Figure and Table | Disease-specific Nutritional Physical Therapy: A Position Paper by the Japanese Association of Rehabilitation Nutrition (Secondary Publication)

Table 1. Disease-specific Nutritional Physical Therapy.

From: Disease-specific Nutritional Physical Therapy: A Position Paper by the Japanese Association of Rehabilitation Nutrition (Secondary Publication)

Disease	Disease-specific nutritional physical therapy
Sarcopenia and frailty in the community-dwelling older adults	Physical therapy for older people with sarcopenia and frailty includes a combination of resistance training, aerobic and balance exercises, and nutrition. Amino acid (EAA), and leucine metabolites such as β-hydroxy-β-methylbutyrate (HMB) and creatine, is effective for muscle protein synthesis^{(16), (17)}.
Obesity and metabolic syndrome	Nutritional therapy for obesity and metabolic syndrome aims to increase muscle mass and decrease body fat mass simultaneously ⁽²⁴⁾. To reduce 1 kg of stored fat, 7,500 kcal must be consumed. To increase muscle mass, protein should be unrestricted, and resistance training and protein intake should be combined. Aerobic exercise is effective for reduction of fat mass ^{(25), (26)}.
Critically ill	Prevention of ICU-AW is an important intervention. Within 3-5 days after ICU admission, avoid over-feeding and gradually increase protein intake to 1.3 g/kg/day and calories to 70% of predicted levels ⁽¹²⁹⁾. Start early mobilization with adequate protein intake and moderate energy expenditure by exercise, as muscle protein degradation increases due to hypercatabolism. After 5 days, nutrition should be maintained at a protein intake of at least 1.2 g/kg/day to induce muscle protein anabolism in collaboration with exercise stimulation. The exercise load should be 40% of the maximum load.
Musculoskeletal diseases	Emphasizing protein intake throughout the entire surgical process (pre- and postsurgical periods) reduces muscle atrophy and loss of function due to increased muscle protein catabolism and immobilization after orthopedic surgery ⁽¹³⁰⁾. Protein intake of 1.2-2.0 g/kg/day is considered for the rehabilitation period following major surgery. For obese osteoarthritis patients, a combination of energy restriction (estimated energy expenditure −300-1000 kcal), meal replacement supplements with protein, resistance training, and aerobic exercise improves function and relieves pain⁽¹³¹⁾.
Stroke	Nutritional interventions include adjusting food texture and initiating oral intake early in patients with mild dysphagia. Tube feedings early and percutaneous endoscopic gastrostomy are recommended for patients who require enteral feedings for more than 28 days ⁽¹³²⁾ in patients with severe dysphagia. Rehabilitation includes early mobilization, swallowing training, and assessment of eating posture. Administration of fortified nutritional supplements, a combination of leucine-enriched amino acid intake, and rehabilitation effectively improve sarcopenia and ADL ^{(57), (58)}.
Respiratory diseases	Nutritional therapy such as dietary advice and fat and/or protein-enriched supplementation for stable COPD patients increased body weight, muscle mass, 6-min walk distance, and health-related QOL ⁽⁷¹⁾. Small and frequent oral intake is effective in avoiding dyspnea. The combination of exercise therapy such as resistance training and walking exercises and nutrition therapy effectively increases body weight and muscle mass and improves exercise tolerance, especially in patients with malnutrition⁽⁷¹⁾.
Cardiovascular diseases	In the therapeutic strategies for cardiac cachexia, comprehensive cardiac rehabilitation is useful, including appropriate heart failure medications, nutrition therapy, and exercise. Aerobic exercise training counteracts skeletal muscle wasting in addition to improving exercise tolerance. Resistance training is also recommended for cardiovascular disease patients with frailty and sarcopenia. In patients with chronic heart failure, protein intake of 1.2-1.5 g/kg and caloric supplementation based on 25-30 kcal/kg depending on the degree of stress ⁽¹³³⁾ should be combined with exercise therapy.
Diabetes	Aerobic exercise and resistance training or a combined approach reduce the risk of developing type 2 diabetes and improve cardiovascular disease risk factors ⁽¹³⁴⁾. Nutritional therapy optimizes total energy intake (25-35 kcal/target body weight/day) and corrects nutrient imbalances such as limiting saturated fatty acids.
Kidney disease	Aerobic exercise and resistance training are recommended to improve exercise tolerance and QOL. In nondialysis patients with severe renal dysfunction, exercise intensity is adjusted according to age and physical function ⁽¹³⁵⁾. Energy and protein intake according to the severity of kidney disease and sarcopenia. In patients with low L-carnitine levels, the administration of L-carnitine maintains and improves exercise tolerance and muscle mass ⁽¹³⁶⁾.
Liver disease	Nutritional therapy (energy: 35-40 kcal/kg/day, protein: 1.3-1.5 g/kg/day) such as BCAA supplementation and late evening snacks are recommended ⁽¹³⁷⁾. Aerobic exercise, resistance training, or a combined approach is effective, but it needs to be careful with decreasing hepatic blood flow during and after exercise.
Cancer	A multidisciplinary approach, including physical and nutritional therapy, is recommended to improve the response to treatment, prognosis, and QOL ⁽⁴⁴⁾. The combination of aerobic exercise and resistance training effectively improves fatigue and QOL. Nutritional physical therapy needs to be considered based on cancer treatment or palliative care.
Sports	Athletes’ physical activity decreases immediately after injury or surgery, while rehabilitation and training for returning to competition often involve high-intensity exercise ⁽¹⁰⁶⁾. Therefore, exercise energy expenditure and energy stores need to be considered in terms of energy needs ⁽¹⁰⁶⁾. Because female athletes are prone to low energy availability (LEA), physical therapists should conduct nutritional screening including LEA (weight, eating disorder, bone density/damage, amenorrhea, etc.) ^{(110), (138)}, when conducting rehabilitation.
Anorexia	The American Psychiatric Association guidelines recommend starting at 30-40 kcal/kg/day and increasing 70-100 kcal/kg/day during the weight gain phase ⁽¹¹²⁾. The National Institute for Clinical Excellence guidelines for anorexia nervosa set a weekly weight gain goal of 0.5-1 kg for inpatients and 0.5 kg for outpatients, adding approximately 3,500-7,000 kcal/week ⁽¹¹³⁾. Controlled physical activity ⁽¹¹⁶⁾ and low-intensity resistance training ⁽¹¹⁷⁾ are safe and beneficial for restoring body composition, maintaining bone density, and decreasing anxiety ⁽¹¹⁵⁾.
Depression	The Mediterranean diet is associated with a lower risk of depression ⁽¹²⁰⁾. Eicosapentaenoic acid and docosahexaenoic acid are effective in treating mood disorders, impulse control disorders, and psychotic disorders ⁽¹²¹⁾. Both aerobic and resistance exercise are beneficial for depression, and the higher the intensity and volume of exercise, the more effective ^{(123), (124)}.

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