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Recommendations Summary

NPA-GP: Nutrition and Physical Activity Interventions (2023)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    NPA-GP: Healthy Adults

    Nutrition and exercise practitioners should provide individualized nutrition and physical activity interventions to healthy adults (those without cardiometabolic risk factors or disease), within their professional scopes of practice, and refer to practitioners with necessary specializations when appropriate for or desired by each client to improve dietary intake and physical activity behaviors.

    Rating: Level 1(B)
    Imperative

    NPA-GP: Adults with Cardiometabolic Risk Factors

    Nutrition and exercise practitioners should provide individualized nutrition and physical activity interventions to adults with cardiometabolic risk factors, within their professional scopes of practice, and refer to practitioners with necessary specializations when appropriate for or desired by each client to improve cardiometabolic risk factors.

    Rating: Level 1(B)
    Imperative

    • Risks/Harms of Implementing This Recommendation

      Adverse Outcomes 

      Few adverse effects were reported from the intervention on outcomes of interest, and nearly all outcomes of interest were improved, however narrowly, from the intervention (Nitschke, Gottesman et al. 2022). Thus, the benefits of the interventions would likely outweigh the risk of harm.

      Social Determinants of Health  

      Social Determinants of Health (SDoH), including healthcare access, economic stability, food access and neighborhood and built environment, can affect a wide range of health risks and outcomes (Centers for Disease Control and Prevention 2021). For example, adults who are members of Black or Hispanic communities have higher rates of type 2 diabetes and cardiovascular disease compared to adults who are White (Rodríguez and Campbell 2017, 2019). According to Jardim et al 2019, annual costs of cardiometabolic diseases are among the highest in those over 65 years of age, individuals identifying as Black, those with less education, and individuals on Medicare (Jardim, Mozaffarian et al. 2019).

      Some adults may have fewer resources, both tangible and intangible, to access nutrition and physical activity counseling and coaching (Brownson, Baker et al. 2001, Middleton, Anton et al. 2013, Stotz, Ricks et al. 2021). Tangible resources include time, money, childcare, distance from facilities and transportation; while intangible resources include health literacy and distrust of healthcare providers, among others (Alvarado, Murphy et al. 2015, Munt, Partridge et al. 2017, Jones, Lawlor et al. 2021). Further, healthcare insurance often only covers limited nutrition counseling for individuals without a diagnosed disease (Academy of Nutrition and Dietetics 2022). Counseling or coaching to improve dietary intake and physical activity for disease prevention may require out-of-pocket expenses, which could negatively impact accessibility for adults with low socioeconomic status. Strong efforts to make interventions accessible to all populations are necessary to ensure equity and improve population health.

      Adults with low incomes may have the barrier of paying for services provided by nutrition and exercise practitioners. Other financial costs might include nutritious food, cooking and exercise equipment, and a safe location for physical activity. Nutrient-dense food options such as fruits and vegetables have a higher cost than less nutrient-dense options (Darmon and Drewnowski 2015). Compared to those with food security, food-insecure adults reported lower diet quality as defined by the Healthy Eating Index-2015 score, with more disparities in non-Hispanic white adults, and adults who are members of Asian or other racial/ethnic communities (Leung and Tester 2019). Socioeconomic status as defined by income level, education, and current occupation is further correlated with poorer diet quality and access to nutrient-dense food options (Psaltopoulou, Hatzis et al. 2017). Adults living in lower income neighborhoods may lack access to safe recreational areas, which is associated with less physical activity (Volaco, Cavalcanti et al. 2018). These barriers may vary intervention effectiveness, thus negatively impacting equity. Education alone or resources pertinent to more affluent populations function inadequately to serve clients with unique needs due to SDoH.

      More information on methods to address SDoH when designing and implementing interventions can be found in the “Inclusion, Diversity, Equity and Access” in "Conditions of Application" section.

    • Conditions of Application

      Implementation Considerations/Conditions of Application 

      Utilizing a treatment framework can provide a flexible guide for nutrition and exercise practitioners to customize care, considering each individual’s unique requirements and goals. Some healthy adults may not require guidance provided by a trained/certified practitioner to eat a nutritious diet or achieve sufficient physical activity. Among those who would benefit from dietary and physical activity guidance, intervention focus will vary, and a qualified nutrition and/or exercise practitioner should offer evidence-based, targeted interventions based on the current needs and values of the client, while staying within the scope of practice. An overview of a framework for providing nutrition and physical activity care to the general population is described in the Framework for Providing Nutrition and Physical Activity Interventions. However, applying a standardized framework should not imply homogenous nutrition and physical activity care for clients. Practitioners may also employ frameworks from their own fields, such as the Nutrition Care Process for dietitians (Committee 2018, Daigle, Subach et al. 2021) and the American College of Sports Medicine (ACSM) Guidelines for Exercise Testing and Prescription (American College of Sports Medicine 2022) for exercise practitioners.

      Screening

      Nutrition and exercise practitioners should properly screen adults to determine the need for comprehensive assessment or referral to a practitioner with necessary specializations. Practitioners should begin their care process with screening, which is meant to be a relatively quick practice to determine the necessary depth of assessment, level of care, and appropriate referrals. Screening may be conducted by other healthcare practitioners, such as nurses or physicians, to identify the need for referral to nutrition and/or exercise practitioners. For the general population, screening should focus on determining client needs and goals using various tools, such as questionnaires, interviews, basic anthropometric measurements, current medical records, and other instruments validated within the target population (see Components of Screening and Assessment). Practitioners should use screening results to guide thorough assessments and referrals to practitioners with necessary specializations, as appropriate for or desired by the client. In this context, “practitioners with necessary specializations” means credentialed, skilled practitioners whose scope or focus area differs from the assessing practitioner; for example, dietitian to personal trainer, personal trainer to physical therapist, or clinical dietitian to sports dietitian.

      Assessment

      Nutrition and exercise practitioners should conduct a thorough assessment to inform individualized interventions. Nutrition and exercise practitioners should use screening results to determine the depth and detail of assessment. Proper assessment involves ongoing, dynamic processes with thorough investigations of a client’s health history, current health status, behaviors, and motivations, among other factors. Nutrition and physical activity assessments for the general population should determine lifestyle behaviors, social and environmental circumstances, and physical health details. Nutrition and physical activity assessments may be performed in-person or via a Health Insurance Portability and Accountability Act (HIPAA) compliant telehealth platform (which varies by state in the U.S.) (Daigle, Subach et al. 2021).

      All nutrition and exercise practitioners should investigate client nutrition and physical activity practices, though the level and method of assessment may vary according to field of practice. Nutrition assessment includes investigation of food or nutrition-related history, biochemical data, medical test and procedure history, anthropometric measurements, nutrition-focused physical exams (NFPE), and additional relevant history using interviews, medical charts, and validated questionnaires and procedures (see Components of Screening and Assessment). The goal of physical activity assessment is to understand the frequency, duration, and intensity of physical activity and to identify the relationship between physical activity and health. Assessments may include behavioral observations, self-reporting, questionnaires, physical tests, biochemical tests, and/or interviews.

      Nutrition and exercise practitioners should assess each client for readiness to achieve and sustain a healthy diet and adequate physical activity levels (Prochaska and Velicer 1997). For example, clients in the precontemplation phase may require evidence regarding why making lifestyle changes positively impacts health; while clients in the contemplation stage may have higher self-efficacy and intrinsic motivation and might benefit from understanding how to incorporate new nutrition and/or physical activity behaviors.

      After screening and assessment, nutrition and exercise practitioners should determine if they should refer a client to practitioners with necessary specializations for advice based on disease risk, specific nutrition or physical activity goals or client preference/request. See Components of Screening and Assessment and the “Scope of Practice” section for more information on when to refer to specific practitioners.

      Monitoring and Evaluation

      A client’s journey does not end after the initial consultation. Monitoring and re-evaluation of client barriers and facilitators to healthy lifestyle behaviors breed success for long- term results (Kuller, Pettee Gabriel et al. 2012, Lindström, Peltonen et al. 2013). Throughout the nutrition and physical activity intervention and during post-intervention follow-up, nutrition and exercise practitioners can continue to collect and analyze assessment components, such as weight status, and to adapt suggested lifestyle interventions as needed. As with all aspects of nutrition and physical activity care, practitioners should individualize monitoring and re-assessment components dependent on clients’ history, personal goals, and current challenges. Those components may include anthropometric measures, biomarkers, and opportunities for maintaining healthy lifestyle behaviors. 

      Whether weekly, monthly, annually, or as-needed,  the frequency of monitoring depends on the intensity of care needed and preferred, with higher intensity programming requiring more-frequent re-evaluation. Other considerations include the client’s interest in continuing care with a practitioner and their ability to utilize insurance or cash for on-going consultations.

      Nutrition and exercise practitioners may further monitor and evaluate the interventions they provide for their clients collectively. For example, practitioners may assess behavioral adherence, program drop-out, rates of weight regain, and other factors to assess and track the efficacy of their practices and adapt as necessary.

      Scope of Practice

      All nutrition and exercise practitioners have their own areas of expertise and, thus, will benefit from collaborating with health professionals who have complementary expertise to provide comprehensive and well-balanced client care. A Scope of Practice is determined by national certifications and credentialing (Institute for Credentialing Excellence 2021), state laws and regulations and qualifications, training and experience of the practitioner. Maintaining a personal network of interdisciplinary practitioners for referrals allows a practitioner to ensure that their clients are working with appropriately credentialed and educated individuals to effectively address all relevant aspects of health care. In addition, providing suggestions for referrals may limit the stress a client experiences when searching for an appropriate interdisciplinary practitioner to meet their needs.

      Dietitian Scope of Practice

      Dietitians provide the most advanced scope of practice for delivering nutrition care, including delivery of medical nutrition therapy (MNT), nutrient analysis and individualized meal planning (2018). The registered dietitian (RD) or registered dietitian nutritionist (RDN) credential requires completing a bachelor’s degree focused on nutrition science from an accredited college or university, a supervised internship, and passing a registration examination (Academy of Nutrition and Dietetics 2022). This requirement will be elevated to require a master’s degree for new practitioners as of 2024. The extensive education and patient-focused clinical experience required of a dietitian allows these practitioners to understand and address the nuances of how underlying health conditions can affect nutrition needs and energy metabolism (Committee 2018). Licensing of dietitians has expanded to nearly all states in the U.S., and in many cases this license is required to provide MNT and to practice dietetics, including personalized meal planning (Academy of Nutrition and Dietetics 2022). Dietitians may possess specialized credentials, such as a Certified Diabetes Educator or Certified Specialist in Sports Dietetics, after completing additional hours with clients/patients pertaining to their specialization and passing additional exams (Daigle, Subach et al. 2021, Commission on Dietetic Registration 2022). Some dietitians may refer clients to other dietitians with specific areas of expertise when needed.

      Providing general recommendations that align with national guidelines for physical activity (U.S. Department of Health and Human Services 2018) for healthy populations falls within the scope of practice for most health professionals, including dietitians. For example, dietitians can and should encourage increasing physical activity and reducing sedentary time. However, specific exercise recommendations, including recommendations for adults who have mobility issues or other health concerns affecting physical activity should come from an exercise practitioner, because even the “minimum” physical activity recommendations may be out of reach for these individuals. If a client is experiencing any injuries, has previously been sedentary, is not achieving fitness goals, has been diagnosed with a disease or illness, or has doctor-ordered physical restrictions (e.g., cardiac restrictions), they should be referred to an exercise practitioner.

      Exercise Practitioner Scope of Practice

      Exercise practitioners are qualified to provide safe and effective exercise programs for apparently healthy individuals and individuals with special needs who have medical clearance from their primary care providers (American Council on Exercise 2020). Exercise practitioners include a range of specialties, including personal trainers, group fitness instructors, and strength and conditioning coaches (American Council on Exercise 2020, US Registry of Exercise Professionals 2021). Further, if a client becomes injured or requires therapy, they should be referred to the appropriate credentialed practitioner, such as a physician, physical therapist, or certified athletic trainer. With regards to nutrition, exercise practitioners are free to share population-based, evidence-based dietary guidelines and resources (U.S. Department of Agriculture and U.S. Department of Health and Human Services 2020), as well as discuss general topics pertaining to healthy nutrition and food preparation. However, clients who have specific health concerns such as pre-diabetes or obesity should be referred to a dietitian for MNT, as should clients interested in nutrient analysis or specific dietary plans.

      Health Coach Scope of Practice

      A health coach’s focus is on aiding clients in enhancing their health and well-being through sustainable lifestyle changes. Health coaches employ effective communication skills to promote self-directed change with their clients, guide clients in developing achievable and measurable goals, and help clients uncover their individual strengths to maintain behavior change (American Council on Exercise 2019). As with exercise practitioners, health coaches can share population-based, evidence-based nutrition recommendations but must refer clients when more specific or individualized nutrition plans need to be developed. For physical activity needs, health coaches are free to share the current physical activity guidelines and recommendations (U.S. Department of Health and Human Services 2018) as well as explore how clients can increase their current activity level. If a client requires or would like an individualized exercise prescription, the health coach should refer to an exercise practitioner.

      Referrals and Creating an Interdisciplinary Network

      Practitioners providing nutrition and physical activity interventions should be qualified in the respective field before delivering individualized advice (see Scope of Practice). Nutrition and exercise practitioners should engage in updating their knowledge through training and certifications and with the latest practice guidelines. A team approach should be encouraged to provide comprehensive, multi-component care and may include a dietitian, health coach, personal trainer, mental health professional, and/or physician. Practitioners and clients can search for qualified practitioners in other areas of practice through recommendations of trusted peers and by searching “find an expert” tools on websites of reputable organizations such as the Academy of Nutrition and Dietetics, the American Council on Exercise (ACE), the American College of Sports Medicine (ACSM), and the National Commission for Certifying Agencies (NCAA) (Institute for Credentialing Excellence 2021, Academy of Nutrition and Dietetics 2022, American College of Sports Medicine 2022, American Council on Exercise 2022).

      Creating a robust, reliable interdisciplinary network can be a career-long process. Even experienced practitioners will likely encounter clients living in different areas, with different cultural backgrounds and different physical needs, which require them to seek new professional networks to help support their clients. It may be beneficial for nutrition and exercise practitioners to search for practitioners with necessary specializations in their area and send out a form letter or email asking if the complementary practitioner is interested in collaborating and what their specific specializations and approaches are. This will allow the practitioner to identify willing collaborators and to have a library of practitioners with specializations that address diverse client needs. 

      When determining which practitioner to refer a client to, one should consider the client’s specific needs and preferences. Before contacting a potential collaborator, make a short list of the client’s priorities. While not exhaustive, some examples of factors to consider include:

      • Does the client have specific nutrition need(s) requiring a dietitian with specialties, such as specialization in overweight/obesity treatment, eating disorders, or sports nutrition?
      • Does the client require an exercise professional, such as a personal trainer, physical therapist, group fitness instructor or health coach?
      • Does the client require a practitioner with competence in specific cultural or ethnic practices?
      • Does the client have preferences or limitations regarding mode (e.g., telehealth, group) or cost of intervention delivery?
      • Would the client benefit from counseling methods such as motivational interviewing or cognitive behavior therapy?

      When referring a client to another practitioner with necessary specializations, confirm if the client is comfortable with sharing client information between practitioners and obtain client permission to share information when appropriate. As appropriate and desired by the client, collaborating practitioners should continue to communicate about client needs and intervention plans and work together to help the client meet desired goals.

      Intervention Amount and Delivery Methods

      Intervention Duration and Number of Contacts with Nutrition and Exercise Practitioners

      In the systematic review supporting this guideline, the expert workgroup examined the contribution of intervention components to results through sub-group analyses defined a priori. No clear patterns were identified between the number of contacts with nutrition and exercise practitioners or study duration and outcome effect sizes (Academy of Nutrition and Dietetics' Evidence Analysis Center), implying that there is no “one-size-fits-all” approach, and intervention amount should be individualized to the needs and preferences of each client.

      Following up with clients after interventions and providing recurrent feedback is critical for behavior change (Barkmeijer, Molder et al. 2021). Such feedback includes maintaining contact with clients, monitoring their progress, and when necessary, altering and adapting advice. Hence, the number of contacts planned with a client should take into consideration follow-up visits. Contacts may include weekly outreach including motivational techniques, weekly e-mail contact combined with a monthly request to disclose current body weight, attending at least two sessions of point-of-testing counseling, or even having weekly contact for the first three months and every other week for the following next three months (Barkmeijer, Molder et al. 2021). Point-of-testing counseling is a technique for offering quick feedback on individual lab results to participants (Walker, Murimi et al. 2012). There are several factors that affect how many consultations a client needs, including motivation, progress, finances, and personal objectives. Also, nutrition and exercise practitioners need to be aware of each client’s needs and individualize the number and duration of consultations accordingly.

      Delivery Methods

      Nutrition and exercise practitioners can utilize various methods to deliver care, such as in-person or remote contact and individual or group counseling methods. Individualizing counseling modality to a less traditional format, such as remote counseling, can be as effective at improving outcomes as face-to-face counseling in some circumstances (Barkmeijer, Molder et al. 2021). For instance, using real-time video consultations can yield more satisfaction for some clients, even though practitioners may be less satisfied. In the systematic review supporting this guideline, interventions delivered in-person or through a blend of in-person and remote contacts tended to have a more significant impact on a greater number of outcomes of interest compared to interventions delivered exclusively remotely (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021).

      The first consultation with a client is suggested to be in-person but follow-up visits may occur remotely using telehealth/smartphone-based counseling. However, remote contacts require a stable internet connection and potentially a clear video camera. Hence, the nutrition or exercise practitioner should assess the ability of their clients to be able to participate in online visits. With remote consultations come some privacy concerns that need to be addressed by practitioners to protect the confidentiality of their clients. For instance, executing the online visit in a private room and avoiding recording the sessions unless necessary, and if necessary, then protecting all the video files in a secure portal or location. Practitioners who are required to adhere to HIPAA rules should also adhere to HIPAA rules and state-specific telehealth policies for remote consultations (Academy of Nutrition and Dietetics 2022).

      Group counseling (2-4 clients) can provide advantages when the practitioner’s aim is to share knowledge and raise awareness (Barkmeijer, Molder et al. 2021). Group counseling methods allow peers to motivate each other by sharing knowledge and experiences. In the systematic review supporting this EBNPG, interventions delivered exclusively one-on-one with a client resulted in the most consistent beneficial outcomes, though interventions delivered through a blend of one-on-one and group contacts were also beneficial for improving outcomes (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021). Some challenges of group sessions may include embarrassment of sharing sensitive information, along with other privacy considerations. Therefore, nutrition and exercise practitioners should set guidelines and expectations for group sessions, stress the importance of autonomy, and comply with client preferences. Individual consultations are preferable when there is a need to provide individualized action plans (Barkmeijer, Molder et al. 2021).

      Behavior Change Counseling or Coaching Approaches

      Nutrition and exercise practitioners commonly use behavioral counseling strategies to guide behavior change. Behavioral change requires commitment from the client and skillful guidance from the practitioner to identify when certain counseling or coaching strategies will best align with the client’s current ambition for change, knowledge of what habits to change, and the duration of time that the client and practitioner may be able to work together on the client’s goals. Behavior change strategies are important for encouraging and actualizing behavior change with clients; they are not only based on evidence but offer insight and structure for both the nutrition and exercise practitioner and client when working towards sustainable lifestyle change (Spahn, Reeves et al. 2010, American Council on Exercise 2019, Rigby, Mitchell et al. 2020). The use of these strategies, either separately or in combination with others, provides a framework for understanding the nuances of the process of change, which may allow the practitioner to communicate effectively, increase a client’s intrinsic motivation, and establish client ownership in their unique change journey.

      Some examples of specific strategies that can be utilized by nutrition and exercise practitioners are described in Behavioral Counseling Strategies. These strategies focus on meeting the client where they are in their stage of change and allowing them to identify appropriate goals for their individual needs. Though these strategies are unique and applied at different points in the counseling or coaching process, they are all rooted in the values of empathy, unconditional positive regard, collaboration, and rapport building (Whitlock, Orleans et al. 2002). The values upon which these strategies are founded allow for the practitioner and client to engage in a collaborative process guided by the practitioner but carried out by the client. The practitioner is the content expert while the client remains the expert on themselves (American Council on Exercise 2019, American Council on Exercise 2020).

      A complete strategy for change may encompass multiple specific strategies. These strategies will vary according to client needs and preferences, including stage of change and how/why the client has initiated the intervention (Carvalho de Menezes, Bedeschi et al. 2016). For example, a client who is new to lifestyle interventions may benefit from motivational interviewing with the inclusion of decisional balance to allow them to identify the habits that require change with the thoughtful input of a skilled nutrition or exercise practitioner (Miller 2013, O'Halloran, Blackstock et al. 2014, American Council on Exercise 2019), while a transtheoretical model may be useful for clients who made too drastic of a change in the past, as this strategy may help them take smaller more achievable steps (Marcus and Simkin 1994). Strategies such as these demonstrate the collaborative nature of counseling/coaching health behavior change. Nutrition and exercise practitioners must individualize different intervention strategies based on the current needs of the client to increase the likelihood of acceptance and adherence.

      Population-Based Nutrition and Physical Activity Guidelines

      This evidence-based nutrition practice guideline intends to complement existing nutrition and physical activity guidelines for the general population. When delivering nutrition and physical activity interventions to the public, practitioners should primarily adhere to population-based recommendations, such as the Dietary Guideline for Americans (DGAs) (U.S. Department of Agriculture and U.S. Department of Health and Human Services 2020) and the Physical Activity Guidelines for Americans (U.S. Department of Health and Human Services 2018) in the U.S. Food-based guidelines are available for many countries (Food and Agriculture Organization of the United Nations 2022), however, national, population-based physical activity guidelines are less available, with the World Health Organization providing some guidance (World Health Organization 2021). Guidance from The American College of Sports Medicine (ACSM) (Garber, Blissmer et al. 2011) is considered a global standard. Population-based guidelines normally provide a range of lifestyle behaviors that facilitate positive health outcomes (Key Population-Based Recommendations). For example, the DGAs describe that adults should “Customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural traditions, and budgetary considerations” (DGAs 2020-25, Recommendation 2) (U.S. Department of Agriculture and U.S. Department of Health and Human Services 2020). Thus, any nutrition advice delivered to an adult without a diagnosed disease should adhere to this recommendation. Practitioners should not advise outside of the bounds of population-based guidelines for fields in which they are not certified or licensed. Nutrition and exercise practitioners providing nutrition or physical activity advice within their certified/licensed field should individualize population-based recommendations based on screening and thorough nutrition and physical activity assessment to optimize client adoption and adherence. Please see the sections “Individualizing Nutrition and Physical Activity Interventions” and “Scope of Practice” for more information on individualizing population-based guidelines for specific client needs and preferences and when to refer to an allied health practitioner with necessary specializations, respectively.

      Many adults in the general population may have risk factors for cardiometabolic diseases, including overweight or obesity, pre-diabetes, or pre-hypertension, which may alter nutrition and physical activity requirements. For example, if an individual with obesity desires to lose weight, nutrition and exercise practitioners should utilize recommendations specifically aimed at adult weight management (Morgan-Bathke, Raynor et al. 2022), though future iterations of the Dietary Guidelines for Americans (DGAs) may include recommendations specific to this population (Services 2022). For adults with pre-diabetes, practitioners may utilize diabetes prevention-specific guidelines concurrent with population-based guidelines. Dietitians can find evidence-based recommendations specific to many nutrition-related risk factors on the Evidence Analysis Library website (Academy of Nutrition and Dietetics 2022). The Physical Activity Guidelines for Americans includes guidance for adults with chronic health conditions and disabilities (U.S. Department of Health and Human Services 2018). For clients with specific health conditions or risks, qualified nutrition or exercise practitioners may deviate from population-based guidelines and utilize current best practices and relevant evidence to develop client-specific interventions. Practitioners should ensure the recommendations and positions from stakeholder organizations are evidence-based (e.g., based on systematic review) when considering implementation into practice (Institute of Medicine Committee on Standards for Developing Trustworthy Clinical Practice 2011).

      Individualizing Nutrition and Physical Activity Interventions

      For some adults, encouragement and education from practitioners to achieve dietary intake and/or physical activity population-based recommendations may serve their needs and provide sufficient programming. For example, currently sedentary clients may benefit from meeting the recommended physical activity amount and intensity (e.g. target intensity minutes per week) and those with low fruit and vegetable intake would benefit from increasing intake (e.g. achieving 5+ servings per day). However, even facilitation of meeting population-based recommendations requires understanding each client’s priorities and circumstances to adequately identify facilitators and barriers to success. Thus, nutrition and exercise practitioners should individualize all client encounters – even those interventions aimed to simply meet population-based recommendations.

      Intervention individualization has become increasingly possible with precision nutrition (Rozga, Latulippe et al. 2020) and exercise, which can provide nutrition and exercise practitioners with personalized and detailed client information to guide care, such as genetics, gut microbiome composition, and interindividual exercise response (The White House 2015). Individualization further extends beyond health conditions to client circumstances, values, and behaviors. For example, a client without access to safe exercise areas may benefit from ideas for in-home conditioning or access to affordable, local fitness facilities. A client with a home eating environment non-conducive to creating positive nutritional changes, may benefit from ideas that facilitate healthy behaviors within that context.

      Screening and assessment results, which elucidate client needs and values, will guide personalization of nutrition and physical activity interventions. A client may have several health goals or many lifestyle behaviors to improve for optimal health; as such, clients and practitioners should share decision-making to determine priorities. For example, when working with an adult with pre-diabetes, practitioners may emphasize improved blood glucose regulation and insulin sensitivity to maintain and improve metabolic health. A client with cardiometabolic disease risk factors, such as obesity, may prioritize intake of nutrient-dense, satiating foods to reduce total energy intake and regulate appetite.

      The figure Priorities for Interventions demonstrates intervention priorities that can be individualized for each client, based on comprehensive assessment, and adapted to meet client needs as they change over time (through regular monitoring and re-evaluation). Most clients would likely benefit from improving all four priorities – metabolic health and energy balance, positive health habits, nutrient adequacy and hydration, and well-being. However, the initial emphasis and order of importance of those priorities are very client dependent. For example, a college-aged athlete at a healthy weight, with positive, self-sufficient well-being, and consistent positive lifestyle habits may benefit from detailed nutrient analysis and lab work to develop specific hydration and dietary supplement protocols to optimize performance (Nutrient Adequacy and Hydration). However, should that athlete experience Relative Energy Deficiency in Sport (RED-S) symptoms, then adequate energy intake to promote metabolic health becomes the absolute top priority, along with referral to a physician and dietitian, when appropriate for and desired by the client (Metabolic Health & Energy Balance) (De Souza, Strock et al. 2022). Conversely, an individual without cardiometabolic disease but with risk factors may benefit from establishing positive associations with physical activity (Positive Healthy Habits). These priorities must remain dynamic and flexible to adapt to a client’s individual, and often fluctuating, health and lifestyle goals.

      Inclusion, Diversity, Equity, and Access (IDEA)

      Viewing IDEA principles as fundamental matters when working with all clients has the potential to improve rapport and health outcomes. Healthcare inequities are a pervasive reality in the U.S., even as the population becomes more diverse (Academy of Nutrition and Dietetics 2022). SDoH, including education access and quality, economic stability, social and community context, neighborhood and built environment, and healthcare access and quality, can influence a person’s ability to lead a healthy life (U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion 2022). Chronic diseases are disproportionately represented among members of a minority group (Brown, Burt et al. 2022), adults with low socioeconomic status (Batomen, Sweet et al. 2021), adults with disabilities (Centers for Disease Control and Prevention 2022), and members of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) populations (Rahman and Linsenmeyer 2019). In addition, clients with overweight or obesity can experience weight biases and stigma, which are associated with adverse health outcomes (Wu and Berry 2018). Thus, lifestyle behaviors and related conditions likely result from complex factors, many of which are beyond an individual client’s control or the practitioner’s control.

      Each healthcare system and nutrition and exercise practitioner must embrace a more inclusive, diverse, equitable, and accessible practices. Practitioners should consider how SDoH affects client access to services, needs and preferences, and adherence to healthy lifestyle behaviors. Several organizations offer resources to encourage equitable access of healthy lifestyle behavior programs to diverse audiences. The Centers for Disease Control and Prevention offers a Health Communication Gateway that includes guiding principles for inclusive and respectful communication (Centers for Disease Control and Prevention 2022). The Academy of Nutrition and Dietetics, a membership organization of nutrition and dietetics professionals, provides a variety of resources to help practitioners develop a practice that promotes IDEA (Academy of Nutrition and Dietetics 2022). The U.S. Department of Health and Human Services (USDHHS) Office on Minority Health provides a “Culturally and Linguistically Appropriate Services” (CLAS) behavioral health implementation guide, report, and toolkit (U.S. Department of Agriculture and U.S. Department of Health and Human Services 2022). A summary of principles for providing culturally appropriate services is described in the Excerpt on Guidance for Providing CLAS (U.S. Department of Agriculture and U.S. Department of Health and Human Services 2022). Nutrition and exercise practitioners can use motivational interviewing techniques to examine health priorities from the client’s perspective and should consider cultural and personal preferences and beliefs regarding diet, exercise, body image, and other health-related factors. Collaboratively, the practitioner and client can establish client-centered goals and action items.

      Creating an inclusive and accessible meeting space for clients sets an open and inviting climate for the consultation. Nutrition and exercise practitioners should consistently use person-first language and preferred pronouns and should ask clients about how they would like to be addressed and the terms they prefer (e.g., when talking about weight, race, and ability). Practitioners are encouraged to continue developing their cultural competency to deliver equitable, effective care. Nutrition and exercise practitioners can learn from the client by asking thoughtful open-ended questions.

      Individualized care from empathetic nutrition and exercise practitioners may improve health equity compared to generalized recommendations. Individuals from under-resourced populations may encounter financial barriers to care. For more background information, please refer to the preceding “Social Determinants of Health” section. Nutrition and exercise practitioners should implement creative interventions which address the tangible and intangible socioeconomic constraints of each client to facilitate change according to each client’s (or family’s) circumstances. Practitioners may consider instituting a sliding scale for fees for services to allow greater access to care for adults with lower incomes. Collaborating with public health, low-cost or non-profit entities and encouraging employers to offer services within the workplace may allow nutrition and exercise practitioners to expand services to underserved populations. Qualified nutrition and exercise practitioners should individualize interventions, within the scope of practice, for adults with financial constraints including cost-effective, nutritious meal preparation (Centers for Disease Control and Prevention 2022) and home-based exercise routines or assisting with access to affordable fitness facilities. Dietitians should include food insecurity screening questions during nutrition assessment for susceptible populations to ensure that appropriate subsequent advice (Makelarski, Abramsohn et al. 2017). Clients with food insecurity may benefit from resources to access food assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), or local food banks.

      Barriers and Facilitators to Application

      Low proportions of adults follow population-based recommendations for dietary intake and physical activity (Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS) 2018 (Centers for Disease Control and Prevention 2022) which implies a need for professional behavior-change support for adults interested in preventing disease and associated costs and suffering. However, implementation of nutrition and physical activity interventions may not be feasible for all adults. A major barrier to care is the cost of interventions, described above, and lack of payment available from insurance companies for interventions prior to disease development. In addition to financial costs, additional barriers to engaging in interventions may be time, transportation, and childcare. Nutrition and exercise practitioners can address these barriers by offering flexible methods of delivering care. For example, group interventions may be more financially feasible and incorporating telehealth visits may present less of a time burden on the client. Please refer to the "Inclusion, Diversity, Equity and Access" section for suggestions regarding how practitioners can promote access to care. Another potential barrier to care may be client motivation. Nutrition and exercise practitioners can assess a client’s stage of change and adapt counseling/coaching methods and goals to facilitate clients working toward goals that matter to them (please refer to the Behavior Change Counseling or Coaching Approaches section). Clients may require specific advice to address various behaviors and health risks. Thus, addressing every client's need may fall outside of any one practitioner’s scope. Nutrition and physical activity practitioners can address this barrier by creating a network of trusted, qualified practitioners from disciplines other than their own to encourage collaborative, responsible, high-quality care.

      To aid in the implementation of this EBNPG, a two-page practitioner guide with key figures and take-home messages was created to be used as a quick reference tool. 

    • Potential Costs Associated with Application

      Potential Resources Associated with Application

      A client’s financial expense for interventions may range widely due to variable health insurance coverage as well as variance in intervention duration, intensity and involvement from the nutrition or exercise practitioner. Not all health insurance providers cover nutrition and physical activity services for healthy adults or even for those with cardiometabolic risk factors such as overweight. Thus, practitioners need to consider out-of-pocket expenses when screening, assessing, and designing interventions for clients. Some insurance companies may cover the associated fees for utilizing a nutrition or exercise practitioner, such as for adults with obesity. Practitioners can encourage clients to pursue resources to cover the cost of services, including calling their insurance provider, or utilizing workplace or community resources. Healthier food options such as fruits and vegetables, have a higher cost than less nutrient-dense options (Darmon and Drewnowski 2015). Personalized exercise recommendations may require access to a recreational facility, costly equipment, and time outside of work.

      For practitioners, costs may include time for billing or paying a medical biller. The increasing prevalence of using telehealth (Rozga, Handu et al. 2021) has required increased investment in telehealth equipment, technology, and software. Other expenses for nutrition and exercise practitioners include professional development, licenses, and certifications.

      Despite the expenses, implementing individualized lifestyle interventions prior to disease development can be a cost-effective strategy (Abu-Omar, Rütten et al. 2017, Mattli, Farcher et al. 2020, Zhou, Siegel et al. 2020, Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Galekop, Uyl-de Groot et al. 2021). Interventions appropriately designed, managed, and provided by qualified nutrition and exercise practitioners can greatly reduce costs of secondary care over time (Sun, You et al. 2017). Thus, policies are required to alleviate the cost of such interventions, and these investments may be cost-effective in the long run. Future policy development should address improving ease of access to nutrition and physical activity care and lowering out-of-pocket expenses for these services.

    • Recommendation Narrative

      Problem

      Nutritional inadequacy and physical inactivity contribute to the development of chronic, highly prevalent cardiometabolic diseases (CMDs) such as cardiovascular disease (CVD), type 2 diabetes mellitus (T2DM) and obesity (Centers for Disease Control and Prevention 2022, Centers for Disease Control and Prevention 2022, Centers for Disease Control and Prevention 2022). Adults unable to adhere to dietary and physical activity recommendations increase risk for CMD development, which often accompanies pharmaceutical and/or medical financial costs, along with the burden of disease symptoms. Annual diet-related CMD costs were $301 per person based on National Health and Nutrition Examination (NHANES) data from 2009-2012 (Jardim, Mozaffarian et al. 2019). Medical costs may be 30% higher in adults with obesity compared to those with a normal weight (Withrow and Alter 2011). Clients who develop CVD and T2DM may represent an annual cost of $3, 418-$9, 705 based on literature published between 2007-2017 (Einarson, Acs et al. 2018). Practical and sustainable nutrition and physical activity interventions may offset rising healthcare costs by reducing the risk of CMDs (Krishnan, Finkelstein et al. 2019).

      Most adults follow dietary patterns that do not align with population-based recommendations (Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS) 2018) despite evidence that balanced intake of nutritious food, including fruits and vegetables, reduces risk for CVD, all-cause mortality, T2DM, obesity and other conditions (Aune, Giovannucci et al. 2017, Schwingshackl, Bogensberger et al. 2018, Bruins, Van Dael et al. 2019). More than a quarter of the world’s adult population (1.4 billion adults) are insufficiently active (Centers for Disease Control and Prevention 2022). Meeting physical activity recommendations, compared to not meeting recommendations, has been associated with lower heart failure risk, reduced risk of CVD mortality, reduced blood pressure, reduced risk of metabolic syndrome, and improved insulin sensitivity (Holloszy 2005, Lee, Pate et al. 2014, Nes, Gutvik et al. 2017, Lavie, Ozemek et al. 2019, Mirahmadizadeh, Khorshidsavar et al. 2020). Providing individualized interventions from qualified nutrition and exercise practitioners is necessary to help clients understand how to meet nutrient needs and increase physical activity to effectively reduce CMD risk, which can contribute to improved population health.

      Supporting Evidence

      In the systematic review supporting this EBNPG, seven included studies targeted adults with no noted cardiometabolic risk factors or diseases (referred to as “healthy” adults) (Maruyama, Kimura et al. 2010, Forsyth, Deane et al. 2015, Kennedy, Ryan et al. 2015, Partridge, McGeechan et al. 2015, Fjeldsoe, Goode et al. 2016, Viester, Verhagen et al. 2018, Rich-Edwards, Stuart et al. 2019, Nitschke, Gottesman et al. 2022). Analyses of these studies demonstrated that nutrition and physical activity interventions provided by nutrition and exercise practitioners resulted in improved physical activity amount (Fjeldsoe, Goode et al. 2016, Partridge, McGeechan et al. 2016, Rubinstein, Miranda et al. 2016, Viester, Verhagen et al. 2018, Rich-Edwards, Stuart et al. 2019, Nitschke, Gottesman et al. 2022) and vegetable and fruit intake (all moderate certainty evidence) (Forsyth, Deane et al. 2015, Kennedy, Ryan et al. 2015, Fjeldsoe, Goode et al. 2016, Partridge, McGeechan et al. 2016, Rubinstein, Miranda et al. 2016, Viester, Verhagen et al. 2018, Rosas, Lv et al. 2020, Nitschke, Gottesman et al. 2022). However, in healthy adults, which included adults with “normal” weight status only, there was no significant effect of the intervention on waist circumference in three RCTs (moderate certainty evidence) (Maruyama, Kimura et al. 2010, Fjeldsoe, Goode et al. 2016, Viester, Verhagen et al. 2018, Nitschke, Gottesman et al. 2022). In three RCTs, authors demonstrated a collectively statistically significant reduction in blood glucose levels (moderate certainty evidence) (Maruyama, Kimura et al. 2010, Toji, Okamoto et al. 2012, Williams, Collins et al. 2019, Nitschke, Gottesman et al. 2022). Low certainty evidence demonstrated no effect of the intervention on anxiety and depression (Forsyth, Deane et al. 2015, Rosas, Lv et al. 2020, Academy of Nutrition and Dietetics' Evidence Analysis Center 2021), and very low certainty evidence demonstrated an uncertain effect of nutrition and physical activity interventions on quality of life in healthy adults (Kennedy, Ryan et al. 2015, Williams, Collins et al. 2019, Rosas, Lv et al. 2020, Nitschke, Gottesman et al. 2022). Thus, in healthy adults, improved outcomes were primarily behavioral, and there is likely heterogeneity in the effect size of the outcome according to the individual, intervention, and practitioner (see Summary of Findings table).(Nitschke, Gottesman et al. 2022)

      In the systematic review supporting this EBPG, (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Nitschke, Gottesman et al. 2022) 24 RCTs examined nutrition and physical activity interventions provided by nutrition and exercise practitioners and targeted adults with cardiometabolic risk factors including overweight/obesity, (Gabriel, Conroy et al. 2011, Imayama, Alfano et al. 2011, Colleran, Wideman et al. 2012, Toji, Okamoto et al. 2012, Bennett, Foley et al. 2013, Lindström, Peltonen et al. 2013, Hollis, Williams et al. 2015, Miller, Weinhold et al. 2015, Weinhold, Miller et al. 2015, Huseinovic, Bertz et al. 2016, Blos, Drehmer et al. 2017, Neale, Tapsell et al. 2017, Siddiqui, Kurbasic et al. 2017, Johnson, Alencar et al. 2019, Ma, Rosas et al. 2019, Maddison, Hargreaves et al. 2019, Thomas, Bond et al. 2019, Beleigoli, Andrade et al. 2020, Perri, Shankar et al. 2020, Rollo, Baldwin et al. 2020, Rosas, Lv et al. 2020) diabetes risk, (Roumen, Feskens et al. 2011, Lindström, Peltonen et al. 2013, Nicklas, Zera et al. 2014, Miller, Weinhold et al. 2015, Weinhold, Miller et al. 2015, Siddiqui, Kurbasic et al. 2017, Rollo, Baldwin et al. 2020) or other cardiometabolic risk factors.(Rubinstein, Miranda et al. 2016) These studies reported both behavioral and cardiometabolic outcomes. In regards to behavior, synthesis of 12 RCTs, including meta-analysis of nine RCTs, described those interventions provided to adults with cardiometabolic risk factors improved physical activity amount (low certainty evidence).  (Foster-Schubert, Alfano et al. 2012, Kuller, Pettee Gabriel et al. 2012, Ruusunen, Voutilainen et al. 2012, Nicklas, Zera et al. 2014, Hollis, Williams et al. 2015, Weinhold, Miller et al. 2015, Neale, Tapsell et al. 2017, Maddison, Hargreaves et al. 2019, Beleigoli, Andrade et al. 2020, Rollo, Baldwin et al. 2020, Rosas, Lv et al. 2020, Rosas, Xiao et al. 2021, Nitschke, Gottesman et al. 2022) Synthesis of six RCTs, including meta-analysis of four RCTs, described the intervention improved vegetable intake (moderate certainty evidence), but had no significant effect on fruit intake (low certainty evidence), though heterogeneity of results was high (I2=91.9%) (see Summary of Findings for Healthy Adults)(Colleran and Lovelady 2012, Hollis, Williams et al. 2015, Miller, Weinhold et al. 2015, Neale, Tapsell et al. 2017, Beleigoli, Andrade et al. 2020, Rosas, Xiao et al. 2021, Nitschke, Gottesman et al. 2022).

      Studies targeting adults with cardiometabolic risk factors primarily reported outcomes related to CMD risk. Meta-analysis of fifteen RCTs reported the intervention, compared to control conditions, reduced waist circumference (moderate certainty evidence) (Roumen, Feskens et al. 2011, Colleran, Wideman et al. 2012, Foster-Schubert, Alfano et al. 2012, Kuller, Pettee Gabriel et al. 2012, Toji, Okamoto et al. 2012, Bennett, Foley et al. 2013, Weinhold, Miller et al. 2015, Rubinstein, Miranda et al. 2016, Blos, Drehmer et al. 2017, Siddiqui, Kurbasic et al. 2017, Huseinovic, Bertz et al. 2018, Maddison, Hargreaves et al. 2019, Williams, Collins et al. 2019, Rollo, Baldwin et al. 2020, Rosas, Lv et al. 2020, Nitschke, Gottesman et al. 2022). Twelve RCTs reported percent weight loss as an outcome, including as a continuous variable and likelihood of achieving 5% weight loss (Mason, Foster-Schubert et al. 2011, Colleran and Lovelady 2012, Kuller, Pettee Gabriel et al. 2012, Lindström, Peltonen et al. 2013, Miller, Weinhold et al. 2015, Weinhold, Miller et al. 2015, Huseinovic, Bertz et al. 2016, Siddiqui, Kurbasic et al. 2017, Johnson, Alencar et al. 2019, Ma, Rosas et al. 2019, Thomas, Bond et al. 2019, Rollo, Baldwin et al. 2020, Nitschke, Gottesman et al. 2022). Meta-analysis of eight RCTs reported the intervention resulted in a significant increase in the relative risk of achieving 5% weight loss (high certainty evidence) for adults with overweight or obesity (Kuller, Pettee Gabriel et al. 2012, Weinhold, Miller et al. 2015, Huseinovic, Bertz et al. 2016, Siddiqui, Kurbasic et al. 2017, Johnson, Alencar et al. 2019, Ma, Rosas et al. 2019, Rollo, Baldwin et al. 2020, Rosas, Lv et al. 2020). Generally, weight-loss interventions were only successful when interventions included caloric reduction (Nitschke, Gottesman et al. 2022). Intervention participants with CMD risk factors experienced a significant reduction in fasting blood glucose levels compared to those in control groups in nine RCTs (moderate certainty evidence) (Mason, Foster-Schubert et al. 2011, Roumen, Feskens et al. 2011, Kuller, Pettee Gabriel et al. 2012, Bennett, Foley et al. 2013, Weinhold, Miller et al. 2015, Blos, Drehmer et al. 2017, Siddiqui, Kurbasic et al. 2017, Johnson, Alencar et al. 2019, Rollo, Baldwin et al. 2020, Nitschke, Gottesman et al. 2022), However, those with diabetes risk in the intervention groups did not experience reduced HbA1c levels compared to those with diabetes risk in the control conditions in three RCTs (low certainty evidence) (Roumen, Feskens et al. 2011, Siddiqui, Kurbasic et al. 2017, Rollo, Baldwin et al. 2020, Nitschke, Gottesman et al. 2022). For the outcomes of anxiety and depression and quality of life in adults with cardiometabolic risk factors, results were inconsistent and evidence certainty was low, but there was some evidence that the intervention may have a slight beneficial effect on these outcomes (see Summary of Findings for Adults with Cardiometabolic Risk Factors) (Imayama, Alfano et al. 2011, Ruusunen, Voutilainen et al. 2012, Nicklas, Zera et al. 2014, Neale, Tapsell et al. 2017, Siddiqui, Kurbasic et al. 2017, Krishnan, Finkelstein et al. 2019, Ma, Rosas et al. 2019, Rollo, Baldwin et al. 2020, Academy of Nutrition and Dietetics' Evidence Analysis Center 2021). Thus, in adults with cardiometabolic risk factors, improved outcomes were behavioral and cardiometabolic, and there is likely heterogeneity in the effect size of the outcome according to the individual, intervention, and practitioner.

      In the systematic review supporting this guideline, sub-group analysis of all studies was conducted to determine if nutrition and physical activity interventions provided by different nutrition and exercise practitioners had a differential effect (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021). For the outcomes of waist circumference, achieving 5% weight loss for adults with overweight and obesity, physical activity amount and glucose levels, intervention effects were generally greater, compared to controls, in nutrition and physical activity interventions delivered either by a dietitian or a dietitian and exercise practitioner together than when they were delivered by a health coach alone (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021).

    • Recommendation Strength Rationale

      Certainty of evidence was moderate for the behavioral outcomes for adults who were healthy and for cardiometabolic outcomes for adults with cardiometabolic risk factors. 

    • Minority Opinions

      None.