Relevance of Nutrition in Physiotherapy
Introduction[edit | edit source]
Consuming a suboptimal diet is a preventable risk factor for various non-communicable diseases. In 2017, 11 million deaths and 255 disability-adjusted life-years (DALY) were attributed to dietary risk factors. High intake of sodium, low intake of whole grains, and low intake of fruits were found to be the leading dietary risk factors for deaths and DALYs globally.
Other dietary features associated with mortality include suboptimal intake of:
- Nut and seeds
- Processed meats
- Seafood omega-3 fats
- Sugar-sweetened beverages
- Polyunsaturated fats
- Unprocessed red meats
Physiotherapists provide holistic interventions to their clients with a primary focus on exercise. Because diet can have such a significant impact on patients' ability to engage in exercise rehabilitation and their overall outcomes, it is beneficial for physiotherapists to understand the relationship between nutrition and disease processes.
Malnutrition[edit | edit source]
Malnutrition is common in older adults and is a leading risk factor for disability, morbidity, and mortality. It is estimated that between 30 and 50 per cent of older adults in rehabilitation settings are malnourished, and 10 to 30 per cent of those living in the community. Malnutrition harms functional recovery and quality of life following discharge from rehabilitation facilities.
Risk factors for malnutrition include:
- Changes in dentation (chewing, swallowing can become difficult)
- Changes in cognition (patients may not remember if they have eaten or not)
- Poly-pharmacy (the interaction of multiple medications may decrease absorption of nutrients)
- Financial hardship
Physiotherapists should be aware of the prevalence and risks associated with malnutrition, as it can significantly impact a patient’s rehabilitation progression. It is also associated with a number of the conditions discussed below.
Chronic Conditions[edit | edit source]
In particular, increasing the amount of plants, fruit and vegetables in the diet can positively impact general health. Several studies have shown an inverse association between the amount of fruit and vegetables consumed and coronary heart disease, stroke, cardiovascular disease, total cancer and all-cause mortality.
Various theories have been put forward to explain the relationship between cardiovascular risk and fruit, vegetable and legume consumption:
- The antioxidants and polyphenols in fruits and vegetables (e.g. vitamin C, vitamin E, and carotenoids) might prevent lipid oxidation in artery walls, lower blood pressure, and improve endothelial function
- There may be an inverse relationship between potassium and magnesium and blood pressure
- Dietary fibre (found in fruit and vegetables) reduces the insulin response to carbohydrates, as well as lowers total cholesterol and low-density lipoprotein (LDL) cholesterol
- Consuming legumes (which contain fibre and phytochemicals) can also reduce blood pressure, total cholesterol, LDL cholesterol and triglycerides
COPD[edit | edit source]
Parkinson’s[edit | edit source]
It has been found that adopting a healthy diet may help to reduce some of the non-motor symptoms that develop before a Parkinson's diagnosis. Moreover, it is thought that a well-balanced might be neuroprotective for Parkinson's (e.g., numerous servings of vegetables and fruits, moderate amounts of omega-3 fatty acids, tea, caffeine, and wine).
Multiple Sclerosis (MS)[edit | edit source]
A healthy diet and lifestyle have been related to reduced disability and symptom burden for patients with MS. Interestingly, there is also strong evidence to suggest that childhood/adolescent obesity might have a causal role in susceptibility to MS.
Sarcopenia / Muscle Weakness[edit | edit source]
Sarcopenia is a disease associated with ageing characterised by the loss of lean tissue mass. Adults lose between three and eight per cent of muscle mass per decade after the age of 30. Over time, this loss contributes to a decrease in muscle strength and power, which are important predictors of balance, falls and mortality.
The cause of sarcopenia is multifactorial, and its onset is insidious. It can, however, be worsened or hastened by physical inactivity and poor nutrition. This can be rapid - i.e. three days of bed rest can cause more than a kilogram of muscle mass loss in older patients - or it can occur in the community in individuals who have a sedentary lifestyle and inadequate diet (particularly a lack of proteins and micronutrients like vitamin D).
It is generally acknowledged that sarcopenia should be managed with:
It has also been found that a higher-quality diet throughout adulthood is associated with improved performance in older adults. A diet of higher quality is defined as one that includes greater consumption of:
- Wholegrain bread
And low consumption of:
- White bread
- Added sugar
- Processed meat
- Physical and mental function
- Activities of daily living
- Quality of life
The major causes of disability for patients in rehabilitation facilities (i.e. stroke, hip fracture, and hospital-associated de-conditioning) are often complicated by malnutrition and sarcopenia. See also ICU Acquired Weakness. And while there is clear evidence that resistance exercise can help various patient populations on bed rest combat the loss of muscle mass and function, it will only be effective if it is accompanied by a diet that has sufficient protein and energy. This will ensure that the patient's potential for a synergistic anabolic response is optimised.
Osteoporosis / Osteopenia[edit | edit source]
Osteoporosis is a progressive systemic skeletal disease. It is characterised by low bone density and changes in bony micro-architecture. These changes result in increased bone fragility and risk of fracture.
It has been found that various factors determine an individual’s ability to achieve peak bone mass:
- 60 to 80 per cent relate to genetic factors, such as ethnicity, gender, and family history
- 20 to 40 per cent are determined by environmental factors
Specific factors that may affect an individual’s ability to attain peak bone density include:
- Chronic vegetarian diet
- Hereditary factors
- Impaired hormonal function
- Pregnancy and lactation
- Diseases, such as bronchial asthma and anorexia nervosa
- Corticosteroid use
Nutrition, therefore, plays an important role in bone health. Calcium and vitamin D supplements are the main dietary intervention for osteoporosis. Patients also need sufficient vitamin C, lysine and proline amino acids, and other micronutrients to support collagen structure. Protein also impacts bone health and excessive sodium intake is a risk factor for developing osteoporosis.See also Exercise and Protein Supplements
A key management strategy for osteoporosis provided by physiotherapists is the provision of exercise-based rehabilitation. This is discussed in more detail here. However, for exercise interventions to be successful, patients must also be consuming an appropriate diet to help facilitate recovery post-fracture or to manage osteoporosis.
Post-Operative Recovery[edit | edit source]
After any surgery (e.g. total knee joint replacement, ACL repair, post-fracture), a patient's nutrient needs will change. There will be an increased need for more calories, protein, vitamin C, and amino acids to facilitate collagen synthesis.
It is also beneficial to consider nutritional requirements in the preoperative stage, particularly if patients are immobilised before surgery. As discussed above, immobility is associated with loss of muscle mass, so preservation of as much muscle mass as possible is important.
Chronic Pain[edit | edit source]
Chronic low-grade inflammation is an underlying mechanism in several age-related chronic conditions. Higher levels of inflammatory markers are associated with various negative outcomes, including 
- Reduced physical performance
- Cardiovascular disease
Various studies have demonstrated that diet can help to modulate the inflammatory process. Diets that are high in fruit and vegetables (e.g. the Mediterranean diet) are associated with lower levels of inflammation, while diets that are high in fat and simple carbohydrates are associated with higher levels of inflammatory markers. Other nutrients associated with lower levels of inflammation are:
- Vitamin C, D, E
- Omega 3 / n3-polyunsaturated fatty acids
Adding fibre to your diet and having a moderate alcohol intake are linked with lower levels of inflammation.
While no direct correlation has yet been found, research suggests that there is also an association between chronic pain and diets which are high in inflammatory foods (i.e. highly processed foods, low fruit and vegetable intake).
This relationship has been explored in various conditions:
- Knee osteoarthritis:
- Patients who consumed a more pro-inflammatory diet had an increased prevalence of radiographic, symptomatic knee osteoarthritis than patients with lower dietary inflammatory index scores
- Chronic spinal pain:
- Individuals who consumed higher-quality diets (fruit, whole grains etc.) were 24 per cent less likely to report chronic back pain than those with the lowest-quality diets. Patients who reported chronic spinal pain tended to consume less whole grains, dairy, fruit, and fibre and more saturated fat and sugar
- Rheumatoid arthritis
- A growing body of literature suggests that diet can help decrease disease activity in rheumatoid arthritis. This is due to our increasing understanding of microbiota-mediated disease pathology (see Gut-brain Axis) and the effects of nutrients on inflammation and immunity. It is believed that the early signs of rheumatoid arthritis may potentially be delayed with dietary interventions
Sports Performance[edit | edit source]
Dietary requirements will vary based on an athlete’s sport and goals (i.e. marathon runner vs bodybuilder vs football player). Some athletes may focus on maintaining body weight, whereas others may attempt to achieve high-quality weight loss. It is important for a physiotherapist to be aware of these differences and to provide education/interventions to further enhance an individual’s performance.
Dietary protein, in particular, is considered an important nutrient to enable optimal training adaptation and body composition. Intake should be adequate to improve recovery and maintain muscle mass. In some cases, an athlete's optimal level of protein intake (e.g. track and field athletes) may be higher than the current recommended daily allowances.
Fertility and Pregnancy[edit | edit source]
Women who are trying to conceive will have specific nutritional needs. These needs will change during pregnancy and post-natally (both to enhance the mother's recovery and to help facilitate breast milk production).
It is recognised that women are more likely to have a healthy baby if they adopt healthy behaviours before becoming pregnant, including:
There is also growing evidence to suggest that maternal diet and lifestyle choices can influence the child's long-term health. Inadequate levels of key nutrients during important periods of foetal development can lead to "re-programming" within foetal tissues. This re-programming could result in chronic conditions for the child later in life, including:
- Cardiovascular disease
- Poor bone health
- Cognition issues
- Problems of immune function
Legal Considerations[edit | edit source]
The degree to which a physiotherapist can integrate nutrition into his / her practice depends on several factors, including local legal requirements. In some areas, you may need to be specifically licensed/registered to provide education, counselling, and/or coaching on nutrition. You will need to check the requirements in your area to ensure that you are practising within your scope of practice if you wish to provide nutrition information. You may be required to refer patients to other providers rather than provide education. However, it is important to have an understanding of the importance of nutrition so that you will be able to recognise which patients may benefit from diet optimisation.
Summary[edit | edit source]
- Nutrition has a significant impact on an individual's health throughout the lifespan
- Many chronic conditions can be influenced/managed by an appropriate diet
- While physiotherapists may not be specifically involved in providing nutritional advice, they should understand the importance of diet on a range of health conditions and recognise when it may be necessary to refer a patient on for nutritionist support
References[edit | edit source]
- Budreviciute A, Damiati S, Sabir DK, Onder K, Schuller-Goetzburg P, Plakys G, Katileviciute A, Khoja S, Kodzius R. Management and prevention strategies for non-communicable diseases (NCDs) and their risk factors. Frontiers in public health. 2020:788.
- Yazew T, Daba A. Health benefits of fruit and vegetable consumption: preventive implications for non-communicable diseases in Ethiopia. Advanced Techniques in Biology & Medicine. 2020;8(3):275.
- Micha R, Peñalvo JL, Cudhea F, Imamura F, Rehm CD, Mozaffarian D. Association Between Dietary Factors and Mortality From Heart Disease, Stroke, and Type 2 Diabetes in the United States. JAMA. 2017;317(9):912-924.
- Phadke CP. Why Should Physical Therapists Care about Their Patients' Diet? Physiother Can. 2017;69(2):99-103.
- Severin R, Berner PM, Miller KL, Mey J. The Crossroads of Aging: An Intersection of Malnutrition, Frailty, and Sarcopenia. Topics in Geriatric Rehabilitation. 2019; 35(1): 79-87.
- Marshall S, Bauer J, Isenring E. The consequences of malnutrition the following discharge from rehabilitation to the community: a systematic review of current evidence in older adults. Journal of Human Nutrition and Dietetics. 2014; 27(2): 133-41.
- Berner P. Nutrition Relevancy in Physiotherapy Course. Plus, 2020.
- Alliance for Aging Research. Malnutrition: A Hidden Epidemic in Older Adults. Available from: https://www.youtube.com/watch?v=iPNZKyXqN1U [last accessed 18/12/2020]
- Aune D, Giovannucci E, Boffetta P, Fadnes LT, Keum N, Norat T, Greenwood DC, Riboli E, Vatten LJ, Tonstad S. Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies. Int J Epidemiol. 2017 Jun 1;46(3):1029-1056.
- Miller V, Mente A, Dehghan M, Rangarajan S, Zhang X, Swaminathan S et al. Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study. Lancet. 2017; 390: 2037-2049.
- Mayo Clinic. Reversing heart disease: Mayo Clinic Radio. Available from: https://www.youtube.com/watch?v=ZhGzU0Chv1g [last accessed 18/12/2020]
- Collins PF, Stratton RJ, Elia M. Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis. The American journal of clinical nutrition. 2012; 95(6): 1385-95.
- Hanson C, Bowser EK, Frankenfield DC, Piemonte TA. Chronic Obstructive Pulmonary Disease: A 2019 Evidence Analysis Center Evidence-Based Practice Guideline. Journal of the Academy of Nutrition and Dietetics. 2020. S2212-2672(19)31696-X.
- Molsberry S, Bjornevik K, Hughes KC, Healy B, Schwarzschild M, Ascherio A. Diet pattern and prodromal features of Parkinson disease. Neurology. 2020; 95(15): e2095-e2108.
- Seidl SE, Santiago JA, Bilyk H, Potashkin JA. The emerging role of nutrition in Parkinson's disease. Frontiers in ageing neuroscience. 2014;6:36.
- Fitzgerald KC, Try T, Salter A, Cofield SS, Cutter G, Fox R, Marrie RA. Diet quality is associated with disability and symptom severity in multiple sclerosis. Neurology. 2018; 90(1): e1-e11.
- Gianfrancesco MA, Barcellos LF. Obesity and multiple sclerosis susceptibility: a review. Journal of Neurology & neuro medicine. 2016; 1(7): 1-5.
- Rondanelli M, Cereda E, Klersy C, Faliva MA, Peroni G, Nichetti M, Gasparri C, Iannello G, Spadaccini D, Infantino V, Caccialanza R, Perna S. Improving rehabilitation in sarcopenia: a randomized-controlled trial utilizing a muscle-targeted food for special medical purposes. J Cachexia Sarcopenia Muscle. 2020 Dec;11(6):1535-1547.
- English KL, Paddon-Jones D. Protecting muscle mass and function in older adults during bed rest. Current opinion in clinical nutrition and metabolic care. 2010; 13(1): 34-39.
- Robinson SM, Westbury LD, Cooper R, Kuh D, Ward K, Syddall HE, Sayer AA, Cooper C. Adult Lifetime Diet Quality and Physical Performance in Older Age: Findings From a British Birth Cohort. J Gerontol A Biol Sci Med Sci. 2018 Oct 8;73(11):1532-1537.
- Wakabayashi H, Sakuma K. Rehabilitation nutrition for sarcopenia with disability: a combination of both rehabilitation and nutrition care management. Journal of cachexia, sarcopenia and muscle. 2014; 5(4): 269-77.
- Alliance for Aging Research. Sarcopenia: Taking Charge of Your Muscle Health As You Age. Available from: https://www.youtube.com/watch?v=CAC2g03_-2Y [last accessed 18/12/2020]
- Dolan E, Sale C. Protein and bone health across the lifespan. Proceedings of the Nutrition Society. 2019; 78(1): 45-55.
- Karpouzos A, Diamantis E, Farmaki P, Savvanis S, Troupis T. Nutritional Aspects of Bone Health and Fracture Healing. J Osteoporos. 2017;2017:4218472.
- Veronese N, Shivappa N, Stubbs B, Smith T, Hébert JR, Cooper C et al. The relationship between the dietary inflammatory index and prevalence of radiographic symptomatic osteoarthritis: data from the Osteoarthritis Initiative. Eur J Nutr. 2019; 58(1): 253-60.
- Corley J, Shivappa N, Hébert JR, Starr JM, Deary IJ. Associations between Dietary Inflammatory Index Scores and Inflammatory Biomarkers among Older Adults in the Lothian Birth Cohort 1936 Study. J Nutr Health Aging. 2019; 23(7): 628-36.
- Zick SM, Murphy SL, Colacino J. Association of chronic spinal pain with diet quality. Pain Rep. 2020 Aug 11;5(5):e837.
- Khanna S, Jaiswal KS, Gupta B. Managing rheumatoid arthritis with dietary interventions. Frontiers in nutrition. 2017;4:52.
- Bosse JD, Dixon BM. Dietary protein to maximize resistance training: a review and examination of protein spread and change theories. Journal of the International Society of Sports Nutrition. 2012; 9(1): 42.
- Witard OC, Garthe I, Phillips SM. Dietary protein for training adaptation and body composition manipulation in track and field athletes. International Journal of Sports Nutrition and Exercise Metabolism. 2019; 29(2): 165-74.
- Vitale K, Getzin A. Nutrition and supplement update for the endurance athlete: Review and recommendations. Nutrients. 2019;11(6):1289.
- Institute of Performance Nutrition. High Protein Diets and Body Composition: A Science to Practice Overview. Available from: https://www.youtube.com/watch?v=THFxuA-cBDM [last accessed 18/12/2020]
- Procter SB, Campbell CG. Position of the Academy of Nutrition and Dietetics: nutrition and lifestyle for a healthy pregnancy outcome. Journal of the Academy of Nutrition and Dietetics. 2014;114(7):1099-103.