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Integrative Medicine (Nutritional Implications)

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Integrative Medicine (Nutritional Implications)

اسلاید 1: Integrative Medicine Nutritional Implications

اسلاید 2: Complementary and alternative medicine (CAM): Complementary and alternative medicine (CAM): alternative, adjunctive health care practices: not presently an integral part of conventional medicine; includes botanical use, mind-body approaches, musculoskeletal manipulation, energy medicine, nutrition-diet interventionsThomson in Krause, p. 470

اسلاید 3: CAM Therapies IncludeAlternative medical systems, such as naturopathy, traditional Chinese medicine, ayurveda, and homeopathyMind-body therapies, such as meditation, prayer, art or music therapyBiologically based therapies such as herbs, whole foods diets, and supplementationManipulative therapies such as massage, chiropractic medicine, osteopathy, yogaWhole medical systems based on energy therapies such as qi gong, magnetic therapy, and reiki

اسلاید 4: Integrative medicineIntegration of these approaches into conventional medicine; nutritional care is a primary therapy in this modelFocused on combined use of conventional and CAM approachesEvidence-basedIncludes wellness and preventionThomson in Krause, p. 471

اسلاید 5: National Center for Complementary and Alternative Medicine (NCCAM)Part of the National Institutes of Health —Investigates and evaluates alternative therapies and their effectiveness

اسلاید 6: Theoretical Basis of Holistic TherapiesHealth as a vital, dynamic state; more than the absence of diseaseThe healing force of natureSelf-healing power of living things; organisms have inherent self-defense mechanisms against illnessIncludes naturopathy, chiropractic, homeopathy, traditional Oriental medicine, acupuncture, phytotherapy

اسلاید 7: Health is more than the absence of disease.The body can heal itself.Integrative TherapiesNaturopathyHomeopathyTraditional Chinese medicineAcupuncturePhytotherapy

اسلاید 8: NaturopathyPractitioners diagnose and treat at the primary care levelTrain in 4-year postgraduate institutionsMost states require licensureUses natural methods of healing (light, heat, air, water, and massage)Training includes pathology, microbiology, physical and clinical diagnosis, pharmacognosy, hydrotherapy, physical therapy, nutrition, Treatments include phytomedicines, electrotherapy, physiotherapy, minor surgery, mechanotherapy, nutrition, nutritional supplements, and natural forces

اسلاید 9: Chiropractic ConceptsBody has the ability to heal itself; Practitioner’s role is to assistThe structure and condition of the body influences how well it functionsThe mind-body relationship is important in maintaining health and promoting healingLocate and eliminate subluxations, musculoskeletal problems that interfere with the body’s ability to maintain healthPrimary therapy is manual manipulations, along with lifestyle

اسلاید 10: Chiropractic PractitionersDo not prescribe drugs or perform surgeryLicensed and regulated in all 50 states and 30+ countriesPractitioners must graduate from 4-year accredited college of chiropractic and pass a nationally-administered exam

اسلاید 11: ChiropracticThe most widely-used of the complementary and alternative treatments, particularly for low back pain, neck pain, and headacheEffectiveness is being studied by the Consortial Center for Chiropractic Research, a consortium of chiropractic schools and universities, established by NCCAM

اسلاید 12: HomeopathyLaw of similars: Substances in large doses that produce symptoms of a disease in healthy people will cure the same symptoms when administered in very dilute amountsRemedies become potentized through repeated dilution and succussion (shaking)

اسلاید 13: HomeopathyResults of research on the effectiveness of homeopathy have been contradictoryAppears to have more than a placebo effect, but scientific basis unclearGenerally regarded as safe (many homeopathic remedies are so dilute that the healing substance is nondetectable by chemical means

اسلاید 14: Traditional Chinese MedicineBased on the concept of body life force chi (Qi)Forces that must be balanced—Yin and yang and blood Invisible energy circuits called meridians carry chi and blood throughout the body

اسلاید 15: Nutrition in Traditional Chinese MedicineComponents: Food as a means of obtaining nutrition, food as a tonic or medicine, fastingFoods classified by taste (sour, bitter, sweet, spicy, salty) and property (cool, cold, warm, hot and plain)Regulate yin, yang, chi, blood

اسلاید 16: Acupuncture and MoxibustionAcupuncture: Use of thin needles, inserted into points on the meridians, stimulating the body’s energy or chiMoxibustion: application of heat along meridian acupuncture points, affecting chi and blood, balancing substances and organsTreat disharmony in the body

اسلاید 17: Acupuncture as AnesthesiaHas been used to produce regional anesthesiaAppears to act through needle stimulation, triggering the release of opioidsResearch has been mixedHas been shown to be efficacious in adult postop management, chemotherapy-induced nausea, postoperative dental pain

اسلاید 18: Traditional Chinese HerbsIncludes herbs and minerals as well as animal productsPharmacopoeias published as early as the third century BCMost medicinals include multiple substances

اسلاید 19: PhytotherapyScience of using plant-derived substances to treat and prevent illnessBotanicals: come as bulk herbs, tinctures, capsules and tablets; includes herbs and other plant materialsSometimes the active ingredient has been identified; sometimes notHave a long history of research and use in Europe

اسلاید 20: Botanical FormulationsTeas: weak concentration prepared by steeping fresh/dried herbs for a few minutes in waterInfusions: more concentrated than teas; steeped for 15 minutesDecoction: Most concentrated of beverages; botanical is boiled for 30-60 minutes

اسلاید 21: Botanical FormulationsExtracts: herbs are extracted with an organic solvent to dissolve the active components; concentrated formTincture: extract in which solvent is alcoholGlycerite: extract in which the solvent is glycerol or mixture of glycerol, propylene glycol, and water; more suitable for children

اسلاید 22: Botanical FormulationsCapsules: Herbal material enclosed in a hard shell made from gelatin or celluloseTablets: herbal material is mixed with filler to form the hard tablet; may be coated or uncoatedLozenges (troches): active components are released in the mouth when chewed or suckedSoft gels: used to encase liquid extracts, such as omega-3 fatty acids or vitamin EEssential oils: fragrant, volatile plant oils used for aromatherapy, bathing; not to be used internally unless specifically directed

اسلاید 23: American Herbal Products Assoc Botanical Safety Rating SystemClass 1: herbs that can be safely consumed when used appropriatelyClass 2: herbs for which restrictions apply, e.g. for external use only, not to be used during pregnancy, nursing, etcClass 3: herbs labeled “To be used only under the supervision of an expert qualified in the appropriate use of this substance.”Class 4: insufficient data for classification

اسلاید 24: Dietary Supplement Health and Education Act of 1994 (DSHEA)Defined dietary supplements as “a product intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, a mineral, an herb or other botanical, an amino acid, a dietary substance for use by man to supplement the diet by increasing the total daily intake, or a concentrate, metabolite, constituent, extract, or combinations of these incredients Reclassified botanicals as dietary supplements, distinct from food or drugs

اسلاید 25: Dietary Supplement Health and Education Act of 1994 (DSHEA)Plant extracts, enzymes, vitamins, minerals, hormonal products available without prescription may carry “structure-function” claimsCannot claim to prevent or cure specific conditionsMust display disclaimer, “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.”

اسلاید 26: Required Labeling of Dietary Supplements under DSHEAName (echinacea, for example) Ingredient information Disclaimer: This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease. Supplement Facts panel, which includes serving size, amount and active ingredient. Name and address of manufacturer, packer or distributor.

اسلاید 27: Supplement Facts Panel

اسلاید 28: Dietary Supplement ClaimsHealth claim: describes the relationship between a substance and a disease condition; FDA does not approve, but must be notifiedQualified health claim: based on emerging scientific evidence; must be approved by FDAStructure-function claim: most common; does not claim to prevent disease, but a physiological effect is noted, e.g. “increases blood flow to the heart.”

اسلاید 29: Labeling Under DSHEAAllowedThis product helps to increase blood flow to the heart.This product promotes urinary tract healthThis product improves absent-mindedness. This product reduces stress and frustration Not AllowedThis product prevents heart diseaseThis product prevents urinary tract infections.This product reduces risk of Alzheimer’s Disease.This product improves depression.

اسلاید 30: Regulation of Dietary SupplementsDietary supplements are not subject to the same standards as prescription or over-the-counter drugsManufacturers do not have to prove their products are safe or effective before they put them on the marketFDA can pull supplements proven to be dangerous, but only after the fact; it is up to the FDA to make its case

اسلاید 31: Regulation of Dietary Supplements: MedwatchThe FDA’s Medwatch system can be used to report possible adverse reactions to dietary supplements http://www.fda.gov/medwatch/report/hcp.htm

اسلاید 32: Examples of FDA WarningsJanuary, 2004: FDA warns consumers not to feed their babies “Better than Formula Ultra Infant Immune Booster 117 being sold over the internet as a dietary supplementFebruary, 2002: Consumers warned to stop using the products PC SPES and SPES capsules because they contain undeclared prescription drug ingredients that could cause serious health effects

اسلاید 33: Examples of FDA WarningsNovember, 2001: consumers warned to immediately stop use of LipoKinetix, a weight loss product; implicated in a number of serious liver injuries. March, 2002: consumers advised of risk of severe liver injury associated with the use of kava-containing dietary supplements to ease stress and anxiety. February, 2004: issues final rule forbidding sale of ephedra-containing weight loss products; associated with significant adverse health effects including heart attack and stroke

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اسلاید 35: Dietary Supplement and Nonprescription Drug Consumer Protection Act 12/06Requires manufacturers and distributors of dietary supplements and OTC drugs to report all serious adverse events to FDARequires manufacturers to keep all adverse event records, serious and non-serious, for six years; allows FDA to inspect these records. Sets a 15-day time limit for manufacturers to give FDA the serious reports they receive.

اسلاید 36: Cautions Regarding Dietary SupplementsThere may be a discrepancy between the ingredients on the label and what’s insideThis is especially true of herb mixtures, such as Chinese herbsThe dosage of the “active ingredient” in herbals can vary widely depending on the variety of plant, where it’s grown, climate, etc.

اسلاید 37: Read the Dietary Supplement Label and Verify….Complete botanical name of the product (make sure it is the right botanical)The part of the plant used to make the product; it should be the part that contains the active componentsThe concentration of the botanical and if it is appropriate, neither too weak or two strongDebusk, RM. A practical guide to herbal supplements for nutrition practitioners. Top Clin Nutr 16:53, 2001

اسلاید 38: Read the Dietary Supplement Label and Verify….The daily dosage needed to obtain the desired effectThe list of ingredients used to identify fillers, potential allergensLot numberExpiration dateRecognized seal of approval (Good Housekeeping, USP, Consumerlab)Compare prices: prices vary widelyDebusk, RM. A practical guide to herbal supplements for nutrition practitioners. Top Clin Nutr 16:53, 2001

اسلاید 39: Evaluating Dietary SupplementsObtain unbiased evaluative information from resources like Supplement Watch and Consumer Lab www.consumerlab.com Encourage patients to purchase supplements from well-known manufacturers

اسلاید 40: ConsumerLab Study of 20 MultivitaminsVitamins that failed:The Vitamin Shoppe Multivitamins Especially for women: Contaminated with lead— Hero Nutritionals Yummi Bears: Had twice the labeled amount of vitamin A— Natures Plus Especially Yours for Women: Took twice as long as allowed to disintegrate— AARP Maturity Formula: Took nearly twice as long as allowed to disintegrate— Eniva VIBE: Only 54 percent of claimed vitamin A— Pet-Tabs Complete Daily Vitamin-Mineral Supplement for Dogs: Contained leadAccessed at MSNBC http://www.msnbc.msn.com/id/16655168/Released 1/2007

اسلاید 41: ConsumerLab Study of 20 MultivitaminsVitamins that passed:Centrum Silver Members Mark Complete Multi One A Day Womens Flintstones Completehttp://www.msnbc.msn.com/id/16655168/ January, 2007

اسلاید 42: Tips for Picking a Multivitamin from CSPIChoose well-known mainstream brands by companies that have a lot at stake.Buy from large, trusted retailers, not unknown sellers on the Internet.Look on the bottle for a stamp from USP, NSF or ConsumerLab.com. While the stamp doesnt guarantee the product is safe and effective, it does indicate that the manufacturer has submitted the product for testing to show that it contains what is stated on the label.Don’t spend a fortune on vitamins. Pricey products toting all sorts of extras arent necessary and may be trouble.Center for Science in the Public Interest accessed at http://www.msnbc.msn.com/id/16655168/ 1/07

اسلاید 43: Evaluating Dietary SupplementsUnited States Pharmacopeial Convention (USP) Dietary Supplement Verification Program (DSVP)Certification mark (USP®) indicates that the product contains the dietary supplement listed on the label in the stated amount and that the product is manufactured properlyDoes not speak to the safety or efficacy of the ingredients, only to good manufacturing practices

اسلاید 44: CAM Providers: MDs/DOsOver 1/3 of medical schools offer instruction in alternative medicineMore than half of family physicians in the US regularly prescribe alternative treatments or have used themselves

اسلاید 45: CAM Providers: RDsNutrition in Complementary Care DPG, a subunit of the American Dietetic Association http://www.complementarynutrition.org/Some RDs are incorporating counseling about CAM into their practices

اسلاید 46: CAM Providers: OtherRNsRPhND: naturopath providerDC: chiropractorOMD: oriental medical doctorAccupuncturistMassage TherapistHypnotherapistHerbalist

اسلاید 47: Tips for Patients: Evaluating CAM ProvidersCheck for licensing, education, accreditation of providerCheck for complaints (BBB, Board of Health, Attorney General’s office, patient support groups)Speak with the practitioner in person, evaluate facilities and neighbors

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اسلاید 53: Trends in Use of CAM by US Adults 1997-2002The number of Americans using CAM remained stable at 72 million50% ↑ in use of herbal supplements, from 12.1% in 1997 to 18.6% (38 million). Yoga increased 40%, from 3.7% to 5.1% (10 million adults)Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in the use of complementary and alternative medicine by US adults: 1997-2002. Alternative Therapies in Health and Medicine; 1; 1: 2005.

اسلاید 54: Trends in Use of CAM by US Adults 1997-2002Use of CAM therapies including acupuncture, biofeedback, energy healing, hypnosis remained essentially unchangedUse of homeopathy, high-dose vitamins, chiropractic, and massage therapy declined slightlyIncreased use of herbal medicine practitioners among those who use herbs (5% to 15%)

اسلاید 55: Commonly Used BotanicalsEchinaceaGarlicGingerGingko bilobaGinsengHawthornMilk thistleSaw palmettoSt. John’s wortValerian

اسلاید 56: EchinaceaSource: Purple cornflowerIndication: Stop or moderate colds or fluAction: Macrophages and their secretionsCautions: Avoid if immune system is hampered and do not use continually

اسلاید 57: GarlicSource: Garlic plantIndication: Lower serum cholesterol and triglyceridesAction: Chewing or crushing activates several sulfur-containing compoundsCautions: Allergies, GI symptoms, interaction with anticoagulant drugs

اسلاید 58: GingerSource: Root of ginger plantIndication: For nausea and vomiting of pregnancy and motion sickness; anti-inflammatoryAction: Volatile oils in the rhizome, called gingerols; may act on serotonin receptors in the ileumCautions: Interaction with anti-coagulant, antihypertensive, glucose-loweringdrugs

اسلاید 59: Gingko BilobaSource: Gingko treeIndication: Improved blood circulation; used to treat age-related mental function decline r/t cerebrovascular insufficiency Action: Flavone glycosides have antioxidant effect, inhibit platelet aggregationCautions: Class 2d botanical; may potentiate MAO inhibitors; GI complaints, headache, allergy

اسلاید 60: GinsengSource: Ginseng plant (radish-like herb) rootIndication: General improvement from the steroidlike componentsAction: Ginsenosides, enhanced immune function; studies mixedCautions: Class 2d botanicals; contraindicated in persons with hypertension; overstimulation, GI distress

اسلاید 61: HawthornSource: Native European tree; leaves, blossoms, fruitIndication: Improve blood flow in circulatory disordersAction: Dilates coronary vessels; strengthens heart contractions and rateCautions: Class 1 botanical

اسلاید 62: Saw PalmettoSource: Palm tree Indication: Reduce incidence of BPHAction: Action unclear; research results mixedCautions: Contains phytoestrogens, could interfere with estrogen therapy, oral contraceptives, other phytohormone-containing herbs

اسلاید 63: St. John’s WortSource: Perennial herbIndication: Mild to moderate depressionAction: Hypericin and hyperforin in flowering tops; reuptake of neurotransmittersCautions: Rated as 2d botanical; may potentiate pharmaceutical MAOIs; interact with other antidepressives; photosensitivity

اسلاید 64: ValerianSource: Perennial herb; active element in roots and rhizomesIndication: Minor tranquilizer and sleep aid; fewer side effects than medicationsAction: Volatile oils (bornyl acetate and valerenic acid) mode of action GABA bindingCautions: Class 1 botanical; abrupt withdrawal may precipitate symptoms

اسلاید 65: Milk ThistleSource: Herb in daisy family; seeds are highest in silymarinIndication: Hepatoprotective; used to treat liver damage in cirrhosis, hepatitis, fatty infiltrationAction: Silymarin stimulates protein synthesis, antioxidant; shown to be moderately effectiveCautions: Class 1 botanical; mild laxative effect; allergies

اسلاید 66: Working with Clients who Use CAMMost clients will not tell their allopathic (mainstream medicine) providers about CAM use, unless askedEstablish a rapport with clientsBe non-judgemental; assume role of coachAsk clients to bring all prescription, OTC, and dietary supplements with them to their visitDebusk RM. Integrative medicine and phytotherapy. In Krause, p. 491-492.

اسلاید 67: For Each SupplementAsk client what he/she hopes to achieve by taking itDiscuss whether the formulation is appropriate to achieve the client’s health goalsDiscuss whether dosage taken has been found to be safe and effective in clinical trialsReview quality of the particular preparation and how to evaluate Debusk RM. Integrative medicine and phytotherapy. In Krause, p. 491-492.

اسلاید 68: For Each SupplementDiscuss any known safety or contraindication concernsReview potential or known interactions between each supplement and prescription or OTC preparations, other dietary supplements, and foodsInstruct client to use dosage commonly recommended and instructions for where to obtain credible informationDebusk RM. Integrative medicine and phytotherapy. In Krause, p. 491-492.

اسلاید 69: For Each SupplementRecommend a low starting dosage, even lower than that commonly recommended and evaluate responseUse this as an opportunity to teach consumers analytical skills that will be useful in managing their own health.Debusk RM. Integrative medicine and phytotherapy. In Krause, p. 491-492.

اسلاید 70: Working with Clients Who Use CAMIt is the responsibility of health professionals to ask clients about use of CAM and to be familiar with commonly-used therapiesNutrition professionals can take the same evidence-based approach to CAM as to any other therapy or medical intervention

اسلاید 71: Links for Integrative Medicine InformationIntellihealth Index of Herbal Medicines and Supplements http://www.intelihealth.com/IH/ihtIH/WSIHW000/8513/31402.htmlHerb Med: An interactive electronic herb database. http://www.herbmed.org/Rosenthal Center Botanical Medicine Information Resources (Columbia University) http://www.rosenthal.hs.columbia.edu/Botanicals.htmlNational Institutes of Health National Center for Complementary and Alternative Therapy http://nccam.nih.gov/

اسلاید 72: SummaryIdentify use of herbs and botanicals.Monitor for side effects.Document for records.Discuss with physician.

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