March/April 1998

Challenge: How can you and your patients profit from nutrition?

Chiropractors like to say they are wellness-oriented physicians. This claim is often made even though the DC does not perform dietary assessments or exercise/strength assessments. Fundamentally, it is nearly impossible to assess health and wellness without a dietary analysis.

This article offers a nutritional approach that is:

1. Thorough and scientifically based.
2. Easy to implement.
3. Chiropractic-friendly.
4. Patient-friendly.
5. Profitable.

In the past, dietary assessments tend to be time-consuming and cost ineffective. With nutritional analysis provided by companies that specialize in this service, both problems are solved. The companies basically do all the work, and the doctor makes a reasonable profit. The nutritional assessment can also demonstrate why a patient should be taking a vitamin/mineral supplement, which can add to the doctor's income.

If the doctor doesn't want to get personally involved with nutritional assessments, another option is to send the patient directly to the servicing company. This allows the doctor to have a wellness practice without actually having one. Either way, the doctor's patients can benefit greatly.

Important facts not widely known about nutrition

It is commonly thought that each disease process can be caused by different nutritional factors, which is why many think that nutrition is confusing and overwhelming. Generally speaking, this commonly held belief is a myth.

In fact, conditions such as diabetes, cancer, heart disease, chronic pain, low energy, fibromyalgia and many others, are all caused by similar dietary imbalances. For example it is thought that most diseases are promoted, in part, by free radical generation, which is enhanced by a deficiency in antioxidants. There are many other dietary imbalances which promote disease through different mechanisms [these will be discussed below].

Office procedures

During the initial exam, it is common to find that patients are sensitive to normal palpation. In other words, normal palpation of the spine, spinal muscles, shoulder muscles and pelvic muscles can often be very painful. From a biomechanical and musculoskeletal perspective, this exam finding suggests that manual therapy is required such as chiropractic adjustments and trigger point therapy. However, from a biochemical perspective, this exam finding suggests the presence of biochemicals that cause inflammation, nociception and pain. It is known that the production of these biochemicals is greatly influenced by the content of our diet.

Phase 1: After you finish your exam and any treatments you might provide, explain to the patient that you need to assess their diet for any imbalances that may be promoting inflammation and inhibiting tissue healing. Give a diet diary to the patient and explain that s/he must carefully list all the foods and beverages consumed each day, including specific quantities and food labels. Ask the patient to read the diet diary instructions in the waiting room and make sure that everything is clear and understandable. This nutritional encounter usually takes less than a minute of the doctor's time, and patients rarely have any questions because the instructions should be very clear and precise.

Phase 2: We have 3-, 5-, and 7-day diet diaries available. I mention this because you will usually see the patient at least once before the diary is completed. During this visit, ask the patient if everything is going well with the diary and mention again that it is important to report food intake as accurately as possible. This nutritional encounter involves only a few seconds.

Phase 3: On the next visit, the patient will usually bring their completed diet diary. Have one of your assistants put the diet diary into the mail, and send it to a nutritional analysis company. (There are several companies who provide similar services; check with your supplier or manufacturer for the name of one if you do not currently have one). This nutritional encounter involves a few moments of the CA's time and none of the doctor's time.

Phase 4: Give the patient a "workbook" for nutrition, and any supplemental information such as an audio cassette. The workbook should include information such as: special instructions, personal information, more diet diary forms, vitamin and supplement information and contact information. You can create your own workbook or use one from the servicing company, if available.

Tell the patient to go through the workbook program before their next visit (it takes about 40 minutes). The workbook explains how nutritional imbalances can impact upon general health and subluxation/joint complex dysfunction, and also explains how to eat properly. Most questions that a patient may have about nutrition should be answered in the workbook program. This nutritional encounter takes only a few seconds. [A workbook program is optional, but will really help educate the patient and reduce/eliminate the number of questions asked.]

Phase 5: By the next visit the nutritional report should be in the doctor's office. Schedule the patient so they arrive 15 minutes early and have the patient look over the report while they are in the waiting room. This will allow the patient to become familiarized with the report and make it easier on the doctor to explain the "almost" self-explanatory results. This nutritional encounter does not take up any staff time at all.

After chiropractic care, take the patient into your office or consultation room to go over the report (Phase 6). At this point, your total time investment may be around five minutes.

Phase 6: Review of nutrition report. (This nutritional encounter takes about 10 minutes, for a total of 15 minutes. At the most, maybe an hour will be devoted to nutrition over a period of visits. Of course, you can always spend more time if you wish.)

Step 1: Ask the patient if the information in the report, a basic overview, was understandable. Then provide the average caloric intake per day during the diary period. Explain that this is a good reflection of their general eating habits. Also mention that most people do not eat a sufficient amount of calories to insure nutrient adequacy. Next, comment on the quantity of fiber in their diet if it is low, and read the recommendations.

On the following pages, you will find bar graphs that compare intake of amino acids, vitamins and minerals. Make sure your patients see how they compare to the RDA. Most patients are low in several nutrients. Despite the fact that multiple deficiencies can exist, patients do not typically understand what this means for them personally as it relates to their clinical condition and long-term health prospects. To solve this problem, we have created graphs with direct clinical and personal significance, as they illustrate the nutrients needed for effective tissue healing, energy production, antioxidant defense and many more topics. Upon viewing this information, most patients finally begin to see how their nutritional habits are at odds with their desire to feel well, and consequently patients feel compelled to change their nutritional habits.

The remaining steps, 2-8, are devoted to discussing the clinically relevant graphs. As you read along and look at the graphs, imagine that these graphs represent the nutrient intake of yourself, a loved one, or one of your patients.

Step 2: Figure 1 illustrates some of the nutrients needed in tissue healing. Explain that adjustments improve the function of muscles and joints, but nutrients allow for tissue healing. Explain that tissue healing can be delayed due to poor dietary habits. Ask the patient what their low levels will mean for them personally. It is always best to let patients comment on the obvious problems, for it encourages patients to convince themselves of the need to modify their diet.

Step 3: Figure 2 graphs the nutrients needed for energy production. This graph is particularly significant for most patients considering the fact that "fatigue" and "lack of energy" are extremely common complaints. Most patients incorrectly think that sugar or coffee gives the body energy, when in fact the listed nutrients are the real drivers of energy production in the human body. It takes only seconds for patients to better understand why they may feel fatigued. You can also explain that spinal muscles are a special type of muscle (i.e, type 1, slow twitch, oxidative) that require a continuous production of energy.

Step 4: Figure 3 graphs some of the varied nutrients involved in antioxidant defense. Explain that antioxidants protect against free radical damage. Free radicals come from a variety of sources such as cigarette smoke, drugs, pollutants, and normal body reactions. Research has shown that free radicals are associated with arthritis, cancer, cataracts, multiple sclerosis, heart disease, Parkinson's disease, Alzheimer's disease, and many other diseases. Explain to the patient that it is important to consider the long-term ramifications associated with low intake of antioxidant-related nutrients.

[Special note for the doctor: Many of the nutrients listed are not typically thought of as antioxidants; however, each nutrient plays a role in antioxidant metabolism. For example, riboflavin (B-2) is not typically thought of as antioxidant nutrient; however, B-2 is a cofactor for glutathione reductase, which is an antioxidant enzyme that works in conjunction with selenium-dependent glutathione peroxidase.]

Step 5: Figures 4 and 5 should be discussed together. Figure 4 lists the average number of calories consumed and also illustrates the percent of calories contributed by carbohydrates, proteins, and fats. Recall that 1 gram of protein and a gram of carbohydrate will provide 4 calories, while a gram of fat provides 9 calories.

At the present time there is no known "ideal balance" of these three dietary components. It was once thought that a balance of 60-70% carb, 10-15% pro, 20-25% fat was appropriate, i.e., a 65:10:25 balance. Unfortunately, many still mistakenly interpret this somewhat arbitrary estimate as the gospel truth.

Research now suggests that carbohydrates should not exceed approximately 50% of calories, because they tend to promote the release of diabetogenic, atherogenic and pro-inflammatory substances [excessive insulin release over time is considered to be one of these substances]. The most well-known promoter of a low carbohydrate diet is Barry Sears, PhD, author of "The Zone." Sears proposes that a 40:30:30 balance is desired.

Researchers at Stanford University suggest that a 45:15:40 balance is optimal. However, it may be that a 50:25:25 or a 40:20:40 balance is best. In actual fact, we may never know the optimal balance; and "optimal" may even vary from person to person. However, it does appear that the high-carb, low-fat diet should be avoided by all. This is the main point that should be stressed as you review Figure 4 with your patients.

Figure 5 focuses on the carbohydrate to protein ratio. Once again, we find that there is no known "optimal balance" for all. When reviewing Figure 5 with your patients the easiest way to explain carb:pro balance is to say that the ratio should be less than 3:1,** and anything higher tends to be pro-inflammatory, i.e., disease promoting.


**The ratio of 3:1 was derived from the percent of calories as illustrated in Figure 9. As described above, we have been known to go as low as 40:30:30 and as high as 45:15:40 for carbohydrates, proteins and fats, respectively. This translates into a 40:30 [1.3:1] to 45:15 [3:1] ratio of carbohydrate to protein.

Step 6: Figure 6 illustrates dietary fat balance, and Figure 7 lists individual fatty acids.

The first topic to discuss is dietary fat balance (Figure 6). Researchers at Stanford University propose that total fat intake should be balanced as follows: 50% monounsaturated, 25% polyunsaturated, and 25% saturated. Most patients are far from this balance. Explain that olive oil is an excellent source of monounsaturated fatty acids, and should be used for cooking and in the making of salad dressings.

The second topic to discuss is the omega-6 (n-6) to omega-3 (n-3) fatty acid ratio Commonly known n-6 fatty acids include linoleic acid (safflower, sunflower, corn oils) and arachidonic acid (animal products), and common n-3 fatty acids include linolenic acid (leafy green vegetables and flaxseed oil) and eicosapentanoic acid (cold water fish).

Both the n-6 and n-3 fatty acids are considered to be polyunsaturated. Research suggests that we should consume a 1:1 ratio of n-6 to n-3 fatty acids. Most people average around a 15:1 ratio, which is thought to promote inflammation and a variety of diseases.

Let your patient consider how far off the mark they are from optimal balance. Let them know that it is very difficult to approach a 1:1 ratio with diet alone, which is partially due to the changes in feeding practices of the various animals before their products are brought to market. Consequently, it appears to be necessary to supplement the diet with n-3 fatty acids. Fish oil appears to be the best choice, as it contains appreciable amounts of eicosapentanoic acid (EPA) and docosahexanoic acid (DHA). It should be mentioned that the n-3 fatty acids have significant anti-inflammatory properties which are very beneficial to chiropractic patients.

Step 7: Figure 8 illustrates some of the nutrients needed for neurotransmitter synthesis. The neurotransmitters we are referring to include dopamine, norepinephrine and serotonin. These neurotransmitters are produced in the brain stem and then projected into various parts of the brain, particularly the limbic system. The limbic system can be referred to as the "motivational" and "emotional" brain. In brief, you can explain to your patient that the nutrient-transmitter-limbic relationship is very important for promoting the feelings of wellness, and for preventing symptoms such as depression.

Step 8: It is possible that your patient may feel slightly overwhelmed by the degree to which s/he is biochemically compromised. Explain that there is no need to worry and that the dietary recommendations in Figure 9 will solve the problems that were seen in the nutrition report. An expanded version of Figure 9 can be included in your nutritional workbook.

If you decide to use supplements, you will need to provide a form that explains how much and when to take the different supplements. Have the patient review the form and then ask if there are any questions. Because your procedures and presentation were so thorough, the patient is not likely to ask many questions. At this point, the formal nutrition encounter is complete and it took less than 30 minutes over a period of many days. A follow-up analysis should be performed approximately one to three months after completing the first diet diary, to reassess a patient's nutritional habits and their resultant nutrient intake.

In the final analysis, you will make money by using the diet diary and by selling supplements. You also can market your practice by doing seminars on the subject of nutrition and highlight the nutrition program that you offer in your practice. Such nutritional seminars are extremely popular in the business community, social organizations, country clubs, and various women's/men's clubs. We have slides and overheads available for such presentations.

How badly do your patients need nutritional advice?

In fact, the overwhelming majority of patients need the information and procedures discussed in this article. The problem is that only a small percentage of doctors include nutrition in their practice. This should not be the case considering the fact that nutritional deficiencies are pandemic in the United States. For example, in 1985 the US Department of Agriculture published the results of their Nationwide Food Consumption Survey and found that 78% of women did not take in the RDA for calcium; 95% were below the RDA for iron, zinc, vitamin B6, and folic acid; 55% were low in vitamin A, 44% were low in vitamin C, and 76% were low in vitamin E.

These low values should shock most doctors, and demand that we ask how these deficiencies may influence the musculoskeletal structures of our chiropractic patients. Dr. Janet Travell provides some sobering words on this issue. She states, "nearly half of the patients whom we see with chronic myofascial pain require resolution of vitamin inadequacies for lasting relief." Travell emphasizes this point again by stating that nutritional factors "must be considered in most patients if lasting relief of pain is to be achieved." (her emphasis)

Over the last couple of years, most of our clients have been chiropractors. At one point we collected the results of 62 consecutive patients and compared their nutrient intake to the RDAs. We found that 85% were low in calcium, 63% were low in iron, 94% were low in copper, 98% were low in manganese, 68% were low in magnesium, 73% were low in potassium, 44% were low in thiamin, 39% were low in niacin, 53% were low in riboflavin, 98% were low in pantothenic acid, and 94% were low in zinc. Clearly, these patients needed nutritional advice in addition to good chiropractic care and exercise. It is very likely that the great majority of your patients need nutritional advice as well.

Dr. David Seaman is a post-graduate faculty member for several chiropractic colleges and has written numerous articles for trade journals. In addition, his third paper for the Journal of Manipulative and Physiological Thera-peutics (JMPT) will be published in May of 1998. He has also lectured extensively in the United States for State Chiropractic Associ-ations and Chiropractic Colleges on the topics of neurology and nutrition. His lecture focus often centers around the nutritional and dietary factors which reduce inflammation, nociception and pain. Dr. Seaman has translated his postgraduate lecture information into patient education programs on chiropractic care and nutrition, which are marketed through Drs Systems 704-625-2019. In addition, he helped develop the NutrAnalysis program described in this article. To contact them, call 704-692-0779, and/or you can visit their website www.NutrAnalysis. com.