Elusive Boundaries for Nutrition Scope of Practice
With obesity rates astronomically high, is it time to rethink our approach?
It’s a source of perennial confusion in our industry: Clients ask fitness professionals for nutrition advice daily, but it’s hard to know how much we can give without straying onto the turf of professional nutritionists and dietitians. Can our answers get us fired from our jobs—or even charged with a crime for violating state licensing laws?
Ten years ago, IDEA issued a strong declaration on what fitness professionals should—and should not—tell clients about their diets, but today fitness pros are on the frontlines of an obesity epidemic which challenges whether that declaration still makes sense (see the sidebar “Origins—and Limitations—of Nutrition Scope of Practice”). After all, people needing guidance on diet are far more likely to bring their concerns to a personal trainer than to a dietitian. So where do we draw the lines?
A special panel moderated by IDEA Fitness Journal editor in chief Sandy Todd Webster at the 2012 IDEA World Fitness Convention™ discussed the tangled complexities of nutrition scope of practice. Joining her were
Nicki Anderson, health and fitness columnist and author;
John Berardi, PhD, president of Precision Nutrition, an online nutrition coaching company;
Teri Gentes, international speaker, educator and health coach; and
Steve Hertzler, PhD, RD, LD, research scientist at Abbott® Nutrition and an authority on performance nutrition.
The following is an edited version of the discussion.
As you read, know that IDEA has spearheaded a collaboration with other industry leaders to draw consensus on this topic. We are in the process of developing a “toolbox” that will contain guidelines describing specifically how professionals can work through these issues safely while maintaining scope-of-practice boundaries. We are also creating practical resources you can feel confident about using. Look for the first part of this nutrition resource in a summer issue of IDEA Fitness Journal.
John Berardi: The critical thing that this discussion must do is work through the clouded, generalized fear that fitness professionals seem to have when doing anything with nutrition and clients: “Will I lose my job? Will I get sued? Will my life start to suck because I told someone to eat more broccoli and take multivitamins?”
The laws are very specific: You cannot do medical nutrition therapy. So if someone comes to you and says they have diabetes, you cannot say, “Follow this diet and your diabetes will go away.” That is illegal and rightfully so. Also, you should not call yourself certain things—for example, you can’t say you’re a “registered dietitian” or a “licensed nutritionist” if you’re not registered as a dietitian or licensed as a nutritionist.
Scope of practice fundamentally says this: Do not write your clients a diet if you’re not a registered dietitian.
Once we clarify the heart of the law, it’s easy to understand what we can do and what we can’t do. For [fitness professionals], in particular, it’s very simple. Talking to healthy clients about healthy habits is not only okay—it’s our responsibility.
Steve Hertzler: I’ve found that a lot of personal trainers who think they can’t talk about nutrition with clients are not aware of their state licensure guidelines. In [my home] state of Ohio, there is a really nice list that outlines what nutrition information nonlicensed professionals can provide in terms of essential nutrients and things like that. In Ohio, in particular, the guidelines are better spelled out than they are in other states, but I encourage you to seek out guidance in your own state laws.
Berardi: Honestly, when I read the legislation for my particular state, I’m not sure what it means. Do I need to hire a lawyer to interpret the language and translate for me what I am not supposed to do?
Hertzler: There’s usually contact information listed [in each state’s guidelines] for the person who is the chair of the dietetic licensing board. This person can help you understand the ins and outs of the laws. I think John is right. Some of these guidelines are not written very clearly and can be difficult to wade through, as I know from personal experience. But I also know that in some states the law is very clearly spelled out and there’s good guidance. Know that you have access to a lot of resources that dietitians have.
Nicki Anderson: I think it’s incumbent on each of you [who are here in the audience] to go back to where you live and look at your state laws and just know what you can and cannot do.
I liken this discussion to when personal trainers first started calling themselves “PTs.” How did physical therapists like that? Not very well. As fitness professionals, we are starting to realize that nutrition is a very large part of what we do. My concern comes in when I hear trainers telling me they’re making up diet programs for their clients. I don’t think that’s a good idea, and I’ll tell you why: The trainers “prescribing” these diets are giving their own diets to other people. I really struggle with that.
Berardi: I think this is important because it seems to be embedded in all of our conversations—the assumption that the best possible thing we can do for a client is write a diet. It’s an assumption that we fail to question and that is false. I think handing clients a diet is a recipe for failure, and it’s been proven time and time and time again in this field, and in the dietetics field. In the Precision Nutrition program, which is where a lot of my experience lies, we don’t give diets at all. We use a habit-based approach. Every 2 weeks a single nutritional habit is introduced as part of a nutritional progression model.
In the gym, if you want to teach someone a complex exercise—let’s say a snatch—you don’t say, “Grab this bar and copy me.” You do little chunky progressions until the client can safely get it. I feel nutrition is the same.
Hertzler: I agree with that perspective. I think sometimes people get confused about the therapeutic part of dietetics. For example, writing a diet for a person who has type 1 diabetes and needs a certain amount of carbohydrates per unit of insulin or something like that—that’s very prescriptive, and you try not to deviate from those numbers. But it’s very important not to confuse the therapeutic application with what [applies to apparently healthy] individuals. There’s a certain amount of personal interest that clients need to take in their nutrition. Hopefully, when I, or any of us, talk with clients, we can get them interested in promoting their own health and becoming active participants in this process.
Sandy Todd Webster: What do you think a good working relationship between a personal trainer and an RD looks like? What’s the give and take there? What’s the communication like?
Hertzler: I think the bottom line is that we need to cross-promote dietetics and fitness partnerships and collaborations. We want to help you do your job better, and I think you want to help us do our job better. This is also the way all of us advance in being able to help clients. I encourage you to check out what’s available from the Academy of Nutrition and Dietetics. Their Sports, Cardiovascular, and Wellness Nutrition (SCAN) dietetic practice group has a really good referral page at www.scandpg.org. They also have the www.cdrnet.org page, which goes state by state and tells you which states have licensure and even links you to the licensure board so you can the legislation and see what’s defined in a particular state (see the sidebar “Essential Nutrition and Dietetics Links”).
Anderson: I love the idea of registered dietitians and trainers coming together and saying, “Okay, what makes sense? How can we collaborate [so that I can] disseminate information that I’m comfortable disseminating because it comes from someone who clearly has more knowledge?”
I don’t know the nutrient make-up of foods. That’s not my job; it’s not what I do. I work with a registered dietitian who gives me handouts for my clients—for snacks, for a quick breakfast, things like that. Then I give those handouts out, and I feel comfortable doing that. But some trainers think they can write diets themselves, and that’s where the waters get really murky.
Hertzler: It seems that in some ways dietitians have felt a little threatened by individuals talking about nutrition without having the right education. Anybody can write a book about nutrition, whether they know anything about it or not. You can find all kinds of books [by uneducated authors] on the shelves.
But the reality is that there are not enough dietitians to go around. [Personal trainers] way outnumber us. At Abbott Nutrition a lot of focus groups have told us, “Wow, our target audience here for continuing education about nutrition is not dietitians; it’s personal trainers, because you’re the ones who are most on the frontlines.”
So, the only way to fix the problem is to enhance the collaboration and not have this hard line that says, “You can’t talk about nutrition or you’ll get slapped on the wrist.”
Anderson: I want to revisit the analogy I used regarding the early relationship between physical therapists and personal trainers. After all this time, there are still personal trainers who are doing work that, in my humble opinion as a trainer, only physical therapists should be doing. So the biggest battle we’re fighting is about using common sense.
And back to your point: 88% of people get their nutrition advice from magazines, television, radio; 10% from their doctor; and 2% from registered dietitians. Although I have worked very closely with an RD, it took me a while to find one. Every RD has a unique way of looking at nutrition. You have to find the one who suits your clientele and your philosophy.
Berardi: Dietitians, unless self-directed, get very little direction in exercise nutrition, which is what we’re talking about here today. Trainers are not going to hospitals and working with sick people; trainers are working with people who are coming to the gym to exercise. What we’re talking about here today is actually exercise nutrition, not general nutrition.
Webster: Steve, in some of the meetings you’ve had with SCAN, what were the conversations like? What are the concerns?
Hertzler: It was really interesting because SCAN members are totally on board here. It’s a concern to [Abbott] because we want to promote better sports nutrition education all the way around. Do you know how many members of SCAN there are? Approximately 7,000; and not all of those people do sports nutrition—just a small percentage. While the SCAN subgroup of the Academy of Nutrition and Dietetics is made up of people who deal with those types of issues, maybe a third of them are actually sports dietitians, and even fewer of them are board certified in sports dietetics.
So the issue we were having was this: While we want to promote education among dietitians—that’s great—dietitians are outnumbered by personal trainers, who are dealing firsthand with individuals, so the model has to change. You can’t slap fitness pros on the wrist anymore and say, “Leave it to the dietitian.”
Teri Gentes: I really feel it’s important that we get a clear bridge with the medical community, as well as RDs, in order to work as a unit for the good of the whole.
Along with the thought process that we need medical doctors to start referring patients to fitness professionals for the imperative of exercise, we now understand that nutrition is imperative as well. People need nutrition coaching; they need to understand how to fuel themselves better for everyday life as well as for disease prevention, treatment and reversal. Integrated medicine is a part of my world, too—allopathic, naturopathic and homeopathic—and we’re starting to see more of a bridge there.
Webster: Let’s talk about supplementation. According to IDEA nutrition surveys, many personal trainers are recommending and selling ergogenic aids, even though scope of practice says you’re not supposed to. Is doing this ever okay for personal trainers and, if so, in what instances is it okay?
Gentes: Doesn’t it come back to the very thing we’re talking about right now? Recommending a dietary approach is one thing, but recommending supplementation is taking a step up from there, I would say. I think if we can’t [reach consensus on] what we can deliver to our clients [in terms of] a dietary approach, then stepping into supplementation puts us on really shaky ground.
Berardi: I wonder why we feel that way? I don’t question the idea; I’m just curious.
Gentes: First and foremost, we need to know what a healthy dietary approach is and how much of that we can share with our clients.
Anderson: In response to John [Berardi]: There’s a lot of money to be made in supplements, but in 20 years I’ve never touched it. I will never touch it. It’s beyond what I understand. I have no idea how somebody’s body is going to respond to what’s in a bottle. I feel it’s beyond my scope of practice, even if I know a supplement is beneficial. That would never give me the right [to recommend it to a client]; I would never presume to do that for anybody.
But that’s me. I know personal trainers are selling supplements all the time. I would never ever, ever presume to sell supplements to anybody, or even recommend them. Clients ask me, “What are you taking?” Or a client says, “As a 50-year-old woman, shouldn’t I be taking this and that? That’s what I take.” I would never tell a client what to take.
Berardi: But you do use nutritional supplements personally?
Anderson: I do, personally.
Berardi: I’m not asking why we shouldn’t recommend supplements. I guess I generally wonder why we feel that supplements are such a potent concern versus food. If we’re willing to monkey around with a person’s sleep schedule, and we’re willing to monkey around with what we’re going to tell clients to eat for every single meal of the day, why does it become a next-level thing to recommend vitamin D when we know they’re deficient? Is that a harder thing to do?
Anderson: As a trainer, though, how do we know they’re deficient?
Berardi: Oh, you can measure that.
Anderson: That’s not something I’d want to do.
Gentes: But are trainers doing that? It brings us back to that very question: What’s the scope of practice for trainers? And do we feel now that they need more formalized nutrition education? It probably will happen, but at the present they’re not getting that breadth of education.
Hertzler: The biggest issue is that if trainers don’t have access to a person’s true medical history and other pertinent information, there’s potential for some bad decisions to be made. [About 10 years ago] there was a case of an individual whose personal trainer recommended an ephedrine supplement to her, causing an explosive increase in her already elevated blood pressure [she suffered from hypertension, unbeknownst to the trainer]. The reaction triggered a massive intracranial hemorrhage. After a huge lawsuit, that activity kind of stopped. This is why I really want to focus on the basic safety part of certification. Making sure that we do no harm to clients is top priority.
But I also encourage fitness pros to learn the fundamentals about these supplements. At least learn what you know and what you don’t know about these kinds of things—because you’re going to get questions from clients, for sure. And at least if you don’t know the answer, maybe you know of a referral network of people around you who can help you answer the question.
Gentes: You just said, “Do no harm.” But for us to not share some information with our clients as personal trainers, isn’t that doing harm? Especially when we know how imperative good nutrition is to overall well-being. To not say anything because we’re scared or we’re fearful of legalities—that seems like doing harm as well.
Question from the audience: If we don’t have the resources, how can we recommend them to clients? I work with overweight U.S. Marines who need basic nutrition guidelines. We don’t have dietitians, so what can we do? Where can we turn for help?
Berardi: It sounds to me more like a frustration than a question. And I get it. I feel that’s why we’re having this discussion in the first place—because everyone in the room feels that to some extent. I feel we’re preempting a revolution with conversations like this, quite frankly. There’s lots of pressure from the fitness profession to do something different. You guys feel that, you see it. If you’ve been in this field long enough, you can feel the winds of change are blowing through. And so to quell this revolution that could take place, we’re having discussions with dietetics professionals. Hopefully, it’ll be a peaceful rebellion.
Webster: What makes a revolution happen is being open to talking about it. I don’t know that we’re going to walk out of here having solved anything, but simply having a stronger sense of your frustrations better equips fitness leaders like IDEA to address it.
Berardi: Pressure is what makes change. If we’re all sitting back quietly and just brooding about this in our own lives, then no change happens. It’s the pressure, it’s the tension, the gap between where we are and where we feel we can be, that will help define change.
Question from the audience: What can we do? What action can we take once we leave here?
Anderson: I think maybe you’re also saying, “What can I do? Because now I’m kind of fired up and I want to do something.” I would go out and call a couple of dietitians and say, “Hey, I’m a trainer in town, and I just got back from this conference, and this was the discussion” and meet with them to see if perhaps there isn’t a relationship you can create.
Gentes: Much of this is on you guys, really. You’re the frontline, so you can start bridging the gap.
Berardi: Also, I hate to make this into a “write your senator” campaign, but ultimately that’s what we need: some pressure on the different organizations, telling them this is important to you. So write to your certification organizations, write to the dietetics organizations and let them know that this is really, really wanted and needed.
Your voices can begin taking this discussion into the places where the decisions are made. Your voices as personal trainers, who pay certifying organizations, which rely on your revenue, can make an impact.