Nutrition has never been a topic stressed in medical schools.   Most doctors have little if any formal education in this area.   This is surprising, since so many people suffer from eating disorders.   Who then do you turn to when you need help with your nutritional needs? If it's not your personal physician, who then?   Do you simply follow the old adage, Trust me, I'm a Doctor. Physicians are taught, First do no harm?   But, people are more aware of their health in this new millennium. They are less trusting of doctors.   Instead they place their confidence in Herbalists and Alternative Medical Personnel for their needs, without the definite knowledge that these practices are safe.   Doctors must attain a higher level of training in the field of nutrition and wellness, so they can renew that relationship of trust and confidence with the people they care for.

 

Unfortunately there have not been many scientific studies assessing the efficacy and safety of Complementary Medicine.   For this reason many physicians shun these practices.   What they don't realize is that fully 50% of Conventional Medicine is NOT Evidence Based but rather just as anecdotal as Alternative Medicine.  Anecdotal means: based on casual observations or indications rather than rigorous or scientific analysis.   A compromise must be achieved and doctors must use the best available evidence for their care, be it Conventional or Alternative and to First do no harm?.

 

 People are more aware of their health in the new millennium and they are less trusting of doctors.

 

Chinese Herbal Medicine has been around for over 3000 years.   This has been a very long time, and wealth of observations of efficacy has been made over these centuries.   Much of this wisdom has been banished as unscientific by modern medicine simply because it hasn't been studied yet.   I believe that this fund of knowledge should be utilized and studied.   One big problem is that modern medical research is very expensive.   It has actually come to a point that funding for this research must be derived predominately from large pharmaceutical agencies.   These companies often have a vested interest in the results of the studies that they fund.   Many times there is a conflict of interests.   Thus, it seems unlikely, unless the large corporations begin manufacturing Alternative products, that meaningful scientific studies of these agents will be performed.    I propose in this essay to present State of the Art evidence for the usage of Herbal and Botanical Medicines in the fields of Nutrition, Wellness and Preventive Medicine.

 

Nutrition

What constitutes a nutritious diet?   Luckily we have a ton of evidence regarding the optimal needs for both men and women in terms of calories, minerals and vitamins in both health and disease.   So how are we doing in the United States?   The answer is terribly, abysmally.   Only 12% of Americans have a good diet.   Our typical Junk Food Diet is high in saturated fat.   There is an epidemic of obesity, diabetes and heart disease in this country.   Likewise, this diet is deficient in micronutrients and vitamins.   Deficiency of vitamins such as folic acid, B12, B6, C, and E, iron, zinc and probably selenium are well documented.   Our western diet is also deficient in antioxidants.   Over 20% of the population manifests some or all of these deficiencies.   Upwards of 55% (some state 61%) of the people in the United States are overweight?    For the first time in history the number of overfed and overweight people rival the number of the underfed and underweight in the world.   But the fattest people eat the lowest amount of fruits and vegetables and have the greatest deficiencies and are therefore overfed but malnourished.

Only 12% of Americans have a good nutritious diet. 

Interestingly, not only do these poor people have the highest incidence of those diseases mentioned above, but they also have double the cancer rate.   This is because the deficiencies allow cellular damage of DNA, not unlike that of radiation.   Mutations occur and this leads to cancer.   Free radicals are basically supercharged oxygen molecules, which also mutate and burn DNA.   Antioxidants combat the actions of free radicals.   The important thing is to get enough of the essential vitamins and nutrients, as too many are also dangerous.

 

Vitamin C (Ascorbic Acid) 

Did you know that too much of a good thing can be bad for you?   Most people do not know that, when it comes to nutritional supplements.   They reason that if a little is good then a lot must be better.   Vitamins are commonly abused in this fashion.   Linus Pauling was the son of a pharmacist and became a chemical engineer in the mid-twentieth century.   He basically was the founder of Molecular Biology.   He was an outspoken man and a political activist.   His research into the effects of very high doses of Vitamin C (Ascorbic Acid) on the common cold and some forms of cancer were very popular.   Many people followed his prescription of using mega-doses of Vitamin C for colds and flu.   Recent studies have looked at the role of Vitamin C in the common cold and concluded:  Long term daily supplementation with vitamin C in large doses daily does not appear to prevent colds. There appears to be a modest benefit in reducing duration of cold symptoms from ingestion of relatively high doses of vitamin C. The relation of dose to therapeutic benefit needs further exploration.  Yet, there are over 1 billion colds a year in the United States.   They are most prevalent amongst children.   Many people still remain convinced that high doses of Vitamin C are beneficial at both preventing and relieving this benign malady.    I should point out that despite the incredible popularity of mega-dose Vitamin C therapy, very few recent studies have been performed in humans regarding its use in the common cold.

Ascorbic acid and the common cold. Evaluation of its efficacy and toxicity.

Journal of the American Medical Association 1975 Mar 10; 231(10): 1073-9  Dykes MH, Meier P.

We reviewed the clinical data relating to the efficacy and safety of pharmacologic doses of ascorbic acid in the prevention and treatment of the common cold. Although one study tentatively supports the hypothesis that such doses of ascorbic acid may be efficacious, a second study by the same group did not confirm the significant findings, and no clear, reproducible pattern of efficacy has emerged from the review of all the evidence. Similarly, there is currently little adequate evidence on either the presence or the absence of serious adverse reactions to such doses of ascorbic acid, although many such reactions have been hypothesized. The unrestricted use of ascorbic acid for these purposes cannot be advocated on the basis of the evidence currently available.

This would be fine and good if they were only throwing their hard earned money away and basically depositing the excess dosage in the toilet bowl.   But there is well-defined toxicity with Vitamin C, especially in children and especially when taken over long periods of time.   too much vitamin C can cause severe diarrhea, a particular danger for elderly people and small children.  In addition, too much vitamin C distorts results of tests commonly used to measure the amount of glucose in urine and blood.   Combining oral anticoagulant drugs and excessive amounts of vitamin C can produce abnormal results in blood-clotting tests.?(http://www.niaid.nih.gov/factsheets/cold.htm)    Vitamin C also interferes with stool testing for occult blood.    It also affects blood tests for cholesterol.   The gastrointestinal side effects of Vitamin C, such as severe gas and diarrhea, occur predominately at dosages in excess of 3000 mg daily.

 

There have been concerns that high doses of Ascorbic Acid might increase Iron absorption and lead to Iron toxicity especially in those prone to Iron overloaded states such as Hemochromatosis, Thalassemia and Sickle Cell Anemia.   Recent literature has shown that this is not the case (High-dose vitamin C: a risk for persons with high iron stores? Int J Vitam Nutr Res 1999 Mar; 69(2): 67-82).     There is no question that Vitamin C is intimately involved in the production of toxic Iron associated free radicals especially in the setting of Iron excess.   It has been postulated that when there is a very high level of Ascorbic Acid (Vitamin C) in the body and the cells, Iron leaks from its storage protein molecule, Ferritin, and forms billion of these free radical scavengers.   You can think of free radicals as little energized oxygen enriched Pac-men which gobble up (and burn) proteins and molecules, resulting in cell death.    Vitamin C was proposed as a therapy in HIV and AIDS, as well as in cancer, since by itself it is a potent antioxidant (anti-free radical scavenger).   Interestingly, a recent study found that mega-dosages of Vitamin C (much higher than the recommended 250 ?1000 mg daily) severely suppressed immune function in white blood cells  (human T-Cells).  These authors cautioned against the use of mega therapy in HIV, AIDS and cancer (Sustained levels of ascorbic acid are toxic and immunosuppressive for human T cells. P R Health Sci J 1996 Mar; 15 (1): 21-6).    There has been anxiety in the medical community fearing that mega-dose Ascorbic Acid therapy might lead to oxalate kidney stone formation, high levels of uric acid in the urine, vitamin B-12 destruction, and mutations of chromosomes and DNA.   But the consensus now is that these adverse effects do not occur in healthy subjects ingesting large amounts of vitamin C.

One problem is that the optimal, best or even the correct dosage of Ascorbic Acid is not known.   The daily optimal intake of Vitamin C has been stated to be anywhere from 250 mg to 5000 mg daily.   We know that dosages in excess of 400 mg daily result in increased tissue levels.   Most species of plants and animals make their own Vitamin C, but we humans do not and we need to ingest it.    It is well known that when you are deficient in Vitamin C you can get very sick and even develop Scurvy.   Aching bones, joints, and muscles, loss of appetite, dry skin, fatigue, bleeding, skin thickening, listlessness, loose teeth, muscle cramps, infections, shortness of breath, sore and bleeding gums, and weakness commonly accompany Vitamin C deficiency.   This symptom complex or syndrome is Scurvy.   Ascorbic acid works primarily in the body to maintain the strength of our tissues and especially on the protein collagen.   When it is deficient, tissue weakness results in these signs and symptoms by affecting the joints, muscles, skin and gums to name just a few.    A poor dietary intake of Vitamin C, excessive stress, aging, alcohol abuse, leprosy, and cigarette smoking are all associated with this deficiency.    Scurvy is perhaps the oldest known deficiency disease.   The early Egyptians and Greeks described it.   It wasn't until the 18th century though that James Lind established the association with a poor intake of fresh vegetables and fruits.

Having said all that, I must point out that in general Vitamin C is incredibly safe and well tolerated at most dosages.    In one large recent study the data from the 1998 Poison Control Centers' Toxic Exposure Surveillance System was reviewed.   Of 2650 total exposures, there were no major outcomes, and not a single death.   The vast number of these exposures actually occurred in children under the age of 6.   There is also good evidence that Vitamin C protects against cigarette induced pre-cancerous changes in the lung.   Evidence exists that Ascorbic Acid is protective against alcohol induced liver damage.   High doses of Vitamin C have been used with chemotherapy (Cisplatinum) for cancer and been found to prevent the toxicity and damage to blood cells such as platelets which prevent bleeding.    When used in concert with another chemotherapeutic drug, Adriamycin, Vitamin C may protect against heart damage.    Numerous epidemiological studies have pointed to the importance of dietary and supplemental ascorbate in the prevention of various types of cancer including bladder, breast, cervical, colorectal, esophageal, lung, pancreatic, prostate, salivary gland, stomach, leukemia, and non-Hodgkin's lymphoma (Ascorbic acid in the prevention and treatment of cancer. Altern Med Rev 1998 Jun; 3(3): 174-86).   Some have even found that very high doses of Ascorbic Acid is cytotoxic (kills cells) against cancer cell and propose the use of mega-dose Vitamin C as a form of actual chemotherapy (Intravenous ascorbate as a tumor cytotoxic chemotherapeutic agent. Med Hypotheses 1995 Mar; 44(3): 207-13).    Most studies show that people whose intake of vitamin C is adequate have a lower incidence of Coronary Heart Disease and Cancer.    Ascorbic Acid also appears to be effective in the treatment of Idiopathic Thrombotic Purpura (ITP). 

In my opinion Vitamin C is a very safe and effective agent.   When assessing the Risk to Benefit ratio of this therapy, I strongly support supplementation.   I do caution against massive dosages and I await further clinical trials to define the optimal dosage of it.   

 

Other Vitamins and Minerals

Over 100 million people in the United States use vitamins regularly.   They spend over six billion dollars yearly on them.    This practice has actually doubled in the past 6 years.   A very recent study documented that the Hispanic population on the US-Mexican border are the highest consumers of vitamins and of Complementary Medicine in the US (Pharmacotherapy 22(2): 256-264, 2002).    Often times, vitamins are consumed with minerals and the most common combination is with Iron.   Iron containing vitamins are the most dangerous and most toxic.   We also know that Fat Soluble vitamins such as Vitamins A (retinol), D (cholecalciferol), E (alpha-tocopherol) and K (phytonadione) are also very toxic when acutely taken in overdosage.  [Water-soluble vitamins include Vitamins C, B-1 (thiamine), B-2 (riboflavin), B-6 (pyridoxine), B-12 (cyano-cobalamin), Folate, B-3 (Niacin), Pantothenic Acid, and Biotin.]   Interestingly, the 1998 Poison Control Centers' Toxic Exposure Surveillance System found no deaths associated with over 49,709 exposures to multiple vitamins, multiple vitamins with Iron, multiple vitamins with fluoride, Vitamin A, Vitamin E, Vitamin C, Niacin, Pyridoxine, and other B-complex vitamins.   The only major outcomes occurred with adult multivitamins, adult multivitamins with Iron, and with Vitamin E.   Thus the morbidity (the rate of incidence of a disease) and the mortality (the number of deaths) associated with pure vitamin ingestion and overdosage are very rare.   In fact one other study of over 40,000 people found only 8 adverse outcomes and one death.

The same problem exists for these vitamins and minerals as was described for Ascorbic Acid.   People take too much sometimes of a good and essential thing.   Iron is perhaps the most dangerous mineral supplement.   Although acute overdose is dangerous but often not fatal, the syndrome of Iron Overload is dreaded.   Iron is everywhere.   It is contained in almost all foods.   Iron is not excreted (wasted) in the urine or stool, but is lost in the hair, fingernails and dead skin (1 mg daily).   Menstruating females lose 1.5 mgs of Iron on the average daily.   When you bleed, you lose Iron and what often results is an Iron Deficiency Anemia (Blood Loss Anemia).   Iron is an essential mineral and without it we would die.   On the other hand, too much iron can damage your body especially over a long period of time. 

As I mentioned above free Iron in your blood causes a massive release of toxic radicals, which destroy tissues.   It is felt by some that the only people who should take Iron supplements are those who have lost the ability to absorb this mineral due to surgery or disease involving the bowel.   Excess iron is stored in the liver, heart, brain, pancreas, skin and joints.   When you have too much Iron on board it basically overloads your entire body.   A syndrome of Bronze Diabetes can occur, which basically means that the skin becomes bronze in appearance and that the Iron has taken over the pancreas gland and interfered with insulin secretion causing diabetes.   Symptoms of heart disease, cancer, cirrhosis, diabetes, arthritis, sexual dysfunction and others can be completely prevented when based on iron overload alone, but only if recognized and treated early.   It is felt that maintaining low Iron levels actually improves immunity, making Iron unavailable to viruses, bacteria and cancer cells.   The most common of several Iron storage diseases is Hemochromatosis.  It is caused by the most frequently expressed genetic abnormality in any population and can result in the metabolic defect that leads to Iron overload.  It is estimated that 42 million Americans are at risk, including those with the double gene and those with the single gene.  The single mutation may result in enough excess Iron to cause heart attack or stroke, aside from full blown Hemochromatosis.   Iron therapy and thus supplementation is only indicated when a deficiency state exists.   When someone develops an Iron Deficiency Anemia and there is no cause for a failure to absorb Iron, doctors begin to look for a source of bleeding.   The most dreaded concern is a cancer of the gastrointestinal tract.

As far as the remainder of the vitamins, I will present a few highlights and caveats, but I will not cover each agent in great detail.   Vitamin E is a potent antioxidant and has been used in combination therapy with Vitamin C in many studies.   A high antioxidant status is associated in epidemiological studies with a low incidence of degenerative diseases.   Vitamin E has been shown to be very safe in multiple randomized double blind studies in humans and even at very high dosages.   Long-term studies are really not available.    (The potentially toxic dose is more than 3000 IU/d for 7-9 weeks.)    It has been found that at doses greater than 400 IU daily, Vitamin E decreases Low-Density Lipoprotein (LDL) Cholesterol.    Vitamin E must be avoided in people who have blood-clotting abnormalities associated with Vitamin K deficiency, as excessive bleeding may occur.

Vitamin K is essential for the formation of multiple blood-clotting factors (Serine Proteases).   When deficient, bleeding often occurs.   It is found in many green, leafy vegetables.    Vitamin K1 (phytonadione) is found in plants, while Vitamin K2 (menaquinones) is made by bacteria in the gut.   Coumadin (Warfarin Sodium) is a blood thinner which blocks the production of Vitamin K dependant clotting factors (Serine Proteases) in the liver.   It actually depletes Vitamin K in the liver and this leads to a deficiency of Vitamin K and the blood becomes thin (anticoagulated).    If someone on Coumadin takes Vitamin K or eats green, leafy vegetables, the blood thinning effect is reversed and blood clots can form again.   Vitamin K deficiency can also happen when there is an obstruction to bile flow, which is needed for Vitamin K to be absorbed in the bowel.      Antibiotics can cause a Vitamin K deficiency by killing the bacteria in the bowel that makes Vitamin K2.   A physician, therefore, should only prescribe Vitamin K in carefully measured dosages.

Vitamin A or Retinol is needed to maintain healthy hair, skin and mucus membranes (gums).   It is also needed for proper bone and tooth growth and reproduction.   Vitamin A also is important for night vision and seeing in dim lighting.   When taken together, Vitamin E will decrease the absorption of Vitamin A from the diet in the bowel.    A water-soluble form of Vitamin A is available which is absorbed more readily.   True form Vitamin A is called Retinol and is found in liver and fish oils.    Beta-carotene is Pro-vitamin A and is found in many vegetables (e.g. carrots).   Pro-vitamin A must be converted to Vitamin A in the liver, in the presence of fat and bile.   Retinol is also a potent antioxidant.   For adults, 5000 IU are the daily-recommended dosage (US RDA see medical calculators above) of Vitamin A.   Toxicity is rare while the acute toxic dose is 25,000 IU/kg, and the chronic toxic dose is 4000 IU/kg every day for 6-15 months.   There has been some controversy regarding Vitamin A in pregnancy.   It is now felt that up to 10,000 IU of Retinol daily is completely safe in any pregnant woman.   At doses in excess of 10,000 IU, there is a definite risk of fetal malformations (teratogenesis) and these high levels should definitely be avoided during pregnancy.   A pregnant mother should likewise not eat liver, which can be very high in Retinol, and it is of note that fish liver oil (e.g. Cod Liver Oil) may contain in excess of 180,000 IU of Vitamin A.   Beta-carotene (Pro-vitamin A) is not associated with any fetal malformations. 

Vitamin D not only exists in many foods (dairy and eggs) but can also be made by your body, which requires exposure to sunlight (ultraviolet light).    It is central in maintaining the minerals Calcium and Phosphorus and thus participates in bone health.    When deficient a condition called Rickets can occur in children and the bones become weak, brittle and deform.   Rickets had been considered a childhood disease of the past.   Interestingly there seems to be resurgence in Rickets in the UK, as there were 24 cases recently reported between May of 2000 and April of 2001.   In adults, a lack of Vitamin D results in Osteomalacia (softening of the bones).   In excess, Vitamin D results in high levels of calcium in your blood (hypercalcemia) which can be life threatening.   Adults should take about 400 IU units of Vitamin D daily.   This is especially important in those who have a limited exposure to sunlight.    The elderly are thought to have a higher incidence of Vitamin D deficiency, and people over 50 years of age should definitely take a supplement.  The chronic toxic dosage of Vitamin D is greater than 50,000 IU daily.    There may be a lower incidence of colon cancer in people taking Vitamin D and Calcium.   Calcium and Vitamin D are essential in both the treatment and prevention of Osteoporosis (decreased bone mass with increased fragility).   Calcium and Vitamin D may be protective against hip fractures as well.    A recent study has shown that in elderly women animal protein consumption was associated with improved bone density (April 1st 2002 issue of the American Journal of Epidemiology). 

Calcium should be supplemented as follows:


Age

Intake


7 to 9
10 to 12 (boys)
10 to 12 (girls)
13 to 16
17 to 18
19 to 49
50+

700 mg
900 mg
1200-1400 mg
1200-1400 mg
1200 mg
1000 mg
1000-1500 mg


There really is no upper limit on the amount of calcium a person could take daily.  It used to be thought that too much calcium resulted in kidney stones, but this has been disproved.   Another current study out of New Zealand found that Calcium supplementation improved Lipid profiles in post-menopausal women (April 1st 2002 issue of The American Journal of Medicine).   One gram of Calcium Citrate was administered daily (in a placebo controlled double blind format) and HDL Cholesterol increased 7%.   More studies are needed to see if this data also applies to men.

Of further note and in this same context, a very recent release (April 23, 2002) at the American Heart Association (AHA) found that Vitamin D supplementation decreased the risk of cardiovascular death in women.   It is thought that low levels of Vitamin D are associated with increasing calcium levels in the arteries of the heart. Therefore the arteries are hardened and diseased.   Heart attacks may occur in this setting.   There were almost 10,000 women in this study but it was not a randomized, controlled, double blind study and was weakened in this respect. The data tended to show that women using Vitamin D supplements had a 43% reduction in the risk of dying from a heart attack.    In this study, they didn't find any relationship between calcium intake and risk. Further study is planned in this area and the AHA does not recommend Vitamin D supplementation for this reason yet. They do recommend getting the necessary vitamins in a nutritionally sound diet.  As  we've already seen though, only 12% of the US population has a nutritionally sound diet.   Thus the paradox exists and I see no other alternative besides nutritional and vitamin supplement for most people.

A recent article in the journal Science from University of Texas Southwestern in Dallas looked at nutrition and the incidence of colon cancer.   David Mangelsdorf, observed that the Japanese diet being low in fat results in a markedly reduced rate of colon cancer compared to our Western diet.    Lithocholic Acid, a bile acid produced to help digest fat, was felt to be the primary agent in the development of colon cancer as it is at very high levels in colon cancer patients and causes chromosomal damage resulting in colon cancer in animals.   They found that Vitamin D actually functions at a receptor site to detoxify Lithocholic Acid and prevents colon cancer in animals. They caution that it is NOT possible at to take very high doses of Vitamin D due to the resulting effect on calcium and bone homeostasis.   Rather it is hoped that eventually compouns will be developed which mimic this effect of Vitamin D on Lithocholic Acid.   In the mean time the best solution to colon cancer seems to be a low fat diet.

 

Osteoporosis

Osteoporosis is an incredibly common disorder.   It is estimated that there are 6 million women and 2 million men with this malady (NHANES III).   Seventeen million women and 9 million men have Osteopenia (below). Osteoporosis occurs in all populations at all ages but is most prevalent in postmenopausal women.   In the other people who have it, besides postmenopausal females, it often is unrecognized.   It is said that anyone who suffers a fracture from a trivial injury such as a fall (e.g. not a high impact motor vehicle injury) probably has osteoporosis.   Osteoporosis is an important and serious disorder.   There are financial, psychosocial and physical consequences of it.   Fractures and pain accompany osteoporosis and with these recurrent problems comes debility and disability (see the medical calculators above).   Hip fractures are an important cause of death and functional dependence in the United States and worldwide.   There are about 350,000 hip fractures yearly in the US.   The death rate for persons in the U.S. Medicare population who fracture a hip is 7% at 1 month, 13% at 3 months and 24% at 12 months.   That means that over 120,000 people die yearly in the USA from hip fractures which result from osteoporosis. Advanced age, history of confusion and greater severity of other diseases are associated with higher morbidity and mortality.   Interestingly men who sustain hip fractures tend to have a higher rate of death than woman.   Common complications of these people include thrombophlebitis (blood clots in the leg veins), surgical wound infections, urinary tract infections, urinary retention, skin ulcers, heart complications and confusion (delirium).    Hip fracture is a well-recognized cause of death worldwide.

 

How do we approach and treat Osteoporosis?   First we have to be able to identify people who are at risk for the disease and this can be a difficult process sometimes.   Postmenopausal women are all at risk, but so are all people on long-term cortisone therapy, Inflammatory Bowel Disease such as Crohn's Disease and Ulcerative Colitis, Current cigarette smokers, Vitamin D deficiency, anyone with a trivial fracture, history of a fracture in a first degree relative, advanced age, Caucasian race, poor health and frailty, female sex, sedentary life style (no exercise), dementia, Estrogen deficiency as caused by early menopause or after surgical removal of both ovaries, life-long inadequate calcium intake, alcoholism, low body weight (less than 127 pounds), recurrent falls and impaired vision despite correction.   The items in bold and underlined are the most important risk factors besides being postmenopausal.   (Please see the Medical Calculators above.)

Now that we know who is at risk for Osteoporosis what do we do?   It is in these people that screening is indicated.   How do we screen?   We perform a Bone Mineral Density (BMD) test and there are many different types of these.   In general this test will tell us the status of the bone mineral content and when it is deficient, Osteoporosis is present.   Without going into a lot of detail about the scan, a T-score less than ?.5 (by World Health criteria) is significant for this diagnosis. [Osteopenia is defined byT-scores between -1 and -2.5 and these people are also at increased risk of fracture and disability, and many would argue should be treated preventively.]   "In a recent review of computerized records of 33,662 US women older than 50 years of age, BMD had been measured in fewer than 2% of women, and only 14% of all women had recently been dispensed a bone-protective agent." Therefore we are not doing too well either screening for, protecting against or treating Osteoporosis.

How do we treat Osteoporosis and Osteopenia?   The first concept in therapy is always prevention.   Therefore we must stress and address skeletal and bone health lifelong.   Cigarettes should be avoided completely!   In moderate smokers with low body weight ( less than 75 kg or less than 165 pounds), increased bone resorption occurs and this results in a decreased BMD and an increased prevalence of vertebral deformities and fractures.  In former smokers, bone resorption is not increased, but BMD remains lower compared with that in never-smokers (J Clin Endocrinol Metab 2002 Feb; 87(2): 666-74).   Next, we must stress supplementation.   Vitamin D and Calcium both must be provided in adequate amounts, keeping in mind that in general the US diet is deficient, but that the elderly are at particular risk for nutritional deficiencies and Osteoporosis and Osteopenia.   The currrent pharmacologic Standard of Care for both of these conditions is the Biphosphonates.    Alendronate was effective in reducing fracture risk in multiple studies.   In women often times Hormone Replacement Therapy (HRT) is recommended.   The most recent addition to pharmacologic therapy for these diseases is Parathyroid Hormone (and fragments). To my knowledge, Parathyroid Hormone is the only therapy which actually increases bone mass density by the formation of new bone.   

All of these drugs have their risks and benefits and it is not my intent to discuss this topic in depth. Hopefully your personal physician can explore these regimens with you and help you decide which is best for you.  One word of caution is that you must be very attentive to the manner in which drug therapeutic information is presented to you and try to be unbiased.   This is equally important for your physician.   A very rececnt study from the University of Sydney (Med J Aust 2002;176:401-402) found that the "Order in Which Drug Information Is Given Influences Patient Decision-Making." Patients who are advised of the positive effects of a drug before being told about negative effects are more likely to decide that they will take it than if the information is presented the other way around."  

 

Commentary and Summary

Before we leave the general nutrition, minerals, vitamins and antioxidant discussion, I'd like to comment on a very interesting study from the journal Nutrition and Cancer.   Despite the fairly specialized conclusions of this article, I want to highlight it as typical of the State of the Art for nutrition in Medicine.   In fact we are really only in our infancy when it comes to understanding the impact of nutrition on human health and disease.   The biochemistry is still slowly evolving.   The cellular mechanisms are only now becoming evident.   The genetics of nutrition really is the promise of the future.

Aaron T. Fleischauer and associates in Nutrition and Cancer (Nutr Cancer 40(2):92-98, 2002) looked at "Dietary Antioxidants, Supplements, and Risk of Epithelial Ovarian Cancer".   They observed that many prior studies had shown an association between increased dietary intake of and higher blood levels of antioxidant micronutrients (vitamins A, C, and E and beta-carotene), but no one had studied the effects of supplementation.   That is what they studied and what they found is astounding.   First of all they found that supplementation especially with Vitamins C and E was protective against Ovarian Cancer.   Just as important though was their finding that these levels of protection were only achieved at doses "well above the current US Recommended Dietary Allowances (US RDA)".   This is both exciting and confusing.   We know that nutritional factors play an important role in health and disease and it appears that alterations in consumption can prevent and even cure some maladies.   The confusing part (and one of great concern) is that the status quo, be it the US RDA, the FDA or the physicians, simply do not yet know what the best approach is.   In this example, US RDA for Vitamins C and E are inadequate to protect against Ovarian Cancer.   It is really up to you decide, with your physician, who is hopefully open-minded, what are the best choices to make in this era of uncertainty using a risk to benefit analysis.

 

 Diets and Dieting 

 People don't and can't stick with fad diets.

What about all of those fad diets out there, are they properly balanced for optimal cellular nutrition?   Unfortunately, they are not.   Furthermore, most people who are successful losing a few pounds on one of them, typically rebound above their baseline weight when they stop the diet and have nowhere to turn except back to their old, bad habits.   People don't and can't stick with fad diets.   Calories are important to consider when eating but hard to consider when counting.   In general most women need about 2000 calories daily and most men require about 2500 calories.    One pound of fat is basically an extra 3500 calories consumed.   Despite emphasis on a low fat, low calorie, conventional diet, mixed with exercise on a daily basis; the fact remains that it is very hard for most people in our society to do this.   What results is an obese population, which is ever expanding.

 

What does modern medicine have to offer?   As I already mentioned, most primary care physicians are poorly educated in nutrition and dieting.   This is unfortunate, as they really should have a pivotal role here.   Perhaps a little counseling is offered and a tattered copy of an old diet handed out in a busy office setting with instructions to come back in a few months.   Maybe if you are lucky you might get an appointment with a hospital dietician.   Amphetamines used to be prescribed like candy for weight loss until their addictive potential was recognized and abuse was rampant.   Many untimely deaths occurred from these medications, which were often combined with sedatives to combat the insomnia that resulted.   That certainly wasn't, First do no harm?   It wasn't very long ago that the combination Phen-Fen became popular.   Unfortunately another rash of deaths from heart and lung disease occurred and this combination was discontinued in a flurry of headlines, controversy and law suits.   Now Meridia or Sibutramine is starting to have deaths associated with cardiac and pulmonary disease.   In some European countries it has been removed.   Orlistat is a novel agent, which decreases fat absorption up to 30%.   Unfortunately, diarrhea and unpredictable gas are frequent side effects especially if you eat your typical fatty meal.   Weight loss on Orlistat has been variable and you must maintain a low calorie diet to be successful.   Finally there are the heroic surgical procedures (Bariatric Surgery) usually reserved for the morbidly obese and especially those with serious coexisting disorders.   These procedures can now be done laparoscopically (meaning no large scar and faster recovery times.)   The stomach is basically cut down to a small remnant (pouch) and a variable amount of small bowel is bypassed to decrease absorption.

 

I conclude that modern medicine has little to offer the obese population to date. 

 

There are many complications with these procedures.   After the surgery, you must eat a very specialized diet to maintain your health as well.    Profound results have been achieved with these procedures but they are clearly not for everyone.   Thus, I conclude that modern medicine has little to offer the obese population to date.   We may have to wait another 50 years while they unravel the genetics of the disease.   What do we do in the meantime?

 

I mentioned that so many people suffer from eating disorders that it is an epidemic.   By addressing a weight reduction program, I have been talking predominately about people who are overweight, obese or morbidly obese.   There are many other eating disorders which plague our society and I am not claiming that the program I am using is appropriate for all of these disorders.   Some of these people really require a multidisciplinary medical and psychosocial intervention.   I will discuss some of these topics now.

 

Obesity and Eating Disorders 

Overweight and obesity are by far the most frequent nutritional and eating disorders in the United States.   According to a recent article in The New England Journal of Medicine, "Overweight and obesity are the most common nutritional disorders in the United States, affecting the majority of adults in the country...The prevalence of obesity has increased by more than 75 percent since 1980...Health care professionals should be concerned about overweight and obesity because of the well-established relations between excess body weight and such medical conditions as type 2 diabetes, hypertension, and osteoarthritis...29 percent of the men in the United States and 44 percent of the women describe themselves as trying to lose weight."   (N Engl J Med, Vol. 346 February 21, 2002.)    Women who are overweight are at increased risk of developing breast cancer. Breast cancer involves 1 in every 8 women worldwide.   In addition, increased dietary fat intake is a risk as well.   These medical conditions are referred to as co-morbidities.

 

What does it mean to be overweight and how do you know if you are?     The question really is what is your Ideal Body Weight?   Unfortunately there is really no consensus on this question but the best evidence comes from large studies.   Your ideal body weight is based upon your age, sex, height and body frame.   There are many reference standards used.   Here is just one of them described in inches of height and pounds:

 

 US National Center for Health Statistics - Females

Height

18-24 Yrs.

25-34 Yrs.

35-44 Yrs.

45-54 Yrs.

55-64 Yrs.

4'10"

114

123

133

132

135

4'11"

118

126

136

136

138

5'00"

121

130

139

139

142

5'01"

124

133

141

143

145

5'02"

128

136

144

146

148

5'03"

131

139

146

150

151

5'04"

134

142

149

153

154

5'05"

137

146

151

157

157

5'06"

141

149

154

160

161

5'07"

144

152

156

164

164

5'08"

147

155

159

168

167

 

 

 

 

 

 


 

 

 

Height

18-24 Yr.

25-34 Yrs.

35-44 Yrs.

45-54 Yrs.

55-64 Yrs.

5'02"

130

139

146

148

147

5'03"

135

145

149

154

151

5'04"

139

151

155

158

156

5'05"

143

155

159

163

160

5'06"

148

159

164

167

165

5'07"

152

164

169

171

170

5'08"

157

168

174

176

174

5'09"

162

173

178

180

178

5'10"

166

177

183

185

183

5'11"

171

182

188

190

187

6'00"

175

186

192

194

192

6'01"

180

191

197

198

197

6'02"

185

196

202

204

201

 

Generally, if you are more than 10% heavier than you should be by these charts, you are considered overweight.   Therefore, if you should be 140 pounds and instead you weight 155 pounds (10% of 140 is 14 pounds and 140 + 14 = 154), you are overweight by about 1 pound.    Likewise, if a man is more than 20% over his ideal weight or a woman is over 25% her ideal weight, he or she is considered obese.   Morbid obesity is basically defined as being 100 pounds or more above your ideal weight.  

 

Recently classifying people in terms of Body Mass Index (BMI) has become very useful and there are many calculators available for this (see BMI Calculator Above).   The formula for this is a little tedious and is BMI = [Weight in pounds ?Height in inches ?Height in inches] x 703.   The following is a good reference to the normal and abnormal ranges: 

Men

Women

Risk Factor

<20.7

<19.1

Underweight. The lower the BMI the greater the risk

20.7 to 26.4

19.1 to 25.8

Normal, very low risk

26.4 to 27.8

25.8 to 27.3

Marginally overweight, some risk

27.8 to 31.1

27.3 to 32.2

Overweight. Moderate risk

31.1 to 45.4

32.3 to 44.8

Severe overweight, high risk

> 45.4

> 44.8

Morbid obesity, very high risk

Sources: 1. Indiana University 2. Hamilton and Whitney's Nutrition Concepts and Controversies

The co-morbidities associated with obesity, but especially with morbid obesity, are frightening.   The severely obese are six times more likely to have heart disease and cardiovascular disease in general and they have a forty times increased risk of dying suddenly from heart beat irregularities.   They have a marked increased incidence of high blood pressure (Essential Hypertension), which also increases the risk for heart disease as well as stroke, kidney failure and hardening of the arteries.    High cholesterol levels also often accompany obesity and with it the risk of heart and vascular disease also follow.   Type II Diabetes Mellitus is ten times more likely in the obese and besides causing cardiovascular diseases, stroke and kidney failure, it is the leading cause of blindness in the United States.   It is associated with half of all amputations performed and it is the third leading cause of death in the United.    Many Cancers (breast, colon, prostate, uterine, cervical, ovarian, gall bladder, kidney, liver, pancreatic, rectal and esophageal), Obstructive Sleep Apnea, Obesity Hypoventilation Syndrome, Respiratory Insufficiency, Heart Burn and Reflux, Gallbladder Disease, Degenerative Arthritis, Venous Insufficiency and Blood Clots, Emotional and Social Maladies are all highly associated with obesity.   The worst of the worst are the morbidly obese.   It is in this group of people that Obesity (Bariatric) Surgery is often considered.    People with BMI's over 35 with any of these co-morbid conditions may also be considered candidates for surgery.   Personally, I would first prescribe the weight management program above before embarking on an invasive, risky surgery.   Still, there are people who are so sick with their multiple diseases that surgery is the best immediate option.   Ultimately it is up to the patient to discuss the options with their physician in a risk-benefit format.

 

Type II Diabetes Mellitus is ten times more likely in the obese and besides causing cardiovascular diseases, stroke and kidney failure, it is the leading cause of blindness in the United States, it is associated with half of all amputations performed and it is the third leading cause of death in the United States

 

Another eating disorder, which may be closely linked with overweight and obesity, is Binge Eating Disorder.    This is really a psychiatric problem highly associated with low self-esteem, guilt and depression.    These people tend to eat huge quantities of food until they become uncomfortably full.   This is done over a relatively short period of time.   Unlike Bulimics, they do not purge (e.g. induced vomiting, laxatives, enemas or fasting).   The result is weight gain and obesity and a very poor self-image.   They are out of control when it comes to eating.   They require psychotherapy and a sound weight management program.   Besides the psychiatric problems, binge eaters have the same co-morbidities as the obese, mentioned above.

Compulsive Eaters eat to deal with stress and emotions.   They gain weight also as they loss control over their eating habits.   These problems often date back to childhood and a failure in coping mechanisms for stressful and emotional problems.   Men and woman are equally affected by this disorder in which binge eating often coexists.   The cycle of over-eating and dieting failure will continue in these individuals until the emotional issues are dealt with.   Depression is very common as is a history of sexual abuse.   Sometimes, being fat is a protective mechanism for them in society and against their abusers.    They are at risk for the same health issues alluded to above.

 

Psychological and psychiatric problems both cause and are caused by obesity.   The cost is human suffering and life is enormous, not to mention the incredible financial burden placed on our health care systems.

 

The epidemic of obesity is a complicated one.   As you can see it is highly associated with our society in general.   Psychological and psychiatric problems both cause and are caused by obesity.   The cost is human suffering and life is enormous, not to mention the incredible financial burden placed on our health care systems.   Could you imagine a world without overweight-obesity?   How long might we all live?   What better a quality of life might we all have?   This is my dream and I hope that you can share it.

The Underweight and Underfed

You will note that I haven't referred to the other end of the spectrum, the underweight.   In this country, it seems almost impossible to imagine being too thin.   All you have to do is watch television and see your favorite actresses.   They get thinner and thinner especially with additional cosmetic surgery.   Thin is really in as far as fashion goes.   Look at the world-class models and the designer lines of clothing.    This is paradoxical since over 50% of the population is overweight or obese.   Still this standard is what our children are socialized into, especially young women.   You will note that a BMI of less than 20.7 for men and 19.1 for women is considered underweight.

Malnutrition is rampant in the world especially with the AIDS epidemic.   In developing nations one in every five people is hungry (841 million people).   But malnutrition affects both the underfed and the overfed since it is defined in terms of the intake of adequate nutrients (above).    While the world's underfed population has declined slightly since 1980 to 1.1 billion, the number of overweight people has surged to 1.1 billion.  In the United States with our higher standard of living, it is surprising to find many people hungry.   Based on the 1999 U.S. Census, 19 million adults and 12 million children lacked the resources for adequate nutrition.   They conclude that five million adults and 2.7 million children lived in these hungry households.   Now this is not an Eating Disorder per se but rather a Disordered Eating and it is inexcusable.   Often times, malnutrition, underfeeding, hunger and underweight coexist. 

 

We are so fortunate in the United States and it's curious that this same society drives people to self-induced starvation to attain a movie star or model appearance.

On the other hand, it's hard to believe then that people with adequate resources and ready access to ample supplies of food wouldn't eat enough especially with so many people hungry and starving.   I still remember my mother encouraging me to eat, considering all those starving children around the world.   We are so fortunate in the United States and it's curious that this same society drives people to self-induced starvation to attain a movie star or model appearance.   When taken to an extreme, this compulsion is just as, if not more, dangerous than obesity.

Anorexia Nervosa is an extreme disease of body image.   Insight means that you have the ability to recognize that you have a problem with a disease or disorder.   Anorexics have no insight.   They diet constantly and starve themselves into profound malnutrition becoming extremely underweight.   They deny hunger and may exercise excessively to lose weight.   No matter how thin and skeletal they appear, they will always look in the mirror and see a fat person who still has fat to lose.   Some anorexics weighing less than 80 pounds and near death will still contend that they are fat!   10 to 20% of anorexics will die from the disease, that is malnutrition.   They experience sudden death, very low potassium levels, dehydration, liver failure and kidney failure.   They tend to purge with self-induced vomiting and enemas.   Some use Syrup of Ipecac, laxatives and diuretics as well.   Anorexics really require a multidisciplinary approach with a psychiatrist, psychologist and an Eating Disorders Specialist.   Bulimia Nervosa shares features of Binge Eating and Anorexia.   They also have a disordered body image.   They may purge as well.    A similar but really unrelated abnormality is Body Dysmorphic Disorder (BDD).   These people seem to have an obsessive-compulsive disorder in which they become preoccupied with one or many non-existent or minimal cosmetic defects.   They often seek cosmetic surgery.   A subset of these people manifests an eating disorder when they exhibit Muscle Dysmorphia.    The individual thinks he or she is too puny, when in fact they are not.  One to two percent of body builders are plagued by this illness.  BDD is not exclusive to the United States.   People with Muscle Dysmorphia may abuse anabolic steroids in combination with excessive weight training.

 

Glycemic Index

This index is a concept which has been around for quite some time.   It at first may appear to be a very complicated term and hard to apply to nutrition in general. I hope to show you how easy it is to understand and how important it is in your nutritional approach.   So what is the "Glycemic Index"?   All carbohydrates be they complex starches such as breads and pastas or simple sugars such as table sugar or sucrose are converted by your body into glucose. Glucose is your basic building block of energy metabolism.   Also whenever we refer to your Blood Sugar level, we mean your Blood Glucose level.   The Glycemic Index simply is the effect that any given carbohydrate has on your level of Glucose in the blood.   In other words, the glycemic index of pasta is the blood glucose response to a known quantity of spagetti. Immediately you can appreciate the importance of this measure in the setting of Diabetes.   If a diabetic knows the effect of a specific food on their blood glucose level, they can give themselves just enough insulin to keep the blood sugar normal. This is especially important in Type I or Juvenile Diabetics.   Luckily over the past 25 years researchers have determined this index for just about any carbohydrate.   In essense the Glycemic Index tells you how rapidly a food turns into glucose.   "In general, most refined starchy foods eaten in the United States have a high glycemic index, whereas nonstarchy vegetables, fruit, and legumes tend to have a low glycemic index. Coingestion of fat or protein lowers the glycemic index of individual foods somewhat" (JAMA, May 8, 2002,Vol 287, No.18 p 2414).

The diet in the US has shown a steady increase in foods with a high Glycemic Index.   The empty calories of junk and fast foods are the major factors and this same trend is seen worldwide.   Co-existant with this has been an epidemic of Obesity, Cardiovascular Disease, Insulin Resistance Syndrome and Diabetes.   We have already discussed these comorbidities above.   It is felt that these conditions are a direct result of a High Glycemic Index diet. Studies have shown that a low Glycemic Index diet has many beneficial effects and may lead to the reversal of the above mentioned conditions.   

So you ask, how can we possibly apply this complex concept to our daily lives? Do we have to weigh and measure each type of food and consult a chart as to the specifics before eating.   "The concept of glycemic index may be complex from a food science perspective, its public health application can be simple: increase consumption of fruits, vegetables, and legumes, choose grain products processed according to traditional rather than modern methods (eg, pasta, stone-ground breads, old-fashioned oatmeal), and limit intake of potatoes and concentrated sugar. Indeed, these recommendations would tend to promote diets high in fiber, micronutrients, and antioxidants and low in energy density. Thus, the physician should consider this concept a practical guide, although routine measurement of the glycemic index and glycemic load of patients' diets must await development of applicable computer programs." (JAMA, May 8, 2002,Vol 287, No.18 p 2414).   That really makes great sense and is easy to implement.

 

Cardiovascular Disease

Do you know what the number one cause of death is in the United States?   It is Cardiovascular Disease and there are almost one million deaths yearly associated with it.   Almost everyone knows of someone who has died of a heart attack (myocardial infarction).   Certainly nutrition is a major factor in these diseases as I mentioned above.   The nutritional management program that I prescribe will lower Cholesterol and LDL Cholesterol and raise HDL Cholesterol.   For many people though, diet is not enough to bring their lipids into the desired range.   Often, medications, such as Statins, Bile Acid Sequestrants, Nicotinic Acid and Fibrates are needed.   These drugs all have side effects, and risks associated with them.   In many instances they are the very best option for someone.  

Doctors Are The Third Leading Cause of Death in the US, Causing 250,000 Deaths Every Year

Keep in mind that medication errors do occurs, and many things can go wrong under a physician’s care.   A recent study actually found that there were:

         12,000 -----unnecessary surgical deaths

         7,000 -------medication errors in hospitals
                         resulting in deaths

        20,000 -----other errors in hospitals resulting
                        in deaths

         80,000 ------infections in hospitals resulting
                         in deaths

         106,000 ----non-error, negative effects of
                         drugs resulting in deaths

These total to 250,000 deaths per year from iatrogenic causes!!

Iatrogenic means: Induced in a patient by a physician's activity, manner, or therapy. Used especially of an infection or other complication of treatment?   Since Cardiovascular Diseases result in 948,088 deaths per year, Cancer causes 529,904 deaths per year and Pulmonary Diseases (such as Emphysema) cause 101,077 deaths per year, doctors are the third leading cause of death in the US, causing 250,000 deaths every year.   Once again the adage, First Do No Harm?comes to mind.   Medicine remains much more of an art than a science and I believe physicians should exhibit more humility considering these statistics.   The bottom line is that we still aren'T doing an impeccable job with the tools that we have.   Does Alternative medicine have anything else to offer?
 

Omega-3 Fatty Acids

It is very interesting that Eskimos and the Japanese in general have a greatly reduced incidence of cardiovascular disease.   The common denominator is that these people consume a lot more fish than the typical American.   Fish oil is very high in Omega-3 Fatty Acids (Eicosapentaenoic - EPA and Docosahexaenoic acid - DHA). Typical vegetable oils are high in Omega-6 Polyunsaturates while Flaxseed oil, alpha linoleic acid, is converted to the longer chain Omega-3 Fatty Acids in the body.   [Flaxseed is also the only significant source of omega-3 fatty acids for vegetarians.]   The Omega-3 Fatty Acids had been thought to act as blood thinners and to prevent blood clots from forming.   Thus, the arteries to the heart wouldn’t become clotted and a heart attack would not occur.   Likewise it was felt that cholesterol levels were reduced by their consumption.   Very recent evidence from Italy suggests that the reason these agents decrease cardiovascular deaths is by reducing irregularity of the heartbeat and thus by stopping sudden cardiac deaths.   Two studies in April of 2002 demonstrated this effect and these were very large studies, one in the Journal of the American Medical Association and the other in the New England Journal of Medicine.     One large study found that the consumption of Omega-3 Fatty Acids and fish was associated with a lower incidence of thrombotic (blood clot) stroke in women who were not taking aspirin (JAMA. 2001; 285: 304-312).   Other studies have found that in both men and women there is both a reduction in the rate of heart attack and sudden cardiac death with these agents (Am J Med. 2002 Mar; 112(4): 316-9 and JAMA 2002 Apr 10; 287(14): 1815-21). 

Some very recent and intriguing data was presented by Dr. Yvonne Denkins at the annual Experimental Biology 2002 conference.   They found in a very small study of overweight men and women with Insulin Resistance Syndrome (which is a pre-diabetic condition) that the consumption of DHA improved the condition significantly after only 12 weeks.   Further studies are definitely needed in this area to better define the role of fish oils, glucose tolerance and Diabetes.   The implication is that Omega 3 fatty acids may delay the development of Diabetes. The Insulin Resistance Syndrome is an integral part of the Metabolic Syndrome which is also highly related to cardiovascular risk.

Some other medical problems also seem to be improved with the Omega-3 Fatty Acids.   They have been used both in Unipolar and Bipolar Depression with good results.   Boys with Attention Deficit Hyperactivity Disorder (ADHD) have been found deficient in Omega-3 Fatty Acids and seem to respond favorably to them.   Some people with seizures respond to these agents.   Fish oil also appears to possess potent anti-inflammatory properties and has been used in Multiple Sclerosis and diseases of autoimmunity (Systemic Lupus Erythematosis and Rheumatoid Arthritis).   In one large well designed study Omega-3 Fatty acids offered significant protection against relapse in Crohn’s Disease (an Inflammatory Bowel Disease).    They have been found to decrease the incidence of Preeclampsia in pregnancy and improve painful menstruation (dysmenorrhea).     They are of benefit in IgA Nephropathy and Cyclosporine induced Kidney damage.   The consumption of Omega-3 Fatty Acids has been found to prevent Prostate Cancer and is postulated to be effective in reducing Breast Cancer risk as well.   Conjugated Linoleic Acid is found in red meat and cheese (unlike alpha linoleic acid from Flaxseed.)   It appears to be a fatty acid of great potential as well.

This therapy, essentially fish oil, seems very safe and readily available.   The only thing that many people complain about is that after taking the capsules they have a decidedly fishy aftertaste.   It is also very important to be taking a product that supplies an adequately standardized dosage of the Omega-3 Fatty Acids. 

 

Coenzyme Q10

Have you heard of this substance?   Maybe you are already taking it but how much do you really know about it?   Realize that Coenzyme q10 (CoQ) is not an age old remedy or even based on Chinese Herbal Medicine.   It is a substance of active medical and biochemical research which has found its way into Alternative Medicine.   CoQ is a ubiquitous substance in breathing, living beings including man (and plants). For that reason, it was originally called Ubiquinone.   It is found within the energy generating portions of cells, the mitochondria.  This is really where you are breathing at a sub-cellular level (cellular respiration). In these tiny organelles oxygen is processed into energy or ATP which powers the cells and keeps you alive.   CoQ in concert with other enzymes and iron is central in this process.   CoQ also functions as an antioxidant, scavenging toxic oxygen radicals as discussed above.   The highest levels of Ubiquinone in humans is in the heart, liver, kidney and pancreas.

The fact that CoQ is so abundant in the human body is probably why some people believe it is a panacea or a cure for everything.   Presently claims are being made that it can reverse the aging process, increase your energy and exercise tolerance and detoxify every living cell.   These claims are really unsubstantiated, but they certainly sell a lot of product.   So lets look at some of the evidence that does exist.

The heart is an organ which has a critical need for continual energy and CoQ is concentrated there.   One well designed but small study more than a decade ago looked at patients with Congestive Heart Failure (CHF).   This is when the heart muscle fails to pump blood forward due to weakness or damage. This results in fluid on the lungs and swelling of the feet.   They found that with a dose of 2 mg/kg of CoQ daily there was a significantly improvement in those taking it compared with a placebo. Not only were there less episodes of fluid on the lungs but they found less irregularities of the heart beat in the treated group as well.   It also seemed that ubiquinone resulted in fewer hospitalizations for CHF but there was no difference in death rates.   Basically the patients on the coenzyme Q10 felt and did better.   The Japanese have been using this therapy for heart disease since 1974 but it is not approved for this indication in the US.   

Controversy exists.   A small but well designed study was published (18 April 2000 ?Annals of Internal Medicine ?Volume 132 ?Number 8).   They found no improvement in any measured end-points with 200 mg of CoQ daily and this was despite a documented increase of coenzyme Q10 levels in blood specimens.   There was no improvement in symptoms of CHF for the study participants either. The study has been criticized as being too small and, despite lasting 6 months, as being too short and that the dosage was too small to register an improvement.   The issue in medicine is always the quality of the evidence.

A recent study in the South Med J 2001 Nov;94(11):1112-7 looked at treating high blood pressure (isolated systolic hypertension) with ubiquinone. After 12 weeks of therapy, using 60 mg twice a day,  they found a significant reduction in blood pressure with no adverse effects.   There had been a concern that Statin drugs used to lower cholesterol also reduced CoQ levels (Clin Chim Acta 1997 Jul 4;263(1):67-77) leading many to supplement CoQ in people on such drugs as Pravachol (pravastatin) or Lipitor (atorvastatin).    A study from the University of Michigan found that these drugs had no effect on CoQ blood levels. (Am Heart J 2001 Aug;142(2))   

Parkinson's disease is a common ailment involving 1% of people older than 50. Deficient function of a CoQ complex (Complex 1) is felt to contribute to the degeneration that occurs in the brain even though blood levels of CoQ are normal (J Neural Transm 2000;107(2):177-81).  The administration of CoQ has been shown to decrease this process in the laboratory. (Biol Signals Recept 2001 May-Aug;10(3-4):224-53)    A mitochondrial dysfunction therefore is felt to exist in Parkinson's disease and may be central to its etiology. (Biochem Soc Symp 1999;66:85-97)

Since ubiquinone is intimately involved with the mitochondria, it has led many to speculate that therapy with it might be valuable in Mitochondrial Diseases. These include muscle diseases called Mitochondrial Myopathies, mitochondrial encephalomyopathy with lactic acidosis and strokelike episodes, myoclonus epilepsy with ragged red fibers, mitochondrial encephalomyopathies and myopathies, Leigh's syndrome, Neuropathy, ataxia and retinitis pigmentosa and many more rare processes.    These are genetic diseases. CoQ as well as creatine and vitamins has been tried with mixed and uncontrolled results

One study suggested a protective role for CoQ in Age-Related Macular Degeneration.   They found that many patients had low levels of CoQ and postulized that the antioxidant effects prevented the attack of free radicals. Others postulate a protective role for CoQ in a variety of cancers.   

So, the evidence although intriguing and exciting seems very premature for ubiquinone.   Even in its most common application, cardiovascular disease, there is really no consensus.   Is there a down side to this therapy that might be of concern. Multiple studies found it well tolerated even in fairly high dosages.   Coenzyme Q10 is known for producing minor gastrointestinal discomfort and elevation in SGOT and LDH (liver function tests) when used.   It exists plentifully in food and the body makes it from certain B complex vitamins.   In addition it is important to realize that an interaction with the blood thinner Coumadin may occur with CoQ resulting in "thicker", more clottable blood.  (Reduced effect of warfarin caused by ubidecarenone. Lancet Nov 12 Vol. 344, pp. 8933)

 

Garlic

Garlic has been around for centuries and used extensively for culinary purposes. For centuries it has also been used as a medicinal supplement and tonic.   Mention of it was found over 5000 B.C. in Egyptian hieroglyphics.   It was used to repel mosquitoes and insects.   At times it was worshipped and at others used to ward off evil spirits.   Now, Americans alone consume more than 250 million pounds of garlic annually.    In modern medicine a number of health benefits have been observed with it.   Some studies have suggested that individuals regularly consuming garlic show fewer stomach cancers, have thinner, less clottable blood and lower cholesterol and lipid levels.  This may translate into a reduced risk of stroke and cardiovascular disease.   Now we do not really understand how garlic works, but it's felt that sulfur related enzymes that are released by processing may be at work. "Ajoenes and dithiins are among the most active compounds formed from fresh garlic. Ajoenes have been shown to: possess antithrombotic (anticlotting) activity in human platelet suspensions; possess antitumor activity; display significant antifungal activity... (they) inactivate human gastric lipase, a sulfhydryl enzyme involved in the digestion and adsorption of dietary fats; function as antioxidants by inhibiting the interactions of leukocytes which mediate release of superoxide anion."

A  recent report from the International Scientific Conference on Complementary, Alternative, and Integrative Medical Research on April 12, 2002 found that "Garlic Blocks the Earliest Stages of Arteriosclerosis".   It seemed to block or slow the action of LDL-Cholesterol on the formation of plaques.   This study was entirely performed in the laboratory and clinical trials have not been performed yet to assess the effect in humans.   Still it is exciting.   

 

Conclusion

I hope this newsletter has been as informative and enjoyable for you to read as it was for me to write.   I have tried to present an overview of nutrition, nutrients and some aspects of Alternative Medicine.   I realize that there is still much to say, but the good news is that there will always be more time for me to say it.   I plan on publishing this newsletter on a monthly basis.   I hopefully will be able to cover many other topics in Alternative-Complementary Medicine, but I will also strive to keep you current on the latest information from conventional sources. I read over ten medical journals monthly and explore medical sites on the internet frequently.   I may at times direct you by links to various places usually as reference.   I will do my best to choose reputable, accurate sources as well.   

 

Warren S. Goff, D.O., P.A., F.C.C.P.
wgoff@tampabay.rr.com