Answer: Even though you were drilled in school about being primary care, the fact is you will not see sore throats, fevers, stomachaches, lacerations, or infections on a regular basis. You will see acute and chronic articular and muscular pain. Thus, I recommend you target your nutritional products on the conditions that will make up the majority of your practice. When you feel comfortable with neuromusculoskeletal nutritional support, it is likely you will begin to get referrals for other nutritional conditions. You can expand to those areas you feel comfortable managing, with substances supported by the literature.
The following are the types of formulas and the key ingredients you should look for. No two companies have the exact same formula and accessory nutrients will vary:
- Anti-inflammatory formula: Many micronutrients such as vitamin C can reduce inflammation. Enterically coated proteolytic enzymes are the most powerful natural anti-inflammatories available to the DC. The most common enzymes used to reduce inflammation are the animal-based trypsin, chymotrypsin, and the vegetable-based papain, and bromelain.
- Antispasmodic formula: A good antispasmodic formula will include the minerals calcium and magnesium, and the herbs valerian and passiflora.
- Sprain-strain formula: Vitamin C, vitamin B6, bioflavonoids, zinc, copper, and manganese are the nutrients I like to see in formulas of this type.
- Bone-building formula: Look for high amounts of calcium, magnesium, and vitamin D. Of the many support factors for bone metabolism, I prefer formulas that contain the trace minerals manganese and boron.
- Osteoarthritis formula: Glucosamine sulfate or hydrochloride. Better formulas will list the exact amount of elemental glucosamine.
Q: What do you think of proteolytic enzymes?
A: Regular readers of this column know we have discussed this topic in depth numerous times. To make a long story short, proteolytic enzymes will work best when you (1) give enterically coated preparations on an empty stomach; (2) begin as soon as possible following trauma (first three days, and continue for three to seven days); (3) dose at least four times a day in amounts high enough that will loosen the stool; when stool becomes loose, reduce the dose 25% and maintain; (4) use preparations with vegetable and animal sources. Multiple enzymes have a wider spectrum of activity than single enzymes. Thus, I prefer products that contain more than one type of enzyme.
The downside to proteolytic enzymes is the lack of standardization concerning units of activity. Unfortunately, there is no one uniform unit of measurement of activity in enzymes. Furthermore, many products do not list activity, but instead list the weight of the product, which means nothing. I recommend that you call the manufacturers and ask for a technical adviser (usually a DC, MD, ND, or PhD) to give you specific information on dosing to reduce inflammation. Due to FDA regulations, the amount of proteolytic enzymes needed to reduce inflammation is substantially greater than the directions printed on the label. To have success with proteolytic enzymes, be prepared to dose two to five tablets every one to four hours, depending on the nature and extent of the trauma as well as the size of the patient.
Q: Do you have any dietary advice you give patients with injuries?
A: Yes, and you don't have to be a chiropractic nutritionist to help your patients nutritionally when they are injured. I recommend the following for the average injured patient:
- Increase protein consumption to one gram per pound of body weight. This will maintain a positive nitrogen balance in the initial important stages of the healing process. Depending on the nature and extent of the injury, I advise patients to eat extra protein for one to three months following their injury or accident.
- I recommend that patients drink extra water above their normal intake. For injured patients I request they drink an extra three large glasses per day. Remember, most of your patients probably don't drink enough water anyway, although the compliance factor will be low if you try to have someone drink eight glasses a day.
- Reduce or eliminate the amount of junk food.
- Do not attempt to be on a strict weight-loss diet when you have a serious injury. This does not mean it is alright for the patient to gain weight, but you do not want them consuming inadequate calories at a time when the body needs to heal.
- Take a strong multivitamin-multimineral with antioxidants (at least 15,000 IU of beta carotene or mixed carotenoids, 400 IU of vitamin E, and 500 mg of vitamin C), B complex (20-50 mg of B1, B2, B3, B5, and B6), with 100 percent RDA of all minerals including calcium and magnesium.
Q: I am confused about glucosamine. What is it used for, how much is given, and is there a best kind?
A: Glucosamine is a micronutrient that stimulates the synthesis and repair of connective tissue. In European studies it has reduced pain and degeneration in animals and humans with osteoarthritis. Theoretically, it should also be beneficial for sprain-strain and disc injuries, although I have not seen any human studies in this area yet.
There are three types of glucosamine: glucosamine sulfate, glucosamine hydrochloride, and N-acetyl glucosamine. Glucosamine sulfate and glucosamine hydrochloride are the forms that will stimulate connective tissue repair. N-acetyl glucosamine is used by cells in the gastrointestinal tract. It can be quite helpful for stomach and intestinal disorders, but is not effective for musculoskeletal conditions.
All the studies on glucosamine used at least 1500 mg a day for six to eight weeks in arthritic patients. There are a lot of new products on the market boasting that they contain glucosamine. When you read the fine print, you may see amounts in the 20 to 100mg range per tablet. This is called nutritional fluff. The salesperson will tell you the other ingredients in the formula are synergistic, so you do not need as much glucosamine (which is expensive). When this happens, ask the representative to give you copies of the studies on their products that were published in reputable journals.
Finally, many of the patients you encounter will be on nonsteroidal, anti-inflammatory drugs (NSAIDs). When a person is uncomfortable, NSAIDs can significantly reduce pain. NSAIDs also have negative side effects such as gastrointestinal irritation. A lesser known side effect of NSAIDs is (in animal studies) the inhibition of collagen and glycosaminoglycan (GAG) synthesis. Even though a patient will feel better, they will be healing slower. Glucosamine can reverse NSAIDs' inhibition of GAG and collagen synthesis, and thus is recommended for patients who regularly take medications in this family.
Q: What is your favorite product for overall good health?
A: I like to see patients eat two kinds of fruit and consume six servings of vegetables from the dark green leaf, cruciferous, and red, orange, yellow families each day. A serving size is approximately a half cup of a chopped or grated vegetable. You can easily consume six to eight servings of vegetables in one sitting by simply having a large salad.
G. Douglas Andersen, DC, DACBSP, CCN
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