Can PTs Give Nutrition Advice?
By Dr. Sean M. Wells, DPT, PT, OCS, CNPT, ATC/L, CSCS, NSCA-CPT, Cert-DN
Over the past decade physical therapists (PTs) have been branding themselves as “movement specialists” and “experts in exercise.” Much of this branding has come from the help of the American Physical Therapy Association (APTA), as well as the advancement of the entry-level PT degree from Masters to Doctorate (DPT). With a new image and education, PTs are even better positioned to be in primary care, prevention, wellness, and many other settings other than simple outpatient clinics and hospitals. Despite such a push for new branding and education, a burning questions still exists within the physical therapy profession: can PTs give nutrition advice?
What the Profession Says
Such was the topic during the Oxford Debate at last year’s (2018) APTA Next Conference in Orlando, FL. I was fortunate enough to be in the crowd and enjoy some of the action. If you’ve never been a part of the Oxford Debate then let me offer you a summarization. Two panels of experts attempt to convince the chairperson of the debate on a certain topic or question. Each panel of experts offer their opinions and evidence. During the arguments the members of the audience move to one side of the auditorium or the other in favor of whichever side they wish to support.
In this particular Oxford Debate the question was whether nutrition ought to be part of physical therapy practice. Any decision made does not directly impact the house of delegates (HOD), the APTA practice patterns, or even licensure status. The decision made, however, sends a clear message to what PTs want, where PTs should invest their time studying and researching further, and a where the profession is moving. The PTs in the crowd, as well as panelist from both sides of the argument agreed: physical therapists are qualified to offer nutrition.
While I am a staunch supporter of nutritional approaches, I don’t fully agree that all PTs are qualified to offer nutrition. First, many older PTs graduated from programs that never addressed nutrition let alone wellness. Without nutritional continuing education classes or courses focused on PT practice how could these PTs be qualified? Second, even current PT graduates have cited their nutrition exposure in DPT school is not enough. From this 2018 study the researchers concluded that PT students do learn more about nutrition when they are actually exposed to nutrition courses in PT school. Such a conclusion seems obvious but some academics argue that the CAPTE curriculum is already “bloated.” The argument I can agree with is that PTs that are educated and certified in nutrition are qualified to provide nutrition care; the others may be left with a simple task of referring to dietitians.
The State by State Issue
Offering dietary advice has been a divisive fight between dietitians, nutritionists, and other healthcare providers. The Academy of Nutrition and Dietetics (AND) has fought hard in the last decades to draw a line in the sand of who can offer nutritional services. Rightfully so, dietitians (also known as registered dietitians, or RDs) attend University earning a minimum of a Bachelor's degree in nutrition, with many graduates also obtaining Master’s degrees. One can only earn the RD after passing a credentialed University program and national exam; whereas a nutritionist is a person that is only certified or claims to know about nutrition (for a full review of the differences see this link). RDs study long hours, attend multiple clinical internships, and perform various dietary tests and interventions to become registered and/or licensed. Such progress in their education and profession has led to certain States in America to apply very tight regulations on who can offer nutrition.
In certain states anyone can offer nutritional advice. Before we jump too far ahead it’s important to understand the two different types of nutrition counseling exists: 1.) general advice/recommendations for health/wellness; 2.) nutritional advice specific to treat disease. It is also important to understand that how a provider is credential may impact if that provider gets payment. Understanding these two concepts is important for your State and your ability, as a PT, to offer what you can. It should be said that any provider can offer general guidelines for health and wellness for those apparently healthy. In other words, you have a client that ask you about what a “healthy” diet looks like, you as a PT can certainly provide them patient education, resources such as NutritionFacts.org, Government Guidelines, or similar. As PTs, general health-related nutritional counseling can easily be shelved under the patient education CPT code 98960. Now, if you dive into providing nutrition advice specific to a disease things get slippery.
For instance, in New York, a PT, personal trainer, or even a random guy from the street can confer nutritional counseling for an issue. Now, will insurance reimburse a random guy from the street versus a PT -- maybe, but nothing is holding a person back from making a cash-based business through nutritional counseling in such States. Now, in California anyone can offer nutrition, but to get reimbursement through insurance that provider must be an RD. In Illinois if you want to offer dietary help for an issue you must be licensed as a nutritionist or dietitian. In Florida, if you want to treat a specific issue with diet alone you need to have earned an RD. Lastly, did I mention nurse and medical doctors, who get barely 19 hours of nutrition education in med school, are exempt from these laws? I am continually amazed at how allied health care providers, physician extenders, and other health workers get short-changed next to MDs and RNs. The variability of these laws seem endless and the nuances about what can and can’t be offered seems confusing. To clear some of this up, check out this map from NutritionEd.com.
You can thank the AND and their continual fight to form silos amongst professions for such variability (not to mention poor government management/understanding of professions, lobbies, etc.). I completely agree that those providing advanced nutritional care, such as tube feeds, enteral nutrition, intensive care re-feeding, need solid education and regulation. However, the overall notion that a man with knee arthritis in PT needs only an RD to recommend a diet seems like an overutilization of a precious resource for a minimal injury.
Most lifestyle interventions offer good health returns with little side effects: I mean, when was the last time you heard your patient with arthritis complain that eating too many fruits or vegetables were killing his knees let alone his body? My team and I have put forth an easy clinical (not legal) algorithm for PTs to know when nutrition is appropriate to address, refer, or stay away from altogether. In the end, I know that RDs are super skilled and they certainly have the right to stake claims to some of their tools; however, I often think broader, demand what’s best for the patient, and consider what other providers (like personal trainers, nurses, and Chiropractors) are spewing -- I can’t imagine a well-trained, evidenced-based nutritional PT could do worse!
Training and Education
Yes, it does come back to education. From a reflective perspective you ought to provide tests and interventions you are comfortable and trained in. I think we all were taught this along our educational journeys. Moreover, many of the legal ramifications in each state pivot back to education and training as well. Nutritionists are often given licensure when they show proof of a certificate in nutritional training. Should PT students come out of PT school with a cert in nutrition? Well...maybe, maybe not. As we mentioned before in another blog post, CAPTE is beefing up their nutrition educational standards for DPT students, but there’s no mention of certifying students. Plus, I can’t imagine the overly-conservative APTA would ever leap into certifying students in nutrition without a team of lawyers screaming about compliance matters and debating the notion until exhaustion.
I am excited students may be getting more dietary academic exposure. I am hoping more physios in the field start actually engaging their clinical rotations with nutrition. In order to make this leap, where older non-nutritionally educated PTs are teaching novice DPTs, we need the older PTs to become certified and trained in nutrition. Several resources exists for licensed PTs looking for training in nutrition. The APTA has a few on their website, and of course consider our board-approved, evidenced-based continuing education (CEU) online nutrition courses. I can certainly vouch that our graduates walk away with a compendium of knowledge they can apply the next day in clinic, hospital, or gym.
Caveat: this article should not be used as a legal reference for offering nutrition in any State or country. The article is used as an informative and opinion piece to raise the awareness about PT and nutrition. Please seek counsel and check your practice act before offering any services.
Keywords: online courses, nutrition PT, physical therapy CEU, continuing education, nutrition advice