Transcript An Update on Evidence-based Integrative Medicine

Edward R. Rosick, DO, MPH, DABHM
Chair/Medical Director, Family &
Community Medicine Dept.
Michigan State University COM
[email protected]
Use of modalities that are not commonly used
in modern medicine:
---Vitamins/minerals
---Herbs
---Prayer
---Relaxation techniques
---Things we weren’t taught in medical
school!
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Some modalities once thought to be
alternative (such as osteopathic
manipulation,acupuncture, and biofeedback)
have gained some acceptance in modern
medicine.
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A recent study (2014) in the Journal of the
American College of Nutrition reported that
45-50% of U.S. adults regularly take
supplements, with those females and aged
>50 the highest users
Two studies looking at cancer patients
showed an even higher percentage of
supplement use at 50-70%
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Among CIM users, 41% report using 2 or
more therapies concurrently
Most popular CIM therapies include:
vitamins & herbal supplements, relaxation &
meditation, and yoga.
---Prevention/treatment of chronic diseases
such as cancer, Alzheimer's, heart disease
---As adjunctive therapies to conventional
treatment
---Rising costs of prescription drugs and the
increased attention to side effects (i.e., belief
that “natural is better and safer”)
 The
Bottom Line is that
patients use supplements to
enhance their sense of control
over their own health
Recent article in the Journal of Clinical
Nutrition reported that 20% of physicians
dismiss CIM out of hand and 33% report they
don’t know enough about supplements to
give their patients any worthwhile advice.
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Supplements can cause side effects,
symptoms, and outcome measurements that
may be attributable to pharmaceutical
medication
This can lead of changes in therapy,
medications, expensive tests, or more serious
consequences.
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Report out of the Mayo Clinic stated that over
40% of dietary supplement users DO NOT
report use to their providers and that 70% of
these responders stated that their provider did
not ask them.
Multivitamin-mineral complex
 Vitamin D
 Glucosamine/chondroitin
 Fish Oil
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Some argue that we get all the nutrition we
need from our diet
Reality is that only 6% of adults meet the
food group requirements of 5 servings of
fruit a day and 5 servings of vegetables a
day
Example: Potatoes, iceberg lettuce, and
ketchup account for 50% of our vegetable
intake
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The non-adherence to the
recommended food guidelines means
that we’re not meeting the RDAs of
most vitamins and minerals
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Percent of US populations aged 2 or greater
not meeting the RDA of:
Vitamin B12-17.2%
Vit C-37.5%
Niacin-25.9%
Iron-39.1%
Phosphorous-27.4%
Vit B6-53.6%
Riboflavin-30%
Vit A-56.2%
Thiamine-30%
Mg-61.6%
Folate-33.2%
Calcium-65.1%
Some would argue no, since overt
vitamin deficiencies are rare
 However, if one takes into account the
poor nutritional value of the standard
American (SAD) diet, then taking a MV
supplement may be a reasonable
choice
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In 2002, researchers at Harvard concluded,
in a JAMA editorial, that adults should be
advised to take a multivitamin
“Pending strong evidence of effectiveness
from randomized trials, it appears prudent
for all adults to take vitamin supplements”
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RDBPC trial enrolling 14,641 male physicians
50 yrs. or older
Published in JAMA Nov. 14, 2012
Results: daily multivitamin supplementation
had a statistically significant effect in
reducing the risk of total cancer.
2014 report in Ophthalmology showed that
those physicians taking MV also had a
statistically significant risk of developing
cataracts.
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Laboratory studies, observational studies, and
secondary prevention trials suggest that
vitamin D can reduce the risk of chronic
diseases (heart disease, diabetes, cancer)
VITAL trial (Vitamin D and OmegA-3 Trial)—
RDBPC trial of 2,000 IU of vitamin D3 and
1,000 mg fish oil in the primary prevention of
cancer and CVD among approx. 20,000 men
and women >50 years of age. (Mason et al
2012)
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Vitamin D and heart disease
◦ VDR found on vascular smooth muscle,
endothelium, and cardiomyocytes
◦ 2010 article in the American Journal of
Cardiology examined the prevalence of
vitamin D deficiency and the relationship
of vitamin D deficiency with CVD in a
prospective analysis of 41,504 patients
(Anderson et al 2010)
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Vitamin D deficiency (<30 ng/ml) was
significantly associated in the prevalence of
hypertension, PVD, diabetes, and
hyperlipidemia, coronary artery disease, MI,
heart failure, and stroke.
2012 article in same journal presented the
results of a observational retrospective study
on 10,889 patients (men and women, mean
age of 58 +/- 15 years) examining vitamin D
levels/supplementation and cardiovascular
health (Vacek et al 2012).
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Results: Mean serum vitamin D levels were
24.1 ng/ml. Vitamin D deficiency (defined as
less than 30 ng/ml) was significantly
associated with coronary artery disease,
hypertension, cardiomyopathy, and diabetes,
as well as being a strong independent
predictor of all-cause death.
Vitamin D supplementation (mean intake of
2254 I.U) improved overall survival.
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Authors of the study concluded “vitamin D
deficiency was associated with a significant
risk of cardiovascular disease and reduced
survival. Vitamin D supplementation was
significantly associated with better survival,
specifically in patients with documented
deficiency.”
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Meta-analysis of data from the European
Prospective Investigation into Cancer (EPIC)
Norfolk study showed a definite inverse
association between vitamin D levels and the risk
of developing type 2 diabetes (Forouhi 2012).
A recent cross-sectional study of 2,708 Chinese
men and women (aged 48 +/- 12 years) showed
that those in the lowest quartile (<20ng/ml) had
a statistically significant higher risk of developing
IR and T2D then those with vitamin D serum
levels of 30ng/ml or above (Huang et al 2013)
Vitamin D is postulated to act as an ‘anticancer’ molecule by exerting anti-proliferative,
pro-apoptotic, and pro-differentiating actions
on malignant cells, as well as showing
suppression of tumor angiogenesis and
metastasis (Krishnan, 2013).
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2013 article in the American Journal of
Clinical Nutrition examined prospective
cohort data from the Women’s Health
Initiative Study examining the possible role of
vitamin D and lung cancer risk (Cheng et al
2013).
Examination of data from 128,779 women
showed that supplemental vitamin D intake
(800 I.U. daily) was associated with lower
lung cancer risk.
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Meta-analysis of 10 studies of 7,275 male
and female patients examined the possible
relationship between vitamin D and colorectal
cancer (Yin et al 2011).
Authors reported that there was a statistically
significant inverse relationship between
vitamin D levels and the risk of developing
colorectal cancer.
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A recent study examined the association
between breast cancer risk and vitamin D
levels in Australian women (Bilinski et al
2013).
This case-control study of 214 women and
852 controls (aged 55 +/- 11 years) showed
that those women with a vitamin D level of
less than 75 nmol/l had a statistically higher
risk of developing breast cancer.
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2013 report out of the Boston University
School of Medicine discussed the relationship
between vitamin D and cancer.
Authors concluded that “A multitude of
studies have associated improved vitamin D
status with decreased risk of developing
several cancers including colon, breast,
pancreatic and ovarian cancers…the goal [of
supplementation] is to achieve blood levels of
25-hydroxyvitamin D of 40-60 ng/ml.”
Holick, 2013)
Glucosamine is a substance involved in the
synthesis of structural components of
cartilage. Chondroitin is a component of
cartilage and also inhibits enzymes which
break down cartilage.
---2007 RDBPCT of 318 men and women
showed that Glucosamine was statistically
more effective than either placebo or
acetaminophen in treating OA knee
symptoms.
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A 2009 systematic review showed that G or G/C statistically
reduced the risk of OA (knee) progression.
A 2014 study in the Annals of Rheumatic Diseases discussed
a DBRPC trial of G/C for knee osteoarthritis.
605 patients, aged 45-75 years, received either G, G/C, or
placebo. After 2 years, those taking G/C showed a statistically
significant reduction in joint space reduction as compared to
placebo.
No significant adverse side effects as compared to
placebo.
Dosage: 1,000-1,500 mg daily
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Humans require 2 types of essential fatty
acids—omega 6 & omega-3
Omega 6 sources include sunflower, corn, &
soybean oils
Omega 3 sources include fish, nuts, flaxseed,
& canola oil
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Ideal ratio of omega-6 to omega-3 for
optimal health has been calculated to be 2:1.
However, current ratio is thought to be 10 or
20 to 1 due to the mass introduction of
vegetable oils and modern animal rearing
methods
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Clinical applications for omega-3
supplementation include:
Pregnancy: omega-3 intake in pregnancy
(300 mg DHA) is vitally important for the
neurological development of the fetus; it has
also been shown to prevent pre-term labor.
Also important for infant/child brain
development.
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Recent studies (2012 Journal of Nutrition
review article) show strong evidence that
omega-3 fatty acids can help prevent fatal
CHD,, sudden death, a-fib, and congestive
heart failure.
2013 DBRPC trial of fish oil for MCI showed
those patients (male and female, aged 5970) taking fish oil supplements had
statistically significant improvments in short
term and working memory, immediate verbal
memory, and delayed recall capability.
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2013 study by Brasky et al. in the Journal of
the National Cancer Institute reported that
omega-3 fatty acids are involved in prostate
cancer occurrence, leading to reports in the
media (print, television, web) that fish oil can
cause prostate cancer.
“Hold the Salmon: Omega-3 Fatty Acids
Linked to Higher Risk of Cancer[!]”
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Study measured plasma phospholipid omega3 levels in 834 men who developed prostate
cancer and 1,393 who did not. The men who
had the highest levels of omega 3 fatty acids
had a increased risk of 43%.
Difference between omega-3 levels in men in
highest to lowest quartile was 0.18% (4.48%
to 4.66%)
Study provided no data on fish intake or
omega-3 supplement use.
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Multiple studies point to protective actions of
omega-3 fatty acids/fish oil on prostate
cancer.
2013 article in the American Journal of
Epidemiology examined the association
between omega-3 fatty acids, fish oil, and
risk of developing prostate cancer and
concluded that omega-3 fatty acids from fish
oil were inversely associated with prostate
cancer occurrence.
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CIM will continue to be used by a
significant number of geriatric patients
and has the potential to play a significant
role in health promotion and risk
reduction, especially in the realm of
chronic diseases.
We in the Osteopathic community must
continue to push the envelope as well as
sort out what works and what doesn’t for
the safety and well-being of our patients.