BEYOND THE HEADUNES

Dietitians and exercise: Training and practice

With diet and exercise becoming closely linked in the minds of both the scientific and lay communi­

ties, 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 dietetic techniCians) shows that students that have graduated and obtained their RD or DTR will have knowledge of exercise physiology through the Physical and Bi­ological Sciences knowledge area. Yet, when looking through the rest of the re­quired knowledge areas (Communica­tions) 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 excercise is a component of dietetics education

This article was written by Melissa Thorpe, an Editor oj the Journal in Chicago, IL.

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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 route, 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 Clinic in Corvallis, OR.

Walsh also agrees that dietetics 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 encourage them to continue to do so." Whether a dietetics profes~ siOllal pursues an advanced degree in ex­e rcise physiology or supplements their dietetics education with professional de­velopment courses 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 nutrition is also increased by the fact that people are expending less energy 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 dietetics professionals are trained in the basics of exercise physiol­ogy, the public is demanding tailored ex­ercise plans. How dietetics professionals, without post~graduate training in exer­cise physiology, should address 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,

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Saturday October 25, 2003 12:00-4:00 pm 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.

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 ADAFNCE@eatright.org to register or for more information. Attendance is limited.

Monday, October 27,2003 6:30-7:30 pm Reception 7:30-10:00 pm Dinner

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

Tuesday, October 22, 2002 6:45-8:00 am 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.

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.

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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 for 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

AUTHOR GUIDELINES UPDATE

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 for 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. This would apply for Medicare MNT as well as other types of insurance.

For more information on the qual­ity management and 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!

Starting in June 2003 , all authors should submit their articles to the office of the new Edi tor-in-Chief. The ad­dress is:

676 / June 2003 Volume 103 Nwnber 6

Linda Van Horn, PhD, RD Northwestern University Medical School Department of Preventive Medicine 680 N. Lake Shore Dr., Suite 1102 Chicago, IL 60611

If you wish to submit via e-mail, please send to: lvanhorn@northwestern.edu

Also, this summer, the Journal will be moving to a Web­based submission and tracking system. Please check the "People & Events" section for updates.