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Physiotherapy Theory and Practice, 25(56):408423, 2009 Copyright r Informa Healthcare ISSN: 0959-3985 print/1532-5040 online DOI: 10.

1080/09593980902835369

Strategies for optimizing nutrition and weight reduction in physical therapy practice: The evidence
1 2

David M Morris, PhD, PT,1 Elizabeth M Kitchin, MS, RD,2 and Diane E Clark, DScPT, PT1

Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL 35294-1212, USA Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35294-1212, USA

Poor nutrition and obesity can directly lead to pathological conditions managed by physical therapists or negatively influence recovery from movement dysfunction. The physical therapist/client relationship provides an opportunity for screening for poor nutrition as well as recommending and supporting better nutrition practices by the clients under their care. As such, it is important for the physical therapy professional to understand optimal nutrition for healthy living and serve as a consultant for better nutrition for their clients. To achieve this end, this article addresses strategies for identifying nutritional trends for the specific groups of clients, screening for nutritional problems, assessing clients readiness to change eating habits, providing useful information and resources concerning optimal nutrition, and recognizing the need for referral to nutrition professionals.

Introduction
The choices we make concerning food and activity directly influence our current and future health. Despite an increased effort to educate the general public about nutrition and exercise, data support that a considerable gap remains between pubic health recommendations and actual health practices (Behavioral Risk Factor Surveillance System, 2008). Since 1995, the prevalence of obesity among adults in the United States has risen from 15% to 26%, and the prevalence of high serum cholesterol levels is 48% among adults in the United States. Hypertension remains a major public health problem in middle-aged and older adults (American Heart Association, 2008). Many U.S. citizens are not receiving sufficient calcium and vitamin D for optimal bone health and less than one third of Americans eat the recommended five or more servings of fruits and

vegetables per day (National Health and Nutrition Examination Survey, 2008). Poor diet-related practices increase risk of certain chronic conditions and health outcomes, such as coronary heart disease, some types of cancer, stroke, gallbladder disease, non-insulin-dependent diabetes, bone fractures, respiratory problems, and depression (Albert et al, 2002; Aviram and Fuhrman, 2002; Feldman 2002; Friedman, Reichmann, Costanzo, and Musante, 2002; Hyson, Schneeman, and Davis, 2002; Kris-Etherton et al, 1999; Osakabe et al, 2001; Racette, Deusinger and Deusinger, 2003; Roberts, Kaplan, Shema, and Strawbridge, 2000; Wang et al, 2000; Young, Peppard, and Gottlieb, 2002). Primary and secondary prevention efforts for these nutrition-related conditions are of great concern for all age, racial, ethnic, and socioeconomic groups. Nutrition is a science that examines the relationship between diet and health. Poor nutrition

Accepted for publication 26 January 2009. Address correspondence to David M Morris, PhD, PT, Department of Physical Therapy, University of Alabama at Birmingham, RMSB 360, 1530 3rd Ave. So., Birmingham, AL 35294-1212, USA. E-mail: morrisd@uab.edu

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negatively influences health outcomes, including physical therapy goals, especially since physical therapy interventions stress the body energetically (Chevalier, Saoud, Gray-Donald, and Morais, 2008). Particularly vulnerable patient/ client populations are those who are older and malnourished, overweight/obese, recovering from surgery, have wounds/pressure ulcers, and/ or comorbidities like diabetes (U.S. Department of Health and Human Services, 1988; National Research Council, 1989). Physical therapists can play an important role in screening for and facilitating remediation of nutrition-related health problems, yet evidence exists that they infrequently do so. Rea, Marshak, Neish, and Davis (2004) reported that although physical therapists believe that providing advice on nutrition and weight management would likely improve outcomes for their patients, they did not have confidence in their ability to address these issues. Similar findings have been observed with other health care professions, including physicians and nurses (Mowe et al, 2008). The American Physical Therapy Associations Vision Statement (Vision 2020) encourages physical therapists to incorporate more prevention and wellness services into their patient/client management practices. Prevention and wellness activities in physical therapy practice include screening for and promoting positive behavior change, when needed, in such aspects of health as physical activity, mental function, social resources, spirituality, and nutrition (American Physical Therapy Association, 2001). The purpose of this article is to provide physical therapists with a basic understanding of how to address the nutritional needs of their patients/ clients. With this knowledge, physical therapists should be able to identify nutritional trends for the specific groups of clients they serve, screen clients for nutritional problems, assess clients readiness to change eating habits, provide useful information and resources concerning optimal nutrition, and recognize the need for referral to nutrition professionals. Physical therapists can apply these basic skills across physical therapy patient/client populations (pediatric to older adult) and in all parts of the world. However, specific strategies and informational resources vary depending on the patient/client population in question. This article provides specific examples for enhancing nutrition with patients/clients

in geriatric physical therapy settings. Physical activity is an integral component in the management of many nutrition-related problems (e.g., obesity) and is addressed elsewhere in this Special Issue. Examples emphasize nutrition practices and informational resources available in the United States.

Anticipate nutritional issues of patients/clients


To enhance consultation skills concerning nutrition, physical therapists first need to understand the dietary and health trends of the populations they serve. Like all health data, these trends vary among different groups based on factors such as age, race, ethnicity, geographic location, and socioeconomic status. Trends also change over time with societal influences such as the economy and changes in health care policy. Surveillance is conducted over many years to examine longitudinal trends and is helpful for tracking health behavior (e.g., nutritional practices) of large populations. Surveillance systems can be useful for physical therapists to identify the most recent data available on trends related to health behavior. These systems also allow the observer to examine trends for more specific population segments based on a variety of demographic factors. In this way, the physical therapist can anticipate the needs of clients and prepare specific educational resources for them. Three surveillance systems that are helpful for tracking nutritional trends in the United States are 1) What We Eat in America (WWEIA)/ National Health and Nutrition Examination Survey (NHANES); 2) the Behavioral Risk Factor Surveillance System (BRFSS); and 3) the National Health Interview Survey (NHIS, 2008). These surveillance systems can be accessed on the Centers for Disease Control and Prevention website (www.cdc.gov).

What We Eat in America/National Health and Nutrition Examination Survey


The current NHANES was born out of the National Survey Act of 1956. This legislation established an ongoing National Health Survey

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to gather information about the health status of individuals residing in the United States. The first three National Health Examination Surveys (NHES), NHES I, II, and III, were conducted over the time periods of 19591962, 19631965 and 19661965, respectively. These surveys identified poor nutrition as a significant problem among U.S. citizens leading to the development of NHANES in 1970. The U.S. Department of Health and Human Services administers NHANES through the Centers for Disease Control and Prevention (CDC). Since that time, NHANES has been conducted five times. NHANES I, II, and III were conducted over the time periods of 19711975, 19761980, and 19881994, respectively. A special Hispanic NHANES was conducted between 1982 and 1984 because of the rapid growth in the Hispanic population at that time and the belief that the earlier NHANES were biased against this ethnic group. Beginning in 1999, NHANES became a continuous survey and is now conducted without breaks in the reporting period. The NHANES uses interviews and physical examinations to obtain data on people living in the United States who are 2 years of age and older. More recent versions of NHANES collected a range of data, including high blood pressure, high blood cholesterol, obesity, passive smoking, lung disease, osteoporosis, human immunodeficiency virus, diabetes, food sufficiency, dietary intake, and nutritional blood profiles. In January 2002, the NHANES was integrated into another continuing survey of food intake, the WWEIA, administered by the U.S. Department of Agriculture. The WWEIA is conducted as part of the NHANES and targets national trends on food use and eating habits. When the two surveys are examined together, links between nutrition, food behaviors, and health status emerge. For example, data from WWEIA/NHANES (2003 2004) suggested that individuals 70 years of age and older were receiving insufficient vitamin D, calcium, vitamin E, vitamin K, potassium, and fiber. The data also suggested that these older adults were overconsuming folate and sodium. Further examination suggested that nonHispanic white older adults reported more desirable diets and Non-Hispanic black older adults reported the worst. Older adult respondents with more years of education usually had better dietary habits, and older adult smokers

had the worst. Finally, dental problems and a body mass index (BMI) of 30 or higher were related to lower quality diets in U.S. older adults.

Behavioral Risk Factor Surveillance System


The CDC established the BRFSS in 1984 as a nationwide and state-based telephone survey that assessed behavioral risk factors, clinical preventative practices, and health care access for adults 18 years and older in the United States. Nutrition questions examined trends related to obesity, physical activity, and fruit and vegetable consumption. BRFSS has been particularly helpful in identifying emerging population health problems; establishing and tracking health objectives; and developing, implementing, and evaluating a broad range of disease prevention activities. Data can be easily accessed and categorized on the basis of factors such as age, gender, race, socioeconomic status, and geographic location. For example, 2007 BRFSS data revealed that, of the 30.9% surveyed, Alabama adults reported having a BMI of 30 or more; classifying them as obese. This compares to a nationwide percent of 26.1% reporting obesity. When examined by race, obesity was particularly problematic in African Americans from Alabama, who reported a prevalence of 42.7% with a BMI of 30 or more compared to 27% of Caucasians reporting obesity (BRFSS, 2008). This finding suggests that Alabama health care professionals need to be particularly vigilant toward obesity development and management in patients/clients, particularly those serving African American communities.

National Health Information Survey


The NHIS is also conducted by the CDC and provides national data on health issues such as the incidence of acute conditions, physician contacts, disability days, limitations of activity, hospitalizations, and assessed health status. The target populations for this survey include individuals living in the United States and exclude people living in long-term care facilities, those on active duty with the armed forces, and U.S. nationals living in foreign countries. The survey

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is conducted through face-to-face, household interviews. Questions on the NHIS include those addressing important nutrition-related chronic conditions such as diabetes. For example, from 1997 through 2007, the NHIS revealed an increase in the annual prevalence of adults aged 18 years and overdiagnosed with diabetes from 5.1% in 1997 to 7.8% in 2007. With respect to age, the highest rate of diabetes was 18.7% among adults 65 years and older. Across age groups, no differences existed in the prevalence of diagnosed diabetes between women and men. With respect to race/ethnicity, the age-sex-adjusted prevalence of diagnosed diabetes among adults aged 18 years and over was 11% for people who are Hispanic, 6.2% for people who are white and non-Hispanic, and 12.2% for people who are black and nonHispanic. Physical therapists who serve these populations should be particularly vigilant in screening for diabetes.

section, several nutritional screening strategies that address overweight/obesity and undernutrition are described and recommended for use by physical therapists. Note that all individuals should be screened for malnutrition because this condition may coexist in individuals who are normal weight, overweight, or obese individuals.

Screen for overweight and obesity


Patients can be classified as being overweight or obese by using three key assessments that are commonly conducted as part of the physical therapy examination: 1) BMI; 2) waist circumference; and 3) risk factors for diseases associated with obesity. BMI provides a measure of total body fat based on height and weight that applies to both adult men and women. The BMI can be calculated by using the simple equation of: Weight lbs 703 Weight kgs or Height m2 Height in2

Screen for nutrition problems


A variety of nutrition screening tools are available for use in the clinic or community setting and can be used to determine risk factors and undesirable food-related practices. A survey with European health care providers suggested that failing to use a proper screening procedure was one of the major reasons for not initiating nutritional support (Rasmussen et al, 2006). In addition to enabling health care professional identify the nutritional needs of a given patient/client, screening can reveal specific problem areas and can be used to empower and motivate an individual to act on nutrition advice. Screenings activities differ from those carried out in more detailed nutritional assessments in that screenings are brief and can be selfadministered or conducted with the assistance of volunteers or nonprofessionally trained staff. The screening process assists the health care provider determine the need for referral of the patient/client to a registered dietitian where in-depth nutritional assessments or specialized interventions can be provided. When selecting a nutritional screening strategy, one should look for tools that are simple, acceptable to the patient/client, accurate, cost-effective, precise, reliable, and with acceptable specificity and sensitivity (Holmes, 2000). In the following BMI

Alternatively, BMI can be determined by using a chart. Body mass index is recommended because it provides a highly reliable estimate of total body fat and is related to risk of disease. This risk refers specifically to the likelihood for developing type 2 diabetes, hypertension, and cardiovascular disease compared to people with normal weight and waist circumference. The use of the BMI replaces the previous height-weight terminology (e.g., percent ideal or desirable body weight). Using the BMI, the physical therapist can classify a patient.client as underweight, normal weight, overweight, or obese. Based on BMI, obesity can be further classified as Class I (mild), Class II (moderate), or Class III (severe). Table 1 provides the BMI ranges for these classes of obesity (Kushner, 2003). Caution should be used when interpreting BMI for older adults because the optimal BMI range for adults over 65 is higher than the range for younger adults (Allison et al, 1997; Heiat, Vaccarino, and Krumholz, 2001; Troiano, Frongillo, Sobal, and Levitsky, 1996). Waist circumference is an indicator of abdominal or visceral fat and is an important measure of health. The risk of being overweight and obese is independently associated with excessive abdominal

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Table 1. Classification of overweight and obesity by body mass index, waist circumference, and associated disease risks.**

Disease risk relative to normal BMI* (kg/m2) Underweight <18.5 Normal 18.524.9 Overweight 25.029.9 Obesity (mild) 3034.9 Obesity (moderate) 35.034.9 Obesity (severe/ Z40 extreme) Obesity Men r40 inches (102 cm) Men >40 inches (102 cm) class Women r35 inches (88 cm) Women >35 inches (88 cm)

I II III

Increased High Very high Extremely high

High Very high Very high Extremely high

*Body mass index. ** National Heart Lung Blood InstituteObesity Education Initiative (Kushner, 2003).

fat: clinically defined as a waist circumference of >35 inches (Z88 cm) or women and >40 inches (Z102 cm) for men. Population studies have shown that people with excess abdominal fat have an increased cardiovascular risk and an increased likelihood of hypertension, diabetes, dyslipidemia, and metabolic syndrome compared with people with normal waist circumference (Racette, Deusinger, and Duesinger, 2003). The patient/ clients waist circumference is measured by placing a measuring tape in a horizontal plane around the abdomen at the level of the iliac crests. When measuring waist circumference, the physical therapist should place the tape so that it does not compress the skin and is parallel to the floor. The final measurement should be recorded at the end of a normal expiration. Obesity is linked to many prevalent and costly medical problems encountered in the clinical setting. Obesity has been described as having a profound effect on at least nine body systems (Kushner, 2003). Information gathered during the patient history often reveals obesityrelated symptoms and conditions. Table 2 shows a comprehensive list of obesity-related risk factors and conditions that should alert the physical therapist to examine these further.

Screen for undernutrition


Undernutrition is less commonly examined during the typical physical therapy examination,

yet is prevalent in many populations. Two simple nutritional screens can be easily incorporated into the physical therapy examination for older adults: the Mini-Nutritional Assessment and the DETERMINE Your Nutritional Health Questionnaire. Both screening tools are widely known and meet the criteria of brevity, simplicity, reliability, and accuracy as recommended by Holmes (2000). The Mini-Nutritional Assessment is an 18-item nutritional instrument that has been reported to be highly sensitive (96%), highly specific (98%), and reliable when used with older adults (Guigoz, Lauque, and Vellas, 2002). The survey is administered by a clinician and involves a two-step procedure. The first step is use of the MiniNutritional Assessment-SF (MNA-SF), a short, yet accurate six-item screen taking approximately 3 minutes to administer. The questions address issues such as appetite, eating difficulties, recent weight loss, and fruit and vegetable intake. The brevity of the MNA-SF makes its use feasible during a physical therapy examination. A score of 11 or less indicates the need for a more thorough nutritional assessment (i.e., the remaining 12 items, which include gathering anthropometric data). A score of 12 or over suggests minimal nutrition risk. The MNA-SF is shown in Appendix A. The expanded assessment predicts outcomes of hospitalized elderly people with a score of <17, which is associated with an almost threefold increase in mortality and delayed rate of discharge to a nursing home compared to a score of 24 (Van Nes et al, 2001).

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Table 2. Obesity-related risk factors and conditions: Cardiovascular, endocrine, gastrointestinal, genitourinary, integument, musculoskeletal, neurologic, psychological, and respiratory (Kushner, 2003).

Cardiovascular K Hypertension K Congestive heart failure K Cor pulmonale K Varicose veins K Pulmonary embolism K Coronary artery disease Endocrine K Metabolic syndrome K Type 2 diabetes K Dyslipidemia K Polycystic ovarian syndrome/ angrogenicity K Amenorrhea/infertility/menstrual disorders Gastrointestinal K Gastroesophageal reflux disease (GERD) K Non-alcoholic fatty liver disease (NAFLD) K Cholelithiasis K Hernia K Colon cancer Genitourinary K Urinary stress incontinence K Obesity-related glomerulopathy K Hypogonadism (male) K Breast and uterine cancer K Pregnancy complications Integument K Striae distensae (stretch marks) K Status pigmentation of legs K Lymphedema K Cellulitis K Intertrigo, carbuncles K Acanthosis nigricans/skin tags Musculoskeletal K Hyperuricemia and gout K Immobility K Osteoarthritis (knees, hips) K Low back pain Neurologic K Stroke K Idiopathic intracranial hypertension K Meralgia paresthetica Psychological K Depression/low self esteem K Body image disturbance K Social stigmatization

Respiratory K Dyspnea K Obstructive sleep apnea K Hypoventilation syndrome K Pickwickian syndrome K Asthma

The DETERMINE is a checklist designed by the American Academy of Family Physicians to assess risk of poor nutritional status or malnutrition (Nutrition Screening Initiative, 2001; Posner et al, 1994). The checklist is based on warning signs of poor nutrition including Disease, Eating poorly, Tooth loss/Mouth pain, Economic hardship, Reduced social contact, Multiple medicines, Involuntary weight loss/gain, Needs assistance in self-care, and Elder years above age 80, hence, the acronym DETERMINE. The instrument consists of 10 items that are score-weighted based on their potential to contribute to nutritional complications. For example, reporting that one eats fewer than two meals a day is considered to be a more serious problem (score of 4) than reporting that one eats alone most of the time (score of 1). The 10-item checklist can be self-administered or completed by a caregiver proxy. Scores of 6 or more, 35, and 02 indicate high nutritional risk, moderate nutritional risk, and good nutritional status, respectively. In addition to the 10 brief questions, suggestions for further examination are provided. Field tests have demonstrated the usefulness and accuracy of the DETERMINE when used with older adults (Spangler and Eigenbrod, 1995). The full DETERMINE Questionnaire appears in Appendix B. Both of these screening tools can be administered as part of the physical therapy intake process, when patients/clients provide insurance data and/or complete other medical screen forms. The tools may be administered by support personnel, allowing physical therapists to quickly glance at the scores. Caution should be used when interpreting the results because these tools are merely screens and not all persons with scores indicating risk are truly undernourished. Instead, these nutrition screens are valid and reliable tools for identifying potential risk and the need for a more in-depth assessment by a registered dietitian (Barrocas et al, 1995).

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Diagnose readiness for dietary behavior change


After a patient/client has been identified as nutritionally at risk, the physical therapist then facilitates the needed dietary changes and/or referral. However, adopting a new diet requires a significant, complex, and challenging behavior change for the individual and his or her family. People make such changes when they perceive a need to change, are ready and motivated to change, have the knowledge skills and tools to change, and have a supportive environment. Therefore, information tailored to the patient/ clients unique circumstances and situations will be most effective in facilitating the desired behavior change. Health behavior theories (as described elsewhere in this Special Issue) are helpful in assisting health care professionals to diagnose the patients readiness to change and the barriers they face, ultimately leading the health care professional to select the most helpful informational resources for a given individual. The Transtheoretical Model (TTM), also called the Stages of Change Theory, proposes that at any specific time, patients are in one of five discrete stages of change for adopting a healthier behavior: precontemplation, contemplation, preparation, action, and maintenance (Prochaska, Redding, and Evers, 2002). Patients move from one stage to the next in the process of adopting the healthier behavior and, in fact, oftentimes regress and repeat stages several times before achieving lasting or permanent change. Using the TTM, the health care provider questions the patients/clients to identify their current stage of change and uses the most appropriate type of informational source to move them to the next stage. Table 3 illustrates how this model can be applied to patients/clients who are obese and in need of dietary modification. The Health Belief Model states that people will take action to control ill-health conditions if they regard themselves as susceptible to an undesirable related condition (perceived susceptibility), if they believe that it would have potentially serious consequences (perceived severity), if they believe that the recommended course of action would be of benefit to them (perceived benefits), and if they believe that the anticipated barriers to (or costs of) taking

action are outweighed by its benefits (perceived barriers) (Janz, Champion, and Strecher, 2002). The likelihood of a positive change in behavior is also related to the patients self-efficacy or confidence that they can effectively execute the behavior required to produce the desired outcomes (Janz, Champion, and Strecher, 2002). When patients/clients reveal that their perceptions regarding an ill-health condition are counter to positive change, the physical therapist should tailor informational messages to alter that perception. By assessing patient/client health behavior issues, physical therapists can identify the most important educational resources/informational messages to place before the patient/client. For example, those in the precontemplation stage may not be ready to learn how to change their diets, as they perceive little personal susceptibility to the ill-health condition. Physical therapy interventions should be targeted to inform this population that they are at risk for the condition and that change is needed to modify this risk. Second, the assessment of patient/client health behaviors by the physical therapist could improve patient/client management and outcomes by more accurately identifying those patients/clients who would benefit from a referral to a registered dietitian. Patients/clients who report many barriers and failed attempts to change their behavior may need specialized nutritional assessment and intervention.

Educate and provide nutrition resources


Identifying and adopting appropriate nutrition guidelines is a challenging undertaking for all individuals in contemporary Western society. Consumers are constantly presented with confusing and conflicting information on topics, such as fad diets and nutritional supplements with fantastic claims, and nutrition in general. The physical therapist can positively influence patients/clients nutritional status by directing them to reliable, user-friendly, and evidencebased educational resources on nutrition. In most cases, the best approach to improving nutrition in individuals is to strive for a healthy diet that is low in calorie-dense foods and has an

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Table 3. Application of the stages of change model: Assessment of readiness for change.

Stage Precontemplation

Characteristic

Patient verbal cue

Appropriate intervention

Sample dialogue

Contemplation

Preparation

Action

Maintenance

Provide Would you like to information read some inforabout health risks mation about the and benefits of health aspects of weight loss obesity? Aware of I know I need to Help resolve Lets look at the problem, lose weight, but ambivalence; benefits of weight beginning with all thats discuss barriers loss, as well as to think of going on in my life what you may need changing right now, Im not to change. sure I can. Realizes I have to lose Teach behavior Lets take a closer benefits of weight, and Im modification; look at how you can making planning to do provide reduce some of the changes and that. education calories you eat and thinking how to increase about how your activity during to change the day. Actively Im doing my best. Provide support Its terrific that taking steps This is harder and guidance, youre working so toward than I thought. with a focus on hard. What change the long term problems have you had so far? How have you solved them? Initial Ive learned a lot Relapse control What situations treatment through this continue to tempt goals process. you to overeat? reached What can be helpful for the next time you face such a situation?

Unaware of Im not really problem, no interested in interest in weight loss. Its change not a problem.

appropriate balance of foods from the various food groups. Table 4 provides recommendations for achieving a well-balanced diet. When weight loss is the goal, the physical therapist can advocate for simple and clear plans for making small, sustainable changes in diet (Kushner and Kushner, 2003). For example, the physical therapist can suggest to patients/clients that a first step to calorie reduction may be to simply reduce their calorie intake by 5001,000 kcal each day. This approach has been shown to reduce total body weight by an average of 8%

over a 3- to 12-month period (National Heart Lung and Blood Institute, 1998). Other simple and easily managed steps to weight management appear in Table 5. In 1992, the Food Guide Pyramid was introduced by the United States Department of Agriculture (USDA) and became one of the most recognized and influential food guides in history. Although many consumers were aware of some general concepts about healthy eating, other concepts were still confusing to consumers and that they lacked specific knowledge to help them

Morris et al. /Physiotherapy Theory and Practice 25 (2009) 408423 Table 4. Patient/client recommendations for a well-balanced diet (Kushner, 2003).

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A healthy diet is low in calories and has a good balance between the different food groups. Follow these recommendations to help balance your diet. K Eat at least five to nine servings of fruits and vegetables per day. K Eat 25 to 30 grams of fiber per day (from fruits, vegetables, beans, whole grain breads, pastas, and cereals). K Choose whole grain instead of refined, processed carbohydrates. K Drink at least 64 ounces of water each day. K Eat at least two servings of low-fat dairy each day (low-fat milk, cheese, etc). K Choose more low-fat sources of protein (such as skinless chicken, turkey, and soy products) while choosing leaner cuts of beef and pork. K Eat fish at least two times per week. K Limit sodium intake to 2,400 milligrams per day or less.

Table 5. Food weight loss tips (Kushner, 2003).

1. Establish regular meal times. Try not to skip any meals because skipping meals leads to overeating later in the day. If you dont have time for a full meal, try to eat a healthy snack or meal replacement bar instead. 2. Read food labels when you are purchasing food items. Pay attention to the portion size, the number of calories in each portion, and the amount of saturated fat in each portion. This can help you make the healthiest food choices. 3. Make small substitutions in your diet to cut calories. For example, drink water, diet soda, or unsweetened iced tea instead of high-calorie drinks. Choose low-calorie and low-fat versions of salad dressing, cheese, sour cream, and mayonnaise. Go easy on fried foods-bake, broil, poach, or grill your food instead. 4. Identify guilty pleasures such as ice cream, cookies, or potato chips. Continue to enjoy them by trying the low-calorie versions or eating less of the regular versions. 5. Pre-portion your servings to control the amount. For example, scoop your ice cream in a bowl instead of eating it out of the carton. Bag potato chips or cookies into single-serving sized containers or zip-lock bags. Eat the serving size only when you have a craving. Remember to pass on seconds. 6. Control calories when dining out. At fast-food restaurants, down-size food and drinks instead of super-sizing them. Check favorite fast food restaurant Web sites for nutrition information to select the healthiest options. ` 7. Share an entrue with a friend at sit-down restaurants. However, order a personal salad or side of vegetables. Ask restaurants to: Please hold the cheese, Leave the sauce on the side, Use lowfat salad dressing, and Please substitute vegetables for French fries. As always, try to avoid fried dishes. 8. Pre-plan meals and snacks, and make certain to have the food on hand. This makes it easier to resist trips to the vending machine and unhealthy, unplanned snacking. 9. Avoid places and situations that trigger eating. For example, if walking past the donut shop causes donut cravings, try changing your route. Replace the candy on your desk with fruit or avoid walking near the office candy bowl. Avoid eating while watching television, reading, or driving. Many people do not recall what theyve eaten while doing other things. 10. Try substituting other activities for eating. For example, take a walk, talk to a friend, or listen to music. These activities avoid the extra calories and can be more satisfying than eating.

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implement the recommended nutritional practices. To remedy these problems, the USDA and Center for Nutrition Policy and Promotion (CNPP) initiated a broad-based reassessment and revision of the original food pyramid: the MyPyramid Food Guidance System. Designed to assist QJ;consumers to follow better eating habits, the MyPyramid System was based on the 2005 Dietary Guidelines for Americans, Dietary Reference Intakes from the National Academy of Sciences, and the consumption patterns of Americans. The system extracts information from these sources and translates them into a dietary regimen that emphasizes increased consumption of desirable nutrients and moderates or limits less desirable dietary components that are typically consumed in excess. Specifically, the system attempts to improve the typical diet by 1) increasing intake of vitamins, minerals, dietary fiber, and other essential nutrients that are often low in typical Western diets; 2) lowering intake of saturated fats, trans fats, and cholesterol and increasing fruits, vegetables, and whole grains to decrease risk for chronic diseases; and 3) balancing caloric intake with energy need to prevent weight gain and/or promote a healthy weight. MyPyramid provides Web-based and print materials for consumers that are interactive (United States Department of Agriculture, 2008). This feature allows users to examine dietary recommendations that are specifically tailored to their needs based on characteristics such as gender and age. MyPyramid also contains materials intended for professionals to educate their clients. Educational materials for consumers and professionals include 1) food intake patterns that identify what and how much food an individual should eat for health, based on characteristics such as age, gender, and activity level; 2) an education framework that explains what changes most Americans need to make in eating and activity choices, how they can make these changes, and why these changes are important for health; and 3) a glossary that defines key terms used in the system.

the Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet. The DASH diet The DASH eating plan resulted from a landmark study demonstrating that the plan can both reduce the risk of developing hypertension and lower elevated blood pressure. The DASH diet is based on consuming approximately 2,000 calories/day, yet it may vary according to a specific individuals caloric needs. The plan emphasizes fruits, vegetables, and low fat dairy foods and is low in saturated fat, total fat, and cholesterol. The DASH diet also encourages consumption of whole grains, poultry, fish, and nuts while discouraging red meats, sweets, and sugared beverages. Step-bystep patient instructions that direct patients on how to personalize their DASH plan can be found at National Heart, Lung and Blood Institute Your Guide to Lowering your Blood Pressure http://www.nhlbi.nih.gov/health/public/heart/hbp/ dash/new_dash.pdf. Appel et al (1997) reported that this diet was successful in reducing blood pressure an average of 3.5 points (systolic) and 2.1 points (diastolic) in participants with normal or high normal blood pressure. Results were even more dramatic with hypertensive participants; reducing an average of 11.4 points (systolic) and 5.5 points (diastolic). These reductions in blood pressure are similar to what might be expected from use of hypertensive medications; without the expense or side effects, and the added benefits to overall health and multiple organ systems. The DASH diet is also considered desirable because it is easy to follow, inexpensive, and is less rigid than other diets (i.e., allows for some flexibility in food choices). In addition to lowering blood pressure, the DASH diet may reduce risk for cancer, osteoporosis, and heart disease. The DASH diet has been shown to reduce coronary heart disease, stroke, and hypertension in younger adults. Data for older adults are still limited (Fung et al., 2008; Obarzanek et al., 2001; Sacks et al, 2001). The Mediterranean diet The Mediterranean diet evolved from findings, almost 50 years ago, that coronary heart disease is strikingly low in Mediterranean countries where fat intake is high but coming largely from

Specific diets for weight management


While specific diet prescriptions are the domaine of the registered dietitian, physical therapists can guide patients to diets that are generally healthy and are safe and effective. Two such diets are

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vegetable-derrived fats like olive oil. The key components of this diet include 1) eating generous amounts of fruits and vegetables; 2) consuming healthy fats such as olive oil; 3) eating a small portion of nuts on a regular basis; 4) substituting fish for read meats; and 5) drinking red wine, in moderation, for some. A key distinction of this diet is the view that certain types of fat may actually benefit health. The diet is high in plant fats such as olive oil and tree nuts such as walnuts, pecans, and almonds. Fatty fish contribute high amounts of the most biologically active form of omega-3 fatty acids (eicosapentaenoic acid [EPA], docosahexanoic acid [DHA], and docosapentaenoic acid [DPA]). Studies suggest that 500 mg of EPA DHA daily reduces the risk of cardiovascular disease, lowering blood pressure, heart rate, and plasma triglycerides (Gebauer, Psota, Harris, and Kris-Etherton, 2006; Mozaffarian and Rimm, 2006). The marine omega-3 fatty acids also appear to have antiarrhythmic, antithrombotic, and anti-inflammatory effects (Mozaffarian and Rimm, 2006). Conversely, the diet discourages consumption of saturated fats and hydrogenated oils (trans-fatty acids). The diet advocates moderate consumption of red wine (one glass each day for women and no more than two for men) because of its aspirin-like, anticoagulant effects on the blood, and its high levels of antioxidants. Recently, researchers demonstrated that an intervention designed to increase adherence to a Mediterranean-type diet increased the intakes of olive oil, nuts, vegetables, legumes, fruits, fiber, and unsaturated fats in adults 5580 years of age with diabetes or at least three cardiovascular risk factors (Zazpe et al, 2008). People who adhered to the Mediterranean eating style were more likely than a control group to improve their lipid profile, BMI, and blood pressure.

Refer to an appropriate nutrition professional


With credible evidence-based nutritional resources, physical therapists can effectively provide basic yet essential nutrition-related knowledge to patients/clients and determine when referral to a registered dietitian is indicated for specific nutritional diagnostic, therapy, and

counseling services for the purpose of disease prevention or management. Registered dietitians provide medical nutrition therapy that involves the development and provision of nutritional treatment based on detailed assessment of a patients medical history, psychosocial history, physical examination, and dietary history. The roles of registered dietitians and medical nutrition therapy may be overlooked by health care professionals because they do not understand the services provided by registered dietitians and their level of expertise (Mowe et al, 2008). Registered dietitians in the United States are food and nutrition experts who have 1) completed a minimum of a bachelors degree at a U.S. regionally accredited university or college and course work approved by the Commission on Accreditation for Dietetics Education (CADE) of the American Dietetic Association (ADA); 2) completed a CADE-accredited supervised practice programtypically 612 months in length; 3) passed a national examination administered by the Commission on Dietetic Registration (CDR); and 4) completed continuing professional education requirements to maintain registration. Some registered dietitians hold additional certifications in specialized areas of practice (e.g., pediatric, renal, and diabetes). Similar professionals exist in many countries, but their qualifications may vary. American registered dietitians may practice in hospitals, health maintenance organizations, or other health care facilities, sports nutrition and corporate wellness programs, food and nutritionrelated business and industries, community and public health settings, and/or in private practices focused on providing nutritional services. Many also work in universities and medical centers where they teach the science of nutrition to a wide variety of health care professionals (e.g., physicians, physician assistants, nurses, physical therapists, and occupational therapists). In research, registered dietitians may explore critical nutrition questions and find alternative foods or nutrition recommendations for the public. Medical nutrition therapy and registered dietitian services have been shown to improve clinical outcomes for a variety of medical conditions and to be cost-effective (Delahanty, Sonnenberg, Hayden, and Nathan, 2001). Payment can be an obstacle for the provision of nutritional care by a registered dietitian in the United States.

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At this time, the services of a U.S. registered dietitian are reimbursable if the patient has a diagnosis of diabetes, pre-end stage renal disease, post-kidney transplant surgery, and a physicians referral. Patients may self-refer in a fee-for service environment. Physical therapists or their patients can locate a registered dietitian in their local community by visiting www.eatright.org and using the Find a Dietitian tool (American Dietetic Association, 2008). When under the care of a professional dietician, a patients regimen can be reinforced by the physical therapist.

ability to improve patient/client outcomes, reduce morbidity and mortality associated with poor nutrition, and improve the overall quality of life of individuals across the globe and life span. Finally, a comprehensive knowledge of basic nutrition assessment and counseling enables the physical therapist to practice alongside other health care team members including the dietician.

References
Appel LJ, Moore TJ, Obarzanek E, Vollmer VM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N 1997 A clinical trial of the effects of dietary patterms on blood pressure. New England Journal of Medicine 336: 11171124 Albert CM, Campos H, Stampfer MJ, Ridker PM, Manson JE, Willett WC, Ma J 2002 Blood levels of long-chain n-3 fatty acids and the risk of sudden death. New England Journal of Medicine 346: 11131118 Allison DB, Gallagher D, Heo M, Pi-Funjer FX, Heymsfield SB 1997 Body mass index and all-cause mortality among people age 70 and over: The longitudinal study of aging. International Journal of Obesity and Related Metabolic Disorders 21: 424432 American Dietetic Association 2008 Find a Nutrition Professional Options, http://www.eatright.org (accessed December 6, 2008) American Heart Association/American Stroke Association, 2008 Heart Disease and Stroke Statistics, http://www. americanheart.org/presenter.jhtml?identifier 3037327 (accessed July 16, 2008) American Physical Therapy Association 2001 Guide to physical therapist practice. Physical Therapy 81: 9744 Aviram M, Fuhrman B 2002 Wine flavonoids protect against LDL oxidation and atherosclerosis. Annals of the New York Academy of Science 957: 146161 Barrocas A, Bistrian BR, Blackburn GL, Chernoff R, Lipschitz DA, Cohen D, Dwyer J, Rosenberg IH, Ham RJ, Keller GC, Wellman NS, White JV 1995 Appropriate and effective use of the NSI checklist and screens. Journal of the American Dietetic Association 95: 647648 Behavioral Risk Factor Surveillance System 2008 Centers for Disease Control and Prevention, http://www.cdc.gov/ brfss/index.htm (accessed July 16, 2008) Chevalier S, Saoud F, Gray-Donald K, Morais JA 2008 The physical functional capacity of frail elderly persons undergoing ambulatory rehabilitation is related to their nutritional status. Journal of Nutrition, Health, and Aging 12: 721726 Delahanty LM, Sonnenberg LM, Hayden D, Nathan DM 2001 Clinical and cost outcomes of medical nutrition therapy for hypercholesterolemia: A controlled trial. Journal of the American Dietetic Association 101: 10121023

Conclusion
Poor nutrition negatively impacts health outcomes and the quality of life of individuals. As physical therapists move toward the future, they must embrace an expanded role in health care models. Health promotion, wellness, and prevention are critical areas of focus for physical therapists in meeting the expectations of consumers, communities, and societies across the globe. As experts in the management of movement dysfunction, physical therapists have the opportunity to integrate their expertise in movement dysfunction into the development and implementation of comprehensive management plans for patients/clients across the life span. By actively seeking and managing issues such as nutrition across the health and wellness spectrum, physical therapists may significantly improve physical therapy outcomes as well as contribute to the improvement of health and quality of life of populations who experience activity limitations and participation restrictions. Physical therapy management of nutrition issues encompasses screening individuals for problems, evaluating the severity and needs of the patient/client related to nutrition, and determining the appropriate interventions needed to address the problem. Interventions may involve patient education and counseling by the physical therapist and/or the referral of the patient/client to a more specialized health care professional such as a registered dietician. Physical therapists are uniquely positioned to provide these services because of the intensity and frequency of visits within a typical patients/clients episode of care. Application of the knowledge and skills presented in this article could enhance physical therapists

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Appendix A. Mini-Nutritional AssessmentShort Form


Mini-Nutritional AssessmentShort Form ______ A. Has food intake declined over the past three months due to loss of appetite, digestive problems, chewing or swallowing difficulties? 0 severe loss of appetite 1 moderate loss of appetite 2 no loss of appetite Weight loss during last three months 0 weight loss greater than 3 kg (6.6 lbs) 1 does not know 2 weight loss between 1 and 3 kg (2.2 and 6.6 lbs) 3 no weight loss Mobility 0 bed or chair bound 1 able to get out of bed/chair but does not go out 2 goes out Has suffered psychological stress or acute disease in the past three months 0 yes 2 no Neuropsychological problems 0 severe dementia or depression 1 mild dementia 2 no psychological problems Body Mass Index (BMI) (weight in kg)/(height in meters) 0 BMI less than 19 1 BMI 19 to less than 21 2 BMI 21 to less than 23 3 BMI 23 or greater Screening score (subtotal maximum of 14 points) 12 points or greater: Normalno need for further assessment 11 points or below: Possible malnutritioncontinue assessment

______ B.

______ C.

______ D. ______ E.

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Note: If greater specificity is desired, consider 10 points or below as indicative of possible malnutrition. Alternative height calculations using knee to heel measurements: With knee at 901 angle (foot flexed or flat on floor or bed board), measure from bottom of heel to top of knee. Men (2.02 knee height, cm) Women (1.83 knee height, cm) (0.04 age) (0.24 age) 64.19 84.88

Body weight calculations in amputees: For amputations, increase weight by the percentage below for contribution of individual body parts to obtain the weight to use to determine Body Mass Index. Single Single Single Single leg below knee: 6.0% at knee: 9.0% leg above knee: 15.0% Single arm: 6.5% leg arm below elbow: 3.6%

Appendix B. DETERMINE Your Nutritional Health Survey


Determine Your Nutritional Health The warning signs of poor nutritional health are often overlooked. Use this checklist to find out if you or someone you know is at nutritional risk. Read the statements below. Circle the number in the yes column for those that apply to you or someone you know. For each yes answer, score the number in the box. Total your nutritional score. I have an illness or condition that made me change the kind and /or amount of food I eat. I eat fewer than two meals per day. I eat few fruits or vegetables, or milk products. I have three or more drinks of beer, liquor or wine almost every day. I have tooth or mouth problems that make it hard for me to eat. I dont always have enough money to buy the food I need. I eat alone most of the time. I take three or more different prescribed or over-the-counter drugs a day. Without wanting to, I have lost or gained 10 pounds in the last six months. I am not always physically able to shop, cook and/or feed myself. TOTAL Total your nutritional score. If its 02 35 6 or more Good! Recheck your nutritional score in six months. You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizens center or health department can help. Recheck your nutritional score in three months. You are at high nutritional risk. Bring this checklist the next time you see your doctor, dietitian or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health. YES 2 3 2 2 2 4 1 1 2 2 _____

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Remember that warning signs suggest risk, but do not represent diagnosis of any condition. The Nutrition Checklist is based on the warning signs described below. Use the word DETERMINE to remind you of the warning signs. Disease Any disease, illness or chronic condition that causes you to change the way you eat, or makes it hard for you to eat, puts your nutritional health at risk. Four out of five adults have chronic diseases that are affected by diet. Confusion or memory loss that keeps getting worse is estimated to affect one out of five or more of older adults. This can make it hard to remember what, when or if youve eaten. Feeling sad or depressed, which happens to about one in eight older adults, can cause big changes in appetite, digestion, energy level, weight and well-being. Eating Poorly Eating too little and eating too much both lead to poor health. Eating the same foods day after day or not eating fruit, vegetables and milk products daily will also cause poor nutritional health. One in five adults skips meals daily. Only 13 percent of adults eat the minimum amount of fruits and vegetables needed. One in four older adults drinks too much alcohol. Many health problems become worse if you drink more than one or two alcoholic beverages per day. Tooth Loss/Mouth Pain A healthy mouth, teeth and gums are needed to eat. Missing, loose or rotten teeth or dentures which dont fit well or cause mouth sores make it hard to eat. Economic Hardship As many as 40 percent of older Americans have incomes of less than $6,000 per year. Having lessor choosing to spend lessthan $25 to $30 per week for food makes it very hard to get the foods you need to stay healthy. Reduced Social Contact One-third of all older people live alone. Being with people daily has a positive effect on morale, well-being and eating. Multiple Medicines Many older Americans must take medicines for health problems. Almost one half of older Americans take multiple medicines daily. Growing old may change the way we respond to drugs. The more medicines you take, the greater the chance for side effects such as increased or decreased appetite, change in taste, constipation, weakness, drowsiness, diarrhea, nausea and others. Vitamins or minerals when taken in large doses act like drugs and can cause harm. Alert your doctor to everything you take. Involuntary Weight Loss/Gain Losing or gaining a lot of weight when you are not trying to do so is an important warning sign that must not be ignored. Being overweight or underweight also increases your chance of poor health. Needs Assistance in Self Care Although most older people are able to eat, one of every five has trouble walking, shopping, buying and cooking food, especially as they get older. Elder Years Above Age 80 Most older people lead full and productive lives. But as age increases, risk of frailty and health problems increase. Checking you nutritional health regularly makes good sense.