Nutrition Coaching: A Primer for Health and Fitness Professionals

Nutrition: How to stay within scope of practice while using proven motivational techniques.

Fitness professionals should discuss nutrition with their clients. 


Historically, many fitness pros have either avoided nutrition
discussions for fear of straying outside their scope of practice or gone
overboard by exceeding their professional limits—recommending nutritional
supplements or individualized meal plans. 


There is a better way: Staying within scope of practice while adopting a
coaching philosophy that uses proven methods of behavior change. 


The need is clear. Few Americans abide by national recommendations for a
healthy diet that prevents disease, promotes health and manages weight,
and many lack access to individualized dietary counseling from
recognized nutrition experts like registered dietitians. It often falls
to health and fitness professionals such as personal trainers, group
fitness instructors and health coaches to steer people toward healthier
nutrition choices.


Recognizing this reality, IDEA has expanded its education, training,
resources and official stand on nutrition. IDEA defers to the American
Council on Exercise’s position statement urging fitness professionals to
talk nutrition with their clients (ACE 2013). At least 10 fitness
organizations offer additional training in nutrition. Clearly, fitness
professionals are a key ally and resource for helping Americans to make
healthy dietary choices.


Many fitness professionals have expanded their knowledge of nutrition
best practices but are still unsure how to do all they can to integrate
nutrition into their work while staying within their scope of practice.
Furthermore, most health and fitness professionals now recognize that
it’s one thing to merely recommend the right way to eat; it’s quite
another to provide the coaching and support that produce meaningful
health changes.


This article addresses key questions about scope of practice and
coaching techniques; it also provides resources and links for further
information, practice and training.


Nutrition Coaching 101

Nutrition coaching starts with an understanding of the science of
nutrition, the key federal dietary guidelines and the methods of
conveying dietary information so that it is readily understood and
actionable. The coaching component requires an understanding of how to
help people identify, nurture and act on their internal motivations to
change their behavior.



The Nutrition Coach: Scope of Practice Defines the Role


Nutrition scope of practice is not just a matter of professional ethics.
In some states it’s a matter of law, and violators can be prosecuted. 


Most U.S. states (47) regulate nutrition and dietetics with laws that
provide guidelines for all health professionals who discuss nutrition
with their clients. Typically, the scope of practice for registered
dietitians includes individualized dietary counseling, individualized
meal plans and medical nutrition therapy. More information is at
www.eatright
pro.org/resources/career/become-an-rdn-or-dtr.


Ultimately, scope of practice is determined by a combination of three
factors: state laws; education, knowledge and skills; and willingness to
accept responsibility for one’s actions, should something go wrong.
State laws come in three forms: 


Licensure. The majority of states have licensure, where people acting
outside of their scope can be fined and prosecuted. 


Certification. In states with certification, noncertified individuals
(non-RDs for the most part) are forbidden from calling themselves
nutritionists, but they can still legally practice the profession. 


Registration. In the one state with registration (California),
unregistered individuals should not call themselves nutritionists or
dietitians, but registered exams are not given and enforcement of
registration is minimal.


The ACE position statement, which is based on a review of the current
licensure laws and the activities within the scope of practice of
nonlicensed professionals, shows there are many ways in which people who
are not registered dietitians can support their clients’ efforts in
making nutrition changes. These ways include developing cooking
demonstrations and recipe exchanges, sharing handouts and informational
packets, offering individual or group classes and seminars, and engaging
in one-on-one encounters. 


To pull it all together, a health and fitness pro who would like to
master the “nutrition” side of nutrition coaching, can do the following:


  • Get up to date on your own state laws. Get started at www.cdrnet.org.

  • Read the Dietary Guidelines for Americans 2010 (www.health.gov/diet

    aryguidelines/2010.asp). Everything in there is fair game to discuss
    with clients. An updated 2015 version is due to be released by the end
    of the year. 

  • Use meal-planning tools based on established dietary recommendations.
    For example, check out www
.supertracker.usda.gov. This can produce
    individualized meal plans for clients. Distributing such meal plans is
    within your scope of practice since they are based on and developed for
    implementation of the federal dietary guidelines.

  • Stay on top of the latest nutrition research. Feel free to share these
    findings, as well as position statements from organizations like the
    Academy of Nutrition and Dietetics. You can also discuss published books
    and other reading materials with your clients. Use your discretion and
    be sure to share only credible and worthwhile information rooted in good
    science.

  • Get to know a few registered dietitians in your community. Search for
    them at www.eatright.org/find-an-expert.

  • Avoid trying to reinvent the wheel. Rely on proven methods and
    programs. At the least, feel free to use educational materials and
    information developed by physicians or dietitians. It is well within
    your scope to implement these methods. A few examples include the
    Centers for Disease Control and Prevention’s group diabetes prevention
    program materials
    (www.cdc.gov/diabetes/prevention/recognition/curriculum
.htm), the Eat
    Healthy*Be Active Workshop series from the U.S. Department of
    Agriculture (www
.health.gov/dietaryguidelines/work

    shops/DGA_Workshops_Complete
.pdf), and the National Heart, Lung, and
    Blood Institute’s We Can! Program
    (www.nhlbi.nih.gov/health/educational/wecan/).


The Coaching: Becoming 
an “Expert” Without Being “The Expert”


Nutrition coaching is not about dumping nutrition education and advice
on clients, then expecting them to take all of your recommendations to
heart and make meaningful and lasting dietary changes. 


Rather, coaching is a process that recognizes a client’s readiness to
change and receptivity to advice. Some clients come to health and
fitness professionals ready to change and hungry to figure out how to
use nutrition to achieve their goals. However, not everyone is at that
point. Being able to identify whether clients are ready to jump right
into a program or are still a little ambivalent about changing—and
tailoring your approach accordingly—is a key skill for coaches to
develop.


When clients are not ready to change, the coach helps them work through
their ambivalence using well-established techniques like motivational
interviewing. 


Coaches play a different role for clients who are ready to change,
helping them challenge themselves to achieve realistic but strenuous
goals, while serving as a supportive guide and advocate. Coaches may
also share nutritional information in an autonomy-supporting way. For
example, a coach will ask permission before providing advice or a
suggestion. A coach will also provide information in a way that
recognizes the six key features of how adults learn best (Knowles, Holton
Swanson 2011):


  1. The need to know. Adult learners want information with practical and
    immediate usefulness in their everyday lives.

  2. Autonomy. Adults need to feel they control how the information
    applies to their daily lives.

  3. Prior experiences. Adults build new learning on top of previous
    learning and experience.

  4. Readiness to learn. Adults want only the information they are ready
    to recieve. 

  5. Orientation to learning. Adults are problem-centered. They want
    information that will help them solve a pressing problem in their lives.

  6. Motivation to learn. Most adults are driven by internal motivations,
    such as the wish for better quality of life, increased job satisfaction
    and more self-esteem. New learning should speak to one of these domains.


A Model Nutrition 
Coaching Session


So what exactly does a nutrition coaching package look like? Of course,
the content will vary considerably from one client to the next, but many
coaching sessions may follow a similar outline. Here is just one
example:


  • Engaging. The coach-client relationship begins with establishing a
    collaborative relationship. Engaging with a client includes asking
    open-ended questions and truly aiming to understand the client’s point
    of view and his or her reasons for wanting to begin the coaching
    relationship. This also provides an opportunity to understand a client’s
    big-picture goals. The process of engaging and establishing a
    collaborative relationship should precede any formal assessment or
    gathering of baseline information.

  • Gathering baseline information. To help a client achieve a big-picture
    aim, it pays to understand the starting point. Asking the client to
    complete a healthy history, a lifestyle questionnaire and/or a food log
    can help with this step.

  • Focusing. Here, coach and client work together to make sense of the
    baseline information and establish readiness to change and best next
    steps, depending on the client’s readiness.

  • Establishing goals. A client who is ready to change can benefit
    substantially from setting nutrition goals via the SMART
    framework—specific, measurable, achievable, realistic and time-bound.
    Putting goals in writing and making a public statement of commitment
    further strengthen the change process.

  • Elicit-provide-elicit.” This three-step process is a key technique
    advised in motivational interviewing and is of great value across
    coaching processes (Miller Rollnick 2013). It means the coach first elicits by asking for
    permission and clarifying gaps in the client’s needs and information
    (“What would you like to know about in order to achieve this goal?” or
    “What information gaps may interfere with your ability to move
    forward?”). Then the coach may provide information, keeping in mind the
    six principles of adult learning noted above. Finally, the coach elicits
    once more, asking the client—through open-ended questions and
    reflections—how he or she understands, interprets or responds to the
    information.


Next Steps

As health and fitness professionals expand their scope and their impact
in communities, gaining skills and expertise in nutrition coaching is
becoming a needed and impactful strategy. See the “Resources” sidebar
for more information and resources to help you get started. 


What Is Motivational Interviewing?

William R. Miller and Stephen Rollnick, founders of motivational interviewing (MI), define it as “a collaborative goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion” (Miller & Rollnick 2013).

MI relies heavily on four key communication skills—open-ended questions, affirmations, reflections and summarizing (OARS)—and proceeds through a series of four phases: engaging, focusing, evoking and planning. For more information, check out Miller and Rollnick’s book Motivational Interviewing: Helping People Change (Guilford 2013).

|SIDEBAR|

What Is Motivational Interviewing?

William R. Miller and Stephen Rollnick, founders of motivational interviewi


References

ACE (American Council for Exercise). 2013. A call to lead: Why fitness professionals should discuss nutrition with their clients. Accessed Feb. 9, 2015. www.acefitness.org/prosourcearticle/3399/a-call-to-lead-why-fitness-professionals.
Knowles, M.S., Holton, E.F., & Swanson, R.A. 2011. The Adult Learner: The Definitive Classic in Adult Education and Human Resource Development (7th ed.). New York: Taylor & Francis.
Miller, W., & Rollnick, S. 2013. Motivational Interviewing: Helping People Change (3rd ed.). New York: Guilford.

Natalie Digate Muth, MD, MPH, RD

Natalie Digate Muth, MD, MPH, RD

"Natalie Digate Muth, MD, MPH, RDN, FAAP, is a board-certified pediatrician and obesity medicine physician, registered dietitian and health coach. She practices general pediatrics with a focus on healthy family routines, nutrition, physical activity and behavior change in North County, San Diego. She also serves as the senior advisor for healthcare solutions at the American Council on Exercise. Natalie is the author of five books and is committed to helping every child and family thrive. She is a strong advocate for systems and communities that support prevention and wellness across the lifespan, beginning at 9 months of age."

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