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Back To Chiropractic CE Seminars
Nutrition: In The Office ~ 6 Hours
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Marcus Strutz, DC
Back To Chiropractic CE Seminars
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Nutrition:In The Office
Marina Rose, DC
Marina Rose, DC
Palmer College of Chiropractic grad
CCSP Certified Chiropractic Sports Practitioner
CCN – Certified Clinical Nutritionist 1996 - 2008
IFM – Institute of Functional Medicine
Palmer – adjunct faculty 1994 – 1996, 2018
Enzyme Formulations – CEU seminars 2007-2011
Private practice – 1995 - present
Learning Objectives 6 hours of Nutrition: In the Office
Section 1 – why nutrition matters, scope of
practice, CAM use, role of supplements
Section 2 – the FOUR PILLARS (sleep,
medications, bowel health, food choices)
assessment tools
Section 3 - pulling history, lab & exam together
for recommendations, research, patient
management skills for compliance
Overview Chiropractic scope of practice being co-opted
Nutrition evaluation should be part of every office
Simple ways to incorporate
Evaluation – history, lab exam
Recommendations – diet, lifestyle, supplements
Management – compliance (motivation and
accountability) inventory
… into your practice
Why Use Nutrition in
Practice?
Transform health care!
It’s in our scope of practice
Reduce drug consumption
Have happier patients
Cuz if patients are eating
this…
…they aren’t going to feel
like this
Do Chiropractors “do” Nutrition?
CA Scope of Practice Article 302, section a (2) – “As part of the course
of chiropractic treatment, a duly licensed
chiropractor may use all necessary … measures
including but not limited to air, cold, diet, exercise,
heat…
Section a(5) … may employ the use of vitamins,
food supplements, foods for special dietary use, or
proprietary medicines.
Scope of practice
Some states had challenges to ability to do
nutrition counseling (NJ, Washington…)
State dietician organizations are passing
laws restricting nutrition counseling
Functional Medicine – MD’s are getting into
the nutrition picture in a big way. (Mark
Hyman)
Who else gives nutrition
advice?
Dieticians – passing laws to restrict
Store employees
Dr. Google
Medical doctors
Acupuncturists
Dr. Oz
Do Patients Want Nutrition
Advice?
Do people come in for adjustments?
No, they come in to feel better.
CAM Use
Greater than 1 out every 3 (38%) of
adults use CAM (complementary & alternative
medicine)
Nutritional supplements (other than
vitamins & minerals) are the most common
use of complementary health care(2012 NHIS study)
Graph of CAM use
What are patients buying? Fish oil
Glucosamine sulfate
Echinacea
Flaxseed
Ginseng
Pre- and Pro-biotics
Melatonin
Use that knowledge
One approach is to stock those most
common supplements
…but then you’re just a retail outlet
trying to complete with Whole Foods/
Amazon
Whole Foods/ Amazon
What are they buying it
FOR?
Fish oil – inflammation/ pain
Echinacea - immune
Glucosamine sulfate – joint pain
Pre- and Pro-biotics – gut issues
Melatonin - sleep
Ginseng - energy
Pareto Principle
80% of the results
comes from
20% of the effort
Now you know
… the most common supplements and
the most common symptoms people
are trying to self-medicate
… help them with a “less is more”
approach
Focus on the basics
Basics
Cells only need 2 things…
NUTRIENTS
WASTE
Goals for Today
Have specific tools for assessing symptomsfor nutritional contribution (ie Subjective history) (ie what to ask)
Specific tools for measuring signs of
deficiency (Objective) (Food Log, labs,
physical exam)
Take Home Action Plans
Specific approach to assess and
manage four common issues:
Heartburn/ indigestion
Trouble sleeping/ energy
Bowel irregularity constipation/
diarrhea
The “S” of SOAPSubjective Assessment
Subjective Assessment
How do you determine:
What is out of balance?
How to fix it?
Questionnaire vs SiMPLE History
Symptoms and Nutrient
Deficiency… can be similar to symptoms of subluxation:
PMS – Mg+, B6, glutathione
Paraesthesia – Mg+, Na+
Headache – Mg+, B6, K+, glutathione
Indigestion – enzymes, HCl acid
Constipation – Mg+, enzymes
Symptoms of Deficiencies
that mimic subluxation
B12 – are they vegetarian? Older?
Alcohol consumption?
Iron – tingling, weakness
Protein – poor would healing,
fatigue
Amylase (Carb excess) –
histamine builds up, craves carb
How to know if Nutrition
could play a role
Does your patient live in the US?
80% deficient in Mg+
Prescriptions per capita
Low longevity, high mortality
Rate of chronic disease… (CDC, 50% of adults
have 1 or more)
Questionnaires
Standard Process
Metagenics
Enzyme Formulations
Apex
Many companies have proprietary forms –
one drawback is that they only recommend
their own products
How to Evaluate…
Subjectively and Objectively
Sleep
Meds
Bowels
Eating
Simple History:
Just remember 4 SiMPLE questions
1.How do you Sleep?
2.What Medications do you take?
3.Poop? (How often do you move bowels?)
4.What do you Eat?
THAT’S IT!
The Details
We’ll start with “E”, the Eating part
What are they eating?
“My diet is ‘pretty good.’”
Dietary Patterns & Deficiencies
Subjective - E
Subjective - E
What does your patient Eat?
Vegetarian? Vegan? Paleo? See-food
diet?
SAD (Standard American Diet)?
Do they skip meals?
Is their priority convenience?
WHERE do they shop?
Subjective - E
S.A.D.
Subjective - E
Convenience
Remind your patients that
Convenience often comes at the cost
of Quality
Cooking is a basic skill
If they are cooking-challenged suggest
a meal-kit service
Meal Kits Services
Sun Basket – has many options including
Paleo and vegetarian. A local San Francisco
company with organic options
Green Chef – based in Colorado. Organic
produce. A wide variety of menu options
Gobble – simple dishes that appeal to kids
for both palate and preparation
Subjective - E
Sleep
Subjective - S
Ask: Trouble falling asleep?
Subjective - S
Or trouble staying asleep?
Subjective - S
Sleep Issues Trouble falling asleep is often due to racing mind
(sympathetic dominance, fight or flight)
Exposure to blue light delays and reduces
melatonin production
Subjective - S
Sleep Issues
Trouble staying asleep
Commonly due to low blood sugar
Sleep aid may help
Small protein snack before bed may help
more
Subjective - S
Medications
Stats
According to Mayo Clinic – 7 out 10 adults
take at least 1 prescription (2013)
Top Five
1. Thyroxine
2. Statins
3. Proton pump inhibitors
4. Asthma
5. Antidepressant
Subjective - Meds
Which meds do your
patients take?
Common side effects of MANY meds:
dizziness, headache
fatigue, nausea
muscle aches, joint pain
bowel issues
Subjective - Meds
Subjective - Meds
Medications
Most middle aged women have been
prescribed:
BCP
Thyroid
Anti-anxiety
Sleep meds
Subjective - Meds
Could these be the cause of
your patient’s complaint?
Subjective - Meds
Common Side Effects
BCP – nausea, bloating, constipation,
blood clots, gallstones
Statins– muscle/ joint pain, diabetes,
cognitive decline, low vit A, D, E, K
Pain meds – constipation, gastritis
Psychiatric meds – insomnia, fatigue
Subjective - Meds
Drug Muggers
Thyroxine
interferes with Ca+ and Fe+
Associated with fatigue, insomnia,
anxiety
Test: look at Free T3 and T4, r T3
Subjective - Meds
Drug Muggers
Statins
Reduces absorption of vit A,D,E,K
Associate with myalgia, diabetes,
dementia
Subjective - Meds
Drug muggers
Proton pump inhibitors
Inhibit absorption of protein, Ca+,
Fe+, Mg+ and …
Can cause food allergies, heart
arrhythmias, paraesthesias,
gastric atrophy, gastric cancer
Subjective - Meds
Sometimes the side effect…
Subjective - Meds
Could nutrition help?The list of drugs included meds for:
Acne
Cholesterol
Pain
IBS
Heartburn
diabetesSubjective - Meds
3 ways nutrition can help:
1.Improving the body’s nutrient reserve
may improve the original diagnosis
2.OR, reduce the need for the
medication. Or improve the body’s
usage of the medication.
3.OR, help manage the side effect of
the meds.
Subjective - Meds
Chiropractic view of Drugs
Be careful about ONLY educating people
about the side effects without giving
effective options
Subjective - Meds
Chiropractic view of Drugs
If they stop a medication without changing
their diet or supplements… they’ll probably
go back on it.
Subjective - Meds
Digestion and Bowel Function
Subjective - P
Digestion vs Elimination
Above the belly button or below?
If it’s above the belly button consider
these three common issues:
1.Gastritis
2.Weak digestion
3.Hiatal hernia
Subjective - P
Heartburn/ Gastritis
Inflammation
Loss of protective mucus lining
Subjective - P
Digestive Insufficiency
Low pancreatic enzymes
Inadequate stomach acid
Sluggish gallbladder
Subjective - P
How’s your Poo?
DON’T ask are you constipated, or “how’s
your digestion”, ask “how often?”
Gut function –
Gas bloating
Indigestion or Heartburn (vs GERD)
Diarrhea – or Constipation
Differentiate between digestion and
elimination
Subjective - P
What about the poop chart?
Subjective - P
Objective FindingsFood Logs,
Labs & Exam
Dietary Assessment
Keep track on an App or paper FOOD
Log (NOT “Diet” Log)
Focus on the ONE or TWO changes
that will make an impact
Objective - M & E
Food Log
Objective - M & E
Objective - M & E
Physical exam - skin
Chicken bumps on back of arm (hyperkeratosis pilaris)
Vit A
Vit C
EFA (Essential fatty acids)
Excess bruisingVit C
Vit K
Objective - M & E
Physical signs - nails
White spots on nails in absence of
trauma
Zinc
Objective - M & E
Physical signs - nails
Koilonychia (spoon like)
CVD
iron deficiency
Objective - M & E
Physical exam - eye
Pale lid - anemia
Objective - M & E
Physical exam - mouth
Angular stomatitis
Can mimic herpes
B2, B3, B6, iron, zinc
Objective - M & E
Physical exam - abdomen
Abdominal tenderness
Upper quadrants = digestion
Lower quadrants = elimination
Objective - M & E
Sleep – objective findings
Two hormones to consider
that can be evaluated
through urine or saliva
with several Functional Medicine labs
Melatonin
Cortisol
Sleep - Cortisol
Cortisol is not just a stress hormone
It’s required for normal functioning
upon waking
Low morning cortisol is associated
with fatigue
High Evening Cortisol
Sleep – objective findings
Cortisol – elevated evening cortisol
can delay sleep onset or disrupt sleep
Melatonin – low evening production
will alter circadian rhythm and delay
sleep onset
What Interferes with
Melatonin?
Blood Chemistry
Basic Blood Lab
CBC – complete blood count
CMP – comprehensive metabolic profile
Cholesterol
Vit D
Thyroid - TSH
Fasting Glucose
Hba1c
Anemia Stats Risks – increased morbidity and mortality
Prevalence – has nearly doubled from 2003 to 2012*
3 x more prevalent in black women than white women
*(NHANES 2003-2012)
Anemia Symptoms Fatigue
Weakness
Reduced cognitive function
Shortness of breath
Dizziness and headache
Heart palpitations
Dry skin and hair
3 Types of Anemia
1. Iron deficiency anemia
low RBC, low HCT and low Hgb
Consider insufficient stomach acid for
protein and mineral absorption
CBC - Anemia
2. Megaloblastic anemia
Increased RDW (RBC distribution width)
B12 deficiency
Consider insufficient protein, poor
digestion
CBC - Anemia
3. Thalassemia
Multiple measures outside normal range
Genetic – do NOT give iron
Basic Lab - CMP
Look at liver enzymes
AST
ALT
GGT
Basic Lab - cholesterol
Poor predictor of heart disease
Elevated by sugar
Higher cholesterol associated with lower
risk for dementia
Basic lab
Vit D – fat soluble, are they lipase deficient?
Increases absorption of Ca+
Sun exposure is safest
If supplementing make sure there is
sufficient K2 in diet
Thyroid
TSH is a gross measure
If on thyroxine, check rT3
Options for Labs
Have the patient ask their MD
Order through Quest or LabCorp
Order through a 3rd-party like
Principal Lab
Patient orders through an online
discount lab
Principal Lab
Basic Lab – blood sugar
Fasting glucose – short term measure
HgbA1c –glycosylated hemoglobin
measures sugar stuck to RBC over period of
3 months
>5.7 = pre-diabetic
Treatment Plans
Heartburn
Before assuming
that heartburn will respond
to diet changes and supplements…
check for physical causes
Hiatal Hernia
Hiatal Hernia - Type 1
Type 1
Most common type – about 95%
Also called a “sliding hiatal hernia”
The upper part of the stomach goes up
inside the esophagus through the LES
(lower esophageal sphincter)
Type 2 Hiatal Hernia
Type 2
Less common, about 5% of cases
The stomach protrudes through the
diaphragm next to the esophagus
These may be surgical cases
Hiatal Hernia – Hx
Risk Factors:
Smoking
Obesity
Pregnancy
Tight clothes – “not your mom’s
jeans”
Laparoscopic abdominal surgery
Hiatal Hernia – sxs
Pressure at top of abdomen
Bloating
Feeling full after a few bites
Shortness of breath
Nausea
Anxiety
Hiatal Hernia – exam
Slide your hand off the xiphoid
process
Use slight pressure to palpate S → I
Feel for a tight muscular band
Hiatal Hernia – Tx Have patient stand with back flat against wall
Patient turns head away
Press A-->P above the tight band as patient inhales (diaphragm descends)
Use moderate pressure pulling S→I as patient exhales
May hear and feel audible release.
Should only need to be done once or twice
Adjusting
Hiatal Hernia – Tx
The stomach slips through the L.E.S. (lower
esophageal sphincter) an opening in the
diaphragm
Where does the diaphragm attach? Lower
thoracic spine
Check lower T-sp for dysfunction
Treatment – Create a plan
Spinal adjusting is one tool
Nutrition is an essential adjunct
Start with Food – what 1-2 changes to focus
on until next visit
Then address the other 3: bowels, sleep and
meds
Recommendations
Combining Hx, Lab & exam
Diet – what’s the ONE (mabye 2) key
changes
Lifestyle – address sleep & bowels. Risk of
probiotics
Supplements –quality:
no iron after menopause or for men,
avoid titanium dioxide…
Patient compliance
Diet-related Deficiencies Vegetarian – B12, iron, EFA’s
Vegan – B12, iron, EFA’s
Paleo – minerals, tryptophan (needs carb after
meal to be absorbed after preferential tyrosine)
Standard American Diet – multiple deficiencies:
Mg+, B Vitamins, Vit C, trace minerals, Anti-
oxidants, Vit K
Case study History: mid back pain worsening over months,
tired, heart palpitations, dry skin. Has trouble
falling asleep so stays up watching TV. Recently
switched to Paleo Diet from vegetarian
Meds: acid blockers
Exam: spoon nails, pale eye lid
Lab: low RBC, low Hg, low HCT
Case study - Dx
Assessment?
Anemia from vegetarian diet and acid
blockers
Spinal segmental dysfunction
Case Study - Tx
Diet – food sources of iron
Grass-fed beef
Lentils, soy, spinach…
Lifestyle – stress reduction
Meditation app
exercise
Supplements – DGL for heartburn
Ferrous sulfate iron (non-constipating)
Food Don’t recommend a ‘diet’
Just focus on one to two key changes
That gives a sense of progress without overwhelm. Ex:
Reduce coffee
Eat breakfast
Increase variety of vegetables
Have to have patient buy-in
Where are they shopping?
If it has a label… it’s a food product
Buy ingredients, not dishes
“Nutrient dense” is the key
Colorful fruits and vegetables
Buy local!
Dietary Recommendations
Gluten & Dairy = the most common
food allergies
Glyphosate – new research shows this
could be cause of exponential
increase in gluten sensitivity
Common Food AllergensAllergists, dermatologists and pediatricians will sometimes recommend avoiding these:
1. Corn
2. Soy
3. Nuts
4. Shellfish
5. Wheat
6. Dairy
7. Chocolate
The Big Two
In my clinical experience 80% of those with
food sensitivities have issues with:
Wheat
Dairy
Gluten & Dairy Link
50% of people who are intolerant of gluten
are also intolerant to dairy protein
This is different from lactose intolerant,
which is a reaction to the sugar in dairy
Gliadin (a component of gluten) and casein
(a protein in dairy) will both bind to a
gliadin antibody (Ab)
Gluten Challenge
Do NOT get instructions from Dr. Google
If you suspect an issue with gluten do
NOT increase consumption of it for
testing purposes
The antibodies to gluten have a half life
of 23 days
Strict avoidance must be for > 3 weeks
Gluteomorphins
It’s possible, not common, to feel worse
from avoiding gluten
Gluten that’s not completely digested
can form these opioid-like metabolites
For these people – stopping gluten
causes withdrawal symptoms
Testing Gluten Intolerance
Celiac vs Gluten Sensitivity
Gold standard test is Cyrex array 3
However, it requires gluten
consumption before testing
Symptoms Improve?
It’s more common that they feel better
If improvement when off gluten:
Conclude they are sensitive to
gluten and skip adding it back to
diet to challenge
Or add gluten back in to verify
Gluten Challenge
Avoid gluten strictly for 3 weeks.
Do not add a lot of “gluten-free” foods
(introduces new variables ie tapioca)
On the 22nd day add in ½ cup serving of
gluten with each meal on ONE DAY
Wait THREE DAYS since the antibodies
ramp up over 48-72 hours
Possible Symptoms Headache
Fatigue
Gut issues
Joint pain
Itchiness
Sinus issues
Irritability
Constipation
Prunes
Smooth Move tea (Traditional
Medicinals)
Magnesium (Natural Calm)
Increase pre-biotics (unless SIBO
present)
Loose/ frequent Stool
FODMAPS – short term only
IRB – Enzyme Formulations, short
term
Stool test – Genova or Doctor’s Data
Anti-microbials based on test results
FODMAPs
Fermentable Oligo-Di-Monosaccharides &
Polyols
carbohydrates (sugars) that are found in
foods
Not all carbohydrates are FODMAPs
When not digested they are osmotic → loose
stools
eating
Sleep Hygiene
Dark room – black out curtains
Even 8 lux (twice nightlight)
Avoid screen time before bed
Cool temperature – 65 degrees
Avoid emf’s/ LED’s near bed
Sleep Aids - Lifestyle
Meditation
Sleepy Time tea
Avoid blue light 2 hours before bed
TV
Computers
Cell phones
Sleep Aids - supplements
Supplements:
Calms Forte
Formula 303
5-HTP
Melatonin – only short term
Phosphatidyl-serine – only if
indicated on lab
Remedies can vary from meditation to an herbal or
homeopathic:
Calms Forte – safe for kids
Sleepytime tea – mild
Formula 303 – muscle relaxer (valerian)
Melatonin – only for short term use
Medications
Are any meds PRN? (per required
need) If so the patient doesn’t need
their doctors approval to reduce usage
Otherwise, the patient should work
with their medical doctor to lower
medications as needed
(Former)Editor of NEJM
Look up side effects
NNT
Number Needed to Treat:
the number of people required to
undergo treatment
in order for one person to benefit
Statins
The often-cited Heart Protection Study
https://www.ncbi.nlm.nih.gov/pubmed/12114036 has been
broadly misinterpreted to mean that statins
are safe and effective for reducing heart
attacks and stroke.
NNT(number needed to treat) = 104
NNH (number needed to harm) = 50
(diabetes, rhabdomyolysis)
Diet vs Statins
The Mediterranean Diet
has an NNT of 61 which means it is
more effective than statins at preventing
stroke, heart attack and death
Obstacles
What could get in the way of patient
compliance?
What can get in the way of office
implementation?
Patient Compliance OR
How Easy Is It to Follow Your
Recommendations?
“I don’t want to take
supplements.”
Your body’s job is to replenish the
nutrients you burn through just from
everyday living
Our food supply no longer contains
sufficient nutrients
Ex. Omega 3 fatty acids
Make it Relevant
Connect
your recommendation
to
their chief complaint
Let’s face it, if you don’t make it easy for the patient
to buy from you or order through you they’re going to
buy from Amazon.
Or Trader Joe’s.
There are only a handful of products that I suggest for
OTC purchase, most use binders, fillers and excipients
that the patient could be sensitive or could be
harmful.
What to look out for in OTC
supplements:
Titanium dioxide
Carnuba wax
Pharmaceutial
glaze
Coloring
Oxide forms
Supplement Companies
Standard Process & MediHerb – good
products, longtime supporters of chiropractic
Thorne – recently started selling direct to
consumers
Pure Encapsulations – just bought by Nestle
Enzyme Formulations – good products,
seminars with good biochemistry
Bioresource – German Biological Medicine
Inventory
Inventory
OTC or Amazon
Physical inventory In-house
Online Dispensaries
Sales Tax
If you sell any products – supplements or low
back braces or orthotics – you are required to:
file a sales tax report
pay sales taxes
To avoid pay taxes on products you purchase
you can apply for a resale certificate
Sales Tax Reports For a low volume you will report annually. For higher
volume sales you will be required to files a sales tax
report quarterly.
Create an account at the California Department of
Tax and Fee Administration (CDTFA)
Sales tax varies by county
http://www.cdtfa.ca.gov/services/#Overview
Resale Certificate
There is no fee to apply. Here is the form:
https://www.cdtfa.ca.gov/formspubs/cdtfa230.pdf
In-house Inventory
Physical inventory drawbacks:
Time to order, unpack and stock
Updating prices in software
Risk of expired stock
Not having what you need
File sales tax report
Physical Inventory
Benefits
convenience of purchase at time of
recommendation
revenue
Virtual Dispensary
Drawbacks
Don’t carry every company you want to
use
Lower revenue if giving a discount
Benefits
No need to order or stock inventory
Easy for patient to reorder
No sales tax reporting
Virtual Dispensaries
Emerson Ecologics
Natural Partners
FullScript
Canadian
Great user interface
Research that’s Relevant
Review literature
World Health Organization rates US
healthcare as #41
Nation of chronic disease caused by lifestyle
Recalled drugs – increased risk of heart
disease
Gluten – glyphosate
Problem with Industry-funded Research
Gluten – glyphosate link
BCP
How to Reduce Testosterone
“The striking dual effect of ibuprofen …
makes this NSAID the chemical
compound… with the broadest
endocrine-disrupting properties
identified so far in men.”
Jan 2018 Univ of TX study
Ibuprofen drug names
Advil
Motrin
Brufen
Nurofen
PPI’s
Published in Pharmaceutics March 2018
“Evidence of Drug-Nutrient Interactions with
Chronic Use of Commonly Prescribed
Medications”
Medication & Depression
JAMA June 2018
200 Common medications cause
depression
Common Drugs Cause
Depression PPI’s (Proton Pump Inhibitors) – acid blockers
Beta blockers – for HTN, atrial fib
BCP (Birth Control Pill)
Gabapentin – anticonvulsant used off label for
nerve pain
Prednisone
Ibuprofen
Summary
Take a SiMPLE history
Consider drug contribution to sxs
Consider nutrient deficiency
contribution
Collect objective data
Food Log
Basic blood work
Summary
Limit recommendations to a few do-
able steps
Identify where patients will get
supplements
Sleep, Meds, Poop, Eat
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