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

2. 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!

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

4. 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%

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

6. ---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”)

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

8. 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.

9.  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.

10.  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.

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

12.  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

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

14.  Percent of US populations aged 2 or greater not meeting the RDA of:  Vitamin B12-17.2%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%

15. 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

16.  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”

17.  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.

18.  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)

19.  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)

20.  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).

21.  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.

22.  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.”

23.  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)

24. 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).

25.  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.

26.  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.

27.  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.

28.  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 40-60 ng/ml.” Holick, 2013)

29.  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. ---2007 RDBPCT of 318 men and women showed that Glucosamine was statistically more effective than either placebo or acetaminophen in treating OA knee symptoms.

30.  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 45-75 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

31.  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

32.  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

33.  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.

34.  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 59- 70) taking fish oil supplements had statistically significant improvments in short term and working memory, immediate verbal memory, and delayed recall capability.

35.  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[!]”

36.  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.

37.  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.

38.  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.