You don’t have to choose to see people with diabetes in your practice; however, the prevalence of the disease among the population means you almost certainly already are.
Now, an increasing number of practitioners are making the management of diabetes and prediabetes part of their practices.
Their reasons for this are multiple. For one, their help is certainly needed. Nearly 1 in 3 Americans is diabetic or prediabetic, according to a recent Centers for Disease Control and Prevention report.1
Diabetes is a complex disease that requires treatment from a range of healthcare providers. Trained as they are in nutrition and in assessing the overall well-being of patients, chiropractors can add their valuable expertise to care.
On the financial side, managing diabetes and prediabetes can broaden your patient base while also bringing in additional revenue, much of it free of third-party payer hassles.
But the growing involvement of chiropractors in diabetic care is not without controversy. Some medical doctors say chiropractic has no role in treating diabetes and decline to collaborate with DCs. Third-party payers generally will not reimburse chiropractors for services related to diabetes. And some practitioners have gotten into legal and regulatory trouble for making exaggerated claims about how they can help those with the condition.
Nonetheless, the trend is likely to continue. Chiropractors who want to start managing diabetes and prediabetes cases or make them a bigger part of their practices should do it carefully and correctly.
Guiding self-care
Medically speaking, diabetes cannot be cured. The disease can cause a range of associated problems, including heart and kidney disease, stroke, nerve damage and vision problems. However, it can go into remission, meaning the body does not show any signs of diabetes.
Depending on the type and severity of the disease, treatments can range from diet, exercise and weight loss to insulin and other drugs.
While some claim that spinal manipulation alone can improve diabetes by improving the efficiency of organs and the immune system, most chiropractors who make diabetes management a major part of their practices go beyond that.
Weight loss is one of the best strategies to lessen the severity of diabetes and chiropractors can guide patients to healthier lifestyles through exercise and diet. Others use their knowledge of nutrition and supplements to augment lifestyle changes.
Too often, newly diagnosed diabetics resign themselves to a lifetime of insulin, says Corey Schuler, DC, who has an integrative practice in Hudson, Wisconsin. “Primary care physicians don’t give them a lot of hope,” he says.
With their overall emphasis on wellness, chiropractors are in a position to guide patients to healthier lifestyles.
“Diet and lifestyle have always been thought of as self-care. Now we know self-care can require guidelines,” Schuler says.
Evaluating patients
Some patients arrive already diagnosed with diabetes by a medical doctor. Others demonstrate symptoms of the disease or prediabetes, but have not yet been diagnosed. While chiropractors cannot diagnose diabetes, they can encourage patients to be tested.
Patient evaluation varies by chiropractor, but it typically begins with discussions about lifestyle, exercise, nutrition, existing medical conditions, stress and thoughts about treatment and the disease. Not only does that give the chiropractor a more complete picture of the patient, but it can reveal how best to approach patient management.
Depending on what the evaluation reveals, chiropractors might order standard lab tests, such as a complete blood count, metabolic panel, glucose test, A1C and urine. Individual practitioners often add additional tests based on their own specialties and expertise.
For example, Andrew Marrone, DC, owner of Redmond Ridge Nutrition & Chiropractic in Redmond, Washington, checks for sources of mechanical, emotional and nutritional stress in patients. One test involves touching parts of the body related to various organs and looking for muscle contractions that indicate inflammation. This specialist in enzyme nutrition does it for fasting patients, then gives them a nutrition shake and repeats the test in 45 minutes to reveal the troubled organs.
Nutrition is also a focus for Schuler, who is director of clinical affairs for a company that makes and distributes nutritional supplements. The certified nutrition specialist and licensed nutritionist evaluates a patient’s muscle mass visually or by measuring body fat. “Skeletal muscle is the primary metabolic engine,” he says. “The more muscle mass, the easier it is to change the body.”
He then asks if a patient has ever been vegan or vegetarian and checks to see how they respond to three diets: vegetarian, Paleo-Mediterranean, and nutritional ketosis. Because different diets work for different patients, Schuler has them try all three while charting their moods, energy levels, sleep patterns and pain. Usually, the testing reveals which diet will help the patient most, he says.
In addition to standard labs, Wayne Carr, DC, of Carr Chiropractic Clinic, which has five locations in South Dakota, might take stool samples and perform tests for food sensitivities. “I don’t want to just treat the blood sugar and not the other issues because what I’ve learned is the blood sugar is a symptom of other things going on,” he says.
Overcoming skepticism
Many patients don’t think of asking their chiropractors for help with diabetes or prediabetes, even if they’ve benefitted from other chiropractic treatment. For them, the perception that chiropractic is solely about spinal manipulation is just too strong to overcome.
“It’s challenging to get people to listen when they come in with an ankle injury or pain in their lower back and to tell them you want to integrate wellness into their treatment,” Carr says.
Chiropractors who practice functional medicine or who have incorporated wellness treatments into their practices are likely to have an easier time than are those whose practices are solely about manipulation.
Marrone says he counters patient skepticism by pointing out that chiropractors and medical doctors receive similar educations, only chiropractors have additional training in nutrition. If they’re still doubtful, he challenges them: “You’ve tried everything else and it hasn’t helped. You’re already doing what Dr. Google tells you to do and it isn’t working.”
Carr built his credibility in his small community by volunteering with civic health initiatives and working with local schools to address student obesity. “I’ve earned a repu- tation around here as a wellness guy, not just a chiropractor,” he says.
A wellness message can be a tough sell in rural South Dakota, so Carr works slowly, focusing first on diet, then exercise, mindfulness, stress, sleep and social interaction before turning to supplements.
“You keep going and change one person at a time and hope they change someone else,” he says. “I don’t want to be the doctor who hands them a pill without the lifestyle change.”
Once they’ve experienced the improvements that come with an improved diet, exercise and effective supplements, once-skeptical patients become believers and are motivated to continue the treatment.
Money matters
As a rule, third-party payers, whether private or government, will not reimburse chiropractors for diabetes management or related wellness services.
The plus side of that is that it means it’s often a cash-only service, free of insurance company red tape, negotiated rates, and reimbursement delays. Chiropractors can set their own rates and get paid directly. Supplements sold as part of the treatment also can be a robust profit center.
Adding wellness services, including diabetes management, increased Carr’s revenues 25 to 40 percent.
The downside is that, without insurance coverage, many patients will decide that they cannot afford treatment, particularly if they already are paying for treatment from medical doctors.
Marrone stresses to patients the value of being able to live the lives they want with fewer restrictions from diabetes. He also offers patients flexible payment plans.
Carr says some insurers will pay for lab tests if ordered by a chiropractor, but many will not. So plan on cash-only services.
Coordinated care
While successful management of diabetes typically requires a team of healthcare providers, which might include a primary care physician, endocrinologist, dietitian, nephrologist, ophthalmologist and others, chiropractors typically aren’t on the roster.
In his 10 years of practice, Schuler says he’s never had a patient referred for diabetes by a primary care physician, something he views as a significant hurdle. And medical doctors aren’t always happy to hear that their patients are seeing a chiropractor for help.
But it’s crucial for chiropractors who work with patients with diabetes or prediabetes to collaborate with the primary care providers leading the care team.
“While we have a role in the management, it’s really important that we not scare people away from the care being given by their primary care physician or specialist,” Schuler says, adding that communication with primary care physicians and others has improved greatly in the past five years. The most common source of disagreement is over supplements, he adds.
Chiro One Wellness Centers, a group of more than 40 independently owned and operated clinics in the Chicago area, stresses communications with other providers, says Stuart Bernsen, DC, CEO of Medulla, LLC, Chiro One’s parent company.
“We can work in tandem with our patient’s PCP or specialist to coordinate the proper therapeutic exercises and nutritional needs into our chiropractic treatment programs. Best practices still remain as a phone call and verbal follow ups with the patient and their ancillary providers,” Bersen says.
Legal pitfalls
The opportunity to further help patients, as well as the money to be made in treating diabetics, has drawn a growing number of chiropractors into this specialized field.
However, those who overstep and overpromise in their management of diabetes can find themselves in legal and regulatory trouble. Some unscrupulous DCs have taken out ads promising to cure diabetes. These practices promote free seminars and dinners, where guests are told of groundbreaking new research and pressured to sign up for expensive treatments.
State licensing boards have cited practices for running misleading ads, for claiming to be able to cure diabetes, and for implying that their services are provided by medical doctors, not chiropractors.
While there is nothing wrong with promoting diabetes management, chiropractors must be careful not to overstep their legal bounds.
Though it presents challenges, diabetes management is an exciting and rewarding opportunity for chiropractors who desire to help patients while increasing their revenues.
For some, like Carr, it’s a chance to practice to the fullest extent of their knowledge and ability.
“This is what chiropractic is and was supposed to be. We just don’t toot our horns loud enough. We just need to include it more and let people know this is what we do,” he says.
James F. Sweeney is a freelance writer in Cleveland. He is a former newspaper and magazine reporter and editor. He can be contacted at jfsweeney61@gmail.com
Reference
1 Centers for Disease Control and Prevention. “New CDC report: More than 100 million Americans have diabetes or prediabetes.” CDC Newsroom. https://www.cdc.gov/media/ releases/2017/p0718-diabetes-report.html. Published July 2017. Accessed Dec. 2017.
