As PTs, we get asked A LOT of questions. What exercise helps if I have pain here? How many reps do I do? How long will it take me to get better? What’s wrong with me? Will I ever not have pain? How long should I hold this for? Am I doing this right?
These are all common PT questions. Sometimes they’re easy to answer and sometimes they’re hard. Sometimes the questions are PT-adjacent and more related to general health and fitness. I find many of these questions are about nutrition. Given the amount of chronic disease and the obesity epidemic in the US, there are plenty of people wanting help with their nutrition, but they’re not sure where to start or who to trust.
Most PTs are comfortable giving some nutrition advice, but it’s still difficult to know where to draw the line. We don’t want to step too far into dietician territory. We also don’t want to go down what could be a very large and long rabbit hole, detracting from PT rehab, but we also want to give enough info to help the patient. Let’s talk about where’s the line on what to say, what are the basics that we can stress, and where we should use caution answering patient questions about nutrition.
What do the Practice Acts Say?
Let’s start with asking what’s even legal for us to say? So the answer is everyone’s favorite PT answer – “it depends” because it depends on your state practice act. Most state practice acts are what we call “silent” on the issue of PTs giving nutrition and supplement advice. They don’t specifically ban it, but they don’t say we can either.
What most if not all practice acts do say is that PTs are allowed to educate on topics related to general health, wellness, and fitness. I’d say some basic nutrition advice would fall under these categories.
Now we’re allowed to give general advice and suggestions, but we’re not allowed to be making diet/meal plans or recommending specific diets without the proper education. We’re also not allowed to advertise ourselves or refer to ourselves as nutritionists or dieticians. You may have taken a lot of continuing education. Maybe you got some type of legitimate nutrition certification. You can say that and talk about that all you want. However, you’re still not allowed to call yourself a dietician or nutritionist. Much like we wouldn’t want someone calling themselves a physical therapist without our level of education.
The Must Know Basics of Nutrition
Before I get into some basic nutrition concepts that I think are a must for patient education, I want to preface with the fact they are indeed very basic. Your “musts” will vary depending on your patient population. The majority of my patient population very much relates to the general public. Most of my patients are sedentary and have comorbidities. They’ve never had the opportunity to be properly educated on general health and wellness principles or they’re confused by all the information they see about it on the internet.
If this sounds like your population, no matter how basic these concepts are, don’t assume patients know or have heard this info before. It’s possible they might have, but never straight from the mouth of a trusted healthcare provider.
Calories in vs Calories Out
“How do I lose weight?” Or “What’s the best way to lose weight?” are common questions I’ve gotten from patients. Our short traditional PT answer might be “oh just exercise more”, which we all know helps. However, we also know there’s more to it than that because we know you can’t out-exercise a bad diet.
I always stress that you have to be in a caloric deficit in order to lose weight. You have to get rid of more calories (through daily activity and/or exercise) than what you take in. I often recommend people start by tracking their calories. When first starting, I tell patients: “Don’t even try to change your diet yet. Just track.” Most people are eating way more calories than they thought. Even just a few days of tracking can be a real eye opener. Tracking also helps them identify some of the foods that consistently put them in a calorie surplus such as that daily soda or nightly bowl of ice cream. Patients who initially just cut back on the amount of those foods can get some positive results.
I’ve had several patients return after tracking their calories, surprised at how much they were over-eating. From there we can have a larger conversation about what’s a reasonable daily deficit to be in and what kind of foods they should be trying to work into their diet, which brings me to my next point.
Stressing the Difference in Quality of Carbs and Fats
After the calories in vs calories out conversation, the follow-up question I get is usually something like this: “So should I not eat____?” or “Is ____ bad for you?” or “should I do one of those ___ diets?” (insert whatever kind of diet trend you want in the blank).
This is where we have the “not all calories are created equal” talk. I educate about the difference between the kind of carbs in veggies (complex carbs) vs the carbs in a donut (simple carbs). I also compare the healthy fats of an avocado vs the fat in a piece of bacon. We discuss that much like exercise, it’s not just about quantity, but quality as well.
Stressing the Importance of Protein
I give protein its own highlight because of its massive importance when it comes to healing. It also tends to be the macronutrient people are the most deficient in. When I tell patients all the benefits of eating more protein like better healing, feeling fuller, and helping build lean muscle mass patients become interested real quick.
For my sedentary adults I recommend the standard 0.8 grams of protein per kg of body weight. However, I will often nudge people to go for a little more if they’re recovering from surgery or torn muscles/ligaments, are older than 65 (especially if they’re a female), or if they have an active job or live an active lifestyle. A lot of research suggests the standard 0.8 grams isn’t enough for these populations.
One thing to keep in mind when educating patients is many of them feel a little embarrassed or self-conscious because they struggle with diet or exercise. Make sure they don’t regret trusting you with these questions. Like I said, even though it feels basic to us, be patient clients when discussing these topics. (Trust me there are plenty of other things we have every right to be impatient about but this isn’t one of them.)
Control your tone of voice and facial expressions. These are good questions and it shows they’re maybe in the “pre-contemplative stage” of making a lifestyle change. I will often tell them “that’s a good question” or acknowledge that with all the info out there it’s hard to know what’s what or who to trust. I also find sharing my own struggles makes them a little more comfortable. For example, I struggle getting enough protein. I’ll occasionally have to go back to tracking my protein because I’ll think I’m eating a lot and then I’ll track a day and turns out I am DEFINITELY not. So I share this with them. It shows we’re all on our own health journey and everyone struggles at times.
Caution in Nutrition
There are a few areas we should be cautious with when it comes to nutrition. I’d guess many of us have tried different supplements or diets, maybe with some good experiences. However just because a certain diet or supplement worked for us, doesn’t mean it will work for our patients. For some of our patients it may even be harmful.
Supplements have become increasingly popular over the last few years. However we need to be judicious about what and to who we recommend them. Even the most popular and seemingly harmless supplements may not be good for some of our patients.
For example, we’d want to be careful about recommending magnesium or calcium to patients with any cardiac history. Another example is patients with kidney disease and protein amounts. Patients with kidney disease still need protein obviously, but types and amounts vary depending on the stage of the disease in terms of what is safe. Some types of protein supplemented or taken in through food naturally may not be good for these patients. In this case, it’s definitely best to advise them to talk to their doctor or dietician who knows their medical history well or is experienced with their chronic disease population.
Natural supplements have become increasingly popular as well. Ashwagandha is one that’s frequently mentioned. However, it’s cautioned not to use this everyday or for extended periods over time due to a myriad of side effects it can have.
Closely related to supplementation is any specific diet. Again thinking about the patient with renal disease, if a diet recommends a certain type of protein that’s not appropriate for them, it’s no good. Also, you may have had good results on the keto or carnivore diet but it would be no bueno for your patient with CAD.
My best advice when it comes to supplementation and diets is not to take your own personal results and generalize them. Unfortunately, a lot of healthcare providers do this. I once had a patient whose doctor swore by double leg lifts to fix low back pain because it fixed his. Guess what, she tried them and it made her back hurt waaaaay worse. Really know what you’re talking about. Do your homework and feel 100% comfortable with anything you recommend to patients.
Lastly I want to make a quick note on patients with diabetes. In my opinion, any patient with diabetes showing interest in changing their nutrition habits should get referred to a dietician. A1c can be greatly reduced by lifestyle changes, particularly diet. Some get to the point they no longer need insulin, or significantly less of it. Dietitians are well-equipped to provide the detailed information and meal plans these patients would need.
In fact, if you’re uncomfortable addressing certain nutrition questions in general, advise your patient to seek help from a certified dietician. There’s also a lot of quick online CEUs that take you through the basics if nutrition is something you want to get more comfortable educating on.
What do you think is our role as PTs when it comes to nutrition? I’d love to hear your thoughts. Anyone have some good resources they trust that they turn patients onto? Or taken some great nutrition CEUs? Drop these in the comments too, like I’ve said in the past no one likes a gatekeeper.
If you liked this post, I’d recommend checking out this one from a couple months back. It touches on PTs role in promoting overall health and wellness. I’ll be sharing one of my favorite healthy meals on Instagram this week. I’m not kidding when I say this is in my weekly rotation every friggin week. So make sure you’re following on Instagram @the_pt_page. Lastly, hit that subscribe button below to get all new posts sent directly to your inbox to stay up to date on all things PT.
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