As more registered dietitians seek opportunities in private practice/consulting or sports nutrition and wellness, they may find that they are the only person in the organization with a medical background. This is often the case in a wellness/health and fitness center setting. From both a legal and ethical stand point it is essential that an RD in this type of setting be able to perform basic health screening and fitness assessment within their scope of practice. They must also be able to make sound decisions to refer clients to other health professionals or certified fitness specialists. Often times an RD in this type of setting will benefit from knowledge gained in obtaining nationally recognized credentials in fitness instruction/training. This additional knowledge can also be particularly helpful for RDs working in cardiac rehab settings. This unit will discuss the basics of health and fitness assessment and direct you to some resources you can use with future clients.
The main purpose of this unit is to introduce you to how to apply principles of the nutrition consult and to additional assessment tools used in sports environment.
What athletes typically know about nutrition, they learned in elementary school, from friends, teamates, magazines, or coaches. As the understanding of the role of nutrition in sports performance continues to gain momentum, more and more athletes are seeking consultation to improve their nutrition habits. As the sports RD, your job is to educate athletes and perhaps their coaches about nutrition while also helping them achieve the skills needed to grocery shop, prepare food, follow a recipe or meal plan, choose healthy foods on a menu, etc. You can also help personalize nutrition to fit the athletes specific needs. Ultimately, you aim to help the athlete achieve better physical performance.
When working with athletes, it is important that the RD builds a good rapport with other members of the athletes circle. Athletes have a great deal of respect for their coaches, athletic trainers, and strength and conditioning coaches. The sports RD must communicate with these individuals to get on the same page with nutrition messages to the athletes. The athlete may be more inclined to listen to the coach even if the information is in conflict with what the RD has told them. For athletes with medical conditions such as diabetes or eating disorders, it is particularly important that the coaches understand nutrition recommendations. In some settings, the RD may be the only member of the team with medical related training.
Athletes, coaches and trainers will often have misconceptions about nutrition that you have the opportunity to clear up by being part of the team. These are just a few misconceptions found in the research literature and ones that I have come across when working with active individuals. For those who may be wondering what bonk training is, this is basically the practice of not eating before activity with the intention that it will cause you to lose more body fat. It really just leaves you feeling tired and hungry.
In a sports environment, you will not have the luxury of turning to the electronic medical record. You will need to be particularly vigilant in obtaining information directly from the client about nutrition intake, behaviors, and health concerns. It is also important to inquire about supplement use. Supplements do not have to be proven safe or effective to be sold. Also many supplements have resulted in athletes testing positive for banned substances. Your job is to keep the athlete safe and on the play field not the bench. The type of supplement the athlete may be taking can also tell you something about their athletic goals. To accurately assess dietary intake, a food record is best. You will need to be very specific in your instructions about how to complete the food record. Let the athlete know that the more accurate and complete they are in keeping food record, the better you will be able to help them. In addition, a training log is necessary to help you better assess total calorie needs and understand the athletes training schedule and how it impacts the athletes ability to consume or prepare healthful foods. Finally, obtain laboratory data if possible. This can reveal underlying conditions affecting performance such as anemia. If you suspect an athlete may have iron deficiency anemia, you can ask them to provide you with recent lab reports or recommend testing.
A health history questionnaire will help you identify any underlying medical issues related to nutrition and whether or not the athlete may need to be referred for additional evaluation. You will find a sample HHQ in your text and you can also find several examples online that you can adapt for your own needs.
There are several industry standard tools available for health screening. One such tool is the PAR-Q. The PAR-Q is a valid and cost efficient way to determine a clients risk and need for further medical evaluation before starting an exercise program. Although it is intended to assess readiness for exercise, how the athlete answers the questions may tell you something about their nutritional needs as well. You would most likely use this tool if you were working with a client in a health club type setting and may also be making exercise prescription recommendations. Usually high school, collegiate, or professional athletes have already been cleared by a physician to participate. You should also be properly credentialed to make exercise recommendations beyond that of the general CDC guidelines. Obtaining a personal trainer or group fitness instructor certification would give you the credentials and training. If a client has a positive response to the PAR-Q, a more in depth assessment, PAR Medical Examination (PARmed-X) is administered and a referral made to a physician for exercise clearance. Follow the link provided to download the PAR-Q form.
Another tool to use is the ACSM risk stratification. The American Council on Sports Medicine (ACSM) has established guidelines and risk stratification based on health parameters and responses to the PAR-Q. The risk stratification and PAR-Q should be used together. You can check your risk by going to the risk calculator online.
A complete health screening will include a medical history, physical exam, and nutrition screening and assessment. As an RD it is within your scope of practice to gather a medical history from a client if this information is not readily available. This will only help you do your job better. You can also do some basic physical assessments including measuring blood pressure, heart rate, anthropometrics, and fitness assessment if trained and certified. Again these assessments help you identify if a client may need a referral for further evaluation and to help you set appropriate goals for the client. Sports RDs working with professional teams or collegiate athletes will likely work in conjunction with a team physician and trainer to gather this information from the athlete.
The steps of the nutrition consult for an athlete are similar to the steps you would take with any other client or patient. Differences may be in reasons why the athlete has come to you and the type of data you may collect. Understanding the athletes reasons and goals for the visit will help you tailor your advice.
When working with athletes, particularly collegiate or professional athletes, you may want to do a little homework before your first visit. Find out more about who they are, the position they play, and what kind of physical demands the sport requires. Also, showing up for a competition or practice demonstrates to the athlete that you are on their side. This shows the athlete that you are interested in them and know something about their world. Project a positive attitude both in what you say and your body language. Athletes are used to positive talk. They excel at what they do because they believe they can do it. Discuss nutrition strategies as if they are a game plan not a diet. Lastly, athletes may have some unique beliefs or superstitions about foods that you may disagree with. Be delicate in how you approach to this sort of thing and avoid being defensive. An example might be that an athlete insists on drinking flat regular soda before an event, believing that it gives them extra energy from the caffeine. You happen to know that soda can result in stomach cramping and maybe even diarrhea due to the high concentration of carbohydrate, it is also not the best choice for hydration. Rather than immediately tell the athlete not to drink soda, find out if they are having any gastrointestinal distress symptoms and if so, then discuss how drinking soda might contribute to that and suggest some alternatives.
The nutrition assessment of active individuals is similar to what you would do with others. One key difference is obtaining detailed information about type, frequency, and duration of physical activity in order to make an accurate assessment of calorie needs and recommendations for timing of meals for enhancing performance and recovery. Also when working with athletes, obtaining body composition measurements is more common than when working with other populations.Lastly, screening for disordered eating patterns is important, particularly with athletes in weight conscious sports such as wrestling, gymnastics, figure skating, or cross country.
The type of nutrition assessment data you collect on an athlete is similar to other types of clients. The exception being obtaining % body fat, training schedules, and disordered eating screening. Knowing the training schedule helps you better assess energy needs. Knowing body fat levels helps you better assess whether or not the athlete needs to lose weight or simply work to change body composition. Lastly, screening for disordered eating patterns is important, particularly with athletes in weight conscious sports such as wrestling, gymnastics, figure skating, or cross country. A number of screening tools exist to determine one’s risk for eating disorders. Links to a few basic questionnaires are included on the slide.
Athletes will often come to you with a long term or outcome oriented goal in mind. You will need to help the athlete determine the short term nutrition goals that will help them reach the long term goal. Nutrition education must address the short tem goals. In the example on the slide, you may need to provide the athlete with sample meals of 300-500 calories each or show the athlete how to read food labels to determine calories in foods. You may also need to give specific education as to what part of the day or meal to include these additional calories and types of foods to choose.
The follow-up visit is an opportunity for you and the athlete to fine tune goals, address questions or nutrition related problems, and to review the findings of analyzed food records. It is also a time to find out from the athlete if they feel the nutrition changes have made an impact on their performance. Hopefully they do see positive performance outcomes or energy levels. This will help them stay motivated to continue with improving nutrition.
Just because you see an athlete in a non-medical setting, does not mean HIPAA rules do not apply. Whatever health and nutrition information you collect from the athlete, must be kept confidential even from other health professionals, coaches and trainers unless the athlete signs a consent for disclosure of medical information. The form should explicitly state what type of information would be shared and with whom. A sample form is provided in your text. Maintaining confidentiality protects both the athlete and you.
An RD with additional credentials in the exercise and fitness realm can provide the added value of fitness assessment for active individuals in a recreational or health club type setting. In a sports team setting, strength and conditioning coaches would most likely perform these measures. The fitness assessment serves as a basis for determining an exercise prescription, goal setting, and evaluation.
There are 5 components to fitness assessment: Body composition, cardiorespiratory endurance, muscular strength, muscular endurance, and flexibility. As an RD you do have the skills and knowledge to assess body composition and educate both athletes and coaches about appropriate levels. Body composition can most cost effectively be measured using skin calipers or bioelectrical impedance analysis (BIA) scales. Accurately interpreting these results and taking into consideration potential for error is essential. Waist-to-hip ratio and BMI can assist in interpretation of body fat distribution and potential health risks. The minimum body fat needed for health for men is 5% and 12% for women. Going below these levels impacts hormones that effect bone density and other body functions. Healthy body fat ranges are shown in the table. Athletes will tend to be on the lower end of the range. But it is important to know that a lower body fat is not necessarily associated with better physical performance.
A resting heart rate and blood pressure is often used in conjunction with a graded exercise test (GXT) to determine cardiorespiratory endurance. The GXT is commonly known as a stress test and is performed under the supervision of a physician. However for low risk exercisers, field test options include a treadmill or bench-step test that can be easily performed in a fitness center setting by a certified fitness specialist. Assessing target heart rate or rate of perceived exertion can also be a self-administered assessment of cardiorespiratory endurance. The RPE scale is shown on the slide. During exercise, the participant rates how hard they feel they are working on a scale of 0 to 10.
Muscular strength and endurance go hand in hand. Improvement in one usually leads to improvement in the other. Muscular strength can be evaluated using the one rep max method, the amount of weight than can be lifted only one time to fatigue the muscle group being used. Commonly used muscular endurance tests include the 60 second sit-up or push-up test. The client performs the maximum number possible within the time limit. Results are compared to a standard classification system.
Flexibility testing measures the range of motion of a joint. Flexibility is affected by many variables including age, gender, ability of the joint capsule to expand, muscle size, temperature and viscosity, body fat, tightness of ligaments and tendons, and physical activity status. The most commonly used flexibility assessment is the sit-and-reach test that measures flexion of the trunk. A tape measure and yard-stick is all that is needed.
In an ideal setting, the exercise prescription is based on results of exercise testing as explained previously. However, this information is not always available. The exercise prescription will incorporate behavior strategies for long-term compliance and attainment of fitness goals. Exercise type, intensity, duration, frequency and planned progression are the components of a complete exercise prescription. The prescription incorporating all components of fitness is based on established exercise guidelines that are adapted to the client’s individual needs and goals.
Current CDC guidelines recommend a minimum of 150 minutes per week of moderate intensity aerobic exercise coupled with full body strength training 2 times per week for most adults.Children should have 60 minutes of activity and strengthening activities and high impact activities at least 3 days per week. Activities chosen to meet the guidelines should be age appropriate.
The Sports Nutrition Consult Lecture
THE SPORTS NUTRITION CONSULT Lona Sandon, M.Ed., R.D., L.D. Assistant Professor, UT Southwestern Spring 2012
OBJECTIVES Collect pertinent data to conduct a nutrition consult for an athlete Become familiar with the use of a health history questionnaire Utilize tools to obtain and assess dietary information from athletes Understand the roles of coaches and trainers in providing nutrition information Describe the five components of fitness State CDC physical activity guidelines
WHAT IS THE ROLE OF THE CONSULTATION? Educate athletes about nutrition Develop skills to support good nutrition Empower athletes with quality information Personalize nutrition recommendations Improve sports performance
WHO IS PART OF THE NUTRITION TEAM? Coaches Athletic trainers Strength & conditioning coaches Team physician/primary care physician Typically non-RDs only qualified to provide nutrition information in the public domain Myplate Position papers
WHAT ARE SOME MISCONCEPTIONS? Protein is the main energy source Water is best for replacing fluid losses Vit/Min supplements increase energy Protein powders are necessary for muscle building Energy bars/drinks can replace real food “Bonk” training helps lose body fat
WHAT IS THE CONSULTATION PROCESS? Obtain thorough diet Accurate food record history Training log Typical intake Lab data if available Eating behaviors/patterns Inquire about supplement use Complete a health history questionnaire & assessment
WHY HEALTH SCREENING & ASSESSMENT? Identify medical contraindications High risk individuals: age, symptoms, risk factors Clinically significant disease Special needs
TOOLS FOR HEALTH SCREENING PAR-Q – physical activity readiness questionnaire Questionsre: CVD symptoms Musculoskeletal problems PARMed-X If answered yes to PAR-Q Recommend MD evaluation http://uwfitness.uwaterloo.ca/PDF/par- q.pdf
TOOLS FOR HEALTH SCREENING ACSM risk stratification Low risk – men <45; women <55 No more than 1 CAD risk factor Moderate risk – men > 45; women >55 2 or more CAD risk factors High risk – 1 or more signs/symptoms of CAD or known disease http://www.exrx.net/Calculators/RiskClass.html
COMPONENTS OF HEALTH SCREENING Medical History Physical exam Any diagnosis Typically done by MD/NP Any symptoms Blood pressure Hx of illness Heart rate/pulse Joint problems Anthropometrics Medication use Fitness assessment if Menstrual hx trained Exercise hx Biochemical data Family health hx Nutrition Assessment
STEPS OF THE NUTRITION CONSULT Establish rapport Determine goals Clarify reason for Provide education consult Determine follow-up Complete nutrition assessment Assess readiness for change
HOW TO BUILD RAPPORT WITH ATHLETES Address them by name Nutrition training plan – Know their: not a diet Sport Don’t be defensive Position they play Training & skill needs Be positive Show up to practice, game, or competition
COMPONENTS OF HEALTH SCREENING Nutrition Estimated typical energy Assessment intake Diet hx & analysis Type, frequency, & duration of physical Supplement & activity medication use
WHAT ASSESSMENT DATA TO COLLECT? Height Eating patterns, screen Weight for disordered eating BMI Tools: http://psychcentral.com/q % body fat uizzes/eat.htm Usual body weight http://psychcentral.com/e Weight changes atingquiz.htm Readiness for change Training schedule 1-3 day food record Supplement use Food likes/dislikes Medications
SETTING GOALS FOR ATHLETES Outcome oriented – the end result the athlete wants to achieve Ex: Gain 5 pounds muscle mass in 3 months Process oriented – steps to get to the desired outcome Ex:Eat 300-500 addition calories of nutrient dense foods per day
INSIST ON FOLLOW-UP Motivation Address problems Assess progress toward goals Set new goals Answer questions Further educate about nutrition Discuss assessment of food record
WHAT ABOUT HIPAA? Any health related information collected must be kept confidential Consider a consent for disclosure form
AN ADDED VALUE FOR THE RD Fitness Assessment Basis for exercise Rx Baseline data for f/u & evaluation Motivation & goal setting Educate athlete
COMPONENTS OF FITNESS ASSESSMENT Body composition BIA Healthy Body Fat Ranges Skin fold Age Women Men Waist-to-hip ratio <55 16-28% 5-15% Body fat >55 20-33% 7-18% Minimum 5% for men; 12% women
COMPONENTS OF FITNESS ASSESSMENT Rate of Perceived Exertion (RPE) Cardiorespiratory Scale endurance Rating Perception of Intensity Heart rate – avg. 60-80 0 Nothing bpm 1 BP <120/80 2 Light, Weak Treadmill or step test 3 EKG, graded exercise test 4 Moderate/Somewhat strong Target heart rate or rate of 5 Strong perceived exertion 6 http://www.acefitness.org/ 7 High, Hard fitfacts/fitfacts_display.asp x?itemid=48 8 9 10 Very, very hard
COMPONENTS OF FITNESS ASSESSMENT Muscular Strength & Endurance Preserve function with aging Prevent loss of lean body mass & bone density Muscular strength Measured by 1 rep max – how much can be lifted one time Muscular Endurance How many times sub maximal amount can be lifted until fatigue Push-up test, sit-up test Complete reps at a specific rate (60 bpm) until fatigue
COMPONENTS OF FITNESS ASSESSMENT Flexibility Range of motion of joints, ligaments, tendons Sit and reach test standard measure
EXERCISE PRESCRIPTIONFrequency – how oftenIntensity – how hardType – aerobic, strength, flexibilityTime – how long Think FITT
CDC PHYSICAL ACTIVITY GUIDELINES Adults: minimum recs 150 minutes moderate intensity aerobic activity/wk 2 x’s/wk strength train all major muscle groups Children 60 min/d moderate to vigorous activity 3 d/wk strengthening activities 3 d/wk high impact for bone strengthening
REFERENCESFink HH, Burgoon LA, Mikesky AE, eds. Practical Applications in Sports Nutrition. Sudbury, MA: Jones and Bartlett; 2008.Dooly CR, Beals KA. Physical fitness assessment and prescription. In M. Dunford, ed., Sports Nutrition: A Practice Manual for Professionals, 4th ed. Chicago, IL: American Dietetic Association; 2006.Modlesky CM. Assessment of body size and composition. In M. Dunford, ed., Sports Nutrition: A Practice Manual for Professionals, 4th ed. Chicago, IL: American Dietetic Association; 2006.Nutrition and athletic performance - Position of the American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine. J Am Diet Assoc. 2009;109:509-527.