Professionals

Nutrition Does Matter! 

By Carin Shuler PT, DPT, MS, CHC

As a Physical Therapy professional, you are most likely familiar with the role that nutrition plays in enhancing health and recovery.  Most of you are well aware that the Standard American Diet (or Western Diet) is not considered to be “healthy”. Indeed the acronym for the Standard American Diet is SAD!  It is indeed, sad! (https://blog.designsforhealth.com/bid/175447/It-s-not-called-SAD-for-nothing). Most of the SAD is high caloric, highly processed and refined carbohydrates and food-like products vs real, whole food. You too may be familiar with traditional nutritional standards by our government or other organizations such as the American Diabetes Association, the National Osteoporosis Foundation or the American Heart Association.  Maybe you are questioning the traditional recommendations of nutrition in America.  It would be no wonder! The history of nutrition in our country has been confusing at best!  MyPlate is the most recent nutrition guide from the United States Department of Agriculture (USDA)  (https://www.choosemyplate.gov/eathealthy/brief-history-usda-food-guides ).  The USDA has provided nutrition guides for the public since 1894, including     the Basic 7 (1943–1956), the Basic Four (1956–1992), the Food Guide Pyramid (1992–2005), and MyPyramid (2005-2013) (https://en.wikipedia.org/wiki/MyPlate).   All of these have been met with criticism as the USDA has had many strategic agricultural and corporate partners in promoting the guides. Conflicts of interest were and are inherent in this. Luckily, the answers to most of our confusion and nutritional questions are now in contemporary scientific literature.  That’s the good news! However, social media hype, “fake” news, the latest-greatest fad “diet” and corporate disinformation continue to muddy the waters for all of us and our clients!

Ask yourself, how often are you engaging your clients in a frank discussion about cutting edge, emerging science in nutrition and lifestyle management to improve their health and wellness?  Do you have a keen interest in pursuing nutritional matters in physical therapy to elevate your interventions and plans of care for your clients? If so, then Rehab House Call (RehabHouseCall.org) is the place to be!  RHC is committed to being a wellness and health-centric practice above and beyond a traditional physical therapy practice.  Rehab House Call’s goal is to have our clients’ health-span equal their lifespan!  RHC will bridge the gap between limited physical therapy visits in standard third party payer models of care to a full life cycle of care.   In this new expanded paradigm of health-centric care, lifestyle management and nutrition does matter!  What about our role as Physical Therapists, then, in the area of nutrition, lifestyle assessment and education?   

Our Role in Nutrition, Lifestyle & Education

Despite this exciting emerging science, many Physical Therapists still question our role in nutrition or in lifestyle management such as in smoking cessation.  You may be unclear as to how all of this fits into your scope of practice. Let’s take a look at what the American Physical Therapy Association’s position is on this. Due to the clear science on the impact of nutrition in the role of overall health, physiological healing and recovery, as well as in chronic diseases and conditions, in June of 2015, the American Physical Therapy Association (APTA) House of Delegates passed a landmark motion. This motion was RC 12-15: The Role of the Physical Therapist in Diet and Nutrition. This important acknowledgement of the Physical Therapist’s broader scope of care in health, wellness and lifestyle management includes nutrition. The motion states:

“as diet and nutrition are key components of primary, secondary and tertiary prevention of many conditions managed by physical therapists, it is the role of the physical therapist to evaluate for and provide information on diet and nutritional issues to patients, clients and the community within the scope of physical therapist practice. This includes appropriate referrals to nutrition and dietary medical professionals when the required advice and education lie outside the education level of the physical therapist.”   (http://www.apta.org/uploadedFiles/2015PacketI.pdf)

Indeed, the APTA does not seek to have Physical Therapists become Registered Dieticians or Certified Nutritionists, nor expect them to change a client’s prescribed or ordered diet by a physician. Instead, we should be embracing the assessment of and guidance in the nutritional and lifestyle habits that may be enhancing or degrading the client’s health and condition.

APTA's Vision Statement

And yet, here we are in 2020, five years after this landmark motion! Furthermore, the APTA’s Vision Statement for the Physical Therapy Profession (http://www.apta.org/Vision/) also was updated and now states that its vision for physical therapy is:

 “transforming society by optimizing movement to improve the human experience.”

 The APTA’s guiding principles to achieve this vision state:

“Movement is a key to optimal living and quality of life for all people that extends beyond health to every person’s ability to participate in and contribute to society. The complex needs of society, such as those resulting from a sedentary lifestyle, beckon for the physical therapy profession to engage with consumers to reduce preventable healthcare costs and overcome barriers to participation in society to ensure the successful existence of society far into the future.

Continuing on with the information provided by the APTA, it is stated on the APTA website that:

“Diet and nutrition are key components of many conditions managed by physical therapists. What’s more, nutrition can directly affect recovery and function while an individual is under a physical therapist’s care. It makes sense, then, for physical therapists to be concerned with and address nutritional intake and eating patterns of their patients and clients. Nutrition is part of the professional scope of practice for physical therapists. (2018) Nutrition and Physical Therapy, APTAPhysical Therapy – “the Quintessential Noninvasive Health Care Practitioner”

 Are you still uncertain about your role in nutritional matters as a rehab professional even if you have been educated at the Masters or Doctor of Physical Therapy level?  Elizabeth Dean PT, PhD from the University of British Columbia may clear this up for you as I believe she says it best:

“The physical therapist is uniquely positioned to lead in health promotion and prevention of the lifestyle conditions, address many of their causes, as well as manage these conditions”.   (Dean, 2009)

Furthermore, Dean states

“This role is consistent with contemporary definitions of physical therapy as the quintessential noninvasive health care practitioner, and the established efficacy and often superiority of lifestyle and lifestyle change on health outcomes compared with invasive interventions, namely drugs and surgery”.    (Dean, 2009)

Nutritional Needs Change

As Physical Therapists, you instruct your clients in a physical activity or an exercise program and their nutritional needs rise or change as the metabolic demands change.  Their body is also demanding specific nutritional support to heal and recover.  In fact, Elizabeth Dean also states

“Optimal nutrition is essential for healing and repair, immunity, maintaining an optimal body weight as well as providing energy for metabolism. Physical Therapists who exploit exercise as a primary therapeutic intervention to prevent, remediate, or mitigate the effects of disease and disability perturb metabolic demands in their clients and patients.”   (Dean, 2009).

Indeed she expands on this by stating:

“Physical Therapists need an understanding of metabolism and the factors that influence it, and of healthy nutrition, nutritional assessment, and nutritional regimens to maximize human performance in patient populations.” (Dean, 2009).

Our Education Guides Our Understanding

Do we have such an understanding as Dean states above?  What does the research tell us? DiMaria-Ghalili  in 2014 noted that:

“Nutrition is also an important component of education, training, practice, and research for PAs, physical therapists (PTs), occupational therapists (OTs), and speech and language pathologists (SLPs). These graduates are ideally positioned to serve as health coaches promoting lifestyle modifications, especially during the rehabilitative continuum.”   (DiMaria-Ghalili et al 2014)

Indeed, as our profession has advanced to a Doctor of Physical Therapy post-graduate degree and curriculum, nutrition is included as a requirement in the doctoral physical therapy programs. This has been set as a standard by the Commission on Accreditation in Physical Therapy Education (CAPTE). CAPTE is the accrediting body for both the Doctors of Physical Therapy and Physical Therapist Assistant programs across our nation (CAPTE standards). In fact, CAPTE’s Standard 7A states:

“The physical therapist professional curriculum includes content and learning experiences in the biological, physical, behavioral and movement sciences necessary for entry level practice. Topics covered include anatomy, physiology, genetics, exercise science, biomechanics, kinesiology, neuroscience, pathology, pharmacology, diagnostic imaging, histology, nutrition, and psychosocial aspects of health and disability.”

What About the Scope of Practice in Your State? 

Certainly, one must abide by their individual states’ practice acts.  This therapist lobbied to our California State Legislature, along with a multitude of other colleagues and the California Physical Therapy Association (CPTA), for years to have specific health and wellness language included in the Practice Act. Prior to this update, PT’s in California were compelled to seek out further certifications if they were providing such holistic wellness and fitness services in order to have their malpractice coverage intact. Fortunately, our collective work was successful and the State of California’s Physical Therapy Practice Act was updated to include health and wellness language. It should serve as a valuable lesson that you are only as strong as you are as a united front to lobby and to seek out contemporary language updates in your state’s practice acts or in any lobbying efforts statewide or national. California’s Practice Act now states, in part:

“The practice of physical therapy includes the promotion and maintenance of physical fitness to enhance the bodily movement related health and wellness of individuals through the use of physical therapy interventions” (http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=BPC&division=2.&title=&part=&chapter=5.7.&article=2).

What if your state’s Practice Act does not include such language?  According to Joe Tatta, PT, DPT, CNS of the Integrative Pain Institute, if your state’s practice act is silent on the matter, you should look to your state’s language on nutrition. However, Dr. Tatta goes onto say that all the state’s practice acts do not currently prevent physical therapists from using nutrition and lifestyle management in their interventions.  That is indeed good news and in keeping with the APTA’s Vision Statement. (https://www.integrativepainscienceinstitute.com/can-pts-give-nutrition-advice-what-the-law-says-about-physical-therapists-providing-nutrition/)
 

The KISS Principle

Of course, we all continue our education above and beyond our formal schooling. Have you broadened your scope of services to improve the human experience…to include more client education in nutrition and lifestyle management?  Continuing education may improve your confidence in doing so if you have not yet started. Watch for upcoming online education offered by RHC!

In the meantime, you can use the KISS Principle!  Keep it simple for clients.  Use every session as an opportunity! And use it as a challenge each time to your client to improve their nutritional status and lifestyle. For example, perhaps you have discovered your client consumes five regular, sugary sodas per day and therefore is consuming way too much sugar. You need not get into the complex biochemical processes and overwhelming research about sugar with your client at this point. Most people know that too much sugar is “bad”.  Take advantage of this teachable moment and keep it simple. Possibly ask them to start with the simple idea of cutting down to four sodas a day for a week, then three and so on.  Discuss possible healthier alternatives with them and get them to agree to try one of those alternatives daily as a substitute.  As we all know, behavior change is challenging but small steps can lead to great benefits!

Segue Into Topics Like Type II Diabetes Prevention

Following our soda drinker example above, when you deem the time is right, you can broach the subject of prevention (or even reversal) of the well-known condition, Type II Diabetes.  This has gotten a great deal of press lately and especially how it also correlates to obesity. In fact, “Diabesity” is now an in vogue term used in blending of the two conditions.  Begin to educate your soda drinker that excessive sugar in the blood is a factor in this and that preventing Pre-Diabetes or full blown Type II Diabetes is important to their health span equaling their lifespan. As your client continues to progress, you can look at changes to his Standard American Diet to positively improve Diabesity.

Certainly, there are complicated biochemical reasons at the cellular level for this prevention or reversal to occur. Other medical and scientific terms such as Insulin Resistance, Glycation, Advanced Glycation End Products (AGEs), Carbohydrates and Blood Glucose can be overwhelming and confusing to clients.  How all these terms actually matter to your client and impact his physical therapy program and recovery, his overall wellness, weight management and even healthy aging is important for you to address as indicated.  The KISS Principle still applies as you continue to educate your client!  You might simply begin by making your client feel they are not alone and that it is not their fault. This would certainly be true as Type II Diabetes has reached epidemic numbers in the United States. In fact, the number of people diagnosed with Type II Diabetes is estimated to explode to over 70 million by 2050 according to the World Health Organization (WHO) (https://pubmed.ncbi.nlm.nih.gov/30374807/).  Glycemic control is the paramount goal. This is vital for decreasing the possibility of diabetes-related complications such as cardiovascular diseases, neuropathies, retinopathies,  nephropathies and even early death (https://pubmed.ncbi.nlm.nih.gov/30374807/).  Take the time, in small portions of information, to educate on the dangers of Type II Diabetes and the domino effect it has leading to unhealthy aging and other comorbidities.

Continuing with our example, you might explain that often as we (Americans) have followed the historical, conflicting “authoritative” guidelines of nutrition over our lifetime, we may then have gained too much weight.  By eating too many processed or packaged foods (carbohydrates in particular) in the Standard American Diet, our cells can become less sensitive to insulin (defining insulin as a hormone and insulin resistance at this point).  As a very basic explanation, you might tell your client that his cells need energy. Food (or drink) consumed increases blood sugar or in medical jargon, blood glucose, for energy. Explain in simple terms what the pancreas is and what it does; the pancreas produces insulin to escort the blood glucose to your cells that need the energy that the glucose provides. If insulin resistance occurs, the cells can’t take in the needed glucose.  His cells just don’t open their doors anymore when insulin comes knocking to drop off the glucose. Excessive blood glucose and insulin results; explaining that it is still floating in the blood as it can’t get delivered to the cells any longer as it should. Over time, you can explain the cascade of consequences of this. Your soda drinking client may then have an improved understanding at the basic cellular level as why his habit of consuming too much sugar will lead to Pre-Diabetes or onto full-blown Type II Diabetes. Possibly even more importantly, your client will begin to understand that it is not all his fault as we have all struggled with the mixed messages we receive from “authoritative” guidelines and the constant advertising of convenient and fast foods; to begin to heal psychologically and to remove feelings of shame, guilt, embarrassment and remorse. These negative feelings can certainly impede successful behavior change.

 As his Physical Therapist, you can continue to provide him with the most up to date knowledge regarding prevention and reversal of Type II Diabetes through lifestyle and nutritional changes.  Knowledge is power and can lead to the power to change habits. Supportive hard copy or online information is always a plus to provide.

Type II Diabetes and Diabesity are but one example of a topic for discussion with your clients.  As in all we do, each educational opportunity and plan of care is individualized for each client and their unique conditions and needs. You may wish to use this suggested KISS educational template in any other opportunity you have with other clients.

Health Coaching – An Added Benefit!

Your soda drinking client may be the perfect candidate to transition to a Health Coaching Program. Health Coaching engages your client in scientifically evidence-based and skilled dialogue, strategies and plans to actively promote safe and healthy behavior change. The intersecting roles of the Health Coach and Physical Therapist in establishing sustainable lifestyle change, is essential for chronic diseases/conditions management and prevention. As mentioned previously, DiMaria-Ghalili  et al in 2014 stated that DPTs are

“ideally positioned to serve as health coaches promoting lifestyle modifications, especially during the rehabilitative continuum.”  

RHC offers private, personalized Health Coaching as an added benefit to clients. RHC also offers continuing education for their staff to become certified in health coaching. This allows you to continue on with your willing and appropriate clients after their current course of physical therapy is complete.  This helps you to continue to pursue your clients’ health goals above and beyond their physical therapy program.  This is a distinction that sets RHC apart from traditional practices and truly helps your clients to have their health span equal their lifespan!
 

COVID 19 and Possible Future Pandemics – Prepare Your Clients!

 Health Coaching is something to consider for your clients in the midst of the COVID19 pandemic, there is not one American who doesn’t know the recommendations to wash their hands frequently, to socially distance and to wear a mask.  This has been a media blitz!  But are you providing education on how to be metabolically prepared to help boost and maintain the immune system of your clients to prevent infection?  This may sound daunting to you (and to your client). Certainly by again using the KISS Principle and keeping it simple for them is also important. Educating them to reduce their sugar consumption (like our soda drinker) is a start. Or, you may also elect to start educating them in eating whole, real foods vs packaged, processed foods.  Even if they start with one whole food meal per day, you are beginning to change habits in simple, introductory steps. We do not need to expound on the intricate and complicated metabolic processes and physiology in detail to get started. When we incorporate such simple steps into each session with each client, we as a whole will certainly help improve the human condition and experience in this pandemic, or future ones. Remind your clients of the famous quote:

“Let food be thy medicine and thy medicine be thy food”
– Hippocrates 460 B.C.

Watch for an upcoming RHC Blog on this topic!

Health Span Equals Life Span!

Have you been seeking to be kept abreast of ongoing scientific study of nutrition and lifestyle management in physical recovery and bodily functions to improve your clients’ outcomes?   Have you felt that we should be striving for more given the evidence and as such, would like your clients’ health span to equal their lifespan? Have you been wishing to do so amongst other rehab professionals of the same mindset?  Rehab House Call has taken this seriously to provide you, as a rehab professional, with the added continuing education to become not only familiar with, but to excel in nutritional and lifestyle management to provide the full scope of care and coaching your clients deserve.  There is a plethora of scientific evidence available for us to dig into! Watch for our upcoming online Blogs, Educational Articles, Podcasts and Training!

References

• https://blog.designsforhealth.com/bid/175447/It-s-not-called-SAD-for-nothing accessed 8/7/20
• https://www.choosemyplate.gov/eathealthy/brief-history-usda-food-guides accessed 8/4/20
• http://www.apta.org/uploadedFiles/2015PacketI.pdf Accessed 8/3/20
• https://en.wikipedia.org/wiki/MyPlate Accessed 8/6/2020
• Vision Statement for the Physical Therapy Profession and Guiding Principles to Achieve the Vision. P06-13-18-22 [Initial HOD P06-00-24-35][http://www.apta.org/Vision/. Updated September 25, 2019. Accessed August 3, 2020).
• https://www.apta.org/patient-care/public-health-population-care/nutrition Accessed 8/3/20
• Dean, E., et al (2009). Physical Therapy in the 21st Century ((Part II): Evidence-Based Practice Within the Context of Evidence-Informed Practice.  Physiother Theory Pract, 25(5-6), 354-368.
• DiMaria-Ghalili, R. A., Mirtallo, J. M., Tobin, B. W., Hark, L., Van Horn, L., & Palmer, C. A. (2014). Challenges and opportunities for nutrition education and training in the health care professions: intraprofessional and interprofessional call to action. The American Journal of Clinical Nutrition, 99(5 Suppl), 1184S–93S. https://doi.org/10.3945/ajcn.113.073536
• http://www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources/Accreditation_Handbook/CAPTE_PTStandardsEvidence.pdf accessed 8/6/20
• http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=BPC&division=2.&title=&part=&chapter=5.7.&article=2.accessed 8/6/20
• https://www.integrativepainscienceinstitute.com/can-pts-give-nutrition-advice-what-the-law-says-about-physical-therapists-providing-nutrition/accessed 8/5/20
• Okemah, J., Peng, , Quiñones, M. (2018). Addressing Clinical Inertia in Type 2 Diabetes Mellitus: A Review. Adv Ther, 35(11),1735-1745 (https://doi.org/10.1007/s12325-018-0819-5. Epub 2018 Oct 29) (https://pubmed.ncbi.nlm.nih.gov/30374807/)