Healthy People 2020: Nutrition and Weight Status

Leah Bridge & Macayla Greiner

PTH 825

Objectives:

NWS-2.2: Increase the proportion of school districts that require schools to make fruits or vegetables
available whenever other food is offered or sold.

NWS-6.1: Increase the proportion of physician office visits made by patients with a diagnosis
of cardiovascular disease, diabetes, or hyperlipidemia that include counseling or education
related to diet or nutrition.

Search engine strategies used: PubMED, CINAHL, government and national association
journal articles
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Objective #1:

According to the CDC, childhood obesity has more than tripled since the 1970’s and now

1 in 5 school aged and younger children have obesity in the United States.1 The term obesity

refers to an excess of fat. Body fat is measured by the clinical standard body mass index (BMI).2

Genetic factors are non-modifiable in preventing obesity, but the modifiable factors such as the

child’s environment can be influenced by the people and places children surround themselves

with. Obesity not only affects children’s physical health, but also mental psychosocial factors

such as emotional distress. The psychosocial factor emotional distress can contribute to excess

weight gain in children to suppress negative emotions which can lead to poor eating behaviors.2

The increasing prevalence of childhood obesity has led to the emergence of multiple obesity

related co-morbidities that has not only affected the individuals, but also puts a large strain on the

health system.2 Children who are obese are likely to track obesity into adulthood. Older children

who are obese have a greater obesity risk continuing into adulthood. That is why childhood

obesity needs to be addressed as soon as possible to prevent future complications. Future

complications of obesity are children are at risk for “adult” diseases such as type 2 diabetes,

hypertension, dyslipidemia, obstructive sleep apnea, non-alcoholic fatty liver disease and more.2

Major lifestyle modifications such as dietary changes, increasing physical activity and decreasing

sedentary activity is crucial for weight management not only in children but in all ages.

Childhood obesity has presented itself as one of the most pressing and relevant medical and

public health problems. The prevalence is only continuing to increase and affects physical and

mental health. An initial management needs to be implemented at all levels in the healthcare field

helping children focus on a healthy diet and active lifestyle.

A modifiable factor in childhood obesity is one's environment. Children spend more of

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their time at school than any other location outside of their home environment.2 To help control

the increasing childhood obesity epidemic, the school environment has been targeted for obesity

prevention.3 Schools can adapt policies to help young people eat more fruits and vegetables and

increase daily physical activity. Laws and policies in 2007 were enacted to strengthen school

nutritional standards, but the studies on the effects of these laws/policies have shown mixed

results. Palakshappa et al., researched the strength of the nutrition laws in schools in relation to

childhood obesity. The study found that strong state laws restricting the sale of competitive food

and beverages in elementary schools and strong advertising laws across all grades was associated

with decreasing the odds of obesity.3 The study also found that those states with nutritional laws

compared to those states with no school related nutritional laws had a significant decrease in

obesity rates. This article explains the importance of schools supporting and promoting a healthy

lifestyle and how it can be beneficial in preventing increasing obesity rates.

Schools are the key public setting for promoting proper public health strategies and

obesity prevention, but schools alone cannot solve the obesity epidemic. It is important that

multiple groups of people are working together to make this an effective environment to promote

the school-based policies and programs to support healthy eating and physical activity.4 The

school environment has the potential to have a large impact on a child’s nutritional consumption.

A child consumes 19-50% of their daily calories at school.4 In 2004 the Child Nutrition and WIC

reauthorization act and enhanced by the Healthy, Hunger-Free Kids Act of 2010 required all local

agencies participating in funded school meal programs to create a school wellness program. A

school wellness program is a written document that guides a local school district to create support

school nutrition and physical activity environments.1 The school wellness program has policy

requirements such as promoting nutrition and physical activity education, nutrition guidelines for
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all foods available, making sure meals are not less restrictive than federal regulation, plans for

measuring implementation and involvement of parents, schools administers, students for the

development of the policies.1 This program did have some weaknesses, such as each district was

left to create their own rules and regulations following the guidelines. This led to no minimum

standards and each district varying from the next for nutritional and physical activity standards.4

Although, this is looked at as a weakness, this could be a strength in the eyes of the community

members. This is looked at as a strength because members can be involved to put into action and

develop an effective wellness policy for their specific school district. Research consistently shows

that obesity rates are rising in American children even with the policies and programs already in

place. That is why the programs already implemented need to be more aggressively advocated for

early on and directly focused on the child’s common environments (school and home). School

districts can work together with policymakers, parents and communities to promote physical

activity, healthy diet habits to contribute to wellness, healthy lifestyles and decrease the likelihood

of childhood obesity.

Physical therapists in all settings, but especially in school-based settings, are in an optimal

position to advocate, promote healthy diets and physical activity to fight against childhood

obesity. The American Physical Therapy Association (APTA) position on a physical therapists’

scope of practice in nutrition is “the role of the physical therapist to screen for and provide

information on diet and nutritional issues to patients, clients, and the community within the scope

of physical therapist practice.”5 Nutrition is a key component in the direct recovery and

management in many conditions in the professional scope of physical therapy practice. Since

children are now acquiring more “adult” diseases, it is important that nutritional education is

provided in all possible health settings a child might encounter. Physical therapists are in a
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position to help advocate for healthy nutritional programs with the objective to increase the

proportion of school districts that require schools to make fruits or vegetables available whenever

other food is offered or sold. This avocation may not directly affect the profession of physical

therapy, but can indirectly benefit the childhood obesity epidemic and overall current and future

patient’s health.

School based physical therapists have a role in obesity prevention and nutritional

avocation. School based physical therapists are first hand witnessing school policies and

nutritional options available to students. The academy of pediatric physical therapy states that one

of the roles of a school based physical therapist is to serve as a knowledge bridge for

understanding education policies regarding physical activity such as academic achievement,

obesity prevention and health promotion; and implementation of these policies are at a local

level.6 Obtaining this role provides us a gateway to represent our profession in participating in

implantation policies such as head start program, Let’s Move! and school meal programs. For

example, Let's Move! program is striving to deliver healthier foods to our nation's school

children. This program has a subsection to implement salad bars in schools giving children the

choice of fresh vegetables and fruits every day. This program supports and promotes the objective

to increase the proportion of school districts that require schools to make fruits or vegetables

available whenever other food is offered or sold. School salad bars can be supported and

advocated for by health care professionals such as physical therapists to increase intake and

acceptance of fruits and vegetables by kids.

Pediatric physical therapist should be involved in the nutritional and physical activity

assessment of their patients’ health in treatment of childhood obesity. Physical therapists can

work with primary care physicians, nutritionists and other healthcare providers to assess and
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evaluate children’s risk factors and level of physical activity. It is the physical therapist’s duty

stated in principle #3 in the code of ethics, “Physical therapists shall be accountable for making

sound professional judgements”7 to make judgements within their scope of practice to provide

proper care and referrals when necessary. Some recommendations in treating obese children

include but are not limited to, to not rely on BMI, evaluate psychosocial factors, and help build

patients sense of self efficacy and increase motivation.8 These recommendations can guide

physical therapists in achieving successful treatment sessions with children who are obese. In all,

childhood obesity is an increasing medical and public health problem. Health care professionals

and physical therapists can participate in local policies to increase nutritional foods in schools and

promote healthy diets and active lifestyles in children.

Objective #2

According to the American Heart Association, cardiovascular disease (CVD) took more

lives in 2016 than all cancer types and chronic lower respiratory diseases combined.10 Not only is

the high prevalence of cardiovascular disease in America an issue, but it is also the leading cause

of death globally, accounting for greater than 17.6 million deaths in 2016, and is expected to

increase to more than 23.6 million deaths by 2030.10 The American Heart Association (AHA) has

identified several risk factors that are associated with cardiovascular disease, some of which

include smoking, diet, body weight, physical activity, and diabetes. Diabetes also exists as a

prevalent issue in America, and seemingly continuing to increase. As of 2016, approximately 9.4

million American adults had undiagnosed diabetes, with an addition of 91.8 million with

prediabetes.10 The need for health care interventions is imperative for the future of America, as

well as worldwide, as obesity and diabetes have been found to increase the risk of CDV by two-

fold.10
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In the management of diabetes, many key components are required to be addressed

frequently such as healthy eating patterns, regular physical activity, and pharmacotherapy.11

Specifically, the role of diet has been associated with diabetes. Micha et al., recently examined the

suboptimal intake of dietary factors and compared the relation to the amount of cardiometabolic

deaths in the United States.12 It was found that poor diet was associated with approximately 318,

656 cardiometabolic deaths, with the highest proportion of deaths related to excess sodium intake,

insufficient intake of nuts/seeds, high intake of processed meats, and low intake of seafood

omega-3 fats.12 It was concluded after these findings that suboptimal intake of specific foods and

nutrients is associated with a large portion of deaths due to diabetes, heart disease and stroke.

In cardiovascular disease specifically, the reduction of salt intake has been found to be

extremely effective in management and treatment. A study performed by Feng, Burnier, and

MacGregor found a pure causal relationship between salt intake and cardiovascular disease.13

They claim that a reduction in salt in one’s diet reduced blood pressure and decreases the need for

drug therapy.13 There are several available diets that are recommended to accompany a low salt

diet, such as the DASH. This particular study outlines the positive effects in reducing blood

pressure by utilizing the combination of a low salt and the DASH diet. Furthermore, this study

emphasizes that a reduction of just 6g/day of salt intake would decrease stroke by 24% and

coronary heart disease by 18%; which would prevent 35,000 stroke and coronary heart diseases

per year.13

It is evident that education on diet and nutrition is a key factor in individuals with diabetes

or cardiovascular disease, and that many deaths and complications caused by these diseases can

be prevented by simple education in these specific factors. A study by Bowen et al., looked at the

effectiveness of education on nutrition and self-management in individuals with diabetes.14 After

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education on diet and nutrition, it was found that Hba1c improved with the subjects that received

education and did not improve in those that did not receive education. Specifically, this study

looked at different strategies of nutrition education and found that both carbohydrate counting and

the modified plate method improved glycemic control compared to individuals without any

nutritional intervention.14

With this great need for education and management of these particular diseases, it is

known that the best approach in the management is often multidisciplinary in order to receive

multiple components of management. Although registered dieticians often play an important role,

all healthcare professionals must educate as well as they see fit. Nutritional therapy can be defined

as “the treatment of a disease or condition through the modification of nutrient or whole-food

intake” stated by Evert et al.,11 Therefore, the definition does not specify that it must be provided

by a registered dietician.11 The importance of referrals to registered dieticians is recognized for

proper assessment and treatment, health care professions such as registered nurses, physicians,

and therapists. It also holds a major impact in the ability to educate their patients on diet and

nutrition in order to benefit the overall outcome of their disease management.11 It is imperative for

health care professionals to not only provide care within their direct field, but also provide care on

a holistic approach, as long as they stay within their scope of practice.

Physical therapists, in particular, are in a great position to impact individuals’ health and

wellness. Lifestyle and chronic diseases, such as heart disease and diabetes, are strongly

associated with lifestyle and behavioral factors that physical therapists often address via

management and preventative interventions.15 Physical therapists obviously play a major role in

advocating for physical activity, which can alone impact the management and risks of these

diseases. However, physical therapists are also in a prime position to prevent and treat these
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chronic or lifestyle diseases by providing client education.15

With this particular objective, it is evident that physical therapist can play an active role in

nutrition and weight status related to diabetes and cardiovascular disease. Specifically, a strategy

that a physical therapist may use to assist individuals with these types of diseases are specific

education on the nutrition related to that individual.15 Along with exercise prescriptions and logs

given to patients, a physical therapist may choose to give the individual a diet log to help keep

them on track and to recognize their eating patterns. Additionally, if patients have not had a

consultation with a dietician related to their disease, a physical therapist can refer individuals as

needed to ensure they are receiving the proper treatment in that aspect if they feel it is out of their

scope of practice. In order to make the public more aware of the importance of nutrition and

weight status—in general and specifically related to chronic diseases—physical therapy clinics

may also choose to advocate through providing supplements and resources via pamphlets in the

clinic or online resources through their clinic website. Many individuals with chronic diseases

may not recognize the impact that their diet and weight status has on their overall wellbeing and

the disease-related symptoms. Therefore, by allowing these individuals to gain awareness on the

topic, physical therapists can act as an imperative agent for change.

By advocating, providing education, and referring patients to registered dietitians as

needed in order to provide necessary information about nutrition, physical therapists will be

representing multiple core values and principles outlined by the American Physical Therapy

Association (APTA). For example, Principle #3 in the code of ethics states, “Physical therapists

shall be accountable for making sound professional judgements”.7 This principle includes

physical therapist making appropriate judgements within their scope of practice and expertise, as

well as stipulating constant communication and collaboration with other health care professionals.
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It is a physical therapist’s duty to provide appropriate educational services to patients that they see

fit if it is the services that will enhance their well-being and improve their therapeutic outcomes.

Additionally, Principle #8 states, “Physical therapists shall participate in efforts to meet the health

needs of people locally, nationally, or globally”.7 Therefore, it is the duty of physical therapists to

individuals with these types of chronic diseases, and others, with the necessary resources and

knowledge to increase their quality of life.

In addition to the code of ethics, the strategies outlined in these objectives also represent

the APTA core values. Specifically, the core values of social responsibility, professional duty,

accountability, excellence and integrity are utilized by using our clinical skills and judgement to

provide necessary education and nutritional information to patients and school systems while also

remaining in our scope of practice. By providing services related to nutrition in the physical

therapy scope of practice, and recognizing when there is a need for further referring for a patient,

this also encompasses the standards of practice specifically by following the legal considerations

and administration of service by improving the quality of care and collaboration with all

disciplinaries. Importantly, education is outlined specifically in the standards of practice, as it is a

responsibility for physical therapists to provide consultation and information to all clients.

Through education, these objectives aim to increase awareness and knowledge to Americans of all

ages in order to promote overall well-being and strive for healthy living.
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References

1. Centers for disease control and prevention. Centers for disease control and prevention.
https://www.cdc.gov/. Accessed July 8, 2019.

2. Kumar S, Kelly AS. Review of childhood obesity: From epidemiology, etiology, and
comorbidities to clinical assessment and treatment. Mayo Clin Proc. 2017;92:251–65. doi:
10.1016/j.mayocp.2016.09.017.

3. Palakshappa D, Fiks AG, Faerber JA, Feudtner C. Association between state school
nutrition laws and subsequent child obesity. Preventive Medicine. 2016;90:107-113.
doi:10.1016/j.ypmed.2016.06.039.

4. Story M, Nanney MS, Schwartz MB. Schools and obesity prevention: creating school
environments and policies to promote healthy eating and physical activity. Milbank
Quarterly. 2009;87(1):71-100. doi:10.1111/j.1468-0009.2009.00548.x.

5. Gardner K. Nutrition and Physical Therapy. APTA.

http://www.apta.org/PatientCare/Nutrition/. Accessed July 8, 2019.

6. Home - Academy of Pediatric Physical Therapy, APTA. PediatricAPTA.org.

https://pediatricapta.org/. Accessed July 8, 2019.

7. Code of Ethics for the Physical Therapist - apta.org.

http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Ethics/CodeofEthi
cs.pdf. Accessed July 8, 2019.

8. From PTJ: New recommendations for PT treatment of childhood obesity. APTA.

http://www.apta.org/PTinMotion/News/2016/6/13/PTJChildhoodObesity/. Accessed July
8, 2019.

9. National Archives and Records Administration.

https://letsmove.obamawhitehouse.archives.gov/healthy-schools. Accessed July 8, 2019.

10. Bhupathiraju SN, Hu FB. Epidemiology of obesity and diabetes and their cardiovascular
complications. Circulation Research. 2016; 118:1723-1735.
doi:10.1161/CIRCRESAHA.115.306825

11. Evert AB, Boucher JL, Cypress M et al. Nutrition therapy recommendation for the
management of adults with diabetes. Diabetes Care. 2014;37(suppl 1): S120-S143.
https://doi.org/10.2337/dc14-S120

12. Micha R, Peñalvo JL, Cudhea F, Imamura F, Rehm CD, Mozaffarian D. Association
between dietary factors and mortality From heart disease, stroke, and type 2 diabetes in the
United States. Jama. 2017;317(9):912. doi:10.1001/jama.2017.0947.
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13. He FJ, Burnier M, Macgregor GA. Nutrition in cardiovascular disease: salt in

hypertension and heart failure. European Heart Journal. 2011;32(24):3073-3080.
doi:10.1093/eurheartj/ehr194.

14. Bowen ME, Cavanaugh KL, Wolff K, et al. The diabetes nutrition education study
randomized controlled trial: A comparative effectiveness study of approaches to nutrition
in diabetes self-management education. Patient Education and Counseling.
2016;99(8):1368-1376. doi:10.1016/j.pec.2016.03.017.

15. Bezner JR. Promoting health and wellness: implications for physical therapist practice.
Physical Therapy. 2015;95(10):1433-1444. doi:10.2522/ptj.20140271.

Individual Roles of Authors: Leah Bridge and Macayla Greiner

Each author:
● Went on Healthy People 2020 website to pick out and agree on a topic and two objectives
of interest together.
● Using literature searches each author identified information on both objective topics.
● Found articles and information related to the epidemiological data related to our
topics/objectives supporting the need for change individually, then reviewed each article
together.
● Found physical therapy literature supporting and justifying the topic/objectives together.
● Researched the documents related to physical therapy practice (example: APTA code of
ethics) related to our topic/objectives.
● Co-wrote parts of both objective topics and subsections/questions.
● Properly cited references in AMA format together.
● Proof-read and made necessary corrections to the paper through collaboration and
communication.

Requirement #2:

The Healthy People 2030’s current mission is “to promote, strengthen and evaluate the

Nation’s efforts to improve the health and well-being of all people.”1 Physical therapists impact

the role of health and well-being daily while consulting many individuals with a variety of

different backgrounds and conditions. Through direct access, physical therapists are becoming

another gate keeper in the health professional field, as they work to collaborate with multiple

other disciplinaries through co-treatments and referrals. As more research and knowledge is
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found on preventative medicine, many individuals are searching for ways, other than

pharmacological, to manage their symptoms. Physical therapists would be an appropriate and

very necessary person to include on the consulting team/committee as they have a wide scope for

educational knowledge, and non-pharmacological interventions that help to manage many

conditions and diseases that are highly prevalent in America today.

A new area within the healthy people 2030 in which physical therapists can provide

expert insight in is pain management. Physical therapists’ role in pain management has become

more and more imperative within the past few years as the opioid epidemic arose. In America,

approximately 116 million individuals suffer from chronic pain.2 This chronic pain causes over

$600 billion dollars a year in medical expenses.2 Additionally, the management of acute pain is

critical in preventing to progression to unrelenting, chronic pain. In 2001, the Joint Commission

in the United States lead to the adoption of pain as the fifth vital sign. This emphasis on pain

brought about many changes in the medical industry, specifically the rise in pharmaceutical use

to manage pain. Since then, America has experienced a plethora of misuses of opioid

medications nationwide, and in many cases even overdose. As of 2015, approximately 92 million

Americans were using prescription opioids, and 63.5% of those individuals were taking the

opioids to relieve physical pain.2 Recent polls of Americans have indicated the demand for new

strategies to manage pain, apart from drugs. Many health care providers believe that physical

therapy can provide the safest and most-effect drug-free pain management to individuals,

however, before seeking the help of physical therapists, individuals are more likely to seek care

for neck or back pain from a physician (53%), chiropractor (28%) or massage therapists (7%).2

Only 6% of individuals reported seeing help for pain management from a physical therapist.2

Unfortunately, the lack of awareness of other pain management options leads Americans to not
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consider physical therapy as their first option in pain management. As of 2015, all 50 states

allow patients to receive some level of treatment from a licensed physical therapist without the

need of a prescription or referral. Again, however, the lack of awareness is what keeps

individuals from seeking out the benefits that physical therapy has to offer.2

Physical therapists have a major role in pain management moving forward in the

American society. They have the responsibility to increase the knowledge and awareness and

advocate for physical therapy as a non-pharmaceutical and nonsurgical pain management

strategy. Physical therapists must also remain honest with their clients about the use of opioids

and risks to themselves and their families. Additionally, education on the findings of

pharmaceutical treatment of pain management not being superior to non-pharmaceutical

management, such as physical therapy, is critical.2 Importantly, education to the patient

explaining their pain is also a crucial responsibility of physical therapists in the role of pain

management. Many other health care providers may not take the time to explain the pain to these

individuals, and understanding their pain can go a long way. Constant communication with other

health care providers about our contributions to patients’ overall well-being will also be

important going forward.

Physical therapists embrace a role that must advocate for the promotion of health,

wellness, and prevention strategies in order to progress towards living a healthy lifestyle for

individuals nationwide. Through education and communication, physical therapists have the

ability to increase awareness on pain management strategies without the use of pharmaceuticals.

I believe this area of health is critical to address going forward in the next decade, and I believe

physical therapists can aid in the transition to better living.

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References

1. Healthy People 2030 Framework. Healthy People 2030 Framework | Healthy People
2020. https://www.healthypeople.gov/2020/about-healthy-people/development-healthy-
people-2030/framework. Accessed July 9, 2019.

2. Mintken PE, Moore JR, Flynn TW. Physical therapists’ role in solving the opioid
epidemic. J Orthop Sports Phys Ther. 2018;48(5):349-353. doi:10.2519/jospt.2018.0606.