Chiropractors have an opportunity to become the go-to experts in dietary counseling and treatment.
THERE’S A LAND GRAB TAKING PLACE THROUGHOUT THE U.S., a no-holds-barred fight for that great American sprawl: waistlines out of control. Who, ultimately, will command the country’s multibillion-dollar nutrition industry is anyone’s guess.
Like a military combatant, nutrition’s victor will vanquish all comers by successfully staking out and acquiring three strategic targets: the legal authority to diagnose and counsel health conditions associated with nutritional deficiencies, an expertise sufficient to warrant granting this legal authority, and a brand that instills confidence in patients and consumers.
In 2009, the New York Times reported a surge in the sale of vitamins and nutritional supplements just as people were cutting back on many household items due to worsening economic conditions.
The cash-strapped public was self- medicating with dietary supplements, showing a preference for natural remedies and a desire to manage disease at its root. Sales of cold remedies, first-aid products, and pain relievers dipped, while supplements sold briskly.
A question of legal authority
Whoever ultimately “owns” nutrition should be empowered to both diagnose and treat patients on matters related to nutritional deficiencies. Authority that falls short of these elements would unduly restrict practitioners by requiring that someone else perform the diagnosis.
Chiropractors interested in nutrition must tiptoe around the dreaded “unlicensed practice of medicine” charge. Only medical doctors and osteopaths enjoy broad authority to diagnose, treat, correct, and prescribe for disease. Other providers are constrained in the care they can offer, and are generally restricted to specific anatomical areas as with podiatry, or precise methods of administering treatment as with needling points in acupuncture.
Should nutritional counseling therefore be considered “medical treatment” whenever you urge the consumption of foods and dietary nutrients that eradicate nascent diseases? Thankfully, from a legal standpoint, the answer is “no.” Otherwise, instructing someone to breathe deeply could potentially constitute medical advice.
Angling for an advantage
There are more than 60,000 dietitians and nutritionists in the U.S. Among them are certified clinical nutritionists, who are keenly aware that diagnosing disease and rendering treatment will raise the hackles of their medical counterparts.
Pursuant to their 2011 Professional Practice Guidelines, certified clinical nutritionists steer clear of disease nomenclature, electing instead to “educate” their consumers (not patients) rather than “treat” them. They measure and assess people’s nutritional needs with laboratory tests, case histories, and nutritional lifestyle analysis, but only after requesting a signed disclaimer acknowledging that the counsel they offer is “education,” not “treatment.”
The American Dietetic Association (ADA) bills itself as the world’s largest organization of food and nutrition professionals. Its members work with medical teams in such settings as hospitals, nursing homes, and private practice settings. Dietitians defer to MDs by defining a nutritional diagnosis that is distinct from a medical one.
In staking out its territory, the ADA knows licensure is essential. Its website reports that 46 states and jurisdictions currently have laws governing dietetics, 33 currently require licensure, 12 require statutory certification, and one requires registration.
A dietetic licensure advocate in Nevada informed state legislators that “by legally recognizing dietitians as licensed persons in Nevada they would be able to bill direct.” Medicare currently covers nutrition therapy services prescribed by a doctor for diabetes or kidney disease, and several insurance companies already cover nutritional counseling. Other insurance companies could be enticed to offer coverage as states establish standards through licensure and oversight.
Chiropractic scope and nutrition
As a chiropractor, even if you are careful not to tread on medicine’s turf, you may find yourself scrutinized by other disciplines as they act to protect their territory. Assemblywoman April Mastroluca, who recently introduced Nevada’s dietetics licensure bill, gave assurances that Nevada’s new law won’t affect anyone other than the state’s 681 registered dietitians unless someone offers services defined under the scope of dietetics.
For those set on widening their scope, the authority to diagnose and treat disease is the crown jewel. But angling for the perfect scope is like the game “rock-paper-scissors.” It begins with a state association asking its legislature to relax certain scope-of-practice restrictions. Competing healthcare providers then line up to scuttle the request — a scenario played out in a failed throw-down as the Certification Board for Nutrition Specialists (CBNS) urged Nevada’s legislators to deny dietitians’ request for licensure. Rock beat scissors, however, and the dietitians got their license in October 2011.
A chiropractic scope that fails to mention nutrition by name would confer little authority to provide nutritional counseling, and leave chiropractors to fold nutritional therapy into generic chiropractic tenets regarding the promotion of overall health. A scope that specifically authorizes nutritional counseling, with little else, might impede the extent to which you could diagnose and treat diseases with supplements and dietary counsel.
Why is it that health-food store employees, family, and friends can impart nutritional advice with impunity yet chiropractors are ever looking over their shoulders? Court rulings suggest it’s because chiropractors who provide nutritional advice aren’t simply selling vitamins to customers.
Whenever you proffer advice, courts say, the patient hears the word “cure” (whether or not the word is uttered). When you recommend vitamins for an ailment or disease and charge compensation for your advice, it can cause the patient to believe a cure is imminent.
Some states, however, confer chiropractors with broad authority to diagnose and treat patients through nutrition. They pass scopes of practice that seem to have lives of their own and “evolve” alongside chiropractic instruction.
Montana, Ohio, Oklahoma, and Oregon, for example, allow practitioners to perform diagnostic and treatment procedures as taught by board-approved chiropractic colleges. The colleges, in essence, determine the scope.
Chiropractors may opt to increasingly link their scope to coursework taught in chiropractic colleges while simultaneously encouraging the colleges to offer a robust array of nutritional instruction. Several chiropractic colleges now offer master’s degrees in clinical nutrition and at least one certifies students who have undertaken significant nutritional and dietary instruction.
Such curricula, particularly those that include the diagnosis and treatment of nutrition-related diseases, provide a framework that will help courts determine whether chiropractors have exceeded their scope of practice in states where scope is linked to instruction offered by chiropractic schools.
Alternatively, associations may choose to craft scopes that empower practitioners to diagnose and treat nutrition-related diseases, though this may result in chiropractic’s own version of “rock-paper-scissors” as those within the medical establishment (and others) scramble to compete for their piece of the action.
Finally, chiropractors may simply encourage an expanded scope similar to that of Nevada’s dietitians, permitting them to offer nutritional care. Chiropractors might, as Nevada’s dietitians did, offer a conciliatory gesture to MDs and osteopaths by distinguishing nutritional diagnoses from medical ones.
Any challenge suggesting chiropractors are not sufficiently qualified could be countered by requirements that chiropractors demonstrate successful completion of prescribed study in nutrition sufficient to prepare graduates to administer appropriate nutritional care.
Expertise and branding
Securing state authority to offer nutritional counseling doesn’t guarantee a place at the table, as the public must weigh in. Though states may accede to chiropractors’ expertise, the public must view them as nutritional “grand masters.”
If you’re struggling to convince people that chiropractic extends beyond the spine, you are already aware of the marketing challenge. Dietitians, too, have their branding challenges and physicians responding to surveys said they’d be more likely to refer to dietitians if they marketed themselves better.
As for introducing nutrition into patient care, nearly half the doctors surveyed claimed they had insufficient time during patient consultations. Doctors’ ages were also a factor: Older doctors were less likely to refer to dietitians. Most MDs are disinclined to give nutritional counsel or refer it out because they are unfamiliar with its benefits.
In fact, only 30 percent of responding medical schools taught a separate required nutrition course, according to a UNC–Chapel Hill School of Medicine survey published in 2006. Eighty-eight percent of medical school instructors felt that additional nutrition instruction was needed. Physicians rated their nutrition knowledge and skills as inadequate and most graduating medical students said insufficient time was dedicated to nutrition instruction.
Unlike their medical counterparts, chiropractors are usually eager to provide nutritional guidance to their patients. A 2007 study of New York chiropractors and nutrition revealed that chiropractors are aware of the role nutrition plays in their patients’ overall health. Eighty percent of the respondents used nutritional counseling in their practices, even though almost half felt their nutritional education wasn’t adequate.
The home stretch
Chiropractors are frontrunners well positioned to satisfy an eager public as chiropractic colleges expand their coursework, develop certifications, and offer advanced degrees in nutrition that inform nutritional clinical protocols. Chiropractic’s scope of practice will likely continue widening, accommodating nutrition’s vital place in patient care.
Twenty four states currently allow chiropractors to offer some form of nutritional counsel, dietary aids, food extracts, and concentrates. Nine states pair chiropractic authority with course- work offered in the chiropractic colleges. While it remains to be seen which profession will successfully seize the legal authority, develop the expertise, and elicit sufficient confidence from the public, chiropractic has as good an opportunity as any to champion clinical nutrition.