When it comes to providing nutrition advice, some exercise professionals are reluctant to discuss any aspect of nutrition and diet. Conversely, some have been known to perform detailed dietary analyses and nutrition assessments, offer individualized nutrition advice, and provide complete meal plans. Thus, confusion exists among exercise professionals about where to draw the line when assisting their clients with nutrition and diet-related questions and goals.
Nutrition professionals have the same dilemma. Because exercise is important to health and weight management, they may feel tempted to provide exercise guidance to their clients. As such, this article has three distinct purposes:
- To compare and contrast the training and competencies of certified exercise professionals and Registered Dietitian/Nutritionists (RDNs).
- To discuss the potential legal implications of exercise professionals crossing into the RDN’s scope of practice (SOP) and for RDNs providing exercise advice outside their SOP.
- To provide guidelines for how health and exercise facilities can best support the nutrition and diet-related needs of their clients while protecting both practitioners and organizations from any potential legal liability.
OVERVIEW OF THE REGULATION OF NUTRITION AND DIETETICS PROFESSIONALS
Nutrition and dietetics professionals have one organization, the Academy of Nutrition and Dietetics (Academy) that provides the RDN credential for practice. The credential RDN is granted and maintained by the Commission on Dietetic Registration (CDR) of the Academy (3). These professionals call themselves Registered Dietitians (RD) or RDNs because the training is the same. To be eligible to sit for the National Registration Examination for Dietitians, one must first obtain a bachelor’s degree and complete a Didactic Program in Nutrition and Dietetics (DPND) accredited by the Accreditation Council for Education in Nutrition and Dietetics (ACEND) of the Academy and complete an ACEND-accredited Dietetic Internship Program that provides at least 1,200 hours of supervised practice experience (16).
Most DPND programs do not require courses in exercise science or exercise physiology; thus, many RDNs are not qualified to discuss detailed issues regarding fitness assessment and exercise prescription. Instead, most RDNs, depending on their formal education and training, are limited to providing education on the current 2008 Physical Activity Guidelines for Americans (5) and the health benefits of exercise. There are additional board certifications beyond the RDN credential, including the Certified Specialist in Sports Dietetics (CSSD) (1). This person has demonstrated training in both exercise and nutrition and specialized expertise in working with athletes and active individuals. Once credentialed, an RDN must submit a professional development portfolio (PDP) to the CDR every 5 years to maintain his or her credentials. The PDP outlines how the RDN completed his or her predetermined continuing education (CE) goals.
Most states do not regulate exercise physiologists and their practice; however, most states do regulate the profession of dietetics independent of CDR. Currently, 46 states, the District of Columbia, and Puerto Rico have enacted statutory provisions regulating the practice of nutrition and/or dietetics either through state licensure or statutory certification. 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 SOP of a profession. Currently, 35 states and the District of Columbia and Puerto Rico have licensure in place for nutrition and/or dietetics. Although statutes vary, many states dictate that it is illegal to engage in the profession without first obtaining a license. 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, the RDN must be in good standing with the CDR to become licensed. Engaging in the professional practice of dietetics is prohibited without a license; thus, if an RDN moves to a state with licensure, he or she cannot practice until a license has been granted even though he or she is an RDN and eligible for licensure.
Statutory certification limits the use of particular titles (e.g., certified dietitian, certified nutritionist) to individuals meeting the state’s credentialing requirements; noncertified individuals can practice but cannot use certain titles. Approximately 10 states have opted for statutory certification or title protection for nutrition and dietetics professionals in lieu of licensure. 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, but he or she cannot refer to him- or herself as a certified dietitian or certified nutritionist. Similarly, title protection for RDN means that only those with the credential may use the title. There is currently no state statute in Arizona, Colorado, Michigan, and New Jersey.
The third credential that RDNs (and other professionals) can obtain involves nonstatutory (non-state 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 the dietetics professions, you should be aware that licensure trumps both registration and certification. Thus, in most states with licensure, if you have obtained the RDN credential or a nutrition or weight management certification, you cannot practice dietetics until you have been granted a license. Essentially, the SOP of dietetics/nutrition is well defined and legally enforced in states with licensure. The question then arises: In states without licensure, should an exercise professional provide nutrition services? If so, where should he or she draw the line? An important consideration is the depth and breadth of nutrition training an exercise professional possesses compared with the level needed to provide various types of nutrition services.
OVERVIEW OF THE REGULATION OF EXERCISE AND EXERCISE PROFESSIONALS
Unlike nutrition and dietetics, there is no single accrediting body for programs in kinesiology or exercise science that results in a uniform nationally recognized credential. Many kinesiology and exercise science degree programs may require one or two nutrition courses or include nutrition content in an existing course. However, this general nutrition overview does not provide the education and training necessary to perform individualized nutrition assessment, counseling, and meal planning, especially for those who have health issues. An exercise professional can use this nutrition information to provide general, nonmedical nutrition information and guidelines published by governmental organizations such as the U.S. Department of Agriculture (USDA). He or she also may reinforce individual recommendations provided by a licensed RDN.
The term exercise professional is broad and encompasses those with no, or very little, formal training to those with significant patient/client experience and graduate and postgraduate training. Unfortunately, beyond the American College of Sports Medicine (ACSM) and several other reputable certifying organizations, there are many fitness or personal trainer online or day-conference certifications available to those who may not have even completed their high school education. Therefore, there are likely thousands of individuals practicing and calling themselves exercise professionals with very little (or no) formal education or experience in any aspect of individual or group exercise planning/counseling and leadership. This can lead to potentially dangerous situations for which many of these exercise professionals are poorly equipped. For instance, approximately 85 million Americans (>33% of the adult population) have diagnosed heart disease (12), 7 in 10 Americans take prescriptions medications (18), approximately 50% of all U.S. adults have at least one chronic health condition (one in four have two or more) (17), and it is likely that up to two in every three clients seeking professional exercise advice may be overweight or obese (13). In April 2015, the Physical Activity Council reported that physical inactivity rates were the highest since 2007 with approximately 83 million Americans reporting they were totally sedentary during the past year (15).
It is critical to understand the laws of the state(s) where you live and practice. In the exercise profession, there is a reliance on self-regulated certification. Only Louisiana requires a license for clinical exercise physiologists; no other U.S. state or territory requires a license to provide exercise advice or direct training to clients. Therefore, terms describing a person’s professional title such as personal trainer, yoga instructor, and exercise physiologist can be used by anyone. Even those who use the descriptor certified can be a wide-ranging group as far as their education and experience. Hence, it is difficult to ensure the public that an exercise professional has the education and experience to provide adequate care.
Because of these concerns, ACSM and other professional organizations suggest that the general public seek an exercise professional, either for general fitness advice or group/personal training or for a clinical program for those with chronic diseases, who is certified from a National Commission for Certifying Agencies (NCAA) accredited professional society (8). The NCCA provides a standardized, independent, and objective third party evaluation of the design, development, and performance of the certification examination in an effort to provide a high level of integrity and quality of the exam. A certification exam’s goal should be to identify capable individuals who meet at least a minimal level of competency as established by the professional organization. A search of NCCA-accredited fitness/wellness certifications found 16 organizations that provide a variety of certifications, ranging from personal training to group exercise instruction to strength and conditioning and clinical exercise physiology (8).
ACSM provides NCCA-accredited certifications in four levels of exercise professional certification, including Certified Personal Trainer (CPT), Certified Exercise Physiologist (EP-C), Certified Clinical Exercise Physiologist (CEP), and Registered Clinical Exercise Physiologist (R-CEP). The minimum requirements to sit for an ACSM credentialing examination are listed in Table 2.
For ACSM, each certification has an associated job task analysis (JTA) that is performed every several years that informs the ongoing development of each certification examination. As seen in Table 3, each certification has a list of nutrition and weight management knowledge or skill tasks. The health and fitness certifications seem to have many more knowledge and skill tasks than the clinical certifications. However, the clinical credentials simply refer to the exercise professional knowing the SOP of dietary professionals to whom a patient can be referred. Many clinical exercise professionals work in multidisciplinary units that often have an RDN who provides dietary and nutrition advice to the clients. Conversely, there are 12 knowledge and 17 skill tasks listed for the personal trainer and exercise physiologist certifications. Most of these tasks are knowledge statements that do not suggest that dietary treatment information is provided to a client. Rather, these statements reflect possible discussion items in the event that they “come up” during a discussion or are an item that the exercise professional determines requires addressing (e.g., possible referral to an RDN). The health and fitness exercise professionals may have more opportunity to discuss nutrition issues with their clients because they often work independently unlike the clinical exercise professionals who typically are part of multidisciplinary teams. Thus, the JTA reflects this increased occurrence of nutrition encounters for the health and fitness exercise professionals.
REGISTERED DIETITIAN NUTRITIONIST AND EXERCISE COUNSELING
Several states have proposed licensure bills for exercise professionals (e.g., personal fitness trainers and group exercise leaders) but, to date, these bills have not become law. Therefore, an individual in any U.S. state or territory can provide exercise advice, including RDNs. In fact, the SOP for the RDN as put forth by the Academy lists the following as an activity/service performed by RDNs: Provide nutrition counseling; nutrition behavioral therapy; lactation counseling; health coaching; and nutrition, physical activity, exercise counseling, and health education as components of preventative, therapeutic, and restorative health care. It would seem that both physical activity and exercise counseling are within the SOP for RDNs. However, it is the responsibility of the RDNs to thoroughly understand their own knowledge and skills and decide whether this is within their SOP. Furthermore, it is important to realize that courts will rely on the SOP as defined in the state statute versus an SOP definition provided by a professional organization.
As mentioned earlier, few dietetic programs require exercise science courses as part of the curriculum; thus, most RDNs are not qualified to provide physical activity advice or exercise prescriptions. This is especially true when giving physical activity advice to a clinical population who typically requires special instructions or monitoring during exercise. However, RDNs frequently work as part of multidisciplinary teams that include exercise physiologists and, thus, understand the role of each team member.
Although there do not seem to be any lawsuits (at least by Google search) against RDNs who provided inaccurate or dangerous exercise advice, there have been many negligence lawsuits made against exercise professionals in a variety of settings. Often, these “exercise professionals” were found liable, with the lack of education, training, and experience being common negligent claims made against them (10). If an RDN lacks sufficient education and experience to provide exercise guidance beyond “general physical activity” advice (e.g., encourage physical activity/educate on benefits of exercise), it is best for them to avoid providing “individualized” exercise advice for the protection of both the client and themselves. Thus, RDNs who do not hold appropriate knowledge, skills, or certification should not provide individualized exercise advice and should seek out (or refer clients/patients to) qualified professionals.
POTENTIAL LEGAL CONSEQUENCES
One of the competencies for the ACSM Certified Exercise Physiologist® (EP-C) states “Knowledge of federal, state, and local laws pertaining to staff qualifications and credentialing requirements” (2). Related to this competency are the potential legal consequences that can arise for practicing outside one’s scope. Both criminal charges and civil claims/lawsuits can occur.
Criminal charges can occur for violations of statutes such as state licensing laws. As shown in Table 1, many states have licensing laws that require an individual to have a license to practice dietetics/nutrition. These state licensing laws are usually quite comprehensive and include a definition of the practice (e.g.,Table 5 provides an example from the Ohio statute), the qualifications necessary to obtain a license, the composition and powers of the state licensing board (e.g., rulemaking and disciplinary actions), and criminal sanctions such as fines and/or imprisonment for practicing without a license.
Often, exercise professionals have received nutrition education in their academic programs and/or through CE — attending conferences, Webinars, or reading journals. Some exercise professionals also may have earned specific nutrition credentials such as a degree in nutrition and/or any of the many nutrition certifications. Given this education in nutrition, exercise professionals may think they can provide individualized nutrition assessments and counseling. However, that is not the case, as demonstrated in the Liz Lipski case (9). Although Dr. Lipski had a Ph.D. in clinical nutrition and several nutrition certifications (e.g., Certified Clinical Nutrition and Certified Nutrition Specialist), the North Carolina (NC) Board of Dietetics/Nutrition denied her the right to practice nutrition in NC. They asked her to return to college and complete the undergraduate courses and other requirements to become an RDN. Instead, she moved to Maryland (10). Although she cannot practice nutrition in Maryland, which also requires a license, she could practice in neighboring Virginia as long as she does not violate the title protections specified in that state’s statute, that is, statutory.
Another case in NC, Cooksey v. Futrell (4), dealt with providing nutrition information on a Web site. There is an administrative code in NC (7) that states “Any person, whether residing in this state or not, who by use of electronic or other medium performs any of the acts described as the practice of dietetics/nutrition, but is not licensed…shall be deemed by the [State] Board as being engaged in the practice of dietetics/nutrition and subject to the enforcement provisions available to the Board” (p. 231). In this case, Cooksey launched a Web site titled “Diabetes Warrior” that included offering individualized advice to those wanting to try the Paleolithic diet in exchange for a fee. Once the NC State Board was informed of Cooksey’s Web site, the executive director of the board informed him that his Web site was under investigation and that the board has statutory authority to seek an injunction — a court order to prohibit his unlicensed practice of dietetics. The director instructed him to take down that part of his Web site because it constituted the unlicensed practice of dietetics, stating “You should not be addressing diabetics’ specific questions. You are no longer just providing information when you do this, you are assessing and counseling, both of which require a license” (p. 232).
An important lesson can be taken away from this case: exercise professionals (and health and wellness coaches) who provide nutrition information to clients via the Internet may run the risk of violating individual state licensing laws or administrative codes. It may be wise to seek legal counsel before providing these types of services or to keep the nutrition information provided within one’s SOP; for example, be sure it is general (not individualized), nonmedical nutrition information as shown in Table 5.
In Ohio Board of Dietetics v. Brown (14), the defendant (the person charged with violating the state’s licensing statute) performed nutritional assessments and recommended nutritional supplements to individuals, engaged in nutritional counseling and education for the purpose of treating specific complaints and ailments of individuals, and represented himself as a nutritionist. The appellate court ruled that the defendant was practicing dietetics as defined by the Ohio statute, R.C. 4759.01, and therefore granted the request from the Ohio Board of Dietetics for an injunction. In his defense, the defendant attempted to excuse his unlawful activities by calling himself a “nutritionist” versus a dietitian, but the court stated “the acts defendant performs are more important than his title and since he does not possess a license to provide nutritional counseling and assessments, defendant’s acts are in violation of R.C. 4759.02” (p. 248). It is important to realize that courts will analyze/judge the conduct of the defendant, as it did in this case (i.e., providing nutritional assessments and counseling). These were specified practices stated in the Ohio statute (Table 5) versus the title, unless a certain title(s) is protected by statute.
Civil Claims/Lawsuits — Negligence
In the aforementioned cases, a personal injury or harm to someone was not an issue for the court to investigate — only the conduct that violated state licensing statutes. However, if an individual is harmed because of any nutrition advice provided by a defendant, he or she can sue the defendant (e.g., the exercise professional and/or his or her employer) for negligence; whether the conduct violated a state statute is not the issue. The question is, did the conduct cause the harm? For example, there are many negligent claims and lawsuits against exercise professionals whose conduct (e.g., improper design and delivery of an exercise program) harmed a client/participant (6). These cases had nothing to do with state licensing statutes.
In a negligence lawsuit, the plaintiff (injured party) has to prove that the defendant had a duty (a certain standard of care to follow), breached that duty, and that the breach of duty caused the harm. Courts determine duty — not lawyers, plaintiffs, or defendants. Courts rely on expert witnesses to educate the court as to what the duty was, given the circumstances, and whether the defendant breached his or her duty. Therefore, an exercise professional’s conduct is judged by an expert witness — usually someone with advanced credentials (e.g., Ph.D. in exercise physiology or dietetics) and many years of professional experience.
Exercise professionals should realize that even seemingly benign advice might lead to harm. See examples in Table 4. If faced with a negligence lawsuit, exercise professionals cannot claim, as a legally effective defense, that they did not know about the harmful consequences of the nutritional advice they provided. Several viable legal defenses to refute negligence lawsuits do exist, but ignorance (or lack of knowledge) is not one of them.
Exercise professionals can be found negligent for any improper instruction or advice that caused harm.
Establishing Scope of Practice Guidelines and Staff Training
As previously discussed, practicing outside one’s SOP not only involves practicing dietetics/nutrition without a license but also deals with giving nutrition advice or instruction that could lead to harming someone. True exercise professionals know and understand their SOP based on their credentials (e.g., education, certifications) and experience. Given that exercise professionals have varying educational backgrounds, it is important for fitness managers/supervisors to establish SOP guidelines (as an effective risk management strategy) with regard to nutritional advice/education for their employees to follow — the exercise professionals who work within their facility (e.g., personal trainers, group exercise leaders, health/wellness coaches).
Another competency for the ACSM EP-C states “establish policies and procedures for the management of health fitness facilities based on accepted safety and legal guidelines, standards and regulations” (2). Based on this competency, the development of a written policy that describes the scope of nutrition advice/education provided to participants should be established. For example: It is the policy of (Name of Fitness Facility) that exercise professionals do not provide “individualized nutritional advice” but only “general, nonmedical nutrition education” to facility participants. Once the policy statement is developed, the procedures related to the policy need to be well thought out and reflect a SOP that is consistent with the law and competencies developed by professional organizations. The items listed in the Ohio statute under “general nonmedical nutrition information” (see Table 5) provide a good framework for developing these written procedures as do the many nutrition-related competencies for the ACSM certifications listed in Table 3. It is recommended to seek legal counsel in the development, implementation, and dissemination of this policy and procedures. The leader of the training not only needs to describe the written policy and procedures but explain why (from a safety and legal perspective) they have been developed. A training outcome should be that staff members know how to provide “general nonmedical nutrition education” (Table 5) when communicating with fitness participants and when referring to an RDN. Some fitness facilities have opted to have RDNs available (as employees or independent contractors) who can provide individualized nutritional services for their members/participants.
Ideally, RDNs and exercise professionals work together as part of a medical, athletic, or fitness/wellness team, but the reality is that many exercise professionals and RDNs work independently of each other. This lack of interaction, cooperation, and regular communication can contribute to a blurring of the SOP line. It is not until we work closely with other professionals that we truly understand their professional capacity and how it differs from our own.
Currently, ACSM and the Academy are calling for new educational approaches that will facilitate the nutrition and the exercise science professional working together (11). This means learning about the SOP, language, and skills of the other profession and the role each can play in helping clients. Thus, RDNs need to learn more about physical activity and exercise, whereas exercise science professionals need basic training in nutrition. For example, exercise professionals can develop a working relationship with RDNs who specialize in their corresponding area of practice such as sports nutrition, cardiovascular health, wellness/disease prevention, or special populations such as pediatrics or geriatrics. The reverse also can occur, thus helping to develop a relationship that is mutually beneficial to both parties. Once a mutual relationship has been established, each can act to refer clients for services to the other profession. The RDN can serve as an information and referral resource to the exercise professional and vice versa. Because weight management is one area that overlaps the SOP of RDNs and exercise professionals, health/fitness and clinical facilities need RDNs as part of their staff and to provide individualized diet and nutrition advice to participants, whereas RDNs need to build a working relationship with exercise professionals and facilities that can help their clients participate in an appropriate fitness program based on health and weight goals. The following three Web sites provide searchable databases of RDNs and ACSM certified professionals and their corresponding areas of practice:
- www.eatright.org – the Academy of Nutrition and Dietetics
- www.scandpg.org – Sports, Cardiovascular, and Wellness Nutritionists, a practice group of the Academy. This site also provides information on how to become a CSSD.
- www.usreps.org – U.S. Registry of Exercise Professionals
BRIDGING THE GAP
Understanding what constitutes SOP is an important topic for both RDNs and exercise professionals. The education and credentialing process is not the same for both professions. An individual with the RDN credential completed both didactic and supervised practice experience in accredited educational programs followed by a national examination. There is not a similar process or one credential for all exercise professionals. It is critical that both RDNs and exercise professionals understand their own SOP and obey the state statutes where they practice.