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During my 30-year career in nutritional medicine, one relative constant has been the resistance in medical academia to the notion that nutritional therapy, particularly micronutrient supplementation, can be useful for the prevention and treatment of disease. This bias against nutrition was the topic of an editorial in the Archives of Internal Medicine several years ago.’ The lack of knowledge about, or interest in, nutritional therapy among conventional physicians markedly decreases their therapeutic options. Moreover, sensing that their doctor is indifferent or even hostile to natural medicine, patients frequently keep their doctor out of the loop with regard to the nutritional supplements and herbs they are taking, thereby increasing the risk of drug-nutrient or drug-herb interactions.

In an editorial in Lancet, Tim McAlindon, MD, from the Arthritis Center, Boston University Medical Center, stated: “It is time for the profession to accommodate the possibility that many nutritional products may have valuable therapeutic effects and to regain the credibility of the public at large.”(2) Fortunately, it appears that at least some members of the academic community are beginning to take that suggestion seriously.

In March, more than 100 scientists and practitioners, many from academic institutions, attended the week-long “Food as Medicine” conference in Florida, sponsored by the Center for Mind-Body Medicine in Washington, DC, and organized by James Gordon, MD, and Susan Lord, MD. The conference was designed to provide medical school professors with the tools to bring state-of-the art information about diet and micronutrients back to their institutions. As one of the presenters, I was impressed with the excitement and awareness of new possibilities that resulted from the attendance at this course.

Among the many whole-foods snacks and healthful meals served at the conference, not a crystal of refined sugar was to be found, and none of the fatty acids were present in the transform. Indeed, the only trans-formation was in the hearts and minds of those attending the conference.

Malnutrition

A number of laboratory studies have been used in the nutritional assessment of malnutrition; however, they are unlikely to uncover marginal malnutrition. Although plasma or serum albumin is a popular measure, sick patients may have low levels for several other reasons, such as inflammatory processes, gut losses due to gastrointestinal or cardiac disease, and renal losses due to kidney disease. Moreover, even when malnutrition is chronic, this measure is often normal because of compensatory mechanisms. Typical laboratory findings include serum albumin of less than 3.5 g/dL, serum prealbumin concentration less than 10 mg/dL, total lymphocyte count less than 1,200 mm3, and an anemia of chronic disease. (1)

Since measuring gastric acidity directly by gastric intubation is uncomfortable for the patient, other methods have been devised. Analysis can be done using the Heidelberger pH capsule gastrointestinal radio transmitter or even with a simple, inexpensive gelatin capsule containing specially treated cotton floss*.

Even when it is absent in the fasting state, acid production following the entry of food is often normal; thus testing must be performed after the patient is given a potent parietal cell stimulus. (2)

Basal serum gastrin measurement may also be helpful, as somewhat increased levels can be found in conditions associated with achlorhydria if the antrum is not severely affected–such as atrophic gastritis and pernicious anemia. (3)

Specific Nutrient Abnormalities

Calcium

Ionized calcium measures unbound serum calcium. It is a useful measure of calcium balance when it is low; however, normal levels do not rule out a negative calcium balance. (4)

Hair calcium must be interpreted with caution, as a negative calcium balance may be accompanied by elevated hair levels. (This combination suggests that possibility of a nutritionally-induced secondary hyperparathyroidism related to a low calcium, high phosphorus diet.) (5) Moreover, grey hair is naturally lower in calcium. (6)

Abstract

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder without a known cure. Conventional medicine typically approaches the disease with a treatment plan that includes the use of corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDS), antimalarial drugs, and chemotherapeutic agents. The results vary and safety is questionable. Conservative treatment methods, such as the use of vitamins, minerals, and fatty acids, have been shown to have an impact on the activity of the disease. Alternative medicine treatments, including the use of dehydroepiandrosterone (DHEA) and Chinese medicines, such as Tripterygium wilfordii Hook F (TwHF), have gained a growing interest recently and may prove to be viable treatment options in the future. The elimination of possible associated factors, such as food allergens and SLE-symptom eliciting foods like alfalfa seeds, have also been shown to affect disease activity. Conservative altemative medicine approaches have been shown to provide some benefit in SLE studies; however, the evidence is limited, and the overall effectiveness and long-term safety have not been established. More research must be conducted in this area to further establish firm treatment protocols which provide maximum therapeutic benefit and minimum treatment-related side effects.

Introduction

Systemic lupus erythematosus (SLE) is an autoimmune disease that imposes multiple complications on an affected individual, the family, and the healthcare provider who tries to control its manifestations. The etiology of this disease is unknown and its course often differs from patient to patient. To complicate matters further, SLE is often misdiagnosed or overlooked by healthcare providers.

The diagnosis of SLE is presently based on criteria promulgated by the American College of Rheumatology (ACR).

Introduction

Conventional treatment for alcoholism, or drug dependency, has been focused on mono-therapeutic approaches. The literature is inundated with treatment regimes that are based on medical, counseling, or spiritually-based approaches. Unfortunately, rarely are these protocols used simultaneously and rarely is treatment successful when the holistic approach is ignored. At best, most treatment programs, even those claiming holistic treatment, are bimodal in their approach. And when they are utilized together, nutrition is often overlooked as a necessary component of detoxification and recovery. Certainly, one can find ample information, on the Internet and elsewhere, on the nutritional aspects of treatment of alcoholism. However, rarely do these nutritional protocols address the deeper issues. Fortunately, there are leaders in the field of integrative/functional medicine who are changing the way we look at treating chronic disease–nutritionally. Alcoholism is now recognized as a chronic disease. When treatment programs utilize body-mind-spirit approaches with well-designed nutritional protocols, the successes are dynamic. In this monograph we will attempt to introduce the concepts of functional/molecular medicine for the treatment of alcoholism and suggest why studying the deeper issues of nutritional therapy is an absolute necessity for successful detoxification and subsequent successful recovery.

Although nutrition, as a science, has always been part of conventional medicine, doctors are not taught, and therefore do not practise, much in the way of nutritional therapeutics. Dieticians in conventional settings tend to work mainly with particular patient groups–such as those with diabetes, obesity, digestive or swallowing problems, or cardiovascular risk factors. Apart from the treatment of gross nutritional deficiencies and rare metabolic disorders, other nutritional interventions generally fall outside the mainstream and can therefore be described as complementary medicine.

Background

There is a wide spectrum of complementary nutritional practices. These range from specific, well researched, biochemically understood treatments that are given by well trained practitioners to unresearched, biochemically implausible interventions popularised by spectacular claims in the lay press and largely used without professional supervision.

Just which treatments are “conventional” and which are “complementary” is subject to debate. Some, such as fish oil supplements for patients with rheumatoid arthritis, have many of the features of a conventional medical treatment–a biochemical mechanism and support from randomised trials–but are, none the less, often considered unconventional. Other interventions were originally considered “complementary” but are now part of conventional practice. Probably the best example is the high fibre diet, rich in fruit and vegetables. “Alternative” practitioners of the 19th century, such as John Kellogg, advocated such a diet at a time when conventional nutritional authorities tended to see meat and potatoes as the best food, even to the extent of denigrating the importance of vegetables and describing wheat bran as “refuse.”

Nutritional interventions

Unconventional nutritional interventions can be broadly divided into three categories: nutritional supplements, dietary modification, and therapeutic systems.

The problem of the interference of celiac disease (CD) with the male reproductive system is made evident both by the recognized adverse effects on female reproduction and by the multifactorial nature of the disease. It is important to consider CD as a multifactorial condition since its diverse effects can be modulated, besides gluten, by different concurrent genetic and environmental factors. The male CD patient has a greater risk of infertility and other reproductive disturbances, as well as a greater incidence of hypoandrogenism. In this paper the problems of CD associated to endocrine disorders and to deficiencies of micronutrients are discussed. Affected males show a picture of tissue resistance to androgens. Moreover, attention should be paid to increases of FSH and prolactin: these are not associated to infertility and/or impotence, but they may indicate an imbalance at hypothalamus-pituitary level, with general effects on health: an example is the increased risk of male osteoporosis in CD patients. Hormone alterations are reversible upon start of the gluten-free diet, emphasizing the importance of early diagnosis: this should be performed in the case of clinical suspicion, e.g., unexplained hypoandrogenism. As regards nutritional aspects, the folic acid deficiency of CD can affect rapidly proliferating tissues, such as the embryo and the seminiferous epithelium. More attention should be paid to deficiencies of fat-soluble vitamins, such as A and E, observed in CD. Vitamin A is important for Sertoli cell function as well as for early spermatogenetic phases. Vitamin E supports the correct differentiation and function of epidydimal epithelium, spermatid maturation and secretion of proteins by the prostate. Therefore, CD male patients should be considered as vulnerable subjects: thus, the detection of early biomarkers of andrological or endocrinological dysfunctions should trigger timely strategies for prevention and treatment.

The prevalence of HIV infection and AIDS has increased steadily in all demographic groups since the epidemic began, yet data show that minorities and lower-income populations are disproportionately affected by HIV disease. Nutritional adequacy in all populations is an often overlooked area in the progression of HIV disease, despite the fact that the relationship between poor nutritional status and impaired immune response is well established. It can be hypothesized that minorities and lower-income individuals are likely to have poorer nutritional habits.

The objective of a recent investigation was to determine the correlates of reduced and inadequate nutrient intakes in a large, clinically and socioeconomically diverse cohort of HIV-infected adults. Researchers also sought to determine the extent to which dietary inadequacy is correlated with clinical symptoms, economic inability to procure foods, and lack of health awareness. The Nutrition for Healthy Living (NFHL) is a longitudinal study of wasting in HIV disease. Since the initiation of the study in 1995, 679 HIV-positive participants have enrolled. The data pertaining to this investigation were obtained from two baseline clinical visits per participant. The visits consisted of a physical examination, anthropometric measurements, and administration of several questionnaires on clinical status, physical activity, alternative health treatments, and quality of life. At the first visit, each subject was given a 3-day diet record that was to be completed and returned at the second baseline visit. Dietary intakes were measured as absolute intakes and also as percentages of the US recommended dietary allowances (RDAs). Supplement use was included in all nutrient calculations. The adequacy of energy intake was determined by comparing each subject’s energy intake with the energy needed to sustain minimal physical activity as determined through indirect calorimetry.

Osteoporosis affects as many as 30% of post-menopausal women and about 5% of older men in the United States. More than 1.2 million fractures (primarily of the hip, spine or wrist) occur each year as a direct result of osteoporosis. As recently as the late 19th century, osteoporosis was considered a rare disease. Since that time, the prevalence has increased progressively, even after adjusting for the age of the population. Since our genes have not changed much during the past century, environmental factors are likely responsible for this epidemic of thin bones. I have outlined many of these factors in my book Preventing and Reversing Osteoporosis (Prima Publishing, 1994), and suggested various non-drug strategies for preventing and treating the disease. Following is a summary of that information, updated according to research published since the book was written.

Environmental pollution

Several heavy metals that contaminate the environment (e.g., aluminum, lead, cadmium, and tin) have been shown in animal studies and in some human research to promote osteoporosis. Of particular concern is aluminum, which has become widely distributed in our environment. Sources of aluminum include beverages stored in aluminum cans, some municipal water supplies (aluminum is added to prevent the accumulation of particulate matter), processed cheeses and other processed foods, food additives (including preservatives, coloring agents, and leavening agents), aluminum cookware, aluminum products used to store or wrap food, underarm deodorants, and antacids. While it is not possible to avoid aluminum completely in our modern environment, exposure to this metal can be greatly reduced by making some basic lifestyle modifications.

The main source of tin exposure is food packaged in tin cans. While some tin leaches into foods and beverages before the can is opened, an even greater amount can leach if the food or beverage is allowed to sit in the container after the can is opened. Tin exposure can be reduced by decreasing the use of tin cans, by not allowing tin cans to be stored at high temperatures, and by transferring the contents of the can to another container after it is opened.

I recommend that this textbook be a part of the reference material for every doctor of chiropractic, and that it be referred to often. The information, properly used, will be very valuable to every chiropractor who not only wants to be sure the right message is getting through from the brain to the organ, but who wants to be sure the right raw materials are present to act upon the message.

Before beginning to use this textbook as a reference, the physician should first read Part One very carefully. Without this understanding, the expectations of results of following the protocols in “Part Two: Nutritional Treatments for Specific Illnesses” could be unrealistic. Part One rightly points out that for decades, modem medicine has employed a “single cause, single cure” approach to disease that might have been valid in the days when infection and gross nutrient deficiency were common. Considering today’s lifestyles and stresses, other factors, such as neuroendocrine imbalance (stress response and its numerous effects on endocrine function), improper nutrition (micronutrient imbalance), chemical and/or heavy metal toxicity, compromised mucosal barriers, and genetics, should enter into the decision making when determining proper nutritional therapy. The chiropractor can readily see the importance of the neuroendocrine imbalance as it would relate to ALL other factors.

The treatment suggestions listed in Part Two are easy to read and understand. Many conventional practitioners have objected to nutritional treatment because of a lack of valid scientific studies. This is addressed on page 63 under the title “Efficiency Ratings, ” This book is fight-years ahead of what many of us are used to seeing published by various natural product companies that provide a list of diseases or symptoms and list the supplements they sell to treat the diseases or alleviate the symptoms. I was amazed to see how many recommendations are based on efficacy demonstrated by at least one controlled human trial. There seems to be a great deal more information in the scientific literature, and there are many more scientifically accepted trials reported, than the practitioner on the front fines generally knows about.

It is agreed among most clinicians that patient morbidity, mortality, and hospital length of stay can be negatively affected by malnutrition. In fact, nutrition guidelines state that any patient unable to consume adequate nutrients orally (60% nutrition needs) for at least 5 days in the critically ill, or 7 to 14 days in the general population, should be a candidate for specialized nutrition support and that enteral feeding is preferred over parenteral nutrition.1 However, inadequate attention to nutrition intervention may occur for several reasons, including lack of recognition of need for various patient populations, low priority, and controversial clinical outcomes. Because of variance in research designs where nutrition intervention may be provided to well-nourished or mildly malnourished patients and lack of stratification for comorbidities or surgical pathology, thus resulting in little to no benefit with early nutrition intervention, many clinicians opt not to aggressively feed their patients until complications arise and forgo preoperative nutrition intervention altogether.

Significantly increased postoperative complications, mortality rates, intensive care unit (ICU) and hospital length of stays were found to occur among general surgery patients that were capable of receiving preoperative nutrition but did not.2 Complications were correlated with operative site, magnitude and complexity of the procedures and preoperative albumin levels, with complications rising as albumin levels dropped (Table I). For patients with an albumin level 3.25 g/dL), all differences vanished, reflecting the high number of poorly nourished patients in the VA system and public hospitals.