Evidence-Based Practice for Health and Fitness Professionals

Evidence-based coaching:
Are health and fitness
pros doing it wrong?

By Brian St. Pierre, M.S., RD, CSCS and Helen Kollias, Ph.D.

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Ask any health and fitness professional if they’re “evidence based,” and chances are good you’ll get a resounding, “Yes!” Perhaps even an indignant one. After all, everyone uses evidence… of some sort. But if you think evidence-based practice is only what “research says,” you’re doing it wrong. In this article, we’ll show you the right way to use evidence to inform and enhance your coaching—for more effective advice and better client results. 

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Here at Precision Nutrition, we love science.

In fact, no one loves science more than us!

But is it possible to rely too heavily on scientific literature? Can you actually science too much?

Maybe.

Ever see someone:

  • Dismiss a coach’s successful method solely because some element of it isn’t “research proven?”
  • Refuse to modify a nutrition plan—even though a client hates it—“because science?”
  • Call a respected health professional a “quack” because they cite years of clinical experience instead of a definitive clinical trial?

(If you haven’t, you probably don’t spend much time in Facebook comments.)

In each case, the person’s inflated reverence for research could be limiting their ability to learn, and evolve as a coach. They might also influence others to follow their narrow line of thinking, causing them to miss out, too. And this is often done in the name of “evidenced based practice.”

Now, evidence-based practice, or EBP, is all the rage in certain health and fitness circles, which is a great thing. We heart science, remember? Except there’s just one problem…

A lot of coaches, though well-meaning, are getting EBP wrong. Specifically, they’re over-emphasizing “what the research says” to the exclusion of other relevant information, like their professional experience and the personal preferences and values of the people they work with.

And that’s not good for clients, business, or the health and fitness industry.

To make sure you get EBP right, use this guide to understand what the method really is, why it matters, and how to implement it effectively in your own coaching practice.

Because when used correctly, EBP is a powerful tool that’ll make you a better coach—so you can help even more people achieve lasting change and deep health.

And that we love even more than science.

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What is “evidence”?

There’s “everyday life” evidence.

In our Precision Nutrition Coaching program and Certifications, we tell our clients and coaches to use outcome-based decision making (OBDM).

Very simply, that means you decide what to do next based on the data you got from what you just did.

Did your waist measurement go up after two weeks of vacation buffets? That’s data that says, “Welcome home, maybe dial it back a little.”

Did your blood pressure go down after four months of sticking to your exercise program? That’s data that says, “Keep up the good work!”

We tell our coaches and clients to use as many data points as they can, and look for progress everywhere, including:

  • body measurements
  • blood work and other medical tests
  • athletic performance, such as getting stronger or faster
  • photos
  • how clothes fit
  • recovery
  • sleep
  • mood and wellbeing
  • confidence
  • consistency

And so on. (Here are some more ideas.)

All of these data points, collectively, give us evidence that we can use to make informed choices.

Then there’s scientific evidence.

This includes clinical or case studies, experimental research, basic research (for instance, studying cells in culture), and more.

This evidence can vary widely in quality, who is studied, and how applicable the results are to you and your clients.

However, in general, scientific evidence is one of the best ways we have to know about the nature of reality.

And though it might be obvious, we’re compelled to say it anyway: You’re looking to glean these insights directly from reputable, peer-reviewed scientific papers—not random websites, articles in magazines, or pictures of sunsets with words on them.

Finally, there’s stuff you learn on the job.

We call this “expertise.” It’s the old coach’s intuition, the senior clinician’s knack for diagnosis, the way a master carpenter can tell you if something is a quarter inch off square just by looking.

After you’ve worked with over 100,000 clients, as we have, you start to build a database of collected wisdom. And often, there’s stuff that’s hard to explain or defend—you’ve just seen it enough times that you know it’s a thing.

When we bring together experience, research, and expertise, we have a pretty good set of working hypotheses about what is likely to be effective.

And that’s evidenced-based practice. So it’s not just about clinical research.

EBP is a systematic way of thinking and application that integrates scientific data with clinical experience and the individual needs and preferences of each client or patient.

Yes, that’s the official, eye-glazing definition, but you might find the Instagram-able version even more enlightening. (See the illustration below.)

All three parts are equally important.

That’s because:

1. You aren’t coaching research averages. You’re coaching people.

Most studies report the average results of an intervention. (This is especially true of their headlines.)

Yet, if we look at the actual data of most studies, we see that individual results tend to fall on a bell curve of some sort.

Take this example, noted by James Krieger and Bret Contreras.

A study on resistance training and muscle gain concluded the following:

“Previously untrained people who engaged in resistance training three times a week for 9 weeks increased their muscle mass by 6%.”

Based on that, you might expect a client to achieve similar results on your three-day-a-week program.

But if you look at the individual data within the study, muscle growth ranged from -2.5 to 20 percent. That’s right: minus 2.5 percent. As Krieger and Contreras point out, five of the 53 participants actually lost muscle!

That’s not to suggest the research results are misleading. In fact, most of the study participants experienced muscle mass gains between 5 and 10 percent, and some even more. However, it does show the overall findings may not to apply to every individual. So don’t expect them to.

Another example is broccoli. There’s a significant body of evidence supporting the health benefits of eating this nutrient-dense vegetable.

But if broccoli makes someone gaggy or uncomfortably gassy, it’s not the healthiest food for them, no matter what the research says about it lowering disease risk.

These kinds of patterns happen over and over: Some people get great results from applying the research, some get very little (or negative) results, and most get results somewhere in between.

This is reality.

Research can be incredibly useful for giving us a starting point for most people. But humans differ—often wildly—from one another.

They differ in terms of their habits, mindset, physiology, environment, and personal preferences. They also differ in their ability to follow a program in the first place. And even if they stick to a plan perfectly, they can differ in the results they get.

Coach for the unique human in front of you, not for an average.

Not only will this improve your client results (because you’ll be working with their particular, practical reality), it’ll also improve your client retention (because you’ll be actually listening to them and trying to understand them as individual people, not as data sets).

When a client is suffering, they probably don’t need you to search PubMed for more evidence.

They often need you to provide a solid, trusting coaching relationship and, of course, your coaching skills. This combination can help you ease client resistance, be creative and flexible when typical solutions don’t work, and be compassionate and supportive when a client struggles with dark stuff.

2. Your professional experience really matters.

If you’re a mindful, growth-oriented coach or practitioner, it’s impossible not to develop a certain degree of experience and expertise over time.

A lot of things go into your “expertise bucket”: courses and programs you’ve taken; books you’ve read; lectures you’ve attended; mentoring relationships you’ve had; and all the practical experience you’ve acquired from observing and coaching clients or patients.

The accumulation of knowledge and experience gives you a kind of “intuition” that can help you coach more effectively.

This “intuition” shows up when you see a client perform a wonky squat, quickly identify exactly what’s wrong, and make corrections to improve form.

It shows up when you perform a client intake, and based on their answers (Just had a baby! Prone to perfectionism!), you can anticipate what aspects of a program they might struggle with, and how you might help them.

Or it shows up when you do a postural assessment, and immediately know which exercises to avoid and which could be helpful.

Much of the time, this is knowledge you could have never learned simply from reading studies. It requires time working with people, and exposing yourself to new ideas and methods, including those that have yet to be studied.

But there’s a challenge here, too. The knowledge we gather from our experiences is very prone to human error: Our memories are unreliable, we see patterns that may not actually exist, and we discount information that doesn’t conform to what we already believe.

How can we reduce human error?

  • First, be aware that bias and error exist… yes, even for you.
  • Take notes during or after client sessions, and use a variety of validated measurement tools—such as weight, body measurements, pictures, mood scales, and sleep quality scales—to track the effectiveness of your advice.
  • Get mentorship and feedback on your practice. Coaches need coaches. Or, find a like-minded group of professionals with whom to collaborate. (That’s why we developed the Precision Nutrition Level 2 Certification.)

If you’re aware of the errors you’re likely to make, and take steps to moderate them, you might start to see some reliable, overarching patterns.

Like that very rigid meal plans don’t work for people in the long term. Or that people can only train so long and so hard before they burn out.

Or a thousand other possibilities experienced coaches notice, but perhaps haven’t been fully validated by published research.

For example, here at Precision Nutrition, our coaches observed that when our clients took any steps in a positive direction—even if that meant being just 10% consistent with their healthy eating, exercise, and lifestyle habits—they experienced real, measurable progress. What’s more, our objective data from tracking these clients backed up this coaching observation.

No, this isn’t research from a published, peer-reviewed clinical trial (though we have that, too). But it’s still highly valuable evidence, since we’ve gleaned it from our collective professional experience working with more than 100,000 clients over the last decade.

If you’re just starting out and don’t have the experience gained from coaching many people over many years, you can “borrow” insight from mentors or other coaches with more reps under their belt.

Drawing on the wisdom of your (or a colleague’s) accumulated experience is an essential part of being a good practitioner.

3. Science will never have it all figured out.

The evidence is always evolving. Nutrition research in particular is a relatively new area, and there’s still a lot to be learned.

Plus, some things are really hard (or downright unethical) to test in a research setting, and so we may never have scientific evidence on it.

Even if it is possible to test, quality research takes a long time to gather. Usually, one study isn’t enough to “prove” something true or false. But waiting for multiple studies on a specific topic, or better yet, a meta-analyses (which is kind of like a poll of the research) may require a lot of patience. Maybe decades.

And yet, we still have to help our clients and patients make informed decisions. Like, now.

That’s where evidence-based practice comes in.

The RIGHT way to use EBP.

You can formally apply the EBP process to coaching decisions that feel especially important or uncertain.

EBP offers one of the best tools to help you reach a decision that’s most likely to be safe and effective, and that’ll also make sense in the context of your client’s life.

Follow these 6 steps to see EBP in action.

1. Assess the client.

Identify their unique abilities and needs.

  • What are their strengths?
  • Where might they need help from you?
  • What are their precise goals?
  • What are their identities, values, and beliefs?

Gather this information by asking questions, using intake forms, and taking measurements. This’ll help you create an initial plan of action and also provide a baseline against which to gauge progress.

Plus, as you collect data on many clients, you’ll be accruing practical evidence that can aid with decision making in the future.

Let’s use a hypothetical client to apply these steps.

Her name is Nora. Her goal is to lose fat, and she’s also interested in intermittent fasting. Through your initial assessment you learn that she’s begun to show signs of perimenopause, and her sleep isn’t great these days.

2. Find your research question.

Before you jump to a solution, get clear on the problem you’re trying to help your client with. 

Then, turn the problem into a question that’ll help you isolate the evidence you need for your recommendations. This question should incorporate the problem, as well as relevant factors about your client or patient.

Nora’s main goal is to lose fat, and she’s curious about intermittent fasting. Important factors to consider: Nora is a woman and she’s perimenopausal.

But you’re not sure if intermittent fasting is safe (or effective) for losing fat. And you’re definitely not sure if it’s safe (or effective) for a perimenopausal woman.

So your research question might be: “Is intermittent fasting safe and effective for fat loss in perimenopausal women?”

3. Gather the evidence.

Search for info using an online database like PubMed or Google Scholar. (If you don’t know how to use online research databases, here’s a PubMed tutorial.)

Using a research database will curate your hits so you’re only getting original, peer-reviewed research, rather than someone else’s (potentially biased) interpretation of it.

To find relevant research for Nora, a good keyword combination to type in a search box could be “intermittent fasting + fat loss + menopause”. These keywords contain the intervention you’re interested in learning more about, plus information about Nora’s unique goals and life stage.

To identify the best available scientific evidence on the research subject, use the “Hierarchy of Evidence” pyramid below. The higher up on the pyramid, the more trustworthy the information. So start your search from the top down.

In the case of Nora, prioritize finding a position stand, a meta-analysis, or a systematic review on using intermittent fasting for fat loss in menopausal women. This will give you a comprehensive overview of the current evidence. Basically, scientists and/or academics have already done the hard work—of reviewing, comparing, and analyzing the available scientific evidence—for you.

If that doesn’t exist, look for randomized control trials that compare appropriately chosen groups of people with a control group (such as a group that received no intervention, or a different intervention).

No luck there? You can expand your search to just “women” rather than “menopausal women.” Depending on what’s available, you may have to continue broadening your search and moving down the hierarchy of evidence.

Now, if you’re not well-versed in reading studies or interpreting research, that’s okay. Chances are, if you don’t find a meta-analysis or review, or—best of all—a position stand, the research further down the pyramid will be of limited use to you anyway.

If that’s the case—or you can’t find any scientific research on the topic—you might have to use opinions from other trusted experts, or develop an educated hypothesis based on your own knowledge of how physiology and nutrition work. This still counts as evidence, it’s just not as reliable, so temper your confidence in it accordingly.

All hail the position stand.

If you don’t feel equipped to navigate and interpret scientific literature, consider looking for best practice guidelines or position stands written by an authority in your field.

Position stands are official statements made by a governing body on topics related to a particular field, like nutrition, exercise physiology, dietetics, or medicine.

Here’s an example: The 2017 International Society of Sports Nutrition Position Stand on protein and exercise.

If you have a client who’s older and you’re wondering how to safely increase their training capacity (but don’t want to immerse yourself in a dark hole of research), simply look for the position stand on exercise and older adults.

To find the position stands in your field, consult the website of whatever governing body you belong to.

For example, if you’re a personal trainer certified through ACSM, NASM, ACE, or NSCA, consult the respective website for each organization. They should feature position stands on a variety of topics.

4. Appraise the evidence.

Through your search, you’ll probably find at least some evidence. This might be just a few small studies or some articles from trusted experts in the field.

Now, using the hierarchy of evidence, determine how valid and reliable those pieces of evidence are.

The more you have to broaden your question or move down the quality hierarchy, the less confident you might be about your recommendations.

With Nora, if all you find are some articles by an internet guru who’s never actually seen any real clients, you may want to present your findings as a mere idea, rather than as reliable advice.

On the other hand, if you find a handful of systematic reviews about intermittent fasting in menopausal women, you can go to Nora with more confidence about your recommendations. (Quick fact check, FYI: We couldn’t find any reputable systematic reviews on intermittent fasting in menopausal women.)

5. Create your recommendation.

Unless they ask for it, most clients don’t want to know all the complicated science stuff; they just want to know what to do.

This is where the science of coaching morphs into the art of coaching.

It’s time to see if you can actually apply the evidence you’ve found—along with your own professional experience—to the complex, real, live human standing in front of you.

Notice that the evidence by itself doesn’t make the decision. Nor does your experience, nor do the client’s preferences.

The three simply offer a more holistic perspective on a problem, to ensure you find the best possible solution for your client.

Rather than plunking down a stack of research in front of your client, combine the research with your expertise and your client’s unique circumstances to translate it into practical advice.

It could work like this: Through your research, you find that intermittent fasting is effective for fat loss. However, through your own professional experience, you’ve also noticed that most clients struggle to stick with intermittent fasting long-term. (Aligning nicely with your coaching experience, the research also shows a relatively high drop-out rate with intermittent fasting.)

You’ve also noticed that in some of your female clients, intermittent fasting seems to deregulate menstrual cycles and exacerbate menopausal symptoms.

Thinking about Nora’s unique values and preferences, you know that she wants to lose weight, but you also know that she’s had some trouble sleeping lately. In your experience with other clients, people who are sleep-deprived have an extra-hard time regulating appetite and losing weight.

So… intermittent fasting seems to be effective, but combined with your concerns about Nora’s hormonal health and sleep quality, plus the fact that intermittent fasting can be hard to maintain, you may decide not to recommend it to Nora.

After explaining to her your reasoning, explore with her what she’s comfortable trying. In the end, you may suggest some simple nutrition habits along with some short fasting experiments, plus some sleep tips.

These recommendations include what you’ve found from the best available research, your own coaching experience, and Nora’s unique preferences, goals, and challenges.

Nora’s just gotten some pretty wise, tailored-to-her advice, where you worked as collaborators to come up with her action plan.

That’s the art and science of coaching.

6. Monitor the results.

Once you’ve given your client a little time to practice what you came up with together, you can assess if those actions are working.

Consult those measurements you took in your initial assessments. Compare them to current measurements.

Are things moving in the right direction?

And talk to your client about how the plan is working.

Nora tells you although she’s applying and benefitting from the sleep tips, she’s struggling with fasting, even the shorter experiments. Turns out, it’s hard to fast when you’re having trouble falling asleep because of a grumbling tummy.

As you monitor progress, use what you find to re-evaluate goals and pinpoint where your client or patient needs more support.

Now Nora’s asking you about trying the Paleo diet instead. Looks like you have more research to do.

But keep in mind, over time, you’ll develop a solid grasp of the body of evidence on a number of topics. That’s the good part about science moving slowly: It’s not that hard to keep up.

What to do next.

Be empathetic, supportive, and flexible.

No matter what you believe is “right” or “true,” your first job is to work with your client, wherever they’re at.

Many practitioners intuitively know this, but the bond between coach and client (or patient) is extremely important and influential.

This bond is called the “therapeutic alliance,” and it refers to the level of trust and rapport between a practitioner and the person they’re helping.

Change is hard, and often scary. A strong therapeutic alliance can help a person feel supported and understood while surfing the tides of change.

In fact, some studies show the results a client or patient achieves in your care are up to 85 percent dependent on the therapeutic alliance. So, the stronger that relationship, the better the results.

If you’re constantly butting heads with your client, telling them, “But the research says!” or, “I know best!”, you can wave goodbye to a strong therapeutic alliance.

Many of the obstacles your clients will face are behavioral and emotional, rather than rational and theory-based. So more than facts, your clients often need compassion, support, and creativity to get them through the tough stuff.

Focus on the big rocks.

Given how complicated bodies and behavioral change are, it’s not surprising that science is still “trying to figure things out.”

Rather than using “cutting-edge” protocols like intermittent fasting or precise macronutrient ratios (which should really only be for more advanced clients anyway), focus on “big rocks” that offer the most bang for buck, like:

  • eating enough protein and vegetables
  • moving regularly
  • getting adequate sleep
  • managing stress
  • reducing smoking and/or excessive alcohol consumption

If that sounds boring or too obvious, we ask you this: How many people do you know who are consistently doing all five well? (In case you’re curious, it’s only about three to five percent of the population.)

Just managing those five things will keep most people plenty busy.

Be humble, throw out the rules, and keep learning.

The smartest people are often the ones who are most comfortable asking questions, saying “I don’t know,” and resting in uncertainty.

It’s a cliche but true: The more you know about something, the more you realize what you don’t know.

Be wary when others claim absolute certainty. It may be they don’t fully understand the complexity of the matter.

True expertise is about being comfortable with limited knowledge—while continuing to seek more and better information—and also accepting we may never have complete certainty.

Experiment wisely, and learn from both successes and failures.

Want to see how a theory works in practice? Test it out on yourself, and measure your experience as objectively as possible.

With clients, so long as there is no risk of harm, try out well-informed experiments (with their permission) that are either based on research or expert theory. Then, as always, track and measure their experiences and results to inform your next steps.

Know what you don’t know and work with other experts as needed.

Especially if you’re a beginner in your practice, it’s okay not to know stuff.

Focus on what you know best, whether that’s good lifting form, coming up with healthy meal ideas, or giving support during sticky coaching situations. But also know that some things will be out of your scope of practice.

So build a strong professional network—which could include family doctors, dietitians, massage therapists, naturopaths, chiropractors, and psychotherapists—and refer out whenever you encounter something you feel uncomfortable or especially inexperienced with.

Establishing a deep roster of experts will help clients get the support they need. And we’re pretty sure the evidence will show that’s good for everyone.

If you’re a coach, or you want to be…

Learning how to coach clients, patients, friends, or family members through healthy eating and lifestyle changes—in way that’s evidenced based and personalized for each individual’s lifestyle and preferences—is both an art and a science.

If you’d like to learn more about both, consider the Precision Nutrition Level 1 Certification. The next group kicks off shortly.

What’s it all about?

The Precision Nutrition Level 1 Certification is the world’s most respected nutrition education program. It gives you the knowledge, systems, and tools you need to really understand how food influences a person’s health and fitness. Plus the ability to turn that knowledge into a thriving coaching practice.

Developed over 15 years, and proven with over 100,000 clients and patients, the Level 1 curriculum stands alone as the authority on the science of nutrition and the art of coaching.

Whether you’re already mid-career, or just starting out, the Level 1 Certification is your springboard to a deeper understanding of nutrition, the authority to coach it, and the ability to turn what you know into results.

[Of course, if you’re already a student or graduate of the Level 1 Certification, check out our Level 2 Certification Master Class. It’s an exclusive, year-long mentorship designed for elite professionals looking to master the art of coaching and be part of the top 1% of health and fitness coaches in the world.]

Interested? Add your name to the presale list. You’ll save up to 44% and secure your spot 24 hours before everyone else.

We’ll be opening up spots in our next Precision Nutrition Level 1 Certification on Wednesday, October 2nd, 2019.

If you want to find out more, we’ve set up the following presale list, which gives you two advantages.

  • Pay less than everyone else. We like to reward people who are eager to boost their credentials and are ready to commit to getting the education they need. So we’re offering a discount of up to 44% off the general price when you sign up for the presale list.
  • Sign up 24 hours before the general public and increase your chances of getting a spot. We only open the certification program twice per year. Due to high demand, spots in the program are limited and have historically sold out in a matter of hours. But when you sign up for the presale list, we’ll give you the opportunity to register a full 24 hours before anyone else.

If you’re ready for a deeper understanding of nutrition, the authority to coach it, and the ability to turn what you know into results… this is your chance to see what the world’s top professional nutrition coaching system can do for you.

References

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