A physio’s nutrition guide: Navigating the basics with nutrition 101

Nutrition is something we know is important, but most of us don’t know much about it. While we’re not dieticians, nutrition can play an important role in our patients’ recovery process, so we should at least understand the basics in order to answer possible questions and give appropriate advice. This blog will cover the fundamentals – how to optimize nutrition after injury or surgery, as well as nutrition for healthy bones, and its role in Osteoarthritis (OA) management.

If you like this topic and want to learn more, I highly recommend you watch Ben Steele-Turner’s Masterclass about nutrition HERE!

The fundamentals

Proper nutrition is always important, but its role becomes even more vital in cases of illness and/or injury. After surgery, people may think they don’t need to eat as much as they’re used to because they’re moving less, but this is a wrong assumption. Proper healing consumes energy, lots of energy! Let’s cover the basics before we dive deeper into the more specific needs in cases of injury.

Carbohydrates

Carbohydrates’ primary function is to provide energy. They are our body’s preferred energy source, which is why we should never cut out carbs completely. In cases of shortage, the body will switch to proteins and fats for energy, which will do the job, but isn’t optimal in the long term. Carbs are also our main source of dietary fiber. Fibers are a complex group of substances within plant foods that our digestive system cannot fully breakdown. They are a crucial part of our nutrition as they come with many benefits. They are known to improve glycemic control, prevent diverticulitis and colorectal cancer, reduce Low-Density-Lipoprotein (LDL) cholesterol, and provide important prebiotics to our gut microbiome. We should have at least 30g of fiber per day, which might seem little, but many adults struggle to take it in!

Proteins

Proteins are used as transport molecules and play an important role in DNA expression, antibody function, bone health and muscle structure. They’re made of amino acids which can be divided into three groups: essential, non-essential and conditionally essential. The first are the ones we cannot synthesise, and must therefore come out of our diet. The second group can be synthesised as long as we have enough essential amino acids, and the last group are non-essential in a healthy state, but can become essential during illness, or after surgery/trauma.

Fats

Dietary fats provide essential fatty acids our body cannot synthesise. They are the main components of cell membranes, are required for optimal use of fat-soluble vitamins (vitamin A, D, E, K) and can act as a great energy source, as 1g of fat provides more energy than 1g of carbohydrates (9 kcal vs. 4 kcal). Fats are often simplified as “good” or “bad”. Unsaturated fats make up the former, and include foods that are rich in omega 3, 6, 7 and 9 (e.g. salmon, tuna, olives, avocado). Saturated fats are less healthy and can be found in cheese, butter, processed and red meats, as well as certain oils.

Now that we’re speaking the same language, it’s time to go into a little more detail. .

Nutrition after soft-tissue injury or surgery

If you still need to be convinced about the importance of nutrition after injury/surgery, you should know there are studies that show the risk of a new musculoskeletal injury is reduced by 64% if you’re hitting the recommended nutrient intakes (1). Another study showed that there is a lower risk of injury when taking at least two supplements of protein or carbs per day (2). We don’t yet know whether this is because of the increased calories, or nutrient timing around intense training, but nevertheless, it highlights the importance of food!

Being extra mindful about protein intake is super important after a soft-tissue injury. We always try to limit muscle atrophy by giving our patients exercises, but nutrition plays a key role here as well! Amino acids are needed to heal injuries, but instead of there being a higher muscle synthesis, there appears to be a decreased muscle synthesis after injury or prolonged immobilisation (we also call this anabolic resistance). This makes it hard for the body to maintain muscle mass, therefore directly contributing to muscle atrophy. To make it even more difficult, muscles that aren’t doing much (which is the case after injury/surgery), don’t take in as much protein as muscles that are functioning normally, as the body seems to think it doesn’t need it. Make sure to advise your patients about hitting their daily protein goal, which is 1.6g/kg/day, as well as inform them about optimising the timing of their protein intake. Taking in protein within one hour of waking up, timing it around exercise (before and after) and distributing it evenly throughout the day (3-5 servings), will help optimize the conditions for proper healing. Ben does an excellent job at explaining this, get a sneak peak and check out the short video taken from his Masterclass below:

Carbohydrates are needed to supply energy for rehab sessions. Training fasted can have benefits for health and performances, but should be avoided after injury. The daily target is 3-5g/kg body weight, but carbs shouldn’t make up more than 60% of total calories. Timing your carbs is just as important as timing your protein, as it’s best to take in 50-100g of complex carbs 3-4 hours before rehab sessions, and 30g of fast carbs 15-45 minutes before rehab. Carbohydrates become less important after training, where sufficient protein intake becomes more crucial.

Besides proper carb and protein intake, we shouldn’t forget about taking in enough vitamin C and collagen either. Vitamin C is very important for the musculoskeletal system as it increases type one collagen synthesis, reduces oxidative stress markers and potentially accelerates bone healing. Collagen (logically) elevates collagen synthesis after exercise, but to this day it isn’t known whether supplementing collagen is necessary.

Nutrition and bone health

Though nutrition plays a notable role in bone health and repair, there actually doesn’t appear to be a causal link between the two! But this doesn’t mean that proper nutrition does nothing. People who experience long-term energy deficits have increased osteoclast and decreased osteoblast activity. This means that the cells which are breaking down the bones do more, while the ones that are responsible for building them back up do less, raising the chances of obtaining a stress fracture. For a very long time, it was believed that protein was actually bad for bone health, but more recent evidence debunked this myth (3,4). Greater protein intake appears to be positively associated with bone mass and density, which is important for postmenopausal women, who struggle with this exact problem. Therefore, postmenopausal women are recommended to perform regular physical exercise 3-5x/week as well as take in 1-2g of protein/kg body weight/day, and ideally 20-25g of protein per main meal.

There are three other main players when trying to optimize bone health: Calcium, vitamin D and vitamin K.

Calcium

I think it’s safe to say almost everyone knows that calcium plays an important role in bone health. It is the most abundant nutrient in our body and 99% of it is stored in the skeleton and teeth. Our body maintains a process called “calcium homeostasis”, meaning that blood calcium levels are always kept at the same level (90-110 mg/l). When blood levels are too high, calcium is either stored or excreted, when they’re too low, our body will take it from the bones, resulting in reduced bone mass.

Vitamin D

Vitamin D stimulates bone matrix formation and optimises calcium availability. It’s basically calcium’s best friend, as the two work together closely. By increasing vitamin D, our body is able to absorb more calcium from the same amount of food. Supplementing calcium alone doesn’t seem to do much, but supplementing calcium AND vitamin D is supported for patients with high risk of fractures. Our body gets vitamin D from the foods we eat (e.g. oily fish, egg yolk and milk, cereals or other drinks where vitamin D is added) and from the sun; 10-20 minutes of sun exposure during the summer months is enough to get your daily dose of vitamin D, but supplementing 10-20 micrograms/day is recommended when experiencing minimal sun exposure (e.g. winter).

Vitamin K

Vitamin K is a lesser known component of bone health. It is abundant in green veggies and widely supported as an important micronutrient for skeletal health because it improves osteoblast function. Supplementing is not yet recommended but it remains important to eat your veggies in order to obtain enough vitamin K.

Nutrition and OA management

We all know a higher BMI increases the odds of being negatively affected by osteoarthritis. Losing weight can positively impact symptoms, even when there’s already significant cartilage damage, which is why we as physios should always discuss obtaining or maintaining a healthy body composition as one of the primary steps in OA management.

There is no clear link between carbs and OA, but it is proven that increased saturated and total fat intake makes for an accelerated OA progression (5). When it comes to the omega fats, it appears that a higher omega 6/3 ratio worsens OA symptoms. Advising patients to focus on maximising omega 3 intake, maybe even supplementing when necessary, can be of great benefit!

You already know that vitamin D and K are great players when it comes to bone health, so it’s not very surprising that they turn out to be valuable allies in cartilage health as well. Ben explains how vitamin K contributes to cartilage quality very neatly in the video taken from his Masterclass below:

Many people struggling with OA are being prescribed supplements. But it’s safe to say not all of them are actually doing something… Glucosamine is one of those popular supplements, but there’s actually conflicting information about its use, as some studies suggest it helps but an equal amount of studies suggest it doesn’t (6). A rather new supplement, worth keeping an eye on, is curcumin (the active ingredient within turmeric). There’s not much evidence yet about the effects on OA symptoms, but the small number of studies done showed significant improvement in pain and function, as well as a decrease in inflammatory markers (7), which sounds promising to say the least!

Wrapping up

There you have it! You should now have some basic knowledge about nutrition that’ll help you guide your patients in the right direction. If you’re interested in nutrition and want to know more, Ben Steele-Turner is your guy. Check out his amazing Masterclass “Nutrition 101 for physios” HERE, you won’t be disappointed!