As a health and fitness coach, it is crucial to understand the scope of practice for your profession.
Your scope of practice outlines the boundaries of what you are qualified and legally allowed to do. It helps ensure that you provide safe and effective client services while avoiding legal and ethical issues.
Operating outside of your scope of practice can have serious consequences, including legal liabilities, loss of professional credibility, and risk to client safety. Understanding your scope of practice is crucial to providing quality care, protecting yourself and your clients, and building a successful career in the health and fitness industry.
In this topic, we'll look at:
- Dietitians, Nutritionists, and GPs
- REPs Scope of Practice
- Referral
- Spotlight on Industry
Who can offer nutrition advice? In general, the term Nutritionist is not protected. Therefore, anyone with even a little bit of nutrition knowledge can call themselves a Nutritionist. Only Dietitians can work as nutritionists in hospitals or other settings that provide nutritional assessment and counselling.
Registered and Associate Registered Nutritionists are those who meet the criteria determined by the Nutrition Society of New Zealand and can work in areas such as:
- Public health promotion
- Sports nutrition
- Research
- Teaching
What is the difference between a Nutritionist, a Registered Nutritionist and a Dietitian?
'A Nutritionist has usually completed a degree in Human Nutrition or related Science, has relevant tertiary training, and experience in the field of nutrition. However, not all Nutritionists meet this criterion, which is why it is important to seek the advice of a Registered or Associate Registered Nutritionist.
A Registered Nutritionist must hold a degree or academic qualification from a university or other recognised national institution of education. In addition to their basic academic qualification, they must have 2-3 years of professional experience in the field of nutrition. The selection process is overseen by the Nutrition Registration Panel which is an expert group of Nutrition Society members representing academia, industry, government and private practice. Registered Nutritionists can work in a diverse range of settings. Registered Nutritionists work within their specific fields of expertise (as determined by the Nutrition Registration Panel), adhere to The Royal Society of New Zealand Code of Professional Standards and Ethics and must participate in a Continuing Education Competency Programme. The title of Registered Nutritionist can only be used by those who meet the standards determined by The Nutrition Society of New Zealand.
A Dietitian is a registered health professional who meets standards of professionalism required by the New Zealand Dietitians Board under the Health Practitioners Competence Assurance Act, who has an accredited undergraduate science degree in human nutrition, and a post-graduate qualification in Dietetics. Dietitians are trained in the science of nutrition and diet therapy, and qualified to work in areas that require nutritional assessment and counselling.
Dietitian or Registered Nutritionist may work in a variety of settings ranging from Government, community, public health, sports, research and education and the food industry. Dietitians may also work in hospitals.' (Nutrition Society of New Zealand, n.d.)
As a personal trainer, you must be conscious that you work with clients, not patients. If any of your clients:
- seek advice and/or present with signs of a nutritional-related disease or disorder,
- indicate 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:
- Provide personalised nutritional advice or recommend specific diets.
- 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 are consistent with theMinistry of Health Eating and Activity Guidelines.
The three main examples of professionals you may refer clients to are General Practitioners (GP), Dietitians, and Registered Nutritionists.
General Practitioner (GP)
GPs are medical doctors with broad knowledge and the skills to treat most general health issues. Their scope of responsibilities includes:
- Diagnose various illnesses and injuries and provide treatment or referral accordingly.
- Prescribe medications to treat illness.
- Provide health advice.
- Provide ongoing care for certain chronic conditions.
- Conduct health screening.
- Administer vaccinations.
- Confirm a diagnosis and provide initial care for pregnancy.
- Provide general counselling, medication, and referral advice for people who are overwhelmed and/or depressed.
Situations where referral to a GP would be appropriate include:
- If the client suffers from or is suspected of having a high-risk medical condition that may be impacted by diet and/or nutritional intake.
- If a client's eating patterns are extreme, resulting in them being either excessively underweight or overweight.
- 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 that must be addressed at the same time as nutritional changes.
Dietitian
Dietitians are allied health professionals who have a minimum of a master’s degree in Dietetics (Level 9) or above and have had supervision and practice in clinical settings. They educate communities and individuals on the impact of healthy eating and good nutrition. Dietitians in New Zealand who graduated after 2014 can also prescribe some products such as vitamins, minerals, and nutritional supplements. They cannot prescribe medication.
The scope of their responsibilities includes:
- Identify and assess nutritional problems
- Develop healthy eating plans for clients and prescribe some nutrition-related products
- Counsel clients on special diet modifications such as allergies, gastro-intestinal diseases, diabetes, and many others in a clinical setting
- Monitor weight loss for obese and morbidly obese populations.
Situations where referral to a dietitian would be appropriate include:
A client asks for specific information or advice regarding weight management including specific types of diets or diet trends. If the client is having difficulty achieving their weight loss goals or have large amounts of weight to lose.
The client requires a specific diet to be developed to help them achieve peak performance in a sport or other athletic pursuits, especially if they have additional medical conditions.
Clients were exhibiting signs of emotional distress around body image, eating practices, or exercise habits.
Clients were exhibiting abnormal behaviours around eating or exercise that cause concern – when in doubt, reach out to a nutrition professional.
Registered Nutritionist
Registered Nutritionists are allied health professionals who educate communities and individuals on the impact of healthy eating and good nutrition. They have completed a minimum of a Bachelor of Science in Human Nutrition or similar degree at an approved university AND have completed at least 3 years of supervised practice or 2 years supervised practice and at least one-year post-graduate study (at Level 8 or above).
The scope of their responsibilities includes:
- Identify and assess nutritional problems (non-clinical level)
- Develop healthy eating plans for clients (generally healthy clients with guidance from GPs and Dietitians)
- Monitor weight loss progress
- Support athletes if field is in sports nutrition
- Tertiary education.
Situations where referral to a registered nutritionist would be appropriate include:
When dealing with general population clients who need slightly more nutrition support such as if a client asks for specific information or advice regarding weight management including specific types of diets or diet trends.
If the client is having difficulty achieving their weight loss goals.
The client is seeking information regarding weight-loss support groups that they can join to help with their weight-loss goals.
The client requires a meal plan to be developed (in conjunction with their GP) to help them achieve peak performance in a sport or other athletic pursuits.
If a client has low risk nutritional needs but additional consideration such as for during pregnancy or certain age groups (e.g., over 65)
Referral to a General Practitioner (GP) or a Dietitian may be necessary for some high-risk clients.Additionally, some clients may be outside scope of practice for a personal trainer, but not high-risk enough for a dietitian or GP, this is where a registered nutritionist would be applicable. As mentioned previously, the role and professional boundaries of a personal trainer have limits. 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 can comprehensively analyse an individual's physical and psychological condition and ensure they get the professional treatment and support they require. This may include medication, counselling, support groups, specialised diets, and surgery.
Fitness and exercise often form part of a health treatment plan, and medical or allied health professionals may recommend that their patients work with a personal trainer to achieve this component. However, it is always best to collaborate 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 weight loss goals. Sedentary lifestyles and easy access to unhealthy food have resulted in high rates of obesity.
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.
Though it is not appropriate to promote extremely low calorie or fad diet trends with clients who wish to lose weight, it is appropriate for a Personal trainer to provide general lifestyle change advice that aligns with the Ministry of Health Eating guidelines to assist their client with weight loss.
If the client is wishing to lose large amounts of weight (more than 20 kilgorams), then it may be necessary for them to talk to their doctor or dietitian for how to manage this safely, and you can work with these health professionals to help the client achieve their goals.
Clients with medical conditions that are controlled or affected by diet are also best managed by a medical or allied health professional. These 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:
- 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.
- Prediabetes and type 2 diabetes: Impaired Glucose Tolerance (IGT) or Impaired Fasting Glucose (IFG) are the preliminary conditions often resulting in type 2 diabetes if left untreated. Prediabetes and type 2 diabetes mean the body cannot regulate insulin to control glucose effectively. It is possible to treat and control both prediabetes and type 2 diabetes by adjusting the diet. Type 2 diabetes often runs in families.
- Cardiovascular (heart) disease: Includes multiple conditions that affect the heart and heart vessels. Including high blood pressure, cardiac arrest (heart attack), heart failure, arrhythmia, stroke, and peripheral artery disease. Some of these conditions are genetic or congenital (i.e., present since birth). However, many are caused by poor diet and/or sedentary lifestyles.
- 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.
- 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 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.
- Food allergies and intolerances: An immune system reaction after certain food products have been ingested or come into contact with. Allergies can be severe and/or life-threatening. 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.
- Cancer: A wide-ranging term covering many types of cancer affecting all kinds of body systems. Cancer treatments can be extremely taxing on the body and result 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 likely already have a medical doctor or allied health professional they are consulting with. You should collaborate with these experts and defer any nutrition or diet-related questions that clients may have to them. If your future client displays symptoms of any health-related conditions but does not have a formal diagnosis, then refer to a General Practitioner (GP).
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. These patterns can 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 assess their current physical and psychological state. 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 may utilise nutritional supplements.
Personal trainers may have a generalised understanding of these types of diets and supplements. However, referring the client to a Dietitian or Sports Dietitian is best and then collaborating with this allied health professional. This is because certain products are banned or have strict guidelines on prescription and use, as they may have adverse side effects if taken incorrectly. It is also important to ensure they are taken to support nutritious eating and not as a replacement for meals or food groups. 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 suicide.
If a client displays any indicators that they require support regarding their attitude towards eating or body image, refer to a General Practitioner and/or Psychologist 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 suffer from malnutrition if they cannot shop for themselves or prepare healthy food. Financial pressures, lack of social support, chronic health or physical conditions, and mental health may 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 several 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 vitamins such as folate.
In addition to these dietary exclusions and supplementations, pregnant women will have an increased need for energy intake. Morning sickness and cravings can also affect energy intake.
Lactating (breastfeeding) women require a highly nutritious and regular diet with increased water consumption.
Apart from very generalised, publically available information, it is best to refer the client to their Midwife, Plunket or another Well Child Tamariki Ora provider, General Practitioner (GP), or Obstetrician. This will avoid any potential risk relating to the health and wellbeing of the mother or their baby.
AUSactive has created a Referral Kit. While their kit is specific to the Australian industry, the referral letters and referral kit is quite helpful. When preparing referral letters, use correct processes and industry-standard templates.
