Integrative Medicine Using Complementary and Alternative Therapies in Medical Practice.
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Transcript of Integrative Medicine Using Complementary and Alternative Therapies in Medical Practice.
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Integrative Medicine
Using Complementary and Alternative Therapies in Medical Practice
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Victor S. Sierpina, M.D.
Associate Professor
Family Medicine
University of Texas Medical Branch
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NUTRICEUTICALS
An Introduction and Overview with Practical Clinical Applications
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Learning Objectives To learn the definition of nutriceuticals
(nutraceuticals) To review the most popularly-used over-
the-counter nutriceutical preparations To gain understanding of and become
familiar with several dietary programs To know the special issues about athletes’
ergogenic and dietary programs
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Learning Objectives To be familiar with several primary care
applications of nutriceuticals and review the pertinent supporting literature
To have a useful resource list for information about nutritional therapy to be better able to address patient questions in this area
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Nutrition
Finally!
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Biochemistry
Again?
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Nutriceuticals: Definition and Usage Use of nutritional supplements and food
related constituents therapeutically Why?
Dietary deficiencies Agricultural practices Environmental toxins Lifestyle
Micronutrient debate (Goodwin)
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Diets Ornish
Atkins’
Zone/Sugar Busters
Protein sparing
Mediterranean
DASH
Vegetarian Macrobiotic Eat Right for
Your Type
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Practice Cardiovascular Exercise Per Week UTMB Class of 2004
0
5
10
15
20
25
30
35
40
None 1-2 Days 3-5 Days >5 Days
Percentage
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Time of Aerobic Activity per Session UTMB Class of 2004
0
5
10
15
20
25
30
0-15Mins
20-30Mins
30-45Mins
45-60Mins
>1 Hour
Percentage
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Weight Training Per Week UTMB Class 2004
05
1015
2025
3035
404550
None 1-2 Days 3-5 Days >5 Days
Percentage
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Practice Stretching/Tai Chi/Yoga Per Week UTMB Class 2004
0
10
20
30
40
50
60
70
None 1-2 Days 3-5 Days >5 Days
Percentage
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Servings of Fruits & Vegetables Per Day UTMB Class of 2004
0
10
20
30
40
50
60
70
None 1-3 4-6 7-9
Percentage
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Health Habits to Change105
87
21
102 2
28
0
20
40
60
80
100
120
Habits to Change
Dietary Changes
Exercise
Sleep
Leisure/Sports
Stop Smoking
Do Nothing
Other(Meditation/Prayer)
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Nutriceuticals---What Are They? Amino Acids Diets Enzymes Minerals Vitamins Other Pharmacological/Biological Products
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Enzymes Bromelain CoQ10
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Minerals
Magnesium
Manganese Zinc Calcium
Potassium
Chromium Molybdenum
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Vitamins
A B-Complex B1 (Thiamin) B2 (Riboflavin) B3 (Niacin) B5 (Pantothenic Acid)Beta-carotene
B6 (Pyridoxine) B8 (Folic Acid) B12 (Cobalamin) C D E K Multi
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Other Pharmacological/Biological Agents
Fatty acids—EPO, GLA, flaxseed oil
Glucosamine sulfate, chondroitin, shark cartilage
Glandulars--thymus, adrenal, thyroid Metabolife Steroids--DHEA
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Dr. Andrew Weil’s Anti-Oxidant Cocktail 100-250 mg of vitamin C and 25,000 IU of
mixed carotenes at breakfast 400-800 IU of natural vitamin E and 200
mcg of selenium at lunch 100-250 mg of vitamin C at dinner
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Dr. Natural
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Dr. Victor Sierpina’s Nutritional Supplement Formula 500 mg Vit C in
AM&PM 400 IU Vit E in
AM&PM High potency B-
complex with antioxidants/trace minerals in AM
High fiber, low fat diet, 5-7 servings fruits/veggies per day, garlic, red wine, olive oil, green tea
(Ginkgo biloba 60 mg AM & PM)
Be thankful for your food….
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My Favorite Therapies—stuff you can use every day
Glucosamine Anti-oxidants Vitamins C (1 gram/d), E
800 IU/d), high intakes (5-7 servings/d) of fruits and vegetables
Chromium 200-400 mcg/d
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My Favorite Therapies—stuff you can use every day
Vitamin B6 50-100 mg/d Zinc 15-45 mg/d Magnesium 300-500 mg/d Coenzyme Q10 50-300 mg/d
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Concerns Standardization Purity Potency Bioavailability FDA’s role
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Remember FDA neither establishes nor regularly
enforces any standards of quality for herbs or other dietary supplements
Nutritional supplements and herbs are technically unapproved drugs, in an OTC limbo
Best advice: obtain a standardized extract marketed by a reputable firm
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Nutriceuticals for Common Problems in Primary Care
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Anti-oxidants Oxidant by-products of normal metabolism
result in extensive damage to DNA, proteins and lipids, leading to aging and degenerative diseases including cancer, cardiovascular disease, immunoincompetence, brain dysfunction and cataracts.*
Low intakes of fruits and vegetables double the risk of many types of cancer versus high intakes.
*Proc NY. Acad Sci. 1993; 90: 7915-7922
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Vitamins C and E
Pretreatment with vitamin C and E prevented a fall in vasodilation which occurred after a high fat meal. No such fall was noted after a low fat meal.*
*Plotnick GD, Corretti MC. et al. Effect of Antioxidant Vitamins on the Transient Impairment of Endothelium-Dependent Brachial Artery Vaso- Activity Following a Single High-Fat Meal. JAMA.1997;278(20):1682-1686.
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Vitamin E High risk CV pts. had “no apparent effect”
from Vit E (NEJM, 2000;342:154-60). No significant adverse events
Preventive effect suggested in Stampfer, Rimm studies (NEJM, 1993; 328)
Intermittent claudication Vit E found useful (Goodwin, Ann Int Med, Nov 1997)
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Coenzyme Q10
CHF - Stroke index at rest and work improved significantly (p< .05), the pulmonary artery pressure at rest (p< .05) and work decreased and the pulmonary capillary wedge pressure at rest and work decreased (p< .05) with CoQ10 100mg bid*
*Munkholm H, Hansen HH. Coenzyme Q10 treatment in serious heart failure.
Biofactors. 1999;9(2-4):285-9
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Vitamin B6
27/28 patients diagnosed with idiopathic CTS improved substantially on B6, 100 mg/day vs placebo. ¼ of patients were noted to be pyridoxine-depleted based on serum studies.*
*Carpal Tunnel Nutr Rep Int.1986 34(6):1031-40
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Osteoarthritis--glucosamine sulfate, chondroitin sulfate
Drovanti A, Bignamini AA, Rovati AL. Therapeutic activity of oral glucosamine sulfate in osteoarthritis: a placebo controlled double blind investigation. Clin Ther 1980;3(4):260 72
Morreale P, et al. Comparison of the anti-inflammatory efficacy of chondroitin sulfate and diclofenac sodium in patients with knee osteoarthritis. J Rheumatol 1996; 23: 1385-91.
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Recent studies on Glucosamine
McAlindon, TE, et al. Glucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA 283(11): 1483-84. Feb 2000
RPC study showed reduction in cartilage loss and symptoms of OA over a 3 yr period in 106 pts (Reginster, Jan 2001 Lancet)
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Meta-Analysis of Glucosamine and Chondroitin for Treatment of Osteoarthritis, McAlindon, et al. JAMA.2000;283:1469-1475
Moderate to large effect size in 15 studies reviewed
Product quality issues? Publication bias? Efficacy “appears probable” Studies under way
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Cholesterol--inositol hexaniacinate, Vit C and E.
Murray M. Lipid-lowering drugs vs. Inositol hexaniacinate. Am J Natural Med 1995;2:9-12 (review).
Belcher JD, Balla J, Balla G, et al. Vitamin E, LDL, and endothelium: Brief oral vitamin supplementation prevents oxidized LDL-mediated vascular injury in vitro. Arterioscler Thromb 1993;13:1779-89.
Frei B. Ascorbic acid protects lipids in human plasma and low-density lipoprotein against oxidative damage. Am J Clin Nutr 1991;54:1113S-8S.
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Obesity--Ornish, vegetarian diet, chromium Gould KL, Ornish D, et al. Improved stenosis
geometry by quantitative coronary arteriography after vigorous risk factor modification. Am J Cardio 1992, 69:845-53
Ornish D, et al. Effects of stress management training and dietary changes in treating ischemic heart disease. JAMA, 1983, 249:54-59
McCarty MF. The case for supplemental chromium and a survey of clinical studies with chromium picolinate. J Appl Nutr 1991;43:59-66.
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Integrating Nutritional Therapy Into Your Practice Standard of care Patient preference Safety vs efficacy Alternatives/options Integrative care/adds value
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Ask the Unasked Questions
“What, if any, alternative therapies have you tried for this problem?”
“Considered?” “Have questions about?” “Besides these prescriptions, are you
taking any over the counter products, supplements, or herbs?”
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UTMB’s Alternative and Integrative Health Care Program Website
http://atc.utmb.edu/altmed
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UTMB Licensed Data Bases HealthNotes Online
A data base for nutritional and herbal material on UTMB Alternative and Integrative website
http://atc.utmb.edu/altmed
Scientific Basis for Holistic Medicine
A data base of abstracted article summaries of natural product use in health and illness
http://library.utmb.edu/holistic
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Integrative Healthcare: Complementary and Alternative Therapies for the Whole Person
By: Victor S. Sierpina, MD
FA Davis Philadelphia, 2001
www.B&N.com
www.amazon.com
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Other Useful References Novey DW. 2000. Clinician’s Complete
Reference to Complementary/Alternative Medicine. St. Louis: Mosby
Dossey, L. 1999. Reinventing Medicine—Beyond Mind-Body to a New Era of Healing. San Francisco:Harper Collins
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References
Murray M, Pizzorno J. 1998. Encyclopedia of Natural Medicine. Rocklin, CA: Prima.
PDR for Herbal Medicines. 2000. Montvale, NJ: Medical Economics Co.
Jonas WB, Levin JS (eds). 1999. Essentials of Complementary and Alternative Medicine. Philadelphia: Lippincott, Williams & Williams
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References Rosenfeld I. 1996. Dr. Rosenfeld’s Guide to
Alternative Medicine—What Works, What Doesn’t—And What’s Right For You. New York: Random House.
Pressman AH, Buff S. 1999. The Complete Idiot’s Guide to Alternative Medicine. New York: Alpha Books.
Dillard J, Ziporyn T. 1998. Alternative Medicine for Dummies. Foster City, CA: IDG Books Worldwide, Inc.
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References Wirth S (ed) 1999. Integrative Medicine—A
Balanced Account of the Data. Ukiah, CA: Boitumelo Publishing Inc.
Kemper KJ. 1996.The Holistic Pediatrician. New York: Harper Collins
Alternative Therapies in Health and Medicine. Published by the Innovision Communications, 101 Aliso Viejo, CA 92656 800-899-1712; bimonthly peer reviewed journal.
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UTMB’s Alternative and Integrative Health Care Program Website
http://atc.utmb.edu/altmed