Transcript Integrative Medicine and Phytotherapy

Integrative Medicine
Nutritional Implications
Complementary and
alternative medicine (CAM):
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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
CAM Therapies Include
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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
Integrative medicine
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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
National Center for
Complementary and
Alternative Medicine
(NCCAM)
Part of the National Institutes of Health
—Investigates and evaluates alternative
therapies and their effectiveness
Theoretical Basis of
Holistic Therapies
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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
Integrative Therapies
Health is more than the absence of disease.
The body can heal itself.
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Naturopathy
Homeopathy
Traditional Chinese medicine
Acupuncture
Phytotherapy
Naturopathy
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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
Chiropractic Concepts
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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,
Chiropractic Practitioners
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Do not prescribe drugs or perform
surgery
Licensed and regulated in all 50 states
and 30+ countries
Practitioners must graduate from 4year accredited college of chiropractic
and pass a nationally-administered
exam
Chiropractic
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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, established
by NCCAM
Homeopathy
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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)
Homeopathy
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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
Traditional Chinese
Medicine
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Based on the concept of body life
force chi (Qi)
Forces that must be balanced
—Yin and yang and blood
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Invisible energy circuits called
meridians carry chi and blood
throughout the body
Nutrition in Traditional
Chinese Medicine
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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
Acupuncture and
Moxibustion
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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
Acupuncture as
Anesthesia
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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, chemotherapyinduced nausea, postoperative dental pain
Traditional Chinese Herbs
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Includes herbs and minerals as well as
animal products
Pharmacopoeias published as early as
the third century BC
Most medicinals include multiple
substances
Phytotherapy
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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
Botanical Formulations
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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 3060 minutes
Botanical Formulations
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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
Botanical Formulations
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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
American Herbal Products Assoc
Botanical Safety Rating System
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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
Dietary Supplement Health and
Education Act of 1994 (DSHEA)
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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
Dietary Supplement
Health and Education Act
of 1994 (DSHEA)
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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 by the Food and Drug
Administration. This product is not intended
to diagnose, treat, cure or prevent any
disease.”
Required Labeling of Dietary
Supplements under DSHEA
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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.
Supplement Facts Panel
Dietary Supplement
Claims
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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.”
Labeling Under DSHEA
Allowed
 This product helps to
increase blood flow to
the heart.
 This product promotes
urinary tract health
 This product improves
absent-mindedness.
 This product reduces
stress and frustration
Not Allowed
 This product prevents
heart disease
 This product prevents
urinary tract infections.
 This product reduces
risk of Alzheimer’s
Disease.
 This product improves
depression.
Regulation of Dietary
Supplements
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Dietary supplements are not subject to the
same standards as prescription or over-thecounter 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
Regulation of Dietary
Supplements: Medwatch
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The FDA’s Medwatch system can be
used to report possible adverse
reactions to dietary supplements
http://www.fda.gov/medwatch/report/hcp.htm
Examples of FDA Warnings
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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
Examples of FDA Warnings
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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
Dietary Supplement and
Nonprescription Drug Consumer
Protection Act 12/06
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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.
Cautions Regarding
Dietary Supplements
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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.
Read the Dietary Supplement
Label and Verify….
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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
strong
Debusk, RM. A practical guide to herbal supplements for
nutrition practitioners. Top Clin Nutr 16:53, 2001
Read the Dietary Supplement
Label and Verify….
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The daily 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 Nutr 16:53, 2001
Evaluating Dietary
Supplements
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Obtain unbiased evaluative information from
resources like Supplement Watch and
Consumer Lab www.consumerlab.com
Encourage patients to purchase supplements
from well-known manufacturers
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 A
 — Pet-Tabs Complete Daily Vitamin-Mineral
Supplement for Dogs: Contained lead
– Accessed at MSNBC http://www.msnbc.msn.com/id/16655168/
– Released 1/2007
ConsumerLab Study of 20
Multivitamins
Vitamins that passed:
 Centrum Silver
 Member's Mark Complete Multi
 One A Day Women's
 Flintstones Complete
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http://www.msnbc.msn.com/id/16655168/
January, 2007
Tips for Picking a
Multivitamin from CSPI
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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 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.
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Center for Science in the Public Interest accessed at
http://www.msnbc.msn.com/id/16655168/ 1/07
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
CAM Providers: MDs/DOs
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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
CAM Providers: RDs
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Nutrition 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
CAM Providers: Other
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RNs
RPh
ND: naturopath provider
DC: chiropractor
OMD: oriental medical doctor
Accupuncturist
Massage Therapist
Hypnotherapist
Herbalist
Tips for Patients:
Evaluating CAM Providers
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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
Trends in Use of CAM by
US Adults 1997-2002
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The number of Americans using CAM
remained stable at 72 million
50% ↑ 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.
Trends in Use of CAM by
US Adults 1997-2002
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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%)
Commonly Used
Botanicals
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Echinacea
Garlic
Ginger
Gingko biloba
Ginseng
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Hawthorn
Milk thistle
Saw palmetto
St. John’s wort
Valerian
Echinacea
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Source:
Indication:
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Action:
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Cautions:
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Purple cornflower
Stop or moderate colds
or flu
Macrophages and their
secretions
Avoid if immune system is
hampered and do not use
continually
Garlic
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Source:
Indication:
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Action:
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Cautions:
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Garlic plant
Lower serum cholesterol and
triglycerides
Chewing or crushing
activates several sulfurcontaining compounds
Allergies, GI symptoms,
interaction with anticoagulant
drugs
Ginger
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Source:
Indication:
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Action:
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Cautions:
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Root of ginger plant
For nausea and vomiting of
pregnancy and motion
sickness; anti-inflammatory
Volatile oils in the rhizome,
called gingerols; may act on
serotonin receptors in the
ileum
Interaction with anticoagulant, antihypertensive,
glucose-lowering drugs
Gingko Biloba
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Source:
Indication:
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Action:
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Cautions:
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Gingko tree
Improved blood circulation;
used to treat age-related
mental function decline r/t
cerebrovascular insufficiency
Flavone glycosides have
antioxidant effect, inhibit
platelet aggregation
Class 2d botanical; may
potentiate MAO inhibitors; GI
complaints, headache, allergy
Ginseng
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Source:
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Indication:
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Action:
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Cautions:
Ginseng plant (radish-like
herb) root
General improvement from
the steroidlike components
Ginsenosides, enhanced
immune function; studies
mixed
Class 2d botanicals;
contraindicated in persons
with hypertension;
overstimulation, GI distress
Hawthorn
Native European tree;
leaves, blossoms, fruit
 Indication: Improve blood flow in
circulatory disorders
 Action:
Dilates coronary vessels;
strengthens heart
contractions and rate
 Cautions: Class 1 botanical
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Source:
Saw Palmetto
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Source:
Indication:
Action:
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Cautions:
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Palm tree
Reduce incidence of BPH
Action unclear; research
results mixed
Contains phytoestrogens,
could interfere with estrogen
therapy, oral contraceptives,
other phytohormonecontaining herbs
St. John’s Wort
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Source:
Indication:
Action:
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Cautions:
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Perennial herb
Mild to moderate depression
Hypericin and hyperforin in
flowering tops; reuptake of
neurotransmitters
Rated as 2d botanical; may
potentiate pharmaceutical
MAOIs; interact with other
antidepressives;
photosensitivity
Valerian
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Source:
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Indication:
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Action:
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Cautions:
Perennial herb; active element
in roots and rhizomes
Minor tranquilizer and sleep
aid; fewer side effects than
medications
Volatile oils (bornyl acetate
and valerenic acid) mode of
action GABA binding
Class 1 botanical; abrupt
withdrawal may precipitate
symptoms
Milk Thistle
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Source:
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Indication:
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Action:
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Cautions:
Herb in daisy family; seeds
are highest in silymarin
Hepatoprotective; used to
treat liver damage in cirrhosis,
hepatitis, fatty infiltration
Silymarin stimulates protein
synthesis, antioxidant; shown
to be moderately effective
Class 1 botanical; mild
laxative effect; allergies
Working with Clients who
Use CAM
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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.
For Each Supplement
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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.
For Each Supplement
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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.
For Each Supplement
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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.
Working with Clients Who
Use CAM
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It 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
Links for Integrative
Medicine Information
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Intellihealth Index of Herbal Medicines and
Supplements
http://www.intelihealth.com/IH/ihtIH/WSIHW000/8
513/31402.html
Herb 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.ht
ml
National Institutes of Health National Center for
Complementary and Alternative Therapy
http://nccam.nih.gov/
Summary
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Identify use of herbs and botanicals.
Monitor for side effects.
Document for records.
Discuss with physician.