The statistics are staggering and well known to most fitness professionals. A global obesity epidemic is underway, stubbornly refusing to improve despite massive amounts of resources, attention and advocacy. Millions of U.S. adults—and now a burgeoning number of children—suffer from prediabetes or diabetes. In fact, one study estimates that one in three children born in the year 2000 will at some point in their lives develop diabetes (Narayan et al., 2003). In addition, cardiovascular disease is the leading killer in the U.S., responsible for nearly 600,000 deaths each year (Hoyert and Xu, 2013).

Each of these conditions is directly impacted by lifestyle choices—a combination of physical inactivity and poor nutritional intake. In fact, the prevalence of these diseases can be dramatically improved, if not reversed, or wholly prevented by a physically active lifestyle and wholesome and balanced nutrition choices. One recent study found that someone who follows a Mediterranean eating plan, maintains a normal weight, is physically active and has never smoked has an 80 percent decreased risk of death over eight years (Ahmed et al., 2013).

Despite a relatively widespread understanding of the role of activity and nutrition in optimizing health, very few people actually follow physical-activity and dietary guidelines—but many want to. And millions of people walk through the doors of a health club, medical fitness facility, studio or other locale to engage in some type of physical activity led or coached by an ACE-certified professional. They want to get fit. They want to achieve their health and wellness goals. They want to know more about nutrition. A fitness professional who focuses only on physical activity and avoids discussing nutrition is providing that client with less than optimal service.

Of course, fitness professionals are not nutrition “experts.” Generally, that designation is reserved for registered dietitians and others with advanced degrees in nutrition. However, fitness professionals don’t have to be nutrition “novices” either. With a clear understanding of what is and is not within their scope of practice, fitness professionals can effectively help their clients to achieve their goals, whether through direct provision of information and tools or through referral to a registered dietitian, when appropriate.

Defining Scope of Practice

Scope of practice refers to the range and limit of responsibilities normally associated with a position, job or profession. Scope of practice is determined by rules and regulations as determined by state laws and statutes, the roles and responsibilities as outlined by a certifying or accrediting body, and an individual’s education and training.

State Laws and Regulations

Most states have laws regulating the practice of dietetics. Forty-seven states regulate nutritionists in one of the following three manners:

• Licensure, in which state statute articulates a clearly defined scope of practice. Providing nutrition counseling without the requisite training and possession of a license is illegal. In these states, individuals who practice the profession without a license and who are not specifically exempt are subject to legal action. Most states require licensure.
• Statutory certification, in which individuals must meet specific requirements to be eligible for certification; however, non-certified individuals can still practice the profession. Though the rules are much less stringent in these states compared to those requiring licensure, laws are constantly changing. Fitness professionals practicing in these states should carefully review the legislation with the assistance of an attorney to ensure full compliance with the rules.
• Registration,in which state statute limits who is allowed to refer to him- or herself as a “registered dietitian” or “dietitian,” but does not limit who can practice the profession. California is the only state that requires registration.

Only three states—Arizona, Colorado and New Jersey—do not have any laws regulating the field of nutrition.A state map showing the classification of each of the 50 states is included in Figure 1.

Keep in mind that state laws are constantly evolving and changing. Up-to-date information is available on the Commission for Dietetic Registration website.

In states without licensure, anyone can legally provide nutrition services, though it may be considered unprofessional or unethical for individuals without the appropriate education and training or competencies and skills to do so. Ultimately, state requirements take precedence in determining minimal scope of practice requirements. For example, while a fitness professional in Colorado may legally be allowed to call himself a “nutritionist” and provide nutrition counseling, a fitness professional with the same education, experience and fitness certification in Illinois could face a $5,000 penalty each for calling himself a “nutritionist” or for providing nutrition counseling.

Education and Training

The limitations to scope of practice dictated by state laws trump the other determinates of scope of practice such as education and training or expertise and skill level. However, regardless of the presence or absence of legal restrictions, any services offered should be consistent with a fitness professional’s education and training. Most fitness certifying bodies and professional organizations include a statement outlining the professional’s scope of practice (see box, Scope of Practice: ACE Position Statement on Nutrition Scope of Practice for Fitness Professionals).

Beyond their fitness-related certification, many fitness professionals recognize the value in receiving additional training or certification in nutrition. In these cases, they have spent many hours learning about nutrition and likely have expanded their ability to effectively and accurately answer clients’ questions. While education such as the ACE Fitness Nutrition Specialty Certification broadens a fitness professional’s expertise, fitness professionals should be careful to follow the scope of practice guidelines set forth by the certifying or professional organization that offered the advanced training and recognize the limitations to their education and training. In some cases, a fitness professional may choose to pursue additional training to become a registered dietitian or attain an advanced degree in nutrition, which further expands scope of practice.

 Competencies and Skills

Fitness professionals should work within their own set of competencies and skills. For example, while one fitness professional may have a special interest and expertise in obesity prevention, another may work primarily with athletes and be interested in nutrition to improve sports performance. Prior to sharing a piece of information or initiating a nutrition discussion, fitness professionals should ask themselves whether or not the activity is within their scope of practice, training and skills. If the answer is “no” or if the fitness professional is unsure, referral is likely warranted.

As a fitness professional considers what nutrition information is or is not appropriate to incorporate into sessions with clients, it is important to highlight certain actions that are well within the scope of practice of nearly all qualified fitness professionals and not only can be shared with clients, but should be shared to help the client receive the highest quality service.

Nutrition Content All Fitness Professionals Should Share

Given the alarming worldwide obesity epidemic, the eagerness of the general population to learn more about nutrition, and the large amount of nutrition misinformation readily available and perpetuated online, in magazines and through misinformed and unqualified individuals, fitness professionals should discuss nutrition with their clients. All fitness professionals should share the dietary recommendations and guidelines endorsed by the federal government, especially the Dietary Guidelines for Americans and the MyPlate recommendations. While historically many fitness professionals have considered these guidelines to be limited and basic, they actually contain a wealth of nutrition information and resources. In fact, if most people followed these recommendations (currently very few do), the nutritional status of Americans would be much higher and relatively few people would be overweight or obese.

Several other nutrition tools also are available for fitness professionals to use while staying well within their scope of practice. For example, the federal government’s SuperTracker tool provides an opportunity to help clients participate in food logging, meal planning and goal setting, all in accordance with the Dietary Guidelines.

Nutrition Content ACE Fitness Nutrition Specialists and Others With Advanced Training in Nutrition Should Share

While most states that require licensure of nutritionists emphasize what non-licensed persons cannot do, Ohio’s statute serves as a useful example to help clarify scope of practice for “nonlicensed individuals;” that is, individuals such as ACE Fitness Nutrition Specialists who have occasion to discuss nutrition, but who do not have the registered dietitian credential and state license, where necessary. In Ohio, unlicensed individuals can provide “general nonmedical nutrition information,” which includes, but is not necessarily limited to, the following:

• Principles of good nutrition and food preparation
• Food to be included in the normal daily diet
• Essential nutrients needed by the body
• Recommended amounts of essential nutrients
• Actions of nutrients on the body
• Effects of deficiencies and excesses of nutrients
• Food and supplements that are good sources of essential nutrients

Unlicensed individuals also may freely disseminate nutrition information, including information on vegetarian diets, alternative diet philosophies, government or agency nutrition literature, books and articles. Unlicensed individuals may also deliver a weight-management program that has been approved in writing by a physician or registered dietitian (Ohio Board of Dietetics, 2004).

While this statute legally applies directly only to fitness professionals living in the state of Ohio, these general guidelines serve as a useful and constructive outline from which to build knowledge and competency for ACE Fitness Nutrition Specialists. As such, the guidelines form the foundation for the ACE Fitness Nutrition Specialty certification and ACE’s Position Statement on Nutrition Scope of Practice. ACE Fitness Nutrition Specialists are encouraged to share this information through a variety of venues, including cooking demonstrations, recipe exchanges, development of handouts and informational packets, and individual or group classes and seminars.

Nutrition Content Fitness Professionals and ACE Fitness Nutrition Specialists Should NOT Share

Certain nutrition content is best left to a qualified nutrition professional who holds the necessary training and credentialing to ensure the client’s safety and to best meet the client’s need. This includes:

• Medical nutrition therapy. Medical nutrition therapy is a term that refers to the provision of individualized nutrition assessment and dietary recommendations to help manage disease. Medical nutrition therapy is recognized by Medicare as the domain of the registered dietitian. Clients who have underlying medical diagnoses and illnesses should be encouraged to undergo a nutritional assessment from a registered dietitian. The fitness nutrition specialist may then help the client follow the dietitian’s nutrition recommendations.
• “Nutrition assessment,” “nutrition counseling,” meal planning or individualized nutrition recommendations. The assessment of an individual’s nutritional status and the provision of individualized nutrition recommendations or counseling are outside the fitness professional’s scope of practice. A registered dietitian takes into consideration the client’s full medical history, medications, background and family history, and many other factors when developing a dietary program. Fitness professionals are often not privy to this information and not trained in how to interpret and manage abnormal findings. However, fitness professionals can use government resources such as the USDA’s SuperTracker to help clients access a personalized plan based on the Dietary Guidelines. In addition, fitness professionals may share nutrition information or meal plans developed by a registered dietitian, such as the meals plans offered through Evolution Nutrition, an ACE collaborative partner (see ACE’s Nutrition Tools and Resources for Fitness Professionals).

• Supplement guidance and recommendations.Supplement use is widespread among health enthusiasts, athletes and other individuals that seek the services of the fitness professional. In addition, many fitness facilities promote and sell supplements. As such, fitness professionals frequently field questions about supplements from clients. Due to the potential risks of supplement use, fitness professionals should never advise a client to take a supplement. However, fitness professionals can share information about supplements. When sharing information about supplements, it is important that the client understands that the fitness professional is not recommending or endorsing the supplement. Clients that are considering supplement use should be referred to a qualified medical professional or registered dietitian (see box, Referral to a Registered Dietitian).
• Promotion of credentials as a “nutritionist” or “dietitian.” Most states prohibit promotion of oneself as a “nutritionist” or “dietitian” without verification of specific credentials. Fitness professionals who do not hold these credentials and have not been verified by the state licensing or registration board should NOT refer to themselves or promote themselves as nutritionists or dietitians.

Referral to a Registered Dietitian 

One of the most important ways that an ACE Fitness Nutrition Specialist can gain credibility among other allied health professionals and develop strong relationships with registered dietitians is to “speak the language” of the other professional and thereby establish an effective referral process. This four-step plan will help fitness professionals get started.

•Identify a qualified professional: The first step to initiating a referral is to identify a nutrition professional who you trust. You may identify this person through word of mouth and a recommendation from another allied health professional, through the database of registered dietitians maintained by the A.N.D. (available at www.eatright.org), through the facility where you work, or through other venues.

•Establish a connection: Before referring clients to an individual, it is helpful to establish a connection and relationship with that person. Not only does this communication help to increase the likelihood of success for the client, but it may also help to have a ready contact for future referral and generate return referrals in exchange. There are several ways to establish this connection: a brief introductory phone call or email, following up on a recommendation from another professional or client, or networking through professional meetings, joint acquaintances, or organized networking events, for example.

•Make the referral: Once you have determined to whom to refer a client, the next step is to make the referral. To be most effective, it is important to make the referral in writing. The referral letter should include (1) your name, credentials, and contact information; (2) a brief one- or two-line background about the client; and (3) the reason for referral.

•Follow up: Follow up with both the registered dietitian and your client after the client has visited with the registered dietitian. You can play an important role in helping to reinforce the messages and recommendations provided by the registered dietitian and also help to monitor the client’s progress. To strengthen your relationship with the registered dietitian, write a brief follow-up letter acknowledging that you received the recommendations and will fulfill your intended role by helping the client achieve success with the recommendations. This follow-up letter helps to improve care for the client and demonstrates your professionalism. 

Summary

As nutrition and exercise are both critical to achieve optimal health, fitness professionals are encouraged to share nutrition information with their clients. In those cases in which a client requests individualized nutrition information or when a client has a medical diagnosis that requires special nutrition recommendations, fitness professionals may serve their clients best by referring them to their physician and/or a registered dietitian for an individualized eating plan. The fitness professional still plays an important role in providing support and encouragement for the client to follow the recommended plan. Ultimately, when health professionals work together to help clients reach their goals, everyone benefits: the client receives the best care, while both professionals strengthen their networks and increase their credibility.

References

Ahmed, H.M. et al. (2013). Low-risk lifestyle, coronary calcium, cardiovascular events, and mortality: Results from MESA. American Journal of Epidemiology, DOI:10. 1093/aje/kws453.http://aje.oxfordjournals.org.

American Council on Exercise (2013). ACE Fitness Nutrition Manual. San Diego: American Council on Exercise.

Hoyert, D.L. & Xu, J. (2012). Deaths: Preliminary Data for 2011. National Vital Statistics Reports, 61, 6. Retrieved June 12, 2013:

Narayan, K.M. et al. (2003). Lifetime risk for diabetes mellitus in the United States. Journal of the American Medical Association, 290, 14, 1884–1890.

Ohio Board of Dietetics (2004). Bulletin # 8: General Non-medical Nutrition Information.