Transcript Access Document - University of Arizona Department of

John D. Mark MD
Pediatric Pulmonary and
Integrative Medicine
University of Arizona
History of Medicine
TB: Hang cans of dog fat over your
shoulder
 Ulcers: Goat dung
 Snake bite: Apply ½ of severed mouse
 Baldness: Drink Sea water
 Everything: Enemas (3/wk- Egypt)
 Galen: Blood letting- 1500 yrs!-1910

Health Expo
Supplements, blue green algae, copper
bracelets, vitamin sprays, juicers, foot
massage dowels, water revitalizers,
colloidal silver generators, aromatherapy,
crystal kingdoms, gems for “balance”,
copper embedded wristwatches, aura
photos, diets, books, “dolphin energy”
 Are you a believer??????????

Complementary and Alternative
Medicine (CAM)
Medical interventions not taught in
medical school in the US or generally
accepted at hospitals or routine clinics.
 Includes ideas from cultures or ethnic
groups not considered to be part of
conventional care
 40-60% of adults use CAM
 Over $12 billion dollars spent-public!

Positive Motivation for CAM
Perceived effectiveness and safety
 Philosophical congruence: “Zeitgeist”,
holism, natural, active role of patient
 Good patient/therapist relationship
 Non-invasive, accessibility
 “High touch, low tech”
 Affluence, Control

Negative Motivation for CAM
Dissatisfaction with aspects of
conventional health care, adverse side
effects
 Ineffective for certain condition, time
 “High tech, low touch”
 Rejection of science and technology
 Rejection of “the establishment”
 Desperation

Why is CAM use common in
chronic illness?
Chronic inflammatory illness
 Paradox: increasing despite advances
 Belief that “external” exposures as cause
 Belief that “emotions” can be important
 Meds: “like using a boulder to kill an ant”
 Holism and Empowerment of patients

The Integrative Approach
Whole person and family
 Healing oriented not Disease
 Patient/Physician partnership
 Mind/Body/Spirit
 Family and patient’s belief system
 Holistic in approach, multilevel, and
multifactorial

Integrative Approach to Health

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Conventional vs. Integrative
Healing- restoration vs. evolution
Disease-entity vs. aberrant organiz. pattern
Study of health- linear causality vs. circular
causality
Study of healing-looks at single variables vs.
looks at how all are linked to form a pattern
Medicine
Medicine is not merely a science but an art.
The character of the physician may act
more powerfully upon the patient than
the drugs employed.
Philippus Aureolus Paracelsus (1493-1541)
Chronic Respiratory Conditions
Asthma
 Chronic Obstructive Pulmonary Disease
(COPD) and Emphysema
 Cystic Fibrosis
 Other

Asthma in the United States
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17 million, over 5 million children
Most common chronic illness in children
100 million restrictive activity days per
year
Over 470,000 hospitalizations per year
Over 5,000 deaths per year-highest in
Blacks and children (ages 15-24)
Paradox in Asthma Care
NHLBI Expert Panel Guidelines (92’&97’)
 Understanding airway inflammation
 Early use of anti-inflammatory meds
 Home management/ peak flow monitors
 Practice Guidelines- both for ER & Outpts.
 Morbidity and Mortality- increased?

Asthma Education-MD’s
Study of 108 MD’s and Guidelines
 Asthma Faculty-78%
 Asthma Fellows-69%
 Family Practice-55-60%
 Internal Medicine Residents-51%
 Just understanding classification-problem

Asthma Triggers
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Imbalance of T-helper lymphocytes type-2
(Th2) system
Respiratory viruses and Exercise
Allergens and Irritants: grass, trees, molds,
indoor and outdoor pollution, dust-mites,
cockroach, animal dander
Emotional (laughing/conflict) and Weather
Shift in omega-6/omega-3 fatty acids in diet
Nutrition and Asthma
Dietary habits influence lung function
 Increased incidence in countries with
PUSFA intake
 Allergen exposure to foods and additives
 Dietary intake of fruits, fresh fish and
antioxidants decreased in asthmatics

Fat Classification
Saturated Fats
 Monounsaturated Fats

Omega-9 family

Polyunsaturated Fats
Essential Fatty Acids (EFAs)
Omega-6 Family
Omega-3 Family
Linoleic Acid (LA)
Alpha linolenic acid (ALA)
Gamma linolenic acid (GLA) Eicosapentaenoic acid (EPA)
Arachidonic acid (AA)
Docosahexaenoic acid (DHA)
Omega 6 Fatty Acid
Omega 3 Fatty Acids
(Linoleic Acid)
(alpha-linolenic acid)
Δ6-Desaturase
Gamma-linolenic acid
Eicosapentaenoic Acid
(GLA)
(EPA)
Evening Primrose Oil
Borage Oil
Black Current Oil
Δ5-Desaturase
Arachidonic Acid
COX
Prostaglandins
PGE1, PGE3
(Favorable)
Cyclo-oxygenase
Less Inflammatory
Leukotrienes
Lipoxygenase
(COX)
Prostaglandins (PGE2)
Inflammatory
Lipoxygenase
Docosahexaenoic acid
(DHA)
Leukotrienes
Arachidonic Acid
(in cell membrane)
Phospholipase A-2
Steroids
Free AA
Colchicine
Aspirin
NSAIDs
Cyclo-oxygenase
Lipoxygenase
Pathway
Pathway
COX II Inhibitors:
Celebrex, Vioxx, Mobic
Prostaglandins
&
Thromboxanes
Sulfasalazine
Leukotriene
Inhibitors:
Accolate,
Singulair, Zyflo
Leukotrienes
1985 (25:1)
25
20
Omega 6:3 Ratio
15
10
5
1909 (4:1)
0
Omega 6
Omega 3
CH3
COOH
C=C
CH3
C=C
COOH
Cis
Trans
H H H H HH H H H
H H H H HH H H H
H C C C = C C C = C C COOH
H C C C C C C = C C C OOH
H H
H
H H
Polyunsaturated
H H H H H
H H
Partially Hydrogenated
30 year shelf life
Sources of Omega-3 Fatty
Acids

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Cold Water Fish
Salmon
Mackerel
Sardines
Herring
Fish Oils
EPA & DHA
Sources of Omega-3 Fatty
Acids
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Flax Seed Products
Oil, ground seed.
Walnuts/Oil
Hemp seeds
Soybeans/Oil*
Dark Green Veges*
algae
What to Recommend for
chronic inflammation.
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Reduce saturated fats that contain
arachidonic acid (Animal products, dairy)
Reduce use of Omega 6 products (vegetable
oils, crackers, things with a long shelf life)
Increase use of Omega 3 products (cold
water fish, flax, dark greens and nuts)
Avoid low-carbohydrate (high fat) diets for
prolonged periods of time (Atkins, Zone).
Dietary Supplements
Confusing more than any other area
 DSHEA Act of 1994
 FDA lack of regulation
 Regulating nature?
 When, what, how much, how long,
what form, interactions, who to ask?
 Botanicals, phytomedicine, Internet?

Dietary Supplements
Echinacea
 Coleus forskohlii (inhibits PAF)
 Ma huang (ephedra) (bronchodilator)
 Ginkgo biloba (PAF inhibitor)
 Licorice, coltsfoot, tumerac (anti-inflam.)
 Cordyceps (bronchodilator)
 Green tea (antioxidants)

Ma Huang (Ephedra sinica)
Used in China over 5,000 years
 Ephedrine- principle ingredient
 Commonly used with licorice (mucolytic)
 FDA-Over 600 complaints-22 deaths
 Tighter State regulations-esp diet claims
 Most problems stem from use with
caffeine

Licorice (Glycyrrhiza glabra
radix)
Folk medicine- treat cough
 Glycyrrhetinic acid and carbenoxolonepotent inhibitors of cortisol metabolism
 Enhances endogenous and exogenous
steroids
 Also shown to elevate blood pressure,
peripheral edema, headaches, low K+,
lethargy , muscle weakness

Coleus forskohlii
Ayurvedic medicine
 Acts like theophylline (increases cAMP)
 Another Ayurvedic herbal remedy seems
to be an effective bronchodilatorTylophora indica No studies yet on children, some on
adults

Ginkgo Biloba
Study of asthmatics using Ginkgo leaves
concentrate showed decrease airway
hyperactivity (p<0.05) and pulmonary
function improved (p<0.05)
 Problem- 1997 study, in Chinese and do
not specify the type of airway
measurements used.

Ginkgo
Pilot data in this country has been
described
 PAF antagonist
 Antioxidant
 Can interact with other drugs, esp
coumadin type meds

Vitamins
Vitamin B6 (pyridoxine)- RCT’s-helps for
mild disease, 200 mg per day
 Vitamin C- RCT’s-mixed results -over 1
gm
 Selenium- no studies, antioxidant
 Fish oil (omega 3 Fatty Acids)-RCT’s- long
term help

Case Presentation: Shannon
14 yr old with long standing asthma
(moderate persistent), pets
 Meds: Albuterol, AeoBid (Singulair,
Pulmocort)-followed peds clinic
 PFT’s- FEV1 (60/85), FEF25-75 (40/70)
 Treatment plan: Meds, Environment,
Nutrition, Dietary Supplements, Exercise
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Arizona Botanical Center
One of 4 (UCLA, Chicago, Purdue)
 Anti-inflammatories: Ginger, Tumeric,
Boswellia
 Botanical to Chemical to Animal, to
Human studies
 Ayruvedic- all used for asthma
 Leukotriene inhibitors (esp. Boswellia)

Boswellia serrata gum resin
European J Med Res 98’ Nov:3:511
 40 patients with asthma (double blind
and placebo study)
 70% had improved symptoms, increase
in FEV1/PEFR, decrease eosinophils
 Control group- had 27% improvement
 Boswellia serrata gum resin for asthma
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Lung Support
“Lung Support”
Retinol, Fructus,Salvia, Cordyceps,
Astragalus, Prunus, Morus, Ophiopogon,
Cynachum, Ginseng, Ginkgo, Magnesium
 No amounts listed
 SAFE
 NO DRUGS
 NO SIDE EFFECTS
 100% NATURAL

Claims Made:
Ends..SOB, smoking damage, heart
problems, sinus problems, emphysema,
allergies, fatigue, asthma….
 “Secrets to breathing disordered
unlocked”, “End Bronchial disease”
 “Today’s Medicine is Harmful”
 “Dramatic improvement …few days”
 “100% SATISFACTION & RISK FREE “
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Mind-Body
Influences
on health
Mind/Body Approach
Placebo/Suggestion/Disclosure
 Hypnosis:
 Guided Imagery
 Pediatric study proposal
 Diaphragmatic breathing
 Exercise, Yoga, Martial arts

Accessing the Placebo Response
Develop rapport and trust
 When able, recommend therapy based
on the patient’s belief system
 Recommend any given therapy with
enthusiasm and confidence
 Activate the patient’s expectation of the
therapy with positive statements

Disclosure Chronic Illness

Smyth JM, et al. JAMA, 1999

Effects of Writing About Stressful Experiences on
Symptom Reduction in Patients with Asthma and
Rheumatoid Arthritis.
• Study Group: Wrote about a stressful life event for
20 mins/d for 3 days
• Control Group: Wrote about daily events
• 107 patients.
• Asthma: 20% improvement in lung function vs no
improvement in control
• RA: 28% reduction in disease severity vs no change
in control.
Hypnosis
Multidimensional
 Induces an altered state of consciousness
 Aids in developing a heightened
concentration of an idea or image
 Studies- many in the behavioral
literature, helps if subjects are
“susceptible” to hypnosis

Tracy and the Laryngeal Warts
Massage/Manipulative
Feels good, reduces stress and anxiety
 Recent Asthma study: 20 minutes at
bedtime by parents helped
 Chiropractic Osteopathic- Used with anecdotal success

Osteopathy
Manipulative Medicine-Dr Still
 Structure/Function relationship
 Over 100 different types
 Craniosacral, High-velocity-lowamplitude,muscle energy,counterstrain,
myofascial release, lymphatic pump
 Spiritual Component- Dr Viola Fryman

Other Therapies:
Mind/Body Medicine
 Massage Therapy
 Energy Medicine
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Healing touch
 Reiki
 Johrei
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Ethnocultural Medicine
Homeopathy
Law of Similars
 Potency
 Hahneman, homeopathy schools
 Acute versus Chronic remedies
 Classical versus “Modern”
 Who, When and for what problems

Traditional Chinese Medicine
5 Elements
 5 Branches
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Acupuncture, moxibustion
 Diet
 Herbal therapy
 Physical Therapy
 QiGong, Kung Fu
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Different Systems Approach
COPD
Conventional Care??
 Inhaled steroids/Bronchodilators/Atovent

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Pharmacoeconomic impact- Chest 2000
Regular use of Meds (albuterol?)
 Long-term Oxygen Therapy
 Home Ventilation
 Nutritional Intervention
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COPD and CAM
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Ginseng and chronic bronchitis
Clin Drug Invest Jan 2001, 75 patients
 Increased bacterial clearance

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Music therapy and dyspnea
Holistic Nursing 1999, 24 patients
 Less anxiety and dyspnea, better energy

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Nutritional
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Chest Feb 2001, 21 report review
From Jerusalem to Jericho: a study of
situational and dispositional variables in helping behavior.
J Personality and Social Psychol. 1973;27:100-108
Group #1
Group #2
Group #3
Healing
People come together to form a healing circle,
But the power lies in the empty center.
A person’s chest rises and falls
But the breath that fills it cannot be seen.
Muscle and bone join to make a body
But the life force within is invisible to the eye.
A child’s laugher bursts with joy
And the source of it cannot be touched.
What can one be
But the instrument of unseen bliss?- Lao Tzu