Edward R. Rosick, DO, MPH, DABHM Chair/Medical Director, Family & Community Medicine Dept. Michigan State University COM

Use of modalities that are not commonly used in modern medicine: ---Vitamins/minerals ---Herbs ---Prayer ---Relaxation techniques ---Things we weren’t taught in medical school!

 Some modalities once thought to be alternative (such as osteopathic manipulation,acupuncture, and biofeedback) have gained some acceptance in modern medicine.

A recent study (2014) in the Journal of the American College of Nutrition reported that 45-50% of U.S. adults regularly take supplements, with those females and aged >50 the highest users  Two studies looking at cancer patients showed an even higher percentage of supplement use at 50-70%

 Among CIM users, 41% report using 2 or more therapies concurrently  Most popular CIM therapies include:  vitamins & herbal supplements, relaxation & meditation, and yoga.

---Prevention/treatment of chronic diseases such as cancer, Alzheimer's, heart disease ---As adjunctive therapies to conventional treatment ---Rising costs of prescription drugs and the increased attention to side effects (i.e., belief that “natural is better and safer”)

 The Bottom Line is that patients use supplements to enhance their sense of control over their own health

Recent article in the Journal of Clinical Nutrition reported that 20% of physicians dismiss CIM out of hand and 33% report they don’t know enough about supplements to give their patients any worthwhile advice.

 Supplements can cause side effects, symptoms, and outcome measurements that may be attributable to pharmaceutical medication  This can lead of changes in therapy, medications, expensive tests, or more serious consequences.

 Report out of the Mayo Clinic stated that over 40% of dietary supplement users DO NOT report use to their providers and that 70% of these responders stated that their provider did not ask them.

 Multivitamin-mineral complex  Vitamin D  Glucosamine/chondroitin  Fish Oil

 Some argue that we get all the nutrition we need from our diet  Reality is that only 6% of adults meet the food group requirements of 5 servings of fruit a day and 5 servings of vegetables a day  Example: Potatoes, iceberg lettuce, and ketchup account for 50% of our vegetable intake

 The non-adherence to the recommended food guidelines means that we’re not meeting the RDAs of most vitamins and minerals

 Percent of US populations aged 2 or greater not meeting the RDA of:  Vitamin B %Vit C-37.5%  Niacin-25.9% Iron-39.1%  Phosphorous-27.4%Vit B6-53.6%  Riboflavin-30%Vit A-56.2%  Thiamine-30%Mg-61.6%  Folate-33.2% Calcium-65.1%

Some would argue no, since overt vitamin deficiencies are rare  However, if one takes into account the poor nutritional value of the standard American (SAD) diet, then taking a MV supplement may be a reasonable choice

 In 2002, researchers at Harvard concluded, in a JAMA editorial, that adults should be advised to take a multivitamin  “Pending strong evidence of effectiveness from randomized trials, it appears prudent for all adults to take vitamin supplements”

 RDBPC trial enrolling 14,641 male physicians 50 yrs. or older  Published in JAMA Nov. 14, 2012  Results: daily multivitamin supplementation had a statistically significant effect in reducing the risk of total cancer.  2014 report in Ophthalmology showed that those physicians taking MV also had a statistically significant risk of developing cataracts.

 Laboratory studies, observational studies, and secondary prevention trials suggest that vitamin D can reduce the risk of chronic diseases (heart disease, diabetes, cancer)  VITAL trial (Vitamin D and OmegA-3 Trial)— RDBPC trial of 2,000 IU of vitamin D3 and 1,000 mg fish oil in the primary prevention of cancer and CVD among approx. 20,000 men and women >50 years of age. ( Mason et al 2012)

 Vitamin D and heart disease ◦ VDR found on vascular smooth muscle, endothelium, and cardiomyocytes ◦ 2010 article in the American Journal of Cardiology examined the prevalence of vitamin D deficiency and the relationship of vitamin D deficiency with CVD in a prospective analysis of 41,504 patients (Anderson et al 2010)

 Vitamin D deficiency (<30 ng/ml) was significantly associated in the prevalence of hypertension, PVD, diabetes, and hyperlipidemia, coronary artery disease, MI, heart failure, and stroke.  2012 article in same journal presented the results of a observational retrospective study on 10,889 patients (men and women, mean age of 58 +/- 15 years) examining vitamin D levels/supplementation and cardiovascular health (Vacek et al 2012).

 Results: Mean serum vitamin D levels were 24.1 ng/ml. Vitamin D deficiency (defined as less than 30 ng/ml) was significantly associated with coronary artery disease, hypertension, cardiomyopathy, and diabetes, as well as being a strong independent predictor of all-cause death.  Vitamin D supplementation (mean intake of 2254 I.U) improved overall survival.

 Authors of the study concluded “vitamin D deficiency was associated with a significant risk of cardiovascular disease and reduced survival. Vitamin D supplementation was significantly associated with better survival, specifically in patients with documented deficiency.”

 Meta-analysis of data from the European Prospective Investigation into Cancer (EPIC) Norfolk study showed a definite inverse association between vitamin D levels and the risk of developing type 2 diabetes (Forouhi 2012).  A recent cross-sectional study of 2,708 Chinese men and women (aged 48 +/- 12 years) showed that those in the lowest quartile (<20ng/ml) had a statistically significant higher risk of developing IR and T2D then those with vitamin D serum levels of 30ng/ml or above (Huang et al 2013)

Vitamin D is postulated to act as an ‘anti- cancer’ molecule by exerting anti-proliferative, pro-apoptotic, and pro-differentiating actions on malignant cells, as well as showing suppression of tumor angiogenesis and metastasis (Krishnan, 2013).

 2013 article in the American Journal of Clinical Nutrition examined prospective cohort data from the Women’s Health Initiative Study examining the possible role of vitamin D and lung cancer risk (Cheng et al 2013).  Examination of data from 128,779 women showed that supplemental vitamin D intake (800 I.U. daily) was associated with lower lung cancer risk.

 Meta-analysis of 10 studies of 7,275 male and female patients examined the possible relationship between vitamin D and colorectal cancer (Yin et al 2011).  Authors reported that there was a statistically significant inverse relationship between vitamin D levels and the risk of developing colorectal cancer.

 A recent study examined the association between breast cancer risk and vitamin D levels in Australian women (Bilinski et al 2013).  This case-control study of 214 women and 852 controls (aged 55 +/- 11 years) showed that those women with a vitamin D level of less than 75 nmol/l had a statistically higher risk of developing breast cancer.

 2013 report out of the Boston University School of Medicine discussed the relationship between vitamin D and cancer.  Authors concluded that “A multitude of studies have associated improved vitamin D status with decreased risk of developing several cancers including colon, breast, pancreatic and ovarian cancers…the goal [of supplementation] is to achieve blood levels of 25-hydroxyvitamin D of ng/ml.” Holick, 2013)

 Glucosamine is a substance involved in the synthesis of structural components of cartilage. Chondroitin is a component of cartilage and also inhibits enzymes which break down cartilage RDBPCT of 318 men and women showed that Glucosamine was statistically more effective than either placebo or acetaminophen in treating OA knee symptoms.

 A 2009 systematic review showed that G or G/C statistically reduced the risk of OA (knee) progression.  A 2014 study in the Annals of Rheumatic Diseases discussed a DBRPC trial of G/C for knee osteoarthritis.  605 patients, aged years, received either G, G/C, or placebo. After 2 years, those taking G/C showed a statistically significant reduction in joint space reduction as compared to placebo. No significant adverse side effects as compared to placebo.  Dosage: 1,000-1,500 mg daily

 Humans require 2 types of essential fatty acids—omega 6 & omega-3  Omega 6 sources include sunflower, corn, & soybean oils  Omega 3 sources include fish, nuts, flaxseed, & canola oil

 Ideal ratio of omega-6 to omega-3 for optimal health has been calculated to be 2:1.  However, current ratio is thought to be 10 or 20 to 1 due to the mass introduction of vegetable oils and modern animal rearing methods

 Clinical applications for omega-3 supplementation include:  Pregnancy: omega-3 intake in pregnancy (300 mg DHA) is vitally important for the neurological development of the fetus; it has also been shown to prevent pre-term labor. Also important for infant/child brain development.

 Recent studies (2012 Journal of Nutrition review article) show strong evidence that omega-3 fatty acids can help prevent fatal CHD,, sudden death, a-fib, and congestive heart failure.  2013 DBRPC trial of fish oil for MCI showed those patients (male and female, aged ) taking fish oil supplements had statistically significant improvments in short term and working memory, immediate verbal memory, and delayed recall capability.

 2013 study by Brasky et al. in the Journal of the National Cancer Institute reported that omega-3 fatty acids are involved in prostate cancer occurrence, leading to reports in the media (print, television, web) that fish oil can cause prostate cancer.  “Hold the Salmon: Omega-3 Fatty Acids Linked to Higher Risk of Cancer[!]”

 Study measured plasma phospholipid omega- 3 levels in 834 men who developed prostate cancer and 1,393 who did not. The men who had the highest levels of omega 3 fatty acids had a increased risk of 43%.  Difference between omega-3 levels in men in highest to lowest quartile was 0.18% (4.48% to 4.66%)  Study provided no data on fish intake or omega-3 supplement use.

 Multiple studies point to protective actions of omega-3 fatty acids/fish oil on prostate cancer.  2013 article in the American Journal of Epidemiology examined the association between omega-3 fatty acids, fish oil, and risk of developing prostate cancer and concluded that omega-3 fatty acids from fish oil were inversely associated with prostate cancer occurrence.

 CIM will continue to be used by a significant number of geriatric patients and has the potential to play a significant role in health promotion and risk reduction, especially in the realm of chronic diseases.  We in the Osteopathic community must continue to push the envelope as well as sort out what works and what doesn’t for the safety and well-being of our patients.