- Email: [email protected]
Dietitians and exercise: Training and practice
BEYOND THE HEADUNES
Dietitians and exercise: Training and practice
ith diet and exercise becoming
W
closely linked in the minds of both the scientific and lay communities, dietetics professionals will see their clients asking increasingly sophis ticated questions about appropriate and effective exercise in combination with their eating plans or meal plans. When looking at the knowledge, skills, and competencies for entry-level dietitian and dietetic education programs, the foundation of exercise physiology is found in the core curriculum. According to Beverly Mitchell, MBA, RO, ADA Director of Commission on Accreditation for Dietetics Education (CADE) in Chicago, "The purpose of the foundation courses in dietitian/dietetic technician programs is not for students to become experts in these fields. The expectation is for them to have the foundation to build upon this course~ work and into a specialty, if they so choose." The list of foundation knowledge and skills on the CADE Web site (http://www. eatright.comiimagesicade/eras2002.pdf for dietitians; http://www.eatright.com/ images/cade/eras2002.pdf for di etetic techniCians) shows that stude nts that have graduated and obtained their RD or DTR will have knowl edge of exercise physiology through the Physical and Biological Sciences knowledge area. Yet, when looking through the rest of the required knowledge areas (Commu nications) Social Sciences, Research) Food, Nutrition, Management, and Health Care Systems), the word exercise is rarely seen. As Mitchell pOints out, one does not have to see the word "exercise" to know that students are learning about the relationship between physical activ~ ity and nutrition. She explains, "Understanding the role of exce rci se is a component of di etetics education
This article was written by Melissa Thorpe, an Editor oj the Journal in Chicago, IL. doi: 1O. 1053!jada.2003.50159 ff14 ! June 2003 Vol unle 103l'/wnber 6
coursework. If it is about caloric intake and output, it is about physical activity." HAVE DIET AND EXERCISE BECOME INEXTRICABLY LINKED? The importance of dietetics professionals understanding the role of exercise in relation to diet is multifold and various. Kris Clark, PhD, RD, FACSM, has no doubt nutrition and exercise are inextricably linked. "Nutrition and exercise are the two things people can take charge of to prevent chronic disease," says Clark, who holds a PhD in nutrition science and is the director of sports nutrition at Penn State University. However, she does not believe that the public assumes dietitians have a substantial background in exercise as relative to nutrition. "I believe that dietitians have a relatively bad image in the eyes of the public in terms of exercise." Clark remembers her own training in the late 1970s when there was no mention of exercise. She continues, "Nutrition experts are not exercise experts." However, dietitians can discuss 'Nith their clients the importance of nu~ trition and exercise on overall health, disease management, and disease prevention. Recognizing when dietetics practitioners should refer clients/patients to an exercise physiologist for detailed exercise prescriptions and training programs is important, and can improve the individual's care through multidisciplinary intervention. With all of the coursework required for dietetics professionals, some may feel the topic of exercise is too specialized to be emphasized in a general dietetics education. However, as Carol Walsh, MS, RD, explains, "In order to estimate energy needs, one should understand the role of activity and how that impacts hunger and appetite." Although Walsh took this ro ute, she explains that ad~ vanced degrees are not the only way to enhance knowledge on the subject of exercise. "There are short courses offered [on this subjectj and time could be spent 'Nith a mentor," says Walsh, who works
with patients with diabetes at the Corvallis Cli nic in Corvallis, OR. Walsh also agrees that di etetics professionals are the nutrition experts, but are not the exercise experts. "It is important to know one's role and dietetics professionals are able to guide people to exercise and encou rage them to contin ue to do so." Whether a dietetics profes~ siOllal pursues an advanced degree in exe rcise physiology or supplements their dietetics education with professional development cou rses on exercise in practice, sharing this knowledge with clients is essential to practice. The need for dietetics professionals to have a solid foundation in exercise and n utrition is also increased by the fact that people are expending less ene rgy regularly, says Walsh. "People today are so sedentary. However, the clients I work with do much better in terms of improving blood sugar, blood pressure , blood lipids, and weight loss when they put as much attention on the expenditure side of the energy equation as they do on what they eat. " She believes, "It is even more important to be able to explain the benefits of activity and to encourage it. This means dietitians need to be active themselves." This is particularly true for those who work with clients diagnosed with diabetes and insulin resistance or with kids and families who are overweight, concludes Walsh. THE CHALLENGE OF ADVISING CLIENTS IN EXERCISE Although di etetics professionals are trained in the basics of exercise physiology, the public is demanding tailored exercise plans. How dietetics professionals, without post~g raduate training in exe rcise physiology, should add ress their clients' needs is an issue being raised. Melinda Manore, PhD, RD , professor and chair of the Department of Nutrition and Food Management at Oregon State UniverSity, explains that the public's main concern is about weight manage~ ment: "The obesity issue is driving it,
Wi "
t..---, ~er""""""'r--1
elri"
Saturday October 25, 2003 12:00-4:00 pm
Tuesday, October 22, 2002 6:45-8:00 am
Be among the first to hear the results from the first of its kind Child and Family Nutrition and Physical Activity Study, conducted by the Foundation in partnership with Knowledge Networks. Funding for this study was made possible with a gift from the Val Vaden Family in memory of his mother Allene Vaden. Attendees will learn what children say and think about what they are eating and doing (or not eating and doing) as compared to how parents view their child's eating and hysical activity habits and patterns. Registration is required via the registration form found in the FNCE program preview or the ADA Website. Attendance is limited.
Finish the meeting on the right foot. .. then the left by partiCipating in the 5K Run and Fitness Walk. The run will take place on a pre-marked 5K course. A $35 registration fee includes official rBce number, T-shirt, race results, nutritious finish-line refreshments and transportation to and from the event. Special thanks to PULSE Water + Nutrients.
i
A
A
lilA
Silence is golden and so are the donated treasures you'll find to bid on in the Silent Auction Bidding will take place at the Foundation Booth throughout the meeting.
Sunday, October 26, 12:00-1:30 pm Find the happy trail to successful financial planning. This seminar provides an opportunity to explore the many dvantages of philanthropic giving and solid financial anagement. A certified financial planner will teach ttendees how to manage their portfolio and explore ways at charitable gifts can actually help accomplish personal financial goals as well as benefit the ADA Foundation. iThe session is free to all meeting attendees. Please contact e ADA Foundation at 800/877-1600 , or e-mail [email protected] to register or for more information. Attendance is limited.
Begin and end your busy day during FNCE with a relaxing and invigorating yoga session. Register onsite at the Foundation Booth. Space will be available on a first come, first- served basis. A $10 contribution to the ADA Foundation is suggested. Attendance Is limited.
N Monday, October 27,2003 6:30-7:30 pm Reception 7:30-10:00 pm Dinner
11'8 iatere~ in pa
e FOUl
i
p t 9 In on" 0
p ease co
the ADA
Via em i
adafnc:e@!eatri
elebrate the Foundation award winners and mingle with ellow attendees at a spectacular event to take place in the rand Ballroom of the San Antonio Marriott Rivercenter. Ickets for the gourmet dinner can be purchased via the egistration form found in the FNCE program preview or the DA Website only. Tickets are $100 or $1000 for a table of O. Space is limited. Special thanks to McNeil Nutritionals, nAgra Foods, National Cattlemen's Beef Association, Food arketing Institute, and Kraft Foods for their generous ______________________________________________________________________________ __ ponsorship ~ .
BEYOND THE HEADLINES specifically obesity and kids and the threat of type 2 diabetes." She believes that dietetics professionals know the importance of connecting their patients with health information about exercise. Yet, dietetics professionals should also have a general appreciation fo r those who specialize completely in exercise physiology, for example, and be able to recommend to their clients specific health professionals. "This would require knowing all the certifications and being well-versed in each specialty and would benefit the dietitian as well as the client and other health professionals. In turn , however, physicians, exercise physiologists , and personal trainers would recommend dietetics professionals and vice versa," says Manore. Suzanne Nelson-Steen, PhD, RD , has learned that every dietetics professional will need to address weight management issues in clinical practice, as a healthy lifestyle involves wise food choices and being physically active . Nelson-Steen, a sports nutritionist for the Washington Huskies (University of Washington), continues, "Exercise is a key component to any weight management or weight loss program. An understanding of the role of nutrients and energy systems during exercise is essential in order for nutrition professionals to provide effective nutrition recommendations to clients regarding physical activity and performance enhancement. " Finally, as a form of preventive medicine, diet and exercise work well to-
gether. Manore suggests a general dietetics education might include more courses and instruction on exercise. "If given the scenario such as an athlete coming to my office for advice on nutrition, I would not think they would necessarily need guidance on exercise. Yet if an overweight patient ,vith diabetes comes in , they are going to learn about nutrition, specifi cally how nutritionchronic disease-exercise all relate together to equal prevention," concludes Manore. EXERCISE AND MEDICAL NUTRITION THERAPY
For dietetics professionals who provide Medical Nutrition Therapy (MNT) , there are also many considerations to take into account. For example, the ADA MNT guides/protocols include exercise as an intervention topic, but do not prompt dietetics professionals to provide detailed exercise prescriptions as part of the MNT visit. This can be seen when evaluating the recommendations on physical activity for type 1 and type 2 diabetes mellitus fmmd in the ADA MNT Evidence Based Guides for Practice. This guide states that based on a thorough evaluation of the quality of current research, there is fair evidence that regular physical activity improves insulin sensitivity, enhances weight loss, lowers blood pressure, and improves AIC in individuals with type 2 diabetes. Regular physical activity improves cardiovascular fitness and reduces serum lipids and
blood pressure in individuals with type I diabetes. Also, adjustments in cal'bohydrate intake and/or insulin are necessary to avoid hypoglycemia during excercise. Studies that show a benefit of physical activity report intensities of 50% to 80% VO"",,,,, 3 to 4 times a week for 30 to 60 minutes per session. The dietetics professional in the course of providing MNT would also consider whether this intervention recommendation was appropriate fo r an inclividual based on the decision making that follows an in-depth client-centered nutrition assessment, nutrition diagnosis, and planning component of the nutrition intervention step of the nutrition care process. Anything more than this relative to counseling of physical activity should not be considered as part of providing MNT. Dietetics professionals with advanced degrees in exercise physiology should provide and bill for services related to a detailed individualized exercise prescription separately from the MNT services they may also provide. Th is wo uld apply for Medicare MNT as well as other types of insurance. For more information on the quality management a nd standards of professional practice for dietetics professionals, visit the following resources: • Quality Management: http://www.eatright.comiqmiqa.htm! • Standards of professional practice for dietetics professionals: http://www.eatright.comiqm/ standards.htm!
AUTHOR GUIDELINES UPDATE Starting in J une 2003 , all authors should submit their articles to the office of the new Edi tor-in-Chief. The address is: Linda Van Horn, PhD, RD Northwestern University Medical School Department of Preventive Medicine 680 N. Lake Shore Dr., Suite 1102 Chicago, IL 606 11 If you wish to submit via e-mail, please send to: [email protected] Also, this summer, the Journal will be moving to a Webbased submission and tracking system. Please check the "People & Events" section for updates.
676 / June 2003 Volume 103 Nwnber 6
Dietitians and exercise: Training and practice
ith diet and exercise becoming
W
closely linked in the minds of both the scientific and lay communities, dietetics professionals will see their clients asking increasingly sophis ticated questions about appropriate and effective exercise in combination with their eating plans or meal plans. When looking at the knowledge, skills, and competencies for entry-level dietitian and dietetic education programs, the foundation of exercise physiology is found in the core curriculum. According to Beverly Mitchell, MBA, RO, ADA Director of Commission on Accreditation for Dietetics Education (CADE) in Chicago, "The purpose of the foundation courses in dietitian/dietetic technician programs is not for students to become experts in these fields. The expectation is for them to have the foundation to build upon this course~ work and into a specialty, if they so choose." The list of foundation knowledge and skills on the CADE Web site (http://www. eatright.comiimagesicade/eras2002.pdf for dietitians; http://www.eatright.com/ images/cade/eras2002.pdf for di etetic techniCians) shows that stude nts that have graduated and obtained their RD or DTR will have knowl edge of exercise physiology through the Physical and Biological Sciences knowledge area. Yet, when looking through the rest of the required knowledge areas (Commu nications) Social Sciences, Research) Food, Nutrition, Management, and Health Care Systems), the word exercise is rarely seen. As Mitchell pOints out, one does not have to see the word "exercise" to know that students are learning about the relationship between physical activ~ ity and nutrition. She explains, "Understanding the role of exce rci se is a component of di etetics education
This article was written by Melissa Thorpe, an Editor oj the Journal in Chicago, IL. doi: 1O. 1053!jada.2003.50159 ff14 ! June 2003 Vol unle 103l'/wnber 6
coursework. If it is about caloric intake and output, it is about physical activity." HAVE DIET AND EXERCISE BECOME INEXTRICABLY LINKED? The importance of dietetics professionals understanding the role of exercise in relation to diet is multifold and various. Kris Clark, PhD, RD, FACSM, has no doubt nutrition and exercise are inextricably linked. "Nutrition and exercise are the two things people can take charge of to prevent chronic disease," says Clark, who holds a PhD in nutrition science and is the director of sports nutrition at Penn State University. However, she does not believe that the public assumes dietitians have a substantial background in exercise as relative to nutrition. "I believe that dietitians have a relatively bad image in the eyes of the public in terms of exercise." Clark remembers her own training in the late 1970s when there was no mention of exercise. She continues, "Nutrition experts are not exercise experts." However, dietitians can discuss 'Nith their clients the importance of nu~ trition and exercise on overall health, disease management, and disease prevention. Recognizing when dietetics practitioners should refer clients/patients to an exercise physiologist for detailed exercise prescriptions and training programs is important, and can improve the individual's care through multidisciplinary intervention. With all of the coursework required for dietetics professionals, some may feel the topic of exercise is too specialized to be emphasized in a general dietetics education. However, as Carol Walsh, MS, RD, explains, "In order to estimate energy needs, one should understand the role of activity and how that impacts hunger and appetite." Although Walsh took this ro ute, she explains that ad~ vanced degrees are not the only way to enhance knowledge on the subject of exercise. "There are short courses offered [on this subjectj and time could be spent 'Nith a mentor," says Walsh, who works
with patients with diabetes at the Corvallis Cli nic in Corvallis, OR. Walsh also agrees that di etetics professionals are the nutrition experts, but are not the exercise experts. "It is important to know one's role and dietetics professionals are able to guide people to exercise and encou rage them to contin ue to do so." Whether a dietetics profes~ siOllal pursues an advanced degree in exe rcise physiology or supplements their dietetics education with professional development cou rses on exercise in practice, sharing this knowledge with clients is essential to practice. The need for dietetics professionals to have a solid foundation in exercise and n utrition is also increased by the fact that people are expending less ene rgy regularly, says Walsh. "People today are so sedentary. However, the clients I work with do much better in terms of improving blood sugar, blood pressure , blood lipids, and weight loss when they put as much attention on the expenditure side of the energy equation as they do on what they eat. " She believes, "It is even more important to be able to explain the benefits of activity and to encourage it. This means dietitians need to be active themselves." This is particularly true for those who work with clients diagnosed with diabetes and insulin resistance or with kids and families who are overweight, concludes Walsh. THE CHALLENGE OF ADVISING CLIENTS IN EXERCISE Although di etetics professionals are trained in the basics of exercise physiology, the public is demanding tailored exercise plans. How dietetics professionals, without post~g raduate training in exe rcise physiology, should add ress their clients' needs is an issue being raised. Melinda Manore, PhD, RD , professor and chair of the Department of Nutrition and Food Management at Oregon State UniverSity, explains that the public's main concern is about weight manage~ ment: "The obesity issue is driving it,
Wi "
t..---, ~er""""""'r--1
elri"
Saturday October 25, 2003 12:00-4:00 pm
Tuesday, October 22, 2002 6:45-8:00 am
Be among the first to hear the results from the first of its kind Child and Family Nutrition and Physical Activity Study, conducted by the Foundation in partnership with Knowledge Networks. Funding for this study was made possible with a gift from the Val Vaden Family in memory of his mother Allene Vaden. Attendees will learn what children say and think about what they are eating and doing (or not eating and doing) as compared to how parents view their child's eating and hysical activity habits and patterns. Registration is required via the registration form found in the FNCE program preview or the ADA Website. Attendance is limited.
Finish the meeting on the right foot. .. then the left by partiCipating in the 5K Run and Fitness Walk. The run will take place on a pre-marked 5K course. A $35 registration fee includes official rBce number, T-shirt, race results, nutritious finish-line refreshments and transportation to and from the event. Special thanks to PULSE Water + Nutrients.
i
A
A
lilA
Silence is golden and so are the donated treasures you'll find to bid on in the Silent Auction Bidding will take place at the Foundation Booth throughout the meeting.
Sunday, October 26, 12:00-1:30 pm Find the happy trail to successful financial planning. This seminar provides an opportunity to explore the many dvantages of philanthropic giving and solid financial anagement. A certified financial planner will teach ttendees how to manage their portfolio and explore ways at charitable gifts can actually help accomplish personal financial goals as well as benefit the ADA Foundation. iThe session is free to all meeting attendees. Please contact e ADA Foundation at 800/877-1600 , or e-mail [email protected] to register or for more information. Attendance is limited.
Begin and end your busy day during FNCE with a relaxing and invigorating yoga session. Register onsite at the Foundation Booth. Space will be available on a first come, first- served basis. A $10 contribution to the ADA Foundation is suggested. Attendance Is limited.
N Monday, October 27,2003 6:30-7:30 pm Reception 7:30-10:00 pm Dinner
11'8 iatere~ in pa
e FOUl
i
p t 9 In on" 0
p ease co
the ADA
Via em i
adafnc:e@!eatri
elebrate the Foundation award winners and mingle with ellow attendees at a spectacular event to take place in the rand Ballroom of the San Antonio Marriott Rivercenter. Ickets for the gourmet dinner can be purchased via the egistration form found in the FNCE program preview or the DA Website only. Tickets are $100 or $1000 for a table of O. Space is limited. Special thanks to McNeil Nutritionals, nAgra Foods, National Cattlemen's Beef Association, Food arketing Institute, and Kraft Foods for their generous ______________________________________________________________________________ __ ponsorship ~ .
BEYOND THE HEADLINES specifically obesity and kids and the threat of type 2 diabetes." She believes that dietetics professionals know the importance of connecting their patients with health information about exercise. Yet, dietetics professionals should also have a general appreciation fo r those who specialize completely in exercise physiology, for example, and be able to recommend to their clients specific health professionals. "This would require knowing all the certifications and being well-versed in each specialty and would benefit the dietitian as well as the client and other health professionals. In turn , however, physicians, exercise physiologists , and personal trainers would recommend dietetics professionals and vice versa," says Manore. Suzanne Nelson-Steen, PhD, RD , has learned that every dietetics professional will need to address weight management issues in clinical practice, as a healthy lifestyle involves wise food choices and being physically active . Nelson-Steen, a sports nutritionist for the Washington Huskies (University of Washington), continues, "Exercise is a key component to any weight management or weight loss program. An understanding of the role of nutrients and energy systems during exercise is essential in order for nutrition professionals to provide effective nutrition recommendations to clients regarding physical activity and performance enhancement. " Finally, as a form of preventive medicine, diet and exercise work well to-
gether. Manore suggests a general dietetics education might include more courses and instruction on exercise. "If given the scenario such as an athlete coming to my office for advice on nutrition, I would not think they would necessarily need guidance on exercise. Yet if an overweight patient ,vith diabetes comes in , they are going to learn about nutrition, specifi cally how nutritionchronic disease-exercise all relate together to equal prevention," concludes Manore. EXERCISE AND MEDICAL NUTRITION THERAPY
For dietetics professionals who provide Medical Nutrition Therapy (MNT) , there are also many considerations to take into account. For example, the ADA MNT guides/protocols include exercise as an intervention topic, but do not prompt dietetics professionals to provide detailed exercise prescriptions as part of the MNT visit. This can be seen when evaluating the recommendations on physical activity for type 1 and type 2 diabetes mellitus fmmd in the ADA MNT Evidence Based Guides for Practice. This guide states that based on a thorough evaluation of the quality of current research, there is fair evidence that regular physical activity improves insulin sensitivity, enhances weight loss, lowers blood pressure, and improves AIC in individuals with type 2 diabetes. Regular physical activity improves cardiovascular fitness and reduces serum lipids and
blood pressure in individuals with type I diabetes. Also, adjustments in cal'bohydrate intake and/or insulin are necessary to avoid hypoglycemia during excercise. Studies that show a benefit of physical activity report intensities of 50% to 80% VO"",,,,, 3 to 4 times a week for 30 to 60 minutes per session. The dietetics professional in the course of providing MNT would also consider whether this intervention recommendation was appropriate fo r an inclividual based on the decision making that follows an in-depth client-centered nutrition assessment, nutrition diagnosis, and planning component of the nutrition intervention step of the nutrition care process. Anything more than this relative to counseling of physical activity should not be considered as part of providing MNT. Dietetics professionals with advanced degrees in exercise physiology should provide and bill for services related to a detailed individualized exercise prescription separately from the MNT services they may also provide. Th is wo uld apply for Medicare MNT as well as other types of insurance. For more information on the quality management a nd standards of professional practice for dietetics professionals, visit the following resources: • Quality Management: http://www.eatright.comiqmiqa.htm! • Standards of professional practice for dietetics professionals: http://www.eatright.comiqm/ standards.htm!
AUTHOR GUIDELINES UPDATE Starting in J une 2003 , all authors should submit their articles to the office of the new Edi tor-in-Chief. The address is: Linda Van Horn, PhD, RD Northwestern University Medical School Department of Preventive Medicine 680 N. Lake Shore Dr., Suite 1102 Chicago, IL 606 11 If you wish to submit via e-mail, please send to: [email protected] Also, this summer, the Journal will be moving to a Webbased submission and tracking system. Please check the "People & Events" section for updates.
676 / June 2003 Volume 103 Nwnber 6