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

� Pain

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,

� 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….

Simple History:

Just remember 4 SiMPLE questions

1.How do you Sleep?

2.What Medications do you take?

3.How’s your Poop?

4.What do you Eat?

THAT’S IT!

Let’s Start at the E

� What are they eating?

� “My diet is ‘pretty good.’”

Dietary Patterns & Deficiencies

What does your patient Eat?

� Vegetarian? Vegan? Paleo? See-food diet?

� SAD?

� Do they skip meals?

� Is their priority convenience?

� WHERE do they shop?

S.A.D.

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

Sleep

Ask: Trouble falling asleep?

Or trouble staying asleep?

� Trouble falling asleep is often due to racing mind (sympathetic dominance, fight or flight)

� 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

� Trouble staying asleep

� Commonly due to low blood sugar

� Sleep aid may help

� Small protein snack before bed may help more

Medications

Stats

� According to Mayo Clinic – 7 out 10 adults take at least 1 prescription (2013)

� Top Four

1. Thyroxine

2. Statins

3. Proton pump inhibitors

4. Asthma

5. Antidepressant

Which meds do your patients take?

� Common side effects of MANY meds:

� dizziness, headache

� fatigue, nausea

� muscle aches, joint pain

� bowel issues

Medications

� Most middle aged women have been prescribed:

� BCP

� Thyroid

� Anti-anxiety

� Sleep meds

Could these be the cause of your patient’s complaint?

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

Drug Muggers

Thyroxine

� interferes with Ca+ and Fe+

� Associated with fatigue, insomnia, anxiety

� Test: look at Free T3 and T4, r T3

Drug Muggers

Statins

� Reduces absorption of vit A,D,E,K

� Associate with myalgia, diabetes, dementia

Drug muggers

Proton pump inhibitors

� Inhibit absorption of protein, Ca+, Fe+, Mg+ and …

� Can cause food allergies, heart arrhythmias, paraesthesias, gastric atrophy, gastric cancer

Sometimes the side effect…

Could nutrition help?The list of drugs included meds for:

� Acne

� Cholesterol

� Pain

� IBS

� Heartburn

� diabetes

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.

Chiropractic view of Drugs

� Be careful about ONLY educating people about the side effects without giving effective options

Chiropractic view of Drugs

� If they stop a medication without changing their diet or supplements… they’ll probably

go back on it.

Digestion and Bowel Function

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

Heartburn/ Gastritis

� Inflammation

� Loss of protective mucus lining

Digestive Insufficiency

� Low pancreatic enzymes

� Inadequate stomach acid

� Sluggish gallbladder

How’s your Poop?

� DON’T ask are you constipated, or “how do your bowels move”, ask “how often”

� Gut function –

� Gas bloating

� Indigestion or Heartburn (vs GERD)

� Diarrhea – or Constipation

� Differentiate between digestion and elimination

What about the poop chart?

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

Food Log

Objective – Physical exam

� Physical signs

� Chicken bumps on back of arm

� Dry skin

� White spots on nails in absence of trauma

� Zinc tally test

� Abdominal tenderness – upper quadrants = digestion. Lower = elimination

Blood Chemistry

Basic Blood Lab

� CBC – complete blood count

� CMP – comprehensive metabolic profile

� Cholesterol

� Vit D

� Thyroid - TSH

� Fasting Glucose

� Hba1c

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

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

� HgbA1c -

Treatment Plans

Hiatal Hernia

Hiatal Hernia – Hx

� Risk Factors:

� Smoking

� Obesity

� Pregnancy

� Tight clothes – “not your mom’s

jeans”

� Laparoscopic abdominal surgery

Hiatal Hernia – sxs

� Pressure

� 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 SI as patient exhales

� May hear and feel audible release.

� Should only need to be done once or twice

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

Food� Don’t recommend a ‘diet’

� Just focus on one to two key changes

� That gives a sense of progress without overwhelm

� 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

� 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 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

Gluteomorphogens

� It’s possible, not common, that they’ll feel worse

� Withdrawal from opioid-like metabolites

� Gold standard test is Cyrex array

� However, it requires gluten consumption

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

Sleep Hygiene

� Dark room

� Avoid screen time one hour before bed

� Cool temperature – 65 degrees

� Avoid emf’s/ LED’s near bed

Sleep Aids

� Sleepy Time tea

� Melatonin vs PS100

� Calms Forte

� Formula 303

� 5-HTP

Medications

� Are any meds PRN?

� Work with medical doctor to lower medications as needed

(Former)Editor of NEJM

Look up side effects

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 = 104

NNH = 50 (diabetes, rhabdomyolysis)

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

� Pharmaceutialglaze

� Coloring

� Oxide forms

Supplement Companies

� Standard Process & MediHerb

� Thorne - ??

� Pure Encapsulations - ??

� Enzyme Formulations

� Bioresource – German Biological Medicine

Inventory

Inventory

� OTC or Amazon

� Physical inventory In-house

� Dispensaries

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

� WHO rating is #41

� Nation of chronic disease caused by lifestyle

� Recalled drugs

� Takes 17 years to get new research acted on

� Gluten – glyphosate

� Problem with Industry-funded Research

Tami-Flu

Gluten – glyphosate link

BCP

Don’t…

�be …

�A

�Pill

�Pusher

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

� Remember 4 pillars – sleep, eat, poop, medications

Thanks for attending

Nutrition in the Office with

Marina Rose, DC