PT Crab 🦀 Issue 178 - Nutrition Nutrition Nutrition

Can you tell your patients what to eat? Yes. Should you? Also yes. There are bounds to this, but it is within your scope to do in general. For specifics, we’ll have to dive into these papers.

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Back in 2019, that APTA House of Delegates (those fancy folks who determine the policies and goals of the organization and, eventually, you, even though you have no idea who they are or that they even exist because the APTA is bad at messaging and engagement and value demonstration) passed a position statement that said, “Diet and nutrition are key components of primary, secondary, and tertiary prevention of many conditions managed by physical therapists. It is within the professional scope of physical therapist practice to screen for and provide information on diet and nutritional issues to patients, clients, and the community.”

The statement (HOD P06-19-08-44, in case you were wondering) goes on to say some more, boring stuff but I’ll leave it there for now. So it is something you can and should do. How? Press on.

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Set the Stage

The Gist - The lead author on two of our papers today is Patrick Berner, a PT and Registered Dietician AKA the Fuel Physio, so dude knows his stuff. This first one was published in PTJ in 2021. It’s a perspective paper designed to provide guidelines most relevant to PT practice and the professional scope. You should already know general dietary guidelines (I say as I eat a slice of leftover frozen pizza from dinner last night), but let’s refresh with a basic overview: “An eating pattern that prioritizes protein and unsaturated fat from plant sources, carbohydrate selection from whole grains, includes a minimum of 5 servings/day of fruits and vegetables, and a moderate dairy consumption reduces risk of chronic disease and improves well-being. This pattern also limits sodium intake to <2000 to 2300 mg/d, the amount recommended for healthy populations that alleviates known health risks associated with higher intake.”

Obviously, individual needs vary, but that’s a place to start. If you’re looking for a basic diet to apply for your or a patient, the Mediterranean Diet and the Dietary Approaches to Stop Hypertension are recommended. If you or a patient is purely vegetarian (like me 95% of the time), they may need B12 supplementation (I’m going to have to look into that). 

Knowing what to do isn’t as simple as doing it. Far from it. There is a fantastic section on social and environmental determinants of health eating in the paper. It discusses food deserts and “food swamps”. The former is where there is no grocer and the latter where the only food is junk. 

In recommendations for us here, the paper says that “Physical therapists should educate and support patients/clients to explore potential solutions to address some of these modifiable factors, whether personal or environmental, to help them adopt a healthier eating pattern. Physical therapists may also be able to address some of the environmental factors, such as advocating for healthier eating opportunities in their community, volunteering for Meals on Wheels or at food pantries, supporting affordable transportation to supermarkets, and supporting community gardens.” Just learning about what is available can be a big help. I work in a historically disadvantaged community and many patients struggle with food availability. A new grocery store down the street offers half-price fresh produce to anyone on EBT/SNAP (formerly called food stamps) but very few of my patients know that (until I tell them). 

There’s a lot more information about availability and access, but let’s pop on to scope.

Tell Me More - Your education was supposed to have information about nutrition, at least according to CAPTE (the accreditors), so you should know some stuff. In general, it’s recommended that PTs should refer out for this kind of stuff if the info you’re giving is beyond what is found in the public domain or is outside of general dietary guidelines. Usually, we shouldn’t be giving information to help treat a specific disease. Your state may have different ideas about all this though, since each has their own practice act that details it (or not, often). 

The majority of the practice acts don’t say anything, while some, like NC, say that we shouldn’t sell or promote the use of supplements, vitamins, or OTC medications. If you’re going to look into this in your own state, it would be useful to check out the guidelines for both PT and other healthcare providers, like dietitians. Georgia says, for example, that only people who are credentialed as a dietician can offer dietetic services but many states are less restrictive. 

For a quick finish here, nutrition advice is important for bone health, muscle health, aging, would healing, and more. It’s recommended that older adults consume 1.2 grams of protein per kilogram of body weight (that’s about 90 grams for a 160lb adult, about 2 normal chicken breasts per day), and that’s not even to mention calcium recommendations (1,000 mg/day until 50, 1,200 afterward), vitamin D recommendations (600-800 IU/day until 50 and 800-1,000 afterward) and more. More on this coming soon.

Paper? Right here folks.

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Tools and Strategies to Act

The Gist - This paper is by a similar collection of authors to the previous paper and published at about the same time. This one covers things you can do today to bring nutrition education into your practice. That starts general, with a general health and well-being assessment that can range from something so simple as a line on an intake form that says “In general, would you say your health is” with a spot to fill in or you could use a specific tool like the SF-36. They also recommend that you use a readiness to change element in your intake forms or initial discussions. This rates someone’s readiness to change from 1 to 10 where 10 is ready to change today. 

To get nutrition-specific, there are many nutrition screening tools to use and many are quite simple. The Nutrition Screening Protocol is just 2 questions, Start the Conversation is 8, the Malnutrition Screening Tool is 2, and the Mini Nutrition Assessment Short Form is 6. There are others that are more complete, all outlined in a table in the paper. Any of these will let you get a quick look at what your patient is doing today so you can find ways to improve things for them.

That’s screening, but how can we intervene? Read on.

Tell Me More - Interventions need to be in your scope of practice. That’s defined both by your education and by your state’s laws. Once you know what you can do, you basically have three paths forward:

1) Education - nutrition information is confusing. There’s too much and not enough. But you can help. The previous paper has a breakdown of common nutrient needs, but things as simple as healthy eating principles, like eating at home, not eating packaged food, eating more vegetables, etc. can be helpful. If you become familiar with healthyy eating information, you can help guide your patients through the morass of nutrition info.

2) Behavioral change - readiness to change is key here. The paper has an excellent table that breaks down what to do at each level of readiness to provide maximum support to your patients. There is a nice breakdown of motivational interviewing and goal-setting for nutritional information as well. I highly recommend pulling up the open access paper and checking out what they have in it.

The most important part of long-term behavioral change is autonomous motivation. Patients need to want to do this for their own sake. Fear of disease or desire to look good can help, but they aren’t adequate intrinsic motivations to keep going. Find each person’s motivations and work to convert them to intrinsic motivation to keep them going.

3) Referral or collaboration with dietitians - if your patient is beyond your scope or knowledge, it’s time to refer out. Registered dietitians can help us intervene more effectively for our patients and work within their unique needs and goals. EatRight.org/find-an-expert is your best resource in this area. If your patient has diabetes, a diabetes educator may be a good option for you, and if they’re more complicated, a physician nutrition specialist could help. If they’re suffering from bulimia, anorexia, or a similar disease, a specialist on eating disorders could be the solution. Options are out there. Find the ones in your area and refer to them when you need help.

Paper? Open access here.

And that’s our week! Because those were intense, I’m just doing two papers this week. Open them! Read them! Learn! They’re excellent, non-technical, and very helpful.

And share PT Crab with friends and colleagues. Seriously. Forward this now. Why isn’t everyone in your organization reading this? C’mon guys! 

But seriously, if you’ve found PT Crab helpful, help others get access to it too. You have a custom referral link right here, but you could just forward a copy or bring it up in conversation too. Bye!

Here’s this week’s bibliography:

• Berner, P., Bezner, J. R., Morris, D., & Lein, D. H., Jr. (2021a). Nutrition in Physical Therapist Practice: Setting the Stage for Taking Action. Physical Therapy, 101(5), pzab062. https://doi.org/10.1093/ptj/pzab062

• Berner, P., Bezner, J. R., Morris, D., & Lein, D. H., Jr. (2021b). Nutrition in Physical Therapist Practice: Tools and Strategies to Act Now. Physical Therapy, 101(5), pzab061. https://doi.org/10.1093/ptj/pzab061