Case Approach to Support Digestion

Let’s start with both of you providing some background.

Dr. Balliett: No problem. Let me start, where am I? I’ve been a chiropractor since 1988. I went to New York Chiropractic College after I had an undergraduate degree in biochemistry from Cornell and had worked in research for a number of years and went to a chiropractor and got a lot of help. I went to chiropractic college because of him. And then I’ve also gotten a Master’s in nutrition. I teach biochemistry and physiology and cell physiology at the chiropractic college in New York, and I also practice one day a week.

I am a biochemist by training and nutrition. So I just teach them science, and I teach physiology and am very interested in herb-drug interactions and drug-induced nutrient depletion as a passion of mine, so I got to teach pharmacology to them because of that.

And how about you Dr. Johnson?

Dr. Johnson: I work at Palmer College in Davenport. It’s known as The Fountainhead because it’s where the chiropractic profession started in 1895. I was in private practice for four years before returning to the College and have been there 16 years now. In my previous role at the College I created our Military Care Program, which provides complimentary chiropractic care to soldiers, veterans with a 20 percent disability rating or greater, and their families. It’s currently available at all three of our campus clinic locations and has provided over 3.4 million dollars of in-kind care to this important demographic.

Currently, I am a Faculty Clinician in our Outreach Clinic, have recently been appointed to VA Clinic in Iowa City as part of our Palmer Center for Chiropractic Research VERDICT Study, and provide Functional Nutrition services in our Academic Health Center. I have completed certification as a Functional Medicine Practitioner and am the only chiropractor to complete certification with the Center for Education & Development of Homeopathy as a Homeopathic Medicine Practitioner.

I am serving a second term as the President for the Rock Island Arsenal Association of the U.S. Army Chapter and have been appointed an Army Reserve Ambassador for Iowa by General Charles Luckey, Chief of Army Reserve & Commanding General, U.S. Army Reserve Command.

Thanks for the background from both of you. You two are going to present a case approach to support digestive health?

Dr. Balliett: Dr. Johnson and I love our students. We both are interested in research, and we’ve developed this professional relationship where we realize how many things we have in common and how important in patient care we believe that digestion is. And so we’re going to split it up a little bit, where I’ll talk about a case focusing more on gastroesophageal reflux disease and then Dr. Johnson is going to focus more on dysbiosis, because she can do more functional tests about that than I can.

Dr. Johnson: Based on the academic experience we both have, we’re also viewing this as an opportunity to take our colleagues through a clinical thought process that can be shared with their students. Additional objectives during this presentation are to identify the importance of addressing gut health and we plan to explore two cases using functional and laboratory testing to illustrate that. Dr Balliett will discuss a functional approach to addressing GERD, as estimates show more than 50 percent of the U.S. general population experiences heartburn, and I will review an approach to dysbiosis using stool/saliva laboratory testing, with a specific emphasis on the athlete.

We also plan to review appropriate nutrients that can help restore balance to the gut and provide our colleagues with action steps they can take immediately to benefit from the information in our presentation.

When you’re talking digestive health issues, it’s to support other chronic health conditions, not just digestion issues. Would that be accurate?

Dr. Balliett I think that what we both believe is that if digestion is not dealt with first, it doesn’t seem to matter totally what you do. If they cannot digest and absorb their food or their supplements, then where are you? I think both of us feel that if there is at all any issue in the GI tract, it has to be dealt with more first.

Dr. Johnson: Digestion impacts everything, and right now more than ever, even after doing this for 20 years, in the media there’s a lot more attention being given to the microbiome. So a lot more patients are asking questions about it and realizing that they must become more involved in looking at their own lifestyle and health choices and they need guidance with that. They are beginning to see that from a long-term perspective; management through a “little purple pill” or other means that is a short-term solution isn’t the best way to manage their health. It’s been a great opportunity in my mind to help patients understand that virtually any other disease process that exists is connected to gut health in some way. If they can ensure that as a foundation this system is working well for them, there is a lot to build on from that point. With everything we all face every day, nothing is ever going to be 100 percent perfect. However, we all have choices that we make each day that either builds health or systematically destroys it. This is the Salutogenic model of health that is empowering because it is the co-creation of health and helps patients understand the role they truly play for their own best quality of life.

I also feel that Dr. Balliett and I have an opportunity to expand the conversation beyond physical ailments to include how a person feels in their everyday existence. There is excellent evidence that demonstrates a connection between the gut and the brain and studies that show a correlation between anxiety and depression with poor gut health for example.

We also know that if proper digestion isn’t in place, nutrient absorption is impacted, especially that of protein. This can lead to what’s called protein catabolism, which impacts soft tissue integrity. When tissues aren’t strong, the risk for injury increases, which is a real problem for athletes. We certainly intend to discuss it.

What will be a quick synopsis of how will you look at a patient and start treating? Where do you start and what direction do you go to with them?

Dr. Balliett: I think we are agreed that when first see a new patient we are going to take a history first, and then I personally use a system survey right after the history so that they have that already filled out when they come in and that way, I can have a more functional conversation for why they’re having the symptoms they have. I think that Dr. Johnson would say she’d also order some tests. I’m probably going to do blood work and some possible diagnostic imaging. I use a body composition analyzer to look at their cellular health, their age of their cellular health, and so we really have lot of information when we start to come up with a plan. What do you want to add to that, Dr. Johnson?

Dr. Johnson: Dr. Balliett has given such a great overview that I believe I would only add the inclusion of a food diary for even three to five days. It can be helpful not only for the practitioner to get an idea of the foods most commonly consumed, and it can help the patient really understand what he/she is choosing as well. I couldn’t tell you what I had for breakfast yesterday, and unless a person eats the very same things consistently, for most of us this becomes something we take for granted in life without giving it much thought. There is a lot of information to be had with respect to food choices, and it can be a great way for people to identify how much processed/ultra-processed foods they are consuming. It’s a different conversation with a patient that is already incorporating a great deal of whole foods into their diet and still having problems versus a patient that is attempting to slow their consumption of fast and junk foods. There is a starting point for each patient and this type of discovery can also reveal any emotional factors associated with food or psychological blocks that may be present that they didn’t even know they had. Lifestyle is really a factor, as well as just the financial aspect of people being able to access the foods that they need to heal.

Dr. Balliett: Right. I would go with that. The importance really is individual because compliance is everything, and so you have to really figure out where they are. Maybe they are at the very beginning of the journey or they have just started a journey, but now they’re self-medicating with too many supplements they can buy.

Does your program also include an analysis or breakdown of types of things that they eat and maybe a breakdown of what foods they’re consuming and how it might impact them?

Dr. Balliett: I often have people use a free app on their phones where they can do four days’ diet because it keeps track of those things for you. That’s free. And then I usually can get them to be compliant. The literature says that after four days, people slack, but four days is usually all you need to get a good idea of where people are.

Dr. Johnson: I come from a very similar standpoint and if there is resistance ask for just three days. It’s a way to get started. What I like about it is that it just brings more awareness to the situation, and that can be a great discovery process for patients to have.

How long would you say a person is in the program before they see results?

Dr. Balliett: I usually have people come in, analyze them, give them a functional diagnosis, and have them do their recommendations three to four weeks before I’ll see them again because it takes 21 days on average to make a change in how you are and in your habits. That is why I don’t do a follow-up for between 21 to 28-days after the first visit.

Dr. Johnson: I have patients that notice change within days of changing their lifestyle habits and incorporating supplementation. It’s a process, however, and it’s valuable to check-in to monitor progress and answer questions. I have patients schedule a follow-up appointment within 30 days of starting the program. My process is to complete a thorough review of my intake paperwork, along with other documentation provided and then meet with the patient for an initial report of findings to make sure that I haven’t missed or misunderstood their issues and goals. I plan for an initial period of change that is approximately 90 days and then assess the need to complete re-testing to obtain objective measurements to continue guiding the process forward to help them meet their health goals. Once we’ve achieved resolution of their initial complaints we look at ways to keep that momentum moving in a positive direction through lifestyle choices and maintenance supplementation.

How many different products would you have them on during that, while they’re on this case approach-type program?

Dr. Johnson: The number of products is so individual related to their tolerance, commitment, and issues. I always work toward having the lowest “pill count” possible while still achieving the goals. I might recommend six different products, but only a tablet at each meal, for example, so it may be a “low pill count,” but a variety of tools that they’re using. Most people, by the time that they reach someone like Dr. Balliett or myself, have a lot of complexities that need to be addressed in order to push that momentum where it needs to go. That’s part of what we face as practitioners is figuring out what a good therapeutic threshold is actually going to be to jump start what we need without pushing them too hard, too fast and creating a poor response that we don’t want.

Is the long-term objective to get them off of any types of products and be able to do it through diet?

Dr. Balliett: I’ll speak from my own personal experience. Personally, the reason I’m so involved with this is I went to a chiropractor who used products when I was 28 and I still take a number of things that I’ve been taking since then. Every now and then take myself off for a few days, but I notice that I never feel as good without the supplements as with the supplements.

So, for me, I’ve been on some products for a very long time with great results.

Dr. Johnson: I think that’s always an interesting conversation, but I honestly don’t see how that’s possible for most. I would consider that I eat well and am a careful, conscientious consumer, but in the world that we live in today I am acutely aware of the fact that I’m not getting the same nourishment that my grandmother did out of the same product. My lifestyle is much more hectic, my level of stress is often exceptional, and I am exposed to many more toxins than she was, which pushes my body’s capabilities. It’s my job to support it if I want it to work well, and whole food nutrients are a great way to accomplish that. My patients’ lives are no better and certainly can be much worse. When working with a patient I often ask what they are willing to do and what they are actually going to do. Much of this is lifestyle-related. Many also have demands on their bodies as a result of the occupations they have, and that’s also not going to change, so it needs to be support. If a patient is an athlete with specific demands that are different than a person exercising for fitness, that needs to be supported. I believe that it’s impossible to manage all needs exclusively through diet alone. Food feeds the body.

Dr. Balliett: I’ve got to back you up 100% in that, Dr. Johnson. Even with our current technology, we do not understand everything nor do we understand the mechanism of action of everything, and what I say to my patients is  I could give you a plate with flour and salt and yeast and water or I could give you a piece of hot, fresh bread out of the oven. The experience to your body is 100 percent different. So that’s when you have whole food based supplements, when you have a piece of bread versus the individual ingredients, your body just knows how to deal with that better.

And there’s something else going on that we maybe can’t measure or we don’t understand yet that has impact for that patient. I find you can do a lower dose because it is food-based and they don’t seem to have a reaction. Not that I’ve never given a nutraceutical dose of a B vitamin, high-dose, somebody’s really struggling, but what I find over time is that just drives the body too hard.

And I think that’s why the literature on high-dose multivitamins isn’t good and we need a different way of evaluating a more holistic approach where we’re looking at lifestyle and diet and whole food based supplements. I don’t think we have a good paradigm. I think that our patients speak volumes for us, but I think that’s been a deficit in research, but at the same time, the proof is in the pudding. I think a lot of patients have a lot of great results.

Do you ever see a down side where people try to do it or is it always a success?

Dr. Johnson: It’s hard to change habits, and it’s hard to know what to eat sometimes. We all grow up as well with certain foods that remind us of family and home and those have a place too. I still eat dessert, but I watch my portion size and the frequency with which I’m eating those things. It’s a give and take. There’s a reason why that phrase – “everything in moderation” – exists. It’s important because if people feel like everything they’ve ever loved is being taken away from them there will be resistance. I always tell patients that it’s all about nourishment. That is the key. As often as they can choose foods based on that one word, that will truly help to guide the majority of their meals.

It’s also important to look at the way stress impacts the gut. I may have someone who’s doing really well and they’re feeling great and they’re just on a great path and then they get the phone call that changes everything. Or their spouse comes home and they’ve lost their job.

There are so many things that I think a person has to work with on a daily basis and have an understanding that we’re not going for 100 percent perfection here. It’s the same thing that we’re saying happens with patients we are providing chiropractic care to. The goal is not to make a person 100 percent pain free every day.

There are going to be moments where a person who has had chronic diarrhea and who somewhat lives in fear of food may eat something that triggers a momentary issue that they’re just going to have to psychologically and emotionally work through. That is where the power of this work is so incredible because whether people realize it or not, their gut function truly impacts them every single day. When you get sick or have food poisoning and you don’t leave your house or the bathroom for three days, that is a quick and pretty in-your-face reminder of how important that system is to you.

Dr. Balliett: And getting back to patients, currently I have a patient who was seeing a nutritionist for her weight. And they were just emotionally beating her up. And her acupuncturist sent her to me and we got her on a really good plan and it was really working for her. And I was ready to let her not come back in anymore, using Dr. Johnson’s system of the once a month for a couple of months. And she said, “No. I want to come every month. I want to just check in. I want to see that I’m doing well. I need the support.”

Sometimes I let the patient drive how much care they need because maybe just what Dr. Johnson said, in this patient’s case, her child got hospitalized and that totally threw a wrench in because they have other kids and back and forth to the hospital. She just could not stay on the plan. And then she said, “I don’t remember what the plan was. And can I come back?” And so coming regularly, gets back on track. I think it depends on the patient. Some people come more than others. I think both of us, the thing we have in common is how individualized we do both our chiropractic care and our nutrition.

Julie Johnson, DC, CFMP, is an Assistant Professor serving as Faculty Clinician at Palmer College of Chiropractic, Davenport. She provides clinical chiropractic care to outreach patients that are economically challenged, offers functional nutrition services in the Academic Health Center and has been appointed to work part-time at the VA Clinic in Iowa City, IA, in support of the Chiropractic Care for Veterans: A Pragmatic Randomized Trial Addressing Dose Effects for cLBP (VERDICT) study. She is a certified Functional Medicine Practitioner and sole chiropractor certified as a Homeopathic Medicine Practitioner through the Center for Education & Development of Homeopathy. As a graduate of Palmer College Davenport, she has been in practice for the past 20 years. She has a specific interest in military healthcare and created the Palmer College Military Care Program, available at all campus locations, as the largest and first program of its kind with over $3.4M of complimentary care provided to date. She is the President of the Rock Island Arsenal Association of the United States Army Chapter and has been appointed as an Army Reserve Ambassador for Iowa by LTG Charles D. Luckey, Commanding General, U.S. Army Reserve Command.

Mary Balliett, DC, MSACN, is a full-time Professor in the Department of Basic Sciences at NYCC. She is the former Acting Dean of the School of Applied Clinical Nutrition at NYCC. Currently, she teaches courses in Biochemistry, Cell Physiology and Systems Physiology in the D.C. program and Herb-Drug Interaction class in the Acupuncture and Oriental Medicine program. She has conducted multiple research protocols in nutrition, acting as the clinician on trials with the other members of the Research department, and supervised student-led research projects. She received a B.S. in Biology with a concentration in biochemistry from Cornell University in 1976. She graduated magna cum laude in 1988 from the D.C. program and later graduated with honors in 2008 from the MSACN program, at New York Chiropractic College. She has practiced as a chiropractor for the last 32 years and currently treats both chiropractic and nutrition patients once/week in Ithaca, NY.