Nutritional counseling in the chiropractic practice: a survey of New York practitioners

Abstract

Objective

The purpose of this pilot study is to determine the quality of nutritional counseling that the chiropractic patient receives, for what conditions, and the need to establish easy-to-use protocols for nutritional counseling.

Methods

Chiropractors practicing in the state of New York were surveyed and were asked if they valued the use of nutritional counseling, if they used it, if they charged for it, what are the barriers for not doing more of it, and what types of counseling they put into practice. Information regarding what types of conditions the chiropractors treated with nutritional counseling and the level of interest they had in furthering their education in the field of nutrition was also collected. There was no statistical validation of the survey, but demographics were included to determine if the sample was representative of practicing chiropractors.

Results

Eighty percent of the respondents used some form of counseling in their practices but desired to have more knowledge in the area of clinical nutrition. Most preferred online courses to obtain this knowledge. Chiropractors treated a variety of chronic disorders, such as obesity, diabetes, coronary artery disease, and conditions affecting the musculoskeletal system.

Conclusion

With 80% of the doctors who participated in the survey reporting they incorporate some form of nutritional counseling into their practices, it is suggested that the chiropractic physician is interested in a holistic practice. The next step is a comprehensive survey to determine the needs of chiropractors in the United States, so standardized protocols can be created that suit the needs of practitioners nationwide.

Introduction

Chiropractic is a major leading alternative health care profession in the United States and is a voice of prevention and wellness. Although medical practices typically involve little nutritional consultation, medical doctors rely on the use of dieticians and nutritional counselors for more involved nutritional support for patients. In keeping with this practice concept, conventional medical school education may contain few or no classes in nutrition, with some medical schools offering electives in nutrition. Most chiropractic colleges have a greater emphasis on nutrition by offering at least 2 nutrition courses in the core curricula with some offering extended training in elective programs or in bachelor's or master's programs.¹ Although chiropractic students are taught the importance and relevance of nutrition to wellness, an appropriate model for applying such knowledge to an active patient base appears to be absent.

Chiropractors treat numerous patients with inflammatory conditions or autoimmune disorders, such as rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, scoliosis, and neuritis.¹ A substantial amount of research exists to suggest that dietary changes reduce systemic inflammation which, in turn, alleviates pain and other clinical symptoms caused by inflammation.² Eating less processed foods, more organic fruits and vegetables, using supplementation of ω-3 fatty acids, and drinking more water are examples of changes in diet that may have a positive impact on systemic inflammation. In addition, most chiropractic patients are females,¹ and the management of some of their health issues (eg, dysmenorrhea, premenstrual syndrome, menopause) may be enhanced with nutritional counseling. Therefore, the ability of chiropractors to incorporate nutritional counseling that goes beyond eating a balanced diet would be a valuable tool toward improving their patients' health.

The challenge for many practitioners is incorporating effective nutritional counseling into the flow of a busy chiropractic practice. Effective counseling includes assessing a diet diary, ordering and analyzing the appropriate laboratory tests, creating and administrating a dietary plan for the patient, and monitoring patient improvement in overall health. According to a 2001 study, 53% of the chiropractors surveyed thought their nutritional education was adequate and 81% thought it was their obligation to provide nutritional counseling to their patients. Of these 81%, only 37% actually conducted nutritional counseling as described above, while others recommended supplements (50%) and provided nutritional literature (22%).³ A possible reason that only 37% of chiropractors incorporate nutritional counseling includes time constraints and lack of cost-benefit ratio within the private practice environment. As such, the time necessary to assess the patient, create the appropriate protocol, counsel the patient, and monitor patient progress have to be considered carefully when incorporating nutritional counseling into the private practice environment.

An examination of the quality of nutritional counseling being used by field chiropractors might be the first step in creating standardized procedures that could provide a cost-benefit solution to practitioners. The following types of questions need to be addressed to develop standardized nutritional counseling protocols. Is nutritional counseling important to your practice? What constitutes nutritional counseling in your office? What types of dietary changes are most often recommended? Does the chiropractor recommend supplementation? How often and for what conditions? How is patient progress monitored? Are separate fees assessed for such counseling?

The purpose of the study was to determine the quality of nutritional counseling that chiropractic patients receive, the conditions they receive it for, and the need to establish easy-to-use protocols for nutritional counseling. This information will increase the knowledge on the role nutrition in the chiropractic profession beyond the descriptive survey on the use of nutritional counseling by Smith and Spillman.³

Methods

This survey was designed to measure both the attitude toward nutritional counseling and the quality of nutritional counseling commonly provided by chiropractors. Questions were constructed to extend previous research in the area of nutritional counseling.³ The survey was reviewed by 2 practicing chiropractors, 1 chiropractic researcher, 1 faculty member of New York Chiropractic College, and 1 statistician to ensure that questions were necessary, specific, and objective. There was no statistical validation of the survey, but demographics were included to determine if the sample was representative of practicing chiropractors. The New York Chiropractic College's institutional review board approved this study.

The survey was disseminated via e-mail, as a Zoomerang survey (Market Tools, Inc., San Francisco, CA), to a sample of practicing chiropractors in the State of New York. All chiropractors who had active e-mail addresses registered with the state chiropractic association were sent a survey (ie, eligible to receive a survey). The open response period to return the survey was 2 weeks. The respondents' identities remained anonymous to the researchers. Survey responses were collected, and descriptive statistics were generated by the Academic Quality and Assurance Support Department of the New York Chiropractic College.

Results

There were 125 respondents of the 960 surveys sent, providing a response rate of 13%. The respondents were all practicing chiropractors and mostly male (80%). Forty-two percent had been in practice for 21 to 30 years, 25% in practice for 11 to 20 years, and 20% in practice 6 to 10 years. Most of the chiropractors (73%) were between 40 and 60 years of age with 22% in the 30- to 40-year age group, and the remaining respondents were either older than 60 years or younger than 30 years. Practice volumes varied among the respondents with most chiropractors having 50 to 150 patient visits per week. Table 1 summarizes the characteristics of the respondents.

Table 1.

Characteristics of chiropractors

Characteristics	Categories
Age (y)	<30	30-39	40-49	50-59	≥60
Response Rate (%)	2	22	38	35	2
Practice Years	0-5	6-10	11-20	21-30	>30
Response Rate (%)	9	20	25	42	4
Patient Visits per Week	≤50	51-100	101-150	151-200	≥200
Response Rate (%)	14	35	28	16	7

Eighty percent of the respondents incorporated nutritional counseling into their practices. Of the 20% that reported that they did not incorporate nutritional counseling into their practices, the primary reason given was inadequate education to successfully execute effective counseling, followed closely by the inability to get reimbursement for the time spent with the patients. A third of the respondents cited that lack of time did not permit them to include any form of nutritional counseling into their practices. Only 8% said they were simply not interested in providing the service for their patients.

Fifty percent of the chiropractors who used nutritional counseling in their practices considered nutritional counseling to be an important to very important part of their practice. The most common types of counseling were the prescription of dietary supplements and dispensing literature on topics involving diet and nutrition. Almost half of the chiropractors reported using diet diaries as a tool to monitor patients' dietary habit, while a third monitored weight loss and held meetings with their patients separate from the adjustment time to discuss nutrition. Fig 1 summarizes how the respondents incorporated nutrition counseling into their chiropractic practices.

Fig 1.

The percentages of respondents incorporating different forms of nutritional counseling into their chiropractic practices.

The most common topics of counseling centered around musculoskeletal conditions, mainly osteoarthritis (76%) and osteoporosis (71%). Chiropractors did not, however, limit themselves to addressing structural disorders. More than 50% addressed coronary artery disease, diabetes, obesity, allergies, and fibromyalgia. Fig 2 summarizes the various conditions that the respondents addressed with nutritional counseling.

Fig 2.

The percentages of respondents treating various health care conditions with nutritional counseling in their chiropractic practices.

Of the chiropractors surveyed, 65% did not think that their chiropractic college education was adequate in the area of nutrition. Most of the chiropractors would welcome online classes geared toward incorporating nutritional counseling into their practices, and 64% thought that standardized protocols would be helpful to very helpful.

Discussion

The results indicated that the 80% of chiropractic physicians who responded are incorporating some form of nutritional counseling into their practices. The form of nutritional counseling was holistic in nature in that more than 50% of these individuals did not limit their nutritional counseling to patients with neuromuscular or musculoskeletal disorders; they additionally addressed coronary artery disease, obesity, diabetes, and allergies. Respondents indicated a strong interest in increasing their applied clinical knowledge of nutrition through continuing education. These data provide preliminary insights on the role of nutritional counseling within the chiropractic profession and the need for continuing education hours in nutritional counseling for chiropractors. From previous research,³ our survey results provided additional insights on the importance of nutritional counseling to chiropractors, with respect to the types of conditions treated, its quality, and the needs for continuing education and standardized protocols.

Although the survey was conducted in one state, and there is variability among states with respect to the governing of chiropractic health care, the following descriptive data suggest that our preliminary findings are generalized to the chiropractic profession. The sampling frame was 85% male and 15% female with an average age of 44.7 years and an age distribution similar to the respondents. For the respondents, the estimated average age was 45.6 years with a sex distribution of 80% male and 20% female. The characteristics of chiropractors practicing in the United States are 80% male and 20% female with an average age of 42.5 years.⁴ The distributions of practice years of our respondents relative to national averages, less than 5 years (9% vs 10.2%), between 5 and 15 years (45% vs 42.3%), and more than 15 years (42% vs 47%) were similar.¹ The practice volume of the respondents were similar to national averages with patient visits to chiropractors ranging between 85 and 120 visits per week,¹ which described the practice volume of 63% of our respondents. In summary, the characteristics of the respondents were representative of the individuals in the sampling frame, which were representative of characteristics of chiropractors practicing in the United States.

As holistic health care professionals, chiropractors are the logical health care providers to discuss and implement nutritional changes. For example, according to the National Board of Chiropractic Examiners, 57% of the chiropractors in the United States co-treat obesity and diabetes.¹ Our survey findings are consistent with these national trends. Based on these data, it seems imperative that chiropractors are trained in nutritional counseling as diet and exercise are the most effective treatments for diabetes, obesity,⁵ and a variety of conditions unique to women's health (see below). The need for providing such a service is of growing importance because almost two thirds of Americans are overweight with almost one third of them obese.⁶

Women's health care, as mentioned above, is frequently addressed in chiropractic practice and may benefit from nutritional counseling. A substantial amount of research shows a correlation between tryptophan⁷ and vitamin C⁸ deficiencies and the development of scoliosis. In addition, vitamin B₆ and certain minerals may have a role in scoliosis prevention.⁹ Underweight girls or those with low estrogen and low body fat seem to be most susceptible to scoliosis.⁹ Chiropractors are spinal health care specialists with the expert training necessary to screen for scoliosis susceptibility in young girls. Premenopausal women are often plagued with premenstrual syndrome symptoms that can be diet related, yet they are often treated with medications to control the symptoms.¹⁰ For example, some women are salt-sensitive and tend to become inflamed and retain fluids before menses.¹⁰ The chiropractor could enhance treatment results by counseling the patient on what foods contain sodium, how to look for sodium on labels, how much sodium is safe, how to increase water consumption, and the use of herbs (eg, licorice), which is a natural diuretic.¹⁰ Effective nutritional alternatives also exist to help women cope with the symptoms of menopause.¹⁰ Dietary restrictions of caffeine, nitrites, and hot peppers are often suggested to patients to reduce the number of hot flashes. Also, available evidence suggests that herbs such as black cohosh may minimize hot flashes.¹⁰

Because of time constraints, most chiropractors find that dissemination of nutritional information and supplements are the methods that fit best into their busy practices. Also, 65% of the chiropractors felt their chiropractic education did not adequately prepare them to perform in-depth nutritional counseling with patients. Most of the doctors expressed the need for more education both during chiropractic college and at the postgraduate level. Nutritional counseling in the chiropractic practice could be expanded and enhanced by the development of standardized protocols with clinical decision-making capabilities built into the program. Online seminars could facilitate this process for the current field practitioners, while new information may be integrated into the chiropractic curriculum at chiropractic colleges.

This survey was limited to the state of New York, where practicing chiropractors are not routinely reimbursed for nutritional counseling. This may affect the time allotment a practitioner is willing to devote to nutritional counseling, thereby affecting the types of nutritional counseling reported in the survey. Although the demographics of the survey sample were representative of the practicing chiropractors in the United States, it is not known if the survey results are generalizable to other states.

Conclusion

These survey data indicated that a need exists for further study outside the state of New York to establish a national trend in nutritional counseling in the chiropractic practice. This would lay the groundwork for the development of a postgraduate model for nutritional counseling unique to the chiropractic practice that could be made available online. Once a postgraduate program is developed, another goal may be to establish reimbursement processes nationwide for nutritional counseling by chiropractors. Enhancement of the current chiropractic curricula and postgraduate education programs with nutrition information and nutritional counseling protocols seems like a logical step forward.