Transcript Polishing the Metallic Years Alternative Medicine and

CAM and Senior Health
September 2004
William H. Hardt MD
Assistant Professor of Medicine
Loma Linda University School of Medicine
Riverside County Regional Medical Center
Objectives
1. Understand current types and patterns of
CAM use in the United States.
2. Recognize and address CAM related
questions from your patients
3. Discuss issues involving Quackery in
CAM and Conventional medicine
4. Provide resources for further study
Nineteenth Century Professional Care
Botanical healers
Midwives
Homeopathic healers
Apothecaries
“uncounted cancer doctors, bonesetters,
inoculaters, abortionists, and sellers of
nostrums.”
Allopaths (M.D.’s)
Complementary and Alternative Medicine
(CAM)
Integrative Medicine in 2002
“Medical interventions not widely taught in
medical schools or generally available at
U.S. hospitals.”
Eisenberg DM, et. al. NEJM 1993 Vol. 328
“What most sets alternative medicine apart, in
our view, is that it has not been
scientifically tested and its advocates
largely deny the need for such testing.”
Editors NEJM
“The modern biomedical model of health and
illness [is] based in part on seventeenthcentury cartesian mind-body dualism, [and]
has emphasized the body in isolation, often
neglecting the mind.”
Osher Center for Integrative Medicine, UCSF
CAM
“CAM is a group of diverse medical and health
care systems, practices, and products that are not
presently considered to be part of conventional
medicine--that is, medicine as practiced by
holders of M.D. (medical doctor) or D.O. (doctor
of osteopathy) degrees and their allied health
professionals, such as physical therapists,
psychologists, and registered nurses.”
National Center for Complementary and Alternative
Medicine www.nccam.nih/gov
CAM and Conventional
Medicine
As Medical professionals, what is
to be our approach to CAM?
Charter on Medical Professionalism: Fundamental Principles and Professional
Responsibilities
Blank, L. et. al. Ann Intern Med 2003;138:839-841
Complementary and Alternative (CAM)
Medicine Use
Prevention Magazine (NIH supported telephone
survey)
In 1997 one-third of US population using CAM
therapy
67.6% of respondents had used CAM at least once in
their lifetime
Lifetime use steadily increases with age across age
cohorts
Pre-baby boomers (Born before 1945) - 3/10
Baby boomers (Born 1945-1964) - 5/10
Post-baby boomers (Born 1965-1979) - 7/10
National Health Interview Survey
National Center for Health Statistics
Center for Disease Control
2002 edition of the NCHS's National Health
Interview Survey (NHIS). 2004 release
An annual study in which Americans are
interviewed about their health- and illnessrelated experiences.
31,044 adults aged 18 years or older from the
U.S. civilian non-institutionalized population.
National Health Interview Survey
National Center for Health Statistics
Center for Disease Control
Estimated Annual U.S. Expenditures on CAM
$36-47 Billion overall
$12.2-19.6 Billion was paid out-of-pocket
This is more than the U.S. public paid out of
pocket for all hospitalizations in 1997 and
about half that paid for all out-of-pocket
physician services.
CAM and Senior Health
What has made a difference in
average life expectancy and
maximum life span in the last
100 years?
Leading Causes of Death in US
1900
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Pneumonia and flu
Tuberculosis
Diarrhea and intestinal ills
Heart disease
Stroke and brain lesions
Kidney inflammation
Accidents
Cancer
Senility
Diphtheria
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
2001(latest CDC data)
Heart disease
Cancer
Stroke and brain lesions
Lung disease
Accidents
Diabetes
Pneumonia and flu
Alzheimer's disease
Kidney inflammation
Septicemia
Public Health Measures:
Main Contributor to Improvements in
morbidity and mortality
Water purification
Sanitation
Immunization (diphtheria, polio)
Antibiotics
Current Milieu in managing
Senior Health
Successful Aging
 Longevity
 Maintaining function
 Maintaining independence
Jeanne Calment;
Oldest documented
human.
Died at 122 years old,
August 4, 1997
Senior Health and CAM
A daunting array of options

Homeopathy
 Naturopathy
 Herbal Medicine
 Traditional Medicine
 Mind-Body Medicine
 Energy Medicine
 Ayurvedic Medicine
 Biomedicine

Massage Therapy
 Dietary supplements
 Therapeutic Touch
 Hormone replacement
therapy
 Chelation therapy
 Cancer remedies
 Others
Alternativism and Health

A Multibillion dollar industry and rising

1992 Congress establishes Office of
Alternative Medicine, under the NIH

1994 Dietary Supplement Health and
Education Act (DSHEA)
Problems with Supplements
Few clinical trials with good methodology
Issues of standardization (selection bias, lack
of controls)
Absence of standards for supplements
Where clinical trials are performed different
preparations are used
Evaluations of label contents found gross
errors
As a doctor specializing in nutritional medicine,
I used to think I could get all the extra nutrients I
needed from vitamins and supplements. WAS I
EVER WRONG!
Dr. Nelson and colleagues advertise that algae
(marketed as Sun Chlorella) is a radical discovery
that will. . .
Destroy viruses, bacteria and foreign invaders: "I
haven't had a cold in two years“
Clobber cholesterol: powerful natural breakthrough
Soothe joints: 88 percent success rate - new study
End tiredness: The real reason people get tired-and an
easy solution for you
Banish brain fog: Keep your mind as sharp as a tack
with this secret
Beautiful, smooth, creamy looking skin: Amazing!
Stay trim and slim: "50 pounds just vanished"- one
woman's story
High amounts of DNA & RNA have
been shown to have considerable
beauty benefits!
Now you can fool your friends into thinking you're years
younger with the help of these same nucleic acids,
along with other nutrients.
Your friends won't believe how good you look - year
after year after year. Because you'll just keep getting
healthier and looking younger, while they grow older
and gain more wrinkles!
A rejuvenated love life!
"I can't get enough of
Sun Chlorella, that is...
It's rejuvenated my love life. I am an
athletic 53-year old man. I have found in
the past that I routinely hibernate during
the winter and am more tired. Now that
I've been taking Sun Chlorella, I am reawakened and my much younger fiancée
is very pleased. Our love life has reached
its peak. Thanks, Sun Chlorella, for the
stamina." -Eric Macias, Redondo Beach,
CA
What leading medical
doctors,scientists and health
experts say about this amazing
discovery...
"This is the most significant nutritional
breakthrough I've seen in over 25 years I've seen my patients go from couch
potatoes to active dynamos. It has had a
remarkable effect on thousands..." - Michael
E. Rosenbaum, M.D., noted physician,
nutritionist and expert on Chronic Fatigue
Syndrome
"A remarkable, 100%
natural detoxifier.“
"When my patients come to me
with unsolvable health
problems, I often start them on a
detoxifying antioxidant program.
There's nothing better for rejuvenating
and cleansing body tissues than [this
discovery]..." - David C. Freeman,
M.D., Fellow, American Geriatrics
Society and former Director of the
American Academy of Medical
Preventics
"I strongly advise the
addition of [this breakthrough]
to the diet of anyone interested
in better health. My own clinical studies and studies from around the world - have
convinced me of its value. My family and I
use it regularly, and I recommend it to my
patients." - David Steenblock, M.S., D.O.,
President of the Anti-Aging Research
Institute of America
(16)Merchant
FL, Rice CC, Young HF, et al.
Dietary chlorella pyrenoidosa for patients
with malignant glioma. Phytotherapy
Research, 1990:4(6):220-230
(17)Wilkinson,
S. Golding KH, Robinson
PK, et al. Mercury removed by immobilized
algae in batch culture systems, J Appl
Physical, 1990:2:223-230
Open-mindedness and Healthy
Skepticism
CAM
Benefits (Perceived)
Patient autonomy
Personal control over health
care
Prevention
Improvements in chemical
balance, energy, and
harmony with nature
Costs
Risks
Medical decision making
without appropriate training
False sense of safety
Generally lacking in scientific
evidence of safety and
efficacy
Claims that are difficult to
substantiate
Costs
5-TP/Tryptophan
Aloe Vera Drink
Alpha-Lipoic Acid
Androstenedione
Arginine
Beta Carotene
Bilberries
Black Cohosh
Blue-Green Algae
Calcium
Cat's Claw
Chaparral
Cholestin
Choline
Chondroitin
Sulfate
Chromium
Picolinate
CLA
Coenzyme Q-10
Colostrum,
Bovine
Creatine
DHEA
Echinacea
Ephedra
Evening Primrose
Oil
Exercise in a
Bottle & Fat
Trapper
Feverfew
Flaxseed
Folic Acid
Garcinia
Garlic Pills
GBL
Gero Vita
Ginger
Ginkgo Biloba
Ginseng
Glucosamine
Goldenseal
Grape Seed
Extract
Guggulipid
Hawthorn
Herbal (Diet) Teas
Human Growth
Hormone
Huperzine A
Juice Plus+
Kava
Lysine
Lutein
Melatonin
Memory and Brain
Supplements
Microhydrin
Milk Thistle
Minerals,
Chelated
Minerals, Colloidal
MSM
Pycnogenol
Quercetin
Rose Hips
Royal Jelly
SAM-e
Sassafras
Saw Palmetto
Selenium
Senior Moment
Soy Isoflavones
St. John's Wort
Stanol/Sterol
Supplements
Tocotrienols
Valerian
Vanadyl Sulfate
Vitamin A
Vitamin B-12
Vitamin C
Vitamin D
Multivitamins
Vitamin E
Niacin
Vitamin K
Noni Juice
Phosphatidylserine Yohimbe
Zinc
The Risk-Benefit Profile of Commonly
Used Herbal Therapies:
Annals of Internal Medicine 1 January 2002, Vol.
136. No. 1
 Ginkgo
 St.
John’s Wort
 Ginseng
 Echinacea
 Saw Palmetto
 Kava Kava
The Risk-Benefit Profile of Commonly
used Herbal Therapies:

Ginkgo (Ginkgo biloba)
– Memory impairment – no compelling evidence
– Dementia – 3% pooled difference, likely relevant
– Tinnitis – Therapeutic value uncertain
– Intermittent Claudication – less effective than walking
exercises
– Safety risks: bleeding (subdural hematoma), seizures,
may interact with anticoagulants
The Risk-Benefit Profile of Commonly
used Herbal Therapies:

St. John’s Wort (Hypericum perforatum)
– Herbal antidepressant
Probable SSRI, SDRI, NRI mechanism of action
 For mild to moderate depression
 Similar in effectiveness to low-dose Tricyclic
antidepressants
 Excellent safety profile
 “clearly superior to conventional antidepressants.”
– Safety risks: induces hepatic enzymes P450 system,
Combination with SSRI’s may increase risk for
Serotonin Syndrome

The Risk-Benefit Profile of Commonly
used Herbal Therapies:

Ginseng (Panax ginseng)
Complex terminology and lack of clear
distinction between different types of ginseng
 recommended as having ability to improve
stamina, concentration, vigilance, and well-being.
 Compelling evidence of efficacy lacking.
– Safety risks: insomnia, diarrhea, vaginal bleeding,
mastalgia, severe headache, schizophrenia, and
Stevens-Johnson syndrome

The Risk-Benefit Profile of Commonly
used Herbal Therapies:

Echinacea (Echinacea species)
Products vary considerably, no single ingredient
 Pharmacologic actions include stimulation of immune
system
 Best researched indications are treatment of upper
respiratory tract infections
 Results non-conclusive, may be efficacious, trial data
weak and inconclusive
– Safety risks: Hepatitis, asthma, rash, rash with myalgias
and nausea, dizziness and swollen tongue, anaphylaxis

The Risk-Benefit Profile of Commonly
used Herbal Therapies:

Saw Palmetto (Serenoa repens)
– Benign prostatic hyperplasia
Antiandrogen activity, inhibition of 5--reductase
 Good evidence indicates efficacy short-term and
probably medium term, unknown long-term benefits
 Withdrawal rates (rough indicator of patient
acceptance) better than finasteride
– Safety risks: Constipation, decreased libido, diarrhea,
headache, hypertension, nausea, urinary retention. All
are rare and usually mild

The Risk-Benefit Profile of Commonly
used Herbal Therapies:

Kava Kava (Piper methysticum)
– Anxiolytic
 South Pacific recreational drink
 Central muscle relaxant and anticonvulsant actions
 Short administration of kava is effective in reducing
anxiety
– Safety risks: Reversible yellowish discoloration of skin,
nails, and hair (chronic abuse), visual disturbances,
dizziness, stupor, GI discomfort, extrapyramidal effects
(rare), hepatitis
FDA warning
Kava (Piper methysticum)
Warning about severe liver injury, including
hepatitis, cirrhosis, and liver failure
California Department of Health
Services
PC SPECS and SPES capsules from
Botaniclab, Brea California
“for prostate health: strengthening the
immune system.”
Contains undeclared prescription drug
ingredients
PC SPECS contains warfarin
SPES contains alprazolam
Hormone replacement therapy
and anti-aging
Human Growth Hormone and Secretagogues
Replacement promoters claim remarkable
increases in life span.
Decrease central fat, improves lipid and
glucose levels, reduces severity of Crohn’s,
and others
More studies needed
Hormone replacement therapy
and anti-aging
DHEA (dehydroepiandrosterone)
Promoters claim improved stamina, concentration, mood.
Little know about DHEA physiologic function
Health food stores generally don’t contain DHEA but rather
plant sterols that are “botanical building blocks of
DHEA”
Unknown long term side effects
Warning in use with hormone responsive tumors
Drug companies not likely to pursue
Senior Health, Longevity, and Quality of
Life
Studies that identify factors that contribute to
longevity and health have not yet shown
that supplements have any effect.
Caveat: Omega-3 fatty acids, Glucosamine.
Known factors associated with health
and longevity
Non-smoking
Moderation in alcohol use
Exercise
Weight control
Stable relationships and coping mechanisms
Personal control over lifestyle
Prevention in Senior Care
US Preventive Services Task Force Guidelines
Detection and Treatment of hypertension
Managing modifiable risk factors for CAD
Breast cancer screening
Colon cancer screening
Sensory screening (hearing, vision)
Diet counseling
Injury prevention
Immunization
Education
The Key to protection and safety
Quackery in Health Care
Quackery
“…anyone who promotes medical schemes or
remedies known to be false, or which are
unproven, for a profit.”
Congressman Claude Pepper, 1984
Quackery
Anything involving over promotion in
the field of health
Example: Total body scans?
Vitamin B12 shots?
Ten Ways for Patients to Avoid Being
Quacked
1.
2.
3.
4.
5.
Quackery seldom looks outlandish
“Faulty nutrition” causes most diseases
and requires supplements
Be wary of anecdotes and testimonials
Be wary of pseudomedical jargon
Be skeptical of paranoid accusations
Ten Ways to Avoid Being Quacked
6.
7.
8.
9.
10.
Watch out for “secret cures”
Maintain a healthy skepticism of herbal
remedies
Be wary of products treating a wide range
of unrelated diseases
Ignore appeals to vanity, “think for
yourself”
Don’t let desperation cloud judgment
Summary
1. Keep open-minded about new or unproven
treatments
2. Maintain a healthy skepticism, and apply EBM
techniques.
3. Encourage patients to report use of alternative therapies
in an uncritical environment
4. Provide reliable resources for education of patients
5. Guide patients in appropriate lifestyle changes to
maintain functionality and improve longevity
6. Apply USPSTF guidelines to all senior patients
Resources:
National Center for Complementary and Alternative
Medicine. www.nccam.nih.gov
German Commission E Monographs
www.herbalgram.org
Consumer Health Digest, National Council Against
Health Fraud www.ncahf.org
ConsumerLab.com www.consumerlab.com
Medical Clinics of North America
January 2002
National Library of Medicine, PubMed
www.ncbi.nlm.nih.gov
Resources: PDA downloadable
Tarascon Pocket Pharmacopoeia, Deluxe
2004 Tarascon Publishing and USBMIS, Inc.
www.tarascon.com
ePocrates RxPro, Version 6.13 Palm version
www.epocrates.com
“I took pleasure when
I could. I acted
clearly and morally
and without regret.
I’m very lucky.”
Jeanne Calment