Academy of Plant-based Physical Therapy: overdue to address a nutrition crisis with a transformative population approach

Abstract

This timely evidence synthesis supports the need for an Academy of Plant-based Physical Therapy. Given epidemiological and empirical evidence and the profession’s values and practice scope, the time has come for a specialty of plant-based physical therapy based on population health principles. This review connects these factors. Non-communicable diseases (NCDs) are largely nutrition-related resulting from unnatural elements of our diet (i.e., heart disease, several cancers, hypertension, stroke, diabetes, obesity, gastrointestinal diseases, autoimmune diseases, renal disease, and Alzheimer’s disease). Most adults, even children, have NCD risk factors or manifestations. Alternatively, plant-based nutrition can prevent, manage, as well as potentially reverse these diseases, as well as augment conventional physical therapy outcomes by reducing inflammation and pain. Proposed competencies for plant-based physical therapists include high-level competency in health and NCD risk assessments/evaluations, to establish population health-informed nutrition needs for maximal health, healing and repair, in turn, function and wellbeing; and assessment of patients’ nutrition-related knowledge, beliefs/attitudes, self-efficacy, and readiness-to-change. Population-informed nutritional counseling is initiated as indicated. An Academy of Plant-based Physical Therapy could advance the profession globally at this point in history and also serve as a role model to other health professions through practicing evidence-based, plant-based nutrition built upon population health principles.

INTRODUCTION

The further humans digress from their inherently well-suited, evolutionarily-adapted diet, the greater the adverse health consequences, specifically, prolonged disability over decades of the lifespan and premature death, rather than a long, vibrantly active, disease-free health span. Over millennia, the optimal biomarkers of human health have been remarkably constant¹⁾. Humans however have adapted to a range of eating patterns due to various factors, most of which are manufactured and engineered rather than of necessity. This trend has not been without significant pathological consequences, namely, the nutrition-related non-communicable diseases (NCDs). These diseases include heart disease, several cancers, hypertension, stroke, type 2 diabetes, obesity, gastrointestinal diseases, compromised immunity, renal disease, and Alzheimer’s disease^{2, 3)}. The unnatural standard western diet to which many populations have become increasingly culturally accustomed and find satisfying, is characterized by the reversal of the sodium-potassium ratio, increased dietary acidity, reduced fiber, and reduced micronutrient density. With globalization and the ubiquity of the standard western diet over the past 80 years, nutrition-related NCDs have correspondingly escalated and continue to do so, at an alarming rate—constituting a global health crisis^4,5,6).

Nutrition is the backbone of health⁷⁾. Risk factors and causes of NCDs are largely understood, yet they are of pandemic proportions and growing at unsustainable rates across low- and middle- as well as the high-income countries⁸⁾. Historically, malnutrition has been associated with undernutrition and starvation. Since the end of World War Ⅱ almost 80 years ago, it has become associated with low-quality diets including micronutrient deficiencies characteristic of the standard western diet¹⁾. This diet constitutes greater risk to morbidity and mortality than tobacco, alcohol, and drug use and unsafe sex combined, and now outstrips malnutrition associated with undernutrition⁹⁾. Rather than supporting human and planetary health, contemporary food systems are now threatening them.

This evidence synthesis supports that the time has come, perhaps is overdue, for an Academy of Plant-based Physical Therapy that is charged with the responsibility of board-certifying plant-based physical therapists with expertise in transformative population health dietary approaches. In recent years, there has been an urgent call for physical therapists to engage at the population health level given the profession’s professed commitment to transforming society^10,11,12). To address nutrition-related NCDs and their risk factors in every patient, evidence-informed competencies of the proposed plant-based physical therapist are subsumed under four pillars with an emphasis on consultancy, advocacy, and agency within each: clinical; entry-level professional and continuing professional education; research development and design across physical therapist specialties; and intersectoral partnerships with professional national and international bodies and organizations regarding nutrition- and population health-related policies.

Through its commitment to translating nutrition knowledge relevant to physical therapists into practice, education, research, and population health policy, an Academy of Plant-based Physical Therapy would be strategically positioned to advance the profession globally at this pivotal point in history. In addition, it would be positioned to assume a leadership role within the profession and serve as a role model to other health professions vis-à-vis incorporating population-based principles related to whole-food, plant-based nutrition into standard healthcare practice in the public’s interest.

CONTEMPORARY PHYSICAL THERAPIST SCOPE OF PRACTICE

Today, physical therapists constitute the leading established, largely non-invasive, i.e., non-pharmacologic non-surgical, health profession in the world¹³⁾. As a professional group, they have long held the World Health Organization mission of ‘health for all’ as their vision^{14, 15)} as exemplified through endorsement of the International Classification of Functioning, Disability and Health¹⁶⁾, and have prioritized health promotion in patient management¹⁷⁾.

During the period of rapid economic growth after World War Ⅱ, the global demand for processed and ultra-processed foods¹⁸⁾ and animal-sourced products including meat, poultry, dairy, and eggs, escalated¹⁹⁾. Such escalation has persisted despite these foods being well documented to be pro-inflammatory and are inconsistent with food quality that is tantamount for human growth and development, health over the life course, and being disease resistant through maximally strong immunity⁶⁾.

The NCDs can no longer be viewed as distinct diseases, but rather different manifestations of common underlying lifestyle factors and attributes. The western lifestyle has been well documented to be pro-inflammatory²⁰⁾ contributing to chronic low-grade systemic inflammation (CLGSI). CLGSI is the common denominator of the NCDs^{21, 22)}. Thus, these diseases have a common etiology although they manifest differently. Rather than diseases per se, these conditions are more logically conceptualized as normal adaptations to abnormal cellular environments. Further, CLGSI is associated with musculoskeletal problems commonly managed by physical therapists, and impairs healing and repair²³⁾.

PLANT-BASED DIET IS NATURAL FOR HUMANS: VEGAN-BY-DESIGN

That humans are vegan-by-design has several lines of support. First, based on detailed comparative analysis of carnivores, omnivores, and herbivores (i.e., vegan and do not consume animal foods) vis-à-vis 18 dimensions of the gastrointestinal tract and related digestive organs²⁴⁾, humans are dedicated herbivores (vegan) with no resemblance to omnivores, i.e., both plant and meat eaters. Despite the evidence, that humans are omnivores is commonly held not only by the public, but also by health professionals and so-called ‘disease-focused agencies (e.g., heart, cancer, stroke, diabetes, and Alzheimer’s associations). That as a species, humans are vegan-by-design is consistent with other primates living in their natural settings. Other primates are humans’ closest relatives genetically and are vegan²⁵⁾. Further, the incidence of nutrition-related NCDs that are common in humans, are rare in other primates living in their natural settings²⁶⁾. Conversely, when they are exposed to elements of the standard western diet, nutrition-related NCDs observed in humans, manifest²⁷⁾.

The Mediterranean diet, the most studied diet in the world, has been associated with many health benefits, thus has served as a dietary gold standard²⁸⁾. The basic elements of the Mediterranean are common to the diets of people living in the Blue Zones of the world including Okinawa, Japan²⁹⁾; these individuals often live well over 100 years of age with little-to-no end of life morbidity. Unlike the pro-inflammatory western diet, their diets are anti-inflammatory³⁰⁾, i.e., rich in fiber, micronutrients, vitamins and minerals, legumes (beans, peas, and lentils that are all rich protein), whole grains, nuts, and vegetables and fruit; and with little if any added sugar, salt and fat, particularly no trans nor saturated fat. The PREDIMED diet a hybrid of the Mediterranean diet reduces cardiovascular disease risk even in those who are highly susceptible³¹⁾.

Additional evidence supporting humans being vegan-by-design comes from exhaustive syntheses of the scientific literature. With a view to inform the public, such reviews are reported on Dr. Michael Greger’s non-profit website nutritionfacts.org, and in his New York Times extensively referenced best-selling evidence syntheses, ‘How Not to Die’³²⁾ and ‘How Not to Diet’³³⁾. Dr. Neil Barnard, founder of the long-standing Physicians Committee for Responsible Medicine, and his colleagues have written extensively on the science behind the healthfulness of whole-food, low-fat vegan nutrition and the health risks associated with the consumption of animal-sourced foods³⁴⁾. Similarly, the American College of Lifestyle Medicine promotes healthy lifestyle practices including whole-food plant-based nutrition as a primary healthcare intervention³⁵⁾.

The construct of plant-based diet varies widely in its definition³⁶⁾, thus, the term needs to be operationalized when used by clinicians and researchers, and when reported in the literature. Many diets focus on being plant-based including the most studied diet in the world, the Mediterranean diet, the DASH diet, and the portfolio diet^37,38,39). Clearly, if unbalanced, plant-based diets like any other diet, can be unhealthy. Although studies on plant-based diets tend to specify either vegetarian or vegan, how these are operationalized needs to be established based on both what is excluded as well as included. Otherwise, their true health benefits will be obscured.

Barnard and Greger, preeminent scholars in vegan science, have concluded that the optimal diet for health and reduced disease risk is the whole-food, low-fat plant-based vegan diet^{40, 41)}. Such a diet is associated with the least end-of-life morbidity and premature death. Based on extensive literature syntheses^{32, 42)}, Greger advocates daily—at least three servings of legumes (beans, peas, and lentils), a serving of berries, three servings of other fruits, a serving of cruciferous vegetables, two servings of greens, two servings of other vegetables, a serving of ground flaxseeds, a serving of nuts and seeds, various anti-inflammatory herbs and spices, e.g., cinnamon, ginger, turmeric, three servings of whole grains, and vitamin B12. Because of our sanitized way of life, we can no longer access vitamin B12 through vegetable sources⁴³⁾. Nutritional yeast with vitamin B12 is one source or it can be taken as a supplement. The vegan diet excludes animal-sourced foods including meat, poultry, fish, dairy, and eggs. Healthy nutrition is also associated with avoiding refined and processed foods. Given cultural, seasonal, and economic constraints however, substitutions can be made.

Plant-based diets have been well established to reduce the risk of chronic diseases including heart disease, several cancers, hypertension, stroke, type 2 diabetes, obesity, gastrointestinal diseases, autoimmune diseases, renal disease, and Alzheimer’s disease; diseases associated with the standard western diet^{6, 29, 44)}. Such diets are also associated with lower body mass index and metabolic and inflammatory indices. In addition, Ornish et al. reported over 30 years ago in Lancet, that ischemic heart disease can be reversed with a low-fat vegan diet, based on angiographic evidence⁴⁵⁾. Whole-food, plant-based diets such as the DASH diet, Mediterranean diet, and the MIND diet²⁸⁾, have been shown to reduce and normalize blood pressure, normalize glycemic control, and body weight, and reduce cardiometabolic risk factors. While a range of alternative diets, e.g., Atkins, paleo and keto diets, can effectively manipulate human metabolism to produce short-term metabolic and weight loss benefit, thus have captured the public’s attention, these diets are not associated with the benefits of whole-food, plant-based low-fat nutrition with respect to overall health, and reduced CLGSI, in turn, reduced NCD risk factors or NCD reversal. Therefore, many authorities strongly argue against these alternative diets given their health and disease risks.

The low-fat vegan diet has now surpassed the Mediterranean diet in terms of documented healthfulness and reduced disease risk⁴⁶⁾. Based on a sophisticated crossover study design, the low-fat vegan diet was superior with respect to participants’ body weight, lipid concentrations, and insulin sensitivity. Blood pressure decreased on both diets, but more so on the Mediterranean diet. Given the sophistication of the study including its design and objective measures, and the absence of conflicts of interest of the investigators, the whole-food, low-fat vegan diet is justifiably the new gold standard when evaluating other nutritional regimens with respect to their maximizing health and reducing risk of chronic disabling diseases. These findings further support that humans are vegan-by-design in accordance with several other lines of evidence previously described.

Finally, the number of healthy behaviors practiced is associated with being free of NCDs⁴⁷⁾ and optimal self-rated health among adults⁴⁸⁾. These findings reinforce the support for identifying and implementing clinical and population-based intervention strategies that effectively promote multiple healthier lifestyle behaviors among adults. This observation supports that moderation is not consistent with optimal health and NCD risk reduction. The notion of moderation is typically in reference to unhealthy foods. Some authorities have argued that, in essence, this implies that a little heart disease is okay, a little high blood pressure is okay, a little Alzheimer’s disease is okay, and so on.

COMPETENCIES FOR PLANT-BASED PHYSICAL THERAPISTS

As described, nutrition-related NCDs can be prevented, managed as well as frequently reversed with whole-food, low-fat, plant-based nutrition. To address these diseases, competencies for the proposed plant-based physical therapist are subsumed within four pillars with an emphasis on consultancy, advocacy, and agency within each: clinical; entry-level professional and continuing professional education; research development and design across physical therapist specialties; and intersectoral partnerships with professional national and international bodies and organizations regarding nutrition- and population health-related policies (Table 1). To illustrate the potential role of plant-based nutrition across physical therapy specialties, Table 2 shows existing board-certified specialties within the American Physical Therapy Association (the largest in the world), number of specialists, and a sampling of literature to support plant-based nutrition within each specialty (Panel A) and across specialties (Panel B) to support specialty-specific as well as general health outcomes.

Table 1. Proposed competencies within four pillars (practice, education, research, and health policy) for board-certified plant-based physical therapists related to consultancy, advocacy, and agency.

Pillar 1: Physical Therapist Practitioners
•	With a focus on whole-food, low-fat, plant-based nutrition, lifestyle behavior change competencies including assessment and evaluation and lifestyle behavior change strategies
•	Assessment competencies related to nutritional knowledge, beliefs, attitudes, readiness to change, facilitators and barriers to change, and self-efficacy and related interventions strategies
•	Consider how a whole-food, low-fat, plant-based diet can augment patients’ health and conventional physical therapy outcomes including inflammation and pain reduction
•	Serve as a resource to clinicians, clinical specialists. and other health professionals
Pillar 2: Physical Therapist Educators and Stakeholders
•	Inform physical therapy entry-entry and professional development education related to minimal standards for evidence-based population-informed nutrition for health, non-communicable disease risk reduction, non-communicable disease reversal, and physical and metabolic healing and repair across physical therapists’ areas of practice
Pillar 3: Physical Therapist Researchers
•	Inform researchers about designs and analyses on controlling for nutrition as a confounding variable in their scientific inquiries to establish the power of nutrition in maximizing patient health; augmenting physical therapy outcomes; or eliminating the need for physical therapy
Pillar 4: Health Policy Makers
•	Across levels (regional, national and international), practice competencies in essential related epidemiology evidence synthesis and translation and data gathering; and contributing to high-level national and international position statements and papers; and collaborate in partnership with professional associations such as the American College of Lifestyle Medicine; the Physicians Committee for Responsible Medicine, and the non-profit evidence-based organization nutritionfacts.org

Table 2. Existing American Physical Therapy Association board-certified specialties, their numbers, and sampling of literature to support plant-based nutrition within each specialty (Panel A) and across specialties (Panel B).

Panel A: American Physical Therapy Association board-certified specialties, their numbers, and sampling of literature to support plant-based nutrition within each specialty
As of June 2022, 35,043 individuals have achieved board certification in ten physical therapy specialty areas:
Specialty area	Number	Sampling of literature to support superior physical therapist outcomes in the specialty with plant-based nutrition
Cardiovascular & Pulmonary	459	Abshire M, Xu J, Baptiste D, et al. Nutritional interventions in heart failure: A systematic review of the literature. J Card Fail. 2015; 21(12): 989–999.
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		Greger M. How not to die from diabetes. Chapter 6. In: How Not to Die. Evidence Synthesis Monograph. Flatiron Books: New York, NY, 2015. pp 100–121; 446–452.
		Greger M. How not to die from high blood pressure. Chapter 7. In: How Not to Die. Evidence Synthesis Monograph. Flatiron Books: New York, NY, 2015. pp 122–140; 453–460.
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		Barnard ND, Alwarith J, Rembert E, et al. A Mediterranean diet and low-fat vegan diet to improve body weight and cardiometabolic risk factors: A randomized cross-over trial. J Am Clin Nutr. 2021; 5: 1–13. doi: 10.1080/07315724.2020.1869625.
		Barnard ND, Cohen J, Jenkins DJA, et al. A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a randomized clinical trial in individuals with type 2 diabetes. Diabetes Care. 2006; 29: 1777–1783.
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Clinical electrophysiology	216	Craddock JC, Neale EP, Peoples GE, et al. Plant-based eating patterns and endurance performance: A focus on inflammation, oxidative stress and immune responses. Nutr Bull. 2020; 45(2): 123–32. doi.org/10.1111/nbu.12427.
		Fewkes JJ, Kellow NJ, Cowan SF, et al. A single, high-fat meal adversely affects postprandial endothelial function: a systematic review and meta-analysis. Am J Clin Nutr. 2022; 116(3): 699–729.
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		Miller M, Beach V, Sorkin JD, et al. Comparative effects of three popular diets on lipids, endothelial function, and C-reactive protein during weight maintenance. J Am Diet Assoc. 2009; 109: 713–717.
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		Sutliffe JT, Wilson LD, de Heer HD, et al. C-reactive protein response to a vegan lifestyle intervention. Comp Ther Med. 2015; 23: 32–37.
		Vogel RA, Corretti MC, Plotnick GD. The postprandial effect of components of the Mediterranean diet on endothelial function. J Am Coll Cardiol. 2000; 36: 1455–1460.
Geriatrics	3,837	Ferrucci L, Fabbri E. Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty. Nat Rev Cardiol. 2018; 15(9): 505–522. doi: 10.1038/s41569-018-0064-2.
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		Buettner D, Skemp S. Blue Zones: Lessons learned from the world’s longest lived. Am J Lifestyle Med. 2016; 10(5): 318–321.
		Diet Review. MIND Diet. The Mediterranean-DASH Diet Intervention for Neurodegenerative Delay. Available at: https://www.hsph.harvard.edu/nutritionsource/healthy-weight/diet-reviews/mind-diet/. Accessed January 11, 2023.
		Kim H, Caulfield LE, Garcia-Larsen V, et al. Plant-based diets are associated with a lower risk of incident cardiovascular disease, cardiovascular disease mortality, and all-cause mortality in a general population of middle-aged adults. J Am Heart Assoc. 2019; 8(16): e012865. doi: 10.1161/JAHA.119.012865. Epub 2019 Aug 7.
		Rodopaios NE, Manolarakis GE, Koulouri A-A, et al. The significant effect on musculoskeletal metabolism and bone density of the Eastern Mediterranean Christian Orthodox Church fasting. Eur J Clin Nutr. 2020; 74(12): 1736–1742.
		Mamalaki E, Anastasiou CA, Ntanasi E, et al. Associations between the Mediterranean diet and sleep in older adults: Results from the Hellenic longitudinal investigation of aging and diet study. Geriatr Gerontol Int. 2018; 8(11): 1543–1548.
		Greger M. How not to die from brain disease. Chapter 3. In: How Not to Die. Evidence Synthesis Monograph. Flatiron Books: New York, NY, 2015. pp 42–61; 425–432.
Neurology	4,159	Maharjan R, Diaz Bustamante L, Ghattas KN, et al. Role of lifestyle in neuroplasticity and neurogenesis in an aging brain. Cureus. 2020; 12(9): e10639. Published 2020 Sep 24. doi: 10.7759/cureus.10639.
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		Petersson SD, Philippou E. Mediterranean diet, cognitive function, and dementia: A systematic review of the evidence. Adv Nutr. 2016; 7(5): 889–904.
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		Greger M. How not to die from Parkinson’s Disease. Chapter 14. In: How Not to Die. Evidence Synthesis Monograph. Flatiron Books: New York, NY, 2015. pp 226–238; 491–498.
Oncology	160	Greger M. How not to die from digestive cancers. Chapter 4. In: How Not to Die. Evidence Synthesis Monograph. Flatiron Books: New York, NY, 2015. pp 62–77; 432–438.
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Orthopaedics	20,003	Veronese N, Stubbs B, Crepaldi G, et al. Relationship between low bone mineral density and fractures with incident cardiovascular disease: A systematic review and meta-analysis. J Bone Miner Res. 2017; 32(5): 1126–1135.
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		Frazier M, Cheeke R. The Plant Based Athlete. A Game Changing Approach to Peak Performance. HarperCollins Publishers, New York, NY, 2021.
		The Game Changers. Documentary featuring leaders in the field. Available at: https://gamechangersmovie.com/. January 11, 2023.
		Pohl A, Schünemann F, Bersiner K, et al. The impact of vegan and vegetarian diets on physical performance and molecular signaling in skeletal muscle. Nutrients. 2021; 13(11): 3884. doi: 10.3390/nu13113884.
Women’s health	681	Barnard ND, Kahleova H, Holtz DN, et al. The Women’s Study for the Alleviation of Vasomotor Symptoms (WAVS): A randomized, controlled trial of a plant-based diet and whole soybeans for postmenopausal women. Menopause 2021; 28(10): 1150–1156.
		Greger M. How not to diet. [Evidence Synthesis Monograph]. Flatiron Books: New York. 2019.
		Guzek D, Głabska D, Groele B, et al. Fruit and vegetable dietary patterns and mental health in women: A systematic review. Nutr Rev. 2022; 80(6): 1357–1370.
		Glenn AJ, Lo K, Jenkins DJA, Boucher BA, et al. Relationship between a plant‐based dietary portfolio and risk of cardiovascular disease: Findings from the Women’s Health Initiative Prospective Cohort study. Am J Heart Assoc. 2021; doi: 10.1161/JAHA.121.021515.
		Barnard ND, Goldman DM, Loomis JF, et al. Plant-based diets for cardiovascular safety and performance in endurance sports. Nutrients 2019; 11(1): 130. doi: 10.3390/nu11010130.
		Greger M. How not to die from breast cancer. Chapter 11. In: How Not to Die. Evidence Synthesis Monograph. Flatiron Books: New York, NY, 2015. pp 178–197; 474–482.
Wound management	12	Avishai E, Yeghiazaryan K, Golubnitschaja O. Impaired wound healing: facts and hypotheses for multi-professional considerations in predictive, preventive and personalised medicine. EPMJ. 2017; 8(1): 23–33.
		Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010; 89(3): 219–229.
		Wilson JA, Clark JJ. Obesity: impediment to postsurgical wound healing. Adv Skin Wound Care. 2004; 17(8): 426–35.
		Patel GK. The role of nutrition in the management of lower extremity wounds. Int J Low Extrem Wounds 2005; 4(1): 12–22.
		Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty. 2009; 9: e9.
		Abboud JA, Kim JS. The effect of hypercholesterolemia on rotator cuff disease. Clin Orthop Rel Res. 2010; 468(6): 1493-7.
		Ranger TA, Wong AMY, Cook JL, et al. Is there an association between tendinopathy and diabetes mellitus? A systematic review with meta-analysis. Brit J Sports Med. 2016; 50(16): 982.
		Gumina S, Arceri V, Carbone S, et al. The association between arterial hypertension and rotator cuff tear: the influence on rotator cuff tear sizes. J Shoulder Elbow Surg. 2013; 22(2): 229–232.
		Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010; 89(3): 219–229.
		Patel GK. The role of nutrition in the management of lower extremity wounds. Int J Low Extrem Wounds. 2005; 4(1): 12–22. 78.
		Kavalukas SL, Barbul A. Nutrition and wound healing: an update. Plast Reconstr Surg. 2011; 127(Suppl 1): 38S–43S. doi: 10.1097/PRS.0b013e318201256c.
Panel B: Common therapeutic targets across American Physical Therapy Association specialties that have been shown to be amenable to plant-based nutrition intervention: Sampling of literature to support effectiveness of plant-based nutrition
Source: specialization.apta.org/about-abpts/abpts-certified-specialists-statistics
Therapeutic target	Sampling of literature
Immunomodulation (injury, and inflammation control)	Akbaraly TN, Shipley MJ, Ferrie JE, et al. Long-term adherence to healthy dietary guidelines and chronic inflammation in the prospective Whitehall II study. Am J Med. 2015; 128: 152–160.
	Zabetakis I, Lordan R, Norton C, et al. COVID-19: The inflammation link and the role of nutrition in potential mitigation. Nutrients. 2020; 12(5): E1466. doi: 10.3390/nu12051466.
	Ricker MA, Haas WC. Anti-inflammatory diet in clinical practice: A review. Nutr Clin Pract. 2017; 32(3): 318–325.
	Fighting inflammation. Harvard University Special Health Report. Harvard University Publishing, Boston: MA, 2020.
	Foods that fight inflammation. Designing your diet to lower disease risk. Harvard Health Publishing, Boston, MA, 2021.
	Akbaraly TN, Shipley MJ, Ferrie JE, et al. Long-term adherence to healthy dietary guidelines and chronic inflammation in the prospective Whitehall II study. Am J Med. 2015; 128: 152–60.
	Medzhitov R. Origin and physiological roles of inflammation. Nature. 2008; 454: 428–435.
	Hagan KA, Chiuve SE, Stampfer MJ, et al. Greater adherence to the alternative Healthy Eating Index is associated with lower incidence of physical function impairment in the Nurses’ Health Study. J Nutr. 2016; 146(7): 1341-7.
	Teixeira KRC, dos Santos CP, de Medeiros LA, et al. Night workers have lower levels of antioxidant defenses and higher levels of oxidative stress damage when compared to day workers. Sci Rep. 2019; 9: 4455. doi.org/10.1038/s41598-019-40989-6. doi: 10.1016/j.jpain.2013.08.007.
	Dean E, Söderlund A, Gosselink R, et al. Immuno-modulation with lifestyle behaviour change to reduce SARS-CoV-2 susceptibility and COVID-19 severity: Goals consistent with contemporary physiotherapy practice. Physiother. 2022; 114: 63–67.
Weight management	Obesity Medicine Association. Plant-based diets for obesity treatment. Available at: https://obesitymedicine.org/plant-based-diets-for-obesity-treatment/#:~:text=Both%20ovo-lacto%20vegetarian%20and%20vegan%20diets%20are%20considered,color.%20Plant-based%20diets%20don’t%20have%20to%20be%20boring. Accessed January 11, 2023.
	Greger M. How not to diet. Evidence Synthesis. Flatiron Books, New York, NY. 2019.
Maximizing exercise capacity and performance	Hagan KA, Chiuve SE, Stampfer MJ, et al. Greater adherence to the alternative healthy eating index is associated with lower incidence of physical function impairment in the Nurses’ Health Study. J Nutr. 2016; 146(7): 1341–1347.
	Lynch HM, Wharton CM, Johnston CS. Cardiorespiratory fitness and peak torque differences between vegetarian and omnivore endurance athletes: A cross-sectional study. Nutrients. 2016; 8(11): 726. doi: 10.3390/nu8110726.
	Frazier M, Cheeke R. The Plant Based Athlete. A Game Changing Approach to Peak Performance. HarperCollins Publishers, New York, NY, 2021.
Sleep	Ikonte C J, Mun JG, Reider CA, et al. Micronutrient Inadequacy in short sleep: analysis of the NHANES 2005–2016. Nutrients. 2019: 11(10): 2335.
	Frank S, Gonzalez K, Lee-Ang L, et al. Diet and sleep physiology: Public health and clinical implications. Front Neuro. 2017; 8: 393.
	St-Onge MP, Mikic A, Pietrolungo CE. Effects of diet on sleep quality. Adv Nutr. 2016; 7(5): 938–949.
	Muscogiuri G., Barrea L., Aprano S., et al. on behalf of the OPERA PREVENTION Project (2020). Sleep quality in obesity: Does adherence to the Mediterranean diet matter? Nutrients. 2020; 12(5): 1364.
	Liang H, Beydoun HA, Hossain S, et al. Dietary Approaches to Stop Hypertension (DASH) score and Its association with sleep quality in a national survey of middle-aged and older men and women. Nutrients. 2020; 12(5): 1510.
	Wu Y, Zhai L, Zhang D. Sleep duration and obesity among adults: a meta-analysis of prospective studies. Sleep Med. 2014; 15(12): 1456–1462.
	Sperry SD, Scully ID, Gramzow RH, et al. Sleep duration and waist circumference in adults: A Meta-analysis. Sleep. 2015; 38(8): 1269–1276.
	Grandner MA, Jackson N, Gerstner JR, et al. Sleep symptoms associated with intake of specific dietary nutrients. J Sleep Res. 2014; 23(1), 22–34.
	Nedeltcheva AV, Kilkus JM, Imperial J, et al. Insufficient sleep undermines dietary efforts to reduce adiposity. Ann Int Med. 2010; 153(7), 435–441.
	St-Onge MP, McReynolds A, Trivedi ZB, et al. Sleep restriction leads to increased activation of brain regions sensitive to food stimuli. Am J Clin Nutr. 2012: 95(4), 818–824.
	Han H, Wang Y, Li T, et al. Sleep duration and risks of incident cardiovascular disease and mortality among people with type 2 diabetes. Diabetes Care. 2022; dc221127. https://doi.org/10.2337/dc22-1127.
Mental health, anxiety, stress, and depression	Takeda E, Terao J, Nakaya Y, et al. Stress control and human nutrition. J Med Invest. 2004; 51(3-4): 139–45.
	Berk M, Williams LJ, Jacka FN, et al. So depression is an inflammatory disease, but where does the inflammation come from? BMC Med. 2013; 11: 200.
	O’Neil A, Quirk SE, Housden S, et al. Relationship between diet and mental health in children and adolescents: a systematic review. Am J Pub Health. 2014; 104(10): e31–42.
	Sadeghi O, A, Afshar H, Esmaillzadeh A, et al. Adherence to Mediterranean dietary pattern is inversely associated with depression, anxiety and psychological distress. Nutr Neurosci. 2019; 24(4): 248–259.
	Sarris J, Logan AC, Akbaraly TN, et al. Nutritional medicine as mainstream in psychiatry. Lancet Psychiatr. 2015; 2(3): 271–274.
	Maes M, Kubera M, Obuchowiczwa E, et al. Depression’s multiple comorbidities explained by (neuro)inflammatory and oxidative & nitrosative stress pathways. Neuro Endocrinol Lett. 2011; 32(1): 7–24.
	Beezhold BL, Johnston CS. Restriction of meat, fish, and poultry in omnivores improves mood: a pilot randomized controlled trial. Nutr J. 2012; 11(1): 1–5.
	Beezhold B, Radnitz C, Rinne A, et al. Vegans report less stress and anxiety than omnivores. Nutr Neurosci. 2015; 18(7): 289–296.
	Black CN, Bot M, Scheffer PG, et al. Is depression associated with increased oxidative stress? A systematic review and meta-analysis. Psychoneuroendocrinol. 2015; 51: 164–175.
	Bouayed J, Rammal H, Soulimani R. Oxidative stress and anxiety: relationship and cellular pathways. Oxid Med Cell Longev. 2009; 2(2): 63–67.
	Bremner JD, Moazzami K, Wittbrodt MT, et al. Diet, stress and mental health. Nutrients. 2020; 12(8): 2428.
	Castro-Diehl C, Wood AC, Redline S, et al. Mediterranean diet pattern and sleep duration and insomnia symptoms in the Multi-Ethnic Study of Atherosclerosis. Sleep. 2018; 41(11), zsy158.
	Dinan TG, Stanton C, Long-Smith C, et al. Feeding melancholic microbes: MyNewGut recommendations on diet and mood. Clin Nutr. 2019; 38(5),1995–2001.
	Foster JA, Neufeld KAM. Gut–brain axis: how the microbiome influences anxiety and depression. Trends Neurosci. 2013; 36(5): 305–312.
	Głąbska D, Guzek D, Groele B, et al. Fruit and vegetable intake and mental health in adults: a systematic review. Nutrients. 2020; 12(1), 115.
	Gomez-Pinilla F, Nguyen TT. Natural mood foods: the actions of polyphenols against psychiatric and cognitive disorders. Nutr Neurosci. 2012; 15(3): 127–133.

PILLAR 1: CLINICAL

Greater attention to the role of physical therapists in nutrition counselling has emerged^{49,50,51,52,53,54)}. Levels of clinical competency are twofold. First, the optimal evidence-based nutritional regimen for humans is not what the public nor health professionals is accustomed to. Although they may view them as beneficial to health, they may show resistance to it and even the science supporting it^{55, 56)}. Therefore, plant-based physical therapists need competencies in shifting beliefs and attitudes of patients, the public-at-large, and health professionals, in accordance with the science. Dietary patterns are culturally engrained. People become accustomed to the western diet societally and, over a lifetime, have acquired tastes for those foods vs. a healthful whole-food, low-fat, plant-based diet. Re-calibration of food preferences and tastes need to be considered and built into a new dietary regimen, thus at least 30 days has been recommended in terms of a patient feeling ‘better’ and demonstrating improved health biomarkers. These improved outcomes alone can be sufficient for a patient to adopt a new pattern of eating and abandon their previous adverse eating pattern.

Given the prevalence of obesity and metabolic disease, and consequences for cardiovascular and pulmonary health, the good news for patients is that people who are obese and assume a healthful diet, only need to focus on the quality of the diet, and not restriction nor calorie counting³³⁾.

A second related level of clinical competency is the assessment of nutrition-related knowledge, beliefs, attitudes, and self-efficacy with respect to transitioning to a whole-food, low-fat, plant-based diet. Ornish describes the ‘spectrum’ and taking steps commensurate with the individual’s readiness⁵⁷⁾. Any step in the healthy direction is positive, however the closer aligned the patient’s diet is to healthy vegan nutrition, the greater the health benefits.

Finally, if health professionals including physical therapists profess to practice evidence-based care, promoting plant-based nutrition becomes a moral imperative⁵⁶⁾.

PILLAR 2: ENTRY-LEVEL PROFESSIONAL AND CONTINUING PROFESSIONAL EDUCATION

Plant-based physical therapy practice is distinct from the practices of dieticians and nutritionists. Plant-based physical therapists focus population- and evidence-based nutrition recommendations to support the health of individuals overall, in turn the population, and to support healing and repair through anti-inflammatory whole-food, low-fat, plant-based nutrition, and maximize function and wellbeing, rather than prescribing targeted nutritional regimen for individual patients with unique conditions and diseases. Despite interest in personalized and so-called precision nutrition, the population health literature supports that the nutritional needs of humans are more similar than different.

It is incumbent on the Academy of Plant-based Physical Therapy to align their recommendations with the literature vs. the perceived preferences of the public, patients or other health professionals. Basic nutrition content of the entry-level physical therapist curriculum needs to be established regarding multi-system lifelong health through optimal macro and micronutrients with the least inflammatory immunity-disrupting profiles^{58, 59)}. Students and practitioners need an understanding of how such dietary recommendations augment patients’ health within each area of specialization that they study as well as areas common across specialties, and augment outcomes of conventional physical therapy (see Table 2, for examples).

PILLAR 3: RESEARCH DEVELOPMENT AND DESIGN ACROSS PHYSICAL THERAPIST SPECIALTIES

Physical therapy researchers are primarily interested in the effectiveness of their interventions. Pathologies of interest typically have an inflammatory component that underlies injury, healing and repair. Experimental control enables researchers to isolate the effects of confounding variables. Given the western diet is pro-inflammatory and a healthful diet is anti-inflammatory, attention to diet is imperative. Inflammation is often a direct or indirect contributor to patient problems presenting to physical therapists; and its degree, a direct or indirect research outcome.

In any study involving nutrition including stratifying study participants on this dimension, dietary quality needs to be meticulously operationalized as described in a previous section. Only in this way will the effects of optimal plant-based nutrition be validly evaluated. Experimental control can take two forms. First, participants can be selected a priori based on whether they adopt a plant-based diet or omnivorous diet which needs to be specifically quantified and established. Second, stratification of the participants in the sample based on their diet a posteriori, enables the researchers to analyze the data based on this variable. The central question is: does the physical therapy intervention of interest augment the benefit of a healthful diet on the outcomes? If so, to what extent? For example, given nutrition affects inflammation and pain⁶⁰⁾, to what extent does a given physical therapy intervention relieve these over and above a healthful diet alone?

Finally, as the quintessential established non-invasive health professionals in the world, physical therapists have a moral responsibility to embrace and exploit the evidence often supporting the superiority of non-pharmacological and non-surgical approaches to our leading health care priorities, the NCDs. This is what will revolutionize medicine and health care. Despite the ‘buzz’ around CRISPR gene editing and massive resources being poured into finding ‘cures’ for heart disease, several cancers, hypertension, stroke, type 2 diabetes, obesity, gastrointestinal diseases, autoimmune diseases, renal disease, and Alzheimer’s disease, these conditions are largely normal responses to abnormal cellular environments. How to change the cellular environment to prevent, manage, as well as often reverse these conditions has been well documented. What is lacking, is knowledge translation and a single profession willing to prioritize knowledge translation without influence from multi-national corporations and other conflicts of interest. As a unified body through the platform of an Academy of Plant-based Physical Therapy, physical therapists can lead the way in bringing an end to these leading killers and contributors to human misery, despair and often financial ruin.

PILLAR 4: PARTNERSHIPS WITH PROFESSIONAL NATIONAL AND INTERNATIONAL BODIES AND ORGANIZATIONS

The 2020 United States Department of Agriculture (USDA) Dietary Guidelines, for example, continue to fall short given the USDA’s history of extensive influence by major food and beverage companies which blurs the public’s understanding of what constitutes a ‘healthy’ diet⁶¹⁾. Profit-driven corporations control America’s industrialized food system. Although there is a growing number of unbiased organizations committed to conveying healthy nutrition to Americans, this movement lags seriously behind the science. The meat, poultry, dairy, egg, and beverage industries contribute substantial lobbying dollars resulting in the USDA downplaying nutrition information in its guidelines to appease corporate interests, thereby compromising the health of the nation. Although the guidelines do emphasize the need to reduce saturated fat, and added sugar and sodium, they conspicuously omit the sources of these nutrients. Further, sustainability considerations have also been omitted from the guidelines. Eating sustainably attained food through plant-based nutrition, thereby eliminating the ‘middle animal’, and growing crops grown without toxic pesticides, is unequivocally superior for the health of people and the planet⁶⁾.

Conflicts of interest permeate the governance of the federal advisory committees that make recommendations to consumer protection agencies, such as the Food and Drug Administration (FDA) and the USDA^{62, 63)}. American consumers should expect federal protection. A ‘business-friendly’ food pyramid is an overt conflict of interest given the modus operandi of agribusinesses and food industries is maximizing sales and profits. This includes the well documented manufacturing of scientifically engineered ‘foods’ to maximize their crave-ability index (mostly by manipulating fat, sugar and salt proportions). As a result, the FDA’s and USDA’s dual task of protecting both food producers and consumers, creates a serious conflict of interest within the agencies that often favor the food industry over consumer protection. Given inherent conflicts of interest, governments and the public health community need to prioritize evidence-informed regulation for public health, and not collaboration with food industry whose aim is sales and profits⁶⁴⁾. Commercial interests of industry should not contravene public health policies and programs.

An advocacy role is all-important in tackling the global NCD crisis through supporting innovations in law and governance to support efforts at the population health level, i.e., the profession of physical therapy being part of a marshalled global response⁶⁵⁾. Almost 20 years ago, the WHO’s Global Strategy for Diet, Physical Activity and Health⁶⁶⁾, warned that future health burdens will be increasingly determined by diet-related chronic diseases. Factors such as aggressive super-marketization often targeted disproportionately to vulnerable groups including children and minority groups creating health inequities and cultural shifts, have had a major role⁶⁵⁾. Furthermore, despite the body of knowledge supporting animal-sourced foods being injurious to human health which is downplayed in the USDA’s food guidelines, red meat is a class 2 carcinogen, reported by the International Agency for Research on Cancer, an independent body responsible for rating products and foods⁶⁷⁾. Processed meats are rated as class 1 carcinogens, comparable to tobacco, asbestos, and plutonium⁶⁷⁾. Recommendations for more effective ‘food governance’ and engagement by public health advocates in policy making in the food and agriculture arena has necessitated a prominent role for health professions including physical therapists across sectoral levels.

The Academy would identify innovative ways of supporting national and international initiatives to promote full disclosure of the health effects of consumer goods, regulation of advertisements, government incentives for promoting healthy choices and disincentives for promoting unhealthy choices, direct regulation through removal of government subsidies of the industries such as meat, poultry, eggs, and dairy in favor of subsidies for growing whole grains, vegetables and fruit, performance-based regulation, and optimizing the built environment for health, and making the healthy choice, the ‘easy’ choice⁶⁸⁾.

Unethical corporate strategies to manipulate consumer behavior include consumer ‘preference shaping’, defined as a communications strategy to promote specific beliefs about nutrition and health; manufacturing doubt, where specific evidence and persuasion is used to create public doubt about harmful nutritional effects; and use of self-funded research spread through industry and government leaders⁶⁸⁾. Ample evidence supports that the obesity epidemic reflects increased marketing power over the western diet. Only by reigning in marketing power can rationality be restored to the dietary choices of those living in cultures with increasingly western influence. Policy makers, public health workers, scientists, and health professionals needs to collaborate to ensure that sustainable programs are implemented to address macro and micronutrient deficiencies at the population level⁶⁹⁾.

Physical therapists committed to nutrition could support such international initiatives as the International Network for Food and Obesity/non-communicable diseases (NCDs) Research, Monitoring and Action Support (INFORMAS). This initiative has developed a monitoring tool (the Healthy Food Environment Policy Index (Food-EPI)) and process to rate government policies to create healthy food environments against international best practice^70,71,72). International benchmarking of the extent of government policy implementation on food environments has the potential to catalyze greater government action to reduce NCDs, and increase civil society’s capacity to advocate for healthy food environments.

PLANT-BASED PHYSICAL THERAPY: PLANETARY HEALTH AND ETHICAL IMPLICATIONS

At this pivotal point in history, an Academy of Plant-based Physical Therapy would legitimize the voice and professional representation of those physical therapists who perceive their role as extending beyond direct clinical practice, to population health including environmental and climate issues, through plant-based nutrition. Plant-based nutrition, particularly veganism, is a well-established means of addressing climate change by shifting the food chain away from factory farming⁶⁾. The World Bank and the International Finance Corporation report that at least 51 percent of human-caused greenhouse gas emission is attributable to livestock production and industrial factory farming⁷³⁾. Much of the environmental destruction reported worldwide is from industrial-scale animal agriculture including widespread deforestation, soil erosion, water depletion, water pollution, pesticide and herbicide contamination, species extinction, and greenhouse gas emission, in turn, climate change. Factory farming has given rise to widespread antibiotic use in livestock which poses a risk for antibiotic resistance in both humans and animals. Not consuming animal-sourced products, thereby not supporting factory farming, needs equal weighting by environmentalists and governments in their list of common recommendations such as fuel efficiency, to limit people’s impact on the climate. Physical therapists are committed to societal health, in turn, global and planetary health, thus committed to translating evidence into practice, and setting the standard within healthcare and across healthcare professionals.

Such an Academy would give voice and representation to those physical therapists committed to global health at the level of infectious pandemic diseases, by officially partnering with organizations that based on evidence and on ethical grounds, cannot support factory farming. Factory farms contribute to a range of highly infectious animal-sourced pathogens responsible for pandemics⁷⁴⁾. They have been described as ‘pandemic factories’. The American Public Health Association and other organizations have unequivocally called for an end to the practice^{75, 76)}.

Finally, an Academy of Plant-based Physical Therapy would give voice and professional representation to those physical therapists who do not support animal cruelty inherent in factory farming and are committed to animal rights and welfare. Factory farming raises several ethical issues given it has been unequivocally shown to be unnecessary for human health but harmful to individual and planetary health^74,75,76). As a consequence of its primary mission, factory farms are associated with unnatural stressful conditions for animals such as crowding, their mutilation, enforced confinement to reduce movement, little if any access to outdoors, infusion with drugs, and fed unnatural diets⁷⁷⁾. That Ag-Gag laws exist speaks to the inhumane life and treatment of factory farmed animals⁷⁸⁾. Terminating factory farming has been described as a ‘moral imperative’⁵⁶⁾.

CONCLUSION

Based on extant literature, there is little question that the time has come for an Academy of Plant-based Physical Therapy to provide accreditation standards for specialization in plant-based physical therapy. Plant-based physical therapist specialists promote health, reduce NCD risk, reverse NCDs, and promote healing and recovery through plant-based nutrition to augment the outcomes of conventional interventions and practice, and support patients’ overall health and wellbeing, in turn, function over a long healthy life. They can serve as a resource to physical therapists in general, and to physical therapist specialists in other specialties to augment their patient management outcomes. They can provide agency, advocacy and consultancy to physical therapy educators and advise on minimal standards for entry-level nutrition curriculum and professional development content; to researchers to augment their designs and statistical analyses by ensuring the confounding effects of dietary factors are controlled and maximized; and have legitimate professional voice and representation in legislative and political action groups, locally, regionally, nationally, and internationally.

Funding and Conflict of interest

The author has no funding and no conflict of interest.