probiotics

Alternative MedicineWhat is the Evidence?
DR. MEL BORINS
Associate Professor
Faculty of Medicine
University of Toronto
active staff
St. Joseph’s Health Center
www.melborins.com
Faculty/Presenter
Disclosure
•
Faculty: MEL BORINS M.D.
Program: 51st Annual Scientific Assembly
Relationships with commercial interests:
Grants/Research Support: 0
Speakers Bureau/Honoraria:
PharmaCare Canada
Ferring
MFI Pharma
Consulting Fees: 0
Other: 0
DISCLOSURES
I have received payment for CME
talks given on Probiotics to family
physicians by
Ferring
MFI Pharma
Mitigating Potential Bias
Since I have received and honorarium
from Ferring
MFI Pharma
and am talking about Probiotics and
mentioning their products today there is
the potential for bias
I will mitigate this bias because I will be
discussing generic brands and other brands as
well as the sponsored brands
I will be following ministry guidelines
pertaining to this topic
I will remind the audience that I received an
honorarium from this company years ago when I
mention their products
Why physicians have
comphlementary
medicine?
Physician’s concerns
physppppppcponcerns about
delay in diagnosis and treatment patients avoid
curable medical treatments
no scientific basis
patients get ripped off financially
lack of proper training
promise of miracle cures
no regulation of practitioners
misinformation
FISH OILS
eating fish or by taking supplements.
Fish rich in the beneficial oils known as omega-3 fatty acids
include mackerel, tuna, salmon, sturgeon, mullet, bluefish,
anchovy, sardines, herring, trout
1 gram of omega-3 fatty acids in about 3.5 ounces of fish.
.
Essential Fats (1)
Two types of fat are essential: omega 3
and omega 6 fatty acids
Docosahexaenoic acid (DHA) and
Eicosopentanoic Acid (EPA) are both
long chain omega-3 fatty acids that are
major structural fats of the brain
Dopamine and serotonin receptors are
composed mainly of omega 3 fatty acids
Essential Fats (2)
An omega 6 fatty acid, arachidonic acid
(ARA) is equally important for brain
development (babies)
Found in meat, eggs and milk
Generally, diets contain too much omega
6 fat. Need to increase omega 3s
OMEGA 3 AND
HYPERTRIGLICERIDEMIA
Ten studies show long-chain omega-3 fatty acids to be
effective in the treatment of hypertriglyceridemia.
The average decrease in triglycerides was 29%, total
cholesterol 11.6%, very low density lipoprotein (VLDL)
30.2%, and low-density lipoprotein (LDL) 32.5%.
One study found LDLs to increase by 25%.
many of the RCTs had serious shortcomings the authors
do not recommended routine use of omega-3’s for
hypertriglyceridemia
Lewis A, Lookinland S, Beckstrand RL, Tiedeman ME Treatment of
hypertriglyceridemia with omega-3 fatty acids: a systematic review.J Am
Acad Nurse Pract. 2004 Sep;16(9):384-95.
FISH OILS AND HEART
DISEASE
Yzebe and Lievre did a meta-analysis of 10 RCTs with
14,727 patients that showed that daily intake of omega-3
fatty acids for a mean duration of 37 months decreased all
causes of mortality by 16% and the incidence of death due
to MI by 24%.
because of the suboptimal quality of the studies included
into the meta-analysis and the absence of data in patients
receiving statins, the authors suggest that these results do
not justify adding fish oils systematically to the heavy
pharmaceutical assortment already recommended in CHD
patients
Yzebe D, Lievre M, Fish oils in the care of coronary heart
disease patients: a meta-analysis of randomized controlled
trials. Fundam Clin Pharmacol. 2004 Oct;18(5):581-92.
FISH OILS AND HEART
A Cochrane review-48 RCT’s and 41 cohort analyses
“it is not clear that dietary or supplemental omega 3 fats alter
total mortality, combined cardiovascular events or cancers in
people with, or at high risk of, cardiovascular disease or in the
general population.’
no evidence we should advise people to stop taking rich
sources of omega 3 fats, but further high quality trials are
needed to confirm suggestions of a protective effect of omega
3 fats on cardiovascular health.
no clear evidence that omega 3 fats differ in effectiveness
according to fish or plant sources, dietary or supplemental
sources, dose
Hooper L, Thompson RL, Harrison RA, Summerbell CD, Moore H, Worthington HV, Durrington PN,
Ness AR, Capps NE, Davey Smith G, Riemersma RA, Ebrahim SB. Omega 3 fatty acids for prevention
and treatment of cardiovascular disease.Cochrane Database Syst Rev. 2004 Oct 18;(4):CD003177.
FISH OILS AND HIGH BP
8 studies in hypertensive participants found a statistically significant
reduction in systolic and diastolic BP; 2.56 mmHg (95% CI 0.58 to
4.53) and 1.47 mmHg (95% CI 0.41 to 2.53), respectively.
Meta-regression showed no significant relationship between dose
of fish oil and the effect on BP.
Conclusion: The small but statistically significant effects of fish-oil
supplements in hypertensive participants in this review have
important implications for population health and lowering the risk of
stroke and ischaemic heart disease. Their modest effects, however,
mean that they should not be recommended as an alternative to
BP-lowering drugs where guidelines recommend treatment.
Eur J Prev Cardiolog. 2012 Jan 30. A systematic review of fish-oil supplements for
the prevention and treatment of hypertension. Campbell F, Dickinson HO, Critchley
JA, Ford GA, Bradburn M.
EPA AND DEPRESSION
60 outpatients major depressive disorder score
>/=15 in the 17-item Hamilton Depression Rating
Scale (HDRS) were randomly allocated to
receive daily either 1000 mg EPA or 20 mg
fluoxetine, or their combination for 8 weeks.
EPA and fluoxetine had equal therapeutic effects
in major depressive disorder. EPA + fluoxetine
combination was superior to either of them alone.
Comparison of therapeutic effects of omega-3 fatty acid
eicosapentaenoic acid and fluoxetine, separately and in
combination, in major depressive disorder Aust N Z J
Psychiatry. 2008 Mar;42(3):192-8.
FISH OILS AND DEPRESSION
Several epidemiological studies suggest covariation
between seafood consumption and rates of mood
disorders.
Biological marker studies indicate deficits in omega-3 fatty
acids in people with depressive disorders,
several treatment studies indicate therapeutic benefits from
omega-3 supplementation.
Am J Psychiatry. 2006 Jun;163(6):969-78.Omega-3 fatty acids and mood
disorders.Parker G, Gibson NA, Brotchie H, Heruc G, Rees AM, HadziPavlovic D.
EPA-FFA REDUCES COLONIC POLYPS
55 patients with FAP
Treatment with EPA-FFA for 6 months was associated with a mean
22.4% (95% CI 5.1% to 39.6%) reduction in polyp number (p=0.012)
and a 29.8% (3.6% to 56.1%) decrease in the sum of polyp
diameters (p=0.027).
Global polyp burden worsened over 6 months in the placebo group
(-0.34) unlike the EPA-FFA group (+0.09, difference 0.42 (0.100.75), p=0.011).
EPA-FFA was well tolerated with an incidence of adverse events
similar to placebo.
enteric-coated EPA-FFA 2 g daily for 6 months
West NJ, Clark SK, Phillips RK, Hutchinson JM, Leicester RJ, Belluzzi A, Hull MA.
Eicosapentaenoic acid reduces rectal polyp number and size in familial adenomatous polyposis. Gut. 2010
Jul;59(7):918-25. Epub 2010 Mar 26.
FISH OILS AND INFANTS
infant formulas containing DHA provide improved performance on the
Mental Development Index in term infants and better mental
development in pre-term infants.
One study demonstrated significantly better visual maturation of
term infants fed long-chain fatty acids including DHA compared to
control formula for a 12-month period.
A metanalysis of 5 RCT’s involving term infants and three RCT’s
involving pre-term infants found that in term infants, ALA (alpha
linoleic) supplementation was associated with increased weight and
length at 12 months, which was at least 4 months after the end of
dietary intervention.
FISH OIL CONCERNS
high doses of fish oil is POSSIBLY UNSAFE. Taking more than 3 grams
per day might keep blood from clotting and can increase the chance of
bleeding
High doses of fish oil might also reduce the immune system’s activity,
reducing the body’s ability to fight infection
larger amounts can increase levels of the “bad” LDL cholesterol in some
people? Do blood tests periodically to ensure LDL cholesterols is not
elevated
Some fish meats (especially shark, king mackerel, and farm-raised
salmon) can be contaminated with mercury and other industrial and
environmental chemicals,
fish oil supplements typically do not contain these contaminants.
FISH OIL CONCERNS
An implanted defibrillator (a surgically placed
device to prevent irregular heartbeat):
Some, but not all, research suggests that fish
oil might increase the risk of irregular heartbeat
in patients with an implanted defibrillator.
Stay on the safe side by avoiding fish oil
supplements if patient has a defibrillator
DARK CHOCOLATE AND HYPERTENSION
BMC Med. 2010 Jun 28;8:39.Does chocolate reduce blood pressure? A
meta-analysis. Ried K, Sullivan T, Fakler P, Frank OR, Stocks NP.
13 studies
Pooled meta-analysis of all trials revealed a significant blood pressurereducing effect of cocoa-chocolate compared with control (mean BP
change +/- SE: SBP: -3.2 +/- 1.9 mmHg, P = 0.001; DBP: -2.0 +/- 1.3
mmHg, P = 0.003).
subgroup meta-analysis was significant only for the hypertensive or
prehypertensive subgroups
BP was not significantly reduced in the normotensive subgroups
9 trials used chocolate containing 50% to 70% cocoa compared with white
chocolate or other cocoa-free controls,
6 trials compared high- with low-flavanol cocoa products.
Daily flavanol dosages ranged from 30 mg to 1000 mg
BP AND CHOCOLATE
Am J Hypertens. 2010 Jan;23(1):97-103. Epub
2009Nov 12. Effect of cocoa products on blood
pressure: systematic review and meta-analysis.
Desch S, Schmidt J, Kobler D, Sonnabend M, Eitel I,
Sareban M, Rahimi K, Schuler G, Thiele H
confirms the BP-lowering capacity
of flavanol-rich cocoa products
BP AND CHOCOLATE
44 hypertensives randomly
assigned to 6.3 gm dark chocolate
or white for 18 wk.
Significant drop in BP
Rise of nitrosoglutathione (nitric
oxide synthesis
JAMA 2007;298:49-60
Hypertensives should eat 10-30 g
of dark chocolate daily at least
70% cacao (gourmet)
GLUCOSAMINE
Glucosamine is an
aminomonosaccharide, which is a
normal constituent of
glycosaminoglycans in cartilage
matrix and synovial fluid.
POSSIBLE MECHANISM
OF ACTION
experiments on cultured human chondrocytes
have shown that glucosamine increases the
production of aggrecans, and reduces the
formation of nitric oxide and interleukin in
response to interleukin 1ß
Therefore it may have a chondroprotective and
anti-inflammatory effect.
experiments in animals have suggested that
circulating glucosamine can localize in cartilage.
Manson J, Rahman A, This house believes that we should
advise our patients with osteoarthritis of the knee to take
glucosamine. Rheumatology 2004; 43: 100-101
METANALYSIS-OA OF
KNEE AND HIP
McAlinden et al reviewed 15 randomly
assigned double blind controlled trials of
more than 4 weeks duration for
osteoarthritis of the knee and hip and
found glucosamine had a positive effect
on symptoms. The researchers had
some concerns about the methological
flaws of many of the studies.[i]
[i] McAlindon TE, Lavalley MP, Gulin JP, Felson DT.
Glucosamine and chondroitin for treatment of osteoarthritis: a
systematic quality assessment and meta-analysis. J Am Med
Assoc 2000;283:1469–75
OA OF KNEE
Reginster et al[i] and Pavelka et al[ii] followed
patients with mild to moderate osteoarthritis of
the knee for 3 years. They both found that the
glucosamine treated group had better functional
outcomes and reduced narrowing of the
tibiofemoral joint space.
(large dropout rate)
[i] Reginster JY, Deroisy R, Rovati LC et al. Long term effects of
glucosamine sulfate on osteoarthritis progression: a randomized placebocontrolled clinical trial. Lancet 2001;357:251–6
ii Pavelka K, Gatterova J, Olejarova M, Machacek S, Giacovelli G, Rovati
LC. Glucosamine sulfate use and delay of progression of knee
osteoarthritis. Arch Intern Med 2002;162:2113–23
OA OF KNEE
Richy et al did a metanalysis of use of
glucosamine and chondroitin for osteoarthritis of
the knee and found that glusosamine has a
highly significant beneficial affect on symptoms
and joint space narrowing. Chondroitin was also
found to cause a significant improvement in pain
and mobility. Safety is excellent for both
compounds.[i]
[i] Richy F, Bruyere O, Ethgen O, Cucherat M, Henrotin Y, Reginster
JY, Structural and symptomatic efficacy of glucosamine and
chondroitin in knee osteoarthritis: a comprehensive meta-analysis.
Arch Intern Med. 2003 Jul 14;163(13):1514-22
HIP OA
Glucosamine sulfate was no better
than placebo in reducing
symptoms and progression of hip
osteoarthritis.
Effect of glucosamine sulfate on hip osteoarthritis: a
randomized trial.[see comment][summary for patients in Ann
Intern Med. 2008 Feb 19;148(4):I49
Rozendaal RM. Uitterlinden EJ. Et al.
Effect of glucosamine sulphate on joint space
narrowing, pain and function in patients with hip
osteoarthritis; subgroup analyses of a randomized
controlled trial.
Osteoarthritis & Cartilage. 17(4):427-32, 2009 Apr.
COCHRANE REVIEW
2005
20 studies with 2570 patients
Non-Rotta preparation and adequate
allocation concealment showed no
benefit on WOMAC
10 RCT’s using Rottapharm from Italy
preparation superior for pain and
function using Lequesne index
Glucosamine was as safe as placebo
GLUCOSAMINE/CHONDROITIN
ARTHRITIS INTERVENTION TRIAL
1583 patients randomized to 1500 Glucosamine
HCL , 1200 Chondroitin, both or 200 mg
Celecoxib Mild pain (1229) Severe pain (354)
20% decrease in pain from baseline
Overall Celecoxib was 10% higher than placebo
High rate of response to placebo- 60.1%
None of treatments were better than placebo in
mild pain
Combined treatment was better than placebo in
moderate to severe pain
Celecoxib, glucosamine nor chondroitin alone
were not significantly better
TRIAL USED GLUCOSAMINE HCL
N Eng J Med 2006;354:795-808
GLUCOSAMINE FOR RA
51 (RA) patients: 25 in glucosamine group and 26 in
the placebo group.
Glucosamine HCL 1,500 mg and placebo for 12
weeks along with conventional medication.
patients' self-evaluations and the physicians' global
evaluations-glucosamine produced noticeable
improvements in symptoms.
the face scale and a visual analogue scale pain were
significantly in favor of the glucosamine group. ESR
and CRP levels did not change, but serum MMP-3
levels decreased in glucosamine
Rheumatology International. 27(3):213-8, 2007 Jan.
PROBIOTICS
A biotherapeutic agent that is a live
microbial food supplement which
beneficially affects the host by
improving the intestinal microbial
balance
Can be a yeast or bacteria
PROBIOTICS
THANK TO DR. JONATHAN
SPRINGER FOR USE OF SOME
OF HIS SLIDES
FERRING
MFI PHARMA
Mechanisms of
Probiotics?
Suppress growth and colonization or epithelial
binding/invasion of pathogenic Bacteria
Improve intestinal barrier function
Modulate of immune system
Induce protective cytokines ( IL-10,TGF-B)
Suppress pro-inflammatory cytokines (TNF)
Limit migration of T helper 1 Cells
Antibiotic Associated Diarrhea
Antibiotics have helped save millions of lives,
but like most drugs, there are side effects.
The most common side effect is diarrhea (AAD), and it
is reported that 20% of people taking antibiotics are
affected by AAD.
Diarrhea results when the balance between “good” and
“bad” bacteria is disrupted.
PROBIOTICS and AAD
metanalysis of 9 randomized,
double-blind, placebo-controlled
trials -Lactobacillus rhamnosus
and the nonpathogenic yeast S.
boulardii useful in preventing
antibiotic associated diarrhea
compared to placebo.
2 of 9 studies investigated the
effects of probiotics in children.
DSouza A L, Rajkumar C, Cooke J, Bulpitt C
J. Probiotics in the prevention of antibioticassociated diarrhea in humans:
metanalysis. BMJ 2002;324:1361
PROBIOTICS and AAD
metanalysis of 9 randomized, double-blind,
placebo-controlled trials -Lactobacillus
rhamnosus and the nonpathogenic yeast S.
boulardii useful in preventing antibiotic
associated diarrhea compared to placebo.
2 of 9 studies investigated the effects of
probiotics in children.
DSouza A L, Rajkumar C, Cooke J, Bulpitt C J. Probiotics in the
prevention of antibiotic-associated diarrhea in humans:
metanalysis. BMJ 2002;324:1361
Antibiotic Associated
Diarrhea
Double blind placebo controlled study of
180 patients enrolled over 23 months received
Placebo
or 1 gram S. boulardii per day (2X250mg capsule
bid) in addition to antibiotics
14 of 64 (21.9%) on placebo developed diarrhea vs.
11 of 116 (9.5%) treated with S. boulardii
Surawicz C. et al .Prevention of Antibiotic-Associated
Diarrhea by Saccharomyces boulardii: A Prospective Study
Gastroenterology 1989;96:981-8
PROBIOTICS and AAD
this meta-analysis shows the preventive
effect of probiotic supplementation on the
incidence of AAD to be relatively consistent
across different probiotic species used,
various antibiotic regimens and indications,
including H. pylori eradication, and in adult
and paediatric populations.
Videlock EJ, Cremonini F.Meta-analysis: probiotics in antibioticassociated diarrhea, Aliment Pharmacol Ther. 2012 Jun;35(12):135569. doi: 10.1111/j.1365-2036.2012.05104.x. Epub 2012 Apr 24.
Antibiotic Associated Diarrhea
In some cases, the result of “bad” bacterial
over-proliferation is just a mild case of diarrhea.
In other cases, pathogenic bacteria may produce toxins
which can build up and damage the bowel wall, leading
to inflammation.
Clostridium difficile an anaerobic bacteria produces
Toxins A&B which can trigger Pseudomembranous colitis
(toxic megacolon)
Clostridium difficile
Systemic review of probiotic therapy for
the prevention and treatment of
Clostridium difficile found there was
insufficient evidence to suggest the
routine clinical use of probiotics
Studies were of poor quality
Dendukuri N. et al , P robiotic therapy for the prevention and treatment of
Clostridium difficile-associated diarrhea: a systemic review CMAJ
2005;173(2):167-70
Clostridium difficile
11 studies
most were seriously underpowered
2 significantly lower rates of CDI among the probiotic recipients
meta-analysis of 3 studies used probiotic combination Lactobacillus
acidophilus CL1285 and Lactobacillus casei LBC80R and a combined
analysis with 4 studies using Saccharomyces boulardii, showed lower
CDI rates in recipients of probiotics compared with recipients of placebo
(risk ratio=0.39; 95% confidence interval 0.19-0.79).
Johnson S, Maziade PJ, McFarland LV, Trick W, Donskey C, Currie B, Low DE,
Goldstein EJ. Is primary prevention of Clostridium difficile infection possible with
specific probiotics? Int J Infect Dis. 2012 Nov;16(11):e786-92. doi:
10.1016/j.ijid.2012.06.005. Epub 2012 Aug 3.
PROBIOTICS AND AAD AND CDAD
Meta-analysis showed that
administration of probiotics led to a
statistically significant relative risk
reduction of 44% for AAD and 71% for
CDAD.
Probiotics for prevention of antibiotic-associated
diarrhea and Clostridium difficile-associated disease in
hospitalized adults--a meta-analysis. J Am Acad Nurse
Pract. 2011 Jun;23(6):269-74. doi: 10.1111/j.17457599.2011. Avadhani A, Miley H.
Clostridium difficile
S. boulardii, 500 mg twice
daily (plus antibiotics) there
was a 50% reduced
recurrence rate of C. difficile
associated diarrhea in 124
patients with prior CDD
McFarland LV, Surawicz CM, Greenberg RN: A randomizedcontrol trial of Saccaromyces boulardii in combination with
standard antibiotics for Clostridium difficile disease. JAMA
1994; 271(24):1913-8.
PROBIOTICS for
DIARRHEA
metanalysis of 13 trials concluded
that Lactobacillus was useful in
treating infectious diarrhea in
infants and children especially in
those infected with rotavirus.
Szajewska H, Mrukowicz JZ. Probiotics in the treatment
and prevention of acute infectious diarrhea in infants
and children: a systematic review of published
randomized, double-blind, placebo-controlled trials. J
Pediatr Gastroenterol Nutr. 2001 Oct;33 Suppl 2:S1725
PROBIOTICS for
DIARRHEA
metanalysis of 18 trials- use of probiotics
in the treatment of acute paediatic
diarrhea.
Probiotics reduced the duration of
diarrhea by about one day.
Early intervention seems to be
important.
Huang J S, Bousavaros A, Lee J W, Diaz A, Davidson
E J. Efficacy of probiotic use in acute diarrhea in
children: a metanalysis. Dig Dis Sci 2002;47:26252634
PROBIOTICS Rx for
diarrhea
A Cochrane Review of 23 trials of 1917
participants concluded Probiotics reduced
the risk of diarrhoea at 3 days and the mean
duration of diarrhoea by 30.48 hours.
“Probiotics appear to be a useful adjunct to
rehydration therapy in treating acute,
infectious diarrhoea in adults and children.
More research is needed to inform the use of
particular probiotic regimens in specific
patient groups.”
Allen SJ, Okoko B, Martinez E, Gregorio G, Dans
LF. Probiotics for treating infectious diarrhoea.
Cochrane Database Syst Rev.
2004;(2):CD003048
Traveller’s Diarrhea
Irritable Bowel
Syndrome
RATIONALE
Altered intraluminal milieu
Decreased population of bifidbacteria
Small intestinal bacterial overgrowth
Immune activation
Post infectious IBS
Altered cytokine profiles
Enteric Neuromuscular dysfunction
Visceral sensation and motility
Irritable Bowel
Syndrome
Irritable Bowel
Syndrome
YOGHURT (BIFIDOBACTERIUM ANIMALIS) AND IBS
274 primary care adults with constipation-predominant IBS (Rome II) were
randomized to consume for 6 weeks either the test fermented milk or a heattreated yoghurt (control). HRQoL and digestive symptoms were assessed after
3 and 6 weeks
beneficial effect of a probiotic food on discomfort HRQoL score and bloating in
constipation-predominant IBS, and on stool frequency in subjects with <3
stools/week
Effect of a fermented milk containing Bifidobacterium animalis DN-173 010 on
the health-related quality of life and symptoms in irritable bowel syndrome in
adults in primary care: a multicentre, randomized, double-blind, controlled trial
D. GUYONNET, O. CHASSANY, P. DUCROTTE, C. PICARD, M. MOURET, C.H. MERCIER and C. MATUCHANSKY. Aliment Pharmacol Ther. 2007 ; 26: 475486
Crohn’s Disease
Conclusion
“No significant benefit for any
Probiotics in medically or
surgically induced remission in
adults or children compared to
placebo or AZA/5ASA”
IBD
INFANT COLIC
90 breastfed infants controlled
Half got L. reuteri 5 drops once daily
Half got simethicone 60 mg/day, 15
drops bid
Daily median crying time 51 min/day L.
reuteri vs 145 min/day simethicone
On day 28- 95% were responders in L.
reuteri vs 7% in simethicone
Savino F et al, Pediatrics 2007;119:124130
PROBIOTICS
Eczema
When high risk infants were given
Lactobacillus rhamnosus during their first 6
months of age they had half the development
of atopic eczema compared to placebo.
The 4 year follow up of this study found that
the significantly less children developed
eczema taking probiotics.
Kalliomaki M, Salminen S, Poussa T, Arvilommi H,
Isolauri. Probiotics in the prevention of atopic
eczema: 4 yr folowup of a randomized controlled
trial. Lancet 2003;361:1869-71
PROBIOTICS AND ECZEMA
10 double-blind randomized controlled clinical
trials were meta-analyzed Data from the 6
prevention studies (n = 1581) and 4 treatment
trials (n = 299)
Current evidence is more convincing for
probiotics' efficacy in prevention than treatment
of PAD.
Meta-analysis of clinical trials of probiotics for prevention and
treatment of pediatric atopic dermatitis. J Allergy Clin Immunol. 2008
Jan;121(1):116-121Lee J, Seto D, Bielory L.
PROBIOTICS AND ECZEMA
L. rhamnosus GG, seem to be effective for the
prevention of AD.
Probiotics for the treatment or prevention of atopic dermatitis: a review
of the evidence from randomized controlled trials.Am J Clin Dermatol.
2008;9(2):93-103.Betsi GI, Papadavid E, Falagas ME.
PROBIOTICS AND URI’S
57 and 85 healthy elderly (two studies) drank
either 90 g yoghurt or drink 100 ml milk once per d
over an 8- or 12-week period.
A meta-analysis two independent studies showed the risk of catching the
common cold was about 2.6 times lower (OR 0.39; P = 0.019) in the yoghurt
group than in the milk group and the increase of natural killer cell activity was
significantly higher in the yoghurt group than in the milk group (P = 0.028).
Br J Nutr. 2010 Oct;104(7):998-1006
Reducing the risk of infection in the elderly by dietary intake of yoghurt fermented
with Lactobacillus delbrueckii ssp. bulgaricus OLL1073R-1.
Makino S, Ikegami S, Kume A, Horiuchi H, Sasaki H, Orii N.
PROBIOTICS-PROBLEMS
significant differences in the active
ingredients
sometimes no active ingredients can
be found when analyzed
store the containers in the fridge
because it is only effective in the live
bacterial cultures
reports of contamination with
extraneous strains not listed on the
label
PROBIOTICS-PROBLEMS
Sepsis from bacterial probiotics and
fungemia from S. boulardii
reports of complications of infections
in immunocompromised patients, low
white countsprobiotics should not be used in
immunosuppressed patients, central
venous catheters, artificial heart
valves
Reliable probiotics?
Tu Zen
BioGaia drops for children
Florastor
Activia yoghurt; Danone-Bifidobacterium lactis
VSL#3; Seaford Pharma-lactob,bifido,strep
Fermalac Vaginal; Rosell Lallemand
Probaclac
Culturelle (ramnosus) Walmart?
Organic Meadow yoghurt Bulgaricus
Vitamin D3 Deficiency
Prevalence high at higher latitudes north/south
Sunscreen-induced; worse in winter
Diets deficient in liver, egg yolks, fatty fish
Darker skin takes longer to make Vitamin D
Weak bones and weak muscles
Correlates with chronic pain (<50 nmol/L)
Can be measured: 25 OH Vitamin D3 should be
75 nmol/L minimally, 140-170 nmol/L optimally
Common in covered women
VITAMIN D AND
breastfed NEWBORNS
IOWA
78% VIT D deficient in the winter
All breastfed babies should be
supplemented
VITAMIN D AND
DIABETES ?
Vitamin D treatment improved
glycemic control and insulin
sensitivity in Type 1, Type 2
diabetics and normal people
Low Vitamin D levels has been
association with insulin resistance,
B-cell dysfunction and glucose
intolerance
VITAMIN D AND FALLS
A meta-analysis based on 5 RCTs
involving 1237 participants found Vitamin
D supplementation appeared to reduce
the risk of falls among ambulatory or
institutionalized older individuals with
stable health by more than 20%.[i]
[i] Bischoff-Ferrari HA, Dawson-Hughes B, Willett
WC, et al, Effect of Vitamin D on falls: a meta-analysis.
JAMA. 2004 Apr 28;291(16):1999-2006
VITAMIN D AND FALLS
1,000 IU OF VITAMIN D over 2 yr.
Reduced the incidence in falls by
59% compared to placebo and
there was increased type 2 muscle
fibers and strength in the treated
group
Sato Y, Iwamoto J,Kanoko T, Satoh K, Low-dose vitamin D prevents
muscular atrophy and reduces falls and hip fractures in women
after stroke: a randomized controlled trial. Cerebrovasc Dis.
2005;20(3):187-92
VITAMIN D AND
FRACTURES
meta-analysis of five RCTs for hip fracture 9294
participants
and 7 RCTs for nonvertebral fracture risk involving 9820
patients concluded
taking oral vitamin D supplementation or cholecalciferol
between 700 to 800 IU/d reduced the risk of hip and any
nonvertebral fractures in ambulatory or institutionalized
elderly persons.
400 IU were not enough
Bischoff-Ferrari HA, Willett WC,Wong JB, et al, Fracture prevention with vitamin D
supplementation: a meta-analysis of randomized controlled trials. JAMA. 2005 May
11;293(18):2257-64
GINGER
Zingiber officinale (ginger) has
been used as medicine by Folk,
Chinese and Indian herbalists for
centuries.
NAUSEA AND VOMITING
There have been a number of
randomly assigned, double blind
controlled trials for nausea and
vomiting
Ernst E, PittlerMH. Efficacy of ginger for nausea and
vomiting: A systemic review of randomized clinical
trials. Br J Anaesth 2000;84/3:367-371
NAUSEA AND VOMITING
One gram of ginger powder given
as a single dose to 80 cadets,
decreased seasickness compared
to placebo.
PREGNANCY
30 pregnant women with hyperemesis
gravidarum had significantly greater relief of
symptoms after 250 mg. of powdered ginger root
qid for four days compared to placebo with no
reports of fetal abnormalities.
J Med Assoc Thai. 2007 Sep;90(9):1703-9.
A randomized comparison of ginger and dimenhydrinate in the treatment of
nausea and vomiting in pregnancy.
Obstet Gynecol. 2004 Apr;103(4):639-45.
A randomized controlled trial of ginger to treat nausea and vomiting in
pregnancy.
HYPEREMESIS GRAVIDARUM
Try ginger, an alternative remedy thought
to settle the stomach. Dosages of up to
250 mg four times a day appear to be safe
© Copyright SOGC 2000-2004 - The Society of Obstetricians and
Gynaecologists of Canada web site provides information on a wide range
of health and medical topics
.
SURGERY
In two studies involving elective laparoscopic and major
gynecological surgery the incidence of nausea and
vomiting were statistically better than placebo and the
request for postoperative antiemetics was lower in those
receiving ginger.
J Med Assoc Thai. 2006 Oct;89 Suppl 4:S130-6.
The efficacy of ginger in prevention of postoperative nausea and vomiting after
major gynecologic surgery.
However in another laparoscopic gynecological surgery
study on 108 women there was no significant difference.
AROMA THERAPY AND NAUSEA
303 subjects reporting nausea were enrolled (26.3% of 1151)
received a gauze pad saturated with a randomly chosen aromatherapy
agent and were told to inhale deeply 3 times
(1) essential oil of ginger, (2) a blend of essential oils of ginger,
spearmint, peppermint, and cardamom, or (3) isopropyl alcohol.
change in nausea level was significant for the blend (P < 0.001) and
ginger (P = 0.002) versus saline but not for alcohol (P < 0.76). The
number of antiemetic medications requested after aromatherapy was
also significantly reduced with ginger or blend aromatherapy versus
saline (P = 0.002 and P < 0.001,
Aromatherapy as Treatment for Postoperative Nausea: A Randomized Trial. Anesth
Analg. 2012 Mar 5,Hunt R, Dienemann J, Norton HJ, Hartley W, Hudgens A, Stern T,
Divine G.
MOTION SICKNESS
The powdered rhizome of ginger
reduced the symptoms of motion
sickness better than
dimenhydrinate and placebo in
patients that were experimentally
provoked by a revolving chair.
Ginger was as effective as mefenamic acid and
ibuprofen in relieving pain in women with
primary dysmenorrhea
Ginger at a dose of 250 mg
capsules of ginger rhizome powder
four times a day for three days
from the start of their menses
was as effective as mefenamic
acid and ibuprofen in
relieving pain in women with
primary dysmenorrhea.
Journal of Alternative & Complementary
Medicine. 15(2):129-32, 2009 Feb.
SIDE EFFECTS
Few side effects are linked to
ginger when it is taken in small
doses.
Side effects most often reported
are gas, bloating, heartburn, and
nausea. These effects are most
often associated with powdered
ginger.
MASSAGE THERAPY
Pre-term infants who were given 15 minute
massage 3 times a day for 10 days while still
in the incubator gained 47% more weight than
control and performed better on infant
development scores
Similar results were found in cocaine
exposed babies, HIV exposed babies and in
full term infants
When parents were taught to massage their
infants it seemed that parents had less
anxiety and reduced stress.
Field T. Massage Therapy Effects. American Psychologist
1998;53(12):1270-1281
MASSAGE THERAPY
Pregnant woman who were massaged versus
receiving relaxation therapy reported lowered
anxiety and depression, less pain and fewer
obstetrical and postnatal complications.
When significant others were taught to
massage their pregnant partners during
childbirth, the massaged women had lower
anxiety, and depression, less need for
medication, less postpartum depression and
fewer days in hospital compared to women
who received standard breathing coaching
Field T. Massage Therapy Effects. American Psychologist
1998;53(12):1270-1281.
MASSAGE THERAPY
Parents were taught to massage their diabetic and
asthmatic children at bedtime daily for 20 minutes
for one month. Diabetics noted improvements in
glucose control, and asthmatics had fewer attacks
and significantly improved pulmonary function
tests.
decreases in cortisol and catecholamine levels and
postulated increased parasympathetic activity as
an underlying mechanism for changes.
Many of the studies quoted had many
methodological weaknesses and need to be
replicated.
Field T. Massage Therapy Effects. American Psychologist
1998;53(12):1270-1281
MASSAGE
RCT 122 icu patients
either massage, massage with 1%
lavender (Lavendula vera) oil, or rest
periods
Those who received the massage
with lavender oil reported a greater
improvement in mood as measured
by a self-rating 4-point scale.
TOO SHORT TERM AND CRUDE
Dunn C, Sleep J, Collett D. Sensing an improvement: an experimental
study to evaluate the use of aromatherapy, massage, and periods of
rest in an intensive care unit. J Adv Nurs. 1995;21:34-40.
MASSAGE
RCT 72 hospitalized children and adolescents
half with adjustment disorder and half with
depression
either received 30-minute back massages
(n=52) daily for 5 days or watched a relaxing
video (n=20)
depression scores were significantly lower
immediately after massage compared with pretreatment values (P=.005)
the pre-massage profile of mood states scores
significantly declined during the 5-day treatment
(P=.01), and the massage group was less
depressed than the control group at the end
small sample size, short treatment period data
insufficient to judge the value of massage for
depression.
Field T, Morrow C, Valdeon C, Larson S, Kuhn C, Schanberg S.
Massage reduces anxiety in child and adolescent psychiatric patients.
J Am Acad Child Adolesc Psychiatry. 1992;31:125-131.
MASSAGE THERAPY
Patients with low back pain
were shown to benefit from
massage therapy
Massage for low-back pain: A systemic review within the
framework of the Cochrane Collaboration Back Review Group
Spine 2002;27:1896-1910
Effectiveness of massage therapy for sub-acute low-back
pain:a randomized controlled trial.
CMAJ 2000;1629130:1815-20
MASSAGE THERAPY
METANALYSIS OF 37 STUDIES
RANDOMLY ASSIGNED
Singe applications reduced
anxiety, blood pressure, and heart
rate
multiple applications reduced
delayed assessment of pain,
depression and anxiety
Met-analysis of Massage Therapy Research Psych
Bulletin 2004;(130):3-18
ACUPUNCTURE
SCIENTIFIC SUPPORT?
Who is doing it?
Which condition?
Western vs TCM diagnosis?
How frequent and over what period
of time?
Electroacupuncture? moxibustion?
LASER?
Acupuncture for Postoperative
Nausea and Vomiting
A systemic review of 26 trials.
significant reductions in the risks of
nausea, vomiting and the need for
rescue antiemetics in the P6
stimulation point, compared with
sham treatments.
Lee A, Done M: Stimulation of the wrist acupuncture
point P6 for preventing postoperative nausea and
vomiting. Cochrane Database Syst Rev 2004; 3:
CD003281.
Acupuncture for
Nausea and Vomiting
P6 is located two thumb widths
proximal to the distal crease of the
wrist
Between tendons of flexor carpi
radialis and palmaris longus
Acupuncture for
Nausea and Vomiting
A randomly assigned, double-blind,
placebo-controlled study of 187 children aged 7 to 16
Children were injected with 0.2 mL of glucose
solution with a 1 mL tuberculin syringe vertically to a depth
of 5 mm to 7 mm in the P6 acupoint before the
conclusion of surgery
P6 injections were found to be as effective as droperidol
in controlling early post-operative nausea and vomiting.
Author concluded P6-related techniques should be
incorporated in the curriculum of anesthesia residency
programs because the technique is simple to learn and is
a low-cost procedure with few side-effects
Wang SM , Kain ZN: P6 acupoint injections are as effective as
droperidol in controlling early postoperative nausea and vomiting
in children.
Anesthesiology 2002; 97(2):359-66.
ACUPUNCTURE FOR
OA OF THE KNEE
570 patients OA knee randomly assigned and
controlled to 1.acupuncture 2. Sham acupuncture
3. education control attended 6X2hr sessions
25 treatments over two months
statistically significant improvement in pain and
function in true acupuncture group
Berman BM,, Lao L, Langenberg P, et al . Effectiveness of
acupuncture as adjunctive therapy in osteoarthritis of the
knee. A randomized controlled trial. Ann Int Med
2004;141:901-910
ACUPUNCTURE FOR ELBOW PAIN
Five of the six studies indicated
that acupuncture treatment was
more effective in relieving lateral
epicondyle pain compared to a
control treatment.
Using the Jadad scale, all of these
studies were considered to be of
high quality
K. V. Trinh, S.-D. Phillips, E. Ho and K. Damsma,
Acupuncture for the alleviation of lateral epicondyle pain:
a systematic review Rheumatology 2004 43(9):1085-1090
ACUPUNCTURE-
PROBLEMS doing research
ACUPUNCTURESIDE EFFECTS
Certain points are dangerous to
needle
pneumothorax
pregnancy
infection
bruising and bleeding
syncope
MIGRAINE
In two randomized studies
chiropractic manipulations
reduced migraine frequency
and severity.
Parker GB, Tupling H, Pryor DS. A controlled
trial of cervical manipulation of migraine.
Aust N Z J Med 1978;8:589-93
Parker GB, Pryor DS,Tupling H. Why does
migraine improve after a clinical trial? Further
results from a trial of cervical manipulation of
migraine.
Aust N Z J Med 1980;10:193-4
LOW BACK PAIN
A randomized controlled trial of 741 patients
showed chiropractic more affective than
hospital outpatient management for the
treatment of low back pain of mechanical
origin.
Meade TW, Dyer S, Browne W, et al. Low back pain of mechanical origin:
randomized comparison of chiropractic and hospital outpatient treatment.
Br Med J 1990;300:1431-7
MANIPULATION
2870 non-randomized LBP patients with acute or
chronic back pain attending primary care physicians or
chiropractics.
In the short term patients with chronic back pain
treated by chiropractors reported less pain and both
acute and chronic chiropractic patients experience
somewhat greater relief up to one year.
Chronic back pain patient with leg pain below the knee
seemed to do better with chiropractic care.
Haas M, Goldberg B, Aickin M, Ganger B, Attwood M, A
practice-based study of patients with acute and
chronic low back pain attending primary care and
chiropractic physicians: two-week to 48-month
follow-up. J Manipulative Physiol Ther. 2004 MarApr;27(3):160-9
MANIPULATION
672 patients randomized to receive medical or
chiropractic care of low back pain
expressed greater satisfaction from chiropractic
care even though there was no significant
difference in pain improvement or disability
scores.
They found that receipt of self-care advice and
explanation of treatment accounted for the
difference in patient satisfaction.
Hertzman-Miller et al. Comparing the Satisfaction of
Low Back Pain Patients Randomized to Receive
Medical or Chiropractic Care: Results From the
UCLA Low-Back Pain Study
Am J Pub Health 2002;92(10):1628-33
META-ANALYSIS
Dutch researchers did a meta-analysis of 35
randomized trials that compared
manipulation with other treatment
modalities
In 18 of the 35 studies spinal manipulation
improved outcome studies
However most of the studies were of very
poor quality.
Koes BW, Bowler LM, Kripschild PG, et al. Spinal Manipulation and
mobilization for back and neck pain: an indexed review.
Br Med J 1991;303:1298-1303
CONTRAINDICATIONS
con
blood dyscrasia, or anticoagulant therapy
vertebral artery syndrome
abdominal aorta with extensive
atherosclerosis
there is a neurological lesion
involving the spinal chord
vertebra which is weakened by
osteoporosis or the presence of
an unrecognized tumour.
There is great
controversy over the
relationship between
neck manipulation
and stroke
Estimates between 1 in 400,000 to between 3 and
6 per million manipulations
Neurology 2003;60:1408-9, 1424-8
Stoke 2001;32-1054-60
BOOKS
“An Apple a Day- A Holistic Health Primer”
Mel Borins M.D.
“Professional Handbook of Comp &
Alternative Medicine” Fetrow/Avila
“Rational Phytotherapy- A Physician’s Guide
to Herbal Medicine” Shulz/Hansel/Tyler
“Encyclopaedia of Natural Medicine”
Murray/Pizzorno
The ACP Evidence-Based Guide to
Complementary and Alternative Medicine
Bradley P Jacobs and Katherine Gundling
Recommended
Websites
National Centre for
Complementary and Alternative
Medicine. National Institutes of
Health, USA http://nccam.nih.gov/