[header]
Drugs: Safe and Effective?
Nutrition: Surgery and Healing
Supplements for Recovery
Vitamin A Safety
Ask Dr. J: Vitamin C Forms
In the Health News
Diet and Disease
Recipe of the Month: Cauliflower Millet
Casserole
References
Dear Friends,
While I believe that modern pharmaceuticals have great value
in treating disease when they are administered properly, I
am also aware that properly administered medications are among
the leading causes of death in the United States (they are
far more damaging than illegal drugs, other than the societal
harm created by their illegality). However, they are often
used far too frequently when safer alternatives are available.
Large drug companies have an enormous influence on medical
education and research. By funding research in medical schools
and hospitals, they often determine what studies are done
and what gets published. They hire scientist spokespeople
(so-called “thought leaders”) to tout their drugs
at medical conferences, and they send reps to doctors’
offices to influence prescribing practices.
The drug companies advertise to both physicians (most of
the pages in many medical journals are in fact drug ads) and
to the public, in all the major media. A recent analysis on
National Public Radio (NPR) was highly critical of the drug
companies because the “information” they provide
is often not backed by the weight of the scientific evidence.
They may find some studies to support their claims, but they
emphasize these even when other studies contradict their conclusions.
The FDA approves both the availability of drugs and the uses
for which they can be advertised. But in some cases drugs
can be valuable for other conditions, and doctors have the
flexibility to prescribe them for “off-label”
uses. (Chelation therapy with EDTA for heart disease is an
example of a valuable off-label use of a drug approved for
lead toxicity.) However, drug companies spend enormous amounts
of money to market their products to doctors for unapproved
(and unproven) uses that are not always beneficial, and in
many cases may be more harmful than other treatments.
The NPR analysis criticized this practice, and quoted a former
editor of the New England Journal of Medicine, who felt that
the companies were acting improperly when they offered PR
in the guise of education, and when they sent drug salesmen
to doctors saying “I know “drug X” is not
approved for “condition Y” but a lot of your colleagues
are finding that it is a great treatment.” (The analysis
referred to the unscientific and unsuccessful use of gabapentin
(Neurontin), an epilepsy drug, to treat manic depression.)
These statements are not scientific, but in a busy physician’s
office, they may be taken at face value, while the drug rep
is only trying to sell more product.
The smart patient asks the doctor in-depth questions, and
makes sure that the safest, most effective option is the first
choice in treatment, even if it is another drug. My first
choice, if possible, is almost always natural therapy with
diet, exercise, stress management, nutritional supplements,
and herbs.
People who are admitted to hospitals are known to have relatively
poor nutritional status, probably reflecting the poor diet
of the population at large. They have poor muscle mass as
well as vitamin and mineral deficiencies. Unfortunately, their
nutritional status tends to decline while in the hospital,
indicative of the low nutrient value of typical hospital food.
A number of studies over the years have shown that if you
have any kind of trauma, including surgery, or if you are
hospitalized for non-surgical health problems, you can improve
your chances of recovery and reduce your hospital stay by
enhancing your nutrition. You should not only take dietary
supplements, but also consider having family or friends bring
in healthier food for you during your hospital stay.
In a study 15 years ago, doctors were unable to recognize
the nearly 50 percent of patients who were malnourished on
admission to a hospital. As a result, they made no effort
to correct their nutritional status, which declined during
their hospital stay. After some basic training, those same
doctors were able to recognize every patient who had malnutrition.
Unfortunately, doctors today are still not well trained in
nutrition.
Poor nutrition is one of the reasons that infections are
rampant in hospitals. Often the patients don’t even
receive enough food to maintain their weight and muscle mass.
I have recently been visiting in a hospital, and I can tell
you that the food they served looked exactly like the food
I saw when I was in training 35 years ago (although I think
it was reheated!).
Studies have shown that immune function is compromised by
poor nutrition, and a number of dietary supplements help,
including vitamins, minerals, essential fatty acids, and amino
acids. A Seattle medical group did a randomized study of trauma
and emergency surgery patients. One group received extra vitamins
C and E, while the other received only “nutritionally
adequate” levels (so they were not technically deficient).
These researchers reviewed almost 600 patients who were at
high risk of respiratory distress and pneumonia, as well as
multiple organ failure. They administered 1000 IU of vitamin
E and 1000 mg of intravenous vitamin C in half the patients,
and RDA levels in the other half. (They used conservative
levels to avoid having to change the study protocol safety
measures.) In the supplemented group, they saw a 20 percent
decline in combined pneumonia and acute respiratory distress
syndrome. Even more impressive was a 57 percent decline in
multiple organ failure.
The supplemented group also had faster recovery, shorter
stays in intensive care, and less time on mechanical respiratory
support. This information is not new, but it takes time for
evidence to accumulate to the degree that impresses physicians
enough to change practice.
In 1992, and again in 1999, researchers reported on supplements,
including L-arginine and omega-3 essential fatty acids, in
surgical patients. The subjects had fewer infections (70 percent
lower), improved immunity, hospital stays that were 2 to 4
days shorter, and lower treatment costs. These patients had
non-emergency surgery, so they were able to start their supplements
5 to 10 days before the operations.
A new study sheds some light on another mechanism for help
from supplements. Antioxidants and L-arginine were added to
human cells in a culture dish. The cells were exposed to mechanical
stress, but nutrient pretreatment protected them from damaging
inflammatory compounds.
Antioxidants have other benefits. Coenzyme Q10 protects the
heart during surgery. Operations on the heart lead to “reperfusion
injury,” or the damage from oxygen free radicals when
blood starts flowing back into oxygen-deprived tissues. Pretreatment
with coenzyme Q10 prevents this damage. The information was
published in 1996 in a heart surgery journal, but coQ10 is
still not commonly administered by surgeons.
In an animal study, vitamin C was helpful in preventing reperfusion
injury. The antioxidant glutathione is another beneficial
substance, made in the body from the amino acids glycine,
glutamine and cysteine. These plus other vitamins, minerals,
and amimo acids, reduce inflammation, protect from free-radical
damage, and are important for healing from trauma or surgery.
Good nutrition promotes healing, and will give you the best
chance of recovery.
Recent analyses have suggested that excessive levels of vitamin
A in the blood may be associated with an increased risk of
osteoporosis and fractures. The most recent population study
in Sweden suggested that men in the highest fifth of serum
levels had about twice the risk of hip fracture compared to
those in the middle range of vitamin A levels.
This was widely reported in the press, but what they did
not mention was that those in the next to highest and middle
ranges had a significantly lower risk than those with lower
blood levels. The amounts in normal vitamin supplements appear
to be quite safe, but if someone is also taking cod liver
oil, eating chicken or beef liver and dairy products with
added vitamin A, they may have some risk, so I do recommend
caution.
One problem with the latest study is that they measured blood
levels just once at the beginning of the study 30 years ago.
They assessed dietary intake with a questionnaire in only
half of the subjects, when they were 20 years into the study.
While this study gives cause for some concern, other studies
are contradictory, so we have to be careful before drawing
firm conclusions.
Beta-carotene has not been associated with any bone density
risk, even though a portion of it may be converted to vitamin
A in the body.
Q. I heard that ascorbic acid is not the best form of vitamin
C. Is there another kind that is better?
BG, via the Internet
A. A few forms of vitamin C are currently available at health
food stores and through mail order companies. Ascorbic acid
is the most basic form of vitamin C, and it has been around
for a long time.
Ascorbic acid is mildly acidic, and it is generally very well
tolerated, although high doses of any form of vitamin C can
lead to loose bowels or even diarrhea if you take enough at
one time.
You can also find buffered ascorbate, in which the acidity
is eliminated by combining the ascorbic acid with minerals,
making a “salt.” This combination may be with
sodium, potassium, calcium, magnesium, or a combination of
these minerals.
Some people report that they have some digestive upset when
they take plain ascorbic acid, although this is not usually
a problem. They may tolerate the buffered form of vitamin
C better.
You can also find a product called Ester-C, a buffered form
of vitamin C that the manufacturer claims is better than plain
vitamin C or other buffered forms. Ester-C combines calcium
ascorbate with dehydroascorbate and calcium threonate, both
metabolites of ascorbic acid.
So far, I have seen no convincing evidence that Ester-C is
any better than other forms, and some suggestive evidence
that it may not be as good. Linus Pauling took buffered ascorbate.
I take plain ascorbic acid. Although I take about 9 grams
a day, I usually recommend about 3 to 4 grams for most of
my patients, or more for specific health problems, such as
viral infections, cancer, heart disease, healing of wounds,
or surgery.
Ascorbyl palmitate is a lipid ester of vitamin C used in
pills, and also in skin creams as an antioxidant and to help
maintain skin collagen.
•Regular exercise has a new benefit for cardiovascular
disease: it appears to stimulate the production of anti-inflammatory
substances by increasing blood flow and stress on the vessel
lining. Recurrent inflammation, leading to elevation of markers
such as C-reactive protein (CRP) in the blood, appears to
be one of the strongest risk factors for heart disease. Reducing
inflammation through the local effect of exercise may be one
of the best defenses. (Ji JY, et al., Shear Stress [...and]Endothelial
Glucocorticoid Receptor and Expression... Circulation Research
2003, 10.1161/01.RES.0000057753.57106.0B.)
•Costly modern drugs for hypertension are not only more
expensive than the older thiazide-type diuretics, but also
no better for treatment, and far more risky. The study (ALLHAT…Research
Group, Major outcomes in high-risk hypertensive patients....
JAMA 2002 Dec 18;288(23):2981-97.) compared a thiazide with
an ACE inhibitor (lisinopril) and a calcium channel blocker
(amlodipine, or Norvasc). The diuretic controlled blood pressure
and mortality as well, but had fewer side effects. The amlodipine
had a 40 percent higher rate of heart failure in five years.
Still better: try coenzyme Q10, essential fatty acids, magnesium,
garlic, and vitamins C and E as first treatments; they all
have side benefits, rather than toxic side effects.
• Yet another study reports on the value of whole grains
(Liu S, Intake of refined carbohydrates and whole grain foods
in relation to risk of type 2 diabetes mellitus and coronary
heart disease. J Am Coll Nutr 2002 Aug;21(4):298-306.) Complex
carbohydrates and fiber reduce the risk of diabetes, obesity,
and heart disease. They lead to more favorable blood lipids
and less insulin resistance, a precursor to both diabetes
and heart disease. Refined carbohydrates (sugar and white
flour, for examples) increase those risks.
Here is one way to add a tasty whole grain to your diet. Bring1½
cups of millet in 3 cups of water (or diluted organic vegetable
broth) to a boil, then simmer until the liquid is gone. Cut
a cauliflower into 2-inch pieces. Chop 1-2 onions plus fresh
garlic and stir-fry them in olive oil with cumin, thyme, dill,
and cayenne to taste. Add cubes of tofu (½ pound) and
let it sizzle, then add the cauliflower, cooking until it
is almost soft, and add a pound of chopped mushrooms. Next,
fold in a bunch of chopped spinach, 2-3 Tbsp of chopped parsley,
and the juice of one lemon, cook briefly, then mix in the
millet. Place it all in a casserole, with or without a sprinkle
of organic parmesan cheese, and add some slices of tomato.
Place this in the oven at 350° for about 30 minutes, or
until the top is brown.
National Public Radio, All Things
Considered, January 16, 2003.
Macdonald KJ, Young LT, Newer antiepileptic drugs in bipolar
disorder.... CNS Drugs 2002;16(8):549-62.
Roubenoff R, et al., Malnutrition
among hospitalized patients. A problem of physician awareness.
Arch Intern Med 1987 Aug;147(8):1462-5.
Nathens AB, et al., Randomized...antioxidant supplementation
in critically ill surgical patients. Ann Surg 2002 Dec;236(6):814-22.
Daly JM, et al., Enteral nutrition with supplemental arginine,
RNA, and omega-3 fatty acids... Surgery 1992 Jul;112(1):56-67.
Gianotti L, et al., A...clinical trial on perioperative feeding
with an arginine-, omega-3 fatty acid-, and RNA-enriched enteral
diet.... JPEN J Parenter Enteral Nutr 1999 Nov-Dec;23(6):314-20.
Sullivan DH, et al., Protein-energy undernutrition among elderly
hospitalized patients... JAMA 1999 Jun 2;281(21):2013-9.
Coats KG, et al., Hospital-associated malnutrition: a reevaluation
12 years later. J Am Diet Assoc 1993 Jan;93(1):27-33.
De Nigris F, et al., Beneficial effects of antioxidants and
L-arginine .... Proc Natl Acad Sci USA 2003 Jan 13; 10.1073/pnas.0237367100.
Crestanello JA, Elucidation of...mechanism underlying the
improvement in cardiac tolerance to ischemia by coenzyme Q10
pretreatment. J Thorac Cardiovasc Surg 1996 Feb;111(2):443-50.
Demertzis S, et al., Ascorbic acid for amelioration of reperfusion
injury...in sheep. Ann Thorac Surg 2000 Nov;70(5):1684-9.
Michaelsson K, et al., Serum retinol
levels and the risk of fracture. N Engl J Med 2003 Jan 23;348(4):287-94.
Ballew C, et al., High serum retinyl esters are not associated
with reduced bone mineral density... J Bone Miner Res 2001
Dec;16(12):2306-12.
Wang S, et al., Pharmacokinetics in
dogs...of two different forms of ascorbic acid. Res Vet Sci
2001 Aug;71(1):27-32.
drjanson@drjanson.com
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through May: 386-409-7747
June
through October: 603-878-2256
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