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Dynamic Chiropractic – May 6, 2008, Vol. 26, Issue 10

Wellness Care: Where Does It Fit in the Health Care Jigsaw Puzzle?

By Edward Brown, DC, DABCI

Wellness is the new buzzword in health care. Chiropractic, which has been drugless since its inception, quite rightly wants to stake its claim in this area.

However, is being drugless sufficient to qualify us as the experts in wellness care? Saying what we don't do is a poor substitute for detailing our wellness expertise qualifications.

The core questions which must be explored are: What constitutes wellness care? Does chiropractic qualify?

According to the CDC, the four leading causes of death in 2004 were heart disease (652,486), cancer (553,888), stroke (150,074) and chronic lower-respiratory diseases (121,987).1 These chronic degenerative conditions collectively account for almost two-thirds of all deaths and consume the large majority of our health care dollars. However, is this money being well spent?

While heart disease, cancer, stroke and chronic lung disease are the conditions from which most people die, these are not the fundamental underlying causes of death. In 2004, Mokdad et al., updated the classic 1993 "Actual Causes of Death" study.2 Based upon their research, it is estimated that 50 percent of the deaths in the U.S. can be traced directly to lifestyle factors such as:

  • cigarette smoking;
  • lack of exercise;
  • poor eating habits;
  • excessive alcohol intake;
  • abuse of drugs and medications;
  • prolonged stress; and
  • negative mental attitude.

What is the common thread running through each of these causes? No drug or treatment can change these factors. These factors require personal responsibility to change the way we eat, think and move. Our profession promotes itself as wellness care. However, if we truly are interested in preventing chronic disease in our patients, we must actively work to optimize their health in these areas, in addition to their spinal health. Of all health care professionals, who has the best training in diet, exercise and lifestyle modification? We do! Chiropractors, by virtue of their training and experience, can and should be the acknowledged experts in wellness.

Wellness, first and foremost, is a philosophy that emphasizes personal responsibility. The chart illustrates some of the key differences between illness care and wellness care.

Illness Care Wellness Care
  • The goal of illness care is to return the individual to "normal," characterized by an absence of disease or symptoms.
  • Illness care intervention is often "heroic" and generally works best with life-threatening conditions (major trauma, heart attack, stroke, etc.).
  • Illness care is typically rendered by a specialist (cardiologist, gastroenterologist, urologist, etc.).
  • Emphasis is placed on the precise diagnosis of specific conditions. Once the diagnosis is established, the prescribed treatment is fairly uniform for all individuals with that condition.
  • The doctor is responsible for the treatment regimen. The individual is usually a passive recipient of treatment.
  • The philosophy of illness care is mechanistic: Fix the diseased or malfunctioning body part.
  • Wellness care focuses on optimizing function in all aspects of the individual's life: body, mind and spirit.
  • Wellness care mobilizes the inherent self-healing ability of the body for individuals wanting to prevent the need for crisis medical intervention.
  • Wellness-care advisors are generalists who serve to guide and motivate the individual in their self-care program.
  • Wellness care is tailored to meet the needs of the individual, rather than the condition. As such, two individuals with the same condition may receive very different recommendations.
  • The individual is responsible for their health and wellness, and must become an active participant in lifestyle changes.
  • The philosophy of wellness care is vitalistic: Help the individual to grow into a greater measure of health.

Our health care system needs both kinds of doctors. When you suffer major trauma, you need the best crisis care medicine can offer. This is the area in which modern medicine excels. What we need are wellness care specialists. As chiropractors, our niche in the health care jigsaw puzzle is to pick up where orthodox medicine has dropped the ball. However, if we are to become the acknowledged authority in wellness care, we must address the total wellness needs of our patients. Here are some suggestions as to what needs to be covered.

Tobacco

D.D. Palmer, the founder of chiropractic, was a visionary. In 1910 he wrote, "The smoking of cigarettes poisons the nervous system."3 Contrast this with the fact that in the 1930s and 40s, the Journal of the American Medical Association (JAMA) regularly ran ads saying, "More doctors smoke Camels than any other cigarette!"4 At one time Philip Morris was the largest advertiser in JAMA,5 and the AMA did not pull tobacco ads from its journal until 1954.6

Tobacco caused 435,000 deaths in 2000,7 yet only 45 percent of patients say their physician has ever discussed smoking-cessation with them, and only 15 percent have been offered any assistance on how to quit.8 Unfortunately, chiropractors are not doing much better. If our claims of being an expert in wellness care are to be credible, this must change. We should treat smoking status as the fifth vital sign and ask all patients whether they smoke. If your patient is a smoker, you must encourage them to quit and support them in their attempt to quit.

Spirometry testing of pulmonary function is a valuable tool in a wellness practice. When performing this test on a smoker, you might comment, "Your lung function is less than normal. Why do you think this is?" The patient probably will respond, "Well, I smoke." To which you might reply, "Are you interested in discussing ways we can help you quit?"

Exercise

The CDC and the American College of Sports Medicine recommend every adult engage in 30 minutes of moderately intense physical activity on most days of the week.9 Unfortunately, only about 15 percent of us meet this goal, and 40 percent of adults engage in no leisure-time physical activity of any kind.10 Exercise has documented benefit in preventing high blood pressure, heart disease, diabetes and colon cancer, and it's estimated that approximately 12 percent of all deaths are caused by a lack of physical activity.11 Despite this, only one-third of patients receive counseling about exercise from their doctor.12 Chiropractors should encourage all patients to exercise more, consisting of a balanced program of stretching, weight training and aerobic exercise.

Diet

The high-fat, high-sugar, processed-food "Standard American Diet" has created a nation of overweight people. According to the most recent 2003-2004 National Health and Nutrition Examination Survey data, 66.2 percent of adults are overweight and 32.9 percent of adults are clinically obese (BMI > 30).13 The health and economic consequences of our dietary choices are staggering. In 1998, the cost of medical expenses for obesity amounted to 9.1 percent of all U.S. medical expenditures.14 This does not include indirect costs such as lost wages when people are unable to work because of illness or disability. If current trends continue, it's expected that obesity will soon overtake tobacco as having the largest negative impact on health status.

While the subject of diet and nutrition is worthy of lifelong study, the reality is that most of our patients eat so poorly that just about any change for the better will begin to show benefit. The recommendations of the U.S. Senate Select Committee on Nutrition and Human Needs are as valuable today as when they were first published in 1977:15

  • Increase consumption of fruits, vegetables, whole grains and legume products.
  • Decrease consumption of red meat, and increase consumption of fish and skinless poultry.
  • Decrease consumption of foods high in fat and partially substitute of polyunsaturated oils for saturated animal fat products.
  • Substitute low-fat milk for whole milk.
  • Decrease consumption of butter fat, eggs and other high dietary cholesterol.
  • Decrease consumption of sugar and hidden sugar-rich foods.

Alcohol

While some studies suggest mild alcohol consumption, such as one drink a day, can have a cardioprotective effect, for most of our patients, the detrimental effects of alcohol far outweigh this potential benefit. According to the "Actual Causes of Death" study, alcohol consumption is the third leading cause of death, accounting for 85,000 deaths annually.16 Alcohol abuse is a major cause of liver disease, pancreatitis and some cancers. Suicide accounts for approximately 30,000 deaths annually, and alcohol is a factor in about 30 percent of these deaths.17 While the program is not without its detractors, the Alcoholics Anonymous support group has helped many alcoholics stay sober.

Drugs and Medication

According to the Institute of Medicine, there are 7,000 deaths each year due to medication errors in hospitals, and 106,000 deaths each year due to non-error adverse drug effects.18 When you add in the 17,000 deaths each year caused by illicit drug use,19 this brings the total to 130,000, which makes drugs the fourth leading cause of death in the U.S. These statistics do not include deaths due to the use of non-prescription, over-the-counter medicines. For example, it's estimated that 16,500 people die each year due to bleeding ulcers caused by NSAID medication.20 Prescribing drugs is not within our chiropractic scope of practice. Likewise, we cannot legally counsel our patients to discontinue their prescribed medications. However, we can and should educate our patients as to the side effects of the drugs they are taking. We have many safer and more effective nutritional alternatives to offer our patients. Then, in cooperation with their prescribing physician, our patients can reduce or eliminate their use of medication.

Stress

Hans Selye, the pioneer of stress research, said, "If a microbe is in or around us all the time and yet causes no disease until we are exposed to stress, what is the cause of our illness, the microbe or the stress?"21 Obviously, the cause of disease is multi-factorial. The list of conditions caused or made worse by stress is long, including hypertension, heart disease, asthma, ulcers, Crohn's disease, eczema, insomnia, migraine headaches, rheumatoid arthritis and chronic pain syndromes. Essentially, all health problems are made worse by chronic stress. Herbert Benson, the Harvard medical doctor who has studied stress for many years, said, "Other studies indicate that between 60 and 90 percent of all our population's visits to doctor offices are stress-related and probably cannot be detected, much less treated effectively with the medications and procedures on which the medical profession relies almost exclusively." He continued, "Much of the success the medical profession achieves is not due to anything doctors do or dispense that is inherently healing. We should really attribute the success of many medical treatments to the inherent healing power within individuals."22 Dr. Benson's Relaxation Response technique is easy to teach and has profound benefit in mobilizing the "inherent healing power" in our patients.

Negative Mental Attitude

Why do some people heal quickly while others linger with illness for years? Many chiropractors, including Dr. James Parker, have stressed the importance of a positive mental attitude. Again, D.D. Palmer was a man ahead of his time. He wrote, "While it is a fact, that thoughts are things, are entities that we influence each other and ourselves for good or bad by our thinking, it is also a fact that it is a mental condition, in and of ourselves. It is one of the three methods I recognize of creating normal and abnormal nerve and muscle tension."23 While the research is diverse, essentially it boils down to: Optimists are healthier than pessimists. Health and happiness are more a function of how we view and relate to the world than our external circumstances or what we possess. While you may not feel qualified to give psychological counseling, if your patient has "stinkin' thinkin'," someone needs to help them with this or they will remain sick.

Many chiropractic clinics now use names such as "Acme Chiropractic Wellness Center." However, when you look at their service, it does not go beyond treatment of subluxation. Without doubt, the detection and correction of vertebral subluxation is the core of our profession, which all patients should receive. But is this sufficient to qualify as wellness care? If our claims of wellness care expertise are to be credible, we must address the total wellness needs of our patients. Not only will this increase their quantity and quality of life; removing these causes of subluxation also will improve their spinal health. One last reality check: If you are personally deficient in one or more of these wellness areas, you will have little credibility when you discuss wellness with your patients.

References

  1. National Vital Statistics Reports, Aug. 21, 2007;55(19):8. www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_19.pdf.
  2. Mokdad AH, Marks JS, Stroup DF, et al.Actual causes of death in the United States, 2000. JAMA, 2004;291:1238-45. http://jama.ama-assn.org/cgi/content/full/291/10/1238.
  3. Palmer DD. The Chiropractor's Adjuster: Text-Book of the Science, Art and Philosophy of Chiropractic for Students and Practitioners. Portland, Ore: Portland Printing House, 1910:98.
  4. Wolinsky H, Brune T. The Serpent on the Staff: The Unhealthy Politics of the American Medical Association. New York: Tarcher/Putnam, 1994:147.
  5. Ausubel K. When Healing Becomes a Crime. Rochester, VT: Healing Arts Press, 2000:89.
  6. Wolinsky H, op. cit, p. 149.
  7. Mokdad AH, op. cit.
  8. Goldstein MG, Niaura R, Willey-Lessne C, et al. Physicians counseling smokers. A population-based survey of patients' perceptions of health care provider-delivered smoking cessation interventions. Arch Intern Med, June 23, 1997;157(12):1313-9. http://archinte.ama-assn.org/cgi/content/abstract/157/12/1313.
  9. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA, 1995;273:402-7. http://jama.ama-assn.org/cgi/content/abstract/273/5/402.
  10. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, D.C.: U.S. Government Printing Office, November 2000:26. http://www.healthypeople.gov/Document/pdf/uih/2010uih.pdf
  11. Pate RR., op. cit.
  12. Wee CC, McCarthy EP, Davis RB, et al. Physician counseling about exercise, JAMA, 1999;282:1583-8. http://jama.ama-assn.org/cgi/content/abstract/282/16/1583.
  13. National Center for Health Statistics. Prevalence of Overweight and Obesity Among Adults: United States, 2003-2004. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_adult_03.htm.
  14. Finkelstein EA, Fiebelkorn IC, Wang G. National medical spending attributable to overweight and obesity: how much, and who's paying? Health Affairs. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w3.219v1.
  15. United States Senate Select Committee on Nutrition and Human Needs (1977) Dietary Goals for the United States, Government Printing Office Washington, DC. www.becomehealthynow.com/ebookprint.php?id=157.
  16. Mokdad AH, op. cit.
  17. Suicide: Facts at a Glance. Summer 2007. Centers for Disease Control and Prevention (CDC). www.cdc.gov/ncipc/dvp/Suicide/SuicideDataSheet.pdf.
  18. Starfield B. Is U.S. health really the best in the world? JAMA, 2000;284:483-5. http://jama.ama-assn.org/cgi/content/full/284/4/483.
  19. Mokdad AH, op. cit.
  20. Singh G. Recent considerations in nonsteroidal anti-inflammatory drug gastropathy. Am J Med, July 27, 1998;105(1B):31S-38S. www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&list_uids=9715832.
  21. Selye H. The Stress of Life. McGraw Hill, 1976:299.
  22. Benson, H. Timeless Healing: The Power and Biology of Belief. New York: Scribner, 1996:49-50.
  23. Palmer DD, op. cit., p. 354.

Dr. Edward Brown teaches physical diagnosis and wellness concepts at Parker College of Chiropractic. He is the author of Physical Diagnosis for the Chiropractor and can be contacted at .


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