As a fitness professional, you must be conscious of the fact you work with clients and not patients. If any of your clients seek advice and/or presents with signs of a nutritional related disease or disorder, indicates they are undertaking a strict diet, or they are taking supplements or fitness performance enhancers then it is highly advised that you refer them to an appropriate medical or allied health professional (if they are not already under the care of such as professional).
Under no circumstances should you:
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Provide individualised dietary analysis, advice or recommend specific diets.
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Provide dietary advice regarding infants, toddlers, the elderly or people with medical conditions. Always refer these clients to a qualified dietitian or general practitioner.
A personal trainer CAN provide general nutritional advice to healthy adults that is consistent with the Australian Dietary Guidelines and publicly available recommendations outlined in the Eat for Health Program guidelines.
The two main examples of professionals you may refer clients to are:
Medical doctors who have a broad knowledge and the skills to treat most general health issues.
The scope of their responsibilities includes:
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Diagnose various illnesses and injuries and provide treatment or referral accordingly.
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Prescribe medications to treat illness.
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Provide health advice.
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Provide ongoing care for certain chronic conditions.
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Conduct health screening.
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Administer vaccinations.
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Confirm a diagnosis and provide initial care for pregnancy.
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Provide general counselling, medication, and referral advice for people who are overwhelmed and/or depressed.
Situations where referral to a general practitioner would be appropriate include:
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If the client suffers from or is suspected to have, a high-risk medical condition which may be impacted by diet and/or nutritional intake.
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If a client's eating patterns are extreme, resulting in them being either excessively underweight or overweight.
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If the client's mental health is at risk due to poor body image or other eating disorders.
For specific diet and nutritional advice and information a general practitioner is likely to refer the patient to a dietitian, however, the above situations all involve underlying medical and/or psychological problems which may need to be addressed concurrently to nutritional changes.
Allied health professionals who educate communities and individuals on the impact of healthy eating and good nutrition.
The scope of their responsibilities includes:
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Identify and assess nutritional problems.
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Develop healthy eating plans for clients.
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Counsel clients on special diet modifications.
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Monitor weight loss progress.
Situations where referral to a dietitian would be appropriate include:
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A client asks for specific information or advice regarding weight management including specific types of diets or diet trends.
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If the client is having difficulty achieving their weight loss goals.
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The client is seeking information regarding weight-loss support groups that they can join to help with their weight loss goals. Dietitians can conduct an initial nutritional assessment before using their local contacts to refer the client to an appropriate support group, this may be Weight Watchers or it may be another organisation.
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The client requires a specific type of diet to be developed to help them achieve peak performance in a sport or other athletic pursuit. Some dietitians may work predominately with athletes and may be employed directly by professional sports teams, these professionals are known as Accredited Sports Dietitians.
Allied Health Professions Australia provides this overview of Dietetics on their website.
Body composition is directly related to nutrition and can result in various health conditions that are linked to being overweight or underweight.
| The main health conditions associated with excess weight are: | ||
|---|---|---|
| Type 2 Diabetes | Cardiovascular Disease | Hypertension. |
| Metabolic Syndrome | Some Cancers | Musculoskeletal Conditions |
| Respiratory Conditions | Sleep Apnoea | Gall Bladder Disease |
| Hernia | Reproductive Disorders | Urinary Incontinence |
| Fatty Liver Disease | Depression and other Mental Health Disorders | |
Many obesity related health conditions are preventable and also reversible through healthy eating, active lifestyle and weight loss.
| The main health conditions associated with being underweight are: | ||
|---|---|---|
| Body Dysmorphic Disorder | Anorexia Nervosa | Binge Eating |
| Osteoporosis | Depression and other Mental Health Disorders | Decreased Muscle Strength |
| Hypothermia | Malnutrition and Vitamin Deficiencies | Anemia |
| Reproductive Disorders | Decreased Immune Function | Developmental / Growth Delays (in children) |
Fitness professionals are not expected to be experts in any of these health conditions, however, you may become familiar with some of the common symptoms through your studies and work and therefore may be able to recognise when a client should be referred to a suitable medical or allied health professional.
Alternatively, you may be working with clients who have already been diagnosed with one or more of these conditions. In this case, the client is likely to already have a medical or allied health professional they are consulting and with whom you can work in conjunction with to help develop the fitness component of their wellness plan.
A dietary trend is associated with larger population groups and represents long-lasting or even permanent shifts in the types of foods that certain cohorts tend to consume, these shifts are often based on social or cultural influence. For example:
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Low socio-economic status may impact on the dietary trend of individuals eating foods that are highly processed, convenient, and/or cheap.
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A better understanding and appreciation of the welfare of animals influences the dietary trend of veganism.
Fad or popular diets are commonly advertised and discussed in the media. They are a type of dietary trend however are often temporary in their popularity. These diets often utilise extreme tactics, such as limiting certain food groups, fasting, or taking supplements, to promote rapid weight loss that may not be healthy or sustainable. If a client indicates that they are currently undertaking a fad diet or wish to commence one then suggest that they discuss any implications with their doctor or a dietition.
Some examples of dietary trends and fad/popular diets which you may encounter are:
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The Paleo Diet - Follows the theory that human anscestors hunted and gathered their foods without specifically growing or processing them and therefore so should modern humans. This usually means removing all grains, legumes, dairy, and packaged foods. This diet can be beneficial if a good amount of vegetables is included to accompany the high protein intake, however the removal of two entire food groups (grains and milk/yoghurt/cheese) means that fibre and calcium intake may be too low.
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The Raw Food Diet - Advises followers to only consume plant-based foods in their raw state in order to maximise enzyme and vitamins which may be destroyed by the cooking process. Whilst this diet has the benefit of achieving the recommended five servings of vegetables and two servings of fruit which most Australian's do not normally consume, some plant based foods are difficult to digest in their raw form and are actually improved by the cooking process. This diet also has some nutritional limitations because it cuts out the lean meat and milk/yoghurt/cheese food groups.
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Gluten Free Diet - Specifically developed for the treatment of Celiac Disease (which means an individual cannot digest gluten and creates an immune reaction that causes inflammation and malnutrition), it has also become popular amongst the wider public as a method of improving digestion and weight loss. Gluten is a protein found in wheat (including spelt), rye, barley and oats. For people with Celiac Disease or diagnosed gluten intolerance a gluten free diet is very beneficial. The dangers associated with following a gluten free diet include people who self-prescribe the diet and start omitting certain foods unnecessarily, without expert guidance and without replacing them with healthy alternatives.
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Veganism - A lifestyle choice, philosophy or dietary trend. It focusses on the exclusion of any form of food or products that use animals in their production. In dietary terms this means any foods that are wholly or partly derived from animals including meat, fish, dairy, eggs, mayonnaise and even honey. Whilst the restaurant industry is increasingly accommodating vegans in their menu creation this particular lifestyle choice may create limitations from a social perspective. Vitamin B12 deficiancy, is also a concern as this particular vitamin is only derived from animal sources.
Nutritional supplements are usually in the form of tablets, capsules, powders or liquids and are designed to fill a gap that may exist due to a nutritional deficiency or medical/physical condition.
Many people self-medicate with supplements due to a perceived need that may or may not be accurate, in fact studies have shown that many people who take supplements are already getting all their necessary nutrients via their diet. In some cases, nutritional supplements may be required for a short period of time due to a specific medical or physical condition. For example, pregnant women should take Folate supplements during the first trimester (and prior to conception if possible) to help prevent birth defects such as spina bifida.
Note: Any information and advice pertaining to nutritional supplementation should only ever be provided by a medical or allied health professional.
Some common nutritional deficiencies that do exist and may require supplementation are:
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Iron - The best dietary sources of iron (heme iron which is very well absorbed) are red meat, organ meat, shellfish, and canned sardines, so vegetarians and vegans may be at risk of this type of deficiency. Menstruating women are at a greater risk of iron deficiency due to monthly blood losses. Symptoms of iron deficiency include: tiredness, weakness, a weakened immune system and impaired brain function.
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Vitamin D - Adults who are deficient in this vitamin may be at greater risk of muscle weakness, bone loss, and fractures. Vitamin D is naturally produced by the cholesterol in the skin during exposure to sunlight. Symptoms of this type of deficiency are quite subtle however the elderly and people who are indoors during daylight hours are more vulnerable. Dietary sources of vitamin D are cod liver oil, fatty fish, and egg yolks.
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Vitamin B12 - This vitamin is essential for blood formation as well as brain and nerve function. It is not produced naturally in the body therefore must be obtained through either dietary or supplementary means. It is only found in sufficient amounts in animal foods like shellfish, organ meat, meat, eggs and dairy products, although certain types of seaweed does container smaller amounts. Vegetarians and vegans are especially susceptible to this type of deficiency.
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Calcium - Essential for healthy bone and teeth development especially during younger years when rapid growth is occurring. Dietary sources include boned fish, dairy products, and dark green vegetables. Symptoms of severe calcium deficiency include soft bones (rickets) in children and osteoporosis in older adults.
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Iodine - Assists in maintaining normal thyroid function and hormone regulation. Dietary sources of iodine are seaweed, fish, yoghurt, and eggs. Symptoms of iodine deficiency include: enlarged thyroid gland (goiter), elevated heart rate, shortness of breath and weight gain.
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Vitamin A - Helps to maintain healthy skin, teeth, bones and cell membranes. Dietary sources include organ meat, fish liver oil, sweet potatoes, carrots, and dark green leafy vegetables. Vitamin A deficiency can cause temporary and permanent eye damage, suppress immune function and increase mortality.
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Magnesium - Essential for bone and teeth structure. Dietary sources include whole grains, nuts, dark chocolate, and dark green leafy vegetables. Symptoms of magnesium deficiency include abnormal heart rhythym, muscle cramps, restless leg syndrome, fatigue and migraines.
According to the Food Standards for Australia and New Zealand, sports foods are specially formulated to help people achieve specific nutritional or sporting performance goals. They are intended to supplement the diet of sportspeople rather than be the only or main source of nutrition.
Sports foods must be clearly labelled to indicate that they are:
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Specifically formulated as a sports food.
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Not recommended as the sole source of nutrition and should be consumed as part of a nutritious diet.
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Provide directions for safe dosage/consumption.
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Not suitable for children under 15 or for pregnant women.
Ergogenic Aids are used by athletes to increase energy, performance and recovery. Certain products are more common and relatively safe to use (although medical advice is always recommended) and others products are much more dangerous and are either illegal (or banned in competitive sport) or should only be used in special circumstances under close medical observation.
If a client is seeking advice on any ergogenic aid always suggest they speak with a medical or allied professional first to ensure it is safe for them to utilise the product/s.
| Commonly used and relatively safe ergogenic aids | High-risk and potentially illegal ergogenic aids |
|---|---|
| Amino acids | Anabolic and other steroids |
| Bee pollen | Dehydroepiandrosterone (DHEA) |
| Caffeine | Diuretics |
| Carnitine | Blood doping |
| Chromium | Ephedrine |
| Creatine | Human growth hormone (HGH) |
| Ginseng | |
| Protein powders |
Referral to a General Practitioner (GP) or a Dietitian may be necessary for some high-risk clients. The role and professional boundaries of a personal trainer has its limits and unless a client is a healthy adult in need of generic nutrition advice it is best to refer them to a qualified and experienced professional.
Medical and Allied Health professionals are able to do a comprehensive analysis of an individual's physical and psychological condition and ensure they get the professional treatment and support that they require. This may include, medication, counselling, support groups, specialised diets, and even surgery.
Fitness and exercise often form part of a health treatment plan and the medical or allied health professional may recommend that their patients work with a personal trainer to achieve this component, however, it is always best to work in collaboration with experts when dealing with high-risk clients.
The following client types will require a referral process to be initiated if they enquire about nutritional information or advice:
Many clients have the goal of losing weight when they commence a fitness program. Sedentary lifestyles and easy access to unhealthy food have resulted in Australia experiencing an obesity crisis which is being addressed by various health professionals and Government initiatives such as the Eat For Health program.
Assessing a client's current weight, body mass index, and other body composition statistics is acceptable for fitness professionals. It is also acceptable to provide publically available information on healthy weight ranges for their specific gender, age, and height.
It is NOT appropriate for fitness professionals to provide specific dietary or weight management advice. This means you are not allowed to prescribe a personalised one-day or seven-day meal plan with specific foods, amounts, meal timing and frequency of consumption, or promote any specific diets or diet trends.
If they appear to be reasonably healthy and their weight does not fall into extreme categories then refer a Dietitician so that a suitable diet and nutritional plan can be formulated.
Client’s with medical conditions that are controlled or affected by diet are also best managed by a medical or allied health professional. These types of conditions are often very sensitive to even minor changes in diet and nutrition and the ramifications can be quite serious. Examples of such conditions include:
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Type 1 Diabetes - The inability of the pancreas to produce or control insulin levels resulting in high levels of glucose in the bloodstream. Type 1 Diabetes is treated and controlled by a combination of insulin and diet, it is a chronic condition often diagnosed in adolescence.
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Prediabetes & Type 2 Diabetes - Impaired Glucose Tolerance (IGT) or Impaired Fasting Glucose (IFG) are the preliminary conditions that often result in Type 2 Diabetes being diagnosed if they are left untreated. Prediabetes and Type 2 Diabetes mean the body is unable to regulate the amount of insulin required to effectively control glucose. It is possible to treat and controlled both Prediabetes and Type 2 Diabetes by adjusting the diet and both conditions can be reversed through effective weight management. Type 2 Diabetes often runs in families.
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Cardiovascular Disease (Heart Disease) - Includes multiple conditions that affect the heart and heart vessels. Including, high blood pressure, cardiac arrest (heart attack), heart failure, arrhythmia, stroke, peripheral artery disease. Some of these conditions are genetic or congenital (ie. present since birth), however, quite a few are caused by poor diet and/or sedentary lifestyles.
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Renal (Kidney) Disease - The inability of the kidneys to filter the blood and remove waste products. Kidneys also play a role in controlling blood pressure and producing red blood cells. Renal disease is often caused by congenital or abnormal kidney structure, diabetes, high blood pressure, cardiovascular disease, smoking, or obesity. It is treated by dialysis or a kidney transplant.
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Liver Disease - The inability of the liver to regulate chemical levels in the blood, produce bile, and/or process waste products. Liver disease is often caused by infection (hepatitis), immune system abnormality, genetics, cancer, obesity, or alcohol/drug abuse. The liver is capable of a certain amount of self-repair and regeneration, however extensive damage will lead to cirrhosis (scarring) and liver failure, in these circumstances a liver transplant may be the only cure.
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Food Allergies and Intolerances - An immune system reaction after certain food products have been ingested or come into contact with. Can be quite extreme or life-threatening. For example, anaphylaxis. Examples of food that commonly cause allergies and intolerances include peanuts, tree nuts, shellfish, gluten, and lactose. Short-term treatments for some situations include administering epinephrine (adrenaline). Long-term treatment is usually to avoid these types of foods.
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Cancer - A wide-ranging term that covers many different types of cancer affecting all kinds of body systems. Treatments for cancer can be extremely taxing on the body and resulting in severe side effects. Therefore, people who are undergoing treatment or are recovering from cancer will have specific nutritional needs to help boost their energy and promote recovery.
Clients with diagnosed conditions will already have a medical doctor or allied health professional who they are consulting, fitness professionals should work in collaboration with these experts and defer any nutrition or diet-related questions that their client may have to them. If the client is displaying symptoms of any health-related conditions but does not have a formal diagnosis then a referral to a General Practitioner (GP) is required.
Under no circumstances are fitness professionals allowed to contradict any dietary advice that the client has received from a medical or allied health professional and/or attempt to provide them with a 'better' or 'newer' treatment or diet.
As part of the initial pre-exercise health screening, it may be apparent that a client is either extremely underweight for their age, gender, and height or extremely overweight (morbidly obese). Clients who fall within these outlier categories in the Body Mass Index (BMI) scale and other healthy weight charts are best referred to a medical or allied health professional for specific advice and/or treatment.
Clients who are extremely underweight may have extreme eating patterns which include omitting entire meals and food groups or binge eating and purging, which affect the human body in both a physiological and psychological manner.
Clients who are morbidly obese may have poor body image or undiagnosed health conditions such as Type 2 Diabetes or Heart Disease.
Refer clients to a General Practitioner (GP) who will make an assessment on their current physical and psychological state and then work with specialists and allied health professionals to determine the best course of action.
Professional athletes undertaking high-intensity and/or high-level sports training often require specialised diets to meet high energy needs and maximise performance. They also often utilise nutritional supplements.
Personal Trainers may have a generalised understanding of these types of diets and supplements, however, it is best to refer the client to a Dietitian or Sports Dietitian and then work in collaboration with this allied health professional.
This is because certain products are banned in Australia or have strict guidelines on their prescription and use as they may have adverse side effects if taken incorrectly. It is also important to ensure they are taken as a support to a nutritious eating plan rather than instead of certain meals or food groups and a dietitian or sports dietitian is the best expert to provide this advice.
Achieving optimum nutritional intake and having a healthy body composition can be quite psychologically taxing for certain clients. Poor body image or a lack of progress/relapse can lead to low self-confidence, depression, self-harm, and even suicide.
If a client is displaying any indicators that they require support regarding their attitude towards eating or body-image then referral to a General Practitioner and/or Psychologist/Support group is the best course of action.
As people age their bodies may have a reduced capacity to absorb certain nutrients and vitamins. Examples include Calcium and Vitamin D, Vitamin B12, Dietary Fibre, and Potassium. Deficiencies in these essential elements may create or exacerbate other conditions such as Osteoporosis.
Some elderly clients may also be suffering from malnutrition if they have been unable to shop for themselves or prepare their own healthy food. Financial pressures, lack of social support, chronic health or physical conditions, and mental health may all contribute to someone not looking after themselves properly.
If you suspect that an elderly client is suffering from nutritional deficiency then refer them to a General Practitioner (GP) who will be able to assess them for any underlying medical conditions before working in collaboration with a Dietitian long-term.
During pregnancy, women are advised to avoid quite a few types of foods due to the risk of complications that may affect them and the baby. Examples include soft cheeses, sushi, processed meats, alcohol, and excess caffeine. They are also encouraged to increase their intake of certain vitamins such as Folate.
In addition to these dietary exclusions and supplementations, pregnant women will have increased need for energy intake, meaning they need to eat more food more frequently. Morning sickness and cravings may affect energy intake.
Lactating (breastfeeding) women also require a highly nutritious and regular diet with lots of water consumption to avoid dehydration.
Apart from very generalised, publically available information and advice related to pregnancy and lactation diet and nutrition, it is best to refer the client to their treating General Practitioner (GP) or Obstetrician if they have any specific questions or request advice. This will avoid any potential risk relating to the health and wellbeing of the mother or their baby.
When preparing the letters of referral to an appropriate medical or allied health professional ensure correct processes and industry-standard templates or utilised.
