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By Dr. Sean M. Wells, DPT, PT, OCS, ATC/L, CSCS, NSCA-CPT, CNPT, Cert-DN
The Holidays Are Coming!
We have Halloween, Thanksgiving, Christmas/Passover/Kwanza, and New Years coming. Data show that most Americans will on average gain about 0.4% of body fat during this time, most coming just after Christmas. While 0.4% does not seem like much fat, consider some quick math: a 175 lb man would essentially gain 3/4ths of a pound during the holidays. This small weight gain seems insignificant unless you add this weight gain with other gaining periods in the year, and compound the weight gain every holiday season. In other words, consider if this 175 lb 20 year old gained 0.4% every year for the next 20 years. This would equate to an extra 7 lbs of fat just gained in a few months over 20 years!
How does any of this matter for physical therapy practice? Time and time again my team and I are asked, how can we as physical therapists (PTs) educate our clients to lose weight? We are also told: I never learned about how to educate a patient on how to lose weight. We know that patients get better, faster when they lose weight; they have less inflammation, lower pain levels, and are less likely to be depressed. So, weight loss is important for physical therapy practice, and fortunately for you, we are going to outline the top 3 ways that PTs and PTAs can help their clients lose weight.
"Just Walk"
As exercise specialists and rehabilitation professionals, exercise is our go-to treatment for most conditions and issues. Given our bias we may think that offering exercise alone will be enough to help clients lose weight. Unfortunately, exercise can only offer a small portion of weight loss when compared to other factors.
The reality is most PTs under-dose their exercise prescription or fail to also recommend appropriately dosed cardiovascular exercise. "Just walk" is a common commentary that I hear many of clients tell me that their prior PTs would offer them in order to lose weight. Unfortunately without other parameters like walking speed, duration, and progression, such recommendations will yield very poor weight loss and other beneficial results. Moreover, I've had patients come to me with a 3 year old home exercise program (HEP) of standing shoulder flexion and band rotator cuff exercises claiming that this was their "weight routine" given by their prior PT. Seriously?! We can do better...
Instead, PTs ought to be explicit about how clients can achieve cardiovascular, strength, and other realms of fitness. It takes creativity, adaptations, and modifications for many clients; but that's what our clients pay us for! Moreover, we can take the extra time to outline a more comprehensive and robust program that includes the likes of resistance training, balance, and other means of fitness and wellness. Consider your HEP an opportunity to outline how PT can be comprehensive, holistic, and injury- or condition-specific.
Diet and Exercise
Weight loss, and especially weight maintenance, is connected to multiple factors. Study after study has shown that behavior, stress, support, exercise, and access to food all play major roles in weight loss and maintenance. Educating a client that only exercise can help them lose weight is a major flaw.
Despite our background in exercise, we need to be sure to emphasize to our clients that weight loss is mostly from diet, not just exercise. Research has shown that diet changes attribute 60-80% of weight loss, while exercise only contributes about 10-20% of weight loss! I hope this is not new news to my fellow PTs, but perhaps we need to be open to engaging our patients on the topic of nutrition.
According to several large systematic reviews, many various forms of dietary changes help. Here are some the top changes that patients should make to see the fat pounds drop:
- Reduction of calories is must! The laws of thermodynamics are still at play in our human physiology. A reduction in calories can occur by limiting the size of meals, improving the quality of the food eaten, and/or restricting when food is eaten. It should be obvious: weight loss is not about a person starving themselves!
- Transition of processed foods to unprocessed, whole foods. Improving the quality of food is a major way for a client to lose weight. Most of the weight loss is thanks to reducing calorie density. Processed foods are often rich in added fats, sugars, and refined carbohydrates; as such they are very calorie dense (many calories per gram) and contribute to weight gain, diseases, and aging. On the other hand, whole plant foods per gram have less calories than processed foods. So, eating more whole fruits, veges, and legumes will give patients a relative calorie deficit compared to eating junk processed foods.
- Track your food! Study after study have shown that people will start to lose weight even with simple measures like tracking their diet. A daily food diary or journal can give patients more food awareness and help them see possibly unhealthy food patterns. Daily journaling is better than doing it only once per week. Lastly, one added benefit to you, the PT, is you can review their daily diet and possibly provide them beneficial insights and analysis.
Any healthcare provider with nutrition training can offer patients nutrition educate for general health. Physical therapists and physical therapy assistants need to be ready to engage and educate their clients to make simply nutrition changes to promote safe weight loss.
Lifestyle Factors and Support
Losing weight may be easier than keeping future weight gain to a minimum for most adults. Unfortunately this process often leads to yo-yo dieting, fad dieting, and frustration with making positive long-term changes. Plus, if we can make lasting changes that helps patients in all aspect of their lives, then we should aim to make those interventions whenever possible. This why it is vitally important for PTs to emphasis that diet and exercise changes alone are not enough!
We need our clients to see their changes as a larger lifestyle change, with a heavy emphasis on behavior change. Stress management is a major factor that can drive poor lifestyle factors. Individuals with high levels of stress are more likely to abuse substances (e.g. alcohol), seek food to comfort them (resulting in overeating), and may put on more fat mass than those with lower levels of stress. Educating clients on the use of deep breathing techniques, tai chi, and journaling can all be great ways to help clients reduce stress and become more aware. Basic things like organization, scheduling, and time management can also help clients reduce stress and better find time to schedule shopping, meal prep, and exercise.
For those clients not able to manage their stress on their own, PTs should encourage them to seek out counseling from a psychologist, especially if disordered eating or emotional eating appears to be very prevalent. PTs should also recommend alcohol reduction or a referral to an alcohol/substance abuse program to those dependent on these substances to manage their stress. Interventions like Cognitive Behavioral Therapy (CBT) show good promise in helping those with emotional eating patterns and alcohol overuse.
Studies show that once our clients make great lifestyle changes, they will see the benefits and stick with it only for short period of time (often less than a year). As such, most clients will need reinforcement, encouragement, and support after our care. PTs ought to follow-up with their clients after discharge. Simple phone calls or emails can really go a long way to supporting healthy diet and lifestyle changes so that they last a lifetime (or at least 3-5 years). Plus, the constant interaction builds a better relationship between PT/patient, which will help with outcomes and keep business coming in for the clinic or gym. Lastly, good follow-up care is simply the right thing to do. Too often we PTs discharge a patient and literally "hope for the best" for that client. Hope is not enough: we should be empowering our clients to lose weight, eat better, all the while moving optimally.
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