Integrative Medicine

Using Complementary and Alternative Therapies in Medical Practice

Victor S. Sierpina, M.D.

Associate Professor

Family Medicine

University of Texas Medical Branch

NUTRICEUTICALS

An Introduction and Overview with Practical Clinical Applications

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

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

Nutrition

Finally!

Biochemistry

Again?

Nutriceuticals: Definition and Usage Use of nutritional supplements and food

related constituents therapeutically Why?

Dietary deficiencies Agricultural practices Environmental toxins Lifestyle

Micronutrient debate (Goodwin)

Diets Ornish

Atkins’

Zone/Sugar Busters

Protein sparing

Mediterranean

DASH

Vegetarian Macrobiotic Eat Right for

Your Type

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

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

Weight Training Per Week UTMB Class 2004

05

1015

2025

3035

404550

None 1-2 Days 3-5 Days >5 Days

Percentage

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

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

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)

Nutriceuticals---What Are They? Amino Acids Diets Enzymes Minerals Vitamins Other Pharmacological/Biological Products

Enzymes Bromelain CoQ10

Minerals

Magnesium

Manganese Zinc Calcium

Potassium

Chromium Molybdenum

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

Other Pharmacological/Biological Agents

Fatty acids—EPO, GLA, flaxseed oil

Glucosamine sulfate, chondroitin, shark cartilage

Glandulars--thymus, adrenal, thyroid Metabolife Steroids--DHEA

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

Dr. Natural

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….

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

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

Concerns Standardization Purity Potency Bioavailability FDA’s role

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

Nutriceuticals for Common Problems in Primary Care

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

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.

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)

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

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

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.

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)

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

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.

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.

Integrating Nutritional Therapy Into Your Practice Standard of care Patient preference Safety vs efficacy Alternatives/options Integrative care/adds value

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?”

UTMB’s Alternative and Integrative Health Care Program Website

http://atc.utmb.edu/altmed

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

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

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

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

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.

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.

UTMB’s Alternative and Integrative Health Care Program Website

http://atc.utmb.edu/altmed