor fails to comprehend a patient’s frustration with changing his or her diet and lectures him or her, any possibility of helping the client may be lost. The coun- selor must know about cognitive restruc- turing—how to help a client confront irrational thoughts and choose new ways of thinking.

When counseling is totally dominated by client requests and tangential topics, lit- tle psychological or behavior change will take place. A session that is totally domi- nated by the counselor who provides only advice without listening to the client’s concerns can be equally unproductive. The ideal is a mix of client and counselor interaction. Two very good books on the subject of counseling are Nutrition Therapy: Advanced Counseling Skills with 45 con- tributing authors (1) and Linda Snetselaar’s Nutrition Counseling Skills for the Nutrition Care Process (6); please refer to these resources for more in-depth discussion.

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76 THE ENTREPRENEURIAL NUTRITIONIST

Clients also come to nutrition counsel- ing sessions with feelings about themselves that may act as barriers to behavior change. A young, obese woman may say she wants to lose weight but may be so fearful of at- tention from men, she keeps her weight stable. A man may come for nutrition instruction for hypertension but he may want his wife to feel responsible for what he eats. A counselor learns to perceive a client’s needs and level of motivation. The client is then supported in his or her desire for change and encouraged to take respon- sibility for his own constructive behavior.

WELLNESS APPROACH

A counselor may choose to incorporate an emphasis on “wellness” in nutrition con- sultations. This approach believes that nu- trition information should not be separated from other lifestyle decisions. Counseling sessions might include a health risk ap- praisal and discussion of the client’s fitness and exercise program or referral to a fitness specialist.

The counselor may identify a client’s in- ability to handle stress or a dependence on alcohol, drugs, or smoking. The client is then encouraged to consider a change in behavior and perhaps a referral to another program or specialist. To be qualified to dis- cuss these other topics, a nutrition thera- pist must be familiar with health risk factors and their effect on health. A nutri- tion therapist might take course work or seminars on wellness, health education, and exercise physiology.

NONDIET AND INTUITIVE EATING APPROACHES

The nondiet and intuitive eating approaches to weight issues are growing in popularity with the rise and fall of each new fad diet. These philosophies center on size accep- tance, relearning how to recognize satiety, and joyful movement instead of forced exer- cise. The past years of “diet” foods and mir- acle diets have not reduced the overall

TEACHING SKILLS HELP ENSURE THE PATIENT LEARNS THE NEW INFORMATION

The content must be geared to the client’s level of understanding. A patient is often “turned off” by language and nutrition information that is either over his or her head or is too elementary, and thus, un- challenging and uninteresting. Presenta- tions should be organized because random discussions are hard to recall. A good teacher knows how to help patients reach their goals by using various teaching meth- ods and only the information the patients “need” to know. As a patient’s needs change, a good teacher should be flexible enough to adjust the patient’s care plan to handle new problems. If a patient doesn’t respond to one type of approach, you learn to try another.

THE ABILITY TO SELL IS A VITAL SKILL OFTEN OVERLOOKED

Selling is based on meeting the clients’ needs and exciting them with the impor- tance of nutrition intervention. For exam- ple, a client may not realize why the physician wants him or her to control his or her blood sugar and how diet changes can make that happen. Benefits to the client are important selling points. In nu- trition counseling, you sell the client, fam- ily, physicians, and all others involved on the value of nutrition intervention.

CLIENT EXPECTATIONS CAN GREATLY INFLUENCE RECEPTIVITY TO COUNSELING

If a client expects the counselor to be domineering and antagonistic or friendly and helpful, the client may treat coun- selors as if they were actually playing that role (6). Through experience, counselors learn to perceive what the client is expect- ing from them. Qualified counselors then try to correct or validate clients’ precon- ceived beliefs.

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CHAPTER 9 ■ Counseling Expertise 77

weight of the population. Emphasis on being super thin and fit has not worked for the majority, so what’s left? Many people are learning to eat various healthy foods in modest amounts until comfortably satisfied and moving their bodies to have fun (e.g., riding bicycles with the kids, taking a tai chi class, meeting the ladies for a dawn tennis match, and so on). In addition, most pro- grams teach loving yourself and feeling good about yourself, no matter how much you weigh.

FUNCTIONAL NUTRITION THERAPY

Functional medicine is an evidence-based, systems biology assessment of an individ- ual’s unique biochemical function and needs. Nutrition intervention is a corner- stone of therapy in restoring balance and function of body systems. This type of practice requires postinternship education and training to understand the biochemi- cal pathways and absorb and apply the volumes of new terminology, laboratory nutrition assessments, treatment proto- cols, and so on. It is one way wherein medicine will respond to the growing problems in chronic care. Because nutri- tion intervention is at the root of the ther- apy, it stands to reason that more dietitians will need this type of training and education.

VARIOUS APPROACHES ALL “SELL”

Experienced nutrition therapists bring a wealth of practical knowledge. Counsel- ing sessions are usually a mixture of what has worked in the past along with a few ideas the counselor has learned from edu- cation or training. Here are examples of dif- ferent approaches:

■ Many practitioners do not give a diet plan at the first counseling session. They feel the initial session should be used to establish a relationship, collect data, teach patients how to

measure foods for computer analysis, make assessments, and determine habits and needs. A later session is used for giving more instructions after the assessments are completed. A sports practitioner sees patients ini- tially for 30 minutes to instruct the clients on how to fill out the com- puter food intake record; then begins counseling at the next session.

■ Some practitioners offer instruction in “packages.” A consultation for diabetes or heart disease is sold in a package of three or more visits to assure under- standing and compliance. A weight loss program may be 8 to 12 weeks of indi- vidual or group sessions.

■ Other practitioners provide written nutrition instructions at the first visit, of approximately 1 hour or 2 hours, and schedule follow-up visits every 1 to 2 weeks while setting no limitations on the duration of therapy.

■ Practitioners may incorporate various activities in their programs: computer nutrient analysis, menu planning, grocery shopping, skinfold analysis or impedance body analysis, individual- ized fitness program and workout, and long-term follow-up. Sometimes, the nutrition consultant handles all of these functions, and other times, they’re in association with a fitness specialist.

■ Practitioners sometimes choose to send their patients a lifestyle or food questionnaire in advance or some- times ask that patients arrive 30 min- utes early so that session time is not spent filling out the forms. Others want to fill out the questionnaire with the patient in order to interpret insin- uations and body language.

■ Some practitioners who work with obe- sity spend time on psychological issues related to food and lifestyle choices and do not use scales or other measure- ments at all. They work with the nondiet approach and relearning eat- ing and exercise habits. Effort is made

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78 THE ENTREPRENEURIAL NUTRITIONIST

nutrition status, and relate his food intake data to behavioral indicators (6). Assess- ments can be made of many categories of information:

■ Biochemical studies ■ Functional medicine labs ■ Anthropometric studies ■ Vital and health statistics ■ Socioeconomic data ■ Additional medical information

A client’s behavior must be assessed (1,6):

■ General health practices ■ Attitudes, beliefs, and information ■ Physical activities ■ Educational achievements and lan-

guage skills ■ Economic considerations ■ Environmental considerations ■ Family issues ■ Social considerations

MOTIVATION

Motivation must be assessed because it is essential for compliance. Clients are moti- vated by their own needs more than by the counselor’s desires (6). Therefore, in order to assist the somewhat motivated clients, you need to determine their stage of change and what you can do to help the client progress through the stages by determining what is important to them. Clients also be- come motivated when they see results. To that end, it is important for the counselor to initially encourage more intermediate, easily reached goals.

NUTRITIONAL CARE OR TREATMENT PLAN

This plan can be developed once assess- ments are made and problems are identi- fied. In the treatment phase, the counselor assumes the role of both expert and mutual problem solver (3,6). Most novice coun- selors tend to follow one extreme or the other—expert or empathizer. The coun- selor who knows everything and makes all

to improve the person’s self-esteem and feeling of self-worth.

■ Check out Chapter 17 on prices and fees to see how much nutrition thera- pists normally charge for counseling.

THE SESSIONS

Before beginning with a new patient, a counselor should prepare for the role of diagnostician by reviewing all available data on the patient (6). If the patient’s chart is accessible, it should be reviewed. However, in private practice and outpa- tient clinics, it is usually necessary to start your own chart and put in copies of chem- ical scores, intake analysis, anthropomet- ric results, interview sheets, progress notes, etc., as you have them.

THE INTRODUCTION

The patients’ first exposure to you and your office begins to form their opinion of your ability to help them. Trust and respect for the counselor are important motivators to patients. Small, fairly simple actions on your part can help engender good feelings. Try to start counseling sessions on time. Make the office warm and inviting. Greet the patient and his or her family. Offer a beverage to drink. Begin with exploring small talk about the patient; share some of yourself. Find out about the patient and his or her needs. It sounds so elementary, but many medical professionals are so con- sumed with their own needs or the pa- tient’s disease that they forget that it should be all about the patient (6).

THE INTERVIEW AND ASSESSMENT

The session begins with an explanation of the counseling relationship, describing enough so the client knows precisely what will take place (6). If the client has other expectations, this is the time to have them known. You act as a diagnostician, evalu- ate the client’s level of motivation and

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CHAPTER 9 ■ Counseling Expertise 79

of the decisions may overwhelm patients. On the other hand, as mentioned earlier, counselors may become ineffective if they become too friendly or liberal with clients and their diet needs. Clients often seek assistance in setting limits for themselves. A good balance of the two roles is optimal.

TREATMENT PHASE

In the treatment phase, problems, behav- iors, inconsistencies, and wrong beliefs are matched with possible solutions or rational alternatives. Desired changes or goals are ranked, and the client determines which small achievable goal he or she will work on first.

When assuming the training role, the nutrition therapist facilitates change, and the client practices new choices and behav- iors until they are achieved. At each visit, the client shares the successes, challenges, and problems since the last visit. Solutions are discussed that are acceptable to the patient—considering what is known about him now. The patient has time to react, ponder, argue, and provide input. For many reasons, if the counselor determines it’s necessary, a patient may be referred to another health professional.

Keep It Simple Good counselors attempt to keep instruc- tions as simple as possible. People remem- ber more of the information they hear in the beginning of instruction, so discuss top priority items first. Most patients who come to see nutrition counselors have already decided to give the counselor a chance to help. The important determi- nants are whether the patient and his or her family understand and respect what the counselor says, and whether the changes are reasonable, given the patient and his or her lifestyle.

Factors associated with compliance:

■ Belief that following a diet is necessary for good health

■ Supportive family members

■ High level of concern over conse- quences of noncompliance

■ Eagerness to reject the sick role ■ Feeling comfortable about ability to

cope with the diet

Factors associated with noncompliance:

■ Living alone ■ Lack of symptoms or pain ■ Failure to communicate purpose of

diet treatment adequately ■ Multiple restrictions ■ Poverty or unemployment ■ Depression

When teaching nutrition information, a counselor produces her best results when she uses various tools and methods. We re- member 10% of what we read, 20% of what we hear, 30% of what we see, 50% of what we see and hear, and 80% of what we our- selves say. To increase compliance, com- bine visual aids, verbal instructions, written instructions, and learner feedback.

To improve adherence and understand- ing, it is important that the patients receive only the instruction materials and hand- outs that apply to their lifestyle changes or eating pattern—not every free booklet on low-fat foods or diabetes. If the patients or their families express an interest for more recipes or other material, additional mate- rials can be offered.

CONCLUDING A SESSION

To conclude a session, it’s suggested that the client summarize the agreed-upon goal for the next visit and the most important points to remember from that day’s ses- sion. Except in very rare cases, patients need follow-up visits in order to make per- manent changes in their behavior. Clients like to know they can contact you in between visits by phone or email.

EVALUATION/FOLLOW-UP

The counselor uses the follow-up sessions as a time to reinforce the positive behaviors and provide immediate feedback on any

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80 THE ENTREPRENEURIAL NUTRITIONIST

it may prove essential in a dispute or mal- practice suit. In courts of law, the statement is often made that if the service wasn’t documented, it didn’t happen—where is the proof?

Whatever method of recording a prac- titioner uses or if she or he just states the pertinent facts is not important. The most important point is for objective changes, such as improved chemical scores or anthropometric values to be docu- mented along with behavior and belief changes.

COUNSELING ONLINE

As explored by Linda McDonald in Going Global with Nutrition Counseling (7), “Coun- seling and educating by email is a develop- ing communication method that links professional expertise with consumer needs in a convenient, informal format.” Clients like having feedback when it’s pertinent and not having to take off work or spend as much time going to appointments. Counselors like the convenience of answer- ing emails in their free time, when they have more time to ponder client questions. They also enjoy generating income while wearing their sweats.

Courts of law have found that email communication is a unique medium for conflict resolution. Some divorced spouses who haven’t been able to get along in per- son are court ordered to only communi- cate by email because it makes handling problems more objective and less emo- tional (8). Along this same line, nutrition clients sometimes open up more in emails than in person—it is less personal to say something to a screen than to another person.

Communicating with your patients is one thing, but some dietitians are also giv- ing nutrition information and advice to the world from their websites. A few dietitians charge for their services and others offer free nutrition assessment, diet analysis, or diet plans, which are actually paid for by

completed projects, behavior records, or questions. In evaluating clients, counselors again become diagnosticians (6). If no so- lution to the problem has been reached, counseling reverts to the assessment or treatment phase.

ENDING CARE

When it is time to conclude therapy, the practitioner and client should come to a mutual agreement that the client is ready to stop, or that any possible benefits from counseling have been achieved. Monitor- ing the patient with appointments (emails or phone calls) every 3 to 6 months helps identify and solve problems that tend to appear when living in the real world.

Although the goal of the counseling is to provide clients with long-term, self-man- agement goals and skills, many clients may need to remain in treatment longer to maintain the change in eating habits. By being available by phone, by email, and by appointments after structured care has ended, a counselor can help a patient bet- ter handle relapses and new problems. Also, clients that were unmotivated earlier may feel comfortable about reentry into counseling at a later date.

SELF-EVALUATION

Because a practitioner’s success as a coun- selor depends to a large extent on the pa- tients’ outcomes, a counselor needs to evaluate whether his or her patients have succeeded. It is the patients’ responsibility, not the counselor’s, to make changes in their lives. The counselor’s responsibility is to make the patient aware of the food and lifestyle habits necessary for good health, to help the patient identify and alter bar- riers, and to facilitate changes in motivated patients.

DOCUMENTATION

Records should be kept on each patient and his or her progress. The information is not only important and useful to the consultant;

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selling advertising to companies who want exposure to the people coming to the site or to sell them products (7). See Chapters 22–24 for more discussion on the creation of such sites and legal pros and cons.

THE FUTURE: FUNCTIONAL NUTRITION THERAPY

This section was written by Diana Noland Functional medicine considers evidence- based, systems biology assessment of a client and his or her biochemical individ- uality to develop the best intervention plan for personalized therapy with nutri- tion as the cornerstone. It is a joy to prac- tice as a functional medicine nutritionist to improve patients’ outcomes by the incorporation of a functional medicine nutrition assessment and intervention into the primary care physician’s treatment plan. Often, other members of the chronic care team like chiropractors, acupunctur- ists, and biological dentists are involved, and you experience the exhilarating team- work with one goal—to restore that pa- tient’s health.

In the past decade, we have begun to use the test results from the emerging field of nutrition genomics to add more depth and accuracy in personalizing recommenda- tions. Most of my postgraduate training, learning how to look for metabolic imbal- ances that are nutritionally and biochemi- cally based has been through functional and integrative educational programs, keeping current in the literature, and working with physicians and labs who taught me how to clinically utilize the functional test results within my nutritional scope of practice.

Remember acid–base balance and the Krebs cycle of years ago? They are alive and well and are more relevant today than we ever thought. What is becoming clearer in working with the challenge of chronic disease is that there are eight basic metabolic nutritional pathways in the body that the functional medicine nu- tritionist needs to learn to more accurately

understand the metabolic root causes of an illness (9):

1. Mineral status: tissue minerals, acid– base balance, calcium balance

2. Protein status: acid–base balance, growth and repair, enzymes, amino acids

3. Fatty acid status: control of inflamma- tion and hormones, structure, neuro- logical health

4. Methylation: folic acid, B6, B12, TMG (betaine), S-adenosyl methion- ine (SAMe) nutrient dependent

5. Vitamin D and cofactors: vitamin D, A, K and evaluating Phos-Ca-Mag balance

6. Hydration: total body water, intracel- lular, extracellular hydration

7. Oxidative stress and antioxidant status: C, E, CoQ10, Phytonutrients/ curcumin, etc.

8. Elimination systems and gastroin- testinal health: how to restore gut health and kidney function

GUT HEALTH

Restoring gut health is a good place for a nutritionist to start with a patient because it is the inner tube of the body where nu- trients enter, it functions in critical path- ways in detoxification, and it’s the location of about 70% of our immune system. The gut has an enteric nervous system that rivals the brain and spine and it houses 95% of the body’s serotonin, usually thought of as a brain hormone (9). The gut may be damaged by multiple factors such as poor diet, stress, toxins, prescription drugs, infection, etc., causing what is labeled a “leaky gut,” or “intestinal permeability.” This physiological change can allow large proteins to enter the blood and lymph circulation triggering autoim- mune reactions and allergies.

Restoring the gut environment will provide long-reaching benefits to overall health. Functional medicine has provided a disciplined architecture to start toward a

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82 THE ENTREPRENEURIAL NUTRITIONIST

Methylation is a protector of the delicate DNA as it reproduces; it protects our si- lenced genes from expressing negative be- havior, aids in detoxification of enzyme systems, and many others. Each functional medicine nutritionist practices his or her own style but when following its princi- ples, we usually all reach the same patient outcomes. The results of the nutritional therapy in this case study were exceptional and illustrate the potential importance of nutrition assessment and intervention in chronic disease management.

PATIENT PROFILE

During the initial visit, the patient looked attractive, of normal weight but pale. She is a counselor by education, however, was un- able to work consistently; she had seen five physicians so far for her asthma over the years. Upon her annual physical 31⁄2 years ago, her Pap smear revealed cervical dyspla- sia CIN I and �HPV, which continued to progress. After a loop electrosurgical exci- sion procedure (LEEP), cervical dysplasia progressed to CIN III and a surgical coniza- tion was recommended (cervical conization is performed if the results of a cervical biopsy have found a precancerous condi- tion in the cervix).

Initial assessment when patient pre- sented for care:

■ A 33-year-old married woman, no children, pale skin

■ Weight 138 lb / height 69 in / BMI 20.5 / 20.7% body fat / BP 112/62

■ Family history: mother ETOH (alcohol intake significant), GF (m) and uncle (m) depression

■ Medical Symptoms Questionnaire (MSQ ) score is 57 points; good is �25; pri- mary symptoms (see under history); this is a basic assessment tool used by functional medicine practitioners

■ Medical history: fatigue, asthma, eczema, depression, cervical dysplasia

■ Current medical status: cervical dyspla- sia (postLEEP) � 3-month diagnosis

restoration of the gastrointestinal tract called the “4 Rs.” They stand for (9):

■ Remove (offending pathogens and toxins)

■ Replace (replenish enzymes, nutri- tional whole foods, and digestive fac- tors which may be lacking)

■ Reinoculate (reintroduction of desirable bacteria)

■ Repair (reduce inflammation and repair gut lining)

With each nutrition assessment com- pleted, I first approach the “detective” work by collecting the diet data, medical and nutritional history, anthropometrics, and laboratory testing ordered by the team to look for patterns of subclinical meta- bolic imbalances. For example, the person could have a vitamin C insufficiency and it would show up as periodontal disease (NHANES III). Or, a person could have a vi- tamin D insufficiency and it would show up as a tendency toward depression, which is “worse during winter months” or is ini- tiated by the Standard American Diet (SAD) of low fruits and vegetables and many highly processed foods. So often, the nutritional component is overlooked and the patient is directed toward pharmaceu- ticals first instead of considering nutrients and diet.

The following case quickly emerged to be a pattern involving probable genetic tendencies and poor methylation, a ubiqui- tous metabolic pathway moving methyl/ three-carbon groups, which depend on ad- equate nutrient levels of vitamin B6, B12, folic acid, and trimethylglycine (10).

MethylationBOX 9.1

The pattern of methylation has recently become an important topic for research. The overall methylation state in a cell might also be a pre- cipitating factor in carcinogenesis as evidence suggests that genome-wide hypomethylation can lead to chromosome instability and in- creased mutation rates (11,12).

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CHAPTER 9 ■ Counseling Expertise 83

CIN III / �HPV � 3 years. Medical plan: conization

■ Current medications: singular, birth con- trol pills (BCP) (↓Folic acid), ibuprofen (Advil) (↓Folic acid), cortisone prn (↓Folic acid, Ca, Mg, K, Se, Zn, Vitamin C, D), antihistamines prn (Arrows indi- cate that the medication lowers the availability of the nutrients.)

■ Diet history: eats out 50%; eats SAD (Standard American Diet), low veg- etable intake, high casein/milk intake; ETOH 2–3 servings per week

■ Supplement history: none ■ Physical activity: weights/treadmill

45 minutes daily

With each assessment, starting with the first, it’s helpful to navigate and assess the patient’s story by populating a model

called the Functional Medicine Matrix™ illustrated below (Fig. 9.1).

Although this woman appeared to be healthy except for cervical dysplasia, from a functional point of view, there were some major red flags:

■ Depression history with family history of ETOH mother; GF (m) and uncle (m) severe depression

■ Long-term use of BCP, cortisone, and ibuprofen (Advil) medications—all de- plete folic acid (13)

■ Very poor energy levels, with 10� hours sleep and still fatigued when awaken

■ Resistant �HPV �3 years with pro- gression to precancerous cells

■ Medications required to control asthma and allergies

FIGURE 9.1 ■ Functional medicine matrix model.

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84 THE ENTREPRENEURIAL NUTRITIONIST

■ Genomic Methylation markers: ��COMT (catechol-O-methyltrans- ferase polymorphism), �/�MTHFR (methylenetetrahydrofolate reductase polymorphism) (16,17) (implies risk of reduced methylation activity)

■ Genomic Vitamin D Receptor �/� VDR (implies risk of reduced vita- min D receptor activity, responsible for calcium transport)

■ Genomic inflammatory markers: �/� IL-1B, �/�TNFa, �/�IL-4, �/ �IL-6, �/�IL-13 (implies increased tendency to express inflammatory conditions like asthma, allergies, etc.)

Initial nutrition intervention plan for 2 months, then reevaluate.

Diet:

■ Casein free ■ Whole foods organic diet with fish

2x weekly ■ Sea salt 1⁄2 tsp daily on food (continue

as long-term maintenance) ■ Rice Protein “Detox” Shake daily for

2 months

Beverages:

■ Pure spring water ■ Green tea

Supplements:

■ Multivitamin (MVI) with vitamin B6 (25–50 mg) with iodine (rec mainte- nance long term)

■ Folic Acid (5-MTHF): 800 mcg BID (rec maintenance long term)

■ Sulfurophane (indole-3-carbinol from broccoli): 1 cap BID (rec cruciferous veg- etables 5x wk) Folic acid and indole-3- carbinol are known to promote healthy gonadol hormone and glandular tissue (breasts, ovaries/prostate, uterus, and cervix).

■ Black currant oil: 370 mg GLA daily (rec maintenance Omega 3-6-9 long term)

■ Magnesium taurate: 200 mg daily (rec hi-folate veg/calcium-rich foods maint diet)

From the initial assessment, more testing was requested through her physician with the following significant findings received within 2 weeks. The functional medicine review of labs looks for more “optimum lev- els,” rather than only “within normal” lab references. Also, more nutritional laboratory tests are ordered in functional medicine. The following lab results were considered significant:

■ Comprehensive Metabolic Panel: Within Normal Limits (WNL), but low-end sodium/ chloride/ electrolytes ■ Lipids: mildly elevated total

cholesterol ■ Functional Nutrition Laboratory Tests:

■ (Low) magnesium, zinc, and iodine; (hi) copper and aluminum (toxic)

■ Low all essential amino acids (plasma)

■ Red blood cell (RBC) fatty acid: low gamma linolenic acid (GLA) omega-6; low stearic/oleic fatty acid ratio

■ Vitamin D 25-hydroxy (serum) scored 17 (optimum �40–100) (14)

■ Bioelectric Impedance Analysis: phase angle scored 6.5 (normal is 7.5–8.5) (implies lack of cell mem- brane fluidity)

■ Formiminoglutamic acid (FIGLU- folic acid marker) (hi—indicator of lack of folic acid), Homocysteine scored 8.7 (optimum 5–6) (high- end normal—indicator of poor methylation) (15)

■ Casein/milk IgG allergic response (0 � no allergy) scored �3 out of 4

■ Genomic Testing—A positive nota- tion (�) signifies the presence of a variant associated with suboptimal protein function. A negative notation (�) signifies the presence of the more common variant that is associated with optimal protein function. Be- cause we inherit a pair of genes, we have two copies. Therefore, the com- plete results will contain either a �/�, �/�, or �/�.

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CHAPTER 9 ■ Counseling Expertise 85

■ B12 (methylcobalamin - sublingual): 1000 mcg daily

■ Iodine: 450 mcg daily (3x RDA) (impor- tant for health of gonadol tissues)

■ Zinc carnosine: 75 mg daily ■ Probiotics: 450 billion Lactobacillus

acidophilus/Lactobacillus bifidus daily

Medical Report/Two Months:

■ Two-month repeat Pap smear: no HPV; no cervical dysplasia; medical plan: monitor/no conization

■ Fifty percent decrease in inhaler (no asthma episodes since intervention)

■ Decreased use of ibuprofen (Advil) ■ Increased energy ■ Started training to work as a counselor

with abused children

Medical Report/Two Years:

■ Pap smears continue to test normal

■ One episode of asthma when visiting abroad and exposed to mold

■ Working as a counselor with abused children

■ Happy!

Laboratory test follow-up available/all other blood chemistries WNL:

■ Vitamin D, scored 47 (optimum �40–100)

■ Cholesterol, WNL

The patient is very appreciative of her health changes. She came initially seeking therapy as a possible way to stop the need for conization of her cervix and to prevent cervical cancer, but instead experienced many other improvements like decreased medication, more energy, and more joy in life. She is committed to continuing basic supplementation to support her genotype and eat a lot more vegetables!

C A S E S T U D Y 9 . 1

I N T U I T I V E E A T I N G

One of the most fundamental truths by which I live my life and the basis for my nutrition therapy practice is the belief that we are all born with the wisdom we need for eating and, actually, about every aspect of living. The caveat, of course, is that we must listen to this internal wisdom and feel a strong conviction that it will lead us to productive choices. We must also ward off the inaccurate and mis- guided, although often well meaning, external advice and myths with which we are con- stantly bombarded. This deep conviction of mine led me to the ideas which I put into my part of the writing of Intuitive Eating, a book I coauthored in 1995, along with what was added in the second edition in 2003, as well as the new material in the audio version that was released in January, 2009.

So what happens in counseling when you receive a referral that you know is antithetical

to your belief system—in fact, so counter to what you teach that you know it can do your patient great harm? That’s the position I found myself in a couple of years ago. I spoke to this lovely, articulate man, whom, for the sake of confidentiality, I’m going to call Jerry, who told me that his doctor had given him my card, as well as the phone number to a rapid weight loss program at a local hospital. Just to be clear, this program was so geared to speedy results that it only allowed 3500 calo- ries a week—that’s right—500 calories per day for a man who was over 6 ft tall. He had a blood pressure of 114 over 81, a cholesterol level of 154 but with a weight of 280 pounds and elevated blood sugar levels, he was head- ing toward diabetes.

Reconciling Opposite Paths What was I to do? In my heart I knew this

program would only set him up for failure by slowing his metabolism and lowering his self- esteem when he would ultimately fall off the

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86 THE ENTREPRENEURIAL NUTRITIONIST

wagon. Should I tell him to come see me after he’d gone through the program? Or should I give him all of the reasons why this program was bound to fail? Or was there a better alter- native—something unique that some dietitians might feel uncomfortable handling? Well, I didn’t have to think about my answer for more than a moment and I suggested to Jerry that he might truly benefit by coming in to see me while he was going through the program. By engag- ing in nutrition therapy, he would have the op- portunity to learn about intuitive eating and prepare for dealing with normal food at the completion of the program. Little did I know at the time, but Jerry was going to go beyond this expectation and reach new heights of intuitive eating, even while in the program. But more on that later. . .

I want to be very clear about the sensitivity, which I felt was necessary to maintain during our first session. Of course, I knew that in the long run, the chances of a program such as this to succeed were slim or none. Yet, I didn’t want to tear something down that I knew sounded very exciting to Jerry. I certainly did not want to be a part of setting him up for the ultimate failure. My goal was to be supportive during his journey, teach him about intuitive eating, and know that we would develop the kind of trusting relation- ship that could hold him, as he would go through the hard times. He was excited about the quick weight loss program; in fact, he felt that it was his only hope for avoiding the di- abetes with which each of his family members was struggling.

Now, all of this may sound like a cop-out to you. Shouldn’t I have given him the hard line about rapid weight loss? Shouldn’t I have told him that program was worse than any diet he had been on and failed? If I believed so much in intuitive eating, shouldn’t I have tried to convince him that this was the only way to go? NO, NO, NO! Taking away his ex- citement and spirit and trying to convince him to do something else would only lead him to resentment, go away, and never have the opportunity to truly heal his relationship with food.

Treatment And so I began the treatment. I helped him

first to understand that the majority of the overeating he had done in his past was a mech- anism for pushing away some very difficult feel- ings he had been experiencing in his life. Instead of continuing to see himself as a failure because of his overeating and bingeing, he began to accept that this behavior was actually a creative coping mechanism that had helped him survive his life. Later in the treatment, I helped him understand that much of this overeating was also a result of a normal psychological reaction to the deprivation of past diets, as well as the result of the rebellion against being told what to do when on a diet. But that part would have to wait to be introduced until he began to rec- ognize and express some of these feelings while on this current medically supervised diet. Re- member, I didn’t want to discourage him. Instead, I began to teach him the skills that would be fundamental to handling his feelings without using food. These skills included:

■ Self-nurturance ■ Making time for meals ■ Identifying his feelings and learning to sit

with them ■ Finding enjoyable and satisfying experiences

in life ■ Challenging his distorted thoughts, and

shifting negative self-talk to positive self-talk

I also encouraged him to start to notice his sen- sations of hunger and fullness while on the diet. I taught him about the value of making peace with food and that he would be able to experi- ence that freedom when normal eating was introduced to him. We talked about satisfac- tion in eating—again, an experience to which he could look forward to at a later time. We also talked about the value of movement in his life. In the past, exercise had been associated with dieting. When the diet failed, the exercise disap- peared. I helped him to appreciate the wind on his cheeks during his long hikes and the oppor- tunity these hikes gave him for solitude from his busy life. But above all, I taught him to be pa- tient with himself during this process. As he began to fall off the track of the diet, as was

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CHAPTER 9 ■ Counseling Expertise 87

that the sodium content of these meals totaled 4000–5000 mg per day, Jerry began to ques- tion the program. Some of his thoughts in- cluded the following: How could this program, as it was structured, be truly beneficial if he had lost more weight than anyone else while eating far more than anyone? Why did his blood pres- sure spike from normal to above normal when he was eating the food provided by the pro- gram? And, additionally, why was the pro- gram’s staff angry with him, whenever he told them how he had deviated from the program? Why did they want him to follow it perfectly, when he was doing so well following his own signals? After taking some time to reflect on these questions as well as his own internal progress, Jerry dropped out of the program a couple of weeks shy of its proposed 13-week length, continuing to maintain his achievement of having lost more weight than any of the re- maining people who were still in the program.

After leaving the program, Jerry continued private sessions with me, refining his intuitive eating skills and getting the support he needed through the ups and downs of reentering the world of normal eating while dealing with his stressful life. Was Jerry able to maintain his total weight loss? At the end of the program, Jerry had lost 58 pounds and was weighing in the 220s for the first time in years. While deal- ing with a number of serious stressors in his life, including losing his job, he needed to work his way through some rebound overeating experiences, gaining back about 25 pounds within a few months. During the following year of treatment with me, he was able to maintain his weight in the high 240s (a net weight loss of over 30 pounds) while on the path to rediscovering his inner intuitive eater. When his treatment ended, he was able to acknowledge a sense of peace and safety in his relationship with food. He now had tools for managing his life and tolerating his feel- ings without using food and was committed to maintaining this new way of living.

To finish, I found this unique, flexible treatment to be extremely satisfying. It had been so important to stay in the role of sup- porter and teacher, rather than nay-sayer or

expected, he learned to forgive himself, speak kindly to himself, and look at each time as a learning experience that could shine some light on his thoughts and feelings.

Patient’s Experiences So here are some of the experiences that

Jerry did have. First of all, he used his training to observe hunger sensations to give himself permission to have more of the packets of “milkshake” than the program allowed. These milkshakes, whether in liquid form or turned into pudding form were the only food allowed in the beginning of the program. He felt a bit defiant at breaking the rules but knew that his body was more of an expert about what he needed than the “experts” who ran the pro- gram. As a result of eating more than was allotted (6600 calories/week vs. 3500), he began to lose more weight than anyone in his group. He was astonished by that as were the other participants and the doctors. Rather than beating himself up for breaking the rules, he honored his internal wisdom. Had he been critical of himself, he would have likely begun to binge, as a method of self-punishment, and drop out of the program.

At the end of 2 months, Jerry couldn’t put one more shake in his mouth! Fortunately, at this point, frozen meals and peanut butter energy bars were introduced into the program. He promptly ordered two boxes of bars and, just as promptly, ate all 48 bars as soon as they arrived. Rather than condemning himself for this seeming indiscretion, he used his new tools of cognitive restructuring and positive self-talk to explain to himself that this behav- ior might be expected for someone who hadn’t eaten solid food for 2 months and who had just taken a 2-hour hike, leaving him extremely depleted. He basically dusted him- self off and got right back on his path.

Around this time, his calorie intake was up to 1500 to 2000 per day, although the pro- gram still called for only 500 to 600 calories per day. With the new variety of foods and the increase of calories, came an unexpected oc- currence—Jerry’s blood pressure started creep- ing up to 137 over 90. When we discovered

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88 THE ENTREPRENEURIAL NUTRITIONIST

proselytizer. By stepping back and allowing Jerry to go through his process in his own way, he was able to discover the wonders of learning about his internal wisdom and ulti- mately trusting the power of this wisdom. The feelings of failure he had always held around his eating experience shifted to feel- ings of self-assurance. I hope this story will open up new thoughts in the realm of ap- proaching patients who have their own agenda, even though you may know better! —Elyse Resch

SUMMARY

Change is difficult to achieve. The belief held by some clients and many third-party payers that lasting changes in food behav- iors require only a few therapy sessions is an illusion. Change has a complex nature. Nutrition therapists and clients should not feel as if they failed when a perfect, smoothly functioning set of skills is not achieved in a few weeks. The goal of nutri- tion counseling is achieved when the client integrates healthy nutrition guidelines for a lifetime.

REFERENCES 1. King K, Klawitter B. Nutrition Therapy: Advanced

Counseling Skills. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins, 2007.

2. Nutrition Therapist Subunit. Ventures; Summer, 1998.

3. Snetselaar LG, Schrott HG, Albanese M, et al. Model workshop on nutrition counseling for Dietitians. J Am Diet Assoc 1981;79: 678–682.

4. Roth J. Comparison of Nutrition Education and Psychotherapeutic Counseling. 1993.

5. Shortridge R. The Perceptor. A manual of train- ing behavior for professionals. Dairy Council of California, 1980.

6. Snetselaar L. Nutrition Counseling Skills for the Nutrition Care Process. 4th ed. Sudbury, MA: Jones and Bartlett, 2008.

7. McDonald L. Going global with nutrition counseling. Today’s Dietitian, May 1999.

8. Personal interview with Suzanne Levisay, LSW, professional counselor with years of court ex- perience in Denton, Texas, 2002.

9. Jones DS, Quinn S. Textbook of Functional Med- icine. Gig Harbor, Wash: Institute for Func- tional Medicine, 2005.

10. Chen RZ, Pettersson U, Beard C, et al. DNA hypo-methylation leads to elevated mu- tation rates. Nature 1998;395(6697):89–93. doi:10.1038/2577.

11. Childers JM, Chu J, Voigt LF, et al. Chemopre- vention of cervical cancer with folic acid: a phase III Southwest Oncology Group Inter- group study. Cancer Epidemiol Biomarkers Prev 1995;4:155–159.

12. Powers HJ. Interaction among folate, riboflavin, genotype, and cancer, with reference to colorec- tal and cervical cancer. J Nutr 2005;135(12 Suppl):2960S–2966S.

13. Butterworth CE Jr, Hatch KD, Gore H, et al. Im- provement in cervical dysplasia associated with folic acid therapy in users of oral contraceptives. Am J Clin Nutr 1982;35(1):73–82.

14. International Agency for Research on Cancer. Vitamin D and cancer. Nov. 25, 2008. Available at: http://www.iarc.fr/en/Media-Centre/IARC- News/Vitamin-D-and-Cancer. Accessed March 9, 2009.

15. Austin RC, Lentz SR, Werstuck GH. Role of hy- perhomocysteinemia in endothelial dysfunc- tion and atherothrombotic disease. Cell Death Differ 2004;11(Suppl 1):S56–S64. 11, S56–S64. doi:10.1038/sj.cdd.4401451.

About the Author Elyse Resch, MS, RD, FADA, Nutrition Ther- apist, and Coauthor of Intuitive Eating St. Martin’s Press, 1995, 1996, 2005; and Coauthor of Intuitive Eating, Audio Version with Guided Practices, Sounds True, 2009. www.elyseresch.com

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CHAPTER 9 ■ Counseling Expertise 89

16. Leopardi P, Marcon F, Caiola S, et al. Effects of folic acid deficiency and MTHFR C677T poly- morphism on spontaneous and radiation in- duced micronuclei in human lymphocytes. Mutagenesis 2006;21(5):327–333; Epub 2006 Sep 1. doi:10.1093/mutage/gel031.

17. Goodman MT, McDuffie K, Hernandez B, et.al. Association of methylenetetrahydrofolate re- ductase polymorphism C677T and dietary folate with the risk of cervical dysplasia. Cancer Epi- demiol Biomarkers Prev 2001;10(12):1275–1280.

RESOURCES King K, Klawitter B. Nutrition Therapy: Advanced

Counseling Skills. 3rd ed. Baltimore, MD: Lippin- cott Williams & Wilkins, 2007.

Kratina K, King N, Hayes D. Moving Away From Diets. 2nd ed. Lake Dallas, TX: Helm Publishing, 2004.

Snetselaar L. Nutrition Counseling Skills for the Nu- trition Care Process. 4th ed. Sudbury, MA: Jones & Bartlett, 2008.

Myers ES. Winning the War Within. 2nd ed. Lake Dallas, TX: Helm Publishing, 2007.

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III

WORDS OF WISDOM

Unless you try to do something beyond what you have already mastered, you will never grow.

Ronald E. Osborn

To dream anything that you want to dream. That is the beauty of the human mind. To do anything that you want

to do. That is the strength of the human will. To trust yourself to test your limits. That is the courage to succeed.

Bernard Edmonds

MANAGING YOUR BUSINESS

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Successful dietetic business ventures star- ted in many different ways and under a variety of circumstances. Some business op- portunities are handed to the nutritionist by a physician or a chance phone call from a future client, others are outgrowths of jobs, and still others start without contacts or encouragement from anyone. Many busi- nesses are painstakingly researched for years, and others are created over lunch on a nap- kin. In the 2008 survey, 33.2% out of 1373 dietitians said they wrote a business plan be- fore starting their businesses, but 55.2% of the 30 dietitians making over $200,000 net per year said they used a plan (1). Across the board in all income brackets, the majority of dietitians (83%–86%) said they planned their businesses in a year or less (1).

DEVELOPING THE VENTURE ON PAPER

Business consultants agree that a potential business owner should put his or her plans in writing while doing research on the fea- sibility of his or her future venture (2). The tool used to do that this is called a business plan or feasibility study. Its purpose is to share information, find problems, organize the business, and raise capital. This busi- ness tool has more written about it and has more resources to help you create it than any other in business (3). There are online websites, software templates (online and at office supply stores), and business consult- ants ready and willing to help you produce your plan (4). A few available resources are listed at the end of this chapter.

Unfortunately, it’s not rare for a future entrepreneur to be so sold on an idea for a

new business that he is totally blind to ob- vious reasons why the idea has a poor chance at success. Some examples are locat- ing the business too close to the strongest competition—a nationally known hospital with a free clinic—or wanting to become a culinary consultant to only Greek restau- rants in Omaha. Although these ideas have a chance of working, it may take too long before one can generate adequate income.

An experienced businessperson or pro- fessional advisor can look over the execu- tive summary and business plan and find overlooked problems. Having your ideas clearly stated will help reduce the amount of time needed by paid advisors to assess your business needs. Most banks and all potential venture capital investors will re- quest this information when considering a loan or investment. Businesspeople take the time to prepare these documents be- cause they are useful, provide insight to the business owner, and give the appearance of having one’s act together.

EXECUTIVE SUMMARY

If you had to rank all of the components of the business plan, the executive summary will float to the top. Why? It is because the executive summary captures in less than one typed page (and 1 minute of reading) the general excitement, potential success, and resources required for a new product line extension or new business venture. The proposed scope of a new business—what you will sell, to whom, where, how, and when—can all be stated briefly in the exec- utive summary. It introduces the concept to the decision makers. It must stimulate them

BUSINESS PLAN

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94 THE ENTREPRENEURIAL NUTRITIONIST

■ Identify your financial needs to create the venture.

Jim Rose, RD, former food service direc- tor and entrepreneur, stated in Hospital Food and Nutrition Focus, “Write your executive summary in present tense, active voice. Avoid the ‘shalls’ and ‘wills’. Use verbs that show action, and presume existence of the project. Make sentences short. Make para- graphs short. Use some bold or highlighted text—sparingly. However, don’t be too dra- matic, trite, or obviously overblown. Include all the essential information. The executive summary must be possible to read in less than 1 minute. The first 15 seconds of read- ing are critical; during that period, the deci- sion maker determines whether to put it aside, trash it, or continue reading” (5).

When writing the executive summary, think of it as a promotional description of your venture. Avoid unnecessary details and concentrate on the strong, salable points.

to read on, to analyze, and to buy into the idea. Without that stimulation, without that decision maker beginning to grasp the concept and share its excitement, the chances are remote that there will be full consideration of the business plan (5). If the plan is being used to attract financial back- ing, the executive summary should briefly spell out how much money is needed (6) (Fig. 10.1).

Although it’s at the beginning of a busi- ness plan, the executive summary should be written last after all the facts have been ex- plored. The executive summary should (7):

■ Describe in detail the business and its goals.

■ Identify the business ownership and the legal structure.

■ Discuss skills and experience you (and any partners) bring to the business.

■ Identify advantages you and your busi- ness have over your competitors.

FIGURE 10.1 ■ Example of executive summary (5).

EXECUTIVE SUMMARY

The lines in our hospital cafeteria are getting longer, especially at lunch. Why? Our reputation for good food has spread. The local business community is routinely dining here—paying premium prices, providing us with excellent profits. However, seating is at a premium, serving areas are congested, and customers are turning away.

Creating a deli operation in the vending area (now rarely used except during off-hours) that is contiguous to the cafeteria opens up opportunities for take-out services, tapping into new target markets and improving returns on profits.

A 50-seat deli operation faces no real competition within six city blocks. Only five percent of the potential population is now dining with us but the percentage is growing—due to office building expansions with no food service operations included. Deli sales are growing in this region by twelve percent per year.

A capital investment of ___ provides a net return on investment of ___ on annual operations. Breakeven is at month ___. Operating breakeven is at ___ in annual sales. All gross revenues are based on an aggregate ___ cost of goods sold.

Renovation of the vending area requires $___. The current vending activities are incorporated into the deli operations scheme, offering expanded selections during off-hours.

Adequate labor pools exist, with recruitment simplified by our current food service recruitment programming. Management talent is already on staff.

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CHAPTER 10 ■ Business Plan 95

BUSINESS PLAN

The business plan starts with a title page, followed by the table of contents, and then the executive summary. By the time the rest of the plan is researched and written, you should have enough information to evaluate whether your business concept is viable, so you can estimate how much the venture will cost. Your plan can help you organize your venture and set priorities for better time and resource management. The marketing plan (Chapter 11) will be needed to fill out the business plan and to make an accurate assessment of what will “sell.”

Business consultants will charge from $1500 to $15,000 or more to research and fill out a business plan, but you can do it your- self. An accountant can be very helpful with much of the information. Typically, a plan will be 5 to 30 pages long, but consultants report they have seen ones with hundreds of pages when the project necessitated it. The larger size in no way improves acceptance of the plan; it may turn many readers away completely. The important point is to cover the subjects well with pertinent information. The plan should be assessed annually and should be updated and changed as needed.

A banker or venture capitalist uses a plan to evaluate whether he or she wants to in- vest in a business. In truth, according to ex- perts who study funding for entrepreneurs’ ventures, the chance of venture capitalists being interested in a new service business is almost nonexistent; they look for faster growth markets and entrepreneurs with extensive business experience (8).

In his book How to Start, Finance, and Manage Your Own Small Business, Joseph Mancuso, goes into great detail about what a plan should include and highlight (9). He also shares results of his research on what items “sell” to a venture capitalist or banker on a plan.

HOW A BUSINESS PLAN IS READ

Although a business plan needs to be com- plete and thorough, the average banker only spends 5 minutes looking it over.

Therefore, the plan’s layout and high- lighted information are extremely impor- tant. In his research, Mancuso and others have found typical steps in those 5 minutes of reading (2,5,8,9).

Step 1. Determine the characteristics of the project, industry, and company. Is this a growing market of interest to the public? Is competition doing well? Is anyone making much money in this field? Could this company or project do well?

Step 2. Determine the caliber of the people in the deal. Turn to the back of the plan and scan the résumés. This step, most venture capitalists claim, is the single most important aspect of the business plan. The names of em- ployees or founders, board of direc- tors, current investors, and names of professional advisors are scanned in hopes of finding a familiar name. The reputation and quality of the business team or entrepreneur will sell a plan bet- ter than any other single item.

Step 3. Determine the terms of the deal. What is being offered in return for the money? How much is needed, and how will it be used?

Step 4. Read the latest balance sheet. Is the company making a profit or just scraping by? Are the income projec- tions reasonable considering the balance sheet? Do the managers plan to pay themselves salaries that are reasonable?

Step 5. Determine what is different about this deal. This difference is the eventual pivotal issue on whether an investor chooses to back a business venture. Is there an unusual feature in the service or product? Nutrition is “hot,” but are your programs designed to take advantage of it? Are they ex- citing? Does the company have a patent or a significant lead over com- petition? Does the strength of the company match the skills needed to succeed in this industry? Does the inexperienced owner recognize his

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96 THE ENTREPRENEURIAL NUTRITIONIST

business model should also address the breakeven issue: at what level of sales does the business begin to make a profit? When does cash flow turn positive?” (2)

WRITING A BUSINESS PLAN

A business plan is a personal document. Yet, there are some common ideas that should be considered when writing a plan. The different segments of the plan can be written in narrative form, as an outline, or in numbered, highlighted points. The eas- ier it is to read and grasp the unique fea- tures, the better.

The order of the business plan is not as important as what information is included and how the information is highlighted. Adding too much detail can be a mistake. All of the following points of explanation do not have to be included; choose those that fit your needs.

SIX-STEP OUTLINE FOR BUSINESS PLAN

1. Introduction. The title page, table of contents, and executive summary come first.

2. Company Profile. What is the mis- sion of your company? What is your company going to sell—products and services? Describe any unique features of your company. What are the short- term and long-range goals of the busi- ness? What objectives will be used to reach those goals? List the anticipated stages of growth and development. Identify any proprietary information or trade advantages your company may have (patents, copyrights, trade- marks, established brands, etc.).

3. Market Analysis. This section de- scribes the market environment your business wants to enter. It shows whether you have carefully assessed its opportunities (new trends or ventures that could help your business) and

or her limitations and have good ad- visors, or is there an imbalance? Good ideas or products that are better than others will attract capital.

Step 6. Give the plan a once-over lightly. After the above analysis, the final minute is usually spent thumb- ing through the business plan. A ca- sual look at product literature, graphs, unusual exhibits, published articles, and letters of agreement support the argument for unusual enclosures. Al- though additional items seldom make a difference to the outcome, they can extend the readership.

If the plan is rejected, it is customarily returned to you. When trying to interest a banker in your venture, it is not out of line to ask why it was rejected. If the banker wants to work with you, he or she may sug- gest ways to improve the plan, offer a smaller loan, or ask for more collateral to secure the loan.

When an investor looks at a variety of business plans, Mancuso found that four elements determine which one is chosen first (9):

1. The company, department, or per- sons submitting the plan

2. Its geographic location 3. Length of business plan—shorter ones

are read first 4. Quality of cover—interesting but not

necessarily expensive

William Sahlman, chairman of the board for the Harvard Business School Publishing Corporation, asks, “What’s wrong with most business plans? Most waste too much ink on numbers and devote too little to the information that really matters (the people, opportunity, the big picture, and risks or rewards). Financial projections for a new company—especially detailed, month-by- month projections—are an act of imagina- tion. Don’t misunderstand me: business plans should include some numbers (for a nutrition therapist, it could be projected through referrals and follow-up visits). The

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CHAPTER 10 ■ Business Plan 97

threats (new negative trends or strong competitors who could stifle your business). End by discussing why you are unique within the market com- pared with the competitor.

4. Marketing Plan. This part should detail your business position, brand development plans, sales, pricing, and product strategies, promotion plans, referral agents, and potential strategic alliances. (See Chapter 11 for more details.)

What is the business position? How will the brand be developed? Who will sell the services and how? How will the business be advertised? What budgeted amount will be spent for promotion?

Who are the end users of your ser- vices? Describe them demographi- cally. How will they be reached? Who are the intermediate referral agents (physicians, clinics, corporations, hospitals, etc.)? How can they be reached?

Is the business seasonal? Are there any proposed government regula- tions expected to affect your busi- ness (new regulations that do not include the RD or DTR, coverage for MNT, etc.)?

5. Financial Plan. You will need to offer financial reports. (You may need some help to produce projections on a company without any financial his- tory. Ask your banker about which reports he needs.)

If you are already in business or pur- chasing an ongoing practice, show present and past balance sheets, tax re- turns, and profit and loss statements.

If just starting out, list projected start-up costs. Present pro forma bal- ance sheets, giving the effect of the proposed financing. What is your re- payment plan? Give yearly projec- tions of revenues and earnings for 2 to 5 years (don’t waste too much time on this, as everyone knows it is being fabricated). Be positive about your potential, but be as honest as possi- ble when projecting future business revenues. Bankers and others have seen hundreds of plans and often dis- count ones with obvious padding.

6. Appendices. Your résumé can go here along with any published articles defending your market projections, your unique product brochures, prod- uct samples, newspaper articles about your business, letters of agreement, and so on.

E N T R E P R E N E U R I A L N U T R I T I O N I S T S I N I N D I A

Three of us, all in the profession of nutrition and dietetics with multiple years of clinical experience, decided to approach nutrition dif- ferently, but we were quite clueless where to start. After some thought, we came up with the acronym NICHE, for Nutrition Informa- tion, Counselling, and Health Education.

We ran a health awareness program for the public in NICHE’s first month of existence in January, 2000, but it flopped. Then, we were asked to do a 2-hour session on nutrition and

C A S E S T U D Y 1 0 . 1 health awareness for a software company. One of the senior employees who heard us was so impressed that he spoke with his boss about additional services such as one-on-one diet counseling for the employees and improv- ing their cafeteria menu. Thus, began a long partnership between NICHE and Indian corporations.

In the year 2000, there was no other nutri- tion consulting firm that had forayed into cor- porate consulting in India. So, there was no example to follow, no lessons to learn, and no competition! We just went with the flow.

Before the end of that year, both of my colleagues had left the company due to

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98 THE ENTREPRENEURIAL NUTRITIONIST

ment, and accounting work since NICHE was a small consulting firm.

In 2007, online nutrition consulting was starting in India, and I briefly consulted for a company setting up such a project here. In 2008, I realized that I had to either expand big time or shut down.

Just when I was worrying about which path to take, I was approached by an online health consulting firm called ChiHealth, which was still in its infancy. It made business and pro- fessional sense to merge with them and work together. So, in October, 2008, the ChiHealth office took over running my NICHE adminis- trative, finance, and marketing duties, and I got to oversee the nutrition and diet consul- tation work—something that I love to do. I continue with my interests like writing for the media, participating in networking and social activities, and so on.

Even though I write this piece as the Direc- tor of Wellness in ChiHealth, I will always treasure the 8 years that I spent in giving birth to and nurturing NICHE to what it is today. This journey would not be possible if not for my ever-supportive and encouraging husband, and to my team, each of them contributing to the growth and success of the firm. It helped

personal reasons, and I was handling the firm alone. I had managed to hire a junior dietitian to work with me, and when I got the second client—the largest one thus far—we had four members on the team. In 2001, the economic downturn affected us. We almost lost a client, no new companies wanted to look at nutri- tion services, but we hung in there. As always, preventive healthcare took a backseat in the corporations. It was only in the year 2003 that things started to look up again. Growth was slow but steady until 2007. For many reasons, there were not many long-term clients signing with us.

During this period, many weight loss and fitness centers began to mushroom. They offered better salaries and incentives to dieti- tians and nutritionists to “sell” their weight loss packages. As a result, some of the dieti- tians that came for an interview at NICHE, demanded higher salaries even though our jobs didn’t require sales work. Moreover, sev- eral of the dietitians that had joined NICHE were compelled to leave for reasons like mar- riage, childbirth, or relocation of husband, etc. The staff turnover was becoming greater with every passing year. Apart from profes- sional work, I was also handling HR, manage-

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CHAPTER 10 ■ Business Plan 99

that our clients believed in our work and trusted NICHE wholeheartedly. I always believe that whatever the business or profes- sion may be, it is hard work, honesty, and humbleness that pays rich dividends. —Sheela Krishnaswamy, RD, Bangalore, India. Check out ChiHealth at www.chihealth.in and NICHE at www.niche4nutrition.com.

About the Author Sheela Krishnaswamy, RD, is the Director of

Wellness in ChiHealth (her present company) and the Founder of NICHE (her former com- pany). She has over 25 years of professional experience.

SUMMARY

The business plan should be considered as a working tool, one that is just as valuable for internal audit as external promotion or fund raising. A well-thought-out executive summary that outlines expectations for a business venture and a plan to carry out those concepts are invaluable in translating ideas into a successful business.

REFERENCES 1. King K. 2008 World-wide Entrepreneurial Dietitian

plan. In: Harvard Business Review on Entrepreneur- ship. Boston, MA: Harvard Business School Pub- lishing, 1999.

3. Johnson D. Business planning made easy. Home Office Computing; November, 1999.

4. Haskin D. Business Essentials. Home Office Com- puting. November, 1999.

5. Rose JC. Business plan. Hosp Food Nutr Focus 1989;4:10.

6. Business Plan. The Small Business Encyclopedia. Vol. 1. Irvine, CA: Entrepreneur Magazine Group, 1996.

7. The Facts About. . .Starting a Small Business. Wash- ington, DC: Small Business Administration, 2006.

8. Bhide A. Bootstrap finance: the art of start-ups. In: Harvard Business Review on Entrepreneurship. Boston, MA: Harvard Business School Publish- ing, 1999.

9. Mancuso, J. Mancuso’s Small Business Basics: Start, Buy or Franchise Your Way to a Successful Small Business. New Jersey: Prentice–Hall, 1997.

RESOURCES BizPlan Builder Interactive. Available at: http://

www.jian. com (fee). Business Plan Pro 11.0. Available at: http://www.

palo-alto. com (fee). Plan Write Software. Available at: http://www.brs-

inc.com (fee). Small Business Administration. SBA Readiness

Tool. Available at: http://web.sba.gov/sbtn/sbat/ index.cfm?Tool�4.

There are several other free tools online that can be accessed to help you write business plans, marketing plans, and assess your personality traits, etc.

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http://www.jian.com(fee)

http://www.palo-alto.com(fee)

http://www.brs-inc.com(fee)

http://web.sba.gov/sbtn/sbat/index.cfm?Tool=4

http://www.chihealth.in

http://www.niche4nutrition.com

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100

11 MARKETING DECISIONS

Twenty-five years ago, the need for mar- keting became obvious to practitioners in the dietetic profession. We now know that having educational credentials, good prod- ucts, and licensure will not make clients flock to our doors. It takes more. Clients must need or want what we have to sell. We like to think that people can’t live with- out us, but they can. If all we give out is information, the Web takes care of that.

By 2005, it was estimated that 8 in 10 Americans worked giving service instead of manufacturing products. Dietitians counseled, consulted, worked in long-term care, did marketing for grocery chains, and disseminating information—all of these are services.

Too much of our past marketing strate- gies were based on the product model (1). According to Harry Beckwith, marketing expert with 35 years of experience, the service marketing model is based on newer information (1,2):

■ Keep it simple. In our increasingly busy and overcommunicated society, nothing works more powerfully in marketing than simplicity. Market one focus with one positioning statement about your business. Don’t confuse customers by being the “jack of all trades.” You may offer more services but market the most significant one.

■ What customers really do. When choosing a service business (e.g., when a physician refers a client for counsel- ing on a low-fat cardiac diet), customers generally do one of the following three things: (a) nothing at all, (b) do it them- selves (go on the Internet or call the American Heart Association), or (c) use

your services. Seldom do they go to a competitor.

■ It’s all about relationships. People will buy from people they like and with whom they have relationships. It’s very hard to compare services, so customers use other criteria for choosing.

■ The fastest, cheapest, and best way to market your services is to do it yourself or through your employees.

■ People want to avoid making a bad choice; they seldom seek a superior choice. That’s why they will go to someone they “know” who did a good counseling job for a neighbor in- stead of trying someone new, and why “building a better mousetrap” doesn’t always guarantee business success.

■ People tend to buy what they hear most about or what seems most familiar. That’s why you should take the time and spend the money to advertise your presence in your marketplace—create your “brand.” Name brands are purchased in 13 out of 14 sales. People don’t have the time to look around and they learn to trust a brand’s reputation for good service over time, which is important because they can’t see the quality of a service before it’s purchased.

■ Don’t assume that behaviors will follow attitudes. Just because peo- ple think they should eat healthy or stop smoking doesn’t mean they will. Remember that next time when you think about starting a “healthy” fast food restaurant.

■ Research and data have a re- markable ability to fool people.

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CHAPTER 11 ■ Marketing Decisions 101

MARKETING DEFINED

To encapsulate the many formal defini- tions that have evolved to describe the function of marketing, it simply means: Those activities necessary for the delivery of services or products from the producer to the customer, to satisfy the customer and to meet the objectives of the business (4). These activities include:

■ Product or service development ■ Market research ■ Advertising ■ Public relations ■ Sales promotion ■ Customer service ■ Sales

The above definition requires the follow- ing two visions: (a) assessing and reacting to trends in the marketplace and (b) the higher purpose of your business or mission that should keep you focused and on track. For brief definitions of many of the terms used in this chapter, see Table 11.1.

TRENDS

First, the marketing function involves an on- going process of anticipating problems and opportunities through regularly analyzing the trends in the marketplace. Trends can be local, national, or global. Examples of “big” national trends include the following:

■ Population growing older with a huge Baby Boom group about to hit.

■ Obesity is the number one malnutri- tion problem.

■ Large number (44–48 million) of Americans are uninsured for health problems.

■ Big interest by some in culinary skills and organic foods while the majority of Americans are seeking “ready-to- serve homemade” carryout.

■ Too much junk mail—30% of all mail is thrown away before opening.

■ E-commerce will catch on more and change the way we live and commu- nicate.

Focus groups don’t tell more about market dynamics than a good critical thinker can. Look for people to give you advice who think for themselves and draw from a wide perspective.

■ Even if you have an “inferior” product (e.g., experts agree Mi- crosoft DOS was inferior to Apple) from a technical or criti- cal standpoint, you can still make money if your product solves customers’ problems. It just becomes more important to get the other elements in the marketing mix right (3).

How will people know what we sell? Even- tually, they will know it by word of mouth. However, in today’s competitive markets with limited budgets and shortened time- lines, most businesspeople find that organized, aggressive marketing is essential.

Marketing’s goal is consumer satisfac- tion. Too often in the past, we only offered what we felt our target markets should have. That has changed. Good tasting food—gourmet or gluttonous—and infor- mation on nutrition are “big business” now, attracting many people into the fields that were once ours by default.

MARKETING IN HEALTHCARE

The American health sector tried hard to resist the encroachment of marketing phi- losophy. Marketing activities, such as sales and advertising, were not viewed favorably in an industry traditionally grounded in helping and caring. Health marketing seemed to be an oxymoron or at least “commercial” and nonprofessional. Yet, when the costs of healthcare began to spi- ral upward, and the number of patients began to decline, a few innovative hospi- tals hired marketing professionals. Compet- itive change was launched. Today, billions of budget dollars are dedicated to consumer healthcare marketing activities.

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102 THE ENTREPRENEURIAL NUTRITIONIST

Term Definition

Advertising A paid form of communication about an organization and/or its products that is transmitted to a target audience through a mass medium.

Brand Name, term, symbol, design, or combination of these that identifies a seller’s products and differentiates them from competitors’ products.

Marketing Those activities necessary for the delivery of services or products from the producer to the customer to satisfy the customer and to meet the objectives of the business.

Marketing mix (4 Ps) A mix consisting of four major variables: product, price, place or distribution, and promotion.

Marketing plan The written document or blueprint for implementing and controlling an organization’s marketing activities.

Market niche A narrow segment of the potential larger target market that your product or service can satisfy best without as much competition. Marketing dollars are often invested more wisely when pursuing the correct niche.

Mission statement A declaration of the business you are in and its “higher purpose.” It sets your course, improves focus, and helps you decide what your goals should be.

Product or service Anything offered in the marketplace to be exchanged for something of value (i.e., money, commitment to change, etc.).

Public relations Marketing activities designed to create a positive image for you or your business in which to do business, earn recognition, and gain acceptance.

Publicity Publicity is free media coverage of some newsworthy story or event. Look for a news “hook” that will interest the media and its audiences.

Social marketing Activities that influence attitudes, beliefs, or lifestyle choices for the benefit of a person or the public. Media campaigns for stop smoking, pro-literacy, low-cholesterol diets, and the “food guide pyramid” are all examples of social marketing.

Strategic assumptions Statements about trends in the external environment that will affect the future and may present opportunities or threats to your business.

SWOT analysis An analysis used to assess your internal or personal strengths (S) or weaknesses (W), and the external opportunities (O) or threats (T) in the marketplace that may affect your plans.

Target market Primary customer group chosen for the marketing campaign. The group members usually have similar needs, wants, or desires.

TABLE 11.1 MARKETING DEFINITIONS (5,6)

STRATEGIC ASSUMPTIONS

In response to trends, you then develop strategic assumptions on what you expect the market to do. Strategic assumption statements should be concise and easily un- derstood. They help you by excluding ac- tivities and investments that, although they seem attractive, would deplete the company’s time and resources if you fol- lowed them (5).

These assumptions could be as simple as, “The population base in the Phoenix area will continue to grow older, faster than the U.S. population,” or “As long as this region

is in a deep recession, wellness is not a high priority for most corporations, except as a healthcare cost-cutting tool.” By deciding what the strategic assumptions are for your business area, you can better anticipate what will sell and how to sell it.

You base your short- and long-term mar- keting decisions on your assumptions and alter them as your assumptions change. Continuing with the examples, during the recession, you know that, in the short-term, you should immediately change the market- ing focus for your corporate weight loss pro- gram. Your pitch should change from highlighting the satisfied participants and

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CHAPTER 11 ■ Marketing Decisions 103

For example, by choosing a place or location in a very wealthy area of town, the practi- tioner has committed to produce a more comprehensive, high-end product at a higher price to cover increased costs with more expensive looking packaging and styl- ish, tasteful promotion.

According to marketing expert and au- thor, Philip Kotler, “the four Ps are from a seller’s point of view. The four Cs are from the customers’ viewpoint. Marketers sell products, but customers buy customer value. Customers are interested in more than the price; they want to know the costs of ob- taining and using the product. Customers want convenience when seeking to buy; and finally, customers want two-way communi- cation not promotion” (7).

MARKETING STRATEGIES

Entrepreneurs soon learn that it’s easier and less expensive to sell something else to a satisfied customer than it is to find another customer. Some marketing experts estimate that businesses spend five times more to attract new customers than they do to keep old ones (1). In fact, the most successful service businesses become that way because of repeat customers (1,2,7). The strategy is to “grow” a customer; the key is to move the customer through a series of stages, which is described in the following, that strengthen the relationship between the customer and the business (7):

1. First-time customers have no history or commitment to your company—keep them satisfied.

2. Repeat customers not only buy again, but they may spend more.

3. The one-on-one client relationship is next with personalized care and attention.

4. The best customers become advocates and tout your business to others.

5. In some industries, the customer is so close, the relationship becomes a partner- ship, like when an independent caterer becomes the exclusive provider of catered meals in a banquet facility.

pounds lost, to how much less they would spend on healthcare following your pro- gram. Long-term, if you live in Phoenix, you may decide that over the next 3 years, your major services will be changed to satisfy the needs of people more than 60 years old.

MISSION

A second vision associated with marketing is your business mission. A mission state- ment tells the “higher purpose” why your business exists. It could be “To provide high-quality, catered, healthy gourmet en- trees and low-fat desserts to the city of Midland,” or “My mission is to become a consumer–educator in nutrition through the broadcast and newspaper media with special emphasis on disease prevention and vegetarian eating.” The mission state- ment sets your course. It helps you decide what your goals should be to keep your al- location of resources focused. You may have many different business or career op- portunities that present themselves during the course of the day or year. Underlying your decisions on which ones to take should be your ultimate dedication to your mission.

MARKETING MIX

The four Ps of marketing are the variables you have to work with to influence the buyer to purchase your product or service. The standard marketing mix concept was developed by professor Jerome McCarthy in the early 1960s (7).

1. Product. This refers to the product or services the business sells.

2. Price. The money customers must pay for it.

3. Place. Location or where the cus- tomer will purchase the product.

4. Promotion. The marketing or ad- vertising used to attract customers.

By altering the above variables, a business can attract different target or niche markets.

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6. The highest view of the customer is the part owner, where the customer actually becomes part of the enterprise through an investment or bartered agreement.

USING STRATEGIES

An OB/GYN physician in Lewisville, Texas, sends a year-end, signed letter to each of his patients thanking them for their business and discussing what new benefits he offers. His office also sends very attractive thank you cards for patient referrals and reminders for yearly Pap smears. He keeps two large scrapbooks with baby pictures and thank you notes from happy parents on the lobby coffee table to help establish his credibility with expectant mothers. After delivery of a baby, he brings new mothers a baby picture frame and a newborn T-shirt that says, “Hand Delivered by Dr. Franklin.” He hap- pens to be popular with the nurses, not because he is easy to work with but because he has empathy for his patients and gives good medical care. He is an example of the

kind of healthcare specialist who will suc- ceed in the future—a good clinician who is patient-oriented and skilled in marketing.

Market research and your own creativ- ity and ingenuity can help you find niches in the marketplace where your products can flourish without heavy competition— at least initially (8). You will make better marketing decisions if you use the product life cycle model described earlier. Choos- ing the right point on the curve to enter the market is an art as well as a science. See Chapter 21 on promotion ideas.

SOCIAL MARKETING

Social marketing focuses on changing per- sonal or social behavior for the benefit of the person or public. It is used to accom- plish the following three objectives (9,10):

1. Disseminate new data and informa- tion to individuals like why to reduce their intake of high trans fatty acids or high aspartame-containing foods.

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Marketing ApproachesBOX 11.1

CONCENTRATED MARKETING In this approach, you identify one target market but sell multiple products or services to that market. If a patient is referred to you for a lower calorie diabetic diet, what else could you sell to that person? What about a group weight loss class with an exercise component, or grocery store tour, nutritional supplements, or low-fat cooking classes, or cookbooks discounted 10% from bookstore prices? By having a line of products or services, you can satisfy your pa- tients’ needs better and generate more revenue. If you have a catering business and someone comes to you wanting food for a special event, what else could you offer to that person? What about flowers, table decorations, musicians, linens, theme parties, or photography? You may only do the catering and everything else could be subcontracted to others.

DIFFERENTIATED MARKETING Differentiated marketing repackages a proven or new product to fit the needs of new target

markets. This could be as simple as adapting a group weight loss program to fit the needs of patients in cardiac rehabilitation. You could offer a “senior meal” selection in your cafeteria at a lower price to attract a new target market. Keep good records on your clients or patients. Try to identify who are your best-buying cus- tomers and keep in touch with them through a newsletter or year-end thank you note. The goal is to develop ongoing relationships that don’t end when a consultation session or catered event is over. Every client has a sphere of influence that could mean increased business for you.

UNDIFFERENTIATED MARKETING Undifferentiated marketing involves introduc- ing only a single version of the product in the hope it will appeal to everyone. The original Coca-Cola was a good example of this strategy, but so is a nutrition presentation on healthy eating or one on disease prevention through nutrition.

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CHAPTER 11 ■ Marketing Decisions 105

year as well (12). There were of course others (11%) who spent 21% to over 40% of their budget on marketing in their best year. Their most successful marketing techniques in descending order were the following (12):

■ Word of mouth from earlier jobs or contacts

■ Networking with other health or busi- ness professionals

■ Business cards ■ Personal meeting or phone calls to

potential referral agents ■ Networking with dietetic peers ■ Brochures or flyers ■ Speaking ■ Website ■ Writing articles or newspaper columns ■ Calling leads who were referred by a

third party ■ Membership in national dietetic asso-

ciation ■ Membership in national dietetic prac-

tice groups ■ Membership in local dietetic practice

groups ■ Volunteering

It is interesting to note that exhibiting at FNCE (American Dietetic Association’s [ADA] annual convention) came in 24th (last) and exhibiting in ADA’s Product Marketplace came in at 22nd (out of 24 options) (12).

Following are six marketing rules that can help you get your message across in any kind of informal speech (10):

1. Appearance. Use your attire and posture to project confidence, compe- tence, and status. Strive for a look that emphasizes quality and conser- vatism in both dress and gestures. You don’t have to have an extensive wardrobe but do have several “Presi- dent-of-the-Company” suits to wear when power and prestige are called for. In other circumstances, like when working with sports teams, wear ap- propriate sports clothing. Work on looking and acting successful.

2. Offset the negative effects of a practice or promotional effort by a group or or- ganization like warning the public about highly processed or fast food.

3. Motivate people to move from inten- tion to action like motivating clients to take control of their weight.

For a program to succeed, it must meet the following conditions (11):

■ Adequate resources ■ Strong support from agency adminis-

trators and community leaders ■ Marketing skills and savvy ■ Clear authority to make the necessary

marketing decisions and implement them in a timely fashion

SELLING YOURSELF

While credibility and visibility are necessary to successful marketing, they aren’t the total package. You must also know specifi- cally what message you want to communi- cate. What benefits does your business provide? Key words can form your “eleva- tor” 20-second message. For example, “I’m a registered dietitian who has counseled over 6000 patients in the past 35 years. My busi- ness also provides state-of-the-art nutrition presentations and personal consultations.”

In addition to credibility, visibility, and a message, you need to create an image. Image determines how people view you, how much they value you, and whether they are attracted to you. Social and psy- chological research have found that the more similar you are to your audience in terms of attitude, values, interests, and background, the more attractive you will be to them (10). See Chapter 8.

Your image is the first impression poten- tial customers receive about you. It must convey your expertise, professionalism, re- sponsiveness, and reliability as well as create warm, positive expectations.

In the 2008 survey on entrepreneurial di- etitians, the majority of dietitians (59%) said that they spent 10% of their start-up dollars on marketing and in their most successful

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2. Nonverbal behavior. Make direct eye contact. Combined with smiling and nodding, eye contact helps create an image of social attraction, power, and credibility.

3. Verbal behavior. Use simple, di- rect language without jargon; speak clearly and concisely. If you need a speech coach to get rid of poor gram- mar, slang, a bad accent, or what- ever, hire one!

4. Involvement. Listen actively and carefully; tailor your message to your audience—whether one person or a thousand.

5. Illustration. Your words should paint pictures in the minds of your audience. They will remember better what you have to say. Support impor- tant points with examples (and refer- ences if necessary).

6. Control. Stay in control of your image, your message, and your audi- ence’s response by deciding ahead of time exactly what you’re going to say and how you’re going to say it.

WHAT NOT TO DO IN A NEW BUSINESS (13,14)

MISTAKE 1: NOT HAVING A PLAN FOR HOW YOU ARE GOING TO CREATE AND MARKET YOUR BUSINESS

You have a good education, successful clin- ical job history, and decent relationships with clients and colleagues, and you want to be a consultant to sports teams (some- thing you have never done). Aren’t skills and reputation transferrable?

MISTAKE 2: JUMPING IN FULL-TIME WITHOUT A GOLDEN HANDSHAKE FROM YOUR JOB

You may need to test the waters to see if there is business potential out there for you before you quit and lose your fringe bene- fits. Try working your venture on the side to work out the bugs while you stay

employed. If there is an opportunity to get severance pay for downsizing, consider taking it.

MISTAKE 3: BELIEVING EMPTY PROMISES OF FUTURE WORK

Get it in writing if a physician says he wants you to work 3 days per week in his clinic! Try working evenings or Saturday mornings to see if the patient load is stable. It’s easy to underestimate what it will take to survive as an entrepreneur. Don’t count on others handing you business.

MISTAKE 4: NOT CALLING PEOPLE YOU DON’T ALREADY KNOW

You must network and let everyone know who you are and what your business does. You have to make phone calls and join organizations to become known.

MISTAKE 5: WASTING A LOT OF MONEY ON DEAD-END MARKETING AND BUYERS WHO AREN’T SERIOUS

A small business can’t afford to waste money or time on nonproductive market- ing. Drop things that don’t work—if an ad doesn’t generate even one phone call in 2 or 3 months, change what it says or drop it and cut your loses. If a spa wants you to offer a proposal to consult with its guests, ask direct questions like: What is your timeline on this project—when would I start? How many guests do you see each week?

MISTAKE 6: UNDERESTIMATING WHAT IT WILL TAKE TO START THE BUSINESS AND COVER LIVING EXPENSES

Don’t live off credit cards except in an emergency. Don’t live beyond your means. Cut back until the money comes in. Re- member there will be lean months ahead, so save some profit to use during the slower times.

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CHAPTER 11 ■ Marketing Decisions 107

business name on your business cards, brochure, letterhead, advertisements, and so on. This makes you appear more suc- cessful and organized, plus a brand creates the benefit of instant recognition. When a customer thinks of a culinary Registered Dietitian (RD), he or she thinks of Mary Hess, Anne Piatek, or Chef Kyle. When he or she wants a hospital software program, he or she thinks of Ellyn Luros and Com- putrition, or when continuing education self-study courses, I want him or her to think of Helm Publishing.

MARKETING AN INVENTION TO A MANUFACTURER

When you want to sell an invention, there are several things to consider.

■ First, manufacturers are contacted by thousands of people each year who have good ideas for new products. So don’t be discouraged if they want you to sign a form stating the manufac- turer doesn’t owe you anything if they thought of it first. Also, most large manufacturers have their own re- search and development departments that come up with new ideas, and they often discourage bosses from buying an idea that could be developed in- house.

■ Second, if you can’t patent your prod- uct (in other words, it doesn’t have any new ingredients or process or out- come), then often its value isn’t as great because other companies can copy it legally and exactly, if it be- comes popular.

■ Third, if you have a product that still needs lots of work, or one that is only for a small select population, such as for patients with high uric acid levels, or one that has never proven itself on the market, it’s usually not worth as much to the manufacturer. Today, because of the cost of introducing a new product on the market, many companies would rather buy out a

MISTAKE 7: POOR TIME MANAGEMENT CAUSING POOR OUTPUT

Business life can be feast or famine. If sev- eral jobs come in at once with similar deadlines, hire an assistant to help relieve some of the pressure and assure adequate time to maintain quality.

MARKETING AN INTANGIBLE SERVICE

In most cases, dietitians deliver intangible services, instead of tangible products. Ser- vice marketing has some unique concerns:

■ First, the service provider is selling something the potential customer can’t see, feel, or evaluate before he buys it. However, he can hold an attractive brochure or see quality in the business card and other surrogates that represent the service.

■ Second, the production, delivery, and customer evaluation of the service occur at the same moment in time. If the customer does not like the qual- ity of the service, it can make things very awkward. The buyer places a high degree of confidence in the abil- ities of the service provider. In return, the provider must be sensitive to the needs of the buyer and adapt the service as it is happening, to fit those needs.

Because services usually are one-on-one, customers will seldom tell you what they think—if they are unhappy, they just don’t return. So, don’t assume everything was okay if no concerns were mentioned. Dur- ing the delivery of your service, ask ques- tions, actively listen, and backtrack if you have to in order to assure understanding.

It’s your job to create a high perceived value about the benefits of your services through advertising and other forms of promotion (14). Use a distinctive look- ing “brand” on all of your promotion materials—that is, use your logo and

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small profitable company with prod- ucts that are selling than start with an unknown product. According to Ad- vertising Age, it costs $10–$20 million to test market, advertise, and then in- troduce a new product nationwide into grocery stores.

Charlie McCann, a former new products manager for Coca-Cola of New York, once told me that the only way a small, under- financed company can make a lot of money on a new idea is as the granola in- ventors did. Come out with a product that sells like wildfire and then sellout to Gen- eral Mills or Kellogg before everyone else jumps on the bandwagon and puts you out of business. There are thousands of exceptions to that rule, most notably, Ben and Jerry’s Ice Cream, Steve Job’s Apple Computers, and American Beverage Com- pany’s Soho.

Along with product samples, a “pack- age” to interest a manufacturer could in- clude the following:

■ A proposal with a market analysis and the product positioning (this entails determining whom the product is de- signed to sell to, and why they would buy it)

■ A label sample ■ A package design ■ A trademarked slogan and logo

When you have developed a product you are proud of, it’s time to contact a patent and contract lawyer to get feedback on how to protect your specific product. You also must determine what you want from an agreement with a manufacturer, for ex- ample an outright sale, up-front amount plus royalty, staff position, and so on. A businessperson with experience in this area is also very valuable, especially in de- termining whom to contact and how.

If you know individuals who could open doors for you or introduce you to the right people, use them. In some instances, you may choose to use some- one as an agent who knows the industry

and will work for a finder’s fee if he brings a buyer to you. From my own experience, don’t expect someone to come in and do the work unless you can pay them or give them a small ownership in the product.

SEVERAL OPTIONS FOR SELLING A PRODUCT

A manufacturer may show more than a casual interest in your product and want to offer a 90-day contract to look it over. You will have to decide if you want to take it off the market for that period and allow a company to get to know the product inside out. It may be your best chance to make a sale (and to make some money be- cause you will charge for the contract), or it could be a mistake.

One option is an outright sale of your prod- uct to the company that will manufacture it and take it to market. Some companies have a policy of always owning everything they manufacture—it’s cleaner that way—no in- ventors to get in the way. You could sell outright for one lump sum or sell for an up- front sum and a percentage of future sales, or to make the agreement work, you may accept only a percentage of sales, but that’s risky unless you really trust the company will produce as promised. You will want as- surances that the manufacturer will not sit on the product, reduce the quality of the product below the expectations of the tar- get market, price it above what the market will pay, package it poorly, or poorly pro- mote it.

Another option is a license-use agreement where you retain ownership of the product but sell the manufacturer the exclusive or nonex- clusive right to produce the product for a spe- cific period of time. This offers the advantage that you still ultimately own the product, but if you chose the wrong partner again, the product may not be worth much when it’s returned. When you still own the prod- uct and a customer is hurt by it, whether from the original formulation or how it

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CHAPTER 11 ■ Marketing Decisions 109

that everyone needs. They are surprised when only a few want it. The target market is the market segment that you intend to satisfy with your product or service. Therefore, it should fit their needs best and be packaged to attract that group. Traditionally, mar- kets were subdivided by geographic area. Today, customers are more likely to be differentiated by gender, age, in- come, educational level, profession, and other measurable personal charac- teristics. The newest market segmenta- tion schemes are based on particular lifestyles that predict customer pur- chase decisions (15).

Profitable survival requires some combination of a creative idea and a superior capacity for execution. Entre- preneurs can’t rely on just inventing new services or anticipating a trend. They must also execute well, espe- cially if their concept can be easily copied (5).

Successful ventures don’t always proceed in the direction they started, a significant proportion develop entirely new markets and products. If cus- tomers that were expected to place orders don’t, the entrepreneur must rework the concept while looking for new opportunities to exploit (5).

■ Narrow the possibilities: Ask your- self questions that will define areas of concentration. Think in terms of a 3- to 5-year period. The purpose of this section is to make your target market as specific as possible. Who do you like working with the most? What client settings do you enjoy the most? Who will buy your product the most? De- scribe the characteristics of your target market.

■ Identify other opportunities: During your evaluation phase, you may have thought of secondary target markets that could use your service. Identify them, but concentrate on your primary market.

was manufactured, you could have liabil- ity risk.

Dietitians have become partners with pro- grammers, venture capitalists, small manufac- turers, marketing specialists, and others to get their products to market. Call your advisors and lawyer and involve them in securing a contract that will protect you and your product.

There are no guidelines on how much you can sell a product for or how much percentage to negotiate for. It all depends on how much a buyer is willing to pay and how bad you want to work with that buyer. The value is influenced by the uniqueness of the product, the size of the potential market, the markup and profit potential, the strength of the competition, and whether the product is already a proven success with packaging, trade name, patents, and copyrights established. The more you have done on the product, the greater the value.

WRITING THE MARKETING PLAN

For many projects, the marketing plan serves as the organization’s sales tool. Along with a business plan, a marketing plan is essential when you start a business.

Once you have identified one or more “big ideas,” work through the following eight steps and evaluate the market poten- tial for your concept(s). The trick is to adopt an objective approach and to thor- oughly analyze as you go (14,15).

STEP 1: IDENTIFY THE PRODUCT LINE AND TARGET MARKET

There are three basic parts to this step: identify the major product, narrow possi- bilities, and identify other opportunities.

■ Identify the major product and target market: What is the “big idea”? What are the services or prod- ucts you could sell? Who will buy it? Too many people wrongly believe they have universal products or services

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STEP 2: CONDUCT MARKET RESEARCH

Here you will begin to find out if your assumptions about your “big idea” and its target market will work. Without knowing it, you probably have started your market research already. Have you started talking to people about the possibility of your ven- ture? Have you started attending seminars or reading about ventures similar to the one you want to start? If so, you have started to research the waters.

■ General Situational Analysis: What are the general characteristics of the market where you want to sell your product or service? What are the trends? Is the marketplace expand- ing? Shrinking? Is technology com- ing in rapidly? Are your current skills capable to meet the needs? What does your target market spend its money on? Primary market research is the research you conduct yourself. Secondary research involves statistics and information collected by some- one else, such as businesses, or trade, government, university, and profes- sional groups. Use both sources to be assured that you have thoroughly researched the concept. The Internet can help you with this process.

Talk discretely to potential cus- tomers and trusted referral agents or business associates about your plans. Ask open-ended questions and get them to give you feedback on the concepts.

Mailed surveys today must com- pete with mounds of junk mail and solicitations. Don’t mail surveys! Call people and you may find that a few minutes on the phone with someone could give you all the information you need in a fraction of the time and effort. Write out questions and have them ready when you call (2) or send an email with a link to an online sur- vey and offer an attractive perk to the person for taking the survey.

■ SWOT (Strengths, Weaknesses, Opportunities, and Threats) Analysis: The strengths and weak- nesses are internal characteristics. In other words, what do you (or your em- ployees) do well that could make this project a success? What are your weak- nesses that must be delegated, re- trained, or compensated for to make this project work? Opportunities and threats are in your external environ- ment or marketplace. The opening of a new fitness center or research unit could offer you an opportunity to use your new product or service. Things that could threaten the success of your project are like an oversupply of outpa- tient dietitians, changing government regulations, or a recession.

■ Analysis of the competition: Go deeper in your analysis. Identify your competition, its locations, its products or services, and any advantages or dis- advantages it may have. The purpose is to find niches or weaknesses that the competition has for you to position your services or products as “different or better.” When entering the market- place, it’s important to determine if you are a leader or a follower. A leader sets the pace and usually has the largest market share, such as Quaker Oats in the oat cereal market. A fol- lower like Total oatmeal marketed it- self as being different and better in the one area in which Quaker Oats was weak: fortification. Without an advan- tage over its competition, a product or service must either compete on price or spend lots of money on advertising to make a niche for itself.

STEP 3: SETTING GOALS AND OBJECTIVES

Define what you want to achieve, given the mission you have chosen. Make goals as suc- cinct and measurable as possible. Identify short-term goals that can be accomplished in several months to a year and long-term goals that will take 3 to 5 years. Reevaluation

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CHAPTER 11 ■ Marketing Decisions 111

required, the budget allocation, and the deadlines. Assign responsibilities if there is someone other than you also working on the project, such as a printer, graphic artist, publicist, and so on. Don’t assume any- thing. Stay on top of the project.

STEP 6: ESTABLISH A FINANCIAL REPORTING SYSTEM

Which resources will it take to complete your project and market it? What return on investment do you expect? How much do you have to sell to breakeven? Is the return worth the effort and investment? Look at the project over a 3- to 5-year span, not just start-up costs.

STEP 7: MEASURE AND EVALUATE RESULTS

If your research and estimates are favorable, what criteria will you use along the way to show you are on the right track to your goals?

STEP 8: ENLIST SUPPORT

If you have a client account, supervisor, or family who will be affected by this plan, how do you intend to approach them? What points can you offer that will sell the concept? Will this plan need to be formally packaged and presented, and if so, to whom and when?

When you produce this tangible report of your best research on the feasibility and costs involved in promoting your product or service, you will have a feel for whether the project should go forward.

USE THE MARKETING CAPABILITIES OF ADA

The ADA has an extremely capable staff of professionals at headquarters, along with volunteers, that produce a terrific number of marketing opportunities for members with services or products to sell or for you to gain exposure. For a few chosen members, there

of the marketplace through trends and strategic assumptions is a continuous process that will help keep the business goals on target. Think about the driving force of your project or career—the ultimate goals that will make you feel you succeeded pro- fessionally. Write down specific profit and marketing objectives that will help you reach your goals. Also, write down bailout signals that if they occur, would mean it’s time to change direction or abandon the project.

STEP 4: DETERMINE MAJOR STRATEGIES

Here is the place to determine your market- ing mix, or the 4 Ps of marketing for your product or service: Product, Price, Place, and Promotion (some people add Packaging as a fifth option). What you decide can deter- mine the success of your venture. You know your product or service but take a few minutes to describe its positioning in the marketplace. Your business position message should (2):

■ Have only one focus ■ Set you apart from competitors ■ Its goal is to have customers think of

your business first.

For example, Italian Food Tours is an Amer- ican business that plans culinary adven- tures for women’s groups to Italy.

What is its market niche? What benefits will the consumer get? How is it unique? What are your pricing strategies (see Chap- ter 17)? Place refers to the location or dis- tribution system where the customer buys your product or service. Is it convenient? If it’s a product for the grocery shelf, where will it be sold? The key is to make your products or services as available and con- venient as possible. What means of pro- motion do you plan to use (see Chapter 21)? Specifically explain your promotion plans.

STEP 5: DEVELOP ACTION PLANS AND ASSIGN RESPONSIBILITIES

Take the strategies in Step 4 and break them down into specific activities and add a timetable with dates, list the resources

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are the media ambassador and state-spon- sored media representative programs. You can be on the national resource list of experts who are called at times by the media, the nationwide referral network, and sometimes ADA leaders might call on you to offer your expertise in position papers or tes- timony.

If you have an idea for a study kit, audio- tape program, book, or other publication, you can submit a proposal to ADA’s Publi- cation Department for consideration by the Publication Committee. If you have a re- search study or project that is unique, con- sider writing an article for the ADA Journal. Your idea could be a major presentation or a poster display at ADA’s annual meeting. If you belong to a dietetic practice group, you could present the idea at a meeting or write about it in a newsletter. There is the Prod- uct Marketplace for members to exhibit their products and services on the first day of the annual convention and there are commercial booths available in the exhibit area. There are many similar opportunities at the state level for leadership and market- ing opportunities.

SUMMARY

The marketplace is always changing, and what sells today, may sell half as well or twice as well next year. Be watchful of busi- ness trends and read about changes in pub- lic-buying habits. Listen to stories that make the news and get feedback from your clients about what’s important to them. Ask each client how he or she heard about your serv- ice or product and then use that market re- search in the future.

The marketing plan organizes your pro- motion efforts and helps you assess how best to reach the people who will buy what

you sell. Whether it’s a formal document or a couple pages in a spiral notebook, these functions must be considered for an entrepreneur to be successful in his or her business.

REFERENCES 1. Beckwith H. Selling the Invisible. New York:

Warner Books, 1997. 2. Beckwith H. The Invisible Touch. New York:

Warner Books, 2000. 3. Gorman T. The Complete Idiot’s Guide to MBA

Basics. New York: Simon & Schuster MacMillan Company, 2003.

4. Sobel M. The 12-Hour MBA Program. Paramus, NJ: Prentice Hall, 1993.

5. Bhide A. How Entrepreneurs Craft Strategies That Work. In: Harvard Business Review on Entrepreneurship. Boston, MA: Harvard Business School Press, 2004.

6. Goodale J. Presentation May 2002: Marketing for Small Business. Corinth, TX: Dark Horse Productions, 2002.

7. Kotler P. Kotler on Marketing: How to Create, Win, and Dominate Markets. New York: Simon & Schuster, 1999.

8. Kotler P, Zaltman G. Social marketing: an approach to planned social change. J Mark 1971;35:3–12.

9. Altman L, Poitrow PT. Social Marketing: Does it Work? Population Reports, Series J, no. 21. Balti- more: Johns Hopkins University, Population Information Program, 1980.

10. Ward M. Marketing Strategies: A Resource for Reg- istered Dietitians. New York; 1984.

11. Helm KK. Becoming an Entrepreneur in Your Own Setting. Study Kit. Chicago, IL: American Dietetic Association, 1991.

13. Hudson D. How Not to Run a Business. Home- Office Computing, July 1991.

14. King K. The Competitive Edge. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.

15. Bagozzi R. Principles of Marketing Management. Chicago, IL: Science Research Associates, 1986.

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Disclaimer: Talk to your business advisors about your self-employment plans, your fi- nancial state, your possible risks or liabili- ties, your family’s needs, and get their opinions on which form of business might suit your needs best. Read the discussion below so you know some of the terms and pros and cons of each business structure be- fore you go. States vary in their rules and laws, and federal tax laws are constantly changing.

When starting your business, there are three basic business structures from which to choose:

■ Sole proprietor ■ Partnership ■ Corporation (C [full] or S [small] corpo-

ration or an LLC [Limited Liability Cor- poration] or Professional Corporation).

In the 2008 full survey of entrepreneurial dietitians, by far the most common form of business structure is sole proprietorship (1):

■ 69% were sole proprietors ■ 12.1% were LLCs ■ 8.5% were S corporations ■ 4% were in full corporations ■ 3.5% were in partnerships ■ 2.8% in professional corporations

Dietitians making over $100,000 per year (net), chose business forms that offered more protection, increased tax benefits, and limits on their liability (1):

■ 37.1% were sole proprietors ■ 27% were S corporations ■ 16.9% were full corporations ■ 11.2% were LLCs

■ 5.6% were partnerships and ■ 2.2% were professional corporations

The type of structure is often vital to the success of a business:

■ It can affect your ability to attract fi- nancial backing.

■ It can negatively increase the cost and paperwork of doing business.

■ It affects what you pay in taxes. ■ It determines the extent your personal

belongings are at risk if the business gets into trouble (or if a spouse loses a lawsuit in a community property state).

The structure also affects the amount of con- trol you have running the business and the amount of bookkeeping you must do. Also, the more partners or investors you have, the more bookkeeping is required (2–4).

No business form is best for all purposes. A sole proprietorship offers freedom, but if a person needs money, it may be useful to find a partner with capital. At the same time, disagreement between partners on something so simple as how to spend the profit has undermined many ventures. A corporation may require too much money and bookkeeping to make it feasible for a very small operation, or it may give the tax write-offs that the owner needs.

To organize your business in the most advantageous way, talk with a good small- business lawyer at the outset. Because tax laws are in a state of flux, consult with an ac- countant or CPA as well. You will feel more comfortable with business, if you become familiar with the different types of owner- ship and their pros and cons (Table 12.1).

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LEGAL FORMS OF BUSINESS OWNERSHIP

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114 THE ENTREPRENEURIAL NUTRITIONIST

FEDERAL IDENTIFICATION NUMBER

Each employer must be registered with the IRS on Form SS-4 to comply with Federal Income Tax, Social Security, and Unem- ployment Insurance regulations. This form requests a federal identification number that should be used when filing your taxes and when you’re paid by a client, instead of your Social Security

To be recognized for tax purposes, whatever form you choose must be a gen- uine business—in other words, started and pursued in good faith to make a “profit.” This makes it different from a hobby or philanthropic work. It’s the Internal Rev- enue Service (IRS), not local or state laws, that decides your federal tax and business status (2). Your work will be classed as a business if it produces a profit in 2 years out of 5 consecutive years.

Advantages Disadvantages Sole Proprietorship

Low start-up costs Unlimited liability Greatest freedom from regulation Lack of continuity if owner dies Owner in direct control Difficulty raising capital Minimal working capital required Tax advantage to small owner All profits to owner

Partnership

Ease of formation Unlimited liability Low start-up costs Lack of continuity Additional source of capital Divided authority Broader management base Difficulty in raising additional capital Possible tax advantage Difficulty finding suitable partners Limited outside regulation

Corporation (Full or C)

Limited liability Closely regulated Specialized management Most expensive (feeds, taxes, bookkeeping) Ownership is transferable Charter restrictions Continuous existence Extensive recordkeeping Legal entity Double taxation Possible tax advantages Relative ease of raising capital

Corporation (Small or S)

Limited liability State fees—initial and yearly Profit taxed once Added bookkeeping and business records Ownership is transferable One class of stock, 75 maximum investors Legal entity Money borrowed can’t lower taxes for owner Limited outside regulation Only salary subject to 15.3% self-employment tax

Limited Liability Corporation (LLC or LLP)

Limited liability Legal limits not tested in court Legal entity separate from owners Salary and profits subject to Social Security Profit taxed once and Medicare taxes (15.3%) Money borrowed can reduce taxes Stock easier to sell than membership in LLC

TABLE 12.1 FORMS OF BUSINESS ORGANIZATION (2–9)

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number. Your local IRS office can give or mail you the form, your accountant will have it, or you can fill it out online at the IRS website (apply for an Employer Iden- tification Number [EIN] online, http:// www.irs.gov/businesses/small/article/0,,id �98350,00.html).

FEDERAL AND STATE REGULATIONS

EMPLOYEE CONSIDERATIONS

You must make periodic payments and/or file quarterly reports about payroll taxes and other mandatory deductions, if you have any employees, including officers of a corporation, but not the sole proprietor or partners (5). You should talk to your ac- countant or CPA about the ramifications of having full- or part-time employees or sub- contractors and contact these government agencies for information, assistance, and forms:

■ Social Security Administration: (800) 772-1213; http://www.ssa.gov

■ Federal Withholding (IRS): (800) 829- 1040; http://www.irs.ustreas.gov

■ Workers’ Compensation: Contact your state unemployment office

PERMITS, LICENSES, AND DBA TRADE NAME FORMS

In most localities, a person can do a business under his or her own name without registering it with anyone. In other locations, certain types of busi- nesses need a permit, a small business li- cense, or various other documents that someone at your state taxation depart- ment, city hall, and county courthouse can advise you about. Some states require professionals and consultants to have business licenses or add sales tax to their invoices given to clients, so a sales tax li- cense is necessary.

DOING BUSINESS AS

If you want to use a trade name or fictitious business name other than your own as a sole proprietor or partnership, you will need to check county files to see if the name is available. If it is, then register it at the county clerk’s office or some similar place as a “fictitious” or trade name or doing business as (DBA) name. This form lets people know that “Seattle Nutrition Consultants” is Jane Perkins’s business. This form is necessary to obtain bank ac- counts in the business name or to bill clients in your county.

SOLE PROPRIETORSHIP

If you plan a low-risk business, carry liabil- ity and malpractice insurance, or if you don’t own many assets, a sole proprietor- ship may be your best bet. It means a one- owner (or two spouses) operation. This is the business form chosen most often by new business owners and private practi- tioners (6). The owner is responsible for all debts of the business, and he or she reaps all its profits. Other than for initial questions and occasional problems, lawyers are seldom needed. They’re the least in- volved of the business structures under the least government control (6). It’s interest- ing to note that in 1995, of the nation’s 501,000 attorneys, 281,000 filed taxes as sole proprietorships and another 134,000 filed as partnerships (7). Nine out of ten attorney businesses are not organized as corporations (7).

STARTING A SOLE PROPRIETORSHIP

Anyone can start a proprietorship by sim- ply stating that you are “open for busi- ness.” Fill out a Form SS-4 to receive a federal ID number if you have employees. To conduct business in your area, you may need a local license, permit, or trade name form filed. Otherwise, very little is required of you. You should keep business records

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116 THE ENTREPRENEURIAL NUTRITIONIST

A sole proprietorship can offer a busi- ness owner the freedom to act out dreams or wishes with only the obvious limita- tions of time, effort, and money. At least no person is in the position of changing your company name or the way you coun- sel patients unless you allow him or her to do it.

Lawsuits can be minimized by being very careful and clear about all business agreements and by having them in writing. Also, by carrying malpractice and other li- ability insurance, litigation expenses and losses can be kept to a minimum. However, if you plan to have a business that pub- lishes controversial exposés, manufactures a food or beverage, pursues large contracts, or in other ways handles large sums of money (or you personally own many as- sets), for peace of mind, the corporate or LLC structure that limits your liability may be more in order.

DISADVANTAGES OF SOLE PROPRIETORSHIP

The most obvious disadvantage to a sole proprietorship is the unlimited liability the owner must assume. An owner is personally liable for all the debts of busi- ness, its obligations, and suits against it. People who have won a suit against you may claim your house, car, savings, and other possessions. Additionally, your busi- ness assets are potentially at risk if you have personal debts that are unpaid. Mal- practice insurance will cover you in a law- suit against your professional nutrition practice, but not for your business ven- tures, financial responsibilities, and un- paid bills.

Another disadvantage that many sole proprietors, especially women, experience is lack of credit. Credit can be difficult to attract both personally from lack of assets and for the business because of lack of track record and business experience. Lim- ited credit makes it hard when an owner needs extra money to expand into a new office, publish a booklet, or cover the cash

and bank accounts separate from personal records for tax purposes.

TAXES

At the end of the year, your tax advisor can help you fill out and file the appropriate forms that briefly list your income and ex- penses (schedule C) and can help you ar- rive at a net profit or loss. The IRS will look closely at your deductions and whether it appears you are actively pursuing your business or just trying to write off your pur- chases and travel.

As a sole owner, your profits are only taxed once as your personal income. The business profit is not taxed separately. A business loss can be deducted from any other income for that year. You will pay self- employment social security and Medicare taxes (15.3% on net income). If you have employees, you will also pay payroll taxes, worker’s compensation, unemployment tax, fringe benefits, and so on (2). A propri- etor may invest in an Individual Retirement Account (IRA), 401-K, Roth IRA, or Simpli- fied Employee Pension (SEP) to help reduce taxable income. Changes in tax laws hap- pen yearly, so check with your accountant before filing taxes and regularly read busi- ness news.

ADVANTAGES OF SOLE PROPRIETORSHIP

Most practitioners choose the sole propri- etorship route in business because it’s less expensive and less cumbersome, and they like to have as much control as possible and to have the option of making all the decisions. There are no partners or stock- holders trying to lobby you, usurp your power, or cut corners and change the quality of service. If you do not like the way the secretarial service answers the phone or how your lawyer works with you—you make a change. This way of doing business can be very efficient and fast with only one person making the final decisions.

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CHAPTER 12 ■ Legal Forms of Business Ownership 117

flow when a big creditor does not pay on time (2).

A sole proprietorship’s success is very dependent upon the abilities, energy, and output of the owner. Also, if the owner gets sick or has personal problems that af- fect his or her work, the business usually suffers. Should the owner pass away, the enthusiasm and knowledge of how to con- duct the enterprise usually goes with him or her unless continuation plans were de- veloped to lead the family and employees through this time until the business is sold or it functions on its own with new man- agement. If a sole proprietorship is sold, the new owner may take over the assets and contacts, but all the business bank ac- counts, licenses, federal taxpayer identifi- cation number, and state sales tax number have to be reestablished in the new owner’s name (7).

PARTNERSHIPS

Two or more people may begin business as partners. The advantage of this type of arrangement is that one partner may com- plement the talents or resources of another. Another alternative to a partnership could be for one person to hire the other as a con- sultant or employee.

Increased financial investment, a broader scope of expertise, or influential personal contacts are advantages of having a partner. A partner may be a well-known person who will attract business. Legally, a partnership is a group of persons having a common business interest, each doing something to make the business succeed (3). However, be- cause of internal problems, our mobile soci- ety, and changing priorities, the average partnership only lasts 18 months (5).

Partners must get along well. They should be clearly able to do better as a team than they could separately. Partnerships take spe- cial understanding and a definite amount of patience. The biggest hurdles to work out are differences in value systems and expecta- tions, lack of delineated of roles (partners step into each other’s territory), and un-

equal contributions of start-up money (the major contributor may expect final say on all decisions) (3).

Successful partners often attribute their working relationships to the fact that they first had talked about exactly how the busi- ness would run and what would be done “in case this happens” before the partner- ship was formed. Also, they had to accept that in many instances, the “good of the business” had to prevail over their own opinions.

A partnership agreement should always be put in writing with the aid of your lawyer. The agreement should describe the proposed business in detail and state the business name. It should tell (2–4,6):

■ What each partner’s initial investment will be either in money or in other valuable consideration

■ The percentage ownership of each partner and how profits and losses will be divided

■ How much time each partner will give to the business

■ Who can sign the checks or if two sig- natures are required

■ Who can sign contracts, incur liabili- ties, and sell assets

■ What each partner’s functions, duties, and powers are

■ How the business will be managed ■ What happens if a partner wants to

get out ■ How a new partner can be admitted ■ Who will arbitrate if partners disagree ■ How the partnership can be dissolved ■ How the value of any partner’s inter-

est will be computed ■ What happens when a partner dies, di-

vorces, goes bankrupt, becomes un- able to function

■ The size and nature of “key-person life insurance policies” to be carried

Financially, a partnership may be able to get bank loans more easily than a sole owner. Often, this is true because the assets of two people instead of one are used to se- cure the loan.

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118 THE ENTREPRENEURIAL NUTRITIONIST

PARTNERSHIP BUY–SELL AGREEMENT

In case a partner wants to leave the busi- ness, a preagreed-upon buy–sell agreement could help make the dissolution easier. Negotiate this agreement when the partnership is formed. The agreement should include the following points (4):

■ A formula to determine the value of the business at the time of a sellout, taking into account initial contribu- tions by each partner, assets, debts, and goodwill generated since the busi- ness start-up.

■ Terms governing the sale—for example, an up-front payment plus monthly payments over a 5-year period at 6% interest.

■ Provisions in the event of death of a partner to protect the survivors against the estate of the deceased. In many states, families can demand that the business assets be liquidated in order to get their inheritance. To cope with the added expense of one less person running the business, partners should consider carrying life insurance (key-person insurance) on each other.

■ An agreement should be made up front before it ever becomes necessary to de- termine how deadlocked negotiations can be resolved—probably through arbitration.

LIMITED PARTNERSHIPS

If a limited partnership is formed, the “lim- ited partners” will have no personal liabil- ity for business indebtedness or the acts of their partners. To have a limited partner- ship, there must be at least one “general” partner who is legally responsible for all business indebtedness and the acts of all general partners. A primary drawback to using a limited partnership, depending on how you look at it, is the requirement that limited partners can’t play an active role in the management of the business or the

The partnership must file a year-end tax return, but it doesn’t pay taxes. The return is for information only, identifying each partner and showing her or his income and deductions from the partnership. The profit or loss is divided among the owners using preagreed-upon percentages. Each partner must attach a copy of the partner- ship’s tax return to his or her personal one and pay any due tax on the year’s income.

PARTNERSHIP PITFALLS (2–4,6)

1. To be recognized as a partner for tax purposes, a person must actually con- tribute money, time, reputation, or something else of value. A joint ven- ture merely to share an office or ex- penses is not a partnership according to the IRS.

2. Conversely, people may sometimes be liable as partners, as determined by the IRS or courts because they func- tioned as partners.

3. Bookkeeping for a partnership can become complicated if the partners own different percentages or draw un- equally for expenses—aggravation can occur when partners don’t perform as agreed in the beginning.

4. Partnership income is passed through to each partner each year on paper even when the partnership decides to retain the profit for future expansion, so taxes may be owed on money that is never actually received.

5. A partnership is only as stable as its weakest member. Usually, it dissolves if a partner doesn’t perform, dies or withdraws, becomes insane or incom- petent, or goes bankrupt.

6. The riskiest drawback is that every partner can be held liable for what the other partners do. This means that one partner binds the others when she or he signs a contract or check. If one partner causes an acci- dent, all can be sued. If one partner is dishonest, all may be prosecuted.

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partnership affairs. Limited partnerships are used most often when the partners want to have some of the advantages of a corporation (limited liability) but pay in- come taxes as a partnership (2).

CORPORATIONS

A corporation is a legal form of business granted by states. A corporation can be cre- ated from a new business or an already existing one (a sole proprietorship or partner- ship). The corporate structure (C or full, S, LLC and professional corporation forms) is the second most common business form in America. Incorporated businesses generate over 88% of total U.S. profits (8).

A corporation is a legal entity separate from its owners with its own property, debts, and responsibilities. Even though shareholders may own the corporate stock, they do not owe the bills, unless they helped secure loans with personal assets or with personal loans. As a shareholder, your personal property is not at risk for your business debts (2).

State laws govern corporations and they differ on the specifics, but generally a cor- poration is formed by filing articles of in- corporation, along with paying a fee to the Secretary of State of any state in the United States. Each state’s records are checked to make sure that no one else is using your proposed business name, and the incorpo- ration forms are checked for completeness. If all is well, you will automatically be sent a charter. Today, this can be done online with a credit card in most states.

The new corporation then issues shares of its total issue of stock (6). In a closely held corporation, only the owner’s family and friends own shares. No shares are sold to others, so control of the business is main- tained. Selling shares is one way to gener- ate capital to run the business but because it dilutes control and can complicate business as you grow, many advisors recommend trying to borrow the money first. People who buy your stock take a chance that the

corporation will be successful, and they don’t have to be paid back if it’s a failure.

The corporation name must include one of the three following words: “Inc.,” “Corp.,” or “Ltd.” It’s required so that oth- ers will know they are doing business with a corporation (2).

It’s important that a business owner seek legal advice when planning to incorporate. It’s possible to incorporate your business yourself. However, if you are sued or au- dited and the appropriate records have not been filed or filled out, it could be far more costly to remedy. Fees charged by lawyers to incorporate a business can vary from $800 to $3500; check around to find the best fee for the level of service. For a smaller fee, there are legal firms on the Internet that will file the forms for you. However, they may offer limited business advice that may be too general in nature for your needs, but it’s an option. The more you know about incorporation, the more you can do for yourself.

CORPORATE ADVANTAGES

Some of the advantages of a closely held C or “full” corporation (2,6):

■ Owners risk only the money they put into their corporation. It can go broke, and the owners can stay solvent.

■ The corporation generally has greater borrowing power than other business structures. More frequently, however, banks have been asking for loans to be secured by shareholders’ personal assets as well.

■ A shareholder can transfer his or her part ownership to someone else in- stantly by selling it or by giving or be- queathing his or her stock certificates.

■ Corporate executives can deduct many expenses from their gross income that probably can’t be deducted as a sole proprietor, for example, the cost of key-person life insurance, the full cost of health insurance, and only half the deduction for social security is taken

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120 THE ENTREPRENEURIAL NUTRITIONIST

S CORPORATION ELECTION

If a corporation has fewer than 75 share- holders and meets other specifications, an “S Corporation,” offered by the federal government for small businesses, should be considered unless you live in California and other states that do not recognize subchapter S corporations. It offers the same limitation on liability as a “full” corporation, but like the sole proprietor- ship and partnership, the business itself pays no income tax. All profits or losses become part of the individual’s personal income tax responsibility. Benefits are also slightly different from a full corporation, so talk to your attorney and accountant about the pros and cons for you. Many private practitioners have been advised to choose this business form. For more infor- mation, contact the IRS through their website (http://www.irs.gov) and request IRS publication 589.

LIMITED LIABILITY CORPORATION OR LIMITED LIABILITY PARTNERSHIP

The limited liability company (LLC) or lim- ited liability partnership (LLP) for profes- sional organizations is rapidly becoming a very popular business form in those states that offer the option. An LLC files “articles of organization” with the state and is gov- erned by an operating agreement that’s comparable to a partnership agreement (7). Some states will allow only one person to form an LLC and others require at least two persons. This form of business structure is similar to a limited partnership or S corpo- ration in that earnings or deductions are passed on to shareholders in proportion to their ownership (7–8). LLCs limit your per- sonal liabilities for business debt or losses. It’s a fairly new structure and it has not been proven in court whether it protects as well as a corporation. You can buy books on how to form your own LLC or go online and have a legal firm file it for you. Again, the drawback here is too little individual- ized advice.

out of the executive’s pay. The corpo- ration pays the other half.

■ If an executive or any employee lives on company premises “for the con- venience of the corporation,” he need not pay anything for it, as well as for company-supplied food, vehicle, and so on.

■ Fringe benefits can be better in terms of pension plans, profit sharing, and stock purchase plans.

CORPORATE DISADVANTAGES (2–4)

■ Incorporation is more costly—both to begin and maintain (fees, bookkeep- ing, records, holding mandatory meet- ings, and electing directors).

■ Corporate income is taxed twice— first on its profits, and then share- holders pay tax on the distributed dividends.

■ Owners can’t write off corporate losses on their personal income tax, nor deduct personal loans or expansion money given to the corporation when it’s short of cash.

■ Many banks and businesses will not accept a corporate signature on a loan without a personal guarantee by one or more of the executives.

■ An executive’s salary must be “reason- able” in the IRS’s eyes or it may be dis- allowed as a business expense. (This has had new meaning recently, be- cause CEO bonuses and salaries have reached new heights without much oversight.)

■ Shareholders may sue a director if his or her incompetence or misdeeds cause the corporation to lose money.

■ Some states tax corporations more heavily than individuals.

■ If corporate stock is offered to the public, the corporations must con- form to the complicated rules of the Securities and Exchange Commission (SEC).

■ Business structure is more difficult to change if your business needs change.

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CHAPTER 12 ■ Legal Forms of Business Ownership 121

FINAL WORDS ON CORPORATIONS

Dietitians, as members of the healthcare professions are being advised to think seri- ously about some form of incorporation for their businesses because of the interest in suing healthcare professionals. If a prac- titioner chooses this route, it’s important

to emphasize that all business and con- tracts should be done in the corporate name. This will establish that it’s the cor- poration doing the work. Also, try to secure loans with only corporate assets and carry liability and malpractice insur- ance for the type of services or products you offer.

C A S E S T U D Y 1 2 . 1

D I E T E T I C P E R S O N N E L S E R V I C E S I N T H E P H I L I P P I N E S

BusinessTeam Nutrition Management Sys- tems, Inc. (BusinessTeam), is the pioneer company in the Philippines in dietetic person- nel services. To build a healthy world has been its advocacy with the vision of becoming the dominant nutrition management service provider. Its missions are to collaborate with agencies and corporations in the promotion of nutrition and wellness and to promote the dietetics profession.

Established in 2003, we initially deployed three nutrition educators to lecture on basic nutrition to industrial workers for a major food company. Since then, BusinessTeam has grown to provide a whole range of nutrition services. The nutrition education interven- tions offered are:

■ Nutrition counseling ■ Lectures and workshops on proper food

and nutrition ■ Effective stress management ■ Proper physical fitness ■ Organization of wellness fairs ■ Customized nutrition and wellness pro-

grams to meet the specific needs of our clients

Our modules have been developed and adapted from existing successful nutrition programs by our experts and practitioner consultants who are registered nutritionist— dietitians (RNDs).

BusinessTeam has built a pool of nutrition consultants and resource speakers who have extensive education, networking, and work ex- perience in the following fields:

■ Dietetics ■ Food services ■ Hospital practice ■ Research ■ Academic ■ Relationship building with health profes-

sionals ■ Educational leadership

We maintain a roster of up to 1000 RNDs nationwide who have been trained to up- grade the image of the profession and to build their competencies. They are deployed on a project basis to year-round engage- ments for our clients. To ensure the high quality of our services, we have a Research and Development group composed of highly trained and experienced RNDs, a research analyst, and statistician.

Our clientele come from several indus- tries—food, communication, power and util- ities, various other manufacturing and service businesses, and educational institutions, as well as civic organizations.

Our latest thrust is a nutrition concept that encompasses our vision and missions: Nutrition TOURISM.

T—Train and travel to hone the skills and competencies as well as expand the knowl- edge of the RNDs through an exchange program

O—Outreach programs to the different com- munities to promote nutrition and wellness

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122 THE ENTREPRENEURIAL NUTRITIONIST

SUMMARY

It’s not necessary to become overly con- cerned about areas of business that are completely unfamiliar to you. There are many resources and advisors to offer help.

You will know more with every discussion and decision you make. Rest assured also, once a decision has been made on the business structure, it can be changed; however, it may mean additional effort and money.

U—Updates by sharing the current informa- tion in the field of foods and nutrition

R—Research as a basis and component of our nutrition programs

I—Image building of the RNDs to heighten the credibility of the profession as the expert in foods and nutrition

S—Spirituality and Social Responsibility. As a part of our corporate social responsibility, we have developed a program package that will address malnutrition and hope to con- tribute to the Millennium Development Goal of eradicating extreme poverty and hunger in 2015

M—Management principles are applied in all these components

—Grace L. Cadayona, RND, founder and the CEO of BusinessTeam Nutrition Management Sys- tems, Inc.

About the Author Grace L. Cadayona is a nutritionist and a candidate for Master of Science in Nutri- tion at the University of the Philippines, Dil- iman. She is the founder and the CEO of BusinessTeam Nutrition Management Systems, Inc.

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CHAPTER 12 ■ Legal Forms of Business Ownership 123

REFERENCES 1. King K. 2008 World-wide Entrepreneurial Dietitian

Owning Your Own Business. New York: Simon and Schuster, 1981.

3. Reuvid J. Start Up and Run Your Own Business: The Essential Guide to Planning, Funding and Growing Your New Enterprise. London: Kogan Page Ltd, 2008.

4. Paulson E. Complete Idiot’s Guide to Starting Your Own Business. 5th ed. New York: Alpha Books, 2007.

5. Shyne D. In Business: From Friendship to Part- nership. Working Woman 1983:48–49.

6. Small Business Administration. TX Small Busi- ness Resource Guide. Fort Worth, Tex: Small Busi- ness Administration, 2000.

7. Curtin R. Running Your Own Show. New York: New American Library, 1985.

8. Edwards P, Edwards S. Working From Home. New York: Penguin Putnam, 1999.

9. Eckert WK, Sartorius AG, Warda M. How to Form Your Own Corporation. 3rd ed. Naperville, IL: Sphinx Publishing, 2001.

See additional Resources at end of Chapter 3.

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124

13 PROTECTING YOUR IDEAS AND INTERESTS

Business owners want to know how to keep others from taking their ideas and how to protect their property from law- suits. The best means of protection are copyrights, patents, trademarks, incorpora- tion, and insurance, but there are other op- tions, including written agreements and personal discretion.

With time and experience, the ability to “read” an individual or situation and evalu- ate the risk involved will come to you more easily. Through networking over the years and your own savvy, the development of ideas will become relatively nonfearful.

PUBLIC DOMAIN

A distinction needs to be made about what kinds of ideas can be protected legally or claimed for ownership. Any new and orig- inal literary, graphic, audio, mechanical, video, process series, or ingredient may be protected as belonging to an individual or company. All “common knowledge” and nonunique items are in the “public do- main.” They can’t be the sole property of any person or business. Examples of com- mon items are the words “food,” “juice,” and “nutritionist,” the Food Guide Pyra- mid, other government materials, and the common medical diets (although unique manuals can be copyrighted that use this information). Everyone can use all items in the public domain.

HAVE IT IN WRITING

To avoid confusion and lawsuits, the best ad- vice is not to assume anything about even a simple agreement; discuss it thoroughly and

have it in writing and signed by the parties involved. Initially, use lawyers to look over all agreements, especially on all risky, impor- tant, and costly agreements. No one should start a job “on good faith” unless you are willing not to collect for the services—unless you know the person and have experienced working with him or her.

PERSONAL DISCRETION

Many good creative ideas become public property because the originator of the idea talked about it indiscreetly. Exceptionally different and quality ideas are of great value personally, also financially, and should be treated as such. Obviously, in the develop- ment of your ideas, consultants or profes- sional advisors may need to be involved, but there is better recourse if any of these individuals take an idea. Businesspeople will tell you that the best way to avoid being fearful in business is to work with only ethical, honest people who come highly recommended, or ones you have checked out through references.

If an original idea must be discussed with a company or an individual you don’t know, have a trusted acquaintance present who could witness the conver- sation, or ask to record the session on tape, or ask that a nondisclosure agree- ment be signed (Fig 13.1). If handled tactfully, no one will be embarrassed or threatened by the precautions. You usu- ally do not need written protection to speak with advisors like bankers, Small Business Administration (SCORE, ACE), and other professional small business advisors. Usually, book proposals going to

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CHAPTER 13 ■ Protecting Your Ideas and Interests 125

should appear on all published works dis- tributed to the public. The use of the copy- right notice is the responsibility of the copyright owner and does not require per- mission from the Copyright Office. To have your questions answered, visit this website: http://www.copyright.gov/circs/circ1.pdf.

Who Can Claim Copyright? (2) Copyright protection exists from the time the work is created in fixed form. The copyright in the work of authorship im- mediately becomes the property of the author who created the work. Only the au- thor or those deriving their rights through the author can rightfully claim copyright. In the case of works made for hire, the employer, and not the employee, is con- sidered to be the author. Section 101 of the copyright law defines a “work made for hire” as:

1. A work prepared by an employee within the scope of his or her em- ployment

2. A work specially ordered or commis- sioned for use as: ■ A contribution to a collective work

publishers and query letters to magazines or journals are not at risk.

TRADE SECRETS AND INTELLECTUAL PROPERTY

Trade secrets and intellectual property are ideas and materials that make the business unique. A trade secret may be protected by not telling anyone about it, which may hinder its usefulness, or by having nondis- closure agreements. Intellectual property may be protected through copyrights, trade- marks, or patents.

COPYRIGHTS

Copyrights are issued by the U.S. Copyright Office for intellectual property: books and pamphlets for new diet programs with orig- inal elements that have not been used be- fore and for other artistic, musical, dramatic, audiovisual, choreographic, or literary cre- ations. Ownership of copyright exists when the work is completed in any tangible form regard- less of whether it is ever registered or the date of registration (1). The copyright notice

NONDISCLOSURE AGREEMENT

Agreed and Accepter: Diet Chef, Inc.

_____________________ _______________________

_____________________ _______________________ Date Date

____________________ agrees to maintain the confidentiality of all proprietary information and trade secrets concerning Diet Chefs, Inc.’s products, services, and printed information of which he or she becomes aware. This obligation of confidentiality shall survive the termination of this Agreement.

FIGURE 13.1 ■ Sample non- disclosure agreement.

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■ A part of a motion picture or other audiovisual work

■ A translation ■ A supplementary work ■ A compilation ■ An instructional text ■ A test ■ An answer material for a test ■ An atlas

3. If the parties expressly agree in a writ- ten instrument signed by them that the work shall be considered a work made for hire

The authors of a joint work are co-own- ers of the copyright in the work, unless there is an agreement to the contrary. Copyright in each separate contribution to a periodical or other collective work is dis- tinct from copyright in the collective work as a whole and vests initially with the au- thor of the contribution.

Copyright Secured Automatically upon Creation (2) The way in which copyright protection is secured is frequently misunderstood. No publication or registration or other action in the Copyright Office is required to se- cure copyright. There are, however, certain definite advantages to registration. Copy- right is secured automatically when the work is created, and a work is “created” when it is fixed in a copy or phonorecord for the first time. Copies are material ob- jects from which a work can be read or vi- sually perceived either directly or with the aid of a machine or device, such as books, manuscripts, sheet music, film, videotape, or microfilm.

Publication (2) Publication is no longer the key to obtain- ing federal copyright as it was under the Copyright Act of 1909. However, publica- tion remains important to copyright owners.

Rights The copyright law grants copyright owners certain exclusive rights to their

works, including the rights of reproduction and of public performance. Only copyright owners have the right to make or authorize copies of educational materials, slides, arti- cles, or videotapes and to show their videos publicly (3,4). An owner may grant permis- sion to others for limited use of one or more of these exclusive rights. Some owners will charge a fee, while others will allow free use.

The copyright term is effective for the life of the author and 70 years after the au- thor’s death. Works created for hire, and certain anonymous and pseudonymous works can be copyrighted for 95 years from publication or 120 years from creation, whichever is shorter.

The notice should be on copies of the work in an obvious location to give reason- able notice of the claim of copyright. The required copyright generally consists of the following three elements:

■ The first is the © symbol, the word “Copyright,” or “Copr.”

■ The second is the year of publication. ■ The third is the name of the copyright

owner.

An example of a typical copyright is “Copy- right 2010 Nutrition Daily.”

In books, pamphlets, and other publica- tions, a printed reminder is usually added that states, “This material may not be copied or reproduced in any manner without the written permission of the copyright owner.” Lawyers who specialize in copyright law suggest that newly published material with the copy- right notice be sent to someone out of state by certified mail. The postage receipt will show when the copyright was first used. In case of a copyright dispute, the documented date may prove to be significant.

Copyright forms and information may be obtained online (http://lcweb.loc.gov/ copyright/), by writing Register of Copy- rights, Copyright Office, Library of Con- gress, Washington 20559, or a local federally authorized library, or by calling (202) 707- 3000 (for information) or (202) 707-9100 (order forms). The copyright application filing fee online is $35 plus an electronic file

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CHAPTER 13 ■ Protecting Your Ideas and Interests 127

copyrighted materials for your employer and if you did not have another prearranged agreement, the employer owns them. A for- mer employer, however, can’t keep you from practicing your profession or using your expertise, so you can create different materials on the same subject. If you want to develop unique materials to use at work and you want to own the copyright, do the work on your own time and at your own ex- pense. This assumes you have not signed an agreement giving your employer rights to all your ideas while employed (common in Re- search & Development).

If you want to use reprints or copies of other persons’ copyrighted material, arti- cles, newspaper stories, and so on, you should request permission first (see Copy- right Release Form in Fig 13.2).

COMMON QUESTIONS ABOUT USING COPYRIGHTED MATERIAL

Q: I recently purchased several videotapes on exercise at the store. Can I show them during my group weight loss class at the hospital? A: No. The exemption allowing teachers to show videotapes in the classroom applies only to nonprofit educational institutions, such as K–12, colleges, and universities (sec- tion 110) (1).

Q: When I give lectures, I show slides of charts and cartoons from books and the newspaper. Is this legal? A: No, although it is often done, it is not legal without permission from the copy- right owner. Photographs in books and magazines are protected by copyrights, just like the written material (section 102) (3).

Q: My public library has books on nutrition. May I photocopy from them? A: Yes, but only small portions may be copied. The library photocopying excep- tion to the copyright law allows an individ- ual to make a single copy of one article from a magazine or one chapter from a book owned by a public library, provided the copy is made only for the personal use of the individual (section 108) (3).

of the completed work or $45 for paper sub- mission. The registration process will take about 16 weeks and copyright registration is effective on the date that all the necessary items (application, fee, and samples) are re- ceived in the Copyright Office. The form is simple enough for most people to fill out. It’s highly recommended that if you are going to register something, you do it within 3 months of going public with the copyrighted material.

As the copyright owner, you, not the gov- ernment, are responsible for protecting the use of the copyrighted material. If the copy- right is abused, you or your lawyer can send a “cease-and-desist” order to the infringing person or organization to ask that the use be stopped. Going to court is costly, but it can be used as a last resort. If you sue someone for unauthorized infringement and you win, you may be awarded statutory damages and attorney’s fees or an additional $50,000 over actual damages and profit (5).

As an example of how a copyright in- fringement can be handled, one nutritionist found out that one of her contract OB/GYN clinics was photocopying her copyrighted prenatal brochure and handing it out to all new patients. She made an appointment to discuss the situation with the clinic director. She stated that her contract agreement did not allow uncontrolled use of her copy- righted materials. The clinic agreed to pur- chase the brochures at a bulk rate of $1 each with 500 brochures as the minimum order.

Other ways to discourage misuse of your copyrighted material include the use of the following:

■ Odd size paper that does not easily fit on a photocopier

■ Blue or brown ink that does not pho- tocopy well

■ The new paper and inks that do not re- produce at all on a photocopier

Formerly employed dietitians are usually in a quandary about ownership of materials and programs they developed while em- ployed. Lawyers agree that if you were paid as an employee when you developed the

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Q: I live in a small town and I am sure no one will know whether I have the permission of the copyright owner to photocopy her educational materials in a book from Aspen Publishers. Aspen can’t give me permission—I’ve already called. Why should I write for permission? A: By using the material without permission, you are stealing or trespassing on the owner’s rights. Infringement of copyright

can result either in a civil lawsuit brought by the copyright owner and/or criminal lawsuit brought by the U.S. government, which car- ries heavy fines and possible prison sentence (3). Do you really want to risk getting caught when it’s so easy to write? You can find pub- lishers’ addresses at the library and the American Dietetic Association (ADA) will help you contact any dietitian.

128 THE ENTREPRENEURIAL NUTRITIONIST

PERMISSION

[Date]

Dear ___________:

I am preparing an educational exercise and nutrition booklet for the patients at the Medical Treatment Center, Garland, Texas. May I please have your permission to include the following:

Table 4-2 Fun Ways to Add Exercise to Your Day In: Johnson P. Exercise for the Weak at Heart. New York: Brown & Co.; 2010

Unless you indicate otherwise, I will use the following credit line:

I would greatly appreciate your consent to this request. For your convenience, a release statement is found below. Please sign and return this letter to me. A second copy has been included for your files.

Permission is hereby granted for the use requested above.

________________________ _________________ Name Date

Sincerely,

Jan Jones, R.D. 101 Harland Street Garland, TX 75075 FIGURE 13.2 ■ Sample re-

quest to reprint copyrighted material.

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CHAPTER 13 ■ Protecting Your Ideas and Interests 129

an unusual manner or it’s in artwork cre- ated to stand for your company (5). For ex- ample, Entrepreneur Business Group is a company name and its product Entrepre- neur Magazine is trademarked.

Before filing an application, a search of trademarks should be made in the Search Room of the Trademark Examining Operation located in the Crystal Plaza Building No.2, 2011 Jefferson Davis High- way, Arlington, Virginia, or online at http://tess2.uspto.gov/bin/gate.exe?f� tess&state�303r1k.1.1. Any trademark that is too similar to one already filed will not be accepted for registration. The search can be conducted by any individ- ual. Trademark lawyers have contacts with companies who can do the research for a fee. You can also call the Chamber of Commerce in Arlington, Virginia, and get the names of several trademark search companies that will research a trademark for around $100. Applications and more information can be obtained from the Patent and Trademark Office, Arlington, VA 22202 or call (800) 786-9199, (703) 308-9000 (Hotline), or (703) 308-4357 or go online (www.uspto.gov) (5). Current fees can be found at http://ebiz1.uspto. gov/v i s ion - se rv i ce /P roduct_Se rv i - ces_P/msgShowProductSets?category�T and http://www.uspto.gov/web/offices/ac/ ido/oeip/catalog/prices/priclist.htm.

To establish rights to a trademark, you file a trademark application with three copies of the mark as it’s actually used in commerce along with the fee for each class of goods. The term of the trademark regis- tration is 20 years from the date of issue, and it may be renewed at the end of each 20-year term as long as the mark is still used in commerce (3). For a trademark to maintain its protection, it must be used (6).

Once a registration is issued, you may give notice of registration by using the ® circle symbol or the phrase “Registered Trademark.” Registration symbols may not be used prior to registration, but it’s recom- mended that trademark owners use a ™ or “SM” to indicate claim of ownership until

Q: What if I write and I never hear back, or the owner wants me to pay $100 for the rights? A: Do not use the copyrighted work unless you have written permission (keep the let- ters on file) and you pay whatever fee is charged. There may also be other restric- tions, such as the number of copies or size of the group or whatever.

Q: I have a chart I want to use in my handouts for a seminar I teach. There isn’t any author’s name on it, and I tried contacting the person who gave it to me—she doesn’t know who the original author is either. What can I do? A: Document your efforts to find owner- ship of the chart and put it in your files for future reference. You will have it in case the owner ever appears and you need to show you tried to find him or her. After the fact, ask the person for proof of his or her own- ership, and if you still want to use the chart, ask permission. If he or she gives per- mission, add the copyright information to the sheet. Pay any agreed-upon fee.

TRADEMARKS

The U.S. Patent and Trademark Office issues trademarks to provide national recognition of a name, logo, or phrase that symbolizes certain products or services. Examples of common product trademarks include: Coca- Cola ®, Kleenex ®, and Crayola ®. When a trademark stands for a service offered by a business instead of a product, it is referred to as a “service mark” (SM). Examples of com- mon service marks include the logo of ADA, McDonald’s name, and Prudential’s rock.

A trade or commercial name is a busi- ness name used to identify a partnership, company or other organization—it’s not eligible to become a trademark. Incorpora- tion of the business will protect the com- pany name from use by others in the original state and where the business legally expands its markets. There is no provision in the trademark law for the reg- istration of trade names used merely to identify a business. However, you can con- trol your name if it’s written or spelled in

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the application for a federally registered mark is finally approved (6–8).

Trademark rights are protected under common law; in other words, the mark be- longs to the first user as soon as it’s used in commerce, whether or not it’s ever regis- tered. However, registering a trademark does have its advantages: it shows official claim of ownership and exclusive right to use the mark on the goods mentioned in the registration. There is no time limitation on when an application for registering a trademark can be filed.

The owner of the trademark, not the gov- ernment, is responsible for protecting the mark from being used by others. If you are going to go to the trouble and expense of getting a trademark on a name, make it dis- tinctive as well as meaningful. Words in the public domain like “juice” and “food” are too common to be given a trademark. If the words are too common, either the trade- mark will not be granted or you will be in court all the time trying to keep other peo- ple from using the words. It’s not worth it.

Business owners claim that trademarks are often more effective than patents be- cause trademarks hold up in court, are less expensive to obtain, are transferable, and they last for the lifetime of the company (6).

PATENTS

Patents are issued to inventors to help pro- tect inventions from being used without the inventor’s permission. To be patented, an invention must have a useful purpose for existing and it must have some new, never before patented element that makes it unique. A new patent can be issued on a new process, machine, composition of mat- ter, or any new and useful improvements on an old patent.

A patent is effective for 17 years. There- after, the invention is considered to be in the public domain and anyone can use it. Because of this fact, some inventors decide not to patent a product that can’t be easily duplicated so that they own it exclusively. The owners of Coca-Cola chose not to

patent their product many years ago so the formula (which was only recently dis- closed) would remain a company trade se- cret. The President of A&W Root Beer once explained that their product didn’t have any proprietary protection (patent) in the market—except for its image and reputa- tion—and the fact people loved the root beer served in the frosty mugs.

Patent claims and/or designs must be re- searched either at the Patent Office or at one of the federally designated libraries across the U.S. A search will tell you what claims have already been issued on similar patents. You may have to alter your prod- uct’s claims after you conduct a search. A search by a lawyer will range from $3500 or more depending on the complexity of the item researched. There are inventors groups in your Yellow Pages and through other sources like the Internet that will do searches for you for more than $500, but you should thoroughly check out any firm first before using it.

What does it take to patent the new product you’ve dreamed up? “Persistence and perseverance,” says patent attorney Ken Schaefer (5). The patenting process can be costly and lengthy, too. Filing cost will be hundreds of dollars and the lawyer’s time may add another $1000 to $25,000 or more. If there are designs and intricate cir- cuitry, you may need an engineer for the drawings. An attorney’s legal fees for a court dispute can mount to the tens of thousands of dollars (6). Once you get a “notice of allowance,” which means your patent has been approved you have to pay an “issue fee” of several hundred more dollars. The entire process takes at least 20 months. Even with all that time and money involved, the Patent and Trademark Office issues about 1400 patents every week, but they estimate only 5% of all patents are ever developed for market. More information and an application can be obtained from the Patent and Trade- mark Office, Washington, DC 20231 or forms can be downloaded directly from www.uspto.gov/web/forms/.

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CHAPTER 13 ■ Protecting Your Ideas and Interests 131

Auto insurance on business-owned vehi- cles is common and necessary. In case of an accident involving the business car, the li- ability coverage should be especially good because the public believes that a business has more assets and the possibility of a law- suit after an accident may be greater. The cost of the coverage is comparable to per- sonal auto insurance, unless younger mem- bers of the family or persons with poor driving records are allowed to drive the car.

INCORPORATION

Many persons choose to incorporate their businesses to reduce the risk of losing their personal property for business dealings. A corporation is a complete, legal entity sepa- rate from its shareholders with its own as- sets. If all business is conducted in the corporate name and under its umbrella, the corporation’s assets alone are at jeopardy for the failures and lawsuits of the business (see Chapter 12 for more information).

BUSINESS QUESTIONS

Q: I have a consulting business where I con- tract with several medical clinics to offer med- ical nutrition therapy. Our agreements are in writing. A year ago, my mother became ill and I had to find someone to cover for me for 4 months. I found a local dietitian and we had a written agreement with a noncompete clause. For the past year, she continued to cover one of my accounts and I received a percentage of her income. Now the clinic wants her to work there as an employee without my involvement. The clinic and dietitian have asked me to walk away without any compensation. Do I have any rights here? Should I just walk away? A: Of course you have rights! You need to show your written agreements to a good small business lawyer and ask what your options are. Depending on what your non- compete clause says, most people would agree the dietitian (or the clinic) should compensate you for giving up the clinic account to the other dietitian. If your

INSURANCE

Insurance was originally devised as a means of spreading the risk of having bad luck through a group instead of being shoul- dered by one individual. It has always been common to insure material possessions, but when starting a private practice, insur- ance to pay your salary in case of disability and malpractice insurance are recom- mended. The costs of malpractice and of- fice insurance premiums are deductible as business expenses.

Malpractice insurance is available to cover the high cost of legal representation and the high incidence of threatened and ac- tual lawsuits against not only physicians but also all persons who come in contact with the patient. Contact ADA to see insur- ance providers it recommends.

Disability insurance pays income when the insured person becomes ill or disabled and is not able to work up to capacity. It’s suggested for sole-supported, self-employed people because they aren’t eligible for worker’s compensation, unemployment benefits, or sick time, except through pro- grams set up by their own company. Social Security disability insurance requires 6 months of no income before payments can begin. No income for an extended period could mean loss of the business as well as personal property. It’s sometimes difficult to qualify for disability insurance if you have a business based out of your home, so if you work or consult somewhere else, highlight that location for disability insur- ance purposes.

Office insurance should include fire, theft, and liability coverage. This coverage is common and can usually be obtained from a practitioner’s existing home insurance company. Office coverage is necessary be- cause many medical buildings’ insurance policies don’t cover tenants’ furnishings, possessions, loss of business, or visitors’ ac- cidents. When working out of your home, it’s still necessary to carry extra insurance for times when clients visit and to cover your computer and other office equipment.

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132 THE ENTREPRENEURIAL NUTRITIONIST

agreements are valid and binding, I would allow your lawyer to negotiate an agree- ment in a meeting with the clinic business manager or director and the other dietitian. If your agreements are vague or not easily defended in court, you may have to walk away because the cost of legal action wouldn’t be worth it.

Q: A year and a half ago, I subcontracted with a dietitian to cover my private practice several days each week while I pursued an advanced degree. We had a verbal agreement, and she was paid for each patient she instructed. There was never any question that she was an inde- pendent contractor who was responsible for her own taxes and benefits. At the end of the year, I gave her a 1099 Miscellaneous Income form to file with her income taxes. Two months ago, we had a falling out over a patient billing issue and I let her go. To my surprise, she went and filed for unemployment benefits as an employee who was fired. The case is pending, but I may lose. What can I do? A: Whoa! Don’t you wish the agreement had been in writing? You, of course, need to see a lawyer with employer/employee rights experience. The fact that you gave the dieti- tian a Form 1099 will help, but there are other criteria that the IRS uses to determine if a person is an independent contractor or employee—no matter what you two had agreed (see Chapters 3 and 15). The main guidelines involve whether you gave her special training or she came in with the re- quired knowledge; whether you determined when she would work and where or she made her own schedule; and whether she only worked for you or she marketed herself and her business to other accounts. Your lawyer will advise you about the criteria that your state unemployment office uses.

As you can tell, there are many gray areas. You may be surprised to hear your lawyer say not to admit guilt but settle in- stead of fighting. Unfortunately, many cases are solved that way because the cost of legal action may be more than the cost of the settlement. Try to stay calm and ra- tional, you both knew what you had agreed, but you need to keep an open mind

at this point and determine how to mini- mize your loss—both in legal fees and po- tential settlement. Good Luck!

Note: These answers should not be con- strued as legal advice. They are presented to describe potential business situations that may confront practitioners in normal business dealings.

SUMMARY

Starting a business venture is not a risk-free endeavor. In fact, it requires an individual to constantly be confronted with numer- ous important decisions, to initiate new untried ideas, to counsel patients on med- ical-related nutrition programs, and to risk financial loss.

The best ways to protect yourself are:

■ To be ethical ■ To ask advice of people who are suc-

cessful in business ■ To make well thought out decisions ■ To document all important agree-

ments and clients’ visits in writing ■ To learn from experience

Most people who have been in business for some time suggest that a person take rea- sonable precautionary measures and then go on with business and living.

REFERENCES 1. Dukelow RH. The Library Copyright Guide.

Quilting; August, 1991. 2. Copyrights Office. Available at: http://www.

3. Sitarz D. The Desktop Publisher’s Legal Handbook. Chicago, IL: NOVA Publishing, 1990.

4. Bagley CE, Dauchy CE. The Entrepreneur’s Guide to Business Law. CA: West Educational Publish- ing Co., 2007.

5. Have you built a better mousetrap? Family Circle, August 15, 1989.

6. The Small Business Encyclopedia. Vol. II. Irvine, CA: Entrepreneur Magazine Group, 1996.

7. Edwards P, Edwards S. Working From Home. New York: Penguin Putnam, 1999.

8. Sobel M. The 12-Hour MBA Program. Paramus, NJ: Prentice Hall, 1993.

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Now that your business venture is devel- oped on paper, you need to evaluate who will make up your team of mentors and professional advisors. You could do it alone. However, to give yourself a better shot at success, create an informal network of advisors you can turn to when you need them. You may be surprised to discover how many people are willing to help you— if you seek them out.

Business authors Sarah and Paul Edwards tell of a sales trainer who needed more in- formation to develop her business, and she noticed a course available at UCLA. She didn’t have time to take the course, so she hired the instructor to give her a series of private instructions. The instructor became an important mentor and introduced her to many business prospects (1).

A team of advisors could include a CPA, lawyer, accountant, banker, insurance agent, business consultant, investment counselor, and a marketing, advertising, or public rela- tions consultant. You will benefit from each profession’s expertise and learn different perspectives on the same issues. These advi- sors will evaluate your business, its liability, marketability, and legalities.

In the 2008 World-wide Entrepreneurial Dietitian Survey, the 1196 respondents who answered this question said that the advi- sors who they felt helped them the most were (2):

1. Dietetic peers (were most helpful) 2. Family and friends 3. CPA or accountant 4. Nutrition Entrepreneurs—National

Dietetic Practice Group 5. Mentors

6. Attorney 7. Small business advisor

Dietitian “masters” had different experi- ences; their most helpful advisors in de- scending order were (2):

1. CPA or accountant 2. Family or friends 3. Attorney 4. Dietetic peers 5. Mentors 6. Web designer 7. Nutrition Entrepreneurs—National

Dietetic Practice Group

In their column “Working Smarter” in Home Office Computing magazine, the Edwards give a few steps to attract bene- factors (1):

1. Go to the source. Go to the best. Go to the people who are clearly authori- ties. If they can’t help you, they may know people who are even better for you to know.

2. Ask specific questions. Many men- tors and advisors will want to help, but only if it appears that you have done your homework first.

3. Be willing to pay. Most people take it as a compliment when you ask for their help. But if what you need requires more than a short phone conversation or taking them to lunch, offer to pay for their ex- pertise. Certainly, asking lawyers and accountants for advice on your busi- ness will cost you when they work on your business. A private consulta- tion with an expert shouldn’t cost

133

CHOOSING YOUR BUSINESS ADVISORS

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134 THE ENTREPRENEURIAL NUTRITIONIST

banker or accountant will not fit your needs.

2. What specific services does the con- sultant propose for your practice?

3. Approximately, how much will you be charged? If it will be on an hourly basis, obtain an estimate of how many hours the consultant feels your practice will take.

4. Will phone calls be charged? Al- though fees are important, be aware that bargain rates sometimes get you bargain services.

5. Does the professional advisor have the time to give you? Will you get both adequate advice and reasonable turn- around times on contracted work?

The better you know your needs, or the more work you can do for yourself, the less you have to pay someone else. Before you commit yourself to a specific consultant, ask yourself (4):

■ Was I comfortable? ■ Did the advisor seem interested in me

and my practice? ■ Does the advisor have the time for my

work? Will I be a priority?

Keep records of all correspondence with a contract consultant. Follow up any tele- phone conversations with a letter reiterat- ing any points you feel uneasy about or that you feel were important to highlight. Keep a copy of the letter for yourself. Don’t assume anything about an agree- ment—always ask! Change to another consultant and transfer your records if you are unhappy with the work you receive. As a rule, don’t hire family and professional friends to do your work, because it is so hard to fire Uncle Charlie when the job isn’t done right or on time.

Learn how to use each consultant’s ex- pertise to your best advantage. Talking with other business owners and professionals will help supplement the research and reading you must do before going into pri- vate practice. See Table 14.1 Business Man- agement Team.

more than $50 to $150 per hour. With the right expert, it will pay for itself many times.

4. Accept and try their advice. Of course, evaluate whether it fits your needs, but if it fits, put in enough ef- fort to see if the idea works. Otherwise, be willing to explain why you didn’t try it.

5. Express appreciation. Most peo- ple like being appreciated, and that’s one of the reasons why they help each other. A phone call, note, or thoughtful gift can go a long way in building a relationship. Also, let your benefactors know that they can call on you if they need to.

6. Pass on good advice. Establish yourself as a resource for others, someone whom others can turn to. You’ll be amazed when the doors open for you.

LOCATING PROFESSIONAL ADVISORS

When seeking professional guidance, ob- tain several different names of highly rec- ommended specialists. Ask for referrals from your friends, other small business owners, and the Small Business Adminis- tration (3–4). Look for names of recom- mended professional consultants or free advisors from SCORE (Service Corps of Re- tired Executives) who have experience set- ting up and working with small businesses.

Be specific in what you are looking for. Remember also that you interview the con- sultant. They work for you, so don’t be in- timidated and feel that you must hire or work with the first person you interview. Consider the following questions as guide- lines when discussing the services of a paid business consultant and her or his suitabil- ity for your practice (3–4):

1. What is the experience of the con- sultant in your area of business? A divorce lawyer or large corporate

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CHAPTER 14 ■ Choosing Your Business Advisors 135

ATTORNEY

Look for an attorney you can trust with rea- sonable fees. Trust means you believe the attorney can do the job, is competent, and cares about helping you (5).

The legal fee quoted to you may be mis- leading. Often, the lawyer with the lowest hourly rate is not always the lowest total bill, especially if the attorney is not familiar with the legal problems of your type of busi- ness. An attorney may spend a lot of time at your expense learning what to do. Legal services are the last of the “cottage indus- tries,” meaning that each item is custom

made—usually from preformed documents on software (5). There is a great deal of dis- cretion involved when an attorney does his or her job, so take the time to find a good one—one who takes your business seriously and has the time to work for you.

On matters such as suing or countersu- ing, obtain a second (independent) deci- sion before pursuing it. Make sure that you agree with the language and possible conse- quences of any legal action before you let your lawyer take action in your name. You have to live with the results. Once you have considered all sides, the costs and probable outcome, you may decide to walk away or go to arbitration. Over the years, many businesspeople have told me that “only the lawyers seem to make anything from a lawsuit.”

Good legal advice at the beginning of your practice can prevent problems in years to come. A lawyer will help you understand regulations and licenses. He or she can write or look over all your contracts or letters of agreement. Most importantly, a lawyer will help you develop the appropriate structure for your practice—sole proprietorship, part- nership, LLC, full or S corporations, and professional corporations. A lawyer can help you copyright materials, trademark your business logo, or patent a product. At- torney fees range from $150 per hour in smaller communities up to $300 per hour or more for specialized work. They usually charge for phone calls.

ACCOUNTANT OR CPA

Accountants are divided into two groups: those who are Certified Public Accountants (CPAs) and those who are not certified. States award certification and verify whether the recipient has completed a 2-year appren- ticeship under a CPA. The person must pass a series of difficult tests in the areas of audit- ing, accounting, and business law. CPAs are accountants with an assured high level of skill; however, other accountants may be highly qualified, but not certified. In most

Advisor Area of Expertise

Attorney Form of business structure Contracts and letters of agreement Office leases Copyrights, trademarks, patents Lawsuits

Accountant or Bookkeeping systems advice CPA Financial statements/audits

Employee deductions Tax decisions Income tax records and reports

Banker Loans Credit information IRA, 401-K, and SEP accounts Business checking and savings Community trends

Business Networking and contacts Consultant Business strategies

Setting priorities Management skills and decisions Marketing suggestions

Public Relations/ Image development Advertising Logo design

Business cards/brochures Market research Promotion ideas Advertising layouts Media contacts

Investment Retirement options Counselor Investment advice

College savings plans Asset management 401(K) plans

TABLE 14.1 BUSINESS MANAGEMENT TEAM (3–5)

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136 THE ENTREPRENEURIAL NUTRITIONIST

friendly banker is more important than which bank you use. Discuss your plans for your practice with him or her. An experi- enced banker can give you a wealth of valu- able business information, not only on financial matters, interest rates, and how to keep your credit rating points high but also on trends in the community.

Ask for a small business loan officer or vice president of the bank when you want to talk about a business loan. Try to use the same personnel when doing your banking, and speak up if you are always directed to new, inexperienced people. Banking per- sonnel don’t charge for their services and can be good advisors.

BUSINESS CONSULTANT

A business consultant will advise you on major decisions, such as your central busi- ness concept, location, image develop- ment, fees, marketing, new market areas, and so on. Good, affordable consultants for small businesses are hard to find, but well worth the research time. Their fees range from $75 to $150 per hour or more.

Very good, free services available in larger cities are the SCORE (Service Corps of Retired Executives, website available at http://www.score.org) and ACE (Active Corps Executives) programs of the Small Business Administration. These two pro- grams will work to match you with a retired or active businessperson who can answer your business questions. Their knowledge and experiences can be valuable resources. Many local banks, Chambers of Commerce, YMCAs or YWCAs, universities, and adult education courses offer programs to help the beginning and expanding business owner as well.

PUBLIC RELATIONS, MARKETING, AND ADVERTISING CONSULTANTS

As your business grows, you may need one of these experts. The services of these three specialists often overlap, depending upon

states, a bookkeeper is not required to meet any standards to use the title, but he or she may be knowledgeable and perfectly matched for your business. The main thing you need is someone with practical small business experience, and that person may be hard to find!

As you look for an accountant or book- keeper, ask other businesspeople whom they use. Your best source of information is a satis- fied customer.

Your accountant should help structure your practice to your best tax advantage. He or she will be valuable in helping you choose a bookkeeping or record system that will fit your needs. If the system is set up correctly and simply, you should be able to do the bookkeeping yourself, aided by year- end income tax assistance. An accountant can prepare financial reports that help de- termine business strategies, or marketing and tax analysis, or help obtain financial backing. Some accountants also give advice on how a business should be operated; this is called management services.

The hourly fee for an accountant or CPA usually ranges from $75 to $275 per hour or more. A bookkeeper may charge $30 to more than $60 per hour. Always ask for an estimate of time and fees before the work begins. Inform your financial advisor of any time limitations you have, and request the work be completed by that date. Be- ware of “bargains” such as new people or staff that just arrived from a large corporate position, or a new graduate for “special” rates. They may take twice as long, and a supervisor may charge full price to look over their work. Even more critical, the per- son may not have any small business expe- rience, and an accountant should be a valuable business resource.

BANKER

Get to know your area banks and the serv- ices they offer. Even if you don’t intend to borrow working capital from a bank, your business accounts will make you a welcome customer. Get to know a bank officer. A

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CHAPTER 14 ■ Choosing Your Business Advisors 137

the consultant and her or his business knowledge and skills. Public relations ex- perts specialize in letting the world know you have arrived. They use their contacts and expertise to put you and your business venture in front of the public. That may sound intimidating, but it may be as simple as being interviewed by a local newspaper or radio station. Many businesspeople credit their success to having a public rela- tions firm working for them at a crucial stage in their business. As nutrition prac- tice becomes more sophisticated, public imaging will, no doubt, be more important.

Hiring a public relations firm is expen- sive (ranging from $1500 to $4500 or more per month, often for a minimum of 6 to 12 months). Be careful and specific in your ne- gotiations on prices and services. To assure that you like what is being produced, ask to be involved in all stages of development.

A marketing or advertising firm usually can offer logo development, business card and brochure design, market research, and advertising savvy—marketing avenues that get your message to your target markets. Again, fees can vary greatly from a few hundred dollars to many thousands. Adver- tising fees can be a percentage of the cost of the ad campaign, or it can be a project fee. Most firms can create the artwork and broadcast ads.

Get quotes from several firms and be honest about what you can afford to pay. Often, if they need the business or they es- pecially want to work with you, they will negotiate a fair price for your needs. All of the options are independent of one an- other so don’t feel you have to buy a full package. Buy what will work best. To deter- mine that, you can talk to people who have marketed other services in your area and to several marketing firms until you feel com- fortable with the answers.

If you want to do your own marketing and feel confident you can generate the art- work or wording, look into using a local university’s art department or freelance artist. All newspapers, magazines, and radio and television stations offer free advice through their sales consultants. Not only can they assist with simple suggestions, but they can also advise you on the best time to run your ad, for example, morning spots on radio or Sunday newspapers, and so on. Use the experts to help sell your products or services, or to improve your image.

SUMMARY

The wise use of professional advisors can save you time, energy, and money. Their combined expertise will enable you to enter into your business venture confident that your organization will run at its optimum. They are also an expensive investment that you need to stay on top of—don’t assume the work will be done as you expect. Con- tinue to stay involved, and have check- points and meetings along the way. Stay in touch with people you want to work with through a phone call, a card, an email, and a small holiday gift even when their services aren’t needed at that time—it’s easier than starting over with someone new.

REFERENCES 1. Edwards P, Edwards S. Working Smarter. Home

Office Computing, July, 1991. 2. King K. 2008 World-wide Entrepreneurial Dietitian

Guide. SBA, 2000. 4. Paulson E. Complete Idiot’s Guide to Starting Your

Own Business. 5th ed. New York: Alpha Books, 2007.

5. Curtin R. Mastering the Basics of Small Business. New York: American Library, 1985.

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138

15 MONEY AND FINANCE

To most people, the measure of success in business is to make money. Others may say a business that pays its bills while it satisfies its clients is more successful. Whatever your definition is, a business venture that doesn’t make enough money is either a hobby or one that has a limited life span. But more than generating revenue, the profit needs to be wisely invested in assets like a small office or other real estate, stocks, bonds, or minerals to grow into a stable financial package for your retirement or to pass on to your heirs.

A financially successful business usually starts with sufficient capital investment, followed by fair prices, good collection of revenue, paying bills on time and appropri- ate record keeping for you, the Internal Revenue Service (IRS), and any lender. Managing money and keeping records should not be difficult tasks. The challenge is to know what needs to be done.

If you are a consultant to a wellness pro- gram, it may advertise that it was created for the enjoyment and health benefit of the employees, but cutting medical insurance costs is usually the underlying reason for in-house programs. From the beginning, you should establish the financial record keeping that shows your programs are suc- cessful and cost-effective. Anecdotes from successful clients can be used in marketing, but the management will want good num- bers to document successful programs.

INITIAL INVESTMENT

Before anyone will be able to help you se- cure a loan or set up your books, he or she will need to know what you plan to do. The information generated in the business plan

will be beneficial, also knowing the type of business structure you will use and your es- timation of your start-up costs. Good fi- nancing offers peace of mind, the option of changing your mind, and freedom to cre- ate without survival being in peril.

In the 2008 survey, 1360 dietitians iden- tified how much money they personally invested into the start-up of their busi- nesses (1):

■ 54.8% spent $1000 or less ■ 30.4% spent $1001–$5000 ■ 9.0% spent $5001–$15,000 ■ 2.9% spent $15,001–$30,000 ■ 1.7% spent $30,001–$60,000 ■ 0.4% spent $60,001–$80,000 ■ 0.8% spent >$80,000

As mentioned earlier, 45.4% stated that they broke even in 6 months or less; 26.8% took 7 months to 1 year to breakeven; and 18.6% took 13 months to 2 years to breakeven. That means that 90.8% of the entrepreneurs broke even in 2 years or less!

Practitioners with well-equipped, well- staffed offices in rented space pay the higher fees. They usually develop the ap- pearance of stability and success much sooner than low-budget small ventures. However, investing more money into a business will not necessarily make it more successful. Nevertheless, an adequately fi- nanced venture has a better chance of be- coming a lucrative business faster.

Practitioners who either have more time than money or those who want to keep the risk and investment low make smaller in- vestments. This is possible by scaling back on all overhead expenditures like sharing office space in a physician’s office or health club, or by working from home, and by

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CHAPTER 15 ■ Money and Finance 139

starting out, but there may be hard feelings if the loan isn’t paid back as expected.

■ Banks and credit unions: These are the most common sources of loans. They want to be involved in successful ventures, and you must show you have done your homework on business planning and have a repayment sched- ule to attract a loan. Small Business Ad- ministration (SBA) loans are usually handled through designated banks and require 20% to 30% of the needed loan amount to be contributed by the busi- ness owner. The loan application and supporting documents will take you many hours to produce and many peo- ple who have gone after an SBA loan say that you usually have to have capi- tal to invest in order to attract a loan.

■ Venture capital firms: These firms help expanding companies grow in exchange for equity or partial owner- ship and a strong involvement in the business.

■ Angel investors: These are people with money who want to help small businesses grow in return for stock, but most don’t want involvement on a daily basis (3).

Your success in obtaining funding depends on your assets, business expertise, connec- tions, and your ability to sell yourself and your business plan.

Lending institutions are in business to make money by loaning money for an in- terest fee. Loaning money involves taking a risk that the new business will be success- ful, and the owner is hardworking, honest, and reliable. To be successful in obtaining a loan, you must be prepared and organized. You must know exactly how much money you need, why you need it, and how you will pay it back (4,5).

It’s common for a lending institution to require you to invest a certain percentage of your own money if a loan is granted, or it may ask you to place your money in an ac- count and borrow against it or secure the loan with personal assets. If you are seeking

doing more public speaking and free media work instead of an expensive public rela- tions campaign for your business.

SOURCES OF FINANCING

One reality to face in developing a business venture is the money commitment. Finan- cial experts encourage new business own- ers to try to use someone else’s money for part of the capital (bank loan), instead of exhausting personal assets and credit sources. This maintains the owner’s finan- cial strength. The owner may need to con- tribute later during financial emergencies or expansion projects.

The majority of dietitians in the 2008 survey financed their businesses themselves with savings or from earnings from another job or from revenue generated by the en- trepreneurial venture (1). When practition- ers did borrow money, the most common loans were (1):

■ 18.1% used credit cards ■ 12.1% used a family loan ■ 5.3% used a bank or financial

institution ■ 2.6% used a business partner ■ 1.8% used a mortgage on a property

For growth and expansion of the business (once it had proved itself), a few more prac- titioners borrowed from the same sources as above and in the same order (1).

The most common sources of business financing are (2):

■ Personal savings: The primary source of capital for most new busi- nesses comes from savings, second mortgages, and personal credit sources. Credit cards should be saved for emergencies, not day-to-day ex- penditures. High credit card debt will keep most lenders from giving you a loan. Being even a day or two late pay- ing the monthly bill can increase your interest rate to over 20%.

■ Friends and relatives: Often, this money is interest free or at low inter- est, which can be very beneficial when

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an expansion or recapitalization loan, your financial business records for the past 3 years, personal credit records, and business reputation will be evaluated.

COMMERCIAL BANKS

Commercial banks are the most common lending institutions. They offer many serv- ices besides checking and savings accounts. Banks offer basic financial counseling and credit analysis at no cost to regular cus- tomers. Most commercial banks make short-, intermediate-, and long-term loans. You may be asked to put personal property, Certificates of Deposit, savings, or other as- sets of value up as collateral. Occasionally, where you have established credit, you may be asked only to sign for the loan. When you use assets to secure a loan, they aren’t to be sold, spent, or used until the lending institution releases them. Read your loan agreement carefully before you sign.

CREDIT UNIONS

Credit unions usually offer low-cost check- ing accounts, savings accounts, and low in- terest loans on autos, personal loans, home improvement (to create a business office), and sometimes on larger items.

SMALL BUSINESS ADMINISTRATION

The SBA of the U.S. Government is another resource alternative for a new or established business loan. The law stipulates that SBA loans can be made only to businesses that are unable to get funds from banks or other private sources. This is usually because the personal assets or type of business will not qualify for a regular loan (except at high in- terest rates), not because the person is a poor risk. A bank, however, will usually make the loan, guaranteed by the SBA up to as much as 70% to 80%. Especially with new busi- nesses, the SBA may ask you to contribute 20% to 50% of the initial investment.

Occasionally, the SBA will make the loan itself, but this is rare. Only one quarter of

the total 30,000 or so loans the SBA makes or guarantees each year goes to new busi- nesses, so competition is tough. Less than 10% of SBA loans go to women-owned busi- nesses each year, although the SBA reports that women are more successful in starting a small business (4). Interest rates on an SBA loan are attractive because they are lower than what banks usually offer. As attitudes change and economic bailout packages dry up funds in the federal government, SBA money becomes more or less available.

The SBA requires extensive information about you and your business venture. You can pull the information together or hire an accountant or a certified public account- ant (CPA) to put the proposal together for you or to guide you in assembling and fill- ing out the documentation required. It used to take months for SBA loans to be ap- proved, but now, the process has been re- duced to several weeks if the paperwork is in order—and the money is available.

SBA loan programs are generally in- tended to encourage longer-term small business financing, but actual loan maturi- ties are based on the ability to repay, the purpose of the loan, and the useful life of the assets financed (5). Maximum loan ma- turities have been established which in- clude the following: (a) 25 years for real estate, (b) up to 10 years for equipment (de- pends on the useful life), and (c) generally up to 7 years for working capital (5).

LOAN PACKAGE

The loan package is the finalized presenta- tion compiled to secure a loan from a bank, investor, venture capitalist, SBA, or a com- bination of these sources (4). It succinctly presents your basic idea through the exec- utive summary and plan. In a nutshell, it explains who you are, your financial status, and how the money will be used and re- paid. Usually, having an accountant or CPA provide a review of the figures pre- sented substantially improves the chances for getting a loan. A review is less involved

140 THE ENTREPRENEURIAL NUTRITIONIST

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CHAPTER 15 ■ Money and Finance 141

Items Needed for a Loan PackageBOX 15.1

Cover letter Table of Contents General Information

■ Business name, names of principals, Social Security number of each owner, and the business address

■ Purpose of the loan—exactly why is it needed ■ Amount required

Business Description ■ History and nature of the business ■ Business plan with its market analysis (prod-

ucts and competition)

BALANCE SHEET

Assets Cash in checking account $ ________ Cash in savings account ________ Credit union savings account ________

Life insurance cash value ________ House fair market value ________ Car(s) (fair value) ________ Furniture and personal effects ________ Other ________

________ Total Assets $ ________

Liabilities Balance on car loan $ ________

________ Home mortgage ________ Credit cards ________

________ Other ________

________ ________

Total Liabilities $ ________

Net Worth (Assets minus liabilities) $ ________

FIGURE 15.1 ■ Sample balance sheet.

Typically, bankers will request or appre- ciate having the items listed in Box 15.1. Ask what is necessary, and then use your best judgment on the other items depend- ing on your loan needs (4–6).

and less expensive than an audit and is only as accurate as the figures used, yet it often satisfies bankers because it offers some limited assurance about the reliabil- ity of the financial information (4).

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142 THE ENTREPRENEURIAL NUTRITIONIST

PROFIT AND LOSS STATEMENT (Date)

Income Nutrition counseling $ ________ Public speaking ________ Nursing home consultation ________ Book royalties ________ Other ________

________ Total income $ ________

Losses (or Expenses) Rent $ ________ Utilities ________ Telephone and answering service ________ Equipment ________ Salaries or consultant fees ________ Insurance ________ Auto ________ Benefits ________ Supplies ________ Other ________

Total expenses $ ________

Net income $ ________

Other reductions Taxes $ ________ Depreciation ________ Other noncash reduction ________

Adjusted net income $ ________

FIGURE 15.2 ■ Sample profit and loss statement.

Management Profile ■ Personal history of each owner (resume, busi-

ness experience, letters of reference)

Company Information ■ Copies of contracts you already have signed,

lease agreements, insurance carried, etc.

Financial Information ■ Personal balance sheet and your personal

income tax returns for the past 3 years (Fig. 15.1)

■ If already in business: ■ Company balance sheet and past 3 years of

tax returns

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CHAPTER 15 ■ Money and Finance 143

■ Company profit and loss statement (Fig. 15.2)

■ Ages of accounts receivable and payables as of current date

■ Business cash flow projections for at least 1 year (Fig. 15.3)

■ Source of repayment ■ Requested duration of loan ■ Collateral to be offered to secure the loan

(official appraisals of assets may be neces- sary when the market value is not easily determined)

CASH FLOW IN

Jan Feb Mar Apr, etc.

1. Beginning cash balance 2. (Income sources) 3. 4. 5. 6. 7. 8.

Total cash available:_____________

CASH FLOW OUT

Operating Expenses 1. 2. 3. 4. 5. 6. 7. 8.

Capital Expense 1. Loan payments 2. Income tax and Social Security

Total cash required Cash available less cash required

Money to be borrowed (if negative total)

Debit payments (if positive)

Ending cash balance

Operating loan balance (at end of period)

FIGURE 15.3 ■ Sample cash flow planning form.

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144 THE ENTREPRENEURIAL NUTRITIONIST

WHAT BANKERS LOOK FOR IN A BUSINESS LOAN (5–7)

■ Experience and track record: You may be new to this venture, but you must convince the banker that you have been successful in your ca- reer and other projects you have managed. Use your business plan to show your expertise.

■ Personal and business credit: Bankers will look closely at your per- sonal credit history, credit score, and how you have repaid debt in the past. Get a copy of your credit report and make sure it is accurate.

■ Personal investment: Banks want to see that you have confidence in your venture by investing your own assets as well.

■ Collateral: Besides personal invest- ment, banks usually want something to secure the loan. This could be real estate, your home, a car, Certificates of Deposit, or other assets.

■ Repayment plan: Explain how you will repay the loan from what sources of revenue. This plan must look feasi- ble so ask for more repayment time to keep the payments lower.

CREDIT SCORES

Each person who makes purchases on credit in the U.S. begins to generate a credit report at the three big credit reporting agencies: Equifax, Experian, and Trans Union. The best score you can have is 850 points, and the median score for people with the best credit is 720 points (8). (You lose points for having too many credit card accounts, by having high balances—even if they are paid on time and, of course, for chronically late or delinquent accounts.)

Does it make any difference what your score is? It can make a BIG difference! According to Kiplinger’s Personal Finance Advisor newsletter (8), for example, on a 30-year fixed rate mortgage of $250,000, having a score of 700 will cost $21 per

month more in interest, or $7560 over the life of the loan. If the person’s credit score is 675, he or she will pay an extra $112 a month, or $40,320 over the life of the mortgage.

How do you improve your score?

1. Only have one or two credit cards that you pay on in a timely manner— not just the minimum payment— keep the balances low.

2. Don’t be tempted by the numerous mailed promotions for credit cards, and the 10% discount at checkout desks to start a new credit card—too many cards will hurt your credit score.

3. Annually, look at your credit reports (they are easy to find in search en- gines under “credit reports”) and make sure that the information is accurate and no one else’s credit has been merged with yours. If you shared credit accounts with a former spouse, make sure your report re- flects separation of the accounts and get bad reports removed through working with your ex-spouse and the credit agency if they were not your purchases.

4. Remember that it may take 6 months to a year to repair a minor flaw (8). A big blemish, such as paying bills 30 days late, will take 3 to 4 years to be removed from your record (8). For a free estimate of your score, visit www.eloan.com.

Before beginning to prepare all of these documents, ask your individual loan agent what forms he or she needs. Most business consultants suggest that the loan package be typed and bound in an attractive folder or notebook (6).

Numerous options exist on loans, so work with your loan officer and financial counselor to choose one that fits your needs. Loans termed “line of credit” are very helpful for peace of mind and yet do not usually cost anything if you don’t use the money. A loan may be set up so that during the first 6 months or first year, you

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CHAPTER 15 ■ Money and Finance 145

count. Personal expenses for groceries or the house note should only be paid out of funds appropriately transferred to the owner’s personal account.

Banks usually charge higher service charges on business accounts than on per- sonal ones, but the charges are deductible. Large amounts of business money should not be left in a non–interest-bearing check- ing account when it will not be used imme- diately. A checking-with-interest, savings, money market, or other interest account should be used even for just a few weeks to generate interest.

A business check should be written and cashed when you need petty cash. Cash taken in as payment from clients should be recorded as income and deposited, not pocketed or used.

GOOD BANKING RELATIONSHIPS

In his column in the Dallas Business Journal, bank executive Guy Bodine suggests that small business owners take the time to develop a relationship with their bankers before they need a loan. He gives the fol- lowing eight points to help the relationship grow (9):

1. Meet your banker for lunch and keep your banker informed.

2. Educate your banker on the type of business you run, and make him or her come to your place of business.

3. Seek counsel from your banker. 4. Build credibility. 5. Limit surprises. 6. Do your homework: Develop a busi-

ness plan. 7. Submit timely financial information

to your banker—good and bad. 8. Keep your money deposited in the

bank.

CASH FLOW

Cash flow is just what the name states, the flow of money through the business—how much money is coming in regularly, as

only make interest payments. A bank may request that you submit semiannual or yearly financial status reports, but occa- sionally, nothing may be needed.

WHEN THE ANSWER IS “NO”

Don’t look at a “no” answer as a total de- feat. Ask the banker what else he or she needs and go back several times to achieve your desired results or until an agreement will not work out. Many loan officers make loan decisions based on past experience with certain professions or industries; being turned down may have nothing to do with you. Move on to the next institution and improve your package presentation.

There are times when you should not accept a loan if one is offered, for example:

■ The term of the loan may be too short, so the payments may be too high and stressful each month.

■ The interest rate may be too high and the payback amount outrageous.

■ The loan may tie up all of your assets as collateral and limit your future growth instead of helping it.

■ There may be closing costs on the loan worth thousands of dollars.

If you can, either try to find another fund- ing source or do without the loan until bills are paid down more and terms improve. If you really need to use someone else’s money to grow and prosper, consider the loan in- terest, closing costs, and so on, as the cost of doing business.

MANAGING MONEY

Whether you decide to incorporate your business or not, when your business be- gins to make money, it has a life of its own. The money generated must be ac- counted for. Records on incoming revenue should match bank deposits into the busi- ness bank account. All business expenses, plus the owner’s salary or consultant fee, should be paid by check from that ac-

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compared to that needed to pay current bills. As a new business owner, it should be assumed that it may take 6 months or more before enough money will come in to cover all expenses. When planning for working capital in your start-up costs, allow enough to keep cash flowing and bills paid. Limited cash flow is not only frustrating, but if it becomes serious, more money may have to be borrowed or supplied by the owner to keep the business open. Cash flow can also be a problem for established businesses when unexpected economic downturns happen, large emergency expenditures in- crease the debt load, or joint venture part- ners back out at the last minute.

Suggestions for improving cash flow in- clude the following (6):

■ Request all payments at the time of the visit from patients; get up-front and interim payments for projects and retainers for consultant positions.

■ Improve collection efforts on outstand- ing accounts, especially the larger ones.

■ Lower inventories of purchased items, including supplies, teaching materials, printed diets, and promotion materials.

■ Avoid making new purchases that will increase the business overhead and ei- ther deplete savings or create addi- tional time payments.

■ Deposit temporary excess funds in a savings account or money market fund to draw interest.

■ Evaluate when to take cash discounts and pay a bill quickly to save money or when to delay paying bills until the end of the pay period to conserve cash outflow. Request longer payback peri- ods from large accounts you spend a lot of money with each year—they may give you 60 or 90 days.

OFFERING CREDIT CARD USAGE

Most self-employed nutrition professionals offer the use of credit cards to their clients as a means of payment. Many clients like this convenience and the fact that they can

then delay their payments. Credit cards help attract patients who would have de- layed or avoided coming because of lack of ready cash. People who conduct group classes have found that there is less resist- ance to the up-front fee when credit cards can be used. According to credit card ex- perts, a business can expect from a 10% to 50% increase in sales and about twice the average cash purchase, when it starts offer- ing credit cards as a payment method (10).

A representative from your local bank can explain the service to you but check around for the best services and prices. Today, it is difficult but not impossible to become a merchant who offers credit card usage from a home-based office. However, you must have a good personal credit rat- ing. To process credit cards, you will need charge forms and an imprinter, software for your office computer, or the automated swipe equipment to buy or rent for any- where from $125 to $1200. You can input the charges by hand into your computer or swipe the card and get immediate confir- mation that the card was charged. You will be charged 2% to 6% per bill, plus a pro- cessing fee of about $0.25 to $0.35 or more per item.

You can increase your fee slightly to cover the service charge cost but that would mean that all patients are subsidiz- ing the credit card users. Actually, the in- crease in business may offset the added service charge so that no fee increase would be necessary.

ONLINE CREDIT CARD PAYMENT

The newest credit card innovations are on- line and eventually wireless payment of bills through services like PayPal and Bill- point (11). These two services are great ways to make payments to individuals and small businesses. Both services make their money by charging the seller (card user) a small fixed fee and a percentage of the total dollar amount sent on each transaction. PayPal is used in an estimated one quarter of all eBay auctions. And Billpoint, which is

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purpose of establishing credit policies and setting credit limits helps assure collection of accounts, and they set limits on the risk of loss.

Contracts or letters of agreement can be written for large consultant contracts so your fee and expenses can be submitted bi- monthly and paid in 2 weeks. Another op- tion is to break the total expense for a project into thirds, for example, and have one portion paid up front when the pro- posal is signed, another halfway through the project, and one at the end upon com- pletion. You can always stop or slow down work if the agreed-upon payment is not made in a timely manner.

BILLING

If billing becomes necessary, here are some hints:

■ Date statements as of the last day of the preceding month, rather than the first day of the current month. The customer will be inclined to pay sooner, since the statement appears to be a month older.

■ Quickly identify delinquent accounts and speed up the collection process with a more vigorous follow-up. Ac- counts delinquent over 60 days should receive a pleasant, tactful phone call from you, or someone representing your business, requesting that a pay- ment be mailed by a deadline date. If you don’t receive payment or if the balance doesn’t shortly follow a partial payment, a second tactful call should be made. Request immediate payment before the account is turned over to collection.

Collection agencies state that small med- ical bills are one of the hardest types of bills to collect. They state that any account over 6 months old, and often only 2 to 3 months, usually isn’t collectible. Most agencies charge 50% of the bill as their fee if they collect it, and few will touch an ac- count with under $100 outstanding.

partly owned by eBay, is used many more times. The services can be used to have pa- tients pay you, clients pay you, and you pay your bills, or send money to pay for your next printing job, instead of sending a certified check or wire transfer. To use Pay- Pal, go to its Website and in a secure area, fill out a short registration form, enter your credit card number, and type in the email address of the recipient—PayPal takes care of the rest.

COLLECTION

Patients should be asked to pay at the time of the visit. When insurance is involved, you can call their insurance companies, PPOs, and HMOs to ask for co-pay amounts or whether your bill is covered at all. Ask patients to pay you the co-pay amount or the full amount and give them an itemized receipt or superbill (see Chapter 18. You can order a billing form at http://www.eat rightPA.org or from http://www.maryann hodorowicz.com).

The older your accounts receivable grow, the less likely you will be able to collect them. In a service business such as nutri- tion counseling, since no inventory is lost, no write-off can be taken for bad debts (ex- cept for actual expenses such as teaching materials, computer printouts, etc.). There- fore, new practitioners must realize that the money has to be collected or else the nutri- tion appointment didn’t have financial value. When you sell a product like catered food, the actual expenses can be deducted, but not the lost profit if the bill is not paid.

A written contract or letter of agreement for a completed consultant job is very good proof that the other party should pay you. You may have to get a lawyer and go to court to get the money. You will be able to deduct your actual expenses for the job and the cost to recover the money. But the ac- tual cost of lost time, mental aggravation, and legal fees may mean you are only breaking even or less. Timely collection of funds should be a business priority. The

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Credit is costly if you can’t collect. As an example, you provide $100 worth of serv- ices to a client, and your profit margin is 25%. If the patient never pays, you will have to collect $400 worth of fees just to re- cover the uncollected $100. When you consider how much you have invested in your business, you can easily appreciate why businesspeople can’t tolerate delin- quent accounts.

BOOKKEEPING

Accounting or bookkeeping keeps track of money you earn or spend and what you own and owe, that is, your worth. Your in- come (revenue minus expenses) is recorded on an income (profit and loss) statement (see Fig. 15.2). Your net worth is assets minus liabilities and is recorded on the bal- ance sheet (see Fig 15.1).

A good bookkeeping system is necessary to record all of your financial transactions, but it should be simple enough for you to use yourself. The larger and more complex the business is, the more comprehensive, but not necessarily the more complicated, the bookkeeping system must be. The in- formation generated will help you know your financial position, evaluate success, and pinpoint problems. These records can also help you make comparisons from year to year and help make more accurate pro- jections for the future.

A good accountant or CPA will be able to help you choose the system most appro- priate for your business. Over the years, my business has used several manual and soft- ware programs to keep our books. The two software programs small business owners say that they use the most in my experi- ence are Quick Books Pro and Peach Tree. My best suggestion is keep it simple—don’t create a monster that you don’t need.

There are various low-cost simple bean counting software programs available for under $100. For full-powered accounting packages for mail order and other busi- nesses with inventories or a large number

of billing needs, there are good programs for under $500. Don’t expect that account- ant on a white horse to set the program up for you and you get away with knowing nothing! Read the book, learn the system, and either set the system up for yourself or pay someone trained in the system to do it, while you sit there and answer all the ques- tions and watch how it is being done. You will need to know how to do it!

BUDGET

In his book, Private Practice, Jack D. McCue, says “fewer than 2% of (medical) practices have a budget” (12). The number of self- employed dietitians using a budget is no doubt as small. Agreeing on a budget, forces you to examine projected expenses and agree on the gross income, hours of work, and charges necessary to generate the projected net income.

Budget projections are very difficult to make during a year when a person’s in- come is dependent on inconsistent projects and short-term consultant jobs. In those cases, a budget for each project and good fiscal management can help assure the year is balanced financially.

Another option is running monthly profit and loss and sales records to compare with the previous month’s records, as well as the previous year’s records, for the same period. This process makes you immedi- ately aware of changes in income so pur- chases can be made or delayed, and bills can be paid or stretched out until the last of the credit period.

CASH VERSUS ACCRUAL ACCOUNTING

The IRS will ask that you to indicate which form of accounting you use in your book- keeping—cash or accrual. Cash accounting is when you record income as you receive it and expenses as you pay them. When you record income as it is earned, not necessar- ily collected, it is called accrual accounting.

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Each day, record all income (checks and cash) on the business bank deposit slip and credit card deposit records in the ac- counting system. All bills should be listed as you pay them under expenses. The check date, check number, amount, and deduction code or account should also be listed.

Monthly, all income and expenses should be tallied and totals to date brought forward. You should also know how much money is uncollected in accounts receiv- able and how old each account is. Send bills out biweekly to shorten the collection cycle.

Whatever method you choose for book- keeping, never lose sight of the fact that as the owner, you will ultimately be held re- sponsible for the accuracy of the reporting system and its figures.

RECORD RETENTION

Files need to be kept on your business for important documents and records of busi- ness transactions. There isn’t total agree- ment among experts as to the actual length of time to hold records, so check with your own advisors.

A suggested record retention schedule follows.

Permanent ■ Audit reports of accountants, financial

statements ■ Capital stock and bond records ■ Cash books and charts of accounts ■ Cancelled checks for important pay-

ments ■ Contracts and leases still in effect ■ Correspondence (legal and important

matters) ■ Deeds, mortgages, bills of sale, ap-

praisals ■ Insurance records, claims, policies, etc. ■ Patient files ■ Corporate minute books of meetings ■ Tax returns and worksheets ■ Trademark registrations and copyright

certificates

Accrual accounting is usually used in busi- nesses that have large inventories of prod- ucts where flexibility of figures and dates may be beneficial. Financial consultants usually suggest that service businesses such as consulting and private nutrition practices use cash accounting because it’s simple and easy to use. A few years ago, Congress passed legislation allowing many small businesses that formerly had to use the ac- crual method to use the cash method. The advantage of this is expenses can be de- ducted when they are paid, not expensed over a long period, and uncollected income doesn’t have to be counted, which saves on tax payments.

RECORD KEEPING

The following list shows the typical pro- gression of record keeping for a physician- referred patient’s visit.

1. Record patient’s appointment and phone number. Call patient day before to remind about the appointment.

2. Obtain medical diagnosis, written or verbal diet order from referring physi- cian, along with pertinent chemical scores.

3. During the appointment, fill out initial interview sheet, assessment, history, and food analysis (or ques- tionnaire given to patient in advance by email or hardcopy). Make nutri- tional diagnosis.

4. Give patient written diet handouts. 5. Give the patient an itemized bill and

request payment as he or she gets ready to leave. Mark the bill paid on patient’s form.

6. Give an appointment card to the pa- tient if there is to be another visit and make an entry in the appointment book or in online calendar.

7. List the payment on the bank deposit slip. Mark the bill paid in accounting system.

8. Send a follow-up communiqué to the referring physician. File the patient’s folder.

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Seven Years ■ Accident reports and claims ■ Accounts payable and receivable

ledgers ■ Cancelled business checks (see perma-

nent listing) ■ Contracts and leases (expired) ■ Invoices ■ Payroll records ■ Purchase orders and sales records

Three Years ■ Correspondence (general) ■ Employee applications and personnel

records (terminated) ■ Insurance policies (expired)

One Year ■ Bank reconciliations ■ Correspondence (routine)

TAXES

Learn which forms to file and how to fill them out, dates to file, and tips to mini- mize overpayment or underpayment of es- timated taxes. Even if your accountant or CPA fills out the forms, you should be fa- miliar with what he or she is doing.

As a self-employed person, you have var- ious tax obligations, in addition to filing the federal and state income tax forms. You will need to estimate your federal tax com- mitment and pay it quarterly, up to 100% of what you paid the previous year if your income is under $150,000 or 110% if your income was over $150,000. There are also self-employment taxes (Social Security and Medicare) at the rate of 15.3% of your ad- justed income as well as additional state or local taxes (income or sales). However, 50% of the self-employment tax is deductible on the 1040 Form. When you have employees, you must withhold and turn in federal in- come tax, Social Security, and Medicare plus match the employee’s contribution to the last two.

Partnerships must file returns and specif- ically state the income items and de- ductions, but the profit or loss is passed

through to the partners, according to the percentage of ownership. Corporations must file and pay taxes on any profit and shareholders must pay tax on dividends. S corporations do not pay taxes but have their profit or loss reflected on the share- holders’ tax returns (unless the state does not recognize S corporations, and then they are taxed as a corporation). Some states also have personal/business property tax to pay each year on the value of the vehicles, copier, desks, etc., owned by the business. For people who own their own business real estate, there is also property tax to pay.

DEDUCTIONS

Check with your accountant or CPA for pres- ent tax laws on deductions. Self-employed practitioners usually deduct the following expenses (10,12–14):

■ Office supplies, postage, teaching ma- terials, etc.

■ Rent paid for a commercial office or a home–office (if it meets IRS rule, used regularly and exclusively for your busi- ness), plus a percentage of the real es- tate taxes, mortgage interest, utilities, insurance, depreciation, repairs, and cleaning cost

■ Cost of gas, water, and electricity at a commercial place of business

■ Advertising and promotion ■ Telephone, answering service, fax,

modem, computer, and copy machine (present tax laws allow up to $24,000 deduction in the year you buy equip- ment without having to depreciate it, otherwise the expenditure must be de- preciated over the life of the car, copier, etc.)

■ Hire of office assistants and subcon- tractors

■ Dues to professional societies (social clubs are usually excluded)

■ Cost of operating an automobile for business (the amount varies each year)

■ Furniture purchased new; used fur- niture can be depreciated but not deducted

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CHAPTER 15 ■ Money and Finance 151

■ Mortgage interest (partial) ■ Real estate taxes (partial) ■ Security system ■ Second telephone line, if it is used ex-

clusively for the business, and business long distance on the first line

■ Utilities attributable to business use of home

LOANS

Since money borrowed is not considered taxable income, repayment of the loan is not an allowable deduction. Interest paid on a business loan can be deducted.

RETIREMENT PLANS

Individual Retirement Arrangement (IRA), Simplified Employee Pension (SEP), 401 (k), Savings Incentive Match Plan for Employees (SIMPLE), and Defined Benefit Plan are ex- amples of retirement plans self-employed people can use. These plans allow an entre- preneur to invest in tax-deductible accounts that accrue interest tax-free until retirement. Roth is an IRA funded with after tax money, but after maturity, the withdrawals are tax- free. Each option has its advantages and lim- itations. Before choosing the program(s) you will use, talk to your investment counselor, banker, accountant, and insurance agencies to see what they offer.

BUYING/SELLING AN ONGOING PRIVATE PRACTICE

Today, more successful dietitians own their own businesses, but with our mobile soci- ety, their businesses might be for sale. After years of working on a private practice, it is painful to think about giving it up, espe- cially if the owner just lets it dissolve in- stead of selling it. However, determining the value of a service-type business whose success is closely associated with the per- sonality of the owner is not easy.

Stuart Rosenblum, CPA with Wilkin and Guttenplan, made a nationwide study of

■ Professional books, newsletters, jour- nals that help you run your business or keep you current

■ Usually, 50% of the cost for business- related meals and entertaining

■ Job hunting expense, if not looking for first job or a position in an unrelated field

■ Expenses incurred in attending busi- ness conventions; be careful, if mixed with pleasure

■ Gifts to clients up to $25.00 each—buy a gift instead of a meal to take the full deduction

■ Health insurance ■ Disability insurance if you have a C

corporation as an employee benefit ■ Contribution to retirement accounts ■ Interest on loans and credit cards if

business-related ■ Bank charges and credit card process-

ing fees on business accounts ■ Professional licenses and fees ■ Special uniforms ■ Social Security taxes: deduct half of

your payment

Any additional types of deductions should be discussed with your tax advisor. Personal, living, or family expenses are not deductible. These would be items such as:

■ Withdrawals of money from the busi- ness by owner

■ Insurance paid on a dwelling house ■ Life insurance premiums ■ Payments made for house rent, food,

clothing (except uniforms), servants, upkeep of pleasure auto, etc.

Possible Deductible Home–Office Expenses (10) (If the IRS criteria are met: exclusive use and principal place of business)

■ Cleaning, repair, trash collection, and maintenance of a home office

■ Condominium association fees ■ Household furniture converted to use

in the home office ■ Household supplies used in the busi-

ness space

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how to set purchase values on various types of businesses (15). Although he did not identify a medical-related private practice, he did mention several service businesses. He estimated that an employment agency owner could ask 0.75 to 1.0 times the gross annual income, equipment included, for the business (the price varying with the business reputation, specialization, and client relations). The owner of an insurance agency with its policies renewed each year could ask 1 to 2 times the amount of the annual renewal commissions. A travel agency owner with good contacts but no ongoing revenue from prior sales could only charge .04 to .1 times the annual gross revenue for his or her business. The major determining factor in valuing a business is how much ongoing worth can be trans- ferred to the new owner.

A buyer should consider the following factors (11,14):

■ Profitability. What is the future profit potential of the business? Start by analyzing balance sheets and profit and loss statements of the present owner for the past 5 years, or however long the practice has existed. If these forms are not available, ask for copies of the income tax forms. Are the prof- its satisfactory? Have profits continued to grow? Ask the seller to prepare a projected statement of profit and loss for the next 2 months and compare it to your own estimations.

■ Tangible and intangible assets. The most common are inventories, computer, furniture, and teaching ma- terials. Make sure that they are in work- ing order and not outdated. Consider whether the items are something you can use. If the asking value seems too high, call around to obtain estimates of similar equipment from dealers of new or secondhand items. Intangible assets would include the business name, any trademarks, copyrights, patents, or sim- ilar items. Make sure the seller owns the assets and can prove it. If a third

party also has rights to the assets, a written consent assigning the rights to you must be obtained. The assets could be licensed to you for your unrestricted use as the buyer of the business. Also, be sure that the seller is restricted from adapting the trademark to use again.

■ Goodwill. This is the dollar amount that the owner is asking for the favor- able public and professional attitudes toward his or her going business. You should be realistic in determining how much you should pay for good- will. Since it is payment for favorable public attitude, you should make some effort to check this attitude. Judge the value of this intangible asset by estimating how much more in- come you will make through buying the going business versus starting a new one. How much of the business will stay, and how much will be lost because of the present owner leaving? Even with the owner’s best marketing efforts, his or her client accounts at nursing homes, drug rehabilitation centers, corporate wellness, or physi- cians’ offices may not choose to con- tract with you for nutrition services. If that is the case, the business owner can’t include those contracts in his or her determination of the worth of the business.

■ Liabilities. You should be sure that there are no outstanding debts or liens on the assets. The seller should pay off all accumulated debts before signing an agreement.

■ Business worth. After you have re- searched the above variables, there is still the question of worth. Deter- mine this through negotiation and bargaining. Are you sure that local physicians and contracts will use your services? Do you have any verbal or letters of agreements to that effect? Have you carefully evaluated the lease agreement, zoning, the growing com- petition, and other possible factors that may affect your business? Will

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CHAPTER 15 ■ Money and Finance 153

money up front followed by regular monthly or quarterly payments for several years. Another option is to pay an up-front amount, followed by a percentage of the gross income for a period of 1 to 5 years.

When the buyer and seller can’t agree on the worth of the practice, several have used the last option: up-front money fol- lowed by a percentage. To keep sales from dropping, it’s advisable for the seller to train the buyer on how to run the business and market it to present and future ac- counts or clients.

INDEPENDENT CONTRACTOR OR EMPLOYEE?

As mentioned earlier in the book, the IRS is very particular about who is claiming to be a self-employed independent contractor and who is actually an employee. The self- employed person may be taking deduc- tions like health insurance or home office that reduce the taxes paid. The key to who is employed and who is self-employed is essentially a matter of control—who calls the shots with regard to how you work (10). IRS Publication 937 details the guidelines, but following are some major distinctions:

■ An employee must comply with your instructions about when, where, and how to work.

■ An employee is trained to perform services in a particular way; independ- ent contractors use their own methods and work for several accounts.

■ An employee is integrated into the business; to remain independent, a contractor should avoid having perma- nent office space on the client’s site.

■ An independent contractor will more likely be incorporated and have a sep- arate business with his own equip- ment, tools, or materials; projects will have end points and not be open ended.

■ An employee is paid by the hour, week, or month; an independent contractor

the seller train you in running the business or offer any other intangible services?

Some business owners have sold out, only to start a new business in competition with the buyer. Consider placing limita- tions on the seller’s right to compete with you for a specific period of time and within a specified geographic area. As a safeguard against costly errors, get legal advice before signing any agreement.

Items typically covered in a contract sell- ing a small business are the following (14):

1. A description of what is being sold 2. The purchase price 3. The method of payment 4. A statement of how adjustments will

be handled at closing (prepaid insur- ance, rent, remaining inventory, etc.)

5. Buyer’s assumption of contracts and liabilities

6. Seller’s warranties (against false state- ments and inaccurate financial data)

7. Seller’s obligation and assumption of risk pending closing

8. Covenant of seller not to compete and any limitations

9. Time, place, and procedures of closing

The seller and buyer must comply with the bulk sales law of the state in which the transaction takes place. The purposes of this law are to make certain that the seller does not sell out, pocket the proceeds, and disappear, leaving creditors unpaid. The seller must furnish a sworn list of his or her creditors, and you, as the buyer, must give notice to the creditors of the pending sale. Otherwise, the seller’s creditors may be able to claim the personal property you pur- chased (14).

PAYMENT

There are several ways in which practitioners have negotiated the payment for a practice. One is a lump sum of money up front. Another way is time payments with either a balloon note at the end of 3 to 5 years, or

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is usually paid by the job or on a com- mission.

SUMMARY

Regardless of the type of business you have and what you sell, there are common problems shared by most businesses. There are also common business practices that may improve a business or business venture:

■ Use a budget, and become involved in the regular evaluation of the output of your business and financial status.

■ Keep accounting systems relevant and effective—reevaluate regularly. Take calculated, well-thought-out risks.

■ Use prosperous periods to reduce your firm’s debts and strengthen finances.

Many businesses and financial consult- ants encourage new business owners to use their first year in business to become established in the marketplace, while keeping overhead minimized. The second year should be used for gaining stability and becoming financially secure. The third year on could be used for expansion and calculated risks. To be rewarded with longevity, a business must first have a stable income generated from clientele support.

REFERENCES 1. King K. 2008 World-wide Entrepreneurial Dietit-

May, 2002. 3. Evanson D, Beroff A. Heaven Sent. Entrepreneur,

January, 1998. 4. SBA Conference: Finding Money. Dallas, TX;

May, 1990. 5. 2000 Dallas/Ft. Worth Small Business Resource

Guide. SBA, 2000. 6. Wexler H. A Businesswoman’s Guide to Working

with Professional Advisors. Denver, CO: Mid States Bank, 1980.

7. Get the Advice You Need Before You Start Your Busi- ness. J.P. Morgan Chase & Co., 2002. Available at: http://www.Chase.com. Accessed July, 2002.

8. After a certain point, higher credit scores don’t win lower interest rates. Kiplinger’s Personal Fi- nance Advisor; June, 2002.

9. Bodine G. Grow a Banking Relationship. Dallas Business Journal, 1991.

10. Edwards P, Edwards S. Working From Home. New York: Penguin Putnam, 1999.

11. Cohen A. Pay It Forward. TIME, November 13, 2000.

12. McCue J. Private Practice. Lexington, MA: The Collamore Press, 1982.

13. Dunlap LB. Accounting Software. Home Office Computing, March, 1999.

14. Starting and Managing a Small Business of Your Own, U.S. SBA, 4th ed. Washington, DC: U.S. Government Printing Office, 1982.

15. Pollan S, Levine M. Playing To Win. The At- lantic Monthly, Fall 1988.

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155

START-UP DECISIONS AND COSTS

The cost of starting a business venture can vary greatly, depending on the region of the country and the tastes of the prac- titioner. Some feel that if they are going to start a business, they are going to do it right. Others try to see how little they can spend and still have the venture fly. Both can be successful, but both also have failed.

Investing a large sum in overhead each month to cover prime office space, exten- sive advertising, a secretary’s salary, and new furnishings can create a successful, sta- ble image right from the start. This should logically attract more business—eventually. Eventually is the important word. There is a point where adding more money to cre- ate a good business will not necessarily bring in more clientele faster. However, an equally bad error can be made by not in- vesting enough to give clients the feeling that you will be there next week.

Before trying to guess how much you are willing to spend on this venture, first decide what kind of office, furnishings, services, staffing, and marketing you would ideally like to have. Then estimate the cost to see if you can afford it. Compromises may have to be made. It may be that initially, the office must be shared with another profes- sional to cut the rental fee, or have it sub- leased for only 2–3 days per week.

As mentioned earlier, most business consultants encourage new business own- ers to buy only the essentials, look for affordable quality, and keep the overhead low, especially during the first year. Dur- ing the second year, try to increase the profit and savings and ordinarily, wait

until the third year to expand and invest in more expensive ventures. The years involved are not as important as the busi- ness and financial growth that should log- ically take place first.

It’s a well-known fact in business that the more metropolitan the area and the more ideal the rental space, the higher the cost, unless the area is overbuilt. This is es- pecially true in the East and West coasts and in more urbanized areas, compared with rural America. You must pay more for office space and services when compe- tition drives up the costs. Fees for consult- ants can reflect these higher costs. The figures that follow are just rough estimates of the costs involved. Call around in your local area to get more accurate figures (Table 16.1).

IMPORTANCE OF WORKING CAPITAL

Up-front money is initially invested to buy or rent the essentials to start your business, for example, office space, printed materials, business cards, scale, calipers, insurance, telephone, answering service, furniture, and so on. The money that maintains these essentials and your salary are the working capital. Therefore, when estimating your expenses, recognize that there are two categories: up-front money to open the doors and maintenance money (working capital) to sustain the business. When planning a business, these two categories don’t include the money being generated by clients.

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156 THE ENTREPRENEURIAL NUTRITIONIST

The working capital should be readily available, but it does not have to be in your checking account. It could be a prearranged line of credit from your bank that isn’t used unless it is needed—or any one of a number of choices mentioned earlier. As a reminder, arrange to have 6 months of working capital.

OFFICE SPACE

Choosing the correct office location, along with good marketing, may decide your ul- timate success in business more than your nutritional expertise. Your office space can be instrumental in conveying stability,

Needs Cost Estimates/Issues

Working Capital Have 6 months of capital available before starting (may be in savings or in a bank line of credit)

Lease Deposit Damage and rent last month Monthly rent $12 to more than $45/square foot

per year Nameplates $45 to $250 Parking Is staff parking included in rent? Is

cost high for clients?

Utilities Deposit Amount varies. If you don’t have a

separate meter, negotiate amount based upon your estimated usage

Telephone Deposit Amount varies Installation $100 to $800 Phone You may buy or lease a phone system

(2-line system about $50/month) Business line (monthly rate) $25 to $65/line Yellow pages listing One line is free; everything else is extra. White pages listing Listing is free, but boldface is extra. Long-distance service $10/month, plus phone bill charges

Services Answering service $7 (phone company) to $125/month

for live person Answering machine $40 to $300, one time purchase,

more features cost more Call forwarding $2/month Call waiting $2/month Accountant fees $50 to $150 /hour CPA $75 to $300/hour, higher fees for

more specialized and experienced Attorney fees $150 to more than $300/hour Temporary secretarial service $12 to $24/hour Receptionist–secretary Salary varies, $10 to $20/hour plus

benefits Virtual assistant $25 to $40/hour, may be on retainer

with a guaranteed number of hours per month

TABLE 16.1 SAMPLE START-UP COST ESTIMATES

Needs Cost Estimates/Issues

Cleaning service $65 to $90/visit

Insurance Office liability, theft, and fire $350 to $1250/year (when you

own the building) Malpractice About $100 to $250/year, depends

on the company and coverage Disability $25 to $40/month Health Amount varies, $250 to

$400/month Life Amount varies, $25 to $50/month,

depends on amount of payout and your age

Office Supplies* Announcements $25 to $65/100 Business cards $10 to more than $99/1000 Letterhead $25 to $60/100 Envelopes $18 to $75/1000 Brochure Varies greatly; get several quotes:

$0.15 to $1.50/brochure Logo Artist fees vary greatly Bookkeeping system $60 to $500 Copying and printing Shop for best prices; prices vary

with quantity printed Postage and miscellaneous Keep supplies in modest amounts Handouts and teaching materials Keep in modest supply

Equipment and Furniture Medical scale: More than $200 Copier $75 to $250/month to rent or more

than $1500 to buy Calipers (good ones) $100 to $450 Computer and software $1000 to $3000 to buy new Printer $150 inkjet and $350 to $700 for

laser Fax machine More than $300; may be a

combination copier, scanner, answering machine, and fax

Furnishings and carpet Amount varies greatly Advertising Experts suggest 10%–15% of the

budget for advertising first year Incorporation $300 to $3500; cheaper legal fees

online, but same filing fees

*Many office supply stores offer nice products for printers you can print yourself—represented by the lower numbers in this table.

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credibility, and success to patients and clients—or just the opposite.

Novices to business often don’t know what to look for. Some choose office space that costs very little but, unfortunately, they sometimes do not get the quality they paid for. Others sign high-dollar leases that des- tine them to work more just to pay the rent. Some practitioners have found that sharing office space with a physician or even rent- ing a space in the same building with an in- fluential or controversial physician may keep other physicians from referring patients.

Knowing that some practitioners work successfully out of their homes, others try it, but have dismal luck. You can avoid most of these problems with a little re- search and objective evaluation.

OFFICE SPACE RENTAL

The ideal office location is convenient, ac- cessible, and one that presents a good image. Clients will be more tolerant of in- conveniences such as limited or paid park- ing, no elevator service, and little waiting room space, as your relationship with them grows. However, you can avoid these prob- lems by anticipating them and by seeking a better location.

It may take several years before your business can attract clients from very far away. Practitioners suggest that offices should be located near the prospective clientele. Market research should help iden- tify that area of a town. Avoid being too close to other more established entrepre- neurial nutritionists unless you plan to spe- cialize in other nutrition services not offered by competitors.

If you want to counsel patients, choose office space in a medical complex instead of an office building. You may find that you will attract more patients, if the physi- cians in the building are good referral agents. Fewer patients may get “lost” be- tween being referred and actually schedul- ing a nutrition consultation.

Although “store-front” businesses in shopping malls or corner retail centers can

do very well, private practitioners are not known for choosing these locations—yet. As emergency medical centers and daytime outpatient services become more prevalent in retail areas, maybe dietitians will opt to be there too.

There are a few final points on a rental location. Before signing the lease, closely evaluate your neighbors, the surrounding businesses in the area, and the landlord. If you are signing a long-term lease, it is important to know if the area is going downhill, if neighboring renters are dis- ruptive, or if the landlord maintains the property well.

SEEING PATIENTS AT YOUR HOME

Before starting a private practice out of your own home, realize that the home envi- ronment can be a blessing or a big mistake. The home setting should be as professional as any private office. That means no in- terruptions or phone calls during patient interviews, and the place should be a com- fortable, clean, and uncluttered setting. If the home does not have an appropriate waiting area, it may be necessary to allow more time between appointments.

A positive benefit of working out of one’s home is that patients and clients seem to relax more quickly. This eases counseling sessions. Also, it is convenient for you since it requires no travel, and overhead is re- duced; therefore, profit per hour can be higher.

On the negative side of using one’s own home:

■ It may be an intrusion into the privacy of your family.

■ Patients or physicians may be hesitant to use your services.

■ You may feel tied to the work setting. ■ The image of the business may not ap-

pear established and successful.

It’s usually a poor business decision to use your home to see patients or clients when it is difficult to find a large apartment or condominium complex.

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158 THE ENTREPRENEURIAL NUTRITIONIST

their patients a flat rate while others charge according to the total time involved.

As home visits become more common- place or when insurance coverage more readily applies to home rehabilitation, this option may be very viable and popular.

OFFICE LAYOUT

If you can afford it, it’s always a nice touch to have a receptionist or a secretary—even one shared in common with other offices— to greet patients as they arrive. Patients ex- pect to have a place to sit and wait, and a more private place for the nutrition consul- tation. Except for group meetings and large families, seldom will there be times when the waiting room will need more than four chairs and your office more than two.

Most practitioners decorate their offices to fit their own tastes, not as a medical clinic. Patients seem more at ease with warmer surroundings.

To establish credibility immediately, practitioners’ certificates, diplomas, and awards should be framed and displayed in their offices. Patients do notice and read these items.

OFFICE SAFETY

For the sake of safety, it’s advisable to have an office fire extinguisher, flashlight, and smoke alarm. A diagram of the exits should be attached to the back of the main door. The furniture and decorations in the wait- ing room and in your office should not be obviously dangerous or fragile. Any steps or stairways should be well marked and well lighted.

When clients are being seen in the evenings, it’s best to ask group members to leave together or to call the building secu- rity person to make sure that the client or you get into your cars without problems. When you are working before or after nor- mal business hours (when few people are around), keep the office door locked. This precaution also applies whenever working out of your home—do not just let people

If a den or another room is used exclu- sively for seeing patients or as your office, a percentage of the square footage and a por- tion of the related expenses may be a busi- ness tax deduction. A multipurpose room, such as a living room or den with the fam- ily television can’t be used as a deduction. Consult with your financial advisor about your specific situation.

Zoning laws for your neighborhood should be checked before starting to see pa- tients at your home. The laws were written to protect the neighborhood quality of life from any undue disruption, excessive traf- fic, or commercialism. Practitioners who work quietly out of their homes and have only one patient per hour do not find zon- ing a problem. If it becomes one, it may be possible to obtain a zoning variance for your business. Unless the zoning is correct for a business at home, an outside sign is usually not permitted.

HOME VISITS

Private practitioners in both rural and af- fluent areas have had success when visiting patients in their own homes. Patients enjoy the convenience.

For practitioners, home visits are not an efficient use of time, if they pull him or her away from the office where other patients could be seen. If, however, the practitioner does home visits instead of renting an office, the savings could make it a good option.

It’s advisable when scheduling home visits to require a 24-hour notice of any cancellation, or a fee will be charged. This is especially applicable when working with very affluent, busy individuals who want your services, but they have lots of changes in their daily schedules. For these people, seeing a nutritionist at home is like seeing a personal trainer—it works well, but scheduling can be a problem. It should not be at your expense.

Travel time, gas, and other related costs must be figured to help you decide your home visit fees. Some practitioners charge

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you do not know walk into an unlocked house. With a little care, potentially nega- tive situations may be avoided.

OFFICE AGREEMENTS

RENTAL OR LEASE

The following guidelines may be helpful to you when renting space:

■ Do not accept the stated rental fee at face value. Virtually all rents are nego- tiable unless there is a shortage of of- fice space in the area.

■ Be on the lookout for especially attrac- tive bargains caused by the economy or overbuilding, or another profes- sional who has too much room and wants to sublease some. Some property owners may be strapped for cash and be willing to make attractive offers.

■ Look for ways to operate with a mini- mum amount of space. Should your business be successful, chances are good you will be able to find additional space when it is needed.

■ When the business is growing and ex- penses are covered, practitioners seek- ing to serve a larger market area should consider renting two smaller offices at different locations (for example, one close to downtown and one in the sub- urbs), rather than one large one. This doubles the exposure and convenience of the business to its clients, while holding down the cost of doing busi- ness, if it’s planned well.

■ Be aware that many leases have addi- tions that boost the rental costs well above the base price per square foot. Maintenance or management fees may not have limitations on escalation. Compute these costs into the amount of the lease before signing.

■ In negotiating for counseling space, be sure to mention that your business will not need special plumbing, extra elec- trical outlets, or private lavatory facili- ties—this will mean less expense and fewer problems for the building owner, and the rental could begin sooner.

■ Be sure to ask what the rental fee in- cludes, such as, shared waiting room, receptionist, utilities, insurance, carpet- ing, and so on. Discuss who will own any shelving, carpeting, or other addi- tions you may pay for in your office— usually the landlord takes ownership if it is “installed,” unless another arrange- ment was agreed upon. If you want to cover the floor but not leave the carpet when you move out, use an Oriental- style or other rug.

■ Will any months of free rent be of- fered to you as an enticement to rent?

■ Check to make sure you can sublease your space in case the need arises.

■ Most leases run a minimum of 1 to 3 years, but occasionally special conces- sions can be made for new or small businesses. Realize that the shorter the term of the lease, probably the sooner the rent will go up.

■ Have a lawyer review the terms of the lease.

The major advantages of having a rental space of your own are that you can control its use, you can decorate it to your tastes, materials and patient records are readily available, and a business phone can be per- manently installed. All of these elements help contribute to a more smoothly run operation and the appearance of order and prosperity. In a food management or simi- lar practice, the office locale can be more flexible, especially when clients seldom come to the office.

Deposits Before moving into a rented space, it may be necessary to pay not only the rent for the first month, but also the rent for the last month and a sizable damage deposit. In general, it may amount to three or more times the monthly rent! Ask your financial advisor about local state laws governing the money held by the landlord and your rights to interest, early payback, and so on.

Rental Fees Rent is quoted in two basic ways: a monthly rate, such as $650 per month or

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160 THE ENTREPRENEURIAL NUTRITIONIST

SUBLEASING

Sharing office space is an alternative for those who want all the amenities of a nice office and locale, but at less expense. In ad- dition to the office telephone and answer- ing service, copy machine and receptionist may be shared. Again, all agreements should be in writing and should be re- viewed by a lawyer.

An office may be subleased from a speech therapist or psychologist who only needs the office several days per week or who has too much space for his or her busi- ness. The office rent and expenses can be split according to the percentage of the week each uses the office, or for whatever amount you agree upon. Be sure to negoti- ate and get the best deal for yourself as you would with any landlord.

SHARING OFFICE SPACE WITH A PHYSICIAN OR CLINIC

Several different options are possible in this instance:

■ A private practitioner could pay rent and remain independent and do her own billing, marketing, printing of materials, and scheduling of her own appointments while subleasing or renting space.

■ Another option would be to give a percentage of the consultant fee in re- turn for the use of the office and its amenities.

■ A third option is to negotiate a re- tainer fee, where you see patients for the physician or clinic during a desig- nated time in return for receiving a re- tainer fee—this is a good option when your services are sought after but the patient load is variable.

■ A final option that some practitioners are still able to find is office space for free so that nutrition services are more accessible to the patient.

As you negotiate rent with a physician or clinic, private practitioners warn that

as cost per square foot. The cost per square foot is usually for 1 year unless in- dicated otherwise. It may range from $12 per square foot in some locales to $45 or more in others. To figure your rent, first determine the total number of square feet to be rented, then multiply that figure times the cost per square foot to arrive at the total cost per year; finally, divide by 12 months to arrive at your monthly rent.

CO-LEASING

Co-leasing takes place when two partners or other people agree to rent an office jointly. This is an advantage when the square footage is too large for one, and it is useful to share the cost. If the office space is only large enough for one person at a time, the days are alternated.

It is not advisable to co-lease with an- other nutritionist, unless you are partners and working for the same goals. Otherwise, trying to advertise two businesses selling the same or similar service under the same telephone number, and handling “walk-in” patients without intruding on the territory of each other has proved too troublesome.

It is again extremely important that you choose a co-lessee well, and that a lawyer reviews the lease agreement. The agree- ment may hold you both equally responsi- ble for damage or theft that your co-lessee or his or her clients inflict. It may leave you with the full responsibility if the other per- son moves or leaves and does not fulfill the entire lease agreement.

No doubt, if you and the other co-lessee present yourselves as “one” to the landlord, he or she will expect you both to be respon- sible for the property and the terms of the lease. You could therefore agree that each of you is responsible for any damage that hap- pens in your space or during your rental time, and each co-lessee owes half the rent for the full term of the agreement. Again, make sure you can sublease the space if nec- essary. Read the agreement carefully, change terms as necessary and make additions, and then submit it back to the landlord.

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office managers and doctors sometimes overestimate the number of persons you will see. Agree on a financial arrangement you can afford, not on one based on huge expectations.

Close association with other profession- als can provide numerous benefits. Several very successful practitioners report that much of their success when they first started in business came from having one or more “mentor” physicians who pro- moted them. Some physicians charge for the space, but others offer it for free out of friendship and respect for the practitioner and as a service to patients.

Depending on your individual situation, some important questions need to be dis- cussed with the physician: Will you be able to see other doctors’ patients at the office? Who will schedule, pull charts, and bill pa- tients? Can you use the copy machine? Who will market you and how? Remember that the more services you request, the more you may have to spend. Write down all agree- ments and have a signed copy for each party. A simple letter of agreement will work. A ter- mination/separation clause is advisable. When a contract is coming up for renewal, you should start negotiating at least a month in advance to work out all differences.

OTHER EXPENSES

Parking In some locations, parking space is at a premium, especially in downtown or med- ical center areas. If a parking lot is owned by your building, does the lease include spaces? Can they be added when negotiat- ing the lease?

Name Plates and Floor Directories Most office buildings have some kind of di- rectory outside the building, in the main lobby, or on each floor, in addition to door nameplates. Seldom will a landlord of a medical building allow you to print your own—they like them standardized. This again could be a lease option to negotiate.

Don’t assume anything; one practitioner had to pay up to $26 per line for four part- ners on six floors.

Utilities When utilities are not included in the lease, utility companies can give you an estimate of your monthly bill. For electricity, they will need to know the number of watts of each light and how many hours per week it will be used in addition to the estimated usage of other equipment, such as air con- ditioning or computer. For gas heating, the square footage of your office can be used in determining an estimate. A money deposit or a letter of credit may be necessary to ob- tain new service. If you live in the area, try to negotiate using your established good credit at home.

Telephone The ongoing changes in phone service will necessitate that you check on the best tele- phone coverage available locally. To sur- vive, a business must have good telephone service and coverage.

A new business phone system may cost $100 to $800 or more to install with new wiring, digital subscriber line (DSL), and multiline equipment. Converting an ex- isting private line in an office or at home is usually only a fraction of that cost. If you have never had a business line, the telephone company may ask for a de- posit—call for an estimate. The monthly fee for the business telephone line will range from approximately $25–$65 or more per line.

Other services you may consider for your phone are call waiting, call forward- ing, conference lines, and a limited serv- ice line. Call waiting will allow you to accept a second incoming call while keep- ing the first call on the line. Call forward- ing allows you to transfer your incoming phone calls to another phone number where you or your answering service can answer it. Limited service lines are not available everywhere, but the line allows a

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162 THE ENTREPRENEURIAL NUTRITIONIST

up your office so that you can handle it yourself, use a temporary service at peak times of the year, hire a dietetic technician, or find shared office space where services of a receptionist are included.

VIRTUAL ASSISTANT

Virtual assistants cover similar skills to those of an administrative assistant, but the person may also have specialized skills in writing, marketing, editing, and so on—and the person may live in Hong Kong. This person is hired to help relieve your work burden on a daily or per project basis. Some virtual assistants ask for a monthly retainer, which will cover a specified number of hours with additional hours charged on a per hour rate. Others will help out on a project basis.

INSURANCE

MALPRACTICE

Call the American Dietetic Association to find the most current malpractice car- rier and policy information. Prices vary according to the number of hours worked, the desired limits on coverage, and whe- ther media work is covered, as well as traditional services. There are several com- panies with different types of coverage available.

OFFICE LIABILITY AND FURNISHINGS

When clients or patients visit your office, there is always the risk that someone will get hurt on the premises. In rental space, the landlord usually carries liability co- verage, but the coverage is often limited. Insurance for office contents in case of fire, theft, or other loss is easily acquired, along with the liability coverage. When sharing space at an office or clinic of a physician, good liability coverage may already be available to you under their policy—check. When working out of your home, home

limited number of outgoing calls to be made each month for a reduced rate. Calls above the limit are charged extra; incom- ing calls are not counted. The rates and availability of these services vary—so call your local company for more information.

Whenever you pay for a telephone line, business or personal, you will be given a listing in the white pages for free; bold print is extra. To have a yellow pages listing, you must have a business line. One listing under the most appropriate heading (probably “Dietitian” or “Nutritionist”) will be given to you. Additional listings, bold print, extra lines, logo, a large ad, and so on will cost extra and will be billed monthly or however you arrange. If you share office space with someone who already has a business phone, for an added fee, you can have your name added to that line. It then will be in infor- mation and in the yellow pages.

Answering Service When you begin your business, the phone should be answered during normal busi- ness hours, Monday through Friday. An an- swering service or voice mail can give you coverage when you are away from the phone. The public is familiar with talking to a machine and will use it if the message is clear, creative, and of good quality. It’s a personal decision whether you want to give out your cell phone number.

SERVICES

ADMINISTRATIVE ASSISTANT/RECEPTIONIST

There is little doubt that a small business owner would enjoy using the services of an assistant or receptionist; however, there are ways to have the duties covered without the full cost of an employee. According to surveys conducted by popular magazines for women, a good assistant is usually paid as much as a good entry-level dietitian.

Some alternatives are to hire someone part-time for several mornings per week, set

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insurance companies ask they be notified so coverage can be increased. Some insur- ance companies are reluctant to offer home office coverage for expensive elec- tronic equipment like computers, laser printers, and so on. Check around to find a good policy.

DISABILITY

Disability insurance will provide a certain level of limited income while you are ill or disabled. The most expensive coverage be- gins after only 15 days of illness and lasts 5 to 10 years up to life. To reduce premium cost, choose coverage that starts after 60 or 90 days of illness and lasts for only 1 or 2 years. You may feel this insurance is an unnecessary added cost, but statistically, more people get ill or disabled by an acci- dent, chemo treatments, chronic diseases, and so forth than get killed. If you are your sole support, or you have family that de- pends on your income, this insurance can keep your life stable while you recover.

The premium and disability coverage are dependent on your age, health, and present income. Unfortunately, self-em- ployed individuals have a more difficult time qualifying for this type of insurance, according to most companies. Check with several insurance companies, including ADA, to see what they have to offer and compare costs and coverage. If you are still employed, start the coverage before you quit your job.

HEALTH

Health insurance is a necessity with health- care costs of today. One hospital stay for 1 week or more could wipe out the savings and business of an uninsured person. To help reduce the cost of a policy, try to join under a spouse’s policy, contact local HMOs or PPOs, or join a group policy (through executive clubs, rural cooperatives, small business owner groups, local chambers of commerce, or local insurance brokers). In some cases, if you have two or more

employees in your business, you can qualify as a group. Another way to keep premium payments lower is to choose major medical coverage instead of a com- prehensive policy. You would have to pay the first $2500 to $5000 of a bill, but then coverage may be 80% after that. Prices and coverage vary so greatly you will need to take the time to get several quotes. Do not go uninsured.

LIFE

Life insurance to pay off your loans and debts, as well as to help support your fam- ily in case of your death is an important consideration. Term life insurance is the least expensive for the amount of coverage if you are younger and in good health. However, as a person grows older, the yearly premiums may increase quickly, un- less you choose a policy with a guaranteed premium.

Variations of whole life policies are read- ily available today. This type of policy is more expensive from the beginning, but eventually can act as a savings account to be borrowed against. This type of policy has a definite total price; therefore, premi- ums do not continue indefinitely as with term insurance.

OFFICE SUPPLIES

BUSINESS CARDS

Before ordering cards, make sure your ad- dress and phone number are stable. A gra- phic designer can design your cards, or you can choose from the layout options at a quick-print store. Because of the cost savings, most businesses order 500 or 1000 cards at a time. Cost for printing depends on the lay- out, paper, ink, embossing, and number of ink colors used. The first time the cards are run, there may be design and layout fees. When the ink color is changed to one not commonly used, there is an ink clean-up charge. Four-color laser cards can be printed from a computer file in a few minutes.

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164 THE ENTREPRENEURIAL NUTRITIONIST

ily convert the final year-end tallies into an income tax return or send the file to your accountant. Don’t purchase a more complicated or expensive system than you need. Upgrade the system as your needs mature.

DIETS AND HANDOUTS

The most important criteria for patient or client materials are to write them in simple, clear language on impressive paper with an easy-to-read layout. Also, don’t load the pa- tient down with every free booklet avail- able on a subject—pick the best ones, free or not. Use online and computer capabili- ties to personalize materials.

EQUIPMENT AND FURNISHINGS

MEDICAL SCALE

If a scale is used, a good balance beam med- ical scale is suggested. A waist-high balance beam is not suggested, because it is awk- ward for very heavy patients to stand on the scale without touching the beam. Spring scales are not always accurate.

SKINFOLD CALIPER

For consultants who work with weight loss, sports nutrition, or nutrition assessment, calipers are a must. They range in price from approximately $5 for the plastic ones to $175–$250 for the metal ones to $450 for the computerized ones.

COMPUTER

A computer, its components, printer, and software are necessities in business for email, word processing, nutrient assess- ment, desktop publishing, scanning, blogs, website sales, search engines, and so on. For businesses where you write manuscripts and letters, search databases, and commu- nicate with other businesses, a computer and fax are standard office equipment.

LETTERHEADS

If the letterhead paper or ink is special, it is more economical to print a larger amount because of the one-time charges for ink clean up, embossing, imprinting, and so on. You can also print the heading as you print letters if you keep the letterhead paper stock on hand.

An economical way to send out a large mailing or form letter on your letterhead is to produce an attractive, clean master copy, and reproduce it on good paper, or print it on a good quality laser or inkjet printer (logo, your name and address, and letter all at the same time). Do not use heavily textured paper, because this inter- feres with the ink attaching to the paper. A 24# weight paper at 90–102 brightness works great. Business letters are usually sent on 8 1/2� � 11� paper, but notes can be on any size with the appropriate size envelopes.

BROCHURES

Good quality brochures are assets to a bu- siness; typesetting or desktop publishing is highly recommended. To save money, the brochure could be a self-mailer, but for times when the best image is required, use an envelope. Before printing your bro- chure, have several people read it and offer suggestions. Make sure it’s copyedited and free of errors before it’s printed.

BOOKKEEPING SYSTEM

A beginning bookkeeping system with an appointment book, cash ledger, receipts, and file folders can be purchased for under $60. Simple software systems are available for under $100. Your accountant or CPA may request that you purchase a definite kind but most are reasonable. It may be to your benefit to use Quicken, QuickBooks Pro, Peach Tree, or another system that can be emailed to your ac- countant for monthly or quarterly reports and review (see Chapter 15). You can eas-

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COPIER

When the volume warrants it, consider buy- ing a photocopier—new or rebuilt. Practi- tioners state having a plain paper copier to reproduce forms, bills, bulk mailings, in- struction materials, and so on saves tons of office time. At the start of a business, it may be more economical to share a copier or find a convenient quick copy store. Used, rebuilt copiers are available for reasonable prices. Also, if your needs are small, con- sider buying an all-in-one machine that scans, prints, photocopies, and acts as a fax and answering machine.

OFFICE FURNITURE

Prices vary with personal taste. Make the setting comfortable for yourself and the client. For dietitians who will be seeing pa- tients who are very large, buy sturdy chairs without armrests or with a wide area be- tween armrests, and not so soft that stand- ing up becomes embarrassing.

For practitioners who will be meeting with executives from large corporations or when image is important to clients, con- sider buying pre-owned office furniture from a reseller or business auction house. Because the furniture is used, it costs less but the quality is usually superior to new fiberboard furniture at the same price.

MARKETING

ADVERTISING

Business consultants suggest that at least 10% to 15% of your budget be allocated to cover the cost of the kickoff campaign of the first year in marketing, such as newspa- per ads, business lunches, brochures, and direct-mail letters. Also, allow 10% or more of each additional year’s budget for ongo- ing marketing.

SUMMARY

Although you may think this covers all of the applicable expenses, there will be more. Memberships and subscriptions will need to be budgeted. Things break and delivery fees will be higher than anticipated. It all takes money—that’s why you need addi- tional cash to cover petty cash expenses and unexpected larger expenses.

Remember to buy only what you need. Keep your overhead low. Spend your money on things that produce the most bang for the buck—such as an impedance machine that measures percentage of body fat and creates another source of revenue instead of buying new curtains when the old ones will do fine. Good preplanning makes the evolu- tion of a business an anticipated pleasure, instead of a crisis management seminar.

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166

17 PRICES AND FEES

An important element of managing money is knowing the value of your time and effort. Too often we spend countless hours doing $12-per-hour office work when we should be doing $125-per-hour “boss work” like making public presenta- tions or negotiating contracts or patient counseling. If you have something more important that you could be doing and you have the money to pay for it, don’t sit around doing work that can be easily delegated.

PRICING STRATEGIES

One decision you must make about each service or product you offer is its price. The price creates an image for a product, as compared to its competitors, that makes it very attractive to its target markets or it turns them off. The perceived value of the product or service must warrant the price being asked.

Historically, dietitians have charged very little for their services and products, but that is changing. We still tend to underes- timate the size of the market willing to buy a “Chevy” option and we keep offering the “Kia.” Perhaps, we have worked with lim- ited budgets too long.

Do you know that there are dietitians charging $225 to $300 for an initial diet consultation of about 1.5 hours with an ad- ditional 30 to 60 minutes for paperwork? Do you realize that there are some dieti- tians charging $2000 or more to speak for an hour, $3000 per day to act as a media spokesperson, or $500 per day to work in a

food booth for a commercial company? A practitioner doesn’t start out at these prices, but they evolve as the person’s skills, reputation, speaking ability, knowledge, body of accomplishments, and sphere of contacts evolve. Does this take 2, 5, 10, 20, or 50 years? The answer is “yes”; it takes different amounts of time for different peo- ple to evolve. Some of course, remain at the status quo, never testing the boundaries nor exploring the possibilities.

The six common pricing strategies are the following (1):

1. Demand oriented: You set the price according to what you think the market is willing to pay; all the strate- gies use a little of this method.

2. Skimming: You charge a very high price to reach a small, elite, and prof- itable market.

3. Trading down: You add a lower- priced, less prestigious service to your existing elite service; this is used to expand to a less elite market segment.

4. Trading up: You introduce an elite expensive service to increase the sta- tus of other generally lower priced services and to attract new buyers.

5. Cost plus: You start with what it costs you to produce the service or product and then add a mark up ac- cording to institution policy (com- monly used on books, clothing, etc.).

6. Under bidding: You set the price with a low profit margin to be more attractive than competitors; this often makes you work very hard with noth- ing to show for your efforts.

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of the 2008 World-wide Entrepreneurial Dieti- tian Survey because the results don’t identify local markets or individuals in any specific country. After you see how other dietitians value their time, you can decide for yourself what you need to charge.

We can also discuss the following factors to evaluate when you establish fees for your work:

■ How much expertise and experience does the work require?

■ How difficult or demanding is the job? ■ How much total time will the job,

paperwork, and follow-up take? ■ How much direct overhead cost (hand-

outs, teaching materials, travel ex- pense, hiring another consultant to help, secretarial time, computer use, etc.) and indirect overhead (to main- tain office, telephone, insurance, etc.) will be expensed to this job?

■ What will the market bear so that you don’t price yourself out of it?

Fees are a curious item. If you charge a small fee, sometimes, not always, patients, physi- cians, and clients think that you aren’t as good as the competition. If you charge a fee that your reputation, years of experience, or expertise can’t support, no one will pay it. Arriving at “correct” fees for different types of jobs is more a process of negotiation and learning from experience. As a practitioner becomes known for quality work and a good reputation, new business will come his or her way. The fee will become less im- portant because people are willing to pay for what they feel is the best. According to Harry Beckwith, marketing consultant, your fees aren’t too high until 25% of your clients complain (2).

SURVEY RESULTS ON FEES (3)

Survey respondents (1369) were asked how they determine what to charge for their services (3).

■ 47.4% based on what other profession- als are charging

■ 27.3% based on what the market will bear

COMMON QUESTION

Q: There seems to be a great variation in the cost of nutrition services. As a new consulting nutritionist, I am struggling to create an image and become known. How do I charge? A: In any transaction, each party gives up something to obtain something else. Price must reflect the perception of a fair ex- change by both parties.

Even when no money is exchanged such as with free public health services, dona- tion of time to dietetic or trade organiza- tions, giving free speeches, and the like, there is still an exchange of something val- ued. If you don’t feel the exchange is fair, you usually won’t continue doing it.

In addition to monetary value, price may reflect the value of your time, effort, personal services, caring, loyalty, power or prestige, goodwill, and many other non- monetary components. A higher price gen- erally connotes more value placed on the product or service that a client receives. Unless there is some advantage to your service as compared to the competition, you will only be able to compete on price.

Many dietitians jeopardize their ability to give time-consuming, higher-quality serv- ices because their prices are so low that they must spend their time seeing many more people just to make ends meet. It appears that the nonmonetary variables such as the uniqueness of the knowledge we share, the highly individualized care, the considerable overhead, and the initial program develop- ment time often have not been considered.

No matter what price you charge, the “per- ceived value” felt by the buyer must be equal to or higher than your fee to continue to at- tract customers. The best way to justify your worth is through measuring the outcome you produce through your consultation.

(Answered by Marianne Franz, MBA, RD, Louisiana Tech)

ESTABLISHING FEES

It’s illegal (price-fixing) for us to discuss what charges you could ask for your services in a local area. But we can share the results

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■ 13.3% based on education and expe- rience

■ 6.8% based on best guess ■ 5.3% based on percentage over ex-

penses

FEE STRUCTURES (3,4)

FLAT RATES

The same fee is charged for the same ser- vice to any client. It is used when selling the same service again and again because you have a good idea of the time and ex- pense involved. It is easy to use for speak- ing engagements, routine clinical consults, and group classes.

PER HOUR RATES

The hours of work are variable or may be unknown in advance so a fee is charged only for the hours worked. It is used for subcontracting, long therapy sessions, and consulting projects. Clients are most com- fortable with an approximate time frame or maximum number of hours.

PER HEAD RATE

This rate changes according to the number of individuals who participate. This rate is often used for workshops, teaching, or speaking to groups who “pay at the door.” It does involve some risk, but if attendance is good, you can do very well. You can cou- ple this rate with a flat rate to charge for a minimum number with each extra person at an added fee.

PROJECT RATE

This rate covers the development of a proj- ect similar to writing a series of educa- tional booklets or comparing bids from contract food service companies for client accounts. Clients like project rates be- cause they are easy to compare. This rate includes your expenses, overhead, profit,

and some room for miscalculations or un- expected delays. If the client is at fault for the delays, your agreement should make him or her responsible for any added costs. After signing the contract, if the project is cancelled through no fault of yours, you should have some compensa- tion for your lost income. To protect your- self from nonpayment, consider asking for your fee in thirds (one third upon signing an agreement, one third midway, and one third at the end upon completion and ap- proval) or half the amount up front and half at the end.

RETAINER FEE

You ask for a retainer fee when the client wants you to be “available” whether for a consultant account, physician’s office, or on a Board of Directors of an organization. The amount you charge may be based on your normal hourly rate or whatever you feel your availability is worth. A retainer should be tied to a limit (such as one 8- hour day per week or 40 hours per month or whatever) and anything over that amount should be charged extra. If you presently work at a job on commission where you take all the risk and the work- load is inconsistent, but you feel that the client wants you, negotiate to have the job changed to a retainer so you can depend on a more stable income.

CONTINGENCY FEE OR COMMISSION PAYMENT

You are paid only if the project is success- ful or the sale is made. Writers are some- times asked to work on speculation, and employment recruiters or many salesper- sons work on commission. The risk is high because a lot of time and overhead may be invested without any promise of in- come, but the income is usually hefty when it does come. If someone asks that you work on commission, make sure the reward is worth it either financially or professionally.

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CHAPTER 17 ■ Prices and Fees 169

FEES IN DIFFERENT SETTINGS

DIET INSTRUCTION FEES

These fees should be consistent or based on an hourly rate so that patients feel that they are charged fairly. There is no stan- dardized way of charging for nutrition con- sultations. Some practitioners charge by the hour but charge a minimum fee for very short appointments. They give their patients an estimate when asked how

FIGURE 17.1 ■ Fee for the initial consultation (3). 929 respondents.

FIGURE 17.2 ■ Duration of the initial appointment (3). 931 re- spondents.

much the fees are. Other practitioners charge by the visit and then try to keep the appointment within a certain time range.

In the survey, 929 respondents reported how much they charge for an initial ap- pointment with a patient, client, or athlete (3). See Figure 17.1.

When asked how long the initial ap- pointment lasts, 931 respondents answered and helped explain why some dietitians would charge less than $50 for an initial appointment. See Figure 17.2.

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The cost of a follow-up appointment was explored next (Fig 17.3).

When asked how long the follow-up appointment usually lasts, 923 respondents answered and helped explain why some dietitians would charge $20 or less for a follow-up appointment (Fig 17.4).

Some practitioners have programs where the diet consultation “package” takes 3 to 8 or more visits. Printed diets are given out only after much education and assessment has taken place. The program commitment

170 THE ENTREPRENEURIAL NUTRITIONIST

FIGURE 17.3 ■ Fee for the follow- up appointment (3). 917 respondents.

FIGURE 17.4 ■ Duration of the typ- ical follow-up appointment (3). 923 respondents.

is made clear in the beginning. The fees are either paid in cash or credit card up-front, or payments are heavily weighted up front or paid as they go.

Following this same way of thinking, many practitioners automatically include several follow-up visits in the fees charged to clients. It’s commonly agreed that a one- visit instruction rarely changes behavior. By having the follow-up included, patients learn the importance of long-term commit- ment to change.

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CHAPTER 17 ■ Prices and Fees 171

are very willing to share and negotiate with you. If the fee is low, try asking for more; also ask that your travel costs be cov- ered or include an extra amount in your fee to cover local travel expenses. Always take your business cards and brochures to pass out and let everyone know where to find you. An easy alternative is printing the information on the handouts for your presentation.

As you become an established and sought-after speaker or an author of some note, your fees can reflect this. Travel and accommodations will be included for out- of-town travel. However, although the fees will be much higher, when you consider the travel time to distant speeches and any lost income while away from the business, the actual net income may be modest. Speakers often look on the opportunity as one to grow professionally, to travel and meet new people, and to sell books, products, consult- ing services, or whatever. With the cost of air travel today, many program planners schedule their meetings so that speakers and attendees can stay over a Saturday night.

Survey results showed that 546 respon- dents were professional speakers. Out of that number, 227 spoke for national or in- ternational groups, which garnered the highest fees (3) (Fig. 17.5).

Survey results showed that the most popular fee for state and national dietetic meetings and local business groups was in the bottom range, $100 to $500. However, looking at the local groups category, for ex- ample, the majority 83.2% (406) charged $500 or less, but 82 people charged $501 to less than $7500 in the same venues. The point is that groups will pay more for high- quality presentations. Forty-six percent of speakers gave speeches at low or no cost for less than a year while they learned their speaking skills; another 25% gave speeches at low or no cost for 1 to 2 years. When promoting themselves as a speaker, 12.4% (49) of dietitian speakers use an agent or speaker’s bureau; 16.5% (65) usually sell a book at presentations; and 8.2% (31) nego- tiate a book signing at most speeches (3).

Group classes for weight loss, gourmet, “natural,” or heart-healthy cooking are very popular with the public. For the pri- vate practitioner, group classes represent a challenge, a creative outlet, and the possi- bility of making more income per hour be- cause of reaching more people at a time. Here are two hints that may be helpful to a practitioner thinking about doing group classes: first, preregister attendees instead of letting them show up at the door, so that you can cancel if attendance will be poor or adjust your room and handouts if a large number plan to come. Second, collect the fee for ongoing classes at the first session or when preregistering so that attendance will be better and your budget more stable.

When asked in the survey if practitioners accept Medicare or insurance, 34.6% (292 respondents) said yes, and 65.4% (551 re- spondents) said no (3). When asked what percentage of their clients use insurance or Medicare if they accept it, the amount ranged from 50% to 90% (3).

PUBLIC SPEAKING

Speaking to professional groups or lay audi- ences can be very satisfying and fun. It should also be financially rewarding. Orga- nizers often work harder to have a better audience turnout when they are excited about the speaker and there is a fee to cover. Occasionally, there will be times when you choose to give a free talk. Let the organizers know that you are waiving the normal fee, so they don’t tell everyone you work for free. If the organization is non- profit, ask for a receipt showing that you donated your fee, or ask that they write you a check, which you will deposit and write back to them. Check with your accountant because they don’t always agree on what is necessary for tax deduction purposes.

When you first begin public speaking, you may not be familiar with what organ- izations are willing to pay. The best way to find out is to ask the person who calls to set up an engagement. They know what their fee boundaries are, and most people

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CONSULTING TO BUSINESSES, MEDIA, OR SPORTS TEAMS

Consulting to businesses usually comes after years of specialized training or experience in the field. However, young practitioners with expertise in sports nutrition, wellness, kids programming, media spokesperson work, and other emerging areas are also being successful.

If you are stumped on how much to ask for a consultant job, ask the client to make an offer, like a daily rate to make a media tour. At least then you would know the ballpark they are in, and you can then ne- gotiate if it is too low. Don’t answer too quickly and agree to a figure without doing your own calculations first. Clients are often hesitant about mentioning a fee first, in case you would have been willing to work for much less.

Charging Commercial Clients This fee should be different than charging a patient in a private consultation because what you produce, like a menu, video script, article for publication, or whatever will potentially bring in revenue to the client. You can always negotiate to arrive at the final agreement. What you want to avoid is coming in too low so you don’t make money or coming in so high that you

sour the client on using your services. You are looking for a well-thought-out begin- ning asking price with room to negotiate. The factors to consider in pricing your ser- vices are the following:

■ The popularity and recognition factor of your name and reputation. How the product will be used and the profit potential for the client.

■ Your best estimate plus a cushion on the number of hours and other re- sources this project will cost you.

■ Consider asking for a royalty for as long as the item is in use. Ask for ed- itorial or revision rights to update the product as needed or yearly. And fi- nally, if the client wants to state that you are a staff member or consultant, ask for a retainer fee and have a letter of agreement on your rights and liability limitations. Talk to your pro- fessional advisors concerning your protection, proposal, fees, and before signing anything.

■ Have your agreement on fees, ex- pected outcomes, review process, proj- ect aborting, etc. down in writing and signed before you start work.

■ Ask for a nonrefundable portion of your fee up front to cover some ex- penses in case the project plans change.

172 THE ENTREPRENEURIAL NUTRITIONIST

FIGURE 17.5 ■ Speaking fees for national or international groups (3). 227 respondents.

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CHAPTER 17 ■ Prices and Fees 173

If you set the fee yourself, use your best calculations on what it will cost you to do the job: estimate your hours, supplies, com- puter usage, secretarial time, telephone, fax, mail, travel, and needed profit. Then esti- mate more hours to do the job by approxi- mately one fourth to one third. Most often the problem is not that we set our fee too low, but that we underestimate how long a job will take. Coming in under budget is al- ways acceptable, if it happens. More negoti- ation suggestions are found in Chapter 19.

In the survey, 749 dietitians consult to businesses (e.g., to create wellness pro- grams, consult to sports teams or spas, design a kitchen layout, or create a new marketing program for a food product) and identified how they charge (3):

■ 65% charge by the hour with an esti- mated number of hours

■ 28% charge by the project with a bid or quote

■ 7% charge work on retainer with an hourly amount for any additional work

See Figure 17.6 for hourly fees. Survey results for media spokesperson

work according to 209 respondents are in Figure 17.7.

Survey results for what dietitians charge when consulting with other individual

When You Aren’t Sure What to Charge: A Personal Experience

BOX 17.1

Many years ago, I was contacted by a national food company about possibly becoming its media spokesperson for a healthy fish product. I sent my demo tapes for evaluation, and the contact woman called to say that I was chosen for the job. We discussed the dates and cities for the media tour, my training at the home of- fice, and my availability—then she asked what I would charge per day.

Well, I hadn’t done this work for 9 years— which was one of the reasons I was chosen—they wanted a fresh face that wasn’t associated with other products. Normally in these situations, I would pick a number out of the sky and say it immediately. The last time I had worked, I had been paid $300 per day, so surely the fee would be up to $450 or $500 per day by now. But, I had just seen the movie, Working Girl, in which Melanie Griffith fakes her way through some negotiations and says something like, “I’m sure you have more experience in that matter and can lead us.” So, I said, “I can call around to find out the going rate or you can make me an offer. Whichever you want!” The woman responded, “We normally pay $1200 per day, is that in your ballpark?” I calmly replied with a huge smile on my face, “Yes, that would be fine. And when did you say we could begin?” —Kathy King

FIGURE 17.6 ■ Hourly fees when consulting to businesses (3). 775 res- pondents.

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who are willing to work as a part-time em- ployee for $23 per hour. A. First, realize a few things about our pro- fession and our marketplaces. Profession- ally, we are in a state of transition from being somewhat passive to more assertive nutrition experts who ask a competitive fee for service or as a wage. Each of us is making the transition according to our own timetables and by what our lifestyles dictate. If someone loses a job to a more flamboyant peer or suddenly becomes the

174 THE ENTREPRENEURIAL NUTRITIONIST

FIGURE 17.7 ■ Fees per day as a media spokesperson (3). 209 re- spondents.

FIGURE 17.8 ■ Fees charged other professionals and the public per hour (3). 443 respondents.

professionals or the public (e.g., web de- sign, coaching, personal chef, etc.) are found in Figure 17.8 (3).

Survey results for what dietitians charge per hour when consulting in long-term care are found in Figure 17.9 (3).

COMMON QUESTION

Q. What can I use for arguments to substan- tiate why as a consultant should I be paid $75 per hour? I am competing with dietitians

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CHAPTER 17 ■ Prices and Fees 175

you must realize that the client must believe and be convinced that you are worth that fee or no amount of logic will sway him or her otherwise! Possible selling points are:

■ As a consultant, you are bringing your own teaching materials, DVDs, weight loss program, and previously successful seminars. The client doesn’t have to pay for development time and a pro- gram with an unproven track record.

■ When the cost of fringe benefits and Social Security, etc., are added to the hourly wage, the amount may in- crease by one third to one half.

■ As a consultant, you come prepared for the job and can produce better work in a shorter period of time.

■ If you have been marketing yourself well and using the media or other ex- posure to build recognition of your name, this is a selling point that may help attract more business to the client or attendees to the program.

■ If you have expertise in computers, culi- nary skills, kitchen marketing, eating disorder programs, or you know people who could be beneficial to the client’s programs or staff, try sharing enough with the client in the additional bene- fits you could bring to the job.

family’s sole support, awareness and atti- tude changes evolve more quickly.

Next, not every client or consultant po- sition is willing to pay the higher fee, no matter how good you are. In other words, you won’t get every job, nor will you want every job you go after. Some jobs aren’t worth more than $18 per hour.

In some instances, if you really want the position, your only other option is to ne- gotiate to do all of the required work in fewer hours for the same total income. For example, if there is $2000 budgeted for nu- trition consultation each month, sell the client on the idea that the money is a flat fee paid to have the job completed and not tied to being on the job physically for 87 hours per month or whatever. You will complete all the group classes, counseling, assessments, documentation, menu review, or whatever is required and be at the job 25 to 35 hours per month or more often if needed. You will have to use your time well and produce for the client, but the pay is better and you didn’t lose the job. The client will have his or her nutrition needs met and still be within budget.

If a prospective client is comparing your consultant fee against that of a $23-per-hour employee, there are some good points that may help your case, but first and foremost,

FIGURE 17.9 ■ Fees charged in long-term care per hour (3). 522 re- spondents.

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Once a “sell” is made to the client, realize that your arguments can’t be just campaign promises if you want to keep the position. You promised short-term excellence and the client will expect you to deliver.

SUMMARY

Prices and fees are good barometers of self- confidence and self-image. Do you see how this all works together? As you learn to do more skills and increase your body of achievements, you feel more self-confident

and what you feel about yourself goes up the scale. Testing the waters and asking for more money if the service or product war- rants it, isn’t as big an issue.

REFERENCES 1. Competitive Edge. Marketing seminar notebook.

The American Dietetic Association, 1987. 2. Beckwith H. The Invisible Touch. New York:

Warner Books, 2000; paperback 2009. 3. King K. 2008 World-wide Entrepreneurial Dietit-

Visibility Enterprises, 1984.

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Over the years, more and more dietetic professionals who provide medical nutri- tion therapy (MNT) seek to obtain third- party (insurance) reimbursement for MNT. In this chapter, an overview of Medicare is provided, along with Medicare’s coverage guidelines for MNT (as of January 2, 2009). Also outlined is a summary of key proto- cols for increasing MNT reimbursement success with private payers. This informa- tion is essential for increasing reimburse- ment success, whether the registered dietitian (RD) is self-employed in a private practice, working as an independent con- tractor in an already-existing facility, or providing MNT as a traditional employee in a traditional hospital setting.

TYPES OF PAYERS

There are significant differences between government healthcare insurance and pri- vate payer insurances.

GOVERNMENT PAYERS

These payers consist of both federal and state programs. The largest is Medicare, which serves the elderly and/or the dis- abled, and Medicaid, which targets certain low-income groups. Medicaid is a joint federal and state healthcare program, au- thorized by Title XIX of the Social Secu- rity Act, to provide medical care for low-income individuals with limited re-

177

REIMBURSEMENT

Mary Ann Hodorowicz

sources regardless of age. Medicaid pro- grams and the services they provide vary from state to state. There are also various other smaller programs that provide healthcare insurance for children, rural underserved populations, veterans, and Native Americans.

Within Medicare, reimbursement for MNT in diabetes, nondialysis renal disease, and postkidney transplant is achievable when all Medicare MNT benefit guidelines are met.

PRIVATE PAYERS

Nongovernment or private payers consist of plans operated by nonprofit companies (such as Blue Cross and Blue Shield), for- profit companies (including managed care), and self-insured employers. Most provide health plans to individuals and groups for prepaid premiums. It is not uncommon for individuals to have both government and private insurance, such as a Medicare ben- eficiary with a secondary health plan from their former employer.

What is important to note is that private payer reimbursement success for MNT in- creases when:

■ The severity of the illness increases (e.g., diabetes mellitus is more severe than food allergies).

■ Provided in more recognized settings (in the payer’s eyes, a hospital-based outpatient MNT clinic is generally

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178 THE ENTREPRENEURIAL NUTRITIONIST

more recognizable than private prac- tice settings).

■ The RD has provider status with the payer.

■ The MNT is medically necessary. ■ The MNT fees are reasonable (in eyes

of physician, payer, and patient). ■ Correct claim forms and correct cod-

ing are used. ■ The status of claims is tracked by the

RD, so that denials are promptly, rigor- ously, and persistently appealed, with the aid of patient’s MNT outcomes, re- search data proving cost-effectiveness of MNT, testimonial letters from pa- tient and physician, etc.

Before the precise details of the Medicare MNT benefit are provided, it is important for the reader to have a basic understand- ing of the Medicare system. Below is an overview of our national federally funded health insurance system.

MEDICARE BASICS: AN OVERVIEW

The Medicare program was established by Title XVIII of the Social Security Act of 1965 in response to the specific medical care needs of:

■ Persons age 65 or older ■ Certain disabled persons younger than

age 65 who are eligible for Social Secu- rity disability payment programs for more than 2 years

■ People of all ages with end-stage renal disease (permanent kidney failure)

Individuals covered by Medicare are referred to as “beneficiaries.” Medicare is governed by federal law and is administered by the Centers for Medicare and Medicaid Services also known as CMS. This governing body used to be called HCFA or the Healthcare Financing Administration. CMS is within the U.S. Department of Health and Human Services (DHHS). The responsibilities of CMS include formulation of policy and guide- lines, contract oversight and operation, maintenance and review of utilization

records, and general financing of Medicare. Employee payroll deductions fund the Medicare benefits covered under Part A. Twenty-five percent of Part B costs are paid for by the beneficiaries’ annual premium dollars, while 75% of these costs come from tax dollars.

MEDICARE PART A, B, C, AND D

Medicare Part A is known as hospital in- surance. It covers inpatient hospital care, skilled nursing facility (SNF) care following a hospital stay, home healthcare services, and hospice care. Virtually all persons age 65 or older are automatically entitled to Medicare Part A. Disabled persons meeting certain requirements are also eligible for Part A, as are persons with end-stage renal disease. There is no application or annual renewal fee.

Medicare Part B is known as medical insurance. It provides coverage for outpa- tient services such as physician services (doctor visits), emergency room visits, am- bulance transportation, laboratory and other diagnostic tests, durable medical equipment, outpatient hospital services, outpatient therapy, various other outpa- tient health services, and for home health- care services for which Part A does not pay. Medicare Part B insurance is optional. Per- sons age 65 or older who are Part A en- rollees can pay an additional monthly premium to receive benefits under Part B. This amount is automatically taken from the beneficiary’s monthly Social Security check before it is mailed to the beneficiary. The Part B deductible in the year 2009 is $135. Therefore, in 2009, the $135 de- ductible has to be entirely met by the ben- eficiary before Medicare will pay any amount of money on a claim for that ben- eficiary. Services that are not reimbursable by Medicare are never applied toward the annual deductible.

MNT is a Medicare Part B benefit.

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CHAPTER 18 ■ Reimbursement 179

Medicare Part C is known as the Medicare Advantage Plan. Its former name was Medicare�Choice. Beneficiaries may choose to get their Medicare coverage through a pri- vate-managed care plan.

The benefit to the beneficiary is that most offer various additional benefits not paid for by Medicare, such as dental care, hearing aids, eyeglasses, and other noncov- ered items and services. Enrollment in any of these plans is voluntary and available at the same time a beneficiary is first entitled to Parts A and B. A beneficiary must have both Parts A and B to be eligible to enroll in Part C.

Medicare Part D is the Medicare Pre- scription Drug Program that took effect in 2006. The program gives beneficiaries a choice of prescription drug payment plans provided mostly through private plans that offer various types of coverage. It is voluntary and available at the same time a beneficiary is first entitled to Parts A and B.

PAYMENT OF SERVICES: PRIMARY VS. SECONDARY PAYER

With regard to payment of all healthcare claims, the rule is that the patient’s “pri- mary” insurance pays first. What is impor- tant to know is this: just because a person is 65 years old or older does not necessarily mean that Medicare is his or her primary insurance. There are several conditions that could make this person’s private insur- ance the “primary” one. If one of these conditions exists, then the claim is to be sent to the primary insurance first . . . not Medicare.

The Medicare provider (including the Medicare RD provider) must determine if Medicare is the primary or secondary insur- ance before the service is furnished. This is quickly and easily accomplished by the beneficiary completing a form specifically designed for this purpose by CMS. It is ti- tled “Medicare Secondary Payer Form” and is available on CMS’ website at http:// www.cms.hhs.gov.

MEDICARE CLAIMS PROCESSING

Medicare Administrative Contractors, or MACs, serve as the primary point of con- tact for:

■ Medicare coverage and billing requirements

■ Processing and payment of Medicare fee-for-service claims for Medicare providers’ respective jurisdictions

■ Provider enrollment

MACs are actually healthcare insurance companies in strategic geographical loca- tions with whom Medicare contracts to perform these services. Medicare providers are assigned to their local designated MAC based on their geographic location and are reimbursed by MACs under Medicare Part B for Part B services and under Medicare Part A for Part A services.

MEDICARE’S REMITTANCE ADVICE

After a claim has been received and processed, a MAC produces a Remittance Advice (RA), which is a vehicle to commu- nicate (to providers, billers, and suppliers) all claim processing decisions such as payments, unmet beneficiary deductibles, adjustments, rejections, and denials. It may serve as a companion to a claim pay- ment(s) or as an explanation when there is no payment. The RA explains the re- imbursement decisions including the rea- sons for payments and adjustments of processed claims. A provider may receive an RA from Medicare transmitted in an electronic format, called the Electronic Re- mittance Advice (ERA), or in a paper for- mat, called the Standard Paper Remittance Advice (SPR).

MEDICARE DEDUCTIBLE AND CO-PAYMENT CHARGES

The Medicare deductible is the amount that must be paid by a Medicare beneficiary be- fore Medicare will pay for any items or serv- ices for that individual. In the year 2009, the

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180 THE ENTREPRENEURIAL NUTRITIONIST

Medicare Part B deductible is $135 per year. A co-payment (coinsurance) is the portion of the cost of an item or service that the Medicare beneficiary must pay. It is illegal to routinely excuse Medicare beneficiaries from insurance co-payments and deductibles. It is legal, however, to waive the fee or the coin- surance payment for a beneficiary with a genuine financial hardship. The provider of the service does not define financial hard- ship. . .Medicare does.

HIPAA REGULATIONS

The Health Insurance Portability and Ac- countability Act of 1996 (HIPAA) mandates strict standards and procedures that promote standardization and efficiency in the health- care industry. The law helps streamline the administration of healthcare by requiring basic standards for conducting several trans- actions in electronic form, including pro- cessing claims and payments. It also governs disclosure of electronic patient-protected health information and provides the mini- mum safeguards required to ensure the se- curity of electronic healthcare information. Below are three of the most common ques- tions among healthcare providers with re- gard to HIPPA and its provisions:

1. “Do the HIPAA laws pertain to me?” HIPAA laws pertain to any health- care provider (including the Medicare RD provider who is providing MNT or other service to patients, and/or is billing Medicare or any other health- care plan for MNT or other services) IF: The provider or the provider’s of- fice conducts any of the following transactions electronically (which in- cludes faxing from a computer), or the provider has someone else con- duct them electronically on her or his behalf, such as a clearinghouse or billing service: ■ Submitting claims or managed care

encounter information ■ Checking claim status inquiry and

response

■ Checking eligibility and receiving a response

■ Checking referral certifications and authorizations

■ Enrolling in and canceling a health plan

■ Receiving healthcare payments and remittance advice

■ Providing coordination of benefits

If the provider conducts any of these transactions electronically, the provider is a covered entity and must comply with all HIPAA require- ments, regardless of the size of the practice.

If the provider conducts all of the above transactions on paper, by phone or by fax (from a dedicated fax machine, as opposed to faxing from a computer), the provider is not a HIPAA-covered entity and the HIPAA laws do NOT pertain to the provider.

2. “Do I have to submit claims to Medicare electronically?” HIPAA law requires that all claims submitted to Medicare be submitted electronically in the HIPAA standard format. Only providers who meet certain exceptions may continue to submit claims on paper. One of the major exceptions is for claims sub- mitted by “a small provider of services or supplier.”

3. “What is the National Provider Identi- fication Number and do I have to get one?” The administrative simplifica- tion provisions of HIPAA established the National Provider Identification (NPI) number for providers, health plans, and employers. HIPAA will re- quire that healthcare providers, health plans, and employers have standard national numbers that identify them on all standard medical transactions, including referrals, prescriptions, etc. The NPI number is a new 10-digit number issued by CMS. It will replace all legacy provider PINs currently used, including the PIN issued to Medicare providers upon enrollment. If the

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CHAPTER 18 ■ Reimbursement 181

RDS’ OPTIONS WITH REGARD TO MEDICARE MNT BILLING

The RD has four options with regard to Medicare MNT:

B � Bill Medicare Part B for the cov- ered MNT; RD must be Medicare provider.

R � Do not become a Medicare provider and refer the beneficiary for covered MNT to a RD who is a Medicare provider.

O � Opt out of the Medicare Program and enter into a private contract with each beneficiary.

X � Exclude Medicare involvement:

■ For statutorily excluded MNT (ex- ample, hyperlipidemia MNT). When MNT in other disease states is statu- torily (legislatively) excluded from the Medicare MNT benefit, the ben- eficiary and the RD provider can in- teract freely without involvement with Medicare, and without having to adhere to any of the Medicare MNT guidelines, restrictions or lim- itations. However, the beneficiary should be told verbally that: ■ The MNT service is prescribed by

his or her physician but it is an excluded benefit in Medicare.

■ That the beneficiary will be re- sponsible for the full MNT fee.

■ When the Medicare beneficiary does not qualify for the Medicare MNT benefit (example, when beneficiary does not meet one of the diagnostic lab criteria). RD may still furnish the covered MNT, but cannot bill Medicare. RD can, however, bill the: ■ Beneficiary directly ■ Beneficiary’s supplemental (sec-

ondary) insurance

Coverage guidelines also stipulate that the MNT can only be furnished in ambulatory (outpatient) settings (e.g., private prac- tice, physician’s office, ambulatory clinic, hospital outpatient department, renal dial- ysis facility, and in nonmedical type of

provider is a HIPAA-covered entity, it must obtain and use the new NPI number. The provider is assigned only one NPI number and it will never change. Non-HIPAA providers are also eligible for the number.

HIPAA-covered Medicare RD providers must obtain and use their NPI numbers on all medical transactions. RDs do not automati- cally become Medicare providers once they have a NPI, or vice versa. RDs still need to enroll with Medicare to qualify as a Medicare MNT provider.

MEDICARE MNT REIMBURSEMENT

INTRODUCTION

In 2002, MNT became a Medicare benefit under Medicare Part B for these specific dis- eases and conditions:

1. Diabetes: Type 1, Type 2, and gesta- tional diabetes

2. Nondialysis chronic kidney disease 3. Post–kidney transplant for a period of

36 months

The benefit legislation described MNT as: “Nutritional diagnostic, therapy, and counsel- ing services for the purpose of disease manage- ment, which are furnished by a registered dietitian or nutrition professional.”

When CMS authorized the Medicare MNT benefit, it stipulated that specific rules had to be followed in order for providers to be reimbursed for furnishing the MNT. These rules are commonly referred to as “coverage guidelines.”

Medicare Part B directly reimburses RDs who are certified Medicare providers for MNT furnished to beneficiaries with these diseases/medical conditions. Medicare ben- eficiaries must meet specific medical neces- sity requirements to be eligible for the MNT benefit. In addition, there are several cover- age guidelines that must also be met in order for the RD to bill Medicare for the MNT and receive direct reimbursement.

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182 THE ENTREPRENEURIAL NUTRITIONIST

■ The forms that may be required, per the RD’s practice setting, are the: ■ CMS 855B: Application for Healthcare

Suppliers. This form should be used to establish a provider group or other supplier that will bill MACs for serv- ices rendered. It is not used for indi- vidual enrollment.

■ CMS 855R: Medicare Enrollment Appli- cation Reassignment of Medicare Bene- fits. The CMS 855R form is used to officially reassign the RD’s benefits (reimbursement) to the employer/ organization for services she or he provided as part of that organization. The organization must also be a Medicare entity provider.

These forms can be accessed and printed from the CMS website at http://www .cms.hhs.gov or from the MACs. No fees are required to submit the forms.

The RD should not submit any MNT claims to Medicare until receipt of the NPI number, as this number must be on the MNT claim forms. The RD can, however, furnish the MNT once the enrollment ap- plication is in the mail. In this scenario, the RD would simply hold all the claims and submit them after the NPI number is re- ceived. The allowed time period for submit- ting claims to Medicare is 12 months from the date of service.

REIMBURSEMENT: Pre-MNT PHASE

To assure that the Medicare beneficiary is ac- tually entitled to and eligible for the Medicare MNT benefit, best practice would indicate that the RD implement the following steps:

1. Verify entitlement to MNT: De- termine if the beneficiary has Medicare Part B Insurance. Medicare MNT is a Part B benefit. Be- cause Medicare Part B insurance is op- tional, the RD or office staff must verify that the senior has Part B insur- ance, and thus entitled to the MNT. It is important to make a copy of the ac- tual Medicare card (front and back)

environments such as the beneficiary’s home, a senior congregate meal site, etc.). The MNT benefit does not extend to bene- ficiaries in an inpatient stay in a hospital, or to those in a skilled nursing facility. Ef- fective January 1, 2006, Federally Qualified Health Center (FQHC) services now include outpatient MNT services as billable FQHC visits when the FQHC meets all relevant program requirements for the provision of such services as set forth in the federal reg- ulations in part 410, subpart G for MNT. The MNT benefit does not extend to bene- ficiaries who are inpatients in a hospital, to those residing in a skilled nursing facility, nor to those receiving renal dialysis.

HOW THE RD BECOMES A CERTIFIED MEDICARE PROVIDER

For an RD to enroll in Medicare as a certi- fied Medicare provider, the RD is to:

■ Contact his or her local MAC (previ- ously known as the Medicare carrier), specifically the Customer Service Rep- resentative (CSR) listed for Medicare Part B benefits. RDs can access the name and contact information of their MAC on ADA’s website (http://www .eatright.org) or CMS’ website (http:// www.cms.hhs.gov).

■ Explain to the MAC’s CSR the type of practice setting she or he works in.

■ Ask the CSR which additional forms must be sent in order to enroll in Medicare as a provider and begin billing for Medicare MNT in her or his practice setting.

■ The form that is required is the: ■ CMS 855I: Medicare Enrollment Appli-

cation for Physicians and Nonphysician Practitioners. This form must be com- pleted by a physician or nonphysi- cian practitioners who render medical services to Medicare ben- eficiaries. Following enrollment, this form should also be used to report any changes, deletions, or additions to information previously submitted.

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before furnishing the MNT; this data is used on the claim and helps ensure accurate and timely reimbursement. The websites of several Medicare carri- ers now allow Medicare providers to check if the beneficiary has Part B in- surance. The ADA website has just been recently updated to include a di- rect link to each state carrier’s web page that explains how providers in their state can verify eligibility for any Medicare Part B service.

2. Determine if the beneficiary has previously utilized any part of or all of the covered MNT hours. Determining if previous MNT services were provided to Medicare beneficia- ries is also important for successful re- imbursement and to be in compliance with MNT utilization limits. Several MACs’ websites now allow providers access to the history of a patient’s claims, such as the number of MNT hours furnished in the calendar year; eventually, all will provide this access. If not determined via the MAC web- site, the RD or office staff should make every effort to determine if the bene- ficiary has used any of his or her MNT benefit hours in the initial (first calen- dar year) episode of care and/or in the follow-up (each calendar year after the first) episode of care.

3. Verify eligibility of the benefici- ary to receive MNT: Obtain physi- cian’s referral and diagnostic lab criteria for diabetes and/or pre- dialysis chronic kidney disease (CKD). A beneficiary’s utilization of the Medicare MNT benefit also depends on establishing medical necessity for the initial and follow-up MNT. This is accomplished by the RD obtaining: ■ A written referral for the initial

and/or follow-up MNT from the se- nior’s treating physician. A referral for MNT is a required coverage guideline.

■ Documentation of diagnostic labo- ratory criteria for diabetes or predial-

ysis kidney disease for the initial MNT. The referral can only be com- pleted by a physician (MD or DO) who is treating the beneficiary. Medicare has stipulated that it can- not be completed by other ancillary healthcare professionals, such as nurses, advance nurse practitioners or those with PhD degrees. The Medicare MNT referral must include the following information:

■ Order for MNT ■ Beneficiary’s diagnosis or Interna-

tional Classification of Diseases, Ninth Revision (ICD-9) diagnosis code re- lated to a disease/condition covered in the MNT benefit (diabetes, pre- dialysis kidney disease, or the period of 36 months following a kidney transplant)

■ Physician’s signature (cannot be stamped or signed by someone else)

■ Physician’s NPI number ■ Date ■ Beneficiary’s name

A joint task force of the American Dietetic Association and the Ameri- can Association of Diabetes Educa- tors (AADE) developed a universal referral form for ordering MNT and diabetes self-management education (DSME). It is available for download- ing on the websites of the ADA and AADE.

■ Additional Hours. Medicare also reim- burses for additional hours over and above the 3 in the first calendar year, and over and above the 2 in all subsequent years. The hours can be increased only if the treating physi- cian determines there is a change in the patient’s medical condition, diagnosis, or treatment regimen that requires a change in MNT, or the patient demonstrates a lack of under- standing of the diet. All coverage rules must be adhered to, which include the following: ■ A new physician’s referral is ob-

tained for the extra hours.

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184 THE ENTREPRENEURIAL NUTRITIONIST

ment, even if the beneficiary has met all the entitlement and eligibility re- quirements for the benefit.

Failure of the provider to maintain a system of identifying the primary payer for each service encounter is viewed as a violation of the provider agreement with Medicare and could result in financial penalties and denial of claims.

5. Communicating beneficiary’s MNT benefits. One of the RD’s most important responsibilities is to communicate all aspects of the MNT benefit to the beneficiary. The bene- ficiary has the right to be told in ad- vance of the following: ■ Utilization limits: This is the num-

ber of hours that are covered in the initial and follow-up MNT episodes of care.

■ Co-payments and deductibles: Medicare provider RDs may forgive the co-payment because of a patient having a financial hardship (hard- ship criteria are established by CMS).

6. Verify Medicare MNT provider eligibility. As discussed earlier, per- sons who are eligible to provide Medicare MNT and bill Medicare Part B for the service are qualified nutri- tion professionals; this includes RDs.

7. Determine if beneficiary needs Advance Beneficiary Notice (ABN). The purpose of the ABN form is to help beneficiaries make an in- formed choice about whether they want to receive a covered service, knowing that they may be responsi- ble for the payment if Medicare de- nies payment. With regard to MNT, an ABN is not required for the 3 hours of MNT provided in the initial episode of care, or for the 2 hours in the follow-up episode. It is required, however, prior to furnishing addi- tional MNT over and above these uti- lization limits. Remember, a second referral from the treating physician is also required. Although Medicare

■ There is documentation on the re- ferral of: ■ The reason for the extra hours

(medical necessity documenta- tion).

■ The exact number of extra hours ordered.

■ Obtaining diagnostic laboratory criteria to verify beneficiary eli- gibility for MNT. The Medicare provider RD must have written docu- mentation in the beneficiary’s chart of Medicare’s diagnostic criterion for diabetes and/or nondialysis chronic kidney disease (CKD) before the MNT is furnished.

For diabetes MNT, one of the fol- lowing diagnostic criteria must be documented in the chart: ■ A fasting blood glucose (FBG) of

greater than or equal to 126 mg/dl on two different occasions.

■ A 2-hour post–glucose challenge test of greater than or equal to 200 mg/dl on two different occasions.

■ A random glucose test or greater than or equal to 200 mg/dl for a person with symptoms of uncon- trolled diabetes. For nondialysis chronic kidney dis-

ease MNT, the following diagnostic criteria must be documented: ■ A glomerular filtration rate (GFR) of

13–50 mL/min per 1.73 m2 (the RD can use the Cockcroft-Gault equa- tion to manually calculate the GFR). For kidney transplantation MNT, the criterion is the time pe- riod of 36 months after the date of the kidney transplant. Documenta- tion that the beneficiary is within this time period is required.

4. Comply with the Medicare Sec- ondary Payer (MSP) regulations. Often times, the question arises, “Who pays first, Medicare or the beneficiary’s secondary insurance?” Federal law re- quires that the primary insurance is billed first and pays first. Medicare is not always the primary source of pay-

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CHAPTER 18 ■ Reimbursement 185

does reimburse for additional MNT hours and has not yet set a limit on these hours, it does require that cer- tain conditions must exist in order for the hours to be covered. It is because of these conditions that the ABN is necessary. Once the beneficiary signs the ABN, he or she cannot expect fi- nancial responsibility for the MNT claim to be waived. If the beneficiary refuses to sign the ABN, the RD can directly bill the beneficiary if all re- quired ABN criteria are met. Medicare has its own ABN form, which Medicare providers are required to use; it can be accessed and down- loaded via the CMS website.

8. Use of clinical protocols for fur- nishing Medicare MNT. When fur- nishing the MNT benefit, Medicare’s final regulations state that “RDs and nutritionists must use nationally rec- ognized protocols, such as those de- veloped by the ADA” (1). These protocols, also known as MNT Evi- dence-Based Guides for Practice (or nutrition practice guidelines) can be either purchased directly from the ADA or in some cases, downloaded with no charge from its website.

REIMBURSEMENT: Post-MNT BILLING PHASE

It is very important that the Medicare provider RD understands and knows how to follow the MNT billing rules set forth by Medicare. The RD can be held accountable by CMS for errors in billing or for otherwise not adhering to the guidelines of the MNT benefit.

1. CPT procedure codes for MNT. CMS requires that one of five ap- proved MNT procedure codes be used when submitting claims to Medicare for payment of MNT. These codes are included in the American Medical As- sociation’s (AMA) Current Procedural Terminology (CPT) code book. (CPT

The MNT codes are time based. The actual code is listed only one time on the claim form along with the number of units of the code that was furnished in the MNT visit. Below is a descrip- tion of each code (set in boldface): ■ 97802: Medical nutrition ther-

apy, initial assessment and intervention, individual, face- to-face with the patient, each 15 minutes (used only once in first year for initial visit). Note: The MNT is considered “initial” if the beneficiary has not received MNT for diabetes or renal disease in the past 3 years.

■ 97803: Reassessment and in- tervention, individual, face- to-face with patient, each 15 minutes.

■ 97804: Group (or more indi- vidual[s]), each 30 minutes. Note: Group is two or more patients; not all patients in the group need to be Medicare patients. Guests do not count as patients.

■ G0270 and G0271: CMS requires the use of these two different MNT CPT codes for billing additional hours of MNT beyond the 3 hours in initial episode of care in first cal- endar year, and beyond the 2 hours in follow-up episode of care in each subsequent calendar year with a physician’s referral: ■ G0270: Medical nutrition

therapy; reassessment and subsequent intervention(s) following second referral in same year for change in di- agnosis, medical condition, or treatment regimen (in- cluding additional hours needed for renal disease), in- dividual, face-to-face with the patient, each 15 minutes. Note: Code is for billing additional

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186 THE ENTREPRENEURIAL NUTRITIONIST

2. ICD-9 diagnosis codes on MNT claims. ICD-9 stands for International Classification of Diseases, Clinical Mod- ification, Ninth Revision (1). The dis- ease(s) diagnosed by the beneficiary’s physician must be entered on the MNT claim that is sent to Medicare for reimbursement. A narrative de- scription of the disease is not written on the claim. Instead, the disease is matched to the correct ICD-9 diagno- sis code, and only the code is entered on the claim.

Because RDs are not allowed to make a medical diagnosis or to assign an ICD-9 diagnosis code, it is very im- portant that the RD obtains the code from the beneficiary’s physician on the MNT referral.

Periodically, ICD-9 codes are up- dated. RD who furnishes Medicare MNT should have a current ICD-9 code book at her or his disposal.

3. MNT claim forms. Most payers stip- ulate the specific forms on which MNT claims are to be filed. Their provider manuals normally include the details of how to fill out the required claim forms. CMS requires that institutional providers, such as hospitals, use the electronic UB-92 claim form to bill Part A for services and items rendered and covered under Part A. CMS now allows these organizations to send MNT claims, a Part B service, to the Part A division on the electronic UB- 92 form. Small providers, however, are permitted to use the paper version of this form, which has been updated and now called the UB-04 paper form.

MNT services furnished in inde- pendent, noninstitutionalized settings, such as clinics and private practices, are typically billed on the CMS-1500 or its electronic equivalent. RDs must submit the original “red” CMS-1500 form to Medicare; photocopies or computer- generated forms will not be accepted.

Whether the RD fills out the claim form or works with a billing

hours of individual MNT be- yond the 3 hours in the first ini- tial episode of care in the first calendar year, and/or beyond the 2 hours in the follow-up episode of care.

■ G0271: Medical nutrition therapy reassessment and subsequent interventions(s) following second referral in same year for change in diag- nosis, medical condition, or treatment regimen (includ- ing additional hours needed for renal disease) group (two or more individuals), each 30 minutes. Note: Group is for two or more patients; not all patients in the group need to be Medicare patients. Guests do not count as patients. Note: Code is for billing additional hours of group MNT be- yond the 3 hours in the first initial episode of care in the first calendar year and/or beyond the 2 hours in the follow-up episode of care in each subsequent calendar year.

Now that qualified dietitians and nutrition professionals may bill Medicare directly under these CPT codes, it is expected that eventually, all private payers will also require these codes on MNT claims. However, the coding requirements of private payers are by no means uniform, and some require other non-MNT codes.

The only sure way to know which code to use is to consult the specific payer. Some providers still require the use of physician’s evaluation and management (E&M) CPT codes for billing the MNT service, yet others re- quire that the MNT be billed under the physician provider number as “in- cident to” physician’s services. Yet others require use of other codes related to patient education, nutri- tional counseling, training, medical team conferences, telephone services, and online medical evaluation.

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department, it is well worth the time to study how claims are filed and how to track their success rate. As an advo- cate for the value and reimbursement of RD services, the RD can help the MNT program obtain better reimburse- ment, making the RD a more valuable member of the healthcare team.

4. Revenue codes on UB92 claim forms. For providers who do bill for MNT on the UB-92 (CMS-1450) form, a revenue code is required in addition to the CPT procedure code. A revenue code is assigned to each hospital charge to denote the type of service and where it is performed—for exam- ple, lab service, radiograph, surgery, clinic, education, and training, etc.

The cost of outpatient MNT serv- ices must be billed to Medicare with revenue code 942, Education and Training. However, some private pay- ers may deny claims that use code 942, as they do not pay for “educa- tion.” Alternative revenue codes that may be accepted are 940 (Other Ther- apeutic Services), 510 or 512 (Outpa- tient Clinic), or 761 (Observation). Terminology is very important, so it is wise to keep in close contact with the hospital’s contract agent during nego- tiations with a payer.

5. Medicare’s MNT utilization lim- its. Medicare reimburses for 3 hours of individual and group MNT fur- nished in the first, initial calendar year (“initial episode of care”) and 2 hours in all follow-up, subsequent calendar years after the first (“follow- up episode of care”) as long as all the coverage guidelines are met.

Note that these limits are based on a calendar year (January 1 through December 31). The RD cannot carry over initial or follow-up hours to the next calendar year, once the MNT has begun; if not used during this time pe- riod, the hours are lost.

Medicare reimburses for additional hours of MNT over and above the 3

initial hours and over and above the two follow-up hours if all coverage rules are adhered to: ■ Documentation of medical neces-

sity for the additional hours of MNT is obtained by the RD.

■ Medical necessity is documented; that is, the treating physician deter- mines that there is a change in the patient’s medical condition, diagnosis, or treatment regimen that requires a change in MNT, or the patient demonstrates a lack of understand- ing of the diet.

■ Another physician’s referral is ob- tained for the extra MNT hours, with the reason (medical neces- sity) for the hours written on the referral.

■ As of January 2009, Medicare has not set a limit on the number of ad- ditional hours it will pay for.

6. Expansion of Medicare tele- health services to include MNT. Effective January 1, 2006, CMS added individual MNT to the list of Medicare telehealth services.

RDs can now furnish and receive payment for individual telehealth MNT using codes 97802, 97803, and G0270. Group telehealth MNT is not reimbursable. Medicare beneficiaries with diabetes or nondialysis kidney disease who reside in rural health pro- fessional shortage areas defined by the federal government now have im- proved access to Medicare MNT. Sev- eral additional coverage guidelines apply, and all the guidelines for non- telehealth MNT also must be met to obtain reimbursement.

7. What types of MNT cannot be billed to Medicare. The RD cannot bill Medicare for the following: ■ MNT in noncovered disease states ■ MNT as “incident to physician’s

services” ■ Diabetes, predialysis CKD and renal

transplant MNT when beneficiary does NOT meet Medicare’s clinical

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188 THE ENTREPRENEURIAL NUTRITIONIST

or her secondary insurance, for the difference between the Medicare ap- proved amount and the RD’s MNT charge.

The RD is expected to collect the MNT co-payment from the benefici- ary and any of the beneficiary’s unmet annual deductible.

Reimbursement from private pay- ers is generally not governed by “as- signment,” but most often is governed by the contractual dis- counts stipulated in the provider’s contract or by fixed (capitated) dollar amounts paid to HMO providers per month by the insurance plan for all services delivered to a HMO member that month. Every contract the RD enters into with the private payer can have different coverage guidelines for MNT.

11. MNT fees charged by RD. Many RDs feel that the best way to deter- mine fees for the MNT is to conduct a fee survey in the area, and base their fee on what is being charged by the competition. Knowing what other RDs in other practice settings are charging is a factor, but using it as the sole factor can be likened to compar- ing apples to oranges. The MNT fee should be customized as it is to be based on several factors, including all costs incurred in providing MNT. Once the usual and customary fee schedule is determined, the RD should abide by this schedule fee for all her or his MNT clients.

12. CMS’ Physician’s Quality Re- porting Initiative. In the summer of 2007, CMS launched a new volun- tary Medicare Part B provider incen- tive program called the Physician Quality Reporting Initiative (PQRI). In addition to physicians, the pro- gram also extends to select nonphysi- cian providers, including RDs. The PQRI provides financial incentives for these providers who meet and report

lab criteria for diabetes and predialy- sis CKD, or does NOT meet Medicare postkidney transplant time frame for renal transplant MNT. But the Medicare beneficiary

and/or the beneficiary’s supplemental insurance may be billed for MNT in noncovered disease states.

8. Medicare MNT reimbursement rates. Reimbursement for Medicare MNT is a Part B benefit and based on Medicare’s physicians’ fee schedule (MPFS). The Medicare MNT rate is 85% of the MPFS. CMS’ allowed, ad- justed MNT rates for the RD’s geo- graphical locations can be accessed on the CMS’ website and also on ADA’s website. Because of CMS now assign- ing relative value units, also referred to as work values to MNT codes, the MNT rate is higher for: ■ MNT furnished in noninstitutional-

type settings, such as a private prac- tice, because of greater practice expenses.

■ Initial MNT, because of greater work effort than follow-up MNT.

■ Individual MNT, as opposed to group MNT.

9. How much is paid by Medicare and by the beneficiary for Medicare MNT? Medicare pays 80% of the allowed adjusted payment amount, and the beneficiary is re- sponsible for 20% of the allowed pay- ment amount, plus any unmet annual deductible.

10. RD accepting assignment from medicare. The MNT benefit cover- age guidelines require that the RD who enrolls as a Medicare provider must accept “assignment” with re- gard to Medicare payment for MNT. Accepting assignment means that the RD must accept Medicare’s approved, adjusted, assigned MNT reimburse- ment as payment in full for the MNT that was furnished and billed. The RD may not bill the beneficiary, nor his

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CHAPTER 18 ■ Reimbursement 189

to Medicare predefined quality meas- ures on their claim forms, using select CPT codes. This incentive is a bonus payment, subject to a cap (2% in 2009) of total allowed charges on claims covered under the Medicare physician fee schedule. More infor- mation on this program, including a summary of the quality measures that can be used by RDs who provide MNT, can be found on the websites of CMS and the ADA.

13. MNT documentation. Communi- cation among team members is important to provide consistent, quality care to persons with diabetes and nondialysis kidney disease. Doc- umentation is one form of commu- nication and is a necessary part of medical care. Documentation is also essential for verifying the quality of care delivered and determining out- comes of care. ADA’s Evidence-Based Nutrition Practice Guidelines pro- vide resources to enable RDs to meet MNT charting essentials.

SUMMARY

Medical nutrition therapy has great poten- tial for advancing the health of people, whether it is through disease prevention or treatment. For RDs to continue to pro- vide this valuable service to people of all ages, it is critical that RDs learn about the structure of insurance plans for filing claims and learn and adhere to the payers’ detailed coverage guidelines for MNT. What is an absolute certainty is that these guidelines will change, so having a system to keep you and your staff updated is also critical.

ABOUT THE AUTHOR

Mary Ann Hodorowicz, RD, LDN, MBA, CDE, CEC, is the owner of Mary Ann Hodor- owicz Consulting, LLC, a private practice in Illinois specializing in nutrition, diabetes care and education, health promotion, and insurance reimbursement for profes- sionals. She self-publishes three resources for RDs and billing professionals: Money Matters in MNT and DSME: Increasing Re- imbursement Success in All Practice Settings, The Complete Guide; Establishing a Success- ful Outpatient MNT Clinic in Any Practice Setting; and EZ Forms for the Busy RD. Con- tact: [email protected]; http://www .maryannhodorowicz.com

REFERENCES 1. American Dietetic Association. Medical nutrition

therapy: The basics. November 2007. Available at: http://www.eatright.org. Accessed January 2, 2009.

RESOURCES Centers for Medicare and Medicaid Services. Regu-

lations and guidance. October 2007. Available at: http://www.cms.hhs.gov/.

American Association of Diabetes Educators. Online Reimbursement Guide for Diabetes Educators: Med- ical Nutrition Therapy (MNT), Module 3. October 2007. Available at: http://www.diabeteseduca- tor.org/.

American Association of Diabetes Educators. Online Reimbursement Guide for Diabetes Educa- tors: Diabetes Self-Management Training (DSMT), Module 2. October 2007. Available at: http:// www.diabeteseducator.org/.

American Diabetes Association. Part B Medicare Ben- efits for Medical Nutrition Therapy. October 2007. Available at: http://www.diabetes.org/.

Hodorowicz M. Medical Nutrition Therapy Reim- bursement Update: 2006. Top Clin Nutr 2007; 22(1):44–67.

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http://www.maryannhodorowicz.com

http://www.eatright.org

http://www.cms.hhs.gov/

http://www.diabeteseducator.org/

http://www.diabetes.org/

mailto:[email protected]

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190

19 NEGOTIATION, SELLING, AND CONTRACTS

Historically, negotiating resulted in one person as the victor and the other as the victim. Stronger individuals used negotia- tions to control the opposition. As a result, the final agreement usually heavily favored the victor. The victim accepted the agree- ment, but later often did not follow through in good faith or learned to manip- ulate to gain lost ground.

WINNING NEGOTIATIONS

In the last 25 years or so, a new era of ne- gotiation strategy has evolved in business called win-win negotiation (1). With this strategy, both parties feel they benefit from the agreement. Now everyone can become quite adept at representing themselves and their points of view, while expecting the other party to negotiate in good faith. Some compromise may be necessary by both parties. Of course, other businesspeo- ple feel compromise is not good—that both parties leave unhappy. Instead both parties should disclose what they want from the agreement and work toward mak- ing that happen. Whatever your choice, avoid being a victim when negotiating.

When negotiations stall on an unbal- anced or unfairly weighted agreement, it’s not uncommon today to hear the “victim” try to nudge the other party into a better agreement. He or she might say, “I can’t see how I will benefit from this agreement as it stands. Would you be willing to agree on. . . ?” Or, “We both need to feel that we benefit from this agreement or we shouldn’t do it. What do you need to make that happen?”

SUCCESSFUL NEGOTIATIONS

There are many good books published on the art of negotiation. In reality though, after you know a few guidelines, the only way to gain expertise is through experi- ence. One negotiation prepares you for the next one. You often learn as much by a ses- sion that went poorly as by one easily won that lacked challenge. Your confidence will grow with each one.

Negotiation should be seen as a game of minds, each vying for its needs to be met without having to give up too much in re- turn. When taken in this light, negotiation can be fun and challenging, worthy of thorough research, and time to develop the strategy. When negotiating:

■ Don’t share all of your information up front.

■ Clarify each point during your discus- sions.

■ Document each concession as each party makes it, so parties can’t renege later.

■ Determine who the other party’s leader is as soon as possible; it may not be the person speaking.

Consider the following points to avoid (2):

■ Don’t be overwhelmed by the suc- cessful position or status of the other party. You are there to negotiate for something you both want. Don’t start off by creating the wrong business relationship.

■ Don’t worry about the results. Walk- ing away should always be an option.

■ Don’t negotiate over the phone. Don’t oversell and push too hard or too far.

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CHAPTER 19 ■ Negotiation, Selling, and Contracts 191

and well financed? Does the fitness center have any intention of contracting with you after you share your nutrition proposal with them? How do you know the other party is worth your investment of time, effort, and money?

The best answer to all of the above ques- tions is to ask tactful, straightforward ques- tions of the other party. Don’t be so caught up in trying to impress them, you fail to evaluate them! Another method of qualify- ing someone is to ask for references or D&B rating. The reputation of a business or its owner can give clues to whether they are credible and honest. Call the Better Busi- ness Bureau to see if there are any com- plaints against the company.

STEP 2: WHAT ARE THE OTHER PARTY’S “NEEDS,” AND ARE THEY OVER A BARREL FOR SOME REASON?

By knowing as much as you can about what the other party “needs” from the ne- gotiation, you have a better negotiating position. Examples could be the Health Department has given them a 30-day ulti- matum to clean up the food service or that business is slow and your name and reputa- tion will draw more clients.

Use this information to your advantage, but don’t always share the fact that you know their problems. Some of the greatest challenges in negotiating are to evaluate the other party and decide how open you should be, and how much not to share.

STEP 3: ARE THERE ANY “DESIRES” THAT ARE STRONG?

In some instances, people or businesses may be more motivated by what they would like or want than what they need. They may want to be the first hospital to offer corporate wellness in the city and may disproportionately allocate funds to it; the sports team coach may want a nutritionist to work with the players, so they can win “state” this year; or a restaurateur may

■ Don’t appear too uptight, but don’t relax!

■ Don’t “lose your cool” and get angry, unless it’s needed for dramatic effect.

■ Don’t allow the other person to intim- idate or manipulate you with dramatic posturing, anger, or “drama queen” tactics.

Advantage points to remember (3):

■ Try to set up the negotiations on your own ground or somewhere neutral where you will feel comfortable. The other party’s home ground or office may be intimidating.

■ Wear your “power” outfit so you feel comfortable and in control. Overdress- ing in business attire may prove to be successful in some instances.

■ Don’t say something you will be sorry about later. Don’t quote figures and offer services until you have a chance to think about them because once spo- ken, they may be difficult to change. If you don’t know what to say, try, “I am very interested in what you’re suggesting. Let me research it and get back to you tomorrow.”

■ Be aware of your body language. Sometimes, it gives information that may be to the other party’s advantage. Nervous movements may sabotage an otherwise strong presentation.

■ If you aren’t comfortable with negoti- ating for yourself, hire a qualified lawyer or other business advisor to go with you to help carry the session or have them coach you before you go into the negotiation session.

STEPS IN NEGOTIATING

STEP 1: QUALIFY THE OTHER PARTY

Is the other party a “middle man” who can only pass along information or the one in charge? Are the businesspersons who want you to write restaurant menus truly solid

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want his or her menu to appeal to more clientele by offering nutritious menu items.

STEP 4: DETERMINE YOUR NUMBERS

What do you need and want from the negotiations? Determine your financial breakeven point and the amount of profit you will need to make the project worth your time. Develop statistics, illustrations, and logical arguments to support and de- fend your views. What can you ask for, but be willing to give up as a concession? Never ask for the minimum you will accept. Ask for more, and then expect that the final agreement will probably be somewhere in between.

STEP 5: DO YOU HAVE A “SEARS PLAN” READY?

Jean Yancey, a former small business advi- sor in Denver, Colorado, encouraged peo- ple to offer the “Sears Plan” (good, better, and best alternatives). If the other party doesn’t like one alternative you offer, have another ready to go. The best offer would be the most comprehensive and costly. The better offer is a good compromise. The good offer will at least get your foot in the door or provide an option in case negotiations stall. Offer fewer services at each level so your expenses are less.

STEP 6: DETERMINE WHAT OTHER ITEMS BESIDES MONEY YOU WILL ASK FOR IN THE AGREEMENT

What interim payments and reports will you want? Ask for regular monthly pay- ments or for some projects, one third up front, a third at midpoint, and the final payment upon completion. What about royalties for as long as your materials are used? What about editorial or revision rights when programs become dated? Are travel, office, mail, and phone expenses included? What staffing or support services will you expect? What marketing support will you request?

SELLING

A sale takes place when a client or pa- tient agrees to pay for a service or product. To survive in business, sales must happen. Of course, everyone wants to offer prod- ucts that are in such demand they “sell themselves,” but that is a rarity. People don’t like to be sold, but they love to buy (4).

Dietitians can increase their sales by im- proving their presentation skills and by taking better advantage of sales opportuni- ties. Constantly be aware of instances where your nutrition services can be ap- propriately sold.

GETTING YOUR FOOT IN THE DOOR

Often before you can sell a physician or corporate leader on your services, you must first get past their secretaries. In a corpora- tion, go as high as you can to give your sales presentation. You want to reach the decision maker(s), but you may have to start several levels below.

Some tricks of the trade shared by Barry Wishner, RD, are to make the client feel that he or she is special, part of an exclu- sive club. Say, “I have heard that your obstetrics practice is one of the most pro- gressive, patient education-oriented prac- tices in the area. I have a nutrition service that OB patients love, which will generate increased revenue for your practice. Can I have 5 minutes of Dr. Johnson’s time to ex- plain it to her?” It also works to appeal to their human nature by saying something similar to, “I had a baby 5 years ago. I am a dietitian, but I know how difficult it is to keep your weight gain under control. Do you offer a nutrition group class to your patients? I have my brochure and sample patient education booklet, could I have 5 minutes of Dr. Johnson’s time to explain my program?”

Sometimes it works to stop by a physi- cian’s office, and ask to schedule an appointment that day to talk to the physi- cian. If he or she is unavailable, then ask to

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CHAPTER 19 ■ Negotiation, Selling, and Contracts 193

specify direct benefits, or warn of dan- ger. For example, “From your year- end report, I saw that your company spends more than $5500 per em- ployee on health insurance. We have a wellness program that reduced med- ical expenses at the Reider Company by 20% last year.”

2. Investigative Phase. This phase is one of the most important in the modern-day sales process. Get the buyer to define his or her other needs, wants, and expectations. Do this by asking open-ended questions and by listening to the answers. The information obtained in this ex- change will help you personalize your presentation and perhaps think of new products to sell. For example, “Have you ever tried any employee nutrition education seminars?” Or, “What are your company’s three worst employee health problems in your opinion?”

3. Presentation Phase. During this phase, carefully choose facts for their effect on your client. Show how his or her needs will be met by what you have to offer. Buyers base their deci- sions on fact and emotion. Garner emotional support for you and your services. If you see that the buyer is drifting or does not appear to under- stand, go back to the investigative phase and refocus attention by ask- ing more questions. You need to be flexible. The outcome of this phase should be a natural progression to the close.

4. Closing. This is the time to bring the presentation to a close, either by ask- ing for a sale or other commitment. One way to accomplish this is by sum- marizing the client’s needs and identi- fying solutions you have to offer. Ask when you can begin, how you can provide more assistance, or when you can provide more information. Your purposes may have been to introduce yourself and explain your services.

talk with the head nurse. If the nurse will talk to you and your message sounds inter- esting, you may be scooted into the physi- cian’s office in between the next two patients.

Try using someone as a referral to get to see the top person. Once you have estab- lished good rapport with a businessperson or physician, it is not out of place to ask if he or she knows of other CEOs, wellness di- rectors, or physicians who might be inter- ested in your program. Ask if you could use his or her name as a referral.

A-B-C ACCOUNTS

In any business, no matter what you sell, there will be some people who use your services or buy your products more often than others (“A” accounts). Sales experts agree that most of your time and resources should be spent maintaining and keeping your “A” accounts happy. “B” accounts use your services on an irregular basis, but given good service or added attention, some might become “A” accounts. “C” ac- counts rarely, if ever, use your services. They might be contacted yearly in a mass mailing.

All three accounts could be in the same medical practice or may be very cordial to you at local Chamber of Commerce meet- ings. Some will be major clients and some won’t. The important lesson to learn is that you spend your time and resources where they are most effective. Take the time to identify who supports you. Keep your “A” accounts happy!

THE SALES PRESENTATION

The sales presentation includes the follow- ing four major components, each with a specific purpose (3):

1. Introduction. The purpose of the introduction is to establish with the prospective client how you are differ- ent from all the others waiting to sell a similar product. You do this by mak- ing statements that focus attention,

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Several ideas for closings might be: “If we have an agreement next week, how soon can I get started?” Or, “What more can I give you to help you make your decision?” Or, “Is there any reason why you wouldn’t want to offer a weight loss program to your employees, given all the possible benefits?” Or, “Can I count on your commitment to this program for the coming year?”

Even if the client is not interested in your services at this time, leave the session as friends and on a positive note. If the client isn’t ready to give an answer, ask when you can call for his or her answer. Don’t give up. After the sales call, drop a note into the mail thanking the prospect for his or her time.

PROPOSALS

A proposal is a comprehensive marketing tool used to present the selling points of an idea. One could be used to interest a corpo- ration in using you to create its nutrition wellness program, to interest a clinic direc- tor in providing an obesity seminar, or to interest a financial backer in a new product or business venture.

Proposals can range from a simple one- page typewritten information sheet to a typeset, bound presentation containing a volume of pages, along with a PowerPoint show and taste session. The scope of the proposal is determined by what is ex- pected, what is used by the competition, and what will be impressive enough to make the sell. The experienced practi- tioner is not the only one to use a pro- posal. The novice may find it to be the very marketing boost to build his or her business more quickly.

Proposals should only be long enough to interest the client and make the sell. Care should be exercised so that explanations of projects are not so detailed that clients can carry them out themselves without you.

Proposals usually represent many hours or days of research of the market and the client so the proposed item is “positioned” correctly to fit the client’s needs. A proposal may include all or part of the following:

■ An introduction or explanation of the scope of the proposal

■ An overview of the market and its potential

■ A short analysis of the competition ■ Background information about the

client and his or her needs ■ Your answer in fulfilling the client’s

needs ■ Why you are best for the job (include

resume and references) ■ Estimates of costs and potential

income ■ Any final selling points

A proposal should build in excitement and interest, as it leads to the answers you have to offer. Which points you use and their order are at your discretion. You want clients to feel that they can’t live without you and what you have to offer.

Whenever possible, the proposal should be made in person to the entire staff of decision-makers. Questions and any con- fusion can be handled immediately. An experienced negotiator may choose to pa- raphrase the proposal and offer a shorter written copy.

However, instances may arise when a proposal must be mailed or left at an office. When you are not there to give the intro- duction and to promote the concept with tact and enthusiasm, a letter of introduc- tion and a written document must do it for you. A phone call should be timed to coin- cide with the day the person receives the document. If the contact person must sell the concept to others, when preparing the proposal, enlist his or her help. Ask what selling points, statistics, or other informa- tion he or she feels will be needed to im- press the others. The answers you receive may give you great insight into the client company and its real interests.

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CHAPTER 19 ■ Negotiation, Selling, and Contracts 195

ASSERTIVENESS IN BUSINESS GROWS IN TIME

As Herb Cohen states in his book, Negotiate This!, we actually negotiate several times per day, every day of our lives (3). Whether we need a refund on poor service, a package delivered on time, or the secretary to an- swer the phone more pleasantly, we are try- ing to have our wishes met. We sometimes have to become more assertive to do it.

To be more effective in your work and to negotiate better contracts and consultant fees, it helps to know when and how to stand your ground. For persons who are not used to being assertive, finding a happy medium between being passive and being overbearing or stubborn is a necessity. Fi- nesse will develop in time.

AGREEMENTS

Agreements, or exchanges of promises be- tween two parties, can take several forms. The more common are a verbal agreement, a bid, letter of agreement, or contract. Some forms do not offer the business novice much protection, in case the other party does not perform as expected. Con- tracts are more detailed but are sometimes too complex and expensive. The best agree- ments are between two reputable people who have adequately discussed their expec- tations with the other person.

VERBAL OR GENTLEMAN’S AGREEMENTS

Verbal or gentleman’s agreements for fees and services are usually considered legally binding in most states and are very com- mon. Professional consultants and advisors often quote their fees for certain services and we agree to them verbally. We may agree to consult at a physician’s office or a health club on a handshake. Verbal agreements are fine when you know the other party, and both of you know what is expected and per- form accordingly. In cases where there are misunderstandings or one person does not

There is always some fear of risk in giv- ing a potential client the opportunity to see a truly unique, clever idea, such as an in- vention or new business concept. A pro- posal should never be detailed on how you will do your job; in most proposals, you are selling the client on using you, your cre- ativity, and expertise. It’s fairly standard to ask before the proposal is offered that the ideas be considered privileged information or to have “confidential” stamped on the proposal. As an added safeguard, if you are very worried about controlling the concept, it is acceptable to bring another person with you as an associate (and witness). Finally, you can ask that the client sign a Nondisclosure Agreement (see Chapter 13). However, some people will take offense to being asked, or will refuse to do so on legal grounds (they may have already had plans to pursue the idea). For example, you may be one of several people presenting a pro- posal on being a nutritionist for a new food company.

If an agreement is never reached, but your unique idea is used by the client, you could sue if your case is strong enough (a witness or written agreement may be necessary to do so). You will have to be able to prove the unique idea was owned by you through copyrights, trademarks, or patents.

A proposal provides a perfect opportu- nity again to offer the “Sears Plan” to a client: the “good, better, and best” ap- proach. Anticipate that the client may be hesitant to buy the most comprehensive plan you have to offer. Be ready to promote the contingency plan of lesser cost, in case the first one doesn’t sell. A third “at least you got your foot in the door” plan could be either offered initially, or you could wait and use it if all else fails.

Presenting a proposal may lead to other new ideas or ventures between you and the client; or, it may only help your client decide what he or she doesn’t want to do. Whatever the extent of the agreement to work together, it should be outlined, signed, and all parties should have a copy.

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produce as expected, a verbal agreement can prove to be inadequate protection.

COMMON QUESTION

Q: I am negotiating with a physician to offer nutrition consultation in his or her office. I am willing to work hard, take a financial risk, and build the program. But what guarantees do I have that as soon as I have become successful financially, I won’t be replaced? How can I pro- tect myself before I make the investment? A: If the physician is a fair and honest per- son, there are ways to avoid problems. If he or she is not, the situation probably will be out of your control. First, realize that it is only a good deal if you both feel you have been fairly compensated for what you have each contributed. So get out in the open what each of you is offering the other. You may be offering time, effort, and some money, and the physician is offering client referrals, facilities, and some money. Later on as you become successful, the possibility of being replaced is reduced if the follow- ing have taken place:

■ You have a working relationship with the physician and the staff and you are considered an asset.

■ You are closely identified with the nu- trition program and, if you go, so will the program and client load.

■ Each of you feels fairly compensated. Also, incentives should be built in so that extra work or effort on your part is rewarded.

■ You developed the teaching materials on your own time and copyrighted them. Your programs can only be used as long as you are a consultant there.

■ Finally, before beginning, you and the physician should put your agreement in writing. At this time, try to add a simple partnership buy-out agreement in case the physician wants the pro- gram but wants to replace you.

You may be surprised; it may be the physi- cian who fears you leaving more than the other way around.

BIDS

A bid, or cost estimate for a job, is legal. It can be a good agreement if it’s specific as to expected output and date of completion, and both parties agree to any changes in writing. The most common shortcoming of bids is too little shared information. To help remedy this, bids may be accom- panied by an explanation or sample of a sim- ilar finished product or a proposal (Fig. 19.1).

LETTER OF AGREEMENT

A letter of agreement is also legally binding but less formal and complicated than a contract. For many people, a letter is also less intimidating. To be good, this form of agreement must be comprehensive and may include the following information:

■ What the agreement is for (i.e., serv- ices, product, etc.)?

■ Who is providing it? ■ When? ■ Where? ■ For how much? ■ How often? ■ Who is paying for it, on what sched-

ule, or by what process, (i.e., billing by invoice, or automatic monthly pay- ment, etc.)?

■ Any additional provisions? ■ Terms of the agreement? ■ Termination clause by either party?

A letter of agreement may be written in the form of a short exchange of promises (Fig. 19.2). It may be in the form of a business or personal letter that outlines what the agreement is as the writer understands it. It’s suggested that both parties sign the agreement. However, courts of law will often stand behind a letter that was sent by certified mail (return receipt requested) when no rebuttal was made, and the work was allowed to progress as if the agreement was accepted.

It’s highly suggested that you consult with your lawyer concerning the provi- sions you should include in your letters of

196 THE ENTREPRENEURIAL NUTRITIONIST

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CHAPTER 19 ■ Negotiation, Selling, and Contracts 197

A contract may have any number of pro- visions and limitations. Don’t be hood- winked when someone tells you, “You can look it over if you want. It’s just a standard contract.” Take the time to read every word and ask questions about clauses you don’t understand.

Parties to a contract exchange promises. These may be expressed (i.e., communi- cated explicitly and clearly, either in ver- bal or written form) or implied (i.e., deduced from actions or behavior) (5).

agreement to cover your particular busi- ness. After you’re more familiar with this type of agreement, you will seldom need legal input, except in cases of higher risk.

CONTRACTS

Contracts are used when the risk is greater, the money higher, and when more control is needed. Legal input is highly recom- mended for the development or review of all contracts before one is signed.

SMITH & JONES NUTRITION SERVICES, INC 2530 Ridgeway, Tucson, AZ 85728

BID

For development of a diet manual for EARTH GROWN FOODS on lacto-ovo vegetarian diets for the following limitations:

Low Calorie Low Cholesterol Diabetic Low Salt

The manual will include sample menus, nutrient charts, references for recipes, fresh produce lists, and a brand- name food guide. The finished manual will contain approximately 100 pages.

Completion date: One month from the acceptance of this bid.

Project cost: $10,000

Accepted by:

__________________________ _________________ Earth Grown Foods Date

FIGURE 19.1 ■ Sample bid.

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198 THE ENTREPRENEURIAL NUTRITIONIST

THE WOMAN'S HOSPITAL 7600 Jones Street Atlanta, GA 30303

January 19, 2010

Ms. Stephanie White, R.D. Nutrition Consultant Services of Atlanta, Inc. 7800 Fannin, Suite 203 Atlanta, GA 30310

Dear Stephanie:

This letter is to confirm our telephone conversation of January 18, 2010.

As agreed in our conversation, your firm will provide its services to this hospital according to the following provisions:

1. The hospital agrees to pay $95 per outpatient consultation to Nutrition Consultant Services of Atlanta, Inc. No other benefits or privileges are offered or implied.

2. This agreement shall be for six (6) months and automatically renewable at the end of each six month period.

3. Appointments will be coordinated by the Food Service Department and Nursing Service. Initially, a nutrition consultant will be available Tuesday, Wednesday and Thursday from 9 am to 5 pm. Lunch break will be from 11:15-12:00 noon.

4. A patient interview sheet will be sent to each referring physician and a copy put into each patient’s chart by the nutritionist of Nutrition Consultant Services of Atlanta, Inc.

5. A super bill will be given by the nutritionist to each patient to file with his or her insurance company, and full payment will be expected at the time of the visit at the clinic cashier’s desk.

6. This agreement may be terminated by either party, with thirty (30) days written notice.

Thank you for your assistance. If you have any questions concerning the agreement, please do not hesitate to contact my office.

Sincerely,

Cary D. Henry Administrator

FIGURE 19.2 ■ Sample letter of agreement.

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CHAPTER 19 ■ Negotiation, Selling, and Contracts 199

terials. Tell your lawyer to make the contract:

■ Practical ■ Easy to understand ■ Complete to protect your reasonable

interests

Unless cautioned otherwise, some lawyers produce very expensive documents that are so detailed and overwhelming that no one will sign them.

SUMMARY

Underlying this discussion on negotiating and agreements should be the awareness that the outcomes work best when both parties are honest, open, and work in good faith. No written document can make peo- ple work together well if the relationship is poor. When the quality of output becomes poor, no one is happy with the results. So, work to maintain good relationships. Learning how to “read” the other party and keeping control of your advantage points becomes easier with experience and trial and error.

REFERENCES 1. Warschaw TA. Winning By Negotiation. New

York: McGraw-Hill, 1980. 2. Negotiating Tricks. Report No. 200, 1978 by

Chase Revel, Inc. 3. Cohen H. Negotiate This! By Caring, But Not T-H-

A-T Much! New York: Warner Books, 2003. 4. Gitomer J. Jeffrey Gitomer’s Little Platinum Book of

Cha-Ching! Upper Saddle River, NJ: FT Press, 2007.

5. Sobel M. The 12-Hour MBA Program. New Jersey: Prentice Hall, 1993.

6. Wiesner DA, Glaskowsky NA. Theory and Problems of Business Law. New York: McGraw-Hill, 1985.

Proper contracts involve the following ethical conditions (6):

1. One party makes an offer, which is accepted by the other party.

2. Each party must offer the other con- sideration (i.e., something of value) in return for what it is to receive from the other party.

3. Both parties must act of their own free will, free of duress, and undue influence.

4. The agreement cannot include fraud- ulent claims or representations or vi- olate the law.

5. Certain types of contracts must be in written form (e.g., real estate).

One item of great concern to consultants, employees, and subcontractors is the non- compete clause in a contract. If one is used, it must be reasonable. Most noncompete clauses state clients provided by the con- tractor or employer are not to be taken or approached for a period of time after the consultant or employee leaves. Some add that “no directly competing business can be started by the consultant within a cer- tain radius of the business for a period of time.” Recently, courts of law have said that special training or proprietary infor- mation must be taught to the employee or consultant by an employer in order for a noncompete clause to be used. Check with a lawyer in your state before signing an agreement with a noncompete clause.

Generating a contract can be expensive and time-consuming. Your legal bill will be less if you know what you want. Write a bulleted list of what you have agreed to do, what the client wants, and any special provisions, such as who will pay for what up-front or who has final edit on the ma-

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20 OFFICE POLICY AND DEALING WITH CLIENTS

There are other factors besides your knowledge and nutrition information given to clients that influence their opin- ion of your services. Clients usually expect their association with you and your office to be courteous, organized, efficient, rea- sonable in cost, and timely. Actually, our clients’ expectations are no different from our own.

CREATING AN EFFECTIVE OPERATION

Competition is growing for the con- sumer’s dollar, and a business owner can’t afford to turn clients off with inadequate service. Personalized care of clients should begin when they first call to ask about your services or schedule an appointment. Attempts should be made to also impress clients with the nondietetic functions of your operation.

Establish office hours and days and try to follow your schedule as closely as possi- ble to help develop an image of stability and continuity. As long as clients can leave a message for you, it is not necessary to be available in the office, in person, 5 days a week. In the beginning, try to condense your patient instructions and interviews with other clients to only a few days per week. The remaining days can then be used to hold down another job while you start your business, or give you time to market your business, write, or whatever.

Telephone coverage for your business is extremely important. The telephone is your clients’ major link with you. During normal business hours, Monday through Friday, clients should be able to either

reach you by phone or leave a message with a secretary, answering service, or voice mail machine. If you can’t answer the phone yourself and you don’t want to give out your cell phone number, be sure to take the time to instruct the secretary or answer- ing service on what to say and what infor- mation to ask for. Check your messages regularly and have someone call to check for you when you are out of town. Mes- sages on telephone answering recorders should be well prepared—keep trying until you record a message that people will not only listen to, but also respond to. A higher level of service is perceived when calls are returned promptly.

Some hints that may be important to you, concerning your telephone answering service include the following:

1. Don’t allow your services and fees to be given over the phone by someone, unless the person is trained to prop- erly “market” your business. Have them say, “I will be happy to take your name and number and have Ms. Buckmaster, the nutritionist, call you back.”

2. Caution your answering service or sec- retary about giving out your private home phone number and address.

3. When you are out of town, instruct your answering service to tell people that “Ms. Buckmaster will be in the office to return your call on Monday, July 10; can she call you back at that time, or is this an emergency?” If you have another dietitian who knows your practice, you might have the an- swering service say, “Mary Jones, RD, is covering all calls and I can have her

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CHAPTER 20 ■ Office Policy and Dealing with Clients 201

CHARTS

The chart system for your office can be as expensive as a computer system or the color-coded system, or as simple as a manila folder for each patient. Because of the im- portance of documentation of a patient’s progress, it is best to have the patient’s nu- trition chart available for all visits. The patient’s medical chart is usually only avail- able when you work in a medical office.

The information to include in the pa- tient’s chart is name, address, work and home phone numbers, their physician’s name, the referring physician’s name (if different), and a copy of the diet prescrip- tion, if available, pertinent laboratory val- ues, a diet evaluation, action plan, and goals. The follow-up sessions should have any changes in laboratory values and other objective measurements listed, as well as more subjective comments, both pro and con. After the initial instruction and when something significant happens to a patient, the referring physician should be notified and the contact documented.

PRODUCTS FOR SALE

Publications for your clients to read en- hance the service and contribute to the positive positioning and image of your practice. Any booklets, programs, etc., that you write should definitely have the copy- right notice added to them. Include the cost of handouts and diets in the fee for the instruction. Many nutrition therapists keep a supply of books, booklets, and other edu- cational items they know patients want to buy. In most states, sales tax must be col- lected, and a sales tax, or even vendor’s li- cense, may be necessary.

If you sell food supplements, food prod- ucts, or herbs, make sure you check expira- tion dates and rotate your inventory when new products come in. If you recommend supplements to clients, make sure they know that they can buy them from other sources and that you do make a profit on the products.

call you if you wish.” If it is an emer- gency, have the number of the cover- ing dietitian or the local hospital clinical nutrition department. In case you need to be reached, leave a num- ber where your secretary/answer- ing service can reach you or leave a message.

SCHEDULING

When you schedule appointments with new patients, use that time to “market” your services. Ask questions about the pa- tient and his or her nutritional needs, per- tinent laboratory values, and referring physician’s name. Request that the patient bring a copy of the most recent laboratory results and, if available, the physician’s written referral for the appointment. Ex- plain what the patient will receive in the way of individualized care and informa- tion. State approximately how long the appointment will take and how much it will cost. Make sure that the patient knows the directions to your office, the suite number, where to park (if it’s a prob- lem), and the date and time of the ap- pointment. Request that the patient give 24-hour notice if the appointment has to be changed or cancelled.

OFFICE SETTING

The office setting should be quiet, comfort- able, and professional. The office furnish- ings usually are not as important as the atmosphere, hospitality, and service pro- vided. However, because of the image they want to portray and their clients’ expecta- tions, some private practitioners spend extra for more affluent looking office space and interiors. Alanna Dittoe, RD, a private practitioner in San Francisco, reports that in a survey of her office patients, the ma- jority mentioned the office coffee as the best amenity. Offering tea, coffee, water, or a snack in an office setting can be “that lit- tle extra” that make patients feel more at home.

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DIETS AND DIET MANUALS

When preparing printed diets, the typeface should be easy to read, not script, as some people with poor eyesight also have trou- ble reading single-spaced 10-point font.

Information overload is a common prob- lem. Avoid giving clients too many publica- tions. Start with one or two at the initial visit and assess what each person needs or wants. Patients and their families can only absorb a small amount of information on a new subject at any one time. Save the less specific material and the larger number of booklets for the few clients who want them.

Many practitioners report their patients are impressed when they use folders to hold take-home materials. The folder usu- ally has pockets on the inside to hold the diet and any booklets. On the outside of the folder, print the company name or logo for easy identification of the contents and for advertising purposes or attach a busi- ness card to the folder to provide your ad- dress and phone number.

Diet manuals are readily available to all practitioners today, including American Di- etetic Association’s (ADA) and many states’ manuals. In writing your own diets, you may choose good ideas from several manu- als and from your experience. If you are unaware of your local medical community’s nutritional biases, try to purchase diet man- uals from the local hospitals, or make an appointment with a hospital dietitian to discuss them. Pages should not be photo- copied directly from a manual, unless it was designed for that purpose or you request permission from the copyright owner.

In private practice, it is not necessary to have a large variety of different diets, such as in the hospital. Practitioners report that the most common nutrition therapies are the following: weight loss, diabetic, gluten free, hypoglycemic, low salt, low cholesterol, hyperlipidemia diets, allergy, high potas- sium, normal pregnancy, eating disorders, and good nutrition for the healthy individ- ual. Specialties in your medical community may dictate that other diets be developed.

DISTINCTIVE SERVICE

Private practitioners and outpatient coun- selors know their consultative sessions and handout materials need to be different and better than those provided by free hospital clinics or by physicians’ nurses or secre- taries. Practitioners must create this differ- ence, or patients and clients will balk at paying the fee. The key words are “quality,” “individualized,” and “personalized.”

Many dietitians, though not all, think that it is important to use different termi- nology, such as the following, in private practice from that used in acute care set- tings: “diet” could be “nutritional care plan” or “food plan,” and “diet order” could be “nutrition prescription.” Some practitioners call the people they instruct “clients” instead of patients, especially in more wellness-oriented settings. Always re- member, differentiate patients from their ill- ness. In other words, a person is not a diabetic or a hypertensive but, instead, a person with diabetes or hypertension.

Whether a consultant wears a white jacket or a laboratory coat is a personal choice. Some patients appear to feel intim- idated by the authority signified by the white, while others expect the white jacket or laboratory coat, which shows that you are the nutrition authority.

COLLECTING FEES AND ENDING A SESSION

The end of the interview is a good time to talk about rescheduling a visit, or to discuss why it is not necessary. This is a good “end- ing” subject and lets the client know the visit is over. As you are winding up, be sure to incorporate some system to collect the fee. You may simply state, “I will make out your receipt now—how do you want to pay for your instruction?” or “The fee for the initial visit is $____ and revisits are $____. I will give you an itemized receipt that you can attach to your insurance company’s form, along with a copy of the referral slip

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CHAPTER 20 ■ Office Policy and Dealing with Clients 203

use for your business. Take copies of your brochure and advertisements. Listen to what the person suggests as solutions and try them out since you have nothing to lose. Don’t get discouraged! We all have things to learn.

One dietitian who had this same prob- lem had to work on lowering her voice be- cause she sounded like she was 12 years old over the phone, instead of 29. An ad- visor told a short, young-looking woman to buy suits, instead of wearing such fem- inine dresses in pastel colors that lacked any “power.” Similarly, a male dietitian who consulted to major hospitals and cor- porations for very big fees found that he was most successful in landing the accounts when he dressed in expensive suits and shoes like the successful corpo- rate president he was (virtual corpora- tion—one person with temporary help as needed).

One experienced clinical dietitian opened her business charging the same higher fees as a practitioner who had been in business in the area for many years and was very well established. It took a while for the new di- etitian’s business to grow because there was price resistance, since she was new and un- known in the community. Does this mean every dietitian should start with low prices as a marketing strategy? Of course not! It just means it takes time for a business to be- come established. If the level of service matches the price asked, and the target mar- ket needs the service or product and can af- ford it, the business will grow.

Once you try a few new ideas and they seem to be working, go back to see the physicians who have not been referring to you and start building a rapport with them and their office staff. Use some of the ideas mentioned in Chapter 21 on Promotion. Good luck!

Q: My patients aren’t returning after the first visit. What might be wrong? What can I do? A: There are many reasons why patients don’t return. Some reasons are in your control; others are not. The reason

from your doctor. Depending on your pol- icy, you can submit these materials to get reimbursed for our visit.” If you have a sec- retary or receptionist, be sure to train him or her on how to collect fees as well.

If a patient continues to linger after the closing of the session and you have other commitments, you can either relax and take a minute longer, or you can try stand- ing up and walking slowly toward the door to show him or her out, and simply state, “I want to thank you very much for coming. I am sorry to rush, but I have another pa- tient waiting.”

COMMON QUESTIONS

Q: I can’t get physicians to refer patients to me, and the patients who call me from my brochure and newspaper advertisement don’t show up. What can I do? A: Your services could be so new that physi- cians and prospective patients haven’t learned how to use them yet (even when you try to tell them). Or, there could be some more painful answers like you haven’t and don’t know how to establish your cred- ibility (check Chapter 6), your appearance or personality may not meet the expecta- tions of your target markets, or you could be saying the wrong things or the right things in the wrong way.

Before you change too many things on your own, I would talk to a business consult- ant, mentor, or coach. In the long term, this could save you a lot of time and money. You can usually find a person like this in the Yel- low Pages, through contacts in professional or business groups, or the Service Corps of Retired Executives (SCORE) through the Small Business Administration (SBA). Talk to the person over the phone and if you like him or her, get an appointment.

In preparation for the appointment, write down what you say to prospective pa- tients over the phone and to physicians when you interview with them. Go over your marketing strategies like the prices, promotion, products, and location(s) you

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physicians overbook and some dentists and psychiatrists charge for no-shows is because a certain number of patients will not keep appointments. This point known, there are still professionals who do not have a problem with no-shows, and there are times when each of us expe- riences it more frequently.

After allowing for bad weather, business advisors will tell you that it is significant whether patients don’t show at all or they call to reschedule. Not calling or showing up is more symptomatic of a problem. Some of the more obvious reasons patients do not return are the following:

■ They feel no commitment to the care plan because you did not involve them enough in developing it, or it did not fit their true lifestyle.

■ It was not their choice to make the ap- pointment, and they only gave lip service while there.

■ The patients did not understand the importance of follow-up and how it would improve their chances for suc- cessful behavior change.

■ They followed your suggested guide- lines and did not get results—or they got results without following it.

■ You did not impress them with the consultation, your manner, or some- thing about the office visit. (Some pa- tients will not take advice from traditional-thinking, young, or inex- perienced counselors.)

■ The fee was too high for what they felt they received, or for their present income.

■ The consultation style and approach may have been too threatening, em- barrassing, or too familiar to suit the patient. (We do not always hit it off with every patient.)

■ The instruction materials or consulta- tion may have been too confusing or too elementary, even insulting for adults.

■ The patient may believe his or her present habits fit his or her needs bet-

ter, and he is not willing to change. Maybe the suggestions weren’t reason- able—or maybe they were, but not at this time.

The following are areas you may want to evaluate and improve if you deem them a problem:

■ Are you marketing and describing your services well over the phone when the patient calls for an appoint- ment? Fees should be mentioned up front, along with what you have to offer and what commitment you ex- pect from the patient. The patient should feel he knows what to expect.

■ Do you impress upon your patients the importance of follow-up visits?

■ Is the patient’s visit a pleasant one? Is he greeted and given good, timely service?

■ Are you up-to-date and knowledgeable in nutrition and counseling? Can you offer various solutions, and are you flexible enough to make changes when they are needed?

■ Are your counseling sessions organ- ized and professionally handled?

■ Do you have the appearance of a cred- ible, competent, stable professional? Can you change your appearance to look more like what is “expected” by your clientele?

■ Are your fees too high or low for what you offer or for your local commu- nity? Could you offer more in the way of services or package them better?

Two of the best ways to take the mystery out of this process are by sending a note to remind patients a week in advance, and by calling all patients a day ahead to re- mind them of the appointment and to ask how they are doing. Calling a patient can serve several purposes: the patient may feel more at ease about stating a problem, he or she may decide to make a greater commitment because of your apparent in- terest, or he or she may cancel future ap- pointments on the spot.

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CHAPTER 20 ■ Office Policy and Dealing with Clients 205

business on the phone or just to take mes- sages. Office policies need to be determined and procedures established to carry out the daily routines. A poor employee can harm your business, so do not hesitate to termi- nate someone who does not work out.

Although there is added expense in hav- ing an employee who can perform such duties as typing, mailing, screening, con- firming patient appointments, scheduling new patients, collecting fees, and greeting clients, they can be as valuable as your right arm.

Several private practitioners have hired registered dietetic technicians (DTRs) in their offices to cover the secretarial duties, as well as to conduct initial interviews with patients and fill out the needed medical, laboratory, and nutritional data. They are very happy with the DTRs and highly rec- ommend that other dietitians consider hir- ing them too. It may take time to find the right person(s), but it is worth it, if in the future, you generate more income and have a better-functioning business.

SUMMARY

Other than having a good background in clinical nutrition and excellent counseling skills, it’s just as important that a consult- ant have good management and business skills to succeed. A practitioner should strive to produce distinctive service and es- tablish relationships with clients, patients, the public, and professional peers.

EMPLOYEE CONSIDERATIONS

If you decide to budget an office employee into your business, there are several consid- erations to think about:

1. Administrative assistant is the term used for secretary in most business settings.

2. How will the person spend his or her day? Write a job description.

3. In the beginning, can he or she work mornings or a short week to help keep overhead lower?

4. Decide how much you can afford to pay. It may be worth paying a little more to keep someone who speaks well on the phone, and is courteous and efficient in the office.

5. Decide what skills are most important for running of your office before you start to interview applicants.

6. Talk to your financial advisor about what “perks,” if any, you can offer as present or future incentives to your employee(s).

7. Discuss with your accountant or CPA the difference in costs to you for an employee versus leased or temporary labor (payroll taxes, social security, worker’s compensation, added paper work, pension plan, etc.).

To assure the person represents you well, take adequate time of your own to train the new assistant. You should decide whether to teach him or her how to market your

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WORDS OF WISDOM

Every job is a self-portrait of the person who did it. Autograph your work with excellence.

Author Unknown

Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction

and skillful execution; it represents the wise choice of many alternatives.

Willa A. Foster

207

TAKING YOUR IDEAS TO MARKET

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A commitment to promotion, a compo- nent of marketing, is essential in any business, small or large. Lack of sufficient promotion is one reason so many busi- nesses stagnate or fail to attract customers. When economic times get tough, advertis- ing is one of the first budget items cut, which often makes sales even worse—it can be the wrong thing to do!

MARKETING A SERVICE: COUNSELING OR MANAGEMENT

Marketing is concerned with getting and keeping customers. Product intangibility has its greatest effect on the process of try- ing to get customers. How do you propose to sell something, like nutrition counseling or management consulting, that a cus- tomer can’t hold in his hand, feel, or see?

Intangible services can seldom be tried out in advance. Prospective buyers are gen- erally forced to depend on surrogates to as- sess what they probably will get. They can look at before and after pictures of weight loss patients. They can talk to current users of your services. They can see and hold your elegant calling card, brochure, or busi- ness proposal in its attractive binder. Ser- vice marketing expert, Harry Beckwith, states that there are four keys to successful service marketing (1):

1. Price: The more it costs (to a point), the better it seems. If customers come to you because you offer the lowest price, they will leave when someone else’s price is better. If that’s all they care about, work to offer more. Make the perceived value much higher than the cost.

2. Brand: It creates a powerful barrier to entry for aspiring competitors. When people think of nutrition, you want them to think of you. Choose a memorable business name—not ini- tials, not frivolous, not common- place. To entice memory, the name should be unique, short, sensory, cre- ative, and outstanding. Your personal name may be good. Spend time and money to have your logo and name in front of potential customers, but back it up with good service.

3. Packaging: When you are timid about investing in your brochure, of- fice, business cards, presentations, and so on, you’re saying you lack confi- dence and passion for your enterprise. Usually, timid marketing doesn’t work.

4. Relationships: Business is personal, especially in a service where you are sitting across from a person. Show clients you are interested in them; offer them a beverage and remember what they chose; remember impor- tant details about them (write notes), and ask how they want something done. Don’t work with “toxic” clients and employees—get rid of them. They will drain you and will run off other productive client relationships. The eight keys to lasting relationships are: (1) ■ Natural affinity. Work with peo-

ple you like and who like you. ■ Trust. ■ Speed. Answer the needs of your

customers in this computer age with next-day shipping, same-day email, or phone response; people now expect things to be done fast.

209

PROMOTING YOUR VENTURE

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210 THE ENTREPRENEURIAL NUTRITIONIST

Public relations (PR) is primarily a com- munications tool, whereas marketing also includes needs assessment, product devel- opment, pricing, and distribution. PR seeks to influence attitudes, whereas marketing tries to elicit specific behaviors, such as buying, joining, etc. PR defines the image of an organization, whereas marketing de- fines the organization’s goals, business mis- sion, customers, services, and so on (2).

Selling products or services, or solicit- ing funds should take place after public relations and marketing campaigns have opened the doors, creating a favorable cli- mate for success (2). Effective public rela- tions does not necessarily require costly expenditures. It does require a clear under- standing of an organization’s image, prod- ucts, and marketplace.

Elements of successful PR and marketing campaigns include the following (2):

■ Planned, not left to chance ■ Continuous, not single shot ■ Proactive, not just reactive, to events

and problems ■ Clearly focused with well-defined goals,

timetables, and specific assignments ■ Well-managed, evaluated, and revised

regularly

PROMOTION

Promotion is the communication you use to help others become familiar with you, and your services or products. Promotion has become more important to dietitians than ever before because of the changes in the marketplace.

First, consumers are now shopping around to find the best nutrition services and products for their money. Second, there is confusion today in the public’s mind about who to believe in the nutrition field. Finally, dietitians aren’t the only le- gitimate players in the nutrition arena. We may have had ownership in the past in some market areas through default, but today that is no longer the case. Nutrition is in demand by the consumer; it’s there- fore a competitive area of business (3).

■ Apparent expertise. Look like you are well respected in your pro- fession (mount certificates on the wall), look successful, and keep current with the newest research.

■ Sacrifice. Bend over backward to please the customer by meeting an earlier deadline, or calling to find out the answer to a client’s ques- tion on a food product.

■ Completeness. If you want to be known as an expert in nutrition, don’t know about only one disease; if you design kitchens, you must know about equipment, ventilation systems, and building codes. Be complete!

■ Magic words. Know the magic words of relationships—the client’s name, “Thanks,” “How are you doing?” and “Welcome.”

■ Passion. Passion will attract peo- ple to you and make them want to return. If you love what you do, it will show. Passion is worth billions!

It is easy to understand why banks build large, sturdy buildings, and hire articulate consultants in business suits. Also, why proposals are in “executive” typeset and leather bindings, and why architects labo- riously draw renderings of buildings. It ex- plains why insurance companies offer “a piece of the rock,” put you under a “blanket of protection,” or in “good hands.”

ROLE OF PUBLIC RELATIONS IN MARKETING

Public relations programs are designed to create a positive climate in which a com- pany or group can do business, earn recog- nition, and gain acceptance. Marketing programs set forth strategies for selling or promoting products and services for which funding is sought or consideration is to be gained. Such strategies define an organiza- tion’s competitive edge and its position within the marketplace (2).

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CHAPTER 21 ■ Promoting Your Venture 211

Dietitians often neglect to plan and oversee adequate promotion for programs, not realizing that poor attendance or lack- luster promotion reflects back on the pro- gram. Actually, it shows lack of foresight and follow-through if a practitioner de- votes total attention to the development of an excellent program, and yet fails to in- sure the success of the program through ad- equate promotion (4).

Promotion will attract far more clients to our doors than any form of legislation. Be- cause the healthcare focus is evolving to more health promotion and to attracting the “well” individual, we must accept that our services are among the many nutrition options available to each consumer. There- fore, dietitians must learn how to promote themselves and their products.

PROMOTION TOOLS

There are many tools that can be used in promotion. The target market, your budget, the degree of competition, and the image you want to project usually de- termine which technique you select. Some promotional tools are far more effective in reaching the target market, but it may also be very expensive (like television or color advertisements in magazines). Other techniques may better meet the expecta-

tions of the target markets, for example, tasteful brochures and business cards at a one-on-one meeting. Medical profes- sionals have been slow in using less tradi- tional promotion tools, such as billboards and neon signs, but sending a bouquet of balloons or Holiday deli tray to top re- ferring physicians’ offices have been very effective.

When trying to evaluate which forms of promotion to use, public relations experts suggest you go down a list of the promo- tion options, and hypothetically try to fit the service or product to it. Look for ideas that are creative, unique, and in good taste. See Table 21.1.

Promotion is most successful when a plan is designed for multiple exposures of the name or message to the target market over an extended period. For a weight loss program at a fitness center, promotion could include:

■ Newspaper and radio advertisements ■ Free media publicity ■ Direct mail promotion ■ In-house newsletter promotion to

members ■ Gym bags printed with the program

name and logo at registration ■ Program T-shirts when fitness goals

are met

TABLE 21.1 PROMOTION TOOLS FOR SMALL BUSINESSES

Getting Involved

Networking Speeches and seminars Volunteering Holding office in dietetic

groups

Web Promotion

Web page Banner

advertisement Involvement in

list serves Email signature

information Column on a website Online directories Hosting chat sessions Email newsletters

Getting Visible

Media appearances Radio or television

advertising National speaking Publicity: newspapers,

magazines, and business publications

Your own book Hosting a radio program Hosting or being a guest on a

television show

Tools

Business cards Yellow Page advertisements Postcards Coupons Phone hold messages Referral forms for physicians’

patients Résumé Brochures and flyers Portfolios for clients’ materials Trade directories Newsletters Samples and giveaways

(T-shirts, mugs, etc.) Media bio

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212 THE ENTREPRENEURIAL NUTRITIONIST

These are just a few promotion ideas; there are dozens more.

There are advertising and public rela- tions firms and individual consultants that can create promotional campaigns for a fee. For most dietitians that is not always an affordable option, but it may be a wise investment for selected projects. Promo- tion costs should be seen as part of the necessary expense and investment made to create demand for what you sell. The challenge is to choose wisely, and be cost effective when investing in promotional programs.

WHAT TOOLS DO ENTREPRENEURIAL NUTRITIONISTS FIND WORK BEST?

As mentioned in Chapter 11 on marketing, when Registered Dietitians (RDs) and Reg- istered Dietetic Technicians (DTRs) identi- fied their most successful promotion tools in the 2008 survey, they didn’t choose the expensive options (5). In descending order out of 24 options, they ranked what worked best (5):

1. Word-of-mouth marketing 2. Networking with other health or

business professionals 3. Business cards 4. Networking with dietetic peers 5. Personal meeting or phone calls to

potential referral agents 6. Speaking 7. Brochures or flyers 8. Website 9. Writing articles or newspaper columns

10. Calling leads referred to you by a third party

11. Membership in the national dietetic association

12. Membership in the national dietetic practice group

13. Membership in the local dietetic practice group

14. Local volunteering

15. Local health fairs 16. Television spots or interviews 17. Newspaper advertisements 18. Direct mail campaigns 19. Radio spots or interviews 20. Cold calling possible leads (buyers) 21. Discounts for first-time customers 22. Exhibiting at Product Market Place

at the Food and Nutrition Confer- ence and Expo (FNCE)

23. Hiring a marketing firm 24. Exhibiting in a commercial booth at

FNCE (ADA’s annual convention)

You can see that the most effective promo- tion tools cost more in time and effort than in dollars.

BRIEF OVERVIEW OF PROMOTIONAL TOOLS

ONE-ON-ONE COMMUNICATION

One-on-one communication can be your most effective form of promotion. It af- fords the opportunity to speak, hear, see, and exchange viewpoints face-to-face. As the promoter, you have the opportunity to read the body language and expressions of your listener and then adjust your presen- tation for best impact. Your employees should be trained in excellent customer service, which starts with good interper- sonal communication.

Satisfied customers are walking pro- moters of inestimable value. Through word-of-mouth advertising, listeners may be more influenced to try a dietitian’s service because the promoter lends credi- bility as a satisfied customer.

PUBLIC SPEAKING

Speaking to individuals and groups is con- sidered an efficient way to market. It lets you get your messages across and establish your credibility at the same time to large numbers of people.

Speaking does not come easily for some people, but there are Toastmasters groups

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CHAPTER 21 ■ Promoting Your Venture 213

and others to join that allow you to prac- tice your skills in a supportive atmosphere. You can also hire a speaking coach to help you with slang, organizing your ideas, and the dramatics of speaking.

Whether speaking to a women’s club, a state dietetic association, or a large national chef’s association, the following are some suggestions that will make speaking more predictable and enjoyable:

■ Ask for an appropriate speaking fee. When you are paid to speak, place it as a higher priority, and get more excited and rehearsed. Your en- thusiasm is often contagious. The fee should cover your honorarium, travel, preparation time, handouts, food samples, or whatever. As you become better known, your fee will greatly in- crease. Local speakers usually make $50 to $500 for presentations. Na- tional speakers can make $500 to $3000 and keynote speakers often make $1500 to $10,000. See Chapter 17 to see the range of what dietitians and dietetic technicians charge for speaking. Of course, writing a best- selling book helps increase your fees. If a meeting planner can’t afford your fee, negotiate. For example, ask to sell your books, or at an all-day meeting, offer to do a second presentation (since you will be there anyway) and ask for 11⁄2 times your normal fee for both speeches. It makes the trip more profitable for you, and it saves the sponsor money by not having to pay for travel and honorarium for a sec- ond speaker. You can handle all of these arrangements yourself, or hire an administrative assistant or agent to do it for you.

■ Find out as much as you can about the audience, its needs, and any human interest facts. What specifically do they want you to speak on? Who will be in the audi- ence and how much do they know about the proposed topic? What are

their educational backgrounds? Have they heard other speakers on this sub- ject? Will there be questions, debate, etc., afterward?

■ Find out about the logistics: physical building, room, audio- visual capabilities (PowerPoint projector), and whether they will reprint handouts. Request a letter or email of confirmation with the date, time, place, topic, expenses that will be reimbursed, and honorar- ium. Be sure to request a cancellation clause of at least 30 days or more, and for professional speakers, a partial pay- ment if cancelled within that time- frame.

■ Be sure to mark your calendar and get the name and phone number of the person who called.

LOGO

A logo is a symbol. If it is used to identify a product, it is called a trademark. If it is used for a service, it is called a service mark. Logos can be fun, or highbrow and sophis- ticated, or somewhere in between. Logos are used to identify the business and draw attention to whatever they are used on, such as stationery, posters, business cards, brochures, or billboards (Fig. 21.1).

BUSINESS OWNER

Private practitioners are potentially their own best marketing assets. Your personal- ity, image, communication and business skills, and expertise in nutrition will be ultimately responsible for attracting and keeping clients. Look good and look profes- sional! Look healthy!

Business advisors suggest business peo- ple to use at least the following four prac- tices to help promote their business.

First, use the phone and its marketing potential, talk to clients regularly, confirm appointments, and respond to referring physicians. Call back people who want to know about your services. Take time to

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214 THE ENTREPRENEURIAL NUTRITIONIST

show an interest in their needs, to tell them briefly what you have to offer, to let them know what you will expect from them, and to discuss an appointment time and your fees. By taking time to market your services instead of just scheduling an appointment, the client will become excited about the ex- pected personalized care.

Second, use your writing skills to corre- spond with people on a timely basis and to publish. For those who feel weak in this area, there are adult education classes,

books, and editors to help you. Write thank you notes for courtesies shown by others.

Third, use public speaking to make your- self more visible in your community and to interest people in nutrition. Speaking to clubs, community groups, PTAs, and at conferences will make people recognize you as a nutrition specialist.

Fourth, become involved in several local or national organizations that could bene- fit you personally or professionally. Attend

FIGURE 21.1 ■ Logo and business card samples.

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CHAPTER 21 ■ Promoting Your Venture 215

meetings, support activities, and run for of- fices. Dietetic organizations, including Di- etetic Practice Groups, need input from active, assertive dietitians on their way up. Small business owners’ groups, executive clubs, Chamber of Commerce, and local political groups offer opportunities to be- come involved.

WRITING FOR PUBLICATION

Writing is an ideal medium for practi- tioners to distinguish and promote them- selves by communicating with the public or their peers. Writing for lay periodicals or books provides the opportunity to reach a potentially large audience, to share your views, to be paid for your work, and to be- come known.

Writing for publication in professional journals does not pay directly, but it helps establish you as a knowledgeable, qualified professional and excellent resource. Articles also lend credibility to your programs and services. This type of promotion may also attract more business in the form of refer- rals or consultation opportunities.

BUSINESS CARDS

Business cards should always be carried and handed out. They can be powerful market- ing tools and one of the least expensive. Other peoples’ cards should be saved and used the next time you want to network or you need some information. Business cards should list your name, credentials, business name, phone number with area code, email address, website, and full address.

Some considerations to think about: do you want to print appointment informa- tion on the back of the card? Does the card look too cluttered as it’s laid out? Can everyone read the typeface (script and Old English are difficult to read)? Since card sizes are fairly standard, will choosing an- other size of card make your card stand out, or be thrown away? How can you best use color, style, paper, and design to attract at- tention to your card? (see Fig. 21.1).

LETTERS AND NOTES

Many business people have boosted their careers through well-written letters. All too often, we overlook the contribution that impressive correspondence can provide. The neatness and grammatical correctness is as important as the content of a letter. Letters with numerous corrections or mis- spelled words are poorly received.

Busy people will often refuse to read obvious mass mailings, such as those ad- dressed to “Dear Sirs,” “Dear Philadelphia Physicians,” or those that are poorly photocopied. By using mail merge on your computer, you should be able to send out an original letter each time. Creativ- ity, time, effort, and money must be invested to ensure that your letters are read. Business consultants suggest that even on mass mailings, the signature and heading should be individualized when- ever possible.

DIRECT MAIL

Direct mail is used when you know specif- ically whom you want to contact (usually potential clients, buyers, or referral agents), and when you want to increase your chances of attracting a higher-percentage response.

Personalize the mailed piece as much as possible to increase the readership. To in- crease the chance of having the direct mail piece read:

■ Put a return address, with the sender’s name or business, on the outside.

■ Add a question or statement to grab the readers’ attention.

■ Add a photo or drawing on a self-mailer to make the sender seem more familiar.

Direct mail is used for brochures, market- ing surveys, announcements, and to acquaint potential clients or referral agents to your services. Postcards have become more popular because they can be read without opening. Membership lists from your local medical society or national

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216 THE ENTREPRENEURIAL NUTRITIONIST

dietetic practice groups, the Yellow Pages, and shared business cards are good sources of names and addresses. Many organiza- tions ask for a fee and an explanation of how the membership lists will be used be- fore use is granted (Fig. 21.2).

RÉSUMÉ

A résumé can be a very effective market- ing tool. It should highlight your skills and experience that best qualify you for the position you are seeking. It can either be chronological (listing your experience in reverse chronological order) or func- tional (highlighting your skills and re- sponsibilities). Résumés can also be used along with letters of introduction to open doors for you, or to establish credibility in a proposal, or to help introduce you at a speaking engagement.

A variation of the résumé would be a cur- riculum vitae or vita (an expanded detailed version that includes published books and papers). The biographical sketch (in para- graph form) is often used for introduction purposes at speeches.

Laser-printed résumés look impressive. Word processing can make updating a ré- sumé very easy. However, the most impor- tant qualities are that it’s free of any typographical errors and it’s interesting and accurate.

LETTERS OF REFERENCE

Letters of reference written by prominent people who know you and your work are impressive. They help establish credibil- ity and may help open doors for you. Keep the original on file, and use good photocopies.

BROCHURES

Brochures are used to introduce and pro- mote. It’s not imperative for a private prac- titioner to have a brochure, but many have found that attractive; clever ones attract business and easily pay for themselves.

The most important things to remember about a brochure are:

■ Write the information with the cus- tomers’ needs utmost in mind; talk about “benefits.” How will your prod- uct or services make the customer hap- pier, healthier, more fulfilled, and so on? Don’t just list what you have to offer!

■ Make the brochure attractive, simple to read, and interesting. Leave open space and use bullets to make scan- ning easier.

■ Your readers may be interested in seeing a good picture of you.

■ Add statements from satisfied cus- tomers.

■ When consulting to businesses, add a listing of former clients.

Brochures seldom list fees because it dates them and sometimes makes them poorly received. If insurance sometimes covers your services or there is an employer co- pay program, it could be mentioned in the brochure. Your name, business name, address, phone number, email address, and website should be highlighted. It is highly suggested that brochures be type- set and printed on good quality paper. See brochure in Figure 21.2.

PORTFOLIO

There are times when dietitians want to show the scope of their creativity and samples of their work, such as creative menus, educational materials, media work, or catering ideas. When a business is new and its reputation and yours are un- known, a portfolio may be the marketing tool you need.

A portfolio is similar to a scrapbook or a slide show designed graphically to show what you have to sell. The portfolio may be in a commercially available portfolio folder, on a tripod display with charts, or on audio tapes or DVDs for dietitians who do media work. Presenting a portfolio to the client helps make the intangible prom- ise tangible, enticing, and clearly defined.

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CHAPTER 21 ■ Promoting Your Venture 217

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218 THE ENTREPRENEURIAL NUTRITIONIST

■ A 5� � 7� black-and-white glossy photo of you or the product

Press kits should be descriptive, attractive, and to the point. They should explain why the public would be interested in the topic. Although press kits can be very elaborate with printed covers and numerous photos, they can also be as simple as several of the above items placed in a large folder with pockets.

BANNERS

Banners draw attention and create name recognition. They can be used at a “fun run” finish line, in a lobby during a well- ness festival, or over the cafeteria door to promote the new line of “light and natu- ral” foods. Banners can be made with paper and paint; however, they can be reused several times if they are made from cloth or heavy vinyl. Banners are great pro- motional tools for a large area where crowds are gathered, and they also create a festive mood (6).

GIVEAWAYS

Giveaways (T-shirts, notebooks, mugs, gym bags, etc.) with the program name or logo are popular promotion items. The more useful and practical the item, the more it will be used and the name or logo dis- played. (These items can be sold as fund- raisers, rather than be given away.)

FREE PROMOTION

EMAIL SIGNATURE

As will be mentioned in the next chapters, using the signature capability on your email is a very easy way to let each person you write to know:

■ Your name ■ Address, phone, toll free number, and

fax ■ Website with a hot link to take them

there

The cost of a portfolio can vary greatly, depending on what is included. Items may range from professionally produced food photos to just copies or samples of educational materials, authored articles, menus, snapshots, letters of reference, and newspaper coverage. Occasionally, it is worth paying a professional artist or calligra- pher to add a special touch. Unfortunately, many of us never use samples of our past creativity to help us win the next contract.

POSTERS

Using posters to promote seminars and classes has proved to be successful for some practitioners. To save money on printing costs, a large number of poster “shells” (ones with four-color designs) can be printed at one time with the artwork, logo, business name, and phone number. The date, place, time, and event can be added as the posters are used. Sometimes a pad is attached with tear-off cards for potential customers to send in for more information.

If the posters are not too large, most stores, health clubs, and beauty shops that allow posters are willing to let you have display space to solicit their customers. When you use this type of marketing and you want to use the locations more than once, call or stop by when the event is over, and take the posters down and thank the owner.

PRESS KITS

Press kits are commonly used to interest the media in writing or broadcasting a story to help you promote your services, product, book, or speaking engagement. The kit may include a variety of items:

■ A cover letter addressed to the person ■ A press release on the service, product,

or book you wish to publicize ■ A sample of the product or book, a

copy of newspaper articles, or critical reviews

■ A résumé and short biographical sketch, or media bio

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CHAPTER 21 ■ Promoting Your Venture 219

■ Slogan, main product line, mission statement, favorite quote, or one sen- tence bio

MEDIA

Working with the media—radio, television, and newspapers—gives free marketing ex- posure to practitioners. One can do years of public speaking and not reach a fraction of the number of people who watch one tele- vision program or read a newspaper.

Nutrition, fitness, and health are “hot” topics right now and probably will be for several years to come. Experts in these fields who have a flair for that type of work and have something unique to say are sought after.

Media people are looking for stories and information that will interest the public. It can be classified as controversial, human interest, new research, exposes, practical, or a scoop story, but it has to have a “hook” or a “handle” (some unique element to attract the audience). Working with the media is discussed in Chapter 28.

Many practitioners got their first start with the media during National Nutrition Month. We sometimes forget that there are 11 other months to work with also. We do not have to wait until we are invited to con- tribute. If you plan to have a successful busi- ness, it is imperative people know about you. Through a phone call, introductory let- ter, over lunch, or at an office interview, however possible, try to talk to the local media program directors and newspaper writers. A private practitioner in Chicago re- ports she has been quoted or consulted on articles over 50 times in the last year in local newspapers. She sent her card, introduced herself, and offered to act as a resource per- son. Eventually, she was credited with a by- line in the article for what she contributed.

PUBLIC SERVICE ANNOUNCEMENT (PSA)

The media inconsistently welcome PSAs. The PSA can announce a new series of dia- betes classes or discuss childhood obesity

for an hour on the radio. It can be printed in a newspaper, read on the air, or it can be a live interview. Obvious commercial pro- motions for your business or to sell some- thing are not permitted unless you pay for commercial time or space. The lead time for PSAs ranges from 3 to 8 weeks, so call ahead and plan accordingly.

Radio and television stations support PSAs because of the service they provide to the community and because it looks good on their record when they reapply for their broadcast licenses. Newspapers usually feel PSAs increase readership.

It’s become common for commercial food and beverage companies to hire dieti- tians as media spokespeople to offer PSAs. The dietitians are trained to provide inter- views on an educational topic relating to food or nutrition and to interject the infor- mation about the company’s product.

PUBLICITY

Publicity is free media coverage of some newsworthy story, program, or event. It is easily recognized as the media coverage for a local health fair or of the local school children during National Nutrition Month. In a recent newspaper article, it mentioned that a man named Lawrence “Herkie” Herkimer was going to be in the Sports Illustrated (SI) magazine for the sec- ond time in 40 years talking about cheer- leading and cheerleading camps. “I’ve got a soft spot in my heart for SI,” says Herkie. “Back in the mid-50s, they did a story on me and it really helped establish my com- pany.” That is what good publicity can do for you.

Practitioners can call or write the media with their requests for publicity. For planned events, such as the beginning of weight loss classes for teenagers or a sports nutrition conference, the media should be contacted several weeks in advance. When planning a special event, consider including a local celebrity or cosponsorship with a philan- thropic organization to improve the possi- bility of media coverage and to attract a larger attendance.

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220 THE ENTREPRENEURIAL NUTRITIONIST

firm. The publicity program cost approxi- mately $200 over a period of 7 months (6). The money paid for printing, postage, and photocopying. His time was donated be- cause he was using them in his master’s thesis. He was able to generate exposure in Newsweek, the Washington Post, and in the United Press International (UPI).

PAID ADVERTISING

It is ethical, professional, and highly rec- ommended that you consider using adver- tising. The U.S. government encourages professionals to advertise, in hopes of pro- ducing more competitive services and bet- ter values for the public. Professional organizations are recognizing that it’s be- coming a fact of life for their members, and stress it be done tastefully.

Most practitioners use advertising as an ongoing budget item used to attract clients. Others use it only at times for special events, for new program announcements, and at the beginning of seasonal peak peri- ods (for example, September and January for weight loss). Whenever it is used, there are two guidelines that should always be followed:

■ First, make it clever and distinctive. ■ Second, plan to have a campaign, not

just a single advertisement. Estimates vary that the average person must see or hear an advertisement be- tween 5 and 11 times before he or she remembers it, so repetition is necessary (7).

A good rule of thumb to determine how much to spend on advertising is 5% to 10% of the gross annual budget. This is after the initial expense of 15% for the first year. Another way would be to divide the cost of the advertising by the cost of the product you are selling or initial con- sultation fee. Evaluate if the number of new clients needed to breakeven on the advertising is reasonable (it’s too expen-

Publicity comes at no cost, but it may be sporadic or completely upstaged if a bigger news item breaks the same day as your story.

In an article by Peter Miller, “Be Your Own Publicist,” he suggests the following refer- ences if you want to reach the media your- self, many libraries will have these resources, and they may be available online (6):

■ Bacon’s Publicity Checker lists more than 18,000 newspapers and maga- zines, as well as 100,000 media con- tacts. (800) 621-0561.

■ Broadcasting Yearbook covers radio, tel- evision and cable, and their staffs. (800) 638-7827.

■ Gale Directory of Publications provides information on 25,000 newspapers, magazines, journals, and newsletters. (313) 961-2242.

■ Hudson’s Newsletter Directory provides listing of 4000 newsletters by subject. (914) 876-2081.

Small companies can compete with large corporations with megabucks for media coverage; if you follow some very basic premises tested and proven by publicist Peter Miller (6):

■ Write about a topic, not about yourself. ■ Be factual. ■ Include your name, address, and

phone number at the top of the page. ■ Be brief. Limit the news release to one

page, but also include a cover page ad- dressed to the individual reporter or editor; there may be a brief biography of yourself and a short history of the business or product.

■ State on the news release “For Imme- diate Release,” which means use it anytime.

■ Describe your material as a “news release.”

Using this approach, Miller helped a small contact lens company in Washington, DC go from five employees working in an apartment to a 40% increase in sales and offers from all over the world to buy the

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CHAPTER 21 ■ Promoting Your Venture 221

sive if you have to see 20 new patients per month just to pay for advertising). There is a point where putting more money into advertisements will not bring more clients or profit to your office. When you first begin a business, budget an amount you can afford to spend, and look for other previously mentioned ways to market yourself for less cost.

Most dietitians cannot afford to com- pete with the amount of advertising pur- chased by commercial weight loss and other nutrition programs. Where we spend our advertising money and the dis- tinctiveness of our advertising are all the more important, because our funds may be tight. To help determine what works for you, ask clients and patients how they heard about your business. Look over the list from the 2008 survey mentioned earlier in the chapter on what worked for other dietitians.

The Yellow Pages and the media all have free sales personnel that can assist clients in determining the best way to use their ad- vertising dollar and help with advertise- ment ideas on a limited basis.

If a practitioner wants help on an overall advertising strategy, plus artwork and a slo- gan, an advertising agency or public rela- tions firm can do it, as well as students and professors at your local colleges and univer- sities. Obtain estimates before you agree to have work done, because good firms are usually expensive.

Fees often range from $2500 to $15,000 or more (advertising not included) to set up an advertising campaign with a logo and slogan for a small business. Fees are less if you come up with the ideas yourself.

YELLOW PAGES OR TELEPHONE BOOK

Telephone books offer a business the op- portunity to advertise to everyone who owns a telephone, for a year. Most busi- nesses find this type of advertising very productive.

Patients and clients know to look under “Dietitians” or “Nutritionists” to find a consulting nutritionist listing. Occasion- ally, practitioners also list under such ti- tles as “Reducing and Weight Loss,” “Physical Fitness,” or “Catering.” One list- ing in the Yellow Pages and white pages is offered when you have a business phone. All other listings, display advertise- ments, extra lines, or bold print are an extra charge.

It is highly recommended that a tele- phone book listing include the words “Registered Dietitian.” The telephone company does not police their listings, so anyone can be listed under a title we, and the public, assume to be ours alone. Choosing a generic business name with- out reference to having a professionally trained dietitian involved may cause busi- ness to be lost. Examples would be “Big Pines Consultant Services” or “Moore & Associates, Inc.”

To help save money but still have a good size advertisement and several listings, buy only one larger advertisement and refer the other listings to it, such as “See advertise- ment under Nutritionists.” Put the adver- tisement under the listing where you think it will be seen best and where clients would look for your name first.

The telephone book closing dates for ordering your advertisement is usually 3 to 5 months before the books are avail- able. Plan ahead and call to ask for assis- tance. Evaluate your listings each year and try new ideas that might work better. Ask new clients how they heard about your business to see if the advertisements really work.

NEWSPAPERS

Dietitians use newspaper advertisements with varying degrees of success. The word- ing and placement of the advertisement are critical. It must be distinctive enough to catch the reader’s eye. The competition to attract attention is very stiff in a

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222 THE ENTREPRENEURIAL NUTRITIONIST

firm or advertising student for the creation of the advertisement.

RADIO

Radio advertising can be geared to a very specific group of the population, depending on the type of music played and the time of day. Radio stations know from surveys their listeners’ average ages, the percentages of men and women, their approximate in- come, and educational levels.

To be remembered, radio advertisements must be repeated. Sales people from sta- tions will offer several “packages” of adver- tisement lengths and airing times to make the campaign more reasonable. They often will help with writing the advertisement and have a station person record it or read it live. Smaller stations have lower advertis- ing fees because fewer people listen to them. In fact, it’s the listenership that de- termines how much a station charges in a given market, but all fees are negotiable. The longer you decide to commit to their station, the lower the rate you will be charged. Don’t accept the first figures you are quoted. Take your time and check for the best air times and prices for the target market you want. Classical stations are sometimes a very good choice to attract af- fluent patients for private consults, and “easy listening” for the over 40-year-old group, and so on.

Businesses that can afford regular radio advertising report are very successful. Smaller businesses with lower budgets and irregular use of radio advertising report hit or miss success. According to business con- sultants, if you plan to use advertising, you need to commit enough financial support to produce results or you should not do it at all.

TELEVISION

A television advertisement is extremely expensive to produce and to show on the air. Again, it must be repeated to be

newspaper, especially a large daily one. Ad- vertisements should run on a regular basis in order to be remembered. Scheduling ads regularly also makes the cost of each indi- vidual advertisement more reasonable.

Large daily newspapers have good ex- posure, but they also have a lot of clutter and are only partly read by most people. Readers go to the sections that interest them most and skim the rest. Fortunately, newspapers know what sections are read most and by whom. Advice columns, horoscopes, comics, letters to the editors, sports score pages and, in small towns, the obituaries are usually read closely. Al- though women’s sections are usually read well, on coupon day, that is often not the case. Request the advertisement to be placed on a page that is mostly writing, so your advertisement will stand out and not be lost among the huge furniture display advertisements.

Small newspapers and weekly papers are usually read more closely and have a loyal but smaller readership. The cost of adver- tising is more reasonable. The preferred placement guidelines for an advertisement are the same as mentioned for large news- papers. Also, smaller papers are usually more open to the idea of a nutrition col- umn written by a local person, or articles that are contributed locally.

An advertisement should catch your attention with a catchy word, phrase, graphic design, photo, or something. It should be easy to read and understand, plus it should be clever. The phone num- ber should stand out. It’s not necessary to condense your brochure or calling card into an advertisement. In fact, you will at- tract more attention with the headline, “Ready for Bikini Season?” than with “Nu- tritional Consultation by a Professional.” If you can’t think of an idea you like, check the advertisements other businesses are using and see what you like and dislike about them. If you have an idea but need artwork, go to a graphic artist. If you don’t see a good idea, budget in an advertising

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effective, and the types of programs being shown determine who the audiences will be. Television advertising reaches a large number of viewers, but is so expensive it would be very difficult for a consultant working alone to breakeven on the num- ber of added customers it would attract. One person usually doesn’t generate enough income in 1 hour to cover this ex- penditure and other overhead, too. It may be possible that several consultants work- ing together, or working for one person, could generate enough added income to warrant television advertising, but exhaust all avenues for getting free television ex- posure first.

A reasonable television advertisement can be produced for $2000 to $15,000, depending on whether you hire someone to act or you do it yourself. The airtime varies greatly, depending on whether it is a small, local cable station or prime time on a major network. The better the view- ership and time slot for the advertisement, the higher the cost—from $1500 to $50,000 or more per week for a daily advertisement.

One private practitioner did invest with a partner in television advertising to pro- mote their quick weight loss program in the fall, during the popular afternoon talk shows. The advertisements cost $30,000 per week for several weeks and they did fill 50 weight loss classes with 12 people each at about $400 per person up-front (plus a weekly fee for meal-replacement bever- ages), or over a quarter million dollars in gross income in 30 days. Figuring the cost of the advertisement, the airtime, the meet- ing rooms, the secretarial time, the educa- tional materials, and the instructors to handle all those people, there was still a good profit—but very high risk if it had not worked.

Infomercials can also be very lucrative (selling more than 10,000 products in a day), but you would need to work with a company that already has the phone banks, credit card capabilities,

staffing, actors, and video production ready to go.

WEB

The Internet has high reach (worldwide access) and high impact (7). It is low cost for the number of potential customers who can be reached, although it may cost thousands to design and maintain a web- site. At first glance, there seems to be low selectivity (who can access your site); how- ever, through skillful use of meta tags and key phrases, you can greatly increase the chances of search engines finding your site and bringing the right customers (see Chapters 22–24).

KEEPING CUSTOMERS

After you have successfully attracted cus- tomers, it’s important to keep them. Ex- perts suggest that it costs businesses five times more to attract a new client than to sell another item to a former customer. Customers are assets for more than just a source of revenue. They are “walking pro- moters” of your services and an advertis- ing medium of great value. Each person has a sphere of influence that reaches far beyond his or her immediate family and business peers to a potential of several hundred people.

There are numerous ways to strengthen relationships with clients or referral agents that can be carried out with a minimum amount of effort on your part, once the sys- tem is established.

■ Phone calls ■ Personal notes ■ Rapport established by showing gen-

uine concern ■ Newsletters (by mail or email) ■ Email communication ■ Gifts and cards around holidays and

special events ■ Coffee or luncheon appointments ■ In-services for staff

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224 THE ENTREPRENEURIAL NUTRITIONIST

it may be difficult in this situation, be sure to look up at the camera. Maintaining eye contact with your audience is imperative, and don’t forget to smile! (You’ll probably need plenty of time to practice coordinat- ing all of this ahead of time.)

■ Proper lighting is essential, and it may be worthwhile to invest in professional fix- tures if you plan to self-shoot. A dark, dreamy atmosphere will present a solemn message; a bright environment will be seen as uplifting and will highlight you more clearly.

■ Be aware of background noise such as airplanes flying overhead, dogs barking, neighbors mowing their lawn, phones ringing, or trucks going by, just to name a few of the reasons camera crews had to stop filming when at my house.

■ Be sure your backdrop is neat and clean. A more simple setting will be less distracting and will help you become the focus of at- tention, allowing the audience to focus on your message instead of what’s piled up on your desk. Pictures are better than a thou- sand words, and sometimes the word is clutter! Try taking a tour of your own home with an objective eye and take a still photo of your room before you film. Those same objects you stare at everyday could be a real eyesore as a backdrop.

■ Do a sound check. Be sure that the loca- tion of your camera is picking up the sound of your voice. You may want to purchase a separate inexpensive recording device or microphone to improve sound clarity. Your message will have no impact if it can’t be heard.

■ Dress for your audience, but dress for success. If you are doing a piece for a corporate audience, a suit or blazer would be appropriate, and sitting at a desk may be the right setting. For a more relaxed crowd (homemakers) or for kids and teens, more casual attire might work best, always keeping professionalism in mind (i.e., no torn jeans, tank tops, low-cut blouses, or clothing that sports logos or designer names). For cooking demos, be sure to tie

C A S E S T U D Y 2 1 . 1

“ S T R E A M ” - L I N E Y O U R B U S I N E S S

Streaming video is here to stay, and for those of us who have teenage children (I have three!), we know this has become a wildly popular mode of entertainment and educa- tion that’s available 24/7. Studies have shown that people prefer watching information rather than reading it, leading to greater retention of material. This high-quality, cost- saving technique has, for many companies and professionals, become a practical and af- fordable way to market themselves and their businesses.

Just as the word “blog” has become an everyday term, laced throughout countless websites, streaming video can be seen every- where from the biggest boardrooms to the smallest bedrooms. Online video clips are able to be accessed from any computer that has an Internet connection, which easily transfers live or prerecorded images over long distances.

Some nutrition entrepreneurs have ven- tured into using streaming video on their own websites, and if you’ve taken this first step, try taking the plunge and explore the endless possibilities for posting your video on social networking sites, like YouTube, MySpace, or Facebook. You can even pitch your video clip to your local television station to help them add a moving picture to your story. Profes- sionally produced videos are welcomed by many busy producers, saving them the time, money, and manpower it otherwise would have taken to send out a camera crew to inter- view you.

But before you push the “record” button on your camcorder, here are a few key points to consider:

■ If you’re setting up shop from your home, be sure you have a tripod to keep your cam- era stable. Don’t just lean the camera on a countertop. If you’re doing a cooking demo, be sure to check to see that you’re staying with the frame of the shot and try not to move around too much. Although,

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CHAPTER 21 ■ Promoting Your Venture 225

your hair back, keep your nails short and neat, and perhaps wear an apron to lend credibility. As with any television or video interview, avoid wearing wild patterns, stripes, and plaids, and big pieces of jewelry or dangling earrings. The camera loves solid, bold colors like pink, aqua, blue, green, or purple.

■ Master the message. Once you post your video to a site, thousands of people could tune in. Be sure that your message is clear, and above all, accurate, in layman’s terms.

■ Practice makes perfect. When doing taped interviews, I still feel the pressure to get it right on the first take, but when you’re the producer, you don’t have to feel that same pressure. Once you have your message down, try practicing in different settings and perhaps try wearing different outfits. Do whatever makes you feel comfortable without feeling distracted.

This is your show, illuminating your skills and expertise, so try to make the most of it and try to have fun. For further information log on to www.eatright.org/media to help you get ready for a marketing tool that keeps on working while you sleep. All it takes are some lights, camera, and action!—Bonnie Taub-Dix, MA, RD, CDN

About the Author

Bonnie Taub-Dix, MA, RD, CDN, is a Na- tional Spokesperson for the American Dietetic Association; Director of BTD Nutri- tion Consultants; Co- author of Kosher By Design Lightens Up (Artscroll, 2008); Food & Nutrition Blogger, USA Today, http://tinyurl.com/5ogx9w; and an Advisory Board Member, Family Circle Magazine.

C A S E S T U D Y 2 1 . 2

M A R K E T I N G Y O U R S E L F T H R O U G H S P E A K I N G

Savor Your Life Today, Inc. helps overwhelmed and overbooked people find purpose and stop overworking and overeating to live happily and healthfully ever after. Speaking is the number one strategy that I use to attract clients through workshops, lunch and learns, keynote presentations, and teleclasses.

What Does Your Audience Need? To obtain paid presentations, you must iden- tify topics that your target audience truly needs and you are also passionate about. What do you do that helps your market solve a problem or make their life easier?

Understanding your audience is the key to future referrals. Whether you are speaking to 20 or 200 people, know why your message is important for them to hear. After you master the art of connecting with 20 audience mem-

bers, you will be able to make each person in an audience of 200 feel as though you are talking directly to them. Showing empathy and understanding of your audience’s life’s challenges and creating practical solutions will have you connecting with them and getting more referrals.

The Presentation Tell great stories. Stories help people think about their lives in a different way. Keep a “story journal”—moments of challenge, crisis, or a life lesson you have learned. For a 1-hour presentation, plan on three key messages and three stories. Your stories become the frame- work for your talking points. People will forget your tools, but they will never forget your stories.

Before You Speak Develop a speaker agreement form. It should include the name of your business, the presen- tation topic, a description of the audience, your fee, audio visual needs, transportation

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226 THE ENTREPRENEURIAL NUTRITIONIST

3. Rose J. The Competitive Edge. Chicago, IL: The American Dietetic Association, 1987.

4. King K. The Competitive Edge. 3rd ed. Balti- more, MD: Lippincott Williams & Wilkins, 2009.

5. Edwards P, Edwards S. Working From Home. New York: Penguin Putnam, 1999.

6. Miller P. How to Be Your Own Publicist. Home Office Computing, December, 1990.

7. Sobel M. The 12-Hour MBA Program. Paramus, NJ: Prentice Hall, 1993.

RESOURCES Heyman JH. All You Need is a Good Idea: How to Cre-

ate Marketing Messages that Actually Get Results. Hoboken, NJ: John Wiley & Sons, 2008.

King K, ed. The Competitive Edge. 3rd ed. Philadel- phia: Lippincott Williams & Wilkins, 2009.

This is the most comprehensive book ever written on marketing dietetics.

SUMMARY

Attracting and keeping clients is necessary to survive in business. Selling and promotion should always be major priorities of any business, whether new or established. Private practitioners soon learn to carry a supply of calling cards wherever they go. Stepping for- ward to shake hands and introducing your- self becomes second nature. Although many things seem awkward at first, after so many hours and days are invested, it becomes very easy to share your enthusiasm.

REFERENCES 1. Beckwith H. The Invisible Touch. New York:

Warner Books, 2000. 2. O’Connor JP. Presentation O’Connor PR & Market-

ing, Washington, DC, 1990.

arrangements, lodging, meals, and anything else relevant to the success of this presentation. Ask for a 50% down payment when the agree- ment is signed to hold the date for you.

Your Time and Fees Dietitians crave for details and love to re- search. To save time, keep in mind that get- ting it done is sometimes better than having it perfect. Think about your hourly fee and calculate how many hours it will take to pre- pare this presentation. Before citing your fee, always ask for their budget. Only discuss your fee over the phone or in person never via email. Ask for the highest fee you can say without choking, then be quiet and wait. As

a Registered Dietitian, strive to get paid for your stellar overdelivery.

The latest American Dietetic Association’s Nutrition and You trends survey shows that con- sumers rated the Reg- istered Dietitian as the most credible nutrition information source. People are waiting to hear what you have to say! What are you waiting for? —Chere Bork, MS RD LN, Licensed Executive Wellcoach ®, Founder of Savor Your Life Today, Inc. http://www.cherebork.com

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The Internet has a huge variety of uses from quick communication with the world and in-depth scientific research to bookkeeping, world-wide conferencing, and informal sharing of videos, photos, résumé, stories on YouTube, blogs, and LinkedIn. Owning a website is only a small part of its potential. Following are several ways to use the Internet in your profes- sional work, regardless of whether you or your company has a website.

COMMON USES OF EMAIL

QUICK COMMUNICATION

With the increased use of computers and the Internet by individuals, email can be a convenient and inexpensive mechanism for communication. It can aid the health- care delivery process by allowing written follow-up on instructions, quicker test re- sults, and dissemination of educational ma- terials to patients. It is a means for business clients and consultant dietitians to easily communicate with each other. At the same time, issues of privacy, confidentiality, and security must be addressed to ensure the ef- ficacy and effectiveness of email.

INDIVIDUAL THERAPY

There also are an abundance of uses for email in professional work beyond a sim- ple communication vehicle. Email has been used as a method to enhance therapy with

patients, both in one-on-one and group set- tings. It also can be useful for surveying clients or members.

A 3-month study on patients with eating disorders found that email therapy looks promising in treating patients with bulimia nervosa (1). Twenty-three patients were asked to email a daily diary of their eating habits and feelings. Psychiatrists responded with advice, encouragement, and other comments. The therapists estimated it took them a maximum of 10 minutes to read and respond to each patient’s email. Re- searchers found there was a significant reduction in depression and symptoms. These results illustrate that a patient’s treat- ment can be enhanced with the combina- tion of email contact and office visits.

GROUP THERAPY

Email can be effective in a group support setting. Often people connect when they are not involved in a face-to-face encounter. Email is famous for drawing out people who have difficulty expressing themselves (2). Many patients feel more comfortable ex- pressing their feelings in the comfort of their own home or own pajamas. Email affords them this benefit. With the crazy schedules of people today, email can be squeezed in between activities or left until winding down at the end of the day.

There are several companies that will host a listserv for a monthly fee or on a per email basis. The advantage of a listserv is

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USING THE INTERNET IN YOUR BUSINESS

Teresa Pangan

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Results of surveys can be viewed in spreadsheet format, graphs, or placed into presentation software. Results can pro- vide insight for making informed business decisions.

Many sites that specialize in surveys offer a free survey version to assess. The number of questions and participants may be lim- ited, so determine your needs before you buy or commit yourself. Following are sam- ple sites to begin your search:

■ http://www.supersurvey.com ■ http://www.freeonlinesurveys.com ■ http://www.surveymonkey.com ■ http://www.zoomerang.com

To locate other sites, use the following key- words: “surveys, online.”

INFORMATION THERAPY FOR PATIENTS

Information therapy is a practical tool for RDs in private practice, public health, and clinical practice. Heading the “information therapy” movement is the Washington, DC, based Center for Information Therapy (http://www.informationtherapy.org/). It is a nonprofit division of Healthwise that aims to support information therapy programs and conduct research to assess impact on

you can have closed membership or limited access to the group. Additionally, you can set up the list so all postings are scanned or preapproved by an appointed moderator. When first starting out, you may want to be the moderator and as things progress, allow members to post without prior approval.

Email group support can be most ef- fective for those groups of patients where issues outside of food need to be ad- dressed. Groups of patients with eating disorders come immediately to mind; newly diagnosed individuals with dia- betes, cardiac problems, and weight man- agement are other groups.

SURVEYS

Surveys are easy to set up through emails. Emails can include a “hot” link that takes participants directly to a survey by merely clicking on the highlighted address. Possi- ble uses include the following:

■ Customer satisfaction or feedback ■ Employee satisfaction or assessment ■ Input for a new member service or

project ■ Opinions of customers regarding a

product or service ■ Input for an upcoming meeting ■ Feedback on effectiveness of a meeting

Information Therapy ScenarioBox 22.1

Sheila has been hospitalized for a heart attack. Before she is discharged, she will be issued an electronic prescription via a secure message system for “information therapy,” an Internet- based patient education tool.

First, Sheila receives an email that contains links to specific, physician-approved online information relevant to her diagnosis and postdischarge needs. By the time Sheila arrives home, her email has arrived. When she is ready, she can sit down at her computer and visit all the links in her “information therapy” email. In Sheila’s case, the links listed are links to “heart disease development overview,” information about “treatment for heart

disease,” and “how to prepare for a visit to a Registered Dietitian (RD) and exercise physiologist.”

The email begins by explaining to Sheila this information is part of the process of care for her heart disease, and encourages her to read and study it. By the time Sheila meets with her RD for the first time, she will have completed 3 days of food and activity records and read an overview of medical nutrition therapy for heart disease. This initial visit preparation will help dietitians in assessing and working a patient through the precontemplation, contemplation, and preparation for action stages of behavior change.

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CHAPTER 22 ■ Using The Internet in Your Business 229

healthcare quality. The nonprofit organiza- tion defines information therapy as the “prescription of right information to the right patient at the right time to help people make ap- propriate decisions of care.” The information is current, evidence-based, and void of com- mercial interests or advertising.

Pilot tests are being conducted on infor- mation therapy with positive preliminary results and feedback. It makes patients aware of the intricacies of their health and any diseases that affect them. It takes them into the pros and cons of their care options. It helps people share in medical decisions and come closer to the self-care and self- management model of healthcare (3).

Currently, there is no reimbursement for information therapy. According to a survey by the American Medical Association, the biggest barrier to therapy is lack of com- pensation (4). However, inroads are being made with payers and policymakers to re- imburse providers for information therapy services.

The concepts of information therapy are not new. Hospital librarians, consumer health librarians, and patient educators already provide these kinds of services. The intent is to standardize this informa- tion service into the treatment process for patients.

Dietitians can become involved in shap- ing information therapy to improve its ef- fectiveness. A valuable addition to the initial “information therapy” email could include links to content on why it is important for heart disease patients to visit an RD and content to erase some of the myths associ- ated with RDs—we can teach you how to eat your favorite foods, not take them away. On the negative side, there could be the sce- nario that diets are prescribed over email in- stead of referring patients to dietitians.

SEARCHING THE WEB

Searching on the Internet today can be compared to dragging a net across the sur- face of the ocean. While a great deal may be caught in the net, there is still a wealth

of information that is deep and, therefore, missed. The reason is simple: much of the web’s information is buried far down on dynamically generated web pages.

DYNAMIC WEB PAGES

Dynamic web pages are created based on a user’s input. A simple illustration is a search engine. When a search is performed with keywords, the search engine uses the words entered into its query box to search its database (index) that is stored offline. It matches the user’s words with words in its index. The results are assembled together onto a “dynamic” web page based on the matches it found in its database.

Another example of the use of a dy- namic web page is MEDLINE, a database filled with information from 4300 biomed- ical journals. When looking for medical information in MEDLINE, you enter an author’s name, search term, or journal title. A search engine searches the MEDLINE database and returns a list of results. The list of results you see is a dynamically gen- erated page. Additionally, you can click on a result that closely matches the topic you want to locate. This will initiate the process of creating another dynamically generated web page. The journal title, article title, ab- stract, authors, date, issue, full-text, and other information is retrieved from the MEDLINE database to be displayed on the dynamic web page. The web page you see (with the journal article information) is not a web page that a web developer created and posted on the Internet. It’s created “on the fly.” This should clarify why there is a huge amount of valuable information that standard search engines never find.

THE DEEP WEB AND SURFACE WEB

Traditional search engines create their in- dices by spidering, or crawling surface web pages that are all linked together. To be dis- covered, the webpage must be static and linked to other pages. Traditional search engines can’t “see” or retrieve content in the deep web. Those pages do not exist

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230 THE ENTREPRENEURIAL NUTRITIONIST

word and keyword “database” or “direc- tory” to find databases with invisible web pages. For academic research topics, great starting points are the Librarians’ Internet Index (http://lii.org) with over 20,000 web- sites compiled by public librarians, and Infomine (http://infomine.ucr.edu) with over 125,000 websites compiled by aca- demic librarians from the University of California and elsewhere.

The exception is Google Scholar (http:// scholar.google.com). Google Scholar is part of the public or visible web. It con- tains citations to journal articles and other publications with links to publishers or other sources where one can try to access the full text of the items. This is conven- ient, but results in Google Scholar are only a small fraction of all the scholarly publi- cations that exist online.

OTHER INTERNET SEARCH HELPERS

There are two additional Internet search helpers for keeping up-to-date in your area of specialty: email news services and web page change notification software.

EMAIL NEWS SERVICES

These services are offered by medical and news websites. They are daily or weekly emails to announce breaking news on a medical topic or topics that you select. Headlines and abstracts with links to the full-text articles are emailed according to the frequency you set up. They are a good way to keep abreast of hot topics in the media. Frequently, the writers are medical journalists and may or may not have any experience or formal training in the topic they are writing on. Also, the content is typically targeted to consumers and may have little informative value to a health professional. However, it is an easy method to keep on top of breaking news stories. Scan the top news sites and medical portal sites for email services. To find email news

until they are created dynamically on the spot as the result of a specific search into an online database. Because traditional search engine crawlers can’t probe beneath the surface, the deep web is hidden to them.

The deep web differs from “surface” web in the way it obtains its indexed data. The “surface” web uses search engines and subject directories for finding informa- tion. Subject directories obtain their infor- mation from authors submitting their own web pages for a listing and search en- gines “crawl” or “spider” documents by following one hypertext link to another. Simply stated, when indexing a given doc- ument or page, if the crawler encounters a hypertext link on that page to another document, it records that incidence and schedules that new page for later crawling. Like ripples propagating across a pond, in this manner search engine crawlers are able to extend their indexes further and further from their starting points. On the other hand, the deep web has systematic information entered into a database that is below the Internet surface and not ac- cessible to search engine crawling. Exam- ples of deep web sources are:

■ National Climatic Data Center (http: //lwf.ncdc.noaa.gov/oa/ncdc.html)

■ U.S. Census (http://www.census.gov) ■ NIH PubMed—this has the MEDLINE

database (http://www.ncbi.nlm.nih .gov/entrez)

■ U.S. Patents (http://patft.uspto.gov) ■ New York Online Access to Health—

NOAH (http://www.noah-health.org)

Deep websites tend to have content that is narrower and deeper than “surface” websites. Also, more than half of the deep web content resides in topic-specific data- bases (5). With proper searching tech- niques, deep web searches can turn up very valuable information. As part of your web search strategy, spend a little time looking for databases in your field or topic of study or research. Search the main stream search engines using a topic key-

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http://scholar.google.com

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CHAPTER 22 ■ Using The Internet in Your Business 231

services, use the following keywords: “health email news.” The American Dietetic Association (ADA) initiated its own email news service in August 2002, for its members. Check http://www.eatright.org for more information.

WEB PAGE CHANGE NOTIFICATION

Web page change notification software is a program set up on your computer to con- nect to the Internet and check whether content on web pages you specify have been updated. This tool is excellent for monitoring valuable web pages in your area of specialty. The program can be set up to check daily, weekly, or monthly. There are several programs that will do this, which you can have for free or for less than $100. To find a web page change notification pro- gram, go to a download or software site like http://www.download.com and use the fol- lowing keywords: “web page notification.”

RSS

RSS stands for “Really Simple Syndica- tion,” and is a protocol that websites use to distribute their content. Websites that use RSS create special files, called “feeds,” that are updated periodically to contain the sites’ latest information. Using RSS feeds is an easy and efficient way to keep track of new updates when a site adds new content. Instead of checking site A, site B, and site C everyday to see if there’s any- thing new, you can subscribe to each site’s RSS feed and will be instantly notified by your RSS reader when new content is added.

An RSS reader is an application you use to view RSS feeds. Similar to how an email application gathers messages from multi- ple email accounts, an RSS reader gathers feeds from multiple sites so you can view them in one location. There are two types of RSS readers: web readers and Desktop readers. The difference between the two is fairly minimal. The main advantage of web readers is that they store all of your

subscribed feeds on the Internet, so you can access them on any computer. An- other option is Desktop readers, which download subscribed feeds to your hard drive, so you can view them even if you don’t have an Internet connection.

Google Reader (web), FeedDemon (Win- dows), and NewsFire (Mac) are popular readers that are available for free. Once you select an RSS reader, you can start subscrib- ing to site feeds. If a feed exists for a site, many modern browsers will display an RSS icon in the right corner of the location bar. Also, most sites display an RSS icon some- where on the page. Clicking on either of these icons will allow you to subscribe to the site’s feed.

If you have a website, consider adding in RSS for pages that users would be inter- ested in being notified of updates. An ac- tive RSS feed can help your website’s ranking in search engines and even create “buzz” about your site. To find out how to set your own site RSS, use the following keywords: “RSS news feeds for website.”

WEB AND VIDEO CONFERENCES

EQUIPMENT

Web conferencing refers to technologies that allow people to communicate or “conference” over the Internet. Web con- ferencing is based on tools that most of us use on a daily basis—computer, tele- phone, camera, headset, and the Internet. For the best-quality video, look for a web- cam with a 2.0 megapixel sensor, and make sure the webcam’s top resolution is true and not interpolated—a method that tries to trick the eye into seeing more vi- sual information than the image really of- fers. Also, pay attention to the webcam’s frames per second. This is an indication of the quality of motion being captured. The best consumer-level webcams today offer 30 fps. Webcams typically come with soft- ware that lets you use the camera with in- stant messaging and other programs supporting video chat.

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the web conference, and communicate with the moderator either through their phones or through web-based chat. The moderator can interact with participants, view a list of who attended the conference, and manage the communication during the event.

Many e-conferencing solutions offer meeting tools that allow you to poll parti- cipants before, during, or after the meeting or presentation. Results of the polling can be tabulated in real time and can be incor- porated into the conference.

Purchasing options include:

■ “Renting” or licensing web confer- encing software that is hosted on the vendor’s server on a pay-per-use or monthly use basis

■ Purchasing the software retail or from a reseller, and hosting it on your own server

■ Working with a full-service vendor who will supply the planning, market- ing, and production of your event, as well as the web conferencing software

Web conference providers include:

■ WebEx (http://www.webex.com)— affordable monthly plans if you are communicating or presenting from your desktop frequently. You can share and lead remote participants through your desktop applications with the ability to integrate a webcam

■ Adobe Acrobat Connect Pro (http:// www.adobe.com/products/acrobat connect/)—audio and video conferenc- ing, file sharing, and whiteboard. It is a complete web communications solu- tion. The price is flexible with several pay-per-use plans. The only software requirement is Adobe Flash Player

■ GoToWebinar (http://www.gotowebi nar.com)—online event product with a self-service interface enabling you to plan, deliver, record, and analyze We- binars quickly and easily without tech- nical support

■ KRM (http://www.KRM.com)—audio and web conferencing event services

The different technologies for web con- ferencing include:

■ Stream audio (downloading sound data onto the user’s computer so it is processed and performed at a steady speed to avoid pauses in the sound)

■ Stream video (downloading video data onto the user’s computer so it is processed and performed at a steady speed to avoid pauses in the picture)

■ VoIP (voice-over-IP) and web-based chat

VOICE-OVER-IP

Voice-over-IP (VoIP) is a two-way audio transmission over an Internet connection through computers that has gained popu- larity in recent years for web conferencing. It is inexpensive (free in many cases) and easy to set up. Both users must have micro- phones and speakers attached to their com- puters (most computers have built-in speakers today), and a VoIP software pro- gram. Then the users can use VoIP to talk to one another, similar to talking on the telephone, but through microphones. Many e-conferencing solutions include a VoIP component.

Free VoIP software programs are:

■ Skype (http://www.Skype.com) offers one-to-one videoconferencing

■ Yugma (http://www.yugma.com) of- fers up to 10 participants in videocon- ference at levels: free, professional, and enterprise

■ Eyejot (http://www.eyejot.com) no download required to get started and its unique feature is its ability to email video

WEBINARS

Web conferences or webinars typical setup is where a presenter provides content over the Internet using a form of slide show presenta- tion (PowerPoint), or streaming video. Atten- dees view the presentation by logging into

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To locate more web conference solutions, enter the following keywords: “online meetings,” “online collaboration,” or “web presentation.”

Prices for a 1.5-hour online web confer- ence range from $25 to $350. Often, pric- ing is done on a per-minute basis per user. Features included vary, but they typically provide online training tutorials. Before de- ciding, test a couple out. Most offer free seminars. They vary in their services, fea- tures, and ease of use. Before your first web conference, plan in training time and extra setup time. A dry run is also a good idea.

USES OF WEB CONFERENCING

Web conferencing solutions can be used in a variety of innovative ways to allow peo- ple to communicate with each other more effectively across any distance at any time. Some common uses of web conferencing technologies include:

■ Employee orientation ■ Focus groups ■ Sales presentations ■ Training ■ Meetings ■ Educational presentations (telesemi-

nars) to small or large groups using PowerPoint

■ Support group or therapy sessions

Web conferencing solutions are available to anyone with access to a computer and an Internet connection. The most obvious benefit from the use of web conferencing is a decrease in travel expenses. Solutions can promote effective communication among colleagues in separate offices and can offer a way to communicate with large audiences for relatively low cost.

When searching for a solution that best meets your needs, screen several vendors. The number of participants in a web confer- ence can determine the type of technology that is needed; also, which types of materi- als to be presented: slide presentation, streaming audio, sharing computer pro- gram documents (e.g., Word files). Evaluate

if special services, like event or project man- agement, are required and select a vendor based on what it can provide. Remember that some degree of technical support is needed for all web conferencing solutions.

SUMMARY

In the not-so-distant future, we will be elec- tronically communicating with patients to deliver just-in-time care. Patients will give feedback throughout the week on their handheld and home computers. Daily, and even hourly, blood pressure, blood sugars, food records, and thought journals, will be stored online for those health professionals treating a patient to access at any time. Physicians and healthcare providers will be able to set triggers or thresholds for data that will initiate an email to the patient’s healthcare team members. For example, when a patient’s blood sugar rises above a specified amount, an email is sent to his or her physician, RD, case worker, and the pa- tient. The email contains the high blood sugar value and a tailored message to the patient on what they should do before the doctor or physician’s assistant calls.

Education and advanced training of practitioners already take place in the con- venience of their offices or home, online, and everywhere else by handheld palm-size computers. For dietitians selling products or services, the capabilities of business soft- ware often replace a bookkeeper or greatly reduce the number of hours needed. The software helps an entrepreneur keep over- head lower while at the same time improv- ing customer service, credit card processing, invoice generation, and keeping track of accounts receivables and payables.

In-person meetings will become rarer as technology improves and costs of travel go up. As young professionals raised with new technology (and thus they have a level of comfort not understood or known by older managers) take positions of influence, tech- nology use will blossom into even more facets of daily life.

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4. Elias M. Internet therapy clicks for patients. USA Today, May 23, 2001.

5. Bergman M. The Deep Web: Surfacing Hidden Value. BrightPlanet’s website, February 22, 2001, available at: http://www.brightplanet.com/re sources/details/deepweb.html. Accessed on December 1, 2008.

REFERENCES 1. Web Trends: Email therapy may be effec-

tive for eating disorders. Internet Healthcare Strategies, September, 2001.

2. “Information therapy” offer provides a new avenue of patient education, Medicine on the Net, March, 2002.

3. Reid B. Rx for the Future: Get an Ix: Washing- ton Post, June 25, 2002.

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DO I NEED A WEBSITE?

Yes, no, maybe, not sure if the investment is worth it? Or, should I try to save money and create it myself? The decision whether or not to create a website should be made after careful assessment of what you expect that website to accomplish. This chapter will help you to make that assessment.

The first critical step is for you to estab- lish specific purposes for the website and rank those purposes by importance. In other words, you need a plan. It is akin to having a roadmap for a trip, you need to know where you are going before setting out on the huge task of designing a website. With- out a well-plotted roadmap, you may take several detours and worse yet, may never reach your destination. Before you can de- cide what all you want in your website, you must know what you are setting out to do with the website. It sounds so simple, yet it is too often overlooked in practice.

ESTABLISHING PURPOSES AND PRIORITIES

Without a clear purpose, the website can- not be effective. Several common website purposes are listed below. Select one as your primary purpose and then rank oth- ers that apply as secondary purposes (1). These are critical to convey to your website designer and developer.

1. Improve/create business or pro- fessional image. This purpose strives to increase credibility in a

specific field (e.g., professional organizations, dietetic programs) or increase visibility as an expert in a specialty area (treatment of burns, diabetes, medical nutrition therapy [MNT], kitchen design, or menu consultation).

2. Better serve your current clients. Enhanced customer service is often the primary reason why existing busi- nesses establish new websites. Exam- ples of this purpose include interactive customer service of all types, product and service descriptions, selling prod- ucts or services, “brochure” and com- pany directories, FAQ (frequently asked questions), hours of operation, regularly used client forms easily ac- cessible for clients, members area for current clients, and online order form that allows clients to pick up items at their next appointment.

3. Attract new clients/customers/ members. This covers both local and outside local geographical area. A common vision today is to expand a reach of business outside local geo- graphic borders to national and even international customers. Fifteen years ago, this was only possible if your business was a large corporation with large resources. Now, with the Inter- net, a high search engine ranking for a website allows a business to reach a broader audience, possibly hundreds and thousands more potential cus- tomers than a local reach. Also, it is common for potential customers to

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e-commerce setup and emails. Shop- ping malls, corner stores, and other physical retail outlets require careful attention to details such as layout and decor. E-stores are no different. Some- thing as simple as listing the steps of placing an order and having the but- tons clearly marked can make cus- tomers happy, yet many sites neglect to do it.

WEBSITE COMMUNICATION APPLICATION

The variety of website styles is infinite, but virtually, all websites communicate at one of these three levels:

■ The first level is strictly informative and functions much like an online brochure by listing the business services, activi- ties, personnel, office locations, tele- phone numbers, etc. A more elaborate version might go one step further and include detailed information on topics related to services or products offered. Goal: Relay information about the busi- ness to users, establish credibility, and identify the uniqueness of the business over its competitors. Benefits: Saves money because it is less costly to create a first-level website than a professional print brochure. Also, it saves time because information pre- sented can answer questions for users and avoid phone calls from users in- quiring about the basics of business.

■ At the second level, websites are in- teractive by inviting an exchange of information through online forums, customer service, discussion groups, blogs, reply forms, etc. Goal: Start forming a relationship with users. User feels heard and important, and a sense of connectedness to the business. Benefits: Users that feel a relationship with a business are more likely to return to the website. When they have a need for a product or service the

go straight to the Internet and search for a local business on the Internet, bypassing phone book or even sur- passing the reach of word-of-mouth referrals. The Internet is easy and quick for potential customers wanting to locate a specific service or product at that moment.

4. Market products. The marketing of products or services is closely asso- ciated with attracting new customers, but they aren’t always the same thing. A registered dietitian (RD) or a dietetic technician, registered (DTR) who gives food safety demonstra- tions, for instance, might attract new customers by displaying past projects on the web, expecting that sales will come later. The design of that website will be different from the design of a site meant for online retail sale of ed- ucational materials.

5. Provide educational resources. This is usually a secondary purpose, unless you sell continuing education. It may be used to attract repeat visits to a site or promote goodwill. Dietet- ics professionals might include sam- ple diets or information on the basic food groups or an area of expertise like eating disorders or allergies. Or- ganizations might see education as the primary purpose of their websites. One example would be an association that serves as a clearinghouse for in- formation about a rare disease.

6. Sell products or services. This re- quires an e-commerce setup where customers can shop and pay online. The focus here is on user-friendliness and speed. It is also a good idea to give multiple ways for users to be re- assured they have purchased the cor- rect product and their purchase was a wise decision. This is done through visual images in the shopping cart of what the user purchased: prominent shipping information, confirmation emails with order and shipment in- formation, and professional-looking

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business offers, they are much more likely to consider making purchases at that business.

■ At the third level, websites are designed to “do business” with the user. This category includes e-commerce sites where items are sold, plus renewing memberships, making appointments, interactive continuing education, or fund raising. Goal: Making it easy for user to “do business” with you from the comfort of their own computer. The action de- pends on the “business” of the web- site, whether to purchase a product or service, call and schedule an appoint- ment, take an online course, call and request a quote for business services, or enter information online to request a quote. Benefits: Business is done via the web- site thus saving overhead costs of doing business in a brick and mortar location. Physical office may be re- quired for a portion of the interaction with the user, but the website is an in- tegral part of what the user experiences during their purchase of a product or service with the business. Depending on nature of business, it can poten- tially attract customers outside the local geographic area.

HOW MANY “HITS” (VISITS) WILL I GET?

Numbers are important, but they tell only part of the story. In theory, your new web- site will put you in contact with more peo- ple than you could reach with a 1-minute Super Bowl advertising slot. The often mis- understood irony is that the number of users that visit your website homepage is not important. Instead, the number of tar- get market users that visit your homepage is what you want to focus on. Most web- sites will succeed or fail on their ability to attract “hits” (visits) from people who are already interested in what that website has

to offer—their target market. Obviously, the mass retailers look for massive numbers of site visits but most websites achieve their success from a special niche. The gross number of site visits is far less significant than what you achieve in new sales or new memberships or whatever else has a direct impact on your success or bottom line. If you will pardon the pun, only the “net” amount is important.

A well-designed website will attract cus- tomers, members, clients, etc., who are ac- tively looking for what you have to offer. To make this happen, however, you have to identify your target market. Actually, you may have more than one target mar- ket, but each will have an identifiable set of characteristics. The site should then be de- signed to attract visits by web users who share one or more of those characteristics.

Take a few minutes to write down all you know about who your target market is— people interested in what you have to offer. Write down their age range, gender, mari- tal status, whether they have children, and possibly, the number of children, hobbies, preference to eat out or cook, physically ac- tive or inactive, rent or own their house, etc. The more mature your business, the more detailed your target market descrip- tion will become. This information is espe- cially important for the designer who will need to select colors and photographs tar- geted to this audience.

A helpful exercise to determine who you are looking to attract is to ask, “What are the pains, challenges, and needs of some- one that would buy my service or prod- uct?” Once you brainstorm this question, you can begin to paint a picture of whom they are and whom you are looking to at- tract—your target market.

WHO WILL DESIGN THE SITE?

Some readers may be thinking of creat- ing their own websites. For those with the time and ability, that may be the way to go. The starting point, however, should be

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■ Ask the designer to walk you through the design process, step by step, to make sure you will be invited to review and comment at frequent intervals.

■ Determine the timetable for the ini- tial design process, but also ask about response time for postproduction glitches (There will be some!) and for updates, etc.

■ Determine the approximate cost and how costs beyond the upper range are communicated and approved. (A cost range is usually appropriate because the designer can’t foresee how the project will change as he or she learns more about your needs and you learn more about what the website can do for you.)

■ Decide whether you like the designer because personal chemistry, especially the element of trust, can help or hin- der a project of this magnitude.

■ Ask about cross-browser compatibil- ity—some design firms only design for the latest version of Internet Explorer. Determine if your target market is cor- porate based or home based. Designing for all browsers and browser versions is also unrealistic, but top browsers and releases in last 2 years is a good guide if your audience consists of the home user market.

The above suggestions hint at a postpro- duction relationship. Unless you plan to part ways with the design firm as soon as the site is up and running, you might ask about additional services:

■ Maintenance—Does the design firm offer maintenance beyond the initial site set-up?

■ Training—Will they train your per- sonnel to maintain your site?

■ Hosting—Does the company offer hosting services? You may avoid buck- passing by having a single firm re- sponsible for design, maintenance, and hosting.

■ E-commerce solutions—Can they develop an e-commerce package, if

a library or bookstore. You will need work- ing knowledge of site navigation, graphics, hosting options, and numerous other tech- nical factors that will determine how your website will function. Study the guide- books and be prepared to work and rework the site as needed to fix the glitches that are bound to crop up. Instructions for a do- it-yourself project are beyond the scope of this chapter. That is probably just as well because site design is a developing art, and the technology and recommended guide- lines change frequently.

CHOOSING A WEB DESIGNER

There are numerous individuals and firms who can design your site for a fee. The pre- ferred methods for locating a designer are to look at sites you admire and ask for the designer’s name and through referrals by other business owners. The trick is to find an appropriate designer for your needs and price range. You can obtain a basic website in an off-the-shelf format for a fraction of what custom design services will cost. You should visit sites created in the same for- mat you are considering. However, the most important test is if sites in a designer’s portfolio perform the functions identified in your plan. Can they do what you want done and can they do it effectively?

The choice of a website designer can be difficult because the average web user sees only the result, not the technical decisions that go into producing that result. The user can appreciate a pleasing visual layout, but may not notice details of the functional de- sign. Both elements—style and function— are critical to the effectiveness of a website. The following steps are suggested to help you make an informed choice about a web designer:

■ Look at the design firm’s portfolio long enough and hard enough to de- cide whether you like their work (2).

■ Obtain references and contact as many customers of the firm as it takes to give you a reasonably consistent rating of the firm’s performance.

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this is in your future expansion plans? Do they offer a secure server, shopping cart software, or online credit card ac- ceptance setup?

■ Database setup and manage- ment—Do they have the capacity to setup a database-driven site for inter- activity (for such things as a site search function, online shopping, or online directories)?

■ Mailing list management—Who will update and maintain the email list for newsletters and promotions? Do they have a solution you can manage yourself if costs are a concern?

WILL EVERYBODY KNOW MY NAME?

DOMAIN NAMES

Each website is identified by a specific IP (Internet Protocol) address. An IP address is numerical and looks something like this: 123.000.123.00 (3). Because words are much easier to remember, each IP address is also assigned a domain name. Each Uni- form Resource Locator (URL) (http:// www.yoursite.com) or domain name is the distinct name that is associated with one specific IP address. A Domain Name Server (DNS) keeps track of which domain names are assigned to which IP addresses. From this hodgepodge of technicalities comes one simple conclusion: you need a domain name that you can call your own.

CHOOSING A DOMAIN NAME

The following are some helpful hints for choosing a name:

■ Choose a domain name that closely matches your company’s name or what your company does.

■ Keep the domain name short and easy to spell. An exception is if the domain has a ring or rhythm to it, you can go a little longer in domain length but it must be easy to spell. If it has a

rhythm to it, it is often easy for people to remember.

■ Choose a domain name that is distinc- tive and easily recalled.

REGISTERING A DOMAIN NAME

Expect some frustration here. No two web- sites can have the same domain name. (Similar names with different suffixes, such as “.com” or “.org,” are actually different names.) With millions of domain names al- ready in use, there is a good chance that your first choice of a name for your site has been taken, and maybe even the second and third choice.

Go to http://www.internic.com, http:// www.register.com, or http://www.network- solutions.com to see if your name is avail- able. Find the link for Whois—this is the database of already-purchased domain names with listings of who the owners are.

Although it is sometimes possible to purchase rights from an owner who previ- ously registered the name you want, it’s easiest to keep searching until you find a name that is both acceptable and available. The gold standard is the .com domain ex- tension. It is possible to market success- fully a .net, .org, or .info domain extension for a business too. Do not give up; I have found creative names available with .com extensions.

It is very important to make certain that your name or business is listed as the reg- istrant in the application for a domain name. That determines who “owns” the name. You do not want to find out at some future date that your site designer or your hosting service controls the use of the name that identifies your organization on the web. Communicate this with your web designer from the beginning. Domain names are the number one challenge in my business over the years because busi- ness owners unknowingly let a domain name expire, not keep their contact email listed current with their domain name, or allow their previous designer be listed as the Registrant.

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large sites or sites that require third party software be installed on the servers.

■ “Free” web space from Internet service providers (ISPs), cyber- malls, e-commerce services, etc. Some hosting services are “free,” but there are some drawbacks: they tend to lack space and features, and most re- quire that you invest in advertising with a banner ad, pop-up ad box, or logo. Another disadvantage is that the website can’t use its own distinct do- main name or URL. Instead, the site must use a URL that is a subdomain under the host’s domain name. (For ex- ample, instead of having your own name, http://www.yourname.com, you would be a subdomain of the com- pany, http://www.thehostingcompany .com/yourname.) If you change host- ing services in the future, you will have to change your URL as well. The bot- tom line is that you should carefully re- search why the service is “free” before committing to hosting with a free web space provider.

■ You can be your own server. You could host your site on your own server from your business location with the appropriate hardware and software. The biggest benefit of hosting your own site is that you have complete control over the site. For a small enter- prise, however, the cost far outweighs any benefits. For the larger organiza- tion, self-hosting may make sense, but it should not be attempted unless you have experienced personnel to set up and maintain the server.

CHOOSING A WEB HOSTING COMPANY

There are multitudes of web hosting com- panies available. Conducting a simple search with the key words “web hosting” will give you an exhaustive list from which to choose. Start first with each company’s home page. See how the information is

COST OF A DOMAIN NAME

The cost of maintaining a domain name varies from one registration service to the next. Current annual rates generally run in the range of $30 to $45.

TRADEMARK YOUR DOMAIN NAME?

There have been disputes over who is en- titled to register a domain name. Obvi- ously, Nike, the footwear giant, should be entitled to the name “nike.com,” but does “tyco.com” go to Tyco Electronics or Tyco the toy maker, each a giant in its own in- dustry? Although you may never get into a legal hassle over your domain name, you should give it as much protection as is rea- sonably possible (3). See Chapter 13 and ask your attorney about the necessity of registering your domain name with the U.S. Patent and Trademark Office. This does not guarantee that no one will ever challenge your ownership, but it does strengthen your case if a challenge does de- velop. (In a small business, no one loses much sleep over this issue.) It is important, if regis- tering a domain name, you consider the trademark implications.

I HAVE AN ADDRESS, BUT WHERE IS MY HOME?

Perhaps the most difficult concept to grasp is the fact that every website needs a home. More exactly, there has to be a physical de- vice (a “server”) that stores—electronically— all the computer code that constitutes any given website. Generally, the physical loca- tion of that device is insignificant, so long as the server is connected to the Internet. There are several options (4):

■ Web hosting company. Without question, this is the recommended option for hosting a serious website. A shared hosting package is sufficient for 98% of non–Fortune 500 busi- nesses on the Internet. A dedicated server is only needed for extremely

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organized, and how much information you can get from each website. The hosting package that you will need depends on what you want to do with your site. If you are planning on a simple informative site, you can get a basic shared hosting package anywhere from $15 to $20 per month from a reputable web hosting company. There are plans for less too, but typically anything less than this is cutting down on customer service and this is not worth the cost sav- ings. For a serious business website, you want hosting with support 7 days a week— both email and telephone support. If you are planning on building an e-commerce site or using any interactivity that requires a database, plans will start at $20 to $60 de- pending on your needs.

Typically, the web company maintain- ing your website will have several recom- mendations for web hosting companies as each hosting company is set up slightly differently.

Also, if you have any database-driven features or forms on your website, they will require specific programming languages to be operational. Get hosting specs from the website company that designed your site to make sure your site is functional.

WHAT SHOULD MY SITE LOOK LIKE?

The overall look and feel of your site should reflect the image you want to portray. If your business has brochures, business cards, etc., that you already like, continue with the “look” and tone (colors, wording, style of writing, etc.) on your website. This may en- tail using slightly different colors and design elements online, but the overall atmosphere is consistent with the offline feel.

A website’s tone is a very important de- sign decision. This sets a site’s overall atmos- phere and mood. The tone information will be used to determine a site’s colors, design accents (bullets, horizontal bars, buttons, etc.), font, and layout. Most importantly, the tone should be consistent throughout

the site. In the marketing world, the tone and atmosphere that your business creates is part of its branding platform.

Come up with three adjectives to de- scribe the tone you want visitors to your site to feel when browsing your site. What adjectives do you want visitors to use to de- scribe your site to their friends? Business- like? Cutting-edge? Warm and inviting? Energetic and passionate? If you want a warm, inviting site, consider which colors would portray that image. If your business is geared toward children, consider which fonts, colors, and graphics would give your site a lively, fun tone.

DESIGN LIMITATIONS

Graphics When using graphics, it is important to re- member that the more graphics on a page, the slower the page will appear on the screen to the user. Graphics should en- hance a web page and its message. Graph- ics need to have a purpose or else their purpose is simply to slow the download time of the page (5,6).

Animation Animation can be overused or used incor- rectly. Any animated feature on a page will draw the viewer’s attention to that spot. If you want their attention drawn there, then use it. If you don’t have a purpose for draw- ing attention, then don’t use it (7). Even with high-speed connections being com- monplace today, research finds that anima- tions that take longer than 3 seconds to load detract from the users’ experience and are best not placed on a homepage as visi- tors will leave before the animation finishes loading.

Fonts There are only a few standard fonts that can be used for main body text on your site that you can be assured all computers will have installed on both Mac and PCs. If you use a nonstandard font, you run the risk that most computer browsers will show the

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provide something your target market val- ues. Typically, a newsletter encourages read- ers to visit your website. By pulling your target market to your site, they will more likely buy or do what you really want them to do—view a page with advertisers’ ban- ners, read a collection of articles you wrote, or schedule a one-on-one chat with you.

A blog can be used to carry on an infor- mal conversion with your users. It is easy to post an entry several times a week on something you read or saw that is of inter- est and even better that is of value to your users. Viewers can be invited to post their comments. It is a more informal interac- tion application than an email newsletter. It is also easy to get something posted quickly. The biggest flaw in blogs is an owner that does not take the time to post. I find many business owners are just too busy to post to a blog regularly. Users will not stop to read a blog with less than bi- monthly entries. Users need to feel the blog information is current and cutting edge.

Discussion groups, chat rooms, and web- casts are effective methods of interactive communication. You can host a discussion group that focuses on a topic of interest to your target market or set up a chat system for customer service. Another option for chat is where visitors with a question press a button on the screen and it sounds a tele- phone ring on the computer at the other end to alert whoever is taking calls that someone is online with a question. This is one-to-one chat. Customer service is the most common use for this, but there are many other uses like dietitian-on-call, on- line customized food orders, and tutor- ing during an educator’s office hours. Chat and webcasts also can be used for two-way discussions at preset times with a leader in charge or a guest speaker where ques- tions are held until after the speaker is done presenting online. Webcasts are online pre- sentations/lecturers with a speaker and au- dience online at the same time. Webcast provider costs have decreased drastically in recent years. It is an affordable option for many businesses to host a lecture for free or

words with their standard font, instead of your font (8). If you feel the need to use a nonstandard font, you can make titles with the nonstandard font as a graphic and use a standard font in the body text.

WHAT SHOULD I PUT ON MY SITE?

Content is the core of the Internet. It’s one of the unique advantages of the Internet. What content is included, how it’s pack- aged, and whether it’s easy to access deter- mine if a website shines among the rest or is lost on the web.

Take time to plan your content for its launch and how it will expand over the next few years. The content included must be of value to your target market. What top- ics are your target market looking for? It must be updated and changed frequently. New and updated content gives your view- ers a reason to come back to your site. Adding interaction gives another reason for visitors to come to your site and revisit it.

ADDING INTERACTION

Interaction (two-way communication with visitors) sets the Internet apart from tradi- tional media. It engages visitors. It’s very ef- fective at establishing a nonemotional relationship with visitors. Interaction adds value to the viewer and is a great method for starting to establish a customer relation- ship (9,10).

Feedback helps your viewers contribute to your site through suggesting links to your site or giving feedback or their opin- ion in a poll. Visitors feel a sense of contri- bution if the questions are worded properly and if their input is taken seriously. Typi- cally, demographic questions are included in order to get to know site visitors better— keep it to only a few to increase chances that the questions are completed.

An email newsletter can be used to an- nounce new services, provide dates and lo- cations of presentations, tips on using products, brief articles, or information left out of publications. The newsletter must

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for a low fee where users are allowed to ask questions at the end or at set times through- out the presentation (see Chapter 22).

A calculator is a great interactive tool for users. A calculator can be as straightforward as a calorie calculator or more advanced as an eating disorder risk calculator (score indicates a risk level for development of an eating disorder) or nutrient assessment calculator. Calculators typically require a skilled web programmer and an investment up front to build it. After the initial invest- ment though, there is no maintenance cost. Be sure to allow for both metric and U.S. measurements in calculations as users may be international. The key is to find a calculator for an outcome that your target market finds useful or interesting. Think over your user’s typical day, what would help them at work or even after work hours? Calculators can be an effective method for drawing in visitors to your site. One step further is to create a simple calcu- lator and offer to give users the coding so they can integrate the calculator on the website of their own business. You are giv- ing your user something of value for free and when it is displayed on their site it can say, “Provided by. . .” and insert your name. Visitors to their site will see your name and search engines will pick up your site name on your user’s site. That helps your search engine rankings significantly.

This list of ways to add interaction is far from exhaustive. Use your imagination and take advantage of this unique edge interac- tion on the Internet offers.

ADDING VIDEO

Video is a very popular and effective web- site addition. According to the YouTube Fact Sheet (http://www.youtube.com/t/fact_ sheet), 10 hours of video were uploaded every minute at the end of 2008 (November, 2008). Video is a visual that keeps users captivated because it is entertaining and informative.

Before embarking into videos, under- stand that they can take up a lot of web

page space (file size) and bandwidth. Be sure to check with your web host if you are not sure how much storage or band- width you are provided. If you are paying a monthly fee for web hosting, you could ex- ceed your limits and be charged an extra fee if too many people view your video file. Every time someone clicks to view the video, they will be taking up some of your allocated bandwidth. Also find out what video file extensions are supported on your website hosting package.

Record your video with any video cam- era and export or have a media specialist convert to the format allowed on your hosting server. The most common ones are the following:

■ MPG—MPEG video file, a widely ac- cepted format because it often pro- duces the smallest file size

■ MP4—MPEG-4 video file ■ AVI—Audio video interleave file: this

is the default format used by many ed- iting programs

■ MOV—Apple QuickTime movie ■ WMV—Windows media video file ■ SWF—Macromedia flash movie ■ FLV—Flash video files

Most website videos should be no longer than 2 minutes. If your video segment is longer, give careful consideration to the size and value the video will relay to your audience. The intent is for the video to be watched and to either build credibility or persuade a viewer to purchase your prod- uct or service.

You can edit your video yourself using software that costs less than $50 or hire a media specialist to edit and save you time learning the software. You will also need to select an output video display screen size. The smaller the screen size, the quicker the start and load time, and the lower the storage and bandwidth. Larger screens (640 � 480) require more storage, higher quality video, and will start loading slower than small screens (320 � 240). During the editing phase, this needs to be decided.

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orders. The message is stored and read in a secure area on the website. The user can compose and send messages while logged onto the website. Users do not need to download the email onto their own hard drive. This is an avenue for providing secure communication.

ELEMENTS EVERY WEBSITE SHOULD HAVE

There are features every website should in- clude for credibility and user friendliness.

HOME PAGE

The home page answers the questions “Where am I?” and “What does this site do?” (11). This is accomplished through graphics and text. The graphics include a large logo and company name prominently displayed, and design elements strategically placed to lead a first-time visitor’s eyes through the screen from top left to bottom right. The home page has three goals:

1. Give a purposeful first impression— this is the tone and atmosphere you want to portray to visitors. This is your company’s personality portrayed visually.

2. Get visitors quickly to where they are going—put yourself in the shoes of visitors that are coming to your site re- ferred to you through search engines or some marketing campaign you placed. What are they looking for? Prominently display links to what most people are looking for when they get to your site. Easy to understand navigation is important for your major site areas.

3. Tell first-time visitors what you do— you want to include at least two sen- tences of text and more if design allows more content. Users do not read below the fold (the bottom of the screen) typically on a home page. Avoid using only graphics on the

The last step is for your webmaster or media specialist to upload your video file and embed it using the protocol accepted by your website hosting server. Most hosting companies will have support documenta- tion to indicate how to embed the file prop- erly. Make sure there are buttons for start, stop, and pause on the video display to give users control when they view the video.

Keep in mind you do not need to shoot professional-looking video to bring value to your site. Video can be used to demonstrate how to use a product, prepare a recipe, com- plete a form or worksheet, convey speaking and media spot samples, estimate serving sizes, and give your site personality and energy.

The following are examples of sites with videos:

http://www.reconnectwithfood.com news/index.htm

http://www.reconnectwithfood.com http://www.hopewarshaw.com

CONFIDENTIALITY

Keep in mind, whenever you are asking for information from visitors, you need to prominently display or link to a privacy and confidentiality statement. This state- ment should tell visitors what data you are collecting, how the site will use collected data, who will have access to the data (third parties need to be identified), how visitors can revise/update their data, and if data will be reported as individuals or as a group. Many sites, unfortunately, do not post this policy information.

Be certain your system is secure for emails as well. Encryption is a possibility. Limit the employees who have access to clients’ and patients’ emails. Be sure all email-handling procedures treat email as confidential. An increasingly popular method of security for email is to go through a website rather than an email box. You receive an email in- forming you there is a message waiting on- line. You must then log onto a website to read your waiting messages or print your

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home page (11). Search engines can’t index words in graphics. When a vis- itor enters a search phrase at a search engine, the search engine index matches the search phrase to text words found at sites it has visited. A home page with graphics and no text misses being indexed properly and thus isn’t found by search engines. The home page example above has both graphics and text that work together to answer the questions “Where am I?” and “What does this

site do?” See Figures 23.1 and 23.2 for examples of how to layout a home page.

ABOUT/BIO

This is information on the business and owner. It should give some history on the business and the purpose of the website in a brief format. Include a résumé or high- lights of your professional career and train- ing too. The main purpose of the bio page is to establish your credibility, experience,

FIGURE 23.1 ■ Gluten Free Easy home page example. http://www.glutenfreeeasy.com (from Marlisa Brown).

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246 THE ENTREPRENEURIAL NUTRITIONIST

SERVICES/PRODUCTS

Make it easy to locate products and serv- ices. If you establish credibility through purposeful design and well-worded con- tent, users will begin to trust you and want to see if they can use what you have to offer. Cross-promote products and services throughout all your pages to make it easy for users to jump to specifics and how to purchase. Focus on descriptions and de- tails around benefits to users. Your goal is for your site users to buy your product or service so you must talk to the benefit they will gain by purchasing from you. If

and training in your line of business. Keep text minimal while trying to achieve this. See Figure 23.3 for a sample bio.

NAVIGATION HELPS

The navigation helps are determined by the size of the site and expectations of vis- itors. Examples of navigation helps are a navigation bar that remains consistent throughout the site, site map, site search engine, index page, next page prompts, in- troductory pages to website areas, and top and bottom prompts. Every web page should have a text navigation bar.

FIGURE 23.2 ■ Home page example. http://www.robinplotkin.com (from Robin Plotkin).

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you can link the benefit to a problem the user has, that’s even better. Lack of time, increased productivity, and lowered costs are good benefits to communicate in your content to users. See Figure 23.4 for an example of cross-promoting products and services.

ADVERTISERS/SPONSORS

Disclose all sponsors and advertisers and how they are involved in the site. Whether they contribute any content and, if so, that content should be clearly indi- cated. Also, an advertising policy should

be described. Several big health websites in the late 1990s received stiff criticism that hurt their credibility when it was disclosed that they were misleading visi- tors regarding advertisers’ contributions to the site.

PRIVACY/CONFIDENTIALITY

This refers to any information collected at the site. If visitors are required or volun- tarily give information, disclose what will be done with the information, who will have access to the information (any third parties), how users can update/modify their

FIGURE 23.3 ■ “About” page example. http://www.kerigans.com (from Keri Gans).

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248 THE ENTREPRENEURIAL NUTRITIONIST

personnel information, and if information will be reported as individuals or a group (12). Box 23.1 contains sample wording.

CONTACT INFORMATION

This should be displayed on every page or link every page to a separate contact page. The contact page may have directions or a map to the office location. Also, commonly asked questions can be posted here. The idea is someone looking for this informa- tion may go right to your contact page and not take time to look throughout the site for the answer. Save your time on the phone by posting answers on the contact page. See Figure 23.5 for a sample of using contact information.

The following are additional website areas to consider:

■ Testimonials/comments from satisfied clients/users

■ FAQ—frequently asked questions, often these are questions that take a significant amount of time to answer on the phone regarding business prod- ucts or services. Save your time by posting them on your site. FAQs are

also great ways to plant questions for users, questions that draw the user into identifying their need for your product or service.

■ Site map/search—especially useful if your site is large with many pages

■ Map to office—at least two versions, “zoom-in” and “zoom-out” should be included

■ Results—page with success stories, re- sults achieved for clients, or case studies

■ News—way of illustrating to users that you keep up-to-date in the field and are an expert (If credibility or fast changing, cutting-edge information is part of your industry, this is a great page to include on your site.)

■ Media—listing of media interviews and coverage; helpful to establish cred- ibility for book authors and speakers

■ Video clips—from various speaking or media interviews to show your skills in action

■ Clients/Partnerships—listing of major clients, if names are recognizable, in- clude small logos that users can iden- tify immediately. (This helps establish credibility.)

FIGURE 23.4 ■ Example of cross-promoting on pages services/products. http://www.gettingthatjumpstart.com (from Beverly Price, RD, MA, RYT - Principal, Jump Start® Consulting, LLC).

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Sample Privacy WordingBOX 23.1

Privacy Policy When you visit our website to browse or read information, we automatically collect and store the following through our website traffic logs: the name of the domain and host from which you access the Internet; the IP address of the computer you are using; the browser software you use and your oper- ating system; the date and time you access our sites; and the Internet address of the site from which you linked directly to our site.

We use this information only as anonymous aggregate data to determine the number of visitors to different sections of our site, to ensure the site is working properly, and to help us make our site more useful. None of this information collected is personally identifiable information. We do not use it to track or record information about individuals.

Information We Collect We collect personally identifying information, such as your name, street address, email address, phone number, and any other information you provide to us only as needed for the fulfillment of orders of products from [name of business] website.

Credit card information entered in the checkout process is in a secure area using secure socket layer (SSL) encryption to protect the information. We do not save this information. This information is only sent to our online merchant vendor to obtain an approval for the credit card purchase, none of the card number or expiration date is stored.

How We Use and Disclose Information We use temporary “cookies” or tracking mechanisms (session IDs) as part of passing information through the shopping cart and checkout process. No personally identifiable in- formation is passed through session variables or temporary cookies. Instead, the cookies allow

us to remember items placed in your shopping cart. Once you finish checking out or close your browser window or 20 minutes passes, the session ID (cookie) is deleted from your computer.

If you order products, we collect personally identifiable information. This includes name, ad- dress, email, and any other information needed for fulfillment of your request.

If you contact us to order products from the website, we use the information to fulfill your order or contact you about your order. We do not use this information for any other purposes or make it available to any third parties.

We use SSL encryption to protect the transmis- sion of the information you submit to us when you use our secure checkout process. The information you provide to us is processed securely.

Please do not use email to send any sensitive information like your credit card or charge card numbers to [name of business]. Any email that you send us is not secure against interception. Please contact us instead via phone or mail if you will be providing sensitive information.

Mailing Lists You have the option of signing up for an email newsletter. If you do so, we will email you regularly with new programs and products. We do not share or sell our email lists with anyone not con- nected with [name of business].

Outside Links [Name of business] may provide as a convenience to you, links to websites operated by other entities and persons, but makes no representations about any other website that you may access through this one. Any link to a non-[name of business] website does not mean that [name of business] endorses or accepts any responsibility for the content, or the use of such website.

ARE THERE OTHER ISSUES I NEED TO BE CONCERNED WITH?

BROWSER COMPATIBILITY

Users who purchase nutrition-related products and services often will be access- ing websites from their home computer.

Home computers typically are not up- dated as frequently as corporate comput- ers. It is key to relay this information to your website designer. There are signifi- cant differences in coding designs for dif- ferent browsers and in some cases, even for different browser versions. For home users, it is recommended you design for

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SECURITY

Security for a website is both security of your visitor’s information, as well as secu- rity of your site’s information. There are several methods of promoting security. The more methods you employ, the more se- cure your site will be. You should con- stantly be updating your security methods and checking for security problems.

The first step to check the security of your site is finding out more about your web hosting company’s security methods.

the top browsers—those with 10% or more of the user market and go back to any ver- sions released in last 2 years. Also, look at your website traffic logs. They can tell you the browser and browser version of users that have visited your site. Many website design companies set up their designing processes to target mid- or larger-sized companies and in reality, only design to the browser Internet Explorer and only Microsoft supported versions. This is far from reality when your user base is access- ing from home.

FIGURE 23.5 ■ Dietitian Advice: contact page with map. http://www.dietitianadvice.com (from Kathryn Fink).

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You can ask them to provide you a copy of their security policy. It is important to know who has access to your site files within their company as well as what methods of security they employ to pre- vent hackers from accessing your site files and using email servers to send out spam (firewalls, encryption, etc.).

As mentioned earlier, if you are asking viewers for any personal information, you should have a copy of your privacy policy available on your website.

Protecting Your Content Stealing content on the Internet, unfor- tunately, is a common practice. Content can be lifted and posted on another site— so the other site gets credit for writing the information.

The most basic way to protect your con- tent is to display your copyright notice; the “c” in a circle or the word “Copyright” fol- lowed by the date and your name (i.e., ©2009, Mary Jane or ©2009, [Your Com- pany Name]). Copyright protection is as- sumed even without the copyright notice, but by posting the notice, you are warning users who think about stealing your con- tent to stop and take heed of your notice.

For photographs and graphics, use digital watermarks on your images. A digital water- mark is encoded in an image file. If someone copies your image file off of the Internet, the digital watermark stays with the image. Your images can also be tracked through digital imaging companies with a watermark.

If you find a graphic from your site or content verbatim posted on another site, a strong cease and desist email to the site owner warning them of the infringement and asking that the content come down in 24 hours or you will take legal action typi- cally will push the owner to take the con- tent or graphic down.

MALPRACTICE

Carefully review any statements on your website concerning nutrition treatment, “cures,” outcomes, and professional quali-

fications to guard against malpractice. Are you promising cures? Do you claim your care meets the highest standards?

Why is Stating That You “Meet High Standards” a Problem? You are making a promise and if the reader finds out there are newer research findings, you can be found at fault. It isn’t that RDs don’t meet high standards, you just don’t want to set yourself up for legal problems. As RD, if you made this state- ment about “highest standards,” you would need to be very careful about up- dating content all the time. This part of the malpractice information is taken from a health lawyer’s column in an online health publication. Now, there is even in- surance for spelling and grammatical er- rors in Internet content. The insurance covers errors that occur in how your ad- vice appears on someone’s screen, and they follow your advice and it wasn’t what you intended. When your content is out there for the world to see, new issues sur- face and this is one of them. These are red flags for malpractice problems (13). It may be in your best interest to rewrite these areas so they provide general information without promises.

Why is Answering a Question a Problem if the Information is Accurate? Online message boards or forums, blogs, and questions emailed to you from website visitors who are not established patients are potential malpractice landmines. Make sure that the answers you post to questions do not establish a professional–patient rela- tionship—even if you have never seen the person, it could look different (13).

The problem isn’t the information you are providing, it’s more the lack of ade- quate patient information and too many assumptions you are basing the informa- tion on. The patients may not be revealing everything about their case, and very im- portantly, you probably didn’t conduct a thorough assessment, which should be done before ever dispensing treatment

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When responding to nutrition ques- tions via email, only answer specific ques- tions for established patients (13). Create office policies that designate for what purposes patients can use email (16). Dis- courage the submission of revealing ques- tions and information in email. This type of information is best handled over a tele- phone, office visit, or during a secure web conference.

Posting frequently asked questions often protects against malpractice while still pro- viding desired health information. All in- formational content and emails should include a disclaimer such as:

Information contained in this website (email) is general in nature and should not be relied on for medical treatment. If you need nutritional advice or services, please contact a registered dietitian in your area.

There are fewer risks in using the Inter- net for scheduling and administrative functions. For instance, email can be a good way to do appointment reminders and schedule appointments. Post estab- lished protocols and turnaround times on your site.

Print copies of all communications with patients and place a copy in the patients’ records (17). It’s recommended that an au- toresponder (an automatic email response setup by your email program) be config- ured in your email system (16,18) to ac- knowledge receipt of all patient messages (consult your email help center). Here is an example autoresponder message:

Nutrition Company at contact@nutritioncom- pany.com has received your email. We will respond to you within 48 business hours. If this requires an immediate response, call our office at 972-321-XXXX. If you have not previously checked, you are encouraged to view our Fre- quently Asked Questions at http://www. nutritioncompany.com/faqs/ to see if your ques- tion has been answered there.

advice. The problem is that the person reading the information or receiving your response may believe you are treating them. If they do, you can get in hot water because you have not performed an assess- ment. You must obtain a consent from an online “patient” before starting any type of counseling or MNT relationship. Practi- tioners must be aware they need to use caution in posting answers to message boards and to questions emailed off the website. Any erroneous advice you pro- vide, perhaps caused by incomplete infor- mation from the patient, could lead to a malpractice claim. Also, ask yourself if the appropriate course for a patient’s question is a face-to-face meeting or phone consul- tation rather than a “cyber chat.” Advise the person appropriately.

It is important to respect state licensure. If a state outside of yours doesn’t have li- censure, it’s fine to counsel a patient there, but if there is licensure, you need to look deeper into the licensure specifics. Dietetic licensure encompasses a state’s scope of practice for dietetics. It is designed to pro- tect the public from fraudulent practice and services being provided by untrained persons. If you work in a state that has licensure and work only with clients who also live in that state, professional liability insurance is sufficient if practicing within American Dietetic Association’s (ADA) scope of practice (14,15). Crossing state lines to states without any required dietet- ics licensure also is covered. The gray areas begin when counseling clients who live in states outside yours that have mandatory dietetics licensure. In these states, avoid es- tablishing a professional–patient relation- ship with individuals.

Many health practitioners offer infor- mation based on established standards of care such as those published by the ADA, the American Diabetes Association, and other professional associations (14). This is done instead of counseling online. The result is avoidance of counseling online and establishing a professional–patient relationship.

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Request patients to notify you when they receive your messages. Lastly, perform regular backups of email into long-term storage and keep for the same amount of time as paper records (13).

The American Medical Association (AMA) has developed guidelines for med- ical and health information communi- cation: Guidelines for Physician–Patient Electronic Communications (http://www. ama-assn.org/ama/pub/category/2386. html) (13). Although these guidelines were developed for the AMA websites and visi- tors to these sites, they also are useful to other providers and users of health infor- mation on the web.

My disclaimer: This information is not com- prehensive and is not meant as a substitute for legal counsel. If you have questions or concerns, consult a lawyer specializing in In- ternet law.

TESTING AND PROOFING THE SITE

It’s essential to test and proof your site before letting visitors have access to it. Because browsers and browser versions can display pages differently, it’s impor- tant to check all the major browsers. Look at your site with Microsoft Inter- net Explorer (http://www.microsoft.com), FireFox (http://www.mozilla.com/en-US/ firefox/), and Safari (http://www.apple. com/safari/) (19). Browser updates are released periodically, and each update be- comes a new browser version (e.g., Inter- net Explorer 7.0, Internet Explorer 8.0). You can check the company’s website to see what the newest version of the browser is, and then find computers that have that version of the browser, as well as the last two browser versions. New browser versions can be updated onto your computer right off of the Internet. Check at least two of the previous ver- sions of each browser.

MAINTENANCE AND REPEAT TRAFFIC

In addition to creating value on your site, something must change on your site peri- odically to bring visitors back and create re- peat traffic. The following are examples for content that might change on your site to draw repeat traffic:

■ Useful articles on a topic of value to your target market with new ones added monthly

■ New sweepstakes every month ■ Blog entries ■ Podcasts ■ New articles added monthly on how

to use a nutrition calculator posted on your site

■ Weekly chat or webcast hosted by dif- ferent experts

■ A nutrition tip that changes every 2 weeks

■ Monthly feature of a vegetable and fruit with tips on buying, storing, and how to prepare

■ Food service special diet menus that cycle weekly

The first time visitors browse your site, they may not buy your service or product nor comprehend the information you are providing. It may be on their second, third, or fourth visit when this desired behavior occurs. This is why repeat traffic is a key to success.

Related to this are time and money. Time and money must be budgeted for maintenance right at the start of planning a website. One of the biggest mistakes that small businesses make in developing a web- site is not allotting sufficient time to update the site and not allotting sufficient money to promote it.

Before the website is finished, determine who will be responsible for updating and adding to the website once it is operational. Someone will need to be responsible for co- ordinating new content, maintaining the graphic and editorial standards, and ensur- ing that the programming and linkages of all

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http://www.microsoft.com

http://www.mozilla.com/en-US/firefox/

http://www.apple.com/safari/

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THE LAST STEP

After planning, developing, evaluating objectives, and making changes to your website, the cycle starts again. Think about how you want your business to grow, and begin to plan and outline those changes. Then take action on those plans, collect feedback, evaluate the re- sults, and incorporate what you learn into your site. A website is a work in progress. It constantly evolves to respond to the needs of its visitors. Think of your on- line business like a garden that thrives with attention, careful watering, and pruning.

pages remain intact and functional. Don’t let your site go stale by starving it of resources just as you begin to develop a following of clients.

Webmasters often are the best people for the job. Many have reasonable rates for maintenance. Another option is to contract someone to train you on how to update your site (if you didn’t develop it). Allow suf- ficient budget for training on how to update your site. Some dietitians combine the two. They reserve the simplest monthly/quarterly updates/revisions for themselves to carry out, and the more advanced revisions and additions to the site are done by a con- tracted webmaster.

C A S E S T U D Y 2 3 . 1

F E E D Y O U R C A R E E R , L L C

Feed Your Career, LLC, was founded by Teresa Pangan, PhD, RD, and Mandi Wong, RD/LD. The venture was launched in October 2008. It took Teresa and Mandi almost 2 years to bring Feed Your Career, LLC, to fruition.

They started off by developing a detailed business plan that included a competitive mar- ket analysis, company overview, marketing strategies and company financials. They also signed a partnership agreement that clearly laid out roles, expectations, and terms for managing the business. Finally, they each took a strength and personality assessment to learn more about their working styles and to identify areas where their talents could be best utilized.

The web development phase took almost 9 months to complete. They hired a branding marketer to cultivate a positive, professional company image. They also hired a graphic designer to create a custom logo for long-term visibility. The website design concept was developed using a wire frame methodology. The result is http://www.feedyourcareer.com.

This comprehensive career management website offers food and nutrition professionals a wealth of tools and information including

customized career and personality assess- ments, articles from leading career experts, well-matched career opportunities, a profes- sional directory for networking, continuing ed- ucation events, a career product and service marketplace, a personalized career manager, and inspirational success stories. They also have a regularly updated career blog and inter- active discussion board on career topics.

Website Logistics Domain Name: http://www.FeedYour Career.com

Website Planning Primary Purpose ■ Create a comprehensive career management

website for food and nutrition professionals ■ Highlight career opportunities and pro-

mote companies that hire and support food and nutrition professionals

■ Provide solutions and strategies for achiev- ing career fulfillment in the food and nutri- tion industry

■ Develop a strong online community for food and nutrition professionals to support one another

■ Ultimately, empower food and nutrition pro- fessionals with tools and resources to create job satisfaction and career fulfillment

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CHAPTER 23 ■ Website Basics 255

Secondary Purpose ■ Promote the registered dietitian as the nu-

trition expert and build relationships with companies that hire dietitians

Target Markets 1. Employers that hire food and nutrition

professionals 2. New dietetic graduates 3. Career changers 4. Professionals that are dissatisfied with

their current job/career status

Value or Pain and Challenge Satisfying

Target Markets Pains Employers that hire food and nutrition pro- fessionals ■ How can I find qualified candidates quickly

with the least amount of time and stress?

New dietetic graduates ■ What job opportunities are available to

new graduates or RD-eligible graduates? ■ What opportunities are available in the

location that I want? ■ How can my résumé stand out from the rest? ■ How can I best prepare myself for the

interview?

Career changers ■ What job opportunities are available that

match my needs, interests, strengths, and personality?

■ How can I really sell myself during the interview?

Professionals dissatisfied with their current job ■ How do I change my current situation so I

feel more passionate about my job and career?

■ What job opportunities would match well with my needs, interests, strengths, and personality?

What Value Will “Feed Your Career, LLC” Provide to Address the Pains of the Target Markets? Employers that hire food and nutrition professionals ■ Flexible and easy payment options includ-

ing multiple listing discounts

■ Visually appealing job posting that accen- tuate unique benefits of position

■ Prescreening questions for potential appli- cants

■ Direct access to food and nutrition profes- sionals with various backgrounds, educa- tion, and experience levels

■ Opportunity to create branding campaign for company image

New dietetic graduates ■ Job filtering capability based on career sta-

tus (new graduate and RD-eligible) ■ Resources for résumé writing and inter-

viewing

Career changers ■ Articles from career experts specifically for

career changers ■ Directory to network with professionals and

employers

Professionals dissatisfied with their current job ■ Personality and career assessments to help

identify their strengths and recommended job tasks

■ Free career manager to help organize their ideas and create an action plan

■ Articles from career experts specifically for professionals that are stuck

■ Inspirational success stories from other food and nutrition professionals

Branding Essence ■ Passionate ■ Resourceful ■ “I can” mindset ■ Credible ■ “WebMD meets Oprah on career ful-

fillment”

Low-Cost Promotion Methods

American Dietetic Association’s Food and Nutrition Conference and Expo (FNCE)—October, 2008 Mandi and Teresa purchased booth space and promoted their business at two events held during this national conference—the Product Marketplace and the Center for Career

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256 THE ENTREPRENEURIAL NUTRITIONIST

Opportunities. Informational postcards were passed out to visitors along with customized fortune cookies that included their logo, website address, and inspirational career quotes. They gathered email addresses and took individual photos that students and professionals could have the option of including in their online profile and in the Feed Your Career Professional Directory.

iPod Raffle Anyone who registered before November 15, 2008, was eligible to win an Apple iPod. This raffle was heavily promoted at ADA FNCE.

Healthy e-Cards Mandi and Teresa hired a graphic designer to create custom e-cards that includes inspira- tional quotes and messages. This value-added product is available to registered users who sign up for a free account.

Blog A career blog was setup to use as a forum for discussing career-related topics, sharing ideas, and connecting with users. It also was an effective tool for increasing search engine rankings.

e-Newsletter Registered users receive a monthly e-zine that highlights expansions on the website along with cutting edge career news. It also draws readers back to the site to view new additions and features.

Email Invite This is the ability for Feed Your Career users to invite others to join. Users generate an

email inviting other colleagues to join Feed Your Career and benefit from all the career management site features.

Referral Program Registered users can post a Feed Your Career logo on their site with a referral link built into coding. The site owner receives a per- centage of any Feed Your Career job posting sales generated from visitors on their site that clicked on the Feed Your Career logo. The program brings in money for the site owner for any sales made and PR for Feed Your Career on external websites—a win/win program.

No-Cost Promotion Methods

Dietetic Practice Group (DPG) Websites Teresa and Mandi are active members of Di- etitians in Business and Communications (DBC) as well as of Nutrition Entrepreneurs (NE). They utilized these DPG’s value-added services and included their company infor- mation in the “Movers and Shakers” section of the DBC website and Products/Services section of the NE website.

LinkedIn Teresa and Mandi use LinkedIn to network with other food and nutrition professionals and promote their website.

Personalized Emails Teresa and Mandi send personal emails and individual e-cards to newly registered users. —Mandi Wong, RD, LD, http://www.FeedYour Career.com

ABOUT THE AUTHOR

Teresa Pangan, PhD, RD, founded her first website design and development company 11 years ago. She primarily works with nu- trition-related businesses and organiza- tions. Her present website design and development company, Webnoxious, is lo- cated in Highland Village, Texas.

SUMMARY

A website is growing in popularity as a marketing tool. It will be required for busi- nesses within the next 5 years or so as peo- ple become even more dependent on the Internet to give them the location of the business (with map), contact information,

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CHAPTER 23 ■ Website Basics 257

hours of business, basic products or serv- ices, and bio of the owner or history of the business. As newer generations of dietetics professionals grow in influence on how businesses work and how people commu- nicate, older media will be less important or be the next “floppy disk.”

REFERENCES 1. Pangan T, Bednar C. Dietitian business Web

sites: A survey of their profitability and how can you make yours profitable. J Am Diet Assoc 2001;101(4):399–402.

2. Kent P. Designing Your Web Site. In: Poor Richard’s Web Site: Geek-Free, Commonsense Advice on Building a Low-Cost Web Site. Lake- wood, CO: Top Floor Publishing, 2000.

3. Kent P. All About Domain Names. In: Poor Richard’s Web Site: Geek-Free, Commonsense Advice on Building a Low-Cost Web Site. Lake- wood, CO: Top Floor Publishing, 2000.

4. Kent P. Where to Put Your Web Site. In: Poor Richard’s Web Site: Geek-Free, Com- monsense Advice on Building a Low-Cost Web Site. Lakewood, CO: Top Floor Publishing, 2000.

5. Nielsen J. Page Design. In: Designing Web Us- ability: The Practice of Simplicity. Indianapolis, IN: New Riders Publishing, 2000.

6. Lynch P, Horton S. Web Graphics. In: Web Style Guide: Basic Design Principles for Creating Web Sites. New Haven, CT: Yale University Press, 1999.

7. Nielsen J. Content Design. In: Designing Web Usability: The Practice of Simplicity, Indianapolis, IN: New Riders Publishing, 2000.

8. Lynch P, Horton S. Typography. In: Web Style Guide: Basic Design Principles for Creating Web Sites. New Haven, CT: Yale University Press, 1999.

9. eTRENDS: Making a Site “sticky” Calls for a Diverse Menu of Tactics. Internet Healthcare, October, 2000.

10. Kent P. Web Sites Are Two-Way Streets – Adding Interaction. In: Poor Richard’s Web Site: Geek-Free, Commonsense Advice on Building a Low-Cost Web Site. Lakewood, CO: Top Floor Publishing, 2000.

11. Nielsen J, Tahir M. Homepage Guidelines. In: Homepage Usability: 50 Websites Decon- structed, Indianapolis, IN: New Riders Publish- ing, 2000.

12. Loch K. How Does Your Website’s Privacy Policy Rate? Beyond Computing, September, 2000.

13. Johnson L. The Internet and malpractice risk. Medical Economics, November 9, 1998.

14. Grieger L. Working Online: Are You Covered? Today’s Dietitian, November, 2001.

15. Horton Eastwood A. Success Online: A Valu- able Resource. Ventures, 17(2), Spring 2001.

16. Guidelines for Physician–Patient Electronic Communications. American Medical Association Website. Available at: http://www.ama-assn.org /ama/pub/category/2386.html. Accessed De- cember 1, 2008.

17. Palumbo C. Using new technology for nutri- tion counseling. J Am Diet Assoc 1999;99(11): 1363–1364.

18. Burgstahler S. Making Web Pages Universally Accessible. Computer-Mediated Communication Magazine. January 1998. Available at: http:// www.december.com/cmc/mag/1998/jan/burg. html. Accessed December 1, 2008.

19. Kent P. Creating an Effective Website. In: Poor Richard’s Web Site: Geek-Free, Commonsense Advice on Building a Low-Cost Web Site, Lake- wood, CO: Top Floor Publishing, 2000.

RESOURCES Books Kent P. Poor Richard’s Web Site: Geek-Free, Com-

monsense Advice on Building a Low-Cost Web Site. Lakewood, CO: Top Floor Publishing, 2000.

Lynch P, Horton S. Web Style Guide: Basic Design Principles for Creating Web Sites. New Haven, CT: Yale University Press, 1999.

Nielsen J. Prioritizing Web Usability: The Practice of Simplicity. Indianapolis, IN: New Riders Press, 2006.

Nielsen J, Tahir M. Homepage Usability: 50 Websites Deconstructed. Indianapolis, IN: New Riders Pub- lishing, 2001.

Siegel D. Creating Killer Web Sites. 2nd ed. Indi- anapolis, IN: Hayden Books. 1997.

Articles Casey C. Accessibility and the Educational Web

Site. Syllabus, September 1999. Flory J. New on the Net: Special Focus: Privacy &

Patient Confidentiality. Medicine on the Net, August 2001.

Learning to use color on your Web site. Inside Web Design, June 2000.

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to access nutrition professionals. J Am Diet Assoc 2000;100(7):757–759.

Techno Web: Getting Really Small: An Ongo- ing Battle With File Size. Inside Web Design, February 2000.

McCray K. Designing around the different browser sizes. Inside Web Design, November 2000.

Net Resources: Making sites more accessible to the disabled. Medicine on the Net, March 2001.

Rourke K, Hern M, Cicciarello L. NetWellness: uti- lizing a consumer health information web site

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Have you ever dreamed about getting thousands of targeted visitors to your web- site each month? It is possible. Promoting a website to draw in potential customers is a reality for small businesses and can be done on a small budget. What it requires is a sig- nificant time investment. After you read this chapter, you will know how to get started promoting your website yourself or if you partner with a website design com- pany, what questions to ask, and how to formulate specific promotion goals. The payoff is gold—targeted traffic coming to your website.

From the first draft of your website, plan on budgeting time for online promotions. During the design phase of a website, a lot of time is spent optimizing it, so search en- gines will find your site. Next, a site typi- cally is submitted to search engines. During the postwebsite design phase, a site’s pro- motion time is directed into activities like:

■ Reciprocal marketing ■ Posting to listservs ■ Advertising in an email newsletter ■ Writing blog entries ■ Emailing out an e-zine

The Promotions Worksheet shown in Fig- ure 24.1 can help you create your promotion plan for your website. Before reading any further, make a commitment to set aside time to promote your website. Through the years in my experience, this has been the number one downfall small business entre- preneurs make—they do not take the time to work on their website promotion.

SEARCH ENGINE OPTIMIZATION

It’s commonplace to refer to the web for in- formation on an existing business or to lo- cate a new business. Telephone book pages are not being ruffled nearly as much in this day of cyberspace. This emphasizes the im- portance of paying careful attention to your site’s ranking in the search engines. The term “optimizing” for search engines means taking steps to increase your rank- ing on the search engine results listings for “keyword phrases” that relate to your web- site and the services and products you offer. There are several simple things that can be done to increase your site’s position in a search engine’s results list:

■ First, the search engine optimization process starts with determining your critical keyword phrases.

■ Next, the keyword phrases are placed in strategic locations throughout your website.

■ Finally, different pages on your site will be indexed for different terms since they cover different topics. Use keyword phrases related to each page’s topic in titles, headings, image alt tags, meta tags, text, and links.

KEYWORD ANALYSIS

“Keywords” refer to words your target market enters in the “search” box in search engines for topics, products, services, or names. To discover what these words

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Teresa Pangan

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260 THE ENTREPRENEURIAL NUTRITIONIST

oping. The words may be different than the target audience would use. An example is the word “dietitian.” If the public is your tar- get market, it is best to use additional words like “nutritionist,” or “dietitian” (spelled with a “c”) along with dietitian (spelled with a “t”) on your website. The words nutrition- ist and dietitian are more commonly en- tered on search engines.

are, ask members of your target market for words they would use to describe your business—ask your clients or cus- tomers who have purchased your products for phrases they would use to find your products.

A common mistake for website develop- ers is to only use keywords they feel are most logical to locate the website they are devel-

Web Promotions Worksheet

SEARCH ENGINE OPTIMIZATION 1. Brainstorm 25 50 keywords that describe your

business/website.

2. Refine keywords to best 10 15 keywords and keyword phrases (critical keyword phrases).

3. Description Meta Tag: Describe site in 1 to 3 sentences (150 characters or less) using at least 2 keyword phrases.

4. Keyword Meta Tag: List top 10 critical keyword phrases, do not put same words next to each other or repeat a word more than 4 times in the entire list.

5. Site Title: Use for site submission to search engines (60 characters or less) Try writing in several and count 40 and 60 characters, including spaces.

SEARCH ENGINE SUBMISSION Date(s) submitted/resubmitted to search engines:

Date(s) checked site in search engines:

PROMOTION METHODS: Choose which ones to pursue, give date begun, and any details.

Date Begun Details Signature file Writing for byline Discussion groups Press release Links Reciprocal marketing Buying links Social bookmarking Pay per click ads E-mail ads Sponsorships Additional ideas FIGURE 24.1 ■ Promotions work-

sheet.

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CHAPTER 24 ■ Promoting Your Website 261

Keywords To begin, brainstorm 25–50 keywords to de- scribe your site. Then narrow these keywords down to the best 10–15 keywords and key- word phrases (2–3 word phrases). Go with keywords and keyword phrases that (1):

■ Are simple ■ Are not hard to spell ■ Include synonyms ■ Include plurals if your target market

enters plurals at the search engines

Rarely is a single keyword appropriate. A single keyword is misleading. For example, “consultant.” Does consultant refer to a food service consultant, banking consultant, party planning consultant, or tax consultant? Vis- itors will be disappointed if they come to your site using the keyword “consultant” and expected tax information. The goal is bringing targeted traffic—buyers interested in what you have to “sell”—not just traffic.

INTEGRATING KEYWORD ANALYSIS RESULTS INTO YOUR WEBSITE

After identifying your critical keyword phrases, they need to be sprinkled at strate- gic locations throughout your site.

Meta Tags Meta tags are hypertext markup language (HTML) code tags (the behind-the-scenes

programming code for web pages) that are placed in a Web page’s program coding. Browsers do not display meta tags; they simply skip over them. Meta tags are in- tended as a method for web developers to communicate information to search en- gines and other developers. The most talked about meta tags that relate to search engine rankings are:

■ Keywords ■ Description

Meta means “information.” Meta tags are information about other data. See Figure 24.2 for an example of meta tags. For years, meta tags have been a critical part of improving your search engine po- sitioning. However, because of “spam- ming” techniques (repeating the same words over and over for pages), and refine- ment of search engine relevancy equa- tions, the weight given to meta tags by search engines has diminished over recent years.

Meta tags are still important to de- velop. However, do not be misled into thinking they will drastically boost your ranking. By following all of the search engine optimization techniques recom- mended in this chapter, your search engine results ranking will increase signif- icantly, but following only one will not do it alone.

FIGURE 24.2 ■ Meta tags from Nancy Clark, RD (http://www.nancyclarkrd.com).

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262 THE ENTREPRENEURIAL NUTRITIONIST

the content of the page. They will not index keywords and phrases that do not ap- pear in the webpages text as well. Search engines are constantly refining their equa- tions to locate webpages that have higher relevancy for a search phrase. They require that words on a page’s titles, alt graphic tags, headings, and meta tags must also ap- pear on a page’s text for relevancy. (Alt tags are “alternative text” programmed into a webpage that is displayed. With most browsers, this text appears when you put your mouse over an image or icon.)

■ First 25 words—important area to include critical keyword phrases; in- clude at least one or preferably two phrases (4).

■ Last 25 words—search engines also look here. Search engine owners be- lieve that it must be an accurate de- scriptive word or phrase for that page’s content, if a keyword phrase appears in the first and last 25 words (4).

Title Title refers to the uppermost phrase in your browser window. It appears as a “bookmark title” if you bookmark the page. See Figure 24.3 for an example of a title.

Use descriptive words in your title. The title should tell visitors what to expect on that page, not on the entire site. If possible, start with a keyword. Search engines do index titles, and the more you can pack into it, the better. Words like “Welcome, One,” or “Best,” are poor choices to start a title. They are a waste of prime search en- gine real estate (4).

A title length should be 60 characters or less. The first 40 characters should contain at least one critical keyword or keyword phrase. Some search engines index 60 char- acters, others index 40 characters.

Examples: “Nutrition: prevention and chronic dis-

ease (41 characters); management services (61 characters)”

“Plant based recipes: easy to make (35 characters) in thirty minutes (52 characters)”

Description Meta Tag This is a brief description of the content of a particular web page or site. It should not be more than 250 characters including spaces since this is the maximum length most search engines will index (2,3). Use at least two of your critical keyword phrases in the description.

Think of the description meta tag as a very short billboard advertisement. Some search engines will use the description meta tag as the description displayed in its results listing. It should reflect the content on that page or site accurately and enticingly.

Keyword Meta Tag Use your top ten keyword phrases together to create your keyword meta tag. See Figure 24.2 for an example of a keyword meta tag. List them in order of importance with the most important listed first. Repeat them no more than three times. The maximum length is 750 characters, including spaces. Typically, you will not come close to using that many characters, but this is the cutoff point for most search engines. Also, do not place the same word next to each other. For example, do not insert these keyword phrases together: “sports nutrition,” “nutri- tion education materials” (3,4). The word “nutrition” is consecutively repeated. Re- versing the order would be fine. Along with that rule, no word should be repeated more than four times in the entire keyword meta tag. The word nutrition is often used in multiple keyword phrases (nutrition educa- tor, nutrition expert, nutrition education materials, nutrition menus, nutrition serv- ices) and may result in appearing more than four times. Search engine software programs will leave out your site altogether if they detect that a keyword meta tag is re- peating a word too often or words are too close together.

Use Keywords in the Body Copy Make sure keyword phrases appear in the text on each page where the description meta tag is inserted because search engines cross-reference keywords in meta tags with

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CHAPTER 24 ■ Promoting Your Website 263

Words in Links Another behind-the-scene technique that contributes to a higher search engine rank- ing is words in links. A search engine gives more weight to words highlighted in a link than nonlinked content text. Words like “click here” will not help your search en- gine rankings, but the phrases “diabetes menu planning” and “vegetarian recipes” (words in blue with underlining) linked to the appropriate pages will. A good web page designer will know how to do this.

Links should describe what a visitor ex- pects to find when they follow the link. It is not necessary to link an entire sentence, just the descriptive keywords.

Alt Image Tag This is an optional HTML tag used to label a graphic. Alt image tags are displayed when moving your mouse over an image or icon (called “mousing”), a phrase will appear over the graphic. See Figure 24.3

for an example of an alt image tag. Not all web designers remember to program this in. Ask your developer to include alt tags for all your graphics. Search en- gines will index these words. They cannot read words in a graphic or artwork, but they can read words programmed into an alt tag.

It is a mistake to use very generic words in an alt tag. Examples are:

■ Fruit ■ Man

Descriptive alt tags will generate more keywords for a search engine to index and helps explain the purpose of a graphic. Im- proved alt tags for the examples given above are:

■ Delicious ideas for a smoothie that is packed with optimal nutrition

■ Patient with cancer visits dietitian for diet to alleviate chemotherapy side effects

FIGURE 24.3 ■ Web page title sample from Banister Nutrition (http://www.BanisterNutrition.com).

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For more sites with links to search engines, use the keywords: �Internet � “search engine” � directories�.

Go to each search engine or subject di- rectory and look for a link labeled some- thing like “Add Link,” “Add URL,” or “Recommend a Site.” They are frequently located near the bottom of the page in small type. Use your completed promo- tions worksheet for keywords, descriptions, and titles requested in each search engine submission form.

Two to four weeks after submitting your site, check your site’s position in all the top search engines and subject directories. This should be done even if you used a submis- sion service. You may need to re-enter your site if it is not listed yet. Many sites never make it into a search engine’s index.

In addition to general search engines and subject directories, there are some spe- cialized health search engines and subject directories (7). Here are some you should consider submitting your site to:

Medical Matrix http://www.medmatrix.org/index.asp

MedHunt http://www.hon.ch/MedHunt

PROMOTION METHODS: MORE TIME BUT LOW COST

EMAIL SIGNATURE FILE

A signature file is an Internet business card tacked onto the end of your email mes- sages. It tells people you communicate with on the Internet: who you are, what you do, and how to contact you. There are four basic parts to a signature file: name, contact information, website address (URL), and teaser line.

Name Give your full professional name with cre- dentials and the name of your company or employer.

Contact Information This includes email address, telephone num- ber, fax number, and address. Not all this

SEARCH ENGINE SUBMISSION

Once a site is optimized, it is ready to be submitted to the search engines. It’s impor- tant to wait until a site is completely ready to go before submitting it. The resultant search engine ranking will be higher with a completed site than with a rushed, not quite finished one.

There are two methods for entering a site into search engines and subject directories:

1.Use a free or paid submission service. 2.Enter your website by hand.

The second option is the most time con- suming, but it’s often more effective than the first option. Many experts recommend enter- ing a site by hand into the top search engines and subject directories (5,6). When submit- ted by hand, the submissions can be cus- tomized. Submission services, both free and commercial, use software to submit a site. Some customization can be done, but not as much as by hand. Many search engines say they are on the lookout for software pro- grams because it is ten times more likely spamming is present with software programs.

SITE SUBMISSION SERVICES

If you are tight on time, here is a sampling of services that can enter your website into 25 or more search engines and subject directories:

@Submit http://www.uswebsites.com/submit

NetMechanic http://www.netmechanic.com

To find more search engine submission services, use keywords: �submission � “search engine”�. Fill in the name of each search engine you want to use.

ENTERING YOUR SITE BY HAND

To enter by hand, go to any of the sites below for a list of links to search engines and subject directories.

Search Engine Guide http://searchenginewatch.com/ 2156221

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http://www.hon.ch/MedHunt

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http://www.netmechanic.com

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CHAPTER 24 ■ Promoting Your Website 265

contact information is necessary, but at least one form of contact should be included.

With email addresses, be sure to put “mail to:” before the actual email address. This tells the email software program to pop up an empty email box with your email address in the “to” box.

For example, in a signature file, it is: email: mail to: [email protected].

Website Address (URL) Include your (URL) website/webpage ad- dress in your signature file, if you have one. Be sure to put “http://” before the web ad- dress. This ensures that the web address is an active link; viewers can click on it and go to your site immediately.

Example: www.hunger.com; in signature file, it is: http://www.hunger.com.

Teaser Line A teaser line provides at least one or two strong reasons to draw people to visit your website or contact you when they read your signature file. It should convey the benefits of your services, products, or content.

A teaser line gives more information on your products or services than saying sim- ply “Nutrition Consultant,” “Book Author,” “Educator,” or “Nutrition Manager.”

Examples:

■ “The roots of education are bitter, but the fruit is sweet.” – Aristotle

■ See our special Valentine’s Day offer, get 20% off all weight loss nutrition videos this week only

■ Food trends and news in supermarket products

■ Get free tips for controlling your blood pressure

■ Managing quality nutritional care and people

Teaser lines are often quotes, specials, phrases, enticements with the word “free,” or a condensed mission statement.

Overall, signature files should be no more than 50 words and 5 lines. The idea is to catch the attention of a viewer and en- tice them to contact you or keep you in mind for future reference.

Most email software programs have an option for creating signature files. Consult the help menu of your email program. This way, every time you send an email, it will automatically attach your email signature.

Two examples of email signature files are:

Krista Foley, RD, LD Nutrition Visions http://www.nutrition

visions.com “Learn to manage your weight for a life-

time.” email: mail to: Krista@nutritionvisions.

com Tanner Bonneman, MS, RD Scott County Hospital Nutrition Services “Food to nourish the soul.” http://www.sch.org email: mail to: [email protected]

Use your signature file every time you send out an email message. It’s the simplest method to increase visibility and to bring visitors to your site.

WRITING FOR A BYLINE

An old-fashioned promotion method is to write content for another website—for a fee or simply for the exposure—and always ask to include your byline with a few words about yourself and a link to your website. Websites are frequently in need of new, fresh content. Find sites where your target market spends time. To write content, you should be well-read and up-to-date on the topic. Choose topics that your target mar- ket may be interested in reading.

DISCUSSION GROUPS

A very effective way to promote a site is by posting comments to online discussion groups where potential customers are sub- scribers to the group (8). By becoming re- spected in the discussion group as an expert on a topic, people will come to trust and respect you. Be sure to include your email signature file on all postings. Be fore- warned, this promotion method can eat up a lot of time, but it is very effective when done properly for the “right” reasons, like

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http://www.nutritionvisions.com

http://www.sch.org

mailto:[email protected]

http://www.hunger.com

mailto:[email protected]

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Reciprocal Links Reciprocal links are when website A links to website B and website B links back to website A. This link building tactic has been used throughout the web for many years and its main purpose is to help web- sites increase their search engine rankings.

Seek links on other sites that satisfy these criteria:

1. Sites/pages with content, products, or services related to yours and not on a page with a long list of different top- ics unrelated to your business.

2. The page your link will be posted on should have less than 20 outbound links (links going to external web- sites), and preferably, less than 10.

3. For the greatest value, the page your link is posted on should be rich in content, not just a listing of links.

4. Anchor text is the wording in the link, the underlined text that web users soon learn means “Click on me to find out more information.” An- chored text ranks higher than non- linked text in search engine formulas.

5. When your anchor text is used on an- other’s website, it should contain your keyword(s), not “Click here,” or “Visit website” or simply your company name, you want to use your keywords in the anchor text if at all possible.

Buying Links Buying links involves paying a site or serv- ice for the purchase of links on other sites. Typically, the sites links are bought on hav- ing similar content or products to yours. The goal is achieving the optimal criteria listing under reciprocal linking through a purchasing plan.

TIP If you want to see benefits from purchased links on popular sites, you need to keep them live for a while. Search engines know that people purchase links, which is why they take the age of the inbound links into account when determining the ranking of a website.

establishing your career as a speaker or au- thor or establishing credibility in a special- ized area in which you offer services.

Press Release A press release can be a very cost-effective promotion method especially if you are of- fering something unique at your website. Press releases are frequently used to an- nounce new websites. However, the only way a media outlet is going to be interested in your story is if you stand out from other websites. You need to find a “hook” when developing your idea for a press release. A press release should focus on benefits to the user (see Chapter 21).

It is critical that you create a newswor- thy press release. Thousands of press releases are generated everyday and sent to the various media. Give your reader a reason to set it aside for further research and not throw into the round filing cabinet on the floor next to his or her desk. Resources on writ- ing an effective press release are:

PRW http://www.press-release- writing.com

For more sites with press release writing tips, use the keywords: �“press release” � “tips”�.

There are free and pay services for dis- tributing a press release. It may be effective to pay for help in distribution. Here are some distribution services that are both pay and free.

WebWire http://www.webwire.com URL Wire http://www.urlwire.com eRelease http://www.ereleases.com

For more sites that distribute press re- leases, use the keywords: <“press release” � “services”>. So you will understand it more clearly, don’t waste your time with this type of marketing unless you have a very unique idea, product, or service.

LINKS

Links can refer to many things. There are reciprocal links, buying links, social book- mark links, and natural links.

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If you are going to buy text links, here are some things to consider:

■ Buy text links from sites with content, products, services, or goals similar to yours.

■ Do not buy all your links; it looks sus- picious to search engines. Mix in some nonpaid links on sites related to your website content and services.

■ Text links within the content of a web- site will generally be more effective than a text link within the footer or the sidebar of a website.

■ Keep links posted for at least 2 months and closer to 6 months if your budget can afford it.

Social Bookmarking A social bookmark is a link that marks a web page so you can find it easily again and so you can share it with others, usually by posting it to one of several dozen social- bookmarking websites. Millions of web users flood social-bookmarking sites to search for information. Users need to spec- ify some keywords, often referred to as tags, which categorize information. This allows other users with similar taste to view the links by topic, category, and so on.

Social bookmarking is unique because of its ability to generate traffic by sharing links. Since bookmarks are categorized, if your business is included in a social bookmark- ing website, you will drive targeted traffic from the bookmark site to your website from users searching within your category. Also, Google is now including social book- marking in its results ranking equation.

As a website owner, you want to encour- age people to bookmark your pages at social bookmarking websites to bring you traffic and increase your ranking in Google. A cre- ative way to encourage your visitors to do this is to include coding at the bottom of your website key pages that allows users to bookmark your page in their favorite book- marking site right from your webpage. Cod- ing to do this is free at TheBookmarketer, http://www.seo-writer.com/tools/book

marker.php. You may need to have your webmaster install the coding, but on con- tent-rich pages, the potential traffic it could bring and its increased search engine rank- ing is worth looking into.

Common social bookmarking sites are:

■ Digg (http://www.digg.com) ■ Yahoo! Buzz (http://buzz.yahoo.com) ■ Technorati (http://www.technorati

.com) ■ Delicious (http://delicious.com) ■ StumbleUpon (http://www.stumble

upon.com)

Natural Links Natural links are simply links that naturally happen through content on a site. The focus on this type of site is content and only good content. Links evolve in the content over time, and there is no strategy for links and getting links on a site that pursues natural links. If you plan on going the natural link building route, make sure you get found by search engines and the top authority sites in your field. Good content is no good to any- one unless it can be found. Be sure that at least a couple sites other than your own have links to your site. That gets the process of being indexed in search engines started.

A strategic method of natural linking is re- serving a location on your pages for related content (called “Related resources” or “Simi- lar topics”), which is often on the right hand column of pages where you link to other pages on your own site. It works to lead visi- tors through your site and is a simple method to include links on your pages with keyword phrases. Keyword phrases used in links on your pages result in a higher weighing in search engines for these phrases.

NETWORK, NETWORK, NETWORK

Despite being a very simple thing to do, many websites miss out on the traffic that can be gained from networking.

Done right, a well-built network of con- tacts, friends, and like-minded bloggers can seriously help you get the link-love you

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268 THE ENTREPRENEURIAL NUTRITIONIST

iar with the term CPM. CPM is cost per thousand (9). The “M” stands for 1000. Ad- vertising prices generally are stated in terms of CPM, or cost per thousand impressions.

For sponsorships, “impressions” refers to the number of times the sponsorship’s ad- vertisements webpage is loaded. One thou- sand impressions do not mean that the advertisement was seen 1000 times. A visi- tor may choose not to look at the advertise- ment even though it is loaded at the top or bottom of the webpage they are reading.

In email advertising, impressions are the number of email messages sent out that contained the advertisement. Just like for sponsorships, an email impression does not mean that the advertisement was read. Re- cipients may delete the message without opening it. Email newsletters are often for- warded to colleagues to read, which in- creases the number of people who read the advertisement.

“Click through” or “clickthru” is when a vis- itor clicks on a banner advertisement or clicks on a link in an email advertisement (10). This is a more accurate accounting method, but does not always translate into the number of people who saw the banner or email advertisement because a visitor may cancel before the page completely loads.

“Click-through rate” is the percentage of people viewing your advertisement that click through (11).

PAY-PER-CLICK ADVERTISING

Pay-per-click campaigns are very popular and can be a productive way to promote your site and jumpstart website traffic to your site if you just opened your doors. Successful campaigns have three major parts: research and implementation, meas- urement, and analysis and adjustment.

Pay-per-Click Campaigns: Research and Implementation It is preferred to start with a single pay-per- click provider and use several different keywords. The goal of your first campaign is to identify the most successful keyword

need, both directly and indirectly. Here are a few tips for working your network to get more traffic to your site:

■ Include an email signature file on all outgoing emails. This can be setup to be automatically entered in all out- going emails. Include an email signa- ture even to those people concerning non–website-related matters. You never know from where your next best cus- tomer will come.

■ Comment and participate on blogs within your niche. The goal is to get to be known as the expert in your niche area. Take time to create well- thought-out blog comments. Include bulleted lists and subheadings in your blog comment if you can.

■ Start a blog yourself. This is an easy way for your visitors to post their mark on your site; they will be back in the future to check in on it. Include links to other good blogs on your blog.

■ Find forums, newsletters, and groups in your topic and participate on them. The goal is to be known as an expert, to be respected for creating value for visitors.

■ Join social networking sites: LinkedIn (http://www.linkedin.com), Facebook (http://www.facebook.com), and Feed Your Career (http://www.feedyour career.com). Show your personality with a professional twist. Golden rule is anything you post or send online must be okay for your mother or boss to see.

■ Be generous. If you respect your net- work and you work hard to be part of the community surrounding your topic, the rewards can really pay off.

PROMOTION METHODS: LOWER COST

Most small businesses do not have large pro- motion budgets. The following promotion methods require a little investment. In the long term, they can pay for themselves by attracting target market visitors to your site.

Before getting deep into low-cost promo- tion methods, you need to become famil-

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phrases. Shortly after starting the cam- paign, you will know which keywords are the most productive—follow the numbers. Then you can invest in pay-per-click cam- paigns with several providers.

Pay-per-Click Metrics: Measurement Keep track of the progress of all your cam- paigns. At minimum, measure and track:

■ Times each specific keyword advertise- ment was clicked

■ Number of people exposed to your ad- vertisement

■ Daily unique visitors ■ Hourly unique visitors ■ First-time visitors ■ Average page views per hour ■ Page views per visit ■ Page views today ■ Visits today

A visit contains all the pages viewed from a user’s entry to the site, browsing, and then exiting from the site. Thus, one visit contains one or more page views.

Pay-per-Click Analysis: Adjustment When you look at the above metrics, which keywords brought you the most targeted traffic to your site? Which brought the most sales? Adjust your providers and key- words accordingly.

Top pay-per-click providers are:

■ Google AdWords (http://adwords .google.com/select/Login)

■ Ask (http://asl.ask.com) ■ Miva (http://www.miva.com) ■ Yahoo! Search Marketing (http://small

business.yahoo.com) ■ MSN Ad Center (https://adcenter

.microsoft.com)

Pay-per-click campaigns require con- stant attention to be successful. If you do not have the time to keep on top of manag- ing it, do not start, it will not be cost-effec- tive (low return on investment [ROI]) in the long term. You also may consider hir- ing an advertisement management service. Locate one using the keywords: “pay-per- click management.”

Email newsletters are an overlooked form of promotion. They also can be the most cost-effective. There are thousands of email newsletters, some operated by websites and others by companies. Many allow ad- vertisers to have a text advertisement for a small fee.

Email newsletters vary quite a bit in their content. Some are brief with the purpose of announcing new products, others are content rich and lengthy. Typically, you want to focus on those that are content rich. Lists of email newsletters are at: http://www.bestezines.com/.

To find email newsletters on a specific topic use the keywords: “email newsletter” � “keyword for topic.”

Search by keywords to locate newsletters that offer topics your target market is inter- ested in and will likely subscribe to. For ex- ample, if you have a website that offers customized menu and recipe writing for the well-to-do, consider advertising in email newsletters on vacations at well-known health spas in the summer and exclusive ski resorts in the winter.

Before handing over some money to ad- vertise in an email newsletter, read at least two past issues. First, check the number of advertisements the newsletter allows. Too many advertisements turn readers off. Read- ers program themselves to skip over the long list of advertisements. The placement of the advertisements is important too. If the ads are all placed in the same location, readers will also learn to skip them. The ideal is for only a handful of advertisements to be ac- cepted and the ads to be placed randomly throughout the newsletter (8). Avoid having your advertisement placed at the very begin- ning or end of the newsletter—these are the least read placements. Research indicates near the middle is better (8).

SPONSORSHIPS

A sponsorship is when an advertiser pays to sponsor content, usually a section of website or an email newsletter. In the case of a site,

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http://smallbusiness.yahoo.com

https://adcenter.microsoft.com

http://www.bestezines.com/

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C A S E S T U D Y 2 4 . 1

T H E R O A D T O W E B S I T E S U C C E S S

In 1999, I attended a Nutrition Entrepre- neurs Dietetic Practice Group Regional Work- shop in New York City. One session that was of particular interest to me was about the Inter- net and how dietitians should consider creat- ing their own websites. While I was sitting in the session, I started thinking of different do- main names for my future website. I couldn’t wait to get back home to San Francisco to type it in and see if my top choice was available. Sure enough, http://www.nutritionexpert.com was available so I reserved it!

My next step was to find someone to de- sign my site on a reasonable budget. I scoured the Internet looking at different sites that I liked and then I tried to figure out who de- signed the site. Through this process, I found someone who specialized in website develop- ment for professional speakers and decided I would hire her. At the time, she only charged $25 an hour and she lived in Utah. I also went to a professional photographer to get a head- shot for my website. I really didn’t like my first headshot, which cost me about $150. A few

years later, I did my first redesign and also had some new headshots done with a well-re- spected photographer in San Francisco. Those headshots cost me about $400, which was a lot of money but well worth it. As a media spokesperson, image is very important since clients are deciding whether or not they want to hire you to represent their company. At this point, I had the following pages on my web- page: bio, speaking, counseling, consulting, sports nutrition, and personal training.

The great thing about a website is you can change it as your goals and business focus change. In January 2007, I decided I needed a major redesign with a “cleaner” look. I also wanted to add my media demo video and create an electronic press kit (EPK), which included my demo, downloadable photos, and a one-sheet bio. It could then be used by PR firms and save me the cost of production and postage for my press kit. I decided I wanted to hire a new designer and got about 8 bids and portfolios from web designers on Craigslist.com. I looked in Los Angeles and San Francisco although at this time, I lived in Kansas City. After evaluating all of their bids and portfolios, I chose my designer who I con- tinue to work with today and who has designed an additional site for me. For me, it has always

270 THE ENTREPRENEURIAL NUTRITIONIST

■ How much of the site is included ■ How involved the sponsor gets ■ What the sponsor plans to accomplish

Sponsorships are effective for building brand awareness in a particular niche market (12). The secret is to go where your customers are already spending time, and sponsor content they read. Sponsor- ship pricing varies depending on the popularity of the site, structure of the arrangement, and the sponsor’s level of involvement. Often, there is a monthly fee with an extra charge when email newsletters are distributed. Unfortunately, there are presently no organized resources on locating or arranging sponsorships. The best method is to approach sites where you believe your target market is spending time.

the sponsorship may include banners or but- tons on the site, and possibly a tag line (12).

The disadvantage is a large initial invest- ment being required before a financial re- turn. However, sponsorships in recent years have gained popularity over banner adver- tisements. Part of the draw is the flexibility of sponsorships. A company can sponsor content with a low-end involvement like a simple tag line: “This section is brought to you by MediNutrition, Inc.” Or, there could be a more involved sponsorship commit- ment with banner advertisements, content in an entire section, an email newsletter tag line, or even a miniwebsite within the web- site. Arrangements vary widely, depending on several factors (9):

■ Whether sponsorship is exclusive or joint

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CHAPTER 24 ■ Promoting Your Website 271

been very important to have a site that is very easy to navigate and looks very professional. I also had new headshots taken again which cost me about $500. In early 2008, I did another re- design by moving my buttons to the top of my website and also adding my speaking demo to my speaking page. My website is my biggest marketing tool and every year it brings in a sig- nificant amount of new business for me.

As my career goals have changed, my web- site also has changed to showcase the areas where I want my business to grow. For example, I am no longer trying to grow my counseling business nor am I personal training. I took both of these off my website while adding a blog and my video demos for speaking and media. It is important to try to stay as current as possible with technology and consider the numerous op- portunities available to you for getting your voice heard such as: podcasts, webinars, video streaming, blogging, YouTube, and e-books.

Mitzi’s Top Twelve Website Tips

1. Hire a professional to take some great head- shots. I am a believer in getting quality head- shots, which will usually cost you more. Consider asking a local modeling agency who they would recommend for headshots. As always, look at their portfolio.

2. Put up only professional-looking websites. This is the first impression you will make on people who find you online. Does this mean you have to spend $5000? Ab- solutely not! You can create a very profes- sional site for as little as $800–$1500. For me, I have spent less than $5000 on my site since 1999 and that includes one orig- inal design, three redesigns, updates with video, photos, and so on. Look at other sites that you like and make sure you give your designer at least 3–5 examples of other well-designed sites so he or she can get idea of what you like.

3. Reserve a domain name on sites such as www.godaddy.com. However, be aware that people are lurking around watching the domain names that you are searching, so my advice is if you want a domain name and it is available reserve it immediately! A

few years ago, I looked up a domain name that was available but then I had to go to a meeting. The next day, I went back to get it and about 1 hour after I searched the day before, someone else reserved it!

4. Find a designer who is a good match for you. You can start by looking at the bot- tom of your favorite websites as they will often include the designer. Then go to the designer’s website and look at their entire portfolio. You should also try to get a rec- ommendation from a current/past client. Try to be as specific as possible about what you want so you can get an accurate quote.

5. Decide if you want to make small changes yourself or if you want your designer to control all of it. I purchased Dreamweaver CS3 and self-taught myself the very basics of simple copy changes. Anything else, I have my designer do.

6. Determine what part of your business you want to grow and make sure your website reflects it.

7. Determine your audience. You must know your target market, as it can change how your website is designed.

8. Get links on other sites to improve your search engine ranking.

9. Create a blog within your website. 10. Add video to your site. 11. Offer a free e-newsletter. I use Constant

Contact. 12. Ask for feedback! This is critical. Some-

times we get so close to a project that we might not see something that doesn’t look so good. During one of my redesigns, my good friend told me the kiwi on the home- page was too bor- ing. I changed it to a strawberry to add more color. She was right!

Good luck and see you on the web! —Mitzi Dulan, RD, CSSD, co-au- thor, The All-Pro Diet; http://www.nutrition expert.com and www.fuel likeachampion.com

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272 THE ENTREPRENEURIAL NUTRITIONIST

8. Kent P, Calishain T. Promoting in the News- groups and Mailing Lists. In: Poor Richard’s Internet Marketing and Promotions: How to Pro- mote Yourself, Your Business, Your Ideas Online. Lakewood, CO: Top Floor Publishing, 1999.

9. Campanelli M. Give and Take: Why It Pays to Partner Up on Your Marketing Efforts. Entrepre- neur Magazine, March, 2001.

10. Marckini F. Buying Advertising on Search En- gines. In: Search Engine Positioning. Plano, TX: Wordware Publishing, Inc., 2001.

11. Kent P, Calishain T. Advertising Your Site. In: Poor Richard’s Internet Marketing and Promotions: How to Promote Yourself, Your Business, Your Ideas Online. Lakewood, CO: Top Floor Publishing, 1999.

12. Wegert T. Sponsorships: The Pathway to Clicks. [Clickz website]. March 28, 2002. Available at: http://www.clickz.com/article.php/998091. Accessed December 11, 2008.

RESOURCES General Web Development • Web Developer’s Journal: http://WebDevelopers

Journal.com.

Domain Names • InterNIC website: http://rs.internic.net. • Registration Authority: http://www.register.com.

Trademarks • Trademark FAQs: http://www.uspto.gov/web/

offices/tac/tmfaq.htm.

Copyrights • U.S. Copyright Office website: http://www.copy

right.gov.

Bibliography McClelland D, Eismann K. Web Design, Studio Se-

crets, 2nd ed. Foster City, CA: IDG Books Worldwide, Inc., 2000.

SUMMARY

Websites can market your business to the world, but like every other kind of promo- tion, they take resources and time to create, use, and maintain effectively. By using the strategies and tips shared in this chapter, you will be able to optimize your website to be ranked higher by search engines and customers.

REFERENCES 1. Marckini F. Choosing the Right Keywords in the

Right Combinations. In: Search Engine Position- ing. Plano, TX: Wordware Publishing, Inc., 2001.

2. Marckini F. META Tabs, Metadata, and Where to Place Keywords. In: Search Engine Positioning. Plano, TX: Wordware Publishing, Inc., 2001.

3. Sullivan D. How to Use HTML Meta Tags. [SearchEngineWatch.com website]. Available at: http://www.searchenginewatch.com/webmas ters/meta.html. Accessed December 11, 2008.

4. Kent P, Calishain T. Web Site Checkup: Prepar- ing for Indexing. In: Poor Richard’s Internet Mar- keting and Promotions: How to Promote Yourself, Your Business, Your Ideas Online, Lakewood, CO: Top Floor Publishing, 1999.

5. Marckini F. Submitting Your Site. In: Search Engine Positioning, Plano, TX: Wordware Pub- lishing, Inc., 2001.

6. Sullivan D. Search Engine Watch: Intro to Search Engine Submission. [SearchEngineWatch.com website]. March 12, 2007. Available at: http:// searchenginewatch.com/2168011. Accessed December 11, 2008.

7. Kent P, Calishain T. Other Placed to Register Your Site. In: Poor Richard’s Internet Marketing and Promotions: How to Promote Yourself, Your Business, Your Ideas Online. Lakewood, CO: Top Floor Publishing, 1999.

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http://WebDevelopersJournal.com

http://rs.internic.net

http://www.register.com

http://www.uspto.gov/web/offices/tac/tmfaq.htm

http://www.copyright.gov

http://www.searchenginewatch.com/webmasters/meta.html

http://searchenginewatch.com/2168011

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WORDS OF WISDOM

If you don’t invest very much, then defeat doesn’t hurt very much and winning is not very exciting.

Dick Vermeil

Never, never, never quit. Winston Churchill

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By the year 2030, the older adult (more than 65 years of age) population in the U.S. will more than double to 71 million, or 20% of the total population (1). For the first time in our nation’s history, 1 in 5 Americans will be more than 65 years old; and some states will have 1 in 4 people in this category (1). In addition, people older than age 85 will more than double to 5% of the population (2). Eighty percent of this population has at least one chronic condition, many of which can be treated cost effectively with medical nutrition therapy (1).

Many opportunities are available for those who enjoy working with older adults in nursing facilities, assisted living facilities, retirement centers, residential care centers, homecare, congregate feeding, or Meals on Wheels. This chapter will discuss the entre- preneurial opportunities to work as a con- sultant dietitian (RD) for agencies and facilities that provide care and services to older adults and other long-term healthcare groups. The focus will be on long-term care (LTC) facilities such as, nursing homes, because these are where most consultant RDs work.

REGULATORY ENVIRONMENT

In its quest to protect the public and maintain Medicare/Medicaid funding, the government has developed very precise regulations governing licensed nursing fa- cilities. Because federal regulations require

a qualified dietitian to perform certain du- ties, and so many nursing home residents are undernourished, opportunities are readily available for dietitians to apply their skills in the LTC industry.

Many smaller facilities of 100 beds or fewer do not require a full-time dietitian and prefer the more cost-effective option of using a consultant RD. Most of these fa- cilities employ a full-time certified dietary manager (CDM) to run the food service operation, and utilize a consultant RD to oversee the clinical needs of the facility. The RD may also guide the CDM to pro- vide high-quality food service, assure safe food and sanitation, provide appropriate special diets, control costs, and meet the many diverse needs of today’s nursing fa- cility population.

CONSULTING IN LONG-TERM CARE

If you like working with older adults, and you are looking for diversity and challenge in your career, LTC may be a great choice for you. Consultant RDs must use various knowledge and skills in both food service and clinical nutrition. Today’s skilled nursing facilities provide highly skilled care and rehabilitation services. Many of them serve multiple generations, provid- ing new challenges in catering to food and nutrition demands. The high acuity levels of residents translate into the need for more intense nutritional intervention

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276 THE ENTREPRENEURIAL NUTRITIONIST

Dietitian consultants in LTC are ex- pected to have an excellent working knowl- edge of the following:

■ Federal and state nursing home regu- lations

■ The survey process ■ Nutritional assessment and care

planning ■ Nutrition interventions for the older

adult ■ Food service and sanitation ■ Cost control ■ Therapeutic diets, and more

Because the RD is acting as a consultant, the expectation is that his or her knowledge level is well above the level of an employee. In addition, because most consultants work with multiple facilities, information sharing among facilities is important, but one must be careful not to share any confidential information.

STANDARDS OF PRACTICE IN LONG-TERM CARE

The climate in LTC is extremely litigious. Facility professionals, including RDs, may be named in lawsuits related to malnutri- tion, weight loss, pressure ulcers, diabetes, dysphagia, and more. Because of all the intense regulations in LTC and current litigious environment, being up-to-date on critical information is imperative for RDs practicing in this area. They should also keep malpractice insurance policies current.

The Consultant Dietitians in Health Care Facilities (CD-HCF), a dietetic prac- tice group of the American Dietetic Associ- ation (ADA), provides members a great deal of information and resources on the practice of dietetics in LTC. These are great resources for anyone new (or even those who are experienced) to the field. There are also state CD-HCF organizations, and even some local chapters. CD-HCF pub- lishes helpful resources for RDs practicing in the LTC setting.

because of complications such as uninten- tional weight loss, dehydration, pressure ulcers, undernutrition, and protein energy malnutrition.

Clinical challenges to the RD include provision of medical nutrition therapy (MNT) for:

■ Therapeutic diets for multiple comor- bidities, renal dialysis, ventilator patients

■ Enteral and parenteral feedings ■ Those who cannot consume enough

food to maintain nutritional status (and need nutrient dense foods and fluids)

■ Dysphagia patients who need altered consistencies of foods and fluids

■ End-of-life nutrition and hydration needs

■ Providing for the needs of obese resi- dents who may also have multiple co- morbidities including pressure ulcers, nonhealing wounds, and protein en- ergy malnutrition

The greatest challenge in LTC may be to assure a quality experience at mealtime:

■ Providing safe, wholesome, and high- quality foods that meet the needs of each patient

■ While promoting a dining environ- ment that is conducive to a pleasant and dignified social experience, pro- moting independence with eating

■ Providing feeding assistance for those who need it and assuring adequate in- take to meet nutritional needs

The demands of clinical documentation become great as federal nursing home regulations specify the need for Medicare patients to be assessed in the first 5 days, with reassessment at 14 days, 30 days, and a minimum of every 90 days there- after. Regulations are very specific regard- ing parameters for nutrition care, unintentional weight loss, pressure ulcers, hydration, enteral feedings, and dining issues.

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CHAPTER 25 ■ Consulting in Long-Term Care 277

ADA has recently released the new Stan- dards of Professional Practice (SOPP). CD- HCF publishes the SOPP for RDs and DTRs (Dietetic Technicians, Registered) practic- ing in LTC.

CHANGES AFFECTING LONG-TERM CARE

I have worked in the industry for more than 25 years and the one thing I know to be true is that change is constant in long- term healthcare. One of the major changes today is the movement toward person- centered care.