By Todd Mexico, DC, and Brandon Blood, DC
Let's start with a simple conclusion: The fact that you're reading this article suggests you sell or are interested in selling/recommending nutritional supplements to your patients. According to statistics, nearly 75 percent of chiropractors recommend and sell nutritional supplements to their patients.1
As chiropractors, our role in health care is ever-evolving. We have successfully expanded our scope of practice in most states from that of a traditional "bone setter" to a well-rounded holistic medical expert. Our patients have come to expect a level of knowledge on alternative medical issues that meets, or in most cases exceeds, that of their primary medical doctor.
Given the fact that most primary medical doctors do not feel comfortable recommending nutritional supplements, where are patients left to turn for this information? Studies reveal that primary care physicians are hesitant to provide information to patients on nutritional supplements.2 Physicians state that this hesitation is not due to low interest or lack of demand from their patients, but rather to low levels of physician confidence resulting from a lack of education and knowledge in this field.2,3
Recently, researchers from Johns Hopkins University School of Medicine, arguably the most prestigious medical school in the country, conducted surveys to determine physicians' general knowledge of nutritional supplements. These surveys were designed to evaluate levels of understanding of dietary supplement regulations and the effectiveness of popular supplements. Results from the initial survey concluded that physicians' overall knowledge of dietary supplements is poor, as reflected by a baseline score of only 59 percent on the questionnaire.4
One of the most revealing statistics, according to the John Hopkins survey, is that only 36 percent of medical physicians are aware that fish oil has been shown to lower triglyceride levels.5 Actual data is not present to substantiate this next statement, but we think you would be hard pressed to find a single chiropractor who is unaware of the triglyceride-lowering effects of omega-3 fatty acids. As chiropractors, our general knowledge of nutrition is likely higher than that of our medical colleagues. That being said, how many of us are basing our nutritional supplement recommendations on comprehensive analyses of our patients' medications? We should be, and here's why.
Medications often achieve their desired outcomes by sacrificing key supporting pathways that are relevant for other functions of the body. Therefore,it is in the patient's best interest to help mitigate these unfortunate interactions. As chiropractors, what would happen to our nutritional supplement sales and patient satisfaction if we were to analyze our patients' medications for adverse biochemical side effects and then make appropriate nutritional supplementation recommendations to minimize those interactions? The answer is that nutritional supplement sales would soar, and patient confidence in our abilities would follow.
Let's use an example that is likely familiar to most practicing chiropractors: Statin medications (Lipitor, Zocor, etc.) are known to interfere with ATP synthesis by reducing the production of Co-enzyme Q10 (CoQ10), a key enzyme in ATP synthesis.6 Supplementation with CoQ10 would therefore be recommended for all users of statin medications (unless otherwise contraindicated) to help restore the enzyme depletion caused by these drugs. If you are not recommending CoQ10 for all of your patients taking statin drugs, you should start. Other examples, perhaps not familiar to many reading this article, include:
- The addition of folic acid (vitamin B9) to the regimen of patients taking SSRI drugs such as Prozac may result in an increase in the medications' effectiveness. This is based on results of a randomized, placebo-controlled trial published in the Journal of Affective Disorders.7
- The addition of CoQ10 for patients taking metformin for diabetes may help combat reduced CoQ10 production as a side effect of the drug, and may also help improve overall blood sugar control.8
- The addition of carnitine (acetyl- L-carnitine) for patients taking Synthroid for hypothyroidism may safely reduce symptoms of iatrogenic hyperthyroidism and also improve bone mineralization.9
There are literally hundreds of specific nutrient-drug combinations that have been studied, suggesting clear benefits of supplementation for patients taking specific medications. Think of the benefit to both patient and chiropractor when we consider and document this information as the basis for recommending supplements to our patients.
While evaluating your patients' medications for potential nutrient drug benefits is important, it is equally important to consider the possibility of a drug-nutrient interaction. Often ignored in clinical practice is the well known fact that certain nutritional supplements may interact with medications your patients are currently taking. It is important to analyze and cross-reference patients' medications against any nutritional supplements they are either taking or you are considering recommending. Consider the following:
- Many nutritional supplements are known to increase the effects of a given medication. For example, patients taking anticoagulant medications such as warfarin should not supplement with omega-3 fish oil without prudent attention to PT and INR values. The well-researched anticoagulation properties of fish oil can serve to increase the desired effects of the medication and potentially lead to serious health complications.10
- Many nutritional supplements are also known to decrease the effects of certain medications. For example, if a patient is taking benazepril or other ACE-inhibitors in combination with an iron supplement, the iron is known to decrease the drug's absorption, which can potentially prevent the medication from producing its intended result.11
In short, it is important for chiropractors to analyze the nutritional supplements and medications each of their patients consume for possible benefits and interactions. While there is an enormous amount of literature with promising results for the potential health promoting aspects of certain nutritional supplements, the risk of interactions with medications deserves equal attention. It should not be left to the patient to decide if a given supplement could have a positive or negative interaction with one of their prescription medications.
It is perhaps equally important to document these results in a manner that exhibits due diligence on the part of the observing chiropractor. We are confident that if you begin to incorporate this approach into your nutritional supplement recommendations, you will begin to see a dramatic increase in your nutritional supplement sales and patient satisfaction.
- Chiropractic Economics, May 2007.
- Levine BS, , et al. A national survey of attitudes
and practices of primary care physicians
relating to nutrition: strategies for enhancing
the use of clinical nutrition in medical
practice. Am J Clin Nutr, 1993;57:115-9.
- Kushner RF. Barriers to providing nutrition
counseling to physicians: a survey of primary
care practitioners. Prev Med, 1995;24:546-52.
- Ashar B, et al. Physicians' understanding of
the regulation of dietary supplements. Arch
Intern Med, May 14, 2007;167(9):966-9.
- Ashar B, et al. Medical residents' knowledge
of dietary supplements. South Med J, October
- Ghirlanda G, Oradei A, Manto A, et al.
Evidence of plasma CoQ10-lowering effect by
HMG-CoA reductase inhibitors: a doubleblind,
placebo-controlled study. J Clin Pharmacol,
- Coppen A, Bailey J. Enhancement of the antidepressant
action of fluoxetine by folic acid: a
randomized, placebo controlled trial. J Affect
- Hodgson JM, Watts GF, Playford DA, et al.
Coenzyme Q (10) improves blood pressure
and glycaemic control: a controlled trial in
subjects with type 2 diabetes. Eur J Clin Nutr,
- Benvenga S, Ruggeri RM, Russo A, et al. Usefulness
of l-carnitine, a naturally occurring
peripheral antagonist of thyroid hormone
action, in iatrogenic hyperthyroidism: a
randomized, double-blind, placebo-controlled
clinical trial. J Clin Endocrinol Metab,
- Jalili M, Dehpour AR. Extremely prolonged
INR associated with Warfarin in combination
with both trazodone and omega-3 fatty acids.
Arch Med Res, November 2007;38(8):901-4.
- Campbell NR, Hasinoff BB. Iron supplements:
a common cause of drug interactions.
Br J Clin Pharmacol, March 1991;31:251-5.
Dr. Todd Mexico and Dr. Brandon Blood are 2006 graduates of Palmer College of Chiropractic Florida and co-founders of eMedFx.com. Dr. Mexico practices in Baldwinville, Mass.; Dr. Blood maintains a practice in Canton, Ohio.