Relevance of Nutrition in Physiotherapy

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (17/12/2020)

Original Editor - Arnold Fredrick D'Souza Top Contributors - Jess Bell, Kim Jackson, Arnold Fredrick D'Souza, Lucinda hampton, Tarina van der Stockt, Ewa Jaraczewska and Aminat Abolade

Introduction

Consuming a suboptimal diet is a significant, and preventable, risk factor for various non-communicable diseases.

It has been reported that in 2017, 11 million deaths and 255 disability-adjusted life-years (DALYs) could be attributed to dietary risk factors, including high intake of sodium, low intake of whole grains, and low intake of fruits.

Other dietary features associated with mortality include suboptimal intake of:

• Nut and seeds
• Processed meats
• Seafood omega-3 fats
• Vegetables
• Sugar-sweetened beverages
• Polyunsaturated fats
• Unprocessed red meats

Physiotherapists provide holistically driven interventions to their clients with a primary focus on exercise. However, because client factors like diet can have such a significant impact on a patient's outcomes, and their ability to engage in exercise rehabilitation, it is important that physiotherapists understand the key role that nutrition plays in recovery from injury and disease.

Malnutrition

Malnutrition is often found in older adults and is a leading risk factor for disability, morbidity, and mortality. It is estimated that between 30 and 50 percent of older adults in rehabilitation settings are malnourished. Malnutrition has a negative impact on functional recovery and quality of life following discharge from rehabilitation facilities. Aside from inpatients, it is estimated that 10 to 30 percent of older adults living in the community are malnourished.

Risk factors for malnutrition include:

• Changes in dentation (chewing, swallowing can become difficult
• Changes in cognition (may not remember eating or not
• Poly-pharmacy (the interaction of multiple medications may decrease absorption of nutrients)
• Financial hardship

Physiotherapists should be aware of the risks associated with malnutrition as it can have significant impact on a patient’s ability to engage and progress in rehabilitation. It is also associated with a number of the conditions discussed below.

Chronic Conditions

There is considerable research to show that dietary factors can impact an individual’s risk of developing various chronic diseases including:

• Obesity
• Type 2 diabetes
• CVA
• Some cancers

In particular, increasing the amount of plant, fruit and vegetables can have a positive impact on general health. A number of 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 suggestions have been made to explain the relationship between cardiovascular risk and fruit, vegetable and legume consumption:

1. 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
2. There may be an inverse relationship between potassium and magnesium and blood pressure
3. Dietary fibre (found in fruit and vegetables) reduces the insulin response to carbohydrates, as well as lowering total cholesterol and low-density lipoprotein (LDL) cholesterol
4. Consuming legumes (which also contain fibre and phytochemicals) can also reduce blood pressure, total cholesterol, LDL cholesterol and triglycerides

COPD

COPD can also be positively impacted by diet. It has been found that nutritional support for patients with COPD can improve:

• Total intake
• Anthropomorphic measures
• Grip strength
• Quality of life
• Exercise capacity

Neurological Conditions

There is evidence demonstrating that healthier eating can result in decreased disability in both Parkinson’s and Multiple Sclerosis.

Parkinson’s

It has been found that adopting a healthy diet may help to reduce some of the nonmotor symptoms that precede a Parkinson’s diagnosis. In general, it is thought that a well-balanced might be neuroprotective for Parkinson’s (e.g. including numerous servings of vegetables and fruits, moderate amounts of omega-3 fatty acids, tea, caffeine, and wine). However, it has also been found that certain nutrients (e.g. milk) might increase an individual’s risk for Parkinson’s.

Multiple Sclerosis (MS)

It has also been found that a healthy diet and corresponding healthy lifestyle is related to reduced disability and symptom burden. Interestingly, there is also strong evidence to suggest that childhood / adolescent obesity might have a causal role in MS susceptibility.

Sarcopenia / Muscle Weakness

Sarcopenia is a disease associated with aging that is characterised by the loss of lean tissue mass. Adults lose between three and eight percent 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:

• Physical exercise
• Optimisation of protein intake
• Vitamin D supplementation

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 one that includes a higher consumption of:

• Fruit
• Vegetables
• Wholegrain bread

And a low consumption of:

• White bread
• Added sugar
• Processed meat

Particularly relevant for physiotherapists is the concept of rehabilitation nutrition Rehabilitation nutrition refers to the combination of nutrition care and rehabilitation. It may help to improve:

• 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 deconditioning) are often complicated by malnutrition and sarcopenia. 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 potential for a synergistic anabolic response is optimised.

Osteoporosis / Osteopenia

Osteoporosis is a progressive systemic skeletal disease. It is characterised by low bone density and deterioration in the micro-architecture of the bone. These changes result in increased bone fragility and risk of fracture.

It has been found that an individual’s ability to achieve peak bone mass is determined by various factors:

• 60 to 80 percent relate to genetic factors, such as ethnicity, gender, and family history
• The remaining 20 to 40 percent 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
• Nutrition
• Exercise
• Diseases, such as bronchial asthma, anorexia nervosa)
• Corticosteroid use

Nutrition, therefore, plays an important role in bone health. The main dietary intervention for osteoporosis is the administration of calcium and vitamin D supplements. However, healthy bones also require healthy collagen. Thus, there also needs to be sufficient vitamin C, lysine and proline amino acids, and other micronutrients that support collagen structure.

Protein also appears to have an impact on bone health through a range of mechanisms.  However, it does not affect bone health in isolation, but depends on various metabolic and nutrient factors. Excessive sodium intake is also a risk factor for osteoporosis.

Physiotherapy can play an important role in the management of osteoporosis through the provision of exercise- based rehabilitation. This is discussed in more detail here. However, it is also important to understand if patients are getting the nutrition they required to help facilitate recovery post-fracture or in order to manage osteoporosis.

Post-Operative Recovery

During the post-operative stage (e.g. total knee joint replacement, ACL repair), the body is in a recovery phase. It will need to build new collagen, to build new tissue, to build new muscle mass, which will change an individual's nutrient needs.

• Increased need for more calories, protein, vitamin C, amino acids that facilitate collagen synthesis

These needs can be relevant both preoperatively and postoperatively. In the preoperative stage, it is important to preserve muscle mass, particularly when patients may be immobilised. As discussed above, immobility is associated with loss of muscle mass.

Chronic Pain

Chronic low-grade inflammation is a recognised underlying mechanism in several age-related chronic conditions. Higher levels of inflammatory markers are associated with several negative outcomes in older adults including:

• Reduced physical performance
• Cardiovascular disease
• Fractures

Various studies have demonstrated that diet can help to modulate the inflammatory process.

In particular, diets that are high in fruit and vegetables (e.g. the Mediterranean diet) are associated with lower inflammation while diets that are high in fat and simple carbohydrates are associated with higher levels of inflammatory markers. Other factors associated with lower levels of inflammation are:

• Vitamin C, D, E
• Beta-carotene
• n3-polyunsaturated fatty acids
• Flavonoids
• Fibre
• Moderate alcohol intake

While no direct correlation has yet been found, research suggests that there is an association between chronic pain and diets which are high in inflammatory foods (i.e. highly processed foods, low amount of fruit and vegetable).

For instance, patients who had a higher dietary inflammatory index scores (which indicates a diet that is more pro-inflammatory) had an increased prevalence of radiographic, symptomatic knee osteoarthritis than patients with lower dietary inflammatory index scores.

There have been similar findings in research on spinal pain. Individuals with higher quality diets (fruit, whole grains etc) were found to be 24 percent less likely to report chronic back pain compared to those with the lowest quality diet. Patients who reported chronic spinal pain were more likely to consume less whole grains, dairy, fruit, and fiber, but more saturated fat and sugar.

There is also a growing body of literature to suggest that diet can be used to decrease disease activity in rheumatoid arthritis. This is due to the increasing understanding of microbiota mediated disease pathology and the effects of nutrients on inflammation and immunity. It is believed that the early signs of rheumatoid arthritis may be potentially delayed with dietary interventions.

Sports Performance

Sports nutrition has evolved and athletes often use diet and various supplementation to enhance their performance.

Dietary requirements will vary based on an athlete’s sport and goals (i.e. marathon runner vs bodybuilder vs football player). Some athletes may be focused on maintaining body weight, whereas others may be attempting to achieve high-quality weight loss. It is important as a physiotherapist to be aware of these differences and to provide education / intervention to further increase an individual’s performance. Specific dietary requirements for track and field athletes are discussed here, and the requirements for endurance athletes are discussed here.

Dietary protein, in particular, is considered an important nutrient to enable optimal training adaptation and optimising body composition. Intake should be adequate to improve recovery and muscle damage, as well as to maintain muscle mass. In some cases, optimal levels of protein intake in athletes (e.g. track and field athletes) may exceed current recommended daily allowances.

Fertility and Pregnancy

Women trying to conceive will have specific nutritional needs. These needs will change during pregnancy and then beyond after the birth (both for her recovery and to help facilitate breast milk production.

It is recognised that the chance of having a healthy baby will increase if women adopt health behaviours prior to become pregnant including:

• Good nutrition
• Recommended supplementation
• Avoiding smoking, alcohol and illicit drugs

There is also growing evidence that maternal diet and lifestyle choices can influence the long‐term health of the child. Following a healthy diet (e.g. Mediterranean Diet, Dietary Approaches to Stop Hypertension, and the alternate Healthy Eating Index) are associated with a reduced risk of gestational diabetes.

Moreover, inadequate levels of key nutrients during essential periods of foetal development could lead to re-programming within foetal tissues, which could result in chronic conditions for the child later in life, including:

• Obesity
• Cardiovascular disease
• Poor bone health
• Cognition issues
• Problems of immune function
• Diabetes

Legal Considerations

The degree to which a physiotherapist is able integrate nutrition into his / her practice will vary depending on a number of factors, including local legal requirements. In some areas, you would 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 if you provide nutrition information. You may be required to refer onto other providers rather than providing education yourself. However, it is important to have an understanding of the importance of nutrition in order to know which patients may require further input from nutritionists / dietitians.