John D. Mark MD Pediatric Pulmonary and Integrative Medicine University of Arizona
History of Medicine • TB: Hang cans of dog fat over your shoulder • Ulcers: Goat dung • Snake bite: Apply ½ of severed mouse • Baldness: Drink Sea water • Everything: Enemas (3/wk- Egypt) • Galen: Blood letting- 1500 yrs!-1910
Health Expo • Supplements, blue green algae, copper bracelets, vitamin sprays, juicers, foot massage dowels, water revitalizers, colloidal silver generators, aromatherapy, crystal kingdoms, gems for “balance”, copper embedded wristwatches, aura photos, diets, books, “dolphin energy” • Are you a believer??????????
Complementary and Alternative Medicine (CAM) • Medical interventions not taught in medical school in the US or generally accepted at hospitals or routine clinics. • Includes ideas from cultures or ethnic groups not considered to be part of conventional care • 40-60% of adults use CAM • Over $12 billion dollars spent-public!
Positive Motivation for CAM • Perceived effectiveness and safety • Philosophical congruence: “Zeitgeist”, holism, natural, active role of patient • Good patient/therapist relationship • Non-invasive, accessibility • “High touch, low tech” • Affluence, Control
Negative Motivation for CAM • Dissatisfaction with aspects of conventional health care, adverse side effects • Ineffective for certain condition, time • “High tech, low touch” • Rejection of science and technology • Rejection of “the establishment” • Desperation
Why is CAM use common in chronic illness? • Chronic inflammatory illness • Paradox: increasing despite advances • Belief that “external” exposures as cause • Belief that “emotions” can be important • Meds: “like using a boulder to kill an ant” • Holism and Empowerment of patients
The Integrative Approach • Whole person and family • Healing oriented not Disease • Patient/Physician partnership • Mind/Body/Spirit • Family and patient’s belief system • Holistic in approach, multilevel, and multifactorial
Integrative Approach to Health Conventional vs. Integrative • Healing- restoration vs. evolution • Disease-entity vs. aberrant organiz. pattern • Study of health- linear causality vs. circular causality • Study of healing-looks at single variables vs. looks at how all are linked to form a pattern
Medicine Medicine is not merely a science but an art. The character of the physician may act more powerfully upon the patient than the drugs employed. Philippus Aureolus Paracelsus (1493-1541)
Chronic Respiratory Conditions • Asthma • Chronic Obstructive Pulmonary Disease (COPD) and Emphysema • Cystic Fibrosis • Other
Asthma in the United States • 17 million, over 5 million children • Most common chronic illness in children • 100 million restrictive activity days per year • Over 470,000 hospitalizations per year • Over 5,000 deaths per year-highest in Blacks and children (ages 15-24)
Paradox in Asthma Care • NHLBI Expert Panel Guidelines (92’&97’) • Understanding airway inflammation • Early use of anti-inflammatory meds • Home management/ peak flow monitors • Practice Guidelines- both for ER & Outpts. • Morbidity and Mortality- increased?
Asthma Education-MD’s • Study of 108 MD’s and Guidelines • Asthma Faculty-78% • Asthma Fellows-69% • Family Practice-55-60% • Internal Medicine Residents-51% • Just understanding classification-problem
Asthma Triggers • Imbalance of T-helper lymphocytes type-2 (Th2) system • Respiratory viruses and Exercise • Allergens and Irritants: grass, trees, molds, indoor and outdoor pollution, dust-mites, cockroach, animal dander • Emotional (laughing/conflict) and Weather • Shift in omega-6/omega-3 fatty acids in diet
Nutrition and Asthma • Dietary habits influence lung function • Increased incidence in countries with PUSFA intake • Allergen exposure to foods and additives • Dietary intake of fruits, fresh fish and antioxidants decreased in asthmatics
Fat Classification • Saturated Fats • Monounsaturated Fats Omega-9 family • Polyunsaturated Fats Essential Fatty Acids (EFAs) Omega-6 FamilyOmega-3 Family Linoleic Acid (LA) Alpha linolenic acid (ALA) Gamma linolenic acid (GLA) Eicosapentaenoic acid (EPA) Arachidonic acid (AA) Docosahexaenoic acid (DHA)
Omega 6 Fatty Acid (Linoleic Acid) Omega 3 Fatty Acids (alpha-linolenic acid) Δ6-Desaturase Gamma-linolenic acid (GLA) Evening Primrose Oil Borage Oil Black Current Oil Eicosapentaenoic Acid (EPA) COX Δ5-Desaturase Lipoxygenase Arachidonic Acid Prostaglandins PGE1, PGE3 (Favorable) Less Inflammatory Leukotrienes Cyclo-oxygenase (COX) Lipoxygenase Docosahexaenoic acid (DHA) Prostaglandins (PGE2) Inflammatory Leukotrienes
Arachidonic Acid (in cell membrane) Phospholipase A-2 Steroids Free AA Colchicine Aspirin Cyclo-oxygenase Pathway Lipoxygenase Pathway Sulfasalazine NSAIDs Leukotriene Inhibitors: Accolate, Singulair, Zyflo COX II Inhibitors: Celebrex, Vioxx, Mobic Prostaglandins & Thromboxanes Leukotrienes
1985 (25:1) 25 Omega 6:3 Ratio 20 15 10 1909 (4:1) 5 0 Omega 6 Omega 3
Polyunsaturated Partially Hydrogenated 30 year shelf life
Sources of Omega-3 Fatty Acids • Cold Water Fish Salmon Mackerel Sardines Herring • Fish Oils EPA & DHA
Sources of Omega-3 Fatty Acids • Flax Seed Products Oil, ground seed. • Walnuts/Oil • Hemp seeds • Soybeans/Oil* • Dark Green Veges*algae
What to Recommend for chronic inflammation. • Reduce saturated fats that contain arachidonic acid (Animal products, dairy) • Reduce use of Omega 6 products (vegetable oils, crackers, things with a long shelf life) • Increase use of Omega 3 products (cold water fish, flax, dark greens and nuts) • Avoid low-carbohydrate (high fat) diets for prolonged periods of time (Atkins, Zone).
Dietary Supplements • Confusing more than any other area • DSHEA Act of 1994 • FDA lack of regulation • Regulating nature? • When, what, how much, how long, what form, interactions, who to ask? • Botanicals, phytomedicine, Internet?
Dietary Supplements • Echinacea • Coleus forskohlii (inhibits PAF) • Ma huang (ephedra) (bronchodilator) • Ginkgo biloba (PAF inhibitor) • Licorice, coltsfoot, tumerac (anti-inflam.) • Cordyceps (bronchodilator) • Green tea (antioxidants)
Ma Huang (Ephedra sinica) • Used in China over 5,000 years • Ephedrine- principle ingredient • Commonly used with licorice (mucolytic) • FDA-Over 600 complaints-22 deaths • Tighter State regulations-esp diet claims • Most problems stem from use with caffeine
Licorice (Glycyrrhiza glabra radix) • Folk medicine- treat cough • Glycyrrhetinic acid and carbenoxolone-potent inhibitors of cortisol metabolism • Enhances endogenous and exogenous steroids • Also shown to elevate blood pressure, peripheral edema, headaches, low K+, lethargy , muscle weakness
Coleus forskohlii • Ayurvedic medicine • Acts like theophylline (increases cAMP) • Another Ayurvedic herbal remedy seems to be an effective bronchodilator- Tylophora indica- • No studies yet on children, some on adults
Ginkgo Biloba • Study of asthmatics using Ginkgo leaves concentrate showed decrease airway hyperactivity (p<0.05) and pulmonary function improved (p<0.05) • Problem- 1997 study, in Chinese and do not specify the type of airway measurements used.
Ginkgo • Pilot data in this country has been described • PAF antagonist • Antioxidant • Can interact with other drugs, esp coumadin type meds
Vitamins • Vitamin B6 (pyridoxine)- RCT’s-helps for mild disease, 200 mg per day • Vitamin C- RCT’s-mixed results -over 1 gm • Selenium- no studies, antioxidant • Fish oil (omega 3 Fatty Acids)-RCT’s- long term help
Case Presentation: Shannon • 14 yr old with long standing asthma (moderate persistent), pets • Meds: Albuterol, AeoBid (Singulair, Pulmocort)-followed peds clinic • PFT’s- FEV1 (60/85), FEF25-75 (40/70) • Treatment plan: Meds, Environment, Nutrition, Dietary Supplements, Exercise
Arizona Botanical Center • One of 4 (UCLA, Chicago, Purdue) • Anti-inflammatories: Ginger, Tumeric, Boswellia • Botanical to Chemical to Animal, to Human studies • Ayruvedic- all used for asthma • Leukotriene inhibitors (esp. Boswellia)
Boswellia serrata gum resin • European J Med Res 98’ Nov:3:511 • 40 patients with asthma (double blind and placebo study) • 70% had improved symptoms, increase in FEV1/PEFR, decrease eosinophils • Control group- had 27% improvement • Boswellia serrata gum resin for asthma
“Lung Support” • Retinol, Fructus,Salvia, Cordyceps, Astragalus, Prunus, Morus, Ophiopogon, Cynachum, Ginseng, Ginkgo, Magnesium • No amounts listed • SAFE • NO DRUGS • NO SIDE EFFECTS • 100% NATURAL
Claims Made: • Ends..SOB, smoking damage, heart problems, sinus problems, emphysema, allergies, fatigue, asthma…. • “Secrets to breathing disordered unlocked”, “End Bronchial disease” • “Today’s Medicine is Harmful” • “Dramatic improvement …few days” • “100% SATISFACTION & RISK FREE “
Mind/Body Approach • Placebo/Suggestion/Disclosure • Hypnosis: • Guided Imagery • Pediatric study proposal • Diaphragmatic breathing • Exercise, Yoga, Martial arts
Accessing the Placebo Response • Develop rapport and trust • When able, recommend therapy based on the patient’s belief system • Recommend any given therapy with enthusiasm and confidence • Activate the patient’s expectation of the therapy with positive statements
Disclosure Chronic Illness • Smyth JM, et al. JAMA, 1999 • Effects of Writing About Stressful Experiences on Symptom Reduction in Patients with Asthma and Rheumatoid Arthritis. • Study Group: Wrote about a stressful life event for 20 mins/d for 3 days • Control Group: Wrote about daily events • 107 patients. • Asthma: 20% improvement in lung function vs no improvement in control • RA: 28% reduction in disease severity vs no change in control.
Hypnosis • Multidimensional • Induces an altered state of consciousness • Aids in developing a heightened concentration of an idea or image • Studies- many in the behavioral literature, helps if subjects are “susceptible” to hypnosis
Massage/Manipulative • Feels good, reduces stress and anxiety • Recent Asthma study: 20 minutes at bedtime by parents helped • Chiropractic- • Osteopathic- Used with anecdotal success
Osteopathy • Manipulative Medicine-Dr Still • Structure/Function relationship • Over 100 different types • Craniosacral, High-velocity-low-amplitude,muscle energy,counterstrain, myofascial release, lymphatic pump • Spiritual Component- Dr Viola Fryman
Other Therapies: • Mind/Body Medicine • Massage Therapy • Energy Medicine • Healing touch • Reiki • Johrei • Ethnocultural Medicine
Homeopathy • Law of Similars • Potency • Hahneman, homeopathy schools • Acute versus Chronic remedies • Classical versus “Modern” • Who, When and for what problems