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National Institute of

Integrative Medicine

Newsletter

September, 2009

www.niim.com.au

Head Office

This edition:

Head Office

- The new NIIM home in

Hawthorn East

- Clinic Update

- Practitioners and

Services

- Institute update

- Research

- Study @ NIIM

News

Upcoming Events

- Seminars

- New Clinic

Developments

Snapshots

- Hawthorn Extract Helps

the Heart

- “Stress Drip”

- Yoga May Alleviate

Depression and Anxiety

- Risk of Stroke Increased

by NSAIDs

- Light Alleviates

Dementia Symptoms

Practical Course Excerpt

- Mindfulness Meditation

Articles

- Alternative Therapies for

Musculoskeletal Conditions

- Life Stressors, Nutritional

Choices and Obesity

- Fertility: Nutritional and

Lifestyle Factors

Book Reviews

About Our Organisation

Thanks - Contributors and

supporters of the



Donations

Contact Details

We are pleased to

announce the completion of

the renovation of the NIIM

headquarters at 759

Burwood Road, Hawthorn

East. Following the purchase of the NIIM property in May

2008, renovations

commenced in order to

upgrade the location

facilities and re-furbish the

stately Victorian building. This

property is now home to the

NIIM Institute and Clinic.

Clinic

The NIIM Wellness Clinic,

located at the rear of the

property, houses 11

consultation rooms, a

supplement dispensary, NIIM

reception and staff facilities. Practicing from the Clinic are

practitioners of:

Integrative General Practice

– Dr. John Piesse and Dr.

Trude Augustat

Traditional Chinese Medicine

(Acupuncture & Herbal

Medicine) – Dr. Xiao Lofstedt

Osteopathy – Dr. Simon

Armstrong

Live Blood Analysis – Hana

Sali and Megan Reilly

Exercise Therapy and Sports

Nutrition – Dr. Ian Gillam

Naturopathy – Megan Reilly

Professor Avni Sali is also

consulting from NIIM,

specialising in oncology and

other difficult cases.

The Wellness Clinic is expanding to include the

Complete Health Program, in-

house Pathology Laboratory,

IV and Chelation Therapy

Clinic, RTM and Thermography

suites, and other Integrative

and Complementary

Therapies. Practitioner Profiles,

including background,

specialties, and treatment

options, are available at

www.niim.com.au.

The NIIM Wellness Clinic will

provide an unparalleled team

of practitioners in Integrative Medicine, with the latest

treatment and diagnostic tools

to offer patients the best in

complete health care.

Institute

The Institute, located at the

front of the property, houses

the teaching and research

facilities, an extensive medical

library, meeting and seminar

rooms and staff offices.

The Institute aims to further

education and

implementation of Integrative

Medicine through research of

Evidence-Based

Complementary Medicine,

such as the work currently

underway with the Swinburne

Brain Sciences Institute. Led by

Professor Sali, research will

be conducted into the

safety and efficacy of

Complementary Medicine

in prevention, detection

and treatment of disease.

Collaborations

In April 2009, NIIM co-

sponsored Dr. Ananda

Bhavani at the Augustine

Centre in conducting

lectures and workshops on

the health benefits of Yoga

and Meditation.

In August NIIM hosted a

joint AIMA/ACNEM seminar

featuring Dr. Robert Verkerk

from the Alliance for

National Health, UK.

Streaming video of the seminar can be viewed at

http://www.acnem.org/Ro

bert_Verkerk.htm

Study @ NIIM

Post-graduate Certificate,

Diploma and Masters

courses are under

construction, designed for

those working in the health

industry. These will include

Integrative Medicine,

Nutritional and

Environmental Medicine,

Mind Body Medicine,

Clinical Toxicology and

Anti-Aging Medicine.

Also, a short course,


and Health will be available

early 2010.

NATIONAL INSTITUTE OF INTEGRATIVE MEDICINE – SEPTEMBER 09

News

Upcoming Events

We congratulate NIIM’s

Professor Sali on his recent

appointment as Professor

(honorary) at the School of

Medicine, University of

Queensland. He has also

been appointed to the

Course Advisory Committee

for the Bachelor of Health

Science – Chinese Medicine,

Southern School of Natural

Therapies. In April, Professor Sali was appointed to the



Research Priorities Cancer

Group.

Professor Sali and Dr. Philip

Hensche, from the

Department of Neonatology

at the Mercy Hospital, have

established a study on the

use of Complementary

Medicine in babies in the first

year of life.

In May 2009, Professor Sali

appeared in an interview

discussing the benefits of

Integrative Medicine. The

segment will air on Channel 7

in the coming months, please

view the NIIM website for

details.

In 2008, Professor Sali was

appointed to the Federal

Government’s expert

assessment panel for the


Complementary Medicine to

assess applicants for Federal

Government research grants

in Integrative Medicine.

Professor Sali has also been

appointed as advisor for the

Minister of Health in Kosovo.

Working toward a more

complete system of healthcare in this region,

Professor Sali will advise on

matters of disease prevention

and the incorporation of

Integrative Medicine into the

healthcare model.

Drawing on his many years

experience composing and

editing medical publications,

Professor Sali is now donating

his time to the Oxford

University Press as the new

reviewer of articles for

Evidence Based CAM. The

appointment will add to his

many contributions to

medical publications,

including Australian Doctor,

the Medical Journal of

Australia and the Journal of

Complementary Medicine.

Acting in his position as the

president of AIMA, Professor

Sali was instrumental in

publicising the potential

dangers of the dredging of

the Yarra River in March and

April of 2008. Representing the concerns of many health

experts, Professor Sali spoke

at several press conferences

and appeared on Channel

Ten in an interview to discuss

the environmental and

health dangers of the

dredging project.

In April of 2008, Professor Sali

met with the Sri Lankan

Minister for Indigenous

Medicine to discuss the

introduction of Ayurvedic

Medicine in Australia.

Although many practitioners

of Ayurveda have

established themselves in the

Victorian healthcare

community, there remains a

lack of awareness of the

benefits of this practice in

mainstream Integrative

Medicine.

As invited speaker, Professor

Sali has given talks over the

past year at various health

conferences, including the

Men’s Health Promotion

Forum in Canberra, Hobart

Integrative Medicine, the

Dental Hygiene Association

of Australia National

Conference, and Beirut

Integrative Medicine.

Professor Sali was invited as

Keynote Speaker at the

Australian Kinesiology

Conference (AKC) discussing

the advances in Integrative

and Complimentary

Medicine in the treatment of

cancer, CVD, diabetes, MS

and others, as well as

developments in the field of nutritional and herbal

supplements.

Following the AKC, Professor

Sali presented at numerous

other events in Australia,

Hong Kong, Germany and

the Czech Republic,

including CK Life Sciences,

Doctors and Pharmacists,

‘An Integrative Approach to

Cancer Care’ at

Dandenong Hospital and the AIMA Annual Conference.

The Melbourne Albanian

Community also invited

Professor Sali to speak at a

community event on

Albanian history, and his life’s

journey.

NIIM Business Manager Steve

Bunce has taught several

free meditation courses this

year in Melbourne and

Geelong. He has run

workshops in meditation and

relaxation, and has also

given regular lectures online.

Steve also travelled to

Brisbane and the United

States in June of 2008 as a

visiting teacher at meditation

retreats, and returned in July

2009 to take classes in San

Francisco and Oregon.

In October of this year, NIIM

will co-sponsor the visit of Dr.

Ursula Jacobs from Germany,

to run a Master Class on the

treatment of cancer patients

with individualised diagnosis

and treatment plan. The program focuses on profiling

genetic behaviour and

chemosensitivity studies with

chemotherapeutic and

natural therapies. Dr. Jacobs

is a world authority in this new

era of developing medical

oncology. NIIM aims to

establish this form of testing in

Australia.

NIIM is also in the process of

establishing a new facility for

laser-based photodynamic

cancer treatment at the

Wellness Clinic in Hawthorn.

Professor Sali has recently

completed work on a new

medical textbook – A Guide

to Evidence Based

Integrative and

Complementary Medicine –

with Dr. Vicki Kotsirilos and

Associate Professor Luis

Vitetta.

He is also involved with Anna

Ryan, Executive Officer of

AIMA, in organising the 2009

annual AIMA conference in

Melbourne.

Later this year, Professor Sali

will be running an Integrative

Medicine Short Course with

the University of Queensland.

He is also an invited speaker

at the annual Gawler

Foundation Conference, the

New Zealand AIMA Branch,

and at the Cancer Council in

Western Australia.


Snapshot: Hawthorn Extract Helps the Heart

Snapshot: Stress Drip

Cochrane researchers

have concluded that

Hawthorn extract, a

popular herbal remedy,

can be of benefit to

those suffering from

heart failure.

The trial involved using

either Hawthorn extract

or a placebo, in

conjunction with

conventional therapies,

on 855 patients with

chronic heart failure.

Those in the Hawthorn

extract group showed

reduced oxygen

consumption by the

heart, improved maximal

workload and increased

exercise capacity. There

was also a reduction in

symptoms such as

shortness of breath and

fatigue.

There were no general

side-effects, although

some reported mild

complaints, such as slight

nausea and dizziness.

Lead researcher Dr.

Ruoling Guo states that

there is “good evidence”

of the benefits of

Hawthorn extract, used in

conjunction with

conventional treatment,

for those suffering from

heart failure.

The Institute for

Progressive Medicine has

announced its use of the

“Stress Drip” – an IV

Therapy designed

specifically to combat stress. The drip contains

vitamin C, B vitamins,

magnesium, other trace

minerals, glutathione,

tryptophan and inositol.

These are basically the

same nutrients used in

the popular “Immune

Drip”, with the exclusion

of the latter two, which

are known to produce a

calming and relaxing

effect.

The drip is designed for

those facing a time of

particular stress in their

lives, such as when

dealing with loss, or

before a stressful event such as an operation. Dr.

Allan E. Sosin, founder

and director of the

Institute explains that not

only does the drip

encourage relaxation,

but also has positive

effects on sleeping

patterns. The drip has no

common side effects and

therefore allows the

therapy to be repeated

as often as needed.

The drip is administered by

trained nurses for a period

of time determined

according to patients’

conditions and needs. The

general relaxation effect

of the therapy results in an

improved ability to deal

with stressful situations and

ailments, and is thought to

be of help in enhancing

the effect of conventional

treatments.

THE NATIONAL INSTITUTE OF INTEGRATIVE MEDICINE

Contact

To contact the

Institute and NIIM

Wellness Clinic:

759 Burwood Rd,

Hawthorn East,

VIC, 3123

Ph: (03) 9804 0646

F: (03) 9015 7264

www.niim.com.au

[email protected]


Snapshot: Yoga may alleviate depression and anxiety

Snapshot: Risk of Stroke Increased by NSAIDs

Snapshot: Light Alleviates Dementia Symptoms

A Dutch study, published

in the Journal of the

American Medicine

Association, has

concluded after three

and a half years, with

pleasing results. The

study, involving several

group care facilities,

investigated the effects

of increased light

exposure and melatonin

supplementation on

residents.

The findings showed that

increased exposure to

light improved both

cognitive and non-

cognitive symptoms of

dementia including

disturbed cognition,

mood, behaviour,

functional abilities and

sleep. It also alleviated

symptoms of depression.

The melatonin, however,

when given alone,

resulted in improved sleep

patterns but produced a

negative effect on

mood, resulting in

withdrawn behaviour.

Combination treatment

of both melatonin and

light was shown to

decrease nocturnal

restlessness and

attenuate aggressive

behaviour. The

researchers concluded

that to counteract the

negative effect of

melatonin on mood, the

supplements should only be given in combination

with increased light

A study conducted at

the Boston University

School of Medicine has

found that practising

one hour of yoga can

increase levels of

gamma-aminobutyric

(GABA) neurotransmitters,

low levels of which are

associated with states of

anxiety and depression.

The researchers used

MRSI to measure levels of

GABA in subjects. The

group was then

separated into those who

participated in a one

hour yoga session, and

those who were

instructed to read for one

hour. The GABA levels

were measured again

one hour after the yoga

and reading sessions.

Those in the yoga group

showed a twenty-seven

per cent increase in

GABA levels, while no

change was measured in

the reading group.

There is now hope that

therapies such as yoga

may be implemented on

a wide scale to assist in

alleviating the symptoms

of disorders such as

anxiety and depression.

According to a recent

study published in the

Archives of Internal

Medicine, the use of

NSAID medications

increases the risk of

stroke. The study,

performed over nine

years, involved 7636

people free of stroke,

aged around 70 years.

It was found that any use

of NSAID medication was

associated with a risk of

stroke double that of non-

users. The risk was

significantly higher with

COX-2 selective NSAIDs,

but is not restricted to this

drug category.

The researchers stated

that although the risk of

stroke was increased

regardless of the COX

selectivity of medications,

they are not ruling out

that a COX-related

process could be

involved. As both COX-1

and COX-2 are important

for normal vascular

function, any substance

which inhibits the COX

enzymes can have a

significant effect on

thrombotic equilibrium.

Professor Avni Sali MBBS,

PhD, FRACS, FACS, FACNEM

is Founding Head and

Director of the National

Institute of Integrative

Medicine (NIIM), President of

the Australasian Integrative

Medicine Association

(AIMA) and Vice President

of the International Council of Integrative Medicine

(ICIM).


Practical Course Excerpt – Mindfulness Meditation

Meditation has been shown to be effective as a stress reduction exercise. Most techniques rely

on the attention being focused or rested on something and in the process, learning to not

struggle with, but let go of, unnecessary and distracting mental activity.

It is a common experience that when the mind is in a distracted state, it wanders. Some of the

wandering is superfluous clutter, while at other times it is stress laden and the imaginary stressors

are recreated vividly in the mind. This triggers the stress response and also impairs the ability to

concentrate on the task at hand.

The practice of mindfulness meditation can help to bring back focused attention and clarity. It

improves the ability to concentrate in an effortless way and to combine relaxation with

awareness. Meditation is about tuning in and being focused, bringing the mind to a point.

Mindfulness meditation technique

It is recommended that this be practised initially for five minutes, twice daily. This can be built up to 10 to 30 minutes or longer if required. Regular short pauses at other times during the day can

help to reinforce the meditation practice, even if one only pauses for long enough to take a

few deep breaths, to help break the build up of tension and mental activity throughout the day.

Preparation

It is important, wherever possible, to have a quiet place to practise the exercise without

interruption. It is usually best to use a room other than the bedroom for this practise to avoid

falling asleep.

Position

A position where you are unlikely to go to sleep is best for meditation and sitting in an upright

position, with the back and neck straight, is recommended. Make sure the position is balanced

and relaxed, with no strain or undue muscle tension.

Progressive muscle relaxation

Allow the eyes to gently close. Be conscious of the body and let it fall still. Now, become aware

of each part of the body and release muscle tension patiently, consciously and methodically.

Start with the feet, and if there is any muscle tension held here, let it go. Become conscious of

the legs, and if there is any tension here, let it pass, and so on to the stomach and back, the

hands and arms, the shoulders, neck and face. If you become aware of any tension coming

back into the body, practise letting it go again. It is important to remember that you do not

have to make yourself relax, rather, just allow yourself to relax. Trying to force things and ‘get it

right’ sets up frustration, failure and strain, and is counterproductive.

Breathing

Feel the breath as it passes in and out of the body, by simply letting the attention rest upon it.

Again, no force is required. If distracting thoughts and feelings come into mind, carrying the

attention away with them, be aware of them but let them go. There is no need to try to stop

these thoughts coming into the mind, nor to try to force them out. You may well notice that

trying to force them out just feeds them with attention, making them stronger. This technique

involves restfully attending to breath. Practise standing back, observing, detaching and letting

go.

Listening

Now, practise the same restful attentiveness with listening by being conscious of the sounds

around you. Let them come and go and let any thoughts about the sounds come and go.

Listen to the sounds that are close and also those that are in the distance. Once again, let go of

the distracting thoughts which prevent you from resting and coming to the here and now. After

you have practised for your allotted time, slowly go backwards through the steps, ie become

aware of the breath, then the body and then slowly allow the eyes to open. After a few

moments move into the activities which need your attention.


Alternative therapies for musculoskeletal conditions

The use of complementary and alternative medicine is complex and nuanced. Patterns of use of complementary and alternative medicine differ among racially and ethnically different groups. Multivariate models of utilization indicate that ethnicity plays an independent role in the implementation of these modalities, in seeking practitioners and in health problems for which assistance is required. Moreover, there are many reasons why people use complementary and alternative medicine: conventional treatment may not be working as well as they would like; they want greater relief of symptoms and/or disability; they have issues with side-effects of pharmaceutical treatment; they wish to reduce some of the stress that comes from living with a chronic illness and want to cope better; they believe that complementary and alternative therapies are safer and ‘natural’; and they are influenced by the widespread advertising and attractive claims that are made for many natural products. Although there are more than 150 different kinds of syndromes and conditions associated with arthritis, this review will focus on currently available evidence-based medicine for the two most common conditions diagnosed in Western countries – osteoarthritis and rheumatoid arthritis – for which people seek and then implement complementary and alternative medicine modalitites.

Although diseases with the greatest consequent mortality (e.g. cardiovascular disease,

cancer) attract much of the public’s attention, musculoskeletal or rheumatic diseases are the major cause of morbidity throughout the world, having a substantial influence on health and quality of life, and inflicting a vast burden of cost on health systems. Musculoskeletal disease is a major cause of disability and handicap, and arthritis is the most prevalent form of musculoskeletal disease.1 Rheumatic diseases include more than 150 different conditions and syndromes, the common denominators being pain and inflammation. Five of these account for 90% of the cases – osteoarthritis (OA), rheumatoid arthritis (RA), fibromyalgia, systemic lupus erythematosus (SLE) and gout.1–4

Arthritis is a chronic disease affecting an estimated 43 million (20.8%) adults in the USA, and is the leading cause of disability in that country3, while OA is reported to be the most common joint disorder in the world.4 In Western populations it is one of the most frequent causes of pain, loss of function and disability in adults. Radiographic evidence of OA occurs in the majority of people by 65 years of age and in about 80% of those aged over 75 years. In Australia in 2004, there were 3.4 million people (w17% of the population) suffering from some form of arthritis, with w60% of these being females. Of this total, 1.39 million had OA and more than 438,000 had RA.5

The associated worldwide trend in morbidity is significant because it often leads to a reduction in quality of life and related conditions such as fatigue,

depression and insomnia. Attendant costs to the health-care system are vast, and current medications, while often effective, are frequently associated with significant side-effects. In the early 1990s an upsurge in the use of complementary and alternative medicine (CAM) was seen from reports that recognized the extensive use of treatments outside the realm of conventional medicine.6,7 A recent review reported that patients with musculoskeletal conditions often employ CAM modalities8 in one form or another. Collectively the evidence demonstrates that some CAM modalities show significant promise: for example herbal medicines, nutritional supplements, acupuncture, and mind–body medicine. HERBAL MEDICINES A number of herbal supplements have been investigated for their efficacy in patients with OA and RA (Table 1).9–13

Camilla sinensis (green tea) The anti-inflammatory and pharmacological properties of green-tea extracts have been attributed to the high content of polyphenols/catechins, of which epigallocatechin-3 gallate (EGCG) predominates.11,14 The emerging molecular evidence thus far gives strong biological plausability supporting the in-vitro observations that catechins extracted from green tea can exhibit both anti-inflammatory and chondroprotective effects and hence may be beneficial to arthritis sufferers.14

“…Arthritis is a chronic disease affecting an estimated 43 million (20.8%) adults in the USA, and is the

leading cause

of disability in

that country.…”


Alternative therapies for musculoskeletal conditions cont...

Uncaria tomentosa, Uncaria guianensis (cat’s claw)

Extracts of cat’s claw have been shown to possess antioxidant, anti-Inflammatory and immunomodulatory properties.10,11 The most investigated of the active constituents in Uncaria tomentosa extract for immunomodulatory and anti-inflammatory effects are pentacyclic oxindole alkaloids, which are reported to induce an immune regulating factor.11 Pain associated with activities of daily living was significantly reduced; however, pain at rest or at night was not reduced during the 4-week trial period. In a further study designed to test the use of an extract of cat’s claw from the part of the vine that is rich in pentacyclic alkaloids (roots) versus placebo showed a reduction in the number of painful joints in patients with RA (53.2% versus 24.1%; P < 0.044).15 As no adverse effects were reported, this small preliminary study showed the relative safety and modest benefit to the tender joint count of a highly purified extract from the pentacyclic chemotype of Uncaria tomentosa in patients with active RA taking sulphasalazine or hydroxychloroquine.15 Other research groups have documented the safety and pharmacological profile of cat’s claw, which is considered non-toxic, and there are no known contraindications or drug interactions.10,16,17 However, there is a need for rigorous testing of the effectiveness of the recommended doses. Until a full pharmacokinetic profile is investigated it would be prudent to avoid its use in women attempting

pregnancy, during pregnancy and lactation, and for children below 3 years of age.10 Harpogophytum procumbens (devil’s claw)

Harpogophytum procumbens has been shown to be effective for arthritis in two reviews.17,18 There is little evidence for efficacy of extracts containing <30 mg/day of the active constituent, harpagoside, and that a correct dose is >50 mg/day for OA of the knee and hip. Devil’s claw exhibits cellular signalling modulating activities that down-regulate inflammatory markers.19–21 Five randomized clinical trials (RCTs) have reported on the effects of devil’s claw in the treatment of OA.22 Of these, three were placebo-controlled and two were compared with common pharmaceuticals (diacerhein and phenylbutazone). Three trials demonstrated significant positive results, while two studies that employed <30 mg harpagoside recorded results that were less significant. An aqueous extract of devil’s claw (consisting of 60 mg harpagoside) was found to be as effective as 12.5 mg of rofecoxib for the treatment of acute non-specific lower-back pain in a double-blind pilot RCT.22 Three other trials have also demonstrated efficacy in lower back pain, with 100 mg of harpagoside considered superior when neurological deficits are present.18,23 Tripterygium wilfordii Hook F Extracts from the roots of Tripterygium wilfordii Hook F (TwHF) have been used for the treatment of various autoimmune and inflammatory diseases, including RA, SLE, nephritis,

psoriasis and asthma.24 An ethanol/ethyl acetate extract has demonstrated therapeutic benefit in patients with treatment refractory RA.25 At the doses of 180 mg/day and 360 mg/day, TwHF extract was of benefit and well tolerated by most patients. A prospective double-blind RCT of TwHF ethanol/ethyl acetate extracts in RA patients has also been reported.25 With a two dose regimen for 20 weeks, patients at the higher dose achieved a rapid ACR-20 response, with 50% of patients improving during the first 4 weeks of treatment. Both treatment groups showed a significant decrease in the number of tender and swollen joints and improvement in the physician’s global assessment. In a further phase-I study, eight out of nine patients treated with TwHF extract (>360 mg per day) showed improvements in both clinical manifestations and laboratory findings.26 It was concluded that the extract of TwHF at dosages up to 570 mg/day appeared to be safe, and doses >360 mg/day were associated with clinical benefit in patients with RA. In both of these studies, no toxic or adverse effects other than diarrhoea were observed in patients receiving the highest dose. An RCT of a topical application of TwHF in 61 patients with RA demonstrated efficacy in improving ACR-20 score.27 Curcuma longa (turmeric)

Turmeric has been used for centuries in Ayurvedic medicine as a treatment for inflammatory disorders, including arthritis.28,29 The major chemical constituent of turmeric is curcumin (diferuloylmethane), which constitutes up to about 90% of the total curcuminoid

content, with the remaining 10% consisting of demethoxycurcumin and bis-demethoxycurcumin.28 Animal studies have demonstrated that oral administration of curcumin to rats decreased the levels of inflammatory glycoprotein, GpA-72, with a concomitant reduction in paw inflammation.30 Curcumin has also been shown to inhibit the carrageenin-induced paw oedema in mice and rats, with an ED50 dose of 48 and 100.2 mg/kg, respectively.30,31 In a double-blind cross-over clinical trial of 18 patients with RA given curcumin (1200 mg/day) for 2 weeks followed by 300 mg/day of phenylbutazone for another 2 weeks, respondents showed a significant improvement in morning stiffness, walking time, and reduction in joint swelling.32 Zingiber officinale (ginger)

The fresh/dried roots of Zingiber officinale is reported to possess anti inflammatory, antiseptic and carminative properties and has been used to treat inflammatory and rheumatic diseases.33 The pungent phenolic constituent of ginger, 6 gingerol, has been shown to inhibit lipopolysaccharide- (LPS-) induced nitric oxide synthase (iNOS) expression and production of NO in macrophages and to block peroxynitrite-induced oxidation and nitration reactions in vitro.33–35 Cumulative laboratory animal data suggest that 6 gingerol is a potent inhibitor of NO synthesis and effective in inhibiting production of prostaglandin E2 (PGE2) and tumour necrosis factor a (TNF-a) and cyclooxygenase 2 (COX-2) expression in human



synoviocytes by regulating nuclear factor kB (NFkB) activation and degradation of its inhibitor IkBa subunit.33 A recent RCT employing Zingiber officinale and Alpinia galanga (Eurovita Holding, Denmark) comprising 255 mg extracted from 2500 4000 mg ginger and 500 1500 mg galanga rhizome, demonstrated a positive effect on knee OA. Clinical trial participants in the ginger-extract group experienced a 63% reduction in knee pain on standing versus 50% in the placebo group. 36 A highly purified and standardized ginger extract had a statistically significant effect on reducing symptoms of OA of the knee with a high safety profile and mild adverse gastrointestinal events in the ginger-extract group. In a further crossover RCT, in patients with OA the ginger extract showed statistically significant efficacy in the first period of treatment before cross over; however, a significant difference was not observed in the study overall.37 In a limited study with RA patients38 ginger was effective in relieving pain and swelling in the joints of seven RA patients. Based on this limited information, recommendation for it use is difficult and limited in treating OA or RA. Capsicum spp

(chilli/cayenne) Capsicum spp are commonly used topically in a cream base for the relief of lower-back pain.39 A recent systematic review included four studies on cayenne and concluded that there is evidence that it reduces lower-back pain more than placebo.20

An early review analysed three RCTs and reported that cayenne had poor to moderate efficacy for the treatment of chronic musculoskeletal or neurological pain.39 Cayenne was responsible for a higher rate of side effects than was placebo; given that the action of chilli is to increase blood circulation, it is prudent to enquire whether it is the heat generated that alleviates the pain. Gaultheria yunnanensis

(wintergreen)

Topical natural products containing wintergreen include liniments, balms, creams, gels, oils, lotions, patches, ointments and other products that are applied to the skin, and these are often sought with the intention of providing relief of mild arthritis pain that affects only a few joints, as well as to ease sore muscles, back pain and OA.40,41 No clinical trials evaluating these effects are currently available. However, in-vivo studies have shown that a salicylate fraction isolated from wintergreen has analgesic and anti-inflammatory properties.42

Caution, even with topical products, is required in patients receiving warfarin, as adverse interactions and bleeding have been reported to be a risk with its use.43 Phytodolor

Phytodolor (Steigerwald Arzeimittelwerk GmbH, Germany) is a herbal proprietary product that includes aspen (Populus tremula), golden rod (Solidago virgaurea) and golden ash (Fraxinus excelsior). Although most of the available literature is German, a recent systematic review of six RCTs concluded that

Phytodolor reduced the pain associated with rheumatic disorders.43 The dose administered was 30 drops three times a day for three of the trials and 40 drops three times a day for the remainder, with duration ranging from 2 to 4 weeks. Boswellia serrata

(boswellia/frankincense)

Boswellia serrata is a popular Ayurvedic herb that is purported to exhibit effective analgesic, anti-inflammatory and anti-arthritic activity.44–47 Pilot studies indicate that boswellia may be an effective intervention for rheumatoid arthritis because of its anti-inflammatory properties.44,45 A recent RCT assessed its efficacy, safety and tolerability in 30 patients with OA of knee over a 16-week period.46 Patients receiving 333 mg of boswellia extract containing 40% BA three times a day reported a significant decrease in knee pain and swelling, and an associated increase in movement. A further RCT compared the same extract with valdecoxib in 66 patients with knee OA over 6 months. This study has a slower onset of action with pain relief persisting for 1 month after ceasing treatment, while valdecoxib acted faster but lasted only for the duration of therapy.47 Willow bark There is a resurgence of interest in willow bark as a treatment for chronic pain syndromes that include RA and OA. While white willow (Salix alba) is the willow species most commonly used for medicinal purposes; crack willow (Salix fragilis), purple willow

“…The emerging

molecular

evidence thus far

gives strong

biological

plausability

supporting the in-

vitro observations

that catechins

extracted from

green tea can

exhibit both anti-

inflammatory and

chondroprotective

effects.…”



(Salix purpurea), and violet willow (Salix daphnoides) are all salicin rich species and are available under the label of willow bark. Randomized clinical trials of short duration have provided evidence of efficacy.48 Rose hip (rose haw)

Recent systematic searches of the literatures49,50 have demonstrated that rosehip powder or the seeds of the Rosa canina subspecies had a moderate effect in patients with osteoarthritis. In a study that enrolled 94 patients with osteoarthritis of the hip or knee in a double-blind placebo-controlled cross over trial51 reported that the 47 patients that were given 5 g/day of the herbal remedy for a period of 3 months resulted in a significant reduction in WOMAC (Western Ontario and McMaster Universities) pain (P < 0.014) as compared to placebo when tested after 3 weeks of treatment. Furthermore, the clinical data suggested that the herbal remedy not only alleviated symptoms but also reduced the consumption of ‘rescue medication’. NUTRITIONAL MEDICINE

Supplements Various nutritional products are commonly used for pain control for rheumatic problems (Table 2). Most reduce pain via their anti-inflammatory effects. Nutrition is increasingly linked to a range of degenerative and developmental disorders. Nutritional deficiencies and imbalances can result in metabolic and systemic disturbances that may increase susceptibility to joint disease. Glucosamine

The therapeutic effectiveness of

glucosamine treatment on OA has been demonstrated by improved mobility and relief of pain in animal models as well as in RCTs.52 A recent meta-analysis concluded that the evidence for efficacy in improving symptoms in OA was conflicting, and that glucosamine hydrocholoride was not effective.53 A Cochrane review concluded that a specific type of glucosamine supplement (from Dona, Rotta Pharmaceuticals Inc) was superior to placebo in the treatment of pain and functional impairment resulting from symptomatic OA.54 Results for the non Rotta preparation were not statistically significant. The review analysed data from 20 RCTs involving 2570 participants, of which ten RCTs used the Rotta preparation. A second systematic review reviewed RCTs of at least 1 year’s duration.55 It was reported that glucosamine sulphate may be effective and safe in delaying the progression and improving the symptoms of knee OA. A previous Cochrane review of 16 RCTs had found that glucosamine was effective; however, these included smaller trials with less methodological rigor.56 A concern with most trials of glucosamine sulphate, glucosamine hydrochloride and chondroitin sulphate in the treatment of OA is weak research design.57 The Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) was designed to address these inconsistencies and provide some clarity on the effectiveness of glucosamine (1500 g/day) and chondroitin (1200 mg/day) for the treatment of knee pain in OA by

employing a rigorous research design.57,58 The GAIT found that glucosamine and chondroitin sulphate, alone or in combination, did not significantly reduce OA knee pain more than did placebo.58 A combination of glucosamine and chondroitin sulphate was found to be effective in a subgroup of patients with moderate to severe knee pain (79.2% versus 54.3% for placebo).59 The combined emerging data suggests that glucosamine has a structure-modifying effect. However, debate remains regarding this, largely in relation to methodological issues surrounding outcome measures used in the positive studies. Chondroitin

An RCT employing galactosaminoglucuronoglycan sulphate (GS) on 40 patients with tibiofibular OA of the knee were allocated to receive 50 intramuscular injections (one injection twice weekly) for 25 weeks. GS had a significant therapeutic effect on all symptoms evaluated. No important local or systemic side-effects were noted.60 Favourable effects have been reported in pain reduction and improvement in mobility when GS was given either intra-articularly or orally to elderly patients with joint degeneration.61 A double-blind RCT with 104 patients receiving oral chondroitin 4-sulphate and chondroitin 6-sulphate (CS4 and CS6) at a dose of 800 mg/day or placebo for 1 year showed that CS4 and CS6 had a beneficial effect in terms of both clinical manifestations and anatomical progression in patients with OA of the knee. The main efficacy criterion was the Lequesne functional score. Functional

impairment was reduced by approximately 50%, with a significant improvement over placebo for all clinical criteria. Tolerance was excellent or good in more than 90% of cases. This study suggests that CS acts as a structure modulator as illustrated by improvement in the inter-articular space visualized on x-rays of patients treated with CS4 and CS6.62 A double-blind RCT of 46 patients with symptomatic OA of the knee examined the effect of 400 mg chondroitin sulphate twice a day for 1 year. After 3 months, joint pain was significantly reduced in the chondroitin sulphate group compared to the placebo group. This difference became more pronounced after 12 months. The increase in overall mobility capacity was significantly greater at 6 and 12 months in the CS group than in the placebo group. After 1 year, the mean width of the medial femorotibial joint was unchanged from baseline in the CS group, but had decreased significantly in the placebo group. Although no statistical comparison was presented for the change in joint-space width between the two groups, the finding suggests the possibility that CS treatment may slow the progression of OA.63 A proprietary CS was studied in a double-blind RCTof 85 patients with OA of the knee. Participants received Condrosulf® at a dose of 400 mg TID or placebo for 6 months. Lequesne’s index, spontaneous joint pain, and walking time all decreased progressively in the CS group, with a significant difference in favour of the CS group for each of these parameters.64 In a double-blind RCT parallel-group study using either CS



“…CS has slow

but gradually

increasing clinical

activity in OA,

and that these

benefits last for a

long period after

the end of

treatment. …”

1 g/day or placebo on 130 patients for 3 months, followed by a 3-month post-treatment period, the CS group experienced greater but non-significant improvement than the placebo group at the treatment endpoint, as measured by the Lequesne index. Improvement became significant in the completer population. In the intention-to-treat population, all variables tended toward greater improvement in the CS group than the placebo group. One month after treatment, CS had a significantly higher persistent effect than placebo on the Lequesne index, pain with activity, and other efficacy criteria. Adverse event rates did not differ significantly.65 To assess the clinical efficacy of CS in comparison with the non-steroidal anti-inflammatory drug (NSAID) diclofenac sodium, a multicentre double-blind RCT double-dummy study of 146 patients for 6 months was conducted.66 Patients treated with diclofenac showed prompt reduction of clinical symptoms that reappeared, however, after the end of treatment. In the CS group, the therapeutic response appeared later but lasted up to 3 months after the end of treatment. It was concluded that CS has slow but gradually increasing clinical activity in OA, and that these benefits last for a long period after the end of treatment. Shortcomings in these studies were that only a relatively small number of patients were involved, and that no dose-finding investigations for CS could be found. A double-blind prospective

RCT study of 300 patients given Condrosulf®800 mg daily or placebo for 2 years investigated the structure-modulating properties of CS in gonarthrosis by measuring the modifications in minimum joint space width, mean thickness, and mean surface of the cartilage in internal femorotibial function. There was a significant difference, with worsening of the affection, in the placebo group compared to the CS group. In the group treated with CS, there were no significant variations in any radiological parameters, which remained remarkably stable. The statistical analysis revealed a significant difference in the CS group compared to the placebo group with regard to maintenance of the cartilage analysed, in both the intention-to-treat analysis (the accepted manner of analysis of clinical trials, where subjects are analysed whether or not they complete the study protocol) and also in the per protocol analysis (when only subjects who completed the study protocol are examined). It was shown that CS was superior to placebo with regard to stabilization of minimum joint space width of the internal femorotibial articular space, the mean thickness, and the surface.67 Hence there are sufficient controlled trial data to support the use of CS in symptomatic OA, CS having fewer side-effects than currently used NSAIDs. Chondroitin sulphates appear to have a role in prevention of disease progression. The requisite is that CS be further evaluated in studies of

longer treatment duration, with larger numbers of patients, and using well-established measures of function and progression. A recent meta-analysis of a set of poor- to moderate-quality trials that were largely heterogeneous in methodology, making interpretation of the data difficult, concluded that the results were unreliable. Furthermore, the authors concluded that – since large-scale and methodologically sound trials indicate that the symptomatic benefit of chondroitin is minimal or non-existent - chondroitin cannot be recommended.68 Collagen hydrolysate

Four open-label and three double-blind trials have been reported.69 In a 24-week multinational double-blind RCT on knee OA, 10 g/day did not improve the WOMAC index.70 Post study analysis suggested that the hydrolysate could be more efficient in severe OA. A 60-day cross-over double-blind RCT on knee and hip OA compared 10 g/day of collagen hydrolysate, gelatin, gelatine þ glycin þ calcium phosphate, or egg albumin.71 The gelatine preparations were not significantly different from each other and were superior to egg albumin in reducing pain as assessed by a patient questionnaire. According to the best-evidence synthesis, evidence of efficacy for collagen hydrolysate is equivocal. However, a growing body of evidence provides a rationale for the use of collagen hydrolysate for patients with OA.69 Methylsulphonylmethane

(MSM) In a 12-week double-blind RCTon knee OA, 500 mg of



MSM three times a day – used alone or in combination with 500 mg of glucosamine hydrochloride three times a day – significantly improved a Likert scale of pain and Lequesne’s functional index (LFI).72 The combination of both ingredients was not more efficacious than each ingredient used alone. A further 12-week double blind RCTon knee OA, 3 g of MSM given twice a day was more efficient than placebo in decreasing WOMAC pain and functional scores.73

According to the best-evidence synthesis, MSM provides moderate evidence of efficacy for knee OA. S-Adenosyl methionine

(SAMe)

A practical amount of research evidence exists to support the use of SAMe for the treatment of pain associated with OA.74 A meta-analysis of 11 RCTs comprising 1442 participants with an average age of 60.3 years from 2002 demonstrated that SAMe is as effective as NSAIDs in reducing the pain of OA, with significantly fewer side-effects.75,76 New Zealand green-lipped mussel

The reported incidence of arthritis in coastal-dwelling Maoris is low, and it has been suggested that this is possibly due to their high consumption of green-lipped mussels.76 However, results from clinical trials have been inconsistent, with a recent review concluding that ‘there is little consistent and compelling evidence, to date, in the therapeutic use of freeze-dried green-lipped mussel powder products for RA and OA treatment’ but that further investigations are

warranted.77 Lipids (avocado/soybean

unsaponifiables, ASUs)

Four double-blind RCTs and one systematic review have evaluated ASUs on knee and hip OA.78–83 In two 3-month RCTs, one on knee and hip OA78 and one on knee OA only79, 300 mg once a day decreased NSAID intake. No statistical differences in any primary or secondary endpoints were detected at 300–600 mg once a day.78 In a 6-month RCT on knee and hip OA, 300 mg once a day resulted in an improved LFI compared with placebo.78

ASUs had a 2-month delayed onset of action as well as residual symptomatic effects 2 months after the end of treatment.79 In a 2-year RCT on hip OA, 300 mg once a day did not slow down narrowing of joint-space width.80 In addition, none of the secondary endpoints – LFI, visual analogue scale (VAS) of pain, NSAID intake, and patients’ and investigators’ global assessments – was statistically different from placebo after 1 year. However, a post-hoc analysis suggested that ASUs might decrease narrowing of joint space width in patients with the most severe hip OA. Although ASUs might display medium-term symptom-modifying effects on knee and hip OA, their symptom-modifying effects in the long term (>1 year) have not been confirmed. Based on the best-evidence synthesis, ASUs are good for symptom modifying effects in knee and hip OA with some evidence of absence of structure-modifying effects. A recent systematic review on ASUs recommended further investigation

because three of the four rigorous RCTs suggest that ASUs are effective symptomatic treatment, but the long-term study was largely negative.81,82 ACUPUNCTURE

Non-pharmacological treatments such as acupuncture are attractive because of their safety profiles and lack of the adverse events that have been well documented with the use of pharmaceuticals, especially when considering elderly populations. A recent meta-analysis and systematic review concluded that acupuncture procedures that meet criteria for adequate treatment were significantly better than sham acupuncture or no additional intervention in improving pain and function in patients with chronic knee pain due to OA.83,84 These recent studies confirm an earlier systematic review and meta-analysis which concluded that: (1) acupuncture is often used for treating and relieving chronic pain due to OA; (2) the meta-analysis of three trials showed a significant effect of manual acupuncture compared to a sham acupuncture procedure; and that (3) there were confirmed beneficial effects for ameliorating pain for peripheral-joint OA.85 However, due to the nature of the heterogeneity in the results, there is a need for further research to confirm these findings and provide more information on long term effects.83 MIND–BODY MEDICINE Multimodal cognitive-behavioural/mind–body therapies (Table 3), in combination with

educational/information components (such as patient education/self-management programmes), may be appropriate adjunctive treatments in the management of rheumatoid arthritis and osteoarthritis.86,87 SUMMARY (TABLE 4: LEVELS

OF EVIDENCE) Patients expect – and should obtain – advice from their general practitioners regarding dietary/supplement therapies for which there is a high level of evidence, as conclusions about efficacy should fit into clinical practice. There is a strong scientific rationale for the use of an integrative approach to the management of OA and RA (see Practice Points).



Practice points

For the management of OA and RA pain and attendant psychological distress: • stress management techniques (e.g. meditation, relaxation therapies) • acupuncture For improved mobility and relief of pain of OA: • glucosamine sulphate To maintain viscosity in joints and stimulate cartilage repair in OA: • chondroitin sulphate • collagen hydrolysate • lipids (avocado/soybean unsaponifiables) To alleviate OA- and RA-associated inflammation and pain: • various herbal medicines (Table 1)

Research agenda

• link the patient’s viewpoint unequivocally with evidence-based medicine • elucidate functions and mechanisms of activity of herbal medicines/nutraceuticals, as the available in-vitro

and in-vivo animal and human data suggest that herbal medicines and nutraceuticals may influence the course of OA and RA through a wide variety of mechanisms. Safety of use may be significantly enhanced by increasing the knowledge base of herbal medicines/nutraceuticals and their interactions with pharmaceuticals

• focus on empirical evidence for dosages to be employed and associated cost effectiveness


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Life Stressors, Nutritional Choices & Obesity

Written by Professor Avni

Sali and Associate Professor Luis Vitetta

Introduction Stress is a widely prevalent

phenomenon that exacts

an heavy toll on the quality

of human life. The most

important factor in why a

person becomes ill lies in

the brain. Stress and

pleasure play a critical role

in wellness and disease,

with stress contributing

significantly to the risk of

disease [1–4]. It is becoming

increasingly clear that

pleasure is also important.

Even if a person is stressed,

if they are also feeling

good, stress will have fewer

ill effects. Other factors also

play an important role such

as diet, smoking and

genetics. An additional

important factor seems to

be the ability and opportunity that persons

have to express their

feelings about how stressed

they are or how they are

feeling about themselves.

Stress is less likely to cause

problems if a person has

some form of emotional

outlet for it. In many cases,

people appear calm on

the outside but they are in

turmoil on the inside. This

may then manifest as a

disorder such as migraine,

irritable bowel syndrome,

rheumatoid arthritis, or

multiple sclerosis [5–7].

Stress and Health It has been and continues

to be the subject of intense

debate and research with

reports that stress may have ameliorating or

detrimental capacities.

Indeed the concepts of

homeostasis and stress can

be traced back to ancient

Greek history. However, the

integration of these ideas

with correlations to

physiologic and

pathophysiologic

mechanisms and their

association with specific

illnesses are much more

recent in origin. As early as

the 6th century BC,

Pythagoras and Alkmaeon

used the terms isonomia

and disharmony to

respectively express the

modern terms homeostasis

and distress, while a

century later, Hippocrates

equated health with proper

homeostasis and disease

with disturbed or

threatened homeostasis [8].

Currently, chronic distress is

frequently referred to as

the allostatic load on an

individual (Figure 1) [9].

The pioneering work of

Hans Selye is often credited

with establishing the

scientific fact that there is a

significant relationship

between

pathophysiological

processes and the onset of

chronic diseases [10, 11].

Selye successfully

advanced the concept

that stress was critically

important in physiology

and medicine, and that

today we recognize that

many contemporary

theories relating to the

aetiology of chronic

diseases have a stress

component as a significant

precipitating variable.

Moreover, recently it has

been shown that stressful

life events can have a significant negative impact

on longevity, by playing an

important role in the onset

of cardiovascular disease,

immunological disorders

and pathophysiological

consequences of normal

ageing.

Stress describes the effects

of psychosocial and environmental factors on

physical or mental well

being. Stressors and stress-

related reactions have

been documented and

recognized and exposure

to chronic social stress has

been associated with many

systemic and mental

disorders. Hypotheses from

different research groups

support the notion that

health consequences are

more likely to occur when

unpredictable stressors of a

social nature chronically

induce physiological and

behavioural adjustments

that may create wear and

tear on the underlying

physiological functions [12].

When stressors challenge

an organism’s integrity, a

set of physiological

reactions is elicited to

counteract the possible

threat and adjust the

physiological setting of the

organism to the new

situation. This has become

known as the stress

response [13].

The stress response that

initiates the

neuroendocrine system has

been extensively studied in

the sympathetic–adreno–

medullary system, which is

under the control of the

central nervous system [13].

A further component of the

stress response is the

hypothalamic–pituitary–

adrenal axis, which is

diagrammatically illustrated in Figure 1, and is an

important modulator of the

brain–immune–endocrine–

neurotransmitter

interconnection cycle.

Life Stressors Social stressors and lifestyle

choices can be a

significant trigger for

disease, which can then affect longevity.

Psychosocial stress is a

personal response

perceived through the

complexities of social

interactions. These

interactions can either be

negative and increase or

be positive and lessen

psychological stress. These

interactions can affect the

hormonal responses that

are elicited as a result,

which can then significantly

“…The most

important

factor in why a

person

becomes ill lies

in the brain…”


Life Stressors, Nutritional Choices & Obesity cont...

alter immune responses.

Moreover, stress can

significantly reduce

physical and mental

tolerances (immune

potential) of humans and it

can induce the progression

of existing illnesses or it can

cause latent disorders to

become active. Therefore,

the control and suppression

of stress is very important in

the improvement of quality

of life and the prevention

of diseases. The

physiological changes that

ensue with unmanageable

stress may then have a

negative impact on health [14]. The social-

psychological network of

stressors that we experience can affect our

susceptibility to

inflammatory and

infectious diseases as well

as the course of these and

other diseases and in so

doing affect the human life

span [14-17].

In humans, loneliness is

associated with a threat, or an adrenaline-like pattern

of activation of the stress

response that results in an

elevation of blood pressure,

whereas exercising is

associated with a

challenge pattern of high

blood flow and cardiac

output. Studies have shown

that people exposed to

chronic social stresses for

more than two months

have increased

susceptibility to the

common cold [18].

It is of significant interest

that in Australia there is a

disparity in the rate of

suicide deaths between

rural and city areas [19-22]

Australia has one of the

highest per capita young

male youth suicide rate as

well as one of the highest

rates of antidepressant use [22, 23]. Young males are

experiencing grave

difficulties with life changes

that occur, whether in the

work or home

environments. In rural areas

unemployment and

isolation play major roles in

the rate of suicide.

Further a recent study

evaluated the association

of glycemic control and

major depression in type 1

and 2 diabetes mellitus [24]. Type 1 insulin–dependent

diabetes mellitus patients

with a lifetime history of

depression showed a

significantly worse glycemic

control, whereas patients

with type 2 non-insulin–

dependent diabetes

mellitus with a similar history

did not have significantly

worse glycemic control [24].

Hence depression can be

a significant marker for

increased risk of ill health

and a decrease in mean

human life expectancy [25].

This link between

depression and ill health is

further strengthened in

studies between depression

and idiopathic urinary

incontinence. It has been

shown that this association

may be due to altered

serotonin functioning and

may help explain the

efficacy of serotonergic-

based antidepressants in

the treatment of urge

incontinence [26].

Also, depression has been

associated with functional

disability in patients with

coronary artery disease

(CAD). Depressive

symptoms are highly

prevalent in patients with

CAD and have been

shown to increase their rate

of cardiac-associated

death and rate of mortality

due to all causes.

Depressed CAD patients

have been shown to have

an 84% greater risk of

cardiac death 5–10 years

later when compared to

non-depressed CAD patients [27].

Evidence continues to

support the fact the

physical disease results

from emotional distress.

School examination–

induced stresses increase

viral infection susceptibility

in adolescents [28, 29]. Stress

from lack of control in the

workplace or from life

events increases

susceptibility to

cardiovascular disease [30].

A recent meta-analysis of

biofeedback and pelvic

floor exercises for female

stress incontinence has

been reported [31]. The

results showed that

biofeedback may be an

important adjunct to pelvic

floor muscle exercises.

Further, interstitial cystitis,

which causes bladder

symptoms, has been shown

to be stress related and

these patients significantly

have an elevated level of

norepinephrine in urine [32].

Other studies have shown

that the immune responses

of long-term caregivers,

such as spouses of

Alzheimer’s patients,

become blunted [33].

Immune responses during

marital discord are also

blunted in the spouse

(usually the female spouse)

who experiences

the greatest amount of

stress and feelings of

helplessness [34]. In such

studies the levels of stress

hormones are elevated in

the affected spouse [34].

Conversely, a positive

supportive environment of

extensive social networks or

group psychotherapy can

enhance immune response and resistance to disease—

even cancer [35, 36]. Studies

have shown that women

with breast cancer, for

instance, who receive

strong, positive social

support during their illness,

have significantly longer life

spans than women without

such support [37]. Similar

trends have been reported in men with CVD [38].

A recent report found that

Professor Avni Sali MBBS, PhD,

FRACS, FACS, FACNEM is

founding head and director of

the National Institute of

Integrative Medicine (NIIM),

president of the Gawler

Foundation and Vice-President

of the Australian Integrative

Medicine Association (AIMA).

Assoc Professor Luis Vitetta

BSc(Hons), PhD, GradDip

IntegrMed, GradDip

NutrEnvironMed is deputy director of the National

Institute of Integrative

Medicine (NIIM) and Senior

Research Fellow, Centre for

Molecular Biology and

Medicine.



smokers treated with

nortriptyline and cognitive behavioural therapy were

significantly aided in

smoking cessation. It is not

surprising that this

treatment was successful,

as other research has

demonstrated that smokers

are more likely to be

depressed [39]. Vigorous

exercise facilitates smoking

cessation when combined

with a cognitive

behavioural program.

Moreover, exercise has

been shown to work as an

antidepressant [40].

The Nutrition–Obesity–Stress

Connection The understanding of the

regulation of function in the

hypothalamo–pituitary–

adrenal (HPA) (Figure 2)

axis has changed greatly in

the last decades [1]. The

discovery of functions of

the distributed cell groups of corticotropin-releasing

factor (CRF) neurons, the

motor neurons for

activation of the pituitary

and adrenal glands, as well

as the tight

interrelationships between

calories, body weight,

energy stores, and the HPA

axis have occasioned for

significant revisions in their

outworking. Recently

Dallman and colleagues [41], have interpreted the

results from studies on

manipulation of energy

balance, central CRF, and

the effects of acute and

chronic stress and

glucocorticoid (GC)

treatment in intact and

adrenalectomized rats and

have thus modified the HPA axis with a metabolism

component critically linking

life style stressors, the output

of which is modifiable

through manipulation of

caloric input. The long-term

consequences of such

output modification in

chronically stressed

individuals may include

deleterious weight gain,

abdominal obesity, type II

diabetes, increased

cardiovascular morbidity,

and mortality [42, 43].

In humans, the scientific

literature shows that stress

affects eating in a

bidirectional manner. A

subgroup, approximately

30%, decreases food intake

and loses weight during or

after stress, while most

individuals increase their

food intake during stress [44,

45]. Given that people living

in Westernized countries live

in a pleasant edible food

environment, with an

abundance of calorically

dense foods, it makes sense

that most people complain

of eating more during

stress, rather than less. It has

been demonstrated that

almost 50% of a US

representative sample was

concerned with the

amount of stress in their life

and that they cope by

engaging in unhealthy

behaviours such as smoking

as well as eating for relief [46]. In a further study it was

reported that increased

food intake occurred

during times of stress,

especially in women [47].

The stress-induced drive for

dense calories is disturbing

in the face of

the continuing and

growing obesity epidemic [48]. This was further emphasized in the recent

Bjorntorp Symposium where

a special emphasis was

placed on the metabolic

consequences of stress,

which might also contribute

to the increasing

prevalence of the

metabolic syndrome and

their associated cardio–

metabolic morbidities [49].

Nutrition, Chronic Diseases

and Life Expectancy

Nutrition is an important

factor that significantly

contributes to how long a

person will live. Decisions

about poor dietary

choices, in addition to

smoking, lack of exercise,

and excessive drinking are

known to be important

causes of disease [50]. The

size and frequency of

meals are fundamental

aspects of nutrition that

can have profound effects

on the health and longevity

of laboratory animals.

Moreover, caloric restriction

is the most potent and

reproducible

environmental variable

capable of extending the

life span in a variety of

animals from worms to rats.

In humans, excessive

caloric intake is associated

with increased incidence of

cardiovascular disease,

diabetes, and certain types

of cancer. It is a major

cause of disability and

death in industrialized

countries [51]. The type of

nutrients consumed also

have significant

correlations to numerous

types of cancer (Table 1) [51-53].

The worsening global

epidemic of obesity has

increased the urgency of

research aimed at

understanding the mechanisms of appetite

regulation. An important

aspect of the complex

pathways involved in

modulating energy intake is

the interaction between

hormonal signals of energy

status released from the gut

in response to a meal and

appetite centres in the

brain and brainstem. The challenges of the obesity

epidemic are not limited to

concerns about bulk and

weight. The disabilities

caused by obesity are

physiologic and

psychosocial. The

increased waist-to-hip girth

is associated

with increased risk of

cardiovascular disease,

hyperlipidaemia,

hypertension and diabetes [54]. Obesity also has been

“...stress can

significantly

reduce physical

and mental

tolerances

(immune

potential) of

humans and it

can induce the

progression of

existing illnesses

or it can cause

latent disorders to

become

active…”



related directly to

increased risk of sleep

apnoea, cancer,

gallbladder disease,

musculoskeletal disorders,

severe pancreatitis,

bacterial panniculitis,

diverticulitis, infertility,

urinary incontinence, and

idiopathic intracranial

hypertension. The

psychosocial factors and

quality of life in the obese

population also have been

documented. Although

there is some debate, the

obese have been found to

be twice as likely to suffer

from anxiety, impaired

social interaction, and

depression when

compared with the non-obese population [54].

Several studies indicate

that adherence to a

Mediterranean diet is

associated with a

reduction in total and

cardiovascular mortality [55-

58]. High intake of olive oil is

considered a hallmark of

the traditional

Mediterranean diet, resulting in high intake of

monounsaturated fatty

acids and lower intake of

saturated fatty acids. The

replacement of saturated

with monounsaturated

lipids is strongly associated

with a significant reduction

in coronary heart disease

risk, through a mechanism

involving reduction of LDL

cholesterol, without a

reduction of HDL

cholesterol or an increase

in triacylglycerols [59].

The Human Stress Condition and Eating Patterns

The relationship between

stress and eating is

complex and it has long

been recognized in

humans [60]. The core

psychobiological

mechanisms that shape the

direction of change–

whether one eats more or

less during stress, are for the

most part unknown, but

fundamentally we believe

due to multiple life factors.

Research has

demonstrated that being

female, overweight, or

scoring high on dietary

restraint are all predictors of

eating more during stress [61].

The link of the HPA axis

activity with elevated levels of cortisol, produces an

increase in caloric intake,

such as that seen with

people taking

corticosteroids for various

medical conditions or

cancer treatment. The

hormonal relationships are

complex (Figure 3).

A controlled study that

investigated the

administration of

glucocorticoids showed a

marked increased food

intake [62]. Hence it appears

that high stress reactivity,

which increases cortisol,

leads to greater intake of

calories, at least in a

physical sense. Thus, one's

psychological stress

reactivity may be an

indication as to differences

in psychobiological

characteristics that explain

stress eating or food

desires. In a study of

healthy medical students,

self identified stress eaters

had significantly higher

urinary cortisol and insulin

during a stressful period

(i.e., during medical

student exams) compared

to a control period (i.e.,

summer vacation), and

also gained more weight

than non-stress eaters,

during stressful periods [63].

One can possibly conclude

that the stress eaters have

underlying high stress

reactivity, which promotes

their overeating, although

this has not been directly

tested experimentally.

There are several studies

that have investigated stress reactivity in different

eating pathologies that

include people with

anorexia, bulimia, and

binge eating disorder.

These people tend to show

either greater basal cortisol

or greater cortisol reactivity

[see reviews by Gluck [64, 65].

In a well controlled

laboratory stress study,

binge eating in women

compared to controls

tended to have greater

cortisol reactivity and

desire to binge after a cold

pressor lab stressor [64].

In humans it is difficult to

characterize types of

psychological stress

responses since humans

tend to include blends of

emotions and aspects of

threat and challenge

appraisals in a simultaneous

manner [66]. In one inducing

threat stress study, with the

Trier Social Stress Test [67],

those who responded with

high cortisol were likely to

consume more calories

after the stressor,

particularly of high fat food.

There were no differences

in caloric intake between

high and low cortisol

reactor groups on the

control day [68]. In a second

study conducted by this

group, a similar threat

stressor to a positive

challenge stressor (identical

tasks but with positive

feedback from the

audience) was compared.

Preliminary results

suggested that indeed, the

threat condition stimulated

greater food intake,

particularly of calorically

dense food, than the

challenge condition [69].

Further, the difference in fat intake by condition was

mediated by psychological

threat appraisals.

A recent study that aimed

to test whether high cortisol

reactivity assessed in the

lab predicted greater stress

related eating in the field [70]; with a method similar to

that of Epel and colleagues [68], high and low cortisol

reactors were identified in

the laboratory. Food intake

“...Repeated

short time stints of

minor daily

stressors may

keep the stress

arousal system in

a chronically

activated

state…”



“…approximately

30% (of people),

decrease food

intake and lose

weight during or

after stress, while

most individuals

increase their

food intake

during stress…”

however was examined

outside the lab, in a naturalistic setting. Daily

stressors were related to

greater intake of snack

food, but only in the high

cortisol reactor group. High

cortisol reactivity to stress

appears to predict greater

intake of calorically dense

food naturalistically, as well

as in the lab.

As has been documented

with rat studies [71, 72],

people experiencing high

cortisol reactivity may

choose dense calories to

blunt their stress response [68] or reduce anxiety. The

co-elevation of insulin and

cortisol is probably

important in comfort food

preference, although it is

difficult to test their

independent effects in

people. The relationship

between cortisol and food

intake in humans may also involve effects of

glucocorticoids on

neuropeptide Y, CRH [73],

leptin [74] as well as opioid [75] and endo-cannabinoid [76] signalling receptors.

Summary

Life stressors and nutrient

intake correlates a

complex set of behavioural

drivers that can lead

people to commonly

describe a similar response

to a severe stressor — that

involves short term appetite

and weight loss and then

weight regain, to a heavier

weight than previously. The

relationship between stress

and adiposity is complex,

and in this brief review we have focused on a

simplified model,

emphasizing the role of

cortisol.

When a crisis state/stressor

has resolved, there is likely

to be observed a

compensatory increase

drive for food intake to

attain weight recovery and

a likely overshoot that then

leads to increased

adiposity.

Repeated short time stints

of minor daily stressors may

keep the stress arousal

system in a chronically

activated state. Indeed, it

has been reported that

cortisol tends to be higher

on working days than

weekend days [77, 78]. This

continuous low but chronic

level input of stress may

modulate appetite and

food intake in a manner

that is only loosely related

to true caloric need for that

particular period.

As presented in Figures 1

and 2, a threat related

stress can lead to greater

cortisol exposure. Cortisol

clearly activates the

recompense system.

Intermittent access to food

engages the reward system

and can enhance the

effects of stress alone.

Although speculative in

humans, high levels of

voluntary dietary restraint

may have similar effects as

food restriction in the rat

model, potentiating the

effects of stress on the

reward system.

Alternatively, the restraint is

merely a response to an

incentive system highly

sensitized to palatable

food.

The effects of cortisol on

the reward system may be

partly mediated through

increases in insulin,

neuropeptide Y and leptin.

Insulin (Figure 3) has acute

effects inhibiting the

recompense system and

possibly chronic exposure

to circulating insulin may stimulate this recompense

system, as in the case of

insulin resistance. The effect

of those mediators on the

brain incentive centre may

contribute to a state of

hedonic withdrawal,

leading to the subsequent

drive to relieve this

negative state. Humans

learn that intake of highly

palatable food can do just

that.

The natural incentive of

highly palatable food has

been reported to directly or

indirectly reduce activity of

the HPA axis [41]. This has

been described as ‘self

medication’ with food [41,

79]. Changes in

neuroendocrine balance

(high cortisol and insulin,

see Figure 1) from eating

when under stress might

further sensitize the brain’s

incentive centre leading to

a positive feedback loop

drive to maintain opioid

stimulation from palatable

food.

Thus, stress eating is a feed

forward process. Given that

cortisol and eating

stimulate insulin, the

combination of stress and

highly palatable food

intake sets up potent

conditions for visceral fat

storage. The cumulative

research data at this point

in time demonstrates that

human stress related

energy intake is not very

different than that of the

rat.

Further, a recent review

suggests that stress induced

cortisol exposure may

impair right prefrontal

cortex activity, thus

impeding the more

reflective cognitive control

over eating that is distinct

to humans [80]. Further, while

recent research has

elucidated likely pathways

for stress-eating, there is

much progress to be made

in the understanding and prevention of stress related

eating and non-

homeostatic eating in

general.


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75. Levine AS, Billington CJ. Opioids as agents of reward-related feeding: a consideration of the evidence. Physiol Behav 2004;82:57–61.

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hypothalamus: a fast feedback mechanism. J Neurosci 2003;23:4850–7.

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and men from the Whitehall II cohort. Psychoneuroendocrinology 2004;29:516–28.

78. Schlotz W, Hellhammer J, et al. Perceived work overload and chronic worrying predict weekend–weekday differences in

the cortisol awakening response. Psychos Med 2004;66:207–14.

79. Pecoraro N, Reyes F, et al. Chronic stress promotes palatable feeding, which reduces signs of stress: feedforward

andfeedback effects of chronic stress. Endocrinology 2004;145: 3754–62.

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Table 1. Specific cancer relationships based on epidemiologica studies.

[Adapted from Cummings and Bingham and Willett [51-53]

Cancer site Incidence association

Oesophageal alcohol tobacco combined use

Stomach salt-preserved foods

possibly BBQ foods

grilling

Pancreatic smoking

processed meats cholesterol

Large Bowel

saturated fat

possibly eggs

grilling

sugar

Liver hepatitis B

aflatoxins

alcohol

Lung smoking possibly alcohol

saturated fats

cholesterol

Breast obesity

early-puberty alcohol consumption

processed meat

saturated fats

Endometrial obesity

oestrogen therapy

saturated fats

Cervical folate deficiency

smoking

Bladder smoking possibly artificial sweeteners

coffee

alcohol

Prostate high saturated fat intake


Figure 2: Diagrammatic representation of the inter-relationships between the hypothalamic–pituitary–adrenal axis and the immune–endocrine responses. Ach = acetylcholine; 5HT = 5 hydroxytryptamine; CRF = corticotrophin

releasing factor; GABA = gamma–aminobutyric acid; A = adrenaline; NA = noradrenaline; IL = interlukin; TNF = tumour necrosis factor; (Adapted and modified from Song and Leonard [1])

Figure 3: Stressors and the physiological responses elicited. (Adapted from A. Sali) (PNI = Psychoneuroimmunology, PNE = Psychoneuroendocrinology)


Fertility: Nutritional and Lifestyle Factors

INTERGATIVE MEDICINE

Nutrition and lifestyle

modification can help

improve fertility. By

Professor Avni Sali and

Associate Professor Luis

Vitetta.

INFERTILITY, defined as the

inability to conceive after

one year of trying, affects

10–15% of couples.

The cause can be found in

about 80% of couples —

female infertility accounts

for 35% and male infertility

for 30%.

In both sexes, infertility can

relate to exposure to

environmental toxins, and

to nutritional disorders and

deficiencies.

In men, these factors can

contribute to major causes

of infertility such as

reduced sperm count,

decreased sperm motility,

sperm agglutination,

impotence and ejaculatory

disorders.

In the past 50 years the

prevalence of male

infertility disorders has

doubled, and sperm counts

have declined by about

one third.

In women, over–exposure

to toxins and nutritional

deficiencies can lead to

anovulation and altered

hormone levels and

processes. Poor nutrition

can also result in a BMI that

is unfavourable for conception.

Risk factors

In addition to more well-

recognised causes, such as

tubal obstruction, risk

factors for infertility include:

Psychological factors

Psychological factors such

as stress do not alone

cause infertility; however,

they can play a role in

factors such as impotence

and menstrual problems.

The two major organs

involved in the production

of stress hormones and

reproductive hormones LH

and FSH are the pituitary

gland and the

hypothalamus.

There is also

neuroendocrine control of

smooth muscle function

within the reproductive

tract.

The ordinary sequence of

the release of reproductive

hormones can be severely

disrupted in times of

significant stress, leading to

menstruation and ovulation

disturbances.

In men, fertility problems

contributed to by

emotional stress include

erectile dysfunction and hormonal imbalances.

Treating infertility in both

men and women often

involves psychological

intervention.

Because difficulty

conceiving can itself be

stressful, a stress/infertility

cycle may be created. This can be ameliorated with

regular exercise,

meditation, relaxation and

breathing techniques,

guided visualisation and

counselling.

In a study measuring the

effects of stress reduction

on fertility, 54 women with

infertility were enrolled in a

behavioural treatment

program and taught a

relaxation response

technique over 10 weeks.

The women were instructed

to use this practice twice

daily for 20 minutes at

home. At the end of the

trial they reported

significantly less stress,

depression and fatigue

than they had before the

intervention.

Within months of the study’s

completion, 34% of the

women became pregnant

— a figure much higher

than expected in women

undergoing typical infertility

treatment. Further, it was

suggested that behavioural

treatment should be

considered for couples with

infertility before or in

conjunction with

reproductive technologies

such as intrauterine

insemination and gamete

intrafallopian transfer.

Nutrient deficiencies

Deficiencies in essential vitamins and minerals can

contribute to infertility by

affecting sperm count and

motility in men, and

hormonal processes in

women.

Males

Antioxidant deficiency in

males can lead to a decline in sperm motility.

Spermatozoa cell

membranes are rich in fatty

acids, which are highly

susceptible to oxidative

damage. Adequate levels

of antioxidants are required

to maintain healthy cell

membranes.

Selenium is an important

nutrient for male fertility.

Two of the structurally

“…In the past 50

years the

prevalence of

male infertility

disorders has

doubled, and

sperm counts

have declined by

about one

third…”

• Psychological factors.

• Nutrient deficiencies.

• Excessive exposure to

toxins.

• Emotional stress.

• Hormonal imbalance.

• Underweight

/overweight


Fertility: Nutritional and Lifestyle Factors cont…

important proteins in sperm

require adequate levels of

selenium. Deficiency is

associated with decreased

sperm motility and

increased abnormal sperm.

Vitamin B12 deficiency can

cause male infertility

because it affects sperm

count and motility.

Because high

concentrations of zinc are

present in ejaculatory fluid,

frequent ejaculation can

contribute to a zinc

deficiency. This is

associated with decreased

serum testosterone levels,

oligospermia and poor

sperm motility.

Females

Folic acid deficiency can

play a role in infertility.

Folate can become

depleted during

pregnancy and can take

up to two years to be

replenished. Women trying

to conceive within this two-year period may

experience difficulty.

Deficiency may also be

caused by digestive

disorders such as coeliac

disease.

Pernicious anaemia can

lead to female infertility.

Conception can be difficult

in women with low iron

stores.

Insufficient vitamin B2 can

lead to altered levels of

oestrogen and

progesterone, often

causing irregular

menstruation. Treatment of

menstrual problems, such

as irregular periods, PMS

and general menstrual

difficulties with vitamin B2

often also corrects infertility

issues.

The effect of zinc

deficiency on female

fertility has not been

extensively studied,

however animal trials have

linked low zinc levels with

impaired ovulation and

greater oocyte

deterioration.

Zinc supplementation can

be beneficial for women

experiencing fertility

problems, but excessive

zinc appears to be detrimental.

Toxin exposure

Caffeine promotes

dopamine production and

this in turn inhibits the

production of prolactin, a

deficiency or excess of

which increases the risk of

infertility in women.

Consuming as little as one

caffeinated drink a day is

associated with a

temporary reduction in

chances of conception.

Excessive alcohol

consumption can cause

hyperprolactinaemia and is

therefore also associated

with female infertility.

In males, a high intake of

alcohol has been shown to

have a negative effect on

Leydig cells, and therefore

possibly on testosterone

production. The degree of

damage depends on the

length of exposure and

quantity of ethanol

ingested.

Exposure to heavy metals

such as lead and mercury

can interfere with fertility-

related processes in men.

For example, mercury can

decrease the ability of the

sperm to penetrate the ova

and causes breakages in

sperm DNA strands.

In women, lead can

contribute to infertility, as

well as to other

reproductive disorders such

as preterm rupture of

membranes and preterm labour.

Cadmium exposure has

also been associated with

altered concentrations of

serum oestradiol, FSH and

testosterone.

Other chemicals that can

affect fertility can be found

in adhesives, cleaning

compounds and cigarette

smoke.

Management of infertility,

especially in males, should

involve limiting contact

with these substances and

supplementing with

antioxidants, in the hope of

reversing the damage

caused by over–exposure.

Hormonal imbalance

Hormonal abnormalities,

such as those caused by

significant, prolonged stress

or dietary imbalances, can

play a role in infertility,

particularly in women.

Thyroid autoimmunity has

been also associated with

infertility in women.

Hypothyroidism in women

of reproductive age can

be associated with

reproductive complications

such as irregular menstrual

cycles.

Other disorders that have a

hormonal component are

endometriosis and ovarian

causes of infertility including

polycystic ovary syndrome.

Underweight/overweight

Excessive or insufficient

body weight in women is

associated with infertility.

For conception, the ideal body fat percentage in

women is between 20%

and 25%. A body fat

percentage below 17%

can result in anovulation

and it may take up to two

years after this is corrected

before regular ovulation

resumes.

In men, obesity (BMI >30kg/m2) is associated

with hypogonadism and,

therefore, with infertility.

“…The ordinary

sequence of the

release of

reproductive

hormones can be

severely

disrupted in times

of significant

stress, leading to

menstruation and

ovulation

disturbances…”


Fertility: Nutritional and Lifestyle Factors cont…

Studies have shown a correlation between

increased BMI and

decreased testosterone

levels, sperm motility and

sperm concentration.

Nutritional supplements

Antioxidants

Supplementation with

vitamins C and E and

coenzyme Q10 can

prevent and reverse

oxidative damage to

sperm and therefore

increase sperm motility.


selenium has been shown

in some trials to increase

sperm count and motility.

However, excessive

selenium can have the

opposite effect.

Glutathione is also instrumental in the defence

against oxidative stress in

the spermatogenic

epithelium. It has been

shown to be particularly

important in the treatment

of oligozoospermia

because of its antioxidant

effect during

spermatogenesis.

Glutathione has to be

supplemented

intramuscularly because it

is destroyed in the

stomach. It is more

practical to increase the

consumption of foods

containing glutathione —

onions, garlic, avocados,

asparagus, watermelon

and cruciferous

vegetables.

Other supplements

Supplementation with zinc

can increase fertility,

particularly in oligospermic

men.

Infertility disorders arising

from B12 deficiency can be

treated with B12

supplementation. Oral

vitamin B12 can also be

used provided the patient

does not have pernicious

anaemia. It may be

worthwhile to supplement

with B12 where decreased

sperm count and motility

are present, even if no

symptoms of deficiency are

obvious.


vitamin B2, to optimise

hormone levels, and

vitamin B6 to alleviate PMS,

can also lead to improved

fertility.

Folate deficiency can be

corrected with folic acid

supplementation.

Arginine deficiency can

contribute to low sperm

count and motility but can

be reversed with

supplementation.


carnitine in open trials has

been shown to increase

both sperm count and

motility.

SUPPLEMENT DOSES

Glutathione Males: 600mg

daily (intramuscularly)

Coenzyme Q10 Males:

60mg daily

Vitamin E Males: 400mg

daily

Vitamin C Males: 200mg

daily

Selenium Males: 100µg

daily

Folate Females: 15mg daily,

for about three months

Vitamin B12 Females: 1000µg IM weekly, then

monthly

Males: 1500µg daily for

about 12 weeks

Vitamin B6 Females: 50mg

daily

Zinc Males/females: 220mg

of zinc sulphatetwice daily,

combined with 2mg daily

of copper

Arginine Males: 4gm daily

Carnitine Males: 1g, three

times daily

Professor Sali is director of

the National Institute of

Integrative Medicine and

Associate Professor Vitetta is principal research fellow,

unit of health integration, at

the school of medicine, University of Queensland.

References available on

request.

“…Within months of

the study’s

completion, 34% of

the women

became pregnant

— a figure much

higher than

expected in

women

undergoing typical

infertility

treatment….”


Recommended Books

About Our Organisation

“The China Study; Startling Implications for Diet, Weight

Loss and Long-term Health”

T. Colin Campbell PhD and Thomas M. Campbell II

The China Study is an

investigation of the links

between nutrition and

disease, a field in which T.

Colin Campbell has had over

40 years experience. Many

findings are supported by the

actual China study, an

analysis of illness and lifestyle

in different regions of China

conducted by some of the

most respected scholars and

epidemiologists in the world.

During this study, over eight

thousand different,

statistically significant

associations were found

between diet and disease.

The book covers obstacles to

optimum nutrition, such as

distortion of nutritional

information in the media, as

well as the relationship

between the food industry

and health research.

Although based on USA

laws and studies, the text is

relevant for Australians in

dispelling food myths and

misinformation often

disseminated through

advertising and labelling.

The focus of The China

Study is on the benefits of

whole foods in disease

prevention over

supplements and extracts.

Although Dr. Campbell

advises on the components

of a balanced diet,

ultimately this is not a food

guide, but rather a wealth

of information helpful in

making nutritional choices.

“The Homework Myth; Why

our kids get too much of a

bad thing” Alfie Kohn

As homework is assigned to

younger and younger

children, the workload is

taking its toll on individual

and family health and

wellbeing, while the benefits

remain unclear. The

Homework Myth explores the

ramifications of an exceeding

workload on children’s study

and lifestyle habits, such as

unnecessary stress and a

declining interest in learning.

An increase in study hours

and workload has been

shown to be largely

ineffective in achieving

academic excellence, and

has not been proven to teach

children other skills, such as

time-management. In his

book, Kohn examines the

attitudes of parents and

teachers in supporting

increased homework loads,

demonstrating that these are

based on flawed arguments

and disproved theories. Based

on educational studies

conducted in the U.S., The

Homework Myth methodically

dismantles the misconception

that more time spent studying

will produce better academic

results in the long run.

“The Homework Myth; Why our

kids get too much of a bad

thing” Alfie Kohn

Publisher: Da Capo Press, 2007

ISBN: 978-0738211114

“The China Study; Startling

Implications for Diet, Weight

Loss and Long-term Health”

T. Colin Campbell PhD and

Thomas M. Campbell II

Publisher: Benbella Books; 2004

ISBN: 978-1932100389

The National Institute of


(NIIM) formed as a natural

development from the

Graduate School of


(GSIM), formerly part of

Swinburne University.

The GSIM was founded by

Professor Avni Sali in 1997,

to educate medical

practitioners in Integrative

Medicine and also to

conduct research into the

field of Integrative

Medicine. Integrative Medicine is

the blending of

conventional and

complementary medicine

with the aim of using the

most appropriate field, be

it a single modality or a

combination, to provide

complete care to the

patient. An emphasis is

also placed on the

patient becoming an

active participant in the

healthcare process.

NIIM brings together the

teaching, research and

practice of Integrative

Medicine and its allied

activities with the objectives of facilitating

improved understanding

of the utilisation, safety

and limitations, evaluation

and development of

complementary and

alternative medicine

(CAM) with mainstream

medicine. The research

carried out at the Institute

is focused on the

establishment of a strong

evidence base for

Integrative Medicine.

The NIIM Courses have

been developed for

medical practitioners,

providing the tools

necessary to assess and

implement the principles

of Integrative Medicine in

health care.

The NIIM Wellness Clinic

operates on these

principles, drawing on

both Complementary and

conventional medicine to

deliver the widest scope

of patient care possible.

NIIM aims to provide

health and education

opportunities and, in line

with the principles of a

not-for-profit organisation,

make them readily accessible to the public

and healthcare

practitioners.


Thanks

The National Institute of Integrative Medicine is a

DGR endorsed charitable organisation.

Donations are tax-deductable. To make a

donation please contact the Institute

NIIM would like to thank the following supporters for their kind contributions to the Institute:

Australasian Integrative Medicine

Association

Best Practice Software Corporate

Locksmiths

The Dara Foundation Hypertech

Janda

Designs

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Rigby Cooke Lawyers

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Spotlight

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and Zervas Lawyers

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