25th Annual Primary Care Update “Complementary Medicine, What’s the Evidence?”
Christopher M. Valley ND
What Is 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 These techniques are used in place of (Alternative) or in addition to (Complimentary).
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CAM Therapies Included in the 2002 NHIS Adopted from the National Center for Complementary And Alternative Medicine (NCCAM) www.nccam.nih.gov An asterisk (*) indicates a practitioner-based therapy. For definitions of any of these therapies, see the full report or contact the NCCAM Clearinghouse. Acupuncture* Ayurveda* Biofeedback* Chelation therapy* Chiropractic care* Deep breathing exercises Diet-based therapies Energy healing therapy* Folk medicine* Guided imagery Homeopathic treatment
Hypnosis* Massage* Meditation Megavitamin therapy Natural products (nonvitamin and nonmineral, such as herbs and other products from plants, enzymes, etc.) Naturopathy* Prayer for health reasons Prayed for own health Others ever prayed for your health Participate in prayer group Healing ritual for self Progressive relaxation Qi gong Reiki* Tai chi Yoga
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First, Do No Harm The Healing Power of Nature Identifying and Treating the Causes Doctor as Teacher Treating the Whole Person Prevention:
Education, Clinical Training and Licensing Naturopathic doctors receive their training at fouryear, graduate level naturopathic medical schools The practice of medicine in the United States is regulated by each state. Currently, 15 states (and Puerto Rico) have licensing laws for naturopathic doctors: Alaska, Arizona, California, Connecticut, District of Columbia, Hawaii, Idaho, Kansas, Maine, Montana, New Hampshire, Oregon, Utah, Vermont, and Washington
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Resources for more information on Naturopathic Medicine can be found at www.naturopathic.org www.ncnm.edu www.bastyr.edu www.swcnm.edu
The current definition from the American Heart Association (AHA) and the National Cholesterol Education Program (NCEP) is as follows: Elevated Waist Circumference
Men Greater than or equal to 40 inches Women Greater than or equal to 35 inches
Elevated Triglycerides
Greater than or equal to 150mg/dl
Reduced HDL “Good Cholesterol”
Men less than 40mg/dl Women less than 50mg/dl
Hypertension equal to or greater than 130/85 mm Hg, or use of medication for hypertension Elevated Fasting Glucose greater than or equal to 100mg/dl or use of medication for hyperglycemia.
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The main reason to consider an integrative strategy is that metabolic syndrome continues to rise, with no plateau in site. This condition poses a large risk of Type II DM (and it’s sequelae), along with Cardiovascular Disease (CVD). This places an obvious strain on the health of patients, as well as on the system of medicine as a whole.
CDC/NCHS; JAMA. 2002;287:356-359
Integrative treatment of Insulin Resistance (IR)/Metabolic Syndrome is likely to be more effective than treatment of the individual components. This is especially true when accompanied by behavior modifications and stress management techniques.
Ford ES, Giles WH, Dietz W. The Prevalence of Metabolic Syndrome in US Population. JAMA 297 (3): 356359
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Many Examples Including: -Nutrition/Diet Therapies -Supplements (chromium, vanadium, LCarnitine, CLA etc..) -Herbs (Gymnema, Fenugreek, Bitter Melon, Cinnamon etc..) -Medications -Exercise therapeutics -Behavior Modification Techniques Many other modalities (too many to list)…
Lifestyle Education about exercise, stress management, weight reduction, nutrition, sleep hygiene etc..
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Lifestyle modification is the foundation of treatment of IR/Metabolic Syndrome. Knowler and colleagues,[1] researchers in the Diabetes Prevention Program, compared lifestyle modification with diet and medication in more than 3000 patients with “pre-diabetes.” After 3 years of follow-up, the metformin group contained 31% fewer subjects with diabetes, and the lifestyle modification group 58% fewer subjects with diabetes than the placebo group.
Lifestyle modification is likely superior to medication and/or nutrition alone because it addresses multiple endpoints (weight, stress, sleep, diet etc…) which all have notable impacts on metabolic syndrome. More info on each of these to come…..
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Increasing Patient Awareness and Accountability is fundamental with Metabolic Syndrome
- Fundamental for long term success of treatment -Increases non-insulin mediated uptake of glucose into cells and improves long term glycemic control2
-Inexpensive
and nearly free of side effects
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Low cardiovascular fitness associated with a 2x greater risk of death associated with Diabetes3 Several studies have documented significant improvement in glycemic control compared with placebo4
Weight Management Obesity greatly contributes to Insulin Resistance (IR)/Metabolic Syndrome. A loss of just 7% body fat significantly improves metabolic syndrome5 In 2001 the prevalence of obesity was 20.1%. In 2007, it’s 25.5%6
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Visceral fat is the key This fat has notable effects on cortisol and other hormones which contribute to Metabolic syndrome. This is the importance of the waist to hip ratio
Less than 0.8 (women) Less than 1.0 (men)
Hu and coworkers[7] found that, irrespective of exercise levels, sedentary behaviors (especially watching television) were associated with significantly elevated risks of visceral adiposity.[8] Of interest, the Diabetes Prevention Program showed that just “a 6% weight loss from baseline reduced the risk of developing type 2 diabetes in patients with impaired glucose tolerance by 58%.”[9] Clinicians must treat patients with IR with education, compassion, and hope. Such patients must be taught that obesity is a chronic, serious disease requiring diligent monitoring for their entire lifetimes.
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Stress Management Relaxation techniques are valuable in the treatment of IR/Metabolic Syndrome because they stabilize adrenal gland function. Stress management lowers both cortisol levels and blood pressure, increases DHEA, improves immunity, and also reduces anxiety and depression. Patients are therefore less likely to abuse their bodies and tend to feel better about themselves. A prescription with an individualized approach involving meditation, relaxation techniques, prayer, visualization, and so on, is appropriate. “Stress management improves long-term glycemic control in type-2 diabetes10.
Links to diabetes, metabolic syndrome, and obesity as a result of insufficient or disrupted sleep (e.g., sleep apnea syndromes) are emerging but are not fully established 11-14. Even in adolescents, one study has uncovered a potential association of poor sleep to obesity, albeit in this case the link is made somewhat indirectly through a reduction in daytime activity associated with disturbed sleep. Thus those youngsters with greater sleep disruption also demonstrated lowered activity in the daytime (measured actigraphically) and manifested a higher likelihood toward obesity; indeed, “for each hour of lost sleep, the odds of obesity increased by 80%” 15.
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A study is published in the December issue of the journal SLEEP suggests a strong correlation between poor sleep quality and the development of Type II Diabetes. Columbia University’s James E. Gangwisch, PhD, looked at the relationship between sleep duration and the diagnosis of Diabetes over a 10-year period among nearly 9,000 subjects who were already participants in the first National Health and Nutrition Examination Survey. Ages ranged from 32 to 86 years 16. Subjects who slept five or fewer hours or nine or more hours were far more likely to be diagnosed with Diabetes during the 10-year period than were those who slept seven to eight hours, even after adjusting for variables, including obesity, hypertension, physical activity, depression, alcohol consumption, ethnicity, education, marital status and age. Dr. Gangwisch believes the effect of short sleep duration on Diabetes incidence may be due to its direct effect on body weight and hypertension. Earlier studies show sleep deprivation decreases glucose tolerance and decreases insulin sensitivity by stimulating the sympathetic nervous system, raising nighttime cortisol levels and decreasing glucose utilization in the brain. With Insulin Resistance, the long term demand on the pancreas for insulin overproduction can lead to Type II Diabetes.
So far, no single dietary approach has shown to be the treatment of choice in Metabolic Syndrome. However, a diet that has reduced Saturated and Trans Fat less than 7% along with soluble fiber 25 grams or more daily looks to be a promising starting point. Patients with IR/Metabolic Syndrome do show increased HDL and decreased Triglycerides with a moderate protein, and slightly lower carbohydrate diet17
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Lipoic acid (1,2-dithiolane-3-pentanoic acid), a derivative of octanoic acid, is present in food (beef, broccoli, spinach, and organ meats) and is also synthesized by the liver. It is a natural cofactor in the pyruvate dehydrogenase complex where it binds acyl groups and transfers them from one part of the complex to another. α-Lipoic acid, which is also known as thioctic acid, has generated considerable interest as a thiol replenishing and redox modulating agent. It has been shown to be effective in ameliorating both the somatic and autonomic neuropathies in diabetes [18-20] . It is currently undergoing extensive trials in the United States as both an antidiabetic agent and for the treatment of DN
In animal experiments, the potent antioxidant and free radical scavenger alpha-lipoic acid has been shown to cause weight loss, ameliorate insulin resistance and atherogenic dyslipidemia, as well as to lower blood pressure, all of these being components of the metabolic syndrome. Recent investigations on its mechanisms of action indicate that alpha-lipoic acid can affect central and peripheral modulation of 5'-AMP-activated protein kinase, activate PPAR-alpha and PPAR-gamma, modulate PPAR-regulated genes and up regulate the expression of PPAR-gamma mRNA and protein in cardiac tissue and aorta smooth muscle. To a large extent, these findings can explain the observed beneficial metabolic effects of alpha-lipoic acid, supporting its potential application as a therapeutic agent for the treatment of the metabolic syndrome21,22.
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ALA looks to be a promising multisystem antioxidant to help stabilize endothelium and prevent atherogenic induced microvascular complications in patients with Type II Diabetes23 Dosage of ALA should be 200mg bid-tid The toxicity of ALA is likely very low as well. Studies have shown no adverse effects in doses up to 60mg/kg/day.
The Omega 3’s EPA and DHA provide significant benefit to the patient with Metabolic Syndrome. These benefits are: 1. Improved treatment of Dyslipidemia 2. Decreased Cardiovascular inflammation 3. Improved endothelial function
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Dyslipidema (elevated LDL, low HDL, high Triglycerides) is a common finding in Metabolic Syndrome. Fish oil at doses of 3-4g/day in divided doses can be used alone or with a statin to aid in treatment of mixed dyslipidemia. Simvastatin (20 mg) was used alone and in combination with omega-3 fatty acids (4 g/day Omacor; omega-3 acid ethyl esters, Pronova AS Biocare, Oslo, Norway) in 41 patients with combined dyslipidemia (total cholesterol >5.3 mmol/L [205 mg/dL] and TGs 2.0 to 15.0 mmol/L [175 to 1,330 mg/dL]).25 The addition of omega-3 fatty acids to simvastatin therapy provided a significant further 28% reduction in serum TG level and a borderline-significant reduction in total cholesterol level without adversely affecting the LDL cholesterol–lowering effect of simvastatin
Combination therapy with atorvastatin and omega-3 fatty acids was also studied for its effect on inflammatory markers in a study in 48 obese men (mean body mass index, 33.6) with combined dyslipidemia (total cholesterol >5.18 mmol/L [200 mg/dL] and TGs >1.19 mmol/L [105 mg/dL]) who were randomized to treatment with atorvastatin 40 mg/day, omega-3 fatty acids 4 g/day, the combination, or placebo for 6 weeks.26 C-reactive protein (CRP) was reduced from baseline by 31% with atorvastatin monotherapy, 0.9% with omega-3 fatty acid monotherapy, and 48% with the combination.
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Omega-3 fatty acids are effective TG-lowering agents; they have also been shown to reduce the incidence of clinical events in patients with CAD irrespective of their effect on TG levels. In a number of small studies, the combination of statins and omega-3 fatty acids has been consistently shown to be an effective, safe, and well-tolerated treatment for combined dyslipidemia. Larger trials with clinical event end points are needed to assess the potential cardiovascular benefit of combination therapy with statins and omega-3 fatty acids as well as to determine the optimal treatment strategy for cardiovascular risk reduction27
Consider the addition of CoQ10 to patients taking Statins. Studies thus far have been conflicting on it’s benefits, however, toxicity is minimal. The addition of 100mg CoQ10 in a solubilized gel cap to a statin may hold promise in decreasing statin associated myopathy. More studies are needed We are fully aware that CoQ10 has cardiovascular benefits including modest effects on blood pressure (around 10% decrease in systolic) and looks to have promise with insulin resistance and dyslipidemia28
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Integrative treatment of Metabolic Syndrome/IR is likely to be more effective than treatment of individual components. This is especially true when accompanied by behavior modifications and stress management Alpha lipoic Acid offers promise as adjunctive therapy of metabolic syndrome patients Omega 3 fish oil provides beneficial effects on mixed dyslipidemia, and decreasing inflammation associated with metabolic syndrome and cardiovascular disease. Strongly consider the addition of CoQ10 to treatment of Met Syndr. As benefits look promising and toxicity is minimal.
Christopher M. Valley ND Integrative Medicine Associates 3424 S. Grand Blvd (509) 838-5800 www.integmedassoc.org
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