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Dynamic Chiropractic Canada – January 1, 2011, Vol. 04, Issue 01
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The Increasing Threat of Syndemics and the Role of Chiropractic Care

By David J. Brunarski, DC, MSc, FCCS(C)

The medical anthropologist Merrill Singer introduced the word syndemic in 1992 and recently updated the definition as "a set of enmeshed and mutually enhancing health problems that, working together in a context of deleterious social and physical conditions, increase vulnerability to significantly affect the overall disease status of a population."1 

This novel concept is gaining momentum because it has become increasingly clear that the burden of modern health care cannot be addressed by the traditional policy of designing therapeutic research trials and prevention programs that only focus on one disease or risk factor at a time. It is now understood that few serious and/or chronic diseases occur in isolation. Comorbid diseases occur simultaneously in the same individual, but may or may not interact with each other. Even if they do interact, this does not necessarily lead to worse health outcomes.2

However, in the case of syndemics, the evidence is that there is influential interaction between diseases that negatively affect the disease course, severity and final outcome.3 Many doctors of chiropractic appreciate this distinction and approach each patient as a constellation of interacting influences, including but not limited to the patho-biomechanical, environmental, and neuromusculoskeletal imbalances that may be resolved or managed with chiropractic care. An increasingly common clinical example is the patient with metabolic syndrome (MSyn) or "syndrome X," which includes obesity, insulin resistance, hypertension, high triglycerides, low HDL cholesterol, abnormal clotting and inflammatory markers.4

Over sixty percent of North American adults are currently overweight and the number of obese children has more than doubled among 2- to 5-year-olds (10 percent ) and more than tripled among 6- to 11-year-olds (15 percent). Clinicians need to educate and monitor these patients to ensure that they participate in daily exercise and follow healthy nutritional principles in order to control obesity. This is a reasonable therapeutic goal and addresses a modifiable risk factor.5

Chronic low back pain adds even more complexity to an already overburdened clinical picture. It is generally known that low back pain affects up to 80 percent of the population.6 Low back pain makes any activity, including walking, difficult and is often given as the reason for noncompliance in following a regular exercise program.7 You will likely appreciate what a challenge this presents to clinicians and their patients. Current clinical research demonstrates that chiropractic manipulative therapy is effective in the treatment of acute, subacute and chronic low back pain, and should be utilized at the earliest opportunity.8 

This is a very serious constellation of linked health problems acting synergistically - increasing morbidity, diminishing quality of life and increasing dependency on multiple health services.

To prevent a syndemic, we must prevent or control each contributor as well as the interactions that connect them. The Centers for Disease Control and Prevention (CDC) considers syndemic orientation "a way of thinking about public health work that focuses on connections among health-related problems, considers those connections when developing health policies and aligns with other avenues of social change to assure the conditions in which all people can be healthy. Related concepts include social ecology, health promotion, health equity, health dynamics, social epidemiology and system change."9

Chiropractic is well-equipped to make a positive contribution in the fight against syndemics by offering new theories of causation, insightful therapeutic options and a readiness to form alliances with other health care providers in the best interest of patient care.


  1. Singer M. Pathogen-pathogen interaction: a syndemic model of complex biosocial processes in disease. Virulence, 2010 Jan/Feb;1(1):10-18.
  2. Bayliss EA, Steiner JF, Fernald DH, Crane LA, Main DS. Descriptions of barriers to self-care by persons with comorbid chronic diseases. Ann Fam Med, 2003;1:15-21.
  3. Singer M, Clair S. Syndemics and public health: reconceptualizing disease in biosocial context. Med Anthropol Q, 2003 Dec;17(4):423-41.
  4. Bray GA, Champagne CM. Obesity and the metabolic syndrome: implications for dietetics practitioners. J Am Dietetic Assoc, 2004 Jan;104(1):86-9.
  5. U.S. Department of Health and Human Services. National Institutes of Health. National Heart, Lung and Blood Institute. Think Tank on Enhancing Obesity Research at the Heart, Lung and Blood Institute. NIH Publication No. 04-5249; August 2004.
  6. Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WD, Carey TS. The rising prevalence of chronic low back pain. Arch Intern Med, 2009 Feb;169(3):251-8.
  7. Escolar-Reina P, Medina-Mirapeix F, Gascon-Canovas JJ, Montilla-Herrador J, Jimeno-Serrano FJJ, de Oliveira SL, del Bano-Aledo ME, Lomas-Vega R. How do care-provider and home exercise program characteristics affect patient adherence in chronic neck and back pain: a qualitative study. BMC Health Services Research, 2010;10:60.
  8. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat, 2010 Feb. 25;18(1):3.
  9. Centers for Disease Control and Prevention. Spotlight on Syndemics. Available at

Dr. David Brunarski, former associate editor of DC Canada, graduated from CMCC in 1977 after completing his undergraduate educa-tion at the University of Alberta. He is president of the Ontario Chiropractic Association and practices full time in Simcoe, Ontario. To learn more, visit

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