2005 Spring 2005 Volume 7, Issue 4

Nutrition In
Complementary Care
NCC
A D i e t e t i c P ra c t i c e G r o u p o f t h e A m e r i c a n D i e t e t i c A s s o c i a t i o n
Contents
Spring 2005 Volume 7, Issue 4
CPE:
Complementary &
Alternative Medicine and
Pediatrics: Focus on
Herbal Products and
Nutritional Therapy . . . .61
CPE Questions . . . . . . .79
Resource Review
. .78
Of Interest to
Members:
Complementary and
Alternative Medicine and
Pediatrics: Focus on Herbal
Products and Nutritional
Therapy
Sunita Vohra, MD FRCPC MSc
Janet Schlenker, BA Sc RD
Roberta Anding, MS RD LD CDE
Reprinted with permission: Copyright © 2004,
Thanks To Our Sponsors 66
Editorial Staff . . . . . . . .78
Key Contacts . . . . . . . . .80
New E-Newsletter for
Dietitians . . . . . . . . . . .77
Member Benefits . . .68,69
Functional Nutrition
Training and Education
Opportunity . . . . . . . . .68
Chair’s Corner
. . . . .62
Editor’s Notes
. . . . . .62
NEXT ISSUE
• Summer 2005
Editor’s Deadline, April 1
• Fall 2005
Editor’s Deadline, July 1
Page
Spring 2005 Volume 7, Issue 4
CPE Article:
61
Pediatric Nutrition Practice Grouprric
The use of complementary and
alternative medicine (CAM) in both
children and adults has been increasing dramatically.1-3 Pediatric health
care providers must inquire about
CAM, as parents may already be integrating treatments without disclosing
them.3-7 To promote communication,
it is important health care providers
are knowledgeable about the various
types and most commonly used CAM
therapies.
The definition of CAM is commonly accepted as a “broad domain of
healing resources that encompass all
health systems, modalities, and practices and their accompanying theories
and beliefs, other than those intrinsic
to the politically dominant health system of a particular society or culture
in a given historical period.”8 The
World Health Organization estimates
most of the world’s population regularly uses traditional medicine as first
line therapy, as opposed to conventional Western medicine.9 The
National Center for Complementary
and Alternative Medicine (NCCAM),
a branch of the National Institutes of
Health (NIH) in the United States,
classifies CAM into 5 main categories
or domains: 1) alternative medical systems, which are built on complete systems of theory and practice (e.g.
Traditional Chinese medicine and
Ayurvedic Medicine); 2) mind-body
interventions, which aim to enhance
the mind’s capacity to affect bodily
function and symptoms (e.g. meditation, prayer); 3) biologically-based
therapies (e.g. herbs, foods, and vitamins); 4) manipulative and bodybased methods (e.g. chiropractic or
osteopathic manipulation); 5) energy
therapies, such as biofield therapies,
which are intended to affect the energy fields that surround the human
body (e.g. qi gong, Reiki, and therapeutic touch) or bioelectromagneticbased therapies, which involve the
unconventional use of electromagnetic
fields (e.g. pulsed fields, magnetic
fields).10 The majority of this paper
cont. on page 63
CONGRATULATIONS!
Members of NCC who are
50 YEAR ADA MEMBERS
Lorraine S. Boykin
Evelyn Mar
Chair’s Corner:
Rick Hall, MS RD Chair 2004-2005
It’s Spring and I’m honored to be writing my final
note to you as Chair of the most dynamic dietetic practice group of the American Dietetic Association. As a
founding member, I’ve been a part of NCC since its
inception. Over the years, I’ve been continually
impressed with the breadth of knowledge from our
members. What I’ve learned the most over the past year
is the commitment NCC leaders truly have to this practice group and their dedication to the advancement of
the group as evidenced by through countless hours of
volunteer work.
It has been a privilege working alongside so many
professionals committed to the progression of complementary care. NCC offers many benefits to each of its
members, several of which became available only after
much effort by those who have been willing to lead specific projects through hours of conference calls, negotiations, and paper work. I want to offer a special thank
you to each of the volunteer leaders of NCC who continue to steer our group ahead in this cutting edge specialty area of nutrition.
As we move forward, NCC will soon see an influx of
new volunteers – led by the capable hands of Susan
Allen, our incoming Chair, and the other leaders members recently voted into office. I am more optimistic
than ever, as I witness the evolution of such a vibrant
community of nutrition professionals, that NCC will
continue to be in the forefront of complementary care
in ADA.
As many of you, I’m always eager to open my
newsletter from NCC. This issue is informative as ever,
complete with an interesting article on Complementary
and Alternative Medicine and Pediatrics: Focus on
Herbal Products and Nutritional Therapy. This topic
has been recently discussed on the NCC list serv, thus
its publication here is timely especially for those who
are not currently participating on the list.
As I bid you farewell as your Chair and I look forward to another great year as we continue to grow our
dynamic group. I hope to see many of you in St Louis
at the 2005 FNCE.
The views expressed in this newsletter are those of the authors and do not
necessarily reflect the policies and/or official positions of the American
Dietetic Association.
We invite you to submit articles, news and comments. Contact us for author
guidelines.
Send change-of-address notification to the American Dietetic Association,
120 South Riverside Plaza, Ste. 2000, Chicago, IL 60606-6995.
Copyright © 2003 Nutrition in Complementary Care, a Dietetic Practice
Group of the American Dietetic Association. All material appearing in this
newsletter is covered by copyright law and may be photocopied or otherwise
reproduced for noncommercial scientific or educational purposes only, provided the source is acknowledged. For all other purposes, the written consent of
the editor is required.
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Editor’s Notes:
Sarah Harding Laidlaw, MS RD MPA
Many of you may have been like I was growing up,
wishing to be another year older and having your parents say, “Don’t wish your life away, it will go fast
enough when you do get older.” I certainly feel that
time flying by now! This year has flown by and we are
preparing to begin another ADA year. With that preparation comes planning for the 2005-2006 newsletters
and for other activities such as FNCE in St. Louis this
October.
I would like to say farewell to Tamara Schryver,
Publications Chair for NCC for the past three years.
She stepped down from this position earlier this spring
and is completing her dissertation for her PhD from the
University of Minnesota. Tamara has been an asset to
the Practice Group with her knowledge of editing and
publishing. I have sincerely appreciated the knowledge
and patience she brought to the position. Thank you
Tamara for everything you have taught me and for all
you have done to make the newsletter, Web site, and
other publications of NCC what they are today.
On the same theme, I would like to welcome Laura
Lagano to the position of Publications Chair. She comes
to NCC with experience as editor of other Dietetic
Practice Group publications. I am looking forward to
working with and learning from Laura.
As I am planning this coming year’s topics and articles for the newsletter I would once again like to ask for
member input on topics as well as potential authors.
This is YOUR newsletter and my goal is to make it
responsive to your interests and need for information.
Because of some glitches in proposed articles for the
spring issue, the original theme was changed from complementary nutrition in cardiovascular disease to the use
of alternative therapies among the pediatric population.
The summer issue will now focus on cardiovascular disease. Articles for this topic are welcome until June 1,
2005. A big thank you to the Pediatric Nutrition
Practice Group for allowing NCC to reprint the excellent and timely article previously published in their
newsletter.
Please email me with suggested topics for the newsletter or to let me know of your interest in volunteering as
an author or to review books or other publications for
the newsletter. You may contact me at [email protected] or the old fashioned way by snail mail
at 1045 Raptor Circle Mesquite, NV 89027 or phone,
702-346-7968.
Page
Spring 2005 Volume 7, Issue 4
62
cont. from page 61
CPE: Complementary & Alternative Medicine & Pediatrics:
Focus On Herbal Products and Nutritional Therapy
will focus on biologically-based therapies, also known
as natural health products.
Natural Health Products
Generally speaking, natural health products
(NHPs) are used in the diagnosis, treatment, or prevention of disease, or maintenance and/or promotion
of health. It is important to note that the majority of
CAM use is without the guidance of a health care
provider (i.e. “self-help”). According to the Natural
Health Products Directorate of Health Canada2,
NHPs encompass:
a) A homeopathic preparation.
b) Substances used for traditional medicine.
Including, but not limited to, substances used in traditional Chinese medicine, traditional Ayurvedic
(East Indian) medicine, or North American aboriginal medicine.
c) Minerals, trace elements, vitamins, amino acids,
essential fatty acids, botanicals, and animal or
microorganism derived substances. The most commonly used natural health products include herbals
and vitamin/mineral supplements.
Incidence and Frequency of Usage
Herbal supplements are part of a growing trend of
patient-directed care in the United States. Herbal
supplement use in the United States is a multibilliondollar industry with sales of over 3.87 billion dollars
in 1998.11 Although sales in 2000 declined by 6.5%
due to negative publicity regarding safety concerns,
industry projections call for a 5-6% growth in the
upcoming years.12 In the United States, 60% of the
population uses some form of dietary supplement on
a daily basis.13 Surveys indicate that over 70% of
those taking supplements do not tell their primary
care provider of their supplement use, leaving both
the practitioner and client in a precarious position.14
This survey also indicated that 12% of adults use
herbal medicines and 5.5% use megavitamins.
Additionally, 20% of those taking herbal medications
also take a prescription medication placing them at
risk for a drug-herb interaction.15
As with the adult population, there is an increased
use of CAM by children and adolescents. “Motivating
factors for using CAM vary by age group and the
extent of parental involvement” thus use of CAM by
parents is predictive of its use in infants and young
children.16 The most common illness that CAM was
used for in young children was upper respiratory illness. Children with chronic or incurable illnesses have
higher usage rates of CAM than their healthy counterparts. CAM use has been reported among 46% of
children with cancer, 55% of children with asthma,
66% of children with cystic fibrosis, 70% of children
with juvenile rheumatoid arthritis, 41% of children
and young adults with inflammatory bowel disease,
20% of children with attention deficit hyperactivity
disorder (ADHD) or depression, more than 30% of
children with autistic spectrum disorder (ASD), and
56% of children with cerebral palsy.17-23
Although adolescents may use CAM for illnesses,
there is also an increasing use of herbal preparations
for a legal “high.” The Internet is a source of nutrition and health information for teens, and information on how to procure and utilize biologically active
compounds abounds. Herbal preparations abused for
this purpose include wormwood, nutmeg, valerian,
catnip, ginseng, and “herbal ecstasy,” which is a combination of caffeine and ephedrine/pseudoephedrine.
Additionally, goldenseal is purported to be a masking
agent for drug tests.24
The Food and Drug Administration (FDA) recently
released a list of supplements that consumers should
not purchase because they contain harmful ingredients, yet are currently being promoted as safe and
legal alternatives of illicit drugs. Included in the list
are products such as Trip2Night, Invigorate II,
Snuffadelic, Liquid Speed, Solar Water, Orange
Butterfly, Smooz, and Green Hornet.25 In addition
to plant-based biologically active compounds, other
ingredients include high levels of diphenhydramine
and dextromethorphan, which are found in over the
counter cold preparations, and gammahydroxybutrate
(GHB) commonly known as the “date-rape” drug.
Dietitians and healthcare providers should routinely
assess for the use of CAM in children and adolescents. See Table 1.
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Spring 2005 Volume 7, Issue 4
cont. on page 65
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Spring 2005 Volume 7, Issue 4
64
cont. from page 63
Issues related to product quality, regulatory standards, and adverse events
Standardization
Lack of standardization is a major difference
between NHPs and pharmaceuticals. NHP heterogeneity can be attributed to a number of factors: 1)
species that are collected in error, (i.e. misidentification), 2) different collection methods, (i.e. aerial vs.
root of plant), 3) different extraction techniques, (e.g.
aqueous vs. alcoholic), and 4) product impurity.
Contamination and batch-to-batch variation in purity
and potency are major concerns. For example, heavy
metal poisoning from traditional Chinese medicines
has been reported several times.26-28 Other studies
examining the quantity of active ingredient across
brands found from 0-200% of the label claim.29
Frequent surveillance by consumer groups show significant issues regarding standards and labeling issues.
Consumer Labs routinely analyzes popular dietary
supplements, over 50% of the supplements tested fail
to meet their own labeling standards. Regulatory
standards to deal with these issues vary between
countries; we will explore the regulatory standards
adopted in Canada and the United States.
In June 2003, Canada approved new regulatory
standards for NHPs, which encompass guidelines for
issuing product licenses, site licenses, and good manufacturing practices (GMP). The GMP for NHPs
describes government standards for premises, equipment, personnel, sanitation, operations, quality assurance, stability, and record keeping of NHPs. The regulations also discuss clinical trials of NHPs with
human subjects. Specific requirements for clinical trials include pre-approval by the regulatory agency,
defining sponsor obligations, and guidelines for
reporting adverse events. NHP manufacturers have
until December 31, 2009 to adhere to these regulatory standards. There remains concern that Canadian
researchers do not know they need to seek regulatory
approval prior to NHP research. Also, Canadian
health care providers do not know they can (and
should) report adverse events related to natural health
products.30 The standards adopted by Canadian regulators were set to distinguish NHPs from foods and
from conventional pharmaceuticals, both of which
are regulated differently than NHPs. As stated in the
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Spring 2005 Volume 7, Issue 4
CPE: Complementary & Alternative Medicine & Pediatrics:
Focus On Herbal Products and Nutritional Therapy
regulatory document, “these Regulations are intended
to provide Canadians with ready access to products
that are safe, effective, and of high quality, while
respecting freedom of choice and philosophical and
cultural diversity.”31 The regulatory burden is not
eased by exponential growth in the number of CAM
products or practices available.
American Regulations and Herbal and Dietary
Supplement Guidelines
The passage of the Dietary Supplement Health and
Education Act (DSHEA) in 1994 significantly
changed the way U.S. herbal and dietary supplements
are regulated. This has overriding affects for practitioners wishing to integrate products into their pediatric practices. Prior to 1994, the FDA regulated
herbs as food additives and over 250 herbs were classified as “generally regarded as safe” (GRAS). In the
early 1990s, the FDA threatened to remove herbalbased medicines from the GRAS list and stated that
when food additives are used as pharmacotherapy,
they should be classified and regulated as drugs. The
passage of DSHEA was, in part, the public’s response
to this impending removal. As a consequence, the
burden of purity, safety and efficacy has shifted from
the manufacturer, as with conventional pharmaceuticals, to the FDA, such that the FDA must prove a
product is dangerous or poses an unreasonable health
risk before it can be removed from the market.
Despite this added responsibility, the FDA was not
allocated additional budget or staff to address these
concerns. As a consequence, at the present time, the
FDA can only react to safety issues rather than proactively address and prevent them.
Three factors combine to increase the likelihood of
drug-NHP interactions. First, patients with serious,
chronic, or recurrent illness are most likely to use
CAM.14,32 These are also the patients most likely to
be on prescription medications. Second, most
patients using CAM use it to complement their
health care, not replace it.14,32 Third, research confirms that a substantial proportion of individuals who
use NHPs use more than one simultaneously.3,33
Lessons learned from experience with drug interactions, whereby the likelihood of an adverse event
increases exponentially as the number of medications
increases,34 would predict that this scenario makes
such patients likely to experience an adverse event.35,36
cont. on page 66
cont. from page 65
CPE: Complementary & Alternative Medicine & Pediatrics:
Focus On Herbal Products and Nutritional Therapy
Adverse Events and NHPs
The recent ban on ephedra highlights some of these
issues. Ephedra, or ma huang, has been used in traditional medicines for thousands of years, primarily for
the treatment of asthmatic or upper respiratory conditions. There have been few reported safety issues
possibly due to the traditional preparation of this
herb. However, analysis of commercial ma huang
products have shown lot-to-lot variations, labeling
inconsistencies and one product having no detectable
active ingredient.37,38 Side effects were rarely listed on
the label and can be considerable for those using ma
huang based products. Side effects include insomnia,
dry mouth, headache, and hypertensive episodes leading to seizures or strokes.39 Dosing recommendations
may be listed on the label, but rarely are given for the
pediatric population. Drug-herb interactions can be a
significant problem and often these contraindications
are not listed on the label for consumers to make
informed choices for their children. In a recent survey
of herbal therapy use in a pediatric emergency room
setting, 5% of those reporting gave ephedra to their
child. The most dangerous drug-herb interaction is
between ephedra and albuterol.40
NUTRITION IN COMPLEMENTARY CARE
Web site: www.ComplementaryNutrition.org
Member Electronic
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Contact Gretchen Forsell
to get connected
([email protected])
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While the lack of regulatory oversight is a significant factor in the adverse reactions reported, consumer belief that “natural” equates to safe or harmless
must be viewed as a contributing factor. In 1996,
400,000 cases of herbal or homeopathic poisonings
were reported to poison control centers.41 Although
data is lacking on the frequency of poisonings in
pediatrics, herbal medicines are rarely packaged in
child resistant packaging.42 Some herbal medications,
albeit “natural,” are inherently dangerous and should
be avoided based on their pharmacological actions
and adverse consequences. Of the toxicities reported,
hepatotoxicity was the most common.43 An example
of a commonly used naturally-occurring hepatotoxin
is germander. Often recommended as an antipyretic
and as a weight reduction aid, germander contains
hepatotoxic alkaloids, which can cause hepatocyte
necrosis and cell death.44 Another popular herb known
to be a liver toxin, is chaparral. Chaparral, used by
Native Americans for centuries as a “blood purifier,”
has been linked to at least 18 adverse effects reported
to the FDA with hepatotoxicity evident in 13 cases.
The pattern of liver injury was consistent with drugcont. on page 68
Vitamin Nutrition Information Service (VNIS)
SILVER
Almond Board of California
National Starch & Chemical Co.
BRONZE
OatVantage
Pioneer Nutritionals
Solgar
FRIENDS OF NCC
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Canyon Ranch
Wild Oats Natural Marketplace
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Spring 2005 Volume 7, Issue 4
66
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Spring 2005 Volume 7, Issue 4
CPE: Complementary & Alternative Medicine & Pediatrics:
Focus On Herbal Products and Nutritional Therapy
induced hepatitis with two patients experiencing acute
fulminant failure requiring liver transplantation.45 The
issues are pervasive throughout the industry and present real challenges for pediatric practitioners attempting to integrate CAM into their practice.
Usage of Vitamin/Mineral Supplements and
Special Diets
Dietary supplements can cause problems related to
nutrient excesses, nutrient imbalances, or adverse
interactions with medical care.46 It is critical to determine the safety of the supplements for use in children. The usage of multivitamin-mineral supplements
has been growing in popularity. There is little scientific evidence of benefit or harm to the average person
using low dose multivitamin-mineral supplements in
amounts that do not exceed 100% of recommended
Functional Nutrition Training
and Education Opportunity
This year, the Clinical Nutrition Certification Board
(CNCB) will once again offer its Post Graduate Studies in
Clinical Nutrition program (PGSCN) to candidates for the
Certified Clinical Nutritionist (CCN) designation. Although
specially scheduled programming is no longer offered to
RDs, the CNCB board will still extend a substantial $1000
discount (a 22% savings) exclusive to RDs who are members of NCC DPG. This advanced training is offered in Feb,
April and June of 2005 in either Phoenix, AZ, Orlando, FL
or Tampa, FL (more dates and locations may be added). The
program offers 27 CEUs for each weekend of training (56
in all). PGSCN’s specific listing of content in functional
nutrition training is listed on page 13 of the CCN exam
candidate handbook which can be accessed at
www.CNCB.org. Please call (972) 250-2829 or visit their
website for more information.
cont. from page 66
intake levels (Recommended Dietary Allowance [RDA] and Adequate Intake). People consuming
both highly fortified foods and multivitamins can easily consume 300% of the RDA/AI for many known
nutrients. Dietitians should provide guidance to consumers concerning the intake of nutrients from both
fortified and unfortified foods and supplements.47
The Dietary Reference Intakes (DRIs) also include
Tolerable Upper Intake Levels (ULs) for many nutrients; intakes above the UL are not safe.
There is the ongoing challenge for parents of children with chronic illness or special needs to decode
the conflicting information and claims from many
anecdotal stories and communications on the Internet
and buying clubs.
Vitamin and mineral supplements are popular for
usage in children with Down syndrome (e.g.
NuTriVene-D ® International Nutrition
Maryland),48-50 ASD (e.g. vitamin B6 and magnesium supplements),51,52 ADHD (e.g. megavitamin or
fatty acid supplementation),53, 54 cystic fibrosis (e.g.
neutraceuticals and glyconutrients),55 diabetes (e.g.
vitamin/trace elements for glycemic control),56 cancer (e.g. megadose supplements and as part of a program from Centre for Integrated Healing).57,58
cont. on page 69
MEMBER BENEFIT
The University of Arizona is offering NCC members
a great opportunity for learning! “Nutrition & Cardiovascular
Health” - a 16.5 CPEU online course offered by the Program in
Integrative Medicine. Sign up online at:
www.integrativemedicine.arizona.edu and receive a 10% discount.
To obtain the discount use the code: NCC1
Page
Spring 2005 Volume 7, Issue 4
68
cont. from page 68
Unfortunately, conclusive, well-designed studies to
determine whether particular nutritional supplements
can achieve the goals claimed by manufacturers are rare.
Research of vitamin and mineral supplements has also
been hindered by a lack of accurate and meaningful
assays that detect functional micronutrient deficiencies.
Dietary restrictions for treatment of ASD have been
reported to reduce the behavioral symptoms of
autism, but there is limited support for the use of
specialized diets like the casein-and or gluten-free
diet, which is based on the “excess opioid peptide
theory.”59 Also there is the risk of amino acid deficiencies.60 The theory backing the therapy remains
unproven and controversial, and further research is
needed to determine the type of child that might
benefit from these interventions.61
Over the years, various dietary therapies have been
proposed as causes and/or treatment for ADHD.53
There were conflicting and puzzling results from
studies using restrictive diets like the Feingold Diet.
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Spring 2005 Volume 7, Issue 4
CPE: Complementary & Alternative Medicine & Pediatrics:
Focus On Herbal Products and Nutritional Therapy
Restrictive diets may limit a child’s food selections
leading to deficiencies. But the usage of foods in less
processed forms along with reduction in sugar and
sweets may be positive for not only the child with
ADHD but also for the whole family. Children with
food allergies may exhibit behaviors such as irritability and decreased attention. Food allergies have not
been determined to be a factor in ADHD.53 Parents
of children with chronic illness or special needs
should be encouraged to consult with their primary
care physician before introducing any new treatment,
medication, or dietary supplement into their child’s
regimen, or before removing a prescribed therapy
from their treatment plan. See Table 2 - Alternative
Nutritional Therapies.
Reliable Sources of Information
Fortunately, for those seeking pediatric specific
information, recent work has identified hundreds of
published randomized controlled trials (RCTs) that
cont. on page 72
TABLE 1 - Herbal Products illustrates the typical use, dosing, side effects, known drug interactions and
contraindications of the most popular herbal medicines. The research studies listed used purported
active ingredients and may not represent the actual products available to consumers.
Herb
Cranberry
Typical Usage
1
Echinacea 2
Ephedra 3
Garlic 5
• Prevent and treat urinary tract infections
• Antioxidant
• Supportive therapy for colds and chronic infections
of the respiratory tract and lower urinary tract
• Wound healing
• Immune stimulation
• Antimicrobial
• Weight Loss
• Performance enhancement
• Energy
• Asthma
Dosing(Daily unless otherwise)
Side Effects
• 7.5 g concentrate in 50 ml
• None known
• Not standardized
• Dried extract: 300-400 mg 3 times per day
• Tincture: 30-50 drops (1 drop = 20 L) 3 times per day
• Parenteral: short-term fever
reactions, nausea and vomitting
• Anaphylaxis (rare)
• Adults: Herb preparations corresponding to 15-30 mg
total alkaloid
• Children: Herb preparations corresponding to 0.5 mg
total alkaloid per kg of body weight
• Insomnia
• Motor restlessness
• Irritability
• Headaches
• Nausea and vomiting
• Disturbances of urination
• Tachycardia
• Gastrointestinal symptoms
• Mild side effects: halitosis, body odor,
topical irritations
• Allergy (rare)
• Reducing cholesterol and triglycerides
• Preventative measure for age-dependent
vascular changes
• Mild antihypertensive
• Antiplatelet
• Antioxidant
• Antimicrobial
• Cancer prevention
• Memory deficits, disturbances in concentration
dizziness, headaches
• Antioxidant
• Fresh cloves: 0.5-1
• Pills: 600-900 mg, standardized to 0.6%-1.3% allicin
• Powder: 0.4-1.2 g
• Use extract standardized to 6% terpenoids, 24%
flavonoids 40-80 mg 2-3 times per day
• Stomach or intestinal upset
• Headaches
• Allergic skin reaction
Ginseng 7-8
• Endurance/adaptation enhancer
• Enhances “quality of life”
• Immune/endocrine stimulant
• Root: 1-3 g
• Pills: 100-300 mg three times per day, extract
standardized to > 7% ginsenocides
Kava 9-10
• Euphoric effect
• Stress
• Wide therapeutic window
• 70-240 mg of dried root extract every day
Goldenseal 11
• Antibacterial/antiviral, ineffective
• Often combined with Echinacea which
drives sales data
• Topical antibiotic
• Mouth sores and sore throats
• Mild to moderate depressive states,
restlessness, anxiety and irritability
• Antimicrobial
• Wound Healing
• Treatment of alcoholism
• As topical preparation, apply cream adequate to
cover wound
• For sore throats and mouth sores 0.5-1.0 g in a cup
water
• Diarrhea
• Euphoria
• Headache
• Hypertension
• Hypotension
• Insomnia
• Mastalgia
• Nausea
• Vaginal bleeding
• Reversible yellowish discoloring of
skin, nails and hair (chronic abuse)
• Visual disturbances
• Dizziness
• Gastrointestinal discomfort
• Extrapyramidal effects (rare)
• Hepatitis
• Photosensitivity
Ginko Biloba 6
St. John’s Wort 12
Valerian 13
• Sleep aid
• Spasmolytic
Evening Primrose Oil 14 • Premenstrual Syndrome
• Cyclical breast pain
• Diabetic neuropathy
• Rheumatoid Arthritis (RA)
• Atopic dermatitis
• Tablets: 320 mg three times per day of extract
standardized to 0.3% hypericin
• Topical
• Photosensitization: especially in fair
skinned individuals
• Cataracts may be a long term
consequence
• Capsules: 400 mg at bed time as necessary
(> 12 years)
• Tea: 2-3 g = 1 tsp 3 times per day
• Tincture: 3-5 ml 3 times per day
• Headache
• Palpitations
• Insomnia
• 2-4 grams
• Active ingredient is Gamma Linolenic acid
• Nausea, best taken with food
• Belching, bloating
1. Reed, J. Cranberry flavonoids, arteriosclerosis and cardiovascular health. Crit Reve Food Sci Nut 2002; 42:301-16.
2. Lindenmuth, GF Lindenmuth EB. The efficacy of Echinacea compound herbal tea on the severity and duration of upper respiratory and flu symptoms: a randomized, double blind placebo controlled study.
J. Altern Complement Med 2001; 6:327-34.
3. Greenway, FL, DeJonge, L, Blancard, D, Frisard, M, Smith, SR. Effect of a dietary herbal supplement containing caffeine and ephedra on weight, metabolic rate and body composition. Obesity Research
2004; 12:1152-7.
4. Naik SD, Freudenberger, RS Ephedra-associated cardiomyopathy. Ann Pharmacother 2004; 38:400-3.
5. Ali M, Thompson M. Consumption of a clove of garlic per day could be beneficial in preventing thrombosis. Prostaglandins, Leukotrienes Essential Fatty Acids 1995; 53:211-212.
6. Solomon PR, Adams F, Silver A, Zimmer, J DeVeaux, J. Ginko for memory enhancement: a randomized controlled trial. JAMA 2002; 288:835-40.
7. Sparreboom A, Cox MC, Acharya MR, Figg WD. Herbal remedies in the United States: potential adverse interactions with anticancer agents. J Clin Oncol 2004; 22:2489-503.
TABLE 1 - Herbal Products illustrates the typical use, dosing, side effects, known drug interactions and
contradictions of the most popular herbal medicines. The research studies listed used purported
active ingredients and may not represent the actual products available to consumers.
Drug Interactions
Contraindications
Research
• None known
• Allergies
• May decrease effectiveness of immunosuppressant medication
• Progressive systemic diseases, such as HIV, tuberculosis, • Although Echinacea may be efficacious, trial data
leukosis, and multiple sclerosis
is weak and inconclusive
• Allergies to the herb
• Species of Echinacea determines effectiveness
• No effectiveness noted in catheterized children
• Do not use with MAO inhibitors or cardiac glycosides 4
• Associated with deaths related to myocardial infarction
and stroke
• Combination of ephedra and caffeine-containing
herbs can cause dry mouth, heart palpitations,
changes in blood pressure and insomnia in some
subjects
• Recently banned by FDA however, available
through internet sites
• Changes pharma-cokinetic variables of paracetamol
• Decreases blood concentrations of warfarin
• Produces hypoglycemia when taken with chloropropamide
• May increase bleeding time with aspirin
• Garlic should not be consumed prior to surgery
• Increases the anticoagulant effect of warfarin
• Dozens of trials suggest, but have not adequately
proven, that garlic can decrease the risk factors
for atherosclerosis
• Garlic is considered safe by the FDA, based on the
lack of known serious adverse outcomes
• Bleeding when combined with warfarin and aspirin. Do not
use with non-steroidal antiinflammatory drugs
• Raised blood pressure when combined with trazodone
• May enhance the action of platelet-aggregation inhibitors
• Decreased effectiveness of anti-cancer medications & warfarin
• Induces mania if used concomitantly with phenelzine
• May decrease effectiveness of antihypertensive & antiestrogens
• May potentate effects of CNS stimulants and hypoglycemic
agents
• May also decrease the effectiveness
of immunosuppressant and potentate
the effectiveness of slidenafil
• Hypertension, cardiovascular disease
• Hypotension
• Diabetes mellitis
• Encouraging data, but currently no compelling
evidence shows that ginko enhances normal
cognitive function
• Has shown to be beneficial in treating dementia
• Poor evidence to support the usage of Ginseng as
as an ergogenic aid or as an energy enhancer
• Ginseng abuse syndrome often reported as a side
effect but quality of original research was limited
• Increases “off” periods in Parkinson patients taking levodopa
and can cause a semicomatose state when given concomitantly
with alprazolam
• Children <12 years of age, renal disease,
thrombocytopenia, neutropenia
• Becoming an herb that is abused by adolescents
seeking a legal high
• In two small trials, results suggested that shortterm administration of kava is effective in reducing
anxiety
• No serious drug interactions known
• May cause jaundice and should be avoided by those
with elevated bilirubin levels
• Women of childbearing age
• No evidence showing goldenseal stimulates the
immune system. Systemic absorption of this herb
is poor
• Significant lot-to-lot variation
• Lowers blood concentrations of cyclosporine, amitrityline,
digoxin, indinavir, warfarin, phenprocoumon & theophylline
• May cause intermenstrual bleeding, delirium or mild serotonin
syndrome, respectively when used concomitantly with oral
contraceptives, lopeamide or serotonin-reuptake inhibitors. List
of drug interactions is substantial
• Should not be taken with other sedatives or before driving or in
situations where alertness is required
• May take up to 4 weeks to be effective
• Caution when taking serotonin uptake inhibitors
• Known photosensitivity
• Do not give to children
• Several studies report St. John’s Wort as an
effective treatment for mild to moderate depression
• Pregnant women due to cytotoxic and mutagenic activity
in vitro
• May lower seizure threshold in patients taking anticonvulsants
or tricyclic antidepressants
• May affect platelet aggregation and should be used with
caution with nonsteroidal anti-inflammatory drugs and
anticoagulants
• In 2 randomized, blind, and placebo controlled
trials, valerian resulted in significantly improved
sleep quality and decreased sleep latency, with no
residual sedation in the morning
• Independent testing has shown valerian prepara
tions may be contaminated with cadmium and lead
• Little solid data to support use in PMS
• Conflicting data on use in RA
8. Block KI, Mead MN. Immune system effects of Echinacea, ginseng and astragalus: a review. Integr Cancer Ther 2003; 2:247-67.
9. Almeida JC, Grimsley EW. Coma from the health food store: interaction between kava and alprazolam. Ann Intern Med 1996; 125:940-1.
10.Wooltorton E. Herbal Kava: reports of liver toxicity. Canadian Medical Association 2002; 166:777-80.
11.Edwards DJ, Draper EJ. Variations in alkaloid content of herbal products containing goldenseal. J AM Pharm Assoc 2003; 43:419-23.
12.Bilia AR, Gallori S, Vincieri FF. St. John’s Wort and depression: efficacy, safety and tolerability - an update. Life Science 2002; 70:3077-3096.
13.Gutierrez S, Ang-Lee MK, Walker DJ, Zacny JP. Assessing subjective and psychomotor effects of the herbal medication valerian in healthy volunteers. Pharmacol Biochem Behav 2004; 78:57-64.
14.Johnston GA, Bilbao RM, Graham-Brown, RA. The use of dietary manipulation by parents of children with atopic dermatitis. Br J Dermatol 2004; 150:1186-9.
CPE: Complementary & Alternative Medicine & Pediatrics:
Focus On Herbal Products and Nutritional Therapy
children.62
investigate NHPs in
The four journals
that published the largest number of pediatric NHP
RCTs were American Journal of Clinical Nutrition,
Pediatrics, Journal of Pediatrics, and Lancet. Medline
indexed 93.2% of these RCTs, suggesting that the
RCT-level evidence is easily accessed if you look for
it.63
Some RCTs demonstrated the effectiveness of certain NHP aspects in the pediatric population, however many of these studies suffer from inadequate
methodological rigor.64 Although some of these
methodological issues are shared with RCTs in conventional medicine, their persistence promotes ongoing skepticism of NHPs. See Table 3 - Where to Find
the Evidence - Reliable Sources.
How to Discuss CAM With Parents
The American Academy of Pediatrics Committee
on Children with Disabilities has developed a statement regarding “Counseling Families Who Choose
Complementary and Alternative Medicine for Their
Child with Chronic Illness or Disability.”65 The following points from the statement can be used as a
guide to follow when discussing CAM with patients
and their families:
1. Ask about use: inquiring does not equal endorsing use.
2. A non-judgmental attitude is preferred.
3. Seek information for yourself and be prepared to
share it with families.
4. Evaluate scientific merits of specific therapeutic
approaches.
5. Identify risks or potential harmful effects (including opportunity costs, whereby known effective
therapies are not pursued, and financial burden).
6. Provide families with information on a range of
therapeutic options (avoid therapeutic nihilism).
7. Educate families to evaluate information about
all treatment approaches.
8. Avoid dismissal of alternative therapies in a way
that communicates a lack of sensitivity or concern for the family’s perspective.
cont. from page 69
9. Recognize feeling threatened and guard against
becoming defensive.
10.Offer to assist in monitoring and evaluating the
patients in ongoing follow-up.
Future Research in Pediatrics and CAM
There is an urgent need to collect safety and efficacy data about CAM in children. Frequently quoted
obstacles to CAM research include limited clinical
data, lack of standardized products, complex interventions that are highly dependent on the individual,
and concerns about the applicability of traditional
research methodology.66-68 Issues related to safety,
including dosing, are critical in pediatric research.
Whereas research in conventional pharmaceuticals has
typically occurred in a sequence of animal and then
adult human studies before exposing children, the
research agenda in children should reflect the fact
that children are already exposed to NHPs. NCCAM
supports rigorous research on CAM, trains researchers
in CAM, and disseminates information to the public
and professionals on which CAM modalities work,
which do not, and why.1 Criteria used by NCCAM
to prioritize research opportunities include quantity
and quality of preliminary data, extent of public use,
public health importance of disease being treated, feasibility, and cost.69 Pediatric CAM research priorities
have been identified as those already widely used by
children and families, those previously researched to
some extent in animal models and adults, and those
with a potentially significant risk of substantial costs
or side effects.70 One could also add to this therapies
of potentially significant benefit or interaction with
conventional therapeutic approaches. Since it is often
not known what CAM therapies are being taken by
sub-populations of children, there are renewed efforts
by some funders to identify utilization data.71 Since
CAM is a patient-led phenomenon, it is appropriate
to guide research priorities accordingly.
Where to Go From Here
The work to be done to improve pediatric CAM is
enormous and varied in scope. Educational initiatives
are needed at every level. For example, consumers
need to be informed about issues related to product
heterogeneity and quality, as well as variations in
cont. on page 74
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Spring 2005 Volume 7, Issue 4
72
TABLE 2 - Alternative Nutritional Therapy (special diets or vitamin/mineral supplements)
Reason for Usage or Claims
Contradictions or Concerns
Research/Comments
• Down Syndrome
(DS) 48,49,50
Condition
Diet or Vitamin/Mineral Supplements
Targeted Nutrition Intervention (TNI)
Example - NuTriVene-D® (International Nutrition
Maryland)
Improved health, growth, and immune function,
cognitive enhancement, prevention of
amelioration of long term degeneration
and disability
A typical TNI supplement contains about
56 nutrients including vitamins, minerals,
enzymes, amino acids, electrolytes etc.
Some of the vitamin/minerals contents
exceed the recommended intake levels and
other compounds do not have any established recommended intakes.
There has been no consistent or
rigorous proof that any form of
nutritional supplementation improves
the outcome in DS. There is increasing
evidence to suggest that increased
oxidative stress may be involved in the
pathology of DS. Therefore clinical trials
are needed to evaluate the hypothesis
that antioxidant supplementation may
improve the outcome in DS.
• Cystic Fibrosis
(CF) 55,56
Mannatech ® Optimal Health Products (OHP),
“neutraceuticals and “glyconutrients” products are
based on the aloe vera plant. The key ingredient in
the product is Ambertose, “a patent pending blend of
specific plant-based complex carbohydrates that
contain sugars necessary for the proper glycosylation
of cellular proteins.”
Carbohydrate Metabolism: When adequate
glucose is not available (as in fasting or high
level energy expenditure), amino acids are
converted to glucose through the process of
gluconeogenesis. Marketing Claims: Acknowledgement that we can synthesize the carbohydrate in Ambertose, but indicates many elements (toxins, stress, drugs, virus, and other
“invaders”) can interfere in the conversion process and “may leave the body without all the
necessary carbohydrate to form proper cell-tocell words.”
Aloe Vera is unstable and inactivated
when processed.
Cystic Fibrosis (CF) Foundation response was that Mannatech Optimal
Health Products (OHP), have been
promoted as a possible treatment or
cure for CF. Whereas these products
may have health benefits for some
people with CF, there is very little scientific evidence to corroborate these claims.
In addition, there is no data as th the
safety of these supplements when taken
in high doses for a period of time.
(Communication with Susan Casey RD,
April 23, 2004. Children’s Hospital and
Regional Medical Center, Seattle, WA.)
Gluten and Casein-free diet is based on the
“excess opiod peptide theory” In theory, autistic
symptoms are thought to be due to opiod
peptides (gluten and casein can become opiod
peptides) entering the blood stream through the
“leaky gut” and reaching the brain or there
could be lack of enzymes to break down the
proteins properly. Too much opiod may have an
undesirable effect in the brain and contribute to
autistic-like symptoms.
To diminish undesirable behaviors and to
improve attention, speech, sleep patterns, eye
contact, reduce hyperactivity and self-stimulation
and improve health.
Elimination diets can be potentially harmful
in young children, there is concern that such
treatment without appropriate guidancce may
result in compromised nutritional status and
impaired growth. Additionally, given that children with ASD tend to be more selective eaters due to behavioral issues than other children, nutritional concerns should remain a
priority in this population.
The theory backing the therapy remains
unproven and contraversial, further
research is needed to determine the type
of child that might benefit from these
interventions. Recent research suggests
that restricted diets may exacerbate the
essential amino acid deficiencies identified in children with ASD.
The vitamin B6 is given along with magnesium
to counterbalance the deficiency of magnesium
that megadose B6 can induce. Overall toxicity
of the B6 has been rare but acute doses have
been known to cause ataxia, loss of fine motor
control, changes in gait and peripheral
neuropathy in humans.
Cochrane review in 2003 concluded that
there was no evidence of an acceptable
high level to state that a combination of
Vitamin B6 and magnesium improves
the behavior or social and communication skills of children with autism.
Restrictive Diets - Feingold Diet or Food Additives
and Salicylates free diets. Later other restrictions
were added like preservatives, sugar, milk and any
other food that the child could not tolerate.
To reduce hyperactivity behavior.
The restrictive diets are being used for a variety of problems leading to possible deficiencies from limiting selections of foods. Families
should work with a dietitian and other health
professionals if the child’s diet is being altered
or restricted for behavioral management.
Earlier results appeared positive but the
studies were not controlled and the positive results reported were believed to be
a placebo effect.
Fatty Acid Supplementation - DHA
(docosahexaeonic acid)
Proposed that altered fatty acid metabolism may
occur in some children with ADHD. Some children with ADHD may have essential fatty acid
deficiency.
Mega Vitamin Therapy (especially Vitamin B6,
thiamine, magnesium, zinc and iron)
Claim that the children with ADHD and learning
problems have biochemical imbalances and that
these disturbances can be eliminated by mega
vitamin therapy.
The use of mega vitamins can be dangerous
leading to liver toxicity. In addition, families
may spend a lot of money on vitamins without
addressing the basic problems related to the
behavior issues.
Diabetes 56
Vitamin/trace elements including Chromium most
studied, L-Carnitine and Vanadium less conclusive
For glycemic control in Diabetes Chromium’s
action is linked with glucose tolerance factor
(GTF) and has been shown to increase the
number of insulin receptors, to enhance receptor
binding, and to potentiate insulin action.
No reported adverse effects from the
chromium used in the trials.
Chromium has been studied the most
but without reliable assays to check for
deficiencies, these theories have been
difficult to test. L-Carnitine and Vanadium
preliminary studies have been promising
but warrant further study.
Cancer 57,58
Centre for Integrated Healing “Holistic healing”
program. Diet is one part of the program. They
prescribe vitamins and minerals and guidelines
for a “healthy diet”. Part of the guidelines stress
minimal dairy and minimal animal fat consumption.
Their philosophy is to eat “whole foods that
nature provides - avoid refined, processed and
adulterated foods.”
Supplements are prescribed at very high levels
(e.g., up to 12 grams vitamin C, 50,000 IU
beta-carotene, and 1600 IU vitamin D daily).
There is concern with recommendations for
usage of mega vitamins and minerals. For a
child who needs extra energy, megadoses
should be avoided.
The program advocates for individualization, but the recommendations made
are often based on anecdotal information
without scientific research to back them
up. There is concern that a patient will be
compromising their care from standard
therapy when they are on this program.72
Gluten and Casein-free Diets
• Autism Spectrum
Disorder (ASD) 59,60,61
Vitamin B6 - Magnesium used in treatment of ASD
Attention Deficit
Hyperactivity
Disorder
(ADHD) 53,54
A recent, randomized, double blind, placebo controlled study trial was conducted
in 63 children where children were given
DHA or placebo for 4 months. However,
there was no statistically significant improvement in any objective (attention
tests) or subjective measures (parent
evaluations of behavior) of ADHD
symptoms.
Additional controlled studies have not
indicated any benefit from mega vitamin
therapy for ADHD.
cont. from page 72
CPE: Complementary & Alternative Medicine & Pediatrics:
Focus On Herbal Products and Nutritional Therapy
practitioner educational backgrounds that are exacerbated when their field is not regulated. Trainees, both
conventional and complementary, need an opportunity for cross-training, so they may learn about issues
critical to shared patient care. Health care providers
must be encouraged to ask about CAM use and be
aware of potential interaction and/or synergy between
natural health products and conventional medications. Policy-makers need to continue to refine regulations of both CAM practitioners and products, so
the public has access to safe CAM therapies. Research
opportunities are many and varied, and in recent
years additional funding has become available.
Improved dissemination of research results would
promote consumer and health care provider knowledge. Fortunately, pediatric CAM research and education is garnering more attention across North
America, and will help promote the safe and
informed use of CAM in children.
Sunita Vohra MD, FRCPC, MSc is Director, CARE
(Complementary and Alternative Research and
Education) Program Stollery Children’s Hospital and
Associate Professor of Pediatrics University of Alberta.
Contact Sunita at 780-407-3798 , fax: 780-407-7136
or [email protected].
Janet Schlenker BA Sc, RD (Corresponding author), is
Senior Clinical Pediatric Rehabilitation Dietitian,
Nutrition Services at Sunny Hill Health Centre for
Children, Vancouver, British Columbia. Contact Janet
at 604-453-8300, fax 604-453-8301 or
[email protected].
Roberta Anding MS, RD, LD, CDE is instructor and
clinical dietitian, Baylor College of Medicine,
Department of Pediatrics, Houston, Texas. Contact
Roberta at 832-822-4005, fax:832-825-3689 or
[email protected].
References
1. Millar WJ. Use of Alternative Health Care
Practitioners by Canadians. Can J Pub Health.
1997;88:154-8.
2. Natural Health Products Directorate. Available at:
http://www.hc-sc.gc.ca/hpfb-dgpsa/nhpddpsn/index_e.html . Accessed 8/24/04.
3. Fraser Institute. Available at: http://www.fraserin
stitute.ca/publications/forum/1997/march/FF-03-
97.html. Accessed 4/25/04.
4. Sibinga E, Ottolini M, Duggan A, Wilson M.
Communication about complementary/alternative
medicine use in children. Pediatr Res. 2000;47:226A.
5. Spigelblatt L, Laine-Ammara G, Pless IB, Guyver
A. The use of alternative medicine by children.
Paediatrics. 1994;94:811-4.
6. Sikand A, Laken M. Paediatricians’ experience
with and attitudes toward complementary/alterna
tive medicine. Arch Pediatr Adolesc Med.
1998;152:1059-64.
7. Spigelblatt L. Alternative medicine: A paediatric
conundrum. Contemp Pediatr. 1997; 14:51-61.
8. NCCAM Clearinghouse. General information
about CAM and the NCCAM. Available at:
http://nccam.nih.gov/health/clearinghouse/.
Accessed 8/24/04.
9. World Health Organization (WHO) Traditional
Medicine Strategy 2002-2005.
10. National Center for Complementary and
Alternative Medicine. Available at:
http://nccam.nih.gov/. Accessed 4/23/04.
11. Natural Foods Merchandiser Available at:
http://www.naturalfoodsmerchandise.com/ASP/
searchresult. Accessed 4/10/04.
12. Drug Store News: Vitamins and Supplements,
2000 sales statistics. Available at:
http://www.drugstorenews.com. Accessed 3/8/04.
13. Consumer Use of Dietary Supplements.
Prevention Magazine. 2000: 1-39.
14. Eisenberg DM, Davis RB, Ettner SL, et al. Trends
in alternative medicine use in the United Sates,
1990-1997-results of a follow up survey. JAMA.
1998 280:1560-1573.
15. Brevoort P. Overview of the US botanical market.
Presented at the Third Conference on Botanicals.
Washington, DC: Drug Information Association,
January 27-28, 1997.
16. Pitetti R, Singh S, Hornyak D, et al.
Complementary and alternative medicine use in
children. Pediatric Emergency Care. 2001;17:165-9.
17. Southwood TR, Malleson PN, RobertsThompson PJ, Mahy M. Unconventional reme
dies used for patients with juvenile arthritis.
Pediatrics. 1990;5:150-154.
18. Stern RC, Canada ER, Doershuk CF. Use of noncont. on page 75
Page
Spring 2005 Volume 7, Issue 4
74
TABLE 3 - Where to Find the Scientific-Based Evidence - Reliable Sources
Resources
Comments
National Center for Complementary and
Alternative Medicine (NCCAM)
Informational website, part of US National
Free. Online: http://nccam.nih.gov/htdig/search.htm
Institutes of Health. Specific treatment
information can be found on the website.
http://nccam.nih.gov/health/bytreatment.htm
AMED (Allied and Complementary
Medicine Database) 1985-present
Includes peer reviewed journals and others Subscription Required. Online:
significant tho the field. Database includes http://ds.datastarweb.com/ds/products/datastar/
English language and European sources,
sheets/amed.htm
journals, newspapers and books. Produced
by the British Library. About 50% of the
journals in AMED are indexed in MEDLINE.
Natural Standard
Systematic, peer-reviewed analyses of
complementary and alternative therapies.
Evidence-based, individual studies are
quality assessed with a validated scale and
graded. Includes observational and
experimental evidence
The Health Professional’s Guide to
Popular Dietary Supplements. 2nd
edition, A. Fragakis, American Dietetic
Association (ADA) 2003
Extensive review of dietary supplements
Book for purchase from ADA Online:
including: media claims, research, key points http://www.eatright.org/Public/ProductCatalog/104.cfm
and references.
Institute of Medicine of the National
Academy of Science. Framework for
Evaluating the Safety of Dietary
Supplements
Informational website with a recently
published framework for evaluating issues
reguarding ingredient safety in dietary
supplements in the United States
United States Food and Drug
Administration. Center for Food Safety
and Applied Nutrition
Informational website providing background Free. Online:
information regarding U.S. regulatory issues http://www.cfsan.fda.gov/~dms/supplmnt.html
surrounding dietary supplements
cont. from page 74
medical treatment by cystic fibrosis patients. J
Adol Health. 1992;13:612-615.
19. Andrews L, Lokuge S. Sawyer M, et al. The use
of alternative therapies by children with asthma.
A brief report. J Paediatr Child Health.
1998;34:131-34.
20. Spigelblatt L Laine-Ammara G, Pless B, Guyver
A. The use alternative medicine by children.
Pediatrics. 1994; 94:811-814.
21. Cala S. A survey of herbal use in children with
attention deficit hyperactivity disorder or depression. Pharmacotherapy. 2003;23:222-230.
22. Levy S, Mandell D, Merhar S, et al. Use of complementary and alternative medicine among children recently diagnosed with Autistic Spectrum
Disorder. J Dev Behav Ped. 2003;24(6):418-423.
23. Hurvitz E, Ayyangar R, Simsom Nelson V.
Page
75
Spring 2005 Volume 7, Issue 4
Access
Subscription Required. Online:
http://www.naturalstandard.com/
Free. Online:
http://www.iom.edu/project.asp?id=4605
CPE: Complementary & Alternative Medicine & Pediatrics:
Focus On Herbal Products and Nutritional Therapy
Complementary and alternative medicine use in
families of children with cerebral palsy. Dev Med
Child Neur. 2003;45:364-370.
24. Tomassoni AJ, Simone K. Herbal medicines for
children: an illusion of safety? Current Opinion in
Pediatrics. 2001;13:162-9.
25. Food and Drug Administration. Available at:
http://www.fda.gov/bbs/topics/news/2004/NEW
01049.html. Accessed 5/4/04.
26. Perharic L, Shaw D, Colbridge M, et al.
Toxicological problems resulting from exposure to
traditional remedies and food supplements. Drug
Safe 1994;11:284-94.
27. Chan TY. Monitoring the safety of Chinese herbal
medicines in Hong Kong. Ann Pharmacother.
1996;30:1039-40.
28. Feldstein TJ. Carbohydrate and alcohol content of
200 oral liquid medications for use in patients
cont. on page 76
CPE: Complementary & Alternative Medicine & Pediatrics:
Focus On Herbal Products and Nutritional Therapy
receiving ketogenic diets. Pediatrics. 1996;97:506-11.
29. Cui J, Garle M, Eneroth P, Bjorkhem I. What do
commercial ginseng preparations contain? Lancet.
1994;344:134.
30. Boon HS, Wong AHC. Kava: a test case for
Canada’s new approach to natural health products.
CMAJ. 2003;169(11):1163-1164.
31. Natural Health Products Directorate. Available at:
http://www.hc-sc.gc.ca/hpfb-dgpsa/nhpddpsn/index_e.html. Accessed 4/23/04.
32. Ernst E. The attitude against immunization with
in some branches of complementary medicine.
Eur J Pediatr. 1997;156:513-15.
33. Berger E. Berger Population Health Monitor #21.
Toronto: Hay Associates; 2000.
34. BG Katzung (ed.). Basic and Clinical
Pharmacology. Toronto: Appleton and Lange; 1989.
35. Boyer EW, Kearney S, Shannon MW, et al.
Poisoning from a dietary supplement administered
during hospitalization. Pediatrics. 2002;109(3).
Available at: www.pediatrics.org/cgi/content/
full/109/3/e49.
36. Palmer ME, Haller C, McKinney PE, et al.
Adverse events associated with dietary supplements:
an observational study. Lancet. 2003;361:101-6.
37. Betz JM, Gay ML, Mossoba MM, Adams S, Portz
BS. Chiral gas chromatographic determination of
ephedrine-type alkaloids in dietary supplements
containing Ma Huang. J AOAC Int.
1997;80:303-15.
38. Haller CA, Duan M, Benowitz NL, Jacob P.
Concentrations of ephedra alkaloids and caffeine
in commercial dietary supplements. J Anal Toxicol.
2004;28:145-51.
39. Haller CA, Benowitz NL. Adverse cardiovascular
and central nervous system events associated with
dietary supplements containing ephedra alkaloids.
NEJM. 2000:21:1833-8.
40. Lanski SL, Greenwald M, Perkins A, Simon HK.
Herbal therapy use in a pediatrics emergency
department population: expect the unexpected.
Pediatrics. 2003:11;981-5.
41. Brevoort P. Overview of the U.S. botanical mar
ket. Third Conference on Botanicals.
Washington, D.C.: Drug Information
Association, January 27-28, 1997.
42. Breuner CC, Barry PJ, Kemper KJ. Alternative
medicine use by homeless youth. Arch Pediatr
cont. from page 75
Adolesc Med. 1998; 152:1071-1075.
43. Gardiner P, Kemper KJ. Herbs in pediatric and
adolescent medicine. Pediatrics in Review.
2000;21:44-57.
44. Akerele O. An expanded program for medicinal
plants. In: Tomilson T, Akerele O,eds. Medicinal
Plants: Their Role in Health and Biodiversity.
Philadelphia, PA: University of Pennsylvania
Press; 1998.
45. Slifman NR, Obermeyer WR, Musser SM, et al.
Contamination of botanical dietary supplements
by Digitalis lanata NEJM. 1998;339:806-811.
46. Fugh-Berman A. Herb-drug interactions. Lancet.
2000;355:134-138
47. Position of the American Dietetic Association:
Food fortification and dietary supplements. J Am
Diet Assoc. 2001;101(1):115-125.
48. Medlen J. Alternative therapies. In: Medlen J. The
Down Syndrome Nutrition Handbook - A guide to
promoting healthy lifestyles. Bethesda MD:
Woodbine House Inc; 2002:113-121.
49. Feucht S, Lucas B. Nutritional issues for children
with Down syndrome. Nutrition Focus; 2000.
50. Ani C, Grantham-McGregor S, Muller D.
Nutritional supplementation in Down syndrome:
theoretical considerations and current status. Dev.
Med. Child Neur. 2000; 42:207-213.
51. Lucas B, Pechstein S, Ogata B. Nutrition con
cerns of children with Autism Spectrum
Disorders. Nutrition Focus; 2002.
52. Cochrane Review. Combined vitamin B6 -magne
sium treatment in autism spectrum disorder. In
Cochrane Library, Issue 1;2003, Oxford: update
software.
53. Nicholson L, Feucht S. Attention
Deficit/Hyperactivity Disorder and Nutrition
Issues. Nutrition Focus; 2002.
54. Voigt RG, Llorent AM, Jensen CL, et al. A ran
domized, double -blind, placebo controlled trial
of docosahexaenoic acid supplementation in chil
dren with ADHD. J Pediatr. 2001;139:189-196.
55. Casey SC. Dietary Supplements. Presented at
North American Cystic Fibrosis Conference,
Anaheim, California, October 2003.
56. Yeh GY, Eisenberg D, Kaptchuk T, Phillips R.
Systematic review of herbs and dietary supplecont. on page 77
Page
Spring 2005 Volume 7, Issue 4
76
cont. from page 76
ments for glycemic control in diabetes. Diabetes
Care. 2003;26(4):1277-94.
57. Agency for Healthcare Research and Quality
(AHRQ). Routine vitamin supplementation to
prevent cancer 2003. Available at: http://www.pre
ventiveservices.ahrq.gov. Accessed 5/4/04.
58. Centre for Integrated Healing. Available at:
http://www.healing.bc.ca/programs_intro.shtml.
Accessed 5/4/04.
59. Panksepp J. A neurochemical theory of autism.
Trends in Neurosciences. 1979;2:174-177.
60. Arnold GL. Hyman SL, Mooney RA, Kirby RS.
Plasma amino acid profiles in children with
autism: Potential risk of nutritional deficiencies. J
Autism and Dev Disorders. 2003;33:449-454.
61. McConnell B. Gluten- and Casein-free diets in
Autistic Spectrum Disorders, Canadian Autism
Intervention Research Network (CAIRN).
Available at: http://www.cairn-site.com.
Accessed 3/9/04.
62. Ottolini M, Hamburger E, Loprieato JO, et al.
Alternative medicine use among children in the
Washington DC area. San Francisco, CA:
Paediatric Academic Societies, 1999.
63. Sampson M, Campbell K, Ajiferuke I, Moher D.
Randomized controlled trials in pediatric comple
mentary and alternative medicine: where can they
be found? BMC Pediatrics. 2003;3:1. Available at:
http://www.biomedcentral.com/1471-2431/3/1.
64. Moher D, Sampson M, Campbell K, et al.
Assessing the quality of reports of randomized tri
als in paediatric complementary and alternative
medicine. BMC Paediatrics. 2002;2:2 Available at:
http://www.biomedcentral.com/1471-2431/2/2.
65. Sander AD, Brazdziunas D, Cooley WC, et al.
On behalf of the American Academy of Pediatrics,
Committee on Children with Disabilities.
Counseling Families Who Choose
Complementary and Alternative Medicine for
Their Child With Chronic Illness or Disability.
Pediatrics. 2001;107(3):598-601.
66. Levin JS, Glass TA, Kushi LH, et al. Quantitative
methods in research on complementary and alter
native medicine: A methodological manifesto.
Med Care. 1997;35:1079-1094.
67. Margolin A, Avants SK, Kleber HD. Investigating
alternative medicine therapies in randomized conPage
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CPE: Complementary & Alternative Medicine & Pediatrics:
Focus On Herbal Products and Nutritional Therapy
trolled trials. JAMA. 1998;280:1626-1628.
68. Vickers A, Cassileth B, Ernst E, et al. How
Should we Research Unconventional Therapies? A
Panel Report from the Conference on
Complementary and Alternative Medicine
Research Methodology, National Institutes of
Health. Int J Tech Asssess Health Care. 1997;13:111-121.
69. Nahin RL, Straus SE. Research into complementary and alternative medicine: problems and
potential. BMJ. 2001;322:161-164.
70. Kemper KJ, Cassileth B, Ferris T. Holistic pediatrics: a research agenda. Pediatrics. 1999;103:902-909.
71. Hospital for Sick Children Foundation. Available
at: http://www.sickkids.on.ca/foundation/.
Accessed 5/6/04.
72. Communication with Marlene Wardle RD, April
21, 2004, Oncology Dietitian at British Columbia
Childrens Hospital, Vancouver, BC, Canada.
Congratulations To The Newly Elected
2005-2006 NCC Leaders
Chair Elect: Doug Kalman
Secretary: Mary Alice Gettings
Nominating Committee Chair Elect: June Gnass
Nominating Committee Member: Mona Treadwell
Of Interest to Members
New e-newsletter for dietitians.
How do you DO it?
NCC members are encouraged to share how
they balance their dietetics career with their
home life for the new e-bulletin,
FULL PLATE ~ Dietitians Balancing
Work and Family.
For more information, go to
and click on
“Submit Your Profile”. A sample issue of
FULL PLATE can be viewed at
http://workoptions.com/fullplate
http://workoptions.com/fullplate/archives/2005-04-01.htm.
From WorkOptions.com the go-to online
resource for individuals who want to have a
flexible work arrangement at their current job.
Resource Review
Concise Handbook of Psychoactive
Herbs
Spinella M
The Haworth Herbal Press.
388 pp., Soft bound; $34.95. ISBN: 0-78901858-6
This is an excellent book for anyone who is interested in how the brain and central nervous system
works as well as for those who want more information on how medicinal plants affect the body—and
mind. I would highly recommend it for anyone who
works with complementary nutrition and/or who has
clients that may be using any of these herbal preparations, considering them or who takes prescribed or
over-the-counter non-herbal preparations.
The subtitle of this book: Medicinal Herbs for
Treating Psychological and Neurological Problems
only scratches the surface of what is offered here.
Since it is written for the non-professional specialist
and individuals with an interest in the subject, it is an
easy read. Do not let that influence your decision
about purchasing this book. It is well-written, understandable, and provides a reputable and well refernced
source of information about the brain and mind and
the effect of various herbs.
Sarah Harding Laidlaw, MS RD MPA is Editor of
Nutrition and Complementary Care newsletter and is in
practice in Southern Nevada. Contact Sarah at
[email protected] or 702-345-4256.
The introduction informs the reader about the history of plants as medicine, how herbal medicines
came to be used, and the science behind them. The
second chapter details the brain and how it works.
The brain includes the nervous system or the physical
organ that process information, controls thoughts,
memories and sensations, behavior and much more.
Each part of the central nervous system is outlined,
with its major function or role described. Common
neurotransmitters are discussed and the relationship
of nutrition to them is made evident. An explanation
of how drugs affect the body and the relationship
between doses and effects provides a better understanding of how herbal preparations effect the brain,
mental state, and behavior.
Copy Editor
The chapters on the psychoactive herbs discuss both
commonly available preparations and those that are
not seen as often. Historical information is both
interesting and informative. Some of the medicinal
plants and their psychoactive actions that are discussed include: stimulants such as caffeine, guarana,
ehpedra and coffee; cognition enhancers like ginkgo
and ginseng; the anti-anxiety and sedative herbs valerian, kava, and chamomile; herbal painkillers such as
willow, morphine, and myrrh; hallucinogens such as
peyote and members of the nightshade family.
NCC EDITORIAL STAFF
Editor
Sarah Harding Laidlaw, MS RD
Rebecca Schauer, RD
Publications Chair
Laura W. Lagano, MS RD
Editors
Christian Calaguas, MPH RD
Karen Lyon, RD
Sheryl Murphy, RD
Danielle Torisky, PhD RD
CPE Editor
Katherine Stephens-Bogard, RD
Web Site
Susan Moyers, PhD MPH LD/N, Web Editor
Cory Gransee, Webmaster
Karen Higgins, MS RD, Heads Up!
Kathie Swift, MS RD, Resources
EML Coordinator
Gretchen Forsell, MPH RD
Page
Spring 2005 Volume 7, Issue 4
78
Complementary and Alternative
Medicine and Pediatrics: Focus on
Herbal Products and Nutritional
Therapy.
Objectives:
After reading this CPE article, the reader should be able
to:
• Define CAM and list the five domain of CAM.
• Categorize therapies into domain.
• Be cognizant of the scope and magnitude of CAM
in the pediatric/adolescent population.
• Identify the regulatory bodies and their respective
scope of jurisdiction for natural health products
(HNP) in North America.
• Improve communication between health care
provider and parent/child on their utilization of
CAM.
• Be familiar with common HNP and specialized
diets currently promoted for use in health mainte
nance/disease management.
CPE Questions:
1. Which is NOT an example of CAM in the United
States health care system?
A. hypnosis and humor therapy
B. antibiotic therapy and vaccination
C. biofeedback and far infrared therapy
D. accupuncture and herbal therapy
2. Herbal therapies such as tinctures, teas and dried
extracts fall into which CAM domain?
A. alternative medical systems
B. energy therapies
C. mind-body interventions
D. biologically based therapies
E. manipulative therapies
3. True/False: The majority of CAM utilization is health
care provider mediated.
4. Which illness is most commonly associated with
parental implementation of CAM?
A. cystic fibrosis
B. upper respiratory illness
C. attention deficit hyperactivity disorder (ADHD)
D. cancer
5. Which substance is known as the “date-rape” drug?
A. wormwood
B. valerian
C. Invigorate II
D. GHB—gammahydroxybutrate
6. Which independent agency analyzes supplements,
finding that > 50% of tested products did not meet
standards?
A. The FDA through DSHEA
B. German Commission E
C. Consumer Labs
D. Natural Medicines Database
E. Natural Health Products Directorate of Health
Canada2
7. Circle those peer reviewed sources which feature the
greatest number of studies on biologically based
therapies in the non-adult population.
A. Journal of the American Dietetic Association
B. American Journal of Clinical Nutrition
C. Journal of the American Medical Association
D. Pediatrics
E. Nutrition in Complimentary Care Newsletter
F. Journal of Pediatrics
G. Lancet
8. True/False: DHA has been conclusively shown to
reduce symptoms and improve attention tests in
children with ADHD.
9. True/False: Modulating opioid peptides via elimination
of casein and/or gluten has garnered wide spread
support in children with autism.
PLEASE CIRCLE THE CORRECT ANSWERS:
1. A B C D
5. A B C D
8. T F
2. A B C D E
6. A B C D E
9. T F
For 2 Hours CPE Credit
CPE Reporting Form • Spring 2005
EXPIRATION DATE:
Please Print or type
Septemb? ?, 200?
Name:
Address:
ADA Membership #:
Daytime phone:
Evening phone:
Email address:
NCC Member
Yes
No
This activity has been approved for two hours of CPE credit. You will be
notified if hours are not approved.
$20 non NCC Members
Cost: $12 NCC Members
Make checks payable to NCC-DPG #18
Page
79
Spring 2005 Volume 7, Issue 4
3. T F 4. A B C D
7. A B C D E F G
Key:1. B 2. D 3. False 4. A 5. D 6. C 7. B,D,F,G 8. False 9. False
CPE Questions
Mail to: Annie Griffin
13611 Fernlace Ct.
Pickerington, OH 43147
NCC 2004-2005
LEADERSHIP CONTACT
INFORMATION
EXECUTIVE COMMITTEE
Rick Hall, MS RD
Chair
3211 West Fuller Drive
Anthem, AZ 85086
voice: 602-284-4607
[email protected]
Susan Pitman, MA RD
Immediate Past Chair
4618 Yuma St, NW
Washington, DC 20016
voice: 202-273-1220
[email protected]
Susan Allen, MS RD
Chair-Elect
7771 Lake St 3W
River Forest, IL 60305
office: 800-917-3688
home: 708-366-8947
cell: 630-853-8891
[email protected]
Susan Drake, MS RD
Member Services Chair
10211 W. Exposition Dr.
Lakewood, CO 80226
daytime: 303-200-0808
fax: 303-750-1996
[email protected]
Gretchen Forsell, MPH RD LD
Treasurer 2004-2006
2002 Highland Dr
Norfolk, NE 68701
daytime: 402-644-7256
fax: 402-644-7254
[email protected]
Alt email: [email protected]
Mary Harris, PhD RD
Nominating Chair
7721 Promontory Dr.
Fort Collins, CO 80528-9306
voice: 970-491-7462
fax: 970-491-7252
[email protected]
Laura W. Lagano, MS RD
Publications Chair
931 Bloomfield St
Hoboken, NJ 07030
Phone: 201-963-4945
Fax: 201-963-5764
[email protected]
Kathie Swift, MS RD LDN
External Fundraising Chair
235 Champlain Dr
Plattsburgh, NY 12901
phone/fax: 518-563-9421
[email protected]
Elizabeth Thompson, MPH RD
Secretary 2003-2005
4896 Valdina Way
San Diego, CA 92124-2432
daytime: 619-578-2000x3106
[email protected]
ADMINISTRATIVE ASSISTANT
Katherine L. Bernard, MS RD CDN
90 Panamoka Trail
Ridge, NY 11961
voice: 631-929-3834
fax: 631-209-1569
[email protected]
ADA STAFF LIAISON
Aiysha Johnson, MA
American Dietetic Association
120 Riverside Plaza, Suite 2000
Chicago, IL 60606
voice: 800-877-1600 ext. 4778
fax: 312-899-4812
[email protected]
PROFESSIONAL ISSUES DELEGATE
Kathleen Rourke, PhD RD RN CHES
6977 Driftwood Ln
Cincinnati, OH 45241
home: 513-487-1155
[email protected]
OTHER LEADERS
Rita Kashi Batheja, MS RD CDN
Reimbursement/Legislative Chair
Membership Chair
825 Van Buren St
Baldwin Harbor, NY 11510
daytime/eve: 516-868-0605
[email protected]
Gretchen Forsell, MPH RD LD
Electronic Mail List Coordinator
2002 Highland Dr
Norfolk, NE 68701
daytime: 402-644-7256
fax: 402-644-7254
[email protected]
Alt email: [email protected]
Cheryl Galligos, MA RD LDN
Administrative Advisor
1773 Lynnville Woodson Rd
Murrayville, IL 62668
daytime: 217-782-8826
fax: 217-557-0299
[email protected]
Cory Gransee
Webmaster
7653 E. Camino St
Mesa, AZ 85207
phone: 480-213-0801
[email protected]
Roz Franta Kulik, MS RD FADA
Marketing/Strategic Planning Advisor
16503 Cerrillo De Avila
Tampa, Fl 33613-1080
voice: 813-960-1557
fax: 813-960-4248
[email protected]
Sarah Harding Laidlaw, MS RD MPA
Newsletter Editor
1045 Raptor Circle
Mesquite, NV 89027
voice: 702-346-7968
fax: 702-346-9031
[email protected]
Natalie Legomarcino-Ledesma, MS RD
Nominating Committee Chair-Elect
Cancer Resource Center
USSF Comprehensive Cancer Center
1600 Divisadero St, 1st Fl
San Francisco, CA 94143-1725
voice: 415-885-7608
fax: 415-885-3701
[email protected]
Susan Moyers, PhD MPH LD/N
Web Editor 2004-2006
1605 Send Way
Lutz, Fl 33549
voice: 813-948-9040
fax: 813-948-0010
[email protected]
Carmen Nochera, PhD RD
Nominating Committee Member
Apt 12
4315 Wimbledon Dr SW
Grandville, MI 49418-2836
voice: 616-538-4226
Fax: 616-331-2090
[email protected]
Rebecca Schauer, RD
Copy Editor
2916 42nd Ave South
Minneapolis, MN 55406
ph/fax: 612-722-6080
work: 612-626-9445
[email protected]
Gretchen K. Vannice, MS RD
Mentoring Chair
PO Box 3812
Tualatin, OR 97062
phone: 503-885-7585
fax: 503-885-7585
[email protected]
Annie Griffin,, RD LD
CPE Liaison
13611 Ferlace Ct NW
Pickerington, OH 43147
phone: 740-927-0773
[email protected]
Ruth DeBusk, PhD RD
Technical Resource Advisor
3583 Doris Drive
Tallahassee, FL 32303-2304
daytime: 850-877-5865
fax: 850-562-7012
[email protected]
Sarah Harding Laidlaw, MS, RD, MPA
1045 Raptor Circle
Mesquite, NV 89027
PRSRT STD
US POSTAGE PAID
Grand Junction, CO
PERMIT 229