integrative medicine and phitotherapy
TRANSCRIPT
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Integrative Medicine
Nutritional Implications
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Complementary and
alternative medicine (CAM): Complementary and alternative
medicine (CAM): alternative,
adjunctive health care practices: notpresently an integral part ofconventional medicine; includes
botanical use, mind-body approaches,musculoskeletal manipulation, energymedicine, nutrition-diet interventions
Thomson in Krause, p. 470
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CAM Therapies Include
Alternative medical systems, such asnaturopathy, traditional Chinese medicine,ayurveda, and homeopathy
Mind-body therapies, such as meditation,prayer, art or music therapy
Biologically based therapies such as herbs,whole foods diets, and supplementation
Manipulative therapies such as massage,chiropractic medicine, osteopathy, yoga
Whole medical systems based on energytherapies such as qi gong, magnetic
therapy, and reiki
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Integrative medicine
Integration of these approaches intoconventional medicine; nutritional care
is a primary therapy in this model Focused on combined use of
conventional and CAM approaches
Evidence-based
Includes wellness and prevention
Thomson in Krause, p. 471
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Complementary and
Alternative Medicine(NCCAM)
Part of the National Institutes of Health
Investigates and evaluates alternative
therapies and their effectiveness
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Theoretical Basis of
Holistic Therapies Health as a vital, dynamic state; more
than the absence of disease
The healing force of nature
Self-healing power of living things;organisms have inherent self-defense
mechanisms against illness
Includes naturopathy, chiropractic,homeopathy, traditional Oriental
medicine, acupuncture, phytotherapy
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Health is more than the absence of disease.
The body can heal itself .
Integrative Therapies
Naturopathy
Homeopathy
Traditional Chinese medicineAcupuncture
Phytotherapy
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Naturopathy
Practitioners diagnose and treat at the primary carelevel
Train in 4-year postgraduate institutions
Most states require licensure
Uses natural methods of healing (light, heat, air,water, and massage)
Training includes pathology, microbiology, physicaland clinical diagnosis, pharmacognosy, hydrotherapy,physical therapy, nutrition,
Treatments include phytomedicines, electrotherapy,physiotherapy, minor surgery, mechanotherapy,nutrition, nutritional supplements, and natural forces
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Chiropractic Practitioners
Do not prescribe drugs or performsurgery
Licensed and regulated in all 50 statesand 30+ countries
Practitioners must graduate from 4-
year accredited college of chiropracticand pass a nationally-administeredexam
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Chiropractic
The most widely-used of thecomplementary and alternative
treatments, particularly for low backpain, neck pain, and headache
Effectiveness is being studied by the
Consortial Center for ChiropracticResearch, a consortium of chiropracticschools and universities, established
by NCCAM
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Homeopathy
Law of similars: Substances in largedoses that produce symptoms of a
disease in healthy people will cure thesame symptoms when administered invery dilute amounts
Remedies become potentized throughrepeated dilution and succussion(shaking)
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Homeopathy
Results of research on theeffectiveness of homeopathy have
been contradictoryAppears to have more than a placebo
effect, but scientific basis unclear
Generally regarded as safe (manyhomeopathic remedies are so dilutethat the healing substance is
nondetectable by chemical means
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Traditional Chinese
Medicine Based on the concept of body life
force chi (Qi)
Forces that must be balanced
Yin and yang and blood
Invisible energy circuits calledmeridianscarry chi and blood
throughout the body
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Nutrition in Traditional
Chinese Medicine Components: Food as a means of
obtaining nutrition, food as a tonic or
medicine, fasting Foods classified by taste (sour, bitter,
sweet, spicy, salty) and property (cool,
cold, warm, hot and plain) Regulate yin, yang, chi, blood
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Acupuncture and
MoxibustionAcupuncture: Use of thin needles,
inserted into points on the meridians,
stimulating the bodys energy or chi Moxibustion: application of heat along
meridian acupuncture points, affecting
chi and blood, balancing substancesand organs
Treat disharmony in the body
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Acupuncture as
Anesthesia Has been used to produce regional
anesthesia
Appears to act through needle stimulation,triggering the release of opioids
Research has been mixed
Has been shown to be efficacious in adultpostop management, chemotherapy-induced nausea, postoperative dental pain
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Traditional Chinese Herbs
Includes herbs and minerals as well asanimal products
Pharmacopoeias published as early asthe third century BC
Most medicinals include multiple
substances
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Phytotherapy
Science of using plant-derived substances totreat and prevent illness
Botanicals: come as bulk herbs, tinctures,capsules and tablets; includes herbs andother plant materials
Sometimes the active ingredient has been
identified; sometimes not
Have a long history of research and use inEurope
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Botanical Formulations
Teas: weak concentration prepared bysteeping fresh/dried herbs for a few
minutes in water Infusions: more concentrated than
teas; steeped for 15 minutes
Decoction: Most concentrated ofbeverages; botanical is boiled for 30-60 minutes
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Botanical Formulations
Extracts: herbs are extracted with anorganic solvent to dissolve the active
components; concentrated form Tincture: extract in which solvent is
alcohol
Glycerite: extract in which the solvent is
glycerol or mixture of glycerol, propyleneglycol, and water; more suitable forchildren
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Botanical Formulations
Capsules: Herbal material enclosed in a hard shellmade from gelatin or cellulose
Tablets: herbal material is mixed with filler to formthe hard tablet; may be coated or uncoated
Lozenges (troches): active components arereleased in the mouth when chewed or sucked
Soft gels: used to encase liquid extracts, such asomega-3 fatty acids or vitamin E
Essential oils: fragrant, volatile plant oils used foraromatherapy, bathing; not to be used internallyunless specifically directed
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American Herbal Products AssocBotanical Safety Rating System
Class 1: herbs that can be safely consumedwhen used appropriately
Class 2: herbs for which restrictions apply,e.g. for external use only, not to be usedduring pregnancy, nursing, etc
Class 3: herbs labeled To be used only
under the supervision of an expert qualifiedin the appropriate use of this substance.
Class 4: insufficient data for classification
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Dietary Supplement Health andEducation Act of 1994 (DSHEA)
Defined dietary supplements as a productintended to supplement the diet that bearsor contains one or more of the following
dietary ingredients: a vitamin, a mineral, anherb or other botanical, an amino acid, adietary substance for use by man tosupplement the diet by increasing the totaldaily intake, or a concentrate, metabolite,
constituent, extract, or combinations ofthese incredients
Reclassified botanicals as dietarysupplements, distinct from food or drugs
Di t S l t
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Dietary SupplementHealth and Education Act
of 1994 (DSHEA) Plant extracts, enzymes, vitamins, minerals,
hormonal products available withoutprescription may carry structure-function
claims Cannot claim to prevent or cure specific
conditions Must display disclaimer, This statement has
not been evaluated by the Food and DrugAdministration. This product is not intendedto diagnose, treat, cure or prevent anydisease.
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Required Labeling of DietarySupplements under DSHEA Name (echinacea, for example)
Ingredient information
Disclaimer: "This statement has not beenevaluated by the Food and Drug
Administration. This product is not intendedto diagnose, treat, cure or prevent any
disease." Supplement Facts panel, which includes
serving size, amount and active ingredient.
Name and address of manufacturer, packeror distributor.
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Supplement Facts Panel
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Dietary Supplement
Claims Health claim: describes the relationship
between a substance and a disease
condition; FDA does not approve, but mustbe notified
Qualified health claim: based on emergingscientific evidence; must be approved by
FDA Structure-function claim: most common;
does not claim to prevent disease, but aphysiological effect is noted, e.g. increasesblood flow to the heart.
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Labeling Under DSHEA
Allowed
This product helps toincrease blood flow tothe heart.
This product promotesurinary tract health
This product improvesabsent-mindedness.
This product reducesstress and frustration
Not Allowed
This product preventsheart disease
This product preventsurinary tract infections.
This product reducesrisk of AlzheimersDisease.
This product improvesdepression.
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Regulation of Dietary
Supplements Dietary supplements are not subject to the
same standards as prescription or over-the-
counter drugs Manufacturers do not have to prove their
products are safe or effective before theyput them on the market
FDA can pull supplements proven to bedangerous, but only after the fact; it is up tothe FDA to make its case
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Regulation of Dietary
Supplements: Medwatch The FDAs Medwatch system can be
used to report possible adverse
reactions to dietary supplementshttp://www.fda.gov/medwatch/report/hcp.htm
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Examples of FDA Warnings
January, 2004: FDA warns consumers not tofeed their babies Better than Formula Ultra
Infant Immune Booster 117" being soldover the internet as a dietary supplement
February, 2002: Consumers warned to stopusing the products PC SPES and SPES
capsules because they contain undeclaredprescription drug ingredients that couldcause serious health effects
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Cautions Regarding
Dietary Supplements There may be a discrepancy between
the ingredients on the label and whats
inside This is especially true of herb
mixtures, such as Chinese herbs
The dosage of the active ingredientin herbals can vary widely dependingon the variety of plant, where its
grown, climate, etc.
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Read the Dietary SupplementLabel and Verify.
Complete botanical name of the product(make sure it is the right botanical)
The part of the plant used to make theproduct; it should be the part that containsthe active components
The concentration of the botanical and if it
is appropriate, neither too weak or twostrong
Debusk, RM. A practical guide to herbal supplements for
nutrition practitioners. Top Clin Nutr 16:53, 2001
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Read the Dietary SupplementLabel and Verify. The daily dosage needed to obtain the
desired effect
The list of ingredients used to identify fillers,
potential allergens
Lot number
Expiration date
Recognized seal of approval (GoodHousekeeping, USP, Consumerlab)
Compare prices: prices vary widely
Debusk, RM. A practical guide to herbal supplements fornutrition ractitioners. To Clin Nutr 16:53, 2001
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Evaluating Dietary
Supplements Obtain unbiased evaluative information from
resources like Supplement Watch and
Consumer Lab www.consumerlab.com Encourage patients to purchase supplements
from well-known manufacturers
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ConsumerLab Study of 20
MultivitaminsVitamins that failed: The Vitamin Shoppe Multivitamins Especially for
women: Contaminated with lead
Hero Nutritionals Yummi Bears: Had twice thelabeled amount of vitamin A Nature's Plus Especially Yours for Women: Took
twice as long as allowed to disintegrate AARP Maturity Formula: Took nearly twice as long
as allowed to disintegrate Eniva VIBE: Only 54 percent of claimed vitamin A Pet-Tabs Complete Daily Vitamin-Mineral
Supplement for Dogs: Contained lead Accessed at MSNBC http://www.msnbc.msn.com/id/16655168/ Released 1/2007
http://www.msnbc.msn.com/id/16655168/http://www.msnbc.msn.com/id/16655168/ -
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ConsumerLab Study of 20
MultivitaminsVitamins that passed:
Centrum Silver
Member's Mark Complete Multi
One A Day Women's
Flintstones Complete http://www.msnbc.msn.com/id/16655168/
January, 2007
http://www.msnbc.msn.com/id/16655168/http://www.msnbc.msn.com/id/16655168/ -
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Tips for Picking a
Multivitamin from CSPI Choose well-known mainstream brands by companies
that have a lot at stake. Buy from large, trusted retailers, not unknown sellers
on the Internet. Look on the bottle for a stamp from USP, NSF or
ConsumerLab.com. While the stamp doesn't guaranteethe product is safe and effective, it does indicate thatthe manufacturer has submitted the product fortesting to show that it contains what is stated on the
label. Dont spend a fortune on vitamins. Pricey products
toting all sorts of "extras" aren't necessary and maybe trouble.
Center for Science in the Public Interest accessed athttp://www.msnbc.msn.com/id/16655168/ 1/07
http://www.msnbc.msn.com/id/16655168/http://www.msnbc.msn.com/id/16655168/http://www.msnbc.msn.com/id/16655168/ -
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Evaluating Dietary
SupplementsUnited States Pharmacopeial Convention
(USP) Dietary Supplement Verification
Program (DSVP) Certification mark (USP)indicates that
the product contains the dietary supplementlisted on the label in the stated amount and
that the product is manufactured properly Does not speak to the safety or efficacy of
the ingredients, only to good manufacturingpractices
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CAM Providers: MDs/DOs
Over 1/3 of medical schools offerinstruction in alternative medicine
More than half of family physicians inthe US regularly prescribe alternativetreatments or have used themselves
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CAM Providers: RDs
Nutrition in Complementary Care DPG, asubunit of the American Dietetic Association
http://www.complementarynutrition.org/ Some RDs are incorporating counseling
about CAM into their practices
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CAM Providers: Other
RNs
RPh
ND: naturopath provider DC: chiropractor
OMD: oriental medical doctor
Accupuncturist Massage Therapist
Hypnotherapist
Herbalist
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Tips for Patients:Evaluating CAM Providers
Check for licensing, education,accreditation of provider
Check for complaints (BBB, Board ofHealth, Attorney Generals office,patient support groups)
Speak with the practitioner in person,evaluate facilities and neighbors
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Trends in Use of CAM byUS Adults 1997-2002 The number of Americans using CAM
remained stable at 72 million
50% in use of herbal supplements,from 12.1% in 1997 to 18.6% (38million).
Yoga increased 40%, from 3.7% to5.1% (10 million adults)
Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in the use of complementary
and alternative medicine by US adults: 1997-2002. Alternative Therapies in Health andMedicine; 1; 1: 2005.
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Trends in Use of CAM byUS Adults 1997-2002
Use of CAM therapies includingacupuncture, biofeedback, energy healing,hypnosis remained essentially unchanged
Use of homeopathy, high-dose vitamins,chiropractic, and massage therapy declinedslightly
Increased use of herbal medicinepractitioners among those who use herbs(5% to 15%)
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Commonly UsedBotanicals
Echinacea
Garlic
Ginger Gingko biloba
Ginseng
Hawthorn
Milk thistle
Saw palmetto St. Johns wort
Valerian
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Echinacea
Source: Purple cornflower
Indication: Stop or moderate colds
or fluAction: Macrophages and their
secretions
Cautions: Avoid if immune system ishampered and do not usecontinually
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Garlic
Source: Garlic plant
Indication: Lower serum cholesterol and
triglyceridesAction: Chewing or crushing
activates several sulfur-containing compounds
Cautions: Allergies, GI symptoms,interaction with anticoagulantdrugs
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Ginger
Source: Root of ginger plant
Indication: For nausea and vomiting ofpregnancy and motion
sickness; anti-inflammatoryAction: Volatile oils in the rhizome,
called gingerols; may act onserotonin receptors in the
ileum Cautions: Interaction with anti-
coagulant, antihypertensive,glucose-lowering drugs
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Gingko Biloba
Source: Gingko tree
Indication: Improved blood circulation;used to treat age-related
mental function decline r/tcerebrovascular insufficiency
Action: Flavone glycosides have
antioxidant effect, inhibitplatelet aggregation
Cautions: Class 2d botanical; maypotentiate MAO inhibitors; GI
complaints, headache, allergy
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Hawthorn
Source: Native European tree;leaves, blossoms, fruit
Indication: Improve blood flow incirculatory disorders
Action: Dilates coronary vessels;
strengthens heartcontractions and rate
Cautions: Class 1 botanical
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St. Johns Wort
Source: Perennial herb
Indication: Mild to moderate depression
Action: Hypericin and hyperforin inflowering tops; reuptake ofneurotransmitters
Cautions: Rated as 2d botanical; maypotentiate pharmaceuticalMAOIs; interact with otherantidepressives;
photosensitivity
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Valerian
Source: Perennial herb; active elementin roots and rhizomes
Indication: Minor tranquilizer and sleep
aid; fewer side effects thanmedicationsAction: Volatile oils (bornyl acetate
and valerenic acid) mode of
action GABA binding Cautions: Class 1 botanical; abrupt
withdrawal may precipitatesymptoms
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W ki ith Cli t h
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Working with Clients whoUse CAM
Most clients will not tell their allopathic(mainstream medicine) providers about CAMuse, unless asked
Establish a rapport with clients
Be non-judgemental; assume role of coach
Ask clients to bring all prescription, OTC,
and dietary supplements with them to theirvisit
Debusk RM. Integrative medicine and phytotherapy. In
Krause, p. 491-492.
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For Each Supplement
Ask client what he/she hopes to achieve bytaking it
Discuss whether the formulation is
appropriate to achieve the clients healthgoals Discuss whether dosage taken has been
found to be safe and effective in clinicaltrials
Review quality of the particular preparationand how to evaluate
Debusk RM. Integrative medicine and phytotherapy. In
Krause, p. 491-492.
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For Each Supplement
Discuss any known safety orcontraindication concerns
Review potential or known interactions
between each supplement and prescriptionor OTC preparations, other dietarysupplements, and foods
Instruct client to use dosage commonlyrecommended and instructions for where toobtain credible information
Debusk RM. Integrative medicine and phytotherapy. In
Krause, . 491-492.
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For Each Supplement
Recommend a low starting dosage,even lower than that commonly
recommended and evaluate response Use this as an opportunity to teach
consumers analytical skills that will be
useful in managing their own health.
Debusk RM. Integrative medicine and phytotherapy. In
Krause, p. 491-492.
W ki ith Cli t Wh
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Working with Clients WhoUse CAM
It is the responsibility of healthprofessionals to ask clients about use
of CAM and to be familiar withcommonly-used therapies
Nutrition professionals can take the
same evidence-based approach toCAM as to any other therapy ormedical intervention
Li k f I t ti
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Links for IntegrativeMedicine Information
Intellihealth Index of Herbal Medicines andSupplementshttp://www.intelihealth.com/IH/ihtIH/WSIHW000/8513/31402.html
Herb Med: An interactive electronic herb database.http://www.herbmed.org/
Rosenthal Center Botanical Medicine InformationResources (Columbia University)http://www.rosenthal.hs.columbia.edu/Botanicals.ht
ml National Institutes of Health National Center for
Complementary and Alternative Therapyhttp://nccam.nih.gov/
http://www.intelihealth.com/IH/ihtIH/WSIHW000/8513/31402.htmlhttp://www.intelihealth.com/IH/ihtIH/WSIHW000/8513/31402.htmlhttp://www.intelihealth.com/IH/ihtIH/WSIHW000/8513/31402.htmlhttp://www.herbmed.org/http://www.herbmed.org/http://www.rosenthal.hs.columbia.edu/Botanicals.htmlhttp://www.rosenthal.hs.columbia.edu/Botanicals.htmlhttp://www.rosenthal.hs.columbia.edu/Botanicals.htmlhttp://nccam.nih.gov/http://nccam.nih.gov/http://nccam.nih.gov/http://www.rosenthal.hs.columbia.edu/Botanicals.htmlhttp://www.rosenthal.hs.columbia.edu/Botanicals.htmlhttp://www.herbmed.org/http://www.intelihealth.com/IH/ihtIH/WSIHW000/8513/31402.htmlhttp://www.intelihealth.com/IH/ihtIH/WSIHW000/8513/31402.html -
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Summary
Identify use of herbs and botanicals.
Monitor for side effects.
Document for records.
Discuss with physician.