Transcript Lecture 14 Complementary and Alternative Medicine

Complementary and
Alternative Medicine,
Dietary Supplements, and
Medications
CAM- Where is it?
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A 14 yr old athlete with moderate, persistent
asthma comes to clinic. He has an asthma action
plan and has been adherent with his controller
medication. Now he wants to try a breathing
technique (Buteyko) so he can “get off” his meds.
A 3 yr old comes to the clinic for a well-child
check-up. On exam you find a right otitis media.
She is asymptomatic and you recommend
watchful waiting. The parents would like to try a
homeopathic remedy because they had heard
that homeopathy worked better than placebo for
children with an ear infection.
Answer: Everywhere
CAM- every where you look
CAM in the News
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Dying Woman Loses Marijuana Appeal
March 14, 2007
Evidence Mounts That Coping Skills Can
Boost HIV Survival March 14, 2007
Omega-3 in Fish Oils Might Ease
Depression March 7, 2007
Insomnia: Alternative Medicine Popular
• 1.6 Million Adults Use Complementary Or
Alternative Medicine For Insomnia September
2006
Jennifer Aniston
Atkins diet
Madonna
Yoga, herbalism
Pamela Anderson
Homeopathy
Sir Paul McCartney
Alexander
Boris Becker
Homeopathy
Demi Moore
Lake algae
Cherie Blair
Acupuncture,
Kate Moss
Acupuncture
Tony Blair
Homeopathy
Martina Navratilova
Homeopathy
Dina Carroll
Reflexology
Olivia Newton-John
Homeopathy
Charles, Prince
Magnet therapy
Gwyneth Paltrow
herbalism
Cher
Homeopathy
Brad Pitt
Atkins diet
Cindy Crawford
Homeopathy
Sir Cliff Richard
Ginseng
Sheryl Crow
Eskimo diet
Sarah, Duchess of York
Bioenergy
Queen Elizabeth
Homeopathy
Arnold Schwarzenegger
Breathing
Jane Fonda
Homeopathy
Hugo Speer
Yoga
Richard Gere
Breathing therapy
Margaret Thatcher
Ayurveda
Whoopi Goldberg
Homeopathy
Uma Thurman
Gem therapy
Jerry Hall
Homeopathy
Tina Turner
Homeopathy
Geri Halliwell
Yoga
Kate Winslet
Acupuncture
Goldie Hawn
Ayurveda
Catherine Zeta-Jones
Homeopathy
Ernst MJA 2006; 185 (11/12): 680-681
Complementary and Alternative
Medicine (CAM)
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Complementary and alternative medicine
• A group of diverse medical and health care
systems, practices, and products
• Not considered part of conventional medicine
• Some scientific evidence exists regarding CAM
therapies
• For most, questions of safety and efficacy
persist
Complementary medicine is used together with
conventional medicine. Alternative medicine is
used in place of conventional medicine.
http://nccam.nih.gov/health/whatiscam/
Integrative or Holistic Medicine
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Integrative combines mainstream medical
therapies and CAM therapies for which
there is some high-quality scientific
evidence of safety and effectiveness.
“Healing-oriented medicine that takes account of
the whole person (body, mind, and spirit),
including all aspects of lifestyle. It emphasizes
the therapeutic relationship and makes use of all
appropriate therapies, both conventional and
alternative.”
http://nccam.nih.gov/health/whatiscam/
http://www.integrativemedicine.arizona.edu/about2.html
Major Classes of CAM
Enhance the
mind’s capacity
to affect bodily
function and
symptoms
Alternative
medical
systems
Homeopathic
Naturopathic
Traditional
Chinese and
Ayurvedic
treatments
Mind-body
interventions
Chiropractice
Osteopathy
Massage
Biologically
-based
therapies
Dietary supp
Herbs
Foods
Vitamins
Natural
substances
Manipulative
& body-based
methods
Energy
therapies
Biofield therapy
Bioelectromagnetic
therapy
http://nccam.nih.gov/
CAM Utilization
Reasons for using CAM:
 Consistent with patient’s and families
values : natural, and empowering
 CAM providers are “patient-centered”,
dedicated to promoting health.
 Conventional therapies are perceived to be
emotionally or spiritually without benefit
Conventional therapies are not effective or
are associated with side effects.
 CAM use is a circular: usage determines
number of CAM practitioners
CAM Treatments Commonly
Thought Effective in Pediatrics
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Effectiveness
uncertain
• Acupuncture for asthma
• Acupuncture for hay
fever
• Acupuncture for
rheumatoid arthritis
• Chromium for diabetes
• Echinacea for common
cold
• prevention or treatment
• Evening primrose for
eczema
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Effectiveness unlikely
• Acupuncture for body
weight reduction
• Acupuncture for
smoking cessation
• Flower remedies for
anxiety
• Homeopathy for anxiety
• Spinal manipulation for
asthma
• Spinal manipulation for
infantile colic
Conventional Medicine, Evidence?
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Most conventional physicians believe in unconventional
medicine because it is not scientific
What is evidence-based medicine? Treatment that will
improve patient outcomes by well-designed, appropriately
powered, randomized, controlled clinical trials.
There is not good evidence (Grade A) that many of the
commonly used therapies in conventional medicine are
effective (ex: heparin, aspirin, and warfarin).
The principal distinguishing characteristic of unconventional
and conventional medicine therapies is the source of
introduction.
Conventional therapies are introduced by mainstream
Western physicians and scientists, whereas most
unconventional modalities are introduced by "outsiders."
One of the reasons that most unconventional modalities are
not evidence based is that the majority of them were
introduced prior to the 20th Century
Whole Medical Systems
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Complete systems of theory and
practice that evolved independently
Traditional systems of medicine that
are practiced by individual cultures
throughout the world
• Includes traditional Chinese
medicine, Ayurvedic medicine,
homeopathy, naturopathy
Biologically Based Practices
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Includes: botanicals, animal-derived
extracts, vitamins, minerals, fatty
acids, amino acids, proteins, whole
diets, and functional foods
• Dietary supplements are a subset
of biologically based practices
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Biologically Based - Supplements
What is a supplement?
Regulated by FDA
http://www.fda.gov
• no requirements for FDA testing
• manufacturers responsible for ensuring
product safety
• label requirements
• safety alerts:
http://www.cfsan.fda.gov/~dms/dswarn.html
Energy Medicine
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Veritable - energy that can be
measured
• Includes sound, visible light, magnetism
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Putative – energy that has yet to be
measured
• human beings are infused with a subtle
form of energy
• Includes qi (ki in Japanese); doshas;
prana, homeopathic resonance
Energy Medicine - Acupuncture
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Few complications
Scientific evidence?
• post chemotherapy
• management of nausea
• pain relief
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NIH Consensus Statement (1997)
• http://consensus.nih.gov/1997/1997Acu
puncture107html.htm
Manipulative and Body-Based
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Structures and systems of the body,
including the bones and joints, the
soft tissues, and the circulatory and
lymphatic systems
• Includes chiropractic manipulation,
massage therapy, reflexology,
rolfing, Alexander technique,
Feldenkrais method
Mind-Body Medicine
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Interactions among the brain,
mind, body, and behavior
The ways in which emotional, mental,
social, spiritual, and behavioral factors
can directly affect health
• Includes relaxation, hypnosis, visual imagery,
meditation, yoga, biofeedback, tai chi, group
support, and spirituality
Other CAM Therapies
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Aromatherapy
Colonic Irrigation
Therapeutic Touch
EDTA Chelation
Cupping
Primordial Sound Meditation
Evaluating Web Sites
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Accuracy
Authority
Bias
Currency
Coverage
Clinical Trials and CAM
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Why are there so few CAM clinical trials?
• Drug companies have to do studies to go on
the market—supplement companies do not, so
clinical trials sponsored by supplement
companies are rare
• Alternative treatments are often customized
for a specific person. Clinical trials try to prove
something works for most people.
• Belief systems of some CAM practitioners do
not agree with the idea of Western studies, so
they do not participate
• CAM has only recently become “legit” in the
scientific community
Dietary Supplements
RUN THE WHOLE GAMUT!!!
vitamins- C, E.
minerals- Ca, Se
amino acids-lysine
fats- fish oil
hormones- DHEA
herbs- ginseng
phytochemicals-garlic
etc
FDA Regulations Protect
Consumers
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FDA regulates: Drugs are highly
regulated by FDA
Vitamins & minerals regulated as
foods
Supplements are considered safe
until demonstrated to be hazardous
by FDA
Herbals & botanicals totally
unregulated
Who Benefits?
Those at risk for developing
nutritional deficiencies only!
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People with vit, mineral deficiency
Vegans- vit D, B12
Pregnant women- folate
Elderly persons- B12/folate
People at risk of osteoporosis- Ca,
vit D
People at risk of losing blood- Fe
People on restricted diets- vit,
minerals
Hormones
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HGH
EPO
BHCG
Steroids
Human Growth Hormone
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Normally secreted by the pituitary
Normal function of GH is growth and
development of every body system,
including bone and muscle
Can be stimulated by propanolol,
vasopressin, clonidine, and levodopa
Synthetic growth hormone
Side Effects:
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Acromegaly (may be irreversible)
Peripheral Neuropathy
Coronary Artery Disease
Cardiomyopathy
Diabetes, Hypothyroidism, arthritis
No available urine test available, but
banned by NCAA and IOC
Erythropoietin
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Hormone released by the kidneys in
response to low Hct
Stimulates RBC production from
bone marrow
Has recently been manufactured by
recombinant DNA technique
Can increase Hct in renal patients by
up to 35%, lasting up to 7 months
Used most by cyclists
Blood Doping
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Induced Erythrocythemia: An
increase in Hb following reinfusion of
an athlete’s blood
Goal: to increase the oxygencarrying capacity of Hb
Has been used as far back as 1947
1984: seven US Olympic cyclists
guilty
Banned by IOC in 1985
Detection:
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Blood doping and Erythropoietin:
banned by IOC
No known urine test to detect
Testing: Measured Hct >50
Measurement of serum Fe and
Bilirubin to detect hemolysis after
frozen PRBC transfusion
Anabolic Steroids
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The ultimate ergogenic aid aka
“Juice”
Creates the Superhuman Athlete
Testosterone derivatives (cholesterol)
Produced in the adrenal/ testes
Anabolic/Androgenic
Steroids
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Anabolism - Constructive
Catabolism - Destructive
Anabolic effects : inc. skeletal mm
mass
anticatabolism
Androgenic effects: secondary
sexual characteristics - pubic hair,
genital size
No Pure Anabolic Steroids
Desired Effects:
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Increase in strength
Increase in weight
Increase in aggressiveness
Increased capability of sustaining
repetitive, high intensity workouts
Enhanced performance
Side Effects:
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CV: MI - hypertension, inc. LDL, dec.
HDL, cardiac hypertrophy,
thrombosis
Endocrine: virilization, testis atrophy,
azospermia, priapism, prostatic
hypertrophy/ CA, gynecomastia,
erectile dysfct, libido
Liver : peliosis hepatitis, hyperplasia,
adenoma, no carcinoma, elevated
LFTs
MS: epiphyseal closure, inc. bone
density, dec. tendon strength
Side Effects (cont’d):
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Skin: acne, hirsuitism, striae,
androgenic alopecia, inc. sebaceous
glands
Metabolic: hypernatremia, kalemia,
phosphatemia, calcemia,
“prediabetic”
Psychiatric : aggressiveness,
extreme mood swings - depression/
mania, dependence, other drug use,
“Reverse Anorexia”
Long Term - dec. life span
Specific Side Effects
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Women
(Virilzation):
• Clitoril
enlargement,
Deepening of
voice, Male
pattern baldness,
dec. breast size,
libido
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Children:
• premature closure
of growth plate in
long bones & thus
“Prohormones”
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Androstenedione
DHEA
Androstenediol
Norandrostenedione
Norandrostendiol
Effects:
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Benefits: Same as Testosterone
• Increased energy
• Enhanced recovery and growth from
exercise
• heightened sexual arousal and function
• greater sense of well-being
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Plasma levels of testosterone
increased from 140% to 330% of
normal levels after 50mg and 100mg
doses
SE’s : Same as Testosterone
Banned by IOC, NCAA, NFL
Stimulants
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Caffeine
Amphetamines
Cocaine
Ephedrine
Amphetamines
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Have been used as far back as
WWII when soldiers used them to
delay fatigue
First study in 1959 showed
significant improvement in
performance
Available data suggest
Amphetamines can improve
performance in sports where
speed, power and endurance are
required
Side Effects:
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Related to drugs’ effect on CNS:
insomnia, instability, agitation and
restlessness
Confusion, paranoia, hallucinations
Dyskinesias, especially in facial
muscles
Cardiac complications: HTN,
arrhythmias
GI disturbances
Severe rebound of fatigue and
depression after discontinuance
Caffeine
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A Methylxanthine: same class as
theophylline and theobromine
Exerts its’ effects by:
• Translocation of Calcium for more
muscular availability
• Increase in cAMP by inhibition of
phosphodiesterase
• Blockage of adenosine receptors,
blocking the sedative properties of
adenosine
Caffeine (cont’d)
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Is banned by IOC and NCAA in
large doses
Legal limit = 15 micrograms / ml
Equal to 6-8 cups of coffee at one
sitting, with testing within 2-3
hours
Beneficial most in endurance
events, such as cycling
Doses up to 5 mg / kg were
required to see benefits. Doses of
17 mg/kg produce the maximum
legal limit.
Side Effects:
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Similar to s/e of other stimulants:
• insomnia, irritability, nervousness
• Tachcardia, arrthymias, and possibly
death!
Ephedrine
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What it is: Is a drug found in herbal
products containing Ma haung, antiasthmatic medications, and many cold
and cough products.
Claims: Increases body fat loss
What really does: Acts as a CNS
stimulant, delays fatigue by sparing
body glycogen reserves. Increase in
B/p respiratory, heart rate, insomnia,
and nervousness
Max dose : 24 milligams per day!!!!!!
Amino Acids
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Creatine
L-Carnitine
Choline
Inosine
HMB (B-OH-BMethylbutyrate)
Amino Acids
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Essential amino acids: found in a
balanced diet
Recommended protein intake: 0.8
g /kg/day
Athletes may benefit from up to
1.4 -2.4 g/kg/day
Most beneficial for athletes on a
poor diet, or vegetarians
In endurance athletes, up to 10%
of energy expenditure is from
protein breakdown
Creatine
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The Other 1/2 of the “Mark
Mcguire Special” - The Creatine
Craze - Sales expected to reach
$200 million in 1998
Use has spread:
• 13% of HS athletes
• 80% of University of Nebraska
football team
• 50% of NFL players
• Vast majority of Olympic sprinters,
cyclists, and sprinters
Creatine
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Methylguanidine-acetic acid - made
from glycine, arginine & methionine
Estimated Daily requirement: 2gms
Available in meats and fish (1/2 EDR)
Sold as Creatine Monohydrate
Stored in Skeletal MM
2000 NCAA banned distribution in
training rooms
Pathophysiology:
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Energy Substrate for muscle
contraction
Creatine binds Phosphorus as
substrate for formation of ATP
(main source of energy of
contraction)
PCr also buffers Lactic Acid
After PCr is depleted must resort
to glycolysis for ATP production
Net result: sustained muscular
contraction, delayed fatigue
Benefits:
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Improved performance in repeated
bouts of high intensity strength work
and sprints
Single sprint activity results are
equivocal
Does not enhance endurance
exercise
More work with less lactic acid
production
No studies on competetion benefits
1998 ACSM meeting: 19/19 studies
showed significant ergogenic benefit
Side Effects:
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Muscle Cramping
Diarrhea
Dizziness
Dehydration
Biggest danger: getting “impure”
creatine
Significant WEIGHT GAIN common
2nd to water retention
The Perfect Supplement?
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“The secret is to find something that
is effective in improving
performance, but not against the
rules, and with no side effects”
“…no clear evidence of harmful side
effects of creatine use has
emerged…”--The Physician and
Sportsmedicine, June 1998
Long term effects of Creatine not yet
studied: Concerns focus on effects to
kidney, pancreas, and liver.
HMB
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Metabolite of KIC (ketoisocaproate)
which is a metabolite of leucine
Leucine & KIC found to have
anticatabolic effects
decreased mm proteolysis, inc. lean
mm mass, inc. strength
no known side effects
Choline
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Precursor for the neurotransmittor
Acetyl Choline & the lipoprotein
Lecithin (Phosphattidylcholine)
choline depletion in marathoners
no studies supporting
Inosine
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Increases myocardial contractility
no performance enhancement in
runners/ cyclists
Metals/ Minerals
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Chromium
Magnesium
Boron
Vanadium
Chromium
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Insulin Cofactor
inc. AA uptake into mm cells
increase mm mass, dec. body fat
found in meats, grains, raisins,
apples, & mushrooms
SE’s: anemia, chromosomal damage,
cognitive impairment & interstitial
nephritis in excessive doses
Magnesium
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Involved in ptn synthesis & mm
contraction
+ effects on oxygen consumption &
lactate production
no change in performance
Boron
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Originally thought to inc.
testosterone levels
not born out in studies
Vanadium
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What it is: Non-essential trace
mineral
Claims: Anabolic effect, enhances
insulin action
What it does: No studies to show
anabolic effect. Doses>10gms/day
causes abd. Pain, cramps, green
tongue,diarrhea, wt. loss
Antioxidants
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Vitamins E & C
potential damage from free oxygen
radicals produced by lipid
peroxidation in exercise
exercise performance is not
improved
Herbs
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Ginseng
Yohimbe
Tribulus Terresteris
Ma haung
Ginseng
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What it is: A root from an Asian
plant (panax ginseng).
Claims: Enhanced performance.
Improved recovery rate.
What it really does: Acts as an
adaptogen- may boost immune
system and protect cells. May
cause insomnia, and should not be
used if B/p is elevated.
Dose: 100-200mg per day used
occ.2-3 weeks on 1-2 weeks off
Yohimbe
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What it is: Supplement derived from
tree bark.
Claims: Anabolic effect, Increased
virility
What it does: Stimulant effect, no
anabolic effect. Can cause
nervousness, HA, nausea, Vomiting,
increased B/P
Tribulus Terresteris
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What is it: A plant hormone
Claims: Anabolic effect
What it does: Increases testosterone
levels
Banned by NFL
Miscellaneous:
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Bicarbinate
Loading
Coenzyme Q
Linoleic Acid
Bicarbonate Loading
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Used prior to competition to
neutralize lactic acid produced by
anaerobic activities
Lactic acid>>lower pH>>fatigue
May improve runners’times if
taken 30 min prior to competition :
best in intermediate distances
800-1500 meter events
300mg/kg required
Terrible GI s/e in 50% of users-cramps, diarrhea, ^ BP
Coenzyme Q10
Conjugated
(coQ10,Ubloquinone) Linoleic Acid
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Produced by the body in
mitochondria
claims: Enhances
performance, delays
fatigue, prevents injury
What really
does:Functions as an
antioxidant
Safe levels:60200mg/day but
also$$$$$
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Naturally
occurring fatty
acid found in
beef ,lamb and
dairy
claims:
decreases body
fat ,increases
muscle
gain,antioxidant
What really
Reviewing the Evidence
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Evidence Based Medicine: “What
evidence do we have to justify the
treatment…”
National Center for Complementary
and Alternative Medicine (NCCAM)
CAM on PubMed