By Amanda Donohue
A recent study showed that natural products (i.e., dietary supplements other than vitamins and minerals) remain the most common complementary health approach in the United States, according to the NIH’s National Center for Complementary and Integrative Health (NCCIH) and the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS).(1)
As the demand for natural products rises, doctors of chiropractic (DCs) continue to incorporate nutrition into their practices. In fact, the National Board of Chiropractic Examiners’ (NBCE) Practice Analysis of Chiropractic 2015 indicates that 97 percent of DCs gave nutritional and dietary recommendations, making nutrition a common part of a treatment plan for chiropractic patients.(2)
In another study, from 2007, on “nutritional counseling in the chiropractic practice,” 80 percent of chiropractic physicians who responded incorporate some form of nutritional counseling into their practice.(3)
More than 50 percent of these DCs did not limit their nutritional counseling to patients with musculoskeletal disorders, but additionally addressed coronary artery disease, obesity, diabetes and allergies. DCs indicated a strong interest in increasing their applied clinical knowledge of nutrition through continuing education.(3)
“Chiropractic is based on the premise that the body is able to achieve and maintain health through its own natural recuperative powers, provided it has a properly functioning nervous system and receives the necessary health maintenance components. These components include adequate nutrition, water, rest, exercise and clean air,” according to the NBCE’s Practice Analysis of Chiropractic 2015.(2)
“As an owner of a private practice, I have found that people are nutritionally sick, and I believe nutrition answers my patients’ questions,” says Donald Feeney, DC, DACBN, CCN, executive director and director of publications of American Chiropractic Association’s (ACA’s) Council on Nutrition.
Robert Silverman, DC, DACBN, DCBCN, finds that earning certifications from various organizations makes a DC stand out from the crowd. He is a certified nutrition specialist, a certified clinical nutritionist and a certified sports nutritionist from the International Society of Sports Nutrition. He has also earned his masters of science in human nutrition. “My nutritional certifications have made me a functional medicine expert,” Dr. Silverman says.
In a typical trimester-based chiropractic program, students take the following courses: the fundamentals of nutrition, clinical nutrition and nutritional assessment.2
“However, this only gives them basic knowledge. The diplomate program gives breadth and depth to the doctors’ knowledge,” says Juanee Surprise, DC, DCCN, DCBCN, vice president of the Chiropractic Board of Clinical Nutrition (CBCN) and lead instructor of the Online Diplomate in Clinical Nutrition at Northwestern Health Sciences University (NWHSU). “Diplomate status in nutrition gives a DC greater confidence and a greater ability to help their patients,” she says.
Anna Jurik, DC, MS, RD, LDN, also believes that the nutritional aspect of a doctor of chiropractic’s education is not as extensive as it could be. At the National University of Health Sciences (NUHS), a chiropractic student will experience 12 months of full-time clinical practice at one of National University’s Whole Health Centers. Dr. Jurik works at one of these health centers and is also a part-time lecturer in nutrition and biochemistry.
“Nutrition is a part of a DC’s scope of practice, but when I was going through the doctorate program itself, I saw some gaps I wanted to help fill,” Dr. Jurik says. She was key in implementing nutritional counseling at the Lombard Whole Health Center, where she is a chiropractic physician and a clinical dietitian/nutritionist, and where she trains chiropractic interns. “This [clinical practice] gives students the opportunity to work with a specific clinician so they can develop in a specific field a little more,” she says.
To gain further knowledge in nutrition as a postgraduate, doctors of chiropractic may also choose to receive their continuing education in nutrition through regional seminars and annual symposiums. For example, at the Council on Nutrition and Council on Diagnosis and Internal Disorders’ Joint Symposium in April 2015, attendees were able to earn up to 18 continuing education units (CEUs).
“Any DC [or chiropractic student] can join the Council on Nutrition,” says Dr. Feeney. Those who wish to join must also be ACA members. “Member benefits include access to the council’s journal Nutritional Perspectives, access to the monthly newsletter, access to the member portal for all information, opportunity to write and publish articles on their own and a discounted rate for our annual symposium,” he says.
The Council on Nutrition’s mission statement is “to encourage and promote a more advanced knowledge and use of nutrition in the practice of chiropractic for the maintenance of health and the prevention of disease.”(4)
Some doctors may want to take their education further and obtain diplomate status with a certifying agency, such as the Chiropractic Board of Clinical Nutrition (CBCN). As part of the CBCN’s diplomate program requirements, students must take a minimum of 300 hours in courses on nutrition. This can be done through a nutrition diplomate program or a master’s of nutrition track offered by a chiropractic college or university, institution, foundation or agency whose program is approved by an accrediting agency recognized by the U.S. Department of Education.(5)
The online diplomate program Dr. Surprise leads consists of 23 sessions that are 14 hours each. Two of the sessions are held on the NWHSU campus for examinations covering material and for the doctor to present a research paper and two written case histories from actual patient files.
The American Clinical Board of Nutrition (ACBN) also requires 300 hours of coursework in nutrition, and is the first certifying agency in nutrition to offer diplomate status to all professionals in the health care field, beyond the doctoral level in the United States and internationally. While it’s open to all health care professionals, “our board must always be 51 percent chiropractic,” says Dr. Elicia Rosen-Fox, MS, DC, DACBN, CDN, president of ACBN. However, DCs have a much higher certificant percentage, she notes.
The ACBN is accredited by the National Commission for Certifying Agencies (NCCA), which means ACBN meets NCCA’s standards developed to help ensure the health, welfare and safety of the public, and also highlights the essential elements of a high-quality program, according to its website.(6)
Many other health care professionals earn their certification from programs accredited by the NCCA, including nurses, physical therapists and registered dietitians. “So when dietitians go to the state legislature and state that they are the only nutrition professionals that should be able to practice, we say that we have the same credentialing and have even more education,” Dr. Rosen-Fox says. “It is so important to keep this [nutrition] in the limelight, because so many people in other professions also love what we do. We have to protect our scope of practice.”
A Better Understanding of the Body
“The human body is composed of two synergistic components that must function at optimum for health,” says Dr. Surprise. “Problems in the biomechanical component, consisting of muscles, tendons, ligaments and bones controlled by the nervous system, are treated by the chiropractic adjustment, ancillary therapies and rehab. Problems in the biochemical component, consisting of the organs with all of their functions and also controlled by the nervous system, are best addressed by nutrition, which includes food, water and supplements. It is extremely important to address and support both components, as one can’t work without affecting the other. Having knowledge of nutrition and the ability to help people make better choices in order to support the health of their bodies makes sense to me.”
As stated in the Practice Analysis of Chiropractic 2015, DCs believe that their patients must take responsibility for their health and well-being. Consequently, DCs will frequently provide exercise recommendations, dietary guidance, health-risk avoidance advice and wellness counseling. “They [DCs] are often active in public health efforts to improve the health and well-being of the residents in their local communities,” it states.(2)
“It’s important to work at the core, which is the gut,” says Dr. Silverman. “All good health starts with the gut. A lack of gut health leads to more musculoskeletal issues. Sixty to 70 percent of our immune cells are in our gut,” he says. His treatment revolves around changing patients’ lifestyles, making them more active and putting them on a proper diet, usually a non-inflammatory diet. “It’s important to suggest a healthy diet and then supplementation to maintain a healthy nutrient supply to assist the body with natural function and repair processes,” says Dr. Silverman.
Supplementation is secondary to diet customization. “Foods contain thousands of compounds that may be biologically active, including hundreds of natural antioxidants, carotenoids and flavonoids. For these reasons, vitamin supplementation is not an adequate substitute for a good diet,” according to a 2002 JAMA article.(7)
When supplementation is the route a DC takes, continuing education in nutrition can substantially inform DCs of the contraindications of nutrients and prescription drug combinations that they should look for.
The ACA, during its House of Delegates meeting at the 2015 National Chiropractic Leadership Conference, acknowledged the importance of having DCs understand pharmacology and drug-nutrient interactions and established a resolution to create a College on Pharmacology and Toxicology. “Pharmacology is defined as the discipline concerned with the use, effects and modes of actions of drugs,” states ACA’s president, Dr. Anthony Hamm. “The clinical understanding of pharmacology and toxicology is critical to our ability to comply with federally mandated meaningful use in electronic health records. Advanced training in drug-drug and drug-allergy dynamics is a necessary component of that mandate.”
Diet and Supplementation
By taking nutrition diplomate program courses like Female Nutrition, Nutrition in Infancy and Adolescence, Sports Nutrition for the Athlete, Bariatrics and Eating Disorders, and Geriatrics and Longevity, DCs become better informed in making effective nutritional and dietary recommendations for a wide array of patients.
“Most of my patients receive an anti-inflammatory diet, which excludes corn, wheat, dairy and soy to name a few, but all of my patients receive a tailored diet individualized for their needs, enabling them to reach their epigenetic potential,” says Dr. Silverman. For example, his athletic patients receive diets based on the sports in which they play.
The most common supplements Dr. Silverman recommends are multivitamin, multimineral nutrients; omega-3 fatty acids to decrease inflammation and improve body composition; vitamin D, as there is a worldwide deficiency; probiotics; and phytonutrient supplements.
His supplement recommendations aren’t far off from the 2012 NCCIH’s National Health Interview Survey, where fish oil/omega-3 fatty acids were the most popular natural product used by adults in the United States. A total of 18.8 million adults and 664,000 children used fish oil in 2012. Following closely behind in popularity, prebiotics/ probiotics were used by 3.9 million adults and by 294,000 children.(1)
“Suboptimal intake of some vitamins…is a risk factor for chronic diseases and common in the general population, especially the elderly. Most people do not consume an optimal amount of all vitamins by diet alone. Pending strong evidence of effectiveness from randomized trials, it appears prudent for all adults to take vitamin supplements,” as stated in a 2002 JAMA article.(7)
Dr. Silverman has used many supplement companies and has found that one brand in particular met the criteria he looks for in a quality product. “I have practiced nutrition for more than 15 years, and my patients reached and exceeded my clinical markers with my protocols,” he says. ”I’ve chosen this brand because it 1) is triple ‘Current Good Manufacturing Practices’ (cGMP) certified, 2) contains FDA-defined ‘Generally Recognized as Safe’ (GRAS) ingredients and 3) has supplied the research demonstrated to be clinically effective for disease/syndrome application.”
Dr. Feeney uses 17 different companies because sometimes he finds one brand might be more effective than another for a patient. “If a person has gluten sensitivity, I would give him or her a particular brand,” he says.
Integration and MD Referrals
Dr. Jurik’s additional education has made her extremely proficient in dietetics and nutrition, and a reliable source for questions and sometimes referrals from the other health care professionals at NUHS’ Lombard Clinic. “A background as an RD and an LDN is an asset,” she says. “Clinicians will refer to me if they have a question about treating a condition, to learn about supplemental regimens or to inquire about possible drug-nutrient interactions.”
Dr. Silverman, too, has received more referrals from medical doctors. If the medical approach hasn’t worked, MDs local to his New York clinic will seek an alternative approach. “They seek it because they are now seeing the power of fixing the body from the inside out,” says Dr. Silverman.
“Ninety-six percent of primary care physicians (PCPs) believe the nation’s health care system should place more emphasis on nutrition to treat and manage chronic disease,” according to a 2009 survey among PCPs.(8)
In a chiropractic scope of practice study by Mabel Chang, vitamin supplementation, diet formulation and botanic therapy could be performed in all jurisdictions.(9) Nutritional disorders are diagnosed by chiropractors in 45 percent of cases. They are likely to solely treat nutritional disorders 35 percent of the time and co-manage nutritional disorders 52 percent of the time.(2)
Dr. Rosen-Fox believes post-graduate education, such as in nutrition, further contributes to chiropractic’s “collaboration with other health care disciplines and integration into all health care delivery models that enhance individual health, public health, wellness and safety,” as stated in the ACA’s Vision.(10)
1. Nationwide study reports shifts in Americans’ use of natural products. National Institutes of Health. Feb. 10, 2015. www.nih.gov/news/health/feb2015/nccih-10.htm.
2. Practice Analysis of Chiropractic 2015. NBCE. www.nbce.org/practiceanalysis.
3. Holtzman D. Burke J. Nutritional counseling in the chiropractic practice: a survey of New York practitioners. 2007. J Chiropr Med. www.ncbi.nlm.nih.gov/pmc/articles/PMC2647073.
4. Mission Statement. ACA’s Council on Nutrition www.councilonnutrition.com.
5. Acceptable Courses in Nutrition. Chiropractic Board of Clinical Nutrition. www.cbcn.us/courses.
6. NCCA Accreditation. Institute for Credentialing Excellence. www.credentialingexcellence.org/ncca.
7. Fletcher R. Fairfield K. Vitamins for Chronic Disease Prevention in Adults. JAMA. June 19, 2002.http://jama.jamanetwork.com/article.aspx?articleid=195039.
8. Hart Research Associates. The Role of Nutrition in the Treatment and Management of Chronic Disease: A survey among primary care physicians. June 2009.www.eatright.org/uploadedFiles/Media/ADA_Press_Releases/2009_ADA_Press_Releases/NutritionReport_FINAL.pdf.
9. Mabel Chang. The Chiropractic Scope of Practice in the United States: A Cross-Sectional Survey July 8, 2014 JMPT www.jmptonline.org/article/S0161-4754%2814%2900091-8/abstract.
10. ACA’s Vision: High Standard, Freedom of Choice, Optimal Health. www.acatoday.org/level2_css.cfm?T1ID=10&T2ID=20.
Source: Donohue, Amanda. ACA.