by Meridel I. Gatterman, MA, DC, MEd,
ACA Wellness Subcommittee on Education
Health promotion often is associated with disease prevention and considered a public health problem.  With the significant reduction in the prevalence of infectious diseases as a result of improved nutrition, sanitation and better living conditions in industrialized nations, chronic diseases related to self-imposed lifestyles have become increasingly important. These “lifestyle diseases,” including obesity, hypertension and chronic pain from arthritis, are as compromising to quality of life as are the more life-threatening conditions such as heart disease, stroke and cancer. So whose job is it to address “lifestyle diseases”? In addition to public health specialists and other governmental agencies, health educators, medical practitioners (specifically primary care doctors) and alternative medical practitioners, including chiropractors, are all suited to promote behavioral modification that leads to healthier lifestyles. Last but not least is the individual patient’s responsibility for promoting their own health. This is emphasized in the World Health Organization’s definition of health promotion: “The process of enabling people to increase control over (and to improve) their health.”  This places the responsibility more on self-care to reduce unhealthy behavior through a partnership with a health professional.
Better health care does not just depend on some new therapeutic standard, but on the level of willingness and competence of individuals to engage in self-care.  Safe self-care is dependent on appropriate screening and accurate information provided by health care practitioners who act as educators. Blaming the victim for an unhealthy lifestyle is inappropriate if accurate information is not available to them. Patients have the ability to judge their own health status, given adequate information, but safe self-assessment is only possible when one’s health status has been evaluated by a professional. Patients who perceive that self-care will lead to valued health benefits and who feel adequately qualified to undertake self-care activities are most likely to embrace this initiative. 
Patient-Centered Care and Health Promotion
Patient-centered care has been proposed as the optimal paradigm for chiropractic practice whereby the patient and chiropractor work as partners, enabling the patient to move toward a healthier lifestyle.  This traditional chiropractic paradigm provides the framework for health promotion and patient self-care. Assessment of a patient’s health status by chiropractic physicians following screening for risky behavior can provide the information necessary for safe patient self-care.
Identifying Risky Behavior: Leading Health Indicators
Information about leading health indicators has been provided by the U.S. Department of Health and Human Services.  Healthy People 2010 lists health indicators chosen for their ability to motivate action. These 10 health indicators, reflecting the major health concerns in the U.S. are as follows: physical activity; overweight and obesity; tobacco use; substance abuse; responsible sexual behavior; mental health; injury and violence; environmental quality; immunization; and access to health care. The process of selecting these indicators was led by an interagency work group within the U.S. Department of Health and Human Services and was intended to help individuals more easily understand factors that lead to health promotion, disease prevention and optimal wellness. Through screening procedures, strategies and action plans that address these health indicators, we can significantly promote health and increase the quality of life.
1. Physical Activity
Regular physical activity throughout life is important for maintaining a healthy body and enhancing psychological well-being. Regular physical activity promotes a healthy heart, lowers the risk of developing diabetes and is associated with a decreased risk of colon cancer. Regular exercise also helps to prevent and reduce hypertension, in addition to aiding in weight control, increasing muscle and bone strength and improving mental health. Screening for physical fitness must include individual differences and the current level of physical activity, individual needs and preferences, and available resources. Conditions that require professional supervision of individualized exercise programs must be identified. Exercise prescription for improving health is an inherent part of chiropractic practice. 
2. Weight Control
Overweight and obesity substantially raise the risk of a variety of diseases. These include hypertension, diabetes, cardiovascular disease, gallbladder disease, arthritis, sleep disorders, breathing problems and some types of cancer. Obese individuals also may suffer from social stigmatization, discrimination and lowered self-esteem.  A healthy diet and regular physical activity are both important for maintaining a healthy weight. Eating disorders that lead to below a healthy weight may be serious enough to be life-threatening. Measurement of height to determine ideal body weight from height and weight charts is a poor method of screening for weight disorders. Utilizing these charts may indicate too much weight from a heavy frame with a high proportion of muscle that weighs more than fat, or an acceptable weight with a small frame and a high proportion of fat that may be unhealthy. Screening for composition of body mass and energy requirements offers a positive method of weight control. Chiropractors can encourage weight loss through a weight-loss management contract. 
3. Tobacco Use
Cigarette smoking is the single most preventable cause of disease and death in the U.S. Smoking results in more deaths each year in the U.S. than AIDS, alcohol, cocaine, heroin, homicide, suicide, motor vehicle crashes and fires combined.  Smoking is a major risk factor for heart disease, stroke, lung cancer and chronic lung diseases – all leading causes of death. Smoking during pregnancy can result in miscarriages, premature delivery and sudden infant death syndrome. Fire-related injuries and environmental damage caused by fires are other effects of smoking. Secondhand smoke increases the risk of heart disease and significant lung conditions, especially asthma and bronchitis in children. There is no safe tobacco alternative to cigarettes. Spit tobacco (chew) causes cancer of the mouth, inflammation of the gums and tooth loss. Cigars and pipes also increase the risk of cancer of the mouth, throat and lungs, and can increase the risk of heart disease.  While many health practitioners are pessimistic about their ability to persuade patients to quit smoking,  it can be promoted by understanding and applying the stages of change associated with behavioral modification. 
4. Substance Abuse
Excessive use of alcohol and other recreational drugs is associated with serious health problems. The annual economic costs to the U.S. from alcohol abuse were estimated to be $167 billion in 1995.  In 1998, 17 percent of adults 18 years and older reported binge-drinking in the past month. Binge-drinking was defined as consuming five or more drinks on one occasion. Alcohol abuse is associated with automotive crashes, homicides, suicides and drowning in leading causes of death among youth.  Long-term heavy drinking can lead to heart disease, cancer, alcohol-related liver disease and pancreatitis. Alcohol use during pregnancy is known to cause fetal alcohol syndrome, a leading cause of mental retardation. 
Screening for warning signs of excessive use of alcohol is a useful device for people who are drinking too much. Light alcohol consumption is controversial and it has been suggested that there is less risk of coronary heart disease if you drink one alcoholic drink each day.  As chiropractors, we should not hesitate to discuss the levels of alcohol consumed by patients since many underestimate the level of their alcohol consumption. 
5. Responsible Sexual Behavior
Sexually transmitted diseases (STDs) and unintended pregnancies can result from unprotected sexual behavior. Abstinence is the only method of complete protection from both. Condoms, if used correctly and consistently, can help prevent STDs and unintended pregnancy. Half of all pregnancies in the U.S. are unintended; that is, the pregnancy was not planned and/or wanted at the time of conception. The cost to U.S. taxpayers for adolescent pregnancy is estimated between $7 billion and $15 billion a year. 
It’s possible to become infected with a sexually transmitted disease by a partner who has no symptoms.  All sexually active people should know how to practice safe sex and know how to recognize the symptoms of infection. Screening for safe sex can determine those at risk for STDs and unwanted pregnancies. Patients at risk for an STD should be advised about measures to reduce this. 
6. Mental Health
No one is immune to mental illness. Approximately 20 percent of the U.S. population is affected to some degree during a given year.  Depression is the most common mental health disorder. Major depression is a leading cause of disability and is the cause of more than two-thirds of suicides each year. Mental health is sometimes considered simply the absence of mental illness, but it actually is much broader. Mental health is a successful state of mental functioning resulting in productive activities, fulfilling relationships and the ability to adapt to change and cope with adversity.  Mental health is indispensable to well-being, family and interpersonal relationships, as well as the ability to contribute to society. Depression can be recognized through screening, with different forms of treatment recommendations. Strategies that enhance coping skills can be taught and learned. A sense of personal control can be developed that contributes significantly to mental fitness.  While a variety of coping skills can be refined through patient application of self-help strategies, professional assistance may be warranted. Patients with indications of significant mental health problems should be referred for appropriate care.
7. Injury and Violence
The risk of injury is so great that most people sustain a significant injury at some time during their lives. Motor vehicle crashes are the most common cause of serious injury. They often are predictable and preventable. Increased use of safety belts and reduction in driving while impaired are two of the most effective means to reduce the risk of death and serious injury.  A motor vehicle accident risk index can identify the risk of being injured. Modification of driving habits can lower the risk of being involved in a motor vehicle accident.
Home safety can be increased when a checklist of factors that reduce the risk of accident in the home are identified. Recommendations for inexpensive equipment and modifications that increase home safety can be made.  Many factors that contribute to injuries are closely related with violent and abusive behavior. A history of abuse often is elicited only through specific probing. A poor response to management may be the result of past or ongoing abuse.  In 1996, more than 80 percent of infant homicides were considered to be fatal child abuse.  Death from firearm injuries numbered 32,436 in 1997, with 42 percent of those victims being homicides. Homicide was the third leading cause of death for children aged 5-14 years, an increasing trend. 
8. Environmental Quality
Physical and social environments play major roles in health and wellness. The physical environment includes the air, water and soil through which exposure to chemical, biological and physical agents may occur. The social environment includes housing, transportation, urban development, industry and agriculture, and results in exposures such as work-related stress and injury.  Occupational activities and postures that pose as risk factors can be identified. And safer, more efficient job design can reduce stress fatigue and injury. Screening and job analysis can lead to ergonomic structuring of the workplace improving the work environment. Chiropractors can help workers by adapting their jobs through information and training. 
Many once-common diseases are now controlled in the Western Hemisphere including smallpox and poliomyelitis.  The use of immunization should be restricted to increasing immunity to those diseases with significant mortality, morbidity or economic consequences. Successful immunization requires a healthy immune system in which a realistic biological challenge to infection does not result in the clinical manifestation of the disease. Contraindications to the use of live vaccines include: acute fevers, acute systemic viral infections, immune deficiency, corticosteroid or other immunosuppressant therapy, malignant disease, pregnancy, hypersensitivity to constituents of the vaccine and passive immunity.  Complications attributable to immunization are considered to be far less frequent than those attributable to natural infections. The greatest risk has been associated with the pertussis (whooping cough) vaccine.  Some of the most reported complications are attributable to the medium in which the vaccine is prepared. As with any health care procedure, it’s important to consider the risks as well as benefits in order that patients can give informed consent to immunizations.
10. Access to Health Care
Financial, structural and personal barriers can limit access to health care. Financial barriers include: not having health insurance, not having coverage for needed services or not having the financial capacity to cover services outside a health plan or insurance program. Financial barriers are a serious consideration that must be addressed in this country since strong predictors of access to quality health care include having health insurance, a higher income level and a regular primary-care provider. It has been demonstrated that doctors of chiropractic as primary-care providers in an integrative medicine organization provided care at substantially reduced costs for patients, compared to care given by medical doctors and osteopaths.  Structural barriers include lack of primary-care providers and access to health care facilities. Community-based chiropractic practices offer ready access to primary- contact chiropractors in most areas. Personal barriers include cultural or spiritual differences, language barriers, not knowing what to do or when to seek care, or concerns about confidentiality or discrimination. The patient-centered nature of chiropractic reduces personal barriers when care is individualized and patients’ values, beliefs and health care needs are respected.
So whose job is it to address “lifestyle diseases?” As chiropractors, it’s incumbent on us to accept the responsibility to promote the health of our patients, as well as to treat the conditions that they pre-sent with in daily practice.
“The nature of chiropractic care with its health-oriented philosophical basis is well positioned to influence patient attitudes about lifestyle related health behaviors.”
– Alan Adams 
It’s not enough to identify risk factors. Health promotion must be built on a positive image of health, rather than just disease prevention. While a strong element of community action and self-care are important factors in promoting health, the commitment of chiropractors to health promotion and wellness is one of their major responsibilities.
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- Attributed to Alan Adams.