It’s 9 am and your patient just arrived at her first physical therapy session for chronic knee pain. She is a heavy but active woman. As she checks-in she sets aside a 32 oz. soda cup and you realize that it will take more than some range of motion and resistance exercises to alleviate her pain. For her treatment to succeed, she’ll need to realize, basically (and hopefully lastingly), that what we eat affects our well-being in multiple and fundamental ways, and may speed up, slow down, or even prevent pain and recovery.
Poor diet habits are directly linked to overweight and obesity, conditions that can lead to a range of diseases, preventable conditions, and both acute and chronic pain. Alarmingly, about 70% of all American adults are now overweight or obese (1). But even among those who are no, undernutrition often occurs as a result of diets high in processed foods and low in vitamins and other micronutrients (abundant for instance in nuts, fruits and vegetables) that are important to properly sustain metabolic and immune functions.
The Obesity Epidemics in America
Obesity leads to changes in body composition that have a dramatic, negative impact on insulin sensitivity and metabolism. Adipose tissue mass is a key factor in regulating lipid and glucose homeostasis, both of which directly influence inflammation, nociception, and pain. Given the role of fat and lean tissue in metabolism and insulin resistance, assessing the body’s tissue composition provides important clues on current and potential risk factors. Body composition assessments vary; some are easy, others are costly and time-consuming. The most common ones are anthropometric and include weight and stature (i.e. Body Mass Index, BMI), abdominal circumference, and skinfold measurements. More complex methods include bioelectrical impedance, dual-energy X-ray absorptiometry, body density, and total body water estimates.
Advice for Physical Therapists: Don’t Just Observe, Intervene!
Just as adequate nutrition can help us prevent disease and injuries, it can also aid in successfully restoring muscle and joint function and managing and overcoming pain. Although physical therapists – but also physicians and nurses – are generally aware of the importance of healthy eating for patient treatment and recovery, due to insufficient knowledge and/or lack of confidence they rarely provide specific nutritional advice (2). The topic of optimizing nutrition and weight reduction in physical therapy practice was reviewed by Dr. David. M. Morris and colleagues (3). The study provides succinct guidelines by which physical therapists can evaluate the nutritional status and needs of clients/patients, with the goal of inspiring changes in nutritional behavior to maximize treatment benefits, speed up recovery, and identify potential risks that may require special attention.
Five Ways to Address Your Physical Therapy Patient’s Nutrition Needs
#1 Understand Your Patients’ Nutrition and Health Needs
As a first step, physical therapists should understand the dietary and health trends of the population they serve. To this end, three US-based surveillance systems, which segregate information based on several demographic factors, offer valuable information to anticipate the patients’ needs and provide them with educational resources. These systems are:
1) What We Eat in America (WWEIA)/National Health and Nutrition Examination Survey (NHANES)
2) the Behavioral Risk Factor Surveillance System (BRFSS)
3) the National Health Interview Survey (NHIS, 2017)
All of these are freely accessible on the Centers for Disease Control and Prevention website (www.cdc.gov).
#2 Screen for Poor Nutrition
Nutritional screening tools that can be easily implemented in the physical therapy setting to identify a patient’s nutritional needs, adverse food-related practices, and disease risk factors. Results of these screens can be used to empower the individual to take on positive dietary changes, alert them on risk factors, and determine the need for referral to a registered dietitian or physician (for example, upon suspicion of diabetes).
- Overweight/obesity can be easily screened by measuring BMI and waist circumference. These screens allow classification of patients as underweight, normal weight, overweight, or obese.
- Undernutrition, while prevalent among all weight ranges, is less commonly assessed during physical therapy examinations. The Mini-Nutritional Assessment and the DETERMINE Your Nutritional Health Questionnaire are brief, simple, and reliable screening tools, aimed at older adults, that are easy to implement in the physical therapy practice (4). Although caution is advised when interpreting the screen results because not all persons with scores indicating risk may be truly undernourished, they are valid and reliable tools for identifying potential risk and the need for a more in-depth assessment by a physician and/or registered dietitian.
#3 Assess Your Patient’s Readiness for Nutrition and Behavior Change
After identifying a patient’s nutritional risks or deficits, the physical therapist then provides advice on defined dietary changes and/or referral. However, because undertaking a new diet can be quite challenging for both the patient and his/her family, evaluating the individual’s motivation and readiness to make this change can be very useful to tailor educational resources and increase patient’s compliance with the proposed dietary plan. Health behavior theories can assist in establishing such a diagnosis.
- The Transtheoretical Model (TTM), also called the Stages of Change Theory, proposes that at any specific time, patients are in one of five discrete stages of change for adopting a healthier behavior: pre-contemplation, contemplation, preparation, action, and maintenance (5). In the process of adopting the healthier behavior patients move from one stage to the next, oftentimes regressing and repeating stages several times before achieving lasting or permanent change. To find out the patient’s current stage of change, the physical therapist makes questions and then suggests resources and stimulates effective actions to facilitate the patient’s transition to the next stage.
- The Health Belief Model states that people’s decision to effectively act on health problems is influenced by self-perception of susceptibility to the illness or medical condition, its potential (perceived) severity, his/her beliefs that the recommended course of action would be of benefit (perceived benefits), and if they believe that the anticipated barriers to (or costs of) taking action are outweighed by its benefits (perceived barriers) (6). This model also dictates that a patient’s self-efficacy or confidence that they can effectively execute the behavior required to produce the desired outcome greatly influences the likelihood of a positive change in behavior.
#4 Implement Specific Diets for Weight Management
After assessing the items outlined above, the physical therapist may guide patients to well-known diets that are generally healthy, safe, and effective. Two such diets are:
- The Dietary Approaches to Stop Hypertension (DASH) diet comes from a landmark study demonstrating the plan’s efficacy in reducing hypertension risk and lowering high blood pressure. It emphasizes fruits, vegetables, and low-fat dairy foods and is low in saturated fat, total fat, and cholesterol. The DASH diet also encourages consumption of whole grains, poultry, fish, and nuts while discouraging red meats, sweets, and sugary beverages. Patient guidance for personalizing the diet’s steps can be found here.
- The Mediterranean diet gained popularity from findings that coronary heart disease is strikingly low in Mediterranean countries where fat intake is high but comes largely from plant fats such as olive oil and tree nuts. In addition, red meats are substituted with fatty fish, with contributing high amounts of the most biologically active forms of omega-3 fatty acids (eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA], and docosapentaenoic acid [DPA]).
Among a plethora of other health benefits, both diets proved to be highly effective in reducing cardiovascular risk and BMI.
#5 Measure and Share Patient Progress
If your nutrition intervention is specifically designed for weight loss you will track one or more evidence-based and objective measures of patient progress (7). Regular, accurate assessment and consistent follow-up will increase patient engagement and potentiate health benefits. Moreover, the assessment of body mass index (BMI) as a primary measure of obesity is a quality measure for the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) (recently rolled over into the Merit-based Incentive Payment System (MIPS), by which physical therapists can receive incentive payments from CMS for measuring and reporting BMI (8).
In a Nutshell
As poor nutrition negatively impacts patients’ quality of life and therapeutic outcomes regardless of disease or medical condition, efforts aimed at reversing poor diet habits and stimulating healthy eating behavior should undoubtedly provide better and faster results in the physical therapy practice. Given the increased frequency of visits within each patient’s episode of care, physical therapists are uniquely positioned to carry out these assessments, design comprehensive plans to improve patients’ nutrition, reduce weight, restore movement, and heal painful joints and muscles. We hope this blog will help achieve those goals.
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2- Rea BL, Marshak HH, Neish C, Davis N. (2004) The role of health promotion in physical therapy in California, New York, and Tennessee. Physical Therapy 84: 510–523
3- Morris DM1, Kitchin EM, Clark DE. (2009) Strategies for optimizing nutrition and weight reduction in physical therapy practice: The evidence. Physiotherapy Theory and Practice, 25(5–6):408–423
4- Holmes S. (2000) Nutritional screening and older adults. Nursing Standard 15: 42–44
5- Prochaska JO, Redding CA, Evers KE. (2015) The transtheoretical model and stages of change. In: Glanz K, Rimer BK, Lewis FM (eds) Health behavior: Theory, research, and practice, 5th ed, Chapter 7. San Francisco, CA, Jossey-Bass
6- Janz NK, Champion VL, Strecher VJ (2015) The health belief model. In: Glanz K, Rimer BK, Lewis FM (eds) Health behavior: Theory, research, and practice, 5th ed, Chapter 5. San Francisco, CA, Jossey-Bass
7- Duren, D. L., Sherwood, R. J., Czerwinski, S. A., Lee, M., Choh, A. C., Siervogel, R. M., & Cameron Chumlea, W. (2008). Body Composition Methods: Comparisons and Interpretation. Journal of Diabetes Science and Technology (Online), 2(6), 1139–1146.