The response rate for this survey compares favourably with other similar studies of chiropractors in the US [24] and UK [25] and the sample was comparable to the demographic characteristics of the Australian chiropractic workforce [40]. Most chiropractors in this survey reported providing some nutritional advice as a part of their day to day practice. The study by Adams et al. found that nutrition was the second most popular topic ‘often’ discussed (51% of the chiropractors) as part of patient clinical care after discussions about physical activity (85%) [40]. In comparison, nutritional and dietary recommendations are frequently provided by 80–99% of chiropractors in the US [24] and 74% in the UK [25].
Nutrition is included as a core competency in the evidence-based preventive clinical care services in chiropractic education in the USA [41]. However a study of chiropractors in New York identified a need for a standardised national nutrition counselling protocol in the US to actively encourage chiropractors to apply nutrition in consideration of patients’ wellness [24]. The study by Adams et al. and the results of our study suggest that there would be interest in a in a similar resource in Australia to clarify the role of nutrition in chiropractic clinical care within Australia as to promote health and to prevent chronic disease [40].
A high percentage of chiropractic patients attend for neuro-musculoskeletal disorders including back and neck pain [24, 34, 40, 42] and this is reflected by the most frequently encountered health problem, inflammatory conditions in this study.
For condition-specific nutritional guidance, our study revealed significant variations between chiropractors with some providing nutritional advice specific to health conditions listed in the survey and others indicating they would ‘rarely’ or ‘never’ provide dietary advice for these conditions. These differences may be attributed to variation in education, knowledge, confidence and personal beliefs about the applicability of nutritional advice within the scope of chiropractic. It is possible that those who chose ‘never’ hold the opinion that nutritional advice is not within the scope of chiropractic care. This indicates a need for communication and consensus within the chiropractic educational institutes and profession to establish a clear framework for how nutritional guidance fits within chiropractic patient management.
The results of this study show that there is considerable interest in nutrition by chiropractors and because of the increasing importance of chronic disease in Australia it would be useful to establish a nutrition competency framework for chiropractic to provide evidence-based nutrition information and resources to their patients. This has been done by other health professions. Results from a survey of Australian general practitioners indicated that there was a lack of consistency in the training and integration of nutritional education and skills across different universities, and that the standard of nutrition education was largely determined by individual course facilitators at each university [43]. Another study examined the need for the delivery of appropriate nutrition education within Australian university medical schools in order to enable future general practice registrars to effectively support patients in making healthy dietary choices [44]. Based on the results from these previous studies, the Nutrition Competency Framework (NCF) for medical graduates was developed by several medical schools in Australia in consultation with the Dietetic Association of Australia [45]. The NCF consists of knowledge and skills competencies, mapped to the Australian Medical Council Graduate Outcome Statements.
The participants in our study reported using a variety of nutritional assessment methods during the initial consultation. Nutritional assessment methods enquired about in the questionnaire were: anthropometric measurements (e.g. height, weight, waist circumference), laboratory assessments (e.g. blood and urinalysis), assessment of physical appearance, dietary assessment (e.g. diet history, food diary, food-frequency questionnaires), asking patient’s perception of their health and nutritional status, alcohol consumption, smoking status, use of medications, herbal medicines and nutritional supplements.
A detailed assessment of patient’s nutritional status includes a combination of anthropometric and biochemical measurements, physical examination (including history) and dietary assessment [46]. The use of anthropometric measurements, height and weight (including the Body Mass Index, BMI) and waist circumference, and dietary assessments were not commonly reported by chiropractors in this survey. They are currently used for essential screening and assessment of nutritional status and included in the clinical practice guidelines for healthcare clinicians to provide relevant lifestyle and promotion of healthy eating especially in overweight and obese patients in Australia [46, 47]. It would be useful for chiropractors to routinely record the BMI and waist circumference in the initial patient consultation to assess general health risks associated with being overweight or obese.
In the US, the use of a food diary is commonly recommended as a dietary assessment method, although the time-restrictions of undertaking this method have been acknowledged [24, 48]. Although a food diary was also used by some participants in this survey, Australian chiropractors apparently view referral to a qualified nutrition professional more favourably regarding dietary assessment, which may be a more efficient use of their time.
Resources used to provide nutritional advice
Almost all chiropractors in this survey are familiar with the Australian Dietary Guidelines., The NHMRC clinical practice guidelines recommend that the current Dietary Guidelines and the Australian Guide to Healthy Eating should be used as the basis of advice on nutrition for adults [46]. This could usefully be reinforced in a future nutrition skills framework for chiropractors.
Surveys of chiropractors in the US of their nutrition education and counselling practices report a need for dietitians to become involved in the nutrition-related practices of chiropractors as sources for information and referral [29, 49]. In our study, 35% of chiropractors reported using resources provided dietitians in their practices, reinforcing the importance of the way nutrition is perceived as beneficial for the health of chiropractic patients in both countries.
Nutritional recommendations and interventions
The most frequent nutritional advice provided by Australian chiropractors in this study was related to nutritional supplements, reflecting the patterns found in the US [24] and Canada [34, 50]. Most chiropractors (95%) surveyed in Alberta (Canada) endorsed health product sales, and most (89%) were engaged in sales including nutritional supplements (68%) and vitamins (52%). The authors of those studies encouraged chiropractors to be aware of the national code of ethics and conduct in endorsing health products [50].
Nutritional supplements are known to have an important role in correcting some deficiencies such as iron, the use of calcium supplements by women to reduce the prevalence of osteoporosis, and folate for the prevention of neural tube defects [51, 52], but generally it is preferable to get all nutrient requirements from a healthy diet. However, nutritional supplements should not be the first call in the promotion of a healthy diet. In this study, the rate of recommendation of general dietary supplements appears higher compared to the provision of healthy eating advice [53, 54]. The rate of recommendation of supplements was 92%, and 72% of the respondents reported “always” or “frequently” discussed “making healthy food and drink choices” with their clients who have nutritional issues. This suggests a need to promote existing evidence-based Dietary Guidelines and its food guide, the Australian Guide to Healthy Eating, within the chiropractic profession.
Specific dietary advice was given by 28% of our respondents and this is comparable to 26% in a survey conducted in the US [28]. In contrast to the US, only one respondent in our study specified dietary risk factors such as reducing saturated fat and low sodium intake which were common nutritional advice reported in the US study. A recent UK survey indicated most chiropractors (80%) considered ‘improved eating’ was a lifestyle issue that they felt responsible to discuss, and ‘poor diet’ is a behaviour to be monitored. Therefore nutrition advice and/or resources including setting goals are considered as a part of preventive and health promotional care offered to patients [25]. In each of these countries the need to address chronic diseases associated with unhealthy eating is a major health priority and chiropractors play and important role. In Australia the equivalent advice could be offered by chiropractors using the Australian Guide to Healthy Eating.
Referral to a dietitian or nutritionist by chiropractors was relatively uncommon in the US at 15% [24]. However, in this study around 90% had referred to dietitians for more detailed information on nutrition problems or dietary plans. Australian chiropractors in this survey acknowledge the importance of nutrition in their clinical practice, especially for patients with chronic disease. Almost all respondents had some nutrition component in their professional education.
Study limitations and further research
There are several limitations that need to be considered when interpreting the results of this study. The response rate was satisfactory for this type of survey and the demographic characteristics were similar to the Australian chiropractic workforce, however the nature of the online survey method meant that the number of questions had to be limited. There may also be the potential for response bias in the self-reported nature of the survey.