NATUROPATHIC MEDICINE - Prevention Slide Decks... · 2017-04-25 · Dietary Fish intake associated...

Overview of naturopathic medicine and some common misconceptions

Assessment of fall risk in naturopathic practice

Nutritive status in older adults and the relationship to falls

Naturopathic treatment of medical conditions associated with increased fall risk

Options to reduce need for medications that increase fall risk

GOALS

NATUROPATHIC MEDICINE

Naturopathic Medicine is a

health care system that blends

modern medical knowledge

holistic and natural approach to the

assessment, diagnosis and treatment

of an individual

By focusing on prevention and

treating the cause of disease

NATUROPATHIC MEDICINE

NATUROPATHIC MEDICINE

6

Principles

of

Naturopathic

Medicine

NATUROAPTHIC MEDICINE

Misconceptions

Naturopathic Medicine….

Is not “Evidence Based”

Is “Alternative”

Is “Complementary”

Is about being “natural”

Is against prescription drugs

Is not regulated

Doesn’t refer / collaborate

Naturopathic Visits are very comprehensive

Complete medical history

Fall Risk Specific Assessment

o Fall risk checklists and algorithms (CDC)

o Orthostatic Blood Pressure

o Grip strength

o Gait speed

o Timed Get-up-and-GO (TUG)

o BERG Balance Scale

Refer to PT or OT for more in-depth assessment

ASSESSMENT OF FALL RISK

Lab testing Vitamin D (25-OH), Vitamin B12, Ferritin, CRP

Physical Exam related to fall risk o Blood pressure + Orthostatic Blood Pressure

o Weight, Hip/Waist ratio, BMI

o General assessment of muscle mass

o Hair Skin and Nail Exam

Nutritional Assessment & Diet Diary

Assess whole-person health and well-being: o Stress, mental health, spirituality, social

circumstances, finances, hobbies etc.

ASSESSMENT OF FALL RISK

Nutritional Risk: o34% of community dwelling older adults

over the age of 65 are at “Nutritional Risk” or risk of poor nutritional status

(Canadian Community Health Survey on Healthy Aging, 2008/2009)

Level of Nutritional risk is a significant indicator of fall risk (Johnson, 2003)

NUTRITION IN OLDER ADULTS

Risk Factors for Developing Malnutrition

Age Related

Physiological

Changes

•Loss of Appetite

•Change in senses

•Poor digestion

Medical conditions •Chronic Disease

•Polypharmacy

•Poor dentition

•Poor vision

•Depression, Isolation, Grief

•Altered cognition

Mobility •Poor Functional Status

•Availability and affordability of

transport

Social •Financial constraints

•Eating along / cooking for 1

•Lack of help preparing food

Physical Environment •Location of grocery stores

•Geographic isolation

Key Points about Nutrition & Fall Risk

• It is not about independent micronutrient deficiencies, rather overall nutritional

health

• Frailty & Weakness caused by malnutrition

• Effect of short term and lifetime diet on disease risk and fall prevention

NUTRITION AND FALL PREVENTION

This is NOT nutrition…

NATUROPATHIC NUTRITION

Drugs to reduce stomach acid

One of the top 5 most of the most prescribed drug

classes in Canada

Men: 5th most common drug (16% men 65-79)

Women: 2nd most common drug (22% women

65-79) • (Statistics Canada, 2014)

Some clinically relevant uses

Health Canada recommends lowest dose, for

shortest duration

PROTON PUMP INHIBITORS

Adverse effects Associated with PPIs (Schoenfield, 2016) (Climacteric, 2016) (Gomm, 2016)(Corleto, 2014, Jacob 2016)

Fracture

Osteoporosis (Decreased bone density & strength

Pneumonia

C. Difficile diarrhea (OR 1.69)

Hospital and community acquired pneumonia (OR 1.3)

Chronic Kidney Disease

Hypomagnesia, B12 Deficiency

Dementia (HR 1.44)

Reduce diversity of good gut bacteria

ALL of above may increase fall risk!

PROTON PUMP INHIBITORS

We will

review:

Naturopathic

Approaches

for select

conditions

that have a

high Odds

ratio (OR) of

Fall Risk

(Centre for Effective Practice, 2016)

Criteria 1:

The presence of low skeletal muscle mass

Plus at least one of Criteria 2 or 3:

Criteria 2: Low Muscle strength (e.g. handgrip)

Criteria 3: Or Low muscle performance (e.g. walking speed or muscle power)

When all three conditions are present, severe sarcopenia may be diagnosed

(Santilli, 2014)

SARCOPENIA OR

≈5

SARCOPENIA

Sarcopenia and Fall Risk Sarcopenia as a risk factor for falls in elderly

individuals: results from the ilSIRENTE study. (Landi, 2012)

oFall Risk Adjusted hazard ratio [HR], 3.23

Sarcopenic Obesity

Sarcopenia may be associated with concomitant increase in fat mass (central obesity)

Sarcopenic obesity associated with a significantly higher 2-year fall rate (vs sarcopenic non-obesity) (Scott, 2016)

OR

≈5

Society for Sarcopenia, Cachexia and Wasting Disease Expert Panel (Morley, 2010)

1. Exercise:

Resistance and Aerobic

In combination with adequate protein and energy

2. Protein:

Adequate protein supplementation alone only slows loss of muscle

mass.

Leucine-enriched balanced amino acids and possibly creatine may

enhance muscle strength.

3. Vitamin D:

Low 25(0H) vitamin D levels require vitamin D replacement

SARCOPENIA- Treatment OR

≈5

Treatment- Exercise

Min of 20 to 30 minutes

Resistance and aerobic exercise

3 times a week

TO slow muscle loss and prevent sarcopenia.

(Morley, 2010)

SARCOPENIA OR

≈5

Treatment- Protein Older persons produce less muscle protein than

younger persons from the same amount of dietary protein

In the Health, Aging, and Body Composition Study Persons in the highest quintile of protein intake lost nearly 40%

less appendicular lean mass than did those in the lowest quintile (Houston, 2008)

1.0 and 1.5 g of protein/kg/d to maintain muscle mass and to increase exercise-induced muscle hypertrophy in older persons (Morley, 2010)

SARCOPENIA OR

≈5

Treatment- Leucine Effects of leucine-rich protein supplements on

anthropometric parameter and muscle strength in the

elderly: a systematic review and meta-analysis. (J Nutr Health Aging, 2015)

Meta-analysis of 16 studies

Leucine supplementation significantly increased:

oBody weight (1.02kg)

oLean body mass (0.99kg)

oMore effective in subgroup of participants with

manifested sarcopenia

SARCOPENIA OR

≈5

Treatment- Vitamin D Levels of vitamin D decline with aging

Replacement of vitamin D in persons with low levels increases Strength and function

Decreases fall (as much as 20%)

Associated with lower mortality

Levels of 25(OH) vitamin D should be measured in ALL sarcopenic patients

Vitamin D should be supplemented in all persons with values less than 100nmol/L

(Bischoff-Ferrari, 2004)(Autier, 2004)(Morley, 2010)

SARCOPENIA OR

≈5

Treatment- Omega 3

6 Month DBRCT to evaluate the effect of fish oil derived n-3PUFA (omega 3) on muscle volume and strength.

Treatment group: 4x 1g pills of omega 3 =1.66g EPA, 1.5gDHA/day

Results:

o Increased thigh muscle volume by 3.6%

o Increased handgrip strength by 26%

o Increase 1-RM muscle strength 4%

These increases suggest omega 3 may prevent 2-3 years of normal age-associated losses in muscle mass (0.5-1%/year) and function (2-3% per year)

(Smith, 2015)

SARCOPENIA OR

≈5

SARCOPENIA- Example Treatment Plan

• Exercise:

• Encourage 20-30 minutes of exercise every day

• Mixture of aerobic, resistance, group, tai chi, etc.

• Refer to PT/OT

• Protein:

• 1.0-1.5g protein / kg/ day

• Educate on dietary protein sources

• Spread protein throughout the day from a variety of sources

• Leucine

• Whey protein powder (naturally high in Leucine)

• Vitamin D

• Test 25(OH) Vitamin D levels

• Supplement to obtain levels over 100nmol/L

• Omega 3

• 1-3g/day combined EPA+DHA

Risk of Falling

and sustaining a fall-

related injury increases

with the number and

type of chronic health

problems.

CHRONIC DISEASE

# chronic

conditions

OR Risk

of Falling

0

1 1.3

2 1.4

3 1.7

4 2.0

5 2.1

6 or more 2.7

(Sibley, 2014)

CHRONIC DISEASE

(World Economic Forum, 2012)

Naturopathic Approach to Chronic Disease

Treat the underlying cause!

CHRONIC DISEASE

Gut Microbiome & Intestinal Permeability

Insulin Resistance

Inflammation Oxidative

Stress

Number of lower-extremity symptomatic OA joints and Risk of Falling (Dore, 2015)

1 joint 53% higher odds

2 joints 74% higher odds

3-4 OA joints 85% higher odds.

OA of Knee (Smith, 2016)

54% greater chance of experiencing a fall

OA of Hip (Smith, 2016)

52% greater chance of experiencing a

RA may increase fall risk especially in ankle/foot

ARTHRITIS + FALL RISK

Underlying Causes Osteoarthritis:

o Degeneration and Inflammation

o Overweight

o Injury, Overuse, Manual labor

o Women > Men after age 55

Rheumatoid Arthritis o Autoimmune Disorder

o Genetic and environmental

o Gut Microbiome (beneficial flora)

o Intestinal permeability (Leaky Gut) (Bischoff, 2014)

o Infections

o Smoking

o Aging and Hormones

ARTHRITIS

(Taneja, 2014)

Mediterranean diet (Veronese, 2016)

Improve QOL, pain, disability and depression in OA Anti-

inflammatory diet:

Foods that promote inflammation:

Sugar and refined carbohydrates, trans fat,

excessive alcohol, processed meat,

Foods that reduce inflammation

Fruits and Vegetables (Colorful!), nuts, fish…

Prebiotic foods + Probiotic Supplement

Early trials of probiotic supplementation and RA promising

ARTHRITIS- Diet

ARTHRITIS

Nutritional

Therapeutic

Snapshot of Evidence

Curcumin Meta-analysis of 8 trials:

8-12 weeks of standardized curcumin extract reduced

joint arthritis symptoms similar to the effects of iburprofen

and diclofenac sodium (Daily, 2016)

SAM-E Meta-analysis of 11 trials:

As effective as NSAIDs for improving pain and functional

limitations in osteoarthritis (Soeken, 2002)

Boswellia

Serrata

90 day RCT

5-Loxin extract improved pain and function in

Osteoarthritis (Sengupta, 2008)

Omega 3 Meta-analysis: >2.7g/day omega-3 for >3 months

reduces NSAID consumption by rheumatoid arthritis

patients (Lee, 2012)

Acupuncture for OA

Meta-analysis of 12 trials:

oSignificant reductions in pain intensity

oImprovement in functional mobility

oImprovements in quality of life

(Manyanga, 2014)

ARTHRITIS- Acupuncture

Depression & Risk of Fall For older adults starting home health care

depressive symptoms doubled the risk of adverse fall event o This was independent of medical, medication,

environmental, and functional factors) (Contemp Clin Commun, 2016)

Depression screening in Naturopathic Practice Patient Health Screening tools

Lab testing to rule out underlying contributions:

o CBC, TSH, Vitamin B12, Ferritin, hormone testing

DEPRESSION OR

≈2

SSRI and TCA

antidepressants are

considered independent

risk factors for falls and

fracture due to falls (Dyks, 2015)

ANTIDEPRESSANT MEDICATION & FALL RISK OR≈ 1.3-1.6

Antidepressant Odds Ratio

(95%CI)

TCAs 1.30 (1.23-1.38)

SSRIs 1.66 (1.58-1.73)

Meta-analysis of 13 trials found SSRIs significantly

increased risk of fracture (RR 1.72) from falls

independent of depression and bone mineral density (Wu, 2012)

Nutrition

Dietary Fish intake associated with lower risk of

depression (Grosso, 2016)

Mediterranean diet pattern may have a protective

role in the prevention of depressive disorders.

o Inverse dose response with nuts, fruit, monounsaturated

to saturated fat ratio and legumes o (Majem, 2009)

“Healthy Dietary Pattern” (whole grains,

vegetables, fruits, fish, nuts and seeds) inversely

associated with depression scores (Kim, 2016)

OR

≈2 DEPRESSION

Probiotics

Gut brain axis! “psychobiotics”

8 week probiotic supplementation in patients with

MDD: o Decreased beck depression inventory scores

o Decreased serum insulin levels

o Decreased insulin resistance

o Decreased serum hs-cRP

o Increase in glutathione levels (Akkasheh, 2016)

Probiotics also have a positive effect on subclinical

depression, anxiety and perceived stress (McKean, 2016)

DEPRESSION OR

≈2

Saffron

Most expensive spice on earth

Saffron as effective as Citalopram for Major Depressive Disorder (Talaei, 2016)

Saffron as effective as fluoxetine in several trials o (Shahmansouri, 2014) (Salimi, 2016) ( Noorbala, 2005)

Meta-analysis (6 studies): Large treatment effect with similar activity to anti-depressant medication o (Lopresti, 2014)

DEPRESSION

Curcumin

Significant improvements in atypical

depression versus placebo (Lopresti, 2014)

Curcumin+Saffron combined

oSignificantly reduced depressive and

anxiety symptoms in major depressive

disorder (Lopresti, 2017)

DEPRESSION OR

≈2

Tai Chi

Positive studies for depression AND o hypertension, fall prevention, cognitive performance,

osteoarthritis, depression, COPD, pain, balance confidence and muscle strength (Solloway, 2016)

• ALL independent risk factors for FALLS!!!

Meditation and Mindfulness Based Programs Meta-analysis of 47 trials

Moderate evidence of improved anxiety, depression and pain (Goyal, 2014)

Yoga (Pilkington, 2005)

Refer: Counselling & CBT

DEPRESSION OR

≈2

Alzheimer’s Doubles Fall Risk Causes of Falls in Dementia:

Physical weakness, Gait change, Balance

Memory impairment

Fatigue

Medication

o Anti-psychotic medications

o Proton Pump Inhibitors may increase incidence of dementia 40% (Gomm, 2016)

Underlying causes of Dementia / Alzheimer’s / Cognitive Decline

Micronutrient deficiencies (Cardoso, 2013)

Oxidative stress, inflammation (Fusco, 2007)

“Diabetes of the Brain” ?

DEMENTIA OR

≈2

Strictly

Followed =

53% reduced risk

of Alzheimer’s

disease

Moderately

Followed =

35% reduced risk

of Alzheimer’s

disease

(Alzheimer's Dement,

2015)

Factors increasing fall risk in Diabetes: Peripheral neuropathy

Diabetic retinopathy

Diabetic Nephropathy

Wounds/ulcers

Medications: o Insulin

oMetformin

DIABETES & FALL RISK OR≈

1.6-2

DIABETES DIET OR≈

1.6-2

REDUCE: Refined Sugar, High GI/GL Carbohydrates,

Alcohol, Trans Fat, Food that’s not food!

Eat a diet full of:

Fiber

Low GI fruits and vegetables

Protein

Chromium food s(Broccoli!)

Unsaturated fatty acids (fish)

Monounsaturated fats (olive oil)

Nut & Seeds

Cinnamon, Turmeric

Resistant starch

DIABETES OR≈

1.6-2

Encourage weight loss

Exercise!

MBSR (Mindfulness Based Stress Reduction)

Helpful in many models of chronic disease

May reduce HbA1c levels and blood pressure

after 8 weeks (Rosenweig, 2007)

Acupuncture:

Limited RCTs, but show overall positive effect

Nutritional Therapeutics

PGX (PolyglycopleX) o Viscious fiber complex

o Reduces food cravings

o Supports weight loss

o Controls and balances blood sugar

o Lowers cholesterol levels

o Reduces glycemic index of a meal up to 50%

Treatment of Diabetic Neuropathy o Alpha lipoic acid

o Acupuncture

Nutritional

Therapeutic

Snapshot of Evidence

Alpha

Lipoic Acid

Improves insulin sensitivity and glucose disposal rates in T2DM

Particularly useful in diabetic neuropathy

600mg/day

PGX Reduces appetitie

Reduce blood glucose response regardless of food

berberine

Magnesiu

m

Optimizes insluin production, improves glucose metabolism, increases

insulin sensitivity (200-400mg/day)

DIABETES

Prescription sleep medications increase fall risk

Older age associated with sleep issues:

Advanced sleep phase: urge to sleep much

earlier

Many medical and mental health

comorbidities

Polypharmacy

May not require as many hours of sleep as

age

SLEEP

Benzodiazepines consistently found to be associated with falls (Dyks, 2015)

Nonbenzodiazepine Sedative Hypnotics (e.g. Zolpidem) also associated with increased fall risk (Tom, 2016)

Mechanism of Action: Activate GABA receptor, causing muscle weakness, dizziness, incoordination, somnolence, and confusion

Benzodiazepine use significantly associated with dementia (OR 1.78) Increase fall risk

(Masud, 2016)

SLEEP Rx

Ideally: Sleep hygiene coaching prior to being prescribed

Discontinue Medication With help from:

opharmacist and MD

owww.deprescribing.org

oSTOPP Protocols

Very slow taper

CBT: Tapering combined with CBT more effective at achieving long-term discontinuation than tapering alone

SLEEP

Educate on Sleep Hygiene: Regular sleep schedule

Restrict artificial light at night

Therapeutic therapy lamp in morning

Limit caffeine and alcohol

Eat more carbohydrates at dinner High GI meal 4h before bed shows a significant

shortening of sleep onset latency (Afaghi, 2007)

Keep bedroom dark and cool

Manage stress during the day

Exercise and light during the day

SLEEP HYGIENE

Stick to a regular sleep schedule – even on

weekends • Get regular exercise – avoid

exercising in the late evening9,10 • Go to

bed only when you feel tired • Use your

bedroom only for sleep and sexual activity

• Avoid large meals just before bedtime •

Limit caffeine, alcohol and nicotine • Keep

bedroom dark and quiet • Avoid daytime or

evening napping • Remove bedroom clock

from sight • Avoid light-emitting devices or

bright lights in the hours before bedtime

(e.g., e-books, cell phones)11

Cognitive Behavioral Therapy CBT more effective than medication for short and

long term management of insomnia in older adult

Find a Relaxation technique: Practice progressive muscle relaxation

Breathing exercises

Meditation

Being in nature

Try this throughout day, and 30-60 min before bedtime

Acupuncture, massage or other body therapy (Centre for Effective Practice- Management of chronic insomnia, 2017)

SLEEP & RELAXATION THERAPY

Exogenous Melatonin Supplementation

Studies mixed

Side Effects: vivid dreams, morning grogginess

My approach

oTry 0.5-5mg 30-60 min before bed

oProlonged release melatonin to help stay asleep

oTake 1 week to “reset” circadian rhythm then

discontinue

SLEEP- NUTRITIONAL THERAPEUTICS

Magnesium

DBRT: 46 older adults, 500mg magnesium versus placebo for 8 weeks o in sleep time, sleep efficiency, melatonin

concentration

o in insomnia severity index, sleep onset latency, and cortisol concentration, early morning waking

oWill also help with restless leg and muscle spasm

oNote: At higher doses may cause loose stool, reduce dose

• (Abbasi, 2012)

SLEEP- NUTRITIONAL THERAPEUTICS

Contribution Long visits, holistic approach to all areas of health

Focus on prevention of chronic disease

Focus on underlying causes of many conditions (inflammation, oxidative stress, gut health etc)

Empowering patients to pursue healthy habits

Barriers Cost

Integration with health system

Patient population skewed to proactive patients

NATUROAPTHIC FALL PREVENTION

The doctor of the future will give no medicine, but

will interest her or his patients in the care of the

human frame, in a proper diet, and in the cause and

prevention of disease.

-Thomas Edison

Dr. Kara Dionisio, ND

Naturopathic Doctor

Nature Med Naturopathic Clinic

1095 1st Ave West

Owen Sound, Ontario

(519) 416-9355

drkara@naturemed.ca

www.naturemed.ca

Questions? Or Say Hello….