Transcript Integrative Medicine - New York Buyers` Club

Vani Gandhi, MD
Attending Physician, Director, Integrative Medicine
Spencer Cox Center for Health
Mount Sinai St. Luke’s and Mount Sinai Roosevelt Hospitals
Assistant Clinical Professor of Medicine
Icahn School of Medicine at Mount Sinai
Integrative Medicine
 Integrative medicine is a combination of treatments from
conventional medicine and Complementary and
Alternative Medicine (CAM) for which there is some highquality evidence of safety and effectiveness.
 It includes the practice of conventional, natural,
alternative, complementary and herbal remedies.
 It is also about patient-centered care always involving
active collaboration with the physician and the patient.
 It takes into account the whole person (body, mind and
spirit), including all aspects of lifestyle.
Healthy aging
 Multidimensional
 Avoidance of disease and disability
 Maintenance of high physical and cognitive function
 Sustained engagement in social and productive
activities.
Aging
 Ageing is often characterised by decreasing health status
and increasing probability of acquiring age-related disease
such as cancer, Alzheimer's disease, atherosclerosis,
metabolic disorders and others.
 This is not inevitable and can be prevented with lifestyle
changes, calorie restriction and nutraceuticals.
 Increased level of pro-inflammatory cytokines such as IL-1,
IL-6 and TNF-α, mediated by genes activated by the
transcription factor NF-κB.
 Slowing down ageing and postponing the onset of agerelated diseases might be achieved by blocking the NF-κBdependent inflammation.
HIV relating aging
 HAART can lead to long term and possibly lifelong viral
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suppression and is well tolerated with number of safe
regimens
HIV infected persons are living longer but still do not
achieve a normal life span
Increased number of diseases are observed among older
persons in the general population and in people with HIV
These include non-AIDS-defining cancers, cardiovascular
disease, kidney disease, osteopenia/osteoporosis, liver
disease, frailty, and neurologic complications
Most are associated with normal aging process, many
are thought to be driven in part by chronic inflammation
related to HIV or other factors
Age-Associated Non-AIDS
Diseases
 Combination of factors lead to increased risk of
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age-associated non-AIDS diseases
Inflammation
Drug toxicity
Lifestyle factors (nutrition, exercise)
Environmental toxins (in air, food, water, soil)
Tobacco, drugs, alcohol
Stress, lack of social support
Aging process
 Lifelong exposure to various antigens (bacterial, viral,
other) leads to a gradual decrease in naive T cells and an
accumulation of memory T cells
 Increased amounts of pro-inflammatory cytokines and the
presence of viral infections caused by CMV and EBV.
 Imbalance between inflammatory and anti-inflammatory
networks.
 NF-κB is the main mediator of inflammation and
endothelial dysfunction in the elderly
What is happening in integrative
medicine to help slow down aging?
 Nutrition
 Exercise
 Stress reduction
 Supplements
 Herbal products
 Mind body medicine
Mucosal immunity and
gastrointestinal lymphoid tissue
 HIV replicates most intensely in gut-associated lymphoid
tissue (GALT)
 Rapid depletion of CD4+T cells occurs in GALT long
before that in the peripheral blood
 Population of central memory cells in the gut predicts the
rate of disease progression and AIDS events
 Reduced numbers of CD4+T cells in the GALT do not
reconstitute after HAART as they do in peripheral blood
Inflammation and HIV-Associated
Aging
 Chronic untreated HIV infection is associated with
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high levels of immune activation
50% of peripheral CD8+T cells are activated
More the activation of T cells, more the disease
progression
HAART reduces HIV-associated T-cell activation
Markers of inflammation such as IL-6, hsCRP,
cystatin C, and d-dimers are elevated with untreated
HIV infection and are only partially reversed during
effective HAART
Treatment of HIV
 Everyone with HIV is recommended HAART
 Early treatment is recommended
 Side effects are minimal with newer medications
 Less risk of diabetes, hyperlipidemia, neuropathy,
gastro-intestinal side effects with currently used
medications
 If side effects occur they can be effectively managed
with lifestyle changes, supplements or acupuncture
Case reports
 Diabetes
 Obesity
 Arthritis
 Peripheral neuropathy
 HIV related diarrhea
Hba1c decrease from 10 to 5.5 with
diet alone
How IM Helps Patients
 43 year old Man with HIV since 1988
 Long time patient of Center
 Obesity and liver enzyme abnormalities
 Initial visits with Nutrition and IM, 9/2013
 Fruits, veggies, nuts, and seeds
 Protein shakes
 Turmeric
 And more…
 Success!
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23 pound weight reduction in 2 months
“I can see my chin and I have a flat tummy!”
Follow up visit Jan 10, 2014
 Patient lost another 10 lbs (total weight loss of 33 lbs since September
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2013)
Maintains his “flat tummy”
“I have tried so many diets, Jenny Craig, Weight Watchers”
Still follows diet with lots of vegetables, beans, whole grain steel cut
oats or muesli for breakfast, fruits, nuts
Has a large salad with small portion of chicken, or fish for dinner
Buys beans by the case from Korean supermarket
Removed few links from his watch
Currently has lost more than 40 lbs of weight in the last one year
Continues exercise
Arthritis
 32 year old African American male with HIV/AIDS and
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Reactive arthritis was referred to me due to on-going knee
arthritis, needing arthroscopic steroid injections 2 years
ago
Nutrition- cut out all processed foods, increased fruits and
vegetables, cut down meat, increased fish intake
Herbs- turmeric supplement 400 mg twice a day
Herbs- holy basil (tulsi) with green tea once or twice a day
Brief meditation, relaxing breath several times a day
No pain since more than 4 years, runs few miles per week
Mood and attitude changed, energy increased, family and
friends noticed he is less irritable, less moody, and is
overall “nicer”
Diarrhea
 2 separate case reports
 1. Patient with HIV/AIDS with hx stroke, diarrhea,
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consulted me for integrative recommendations
Diarrhea resolved after adding zinc supplements
2. Patient with HIV/AIDS with chronic diarrhea since
many months, without any specific diagnosis despite
various tests, including colonoscopy, consulted me for
integrative recommendations
Pulled out one food from diet
Diarrhea completely resolved in 1-2 weeks
Gluten/wheat
 Gluten/wheat intolerance is being increasingly recognized
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in general population and it is a definite factor in my HIV
and primary care practice
Gluten can cause GI disturbances, skin diseases, certain
neurologic diseases
Stop gluten (wheat, rye, barley) for 4-6 weeks and reintroduce it to see if you having gluten intolerance
Definitely cut down intake of wheat
Avoid bread, flour based products except sprouted grain
bread
Most people consume too much wheat
If you can tolerate wheat, try cracked wheat, or wheat
berries in small amounts
HIV related neuropathy
 HIV related or due to certain anti-retroviral
medications
 Alpha lipoic acid 300 mg to 600 mg daily
 Stop wheat/gluten
 Acupuncture can help
Reacting to Stress:
 Use of alcohol or other substances to
“relax”
 Loss of sleep
 Conflicted relationships/isolation
 Negative thoughts
 Poor eating habits
 Lack of exercise
 Emotional instability
 Risk of injury
STRESS REDUCTION SKILLS
 There are many options- see what works
for you:
 Mindfulness
 Meditation
 Guided imagery
 Yoga
 Acupuncture
 Massage therapy
 Aromatherapy
 Exercise
Exercise- CDC- and National Institute on
Aging at the NIH
 Being physically active contributes substantially to healthy
aging.
 Regular physical activity prevents or controls many health
problems (e.g., high blood pressure; depression; obesity;
and diabetes) that reduce the quality and length of life for
older adults.
 Strength training is important to older adults, as it
provides relief from arthritis pain; improves balance and
reduce the risk of falling; strengthens bones; and reduces
blood glucose levels.
 Choose all four types of exercise — endurance, strength,
balance, and flexibility.
Meditation
 Sit upright in your chairs
 Keep your back straight if possible
 Rest your feet fully on the floor
 Bring your awareness to your breath
 Follow the flow of your breath
 Keep your awareness on your breath
The Relaxing Breath
 The Relaxing Breath (the 4-7-8 breath)
 (University of Arizona, Program in Integrative Medicine)
 Sit up with your back straight
 Put the tip of your tongue on the ridge behind your top front teeth
 Exhale through mouth making a whoosh sound
 Steps
 -Close your mouth and inhale through your nose to the count of 4
 -Hold your breath for count of 7
 -Exhale through your mouth making a whoosh sound to a count of 8
 Repeat steps 1-3 three more times
 Do this exercise at least twice a day
 You may repeat it more often
 Don’t do more than four breaths at a time
Immune boosting diet and lifestyleDr. Vani Gandhi
 Plenty of vegetables of different colors-6 servings per day especially dark leafy
green vegetables (broccoli, cauliflower, spinach, kale, chard, collard greens,
sweet potato, okra, pumpkin, asparagus, carrots, beets), eat a combination of
raw and cooked vegetables
 Fruit of different colors-2-4 servings per day (especially berries, dark grapes,
oranges, kiwi, melon, bananas, avocado)
 Healthy nuts- one handful of mixed nuts per day (almonds, walnuts,
pistachios), 1-2 brazil nuts, 1-2 tbsp of almond butter per day
 Dried fruits-small handful per day (raisins, dates, figs)
 Dark chocolate- 2 small pieces per day
 Seeds- 1 tablespoon per day (ground flax seed, pumpkin seed, sunflower seed,
sesame seed)
 Lentils and beans of different colors-2 cups per day (green lentil, yellow lentil,
pink lentil, kidney beans, pinto beans, navy beans)
 Brown rice-1/4 cup per day
 Whole grains-1-2 servings per day (quinoa, amaranth, buckwheat, gluten free
steel cut oatmeal)
Immune boosting diet and lifestyle
 Use turmeric daily in foods, add herbs such as cilantro,
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parsley, rosemary, oregano, basil to your food when
cooking
Use tomatoes, onions, ginger, garlic, black pepper or green
peppers in foods
Use extra-virgin olive oil, extra-virgin coconut oil only
Include 1 serving of cultured/fermented foods such as
miso, sauerkraut, kimchi, kefir daily
Include cooked mushrooms- button, Portobello, shitake
twice a week
Include whey protein in diet mixed with almond milk or
coconut milk
Immune boosting diet and lifestyle
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Omega 3 fish oil 2-3 gm per day
Fish-2 servings per week (low mercury- wild salmon)
Food sourced Multivitamin tablet daily
Food sourced Vitamin C 500 mg tablet per day
1 glass of warm water with juice of one lemon with ½ teaspoon of
honey in the morning
Green tea 1 cup 2-3 times a day
Vitamin D 2000 IU per day
15 minutes sun exposure per day on hands and legs
30-45 minutes of daily exercise (stretching, yoga, running)
10-15 minutes of daily breathing exercise
7-10 glasses of filtered, or bottled water every day
7-8 hours of sleep at night
Immune boosting diet and lifestyle
 Avoid drugs, alcohol, smoking
 Avoid processed foods, fried foods, processed meats,
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factory farmed meat
Avoid sodas (regular and diet), avoid juice except fresh
vegetable juices
Avoid refined sugar, corn syrup, refined salt, use pink
Himalayan salt or good quality sea salt in small quantity
while cooking, use honey or agave or stevia sparingly
Avoid refined vegetable oils, margarine
Avoid meat except for free range organic chicken or grass
fed beef once a week
Herbs/Supplements
Garlic
 Helpful in common cold, sore throat, fungal or yeast
infections- 2 cloves of garlic daily
 Helpful for GI tract and respiratory tract
 Natural antibiotic and antiviral agent, effective against
E.coli
 Mash and let it sit for 5 minutes
 May improve lipid levels, no effects on BP
 Anti-emetic (prevents nausea), anti-giardia, antiSalmonella, anti-E.coli)
 Should not be used with saquinavir
 Can reduce saquinavir blood levels by 51%
 Do not use garlic supplements if taking protease inhibitors
 Stop garlic 2 weeks before surgery
Ginger
 Rhizome, underground stem, not root
 4-6 gm crude ginger/day
 Used for arthritis, bursitis, motion sickness, nausea, morning
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sickness, chest congestion
Natural anti-inflammatory agent
Dry ginger- has anti-inflammatory properties
Fresh ginger- active on respiratory and GI tract
Stimulates stomach empyting
Take one inch piece, grate, boil in water for 15 mins, add honey, lemon
Dissolves mucus, and is an expectorant
Very effective for arthritis when combined with turmeric
High dose can cause heartburn
Acts as a blood thinner
Stop ginger 2 weeks before surgery
Turmeric
 Active ingredient is curcumin (curecumin!)
 Helpful in post-herpetic neuralgia
 Turmeric is the most powerful agent to recommend to decrease
inflammation in gut
 Useful in Ulcerative colitis, Crohn’s disease
 Decreases recurrence of familial adenomatous polyposis by 50%
 Reduces apoptosis (cell death)
 Antioxidant, anti-inflammatory, antiviral, antibacterial,
antifungal, and anticancer activities
 Helps in arthritis when used with ginger
 Decreases colon cancer, prostate cancer and skin cancer
 Helps in prevention and ? treatment of Alzheimer’s disease
Turmeric
 Turmeric used with black pepper increase absorption of
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turmeric by 2000%
For gastrointestinal tract- take turmeric without food
Milk or fat increases absorption- goes to body other than
GIT
1200-2400 mg/d curcumin needed to see effects in specific
conditions
For shingles- use turmeric paste with water
Do not use turmeric products with Warfarin (Coumadin)
Inhibits NF-κB, blocks proliferation of tumor cells
Mushrooms
 2-3 servings per week
 Button, cremini, portobello, reishi, maitake, shiitake
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mushrooms
Aromatase inhibitors
Anti cancer activity
Immune enhancing activity
Need to be cooked
Heat stable
Better effects when combined with other immune
boosting foods such as greens, onions, garlic
Omega- 3 fatty acids
 Uses- for thinning blood, preventing blood clots, and to
decrease inflammation
 1. Alpha linolenic acid (essential fatty acid)
 Plant sources, ground flax seed is the best source
 2. EPA (eicosapentaenic acid) and DHA (docosahexaenoic
acid)
 Both are long chain omega 3 fatty acids
 Sources are marine foods, algaes
 Dose is 2-4 gm of omega-3 fish oil daily
 Plant sources are flax seeds, chia seeds, sea weed, algae,
green leaves, pumpkin seeds, walnuts
 Marine sources (fish) contain EPA and DHA
Magnesium citrate or glycinate
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Dose: 400-500 mg daily/at night
Food sources are green vegetables, nuts, beans
Has number of functions in the body
Improves bone function
Avoid taking magnesium supplements if you have kidney failure
Indications:
High blood pressure
Migraine
Constipation
Stress
Muscle pains, Arthritis
Zinc citrate
 20-30 mg daily
 Improves immune function
 Decreases diarrhea, decreases pneumonia related
mortality
Probiotics
 1-2 capsules daily or more depending on condition
being treated and potency of the product
 Improves immune function
 Improves brain function
 Helps in prevention and treatment of certain diarrhea
Gut Immune system
 Gut is the largest immune system organ in the body. Soon
after an individual becomes infected with HIV, the virus
directly infects gut-associated lymphoid tissue (GALT),
where 70%- 80% of all immune cells exist, destroying a
massive amount of CD4 cells – up to 80% within a month
of infection.
 Prebiotics are non-digestible food ingredients that
selectively stimulate the growth or activity of ‘good’ and
‘bad’ bacteria in the colon. Probiotics, such as 'live' yogurts
and similar dairy products work in the small intestine.
Lactobacillus Acidophilus, L. rhamnosus, L.
reuteri, Saccharomyces boulardii (Probiotics)
 Can help decrease the risk of traveler’s diarrhea
 Can help in antibiotic related diarrhea
 Helps prevent C. difficile infection
 Helps in asthma and eczema
 Probiotic enriched Yogurt
 Sauerkraut, kimchi, natto, miso, kefir, kombucha
 Helps in irritable bowel syndrome, inflammatory
bowel disease
Prebiotics
 Bananas
 Soybeans
 Chicory, leeks, artichokes
 Raw oats
 Unrefined wheat
 Unrefined barley
 Onions, garlic, honey
 Inulin, fructo-oligosaccharides, oligofructose
Pain-free diet
 Stop sodas (regular, diet, caffeinated, decaffeinated)
 Limit sugar intake/carbohydrates
 Avoid trans fat/processed food (cookies, chips,
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candies, pastries, etc)
Avoid aspartame/other artificial sweeteners
Avoid MSG
Avoid tomatoes, potatoes, eggplant (for some)
Avoid processed red meat
Avoid dairy (can have small amount of plain yogurt)