Download Vitamins & Minerals

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Herbs & Supplements
Did you remember to take
your Gingko today ?
Robert Baldor, MD
Professor
Family Medicine & Community Health
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Why patients use CAM
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38% of US/$34 billion out-of-pocket in 2007
Arthritis/Back/Neck/Joint pain
Anxiety
Cholesterol management
URIs
Headache/Migraine
Insomnia
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A Clinician’s Perspective
• What’s available
• Efficacy
• Safety
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Herbal Therapies
(Top Dozen)
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Gingko biloba
St John’s Wort
Ginseng
Garlic
Echinacea
Saw Palmetto
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Kava Kava
Valerian
Soy
Evening Primrose
Grape seed
Milk Thistle
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Gingko Extracts
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Ancient Chinese herbal treatment
Maidenhair tree leaves
Effects from flavonoids - antioxidant
Reduces capillary fragility, vasodilator
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Ginkgo Considerations
• Recommended to stabilize cognition in
Alzheimer's or multi-infarct dementia;
improves walking with claudication
• 120-240 mg BID, TID
• Appears safe
• Avoid with anticoagulants
(2002 Cochrane)
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Marketed For ...
• Memory enhancement
• Improved concentration
• No evidence for improved
memory/concentration in normal,
healthy individuals (NEJM 2002)
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St. John’s Wort
• Flowering plant (H. perforatum)
• Hypericin, a naphthodianthrone is the main
active ingredient
• Inhibits neurotransmitter uptake of serotonin,
norepinephrine, & dopamine
• Binds to GABA receptors
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St. John’s Wort
• Outsells Prozac in Germany 7:1
• Meta-analysis - appears effective as low
doses of standard antidepressants
• Phototoxicity
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Depression
Consumers Report 2004
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Ginseng
• From genus panax (panacea!)
• An adoptogen - no studies compared to
stimulants such as caffeine
• Considered safe
• Siberian Ginseng
– An abundant Russian herb thought to have the
same properties as Ginseng
– No published studies
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The wonder herb . . .
• Ginseng is expensive - study of 54 products 85% contained little or no ginseng, but ….
varying amounts of caffeine!
• Glacial Tropical Citrus Vitamin Water
21 mg of caffeine – Coke has 24 mg!
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Red Bull…
• Taurine (essential amino acid) 1000mg
• Glucuronolactone (conjugates with toxic
metabolites for excretion) 600 mg
• B complex vitamins
• Caffeine 80 mg (24 gms in Coke)
• Sugar 27 grams (39 gms in Coke)
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• B Vitamins
– Niacin: 30 milligrams, or 150% of the RDV
– Vitamin B6: 40 milligrams, or 2,000% of RDV
– Vitamin B12: 0.5 milligrams , or 8,000% of RDV
and……
– As much caffeine as a cup of premium coffee
• A cup (8oz) of Starbucks has 180mg of caffeine
Garlic (allium sativum)
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Organosulfer compounds
May block carcinogens in food
Garlic extract - decreases cholesterol 7%
Available in ‘odor free’ capsules
• Active agent (allium) is odoriferous
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Long regarded to deter vampires
• Norwegian experiment with leeches (lack of vampires)
• Garlic-smeared hand preferred in 66% of time
• Leeches attached in 14.9 secs vs 44.9 secs when going
to the non-garlic hand (p < 0.05)
• The traditional belief that garlic can deter vampires is
probably wrong
• The reverse may in fact be true
Tidsskr Nor Laegeforen. 1994 Dec 10;114(30):3583-6.
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Echinacea
• For Rx of colds ($100 million in sales)
• Appears to alleviate some cold symptoms no evidence for cure
• 1998 randomized trial showed no ability to
prevent colds (JFP 1999)
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Zinc & Colds
• Inhibits rhinovirus in tissue culture
• Meta-analysis showed no conclusive evidence for
reducing colds (Arch IM 1997)
• Controlled trial of lozengers - ineffective & side
effects - taste, N&V (JAMA 1998)
• Randomized blinded trial of nasal gel – decreased
length of cold by 2 days (ENT J 2000)
• Improved Rx vs. antibiotics ?
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Saw Palmetto
• Appears safe and effective for BPH,
comparable to finasteride (Proscar)
• Inhibits the 5a reductase conversion of
testosterone to dihydrotestosterone
(a prostate growth stimulator)
• 160 mg bid or 320 mg qd
JAMA1998; AFP2003
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Anxiolytics
GABA Binding Activity
• Valerian (insomnia)
• Kava kava (anxiety)
• Chamomile (insomnia)
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Valerian
• Some efficacy for insomnia
• Unclear evidence for anxiety
• Appears safe, maybe helpful to wean from
benzodiazepines dependence
• 300 - 600 mg before bedtime or as tea (2-3 gm
of dried root)
AFP 2003
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KAVA & Hepatotoxicity
• 70 reports of kava induced liver failure, with 4
deaths and 7 liver transplants
• FDA 2002 advisory – avoid kava if having or at
risk for liver disease
• Last year UK banned Kava sales
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Phytoestrogens for Menopause
• Plant compounds resembling estradiol
• Isoflavones most potent
• Supplements of unclear benefits v. foods - Soy,
Tofu, Black Cohosh
• Consider for mild menopausal Sx
• Reports of Black Cohosh induced hepatitis
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Relief of Hot Flashes
Consumers Report 2004
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Milk Thistle
• Flavonoid complex called silymarin
• Used for improving liver function in hepatitis,
cirrhosis
• Meta- analysis – appears safe but no clear
benefit….
Am J Med 2002
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“Not much - just flushing out my arteries.”
The NewYorker
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What about Red Wine?
• ‘The French paradox’ – low incidence of CVD – but a
relatively high fat diet.
• Grapes contain flavonoids (resveratol), potent
antioxidants - ? account for positive effects
• Red wine has 160ug/oz; peanuts 70 ug/oz
• Grape juice is not fermented –negligible amounts
• No enough evidence to conclude that red wine is
more effective than other alcoholic bevearges in
lowering CVD risk
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“It’s a B-complex. Didn’t they used to put chocolate on the pillow?”
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Chocolate (flavonoids)
• 1 oz has as much flavonoids as 6 apples, 5
cups of tea or 2 glasses of red wine
• Flavonoids reduce platelet aggregation
• Decreased platelet activation 6 hours after
eating chocolate
– Didn’t measure glucose or lipid levels (MARS funded)
• Recent meta-analysis dark cocoa products
reduce BP 5/2 mmHg (AJH, 2010)
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Ginger (zigiber officinale)
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Used for centuries to treat nausea
Post-op nausea, motion & sea sickness
Chemotherapy results disappointing
Commonly used but not recommended for
pregnancy (bleeding, miscarriage)
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“Michael has had an interesting side-effect from taking St. John’s Wort”
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FDA Approval
• Drugs must be safe and effective
• Average $230 million & 12 years
• No patent to recoup costs for herbs
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Dietary Supplement Act Of 1994
• Applies to ‘dietary supplements’
– vitamins, minerals, herbs, natural substances
• Health claims not specified on label
• FDA must prove unsafe before removing
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Health Foods?….L-Trypthophan
• An amino acid - assumed safe
• Used for insomnia
• Eosinophilia myalgia syndrome developed
– 38 deaths!!
• Banned by FDA in 1990
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FDA Concerns ….
• Over 2000 reports of adverse effects in 2009
• No manufacturing oversight:
– 1/3rd of supplements <50% of stated ingredients
(Ginseng products only contain caffeine)
– Niacin product contained 10x safe level
( GI distress, hepatic damage, MI)
• Proposed rule to prevent the sale of supplements
that are sub- or super- potent, that contain drugs, or
contaminants (i.e. bacteria, pesticides, glass, lead)
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“Something from the supplement cart?”
The NewYorker
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Common Supplements
• Glucosamine/
chondroitin
• CoQ-10
• Melatonin
• Amino Acids
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Fish Oils/omega FA
DHEA
Acidophilus
Chromium
Sports enhancement
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Glucosamine & Chondroitin
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Glucosamine (crab shell chitin)
Chondritin (cow cartilage)
The ‘raw materials for new cartilage’
Evidence for pain & disability relief in
osteoarthritis, comparable to ibuprofen &
acetaminophen
• Safe – few side effects
Cochrane Review 2005
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Consumers Report 2004
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Coenzyme Q10
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Fat soluble vitamin
Involved in mitochondrial oxidation producing ATP
Some anti-oxidant properties
In CHF, cardiac tissues under ↑’d oxidative stress
w/decreased tissue levels of Q10
Approved in Japan since 1974 to treat CHF
Some evidence for benefit in Parkinson’s &
mitochondrial diseases
200mg qday lower BP 16/10 mmHG
Safe but expensive (50-1200 mg/day)
AFP 2005
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Melatonin
• Modified amino acid (tryptophan)
• Released from pineal gland by diminishing
light levels
• Role in humans not fully elucidated
• Small, conflicting sleep studies
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Melatonin for Sleep
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Induces sleep if plasma levels are low
Shift workers
Jet Lag
0.1 – 10 mg qhs
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Insomnia
Consumers Report 2004
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Fish Oils & Omega 3 fatty acids
• Fish oil supplements supported by RCTs
– Lower triglycerides
– Reduce CAD and stroke risk with known CVD disease
– Lowers BP slightly (10/4 mmHg)
• No evidence for primary prevention
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DHEA (Dihydroepiandrosterone)
• Produced by adrenals, unclear role outside of
Rx for adrenal insufficiency
• Converted to estrogens and testosterone
• Plasma levels decline with age
• Schedule II - an anabolic steroid
• DHEA supplements are Yam extracts, not
converted to DHEA
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Marketed as...
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Anti-aging
Hirsutism & deeping voice seen
Concern for prostate or breast cancer
Series of studies 1995 - 1998 in J. Clin
Endocrinology - some perceived sense of well
being, but no obvious benefits
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Acidophilus - a probiotic
(organism used medically)
• Lactobacillus acidophilus - bacteria that live in the
intestine and vagina
• Good evidence to support L. acidophilus vaginal
suppositories to Rx bacterial vaginosis
• Some studies suggest eating yogurt enriched with
L. acidophilus may be similarly beneficial
• Benefit in colic treatment ?
• Marketed to improve digestion, no clear evidence
of benefit
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Chromium for weight loss ??
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Essential trace mineral - Insulin cofactor
China & Israeli studies for DM treatment
Diabetics not chromium deficient
Mixed results from a variety of studies
Safe up to 1000mcg/day
The Medical Letter 2006
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Marketed To....
• Loose fat
• Boost energy
• ... no published
support for such
effects
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Weight loss ….Health Foods??
• Metabolife contains Ma Hung
• Bitter orange extract contains synephrine
• Chomper is a natural laxative, contains
digitalis - induces arrhythmias
• Tryptophan & phenylalanine - amino acids ?
efficacy
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Health Foods?….
• Associated Press 5/22/00 …Herbalife
Founder Mark Hughes dies at the age
of 44 of ...
.. Natural causes!
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Ma-Huang or Ephedra
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MetaboLife, Herbal Ecstasy
Contains Ephedrine
Linked to 155 deaths & strokes
Banned by NFL, NCAA after heat stroke
deaths while using the supplement
• FDA Ban in 2004
• Ban overturned, FDA overstepped authority
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“I’m taking you off wine, women and song
and putting you on broccoli”
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A Clinician’s Perspective .....
varying approaches
• Acceptance - ask about & tolerate use of
herbal products by patients
• Endorsement - accept patient use of natural
products as initial therapy, monitor for effects
• Integration - prescribe herbs with advice on
use, dosing, etc.
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Resources
• www.NaturalStandard.com
• NIH CAM Center (nccam.nih.gov)
• NIH Office of Dietary Supplements
(odp.od.nih.gov/ods/)
• Food & Drug Administration (fda.gov)
• www.consumerlab.com
• Medical Letter
• Published studies
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Current Consensus
…the best nutritional strategy for promoting
optimal health & reducing the risk of chronic
disease is to choose wisely from a wide variety
of foods, with emphasis on anti-oxidant rich
fruits, vegetables & whole grains .
AHA 2002 ADA 2002
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Best Advice . . .
• Buy from well-known national companies
• Label includes:
– Herbs common & scientific name
– Manufacture’s name & address
– Dosing guidelines
– Potential side effects
– Batch & Lot number and expiration date
• US Pharmacopoeia verification seal
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A Final Thought…..
• The Japanese eat very little fat and suffer fewer heart
attacks than the British or Americans
• However, the French eat a lot of fat and also suffer fewer
heart attacks than the British or Americans
• The Germans drink very little red wine and suffer fewer
heart attacks than the British or Americans
• While the Italians drink excessive amounts of red wine &
suffer fewer heart attacks than British or Americans
• Conclusion: Eat and drink what you like. Speaking English is
apparently what kills you!
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