Relevance of Nutrition in Physiotherapy
- 1 Introduction
- 2 Malnutrition
- 3 Chronic Conditions
- 4 Sarcopenia / Muscle Weakness
- 5 Osteoporosis / Osteopenia
- 6 Post-Operative Recovery
- 7 Chronic Pain
- 8 Sports Performance
- 9 Fertility and Pregnancy
- 10 Legal Considerations
- 11 Summary
- 12 References
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 holistically driven 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 is common 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 and 10 to 30 percent of those living in the community. Malnutrition has a negative impact on 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 have a significant impact on a patient’s rehabilitation progression. It is also associated with a number of the conditions discussed below.
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 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 lowering 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
- Total intake
- Anthropomorphic measures
- Grip strength
- Quality of life
- Exercise capacity
It has been found that adopting a healthy diet may help to reduce some of the non-motor symptoms that develop prior to a parkinson’s diagnosis. Moreover, 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).
Multiple Sclerosis (MS)
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
Sarcopenia is a disease associated with ageing 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:
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
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 patient's 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 changes in bony micro-architecture. 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
- 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
- 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.
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.
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 beneficial to consider nutritional requirements in the preoperative stage as well, particularly if patients are immobilised prior to surgery. As discussed above, immobility is associated with loss of muscle mass, so preservation of as much muscle mass as possible is important.
Chronic low-grade inflammation is recognised as an underlying mechanism in a number of 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
- Moderate alcohol intake
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 percent less likely to report chronic back pain compared to 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
- There is a growing body of literature to suggest that diet can help to decrease disease activity in rheumatoid arthritis. This is due to our 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 potentially be delayed with dietary interventions
Sports nutrition is an ever-evolving area and athletes often use diet and 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 / 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, as well as to 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
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 prior to become pregnant, including:
- Good nutrition
- Recommended supplementation
- Avoiding smoking, alcohol and illicit drugs
There is also growing evidence to suggest that maternal diet and lifestyle choices can influence the long‐term health of the child. 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
The degree to which a physiotherapist is able to integrate nutrition into his / her practice depends on a number of 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 providing education yourself. 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.
- Nutrition has a significant impact on an individual's health throughout the life-span
- 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
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