Nutrition in Physical Therapist Practice: Tools and Strategies to Act Now

Abstract

It has been established that physical therapist practice includes screening for and providing information on diet and nutrition to patients, clients, and the community. Yet, an overwhelming amount of often contradictory diet and nutrition information poses a challenge for physical therapists to identify and maintain knowledge that they can rely on to screen for and discuss these topics with their patients, clients, and community members. The purposes of this perspective paper are to summarize the best known screening tools for general health, diet, and nutrition; provide intervention strategies that can be used to support behavior change related to diet and nutrition; and identify the most relevant resources and approaches from which physical therapist clinicians can build skill in addressing the nutritional needs of patients, clients, and the community.

Behavior Change, Diet, Eating Pattern, Healthy Eating, Malnutrition, Nutrition

Introduction

Physical therapist practice includes screening for and providing information on diet and nutrition to patients, clients, and the community. Yet the availability of an overwhelming amount of diet and nutrition information, which is often contradictory, poses a challenge for physical therapists to identify and maintain knowledge that they can rely on to screen for and discuss these topics with their patients, clients, and community members. The purposes of this perspective paper are to summarize the best known screening tools for general health, diet, and nutrition; provide intervention strategies that can be used to support behavior change related to diet and nutrition; and identify the most relevant resources and approaches from which physical therapist clinicians can build skill in addressing the nutritional needs of patients, clients, and the community. This manuscript is organized into 2 sections: screening tools and interventions within physical therapist scope of practice, including education, behavior change, and referral and/or collaboration.

Screening Tools

General Health and Well-being

As a part of conducting a patient examination, physical therapists take a patient history, which includes, among other things, inquiring about general health status and social/health habits, including past and present diet and nutrition habits.¹ General health status can be assessed by collecting perceptions of health through general questions such as a single-item commonly used question: “In general, would you say your health is” with the response items “excellent,” “very good,” “good,” “fair,” or “poor.”² Numerous general health perception questionnaires exist that are used to gather general health perceptions, including the Medical Outcomes Short-Form Health Survey³ and the World Health Organization Well-Being Index.⁴ Information collected from these types of questions and surveys provides important clues about how a patient or client views themselves and can provide insight about how motivated or engaged a patient or client may be in addressing their overall health. Further, a physical therapist should inquire about general readiness to change nutrition/dietary habits and how confident a patient or client feels related to modifying their current dietary habits. Readiness to change (on a 1 to 10 scale, with 1 being not ready and 10 being ready to change today) provides an indication of the client’s interest in a more in-depth conversation and valuable insight for the physical therapist about appropriate intervention strategies. Confidence, or self-efficacy, has been shown to predict success with behavior change and the amount of effort a patient or client is willing to expend, and can be assessed using a 1 to 10 scale (1 = not confident, 10 = extremely confident).⁵ Both readiness and confidence will be discussed in the interventions within the physical therapist scope of practice section. As part of general health screening, physical therapists should follow clinical practice guidelines for weight management that call for measuring weight and height to calculate body mass index (BMI) (kg/m²) and waist circumference.^6,7 Though outside the scope of this manuscript, it is important to note that dietary habits have an effect on an individual’s weight status. Both of these measurements can be associated with risk of disease regardless of whether an individual is classified as underweight, overweight, or obese, as indicated by a BMI ≤ 18.5, 25.0 to 29.9, or ≥30.0 or greater, respectively. If an individual is classified as being overweight by BMI, clinical practice guidelines recommend that practitioners also perform a waist circumference measurement.⁶ This measurement is performed by placing a tape measure above the peak of the iliac crest, ensuring that the tape measure is horizontal and parallel to the ground, and taking the measurement when the person exhales.⁸ Males are at a higher risk of developing obesity-related conditions if waist circumference is >40 inches (102 cm), and non-pregnant females have a greater risk for obesity-related conditions if their waist circumference measures >35 inches (88 cm). If weight status is of concern, the physical therapist should be prepared to discuss the benefits of a healthy weight while considering the shortcomings of BMI.⁹ A clinical limitation of BMI is that other factors (eg, age, gender, ethnicity, and muscle mass) may confound the association between body fat and BMI.⁹

Nutrition Screening

For physical therapist clinicians to effectively and efficiently identify nutritional needs, screenings should be performed and can easily be accomplished with the use of standardized screening tools. Most valid nutrition screening tools are food frequency questionnaires, which provide a small window into a patient’s overall eating pattern. Examples of these tools, along with the time to administer them and a description, can be found in Table 1. Physical therapists can also inquire about general diet and nutrition as a healthy habit through the use of simple questions about fruit and vegetable intake (number of servings per day), consumption of packaged or processed foods (number of servings per day), the number of glasses of water consumed per day, and the number of sodas consumed per day, for example.

Table 1

Nutrition and Malnutrition Screening Tools

Screening Tool	Length, (Time to Complete), and Description
Nutrition Screening Protocol54	2 items (< 1 min)
	Identifies frequency of consuming fruits/vegetables and sugary foods/drinks and determines whether intervention is warranted.
Start the Conversation55	8 items (2–3 min)
	Identifies frequency of various food groups/items (eg, fruits, vegetables, sugar-sweetened beverages, snacks, fast foods, use of fats for seasoning) over past few months. Screening tool scores reported frequency to determine if improvements can be made.
Rate Your Plate56	24 items (4–5 min)
	Identifies frequency of usual eating pattern by asking about food groups/ items (eg, protein sources, dairy, whole grains, fruits, vegetables), cooking methods, eating out, and others. Screening tool scores reported frequency to determine if improvements can be made.
Weight, Activity, Variety, and Excess (WAVE)57	4 categories (5–10 min)
	Collectively looks at weight, activity, and eating habits. Identifies recommendations for education based on weight status (body mass index), amount of physical activity, and variety and excess of food groups/items (eg, grains, fruits, vegetables, protein, dairy, saturated fat, salt, sugar, and alcohol).
	Assessment suggests provider to conduct a 1-day dietary recall or provide a self-administered food frequency questionnaire, pending available time.
Rapid Eating and Activity Assessment for Patients (REAP)57	31 items (8–10 min)
	Identifies frequency of various food groups/items (eg, fruits, vegetables, dairy, processed foods, sugar-sweetened beverages, snacks, sodium, alcohol) in average week. Also includes questions on physical activity, readiness to change eating habits, eating out, and ability to shop or cook. Screening tool scores reported frequency to determine if improvements can be made and identifies educational opportunities.
Malnutrition Screening Tool (MST)14	2 items (1–2 min)
	Identifies risk of malnutrition by asking about recent weight loss (categorizing the severity) and decrease in appetite.
Mini Nutrition Assessment-Short Form (MNA-SF)16	6 items (3 min)
	Identifies older adults who are malnourished or at risk of malnutrition. Addresses risk factors such as decline in food intake, weight loss, mobility, acute disease, cognition, and body mass index.
Nutrition Screening Initiative (NSI)17	11 items (2–3 min)
	Identifies nutritional risk for older adults. Addresses risk factors such as disease state, poor eating habits, oral deficits, financial difficulties, social interactions, weight status, and mobility.

Malnutrition Screening

Physical therapists can play a unique role in the identification and coordination of care in reducing the risk and effects of malnutrition. Malnutrition is defined as inadequate nutritional intake, which may be due to poor selective eating patterns, reduced access to appropriate nutrition, or reduced utilization of nutrients as in the case of biological changes or medication interactions.^10–12 The patients/clients commonly seeking physical therapy can be at higher risk for malnutrition, as their consumption and access to adequate nutrition may be affected by their medical condition (eg, patients diagnosed with hip fracture, stroke, or who are generally deconditioned).¹³ Malnutrition, in general, has been found to increase the risk of sarcopenia, delayed healing, hospital readmission, and mortality, along with many other potential adverse effects.^10–12 Specialized screening tools can be utilized to help identify malnutrition or risk thereof, assisting in the determination of nutritional needs. Suggested tools include the Malnutrition Screening Tool,¹⁴ which is now supported by the Academy of Nutrition and Dietetics (AND) to be used in all settings,¹⁵ the Mini Nutrition Assessment-Short Form,¹⁶ deemed most appropriate in community settings,¹¹ and the Nutrition Screening Initiative,¹⁷ commonly known as the DETERMINE checklist. More information on these malnutrition screening tools can be found in Table 1. Beyond using standardized screening tools, physical therapists have the ability to easily identify characteristics of malnutrition as outlined by AND and the American Society for Parenteral and Enteral Nutrition, where malnutrition is indicated with the existence of 2 or more of 6 characteristics.¹² Some of these characteristics can easily be identified during initial evaluation and intervention by a physical therapist, including loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, and diminished functional status as measured by handgrip strength.¹² The remaining characteristics, including insufficient energy intake and unintentional weight loss, can be confirmed by a review of medical history or through patient discussion.¹² It is important to note that patients who are malnourished may not appear emaciated or underweight and that malnourishment can occur in patients and clients across the weight spectrum. Data indicate that <40% of those identified with malnutrition receive a nutritional intervention¹⁸; therefore, physical therapists can make a significant contribution to patient/client health by recognizing and reporting malnutrition. If risk of malnutrition is indicated, referral and/or collaboration with registered dietitians (RDs) and other members of the health care team should be initiated to deliver comprehensive care.^10,19 Physical therapists can also provide basic education and behavioral change support. In addition to education, behavior change, and coordinating care, physical therapist intervention could address immobility and physical limitations that contribute to reduced nutritional intake.²⁰

Interventions Within the Physical Therapist Scope of Practice

In this section, 3 broad categories of interventions will be discussed, including education, strategies to support behavioral change, and referral to other practitioners. The process of supporting dietary change is very similar to the process suggested for any health behavior change. Given the experience physical therapists have in promoting physical activity in patients and clients, the strategies presented in this paper may be very familiar. Armed with knowledge about diet and nutrition, physical therapists can apply these familiar strategies to support patients and clients to adopt healthier eating patterns.

Education

Numerous authors have advocated for an enhanced role for the physical therapist in educating, supporting, intervening, and monitoring health behaviors in patients and clients receiving physical therapist services.^21–23 Specific to nutrition, physical therapists can support enhanced dietary practices by providing education and support for behavior change.

Patients and clients are likely to be confused, overwhelmed, and generally uninformed due to the barrage of nutrition and diet information to which they are regularly exposed. An important role for physical therapists is to provide reliable, accurate, evidence-based information and information sources.²¹ For example, for a patient who is not ready to change their behavior or who is not convinced of the benefits of eating healthier, physical therapists can provide education to eat more home-cooked meals, given evidence that eating at home more than 3 times a week has been shown to be a strong indicator of consuming a healthier eating pattern.²⁴ Physical therapists should develop a sound knowledge base of healthy eating principles and identify reliable evidence-based resources to access information on diet and nutrition.²⁵ Becoming familiar with this type of information will enable the physical therapist to provide accurate, general, evidence-based information to patients, clients, and the community.

Behavioral Change

Adopting and sustaining a healthy eating pattern is a challenge for most individuals. While education about healthy nutrition and food options is imperative, knowledge is insufficient to support a lifestyle habit of healthy eating (or any health habit for that matter). Patients and clients need intrinsic or autonomous motivation, social support, and environmental supports for behavior change to sustain a healthy eating pattern for a lifetime.

The first step in supporting a patient or client to adopt healthy eating behaviors is to determine if the patient or client is ready to change their eating pattern. The 1 to 10 readiness question can be assessed in writing or orally. Table 2 provides information to guide a physical therapist to next steps based on a patient or client’s answer to the question “how ready are you today to make dietary/nutrition changes?”

Table 2

Interpretation of and Interventions for Readiness to Change Levels in Response to the Question “How Ready Are You Today to Make Dietary/Nutrition Changes?”

Readiness Level	Interpretation	Transtheoretical Model Stage of Change58	Appropriate Interventions
1 to 4	Patient/client not ready to change and/or ambivalent about change	Precontemplation	• Education about benefits of healthy nutrition
		Contemplation	• Motivational interviewing to resolve ambivalence
			• Exploration of personal values that may be supported by healthy diet/nutrition plan
5 to 7	Patient/client ready to make change and would benefit from goal setting and support	Preparation	• Set short-term goals around dietary changes
			• Identify environmental and social supports for making dietary changes
			• Identify and problem-solve around barriers to meeting goals (take “trial and learn” vs “trial and error” approach)27
8 to 10	Patient/client likely already engaged in making diet/nutrition changes	Action	• Inquire about current nutrition/dietary successes and how patient/client has achieved them
			• Set short-term goals to make further dietary/nutrition changes
		Maintenance	• Inquire about impact dietary/nutrition changes have had on quality of life, disease states, sleep, performance, etc
			• Identify additional health habits on which patient/client can focus

The next step in the process of supporting a patient or client to change behaviors depends on the stage of readiness, as indicated in Table 2. For those in the early stages of the transtheoretical model (precontemplation and contemplation), education to provide knowledge of the benefits of a healthy eating pattern is indicated and/or motivational interviewing, a communication technique designed to resolve a person’s ambivalence toward change.²⁶

Although a detailed review of motivational interviewing is beyond the scope of this manuscript, Table 3 contains a brief outline of the steps of motivational interviewing for a patient or client who is ambivalent about improving their eating pattern. The conversation illustrated in Table 3 can occur in 10 to 15 minutes while the patient is receiving other interventions or over the course of several treatment sessions. Goal setting has been established as an important strategy to promote behavior change,²⁷ similar to the way in which physical therapists set goals to address impairments and limitations in the context of physical therapist practice. Setting specific, measurable, action-based, realistic, and time-bound (S.M.A.R.T.) goals or behavioral goals provides accountability for patients and clients.²⁸ S.M.A.R.T. goals set with attention to the values important to the patient or client and with regard for their life and work obligations can provide a beneficial tool to promote change. Examples of S.M.A.R.T. goals can be found in Table 4.

Table 3

Motivational Interviewing Steps for a Patient or Client in Contemplation Stage for Changing Their Diet

Motivational Interviewing Process	Physical Therapist Response	Patient Response
Identify target behavior	Is there an aspect of your diet or nutrition you are interested in changing?	Yes, I want to eat more fruits and vegetables
Explore patient’s/client’s values and priorities	What are your top 3 values? (eg, being considerate, being disciplined, family, friendship, independence, inner peace, health, helpfulness, honesty, responsibility, spirituality).	ResponsibilityIndependenceFriendship
Identify importance and confidence about the behavior	How important is it today for you to eat more fruits and vegetables (1 = not important at all, 10 = most important thing in my life right now)?	6
	Tell me why you answered 6 and not 3.	Because I know I’m supposed to eat 7–9 servings of fruits and vegetables per day to improve my health and prevent heart disease and diabetes
	What would it take to be an 8 or 9 in importance?	I would need to be diagnosed with heart disease or diabetes
	How confident are you today that you can eat more fruits and vegetables (1 = not confident at all, 10 = extremely confident)?	7
	Tell me why you are a 7 and not a 3 or 4.	Because I like some fruit and vegetables, so I know I can eat them. I just do not know how to cook them or buy them beyond the basics like apples and bananas and lettuce.
	What would it take to be a 9 or 10 in confidence?	I would need to learn about fruits and vegetables I have not tried and how to cook vegetables to make them taste good.
Assess decisional balance	What are the benefits of eating more fruits and vegetables?	I suppose I would feel better, maybe not feel as tired after I eat, and I might lose weight if I eat more fruits and vegetables instead of packaged food.
	What are the negatives to eating more fruits and vegetables?	It would take time to learn about fruits and vegetables that I have not been exposed to and to learn how to prepare them. I might not like some of the fruits and vegetables I try.
Summary	So, it sounds like it’s fairly important for you to eat more fruits and vegetables because you know it will improve the way you feel and positively impact your health, which is important because you value your independence. You recognize that you’ll need to learn about fruits and vegetables and try some you have not eaten in the past and maybe even learn how to cook them so that they are tasty. There are some fruits and vegetables you already like, so you can start eating those potentially. Is that correct?	Yes, that’s accurate. I’m ready to take the first step; can you help me?

Table 4

Examples of Nutrition and Diet-Related S.M.A.R.T. Goals^a

I will eat 1 serving of fruit (banana) on Monday and Wednesday and Friday this week.

I will substitute water for soda once per day on 2 days this week and set a reminder on my phone on the 2 days.

I will spend 30 minutes researching recipes that I think my family would like on Saturday.

I will talk to my spouse on Wednesday evening about supporting my desire to eat healthier, including eating at home more often and keeping healthy snacks in the house.

I will go out to eat no more than one time this week and when I do I will make at least 1 healthy selection from the menu (low fat and/or low sugar).

^aS.M.A.R.T. = specific, measurable, action-based, realistic, and time-bound.

Building autonomous motivation is a critical component of providing support for behavior change.²⁸ When patients or clients behave with a complete feeling of volition, interest, and choice, their motivation is intrinsic or autonomous and they tend to enjoy the behavior and find it challenging and interesting. Extrinsic motivation does not sustain behavior change and includes behaving out of fear of disease or retaliation; to achieve an appearance that is socially desirable; to please someone else such as a spouse, medical professional, or friend; and because one believes they should perform a behavior but do not see how it contributes to their values and goals. It is helpful and important for physical therapists to identify how a patient or client is motivated to change a behavior and to look for ways to convert extrinsic motivation into intrinsic motivation so that behavior change will be sustained.²⁹ Motivational interviewing, goal setting, and building self-efficacy as discussed in this section are strategies that build autonomous motivation.

The importance of environmental supports for behavior change, including social support, is indicated by the social-ecological model (SEM), in which interventions at multiple levels (individual factors, settings, sectors, social and cultural norms and values) have been shown to increase the degree of success with behavior change.³⁰ “Making the easy choice the healthy choice” is an effective strategy that enhances the adoption of healthy eating habits. As an illustration of the importance of a multilevel SEM approach, consider an individual patient or client who is motivated to eat more whole foods but who has limited access to whole foods (eg, lives/works in a food desert) and whose family and co-workers do not eat whole foods (lack of social norm supporting desired behavior). Even with stage-of-change appropriate interventions and a focus on autonomous motivation, the chances that this patient or client will be successful in changing their eating pattern will be limited without support at multiple levels of the SEM. Physical therapists can create interventions by inquiring about support for behavior change at all levels of the SEM and by problem-solving with the patient and client to increase the environmental supports for behavior change. Using the scenario in this paragraph as an example, a physical therapist working with this fictional patient/client can discuss the healthiest choices available to the patient (frozen or canned vegetables, alternative proteins, etc) and can role play a conversation with a friend or family member to request support for the patient’s/client’s desire to change and in the process, influence social norms. As well, physical therapist involvement in addressing the social determinants of health through advocacy, volunteerism, and population health approaches are strategies to address environmental support for healthy behaviors.³¹

All of the approaches discussed above will contribute to increasing the patient’s or client’s self-efficacy for behavior change, or their belief that they can change, an extremely important individual characteristic that is behavior-specific. Individuals with higher self-efficacy expend greater effort and are more persistent in engaging in a health behavior in the presence of barriers.⁵ Specific to diet and nutrition, in a systematic review including adults engaging in obesity interventions, self-efficacy, autonomous motivation, and self-regulation were found to be the best predictors of weight outcomes, weight control, positive body image, and flexible eating restraint.³²

Additional specific strategies to enhance self-efficacy beyond successful repetition of the desired behavior include observational learning, or vicarious learning, which is the reinforcement that a patient/client receives from observing another person to whom they can relate engaging successfully in the desired behavior. This method of improving self-efficacy can be applied in physical therapist practice by exposing the patient or client to others who are demographically similar and who are performing the health habit, for example, eating more whole foods. Social persuasion can also enhance self-efficacy, especially when it comes from an individual whom the patient or client respects and believes, like a physical therapist. Asking a patient or client to share their best past experiences with the desired behavior, and exploring key personal values and strengths that support the desired behavior are examples of social persuasion. Finally, ensuring that the patient or client appropriately interprets physical and psychological experiences with diet and nutrition changes can result in improving self-efficacy. For example, when a patient or client changes their eating pattern to increase whole foods and decrease processed foods, they may experience gastrointestinal changes, changes in energy level and daytime sleepiness, and improvements in intellectual and psychological resources such as decision-making and willpower. The clinician can prepare the patient/client to anticipate these feelings and experiences and teach them to connect these feelings and experiences to the diet change, which will become a source of motivation.²⁸

Referral and/or Interprofessional Collaboration With Registered Dietitians and Other Specialists

When the nutritional needs or goals of a patient fall outside the physical therapist’s professional or personal scopes of practice, exceed the physical therapy practitioner’s time commitment or level of competence, or require intervention to address a specific medical diagnosis, a referral to and/or collaboration with an appropriate health care practitioner is warranted. As supported by the American Physical Therapy Association, RDs, also known as registered dietitian nutritionists,³³ should be utilized as collaborative partners to improve patient care and to promote better health of society to meet a patient’s/client’s or community’s nutritional needs and goals.³⁴ When diet or nutrition intervention is required for a medical diagnosis, a patient’s/client’s needs will most likely exceed the practical nutritional education and general recommendations provided by a physical therapist clinician and require skilled medical nutrition therapy, which, in most states, is predominantly reserved for the dietetics profession, where the goal is to influence or manage a medical diagnosis that can be treated or alleviated with specific changes to an individual’s eating pattern. Physical therapists should not provide specific dietary or nutritional advice or intervention to treat a medical diagnosis. Depending on a patient’s unique factors, such as needs, goals, learning style, and motivation, co-management with an RD may be most appropriate, in which the physical therapist can provide behavioral change techniques and reinforce knowledge and skill provided by the RD. For example, relative to the patient presented in Table 3, the physical therapist could refer the patient to an RD for assistance with learning how to buy and prepare fruits and vegetables. To locate an RD, the AND, “the world’s largest organization of food and nutrition professionals,” provides a search feature on their website (https://www.eatright.org/find-an-expert).³⁵

However, in some instances, the referral partner may be another type of practitioner based on availability, accessibility, and patient/client payment options. Other partners could include certified nutrition specialists,³⁶ diabetes educators or diabetes care and education specialists, and physicians with specialized training. A recent consensus report from multiple associations of professionals that provide care for individuals with Type 2 diabetes stated that these patients/clients should receive diabetes self-management education and support (DSMES), since this training helps all individuals with diabetes (regardless of type) manage their daily care with increased confidence and improved outcomes.³⁷ In addition, they state that DSMES is a cost-effective intervention that should be recommended at the time of diagnosis, annually, and/or when treatment goals are not being met, when complicating factors arise, or during life and care transitions.³⁷ Participating in physical therapy could be classified as a complicating factor, and thus referral to a DCES for DSMES may be warranted. A DCES provides patient-centered care that is collaborative and comprehensive to help patients with diabetes manage their condition, which may include components of exercise, blood glucose monitoring, medication management, and nutritional counseling. DCES services are covered by most insurance companies, including Medicare. The consensus report also states that due to the difficulty in maintaining new behaviors, a team of providers can assist with reinforcement, including exercise and rehabilitation specialists.³⁷ An accredited or recognized DSMES program can be found on the Association of Diabetes Care and Education Specialists’ website (https://www.diabeteseducator.org/living-with-diabetes/find-an-education-program).³⁸

As already mentioned, physicians with specialized training are another option for referral. Traditionally, most US medical schools have failed to provide the recommended 25 hours of nutrition education.³⁹ Survey data published in 2010 indicate that, on average, only 19.6 hours of nutrition education were provided in US medical schools, only 20% of medical schools had a separate nutrition course, and most information provided was only basic science,⁴⁰ leading to an environment in which 14% of physicians felt “adequately trained” in nutrition, while 94% of them feel that is their “obligation to discuss nutrition.”⁴¹ However, physicians do have the ability to seek nutritional education and credentialing by engaging in assessment and certification offered by the National Board of Physician Nutrition Specialists.⁴² Nutrition expertise is demonstrated by additional nutritional training or extensive clinical experience in nutrition therapy. A physician who passes this exam is recognized as a Physician Nutrition Specialist, and this designation is a specialty recognized by the American Board of Medical Specialties. A list of Physician Nutrition Specialist providers can be found on the National Board of Physician Nutrition Specialists’ website (http://nbpns.org/online-directory-of-nbpns-certified-physicians/online-directory-by-last-name/).⁴³

Finally, referral and/or collaboration may include mental health experts and medical providers who specialize in eating disorders. The National Institute of Mental Health recommends that treatment for individuals with eating disorders include psychotherapy, medical care and monitoring, nutritional counseling, medication management, or various combinations of these therapies.⁴⁴ Various eating disorders have different signs and symptoms. For example, a person with anorexia nervosa may appear emaciated or have intense fear of gaining weight and distorted body image. A person with bulimia nervosa may appear to be of normal weight or even be overweight with a sore throat and worn tooth enamel. If working with athletes, clinicians should be aware that the prevalence of eating disorders is far greater in female athletes, approximately 45%.⁴⁵ The Eating Attitudes Test⁴⁶ or Eating Disorder Examination⁴⁷ can be provided to an individual suspected of an eating disorder to determine if referral to a qualified individual is warranted. The National Eating Disorders Association website serves as a resource where physical therapist clinicians can find treatment providers for patients/clients with potential eating disorders (https://www.nationaleatingdisorders.org/help-support).⁴⁸

When establishing a professional network for nutritional services, whether for referral and/or collaboration of patient care, it pays to fully vet the qualifications of the provider, understand state laws surrounding who can administer nutrition services, and be conscious of payment options for patients/clients. Resources through AND’s website (https://www.eatrightpro.org/advocacy/licensure/licensure-map)⁴⁹ and through NutritionED.org (https://www.nutritioned.org/state-requirements.html)⁵⁰ can assist in determining state licensure requirements for dietitians and nutritionists.

In addition to the interventions of education, behavior change, and referral to other practitioners, physical therapists can role model healthy eating. Role modeling is a form of vicarious learning, which has been shown to be an effective way for people to learn and increase their self-efficacy, especially when the learner can relate to the role model.⁵¹ Researchers found that physical therapy patients believed that physical therapists should be role models for several health behaviors, including maintaining a healthy weight.⁵² Moreover, investigators reported that a majority of licensed physical therapists and physical therapy students thought that role modeling is a powerful teaching tool, that they should “practice what they preach,” and that they should eat 5 fruits and vegetables per day and maintain a healthy body weight.⁵³ Becoming a healthy eating role model also serves to educate the physical therapist about the challenges of eating healthy and provides the knowledge and skills required to do so, preparing the physical therapist to better guide their patients toward healthy eating.

The primary diet- and nutrition-related interventions provided in the context of physical therapist practice include screening for general health, nutrition, and malnutrition; and education and support for behavior change, including motivational interviewing, goal setting, identifying environmental and social supports, and enhancing autonomy and self-efficacy for the healthy behavior. Remembering to collaborate with and/or refer to an RD or other specialized provider when necessary will ensure physical therapists adhere to their scope of practice and laws governing both physical therapy and nutrition.

Author Contributions

Concept/idea/research design: P. Berner, J.R. Bezner, D. Morris, D.H. Lein Jr

Writing: P. Berner, J.R. Bezner, D. Morris, D.H. Lein Jr

Project management: P. Berner

Consultation (including review of manuscript before submitting): J.R. Bezner, D. Morris

Funding

There is no funding to report.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.