Nutrition Advice, take it or leave it?

Nutrition Advice: Take It Or Leave It, But Should You Give It Out?
From NASM Newsletter

Key Points
Personal trainers help clients achieve their personal health, fitness, and performance goals via the implementation of exercise programs and suggestions in lifestyle modification, including nutritional recommendations.Prudence about scope of practice and providing useful referrals to dietetics professionals when appropriate is essential to responsible practice, and serving clients' needsAccording to a 2002 article in the Journal of the American Dietetic Association , food and
nutrition misinformation can be a serious barrier to public health.

With certifications, continuing education, and even university-based education, fitness professionals bring safe, science-based exercise
> programming to their clients and group class members. But what about dispensing nutrition advice? When a client asks, "what do you think of this supplement? or "what diet should I follow to reduce body fat, improve my mile time, or vertical leap?" What should the answer be?
Personal trainers help clients achieve their personal health, fitness, and performance goals via the implementation of exercise programs and suggestions in lifestyle modification, including nutritional recommendations.
The Issues
> Not many years ago, the fitness field lacked the standardization and
> professionalism it is beginning to enjoy. Today, consumers are
> becoming better informed about how to locate a certified personal
> trainer and trainers are becoming more knowledgeable about how to find
> qualified continuing education. Consequently, the profession is
> benefiting from standards that are producing safe and consistent
> results. However, questions remain about fitness professionals and
> nutrition counsel. Who should dispense nutrition recommendations? What
> are the prudent parameters of scope of practice with dietary advice
> and how can trainers learn to recognize and respect them? Before
> trying to answer these questions, it is important to define some of
> the terms and credentials in nutrition -- both qualified and
> questionable.

> Many accredited universities offer degrees in nutrition. A bachelor's
> degree (B.S.) in nutrition requires four years of full-time study that
> qualify a graduate for entry level positions in dietetics. These
> positions are extremely varied and might include work with a food
> company, a government agency such as the USDA, or a medical environment.
>
> The Registered Dietitian (R.D.) credential is available to individuals
> who obtain a bachelor's degree in nutrition, complete an American
> Dietetics Association (ADA) -approved dietetic internship, and pass a
> comprehensive written test. RDs must keep their credentials current,
> just as fitness professionals keep their fitness certifications
> current, with continuing professional education credits (CECs). RDs
> also have varied employment, including corporate wellness, community
> and public health settings, sports nutrition, universities, medical
> centers, research areas, and many others. Although completion of a
> master's degree and PhD is valuable to nutrition professionals, it is
> not required to become a Registered Dietitian.
>
> There are other credentials in the field of dietetics, some credible
> and many questionable. For example, active membership in the American
> Society for Nutritional Sciences (ASNS) -- formerly called the
> American Institute of Nutrition -- is open to those who have published
> meritorious research on some aspect of nutrition and are presently
> working in the field. The Certification Board for Nutritional
> Specialists was founded by the American College of Nutrition in 1993.
> It offers a Certified Nutrition Specialist (CNS) credential to
> professionals with an accredited master's or doctoral degree that also
> have clinical experience and pass an examination.
>
> However others, like the Certified Nutritional Consultant (CNC),
> issued by the Society of Certified Nutritionists, do not require the
> same rigorous study or clinical experience that an RD must
> successfully complete. Other questionable credentials include
> Certified Clinical Nutritionist (CCN) and Certified Nutritionist (CN).
> Because the titles "nutritionist" and "nutrition consultant" are
> unregulated in many states, they have been adopted by many individuals
> who lack accreditation and are unqualified to practice.
>
> Forty-one states have laws that regulate the profession of dietetics
> and nutrition. (Iowa is one of those)
>
> The regulations fall into the following categories:
>
> licensure
> statutory certification
> registration.
> This is a complicated legal environment. According to Craig Busey,
> legal counsel to the ADA, "The treatment of this issue varies greatly
> from state to state. Some states address the difference indirectly by
> delineating the difference between dietetics and other forms of
> nutrition counseling, while others equate dietetics to nutrition
> practice. This notable lack of uniformity adds to the confusion and
> makes a general answer all the more problematic."
>
> While the discussion can get bogged down in legal minutia, it is
> important for fitness professionals to realize why they got involved
> in fitness. For most, it was the desire to help people. Busey adds,
> "dietetic licensure laws generally do not limit the right of an
> individual to provide nutrition advice and information related to non-
> Medical Nutrition Therapy (MNT)."
>
> With as many as 70% of American deaths due to diet-related diseases
> and conditions(1) , there's plenty of need.

Did you know?
> Twenty-four percent of physical activity professionals believe they
> know enough to provide all the information their clients need on
> nutrition, compared with 14 percent of dietetics professionals who
> stated that they know enough to provide all the information their
> clients need on physical activity. (2) In fact, according to IDEA
> Fitness Journal (2002) 26 percent of personal trainers use nutritional
> analysis software, 70 percent provide nutritional assessment, and 75
> percent provide nutritional coaching - practices that should be
> reserved to the scope of practice of registered dieticians who have
> four years of specific nutrition education. (3)

> With most health professionals looking toward the combination of
> balanced nutrition and regular physical activity to help stem the
> rising tide of obesity, it makes sense that those professionals
> trained in nutrition and those trained in physical activity should
> collaborate to help consumers realize the potential benefits of these
> healthful lifestyle practices. In 1997, the American College of Sports
> Medicine (ACSM), the ADA, and the International Food Information
> Council (IFIC) retained the Gallup Organization to conduct telephone
> interviews of both ADA and ACSM members to determine attitudes on
> nutrition and physical activity. The poll indicated that physical
> activity professionals tended to be more confident in their ability to
> provide nutrition information than dietetics professionals were about
> their ability to provide physical activity information. Even dietetics
> professionals observe specific limits to their practice scope, called
> the Scope of Dietetics Practice Framework (SODPF). (4) In theory, an
> RD without an accredited fitness certification has no more authority
> to give out specific exercise advice than a certified fitness
> professional does to give out specific dietary instructions.
What's the harm?
> For fitness professionals, the dangers of giving advice outside of
> practice are significant. According to a 2002 article in the Journal
> of the American Dietetic Association , food and nutrition
> misinformation can be a serious barrier to public health. Misinformed
> consumers may not only have a false sense of security about their
> health and well-being, but they also may delay appropriate, effective
> healthcare or replace it with products, services, or behaviors that
> may be harmful to their health. (5)

> If a fitness professional does not hold a recognized nutrition
> credential, how should they proceed with nutrition advice? "Certified
> personal trainers can provide general, non-medical nutrition
> information," explains Cynthia Sass, MPH, MS, RD, and ADA
> spokesperson. "But, they should not perform individualized dietary
> assessments, prescribe individualized diets, or even individualized
> dietary advice." Sass adds, "General information can be very helpful
> and still provides a great deal of freedom to talk about nutrition in
> a general way such as educating clients about the difference between
> saturated and unsaturated fat; which foods are good sources of fiber,
> etc. However, the fitness professional should be 100 percent confident
that the information they are providing is accurate, up-to-date, and science-based."
This is a challenging question," adds Dr. Mike Clark, President of the National Academy of Sports Medicine. "Only because there is no easy 'yes' or 'no' answer. Like with exercise, we want our professionals to always provide the best service to their clients, all things considered. If a trainer can help a healthy individual improve their diet, they should, through delivering general guidance which is science-based and well supported by established health authorities.
However, if the individual seeks medical nutrition therapy, they should pursue a qualified professional, a Registered Dietician, to
deliver this support."

Dr. Clark also points out that most accredited fitness certifications, including NASM Certified Personal Trainer, do include some nutrition information as well. NASM and other accredited role and functions of the macronutrients (protein, carbohydrate, and fat) in performance and healthy weight achievement. They should understand the role and importance of water, fiber, and the micronutrients (vitamins and minerals) and the basic nutrition guidelines for altering body composition. Certified fitness professionals should also be aware of issues surrounding supplementation, including the legislative environment regulating
supplements, as well as the government's Dietary Reference Intakes for
healthy people.
How to know what to say when
> With this knowledge, how can fitness professionals determine if they are stepping outside their scope of practice? By asking themselves a few key questions. This will insure that they are giving out sound, science-based information, thereby protecting their liability, professional ethics, and their client's well-being.

When to Refer
If you are a fitness professional, without a qualified credential in nutrition, here are some questions to consider. If the answer is
"yes," the client should be referred to a dietetics professional.
1. Is there a possibility that the client has a disease or co-morbidity associated with their weight or with their health?
2. Would your advice be considered medical or in the context of
disease treatment?
3. Does your advice involve the interpretation of blood work or other clinical tests?
4. Is the client asking you for individualized dietary assessment?
5. Is the client asking you to prescribe an individualized diet or
dietary advice (versus general information like portion awareness or nutrient density)?
6. Are you recommending a supplement as part of your counsel?
7. Is your client trying to manage medical symptoms through diet?
8. Could your assessment or advice possibly cause a delay in treatment
or a misdiagnosis that may result in serious harm to your client?
9. Could your advice result in an unwanted interaction between
foods/drugs, foods/medical condition, supplement/drugs,
foods/supplements?
10. Did you neglect to access the authorities and academic research on the topic in question?

> "The ultimate success of these two groups working together," explains
> ADA spokesperson Cass, "is that it isn't about territorialism. It's
> about working together and respecting scope of practice which is in
> the best interest of the trainer and the client." The need for sound,
> science-based nutrition information is evident. Consumers are confused
> and have a hard time discerning fact from fiction and science from
> marketing. However, an examination of issues surrounding scope of
> practice reveals that the lines are not always clear and ongoing
> vigilance and evaluation are necessary to best serve clients' needs.
> The general consensus among wellness professionals is that
> science-based, general information about healthy nutrition, including
> nutrient density, portion awareness, and the potential dangers of
> supplements and fad diets, remain inside the fitness professionals'
> scope of practice. In all cases, fitness professionals should continue
> to enlighten themselves through qualified continuing education so they
> can always position themselves as their client's best advocate and
> resource.
>
>
> References
>
> (1) Nestle M. Food Politics: How the Food Industry Influences
> Nutrition and Health University of California Press; 2003.
> (2) Professionals' Opinions Concerning the Role of Nutrition in
> Physical Activity for a Healthy Lifestyle. Princeton, NJ: The Gallup
> Organization; 1997.
> (3) Ryan, P. Trendsetting. IDEA Fitness Journal 2004;16(5):S2-S14.
> (4) Understanding and Using the Scope of Dietetics Practice Framework:
> A Step-Wise Approach. J Amer Diet Assoc 2006;106:(3):459-463.
> (5) Ayoob KT, Duyff, RL, Quagliani, D. Position of the American
> Dietetic Association: Food and Nutrition Misinformation. J Amer Diet
> Assoc 2002;102:260-266.
> (6) American College of Sports Medicine; The American Dietetic
> Association; International Food Information Council. For a Healthful
> Lifestyle: Promoting Cooperation Among Nutrition Professionals and
Physical Activity Professionals. J Amer Diet Assoc 1999;99(8).

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