Pulse Wave Analysis Predicts Heart Attack Risk

Transcription

Circulation: 80,000
primary care MDs, DOs,
NDs, NMDs and DCs
Vol. 10, No. 2
•
News
for
H e a lt H & H e a l i N g ®
cardiovascular
Digital Pulse Wave
Analysis Offers NonInvasive Early Heart
Risk Assessment
•
Summer 2009
Inside
nutrition &
lifestyle
The Energetics of Foods
for Health and Healing
p. 5
By August West
C o nt rib u t ing Wri ter
“Ages and Cycles of Nature in Ceaseless Sequence Moving.” Guidance and inspiration
for the future of integrative medicine are present in the words and images of Hildreth
Miere’s painted dome in the Great Hall of the National Academy of Sciences, site of the
Institute of Medicine’s landmark Summit on Integrative Medicine and the Public Health.
Photo by JD Talasek, National Academy of Sciences
news
Institute of Medicine’s
Summit on Integrative Medicine:
Revolution! Reform!
Reimbursement?
By Erik L. Goldman
Ed i t o r- i n - C h ief
W a s h i n g t o n , D C • There was a
lot of talk about revolution and reform at
the Institute of Medicine’s historic Summit
on Integrative Medicine and the Public Health
in February.
But there’s another “R” word, one that
will determine how any future healthcare
system functions, and what it will really
deliver. That word is “reimbursement.” And
while the IOM’s delegates were united in
their view that US health care needs a radical shift toward prevention, there was far
less consensus on how that transformation
will be financed, and who will be fiscally
empowered to provide integrated preventive health care.
Held at the ornate headquarters of the
National Academy of Sciences, the IOM
Summit convened leaders of the integrative/holistic medical movement, along with
major players from academia, healthcare
policy, the insurance industry, and the private sector. The goal? To define and clarify
what, exactly, “integrative medicine” really
is, and how it fits into public health and
reform agendas.
The meeting was sponsored by the
Bravewell Collaborative (www.bravewell.org),
a private philanthropy dedicated to furthering the evolution of integrative medicine. It
was an opportunity for some of the best
minds in the field to make the case for a
range of holistic disciplines that could
engender a culture of wellness and personal
empowerment, and help prevent or at least
delay many of the chronic diseases compromising the nation’s physical and fiscal
health.
Noble Sentiments. No Bull?
With the Obama administration’s hints at
major healthcare reform echoing through
the halls, the air was ripe with optimism
that the moment has finally arrived for a
meaningful move toward preventive medicine and greater acceptance of nutrition,
botanicals, mind-body techniques, massage, acupuncture and other non-allopathic
approaches.
“For those of us who have been working
for years to promote wellness, our time has
come,” Sen. Tom Harkin (D-IA) told the
roughly 700 delegates. He added that Pres.
Obama “gets it,” about prevention, nutrition, and the need to change the focus from
see Reimbursement p. 10
Central Aortic Systolic Pressure (CASP) is
one of the most powerful early predictors of
cardiovascular risk. New digital pulse wave
analysis technology is putting this valuable
test in the hands of prevention-focused
primary care doctors.
Safe and non-invasive, pulse wave analysis applies the principles of sonar to assess
the pliability of the vascular tree, including
the major central vessels as well as the small
peripheral vessels. Central aortic vascular
compliance—or lack thereof—is a key indicator of vascular health status.
“This is a really great test for people who
are seemingly without symptoms, but who
are about to have lots of disease,” explained
J. Joseph Prendergast, MD, director of the
Endocrine Metabolic Medical Center, Palo
Alto, CA. Dr. Prendergast is among the pioneers of pulse wave analysis, particularly as
it applies to the prevention of heart disease
among people with diabetes.
He noted that diabetics show a pattern
of atherosclerosis distinct from what one
typically sees in non-diabetic CVD. “Diabetics
get more long artery atherosclerosis, whereas
in non-diabetics, you tend to see the plaque
only in smaller branches, and at the points
where the vessels branch off.” Pulse wave
see Digital Pulse Wave p. 2
Photo: koi88
Agency: Dreamstime
women’ health
Women’s Health Research
Update: Rhubarb, Maca
Benefit Menopausal
Women
p. 7
Photo: Jbatt
Agency: Dreamstime
chronic disease
Oximation in Practice:
Clearing Acne & Related
Skin Disorders
p. 14
Photo: Courtesy of
Dr. Roby Mitchell
chronic disease
ASU & Pycnogenol Join Glucosamine on
Frontline of Natural Arthritis Therapies
By Erik L. Goldman
Edit o r- in- C h ief
S a n D i e g o • Glucosamine and chondroitin may be the best known non-pharmaceutical therapies for osteoarthritis, but they
are not the only ones.
Pycnogenol, an extract of French Maritime
Pine bark, and Avocado-Soybean Unsaponifiables (ASU), compounds extracted from soy
and avocado oils, deserve a place on the top
shelf of arthritis remedies, said Jason Theodosakis, MD, at the 6th annual Evidence-Based
Update on Natural Supplements, sponsored
by the Scripps Center for Integrative Medicine.
ASU and Pycnogenol can do what neither
glucosamine/chondroitin nor anti-arthritis
drugs can do: they can slow the destruction of
joint cartilage while improving joint function.
“These supplements work as well or better
than available drugs, have fewer side-effects,
and cost no more and often cost less,” said Dr.
Theodosakis, assistant professor of medicine,
University of Arizona.
He reminded conference attendees that
currently, “there are no true disease-modifying
drugs for osteoarthritis.” Non-steroidal antiinflammatory agents have their place, mainly
in reducing acute OA pain. But they offer little
over the long-haul, and should only be used
for short-term pain management.
ASU: Arthritis Suffering Undone
As a nutraceutical, ASU is a newcomer to the
US market, though it has been marketed for
years in France as an over-the-counter arthritis remedy called Piascledine.
There are 4 well-designed randomized
trials of 3–24 months’ duration supporting
the use of ASU for treatment of OA. Blotman
and colleagues randomized 164 patients with
hip/femoro-orbital OA to either ASU, 300 mg
see Arthritis Therapies p. 3
cardiovascular health
2
Digital Pulse Wave
cont’d from page 1
analysis opens a window into the condition
of the long vessels.
Measuring the Bounce
Arterial pulse wave analysis has been available as a research tool for about ten years,
and has just begun to enter clinical practice.
In essence, it measures reflection of pulse
waves off the walls of the aorta and the
peripheral vessels. As the pulse travels down
the aortic trunk, it hits smaller arteries and
is reflected back. This bounce-back wave
runs headlong into the oncoming pressure
wave from the subsequent heartbeat, augmenting pressure on the vessel walls.
Higher pulse reflection scores indicate
stiffer, more plaque-bound vessels, and
therefore greater imminent risk of cardiovascular events. “It’s like dropping a pingpong ball on a carpeted floor versus a hard
marble floor. The harder surface will give a
stronger bounce, while the carpet will
absorb the force.”
Dr. Prendergast said current pulse wave
analysis systems allow assessment of “all
sorts of reflections and pressure subtleties.”
But from a practical viewpoint, you really
only need to look at two key measures: the
central aortic pulse (CASP) reflection, which
shows the flexibility of the aorta and, by
extension, the major vessels, and the pulse
reflection in the small arteries. “The small
vessels can tell you about metabolic syndrome. But the bigger vessels tell you about
imminent cardiovascular risk.”
In a certain sense, pulse wave analysis is
a modern elaboration of the ancient art of
pulse diagnosis developed thousands of
years ago, and still used by practitioners of
traditional Chinese and traditional Indian
medicine. TCM and Ayurvedic practitioners
will spend considerable time evaluating the
pulses, sensing in them subtle indicators of
health or disease.
The new pulse wave technology is based
on a similar premise that the health of the
vasculature, indicated by its degree of elasticity, is a key indicator of overall physical
health. Pulse wave analysis quantifies the
signals and opens up vast new dimensions
of study in this domain.
“I Had to Re-Think Everything”
Dr. Prendergast’s interest in this field grew
out of his effort to meet his own health
challenges. Back in the 1970s, at the age
of 37, he was diagnosed with advanced
Heal Thy Practice Conference Recordings Now Available
www.holisticprimarycare.net
• N e ws f o r He a l t h & He alin g® •
Editor-in-Chief
Erik L. Goldman
Publisher
Meg Sinclair
Contributing Writers
Design
Deb Andelt
Tori Hudson, ND Susan Krieger, L.Ac, MS
Dorri Olds
Brad J. Douglass, PhD Russell Jaffe, MD
Roby Mitchell, MD
New York City
Janet Gulland
Joel Kreisberg, DC, MA Michael Traub, ND
www.DorriOlds.com
Editorial Advisory Board
Robert A. Anderson, MD
Founder, Past-President
American Board of Integrative Holistic Medicine
East Wenatchee, WA
Lev Linkner, MD
Clinical Faculty, Instructor, and Lecturer
Dept. of Family Practice
University of Michigan, Ann Arbor
Robert Alan Bonakdar, MD
Director of Pain Managemnt
Scripps Center for Integrative Medicine
La Jolla, CA
Lee Lipsenthal, MD
Immediate Past-President
American Board of Integrative Holistic Medicine
Medical Director
Lifestyle Advantage
San Anselmo, CA
Cathy Creger Rosenbaum, PharmD, MBA, RPh
Founder, CEO
Rx Integrative Solutions
Cincinnati, OH
Brian Forrest, MD
Medical Director
Access Healthcare
Apex, NC
Sanford H. Levy, MD,
Physician Advisor, Patient Management Services
Buffalo General Hospital,
Diplomate, American Board of Integrative
Holistic Medicine
Michael Traub, ND
Past President
American Association of
Naturopathic Physicians
Kailua-Kona, HI
Steve Zaeske, DC, DABCI
Incoming President
American Chiropractic Association
Council on Diagnosis & Internal Disorders
Orland Park, IL
The ideas, opinions, commentaries, and viewpoints expressed in the pages of Holistic Primary Care
do not necessarily reflect those of its Publisher. Ascending Media, L.L.C. will not assume liability for
damages, injuries, losses, or claims of any kind arising from or related to the information presented
in this publication, including claims related to products or services described herein.
Holistic Primary Care, News for Health and
Healing® is an independent newspaper covering
holistic, natural, and alternative medicine for a
circulation of approximately 80,000 practicing
primary care Medical Doctors, Naturopathic
Doctors, Doctors of Osteopathy and
Chiropractors.
Holistic Primary Care is published quarterly by
Ascending Media, L.L.C., PO Box 953, Peck Slip
Station, New York, NY 10272-0953, Tel. (212)
406-8957. Copyright © 2009, by Ascending Media,
L.L.C. All rights reserved. Material may not be
reproduced in whole or in part in any form without
written permission. Printed in the United States.
atherosclerosis, though he was asymptomatic and had fairly normal serum cholesterol.
Given that his father had a stroke at age 42,
he became worried.
Now in his 70s and quite healthy, he
reflected that “Medicine, at that time, really
had nothing for me. I had to re-think everything. I knew I couldn’t rely just on
pharmaceuticals.”
A friend and colleague, Victor Dzau,
MD, now chancellor for health affairs at
Duke University, introduced Dr. Prendergast to L-arginine, an amino acid which,
when taken supplementally, boosts
endothelial nitric oxide release. Many
researchers and clinicians believe that when
used properly, arginine improves vascular
health and reduces CV risk. It quickly
became a cornerstone not only in Dr. Prendergast’s own personal heart health regimen, but also in his treatment protocols for
patients at risk.
He began looking at pulse wave analysis
after meeting Stanford University researchers
who were exploring the emerging technology to detect early signs of Alzheimer’s
disease, diabetes and CVD. He saw in it the
potential to be a useful guide for arginine
therapy. He is currently consulting with
CardioGrade, LLC (www.cardiograde.com),
a California company focused on bringing
this emerging technology into wider clinical use.
Looking Upstream
Conventional treatment of cardiovascular
disease—a complex multi-system disorder—
is often guided by fairly simplistic measurements: serum LDL, HDL and triglyceride
levels, and blood pressure as measured by
sphygmomanometer cuff readings at the
brachial artery.
Dr. Prendergast sees brachial artery
pressure measurement as convenient but
primitive. Over-reliance on it is one reason
that anti-hypertensive therapy often fails to
prevent life-threatening CV events. “When
you put the cuff on someone’s arm, all
you’re really looking at is the download
pressure back into the hands. All it really
tells you is the condition of the vessels in
the wrist. You need to go upstream into
the central vessels.” Many drugs will lower
brachial pressure but not reduce risk.
Pulse wave devices also take readings
from the wrist, but there is no arterial occlusion as with a standard pressure cuff. “The
wave forms of the pulse tell you what’s
going on in the aorta and the other vessels,”
he said. It gives a very different type of information than standard BP measurements.
The discrepancy between the brachial
arteries and the central aortic trunk was
underscored in the Conduit Artery Function Evaluation (CAFÉ) study. Researchers
compared beta-blockers plus diuretics
versus calcium-channel blockers in hypertensive, high-risk people, and found that
while both treatments gave similar and
significant reductions in standard brachial
artery pressure, the central aortic systolic
and pulse pressures were substantially
lower in patients on calcium-channel
blockers (Williams B, et al. Circulation.
2006; 113(6): 1213–1225).
“You can get similar pressures in the arm
but very different pressures in the central
arteries, depending on what the drugs do to
the wave reflections,” explained Bryan Williams, MD, of the University of Leicester,
UK, who led the CAFÉ study. “Beta blockers
and diuretics, which we use very commonly,
while they lower blood pressure and reduce
risk, are less effective . . . in preventing the
reflected wave from coming back at the
wrong time. You get a slightly higher central
pressure with those drugs than you do with
amlodipine and perindopril.”
Dr. Williams had high praise for pulse
wave analysis, which in the CAFÉ trial
Summer 2009
was done with the Sphygmocor system
(www.atcormedical.com). “I think this type
of technology is going to be increasingly
used in clinical trials because it gives us
information that we haven’t had before. It
can be easily used and can produce very
effective results.”
A Surge of Research
Pulse wave analysis has attracted vigorous
research interest of late, with well over 50
studies published just in the last 6
months.
Investigators at Fukuoka University Hospital, Japan showed a strong correlation
between aortic augmentation index, a type
of pulse wave measurement, and severity of
atheromatous plaques in a cohort of 96
patients with paroxysmal atrial fibrillation.
High augmentation scores correlated with
age, plasma LDL, aortic stiffness scores, and
other risk indicators, leading the researchers
to conclude that this represents, “a novel
tool for determining the severity of central
aortic atheromatous lesions” (Sako H, et al.
Circ J. 2009 Apr 16; epub ahead of print).
Augmentation index and central aortic
pressure also correlates with smoking,
according to researchers at Dokkyo Medical
University, Japan. They looked at 443 otherwise healthy normotensive men, and
found that the augmentation index was
higher in current smokers compared with
never- and former-smokers. Central systolic
pressure was higher in current and former
smokers compared with lifelong non-smokers. Interestingly, brachial systolic pressure
was not significantly different among these
groups (Minami J, et al. Am J Hypertens.
2009 Mar 26; epub ahead of print).
The good news is that most aortic pressure risk indicators will normalize when
people quit smoking. A multicenter Portuguese study looking at pulse wave patterns
in 71 long-term heavy smokers showed that
after 6 months, those who quit had significant reductions in peripheral systolic pressure, augmentation index, pulse wave
velocity and other risk indicators compared
with the men who continued smoking
(Polonia J, et al. Blood Press Monit. 2009;
14(2): 69–75).
Because pulse wave analysis is noninvasive, it is an excellent office-based tool for
tracking patients’ response to treatment
over time. In Dr. Prendergast’s clinic, therapy revolves around diet and lifestyle
change, as well as intensive use of nutraceuticals like L-arginine, vitamin D, resveratrol,
and others. “People still need to change
their diets. You cannot totally over-ride a
bad diet with arginine or any other supplements,” he said.
Currently, digital pulse wave analysis systems cost roughly $10,000, said Dr. Prendergast. But he expects the prices to come
down as the technology improves and gains
in popularity. Ultimately, he hopes to see
the systems simplified for home use. “We’re
not there yet, but we’re working on it!”
Er r At um
The article, “Hormone Therapies Improve
Symptoms and Delay Progression of MS”
in the Spring 2009 edition of Holistic
Primary Care included incorrect contact
information for Katherine Simpson, the
subject of the article. Her center in Solvang,
CA, is now focused exclusively on research,
including a clinical study on endocrine
involvement in ADD/ADHD. She is not
currently affiliated with Dr. Barney Van
Valin. She is launching a clinic in Raleigh,
NC, focused on treating MS, lupus, rheumatoid arthritis, fibromyalgia, and other
chronic conditions. She can be reached at:
[email protected].
per day, or placebo, for 3 months. The active
treatment markedly reduced the percentage of
patients regularly taking NSAIDS by the close
of the study (43% versus 69.7% in the placebo
group). The ASU patients also had better functional index scores (Blotman F, et al. Rev Rheum
Engl. 1997; 64(12): 825–834).
A second trial involving 144 patients with
hip or knee OA, showed that those taking ASU
for 6 months had greater reductions in Lequesne
Functional Index (from a mean of 9.7 at baseline to 6.8) compared with those on placebo
(9.4 at baseline to 8.9 at 6 months). Pain level
and NSAID use were also reduced among the
ASU patients compared with those on placebo.
The improvement seemed to be strongest in
patients with hip versus knee arthritis. The authors
note that the symptom reduction among the ASUtreated patients persisted for as much as two months
after they stopped taking the product (Maheu E,
et al. Arthritis Rheum. 1998; 41(1): 81–91).
A study from Erasmus University Hospital, Brussels, showed similar benefits—reduced pain,
improved joint function, and reduced medication
use—in OA patients taking ASU, 300–600 mg/day
(Appelboom T, et al. Scand J Rheumatol. 2001; 30(4):
242–247). These authors found no therapeutic difference between the lower and higher dose levels.
The 300 mg dose is standard in Europe.
One of the most promising aspects of ASU is its
apparent ability to increase chondrocyte collagen
synthesis, said Dr. Theodosakis. He cited a radiographic study by Lequesne and colleagues showing
that ASU reduces the progression of joint space
loss in people with severe hip OA. This strongly
suggests a true disease-modifying effect (Lequesne
M, et al. Arthritis Rheum. 2002; 47(1): 50–58).
According to Dr. Theodosakis, ASU has anabolic and anti-catabolic effects: It increases collagen production, stimulates production of aggrecan
and TIMP-1, and increases expression of transforming growth factor-b and plasminogen activator inhibitor (PAI-1). It also suppresses TNF-a,
IL-1b, COX-2 and other inflammatory cytokines.
ASU has won the favor of the notoriously
rigorous Cochrane Collaboration, which noted
in a 2008 report that “ASU has beneficial effects
on functional index, pain, use of NSAIDs and
global evaluation,” and that “The evidence for
ASU in OA is convincing.”
It would be nice if one could obtain ASU by
eating avocado and soy, but Dr. Theodosakis
stressed that this is not possible. The unsaponifiable compounds are tightly bound to fiber within
the plant tissue, and impervious to human digestion. The only way to get ASU is via supplementation. ASU is available in the US under the brand
name, Avoca, and also in combination with glucosamine-chondroitin (Nutramax Laboratories,
www.nutramaxlabs.com). Several other companies also sell branded products. Dr. Theodosakis
sells his own private labeled brand, called AvoSoy, via his website (www.drtheo.com).
Take a Load Off, Fannie
Dr. Theodosakis said that both pycnogenol and
ASU have a rightful place alongside the betterknown glucosamine-chondroitin and omega-3
fatty acids for treatment of OA. But he also
stressed that neither supplements nor drugs
alone make for a complete therapeutic plan.
Long-term OA care needs to be grounded in
nutrition-based strategies to reduce inflammation, rebuild cartilage, facilitate weight loss, and
improve overall health. “Non-pharmacologic
approaches should be your first line.”
Encourage patients to adopt a vegetable-rich
Mediterranean diet that will provide plenty of
anti-inflammatory phytochemicals that attenuate inflammation. The Mediterranean dietary
pattern is also low in trans-fats, omega-6 fatty
acids, and refined carbohydrates, all of which
drive inflammation.
Anything you can do to safely help overweight patients lose weight will also help reduce
OA symptom burden. The direct mechanical
impact of excess pounds on the weight-bearing
joints is pretty obvious. Less apparent but no
less damaging is the fact that adipose tissue
secretes a lot of inflammatory cytokines that
stoke the osteoarthritic disease process.
“Fat is an endocrine organ. To be sure, obese
people break down weight-bearing cartilage, but
they also lose cartilage in the finger joints and
other non-weight bearing joints, and this is due
to the excess inflammation,” Dr. Theodosakis
explained.
A systematic review of 35 trials (including 4
randomized controlled studies) on the impact
of weight loss on OA showed that a weight
reduction of 6 kg produces a pooled effect size
of 0.20 for reduction in pain and a pooled effect
size of 0.23 for reduction in disability (Christensen et al. Ann Rheumatic Dis. 2007; 56: 433–
439). These effects are small, but when viewed
in light of the many other benefits of weight
loss, they should not be discounted.
Wisdom
The
of
Wobenzym
®
Systemic Enzyme Support
for balanced immune function.
Be certain you receive
the authentic formula.
Immune System Balance
Bark Takes Bite Out of OA Pain
Since cytokines are involved in the function of the immune system, the binding
to cytokines and the removal of cytokines by the activated α-2- macroglobulin
proteins can help support a balanced and properly functioning immune system.†
Manufactured for: MUCOS
Pharma GmbH, made in Berlin,
Germany. Distributed by: Douglas
Laboratories®, Pittsburgh, USA.
The Authentic Wobenzym® N formula is proudly presented to you by Mucos, LLC. By providing
“Systemic Enzyme Support,” Wobenzym® N assists the body’s immune, regulatory and communication systems.
Counterfeit products have previously been marketed in the U.S., but now you can purchase the authentic
formula—manufactured in Berlin, Germany—directly from the exclusive distributor of Wobenzym® N in the U.S.,
Douglas Laboratories. Wobenzym® N is the leading natural solution in systemic enzymes. Enzymes support healthy
blood flow, as well as immune, joint, muscle and tendon health.† The ingredients are backed by decades of clinical
research with a positive history of use by over 100 million people worldwide. The all natural active ingredients are
safe and effective with a consumer loyalty of over 80 percent.
Trim: 7.375” x 9.875”
Pycnogenol, the standardized extract of French
Maritime Pine bark, is the other emerging star on
the OA horizon. It, too, is available as an OTC medication in Europe but sold as a nutraceutical in the
US. In fact, it is one of the most widely-researched
supplement ingredients, with documented benefits
in reducing cardiovascular disease, deep vein thrombosis, asthma and many other inflammatory conditions (visit www.holisticprimarycare.net and read,
Pycnogenol-Nattokinase Combination Prevents In-Flight
Venous Thrombosis, from our Spring 2004 edition).
Research into pycnogenol’s potential for ameliorating OA began several years ago. In a 3-way international collaboration between the Arizona College
of Public Health, the University of Munster, Germany, and the Ghaem General Hospital, Mashhad,
Iran, researchers showed that OA patients treated
with 50 mg of pycnogenol, thrice daily for three
months showed marked improvements in WOMAC
scores, especially for pain and physical function by
90 days, compared with those taking placebo.
Pain scores dropped by 43% and stiffness by
35%, with a 52% overall improvement in function
(Farid R, et al. Nutr Res. 2007; 27(11): 692–697).
A subsequent study of 100 OA patients randomized to either 150 mg pycnogenol per day
or placebo, showed a 40% reduction in both
pain and joint stiffness in the active-treatment
group, and a 22% increase in physical function
compared with those on placebo (Cisar P, et al.
Phytother Res. 2008; 22(8): 1087–1092).
www.douglaslabs.com
Call us today at 1-888-DOUGLAB (1-888-368-4522) or 1-800-245-4440.
600 Boyce Road • Pittsburgh, PA 15205, U.S.A.
Available to healthcare professionals exclusively through Douglas Laboratories ®
† These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.
1436 DL Woben_Dr_HPC_Winter_v1.indd 1
Pub: Holistic Primary Care - Jr. Standard Page
There is also evidence that pycnogenol can
induce substantial reductions in c-reactive protein among OA patients, at a dose of 100 mg
per day, versus placebo This finding underscores the anti-inflammatory properties of the
compound. In this study of 156 patients, there
was a concomitant 55% reduction in pain and
53% reduction in stiffness (Belcaro G, et al.
Redox Rep. 2008; 13(6): 271–276).
Pycnogenol is manufactured by Horphag, a
Swiss botanical ingredient manufacturer with
a strong commitment to clinical research
(www.pycnogenol.com/health).
3
Kröme Media Code: DL_Woben_Dr_HPC_Winter_v1
Arthritis Therapies
chronic disease
www.wobenzym-usa.com
10/21/08 4:42:25 PM
Bleed: none
Summer 2009
practice development
4
From “Clinical Facility” to “Garden of Healing”:
Creating a Healing Environment for Your Patients
By Deb Andelt
C o n tri b u ti n g Wr it er
Once there were three bricklayers. Each one of
them was asked what he was doing. The first
man answered gruffly, “I’m laying bricks.’” The
second man replied, “I’m putting up a wall.” The
third man said enthusiastically and with pride,
“I’m building a cathedral.”
—Unknown
In many ways, it is not so much what we do, but
the vision and attitude we bring to what we do
that makes the biggest difference in the quality
of our lives and our experiences.
To the cathedral builder in this little parable,
each brick is more than just a brick; it is an element, an aspect of a larger experience—in this
case, the cathedral experience. Change the color,
texture, size or position of the brick and the
cathedral will be different. He pays attention to
each brick, knowing it matters.
Creating a medical practice is no different. Each
aspect of a practice, each “brick,” really matters. The
awareness with which each person engages in his
or her role has an impact. And, the resulting experience is far more than the sum of its parts—for your
patients, for your staff, and also for you.
Medical Clinic or Temple of Healing?
In your practice, do you feel like you’re laying
bricks, or like you’re creating a sacred healing
space? If you’re one of the 60% of doctors who
say they would not recommend medicine as a
career, you probably feel like an indentured servant laying bricks. It doesn’t have to be that way.
The key to creating an effective patient experience is to hold a vision that reaches below the
surface. Neuroscience tells us that we absorb
about 20 million bits of data per second, yet we
are only conscious of 11 bits; 95% of what we
take in is processed below conscious awareness.
To give patients a nurturing, healing experience,
we need to create nurturing, compassionate
input below their conscious radar.
As Bruce Lipton, PhD, author of The Biology
of Belief says: “It’s the environment, stupid.” Our
environment shapes our beliefs and our beliefs
influence our biology. Our cells are programmable, downloading information from the environment. All this information creates our belief
effects. Change the environment and you change
the experience. Change the experience, and you
change beliefs and biology.
According to Dr. Lipton, the “treatment” is
only a small part of what a patient receives in a
medical encounter. From this perspective, it can
be interesting to ask yourself what, besides specific medical treatments, is your practice delivering, and how are these not-so-obvious factors
delivered?
Don’t Do More, Do Differently
Here’s the thing: you’re already creating a
patient experience, whether it is consciously
planned, haphazard, or simply the result of
habit. Every decision, action, and attitude from
you and your staff influences your patients,
sending messages to them, below their conscious awareness.
Creating an experience with intention isn’t
something extra to add to an already overbooked day. It’s about engaging in what you’re
doing with a new vision—a vision of creating a
healing garden, a temple of healing.
A patient experience, or really any experience,
is a combination of people (attitudes and actions),
processes (how things work), and the sensory
environment. The goal is to design and align all
three to create and reinforce a common vision.
Humans always respond to all situations
emotionally first. The rational mind doesn’t
catch up until six seconds later. No wonder we
are stumped when people don’t seem to act
rationally. “Rational” satisfaction isn’t the determining factor in our behavior: what matters is
how we feel. Value and quality are in the hearts
of the patients, determined by how they feel.
The Emotional Target
Start by determining how patients want to feel
when they are at your clinic. Diving into research
about healing, we uncover five core feelings that
support healing: feeling comfortable, understood, connected, strengthened and renewed.
The positive feelings you opt to focus on
(hopefully with some input from staff, patients
or both) become your “North Star” for everything you do. Awareness of these feelings will
now guide the decisions, actions and attitudes of
yourself and your staff. This is what infuses new
meaning into everyday actions, so you’re building a cathedral, not just laying bricks.
Let’s explore “feeling comfortable.” If you’re
aiming to create a sense of comfort for patients,
here are a few examples of how everyday things take
on new meaning, and changes naturally evolve:
• Look at your intake paperwork process through
the eyes of the patient. Is there a physically
comfortable place for patients to complete the
intake forms? Are the questions worded in a
way that people feel emotionally comfortable
providing all the information you need to be
an effective clinician? Is your paperwork so
long that patients get bored or overloaded? A
tell-tale sign is a tendency toward clipped, less
thoughtful answers toward the end.
• When you’re buying facial tissue, do you
select the less-expensive scratchy kind or the
cushy 3-ply version? Knowing you’re aiming
for comfort makes this an easy decision. Yes,
even the tissues are sending a message.
• When you’re examining a patient lying on the
table, do you find yourself making suggestions about things for him/her to do at home?
Many doctors do. But it’s actually not very
helpful. Why? Because it obliges the patient
to try and remember what you said and make
a note of it later. Further, patients pay more
heed to things you tell them when they’re sitting up, face to face with you. Something said
casually when they’re lying down does not
register as important.
Discuss what “comfortable” means with your
entire staff. Consider the physical, mental, emotional and spiritual components of comfort.
Take time to focus on one aspect of what happens in the office, and try to identify when
patients don’t seem comfortable, and when they
do. Brainstorm about what can be done differently. Together, you’ll find numerous ways to
make small changes. It always helps to ask your
patients for input!
Use the same process to look at the other core
feelings that engender healing (i.e., feeling understood, strengthened, connected & renewed).
Metaphor & Medicine
This article began with a metaphor: bricklayers
building cathedrals. Words alone rarely capture the
meaning of what we’re experiencing or thinking, so
we turn to metaphors. By understanding the deep
metaphors associated with healing and aligning
your experience to support them, patients feel that
you understand their needs.
One of the metaphors for wellness is movement. Even OnStar®, GM’s car security system,
uses this, with its, “Can you move?” line. We typically consider movement to be physical, but it can
also be emotional, mental or spiritual. For a
patient, moving from the “unknown” to the
“known” (or vice versa) is a big movement, though
much of it may seem routine to you as a practitioner. By recognizing that people move through a
range of emotions that come up around illness,
Summer 2009
you help your patients feel understood. This, in
and of its self, can be quite healing.
There are many ways to look at movement as
you work with patients:
• Perhaps you sense a patient is resistant to a
lifestyle change you’re suggesting. Talk about
what that movement means to them. Maybe
they naturally move in small steps. If you tailor your communication to create comfort for
each patient, you can work together to find a
way to “move” toward new habits.
• Journaling is a great tool to help patients
identify their own movement patterns, and
to bring what’s happening to their conscious awareness. Are they having Oprah
“ah ha” moments? This is movement. Did
they feel something different today, than
yesterday? This is movement. Do they have
a new lens to put perspective on their lives
and their health challenges? This is HUGE
movement. Whenever these steps occur for
a given patient, take a moment to acknowledge and celebrate that with them. It’s very
important.
• Some patients will appreciate getting an outline of what will be done during an appointment, test process, or treatment—especially if
it is a fairly complex multi-step process. In a
sense, you’re tracing out the steps of the
movement of that appointment. You can
then use this to show the patient where s/he
is at any point along the way, and what can
be expected at each step.
Over the next week, look for movement in all
you do. Notice what happens as you stand in line
in the grocery store or how your child quickly
moves through a range of emotions. You’ll start
seeing movement and lack of movement in many
places. It will give you ideas you can put to good
use in your clinic.
What Are You Really Doing?
Just as your patients are on a healing journey,
you and your entire staff are also on a journey to
create the optimal patient experience. Nothing
has to be set in stone. The “bricks” that make up
your clinic experience can be shaped, painted
and moved. You can evolve and adjust things as
you get feedback from your patients, and as you
observe how things work.
Creating an environment that communicates compassion, support, and empowerment
is about aligning the many aspects of the patient
experience with those goals—especially the
subtle aspects of the environment that register
below patients’ conscious awareness.
Transformation (that’s another healing metaphor) comes when we have a new view of ourselves, and our roles in life. Is the person at your
front desk just answering the phone and handing out forms or offering warmth and comfort
to someone who is harried, anxious and fearful? Is your office manager merely administering the practice or setting the stage for healing
encounters? Are you “providing” treatments,
or facilitating the miracle of healing and
transformation?
Ideally, you want everyone in your office,
regardless of their specific tasks to respond
with, “I’m helping people heal,” when someone asks, “So, what do you do?”
If you set this as your goal, and work diligently but joyfully toward it, your patients
will feel the difference, and your practice will
benefit, both clinically and fiscally. Happy
patients refer their family and friends. They’ll
return when necessary, and they will actively
demonstrate their appreciation.
Deb Andelt is co-founder of Experience In Motion,
a customer experience tools company based in
Scottsdale, AZ. She is the author and co-creator of
The Toolkit to Empower Healing and the associated
workshop: Creating Healing Experiences That
Work, filled with tools for practitioners to equip each
person to be an agent of healing. Her personal experiences with practitioners on her own healing journey from decay to vitality provides her with a
unique understanding that it’s more than the
“treatment,” it’s the total experience that matters.
[email protected], (480) 945-7035
nutrition & lifestyle
Summer 2009
5
The Energetics of Foods for Health and Healing
By Susan Krieger, LAc, MS
C o n t ri b u ti ng Wr it er
Traditional Chinese Medicine (TCM) has much
to teach us about how food influences health. The
language of TCM may sound more like poetry
than science, but is grounded in careful observation of human function and detailed study of the
plants and animals that make up our diets.
The lens of biomedical science has reduced
foods to aggregations of calories, vitamins,
minerals, fats and other micronutrients, and
this view governs how most of us think about
nutrition. Blueberries are “good” because they
have anthocyanidins. Soy is “healthy” because it
contains isoflavones. Fish are vehicles for giving
us omega-3s. There are dozens of diets calling
for people to eat more of this or that food,
because it contains this or that nutrient.
The idea that foods are nothing more than the
sum of their biochemical parts has contributed to
our culture’s near-obsession with calorie counting, fat-finding, and nutrient content measurement. At one extreme, people are so overwhelmed
or so lacking in education that they don’t pay
attention to the health value of their food at all;
at the other extreme, people worry constantly
about the amount of fiber in their diet, or whether
they’re getting the right omega-3 to omega-6
ratio, or whether they should drink more wine to
get more resveratrol.
It is important to be mindful of the nutrient
content of what we eat, and it is great when we
can apply the knowledge of biochemistry to
understand how foods influence health. But there
is another approach, an ancient way of looking at
foods qualitatively in terms of their “energies”
and healing properties that can balance the reductionistic view.
The Nei Jing Classic of Internal Medicine (aka,
the Inner Canon of Huangdi or the Yellow Emperor’s
Inner Canon) compiled over 2,000 years ago, may
be the first known Chinese writings on the
dynamic relationship between health and food.
Like other traditional systems from around the
world, TCM posits that we humans are intricately
connected with and are fundamentally part of
nature, and that our individual health is a reflection of the care we give to our environment, to
others, and to our earth—an expanding spiral of
inter-connections.
Yin, Yang, Qi, Shen
The TCM approach to nutrition is a rich, nuanced
combination of art and science that takes years of
study and practice. But if you get a grasp of a few
basic concepts, you can really open the door to a
new way of looking at food and counseling your
patients.
In Asian Medicine, Yin and Yang are the two
complementary yet antagonistic forces or principles that make up all aspects and phenomena of
life. Yin describes all that is earthy, feminine, dark,
wet, cool, passive, receptive and absorbing; Yang
describes that which is “heavenly” or celestial,
masculine, bright, active, expansive, dry, hot, and
penetrating. Together they express the interdependence of opposites.
In relation to diet, fruits and vegetables are
more Yin compared to meats and dairy foods
which are considered more Yang. The balance of
Yin and Yang in one’s body and environment is
essential to one’s health.
Qi (pronounced “chi”) is another core concept, used to mean the circulation of energy in
the body-mind that gives rise to our vitality.
TCM identifies what is called our “pre-natal Qi,”
as the baseline constitution with which we are
born, and “post-natal Qi,” as the energy our
systems are constantly creating to maintain our
present physiologic state. In a sense, pre-natal
Qi is our “nature” while the quality and vitality
of post-natal Qi corresponds to “nurture,” and
is highly dependent on our ability to digest
and transform food.
When a Chinese medicine practitioner
speaks of “stagnant Qi,” it refers to situations
in which the Qi that nourishes a specific organ,
muscle, body part, or meridian is being blocked
and not flowing smoothly. In TCM, health is
all about smooth and harmonious flow of Qi
within and between the systems that comprise
a human being.
Two other important classical Chinese medical concepts are: Jing, a person’s core essence,
which, when strong gives potential for longevity;
and Shen, often defined as “spirit,” and thought
to represent the synergy of emotional, mental
and physical health. Shen is sometimes referred
to as “Heart/Mind.”
Location & Season
The idea of “eating locally” has had a lot of
buzz recently. But it is really nothing new.
Asian dietary philosophies have long suggested
that we embrace, as much as is possible, native
foods locally grown, and eat what is in season.
When we over-consume food imported from
very different climates or regions, we may lose
adaptability to our immediate surroundings.
This is especially true when someone living in
a temperate or cold climate eats a lot of tropical or semitropical foods.
The point is that patterns of illness, according
to TCM, are linked to seasonal climatic changes.
For example, disorders of “Wind invasion”
often come in the Spring, manifesting in stiff
neck, headaches, or the symptom patterns
Western medicine classifies as “colds and flu.”
Heat-related symptoms such as heat stroke and
overexertion occur in Summer.
“Damp,” phlegm-related symptoms arise
in late Summer, manifesting as colds, mucus
in the chest, sluggish digestion and sinus
problems. Symptoms related to “Dryness”
occur in Autumn causing dry skin, dry cough,
and difficulty eliminating from the colon.
“Cold” syndromes in Winter show up as stiff-
ness in the back and lower back, constipation,
and difficulty in keeping warm.
A core principle of TCM-based nutrition is
that one should eat to optimize the body’s adaptability to these seasonal changes. For example, in
Spring and Summer, when physical activity tends
to increase, Yang Qi flows outwards to the body’s
surface, and a person’s internal Yang Qi may
become depleted, thus requiring replenishment
in the warm weather. At the same time, it is good
to increase consumption of cooling Yin foods.
In the colder and dryer climates of Fall and
Winter, it is important to keep warmer and
prevent dryness, and we want to eat foods for
nourishing Yang and warmth, building Yin,
dispelling mucus and phlegm, and enhancing
building the circulation of Qi energy, blood
and bodily fluids for the present and coming
seasons.
Health imbalances can result from the overconsumption of heavy animal-based foods in
warm climates, since this quality of food is more
suited to the colder regions. On the other hand,
not having enough of these kinds of foods in cold
climates can also be detrimental.
Taste & Cooking Style
In Chinese nutritional practice, the primary
taste of a food is an essential aspect of its nutritional content. This is because the specific tastes
send signals through the energy meridians—
specific pathways of Qi in the body related to
corresponding organs.
Sweet foods, which nourish the spleen and
stomach, include: grains, millet, squashes, onions,
sweet fruits, bananas, blueberries, oranges, figs,
dates, honey, molasses, barley malt. Ideally, these
are prepared by steaming, boiling, or Nishimistyle—a Japanese/macrobiotic slow-cooking
method done over a low heat. (See recipe on
page 6 for “waterless” vegetable stew.)
Sour foods, which nourish the liver and gallbladder, include: tomatoes, barley, vinegar, green
apples, lemons, grapefruit, and other sour fruits.
These are best prepared by pickling, steaming,
see Foods for Health p. 6
The leader in
neurotransmitter Testing
& nutritional Solutions
Have you tried
neurotransmitter testing?
Insurance Submittable
Objective Patient Management
Guides Therapeutic Decisions
888-342-7272 • www.neurorelief.com
Improving Health Through The Nervous System
MenTIOn aD CODe HOLI509 fOr a COMPlIMenTary neurOTranSMITTer TeST PrOfIle.
6
nutrition & lifestyle
Foods for Healing
and in pressed salads. A pressed salad is made by
layering very thinly cut vegetables (e.g., Chinese
cabbage, daikon root, onion, leek) either in a
“pickle press” or in a fairly deep dish, adding in a
little pinch of sea salt and rice vinegar (optional)
with each layering. Then put a second dish containing a heavy object over the contents thus
pressing the veggies down.
After an hour or up to 3–4 hours, you will
have a lot of excess water, which should be poured
off. What you have now is a pressed salad, which
has digestive enzymes from this partial pickling
method. It is recommended to have a small portion accompanying a meal while savoring the
fragrance and taste of the salad.
Pungent foods include onions, garlic, ginger,
daikon, peppers, cayenne and other sharp, spicy
foods. They are thought to nourish the lungs and
large intestines. Optimal cooking methods
include sauté, pressure-cooking and Kinpira, a
Japanese method similar to braising. (See accompanying recipe for Kinpira burdock root.)
Bitter foods nourish the heart and small intestine, and include kale, lettuce, dandelion, broccoli, arugula, endive, collard greens, and most
other leafy greens. These are best eaten raw,
pressed, stir fried or blanched.
Salty foods like fish, miso, eggs, burdock root,
sea vegetables (wakame, arame, hiziki, kombu,
kelp), tofu and aduki beans (even though they are
not salty) are thought to nourish the kidneys and
bladder. These are best prepared via stewing, frying, or Nabe-style (cooked in a ceramic pot, prepared at the table).
Generally, in colder seasons one should lean
toward longer cooking times and more salt. In
warmer weather, lighter cooking methods and
less salt is healthier. Steaming, poaching and
blanching-boiling help alter the nature of the
food for more of a Yin-cooling effect. At the other
end of the spectrum, deep-frying, stir frying and
roasting and pressure cooking alter foods for
more Yang-heating and body insulation effect.
Color and Signature
In TCM practice, the color of a food plays a role
in its function. TCM also adheres to the doctrine
of signatures: the idea that there is a synergy
between the appearance of a food and the organs
or parts of the body.
For example, red foods like apples and red
peppers, which somewhat resemble a human
heart in shape, are thought to nourish the heart,
as well as the small intestine. The apple also nourishes the spleen because of its sweet taste, and the
kidneys when it is baked and lightly salted.
A carrot, when sliced cross-wise, resembles an
eye and is thought to be nourishing to the eyes.
Lotus root, pale in color and containing many
hollow tubular passages, somewhat resembles the
lungs and bronchi and in TCM nutritional theory
it is thought to nourish the lungs.
A bitter green vegetable like kale will nourish
the heart because of its bitter taste; will also nourish the liver because of its green color, and the
kidney and the bones, because of its rich
minerals.
Recognizing Individual Needs
There are a few general principles that apply to
everybody: eat in moderation, eat what is in season, cook for optimal nutritional value and great
taste, eat mindfully and enjoy meals with appreciation. But TCM recognizes that every individual
is unique, and that nutritional needs change over
time.
A good nutritional evaluation takes into consideration a person’s present physical, mental,
emotional and spiritual status, his or her baseline
constitution, the current and the upcoming season; present dietary habits; social environment;
personal desires; and the individual’s health condition and goals.
Like any other knowledge base, TCM describes
many “textbook” patterns of imbalance. At the
same time it admonishes us constantly to realize
that in the real world, we are rarely dealing with
pure patterns of imbalance that fit into neat pack-
Summer 2009
ages. There is no “one-size-fits-all” approach to
nutrition!
By taking into consideration how our health
is affected by qualities and properties of various
foods, as well as the methods by which they’re
prepared, we can learn new ways to apply nutrition in clinical practice. This approach adds color
and flavor and makes healthy-eating a joy, rather
than a worry-ridden chore full of calorie-counting
and fretting over package labels.
Susan Krieger, LAc, MS, is a Diplomate of the
NCCAOM in Acupuncture, and Shiatsu-Asian Bodywork Therapy. In addition to her thriving oriental
medicine practice in New York City, she is an internationally acclaimed teacher and counselor specializing in Chinese Medicine, the Energetics of Foods,
Medicinal Remedies, Contemporary-Integrative
Macrobiotics, Whole Health Nutrition, Women’s
Health, Qi-Gong-Yoga, Ki-Shiatsu-Acupressure, and
Meridian-Self Shiatsu. For her treatments, classes,
lectures and her Ki-Shiatsu Instructional DVD she
draws on more than 30 years of clinical experience.
Reach Susan at [email protected] or (212)
242-4217; www.susankriegerhealth.com
Nishimi & Kinpira:
Cooking for Health
Nishimi “Waterless” Vegetable Stew
This is a warming dish—strengthens the
Spleen, Stomach, Intestines.
Nishimi is restorative in times of fatigue &
low vitality; it also strengthens digestion.
Use organically-grown vegetables whenever
possible.
Kombu or Hiziki Sea Vegetable
1 Burdock Root (scrubbed but not peeled)
2–3 Carrots (scrubbed, not peeled)
1 Winter Squash
1–2 Onions
1 Head of Broccoli
Miso (fermented soybean paste) or
Soy Sauce
Cut all veggies into large pieces.
In a pot, boil approx. 1'' of water, layer the
vegetables in the order listed above lower the
heat and cook for 30–45 min. Do not stir.
Add a bit of miso or soy sauce near the end
for flavor and digestive enzymes. Tofu,
“Snow” tofu (i.e., dried, frozen tofu) or Tempeh can be added halfway through the cooking, if you desire more protein.
When Nishimi is finished there should be
almost no water in the pot.
Kinpira Burdock
1 Burdock Root (scrubbed, not peeled)
1 Tablespoon Olive or Sesame Oil
1 Tablespoon Mirin (sweet Japanese rice
wine) (optional) or 1 Tablespoon Barley
Malt
1/2 tablespoon Organic Miso
3 Tablespoons Water
3 Tablespoons Ground Toasted Sesame
Seeds
2 Scallions or 1/3 Bunch of Watercress
Cut the Burdock into thin matchstick-sized
pieces. Soak the matchsticks in water until
you’re ready to cook them.
Heat the oil in a pot until hot. Saute the burdock for a few minutes. Add the mirin or barley malt and stir. Add the miso and water,
stirring until the miso is dissolved. Cover, turn
down the heat, and simmer for a few more
minutes. If you want the burdock to be soft,
cook it for 5–10 minutes. When it’s cooked,
add the ground toasted sesame seeds, scallions or watercress and stir before serving.
To toast sesame seeds, add them to a pan
on low heat stirring the seeds with a wooden
spoon, moving them at all times. They will
smell like sesame when it’s done. To grind
use a spice grinder, a pepper mill, a food
processor, or you can grind the traditional
way by using a mortar and pestle.
women’s health
Summer 2009
7
Women’s Health Research Update:
Rhubarb, Maca Benefit Menopausal Women
By Tori Hudson, ND
C o n tri b u ti ng Wr it er
Several recent studies indicate that an extract
of a specific form of rhubarb are highly effective in improving menopausal symptoms.
A standardized extract of the root of Rheum
rhaponticum (Rhapontic or Sibiric rhubarb),
known as ERr 731, has been used widely in
Germany since 1993, for treating menopause
symptoms. This species does not contain
anthraquinone galactosides, which give other
speces of rhubarb their laxative effects. ERr 731
is available as Phytoestrol N, made by the Mueller-Goeppingen pharmaceutical company,
Germany (www.mueller-goeppingen.de).
Researchers at the University of Frankfurt
undertook an observational study of 363 symptomatic menopausal women, who took 1 ERr
tablet (4 mg R. rhaponticum extract) daily for 6
months. They used the Menopause Rating Scale
(MRS) to evaluate symptoms, and a change in
the MRS was the primary outcome measure.
A total of 252 women seen at 70 gynecology practices completed the study. There was a
significant decrease in the total MRS score
from an average of 14.7 points at baseline to
6.9 points at the end of the 6 months of rhubarb treatment (P < .0001). This was a very
substantial decrease of 7.8 points.
The most pronounced improvement was
within the first 3 months of treatment, and in
women who were the most symptomatic at
baseline (those who had MRS scores > 18
points). Symptom improvement was greatest
for hot flashes, irritability, sleep problems,
depressive mood, and physical/mental
exhaustion (Kaszkin-Bettag M, et al. Altern
Ther Health Med. 2008; 14(6): 32–38).
These encouraging findings prompted a
just-published controlled study of ERr 731, in
which 112 women were randomized to daily
treatment with the rhubarb extract or placebo
for 12 weeks.
Those taking ERr 731 showed a highly
significant reduction of MRS total score, from
27.0 points to 12.4 points. In contrast, the
placebo group showed a far smaller decrease,
from 27 to 24 points (P < .0001). The rhubarb
extract also produced significant reductions in
the hot flush weekly weighted score, while the
placebo did not (Kaszkin-Bettag M, et al. Altern
Ther Health Med. 2009; 15(1): 24–34).
Five women in the rhubarb group reported a
total of 11 minor adverse effects, versus 3 placebotreated women reporting 3 AE’s. Overall, ERr 731
was well tolerated by the majority of patients, and
clearly effective in reducing symptoms.
The Frankfurt studies echo an earlier trial
involving 109 women randomized to placebo
or 250 mg ERr 731 daily for 12 weeks. The MRS
II composite score and each specific symptom
score decreased significantly in the rhubarb
extract group compared to the placebo group
(P < 0.0001). The overall quality of life score
was also significantly better in the treatment
group compared with placebo. There were no
adverse events associated with the rhubarb
extract (Heger M, et al. Menopause. 2006; 13(5):
744–759).
We now have three solid studies demonstrating that this standardized extract of R. rhaponticum is an effective treatment for common
menopause symptoms. I look forward to incorporating ERr 731 into my practice.
BROUGHT TO YOU
BY THE MAKERS OF
Maca: Manly, Yes, But Women Like It Too
Maca, a tuberous root vegetable grown in the
high Andes mountains, and widely promoted for
enhancing male vitality and sexual health, also
has benefits for post-menopausal women, according to a recent placebo-controlled study.
This double-blind crossover trial involved 14
post-menopausal women who took 3.5 gm of
powdered Maca (Lepidium meyenii) for 6 weeks
and then a matching placebo for 6 more weeks.
The investigators at the University of Victoria, St.
Albans, Australia, measured estradiol, folliclestimulating hormone (FSH), luteinizing hormone (LH), and sex hormone binding globulin
(SHBG) at baseline, and weeks 6 and 12. They
also assessed severity of menopausal symptoms
using the Greene Climacteric Scale (GCS).
There were no differences in serum concentrations of estradiol, FSH, LH and SHBG following
either the maca treatment period or the placebo
period. However, the GCS scores revealed a significant reduction in psychological symptoms
including anxiety, depression and sexual dysfunction after maca consumption compared with
baseline and placebo.
These findings were independent of any
androgenic or alpha-estrogenic effects of maca,
based on assays to measure hormone-dependent activity (Brooks N, et al. Menopause. 2008;
15(6): 1157–1162).
This new study adds to the growing body
of evidence supporting the use of maca for
menopause-related symptoms. Anything that
has significant effects on menopause-related
anxiety and depression is welcome, and many
women will be pleased to know of this herb’s
significant reduction in sexual dysfunction.
It is interesting that the effects observed in this
study appear to be independent of any measurable influence on sex hormones or SHBG, and
presumably, independent of any action related
to the beta-sitosterol found in the maca root.
These findings diverge somewhat from those
reported by Meissner et al., who found an elevation in LH and estradiol and a decrease in FSH in
women taking maca daily (Meissner H, et al. Int
J Biomed Sci. 2005; 1: 33–45). However, Meissner
and colleagues were using a slightly different type
of maca (L. peruvianum, not L. meyenii), and in a
gelatinized preparation rather than as a powder.
The variation in findings between the studies may also be due to differences in dosing,
extraction protocols and delivery techniques.
The observed positive effects on depression
and anxiety are consistent in several other studies,
and some researchers have suggested that the
flavonoids in maca inhibit monoamine oxidase
activity, which could account for the benefits. The
improvement in sexual function in postmenopausal women observed in this study is consistent with research on maca use in men.
Heal Emotional Eating
Flower remedies can help manage
the urges to overeat
INTRODUCING
From Bach® Original Flower Remedies
THE EMOTIONAL EATING SUPPORT KIT
The Emotional Eating Support Kit contains three
flower remedies addressing the most common
emotional drivers of compulsive overeating.
LOSS OF CONTROL • GUILT • POOR SELF BODY IMAGE
To help your patients manage compulsive eating call for
your free sample and special offer at 1-800-319-9151
Dr. Edward Bach, a noted British physician, developed the system of 38 Bach
Original Flower Remedies, over 75 years ago. Derived from flowering plants and
trees, these all-natural, safe and gentle remedies have been used as a natural way
to lead emotionally balanced and healthy lives by millions of people in over
66 countries worldwide.
INSTITUTE OF WOMEN’S HEALTH
AND INTEGRATIVE MEDICINE
Topic: Primary Care for Women
Menopause, Neuroendocrinology,
Metabolic Syndrome, & Osteoporosis
Portland, OR • July 17–19, 2009
Program Director: Tori Hudson, N.D.
503-222-2322 [email protected]
Advanced training in women’s health, natural therapies and
integrative medicine for primary care practioners. We provide
you the opportunity to develop expert knowledge and practical
skills in women’s healthcare. We help you to integrate natural
therapies with conventional medical management.
To learn more about the Bach Original Flower Remedies and
how they fit into your practice please visit www.bachremedies.com
women’s health
8
Summer 2009
A Role for Probiotics in Preventing, Treating Bacterial Vaginosis
By Brad J. Douglass, PhD
C o n t ri b u ti n g Wr it er
Say the word “probiotic” and people think,
“gastrointestinal health.” That’s natural,
since probiotics are invaluable in the management of digestive system problems. But
they are also helpful for other health challenges, including infections of the female
urogenital tract, like bacterial vaginosis, vulvovaginal candidiasis and related
problems.
This should not come as a huge surprise.
Although the vaginal tract is not internally
connected to the alimentary canal, the two
are intimately related. Bacteria that pass
through the digestive system can ascend via
the perineum to the vagina. It’s totally reasonable to expect that what promotes GI
health would also have relevance for urogenital health.
But while the intestinal and vaginal
microbiota are similar, they are not the
same. Simply restoring and maintaining
healthy gut flora may not be enough to
ensure urogenital health.
Vaginal Microbiota: What Is It?
Healthy vaginal microbiota consists of large
numbers of lactobacilli (gram-positive rods),
small numbers of gram-negative rods, and
gram-positive coccobacilli. A milliliter of vaginal fluid contains, on average, around 100 million organisms from 5–10 species, 95% of
which are lactobacilli (Anukam KC, et al. Sex
Transm Dis. 2006; 33(1): 59–62).
Vaginal flora are surprisingly similar in
women around the globe, indicating that
these commensal relationships were established long ago and have remained robust
over time. From an evolutionary perspective, this suggests an adaptive advantage for
both the bacteria and the women: the bacteria get a warm, moist place to live; the women
gain protection against vaginal pathogens.
Microbiologists have long held that lactobacilli promote vaginal health by helping
to maintain an acidic vaginal pH through
production of lactic acid. The logic seems
sound: vaginal infections are characterized
by elevated vaginal pH and decreased numbers of lactobacilli, ergo lactic acid-producing lactobacilli likely prevent infection by
maintaining a low vaginal pH. This rationale is behind the common recommendation that women eat yogurt: the lactobacilli,
particularly L. acidophilus, and other “active
cultures” should promote vaginal health.
Poking under the hood of this theory led
to some interesting observations. It turns
out that the interaction between vaginal
microorganisms is complex and depends
on more than just pH. This came to light
when researchers found healthy women
who seemed to lack lactobacilli. If large
numbers of lactobacilli were necessary to
regulate vaginal pH and inhibit pathogens,
why were these women healthy?
It turns out that they weren’t entirely
devoid of lactobacilli, but those organisms
only made up a minute, almost inconsequential portion of the vaginal flora. Something
else besides the presence of large numbers of
lactic acid-producing bacteria was involved in
maintenance of vaginal health.
Lactic acid does play a role, but it seems
that a critical factor is the presence of strains
that produce bacteriocins and other specific
regulating factors that inhibit adhesion,
growth, and survival of undesirable organisms. Such specific factors can have prominent effects even at very low concentrations.
Strains that produce them can be present in
tiny amounts while still having a large
effect.
Heart Disease is
Reversible
Learn how CASP screening can help you:
✔ Improve the cardiovascular health of your patients and
✔ Improve the financial health of your practice!
Introducing a Complete CVD Risk Reduction Protocol
Specifically Designed for Primary Care Practice!
Our Unique Turn-Key Model Features:
■ Cardio Pulse Wave Analysis
An objective, non-invasive, office-based
imaging & risk assessment system
■ Data-Guided Nutritional Support &
Patient Education Tools
Non-Pharmaceutical Interventions that
Support Cardiovascular Health
Call Now for More Information
1-866-366-5040
PRACTICED AND ENDORSED BY
“Pulse wave analysis has been an
invaluable tool for helping my
patients reduce their CVD risk,
while also strengthening the
fiscal health of my practice.”
— Joe Prendergast, MD,
Director, Endocrine Metabolic
Medical Center, Palo Alto, CA
DR. JOE PRENDERGAST
Bacterial Vaginosis: Under the Radar
Bacterial vaginosis (BV) is the most common
vaginal infection, affecting roughly 10–29% of
the female population (Allsworth JE, Peipert
JF. Obstetr Gynecol. 2007; 109: 114–120). BV is
the primary reason for more than 4 million
office visits per year in the US (Van Kessel K, et
al. Obstet Gynecol Surv. 2003; 58: 351–358). Yet
despite these numbers, researchers believe
many cases still go untreated or mistreated.
BV is characterized by a shift in the vaginal
microbiota from predominantly commensal
organisms like lactobacilli, to pathogens such
as species of Gardnerella, Atopobium and Prevotella. Some of these organisms produce
amines that raise the pH in the vagina and
cause a “fishy” smell.
The symptoms of BV are somewhat similar
to those of a yeast infection. Since this is a
sensitive, even embarrassing topic, and because
over-the-counter anti-fungals are readily available, many women try to self-treat BV with
anti-yeast remedies. Unfortunately, these won’t
help, and often make the situation worse.
Be aware that levels of lactobacilli tend to
track with estrogen levels, meaning that even
women who seem healthy may be at increased
risk of BV when estrogen is low, like at the
beginning and end of the menstrual cycle, or
after going into menopause.
BV, Preterm Labor & STDs
On face value BV may seem more like an
annoyance than a serious medical condition. This is a fallacious and short-sighted
view. BV can lead to extensive local inflammation and increased susceptibility to sexually transmitted infections.
It has been associated with increased incidence of HIV, cytomegalovirus, chlamydia
gonorrhea and pelvic inflammatory disease
(Anukam KC, et al. Sex Transm Dis. 2006;
33(1): 59–62. Sewankambo N, et al. Lancet.
1997; 350: 546–550. Ross SA, et al. J Infect
Dis. 2005; 192(10): 1727–1730. Nilsson U,
et al. Sex Transm Dis. 1997; 24(5): 241–246.
Joesoef MR, et al. Int J STD AIDS. 1996; 7(1):
61–64. Brotman RM, et al. J Pediatr Adolesc
Gynecol. 2007; 20(4): 225–231).
None of these studies prove a definitive
causal relationship between BV and STDs,
but the strength of the correlations warrants
serious clinical scrutiny.
BV is also linked with a heightened risk of
preterm labor. In the US, 7–10% of all babies
are delivered preterm, and the number has
risen steadily over the last 10 years. Women
at risk for preterm labor cost the healthcare
system roughly $360 million annually.
We’ve known for some time that there is
a correlation between BV in an expectant
mother and preterm delivery (Hillier SL, et
al. Obstet Gynecol. 1992; 79(3): 369–373.
Chaim W, et al. Arch Gynecol Obstet. 1997;
259: 51–58. Purwar M, et al. J Obstet Gynaecol
Res. 2001; 27(4): 175–181).
Pregnant women are frequently treated
with antibiotics to fend off group B streptococci and also as a precautionary measure
when the amniotic sac ruptures prematurely.
But this increased use of antibiotics means
more frequent assaults on the vaginal microbiota and a greater overall risk of BV. Antibiotics used to treat BV or other conditions can
cause complications during pregnancy and
severely disrupt the vaginal microbiota, thus
facilitating future BV episodes.
This is problematic not only for the
mother but also for the baby, because transmission of endogenous bacteria from mother
to newborn occurs during birth, helping to
establish the newborn’s own gut flora and
immune system. Disruption of the maternal
flora by antibiotic therapy interferes with this
process.
Clearly, antibiotics treatment for pregnant
women has drawbacks. Some researchers have
suggested that orally administered probiotics
specially formulated for vaginal health could
help eliminate the conditions that cause preterm labor and hence avoid many of these
problems (Reid G, Bocking A. Am J Obstet
Gynecol. 2003; 189: 1202–1208).
An Ounce of Prevention
Given the short external distance between the
anus and the vagina, and the fact organisms
naturally migrate across the perineum, it
stands to reason that a healthy urogenital environment begins with healthy GI flora. The
healthier the intestinal microbiota, the lower
the odds that disruptive organisms will pass
from the digestive tract to the vagina.
Beneficial intestinal microbiota are more
apt to flourish on a diet high in fiber (especially prebiotic fibers) and low in simple sugars and refined carbohydrates. In contrast,
pathogenic bacteria tend to outpace friendly
ones when the diet is high in simple sugars
and low-fiber processed foods.
Eating yogurt with live active cultures may
help, although the clinical evidence to support
this is somewhat equivocal. Digestive health
may be better served by taking a probiotic
supplement that contains multiple strains
clinically documented to support gut health.
Women may be able to prevent BV with
probiotic products specifically formulated
and tested for vaginal health. Ideally, these
should contain strains originally isolated
from a healthy woman and well characterized to act against vaginal pathogens. Two
strains that actually meet those standards
are: Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14. Used together, these
have been shown to promote healthy vaginal microbiota (see “Research Review”).
Probiotics & BV Treatment
Standard treatment for bacterial vaginosis
involves oral or intravaginal antibiotic drugs.
The most common agents are metronidazole
or clindamycin for one week. Intravaginal
treatments include metronidazole gel or 2%
clindamycin cream applied daily for a week.
Regardless of which antibiotic is used, statistics show that roughly 30% of BV infections
recur within one month and approximately
80% within 9 months. Also be aware that
local use of clindamycin is contraindicated
for pregnant women because of a possible
connection to birth defects.
Many physicians will recommend probiotics following antibiotic therapy, to bolster
beneficial GI bacteria killed off during treatment. The same advice applies to the urogenital tract: the vaginal commensals are just
as susceptible to broad-spectrum antibiotics
as the ones in the intestines.
Although there is not yet any solid evidence that probiotic monotherapy is effective against existing BV infections, probiotic
supplementation can provide dividends
before, during and after antibiotics Some
probiotic strains can even improve the efficacy of antibiotics (see “Research Review”).
Vulvovaginal Candidiasis:
Bacteria vs.Yeast
About 75% of women have vulvovaginal
candidiasis (VVC), aka “yeast infection,”
during their lives. BV and other disruptions
of bacterial microbiota make VVC more
common, recurrences more likely, and outbreaks more difficult to treat.
Various species of Candida are present in a
healthy vaginal environment, but at very low
levels. VVC is an over-proliferation of Candida, with C. albicans accounting for 85–90%
of cases. A Candida bloom causes inflammation and can lead to vaginal discharge and
irritation. VVC is characterized by a thick,
whitish, non-uniform discharge that does not
typically possess a “fishy” odor. Irritation during sexual intercourse and itchiness of the
vagina and surrounding area are common.
One can easily see the Candidal hyphae via
see Treating Vaginosis p. 13
women’s health
Summer 2009
Urogenital Probiotics:
A Research Review
A number of published studies and case
reports show the value of probiotics in
preventing and treating vaginal infections
and other urogenital problems in women.
Here are a few key papers:
Effects on Urogenital Microbiota
Forty-two clinically healthy women were
randomized into four groups: three active
treatment groups that received various
oral dosages of an L. rhamnosus GR-1/L.
reuteri RC-14 (GR-1/RC-14) probiotic supplement, and a control group receiving L.
rhamnosus GG every day for 28 days. All
three treatment groups saw a significant
increase in healthy vaginal microbiota,
while the control group showed no change.
The twice-daily treatment group accrued
the most benefit, with 90% of patients
showing normal vaginal microbiota two
weeks after treatment. The study suggests
that a daily dose of about 1 billion (109)
live GR-1/RC-14 organisms is adequate as
a preventative regimen (Reid G, et al.
FEMS Immunol Med Microbiol. 2001; 32:
37–41).
Lactobacilli, Yeast & Coliforms
Sixty-four healthy women were randomized
to receive either a once-daily oral GR-1/RC-14
supplement for 60 days, or a calcium carbonate placebo. Microscopic analysis on Day 28
showed that the treatment group had an
almost 10-fold increase in lactobacilli over
baseline, while the placebo group showed a
lactobacillus decline. The placebo patients
also showed a significantly greater presence of
yeast and coliform bacteria (Fig. 1) (Reid G,
et al. Clin Ther. 1992; 14(1): 11–16).
Bacterial Vaginosis Prevention
In the previous study, blinded observers
used Nugent scoring to assess the development of BV. Of those possessing a
healthy vaginal microbiota at the outset, none of the women on the GR-1/
RC-14 probiotic (0/23), but 24% (6/25)
of those in the placebo group devel-
9
Effectiveness of Combination Treatment
for Bacterial Vaginosis
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
GR-1/RC-14 +
Metronidazole
Placebo +
Metronidazole
Fig. 2. Effectiveness of Metronidazole +
GR-1/ RC-14 Probiotic for BV
oped BV by Day 35 (Reid G, et al. Clin
Ther. 1992; 14(1): 11–16).
Probiotics Plus Antibiotics for BV
Average (Log) Difference in Microbiota
Populations after 1 Month Daily Use
1.2
1.0
0.8
0.6
0.4
Preventing Preterm Labor
0.2
0
-0.2
-0.4
-0.6
In women with BV, the combination of
GR-1/RC-14 probiotic (1 capsule, 10 billion
CFUs), twice daily, plus oral metronidazole
(500 mg), twice daily, more than doubled
(88% response rate) the efficacy of metronidazole alone (40% response) (Fig. 2)
(Anukam KC, et al. Microbes and Infection.
2006; 8: 1450–1454).
Lactobacillus
counts
Yeast
counts
Coliform
counts
GR-1/RC-14 Group
Placebo
Fig. 1. Average (Log) Difference in Microbiota
Populations After 1 Month Daily Use
Thirty pregnant women with BV and at high
risk of preterm delivery, were randomized
to a once-daily oral GR-1/RC-14 capsule for
15 days, or standard care without any BV
treatment. After one month, the treatment
group showed decreased indicators of BV.
But more importantly, 100% of the mothers
in the treatment group delivered at term, as
opposed to 67% of the controls. There were
no adverse events (Dobrokhotova YE, Sci
M. All-Russian Scientific Forum: Mother and
Baby. October 2, 2007).
Treating Vulvovaginal
Candidiasis
Sixty-eight women with VVC were randomized to either fluconazole, 150 mg/
day plus 2 capsules of GR-1/RC-14 (10
billion organisms), once daily, or fluconazole plus placebo. After 28 days, the
treatment group showed more than a
three-fold decrease in yeast levels and
vaginal discharge compared to the control
group (Martinez RC, et al. Lett Appl Microbiol. 2009; 48(3): 269–274).
Preventing Urinary Tract
Infections
Reid and colleagues compared UTI recurrence rates in 41 women treated with
either standard 3-day antibiotics alone or
antibiotics followed by a GR-1 probiotic.
They first treated the women with either
norfloxacin or co-trimazole (the UK name
for trimethoprim-sulfamethoxazole, and
not to be confused with the antifungal,
clotrimazole). Recurrence rates were 29%
in the norfloxacin group and 41% for
those on co-trimazole. Afterward all
women were then randomized to either a
GR-1 probiotic suppository or sterilized
skim milk as a pessary, twice a week for
two weeks, with two additional instillations at 4 weeks and 8 weeks. The GR-1
group had a recurrence rate of 21% over
the ensuing 6 months; for the skim milk
group it was 47% (Reid et al. 1992). In
another randomized trial, a weekly GR-1
combination probiotic (10 billion CFUs)
was given as a pessary for one year. This
decreased UTIs from a mean of 6 infections in the year prior to the study, to only
1.6 per year during the study (Reid G,
Bruce AW, Taylor M. Microecology Therapy.
1995; 23: 32–45).
news
10
Reimbursement
late stage disease treatment to life-long
health promotion.
While the main goal of the Obama reform
is universal insurance coverage, Sen. Harkin
said prevention and wellness are central to the
president’s approach. “It’s not enough to talk
about how to extend insurance coverage. It
makes no sense to try to figure out how to pay
the bills on a system that’s broken and unsustainable. If we pass healthcare reform without
infrastructure for health and wellness and prevention, we will have failed America,” Mr.
Harkin said. Though he is confident about the
ultimate triumph of wellness-centered reform,
he was also very frank that the entrenched
interests of the pharmaceutical, insurance,
and mainstream medical industries will likely
oppose major change.
You Say You Want a Revolution . . .
According to Ralph Snyderman, MD, Chancellor Emeritus of Duke University, and head
of the IOM Summit’s planning committee,
big change is inevitable. He said we are on the
verge of “a new revolution in health care,”
driven by advances in genomics, proteomics,
metabolomics, systems biology, and nutrition
science. These are converging to create a
clearer picture of how gene expression and
disease development are driven by environmental and lifestyle factors.
“We’re moving away from the belief that
disease is caused by a (single) factor and that
your job (as a doctor) is to find that factor and
fix it. This reductionist approach has its place,
but it is not sufficient. We should not be
thinking simply of preventing disease, we
ought to be talking about enhancing health
and well-being.” That, he added, would be a
revolutionary shift in medical thinking.
Dr. Snyderman wasn’t the only one talkin’
’bout revolution. In a burst of surprisingly
populist rhetoric, Reed Tuckson, MD, Executive VP and Chief of Medical Affairs for UnitedHealth Group, declared, “It’s time for a
revolution. We’re all in this together.” He said
UHG is committed to evidence-based, wellness-focused care.
However, he was equally forceful in stating
that integrative medicine advocates are dreaming if they think insurers—and the large
employers who pay them —are going to cover
anything new without reams of good outcomes data. He said UHG is working closely
with 8 integrative care sites funded by the
Bravewell Collaborative, to study best practices and gather data.
Dr. Tuckson had scathing criticism for
America’s healthcare gluttony. “Everybody
wants everything all the time. The person
who’s sick wants it all, and they want it now.
The doctors want it all. The tech people want
it all. And you should see what’s rolling down
the hill from the geneticists.”
Left out of his Glutton’s Roll Call, however,
were insurance industry executives who’ve
reaped record salaries and bonuses over the
last decade, despite the looming healthcare
crisis. It was difficult to accept revolutionary
repartee from a man who heads one of the
country’s most rapacious insurance companies. Last year, UHG’s former CEO, Dr. Bill
McGuire, was indicted in a Dept. of Justice
investigation for illegally timing his $1.6 billion in company stock options.
Throughout the Summit, there was much
talk about the need for patients to change
their lifestyles, their expectations, and their
utilization of health care. There were calls for
doctors to change their modes of communication and ways of practice, and for researchers to change their study paradigms.
But beyond a general invocation of the
virtues of electronic medical records in streamlining healthcare administration and reduc-
ing error—a case eloquently outlined by
George Halvorson, CEO of Kaiser Foundation
Health Plans—there was little mention of the
need to address the layers of administrative
cost insurers add to the healthcare equation,
their longstanding reluctance to cover truly
preventive medicine or the dangerous
entwinement of for-profit health insurers
with the rest of the financial sector.
Balking at Balkanization
The Summit touched on many thorny issues:
the need for new research models to assess
complex holistic approaches that don’t fit the
drug-oriented RCT model; the challenges of
funding new modes of care in a down economy; defining scope of practice for non-MD
professionals; and the difficulties of transcending historical enmity between practitioner groups to create cross-disciplinary working
relationships.
If the meeting itself is an indicator of where
we are on the road to integration, it is clear
we’ve got a looong way to go.
With just one exception, all clinicians on
the Summit faculty were MDs. There were no
representatives of nursing, naturopathy, osteopathy, chiropractic, traditional Chinese
medicine or any of the other Asian healing
disciplines. The one non-MD clinician on the
roster was Janet Kahn, PhD, director of the
Integrated Healthcare Policy Consortium,
and a massage therapist.
Many non-MD professionals attended, but
their input was restricted to brief comments
during Q&A periods and unofficial remarks
during smaller breakout sessions. In many
cases, they sounded like they were making
impassioned pleas for inclusion of their professions under the integrative Big Top.
This was not lost on Tom Donohue, CEO
of the US Chamber of Commerce. “You’re all
petitioners, trying to get this or that sector
included in the (health reform) bill,” he told
the assembly. “You want your piece of the pie.
The big question is, how much pie is there?
And how much pie can we afford?”
Mr. Donohue’s observations were true
enough, as far as they went. But they were
hard to swallow at a time when many of the
nation’s corporate chieftains—some of whom
are, no doubt, members of the Chamber of
Commerce—are petitioning the government
for public “stimulus” money.
The interdisciplinary struggles for inclusion and recognition in the integrative world
are not so different from similar battles
between allopathic physicians’ groups, though
from the outside, MDs seem unified and
monolithic.
Mehmet Oz, MD, the holistically-minded
cardiac surgeon who vice-chairs the Department of Surgery at Columbia University,
decried the “balkanization” of medicine. Its
fragmentation and ever-narrowing interests
only engender conflict and mistrust, which
in turn leads to unnecessary suffering, and
tremendous fiscal waste. Practitioners and
hospitals, he said, have been too focused on
their own narrow needs, and not enough on
their patients’. He believes it will be wellinformed, health-savvy patients who will
ultimately re-set priorities and bring disparate disciplines together.
Defining “Integrative”
One of the biggest challenges confronting
the integrative movement is in defining
what “integrative” really means. Like “complementary and alternative medicine
(CAM)” before it, “integrative medicine” is
a catch-all term of convenience coined by
allopathic medical professionals to describe
a process of coming to terms with healthcare professionals, procedures, and practices
that have evolved outside the domain of
conventional allopathic practice.
Harvey Fineberg, MD, President of the
Institute of Medicine, said the term is a bit
like “a Rorschach blot.” People may see very
different things within it, and what they see
tells you something about where they’re
coming from.
Do the diverse healing disciplines typically called “integrative” or “CAM” really
have anything in common, other than their
“otherness” from allopathy? Dr. Fineberg
believes they do. He sees several common
principles: 1) An understanding that health
is more than the absence of disease; 2) A
recognition that health is influenced not
just by physical or genetic factors but equally
by emotional, psycho-social, environmental and spiritual aspects; 3) A focus on
health maintenance and disease prevention
as well as acute and chronic care; 4) An
emphasis on inter-disciplinary collaboration; and 5) Acknowledgment of biological
variation and the need to treat individuals,
not statistical “averages.”
There is another commonality: a recognition of the inherent ability of the human
body to maintain and restore optimal
health, and a view that a clinician’s job is to
facilitate that innate ability. Though this
principle was not formally articulated at the
Summit, it is central to a bill forwarded by
the American Association of Naturopathic
Physicians and several other organizations
and introduced into the House of Representatives by Rep. Jim Langevin (D-RI) last
summer. (For more on this, see Naturopathic
Perspective, p. 12.)
Tracey Gaudet, MD, Executive Director
of Duke Integrative Medicine, said that integrative medicine represents, “a total change
of mindset.” It is not about incrementally
adding this or that “alternative” modality,
but about re-thinking what health care
could be. “The current healthcare model
does not work because we are starting from
the wrong place. We need a radical departure from the problem-based, disease-oriented approach.”
In practice, this obliges physicians to really
get to know their patients, not just their chief
complaints and lab values. “What gives someone meaning and purpose? If you can’t identify sources of joy in their lives, then nothing
really changes. But if you do touch this, you
can activate (the patient’s) true motivation for
change. If you really get this, you’ll quickly
realize that no aspect of the current healthcare
system is set up for that.”
Coach Class
The decimation of primary care was of great
concern to many at the Summit. At best, only
1–2% of all recent med school grads are going
into primary care, a trend analysts say could
sorely compromise large-scale reform.
Some speakers view integrative medicine as a springboard for re-invigorating
primary care, if—and it’s a big if—federal
programs and insurers were willing to pay
doctors to practice that way. “Primary Care
has the mindset, orientation, and relationship with patients required as a foundation
for integrative healthcare,” said Edward
Wagner, an internist and Director of the
MacColl Institute for Healthcare Innovation. “We need to make a priority of saving
primary care.”
Others argued that most doctors are neither well-trained nor well-positioned to do
the health promotion work so many people
need. They see credentialed non-physician
health coaches as the key players when it
comes to guiding and supporting people in
making lifestyle changes.
“Even if we graduated 50% of all medical students into primary care, it would not
fundamentally change the situation until
we redefine, broaden and re-align the reimbursement. Nurses, physician assistants,
health coaches all have a place, and it all
needs to be expanded,” said Vic Sierpina,
MD, Professor of Family Medicine at University of Texas, Galveston, and a member
of the IOM Summit planning committee.
Summer 2009
Health coaches—and there are now several formal credentialing programs for
them—are not tied to clinics, so they can
work with people in their homes, schools,
gyms, workplaces. A number of corporations have implemented employee wellness
programs with certified health coaches in
the point positions.
Duke’s Dr. Gaudet is a strong advocate of
health coaching. “It has really caught on
recently. The concept really lands with people. I’d like to see health coaches take center
place in the care team,” she said. “A coach
can work directly with a patient to help
implement and stick with lifestyle changes”
recommended by his or her physician. She
called for establishment of standardized core
competencies and a universally recognized
coaching credential. She and her colleagues
at Duke are working on developing a curriculum for integrative health coaching.
Symbolic or Substantial?
Many people in holistic/integrative circles
viewed the IOM Summit as a watershed
moment, the first time the healthcare orthodoxy has formally invited leaders of the
integrative field to the “table” of mainstream medicine. The Institute, which issues
policy recommendations to guide national
healthcare legislation, has historically been
very conservative and less than welcoming
of “alternative” thinking. In that light, the
gathering had huge symbolic significance.
At the same time, some attendees felt a
deep frustration that it has taken epidemics
of largely preventable diseases and the nearbankruptcy of our healthcare system, before
mainstream medicine would undertake a
serious dialog with those who think there’s
more to medicine than drugs, surgery and
acute care.
Efforts toward reform and integration
will not take place in a vacuum, and they
will not go far without recognizing the true
drivers of chronic disease, and the matrix of
socio-economic incentives that drive the
existing healthcare systems. Sen. Harkin
and other speakers at the Summit rightly
pointed out that we cannot have meaningful changes in health care without meaningful reforms in agriculture, energy, education,
and environmental policy.
Everyone present seemed to agree that it
is high time we brought together the best
that all the diverse healing arts and sciences
have to offer. The difficulty will be in determining who gets paid, by whom, and how
value in health care gets determined. But
the wrangling over the details—there are
many, and they are complex—must be
guided by a larger, overarching vision of
improved health for all, lest it deteriorate
into mere turf-battling.
The National Academy of Sciences has a
beautiful central hall, it’s domed ceiling
adorned with gold-leaf paintings of astrological, mythological and alchemical images.
If leaders of the Institute of Medicine wish to
understand the essence of holistic/integrative medicine, they would do themselves a
service by spending some time pondering
the visions on that stunning dome. Hildreth
Meiere’s paintings are all about the four elements, the mysteries of transformation, the
ever-turning cycles of the natural world.
“Ages and Cycles of Nature In Ceaseless
Sequence Moving” says the dome’s central
inscription. As the dialog about integrative
medicine continues, let us hope that those
leading the way will raise their eyes to the
big picture as they struggle with the allimportant minutiae.
The Institute of Medicine will issue a formal White Paper summarizing the Summit
in November. Review and analysis of the
presentations are available at the Bravewell
Collaborative’s website: www.bravewell.org.
Video recordings of all the sessions are
posted at: www.imsummitwebcast.org.
Summer 2009
greening your practice
GreeninG Your Practice
by Joel Kreisberg, DC, MA
Think Globally,
Go Out & Play Locally!
People view healthcare professionals as leaders, and
this affords us the opportunity to have a profound
influence on our communities. As “Green” healthcare givers, we can serve as an essential resource for
people looking to understand how their environment influences their health. There’s no better way
for us to cultivate that connection than to develop a
regular habit of spending time outdoors.
It is easy to talk in generalizations about what’s “good for the planet.” While there are
many recommendations that apply broadly, it is important to recognize that “the planet”
is made up of diverse communities, each of which has its own specific climate, geography,
and environmental challenges.
My patients often come in with limited knowledge of environmental hazards, but
many have questions about the role the environment plays in their health. It’s a subject
of fast-growing public interest, and certainly a big news topic. Many of us are shocked and
horrified to discover hazards in our own communities.
As integrative practitioners, I believe we are obliged to understand environmental
issues as they specifically affect our communities. We have a vital role to play in promoting
the benefits of a healthy environment—both personally and globally.
It is really important to continually inform yourself about common environmental
issues in your area. This is easily done through websites such as Environmental Scorecard
(www.scorecard.org) that allow you to enter your zip code and pull up a detailed report
of local environmental hazards. One physician I know does this for every patient, placing
the scorecard in the chart and giving a copy to the patient! Other useful websites include
the EPA (www.EPA.gov), Environmental Working Group (www.ewg.org), AIRNow
(www.airnow.gov), and the Pesticide Action Network (www.pesticideinfo.org).
Keeping track of local environmental risks allows you to better recognize environmental
illnesses among your patients.
To promote environmental wellness and provide leadership you must take the time to
regularly connect with the outdoors. There’s no substitute for personally experiencing your
local environment. If there are noticeable pollutants in the air, you will understand more
directly the ill effects on your health, and through that, you’ll be better able to relate to
patients facing environmental health challenges.
Sadly, most Americans spend 80% of their time indoors, so if you want to get your
patients outside, you will have to get outside yourself and serve as a role model. Besides,
outdoor recreation can be great fun.
People often ask me if they have to go to a park or some other specially designated
place. I say that any outdoor space is good for your health. For Vitamin D production we
need at least 30 minutes a day of sunlight, best caught in the middle of the day. The time
you spend outdoors allows you to better appreciate where you live, and to connect with
other outdoor enthusiasts, which makes the whole thing more enjoyable.
I’m always pleasantly amazed at how many people meet during outdoor activities and
then naturally build partnerships in support of their shared world. This can be done in a
more formal way, say by building a house with other folks through Habitats for Humanity
(www.habitat.org), purchasing food at local farmers markets, or even gardening at a local
community garden. But it’s always nice when these things come about serendipitously.
Some might consider these suggestions as mere “chores,” another thing to try and fit
into an already overextended schedule. If it is difficult to find the time to participate in
scheduled outdoor activities, consider how you can incorporate more outdoor time into
your current schedule, like walking or riding a bike to work. The single largest contributor
to air pollution in the US is automobiles, and a commitment to get out of your car can
have a big impact on your personal wellbeing and your community’s health.
If you yourself are taking time outdoors, then it is much easier to educate patients
about the various options and benefits of connecting with nature. It helps to have a list
of local organizations that can help your patients engage in outdoor recreation. You might
also do a bit of public advocacy work by keeping up with local or regional ordinances,
writing letters and articles for local papers, websites or blogs, or speaking at public
hearings about the benefits of outdoor activity and the need for a clean environment.
The three foundations of Green Health Care are: 1) working in a green clinic, 2)
advocating for a healthy environment, and 3) practicing medicine sustainably. Of these
three, advocating environmental health is the simplest to implement. It might begin at
the local playground or at a town council meeting.
Find out what is happening—environment-wise—in your area and get involved. By
doing this regularly you will increase your own personal health, create a healthier world
around you and make lasting friendships. You’ll also be role-modeling healthy living
and community engagement, and that can go a long way in empowering your patients
to do likewise.
Resource List
Scorecard: The pollution information site, www.scorecard.org
Environmental Protection Agency, www.epa.gov
Environmental Working Group, www.ewg.org
Collaboration for Health and the Environment, www.healthandenvironment.org
Teleosis Institute, www.teleosis.org
Practice Greenhealth, www.practicegreenhealth.org
Habitats for Humanity www.habitat.org
Joel Kreisberg, DC, MA, a chiropractor and clinical homeopath, is the founder and senior director
of the Teleosis Institute, Berkeley, California, a program of Practice Green Health. Teleosis is
dedicated to reducing healthcare’s footprint while broadening its ecological vision.
RE
11
S
RE TR
DU E S
CT S
IO
N
ON
I
T
A
X
A
L
Patient receiving chemotherapy on
Dr Thompson Sound Journey
TM
Chair
If Sound JourneyTM Tables & Chairs
make even chemotherapy
a positive and relaxed experience–
Imagine what they can do in your
practice!

25 + Years of Clinical Experience
Balancing the Autonomic Nervous System
Relaxation
Sleep
Stress Reduction
Pain Control
Improved Focus and Concentration
High Level of Patient Satisfaction
For more information about the Sound Journey line of chairs and massage tables contact us:
Center for Neuroacoustic Research
Mammoth Professional Building, East
169 Saxony Road Suite 209
Encinitas, CA. 92024-6780
Phone: (760) 942-6749
Fax (760) 942-6768 e-mail: [email protected]
www.neuroacoustic.com
naturopathic perspective
12
Summer 2009
The NaturoPathic PersPective
by Michael Traub, ND, FABNO
Natural Medicine & Healthcare Reform:
Taking Our Places, Raising Our Voices
By combining our industry-leading fish oil with two of nature’s most
potent antioxidants, Nordic Naturals ProOmega Longevity™:
n
Protects cells from the oxidative stress associated with aging*
n
Supports cardiovascular and metabolic health*
n
Optimizes cell membrane fluidity and flexibility*
n
Supports the body’s natural anti-inflammatory response*
The polyphenolic catechins in green tea extract have been shown
to possess biologic activity in antioxidant, antiangiogenesis, and
antiproliferative assays and to produce significantly stronger protective
effects than standard antioxidants.* The green tea extract in ProOmega
Longevity contains 98% polyphenols, 75% catechins, and 45% EGCG
(epigallocatechin gallate).
Resveratrol has been identified as a
multitargeted agent in the prevention
and treatment of common clinical
conditions of aging. By affecting
whole pathways and sets of
intracellular events rather than
a single enzyme, resveratrol is
a potential therapy to restore
homeostasis.*
Nordic Naturals: raising the bar
with science-based innovation.
Doctors for America: www.drsforamerica.org, www.voicesofphysicians.org
Wellness Initiative for the Nation (WIN) created by the Samueli Institute in collaboration with the Integrated Healthcare Policy Consortium and many other visionaries.
www.siib.org
H. Con. Res 58, introduced in August 2008 in the U.S. House of Representatives by
Congressman Langevin (D-RI): “Congressional reform of our disease-based system must
incorporate patient-centered care that addresses the underlying causal factors associated
with chronic disease and facilitates the inherent ability of the human body to maintain
and restore optimal health. This definition of sustainable wellness is essential to any and
all reform initiatives.” Supported by the American Association of Naturopathic
Physicians, American Holistic Medical Association, American Holistic Nurses
Association, American Medical Student Association, Citizens for Health, Consortium of Academic Health Centers for Integrative Medicine, Integrated Health Policy
Consortium and the Natural Products Association.
Americans Living Life Well (“ALL WELL”), an alliance that will be walking to
Washington together in Spring 2010 to promote this fundamental and essential
change. Contact [email protected]
2 soft gel serving supplies:
455 mg EPA
315 mg DHA
120 mg Resveratrol
500 mg Green Tea Extract
800.662.2544 x1
nordicnaturals.com
omega-research.com
Michael Traub, ND, FABNO, DHANP, is past-president of the American Association of Naturopathic
Physicians, and Board Member of the Integrated Healthcare Policy Consortium.
* These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.
nn_holisticpri0609.indd 1
As I prepared to write this column, I read a front-page New York Times (April 27, 2009) article
about how healthcare reform could be stymied by the shortage of primary care providers—
a trend that has reached crisis proportions. What will universal healthcare insurance solve
if there is a severe lack of practitioners?
It is unlikely that the government can provide sufficient incentives to lure more MDs
and DOs into primary care. Conventional medicine seeks to close the gap by relying more
and more on “physician extenders” like physician assistants and nurse practitioners.
Part of the solution could come from recognizing the value of naturopathic physicians,
chiropractors, and acupuncturists/doctors of oriental medicine and including us, and our
academic institutions, in federal healthcare programs. This would enable us to bring a wellness
orientation to primary care that a lot of conventional practices are not able to provide.
In February, Drs. Mehmet Oz, Mark Hyman, Dean Ornish, and Andrew Weil testified
before the Senate Health, Education, Labor and Pensions Committee. They advocated for
training a new cadre of integrative physicians to incorporate health and wellness throughout
the continuum of care, to prevent more expensive interventions and cut the costs associated
with treating preventable conditions.
These are worthy goals, to be sure. But there was a glaring oversight in their testimony:
there are thousands of licensed (or license-eligible) providers fitting that description, already
trained in preventive and therapeutic interventions based in lifestyle change, environmental
health, mind-body modalities, nutrition, botanicals and other natural approaches.
It is essential that the holistic/CAM professions be involved in the early planning stages
of healthcare reform if we hope to achieve lasting, effective change. We are the professions
that responded to the explosion of public interest in nutrition, botanicals, acupuncture,
physical medicine, and mind-body approaches more than 30 years ago. We represent the
disciplines that embodied the kind of relational care that patients sought but rarely found
from conventional physicians working under managed care.
The allopathic profession systematically denigrated and excluded these approaches for
most of those years, using all its power in research, academia, and media to do so. I believe
it is inappropriate, therefore, to put allopathic physicians in sole or primary charge of a
reform process that should involve—and will greatly impact—diverse practitioner groups.
All parties should be at the table.
During a hearing chaired by Senator Mikulski on Feb. 23, there was discussion about
establishment of an Office of Wellness & Prevention that would help to incorporate integrative healthcare into federal programs. This idea first surfaced in 2001 as a recommendation
from the National Policy Dialogue on Integrated Health Care (http://ihpc.info/resources/
resources.shtml). It is still a great idea, but this new office must have the power to direct
action, not just report on it. It will need independent funding and an overarching mission.
System-wide reform will involve many federal agencies and offices; an Office of Wellness &
Prevention needs to have authority and visibility that facilitates effective leadership.
To really solve the healthcare crisis, we must recognize that the current federal healthcare
system is not committed to the ultimate principles of good medicine, but to the narrow interests
of conventional medicine, the pharmaceutical industry, and private insurance companies.
Five congressional committees—two in the Senate and three in the House—are working
on reform legislation. The consensus emerging from the two Senate committees echoes key
elements of Massachusetts’ state-level reforms, including a requirement that all residents
purchase health insurance, with premium subsidies for the poor, and an insurance exchange
through which uninsured adults could purchase coverage.
National health insurance has considerable support within the medical profession,
but it overlooks the degree to which patient empowerment, individual choice, competition, and market incentives could be and are being successfully used to solve healthcare
problems. More than 10 million US families are managing some of their own healthcare
dollars through Health Savings Accounts (HSAs) and Health Reimbursement Accounts
(HRAs). More than half the states have Medicaid Cash & Counseling pilot programs,
allowing disabled people to manage their own supportive care budgets.
Support for universal insurance-centered reform is based on a narrow construal of
selected data, while all too often ignoring contrary data. The reform discussion would
benefit greatly from careful examination of the successes and future potential of reforms
outside of insurance-based solutions.
Holistic Primary Care readers should be aware of various opportunities to participate
in healthcare reform:
4/14/09 3:39:39 PM
There appears to be a strong correlation between teenage obesity
and exposure to phthalates—endocrine-disrupting compounds found
in many personal care products
and a myriad of plastic and vinyl
products.
A recent study of pre-adolescent
girls living in Harlem showed that
the heaviest girls in the cohort of
roughly 400 kids, aged 9–11, had
the highest levels of phthalate
metabolites in their urine, reported
Philip J. Landrigan, MD, chairman
of the Department of Community
& Preventive Medicine, Mount
Sinai Medical Center, New York.
The study is part of a large scale
project titled, “Growing Up Healthy
in East Harlem,” that looks at determinants of health and illness
among children in this predominantly poor, Black and Hispanic
neighborhood.
The phthalate-obesity findings
were published in the journal Epidemiology, and received considerable attention when New York Times
reporter Jennifer Lee covered the
study in the April 17 edition.
The data so far suggest that kids
in this community are growing up
anything but healthy. Roughly 40%
of all school-age children in East
Harlem are overweight or obese.
Dr. Landrigan and colleagues found
that even among normal weight
girls, phthalate metabolite levels
were markedly higher than national
averages reported by the Centers
for Disease Control and Prevention. The girls are most likely being
exposed to phthalates through cosmetics and nail polish, but also
from plastic water bottles, vinyl
pacifiers, and processed food
packaging.
The Mount Sinai investigators
stressed that this is simply a correlation not a causal link between
phthalate exposure and obesity and
they urged caution in jumping to
premature conclusions. Still, given
what is known from animal studies
about phthalates and other plasticderived endocrine disruptors like
Bisphenol-A, the issue warrants
further attention. The findings also
underscore the fact that there’s
more to the obesity equation than
genetic predisposition, excess calories, and lack of exercise.
Phthalates are fat soluble, so
one could explain the correlation
by suggesting that the girls with the
most adipose tissue simply stored
and then excreted more phthalates
than leaner girls. From a public
health perspective, though, that’s
cold comfort: Animal studies show
phthalates to be carcinogenic, diabetogenic, and long-lasting.
Treating Vaginosis
fungi, but also the endogenous lactobacilli
in the vagina, predisposing a woman to
repeated Candidal overgrowth.
There are several published reports
showing that standard antifungal drug
microscopic examination of a vaginal smear
treatment in combination with a vaginal
treated with 10% KOH.
probiotic containing L. rhamnosus GR-1/L.
Maintenance of healthy urogenital
reuteri RC-14 significantly reduces sympmicrobiota decreases the risk of VVC. Protoms of yeast infection as compared to stanphylactic probiotic use is one way to supdard drug treatment alone (see “Research
port the healthy bacterial flora that can
Review”).
inhibit uncontrolled growth of yeast (Reid
The key to understanding urogenital
G, et al. FEMS Immunology and Medical
health is to realize that it is not about the
Microbiology. 2003; 35: 131–134).
absence of bacteria, but rather the presence of
Oral antifungals like fluconazole, daily
the right organisms in the proper balance.
for two weeks, are the standard first-line
Probiotic strains that have been shown to supdrug treatment for VVC. Prescription and
port urogenital health are an excellent option
OTC antifungal creams and pessaries are
Cosamin
ASU AD-Holistic
Care for
5/13/09
10:13
AM Page
1
promoting
a balanced
urogenital
microalso
commonly
used. But keep Primary
in mind that
biota and preventing infection.
these treatments can inhibit not only the
This deserves serious consideration, since
drug treatments for vaginal infections are of
limited efficacy, especially for recurrent infections. Urogenital probiotics can also be a
helpful adjuvant to standard treatment in
many cases, helping mitigate side effects and
in some cases bolstering treatment efficacy.
Women are often very relieved to learn that
there is more they could be doing to prevent
and treat troublesome vaginal infections.
Make sure to tell them!
Brad Douglass, PhD is a Technical Specialist
for Jarrow Formulas. He obtained his PhD
from USC in Organic Chemistry where his
research efforts concentrated on drug discovery.
He was also a postdoctoral fellow at USC
where he investigated novel blood-brain barrier transport methods for use in drug delivery
to the brain.
The best just got better!
Our most POTENT formula–Cosamin ASU
You’ve made your patients happy by recommending
Cosamin DS–wait until you see their response with
Cosamin ASU!
Our MOST POTENT option for your patients.
ASU (Avocado/Soybean Unsaponifiables) is derived from
avocados and soybeans and has been shown in
laboratory research to inhibit components that result in
cartilage breakdown.
RECOMMEND WITH CONFIDENCE
Ingredients shown in laboratory cell culture studies to work
better than just the combination of glucosamine +
chondroitin sulfate.
Cosamin DS has a long, proven track record and is
the #1 Orthopedic and Rheumatologist recommended
Glucosamine/Chondroitin Sulfate Brand
Visit cosaminasu.com
Shown to Work Better
ASU + Glucosamine
+ Chondroitin Sulfate
No
Supplementation
100
Percentage of Marker Activity
Do These Phthalates
Make Me Look Fat?
13
GREATER
FROM THE
MAKERS OF
COSAMIN DS
®
THE ORTHOPEDIC SURGEON
AND RHEUMATOLOGIST
#1 RECOMMENDED BRAND
REDUCTION
LEADING TO
HEALTHIER
JOINTS
INFLAMMATORY
MARKERS
Glucosamine +
Chondroitin Sulfate
INFLAMMATORY
MARKERS
INFLAMMATORY
MARKERS
0
In laboratory cell culture studies of inflammatory markers
associated with joint discomfort and cartilage breakdown
it was found that the combination of
ASU (avocado/soybean unsaponifiables)
+ glucosamine + chondroitin sulfate
was BETTER than the combination of glucosamine +
chondroitin sulfate in reducing these markers.
For more information, or to learn about our
Patient Starter Program, call 1-877-COSAMIN
Our Most POTENT
Formula
Original
Researched
Brand
Available for your patients
at CVS, Walgreens,
RiteAid, and drugstore.com
Vegetarian formula also available,
visit avoca-asu.com
nutramaxlabs.com 1-800-925-5187
▼
Upshots
prevention practice pearls
▼
Summer 2009
These statements have not been evaluated by the Food & Drug Administration.
This product is not intended to diagnose, treat, cure, or prevent any disease.
Source: SLACK Incorporated Market Research Syurvey, July, 2005 and February, 2006.
Surveys conducted of Orthopedic Surgeons and Rheumatologists
relating to glucosamine/chondroitin sulfate brands.
chronic disease
14
Oximation in Practice: Clearing
Acne & Related Skin Disorders
By Roby Mitchell, MD
C o n tri b u ti n g Wr it er
Hopefully, over the last few parts of this
series, I’ve presented the hypothesis of Oximation to you in a way that is academically
cogent. That’s all well and good, but the
hypothesis only means something if it can
help you to practice better medicine, especially in these difficult economic times.
Certainly your patients are looking for
ways to get better outcomes from less expenditure—particularly those who’ve recently
lost their insurance. To meet these needs,
you’ll need to acquire what computer programmers call “killer apps,” that is, applications or skill-sets that give such fantastic
results that it just about kills somebody.
Learning how to clear up skin problems
without using toxic substances is one such
medical “killer app.” It’s one that patients
will appreciate for its own sake, but the good
news is that it will also have many other
health benefits, including reducing the risk
of many other common chronic diseases.
Let’s face it: no one really cares much
about high LDL cholesterol or elevated
C-reactive protein. Who would notice that
at a dinner party? But no one wants to
show up with a big patch of psoriasis or a
face full of zits.
Skin cells reflect the overall health of the
body. I have yet to see a patient with rosacea
who did not go on to develop serious cardiovascular disease! So, skin problems
make for excellent teaching moments that
can help patients make the connection
between diet and health. This is especially
true for teenagers.
The Dermal Ecosystem
There is a very strong correlation between
dermatologic autoimmune disease and other
diseases of oximation such as diabetes,
Alzheimer’s, stroke, heart disease, etc. The
reason is that they all share a common
pathophysiology: when a tissue becomes
hypoxic or there is a compromise in the process of cellular energy production, cells start
to die, or they change their pattern of DNA
transcription (keratoses, cancer, moles).
When this process occurs, the same thing
happens in the human body as happens in
any other ecosystem: saprophytic predators
are attracted to the deteriorating tissue. In
the human body’s ecology, fungi are the
saprophytic predators or recyclers. As fungi
proliferate, they release mycotoxins that act
as immunosuppressants. This immune suppression will open the door for other
microbes to invade, and this can then lead
to more salient disease.
The invasive microbes are not esoteric.
Antoine Beauchamp, Louis Pasteur’s contemporary (and detractor) is famously
quoted as saying, “The primary cause of disease is in us, always in us.” Once there is a
breach in the fragile balance of the human
ecosystem, microbes that are normally commensal or even symbiotic, can become
pathogenic (not unlike elected officials).
The manifestations can range from vaginal
yeast (see A Role for Probiotics in Preventing,
Treating Bacterial Vaginosis, page 8) to acne,
to bladder infections, to flesh-eating
streptococcus.
Prevention and reversal hinges on maintenance of immune system integrity.
Let’s use acne as an example. There is
controversy in the dermatology literature
about exactly which microbe/s cause acne.
But we know that the disease process
involves proliferation of resident bacteria—
microbes that are “always in us.”
Why does this proliferation happen in
select individuals just before a big date, an
all-important exam, or a crucial business
meeting? The genesis of the pimple is likely
the same as the genesis of the atherogenic
“fatty streak”; a nidus of compromise that
presents an opportunity for ambient resident microbes to proliferate and trigger further inflammation.
Buzzards on the Highway
It is important to understand that whenever
a problem begins to arise in a particular tissue, the predisposition for “compromise” is
already there. It is related to generic polymorphisms, and everyone is born with
some sort of inherent weakness in some
part of their physiology. Think of these as
weak places in the levee. For some, the
weakness is in the vasculature, for others it’s
of psoriasis. They were also evaluated for
diabetes and hypertension during the
14-year follow-up.
A total of 1,813 subjects (2.3%) reported
having psoriasis; 1,560 (2%) developed
diabetes, and 15,724 (20%) developed
hypertension over the 14-year period. Those
with psoriasis were 63% more likely to
develop diabetes and 17% more likely to
develop hypertension than women without
psoriasis. The associations remained strong
even after controlling for age, body mass
index, and smoking (Qureshi AA, et al. Arch
Dermatol. 2009; 145(4): 379–382).
The authors posit chronic systemic
inflammation as the common factor underlying all three conditions. “These data illustrate the importance of considering psoriasis
a systemic disorder rather than simply a
skin disease,” they conclude. I couldn’t
agree more heartily. And isn’t it curious that
both psoriasis and atherosclerosis are characterized by plaque formation?
Callin’ Quits on Zits
Before and After photos of a patient with severe acne
the mucosal lining of the GI tract. In still
other’s it’s the skin. Problems don’t necessarily manifest until there’s a big hurricane,
but almost everyone has certain built-in
weaknesses where disease is most likely to
manifest when under stress.
Consider this: there are literally miles of
arteries in the body. Why does a fatty streak
and then an atherosclerotic plaque develop
only at specific loci? There are miles of Texas
highway: Why all the buzzards at one particular spot? The answer’s simple: Saprophytes and scavengers gather where there is
dead or dying tissue.
When someone is under stress, there is
increased adrenal output. This increases
blood sugar. If there is a weakened immune
system, yeast starts to proliferate. They secrete
gliotoxins that compromise macrophage
response. This opens the door for native
bacteria to proliferate, which in turn initiates an immune cascade and we’re off! The
same basic sequence occurs in acne, asthma,
coronary artery disease, and many others.
Plaques and Plaques
I’m certainly not the only one who believes
there is a connection between inflammatory
skin disorders and cardiometabolic disease.
Researchers first posited a correlation
between psoriasis and diabetes in 1908!
Over 100 years later, Abrar A. Qureshi, MD,
MPH, and colleagues at Brigham and Women’s Hospital and Harvard Medical School,
Boston have corroborated this link.
Dr. Qureshi’s group studied 78,061
women involved in the Nurses’ Health
Study II. The women ranged in age from 27
to 44 years in 1991 at the outset of the study,
and all were free of diabetes or hypertension. In 2005, they were given a survey that
included a question about lifetime history
Summer 2009
proliferate, these organisms produce
immunosuppressants that then pave the
way for other microbes that can then
cause acne, or set up the cascade for an
atheromatous plaque.
I encourage my patients to get off high
glycemic foods such as sugar, grains, cow’s
milk, sodas, fruit juice and other sweetened beverages. I advise them to eat more
blue, purple and dark red fruits and vegetables that are imbued with phytochemicals that inhibit fungal overgrowth. Regular
consumption of these healthful foods
helps maintain a homeostatic microbe balance in the skin and internally.
To get immediate resolution of the acne
(or rosacea, for that matter), I have patients
start using my “Touch My Face Masque,” a
combination of natural plant antifungals,
cell nutrients, and collagen promoters.
The Masque is very simple to use:
patients simply apply a few fingertip-fuls
after washing their faces with a mild soap
and hot water. The masque will need to
set for 2 hours, and it is easily removed
with a mild soap. It can be worn overnight, but make sure patients know to rub
it into the skin completely so that it does
not stain fabrics. After washing off the
masque, patients should apply a healing
oil, such as castor oil (my personal
choice), organic coconut or extra virgin
olive oil.
These topical treatments are not a cure,
but they will clear up acne break-outs
pretty quickly. The effect will not last,
however, unless the patient continues the
immune-system augmenting protocol discussed above. It took awhile, but the
patient shown in the accompanying pictures went through enough cycles of recurring acne that she finally cleaned up her
diet. Now she only has to use the Touch
My Face Masque before dates.
Photo courtesy of Dr. Roby Mitchell
Acne is certainly more common than psoriasis, and while I won’t go so far as to say
all teens with acne are at risk for heart disease, it is important to realize that the zits
reflect an inflammatory process that could
pose more serious problems later in life.
Bear in mind that the atherosclerotic process begins relatively early in life, many
years before it manifests as overt heart
disease.
When teens come to see me for treatment of acne, I take that opportunity to
make the connection with them between
diet and disease. I promise them that we
can make the acne go away if we work as
a team. My job is to make sure that any
hormonal or nutritional deficiencies are
addressed. Immune system function can
be compromised by deficiencies of thyroid hormone, zinc, selenium, vitamin
D3, iodine/iodide, essential fatty acids,
stomach acid, and beneficial gut flora.
Suboptimal levels of thyroid hormone,
which can occur in teenagers, will impair
conversion of b-carotene to vitamin. This
may manifest as carotenemia in palmar
and/or plantar surfaces. Adequate levels
of vitamin A are critical for optimal
immune function. If a patient has been
chronically hypothyroid and manifests
carotenemia, I will usually recommend
100,000 IU of micellized vitamin A
(American Biologics) for 1 month.
I put the onus on the patient to not
throw gasoline on the fire—and remember
that “inflammation” is derived from the
Latin word meaning “on fire”—by eating
foods that promote fungal overgrowth.
Native, benign yeast such as Candida
albicans and C. glabrata can, given the
right conditions, pleomorph into filamentous, migrating, pathogenic fungi. As they
Non-Surgical Knee Replacement
By Roby Mitchell, M.D. (DR. FITT)
ASK YOUR TAHOMA CLINIC DOCTOR
425-264-0059
Painful Bone
on Bone
Dark Space Indicates
New Cartilage Growth
NO
MORE
JOINT
PAIN
BEFORE
AFTER
AVAILABLE BY PRESCRIPTION AT D&S PHARMACY
For more information, go to:
www.dspharmacy.com
or call
806-352-2711
leaDinG tHe Way in
Summer 2009
ProBiotiCS
CliniCally DoCumenteD, PatenteD, anD Proven effeCtive!
Jarro-Dophilus
®
CDS
C linically D ocumented S trains
ProteCteD, targeteD
Probiotic Delivery – 20 Billion Per Capsule!
Jarro-Dophilus ® CDS is composed of seven (7) Clinically
Documented strains:
L. acidophilus LA-5
L. helveticus** R0052
B. lactis BB-12
B. breve M-16V
L. acidophilus LAFTI L10
L. rhamnosus R0011
B. longum BB536
These strains have been shown to provide a broad spectrum of
health benefits including promoting healthy digestive function,
enhancing intestinal defense, and supporting immune function.*
Fem-Dophilus
CliniCally DoCumenteD
to Support Female inner Balance!
Fem-Dophilus® is Jarrow Formulas® clinically documented
probiotic formula for women that has been shown to promote
vaginal and urinary tract health.* Fem-Dophilus® is backed by over
20 years of documented research.
Fem-Dophilus ® supplies patented Lactobacillus rhamnosus
GR-1®† and Lactobacillus reuteri RC-14®†, which colonize the
vaginal tract for optimum feminine balance.*
† Under license from Chr. Hansen A/S and protected by Chr. Hansen A/S and BioGaia AB patents WO 00/35465 and
WO 88/08452 patent families, and more.
Jarro-Dophilus® CDS features a scientifically sound formulation
and a special polysaccharide matrix delivery system that helps
to protect beneficial bacteria during transit through the stomach.
Each Jarro-Dophilus® CDS capsule contains a potent 20 billion
total probiotic bacteria.
Available at fine health food stores everywhere.
Couldn’t join us in Tucson?
You Can Still…
Learn Business Strategies
That Put the Health Back In Health Care!
Order Conference Audio/Video Recordings
Physician wanted, MD/DO, to join practice in
coastal region of Connecticut. Practice based on Integrated
Biological Medicine as practiced and taught by Thomas Rau
MD of the Paracelsus Klinic in Switzerland. Contact Frank
Suatoni MD: 203-315-1387/[email protected]
LEADERSHIP IN GREEN HEALTH CARE
Nurturing Tomorrow’s Environmental Leaders in Today’s Healthcare World
when:
where:
Right Now!
www.HolisticPrimaryCare.net
For more information contact us at
[email protected]
orDer ToDAY!
Online Course in
Environmentally Sustainable Medicine
2009 Course Dates
July 24 - September 18
OR
September 11 - November 6
www.teleosis.org
News for Health & Healing®
Don’t miss a single issue.
To continue receiving Holistic Primary Care
Go online and subscribe at
Request a subscription form or Free Digital PDF
at info@HolisticPrimaryCare
Or send
$19.95 for a one year subscription
$29.95 for a two year subscription to:
PO Box 953
Peck Slip Station
New York, NY 10272-0953
Don’t Miss the Latest News!
SubScribe Now
Continuing Education
credits are available for
physicians and nurses!
Learn Effective Strategies for
Integrating Affordable and Renewable
Green Health Care into your Consultations.
(510)558-7285
[email protected]