Integrative Medicine Integrative Medicine

Nutritional ImplicationsNutritional Implications

Complementary and Complementary and alternative medicine alternative medicine (CAM): (CAM): Complementary and alternative Complementary and alternative

medicine (CAM): alternative, medicine (CAM): alternative, adjunctive health care practices: not adjunctive health care practices: not presently an integral part of presently an integral part of conventional medicine; includes conventional medicine; includes botanical use, mind-body botanical use, mind-body approaches, musculoskeletal approaches, musculoskeletal manipulation, energy medicine, manipulation, energy medicine, nutrition-diet interventionsnutrition-diet interventions

Thomson in Krause, p. 470

CAM Therapies IncludeCAM Therapies Include

Alternative medical systems, such as Alternative medical systems, such as naturopathy, traditional Chinese naturopathy, traditional Chinese medicine, ayurveda, and homeopathymedicine, ayurveda, and homeopathy

Mind-body therapies, such as meditation, Mind-body therapies, such as meditation, prayer, art or music therapyprayer, art or music therapy

Biologically based therapies such as Biologically based therapies such as herbs, whole foods diets, and herbs, whole foods diets, and supplementationsupplementation

Manipulative therapies such as massage, Manipulative therapies such as massage, chiropractic medicine, osteopathy, yogachiropractic medicine, osteopathy, yoga

Whole medical systems based on energy Whole medical systems based on energy therapies such as qi gong, magnetic therapies such as qi gong, magnetic therapy, and reikitherapy, and reiki

Integrative medicineIntegrative medicine

Integration of these approaches Integration of these approaches into conventional medicine; into conventional medicine; nutritional care is a primary nutritional care is a primary therapy in this modeltherapy in this model

Focused on combined use of Focused on combined use of conventional and CAM approachesconventional and CAM approaches

Evidence-basedEvidence-based Includes wellness and preventionIncludes wellness and prevention

Thomson in Krause, p. 471

National Center for National Center for Complementary and Complementary and Alternative Medicine Alternative Medicine (NCCAM)(NCCAM)Part of the National Institutes of Health Part of the National Institutes of Health

——Investigates and evaluates alternative Investigates and evaluates alternative therapies and their effectivenesstherapies and their effectiveness

Theoretical Basis of Theoretical Basis of Holistic TherapiesHolistic Therapies Health as a vital, dynamic state; more Health as a vital, dynamic state; more

than the absence of diseasethan the absence of disease The healing force of natureThe healing force of nature Self-healing power of living things; Self-healing power of living things;

organisms have inherent self-defense organisms have inherent self-defense mechanisms against illnessmechanisms against illness

Includes naturopathy, chiropractic, Includes naturopathy, chiropractic, homeopathy, traditional Oriental homeopathy, traditional Oriental medicine, acupuncture, phytotherapymedicine, acupuncture, phytotherapy

Health is more than the absence of disease.The body can heal itself.Health is more than the absence of disease.The body can heal itself.

Integrative TherapiesIntegrative Therapies

NaturopathyNaturopathy HomeopathyHomeopathy Traditional Chinese medicineTraditional Chinese medicine AcupunctureAcupuncture PhytotherapyPhytotherapy

NaturopathyNaturopathy

Practitioners diagnose and treat at the primary Practitioners diagnose and treat at the primary care levelcare level

Train in 4-year postgraduate institutionsTrain in 4-year postgraduate institutions Most states require licensureMost states require licensure Uses natural methods of healing (light, heat, Uses natural methods of healing (light, heat,

air, water, and massage)air, water, and massage) Training includes pathology, microbiology, Training includes pathology, microbiology,

physical and clinical diagnosis, physical and clinical diagnosis, pharmacognosy, hydrotherapy, physical pharmacognosy, hydrotherapy, physical therapy, nutrition, therapy, nutrition,

Treatments include phytomedicines, Treatments include phytomedicines, electrotherapy, physiotherapy, minor surgery, electrotherapy, physiotherapy, minor surgery, mechanotherapy, nutrition, nutritional mechanotherapy, nutrition, nutritional supplements, and natural forcessupplements, and natural forces

Chiropractic ConceptsChiropractic Concepts

Body has the ability to heal itself; Body has the ability to heal itself; Practitioner’s role is to assistPractitioner’s role is to assist

The structure and condition of the body The structure and condition of the body influences how well it functionsinfluences how well it functions

The mind-body relationship is important The mind-body relationship is important in maintaining health and promoting in maintaining health and promoting healinghealing

Locate and eliminate subluxations, Locate and eliminate subluxations, musculoskeletal problems that interfere musculoskeletal problems that interfere with the body’s ability to maintain healthwith the body’s ability to maintain health

Primary therapy is manual Primary therapy is manual manipulations, along with lifestylemanipulations, along with lifestyle

Chiropractic Chiropractic PractitionersPractitioners Do not prescribe drugs or perform Do not prescribe drugs or perform

surgerysurgery Licensed and regulated in all 50 Licensed and regulated in all 50

states and 30+ countriesstates and 30+ countries Practitioners must graduate from Practitioners must graduate from

4-year accredited college of 4-year accredited college of chiropractic and pass a nationally-chiropractic and pass a nationally-administered examadministered exam

ChiropracticChiropractic

The most widely-used of the The most widely-used of the complementary and alternative complementary and alternative treatments, particularly for low back treatments, particularly for low back pain, neck pain, and headachepain, neck pain, and headache

Effectiveness is being studied by the Effectiveness is being studied by the Consortial Center for Chiropractic Consortial Center for Chiropractic Research, a consortium of Research, a consortium of chiropractic schools and universities, chiropractic schools and universities, established by NCCAMestablished by NCCAM

HomeopathyHomeopathy

Law of similars: Substances in Law of similars: Substances in large doses that produce large doses that produce symptoms of a disease in healthy symptoms of a disease in healthy people will cure the same people will cure the same symptoms when administered in symptoms when administered in very dilute amountsvery dilute amounts

Remedies become Remedies become potentizedpotentized through repeated dilution and through repeated dilution and succussionsuccussion (shaking) (shaking)

HomeopathyHomeopathy

Results of research on the Results of research on the effectiveness of homeopathy have effectiveness of homeopathy have been contradictorybeen contradictory

Appears to have more than a placebo Appears to have more than a placebo effect, but scientific basis uncleareffect, but scientific basis unclear

Generally regarded as safe (many Generally regarded as safe (many homeopathic remedies are so dilute homeopathic remedies are so dilute that the healing substance is that the healing substance is nondetectable by chemical meansnondetectable by chemical means

Traditional Chinese Traditional Chinese MedicineMedicine

Based on the concept of body Based on the concept of body life force chi (Qi)life force chi (Qi)

Forces that must be balancedForces that must be balanced

——Yin and yang and blood Yin and yang and blood

Invisible energy circuits called Invisible energy circuits called meridiansmeridians carry chi and blood carry chi and blood throughout the bodythroughout the body

Nutrition in Traditional Nutrition in Traditional Chinese MedicineChinese Medicine Components: Food as a means of Components: Food as a means of

obtaining nutrition, food as a obtaining nutrition, food as a tonic or medicine, fastingtonic or medicine, fasting

Foods classified by taste (sour, Foods classified by taste (sour, bitter, sweet, spicy, salty) and bitter, sweet, spicy, salty) and property (cool, cold, warm, hot property (cool, cold, warm, hot and plain)and plain)

Regulate yin, yang, chi, bloodRegulate yin, yang, chi, blood

Acupuncture and Acupuncture and MoxibustionMoxibustion Acupuncture: Use of thin needles, Acupuncture: Use of thin needles,

inserted into points on the meridians, inserted into points on the meridians, stimulating the body’s energy or chistimulating the body’s energy or chi

Moxibustion: application of heat Moxibustion: application of heat along meridian acupuncture points, along meridian acupuncture points, affecting chi and blood, balancing affecting chi and blood, balancing substances and organssubstances and organs

Treat disharmony in the bodyTreat disharmony in the body

Acupuncture as Acupuncture as AnesthesiaAnesthesia Has been used to produce regional Has been used to produce regional

anesthesiaanesthesia Appears to act through needle Appears to act through needle

stimulation, triggering the release of stimulation, triggering the release of opioidsopioids

Research has been mixedResearch has been mixed Has been shown to be efficacious in Has been shown to be efficacious in

adult postop management, adult postop management, chemotherapy-induced nausea, chemotherapy-induced nausea, postoperative dental painpostoperative dental pain

Traditional Chinese Traditional Chinese HerbsHerbs Includes herbs and minerals as Includes herbs and minerals as

well as animal productswell as animal products Pharmacopoeias published as Pharmacopoeias published as

early as the third century BCearly as the third century BC Most medicinals include multiple Most medicinals include multiple

substancessubstances

PhytotherapyPhytotherapy

Science of using plant-derived Science of using plant-derived substances to treat and prevent illnesssubstances to treat and prevent illness

Botanicals: come as bulk herbs, Botanicals: come as bulk herbs, tinctures, capsules and tablets; includes tinctures, capsules and tablets; includes herbs and other plant materialsherbs and other plant materials

Sometimes the active ingredient has Sometimes the active ingredient has been identified; sometimes notbeen identified; sometimes not

Have a long history of research and use Have a long history of research and use in Europein Europe

Botanical FormulationsBotanical Formulations

Teas: weak concentration Teas: weak concentration prepared by steeping fresh/dried prepared by steeping fresh/dried herbs for a few minutes in waterherbs for a few minutes in water

Infusions: more concentrated Infusions: more concentrated than teas; steeped for 15 minutesthan teas; steeped for 15 minutes

Decoction: Most concentrated of Decoction: Most concentrated of beverages; botanical is boiled for beverages; botanical is boiled for 30-60 minutes30-60 minutes

Botanical FormulationsBotanical Formulations

Extracts: herbs are extracted with an Extracts: herbs are extracted with an organic solvent to dissolve the active organic solvent to dissolve the active components; concentrated formcomponents; concentrated form

Tincture: extract in which solvent is Tincture: extract in which solvent is alcoholalcohol

Glycerite: extract in which the Glycerite: extract in which the solvent is glycerol or mixture of solvent is glycerol or mixture of glycerol, propylene glycol, and water; glycerol, propylene glycol, and water; more suitable for childrenmore suitable for children

Botanical FormulationsBotanical Formulations

Capsules: Herbal material enclosed in a hard Capsules: Herbal material enclosed in a hard shell made from gelatin or celluloseshell made from gelatin or cellulose

Tablets: herbal material is mixed with filler to Tablets: herbal material is mixed with filler to form the hard tablet; may be coated or form the hard tablet; may be coated or uncoateduncoated

Lozenges (troches): active components are Lozenges (troches): active components are released in the mouth when chewed or suckedreleased in the mouth when chewed or sucked

Soft gels: used to encase liquid extracts, such Soft gels: used to encase liquid extracts, such as omega-3 fatty acids or vitamin Eas omega-3 fatty acids or vitamin E

Essential oils: fragrant, volatile plant oils used Essential oils: fragrant, volatile plant oils used for aromatherapy, bathing; not to be used for aromatherapy, bathing; not to be used internally unless specifically directedinternally unless specifically directed

American Herbal Products American Herbal Products Assoc Botanical Safety Rating Assoc Botanical Safety Rating SystemSystem

Class 1: herbs that can be safely Class 1: herbs that can be safely consumed when used appropriatelyconsumed when used appropriately

Class 2: herbs for which restrictions apply, Class 2: herbs for which restrictions apply, e.g. for external use only, not to be used e.g. for external use only, not to be used during pregnancy, nursing, etcduring pregnancy, nursing, etc

Class 3: herbs labeled “To be used only Class 3: herbs labeled “To be used only under the supervision of an expert under the supervision of an expert qualified in the appropriate use of this qualified in the appropriate use of this substance.”substance.”

Class 4: insufficient data for classificationClass 4: insufficient data for classification

Dietary Supplement Health and Dietary Supplement Health and Education Act of 1994 (DSHEA)Education Act of 1994 (DSHEA)

Defined dietary supplements as “a Defined dietary supplements as “a product intended to supplement the diet product intended to supplement the diet that bears or contains one or more of that bears or contains one or more of the following dietary ingredients: a the following dietary ingredients: a vitamin, a mineral, an herb or other vitamin, a mineral, an herb or other botanical, an amino acid, a dietary botanical, an amino acid, a dietary substance for use by man to substance for use by man to supplement the diet by increasing the supplement the diet by increasing the total daily intake, or a concentrate, total daily intake, or a concentrate, metabolite, constituent, extract, or metabolite, constituent, extract, or combinations of these incredientscombinations of these incredients

Reclassified botanicals as dietary Reclassified botanicals as dietary supplements, distinct from food or supplements, distinct from food or drugsdrugs

Dietary Supplement Health Dietary Supplement Health and Education Act of 1994 and Education Act of 1994 (DSHEA)(DSHEA) Plant extracts, enzymes, vitamins, Plant extracts, enzymes, vitamins,

minerals, hormonal products available minerals, hormonal products available without prescription may carry without prescription may carry “structure-function” claims“structure-function” claims

Cannot claim to prevent or cure Cannot claim to prevent or cure specific conditionsspecific conditions

Must display disclaimer, “This Must display disclaimer, “This statement has not been evaluated by statement has not been evaluated by the Food and Drug Administration. This the Food and Drug Administration. This product is not intended to diagnose, product is not intended to diagnose, treat, cure or prevent any disease.”treat, cure or prevent any disease.”

Required Labeling of Required Labeling of Dietary Supplements Dietary Supplements under DSHEAunder DSHEA Name (echinacea, for example) Name (echinacea, for example) Ingredient information Ingredient information Disclaimer: "This statement has not been Disclaimer: "This statement has not been

evaluated by the Food and Drug evaluated by the Food and Drug Administration. This product is not Administration. This product is not intended to diagnose, treat, cure or intended to diagnose, treat, cure or prevent any disease." prevent any disease."

Supplement Facts panel, which includes Supplement Facts panel, which includes serving size, amount and active ingredient. serving size, amount and active ingredient.

Name and address of manufacturer, packer Name and address of manufacturer, packer or distributor. or distributor.

Supplement Facts Supplement Facts PanelPanel

Dietary Supplement Dietary Supplement ClaimsClaims Health claim: describes the Health claim: describes the

relationship between a substance and relationship between a substance and a disease condition; FDA does not a disease condition; FDA does not approve, but must be notifiedapprove, but must be notified

Qualified health claim: based on Qualified health claim: based on emerging scientific evidence; must be emerging scientific evidence; must be approved by FDAapproved by FDA

Structure-function claim: most Structure-function claim: most common; does not claim to prevent common; does not claim to prevent disease, but a physiological effect is disease, but a physiological effect is noted, e.g. “increases blood flow to the noted, e.g. “increases blood flow to the heart.”heart.”

Labeling Under DSHEALabeling Under DSHEA

AllowedAllowed This product helps to This product helps to

increase blood flow to increase blood flow to the heart.the heart.

This product promotes This product promotes urinary tract healthurinary tract health

This product improves This product improves absent-mindedness. absent-mindedness.

This product reduces This product reduces stress and frustration stress and frustration

Not AllowedNot Allowed This product prevents This product prevents

heart diseaseheart disease This product prevents This product prevents

urinary tract urinary tract infections.infections.

This product reduces This product reduces risk of Alzheimer’s risk of Alzheimer’s Disease.Disease.

This product improves This product improves depression.depression.

Regulation of Dietary Regulation of Dietary SupplementsSupplements Dietary supplements are not subject to Dietary supplements are not subject to

the same standards as prescription or the same standards as prescription or over-the-counter drugsover-the-counter drugs

Manufacturers do not have to prove Manufacturers do not have to prove their products are safe or effective their products are safe or effective before they put them on the marketbefore they put them on the market

FDA can pull supplements proven to be FDA can pull supplements proven to be dangerous, but only after the fact; it is dangerous, but only after the fact; it is up to the FDA to make its caseup to the FDA to make its case

Regulation of Dietary Regulation of Dietary Supplements: Supplements: MedwatchMedwatch The FDA’s Medwatch system can The FDA’s Medwatch system can

be used to report possible be used to report possible adverse reactions to dietary adverse reactions to dietary supplements supplements http://www.fda.gov/medwatch/report/hcp.htmhttp://www.fda.gov/medwatch/report/hcp.htm

Examples of FDA Examples of FDA WarningsWarnings

January, 2004: FDA warns consumers not January, 2004: FDA warns consumers not to feed their babies “Better than Formula to feed their babies “Better than Formula Ultra Infant Immune Booster 117" being Ultra Infant Immune Booster 117" being sold over the internet as a dietary sold over the internet as a dietary supplementsupplement

February, 2002: Consumers warned to February, 2002: Consumers warned to stop using the products PC SPES and SPES stop using the products PC SPES and SPES capsules because they contain undeclared capsules because they contain undeclared prescription drug ingredients that could prescription drug ingredients that could cause serious health effects cause serious health effects

Examples of FDA Examples of FDA WarningsWarnings November, 2001: consumers warned to November, 2001: consumers warned to

immediately stop use of LipoKinetix, a immediately stop use of LipoKinetix, a weight loss product; implicated in a weight loss product; implicated in a number of serious liver injuries. number of serious liver injuries.

March, 2002: consumers advised of risk March, 2002: consumers advised of risk of severe liver injury associated with of severe liver injury associated with the use of kava-containing dietary the use of kava-containing dietary supplements to ease stress and anxiety. supplements to ease stress and anxiety.

February, 2004: issues final rule February, 2004: issues final rule forbidding sale of ephedra-containing forbidding sale of ephedra-containing weight loss products; associated with weight loss products; associated with significant adverse health effects significant adverse health effects including heart attack and stroke including heart attack and stroke

Dietary Supplement and Dietary Supplement and Nonprescription Drug Nonprescription Drug Consumer Protection Act 12/06Consumer Protection Act 12/06

Requires manufacturers and distributors of Requires manufacturers and distributors of dietary supplements and OTC drugs to dietary supplements and OTC drugs to report all serious adverse events to FDAreport all serious adverse events to FDA

Requires manufacturers to keep all adverse Requires manufacturers to keep all adverse event records, serious and non-serious, for event records, serious and non-serious, for six years; allows FDA to inspect these six years; allows FDA to inspect these records. records.

Sets a 15-day time limit for manufacturers Sets a 15-day time limit for manufacturers to give FDA the serious reports they to give FDA the serious reports they receive. receive.

Cautions Regarding Cautions Regarding Dietary SupplementsDietary Supplements There may be a discrepancy There may be a discrepancy

between the ingredients on the label between the ingredients on the label and what’s insideand what’s inside

This is especially true of herb This is especially true of herb mixtures, such as Chinese herbsmixtures, such as Chinese herbs

The dosage of the “active The dosage of the “active ingredient” in herbals can vary ingredient” in herbals can vary widely depending on the variety of widely depending on the variety of plant, where it’s grown, climate, etc.plant, where it’s grown, climate, etc.

Read the Dietary Read the Dietary Supplement Label and Supplement Label and Verify….Verify…. Complete botanical name of the Complete botanical name of the

product (make sure it is the right product (make sure it is the right botanical)botanical)

The part of the plant used to make the The part of the plant used to make the product; it should be the part that product; it should be the part that contains the active componentscontains the active components

The concentration of the botanical and The concentration of the botanical and if it is appropriate, neither too weak or if it is appropriate, neither too weak or two strongtwo strong

Debusk, RM. A practical guide to herbal supplements for nutrition practitioners. Top Clin Nutr 16:53, 2001

Read the Dietary Read the Dietary Supplement Label and Supplement Label and Verify….Verify…. The daily dosage needed to obtain the The daily dosage needed to obtain the

desired effectdesired effect The list of ingredients used to identify The list of ingredients used to identify

fillers, potential allergensfillers, potential allergens Lot numberLot number Expiration dateExpiration date Recognized seal of approval (Good Recognized seal of approval (Good

Housekeeping, USP, Consumerlab)Housekeeping, USP, Consumerlab) Compare prices: prices vary widelyCompare prices: prices vary widely

Debusk, RM. A practical guide to herbal supplements for nutrition practitioners. Top Clin Nutr 16:53, 2001

Evaluating Dietary Evaluating Dietary SupplementsSupplements Obtain unbiased evaluative information Obtain unbiased evaluative information

from resources like Supplement Watch from resources like Supplement Watch and Consumer Lab and Consumer Lab www.consumerlab.com www.consumerlab.com

Encourage patients to purchase Encourage patients to purchase supplements from well-known supplements from well-known manufacturersmanufacturers

ConsumerLab Study of ConsumerLab Study of 20 Multivitamins20 MultivitaminsVitamins that failed:Vitamins that failed: The Vitamin Shoppe Multivitamins Especially for The Vitamin Shoppe Multivitamins Especially for

women: Contaminated with leadwomen: Contaminated with lead — — Hero Nutritionals Yummi Bears: Had twice the Hero Nutritionals Yummi Bears: Had twice the

labeled amount of vitamin Alabeled amount of vitamin A — — Nature's Plus Especially Yours for Women: Took Nature's Plus Especially Yours for Women: Took

twice as long as allowed to disintegratetwice as long as allowed to disintegrate — — AARP Maturity Formula: Took nearly twice as AARP Maturity Formula: Took nearly twice as

long as allowed to disintegratelong as allowed to disintegrate — — Eniva VIBE: Only 54 percent of claimed vitamin Eniva VIBE: Only 54 percent of claimed vitamin

AA — — Pet-Tabs Complete Daily Vitamin-Mineral Pet-Tabs Complete Daily Vitamin-Mineral

Supplement for Dogs: Contained leadSupplement for Dogs: Contained lead– Accessed at MSNBC Accessed at MSNBC http://www.msnbc.msn.com/id/16655168/http://www.msnbc.msn.com/id/16655168/– Released 1/2007Released 1/2007

ConsumerLab Study of ConsumerLab Study of 20 Multivitamins20 Multivitamins

Vitamins that passed:Vitamins that passed: Centrum SilverCentrum Silver Member's Mark Complete MultiMember's Mark Complete Multi One A Day Women'sOne A Day Women's Flintstones CompleteFlintstones Complete

http://www.msnbc.msn.com/id/1665516http://www.msnbc.msn.com/id/16655168/8/ January, 2007 January, 2007

Tips for Picking a Tips for Picking a Multivitamin from CSPIMultivitamin from CSPI Choose well-known mainstream brands by Choose well-known mainstream brands by

companies that have a lot at stake.companies that have a lot at stake. Buy from large, trusted retailers, not unknown Buy from large, trusted retailers, not unknown

sellers on the Internet.sellers on the Internet. Look on the bottle for a stamp from USP, NSF or Look on the bottle for a stamp from USP, NSF or

ConsumerLab.com. While the stamp doesn't ConsumerLab.com. While the stamp doesn't guarantee the product is safe and effective, it guarantee the product is safe and effective, it does indicate that the manufacturer has does indicate that the manufacturer has submitted the product for testing to show that it submitted the product for testing to show that it contains what is stated on the label.contains what is stated on the label.

Don’t spend a fortune on vitamins. Pricey Don’t spend a fortune on vitamins. Pricey products toting all sorts of "extras" aren't products toting all sorts of "extras" aren't necessary and may be trouble.necessary and may be trouble.

Center for Science in the Public Interest accessed at Center for Science in the Public Interest accessed at http://www.msnbc.msn.com/id/16655168/http://www.msnbc.msn.com/id/16655168/ 1/07 1/07

Evaluating Dietary Evaluating Dietary SupplementsSupplementsUnited States Pharmacopeial Convention United States Pharmacopeial Convention

(USP) Dietary Supplement Verification (USP) Dietary Supplement Verification Program (DSVP)Program (DSVP)

Certification mark (Certification mark (USP®)USP®) indicates that indicates that the product contains the dietary supplement the product contains the dietary supplement listed on the label in the stated amount and listed on the label in the stated amount and that the product is manufactured properlythat the product is manufactured properly

Does not speak to the safety or efficacy of Does not speak to the safety or efficacy of the ingredients, only to good manufacturing the ingredients, only to good manufacturing practicespractices

CAM Providers: CAM Providers: MDs/DOsMDs/DOs Over 1/3 of medical schools offer Over 1/3 of medical schools offer

instruction in alternative medicineinstruction in alternative medicine More than half of family More than half of family

physicians in the US regularly physicians in the US regularly prescribe alternative treatments prescribe alternative treatments or have used themselvesor have used themselves

CAM Providers: RDsCAM Providers: RDs

Nutrition in Complementary Care DPG, Nutrition in Complementary Care DPG, a subunit of the American Dietetic a subunit of the American Dietetic Association Association http://www.complementarynutrition.orhttp://www.complementarynutrition.org/g/

Some RDs are incorporating Some RDs are incorporating counseling about CAM into their counseling about CAM into their practicespractices

CAM Providers: OtherCAM Providers: Other

RNsRNs RPhRPh ND: naturopath providerND: naturopath provider DC: chiropractorDC: chiropractor OMD: oriental medical doctorOMD: oriental medical doctor AccupuncturistAccupuncturist Massage TherapistMassage Therapist HypnotherapistHypnotherapist HerbalistHerbalist

Tips for Patients: Tips for Patients: Evaluating CAM Evaluating CAM ProvidersProviders Check for licensing, education, Check for licensing, education,

accreditation of provideraccreditation of provider Check for complaints (BBB, Board Check for complaints (BBB, Board

of Health, Attorney General’s of Health, Attorney General’s office, patient support groups)office, patient support groups)

Speak with the practitioner in Speak with the practitioner in person, evaluate facilities and person, evaluate facilities and neighborsneighbors

Trends in Use of CAM Trends in Use of CAM by US Adults 1997-by US Adults 1997-20022002 The number of Americans using The number of Americans using

CAM remained stable at 72 millionCAM remained stable at 72 million 50% 50% ↑ in use of herbal ↑ in use of herbal

supplements, from 12.1% in 1997 supplements, from 12.1% in 1997 to 18.6% (38 million). to 18.6% (38 million).

Yoga increased 40%, from 3.7% to Yoga increased 40%, from 3.7% to 5.1% (10 million adults)5.1% (10 million adults)

Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in the use of complementary

and alternative medicine by US adults: 1997-2002. Alternative Therapies in Health and Medicine; 1; 1: 2005.

Trends in Use of CAM Trends in Use of CAM by US Adults 1997-by US Adults 1997-20022002 Use of CAM therapies including Use of CAM therapies including

acupuncture, biofeedback, energy acupuncture, biofeedback, energy healing, hypnosis remained essentially healing, hypnosis remained essentially unchangedunchanged

Use of homeopathy, high-dose vitamins, Use of homeopathy, high-dose vitamins, chiropractic, and massage therapy chiropractic, and massage therapy declined slightlydeclined slightly

Increased use of herbal medicine Increased use of herbal medicine practitioners among those who use herbs practitioners among those who use herbs (5% to 15%)(5% to 15%)

Commonly Used Commonly Used BotanicalsBotanicals EchinaceaEchinacea GarlicGarlic GingerGinger Gingko bilobaGingko biloba GinsengGinseng

HawthornHawthorn Milk thistleMilk thistle Saw palmettoSaw palmetto St. John’s wortSt. John’s wort ValerianValerian

EchinaceaEchinacea

Source: Source: Purple cornflowerPurple cornflower Indication: Indication: Stop or moderate Stop or moderate

colds colds or fluor flu

Action: Action: Macrophages and Macrophages and their their secretionssecretions

Cautions: Cautions: Avoid if immune Avoid if immune system is system is hampered and do not hampered and do not use use continuallycontinually

GarlicGarlic

Source: Source: Garlic plantGarlic plant Indication: Indication: Lower serum cholesterol Lower serum cholesterol

and and triglyceridestriglycerides Action: Action: Chewing or crushing Chewing or crushing

activates several sulfur-activates several sulfur-containing compoundscontaining compounds

Cautions: Cautions: Allergies, GI symptoms, Allergies, GI symptoms, interaction with interaction with

anticoagulant anticoagulant drugsdrugs

GingerGinger Source: Source: Root of ginger plantRoot of ginger plant Indication: Indication: For nausea and For nausea and

vomiting of vomiting of pregnancy and motion pregnancy and motion sickness; anti-sickness; anti-

inflammatoryinflammatory Action: Action: Volatile oils in the Volatile oils in the

rhizome, rhizome, called gingerols; may act called gingerols; may act on on serotonin receptors in serotonin receptors in the the ileumileum

Cautions: Cautions: Interaction with anti-Interaction with anti-coagulant, antihypertensive, coagulant, antihypertensive, glucose-loweringglucose-lowering drugsdrugs

Gingko BilobaGingko Biloba Source: Source: Gingko treeGingko tree Indication: Indication: Improved blood Improved blood

circulation; circulation; used to treat age-related used to treat age-related mental function decline r/t mental function decline r/t cerebrovascular insufficiency cerebrovascular insufficiency

Action: Action: Flavone glycosides have Flavone glycosides have antioxidant effect, inhibit antioxidant effect, inhibit platelet platelet aggregationaggregation

Cautions: Cautions: Class 2d botanical; may Class 2d botanical; may potentiate MAO inhibitors; GI potentiate MAO inhibitors; GI complaints, headache, allergycomplaints, headache, allergy

GinsengGinseng

Source: Source: Ginseng plant (radish-like Ginseng plant (radish-like herb) rootherb) root

Indication: Indication: General improvement General improvement from from the steroidlike the steroidlike componentscomponents

Action: Action: Ginsenosides, enhanced Ginsenosides, enhanced immune function; studies immune function; studies mixedmixed

Cautions: Cautions: Class 2d botanicals; Class 2d botanicals; contraindicated in persons contraindicated in persons with with hypertension; hypertension; overstimulation, GI overstimulation, GI distressdistress

HawthornHawthorn

Source: Source: Native European tree; Native European tree; leaves, blossoms, fruitleaves, blossoms, fruit

Indication: Indication: Improve blood flow in Improve blood flow in circulatory disorderscirculatory disorders

Action: Action: Dilates coronary Dilates coronary vessels; vessels; strengthens heart strengthens heart contractions and ratecontractions and rate

Cautions: Cautions: Class 1 botanicalClass 1 botanical

Saw PalmettoSaw Palmetto

Source: Source: Palm tree Palm tree Indication: Indication: Reduce incidence of BPHReduce incidence of BPH Action: Action: Action unclear; research Action unclear; research

results mixedresults mixed Cautions: Cautions: Contains Contains

phytoestrogens, phytoestrogens, could interfere could interfere with estrogen with estrogen therapy, oral therapy, oral contraceptives, contraceptives, other other phytohormone-phytohormone- containing herbscontaining herbs

St. John’s WortSt. John’s Wort

Source: Source: Perennial herbPerennial herb Indication: Indication: Mild to moderate depressionMild to moderate depression Action: Action: Hypericin and hyperforin in Hypericin and hyperforin in

flowering tops; reuptake of flowering tops; reuptake of neurotransmittersneurotransmitters

Cautions: Cautions: Rated as 2d botanical; may Rated as 2d botanical; may potentiate pharmaceutical potentiate pharmaceutical MAOIs; interact with other MAOIs; interact with other antidepressives; antidepressives;

photosensitivityphotosensitivity

ValerianValerian

Source: Source: Perennial herb; active Perennial herb; active element element in roots and rhizomesin roots and rhizomes

Indication: Indication: Minor tranquilizer and Minor tranquilizer and sleep sleep aid; fewer side effects aid; fewer side effects than than medicationsmedications

Action: Action: Volatile oils (bornyl Volatile oils (bornyl acetate acetate and valerenic acid) and valerenic acid) mode of mode of action GABA bindingaction GABA binding

Cautions: Cautions: Class 1 botanical; abrupt Class 1 botanical; abrupt withdrawal may withdrawal may

precipitate precipitate symptomssymptoms

Milk ThistleMilk Thistle

Source: Source: Herb in daisy family; seeds Herb in daisy family; seeds are highest in silymarinare highest in silymarin

Indication: Indication: Hepatoprotective; used to Hepatoprotective; used to treat liver damage in treat liver damage in

cirrhosis, cirrhosis, hepatitis, fatty infiltrationhepatitis, fatty infiltration Action: Action: Silymarin stimulates protein Silymarin stimulates protein

synthesis, antioxidant; synthesis, antioxidant; shown shown to be moderately effectiveto be moderately effective

Cautions: Cautions: Class 1 botanical; mild Class 1 botanical; mild laxative effect; allergieslaxative effect; allergies

Working with Clients Working with Clients who Use CAMwho Use CAM Most clients will not tell their allopathic Most clients will not tell their allopathic

(mainstream medicine) providers (mainstream medicine) providers about CAM use, unless askedabout CAM use, unless asked

Establish a rapport with clientsEstablish a rapport with clients Be non-judgemental; assume role of Be non-judgemental; assume role of

coachcoach Ask clients to bring all prescription, Ask clients to bring all prescription,

OTC, and dietary supplements with OTC, and dietary supplements with them to their visitthem to their visit

Debusk RM. Integrative medicine and phytotherapy. In Krause, p. 491-492.

For Each SupplementFor Each Supplement

Ask client what he/she hopes to Ask client what he/she hopes to achieve by taking itachieve by taking it

Discuss whether the formulation is Discuss whether the formulation is appropriate to achieve the client’s appropriate to achieve the client’s health goalshealth goals

Discuss whether dosage taken has Discuss whether dosage taken has been found to be safe and effective in been found to be safe and effective in clinical trialsclinical trials

Review quality of the particular Review quality of the particular preparation and how to evaluate preparation and how to evaluate

Debusk RM. Integrative medicine and phytotherapy. In Krause, p. 491-492.

For Each SupplementFor Each Supplement Discuss any known safety or Discuss any known safety or

contraindication concernscontraindication concerns Review potential or known interactions Review potential or known interactions

between each supplement and between each supplement and prescription or OTC preparations, other prescription or OTC preparations, other dietary supplements, and foodsdietary supplements, and foods

Instruct client to use dosage commonly Instruct client to use dosage commonly recommended and instructions for recommended and instructions for where to obtain credible informationwhere to obtain credible information

Debusk RM. Integrative medicine and phytotherapy. In Krause, p. 491-492.

For Each SupplementFor Each Supplement

Recommend a low starting Recommend a low starting dosage, even lower than that dosage, even lower than that commonly recommended and commonly recommended and evaluate responseevaluate response

Use this as an opportunity to Use this as an opportunity to teach consumers analytical skills teach consumers analytical skills that will be useful in managing that will be useful in managing their own health.their own health.

Debusk RM. Integrative medicine and phytotherapy. In Krause, p. 491-492.

Working with Clients Working with Clients Who Use CAMWho Use CAM It is the responsibility of health It is the responsibility of health

professionals to ask clients about professionals to ask clients about use of CAM and to be familiar with use of CAM and to be familiar with commonly-used therapiescommonly-used therapies

Nutrition professionals can take Nutrition professionals can take the same evidence-based the same evidence-based approach to CAM as to any other approach to CAM as to any other therapy or medical interventiontherapy or medical intervention

Links for Integrative Links for Integrative Medicine InformationMedicine Information Intellihealth Index of Herbal Medicines and Intellihealth Index of Herbal Medicines and

SupplementsSupplementshttp://www.intelihealth.com/IH/ihtIH/WSIHW0http://www.intelihealth.com/IH/ihtIH/WSIHW000/8513/31402.html00/8513/31402.html

Herb Med: An interactive electronic herb Herb Med: An interactive electronic herb database. database. http://http://www.herbmed.orgwww.herbmed.org//

Rosenthal Center Botanical Medicine Rosenthal Center Botanical Medicine Information Resources (Columbia University)Information Resources (Columbia University)http://http://www.rosenthal.hs.columbia.edu/Botanicals.htwww.rosenthal.hs.columbia.edu/Botanicals.htmlml

National Institutes of Health National Center National Institutes of Health National Center for Complementary and Alternative Therapyfor Complementary and Alternative Therapyhttp://http://nccam.nih.govnccam.nih.gov//

SummarySummary

Identify use of herbs and Identify use of herbs and botanicals.botanicals.

Monitor for side effects.Monitor for side effects. Document for records.Document for records. Discuss with physician.Discuss with physician.