“Lettuce” be Sustainable: Why does (and should) a Physical Therapist Care About Sustainable Agriculture in 2020?

Masks, fear, illness, death, economic shutdown, hoarding and empty grocery store shelves.  These things are forever etched in the history books of 2020 in association with the COVID19 pandemic.  Pre-pandemic, most Americans were fortunate enough to have never experienced any problem with food supply and took fully stocked grocery stores for granted. However, for years, food production and distribution processes have been vulnerable to breakdown in the face of environmental, economic and sociopolitical crisis.  The COVID19 pandemic has merely illuminated this.  But the problem runs deeper than simply not having the grocery store shelves fully stocked. Even when contemporary food production and distribution processes are running smoothly, they produce foods that have diminished nutritional value by the time they get to the grocery store shelves. And it gets worse every year. To put it simply, the broccoli in today’s produce section has less nutritional value than the broccoli of 5 years ago.  The declining nutritional value of our food has been a key driver of the rise of illness resulting from metabolic disorders in the United States.  And those with metabolic disorders have weakened immune systems and are more prone to illness such as COVID19. All of the processes associated with production, distribution and waste management, otherwise known as our “food system” is intimately intertwined with human health.  

And the intimate relationship between our food system and human health is exactly why I care about this as a physical therapist.  Lack of access to healthy foods lowers the potential for all of us to lead active and healthy lives. Poor nutrition is even the root cause of why people end up in physical therapy in the first place.  I spend part of my time as a physical therapist working at a skilled nursing facility.  We frequently receive patients from hospitals that have been diagnosed with metabolic encephalopathy, which alters ones mental state.  The cause of metabolic encephalopathy is often liver disease, uncontrolled diabetes and kidney disease, which for many people is preventable with good nutrition.  Poor nutrition also increases the risk of infection and often our metabolic encephalopathy patients come in after they’ve suffered a urinary tract infection.  While these types of metabolic encephalopathy are reversible with overcoming infection and getting metabolism back in check, these people spend weeks in recovery and develop severe weakness and difficulty with daily activities (i.e., walking, getting out of a chair).  This health decline often results in significant loss of quality of life and for some causes them to lose their ability to live independently.  Furthermore, lack of access to good nutrition is especially problematic for people overcoming injury or coping with chronic illness.  The outcomes that I can help my patients achieve through physical therapy interventions (i.e., increased strength, endurance, mobility, decreased pain) are diminished when they don’t have access to healthy foods that complement their physical rehabilitation.  The role of nutrition in our physical well-being is not to be underestimated.  

COVID19 has monopolized the news in terms of illness and death rates, for obvious reasons, but it is interesting to put some facts and figures into perspective.  About 50% of Americans have diabetes or are pre-diabetic and 530,000 people die annually in the U.S. due to poor nutrition, which is almost 1500 deaths per day (Dr. Mark Hyman podcast: What does food have to do with COVID19?).  By comparison, about 265,000 people have died from COVID19 in the US so far this year, with only about 1 month left in the year.  This is absolutely not to diminish the gravity of the COVID19 situation or diminish the value of the lives that have been lost due to it.  However, it is important to point out the magnitude of the nutrition problem in the U.S.  Most perceive that malnutrition is a problem that is restricted to 3rd world countries.  Not so.  What’s more is that poor nutrition and COVID19 have an important linkage.  People who are more vulnerable to COVID19 infection and subsequent death are those that are “metabolically compromised”.  Good nutrition is necessary to have a strong immune system to fight of infection of any kind—including COVID19.  Specifically, one might consider zinc, vitamin A and vitamin C which are critical, among other nutrients/vitamins, for a strong immune system and nearly 40% of Americans are not getting adequate daily intake of these.  The short story is that our resilience against death from COVID19 or any infection could be drastically improved through good nutrition that supports our immune system.  Should I mention at this point that 60% of your immune system resides in your gut?  Hyman podcast: What does food have to do with COVID19?)  Yep.  That means the quality of the food you eat is of utmost importance.  


To illustrate why food insecurity exists as well as the relationship between the food system and human health, let’s examine the three major parts of our food system and their vulnerabilities to environmental, economic and sociopolitical crises:

  • Food Production/Processing: In the United States, food production utilizes 50% of land and 80% of the total freshwater that is consumed (Gunders, 2012).  This rate of water usage is faster than aquifer recharge in some regions (Sachs 2015). Food production also depends heavily on fertilizer and pesticide application, which is adversely impacting ecosystem biodiversity (Sachs, 2015).  Additionally, farming is increasingly focused on the mass production of fewer staple crops (i.e., wheat, corn and soy).  Reduced crop diversity reduces the nutritional value of the average diet and makes food production less resilient to environmental change (Khoury et al., 2014; Hunter et al., 2016).  For instance, should an insect that damages wheat dramatically increase in abundance during a particular growing season, a region that is focused solely on mass production of wheat will have its entire product decimated. On the contrary, a region that is producing greater crop diversity, might still, on the whole, be successful that season. The amount of processing a particular crop requires has been especially highlighted by the pandemic.  During COVID19, meat producers got hit especially hard as workers became infected with the virus and were unable to work.  Slow production increased prices and slowed supply of meats across the country.  In contrast produce that is processed in more automated ways using machinery (e.g., nuts) was less affected by the Pandemic.  
  • Food Distribution: Much of America’s produce is transported over long distances from farms to urban centers.  This transport consumes 10 % of the total energy budget in the U.S. (Gunders, 2012) and contributes to food waste as it spoils or is contaminated enroute (Sachs, 2015).  The average meal in the U.S. has traveled 1500 miles from farm to table (CUESA).  By the time produce has traveled 1000 miles or more to its destination, it has likely lost substantial nutritional value (Rickman et al., 2007).  Reliance on these long food distribution routes threatens food security in urban areas, where over 54% of the World’s population is concentrated (UN, 2018); Reliance on food supply from distant regions puts sustenance of Urban centers at the mercy of natural disasters in distant locations.  For instance, when people of the intermountain West rely heavily on produce from California’s Central Valley, their food supply may suffer in the event of large wildfires in California.  Furthermore, urban reliance on food produced in distant locations limits accessibility to produce that has short shelf-lives and, therefore, poor transportability.  This in turn, increases urban dependence on heavily processed and packaged foods that travel well but do not contain well-rounded nutrition.  Many urban areas are turning into “food deserts” in which people do not have ready access to a complete compliment of required nutrients (Walker et al., 2010).  Many pre-packaged foods contain excessive amounts of calories, but lack the well-rounded nutrition (i.e., sufficient amounts of vitamins and minerals) that humans need.  As a result, urban areas experience a dichotomous problem of nutritional excess, yet insufficiency.  This is exemplified by one-third of the world’s people being overweight and/or undernourished (Sachs, 2015; Garnett, 2013; Remans et al., 2014).  This problem impacts countries of every economic status (Garnett, 2013). It is now estimated that 19 million Americans now live in food deserts and the Pandemic could double the number of people across the globe that are experiencing food insecurity (Silva, NPR, 27 Sep 2020).  Food insecurity may have hit as many as 23% of American households in early 2020, up from 10.5% (13.7 million households) last year (Silva, NPR, 27 Sep 2020).  These numbers include people who were not able to obtain enough food to meet their needs or had uncertainty in how to obtain their next meal (Silva, NPR, 27 Sep 2020).  During the COVID19 pandemic in early 2020, issues surrounding distribution were observed in the dairy industry.  For instance, dairy producers that package and sell to restaurants and schools could no longer do so as restaurants and schools closed during the pandemic. Because of the specificity of their production and distribution lines to restaurants and schools, dairy companies were not able to quickly pivot and redirect milk to other end users.  This resulted in a lot of dairy products in both the US and the UK being dumped.  
  • Food Waste Management: 40% of the food produced is never consumed, comprises the largest component of municipal waste and is responsible for a large fraction of annual methane emissions in the United States (Gunders, 2012).  Food waste occurs at several different points during its life cycle: 1) food spoil and are thrown away during transport from farms to urban centers, 2) Food spoils or expires on store shelves or in consumer’s homes before it can be eaten, 3) food is wasted during meal preparation in the home (i.e., broccoli stems are trimmed and thrown away instead of eaten), 4) people don’t eat 100% of each meal that they prep and the unwanted food is thrown into the trash.  Uneaten food contains vitamins and minerals, that, if composted and returned to the soil, could be used to fuel the production of more nutritious food.  But instead, food that is thrown into the trash makes its way to the landfill where nutrition is lost forever rather than being used to recondition our soils and thus allowing us to continue producing food with high nutritional value. In throwing food into the landfill, we are defeating the natural process of composting that replenishes soils of their nutrients.  This in combination with farming processes increase erosion and result in nutrients being leached out of soils and washed into rivers and waterways has greatly diminished the quality of our soil and our ability to produce nutritious food.  Food waste increased during the COVID19 pandemic as producers were unable to redirect their product to alternative consumers.    Potato farmers in Idaho were left with piles of potatoes in the fields that went to waste because restaurants were closed.  Some of these potatoes were redistributed to the average consumer and some were trucked off to New York (what did we say above about the problems of long transport lines?), but more waste than usual was incurred.  Even cabbage farmers in India, who rub elbows with starving neighbors had excess food waste secondary to people losing their jobs and being unable to buy the produce.  But the COVID19 food crisis was not limited to third world countries—it hit hard in the United States too, with many people needing assistance from food banks as jobs dried up and people became unable to afford basic needs (Martin, NPR, Sep 27, 2020).  It is estimated that nearly 1 in 4 households in America have experienced food insecurity this year (Silva, NPR, Sep 27, 2020). 

Our food System Creates Mineral Deficient Foods

To specifically illustrate how our food system fails in producing food with maximal nutritional value—even in the absence of a Pandemic– we can talk about minerals (i.e., iron, zinc). Because our food system generates foods that are deficient in minerals, over 60%, 30% and 15% of the World’s seven billion people are iron, zinc and selenium deficient, respectively (White and Broadley, 2009).  Rates of mineral malnutrition are especially high in Asia and Africa (Muthayya, et al., 2013), where soil degradation is especially severe and has significantly decreased the nutritional value of crops (Lal, 2009).  Iron, zinc and selenium are just three of the minerals that the human body needs for overall health and wellness—there are many more, but are beyond the scope of this article.  Using iron, zinc and selenium as examples, here are some of the profound effects that they can have on our health in general and can specifically affect one’s course through physical therapy/rehabilitation:

Iron is critical for proper nerve functioning, temperature regulation, immune system function—just to name a few important things.  It is also critical for the ability to brain derived neurotrophic growth factor to signal other neurons and assist one’s body with learning new motor patterns—a concept known as neuroplasticity.  After neurological injury (i.e., stroke) or in the presence of a degenerative neurological condition (i.e., Parkinson’s Disease) it is especially important that good nutrition be part of a physical rehabilitation program so that the body can optimally learn and perform new movement skills.  

Zinc plays important roles in motor function (again, especially important for physical rehabilitation!), immune system function, mood and improving attention span (both of which are critical for learning!). 

Selenium is very important for cognitive function, immune system support and thyroid metabolism.  Thyroid metabolism is critical in maintaining one’s energy and mood and motivation for effortful things such as physical rehabilitation.  

More than likely, you or someone you know are affected by one or more of these deficiencies.  And with improved nutrition, their overall quality of life and ability to maximize their potential could be greatly enhanced.  


The solution lies in getting to the root of the problem—literally.  To summarize in the simplest way possible: 1) The problem begins with our soils, which are being more and more nutrient depleted through the years and crop plants do not have access to enough nutrients to produce a nutritious end product.  2) We then transport food long distances from farm to table, during which it loses more nutrition.  3) We then throw away a lot of food either as it spoils enroute to supermarkets, during prep or after it spoils in individual households; the food that goes to the landfill rots and produces greenhouse gases rather than being composted by mother nature to replenish the soil for growing the next crop.  This means that we need a three-part solution which includes the following 1) bringing the farm closer to the table, 2) reducing overall food waste and 3) properly composting unavoidable food waste in order to replenish our soils with the nutrients needed to grow the next nutritious crop. 

There are solutions in the works on bigger scales through the regenerative agriculture movement, which is shifting farms away from traditional industrial farming.  Regenerative agriculture includes methods that do not apply chemicals and fertilizers at massive scales, involve no till methods to preserve our soils and, overall, work with mother Nature rather than against her.  A review of regenerative agriculture is beyond the scope of this article and you can learn more about that here: Dr. Mark Hyman. Can regenerative agriculture really heal humans and the planet?.  While regenerative agriculture could greatly improve the quality of the foods that are being produced and prevent degradation of the land, it requires wide adoption across the United States to make it effective in improving public health which will take time and it does not necessarily solve the fact that food would still be traveling 1000’s of miles to market.  We need a solution in the interim that people can act on now and have healthy food on their table quickly.   

So what is a concerned physical therapist to do?  Let’s first talk about the role of a physical therapist in patient nutrition.  

A physical therapist’s role in patient nutrition

It’s been slow for the masses—and even those within the physical therapy profession—to realize and embrace that it is within our scope of practice to educate patients on nutrition.  In fact, in a seminal paper published back in 2009, physical therapist Elizabeth Dean, stated that “….physical therapists are uniquely qualified to lead in the assault on lifestyle conditions” (Dean 2009).  She also goes on to note that in leading the assault on lifestyle conditions, physical therapists are positioned to promote the health of communities.  The American Physical Therapy Association’s stance on the role of physical therapists in patient nutrition is that “it is within the professional scope of physical therapist practice to screen for and provide information on diet and nutritional issues to patients, clients, and the community.” (APTA).  While physical therapists certainly don’t replace registered dieticians who can come up with very specific nutritional plans, physical therapists can be instrumental in screening for nutritional red flags and educate patients on what avenues might be good to go down with their nutrition as well as what specifics may be important to pay attention to given a patient’s unique situation.  For example, those with rheumatoid arthritis may want to consider a Mediterranean Diet which has been shown to reduce overall levels of inflammation in the body (Arthritis Foundation).  

However, a physical therapist’s job becomes more difficult when the problem has deeper roots than someone simply not eating the right foods.  Even when all of us eat the “right foods” we are likely not getting a full complement of vitamins and minerals due to our failing food system.  

So can a physical therapist still play a role in solving this problem? If we take an unconventional approach, I believe the answer is yes. We need to add some elements to our education—which include empowering people to produce some of their own food.  And YES.  The great majority of people living in all kinds of climates and parts of the country CAN do this.  

What I am doing to change the face of nutritional education

As a former professor and researcher at Idaho State University (Pocatello, ID, USA), I began developing a method for sustainable agriculture that can be implemented in even the smallest of urban apartments.  My students and I determined that by composting household wastes (i.e., vegetable scraps, paper, coffee filters), we could reduce the waste of a single person household by 46% all while generating compost that we could utilize to grow nutrient rich greens—microgreens specifically. To do this, we used a commercially available vermicomposter from Uncle Jim’s Worm Farm (https://unclejimswormfarm.com).  Yes—vermicomposting means composting with worms. 

In doing so, individuals could reduce their dependence on buying produce from the supermarket that had traveled 1000’s of miles from the farm where it was produced using methods that are resource heavy and degrade soils.  All the while, individuals could increase their food security and nutritional intake by bringing their farm and table right next to each other.   

For those of you who haven’t heard of microgreens, they are the edible seedlings that are usually harvested seven to fourteen days after germination when they have two fully developed cotyledon leaves (Xiao et al. 2012).  A wide variety of herbs (e.g., basil, cilantro), vegetables (e.g., radish, broccoli, mesclun) and even flowers (e.g., sunflowers) are grown as microgreens.  Microgreens are generally more flavorful, some of them quite spicy, than their mature counterparts and have grown in popularity among culinary artists for adding texture and flavor accents to salads, sandwiches and other dishes (Treadwell et al. 2010; Wallin, 2013). The increasing culinary demand as well as the ease with which microgreens can be grown, even by inexperienced gardeners in urban settings, has piqued interests in growing and eating them.  Interest in microgreens has also been generated by popular websites (e.g., Warner, 2012) touting the findings of Xiao et al. (2012), which indicate that microgreens may have four to 40 times the amount of some nutrients and vitamins as the vegetables a mature plant would produce.  However, Xiao et al. (2012) note that the nutritional aspects they measured varied widely among microgreen types, providing fodder for future study and Weber (2016) noted that the methods used to grow microgreens (i.e., soil, compost, hydroponic) can significantly impact their nutritional value.  Additionally, a systematic comparison of the environmental impacts (i.e., water use, nutrient demand) of microgreen cultivation methods has not been conducted and should be considered alongside their impacts on nutritional value when deciding how to grow microgreens and if they provide a nutrient-rich crop that can be sustainably produced.  

You can also use these methods to produce baby greens which are a more mature stage of growth than the microgreen stage.  

Seeds can be purchased from True Leaf Market.

If each one of us could begin producing even some of our own produce using sustainable methods for composting household waste, we could greatly reduce out impact on the environment, increase our food security, relying less on produce that is transported 1000’s of miles and increase our nutritional intake. I call this distributed Agriculture—each household operating as its own little producer.  Distributed agriculture makes one more resilient to environmental and socioeconomic change that is going on in the world outside of our homes.  We specifically looked how growing and consuming broccoli microgreens could reduce impact on the environment relative to consuming broccoli vegetable that is produced in California’s Central Valley. To summarize quickly, broccoli microgreens can go from seed to harvest in 7 days (93-95% less time than needed to produce broccoli vegetable), there is no need for fertilizer, distance of transport from farm to table is zero, and the mineral nutrition the microgreens is 1.73 times that of the vegetable with respect to iron, zinc, magnesium and calcium among other minerals (Weber, 2017). The full summary of this data was published in Frontiers in Nutrition in 2017 (Weber, 2017).  

In addition to the above benefits, growing one’s own food has been shown to be great for reducing stress and enhancing a sense of pride in being able to be more self-sufficient.  The therapeutic effects of growing one’s own food have been proven in many studies and in case you didn’t know there is a form of therapy called Horticultural Therapy.  The therapeutic effects span across all ages and include improved concentration, memory, cognitive function, fine motor skills, personal satisfaction as well as decreased heart rate, stress, and anxiety (Haller et al. 2019).  

If you are interested in learning more about the methods for taking charge of your nutrition and growing your own produce at home, please contact me.  I am currently producing an online course and you can be the first to know when it is being released!  I have had the pleasure of teaching/Lecturing about this topic within the past few years at County Extension Offices in Iowa and the Greater Des Moines Botanical Garden (Des Moines, IA, USA).  Due to the pandemic and the widespread need of this information, I am hoping that a digital course will make this more accessible to the masses.  


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