Chiropractic Practice: Public Health Issues and Wellness

When it comes to changing adverse health behaviors, patients frequently will listen to your advice as a doctor and change their lifestyles in a positive way. On the other hand, many times they won't change, just because of what they read and hear in the media.¹ Knowing that chiropractors have the ability to impact the lives of their patients in such a powerful way should be very encouraging news to everyone in the profession. However, I am concerned that some chiropractors do not educate their patients about these matters, either because they do not recognize their importance or because they assume their patients and communities already have been exposed to the information. The evidence does not support this mindset, however, given that in the United States, obesity has reached epidemic proportions, involving more than 30 percent of the population; heart disease continues to be the number-one killer; and high blood pressure, diabetes, and some forms of cancer are reported to be on the rise.

Table 1 lists the leading health indicators that have been targeted by the Healthy People 2010 national health objectives as the most significant modifiable influences on health.² Chiropractors are in an excellent position to assist their patients and communities in affecting positive change with regard to these health indicators, through education, intervention, and the monitoring of patient progress. Chiropractic leaders are aware of the remarkable benefits that take place when people take on healthy lifestyles. For example, the first strategy for implementation of a chiropractic wellness model, found in the American Chiropractic Association Wellness Model - Consensus Document from Core Committee, is the "recognition by the chiropractic profession that the greatest need in health care today is promotion of health and wellness."

Many risk factors that negatively affect people's lives are related to their behaviors, such as smoking, poor diet, and physical inactivity, to name a few. These poor lifestyle choices play a huge role in the onset, progression, and management of many diseases. In fact, much of the morbidity and death that occurs in the United States could be avoided if people would simply change their behaviors⁴ (see Table 2). Physical inactivity and unhealthy eating often lead to obesity and several chronic diseases, including cardiovascular disease, type-2 diabetes, and even cancer. Couple this with the fact that more than half of adults in this country do not get enough physical activity to positively influence their health and about one-quarter do not take part in any physical activities whatsoever during their leisure time.⁵ Indeed, it is a nationwide tragedy!

A review of the literature that considered studies dealing with primary-care-based interventions for increasing physical activity indicated health care providers have a great potential to influence their patients to implement healthy behaviors.⁶ The review pointed out that while primary care-based interventions aimed at increasing physical activity have a high success rate, many other types of health promotion do not have a substantial impact. On the other hand, there was little support for the long-term maintenance of these lifestyle changes, which points to a need for periodic reinforcement by clinicians.

Even though it is generally accepted that practitioner advice, counseling, and follow-up are important in order to increase physical activity levels, the results of a national survey showed that only 28 percent of patients actually reported receiving any such advice from their doctors. Furthermore, of those who did receive advice, only 38 percent were given an explicit activity plan and only 42 percent were given follow-up support.⁷ A recent study carried out by Hawk and Evans⁸ reported that only 39.7 percent of smokers presenting to chiropractic college clinics for treatment indicated that their doctor (intern) at that clinic had advised them to quit. This illustrates the fact that the important public health issue of tobacco use is not adequately addressed in chiropractic education. It follows that if chiropractors are not learning about these matters in school, they probably are not practicing them in the field to any great extent.

If patients could be relied on to take home health-education brochures and then change their lifestyles accordingly, it would be wonderful. However, in a study that followed patients who selectively took brochures that dealt with their health concern or specific interest, less than 25 percent actually changed their lifestyles.⁹ As a result, chiropractors should actively get involved with their patients and teach them about these health matters. Brochures may be a useful part of the educational process, but are primarily for reinforcement. Coupled with ongoing follow-up, these procedures have a much better likelihood for success than relying on patients acting on information they receive elsewhere.

The point of this article is to point out that chiropractic patients will listen to you about wellness matters and actually change their lifestyles accordingly. This has the potential to dramatically affect their health in a positive way, often leading to less disease and longer life.¹⁰ Even if you have limited your practice to spinal adjusting only, you owe it to your patients to teach them how to take care of their health outside of your office. An assessment of patients' lifestyles to discover risk factors can easily be implemented during history taking. Some chiropractors incorporate smoking cessation, nutrition counseling, and weight-loss programs in their practices, while others do not. If you are one who does not, please refer at-risk patients to other health care providers for management. And above all, don't assume that because patients have already heard and read about this information, they don't need your input.

In addition to poor lifestyles, environmental factors also have a strong negative impact on health, contributing to cardiovascular disease, cancer, diabetes, and other conditions.¹¹ These problems represent another way to help your patients, by advising them on ways reduce their exposure to such things as chemical pollutants, unsafe practices (e.g., driving without safety belts), secondhand smoke, etc. Furthermore, there are numerous opportunities available for chiropractors to get involved in their communities, to educate the public about problems with the environment and bring about lifesaving changes on the aggregate level.

In conclusion, what I have appealed for is the routine practice of public health by chiropractors. Indeed, chiropractors historically have been intimately involved in public health matters, recognizing that the behaviors of their patients and the environment they live in have a powerful influence on health. The American Public Health Association (APHA) is in accord with this way of thinking; thus, it only makes sense that chiropractors should be involved in and have a voice in this powerful organization.

The Chiropractic Health Care (CHC) Section of the APHA is one of 24 other discipline-based sections, such as Medical Care, Oral Health, Podiatric Health, etc. Current members of the CHC Section are working together to ensure that the chiropractic point of view is heard within the APHA. For more information about APHA and the CHC Section, go to www.apha.org. Click the "Sections, SPIGs & Caucuses" link to go to a page where you can link directly to the CHC Section Web site and see what we are up to in this, our 10^th anniversary year as a full section within APHA. Click the "Join or Renew" link from the APHA home page to sign up; we'd love to have you join us.

References

1. Taylor SE. Health Psychology, 3^rd edition. New York: McGraw-Hill, 1995.
2. Healthy People 2010: Understanding and Improving Health, 2^nd edition. U. S. Department of Health and Human Services, Washington, DC: U.S. Government Printing Office, 2000.
3. American Chiropractic Association. American Chiropractic Association Wellness Model: Consensus Document from Core Committee, 2001.
4. Mokdad AH, et al., Actual causes of death in the United States, 2000. JAMA 2004;291(10):1238-45.
5. Centers for Disease Control and Prevention (CDC). Physical Activity and Good Nutrition: Essential Elements to Prevent Chronic Diseases and Obesity, 2005. National Center for Chronic Disease Prevention and Health Promotion: Chronic Disease Prevention. Available at: www.cdc.gov/nccdphp/publicat.htm. Accessed June 16, 2005.
6. Eakin EG, Glasgow RE, Riley KM. Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research. J Fam Pract 2000;49(2):158-68.
7. Glasgow RE, et al. Physician advice and support for physical activity: results from a national survey. Am J Prev Med 2001;21(3):189-96.
8. Hawk C, Evans M. Does chiropractic clinical training address tobacco use? J Amer Chiropr Assoc 2005;42(3):6-13.
9. Jamison JR. Prescribing wellness: a case study exploring the use of health information brochures. J Manipulative Physiol Ther 2004;27(7):262-66.
10. Wallace LS, Rogers ES, Bielak K. Promoting physical activity in the family practice setting. Am Fam Physician 2003;67(6):1199-1202.
11. U.S. Department of Health and Human Services. What is Environmental Health? National Institute of Environmental Health Services 2005: Research Triangle Park, NJ, p. 2.

Michael Haneline, DC, MPH
Associate Professor,
Palmer College of Chiropractic West