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Complementary and Alternative Medicine, Dietary Supplements, and Medications CAM- Where is it? A 14 yr old athlete with moderate, persistent asthma comes to clinic. He has an asthma action plan and has been adherent with his controller medication. Now he wants to try a breathing technique (Buteyko) so he can “get off” his meds. A 3 yr old comes to the clinic for a well-child check-up. On exam you find a right otitis media. She is asymptomatic and you recommend watchful waiting. The parents would like to try a homeopathic remedy because they had heard that homeopathy worked better than placebo for children with an ear infection. Answer: Everywhere CAM- every where you look CAM in the News Dying Woman Loses Marijuana Appeal March 14, 2007 Evidence Mounts That Coping Skills Can Boost HIV Survival March 14, 2007 Omega-3 in Fish Oils Might Ease Depression March 7, 2007 Insomnia: Alternative Medicine Popular • 1.6 Million Adults Use Complementary Or Alternative Medicine For Insomnia September 2006 Jennifer Aniston Atkins diet Madonna Yoga, herbalism Pamela Anderson Homeopathy Sir Paul McCartney Alexander Boris Becker Homeopathy Demi Moore Lake algae Cherie Blair Acupuncture, Kate Moss Acupuncture Tony Blair Homeopathy Martina Navratilova Homeopathy Dina Carroll Reflexology Olivia Newton-John Homeopathy Charles, Prince Magnet therapy Gwyneth Paltrow herbalism Cher Homeopathy Brad Pitt Atkins diet Cindy Crawford Homeopathy Sir Cliff Richard Ginseng Sheryl Crow Eskimo diet Sarah, Duchess of York Bioenergy Queen Elizabeth Homeopathy Arnold Schwarzenegger Breathing Jane Fonda Homeopathy Hugo Speer Yoga Richard Gere Breathing therapy Margaret Thatcher Ayurveda Whoopi Goldberg Homeopathy Uma Thurman Gem therapy Jerry Hall Homeopathy Tina Turner Homeopathy Geri Halliwell Yoga Kate Winslet Acupuncture Goldie Hawn Ayurveda Catherine Zeta-Jones Homeopathy Ernst MJA 2006; 185 (11/12): 680-681 Complementary and Alternative Medicine (CAM) Complementary and alternative medicine • A group of diverse medical and health care systems, practices, and products • Not considered part of conventional medicine • Some scientific evidence exists regarding CAM therapies • For most, questions of safety and efficacy persist Complementary medicine is used together with conventional medicine. Alternative medicine is used in place of conventional medicine. http://nccam.nih.gov/health/whatiscam/ Integrative or Holistic Medicine Integrative combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness. “Healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.” http://nccam.nih.gov/health/whatiscam/ http://www.integrativemedicine.arizona.edu/about2.html Major Classes of CAM Enhance the mind’s capacity to affect bodily function and symptoms Alternative medical systems Homeopathic Naturopathic Traditional Chinese and Ayurvedic treatments Mind-body interventions Chiropractice Osteopathy Massage Biologically -based therapies Dietary supp Herbs Foods Vitamins Natural substances Manipulative & body-based methods Energy therapies Biofield therapy Bioelectromagnetic therapy http://nccam.nih.gov/ CAM Utilization Reasons for using CAM: Consistent with patient’s and families values : natural, and empowering CAM providers are “patient-centered”, dedicated to promoting health. Conventional therapies are perceived to be emotionally or spiritually without benefit Conventional therapies are not effective or are associated with side effects. CAM use is a circular: usage determines number of CAM practitioners CAM Treatments Commonly Thought Effective in Pediatrics Effectiveness uncertain • Acupuncture for asthma • Acupuncture for hay fever • Acupuncture for rheumatoid arthritis • Chromium for diabetes • Echinacea for common cold • prevention or treatment • Evening primrose for eczema Effectiveness unlikely • Acupuncture for body weight reduction • Acupuncture for smoking cessation • Flower remedies for anxiety • Homeopathy for anxiety • Spinal manipulation for asthma • Spinal manipulation for infantile colic Conventional Medicine, Evidence? Most conventional physicians believe in unconventional medicine because it is not scientific What is evidence-based medicine? Treatment that will improve patient outcomes by well-designed, appropriately powered, randomized, controlled clinical trials. There is not good evidence (Grade A) that many of the commonly used therapies in conventional medicine are effective (ex: heparin, aspirin, and warfarin). The principal distinguishing characteristic of unconventional and conventional medicine therapies is the source of introduction. Conventional therapies are introduced by mainstream Western physicians and scientists, whereas most unconventional modalities are introduced by "outsiders." One of the reasons that most unconventional modalities are not evidence based is that the majority of them were introduced prior to the 20th Century Whole Medical Systems Complete systems of theory and practice that evolved independently Traditional systems of medicine that are practiced by individual cultures throughout the world • Includes traditional Chinese medicine, Ayurvedic medicine, homeopathy, naturopathy Biologically Based Practices Includes: botanicals, animal-derived extracts, vitamins, minerals, fatty acids, amino acids, proteins, whole diets, and functional foods • Dietary supplements are a subset of biologically based practices Biologically Based - Supplements What is a supplement? Regulated by FDA http://www.fda.gov • no requirements for FDA testing • manufacturers responsible for ensuring product safety • label requirements • safety alerts: http://www.cfsan.fda.gov/~dms/dswarn.html Energy Medicine Veritable - energy that can be measured • Includes sound, visible light, magnetism Putative – energy that has yet to be measured • human beings are infused with a subtle form of energy • Includes qi (ki in Japanese); doshas; prana, homeopathic resonance Energy Medicine - Acupuncture Few complications Scientific evidence? • post chemotherapy • management of nausea • pain relief NIH Consensus Statement (1997) • http://consensus.nih.gov/1997/1997Acu puncture107html.htm Manipulative and Body-Based Structures and systems of the body, including the bones and joints, the soft tissues, and the circulatory and lymphatic systems • Includes chiropractic manipulation, massage therapy, reflexology, rolfing, Alexander technique, Feldenkrais method Mind-Body Medicine Interactions among the brain, mind, body, and behavior The ways in which emotional, mental, social, spiritual, and behavioral factors can directly affect health • Includes relaxation, hypnosis, visual imagery, meditation, yoga, biofeedback, tai chi, group support, and spirituality Other CAM Therapies Aromatherapy Colonic Irrigation Therapeutic Touch EDTA Chelation Cupping Primordial Sound Meditation Evaluating Web Sites Accuracy Authority Bias Currency Coverage Clinical Trials and CAM Why are there so few CAM clinical trials? • Drug companies have to do studies to go on the market—supplement companies do not, so clinical trials sponsored by supplement companies are rare • Alternative treatments are often customized for a specific person. Clinical trials try to prove something works for most people. • Belief systems of some CAM practitioners do not agree with the idea of Western studies, so they do not participate • CAM has only recently become “legit” in the scientific community Dietary Supplements RUN THE WHOLE GAMUT!!! vitamins- C, E. minerals- Ca, Se amino acids-lysine fats- fish oil hormones- DHEA herbs- ginseng phytochemicals-garlic etc FDA Regulations Protect Consumers FDA regulates: Drugs are highly regulated by FDA Vitamins & minerals regulated as foods Supplements are considered safe until demonstrated to be hazardous by FDA Herbals & botanicals totally unregulated Who Benefits? Those at risk for developing nutritional deficiencies only! People with vit, mineral deficiency Vegans- vit D, B12 Pregnant women- folate Elderly persons- B12/folate People at risk of osteoporosis- Ca, vit D People at risk of losing blood- Fe People on restricted diets- vit, minerals Hormones HGH EPO BHCG Steroids Human Growth Hormone Normally secreted by the pituitary Normal function of GH is growth and development of every body system, including bone and muscle Can be stimulated by propanolol, vasopressin, clonidine, and levodopa Synthetic growth hormone Side Effects: Acromegaly (may be irreversible) Peripheral Neuropathy Coronary Artery Disease Cardiomyopathy Diabetes, Hypothyroidism, arthritis No available urine test available, but banned by NCAA and IOC Erythropoietin Hormone released by the kidneys in response to low Hct Stimulates RBC production from bone marrow Has recently been manufactured by recombinant DNA technique Can increase Hct in renal patients by up to 35%, lasting up to 7 months Used most by cyclists Blood Doping Induced Erythrocythemia: An increase in Hb following reinfusion of an athlete’s blood Goal: to increase the oxygencarrying capacity of Hb Has been used as far back as 1947 1984: seven US Olympic cyclists guilty Banned by IOC in 1985 Detection: Blood doping and Erythropoietin: banned by IOC No known urine test to detect Testing: Measured Hct >50 Measurement of serum Fe and Bilirubin to detect hemolysis after frozen PRBC transfusion Anabolic Steroids The ultimate ergogenic aid aka “Juice” Creates the Superhuman Athlete Testosterone derivatives (cholesterol) Produced in the adrenal/ testes Anabolic/Androgenic Steroids Anabolism - Constructive Catabolism - Destructive Anabolic effects : inc. skeletal mm mass anticatabolism Androgenic effects: secondary sexual characteristics - pubic hair, genital size No Pure Anabolic Steroids Desired Effects: Increase in strength Increase in weight Increase in aggressiveness Increased capability of sustaining repetitive, high intensity workouts Enhanced performance Side Effects: CV: MI - hypertension, inc. LDL, dec. HDL, cardiac hypertrophy, thrombosis Endocrine: virilization, testis atrophy, azospermia, priapism, prostatic hypertrophy/ CA, gynecomastia, erectile dysfct, libido Liver : peliosis hepatitis, hyperplasia, adenoma, no carcinoma, elevated LFTs MS: epiphyseal closure, inc. bone density, dec. tendon strength Side Effects (cont’d): Skin: acne, hirsuitism, striae, androgenic alopecia, inc. sebaceous glands Metabolic: hypernatremia, kalemia, phosphatemia, calcemia, “prediabetic” Psychiatric : aggressiveness, extreme mood swings - depression/ mania, dependence, other drug use, “Reverse Anorexia” Long Term - dec. life span Specific Side Effects Women (Virilzation): • Clitoril enlargement, Deepening of voice, Male pattern baldness, dec. breast size, libido Children: • premature closure of growth plate in long bones & thus “Prohormones” Androstenedione DHEA Androstenediol Norandrostenedione Norandrostendiol Effects: Benefits: Same as Testosterone • Increased energy • Enhanced recovery and growth from exercise • heightened sexual arousal and function • greater sense of well-being Plasma levels of testosterone increased from 140% to 330% of normal levels after 50mg and 100mg doses SE’s : Same as Testosterone Banned by IOC, NCAA, NFL Stimulants Caffeine Amphetamines Cocaine Ephedrine Amphetamines Have been used as far back as WWII when soldiers used them to delay fatigue First study in 1959 showed significant improvement in performance Available data suggest Amphetamines can improve performance in sports where speed, power and endurance are required Side Effects: Related to drugs’ effect on CNS: insomnia, instability, agitation and restlessness Confusion, paranoia, hallucinations Dyskinesias, especially in facial muscles Cardiac complications: HTN, arrhythmias GI disturbances Severe rebound of fatigue and depression after discontinuance Caffeine A Methylxanthine: same class as theophylline and theobromine Exerts its’ effects by: • Translocation of Calcium for more muscular availability • Increase in cAMP by inhibition of phosphodiesterase • Blockage of adenosine receptors, blocking the sedative properties of adenosine Caffeine (cont’d) Is banned by IOC and NCAA in large doses Legal limit = 15 micrograms / ml Equal to 6-8 cups of coffee at one sitting, with testing within 2-3 hours Beneficial most in endurance events, such as cycling Doses up to 5 mg / kg were required to see benefits. Doses of 17 mg/kg produce the maximum legal limit. Side Effects: Similar to s/e of other stimulants: • insomnia, irritability, nervousness • Tachcardia, arrthymias, and possibly death! Ephedrine What it is: Is a drug found in herbal products containing Ma haung, antiasthmatic medications, and many cold and cough products. Claims: Increases body fat loss What really does: Acts as a CNS stimulant, delays fatigue by sparing body glycogen reserves. Increase in B/p respiratory, heart rate, insomnia, and nervousness Max dose : 24 milligams per day!!!!!! Amino Acids Creatine L-Carnitine Choline Inosine HMB (B-OH-BMethylbutyrate) Amino Acids Essential amino acids: found in a balanced diet Recommended protein intake: 0.8 g /kg/day Athletes may benefit from up to 1.4 -2.4 g/kg/day Most beneficial for athletes on a poor diet, or vegetarians In endurance athletes, up to 10% of energy expenditure is from protein breakdown Creatine The Other 1/2 of the “Mark Mcguire Special” - The Creatine Craze - Sales expected to reach $200 million in 1998 Use has spread: • 13% of HS athletes • 80% of University of Nebraska football team • 50% of NFL players • Vast majority of Olympic sprinters, cyclists, and sprinters Creatine Methylguanidine-acetic acid - made from glycine, arginine & methionine Estimated Daily requirement: 2gms Available in meats and fish (1/2 EDR) Sold as Creatine Monohydrate Stored in Skeletal MM 2000 NCAA banned distribution in training rooms Pathophysiology: Energy Substrate for muscle contraction Creatine binds Phosphorus as substrate for formation of ATP (main source of energy of contraction) PCr also buffers Lactic Acid After PCr is depleted must resort to glycolysis for ATP production Net result: sustained muscular contraction, delayed fatigue Benefits: Improved performance in repeated bouts of high intensity strength work and sprints Single sprint activity results are equivocal Does not enhance endurance exercise More work with less lactic acid production No studies on competetion benefits 1998 ACSM meeting: 19/19 studies showed significant ergogenic benefit Side Effects: Muscle Cramping Diarrhea Dizziness Dehydration Biggest danger: getting “impure” creatine Significant WEIGHT GAIN common 2nd to water retention The Perfect Supplement? “The secret is to find something that is effective in improving performance, but not against the rules, and with no side effects” “…no clear evidence of harmful side effects of creatine use has emerged…”--The Physician and Sportsmedicine, June 1998 Long term effects of Creatine not yet studied: Concerns focus on effects to kidney, pancreas, and liver. HMB Metabolite of KIC (ketoisocaproate) which is a metabolite of leucine Leucine & KIC found to have anticatabolic effects decreased mm proteolysis, inc. lean mm mass, inc. strength no known side effects Choline Precursor for the neurotransmittor Acetyl Choline & the lipoprotein Lecithin (Phosphattidylcholine) choline depletion in marathoners no studies supporting Inosine Increases myocardial contractility no performance enhancement in runners/ cyclists Metals/ Minerals Chromium Magnesium Boron Vanadium Chromium Insulin Cofactor inc. AA uptake into mm cells increase mm mass, dec. body fat found in meats, grains, raisins, apples, & mushrooms SE’s: anemia, chromosomal damage, cognitive impairment & interstitial nephritis in excessive doses Magnesium Involved in ptn synthesis & mm contraction + effects on oxygen consumption & lactate production no change in performance Boron Originally thought to inc. testosterone levels not born out in studies Vanadium What it is: Non-essential trace mineral Claims: Anabolic effect, enhances insulin action What it does: No studies to show anabolic effect. Doses>10gms/day causes abd. Pain, cramps, green tongue,diarrhea, wt. loss Antioxidants Vitamins E & C potential damage from free oxygen radicals produced by lipid peroxidation in exercise exercise performance is not improved Herbs Ginseng Yohimbe Tribulus Terresteris Ma haung Ginseng What it is: A root from an Asian plant (panax ginseng). Claims: Enhanced performance. Improved recovery rate. What it really does: Acts as an adaptogen- may boost immune system and protect cells. May cause insomnia, and should not be used if B/p is elevated. Dose: 100-200mg per day used occ.2-3 weeks on 1-2 weeks off Yohimbe What it is: Supplement derived from tree bark. Claims: Anabolic effect, Increased virility What it does: Stimulant effect, no anabolic effect. Can cause nervousness, HA, nausea, Vomiting, increased B/P Tribulus Terresteris What is it: A plant hormone Claims: Anabolic effect What it does: Increases testosterone levels Banned by NFL Miscellaneous: Bicarbinate Loading Coenzyme Q Linoleic Acid Bicarbonate Loading Used prior to competition to neutralize lactic acid produced by anaerobic activities Lactic acid>>lower pH>>fatigue May improve runners’times if taken 30 min prior to competition : best in intermediate distances 800-1500 meter events 300mg/kg required Terrible GI s/e in 50% of users-cramps, diarrhea, ^ BP Coenzyme Q10 Conjugated (coQ10,Ubloquinone) Linoleic Acid Produced by the body in mitochondria claims: Enhances performance, delays fatigue, prevents injury What really does:Functions as an antioxidant Safe levels:60200mg/day but also$$$$$ Naturally occurring fatty acid found in beef ,lamb and dairy claims: decreases body fat ,increases muscle gain,antioxidant What really Reviewing the Evidence Evidence Based Medicine: “What evidence do we have to justify the treatment…” National Center for Complementary and Alternative Medicine (NCCAM) CAM on PubMed