by Meridel I. Gatterman, MA, DC, MEd,
ACA Wellness Subcommittee on Education
While to some, the terms preventive medicine, health promotion and wellness are used synonymously, the differences are important for chiropractors. Preventive medicine is concerned with the prevention of disease.  Health promotion is broader and deals with dysfunction in addition to prevention of disease. Health promotion is built on a positive image of health, rather than a risk factor model.  Wellness is a dynamic state of health in which an individual progresses toward a higher level of functioning, achieving an optimum balance between internal and external environments.
The definitions of health promotion and wellness adopted by the Council on Chiropractic Education (CCE) are as follows: Health Promotionis the science and art of helping people change their lifestyle toward a state of optimal health. Wellnessis a process of optimal functioning and creative adaptation involving all aspects of life. Health is a state of optimal well-being and functioning. Wellness is an active process employing a set of values and behaviors that promotes health and enhances quality of life. The CCE adopted health promotion and wellness competencies as part of CCE standards in January of 2007.
The Healthy People 2010 document was designed in part to put prevention into the practices of clinicians.  To this end, some of the Healthy People 2010 focus areas deal with prevention of the following diseases: arthritis, osteoporosis, cancer, chronic kidney disease, diabetes, heart disease and stroke, HIV, infectious diseases, periodontal disease, respiratory disease and sexually transmitted disease.
Screening is a central part of preventive medicine strategies for the early detection of those at risk for developing certain diseases. Various levels of disease prevention have been delineated. Primary Prevention prevents a disease or condition from occurring. Secondary Prevention detects early signs of a condition or disease and intervenes. Tertiary Prevention reducessequelaeandissupportiveorrehabilitativeinnature. 
Screening may be invasive or non-invasive. Not all screening can be done without special tests that require laboratory and/or diagnostic imaging such as X-rays. Much information can be gained through the use of questionnaires that can suggest the appropriateness of more invasive testing. Some tests are routinely performed in most health care offices. These include vital signs, and height and weight monitoring.
Common Tests for Disease Prevention Screening
Hypertension Screening. High blood pressure is listed as among the major risk factors for both stroke and heart disease, and the risk increases with age and obesity. Regardless of age and weight, monitoring blood pressure is an important part of any disease prevention examination. The side effects from drug therapy are undesirable, and a more conservative approach may be effective in less severe cases with referral for drug therapy when appropriate.
Cholesterol Screening. While high levels of cholesterol are not considered a disease state, hyperlipidemia has been linked to heart disease and is commonly monitored in patients with a family member who has had a heart attack before the age of 55. Not all forms of cholesterol are harmful and it is important that screening differentiate between low-density lipoproteins (LDLs), high-density lipoproteins (HDLs) and the total cholesterol to HDL ratio. A proportionately high level of high-density lipoproteins is desirable.
Diabetes. Diabetes is a common and serious condition with its complications comprising the third most important cause of death attributable to disease in developed countries.  It is an important cause of blindness, diseases of blood circulation, neurological diseases and kidney failure. The most convenient screening technique for diabetes is a simple blood test.
Osteoporosis. If a screening questionnaire suggests the likelihood of osteoporosis, then bone mass determination is in order. Ultrasound imaging of the heel is used to measure bone density and monitor the level of osteoporosis. Postmenopausal females are more susceptible, but one-third of osteoporotic hip fractures occur in men.  These are but a few of the common screening tests that should be considered if patients appear to be at risk for developing these disease states.
Invasive screening tests can be expensive and are not always without risks. They should not be used as fishing expeditions when a diagnosis is unclear, as a means of practicing defensive medicine or, worse, a means of increasing income.
Health promotion goes beyond preventive medicine, disease surveillance and vaccine development. Health promotion has a strong element of community action and self-care. It also focuses on leading health indicators and promotion of optimal functioning of those without risk of identifiable disease states. Healthy People 2010 focus areas that deal with health promotion include:
- access to quality health services;
- chronic dysfunction conditions (e.g., back pain);
- disability and secondary conditions;
- health education programs;
- environmental health;
- family planning;
- nutrition and food safety;
- injury and violence prevention;
- mental health promotion;
- healthy weight promotion;
- occupational health and safety;
- physical activity and fitness; and
- substance abuse prevention. 
Chiropractic and Health Promotion
Doctors of chiropractic have traditionally been involved in health promotion. This has taken the form of counseling on habits and lifestyle.  Vear describes the
standards of chiropractic practice: “Chiropractic educational institutions place great emphasis on patient counseling.”  Recent data from the National Board of Chiropractic Examiners Job Analysis of Chiropractic reports that nearly all doctors of chiropractic instruct patients regarding promotion of their health. Advice on general fitness and exercise promotion is given by more than 98 percent of chiropractors.  Over 90 percent of chiropractic physicians provide counseling on nutrition and dietary recommendations, ergonomic and postural advice, changing risky and unhealthy behaviors, self-care strategies, and relaxation and stress recommendations.  Not every chiropractic patient receives health promotion and wellness counseling based on individual preferences and needs. The Association of Chiropractic Colleges includes health promotion in its statement of scope of chiropractic practice. 
Without individual responsibility, wellness is not possible. Patients, while becoming increasingly well-informed about health issues, cannot be held solely responsible for healthy lifestyles. Guidance and encouragement from trained health educators are important components of the health promotion-wellness equation. An individualistic approach that promotes health requires a practitioner who serves as a health educator, is patient centered, well-informed about wellness practices and emphasizes conservative health care. Doctors of chiropractic can thus facilitate wellness in their patients through determination of their general state of health, and then educate and encourage them to follow healthy habits and pursue a wellness lifestyle.
Wellness is a way of life. It is a process of optimal functioning and creative adaptation involving all aspects of life. It is an enjoyable approach to living that emphasizes the importance of achieving harmony in all aspects of mind, body and spirit. It is a lifestyle that creates the greatest potential for personal well-being. More than an absence of illness, it is a dynamic balance among all aspects of the person. It is an active process in which one pursues activities with the aim of achieving optimal functioning that promotes health.
Since its inception, chiropractic has been based on an active care model that emphasizes wellness. Wellness requires active patient participation. It is a process of achieving the best health possible given one’s genetic makeup by pursuing an optimal level of function.  Wellness care incorporates active lifestyle changes consistent with the goals of Healthy People 2010. 
The ACA wellness model states, “Wellness begins on day one of chiropractic care.”  It is an active care model that requires the commitment of the doctor of chiropractic to wellness. It emphasizes the collaboration with patients on the development of a lifelong path for health promotion and disease prevention.  Wellness is a patient-centered process that incorporates the knowledge, skills and attitudes acquired through professional training. The doctor of chiropractic can work with patients in a number of domains, including: evaluation/assessment of patients (risk factors, health needs); information/education of patients (awareness); intervention/monitoring (including counseling); and integration with other community resources. 
Strategies for Implementing a Wellness Model
The ACA has recommended a number of strategies for implementation of a chiropractic wellness model:
1. Recognize that the greatest need in health care today is promotion of health and wellness.
2. Create a fundamental shift in the chiropractic college curricula to emphasize wellness philosophy and strategies for implementation.
3. Develop a campaign to inform health educators in schools, colleges and universities of the wellness focus of chiropractic practice.
4. Develop continuing education to foster wellness knowledge, attitudes and skills among doctors of chiropractic and support personnel.
5. Integrate and emphasize the wellness care model in every chiropractic specialty council.
6. Design and seek funding for research studies that assess the chiropractic wellness model.
7. Educate the public, government agencies, and third-party payers about integrating the chiropractic wellness model.
8. Increase the chiropractic profession’s involvement in the American Public Health Association.
9. Develop buy-in to the wellness model by all chiropractic organizations.
10. Use publications and the Internet to provide useful materials on wellness to chiropractic practitioners and their patients. 
Doctors of chiropractic can provide disease prevention, health promotion, and wellness services. As a resource to the community, they serve as conduits to other health care practitioners, services and information resources.4 As direct-access practitioners, chiropractors are ideally suited to act as health educators to serve as health and wellness advocates and to conservatively promote disease and injury prevention, in addition to specializing in spinal care. They are ideally suited to go beyond disease prevention. Working with patients to promote their health and wellness is an integral part of chiropractic practice.
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2. Pedersen A, O’Neill M, Rootman I. Health Promotion in Canada: Provincial, National and International Perspectives. Toronto: WB Saunders, 1994.
3. Healthy People 2010: Understanding and Improving Health. U.S. Department of Health and Human Services. November 2000.
4. ACA House of Delegates September 2001.
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8. Chiropractic Scope of Practice Consensus Statement. Association of Chiropractic Colleges, 1996.