Integrative Medicine (Nutritional Implications)

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Integrative Medicine Nutritional Implications 

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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 interventions Thomson in Krause, p. 470 

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CAM Therapies Include = Alternative medical systems, such as naturopathy, traditional Chinese medicine, ayurveda, and homeopathy =" Mind-body therapies, such as meditation, prayer, art or music therapy ® Biologically based therapies such as herbs, whole foods diets, and supplementation = Manipulative therapies such as massage, chiropractic medicine, osteopathy, yoga =" Whole medical systems based on energy therapies such as qi gong, magnetic therapy, and reiki 

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Integrative medicine = Integration of these approaches into conventional medicine; nutritional care is a primary therapy in this model ™ Focused on combined use of conventional and CAM approaches ™ Evidence-based = Includes wellness and prevention Thomson in Krause, p. 471 

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National Center for Complementary and Alternative Medicine ‘NCCAM) Part of the National Institutes of Health —Investigates and evaluates alternative therapies and their effectiveness N National Center for Complementary and Alternative Medicine 

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Theoretical Basis of Holistic Therapies =" Health as a vital, dynamic state; more than the absence of disease =" The healing force of nature ™ Self-healing power of living things; organisms have inherent self-defense mechanisms against illness = Includes naturopathy, chiropractic, homeopathy, traditional Oriental medicine, acupuncture, phytotherapy 

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Integrative Therapies Health is more than the absence of 01 ‏.عكعوع‎ ‎The body can heal itself. = Naturopathy = Homeopathy = Traditional Chinese medicine ™ Acupuncture = Phytotherapy 

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Naturopathy = Practitioners diagnose and treat at the primary care level = Train in 4-year postgraduate institutions = Most states require licensure = Uses 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 

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Chiropractic Concepts ™ Body has the ability to heal itself; Practitioner’s role is to assist = The structure and condition of the body influences how well it functions = The mind-body relationship is important in maintaining health and promoting healing = Locate and eliminate subluxations, musculoskeletal problems that interfere with the body’s ability to maintain health = Primary therapy is manual manipulations, along with lifestyle 

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Chiropractic Practitioners = Do not prescribe drugs or perform surgery ™ Licensed and regulated in all 50 states and 30+ countries = Practitioners must graduate from 4-year accredited college of chiropractic and pass a nationally- administered exam 

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Chiropractic = The most widely-used of the complementary and alternative treatments, particularly for low back pain, neck pain, and headache " Effectiveness is being studied by the Consortial Center for Chiropractic Research, a consortium of chiropractic schools and universities, ۱ 

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Homeopathy = Law 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 amounts ™ Remedies become potentized through repeated dilution and succussion (shaking) 

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Homeopathy ™ Results of research on the effectiveness of homeopathy have been contradictory ™ Appears to have more than a placebo effect, but scientific basis unclear ™ Generally regarded as safe (many homeopathic remedies are so dilute that the healing substance is nondetectable by chemical means 

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Traditional Chinese Medicine ™ Based 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 

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Nutrition in Traditional Chinese Medicine " Components: Food as a means of obtaining nutrition, food as a tonic or medicine, fasting ™ Foods classified by taste (sour, bitter, sweet, spicy, salty) and property (cool, cold, warm, hot and plain) =" Regulate yin, yang, chi, blood 

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Acupuncture and Moxibustion ™ Acupuncture: Use of thin needles, inserted into points on the meridians, stimulating the body’s energy or chi ™ Moxibustion: application of heat along meridian acupuncture points, affecting chi and blood, balancing substances and organs = Treat disharmony in the body 

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Acupuncture as Nie aif) ™ Has been used to produce regional anesthesia = Appears to act through needle stimulation, triggering the release of opioids ™ Research has been mixed ™ Has been shown to be efficacious in adult postop management, chemotherapy-induced nausea, postoperative dental pain 

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Traditional Chinese Herbs = Includes herbs and minerals as well as animal products ™ Pharmacopoeias published as early as the third century BC =" Most medicinals include multiple substances 

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Phytotherapy ™ Science of using plant-derived substances to treat and prevent illness = Botanicals: come as bulk herbs, tinctures, capsules and tablets; includes herbs and other plant materials = Sometimes the active ingredient has been identified; sometimes not = Have a long history of research and use in Europe 

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Botanical Formulations = Teas: weak concentration prepared by steeping fresh/dried herbs for a few minutes in water = Infusions: more concentrated than teas; steeped for 15 minutes = Decoction: Most concentrated of beverages; botanical is boiled for 30-60 minutes 

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Botanical Formulations = Extracts: herbs are extracted with an organic solvent to dissolve the active components; concentrated form " Tincture: extract in which solvent is alcohol = Glycerite: extract in which the solvent is glycerol or mixture of glycerol, propylene glycol, and water; more suitable for children 

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Botanical Formulations ™ Capsules: Herbal material enclosed in a hard shell made from gelatin or cellulose ™ Tablets: herbal material is mixed with filler to form the hard tablet; may be coated or uncoated ™ Lozenges (troches): active components are released in the mouth when chewed or sucked ® Soft gels: used to encase liquid extracts, such as omega-3 fatty acids or vitamin E ™ Essential oils: fragrant, volatile plant oils used for aromatherapy, bathing; not to be used internally unless specifically directed 

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American Herbal Products Assoc Botanical Safety Rating System ™ Class 1: herbs that can be safely consumed when used appropriately ™ Class 2: herbs for which restrictions apply, e.g. for external use only, not to be used during pregnancy, nursing, etc ™ Class 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 

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Dietary Supplement Health and Education Act of 1994 (DSHEA) ™ Defined diay 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, ora concentrate, metabolite, constituent, extract, or combinations of these incredients = Reclassified botanicals as dietary supplements, distinct from food or drugs 

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۱۱ ]2 ۰-1 7111۰:1۰01 ‏فسات وروت یوت‎ and Education Act of 1994 (DSHEA) = Plant extracts, enzymes, vitamins, minerals, hormonal products available without prescription may carry “structure-function” claims ™ Cannot claim to prevent or cure specific conditions ™ Must display disclaimer, “This statement has not been evaluated 3 the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.” 

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Required Labeling of Dietary Supplements nder DSHEA = Name (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. 

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Supplement Facts ۳۴۵۱۱6۵۱ Supplement Facts Serving Size 1 Packet (6.7 Grams) Servings per Container 20 Amount % Daily PerServing Value* Vitamin, Vitamin BL (as Cvanocohalamin ‘Gomez nn, Sodium (as Sodium Bicarbonate 230 me 10% Potassium (as Potassium Bicarhonaie) 180 me 5% Tyrosine (as N-Acetyl Tyrosine! 2000 4 CLA tas Conjugared Lizolele cid) 1200: Methonyisoflavone (S-Methyl7-Methoxyizoflavenc) 200 Citrus Awrantiun Extract 40mg Gynephrine 95%) + Percent Daily Values ased on2000 cali det + Daily Valuenotertlched INGREDIENTS: Cisic Add, Natural & Articial Beary Flavor; Calin, Sucrose DAC Red, FD&C BhueDye 1. +Mix one packetin 6-8 ounces of waier. 

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Dietary Supplement 605 =" Health claim: describes the relationship between a substance and a disease condition; FDA does not approve, but must be notified Qualified health claim: based on emerging scientific evidence; must be approved by FDA Structure-function claim: most common; does not claim to prevent disease, but a physiological effect is noted, e.g. “increases blood flow to the heart.” 

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Labeling Under DSHEA Allowed Not Allowed = This product helps to ™ This product prevents increase blood flow to heart disease ‏عط‎ ۵ ™ This product prevents = This product promotes urinary tract urinary tract health ۱6106۰ " This product improves = This product reduces absent-mindedness. risk of Alzheimer’s = This product reduces Disease. ۱ و۱۵ ۱۰و22 (ele) ee 

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Regulation of Dietary Supplements =" Dietary supplements are not subject to the same standards as prescription or over-the-counter drugs ™ Manufacturers do not have to prove their products are safe or effective before they put them on the market " FDA can pull supplements proven to be dangerous, but only after the fact; it is up to the FDA to make its case 

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

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Examples of FDA Warnings ™ January, 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 supplement =" February, 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 

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Examples of FDA Warnings = November, 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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Dietary Supplement and Nonprescription Drug Consumer Protection Act 12/06 = Requires manufacturers and distributors of dietary supplements and OTC drugs to report all serious adverse events to FDA = Requires 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. 

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Cautions Regarding Dietary Supplements = There may be a discrepancy between the ingredients on the label and what’s inside = This is especially true of herb mixtures, such as Chinese herbs = The dosage of the “active ingredient” in herbals can vary widely depending on the variety of plant, where it’s grown, climate, etc. 

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Read the Dietary Supplement Label and A(T a ae = 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 components = The concentration of the botanical and if it is appropriate, neither too weak or two stro ‏اک‎ ‎Debusk, 4 practical guide to herbal supplements for nutrition practitioners. Top Clin 0 tee 

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Read the Dietary Supplement Label and erify.... / = The ddlly dosage needed to obtain the desired effect ® The list of ingredients used to identify fillers, potential allergens = Lot number =" Expiration date ™ Recognized seal of approval (Good Housekeeping, USP, Consumerlab) ™ Compare prices: prices vary widely Debusk, RM. A practical guide to herbal supplements for nutrition practitioners. Top Clin 

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Evaluating Dietary Supplements = Obtain unbiased evaluative information from resources like Supplement Watch and Consumer Lab www.consumerlab.com = Encourage patients to purchase supplements fi This seal Product met is aregistered اس لاد ۵ ۱۱۵۱۵۷۲2۲۲۰ Product was tested for ingredient quality. 

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ConsumerLab Study of 20 Multivitamins Vitamins that failed: = The Vitamin Shoppe Multivitamins Especially for women: Contaminated with lead ™ — Hero Nutritionals Yummi Bears: Had twice the labeled amount of vitamin A = — Nature's 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 ‏م‎ = — Pet-Tabs Sou Daily Vitamin-Mineral Supplement for Dogs: Contained lead Ea Noe to Te UcI\ sem alee MT aatal ‏رورم رو‎ - 86۱62560 7 

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ConsumerLab Study of 20 Multivitamins ۷ itamins that passed: =" Centrum Silver = Member's Mark Complete Multi ™ One A Day Women's = Flintstones Complete = http://www.msnbc.msn.com/id/1665516 8/ january, 2007 

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Tips for Picking a Multivitamin from CSPI = Choose 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 doesn't guarantee the product is safe and effective, it does indicate that the manufacturer has 1 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" aren't necessary and may be trouble. غ3 مور رابت را ات ‎Leg)‏ ‎http://www.msnbe.msn.com/id/16655168/ 1/07‏ 

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Evaluating Dietary Supplements United 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 properly ™ Does not speak to the safety or efficacy of the ingredients, only to good manufacturing practices 

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CAM Providers: MDs/DOs = Over 1/3 of medical schools offer instruction in alternative medicine ™ More than half of family physicians in the US regularly prescribe alternative treatments or have used themselves 

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CAM Providers: RDs = Nutrition in Complementary Care DPG, a subunit of the American Dietetic Association http://www.complementarynutrition.or 7 ™ Some RDs are incorporatina counseling abou reer ۱ 28 ‏وت‎ ‎9 ‎= Care 7 نا 

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CAM Providers: Other ترا ی ممم م = ND: naturopath provider =" DC: chiropractor = OMD: oriental medical doctor ™ Accupuncturist ™ Massage Therapist = Hypnotherapist ™ Herbalist 

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Tips for Patients: Evaluating CAM Providers ™ Check for licensing, education, accreditation of provider ™ Check 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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CAM Use by U.S. Adults—2002 Used past 12 months CAM (excluding prayer for health) Ever used CAM (excluding megavitamins) TE Tee Mee) 0 ‘Any CAM 80 70 60 = 50 $40 30 20 10 ent 

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Disease/Condition for Which CAM Is Most Frequently Used* 20 36 ‏اول علض لصوا‎ Ahiis—Anwiety/ Stomach Headache Recurring Insomnia pain cold pain pain depression upset pain “These figures exclude the use of megaitamin therapy and prayer. ۱۴۵/۱ ۸ ۱۷۵/۷۰ ۰ 0 ۸ ۳ 9 Adu 

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Reasons People Use CAM 13.2 Conventional medicine 00 expensive lene Ma eee 0 Conventional medical professional suggested it eRe Thought ‘conventional medicine would not help ۴۵۳۵ ۸ ۷۵۸/۱ ۰ اب۸0 ۸۱۵7۵ Thought it would be interesting to try Thought CAM combined with ‘conventional medicine would help Source: Barnes © Powell-Griner E, Mc Complementary and Alternative Mi 

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Top 10 Natural Products Used by Adult CAM Users—2002 faim Gisemy —Giigo —Gaic Guts St. ohn's Feopemint ‏لدان‎ Gg Soy biloba supplements ‘omega supplements supplements fatly acids 4 ,27 /زقانا 

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10 Most Common CAM Therapies—2002 Prayer! Prayery ‘Natural ‏مه‎ Prayer’_—-Meditaton Chiropractic Yoga ‏اند‎ otbers products, breathing group 

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Trends in Use of CAM by US Adults 1997- 002 ۱ ۱ = The number of Americans using CAM remained stable at 72 million =™50% T 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) Berl Ber MEP ACB ee onli Beet acm Ueber Bias mine complementary and alternative medicine by US adults: 1997-2002. Alternative Therapies in Health and Medicine; 1; 1: 2005. 

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Trends in Use of CAM by US Adults 1997- 002 = Use of CAM therapies including acupuncture, biofeedback, energy healing, hypnosis remained essentially unchanged = Use of homeopathy, high-dose vitamins, chiropractic, and massage therapy declined slightly ™ Increased use of herbal medicine practitioners among those who use herbs (5% to 15%) 

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Commonly Used " ‏نطوم‎ ‏تاره‎ ‎= Saw palmetto = St. John’s wort ‏او تا ی‎ Botanicals = Echinacea ™ Garlic = Ginger ™ Gingko biloba « al=X=J 816) 

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Echinacea | Purple cornflower = Indication: Stop or moderate colds or flu Lae ‏وف‎ Macrophages and della secretions = Cautions: Avoid if immune 32 ‏وت‎ hampered and do not 23 continually 

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Garlic plant Lower serum cholesterol triglycerides Chewing or crushing activates several sulfur- containing compounds Allergies, Gl symptoms, interaction with Garlic = Source: ™ Indication: and ™ Action: ™ Cautions: anticoagulant drugs 

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Ginger | ‏0ت‎ ceo Root of ginger plant "Indication: |For nausea and vomiting of pregnancy and motion ‏لماعلا وبي ليت حتت فاك‎ 2 Nels (ola Volatile oils in the ۲/206, called gingerols; may act on serotonin receptors in the وتلا ‎Cautions: Interaction with anti-‏ ™ coagulant, antihypertensive, glucose-lowering drugs 

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Gingko Biloba ™ Source: Gingko tree = Indication: Improved blood circulation; used to treat age-related mental function decline r/t cerebrovascular insufficiency = Action: Flavone glycosides have antioxidant effect, inhibit ‏ته‎ ‎aggregation ™ Cautions: Class 2d botanical; may potentiate MAO inhibitors; GI complaints, headache, allergy 

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Ginseng ™ Source: Ginseng plant (radish-like herb) root "Indication: |General improvement rom the steroidlike components 0 Ginsenosides, enhanced immune function; studies mixed "Cautions: Class 2d botanicals; contraindicated in persons with ۱۷/۵۲ ۵6۵( ‏لك لكك تك‎ 01655 

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Hawthorn ™ Source: Native European tree; leaves, blossoms, fruit = Indication: Improve blood flow in circulatory disorders ‏و‎ Dilates coronary vessels; strengthens heart contractions and rate "Cautions: Class 1 botanical 

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Saw Palmetto = Source: ۳-1۵۹۵ 22 ™ Indication: Reduce incidence of BPH ® Action: Action unclear; research ‏حت‎ 15-7 Care| ™ Cautions: Contains phytoestrogens, could interfere with estrogen therapy, oral contraceptives, ‏وتات‎ ‎phytohormone- containing herbs 

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St. John’s Wort ™ Source: Perennial herb = Indication: Mild to moderate depression ™ Action: Hypericin and hyperforin in flowering tops; reuptake of neurotransmitters ™ Cautions: Rated as 2d botanical; may potentiate pharmaceutical MAOIs; interact with other antidepressives; photosensitivity 

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Valerian | Perennial herb; active element in roots and rhizomes = Indication: Minor tranquilizer and sleep aid; fewer side effects than medications = Action: Volatile oils (bornyl acetate and valerenic acid) mode of action GABA binding = Cautions: Class 1 botanical; abrupt withdrawal may precipitate symptoms 

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تا ارو اللي ™ Source: Herb in daisy family; seeds are highest in silymarin = Indication: Hepatoprotective; used to treat liver damage in cirrhosis, hepatitis, fatty infiltration ™ Action: Silymarin stimulates protein synthesis, antioxidant; shown to be moderately effective = Cautions: Class 1 botanical; mild laxative effect; allergies 

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Working with Clients who Use CAM = Most clients will not tell their allopathic (mainstream medicine) providers about CAM use, unless asked = Establish a rapport with clients ™ Be non-judgemental; assume role of coach ® Ask clients to bring all prescription, OTC, and dietary supplements with them to their visit Debusk RM. Integrative medicine and phytotherapy. In Krause, p. 491-492. 

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For Each Supplement ™ Ask client what he/she hopes to achieve by taking it = Discuss whether the formulation is appropriate to achieve the client’s health goals =" Discuss whether dosage taken has been found to be safe and effective in clinical trials ™ Review quality of the particular preparation and how to evaluate Debusk RM. Integrative medicine and phytotherapy. In Krause, p. 491-492. 

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For Each Supplement ™ Discuss any known safety or contraindication concerns ™ Review potential or known interactions between each supplement and prescription or OTC preparations, other dietary supplements, and foods = Instruct client to use dosage commonly recommended and instructions for where to obtain credible information Debusk RM. Integrative medicine and phytotherapy. In Krause, p. 491-492. 

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For Each Supplement ™ Recommend a low starting dosage, even lower than that commonly recommended and evaluate response = Use 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. 

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Working with Clients Who Use CAM = |t is the responsibility of health professionals to ask clients about use of CAM and to be familiar with commonly-used therapies " Nutrition professionals can take the same evidence-based approach to CAM as to any other therapy or medical intervention 

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Links for Integrative Medicine Information = Intellinealth Index of Herbal Medicines and Supplements Sea ‏اکتا‎ th.com/IH/ihtlH/WSIHWOO = Herb Med: An interactive electronic herb database. http://www.herbmed.org/ = Rosenthal Center Botanical Medicine ۱ Information Resources (Columbia University) http:// ‏الت عه لاله ردق لدع ار نروكلا لكك قال اقرط اق قر سس بير‎ کر ‎for Complementary and Alternative Therapy‏ ‎http://nccam.nih.gov/‏ 

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Summary " Identify use of herbs and botanicals. = Monitor for side effects. ™ Document for records. " Discuss with physician.