Sass, Cynthia M.P.H., M.A., R.D., C.S.S.D., L.D.N.; Eickhoff-Shemek, JoAnn M. Ph.D., FACSM; Manore, Melinda M. Ph.D., R.D., C.S.S.D., L.D., FACSM; Kruskall, Laura J. Ph.D., R.D., FACSM
When it comes to nutrition, some health/fitness professionals are afraid to utter a word, whereas others perform detailed dietary analysis, offer individualized nutrition advice, and provide complete meal plans. In other words, a great deal of confusion seems to exist among health/fitness professionals about where to draw the line when it comes to assisting participants with nutrition-related questions and goals. This lack of clarity can lead to unwanted outcomes for participants, health/fitness professionals, and facilities. As such, this article has three distinct purposes. The first is to carefully compare and contrast the training and competencies of health/fitness professionals and registered dietitians' (R.D.'s). The second is to discuss the potential legal implications of health/fitness professionals crossing into registered dietitians' scope of practice. And finally, the third is to offer guidelines concerning how health/fitness facilities can best support the nutrition-related needs of their participants while protecting both practitioners and organizations from any potential legal liability.
Overview of the Regulation of Dietetics Professionals
Perhaps the best way to begin a nutrition-focused scope of practice discussion is to review how dietetics professionals are governed. Currently, a dietetics professional can attain three distinct credentials, and each is uniquely regulated. The first is the title of R.D. This credential is granted by the Commission on Dietetic Registration (CDR), a branch of the American Dietetic Association (ADA). The ADA is a national professional organization, similar to the American College of Sports Medicine (ACSM). To become eligible to sit for the R.D. examination, a dietetics professional must first obtain a bachelor's degree, which involves earning an undergraduate degree in dietetics and/or completing the Didactic Program in Dietetics (DPD) course work from a program accredited by the Commission on Accreditation for Dietetics Education (CADE), and complete a CADE-accredited Dietetic Internship Program (DI) that provides at least 900 hours of supervised practical experience. Some undergraduate didactic programs, known as Coordinated Programs, build the DI into the undergraduate degree requirements. Other individuals undertake their DPD course work as part of their graduate degree and then complete their DI program. Once credentialed, an R.D. must submit a Professional Development Portfolio (PDP) to the CDR every 5 years to maintain his/her credentials. The PDP outlines how the R.D. completed his/her predetermined continuing education (CE) goals.
Most states also regulate the profession of dietetics independently of the ADA. Currently, 31 states, the District of Columbia, and Puerto Rico have enacted laws licensing the profession of dietetics (1). See Table 1 for a list of states with licensing laws regulating nutritionists and/or dietitians. Licensing generally involves the provision of a state statute that explicitly defines the scope of practice of a profession. Although statutes vary from state to state, in many states, the statute dictates that engaging in the profession without first obtaining a license is illegal. Breaking a state licensure law is a criminal offense, subject to misdemeanor or felony penalties ranging from a cease and desist order to fines and imprisonment. In most states, dietitians and/or nutritionists must first obtain the R.D. credential to become licensed. Engaging in the professional practice of dietetics is prohibited without a license. In other words, if an R.D. moves to a state with licensure, he/she cannot practice until a license has been granted, despite the fact that he/she is an R.D. and is fully eligible for licensure.
Roughly 19 states have opted for statutory certification for dietetics professionals in lieu of licensure, including New York State (1). Statutory certification differs from licensure in that certification generally limits the use of particular titles to persons meeting the state's predetermined requirements, although persons not certified can still legally practice the occupation or profession. For example, in New York State, a noncertified individual can practice dietetics. However, they cannot refer to themselves as a certified dietitian/dietician or certified nutritionist. Both licensure and statutory certification are governed by state Departments of Health. The third credential that R.D.'s (and other professionals) can obtain involves nonstatutory (nonstate affiliated) nutrition and weight management certifications that are offered by numerous organizations. The educational and practical prerequisites and CE requirements for such certifications vary greatly.
If you live in a state that licenses dietetics professions, you should be aware that licensure "trumps" both registration and certification. In other words, in most states with licensure, if you have obtained the R.D. credential or a nutrition or weight management certification, you cannot practice dietetics until you have been granted a license to do so. Essentially, the scope of practice of dietetics/nutrition is well defined and legally enforced in states with licensure. This point begs the question: in states without licensure, should a health/fitness professional provide nutrition services? If so, where should he/she draw the line? An important consideration is the depth and breadth of nutrition training a health/fitness professional possesses compared with the level needed to provide various types of nutrition services.
Dietetics Competencies Versus ACSM Health/Fitness Instructor® Knowledge, Skills, and Abilities
Clearly, a strong relationship exists between nutrition and fitness, wellness, and disease prevention; certainly, health/fitness professionals should possess knowledge in this area. Accordingly, there are 20 distinct ACSM Knowledge, Skills, and Abilities (KSAs) relating to nutrition and weight management for the ACSM Health/Fitness Instructor® (HFI) certification and 17 for the ACSM Certified Personal TrainerSM (CPT) certification. In contrast, there are 101 nutrition-related CADE competencies for the DPD and over 50 additional competencies related to the DI. In addition, the competencies needed to practice dietetics are much more comprehensive than the HFI KSAs. They include not just knowledge but skills related to nutrition assessment, interpretation, calculation, and counseling. For example, Table 2 provides a comparison of five ACSM nutrition and weight management HFI KSAs to CADE competencies for entry level R.D.'s.
It is important to be aware that all but one of the ACSM KSAs for Nutrition and Weight Management begin with the words "Knowledge of…" (1.8.17 for HFI and 1.8.14 for CPT begin with the words "Ability to describe…"), which reflects the belief that health/fitness professionals should have a general understanding of basic nutrition and weight management information that they can then share with participants in a "general" sense. It is noteworthy that no KSAs exist that indicate that health/fitness professionals should have skills or abilities in providing "individual" nutrition assessments, dietary advice, meal plans, or recommendations for supplements or nutrient intakes. In other words, a health/fitness professional can explain the basic principles of weight loss but is not required to have the training to be able to calculate, outline and counsel, or prescribe an individualized weight management plan. This becomes even more critical if the individual being counseled has medical complications associated with obesity, such as diabetes, heart disease, or hypertension.
Legal Implications-Criminal Charges and Civil Claims/Lawsuits
Health/fitness professionals who "cross the line" into the practice of dietetics potentially can face both criminal charges and civil claims/lawsuits. The following case law examples reflect the seriousness of this point.
Criminal Charges-Violation of State Statutes
The fact that none of the ACSM KSAs reference nutrition assessment, screening, or individualized nutrition education or counseling is probably a result of the belief that these services should only be provided by qualified R.D.'s. In fact, health/fitness professionals who provide such services in the 30 states that have laws that govern the practice of dietetics could be violating these state statutes and be subject to criminal charges. For example, in Ohio Board of Dietetics v Brown (3), the defendant was found to be practicing dietetics without a license for performing nutritional assessments, recommending supplements, and engaging in nutritional education and counseling-a clear violation of Ohio's "Unauthorized Practice of Dietetics" statute (a statute which is described in a subsequent section).
In addition, health/fitness professionals who provide certain nutritional services could be violating other state statutes, that is, those that govern the practice of medicine or some other allied health profession. For example, in Stetina v State Medical Licensing Board (4), the defendant was using questionnaires and examining the eyes of her clients to determine, among other things, nutritional problems and then recommending certain foods and supplements to remedy those problems. The appellate court ruled that the defendant was practicing medicine without a license and therefore was permanently enjoined from practicing medicine until the state of Indiana had issued her one.
The key point that must be emphasized is that criminal charges can occur whether or not there was any harm to a participant. However, in negligence claims or lawsuits, the plaintiff (injured party) must prove that the defendant (e.g., the health/fitness professional) had a duty (i.e, a certain standard of care to follow), breached that duty, and that the breach of duty caused harm to the plaintiff. As such, any nutritional information or advice that a health/fitness professional provides to a participant/client must be appropriate for that particular individual. For example, in Capati v Crunch Fitness (5,6), a personal trainer allegedly advised his client who was taking prescribed medication for hypertension to take a variety of nutritional and dietary supplements-some of which contained ephedra. Research has shown that the combination of hypertension medication and ephedra can be lethal. While working out at the Club one day, the client became very sick and later died of a brain hemorrhage (stroke) at the hospital. As a result, the family filed a $320 million dollar wrongful death claim against the defendants-the personal trainer, the Club, and a variety of other defendants including Vitamin Shoppe Industries. The case was settled before going to trial, with the personal trainer and the Club liable for $1,750,000.
Unfortunately, legal problems related to nutrition information or advice can extend far beyond prescribing dietary supplements. When health/fitness professionals stray from their scope of practice, they run the risk of dispensing seemingly benign advice that can lead to harm. The reasons for this are twofold. First, a standard fitness assessment does not double as a standard nutrition assessment. Therefore, a health/fitness professional lacks the means (and the necessary knowledge) to properly screen a client's nutritional needs. Second, as previously discussed, health/fitness professionals lack comprehensive training in nutrition science. A health/fitness professional with an undergraduate degree in exercise science (or related area) may or may not have had an entire course devoted to nutrition. Even if a health/fitness professional had taken several courses involving nutrition, an additional 3 to 4 years of formal dietetics training would be needed to meet the entry-level practice requirements for an R.D. In fact, the combination of inadequate screening and limited training can lead to errors of omission or commission. Table 3 provides three distinct examples of this point.
Adopting "Scope of Practice" Guidelines for Health/Fitness Practitioners
To minimize legal liability associated with providing nutrition information, health/fitness facilities should adopt written guidelines that their health/fitness practitioners should then follow. Ohio's "Unauthorized Practice of Dietetics" statute (7) provides one of the most distinct delineations between the practice of dietetics and the provision of general nonmedical information on nutrition. According to this statute, only licensed dietitians can provide nutrition education, which is defined as "a planned program based on learning objectives with expected outcomes designed to modify nutrition-related behaviors" (7). Furthermore, nonlicensed individuals, including health/fitness professionals, can provide only "general nonmedical nutrition information." Table 4 outlines these two categories of practice.
According to the Ohio Board of Dietetics, practical examples of general nonmedical nutrition information include the following: demonstrating how to prepare and cook food; providing information about food-guidance systems (such as MyPyramid); providing examples of healthy snacks; talking about carbohydrates, proteins, fats, vitamins, minerals, and water as essential nutrients needed by the body and how nutrient requirements may vary through the life cycle; giving statistical information about the relationship between chronic disease and the excesses or deficiencies of certain nutrients; and providing information about nutrients contained in foods or supplements (8).
It is the opinion of these authors that the Ohio statutes (along with the ACSM KSAs for nutrition and weight management) serve as a valuable scope of practice guide and should be adopted as policy by individual health/fitness professionals and health/fitness facilities. Of course, within Ohio, adhering to the statute is required by law, and health/fitness practitioners should be fully aware of and abide by the dietetics statute within their state of residence. However, for those health/fitness professionals who reside in states without licensure, there can be several meaningful advantages to voluntarily adhering to the Ohio principles, including the following:
* boosts the credibility of a health/fitness professional, both with his/her clients and within his/her organization
* safeguards participants from acting on nutrition or weight management information that may be contraindicated based on their medical and/or nutritional status (which is not assessed by health/fitness professionals)
* reduces the probability that a health/fitness professional or the organization he/she works for will be subject to legal liability associated with either criminal charges (e.g., practicing medicine without a license as demonstrated in Stetina v State Medical Licensing Board of Indiana) and/or civil claims/lawsuits.
Ideally, R.D.'s and health/fitness professionals work together as part of a medical, athletic, and/or fitness/wellness team. In reality, however, many health/fitness professionals work independently of dietetics professionals. This lack of interaction, cooperation, and regular communication can contribute to a blurring of the scope-of-practice line. After all, it's not until individuals work closely with other professionals that they truly understand their professional capacity and how it may differ from their own.
It is the opinion of these authors that health/fitness professionals must develop professional relationships with R.D.'s who specialize in their corresponding area of practice. This step may include sports nutrition, cardiovascular health, wellness/disease prevention, or special populations, such as pediatrics or geriatrics. Such a relationship can be mutually beneficial to both parties. In addition to acting as a practitioner to whom the health/fitness professional can refer clients for services other than general nonmedical nutrition information, the R.D. can serve as an informational resource for the health/fitness professional. Furthermore, the R.D. can become a valuable referral source for the health/fitness professional and an aid in networking with other medical and allied health professionals. Because many participants desire and need sound nutrition and weight management information, it may be wise for health/fitness facilities to hire an R.D. (as an employee or independent contractor), who could become an integral part of the health/fitness team and provide "individualized" nutrition advice to participants for a fee. The following two Web sites provide searchable databases of R.D.'s and their corresponding areas of practice:
* www.eatright.org-the ADA
* www.scandpg.org-Sports, Cardiovascular, and Wellness Nutritionists, a practice group of the ADA. This site also provides information on how to become board certified as a specialist in sport dietetics (CSSD). The CSSD may be earned by an R.D. with advanced experience in sports nutrition or nutrition and exercise, who has passed the board certification examination within the previous 5 years.
It also is the opinion of these authors that health/fitness professionals who possess degrees in nutrition including advanced degrees but who do not possess the R.D. credential or licensure follow the guidelines related to general nonmedical nutrition information. Without a license, they increase their risk of criminal charges and civil claims/lawsuits if they provide participants with individualized nutrition and weight management advice. It is important to realize that practicing within these guidelines still provides a great deal of freedom for health/fitness professionals to educate their participants on a variety of important and helpful facts related to nutrition and weight management including lectures and writing.
The purpose of this article is not to perpetuate professional territorialism. Rather, the article emphasizes the fact that, as synergistic professionals, health/fitness and dietetics practitioners have an obligation to their clients, organizations, and professional associations to work together to uphold the highest standards of care. The all too often gray area of scope of practice between health/fitness professionals and R.D.'s has no doubt contributed to confusion, frustration, liability risk within the health/fitness field, and the possibility of harm to clients. The authors hope that the guidelines proposed in this article will enable both professions to move forward with clarity and cooperation and will help individuals and organizations adopt policies that best serve all parties involved.
Condensed Version and Bottom Line
This article discusses the importance of addressing the scope-of-practice line between health/fitness professionals and R.D.'s. In reality, some health/fitness professionals do not address nutrition issues with clients, whereas others provide a full array of individualized nutrition services. The lack of clear guidelines about what health/fitness professionals should and should not do with regard to nutrition-related issues can lead to unwanted outcomes, including advice that results in harm to participants, and civil claims/lawsuits and criminal charges for both health/fitness professionals and health/fitness facilities. This article compares and contrasts the training and competencies of health/fitness professionals and R.D.'s and reviews the legal implications of health/fitness professionals who cross into an R.D.'s scope of practice. Most importantly, the authors suggest scope-of-practice guidelines for health/fitness facilities that are designed to appropriately support the nutrition-related needs of their participants while protecting both practitioners and organizations from any potential legal liability. These guidelines involve limiting health/fitness professionals to the provision of general nonmedical nutrition education and encouraging health/fitness professionals to work with R.D.'s for the benefit of professions, participants, and health/fitness facilities.