1. Nutritional Implications
Integrative Medicine
Nutritional Implications

2. Complementary and alternative medicine (CAM):
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

3. CAM Therapies Include
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

4. Integrative medicine
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

5. National Center for Complementary and Alternative Medicine (NCCAM)
Part of the National Institutes of Health
—Investigates and evaluates alternative therapies and their effectiveness

6. Theoretical Basis of Holistic Therapies
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

7. Integrative Therapies
Health is more than the absence of disease.
The body can heal itself.
Naturopathy
Homeopathy
Traditional Chinese medicine
Acupuncture
Phytotherapy

8. Naturopathy 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

9. Chiropractic Concepts
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, along with lifestyle

10. Chiropractic Practitioners
Do not prescribe drugs or perform surgery
Licensed and regulated in all 50 states and 30+ countries
Practitioners must graduate from 4-year accredited college of chiropractic and pass a nationally-administered exam

11. Chiropractic
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

12. Homeopathy
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)

13. Homeopathy
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

14. Traditional Chinese Medicine
Based on the concept of body life force chi (Qi)
Forces that must be balanced
—Yin and yang and blood
Invisible energy circuits called meridians carry chi and blood throughout the body

15. Nutrition in Traditional Chinese Medicine
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

16. Acupuncture and Moxibustion
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

17. Acupuncture as Anesthesia
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, chemotherapy-induced nausea, postoperative dental pain

18. Traditional Chinese Herbs
Includes herbs and minerals as well as animal products
Pharmacopoeias published as early as the third century BC
Most medicinals include multiple substances

19. Phytotherapy
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

20. Botanical Formulations
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 minutes

21. Botanical Formulations
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

22. Botanical Formulations
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

23. American Herbal Products Assoc Botanical Safety Rating System
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

24. Dietary Supplement Health and Education Act of 1994 (DSHEA)
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

25. Dietary Supplement Health and Education Act of 1994 (DSHEA)
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.”

26. Required Labeling of Dietary Supplements under DSHEA
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.

27. Supplement Facts Panel

28. Dietary Supplement Claims
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.”

29. 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.

30. Regulation of Dietary Supplements
Dietary supplements are not subject to the same standards as prescription or over-the-counter 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

31. Regulation of Dietary Supplements: Medwatch
The FDA’s Medwatch system can be used to report possible adverse reactions to dietary supplements

32. Examples of FDA Warnings
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

33. Examples of FDA Warnings
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

35. Dietary Supplement and Nonprescription Drug Consumer Protection Act 12/06
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.

36. Cautions Regarding Dietary Supplements
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.

37. Read the Dietary Supplement Label and Verify….
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

38. Read the Dietary Supplement Label and Verify….
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

39. Evaluating Dietary Supplements
Obtain unbiased evaluative information from resources like Supplement Watch and Consumer Lab
Encourage patients to purchase supplements from well-known manufacturers

40. 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
Released 1/2007

41. ConsumerLab Study of 20 Multivitamins
Vitamins that passed:
Centrum Silver
Member's Mark Complete Multi
One A Day Women's
Flintstones Complete
January, 2007

42. Tips for Picking a Multivitamin from CSPI
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.
Center for Science in the Public Interest accessed at 1/07

43. 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

44. CAM Providers: MDs/DOs
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

45. CAM Providers: RDs
Nutrition in Complementary Care DPG, a subunit of the American Dietetic Association
Some RDs are incorporating counseling about CAM into their practices

46. CAM Providers: Other RNs RPh ND: naturopath provider DC: chiropractor
OMD: oriental medical doctor
Accupuncturist
Massage Therapist
Hypnotherapist
Herbalist

47. Tips for Patients: Evaluating CAM Providers
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

53. Trends in Use of CAM by US Adults 1997-2002
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: Alternative Therapies in Health and Medicine; 1; 1: 2005.

54. Trends in Use of CAM by US Adults 1997-2002
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%)

55. Commonly Used Botanicals
Echinacea
Garlic
Ginger
Gingko biloba
Ginseng
Hawthorn
Milk thistle
Saw palmetto
St. John’s wort
Valerian

56. Echinacea Source: Purple cornflower
Indication: Stop or moderate colds or flu
Action: Macrophages and their secretions
Cautions: Avoid if immune system is hampered and do not use continually

57. Garlic Source: Garlic plant
Indication: Lower serum cholesterol and triglycerides
Action: Chewing or crushing activates several sulfur- containing compounds
Cautions: Allergies, GI symptoms, interaction with anticoagulant drugs

58. Ginger Source: Root of ginger plant
Indication: For nausea and vomiting of pregnancy and motion sickness; anti-inflammatory
Action: Volatile oils in the rhizome, called gingerols; may act on serotonin receptors in the ileum
Cautions: Interaction with anti- coagulant, antihypertensive, glucose-lowering drugs

59. Gingko Biloba Source: Gingko tree
Indication: Improved blood circulation; used to treat age-related mental function decline r/t cerebrovascular insufficiency
Action: Flavone glycosides have antioxidant effect, inhibit platelet aggregation
Cautions: Class 2d botanical; may potentiate MAO inhibitors; GI complaints, headache, allergy

60. Ginseng Source: Ginseng plant (radish-like herb) root
Indication: General improvement from the steroidlike components
Action: Ginsenosides, enhanced immune function; studies mixed
Cautions: Class 2d botanicals; contraindicated in persons with hypertension; overstimulation, GI distress

61. Hawthorn Source: 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

62. Saw Palmetto Source: Palm tree Indication: Reduce incidence of BPH
Action: Action unclear; research results mixed
Cautions: Contains phytoestrogens, could interfere with estrogen therapy, oral contraceptives, other phytohormone- containing herbs

63. St. John’s Wort Source: Perennial herb
Indication: Mild to moderate depression
Action: Hypericin and hyperforin in flowering tops; reuptake of neurotransmitters
Cautions: Rated as 2d botanical; may potentiate pharmaceutical MAOIs; interact with other antidepressives; photosensitivity

64. Valerian Source: Perennial herb; active element in roots and rhizomes
Indication: Minor tranquilizer and sleep aid; fewer side effects than medications
Action: Volatile oils (bornyl acetate and valerenic acid) mode of action GABA binding
Cautions: Class 1 botanical; abrupt withdrawal may precipitate symptoms

65. Milk Thistle
Source: Herb in daisy family; seeds are highest in silymarin
Indication: Hepatoprotective; used to treat liver damage in cirrhosis, hepatitis, fatty infiltration
Action: Silymarin stimulates protein synthesis, antioxidant; shown to be moderately effective
Cautions: Class 1 botanical; mild laxative effect; allergies

66. Working with Clients who Use CAM
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

67. For Each Supplement
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

68. For Each Supplement
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

69. For Each Supplement
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

70. Working with Clients Who Use CAM
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

71. Links for Integrative Medicine Information
Intellihealth Index of Herbal Medicines and Supplements
Herb Med: An interactive electronic herb database.
Rosenthal Center Botanical Medicine Information Resources (Columbia University)
National Institutes of Health National Center for Complementary and Alternative Therapy

72. Summary Identify use of herbs and botanicals.
Monitor for side effects.
Document for records.
Discuss with physician.