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Nutrition: In The Office ~ 6 Hours

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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

Nutrition: In The Office

Marina Rose, DC

Marina@DrMarinaRose.com

650-308-9355

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