Newsletters February 2003

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

Drugs: Safe and Effective?

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.

Nutrition for Surgery and Healing
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!).

Supplements Help Trauma Recovery
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.

Vitamin A Safety
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.

Ask Dr. J
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.

In the Health News
•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.

Diet and Disease
• 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.

Recipe of the Month: Cauliflower Millet Casserole
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.


Drugs: Safe and Effective?
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.

Nutrition: Surgery and Healing
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.

Vitamin A Safety
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.

Vitamin C
Wang S, et al., Pharmacokinetics in dogs…of two different forms of ascorbic acid. Res Vet Sci 2001 Aug;71(1):27-32.

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From September to June, I see patients in New Smyrna Beach, Florida. Call 386-409-7747, or send an email to [email protected] to make arrangements.

In summer, I have a variable schedule, and I see patients in offices at the Rothfeld Center for Integrative Medicine in Waltham, Massachusetts. For appointments, send an email to [email protected] make arrangements, or call: 386-409-7747.

I primarily do phone consultations, as well as email and instant messaging consults.

Information herein is not medical advice or direction. All material in this newsletter is provided for information only. Its contents should not be used to provide medical advice on individual problems. Consult a health care professional for medical or health advice.