Course Instructor: Dr. Louis Camilli - The Wise DC Folate Niacin Riboflavin Thiamine Vitamin B6 Vitamin B12 mg mcg mg mg mg mg mcg ... Males 15-18 1200/1300 1200/1250 150 18/12 400/410

Nutritional TherapyThe 21st century health care provider faces many diverse clinical challenges. One of the challenges isthe acquisition of sufficient theoretical knowledge and clinical expertise to be able to offer a patientadvice on myriad topics such as illness prevention and treatment, weight control management, physicalfitness, and dietary supplementation. The goal of this seminar is to provide the Doctor of Chiropracticwith a comprehensive analysis of dietary supplements and to enhance their ability to prescribe anefficacious course of nutritional therapy for their respective patients.Americans of all ages are researching, participating in and following some type of dietary plan to impactbody weight, appearance and overall health. Sadly however, there is an equally large segment of ourpopulation that live sedentary lifestyles. The latest obesity statistics reveal that obesity in the UnitedStates has reached epidemic proportions:

58 Million Overweight; 40 Million Obese; 3 Million morbidly Obese Eight out of 10 over the age of 25 are overweight 78% of American's are not meeting basic activity level recommendations 25% of American’s are completely sedentary 76% increase in Type II diabetes in adults 30-40 yrs old since 1990 In the United States, some 60 percent of adults are overweight or obese, as are nearly 13 percent

of children.1

The obese along with other weight conscious individuals spend more than 1 billion dollars to treatdiseases ranging from heart disease to stroke to diabetes and other ailments directly attributed to beingunfit.Health and nutrition conscious individuals constitute another large group that has significantly impactedthe economy of the United States. This impact is evidenced by the following dietary/nutritionalsupplement facts and figures:

In 2004, 18.9 percent of Americans reported that they had taken one or more dietary supplementsin the past year. 2

The global self-medication market grew 7.4 percent in 1998 – dietary supplements were thefastest growing category with a 16 percent increase. 3

Retail and non-retail sales of dietary supplement products across all distribution channels in theU.S. were $17 billion in 2000. Retail sales of dietary supplement products were approximately$11.3 billion in 2000. 4

The United States leads the world in dietary supplement usage with 100.4 million Americansusing vitamin and minerals every day and 37.2 million using herbal remedies regularly. 5

The most prevalent reason consumers use dietary supplements is to improve overall health andgeneral well being. 6

The average price for dietary supplements has been gradually decreasing. From July 1998 toJune 1999, the average price per container decreased 9.6 percent. 7

The top selling herbal supplements in the U.S. in 2000 were the three Gs: garlic, ginkgo biloba,and glucosamine. 8

By sales, the two leading categories of supplements are "general health" and "sports/energy/weight-loss" with $4.4 billion and $4.7 billion respectively. 9

By specific condition, Americans use dietary supplements most often for menopause, followedby cough, cold, flu, or sore throat in second, and allergy or sinus conditions in third. 10

Course Instructor: Dr. Louis Camilli

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Approximately 135 million hip fractures and $2.6 billion of direct medical costs could have beenavoided in 1995 if hip fracture patients aged 50 or older consumed about 1,200 mg/day ofsupplemental calcium for 34 months. 11 12

“A national survey conducted in 2007 found that 17.7 percent of American adults had used "naturalproducts" (i.e., dietary supplements other than vitamins and minerals) in the past 12 months. The mostpopular products used by adults for health reasons in the past 30 days were fish oil/omega 3/DHA(37.4%), glucosamine (19.9%), echinacea (19.8%), flaxseed oil or pills (15.9%), and ginseng (14.1%).In another, earlier national survey covering all types of dietary supplements, approximately 52 percentof adult respondents said they had used some type of supplement in the last 30 days; the most commonlyreported were multivitamins/multiminerals (35 percent), vitamins E and C (12-13 percent), calcium (10percent), and B-complex vitamins (5 percent)”. 13

Dietary Supplements

A dietary supplement, also known as a food supplement or a nutritional supplement, is a preparationintended to provide nutrients, such as vitamins, minerals, fiber, fatty acids or amino acids, that aremissing or are not consumed in sufficient quantity in a person's diet. 14 15

Dietary supplements are used by the majority of U.S. adults, according to national surveys, including theNational Health and Nutrition Examination Survey (NHANES) 1999–2000.16 17


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Recommended Dietary/ Daily Allowances (RDA) OverviewThe Recommended Dietary Allowance or RDA (sometimes referred to as Recommended DailyAllowance) is defined as "the average daily dietary intake level that is sufficient to meet the nutrientrequirements of nearly all (approximately 98 percent) healthy individuals".18

Age Energy Protein Vitamin A Vitamin D Vitamin E Vitamin

K

k. cal g IU *ug

RE

IU *ug IU *mg

TE

*ug

Children 4-6 1,800 30/24 2,500 500 400 5 9 7 -/20

7-10 2,400/

2,000

36/28 3,300 500 400 5 10 7 -/30

Males 15-

18

3,000 54/59 5,000 1,000 400 5 15 10 -/65

19-

24

3,000/

2,900

54/58 5,000 1,000 400 5 15 10 -/70

25-

50

2,700 56/63 5,000 1,000 - 5 15 10 -/80

50+ 2,400 56/63 5,000 1,000 - 10 15 10 -/80

Females 15-

18

2,100 48/44 4,000 800 400 5 12 8 -/55

19-

24

2,100 46/46 4,000 800 400 5 12 8 -/60

25-

50

2,000 46/50 4,000 800 - 5 12 8 -/65

50+ 1,800 46/50 4,000 800 - 10 12 8 -/65


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first figure refers to the old RDA listing while the second figure refers to the newer DRI listing

RDA for water soluble vitamins:

Age Ascorbic

Acid

Folacin/

Folate

Niacin Riboflavin Thiamine Vitamin B6 Vitamin

B12

mg mcg mg mg mg mg mcg

Children 4-6 40/45 200/75 12 1.1 0.9 0.9/1.1 1.5/1.0

7-10 40/45 300/100 16/13 1.2 1.2/1.0 1.2 2.0/1.4

Males 15-18 45/60 400/200 20 1.8 1.5 2.0 3.0/2.0

19-24 45/60 400/200 20/19 1.8/1.7 1.5 2.0 3.0/2.0

25-50 45/60 400/200 18/19 1.6/1.7 1.4/1.5 2.0 3.0/2.0

50+ 45/60 400/200 16/15 1.5/1.4 1.2 2.0 3.0/2.0

Females 15-18 45/60 400/180 14/15 1.4/1.3 1.1 2.0/1.5 3.0/2.0

19-24 45/60 400/180 14/15 1.4/1.3 1.1 2.0/1.6 3.0/2.0

25-50 45/60 400/180 13/15 1.2/1.3 1.0/1.1 2.0/1.6 3.0/2.0

50+ 45/60 400/180 12/13 1.1/1.2 1.0 2.0/1.6 3.0/2.0

* first figure refers to the old RDA listing while the second figure refers to the newer DRI listingRDA for minerals and other nutritional elements:

Age Calcium Phosphorous Iodine Iron Magnesium Zinc Selenium Fluoride

mg mg ug mg mg mg *ug *mg

Children 4-6 800 800/500 80/90 10 200/130 10 -/20 -/1.1

7-10 800 800 110/120 10 250 10 -/30 -/3.2


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Males 15-18 1200/1300 1200/1250 150 18/12 400/410 15 -/50 -/3.8

19-24 800/1000 800/700 140/150 10 350/400 15 -/70 -/3.8

25-50 800/1000 800/700 130/150 10 350/420 15 -/70 -/3.8

50+ 800/1200 800/700 110/150 10 350/420 15 -/70 -/2.9

Females 15-18 1200/1300 1200/1250 115/150 18/15 300/360 15/12 -/50 -/3.1

19-24 800/1000 800/700 100/150 18/15 300/310 15/12 -/55 -/3.1

25-50 800/1000 800/700 100/150 18/15 300/320 15/12 -/55 -/3.1

50+ 800/1200 800/700 80/150 10 300/320 15/12 -/55 -/3.1

* first figure refers to the old RDA listing while the second figure refers to the newer DRI listing - age groups have also

been changed on certain nutrients to range from 9-13, 14-18,19-30,31-50, 51-70 and 71+ - figures above merely for

illustration and information.

19

The most commonly used and popular dietary supplement in the US is the multivitamin becausemultivitamins typically contain 100% of the Recommended Dietary Allowance (RDA) for all vitaminsand minerals. Usually only 17 nutrients (protein, vitamin A, D, E, C, thiamin, riboflavin, niacin, B6,folacin (folic acid), B12, calcium, phosphorus, magnesium, iron, zinc, iodine and selenium) plus someother nutrients are included. Vitamin K (involved in blood clotting) is only available by prescriptionbecause of toxicity. To get higher dosages (greater than 100%) of vitamins or minerals, you would haveto purchase each separately. Some, including Vitamin A (max. 25,000 IU), are limited to the dosage youcan purchase over the counter without a prescription. The Doctor of Chiropractic should explain to theirpatients that the human body prefers to extract needed vitamins and minerals from whole foods andexcretes excess vitamins and minerals from supplements in urine or feces. The body can only absorbapproximately 10 to 15% of the nutrients in a vitamin pill. Consequently, the purchase of manysupplements may be a huge waste of money.20

The 2002 National Health Interview Survey listed other commonly used supplements to include:echinacea (for colds and flu), ginseng (to increase stamina and energy), gingko (for memoryenhancement), garlic (to lower cholesterol and blood pressure), glucosamine chondroitin (for arthritis),and St. John's wort (to treat mild depression).21


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Cautionary Advice From the Doctor of Chiropractic to their Patients Using DietarySupplements:

Like conventional medicines, dietary supplements may cause side effects, trigger allergicreactions, or interact with prescription and nonprescription medicines or other supplements thepatient might be taking. A side effect or interaction with another medicine or supplement maymake other health conditions worse.

The way dietary supplements are manufactured may not be standardized. Because of this, howwell they work or any side effects they cause may differ among brands or even within differentlots of the same brand. The form of supplement bought in health food or grocery stores may notbe the same as the form used in research.

Other than for vitamins and minerals, the long-term effects of most dietary supplements are notknown.

As defined by Congress in the Dietary Supplement Health and Education Act, which became law in1994, a dietary supplement is a product (other than tobacco) that:

Is intended to supplement the diet. Contains one or more dietary ingredients (including vitamins; minerals; herbs or other

botanicals; amino acids; and other substances) or their constituents. Is intended to be taken by mouth as a pill, capsule, tablet, or liquid. Is labeled on the front panel as being a dietary supplement.22

“Research has shown that some uses of dietary supplements are effective in preventing or treatingdiseases. For example, scientists have found that folic acid prevents certain birth defects, and a regimenof vitamins and zinc can slow the progression of the age- related eye disease macular degeneration.Also, calcium and vitamin D supplements can be helpful in preventing and treating bone loss andosteoporosis. Research has also produced some promising results suggesting that other dietarysupplements may be helpful for other health conditions (e.g., omega-3 fatty acids for coronarydisease)”.23

Dietary supplements are regulated by the U.S. Food and Drug Administration (FDA) as foods, however,they are regulated differently from other foods and from drugs. Whether a product is classified as adietary supplement, conventional food, or drug is based on its intended use. Most often, classification asa dietary supplement is determined by the information that the manufacturer provides on the productlabel or in accompanying literature, although many food and dietary supplement product labels do notinclude this information.Under FDA rules and regulations, drug manufacturers may claim that their product will diagnose, cure,mitigate, treat, or prevent a disease. Conversely, manufacturers of dietary supplements can not makesuch claims.

The label of a dietary supplement or food product may contain one of three types of claims: a healthclaim, nutrient content claim, or structure/function claim:

Health claims describe a relationship between a food, food component, or dietary supplementingredient, and reducing risk of a disease or health-related condition.

Nutrient content claims describe the relative amount of a nutrient or dietary substance in aproduct. A structure/function claim is a statement describing how a product may affect theorgans or systems of the body and it can not mention any specific disease.


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Structure/function claims do not require FDA approval but the manufacturer must provide theFDA with the text of the claim within 30 days of putting the product on the market. Productlabels containing such claims must also include a disclaimer that reads, "This statement has notbeen evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent anydisease."24

FDA Regulation of Dietary Supplements

Supplement ingredients sold in the United States before October 15, 1994, are not required to bereviewed by FDA for their safety before they are marketed because they are presumed to be safebased on their history of use by humans.

Manufacturers of a new dietary ingredient (one not sold as a dietary supplement before 1994)must notify the FDA of its intent to market a dietary supplement containing a new dietaryingredient and provide information on how it determined that reasonable evidence exists for safehuman use of the product. FDA can either refuse to allow new ingredients into or removeexisting ingredients from the marketplace for safety reasons. However, manufacturers do nothave to provide the FDA with evidence that dietary supplements are effective or safe.

“Federal regulations for dietary supplements are very different from those for prescription andover-the-counter drugs. For example, a dietary supplement manufacturer does not have to provea product's safety and effectiveness before it is marketed”.25

Once a dietary supplement is marketed, the FDA has to prove that the product is not safe in orderto restrict its use or remove it from the market. In contrast, before being allowed to market a drugproduct, manufacturers must obtain FDA approval by providing convincing evidence that it isboth safe and effective.

In June 2007 the FDA issued a rule which requires all dietary supplement manufacturers toensure by June 2010 that production of dietary supplements complies with current goodmanufacturing practices, and be manufactured with "controls that result in a consistent productfree of contamination, with accurate labeling."26

Required Information on a Dietary Supplement LabelThe FDA requires that the following information appear on every dietary supplement label:General information:

Name of product (including the word "supplement" or a statement that the product is asupplement).

Net quantity of contents . Name and place of business of manufacturer, packer, or distributor. Directions for use.

Supplement Facts Panel: Serving size, list of dietary ingredients, amount per serving size (by weight), percent of Daily

Value (%DV). If the dietary ingredient is a botanical, the scientific name of the plant or the common or usual

name standardized in the reference Herbs of Commerce, 2nd Edition (2000 edition) and the nameof the plant part used .


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If the dietary ingredient is a proprietary blend (i.e., a blend exclusive to the manufacturer), thetotal weight of the blend and the components of the blend in order of predominance by weight.

Other Ingredients: Nondietary ingredients such as fillers, artificial colors, sweeteners, flavors, or binders; listed by

weight in descending order of predominance and by common name or proprietary blend.

Dietary Supplement CategoriesDietary supplement categories include: botanicals; amino acids; vitamins and minerals.

Botanical Dietary Supplements

A botanical is a plant that has medicinal or therapeutic properties, flavor, and/or scent. Herbs are asubset of botanicals. Products made from botanicals that are used to maintain or improve health areoften called herbals, botanicals, and or phytomedicines .

Botanicals are sold in many forms: As fresh or dried products. As liquid or solid extracts . As tablets, capsules, powders, and tea bags.

Common preparations include teas, decoctions, tinctures, and extracts: A tea, also known as an infusion, is made by adding boiling water to fresh or dried botanicals

and steeping them. Some roots, bark, and berries require more forceful treatment to extract their desired ingredients.

They are simmered in boiling water for longer periods than teas, making a decoction.. A tincture is made by soaking a botanical in a solution of alcohol and water. Tinctures are sold

as liquids and are used for concentrating and preserving a botanical. An extract is made by soaking the botanical in a liquid that removes specific types of chemicals.

The liquid can be used as is or evaporated to make a dry extract for use in capsules or tablets.Herbal dietary supplement sales in the United States increased slightly in 2008, reaching a totalestimated figure of $4,800,000,000. The five top-selling single herbal supplements of 2008 wereflaxseed oil (Linum usitatissimum), wheat grass and barley grass (Triticum aestivum and Hordeumvulgare), stevia (Stevia rebaudiana), aloe vera and milk thistle (Silybum marianum). 27

In the US annual retail sales of botanical products rose from$200 million in 1988 to $ 5.1 billion I 1997,and consumer use increased 380% in that nine year period of time.28

Data from the World Health Organization suggests that 65- 80 % of the populations of Africa, China andIndia depend on botanicals as the primary source of health care.29

The following is a list of popular botanical supplements: Black Cohose Chaparral Comfrey Cranberry


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Echinacea Ephedra Evening Primrose Oil Feverfew Garlic Chamomile Germander Ginger Ginkgo Biloba Ginseng Horse Chestnut Kava Milk Thistle Saw Palmetto St. John’s Wort Valerian

Amino Acid SupplementsAmino acids are commonly referred to as the building blocks of proteins. They help to repair tissues, areresponsible for the production of enzymes, and play a key role in mental health. The breakdown ofproteins into amino acid is the first amino acid function. From here the amino acids combine withnitrogen where they can then be transformed into thousands of different protein forms that the body canuse.

There are 20 amino acids that the body uses to construct proteins. Eight of these amino acids are calledessential amino acids because the body cannot manufacture them. These amino acids must be suppliedin our food.

The other 12 amino acids which are produced by the body are called non-essential amino acids the termnon-essential is very misleading because a shortage of even one amino acid can cause proteinsynthesis to be greatly reduced and it can stop altogether if left untreated. In order to achieve properprotein synthesis all of the required amino acids must be present in the body at the same time and in theright quantity. If there is one essential amino acid in very short supply it is known as the limiting aminoacid and this will restrict the quantity of protein that can be synthesized regardless of how much of theother amino acids are available.

There are singular (L-form) amino acids, di-peptides (2 attached amino acids that may have specialfunctions) and polypeptides, which may be a few amino acids bound together, or 500 amino acids in achain. The L-form (or Levorotatory) amino acids, are the ones that are utilized for protein synthesis. The(L-form) amino acids include: Histidine; Isoleucine; Leucine; Lysine; Methionin; Phenylalanine;Threonine Tryptophan and Valine.30

Most dieticians recommend the use of essential amino acid supplements consisting of the following:(isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan and valine).31


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Essential amino acids for adults and their RDA (Recommended Dietary Allowance 1989) are: isoleucine(10 milligrams); leucine (14 milligrams); lysine (12 milligrams); methionine (13 milligrams);phenylalanine (14 milligrams); threonine (7 milligrams); tryptophan (3.5 milligrams); valine (10milligrams). Infants also need histidine (28 milligrams). These amounts are per kilogram of body weightper day.

Take your body weight and divide by 2.2 to get your weight in kilograms. Next, multiply each aminoacid in milligrams by your weight in kilograms. For instance if your weight was 169 pounds divided by2.2, your weight in kilograms is 77. Next multiply 10 milligrams of isoleucine times 77. Your RDA forisoleucine is 770 milligrams per day. This would include isoleucine from all food sources of protein in aday.

Being in "nitrogen equilibrium", or nitrogen balance is reached when the intake of nitrogen from proteinis approximately equal to the nitrogen lost in the feces and urine.

Estimated amino acid requirements of man*

Requirement (mg/kg. of body weight/day) Table B

Amino AcidInfants(3-6 months)

Child(10-12yrs)

AdultAmino acid pattern forhigh quality proteins,mg/g. of proteins **

Histidine 33 ? ? 17

Isoleucine 80 28 12 42

Leucine 128 42 16 70

Lysine 97 44 12 51

Total sulphurcontainingamino acids

45 22 10 26

Total aromaticamino acids

132 22 16 73

Threonine 63 28 8 35

Tryptophan 19 4 3 11

Valine 89 25 14 48

* From Food and Nutrition32

** 2 g. per kg. of body weight per day of protein of the quality listed in column 5 would meet the aminoacid needs of the infant.

Amino acid, Vitamin B6 and Vitamin C supplements are needed for amino acid metabolism. L- Formamino acid supplements are recommended as they are more acceptable to the body.Amino acid supplements come in the form of pills, capsules, or powders containing a particularcombination of amino acids. Manufacturers usually claim the supplements have special properties, forexample, to cure herpes, strengthen fingernails, cure split ends in the hair, improve sleep patterns,


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relieve pain and depression, weight loss and muscle hypertrophy. Dieters may take them to spare theirbodies' protein while losing weight. One particular combination of amino acids (which includesarginine, lysine, and ornithine), is sold as a slimming aid, accelerating weight loss. There is littlescientific evidence to support these claims.

Most amino acid supplements are sold as anabolic agents to help in body-building; arginine andornithine are two constituents frequently promoted as ‘natural steroids’. Since amino acids are thebuilding blocks of protein, the main component of muscle, some people erroneously believe that, bytaking extra amino acids, they can develop larger muscles. However, voluminous research shows that amuscle grows only in response to extra physical demands placed on it. Excess amino acids not neededfor growth or repair of body tissues are broken down and excreted as urea, converted into glucose andused as an energy source, or converted to body fat. There is some evidence to support the use of aminoacid supplements when there is a natural stimulus to increase muscle bulk, for example during the initialstages of training. There is no scientific evidence, however, to support claims that amino acidsupplements improve strength, power, muscle growth, or work capacity. In general, nutritionists believethat a normal, healthy person eating a well-balanced diet does not need amino acid supplements.Overconsumption causes health risks. Unbalanced amino acid mixtures or single amino acids may betoxic. Amino-acid supplements used as the basis of a high-protein, low fat diet they can cause abnormalheart rhythms.33

Aloe VeraThe use of Aloe Vera can be traced back 6,000 years to early Egypt, where the plant was depicted onstone carvings. Known as the "plant of immortality," aloe was presented as a burial gift to deceasedpharaohs.

Common Names—aloe vera, aloe, burn plant, lily of the desert, elephant's gall.Dietary Uses:

Aloe Vera is taken orally as a laxative. Also taken orally to treat a variety of conditions, including diabetes, asthma, epilepsy, and

osteoarthritis.Aloe leaves contain a clear gel that is often used as a topical ointment. The green part of the leaf thatsurrounds the gel can be used to produce a juice or a dried substance (called latex) that is taken bymouth.

Products made with various components of aloe (aloin, aloe-emodin, and barbaloin) were at one timeregulated by the FDA as oral over-the-counter (OTC) laxatives. In 2002, the FDA required that all OTCaloe laxative products be removed from the U.S. market or reformulated because the companies thatmanufactured them did not provide the necessary safety data.

Side Effects and Cautions: Abdominal cramps and diarrhea have been reported with oral use of aloe vera. Aloe vera taken orally can decrease the absorption of many drugs. People with diabetes who use glucose-lowering medication should be cautious if also taking aloe

by mouth because preliminary studies suggest aloe may lower blood glucose levels.


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Antioxidants Vitamin C, Vitamin E and Coenzyme Q10It is postulated that the antioxidant vitamins C and E and coenzyme Q10 are potentially capable ofcontrolling free radical formation, thereby providing defenses against certain cancers. Antioxidantsprotect cells from the damaging effects of free radicals, which are molecules that contain an unsharedelectron. Free radicals damage cells and might contribute to the development of cardiovascular diseaseand cancer. Unshared electrons are highly energetic and react rapidly with oxygen to form reactiveoxygen species (ROS). The body forms ROS endogenously when it converts food to energy, andantioxidants might protect cells from the damaging effects of ROS. The body is also exposed to freeradicals from environmental exposures, such as cigarette smoke, air pollution, and ultraviolet radiationfrom the sun.

Vitamin C

Vitamin C, also known as L-ascorbic acid, is a water-soluble vitamin that is naturally present in somefoods, added to others, and available as a dietary supplement. Humans, are unable to synthesizevitamin C endogenously, so it is an essential dietary component.

Common Uses:

Vitamin C is required for the biosynthesis of collagen, L-carnitine, and certain neurotransmitters. Involved in protein metabolism. Is an important physiological antioxidant that has been shown to regenerate other antioxidants

within the body, including alpha-tocopherol (vitamin E). Ongoing research is examining whethervitamin C, by limiting the damaging effects of free radicals through its antioxidant activity,might help prevent or delay the development of certain cancers, cardiovascular disease, and otherdiseases in which oxidative stress plays a causal role. In addition to its biosynthetic andantioxidant functions,

Plays an important role in immune function and improves the absorption of nonheme iron, theform of iron present in plant-based foods.

Used to treat the common cold. 34

Insufficient vitamin C intake causes scurvy, which is characterized by fatigue or lassitude, widespreadconnective tissue weakness, and capillary fragility.

Recommended Dietary Allowances (RDAs) for Vitamin C

Age Male Female Pregnancy Lactation

Birth to 6 months 40 mg* 40 mg*

7–12 months 50 mg* 50 mg*

1–3 years 15 mg 15 mg



14–18 years 75 mg 65 mg 80 mg 115 mg

19+ years 90 mg 75 mg 85 mg 120 mg


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Smokers Individuals who smoke require 35 mg/day more vitamin C than nonsmokers.

* Adequate Intake (AI)35

Dietary supplements typically contain vitamin C in the form of ascorbic acid, which has equivalentbioavailability to that of naturally occurring ascorbic acid in foods, such as orange juice and broccoli.Other forms of vitamin C supplements include sodium ascorbate; calcium ascorbate; other mineralascorbates; ascorbic acid with bioflavonoids; and combination products, such as Ester-C®, whichcontains calcium ascorbate, dehydroascorbate, calcium threonate, xylonate and lyxonate.36

Health Risks from Excessive Vitamin C:Vitamin C has low toxicity and is not believed to cause serious adverse effects at high intakes. The mostcommon complaints are diarrhea, nausea, abdominal cramps, and other gastrointestinal disturbances dueto the osmotic effect of unabsorbed vitamin C in the gastrointestinal tract.

Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Vitamin C, Vitamin E,Selenium, and Carotenoids. Washington, DC: National Academy Press, 2000.

Vitamin E"Vitamin E" is the collective name for a group of fat-soluble compounds with distinctive antioxidantactivities [1].

Naturally occurring vitamin E exists in eight chemical forms (alpha-, beta-, gamma-, and delta-tocopherol and alpha-, beta-, gamma-, and delta-tocotrienol) that have varying levels of biologicalactivity. Alpha- (or α-) tocopherol is the only form that is recognized to meet human requirements.

Serum concentrations of vitamin E (alpha-tocopherol) depend on the liver, which takes up the nutrientafter the various forms are absorbed from the small intestine. The liver preferentially resecretes onlyalpha-tocopherol via the hepatic alpha-tocopherol transfer protein [1]; the liver metabolizes and excretesthe other vitamin E forms . As a result, blood and cellular concentrations of other forms of vitamin E arelower than those of alpha-tocopherol and have been the subjects of less research.Common Uses:

Vitamin E is a fat-soluble antioxidant that stops the production of ROS formed when fatundergoes oxidation. Scientists are investigating whether, by limiting free-radical production andpossibly through other mechanisms, vitamin E might help prevent or delay the chronic diseasesassociated with free radicals.

Vitamin E is involved in immune function and, as shown primarily by in vitro studies of cells,cell signaling, regulation of gene expression, and other metabolic processes.

Alpha-tocopherol inhibits the activity of protein kinase C, an enzyme involved in cellproliferation and differentiation in smooth muscle cells, platelets, and

Vitamin E also increases the expression of two enzymes that suppress arachidonic acidmetabolism, thereby increasing the release of prostacyclin from the endothelium, which, in turn,dilates blood vessels and inhibits platelet aggregation.

Used for the treatment or prevention of heart disease, eye disorders, and cognitive decline.


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Recommended Dietary Allowances (RDAs) for Vitamin E (Alpha-Tocopherol)

Age Males Females Pregnancy Lactation

Birth to 6 months*4 mg(6 IU)

4 mg(6 IU)

7-12 months*5 mg(7.5 IU)

5 mg(7.5 IU)

1-3 years6 mg(9 IU)

6 mg(9 IU)

4-8 years7 mg(10.4 IU)

7 mg(10.4 IU)

9-13 years11 mg(16.4 IU)

11 mg(16.4 IU)

14+ years15 mg(22.4 IU)

15 mg(22.4 IU)

15 mg(22.4 IU)

19 mg(28.4 IU)

37

Coenzyme Q10Coenzyme Q10 (CoQ10) is a compound found naturally in the mitochondria of human cells. CoQ10 isinvolved in the production of the molecule adenosine triphosphate (ATP). ATP serves as the cell'smajor energy source and drives a number of biological processes, including muscle contraction and theproduction of protein. CoQ10 also works as an antioxidant.Common Uses:

CoQ10 boosts energy, enhances the immune system, and acts as an antioxidant.Clinical research suggests that using coenzyme Q10 supplements alone or in combination with otherdrug therapies and nutritional supplements may help prevent or treat some of the following conditions:

Heart disease Heart failure High blood pressure- After reviewing 12 clinical studies, researchers concluded that CoQ10 has

the potential to lower systolic blood pressure by up to 17 mm Hg and diastolic blood pressure by10 mm Hg, without significant side effects.

High cholesterol-Levels of CoQ10 tend to be lower in people with high cholesterol compared tohealthy individuals of the same age. In addition, certain cholesterol-lowering drugs called statins(such as atorvastatin, cerivastatin, lovastatin, pravastatin, simvastatin) appear to deplete naturallevels of CoQ10 in the body. Taking CoQ10 supplements can correct the deficiency caused bystatin medications without affecting the medication's positive effects on cholesterol levels. Plus,studies show that CoQ10 supplementation may decrease the muscle pain associated with statintreatment.

Diabetes

Preliminary clinical studies also suggest that CoQ10 may: Increase sperm motility leading to enhanced fertility Be used as part of the treatment for Alzheimer's disease and Parkinson's disease Reduce damage from stroke


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Boost athletic performance Enhance physical activity in people with fatigue syndromes Improve exercise tolerance in individuals with muscular dystrophy Improve symptoms of tinnitus, or ringing in the ears Delay the aging process and increase longevity38

Coenzyme Q10 appears to be generally safe with no significant side effects, except occasional stomachupset. However, the safety of CoQ10 supplementation during pregnancy and breastfeeding is unknownand, therefore, should not be used during that time.

The Southern California Evidence-based Practice Center conducted research on the efficacy ofantioxidants Vitamin C, and E and Coenzyme Q10 and offered the following findings :

No evidence was found for assessing the efficacy of coenzyme Q10 for prevention or treatmentof cancer.

Three large trials assessed the potential of vitamin C and vitamin E in various combinations toprevent cancer when given to persons without cancer. No trial reported a statistically significantbeneficial effect on death due to cancer, nor did any trial show benefit for prevention of newtumor development, except for one arm of the trial, which showed a decrease in the developmentof new prostate tumors.

Seven trials assessed the use of vitamin C in patients with advanced cancer. No trial reported astatistically significant mortality benefit: Vitamin C did not decrease the risk of death fromadvanced cancer.

A single trial of vitamin E in combination with omega-3 fatty acids showed increased survival ofpatients severely ill with a variety of malignancies.

In a single trial of patients with bladder cancer who were also treated with bacillus Calmette-Guerin (BCG) tuberculosis vaccine, Vitamin C was found to be beneficial in reducing theoccurrence of new tumors.

This systematic review of the literature does not support the hypothesis that supplements of vitamins Cor E or coenzyme Q10 generally help prevent or treat cancer.39

Further, it has been postulated that Vitamins C and E and Coenzyme Q10 are capable of limiting,controlling or preventing cardiovascular disease. Research by the Agency for Healthcare Research andQuality (AHRQ) revealed the following observations:

There is no evidence that vitamin E alone or in combination has a clinically and statisticallysignificant favorable or unfavorable effect on lipids

The available evidence did not generally support the assertion that there was any positive benefitassociated with the use of vitamin E either alone or in the combinations tested for the preventionof cardiovascular death

A meta-analysis of the effect of coenzyme Q10 on indices of cardiac function concluded that itsuse was associated with a substantial improvement

Four studies assessing vitamin C (mostly in combination with vitamin E) provide scant evidencethat these combinations of antioxidant supplements have any cardiovascular health benefits


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AstragalusAstragalus has been used for centuries in traditional Chinese medicine. In the United States, the herbgained popularity in the 1980s. There are actually over 2,000 species of astragalus; however, the tworelated species Astragalus membranaceus and Astragalus mongholicus are the ones primarily used forhealth purposes.Common Uses:

To prevent and treat common colds and upper respiratory infections. To treat chronic hepatitis To treat heart disease. Helps bolster the immune system

The root of the astragalus plant is typically used in soups, teas, extracts, or capsules. Astragalus isgenerally used with other herbs, such as ginseng, angelica, and licorice.

Scientific Observations: The evidence for using astragalus for any health condition is limited. Results from small or

preliminary studies suggest that astragalus may benefit heart function and help the immunesystem fight infections

A few studies have shown potential benefits for using astragalus—in combination with anotherherb, glossy privet (Ligustrum lucidum)—as an adjunctive therapy for cancer

Side Effects and Cautions Astragalus is considered safe for most adults. Its possible side effects are not well known

because astragalus is generally used in combination with other herbs. Astragalus may interact with medications that suppress the immune system, such as the drug

cyclophosphamide taken by cancer patients and similar drugs taken by organ transplantrecipients.

People should avoid using astragalus species such as "locoweed" that grow in the United States,as these other species may have different effects and side effects.

B VitaminsThe B vitamins are eight water-soluble vitamins that play important roles in cell metabolism.Supplements containing all eight are generally referred to as a vitamin B complex. Individual B vitaminsupplements are referred to by the specific name of each vitamin (e.g. B1, B2, B3 etc.).

List of B vitamins: Vitamin B1 (thiamine) Vitamin B2 (riboflavin) Vitamin B3 (niacin or niacinamide) Vitamin B5 (pantothenic acid) Vitamin B6 (pyridoxine, pyridoxal, or pyridoxamine, or pyridoxine hydrochloride) Vitamin B7 (biotin) Vitamin B9 (folic acid) Vitamin B12 (various cobalamins; commonly cyanocobalamin in vitamin supplements)

Health benefits of B vitamins: Support and increase the rate of metabolism.


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Maintain healthy skin and muscle tone. Enhance immune and nervous system function. Promote cell growth and division—including that of the red blood cells that help prevent anemia. Reduce the risk of pancreatic cancer, one of the most lethal forms of cancer, when consumed in

food, but not when ingested in vitamin tablet form.40 41 42 43

B vitamin deficiency:

Vitamin Name Deficiency effects

VitaminB1

thiamine

Deficiency causes beriberi. Symptoms of this disease of thenervous system include weight loss, emotional disturbances,Wernicke's encephalopathy (impaired sensory perception),weakness and pain in the limbs, periods of irregular heartbeat,and edema (swelling of bodily tissues). Heart failure and deathmay occur in advanced cases. Chronic thiamine deficiency canalso cause Korsakoff's syndrome, an irreversible psychosischaracterized by amnesia.

VitaminB2

riboflavin

Deficiency causes ariboflavinosis. Symptoms may includecheilosis (cracks in the lips), high sensitivity to sunlight, ,glossitis (inflammation of the tongue), seborrheic dermatitis orpseudo-syphilis (particularly affecting the scrotum or labiamajora and the mouth), pharyngitis, hyperemia, and edema ofthe pharyngeal and oral mucosa.

VitaminB3

niacin

Deficiency, along with a deficiency of tryptophan causespellagra. Symptoms include aggression, dermatitis, insomnia,weakness, mental confusion, and diarrhea. In advanced cases,pellagra may lead to dementia and death.

VitaminB5

pantothenicacid

Deficiency can result in acne and paresthesia.

VitaminB6

pyridoxine

Deficiency may lead to microcytic anemia (because pyridoxylphosphate is the cofactor for heme synthesis), depression,dermatitis, high blood pressure (hypertension), water retention,and elevated levels of homocysteine.

VitaminB7

biotinDeficiency does not typically cause symptoms in adults but maylead to impaired growth and neurological disorders in infants.

VitaminB9

folic acid

Deficiency results in a macrocytic anemia, and elevated levelsof homocysteine. Deficiency in pregnant women can lead tobirth defects. Supplementation is often recommended duringpregnancy. Researchers have shown that folic acid might alsoslow the insidious effects of age on the brain.


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VitaminB12

cobalamin

Deficiency results in a macrocytic anemia, elevatedhomocysteine, peripheral neuropathy, memory loss and othercognitive deficits. It is most likely to occur among elderlypeople as absorption through the gut declines with age; theautoimmune disease pernicious anemia is another commoncause. It can also cause symptoms of mania and psychosis. Inrare extreme cases, paralysis can result.

B vitamin toxicity:

Vitamin NameTolerableUpper IntakeLevel

Harmful effects

VitaminB1

thiamine None No known toxicity from oral intake.

VitaminB2

riboflavin None No known toxicity.

VitaminB3

niacin

35 mg/dayfromsupplements,drugs orfortified food.

Flushing (redness of the skin, oftenaccompanied by itching or a mildburning sensation). Intake of3000 mg/day of nicotinamide and1500 mg/day of nicotinic acid areassociated with nausea, vomiting,and signs and symptoms of livertoxicity. 44 45

VitaminB5

pantothenicacid

None No known toxicity.

VitaminB6

pyridoxine

100 mg/dayfromsupplements,drugs orfortified food.

sensory neuropathy anddermatological lesions. NationalAcademy of Sciences. Institute ofMedicine. Food and NutritionBoard., ed (1998). "Chapter 7 -Vitamin B6". Dietary ReferenceIntakes for Thiamin, Riboflavin,Niacin, Vitamin B6, Folate, VitaminB12, Pantothenic Acid, Biotin, andCholine. 46

VitaminB7

biotin None No known toxicity

VitaminB9

folic acid 1 mg/dayMasks B12 deficiency, which canlead to permanent neurologicaldamage.

VitaminB12

cyanocobalamin None No known toxicity


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Another popular means of increasing one's vitamin B intake is through the use of dietary supplementspurchased at supermarkets, health centers, or natural food stores. B vitamins are also commonly addedto energy drinks. Many energy drinks have been marketed with large amounts of B vitamins (5-HourEnergy contains an astounding 8333% of the recommended dietary allowance of vitamin B12 and2000% of the RDA for vitamin B6. Red Bull offers "360% of the RDA for vitamin B6, 120% of B12,140% of niacin (vitamin B3)")47

In 2006 the Agency for Healthcare Research and Quality performed studies to assess the effects,associations, mechanisms of action, and safety of B vitamins and, separately, berries and theirconstituents on age-related neurocognitive disorders—primarily Alzheimer's (AD) and Parkinson'sdisease (PD). Their findings were :Human studies were generally of poor quality. Weak evidence suggests possible benefits of B1supplementation and injected B12 in AD. The effects of B6 and folate are unclear. Overall, dietaryintake studies do not support an association between B vitamin intake and AD. Studies evaluating Bvitamin status were mostly inadequate due to poor study design. Overall, studies do not support anassociation between B vitamin status and age-related neurocognitive disorders.

Only one study evaluated human berry consumption, finding no association with PD. Animal studies ofberries have almost all been conducted by the same research group. Several berry constituents have beenshown to affect brain and nerve tissue function. Blueberry and strawberry extract were protective ofmarkers of disease, although effects on neurocognitive tests were less consistent. Berry extracts mayprotect against the deleterious effects of compounds associated with AD.

Conclusions: The current research on B vitamins is largely inadequate to confidently assess theirmechanisms of action on age-related neurocognitive disorders, their associations with disease, or theireffectiveness as supplements. B vitamin supplementation may be of value for neurocognitive function,but the evidence is inconclusive. 48

BilberryBilberry is a relative of the blueberry, and its fruit is commonly used to make pies and jams. It has beenused for nearly 1,000 years in traditional European medicine. Bilberry grows in North America, Europe,and northern Asia.

Common Uses: Historically to treat diarrhea, and scurvy Today it is used to treat diarrhea, menstrual cramps, eye problems, diabetes, varicose veins,

venous insufficiency and other circulatory problemsThe fruit of the bilberry plant can be eaten or made into extracts. Similarly, the leaves of the bilberryplant can be made into extracts or used to make teas.

Scientific Observations: Some claim that bilberry fruit improves night vision, but clinical studies have not shown this to

be true


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There is not enough scientific evidence to support the use of bilberry fruit or leaf for any healthconditions

Side Effects and Cautions: Bilberry fruit is considered safe. However, high doses of bilberry leaf or leaf extract are

considered unsafe due to possible toxic side effects49

Bitter OrangeThe bitter orange tree is native to eastern Africa and tropical Asia. Today, it is also grown in theMediterranean region and in the US in California and Florida. Bitter orange oil is used in foods,cosmetics, and aromatherapy products.Common Uses:

Bitter orange has been used in traditional Chinese medicine and by indigenous people of theAmazon rainforest for nausea, indigestion, and constipation.

Current uses of bitter orange are for heartburn, loss of appetite, nasal congestion, and weight lossThe dried fruit and peel (and sometimes flowers and leaves) are taken by mouth in extracts, tablets, andcapsules.Scientific Observations:

There is not enough scientific evidence to support the use of bitter orange for health purposes Many herbal weight-loss products now use concentrated extracts of bitter orange peel in place of

ephedra. The U.S. Food and Drug Administration banned ephedra because it raises bloodpressure and is linked to heart attacks and strokes

Side Effects and Cautions: Bitter orange contains chemicals that may speed up the heart rate and raise blood pressure Due to lack of safety evidence, pregnant women should avoid products that contain bitter

orange50

Black CohoshBlack cohosh is a perennial plant that is native to North America. Other common names include blacksnakeroot and rattleweed. Preparations of black cohosh are made from its roots and rhizomes(underground stems). One commercial standardized black cohosh preparation is Remifemin, whichcontains black cohosh extract equivalent to 20 mg of root per tablet.

Common Uses:Black cohosh was used in North American Indian medicine for malaise, gynecological disorders, kidneydisorders, malaria, rheumatism, and sore throat. It was also used for colds, cough, constipation, hives,and backache and to induce lactation. In 19th-century America, black cohosh was a home remedy usedfor rheumatism and fever, as a diuretic, and to bring on menstruation. It was extremely popular among agroup of alternative practitioners who called black cohosh "macrotys" and prescribed it for rheumatism,lung conditions, neurological conditions, and conditions that affected women's reproductive organs(including menstrual problems, inflammation of the uterus or ovaries, infertility, threatened miscarriage,and relief of labor pains).51


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Scientific Observations: The currently available data are not sufficient to support a recommendation on the use of black

cohosh for menopausal symptoms. The National Center for Complementary and AlternativeMedicine (NCCAM) at the National Institutes of Health is funding a rigorous scientific study todetermine whether treatment with black cohosh reduces the frequency and intensity of hotflashes, and other menopausal symptoms.

In 2001, the American College of Obstetricians and Gynecologists stated, primarily on the basisof consensus and expert opinion, that black cohosh may be helpful in the short term (6 months orless) for women with vasomotor symptoms of menopause.52

Although few adverse events have been reported, long-term safety data are not available.

Bovine/Shark CartilageCartilage from cows and sharks has been studied as a treatment for cancer and other medical conditionsfor more than 30 years. It was once believed that sharks, whose skeletons are made mostly fromcartilage, do not develop cancer. This caused interest in cartilage as a possible treatment for cancer.Although malignant tumors are rare in sharks, cancers have been found in these animals.

Common Uses:

In the 1960s, it was first reported that bovine cartilage decreased inflammation. In the 1970s, it was first reported that bovine cartilage contains a substance that blocks

angiogenesis ( the forming of new blood vessels). In the 1980s, it was first published that shark cartilage contains a substance that blocks blood

vessel growth. In 1998 and 2005, there were published reports of clinical trials of shark cartilage as a treatment

for cancer.Three theories have been suggested to explain how cartilage acts against cancer:

As cartilage is broken down by the body, it releases products that kill cancer cells. Cartilage increases the action of the body’s immune system to kill cancer cells. Cartilage makes substances that block tumor angiogenesis.

Scientific Observations:The following have been reported from preclinical studies of the effect of powdered cartilage on cancercells in vitro:

In a published laboratory study, a powdered form of bovine cartilage called Catrix slowed thegrowth of human cancer cells by half or more. It is not clear if Catrix had this effect only oncancer cells, because its effect the growth of normal cells was not tested. It is also not known ifthe dose used in the laboratory study could safely be used in people.

In a published laboratory study of powdered shark cartilage, there was no effect on the growth ofhuman astrocytoma cells (cancer cells that begin in the brain or spinal cord).

The following have been reported from preclinical studies of the effect of powdered cartilage on theimmune system:

One published study reported that Catrix injected into mice caused their immune systems to bemore active. This effect did not happen when Catrix was given by mouth.

A laboratory study on the effect of shark cartilage on a tumor model reported an increase intumor-fighting immune cells in the tumor but not in the blood.


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A study on the effect of shark cartilage on immune system response in mice reported a numberof different effects, both helpful and harmful. It increased antibody response but decreased theactivity of tumor-fighting white blood cells. The study also reported a decrease in blood vesselgrowth.

A substance made from human cartilage slowed the spread of pancreatic cancer cells in ananimal study and prevented blood vessel growth in both animal and laboratory studies.

The most common side effects of treatment with the bovine cartilage product Catrix include thefollowing:

Inflammation at the injection location. Nausea. Upset stomach. Fever. Feeling dizzy. Swelling of the scrotum .

The most common side effects of treatment with the shark cartilage include the following: Nausea. Vomiting. Abdominal cramps and/or bloating. Constipation. Lower than normal blood pressure. Higher than normal blood sugar. General weakness. A higher than normal level of calcium in the blood. 53

CalciumCalcium is the most abundant mineral in the body. It is found in some foods and is manufactured as adietary supplement. Calcium is required for muscle contraction, blood vessel expansion and contraction,secretion of hormones and enzymes, and transmitting impulses throughout the nervous system.

Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and NutritionBoard, Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, VitaminD and Fluoride. Washington, DC: National Academy Press, 1997.

The body strives to maintain constant concentrations of calcium in blood, muscle, and intercellularfluids, though less than <1% of total body calcium is needed to support these functions. The remaining99% of the body's calcium supply is stored in the bones and teeth where it supports their structure.54

Recommended Intakes:

Intake recommendations for calcium and other nutrients are provided in the Dietary Reference Intakes(DRIs) developed by the Food and Nutrition Board (FNB) at the Institute of Medicine of the NationalAcademies (formerly National Academy of Sciences).


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Calcium as a Dietary Supplement:

The two main forms of calcium in supplements are carbonate and citrate. Calcium carbonate is morecommonly available and is both inexpensive and convenient. Both the carbonate and citrate forms arewell absorbed, but individuals with reduced levels of stomach acid can absorb calcium citrate moreeasily. Other calcium forms in supplements or fortified foods include gluconate, lactate, and phosphate.Calcium citrate malate is a well-absorbed form of calcium found in some fortified juices. 55

Calcium supplements contain varying amounts of elemental calcium. For example, calcium carbonate is40% calcium by weight, whereas calcium citrate is 21% calcium.

Common Uses:Bone health and osteoporosis; blood pressure regulation and hypertension; cancers of the colon, rectum,and prostate; kidney stones; and weight management.Scientific Observations:In 1993, the U.S. Food and Drug Administration authorized a health claim related to calcium andosteoporosis for foods and supplements. In January 2010, this health claim is expanded to includevitamin D. Model health claims include the following: "Adequate calcium throughout life, as part of awell-balanced diet, may reduce the risk of osteoporosis" and"Adequate calcium and vitamin D as part ofa healthful diet, along with physical activity, may reduce the risk of osteoporosis in later life".56

Several clinical trials have demonstrated a relationship between increased calcium intakes and bothlower blood pressure and risk of hypertension.57 58 59

Several studies have found that higher intakes of calcium from foods (low-fat dairy sources) and/orsupplements are associated with a decreased risk of colon cancer.60

The authors of a meta-analysis of prospective studies concluded that high intakes of dairy products andcalcium might slightly increase prostate cancer risk.61

In the Women's Health Initiative clinical trial, postmenopausal women who consumed 1,000 mg ofsupplemental calcium and 400 IU of vitamin D per day for 7 years had a higher risk of kidney stonesthan subjects taking a placebo.62

Age Male Female Pregnant Lactating

Birth to 6 months 210 mg 210 mg

7-12 months 270 mg 270 mg

1-3 years 500 mg 500 mg

4-8 years 800 mg 800 mg

9-13 years 1,300 mg 1,300 mg

14-18 years 1,300 mg 1,300 mg 1,300 mg 1,300 mg

19-50 years 1,000 mg 1,000 mg 1,000 mg 1,000 mg

50+ years 1,200 mg 1,200 mg


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Supplementation with calcium carbonate has led to reductions in the risk of adenoma (a nonmalignanttumor) in the colon, a precursor to cancer.63

In two large prospective epidemiological trials, men and women who consumed 700-800 mg per day ofcalcium had a 40%-50% lower risk of developing left-side colon cancer.64

Side Effects: Some individuals who take calcium supplements might experience gas, bloating, constipation, or

a combination of these symptoms. Excessively high levels of calcium in the blood known as hypercalcemia impair kidney function,

and lead to reduced absorption of other essential minerals, such as iron, zinc, magnesium, andphosphorus. However, hypercalcemia rarely results from dietary or supplemental calcium intakeand is most commonly associated with hyperparathyroidism, advanced cases of cancer orexcessive intakes of vitamin D from supplements.65

Chondroitin and Glucosamine SulfateChondroitin and Glucosamine sulfate are natural substances found in and around the cells of cartilage.Glucosamine is an amino sugar that the body produces and distributes in cartilage and other connectivetissue, and chondroitin sulfate is a complex carbohydrate that helps cartilage retain water.Chondritin and glucosamine sulfate are commonly used to treat osteoarthritis. An estimated 27 millionadults in the United States live with osteoarthritis—the most common type of arthritis. Osteoarthritis,also called degenerative joint disease, is caused by the breakdown of cartilage, which is the connectivetissue that cushions the ends of bones within the joint. Osteoarthritis is characterized by pain, jointdamage, and limited motion. The disease generally occurs late in life, and most commonly affects thehands and large weight-bearing joints, such as the knees. Age, female gender, and obesity are riskfactors for this condition.

66

In 2002 the National Institutes of Health conducted the Glucosamine/chondroitin Arthritis InterventionTrial Primary Study. A total of 1,583 people participated in the study. People age 40 or older with knee


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pain and documented x-ray evidence of osteoarthritis were eligible to participate. Participants could nothave used glucosamine for 3 months and chondroitin sulfate for 6 months prior to entering the study.Participants were about 59 years of age, on average, and nearly two-thirds of participants were women.Of the 1,583 study participants, 78 percent (1,229) were in the mild pain subgroup and 22 percent (354)were in the moderate-to-severe pain subgroup.

Test Dosages: Glucosamine alone: 1500 mg daily given as 500 mg three times a day Chondroitin sulfate alone: 1200 mg daily given as 400 mg three times a day Glucosamine plus chondroitin sulfate combined: same doses-1500 mg and 1200 mg daily Celecoxib (which is a non-steroidal anti- inflammatory): 200 mg daily Acetaminophen: participants were allowed to take up to 4000 mg (500 mg tablets) per day to

control pain, except for the 24 hours before pain was assessed.

Study results: Participants taking the positive control, celecoxib, experienced statistically significant pain relief

versus placebo—about 70 percent of those taking celecoxib had a 20 percent or greater reductionin pain versus about 60 percent for placebo.

Overall, there were no significant differences between the other treatments tested and placebo. For a subset of participants with moderate-to-severe pain, glucosamine combined with

chondroitin sulfate provided statistically significant pain relief compared with placebo—about 79percent had a 20 percent or greater reduction in pain versus about 54 percent for placebo.According to the researchers, because of the small size of this subgroup these findings should beconsidered preliminary and need to be confirmed in further studies.

For participants in the mild pain subset, glucosamine and chondroitin sulfate together or alonedid not provide statistically significant pain relief.

$12.5 million were spent on this study, which in essence was equivocal regarding the effectiveness ofchondroitin and glucosamine sulfates in the treatment of osteoarthritis.

ChromiumChromium is a mineral that humans require in trace amounts, although its mechanisms of action in thebody and the amounts needed for optimal health are not well defined. It is found primarily in two forms:1) trivalent (chromium 3+), which is biologically active and found in food, and 2) hexavalent (chromium6+), a toxic form that results from industrial pollution. This fact sheet focuses exclusively on trivalent(3+) chromium.

Chromium is known to enhance the action of insulin, a hormone critical to the metabolism and storageof carbohydrate, fat, and protein in the body. In 1957, a compound in brewers' yeast was found toprevent an age-related decline in the ability of rats to maintain normal levels of sugar (glucose) in theirblood. Chromium was identified as the active ingredient in this so-called "glucose tolerance factor" in1959.Chromium also appears to be directly involved in carbohydrate, fat, and protein metabolism.67

In 1989, the National Academy of Sciences established an "estimated safe and adequate daily dietaryintake" range for chromium. For adults and adolescents that range was 50 to 200 micrograms (mcg).68


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Chromium deficiency is rare. However, Chromium is used in supplement form to treat diabetes, lowerblood lipid levels, promote weight loss, and improve body composition. Chromium is routinely added tointravenous solutions. Chromium, added at doses of 150 to 250 mcg/day for up to two weeks correctedintravenous patients diabetes symptoms.

Chromium is a widely used supplement. Estimated sales to consumers were $85 million in 2002,representing 5.6% of the total mineral-supplement market.69

EchinaceaThere are nine known species of echinacea, all of which are native to the United States and southernCanada. The most commonly used, Echinacea purpurea, is believed to be the most potent.

Common Uses: Echinacea has traditionally been used to treat or prevent colds, flu, and other infections. Echinacea is believed to stimulate the immune system to help fight infections. Less commonly, echinacea has been used for wounds and skin problems, such as acne or boils.

Scientific Observations: Study results are mixed on whether echinacea effectively treats colds or flu. For example, two

National Center for Complementary and Alternative Medicine (NCCAM)-funded studies did notfind a benefit from echinacea, either as Echinacea purpurea fresh-pressed juice for treating coldsin children, or as an unrefined mixture of Echinacea angustifolia root and Echinacea purpurearoot and herb in adults. However, other studies have shown that echinacea may be beneficial intreating upper respiratory infections.

Most studies to date indicate that echinacea does not appear to prevent colds or other infections. NCCAM is continuing to support the study of echinacea for the treatment of upper respiratory

infections. NCCAM is also studying echinacea for its potential effects on the immune system.70

EphedraIn 2004 the Food and Drug Administration (FDA) issued a rule prohibiting the sale of dietarysupplements containing ephedrine alkaloids (ephedra) because such supplements were deemed topresent an unreasonable risk of illness or injury. Dietary supplements containing ephedrine alkaloidswere extensively promoted for aiding weight control and boosting sports performance and energy. Thetotality of the available data showed little evidence of ephedra's effectiveness except for modest, short-term weight loss without any clear health benefit, while confirming that the substance raises bloodpressure and otherwise stresses the circulatory system. These effects were linked to significant adversehealth outcomes, including heart attack and stroke.

Fish Oil Omega-3 fatty acidOmega-3 fatty acids are a family of unsaturated fatty acids that have in common a final carbon–carbondouble bond in the n−3 position; that is, the third bond from the methyl end of the fatty acid. Common Uses:


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Pain and Inflammation. Omega 3 fatty acids, particularly Eicosapentaenoic acid (EPA), helpsto regulate the body’s inflammation cycle, which prevents and relieves painful conditions likearthritis, prostatitis, cystitis.

Cardiovascular Health. Omega 3 fatty acids help to lower cholesterol, tryglicerides, LDLs andblood pressure, while at the same time increasing good HDL cholesterol.

Protection from Stroke and Heart Attack. Research shows omega 3 fatty acids break up clotsbefore they can cause any damage.

Brain Function and Higher Intelligence. For adults, omega 3 improves memory, recall,reasoning and focus.

Depression and Psychosis. Psychiatry department researchers at the University of Sheffield,along with many other research studies, found that omega 3 fish oil supplements "alleviate" thesymptoms of depression, bipolar and psychosis 71

Reduction of Breast, Colon and Prostate Cancer. Omega 3 helps stop the alteration from anormal healthy cell to a cancerous mass, inhibiting unwanted cellular growth and causingapoptosis( cellular death), of cancer cells.

Acceptable Intake( AI) of Omega 3:The FDA recommends that total dietary intake of n−3 fatty acids from fish not exceed 3 grams per day, of which no more than 2 grams per day are from nutritional supplements. 72

The AI for n−3 is 1.6 grams/day for men and 1.1 grams/day for women.73

Sources: The most widely available source of Omega 3 is cold water oily fish such as salmon, herring,

mackerel, anchovies and sardines. Six times richer than most fish oils in n−3, flax (or linseed) (Linum usitatissimum) and its oil are

perhaps the most widely available botanical source of n−3. Eggs, milk, cheese, walnuts, pecans and hazel nuts are other sources of omega 3.

Usage Risks:

A perceived risk of fish oil n−3 supplementation has been heavy metal poisoning by the body's accumulation of traces of heavy metals, in particular mercury, lead, nickel, arsenic and cadmium foundespecially in less-refined fish oil supplements. However, in reality, heavy metal toxicity from consumingfish oil supplements is highly unlikely. This is because heavy metals selectively bind with protein in thefish flesh rather than accumulate in the oil. An independent test in 2006 of 44 fish oils on the US marketfound that all of the products passed safety standards for potential contaminants.74

Research Findings:

“Research shows that omega-3 fatty acids reduce inflammation and may help lower risk of chronicdiseases such as heart disease, cancer, and arthritis. Omega-3 fatty acids are highly concentrated in thebrain and appear to be important for cognitive (brain memory and performance) and behavioral function.In fact, infants who do not get enough omega-3 fatty acids from their mothers during pregnancy are atrisk for developing vision and nerve problems. Symptoms of omega-3 fatty acid deficiency includefatigue, poor memory, dry skin, heart problems, mood swings or depression, and poor circulation”.75


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Omega 3 Supplements:

Both Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) can be taken in the form of fish oilcapsules. Flaxseeds are also available in ground form in a special mylar package so that the componentsin the flaxseeds stay active.

Omega 6Omega-6 fatty acids are considered essential fatty acids: They are necessary for human health but arenot produced by the body. Along with omega-3 fatty acids, omega-6 fatty acids play a crucial role inbrain function as well as normal growth and development. Also known as polyunsaturated fatty acids(PUFAs), they help stimulate skin and hair growth, maintain bone health, regulate metabolism, andmaintain the reproductive system.

A healthy diet contains a balance of omega-3 and omega-6 fatty acids. Omega-3 fatty acids help reduceinflammation, and some omega-6 fatty acids tend to promote inflammation. However, the typicalAmerican diet tends to contain 14 - 25 times more omega-6 fatty acids than omega-3 fatty acids becauseour diets are typically high in meat consumption.

Common Uses: Diabetic neuropathy-Some studies show that taking gamma linolenic acid (GLA) for 6 months or

more may reduce symptoms of nerve pain in people with diabetic neuropathy. Rheumatoid arthritis-Some preliminary evidence suggests evening primrose oil may reduce pain,

swelling, and morning stiffness; but other studies have found no effect. Allergies. Attention deficit/hyperactivity disorder (ADHD)-Clinical studies suggest that children with

ADHD have lower levels of EFAs, both omega-6s and omega-3s. EFAs are important to normalbrain and behavioral function.

Breast cancer. Eczema. High blood pressure (Hypertension)-There is some preliminary evidence that GLA may help

reduce high blood pressure, either alone or in combination with omega-3 fatty acidseicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).

Osteoporosis-Studies suggest that people who don’t get enough of some essential fatty acids(particularly EPA and GLA) are more likely to have bone loss than those with normal levels ofthese fatty acids. In a study of women over 65 with osteoporosis, those who took EPA and GLAsupplements had less bone loss over 3 years than those who took placebo. Many of these womenalso experienced an increase in bone density.

Flaxseed/Flaxseed Oil

Flaxseed is the seed of the flax plant, which is believed to have originated in Egypt. It grows throughoutCanada and the northwestern United States. Flaxseed oil comes from flaxseeds.Common Uses:

Flaxseed is most commonly used as a laxative. Flaxseed is also used for hot flashes and breast pain. Flaxseed oil is used for different conditions than flaxseed, including arthritis.


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Both flaxseed and flaxseed oil have been used for high cholesterol levels and in an effort toprevent cancer.

Whole or crushed flaxseed can be mixed with water or juice and taken by mouth. Flaxseed is alsoavailable in powder form. Flaxseed oil is available in liquid and capsule form. Flaxseed contains lignans(phytoestrogens, or plant estrogens), while flaxseed oil preparations lack lignans.

Scientific Observations: Flaxseed contains soluble fiber, like that found in oat bran, and is an effective laxative. Studies of flaxseed preparations to lower cholesterol levels report mixed results. Some studies suggest that alpha-linolenic acid (a substance found in flaxseed and flaxseed oil)

may benefit people with heart disease. But not enough reliable data are available to determinewhether flaxseed is effective for heart conditions.

Study results are mixed on whether flaxseed decreases hot flashes.

Side Effects and Cautions: Flaxseed and flaxseed oil supplements seem to be well tolerated. Few side effects have been

reported. Flaxseed, like any supplemental fiber source, should be taken with plenty of water; otherwise, it

could worsen constipation or, in rare cases, even cause intestinal blockage. The fiber in flaxseed may lower the body's ability to absorb medications that are taken by mouth.

Flaxseed should not be taken at the same time as any conventional oral medications.76

GarlicGarlic is the edible bulb from a plant in the lily family. It has been used as both a medicine and a spicefor thousands of years.

Common Uses: Garlic's most common uses as a dietary supplement are for high cholesterol, heart disease, and

high blood pressure. Garlic is also used to prevent certain types of cancer, including stomach and colon cancers.

Garlic supplements may be dried or powdered and used in tablets and capsules

Scientific Observations: Some evidence indicates that taking garlic can slightly lower blood cholesterol levels; studies

have shown positive effects for short-term (1 to 3 months) use. However, an NCCAM-fundedstudy on the safety and effectiveness of three garlic preparations (fresh garlic, dried powderedgarlic tablets, and aged garlic extract tablets) for lowering blood cholesterol levels found noeffect.

Preliminary research suggests that taking garlic may slow the development of atherosclerosis, acondition that can lead to heart disease or stroke.

Evidence is mixed on whether taking garlic can slightly lower blood pressure. Some studies suggest consuming garlic as a regular part of the diet may lower the risk of certain

cancers. However, no clinical trials have examined this. A clinical trial on the long-term use ofgarlic supplements to prevent stomach cancer found no effect.


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Garlic interacts with certain drugs and can thin the blood.

Side Effects and Cautions; Garlic appears to be safe for most adults. Side effects include breath and body odor, heartburn, upset stomach, and allergic reactions.

These side effects are more common with raw garlic. Garlic can thin the blood (reduce the ability of blood to clot) in a manner similar to aspirin. This

effect may be a problem during or after surgery. Garlic has been found to interfere with theeffectiveness of saquinavir, a drug used to treat HIV infection.77

Ginkgo BilobaThe ginkgo tree is one of the oldest types of trees in the world. Ginkgo seeds have been used intraditional Chinese medicine for thousands of years, and cooked seeds are occasionally eaten.

Common Uses: Ginkgo leaf extract has been used to treat a variety of ailments and conditions, including asthma,

bronchitis, fatigue, and tinnitus. Today, people use ginkgo leaf extracts hoping to improve memory; to treat or help prevent

Alzheimer's disease and other types of dementia; to decrease intermittent claudication ; and totreat sexual dysfunction, and multiple sclerosis.

Extracts are usually taken from the ginkgo leaf and are used to make tablets, capsules, or teas.Occasionally, ginkgo extracts are used in skin products.

Scientific Observations: An NCCAM-funded study of the well-characterized ginkgo product, EGb-761, found it

ineffective in lowering the overall incidence of dementia and Alzheimer's disease in the elderly.Further analysis of the same data also found ginkgo to be ineffective in slowing cognitivedecline. In this clinical trial, known as the Ginkgo Evaluation of Memory study, researchersrecruited more than 3,000 volunteers age 75 and over who took 240 mg of ginkgo daily.Participants were followed for an average of approximately 6 years.

Some smaller studies for memory enhancement have had promising results, but a trial sponsoredby the National Institute on Aging of more than 200 healthy adults over age 60 found that ginkgotaken for 6 weeks did not improve memory.

Side Effects and Cautions: Side effects of ginkgo may include headache, nausea, gastrointestinal upset, diarrhea, dizziness,

or allergic skin reactions. There are some data to suggest that ginkgo can increase bleeding risk Uncooked ginkgo seeds contain a chemical known as ginkgotoxin, which can cause seizures.

Consuming large quantities of seeds over time can cause death. 78

GinsengAsian ginseng is native to China and Korea and has been used in various systems of medicine for manycenturies. Asian ginseng is one of several types of true ginseng (another is American ginseng, Panaxquinquefolius). An herb called Siberian ginseng or eleuthero (Eleutherococcus senticosus) is not a trueginseng.


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Common Uses: Increasing a sense of well-being and stamina, and improving both mental and physical

performance. Treating erectile dysfunction, hepatitis C, and symptoms related to menopause. Lowering blood glucose and controlling blood pressure.

The root of Asian ginseng contains active chemical components called ginsenosides (or panaxosides)that are thought to be responsible for the herb's medicinal properties. The root is dried and used to maketablets or capsules, extracts, and teas.Scientific Observations:

Some studies have shown that Asian ginseng may lower blood glucose. Other studies indicatepossible beneficial effects on immune function.

To date, research results on Asian ginseng are not conclusive enough to prove health claimsassociated with the herb. Only a handful of large clinical trials on Asian ginseng have beenconducted. Most studies have been small or have had flaws in design and reporting. Some claimsfor health benefits have been based only on studies conducted in animals.

Side Effects and Cautions: When taken orally, ginseng is usually well tolerated. Some sources suggest that its use be limited

to 3 months because of concerns about the development of side effects. The most common side effects are headaches and sleep and gastrointestinal problems. Asian ginseng can cause allergic reactions. Asian ginseng may lower levels of blood sugar; this effect may be seen more in people with

diabetes. 79

IronIn humans, iron is an essential component of proteins involved in oxygen transport.80

It is also essential for the regulation of cell growth and differentiation. A deficiency of iron limitsoxygen delivery to cells, resulting in fatigue, poor work performance, and decreased immunity . On theother hand, excess amounts of iron can result in toxicity and even death.81

Almost two-thirds of iron in the body is found in hemoglobin, the protein in red blood cells that carriesoxygen to tissues. Smaller amounts of iron are found in myoglobin, a protein that helps supply oxygento muscle, and in enzymes that assist biochemical reactions.

Iron is also found in proteins that store iron for future needs and that transport iron in blood. Iron storesare regulated by intestinal iron absorption.

Iron supplementation is indicated when diet alone cannot restore deficient iron levels to normal withinan acceptable timeframe. Supplements are especially important when an individual is experiencingclinical symptoms of iron deficiency anemia.

Signs of iron deficiency anemia include: Feeling tired and weak. Slow cognitive and social development during childhood. Difficulty maintaining body temperature .


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Decreased immune function, which increases susceptibility to infection. Glossitis.

A serum ferritin level less than or equal to 15 micrograms per liter confirms iron deficiency anemia inwomen, and suggests a possible need for iron supplementation.CDC Recommendations to prevent and control iron deficiency in the United States.82 Supplemental ironis available in two forms: ferrous and ferric. Ferrous iron salts (ferrous fumarate, ferrous sulfate, andferrous gluconate) are the best absorbed forms of iron supplements.83

Iron Toxicity:

There is considerable potential for iron toxicity because very little iron is excreted from the body. Thus,iron can accumulate in body tissues and organs when normal storage sites are full. In children, death hasoccurred from ingesting 200 mg of iron. There is considerable potential for iron toxicity because verylittle iron is excreted from the body. Thus, iron can accumulate in body tissues and organs when normalstorage sites are full. For example, people with hemachromatosis are at risk of developing iron toxicitybecause of their high iron stores.

In children, death has occurred from ingesting 200 mg of iron.84

Doses of iron prescribed for iron deficiency anemia in adults are associated with constipation, nausea,vomiting, and diarrhea, especially when the supplements are taken on an empty stomach.85

MagnesiumMagnesium is the fourth most abundant mineral in the body and is essential to good health.Approximately 50% of total body magnesium is found in bone. The other half is found predominantlyinside cells of body tissues and organs. Only 1% of magnesium is found in blood, but the body worksvery hard to keep blood levels of magnesium constant.86

Magnesium is needed for more than 300 biochemical reactions in the body. It helps maintain normalmuscle and nerve function, keeps heart rhythm steady, supports a healthy immune system, and keepsbones strong. Magnesium also helps regulate blood sugar levels, promotes normal blood pressure, and isknown to be involved in energy metabolism and protein synthesis.87

There is an increased interest in the role of magnesium in preventing and managing disorders such ashypertension, cardiovascular disease, and diabetes. Dietary magnesium is absorbed in the smallintestines. Magnesium is excreted through the kidneys.Early signs of magnesium deficiency include loss of appetite, nausea, vomiting, fatigue, and weakness. Asmagnesium deficiency worsens, numbness, tingling, muscle contractions and cramps, seizures (suddenchanges in behaviors caused by excessive electrical activity in the brain), personality changes, abnormalheart rhythms, and coronary spasms can occur.

Scientific Observations:

Magnesium and blood pressure"Epidemiologic evidence suggests that magnesium may play an important role in regulating bloodpressure”.88


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For 6 years, the Atherosclerosis Risk in Communities (ARIC) Study followed approximately 8,000 menand women who were initially free of hypertension. In this study, the risk of developing hypertensiondecreased as dietary magnesium intake increased in women, but not in men.89

Magnesium and Cardiovascular Disease

Magnesium metabolism is very important to insulin sensitivity and blood pressure regulation, andmagnesium deficiency is common in individuals with diabetes. The observed associations betweenmagnesium metabolism, diabetes, and high blood pressure increase the likelihood that magnesiummetabolism may influence cardiovascular disease.90

Magnesium and osteoporosis

Bone health is supported by many factors, most notably calcium and vitamin D. However, someevidence suggests that magnesium deficiency may be an additional risk factor for postmenopausalosteoporosis. This may be due to the fact that magnesium deficiency alters calcium metabolism and thehormones that regulate calcium. Several human studies have suggested that magnesium supplementationmay improve bone mineral density. In a study of older adults, a greater magnesium intake maintainedbone mineral density to a greater degree than a lower magnesium intake.91

Saw PalmettoSaw palmetto is a small palm tree native to the southeastern United States. Its fruit was used medicinallyby the Seminole Tribe of Florida.Common Uses:

Saw palmetto is used mainly for urinary symptoms associated with benign prostatic hyperplasia(BPH).

Saw palmetto is also used for other conditions, including chronic pelvic pain, bladder disorders,decreased sex drive, hair loss, and hormone imbalances.

The ripe fruit of saw palmetto is used in several forms, including ground and dried fruit or wholeberries. It is available as a liquid extract, tablets, capsules, and as an infusion or a tea.

Scientific Observations: Several small studies suggest that saw palmetto may be effective for treating BPH symptoms. In 2006, a large study of 225 men with moderate-to-severe BPH found no improvement with 320

mg saw palmetto daily for 1 year versus placebo. NCCAM co funded the study with the NationalInstitute of Diabetes and Digestive and Kidney Diseases.

There is not enough scientific evidence to support the use of saw palmetto for reducing the sizeof an enlarged prostate or for any other conditions.

Saw palmetto does not appear to affect readings of prostate-specific antigen (PSA) levels. PSA isprotein produced by cells in the prostate.

Side Effects and Cautions: Saw palmetto may cause mild side effects, including stomach discomfort.


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Some men using saw palmetto have reported side effects such as tender breasts and a decline in

sexual desire.92

SeleniumSelenium is a trace mineral that is essential to good health but required only in small amounts. Seleniumis incorporated into proteins to make selenoproteins, which are important antioxidant enzymes. Theantioxidant properties of selenoproteins help prevent cellular damage from free radicals. 93

Selenoproteins also help regulate thyroid function and play a role in the immune system.

Recommended Dietary Allowances (RDA) for Selenium for Children and Adults

Age(years)

Males and Females(μg/day)

Pregnancy(μg/day)

Lactation(μg/day)

1-3 y 20 N/A N/A

4-8 y 30 N/A N/A

9-13 y 40 N/A N/A

14-18 y 55 60 70

19 y + 55 60 70

94

Selenium Deficiency:

Human selenium deficiency is rare in the U.S. but is seen in other countries, most notably China, wherethe soil concentration of selenium is low.95

There is evidence that selenium deficiency may contribute to development of heart disease,hypothyroidism, and a weakened immune system.

Three specific diseases have been associated with selenium deficiency: Keshan Disease, which results in an enlarged heart and poor heart function, occurs in selenium

deficient children. Kashin-Beck Disease, which results in osteoarthropathy. Myxedematous Endemic Cretinism, which results in mental retardation.

Selenium Supplements:Selenium supplements often contain sodium selenite and sodium selenate, two inorganic forms ofselenium. Selenomethionine is generally considered to be the best absorbed and utilized form ofselenium.

Scientific Observations:


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Observational studies indicate that death from cancer, including lung, colorectal, and prostatecancers, is lower among people with higher blood levels or intake of selenium96

Selenium is one of a group of antioxidants that may help limit the oxidation of LDL cholesteroland thereby help to prevent coronary artery disease. 97

Surveys indicate that individuals with rheumatoid arthritis, a chronic disease that causes pain,stiffness, swelling, and loss of function in joints, have reduced selenium levels in their blood.98

Selenium Toxicity:Selenium toxicity is rare is the US. High blood levels of selenium (greater than 100 μg/dL) can result in a condition called selenosis. Symptoms of selenosis include gastrointestinal upsets, hair loss, whiteblotchy nails, garlic breath odor, fatigue, irritability, and mild nerve damage.99 100

St. John’s WortSt. John's wort is a herb plant with yellow flowers whose medicinal uses were first recorded in ancientGreece. The name St. John's wort apparently refers to John the Baptist, as the plant blooms around thetime of the feast of St. John the Baptist in late June.

Common Uses: St. John's wort has been used for centuries to treat mental disorders and nerve pain. St. John's wort is used as a sedative and a treatment for malaria . St. John's wort is also used by some for depression, anxiety, and/or sleep disorders. The flowering tops of St. John's wort are used to prepare teas and tablets containing concentrated

extracts.

Scientific Observations: Studies suggest that St. John's wort is of minimal benefit in treating major depression. A study

by the National Center for Complementary and Alternative Medicine (NCCAM) found that St.John's wort was no more effective than placebo in treating major depression of moderateseverity. There is some scientific evidence that St. John's wort is useful for milder forms ofdepression.

Side Effects and Cautions: St. John's wort may cause increased sensitivity to sunlight. Other side effects can include

anxiety, dry mouth, dizziness, gastrointestinal symptoms, fatigue, headache, or sexualdysfunction.

Research shows that St. John's wort interacts with some drugs. The herb affects the waythe body processes or breaks down many drugs; in some cases, it may speed or slow adrug's breakdown. Drugs that can be affected include:

o Antidepressantso Birth control pillso Cyclosporine, which prevents the body from rejecting transplanted organso Digoxin, which strengthens heart muscle contractionso Indinavir and possibly other drugs used to control HIV infectiono Irinotecan and possibly other drugs used to treat cancer


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o Warfarin and related anticoagulants When combined with certain antidepressants, St. John's wort may increase side effects

such as nausea, anxiety, headache, and confusion. St. John's wort is not a proven therapy for depression.101

ValerianValerian (Valeriana officinalis), a member of the Valerianaceae family, is a perennial plant native toEurope and Asia and naturalized in North America. 102

Valerian is an herb sold as a dietary supplement in the United States. Valerian is a common ingredient inproducts promoted as mild sedatives and sleep aids for nervous tension and insomnia. Evidence fromclinical studies of the efficacy of valerian in treating sleep disorders such as insomnia is inconclusive.

Valerian Supplements:Valerian, marketed as dietary supplement, is made from roots, rhizomes (underground stems), andstolons (horizontal stems). Dried roots are prepared as teas or tinctures, and dried plant materials andextracts are put into capsules or incorporated into tablets.103

Common Uses: Valerian has been used as a medicinal herb since at least the time of ancient Greece and

Rome. Its therapeutic uses were described by Hippocrates, and in the 2nd century, Galenprescribed valerian for insomnia. 104

In the 16th century, it was used to treat nervousness, trembling, headaches, and heartpalpitations. 105

In the mid-19th century, valerian was considered a stimulant that caused some of thesame complaints it is thought to treat and was generally held in low esteem as a medicinalherb. 106

During World War II, it was used in England to relieve the stress of air raids. 107

In addition to sleep disorders, valerian has been used for gastrointestinal spasms anddistress, epileptic seizures, and attention deficit hyperactivity disorder. However,scientific evidence is not sufficient to support the use of valerian for these conditions. 108

Scientific Observations:The results of some studies suggest that valerian may be useful for insomnia and other sleep disorders.

Side Effects:Headaches, dizziness, pruritus, and gastrointestinal disturbances are the most common side effects.

Vitamin A and CarotenoidsVitamin A is a group of compounds that play an important role in vision, bone growth, reproduction,cell division, and cell differentiation (in which a cell becomes part of the brain, muscle, lungs, blood, orother specialized tissue).109

Common Uses: Vitamin A helps regulate the immune system.


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Vitamin A also may help lymphocytes fight infections more effectively.Vitamin A promotes healthy surface linings of the eyes and the respiratory, urinary, andintestinal tracts. When those linings break down, it becomes easier for bacteria to enter the bodyand cause infection.

Vitamin A also helps the skin and mucous membranes function as a barrier to bacteria andviruses.

In general, there are two categories of vitamin A, depending on whether the food source is an animal ora plant.

Vitamin A found in foods that come from animals is called preformed vitamin A. It is absorbed in theform of retinol, one of the most usable (active) forms of vitamin A. Sources include liver, whole milk,and some fortified food products. Retinol can be made into retinal and retinoic acid in the body.

Vitamin A that is found in colorful fruits and vegetables is called provitamin A carotenoid. They can bemade into retinol in the body. In the United States, approximately 26% of vitamin A consumed by menand 34% of vitamin A consumed by women is in the form of provitamin A carotenoids. 110

Common provitamin A carotenoids found in foods that come from plants are beta-carotene, alpha-carotene, and beta-cryptoxanthin. Among these, beta-carotene is most efficiently made into retinol.Alpha-carotene and beta-cryptoxanthin are also converted to vitamin A, but only half as efficiently asbeta-carotene.

Of the 563 identified carotenoids, fewer than 10% can be made into vitamin A in the body.111

Lycopene, lutein, and zeaxanthin are carotenoids that do not have vitamin A activity but have otherhealth promoting properties. The Institute of Medicine (IOM) encourages consumption of all carotenoid-rich fruits and vegetables for their health-promoting benefits.

Some provitamin A carotenoids have been shown to function as antioxidants in laboratory studies;however, this role has not been consistently demonstrated in humans. 112

Recommended Dietary Allowances (RDAs) for vitamin A

Age(years)

Children(mcgRAE)

Males(mcgRAE)

Females(mcgRAE)

Pregnancy(mcgRAE)

Lactation(mcgRAE)

1-3300(1,000IU)

4-8400(1,320IU)

9-13600(2,000IU)


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14-18900(3,000IU)

700(2,310IU)

750(2,500 IU)

1,200(4,000IU)

19+900(3,000IU)

700(2,310IU)

770(2,565 IU)

1,300(4,300IU)

Vitamin A Deficiency:

Vitamin A deficiency is common in developing countries but rarely seen in the United States.Approximately 250,000 to 500,000 malnourished children in the developing world become blind eachyear from a deficiency of vitamin.113

Fat malabsorption can result in diarrhea and prevent normal absorption of vitamin A. Over time this mayresult in vitamin A deficiency. Those conditions include:

Celiac disease: Often referred to as sprue, celiac disease is a genetic disorder. People with celiacdisease become sick when they eat a protein called gluten found in wheat and some other grains.In celiac disease, gluten can trigger damage to the small intestine, where most nutrient absorptionoccurs. Approximately 30% to 60% of people with celiac disease have gastrointestinal-motilitydisorders such as diarrhea. 114

Crohn's disease: This inflammatory bowel disease affects the small intestine. People withCrohn's disease often experience diarrhea, fat malabsorption, and malnutrition.115

Pancreatic disorders: Because the pancreas secretes enzymes that are important for fatabsorption, pancreatic disorders often result in fat malabsorption. Without these enzymes, it isdifficult to absorb fat. Many people with pancreatic disease take pancreatic enzymes in pill formto prevent fat malabsorption and diarrhea.116

Scientific Observations:There is no evidence of an association between beta-carotene intake, especially from fruits andvegetables, and increased risk of osteoporosis. Current evidence points to a possible association withvitamin A as retinol only.Dietary intake studies suggest an association between diets rich in beta-carotene and vitamin A and alower risk of many types of cancer.117

Health Risks of Excessive Vitamin A:Hypervitaminosis A refers to high storage levels of vitamin A in the body that can lead to toxicsymptoms. There are four major adverse effects of hypervitaminosis A: birth defects, liverabnormalities, reduced bone mineral density that may result in osteoporosis (see the previous section),and central nervous system disorders.118

Vitamin DVitamin D is a fat-soluble vitamin that is naturally present in very few foods and therefore is available asa dietary supplement. It is also produced endogenously when ultraviolet rays from sunlight strike theskin and trigger vitamin D synthesis. Vitamin D obtained from sun exposure, food, and supplements isbiologically inert and must undergo two hydroxylations in the body for activation. The first occurs in theliver and converts vitamin D to 25-hydroxyvitamin D [25(OH)D], also known as calcidiol. The second


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occurs primarily in the kidney and forms the physiologically active 1,25-dihydroxyvitamin D[1,25(OH)2D], also known as calcitriol.119

Vitamin D Uses: Vitamin D is essential for promoting calcium absorption in the gut and maintaining adequate

serum calcium and phosphate concentrations to enable normal mineralization of bone andprevent hypocalcemic tetany.

Vitamin D is needed for bone growth and bone remodeling by osteoblasts and osteoclasts.Without sufficient vitamin D, bones can become thin, brittle, or misshapen. Vitamin Dsufficiency prevents rickets in children and osteomalacia in adults. Together with calcium,vitamin D also helps protect older adults from osteoporosis.

Vitamin D has other roles in human health, including modulation of neuromuscular and immunefunction and reduction of inflammation.

Many gene encoding proteins that regulate cell proliferation, differentiation, and apoptosis aremodulated in part by vitamin D.120

Dietary supplements:

In supplements and fortified foods, vitamin D is available in two forms, D2 (ergocalciferol) and D3(cholecalciferol).

Vitamin D Deficiency:

A vitamin D deficiency can occur when usual intake is lower than recommended levels over time,exposure to sunlight is limited, the kidneys cannot convert vitamin D to its active form, or absorption ofvitamin D from the digestive tract is inadequate. Vitamin D-deficient diets are associated with milkallergy, lactose intolerance, and strict vegetarianism.121

Rickets and osteomalacia are the classical vitamin D deficiency diseases. In children, vitamin Ddeficiency causes rickets, a disease characterized by a failure of bone tissue to properly mineralize,resulting in soft bones and skeletal deformities. In adults, vitamin D deficiency can lead toosteomalacia, resulting in weak muscles and bones.

Health Risks from Excessive Vitamin D:Vitamin D toxicity can cause nonspecific symptoms such as nausea, vomiting, poor appetite,constipation, weakness, and weight loss. Additionally, it can also raise blood levels of calcium, causingmental status changes such as confusion and heart rhythm abnormalities. The use of supplements of bothcalcium (1,000 mg/day) and vitamin D (400 IU/day) by postmenopausal women was associated with a17% increase in the risk of kidney stones over 7 years in the Women's Health Initiative.122

Scientific Observations:Laboratory and animal evidence as well as epidemiologic data suggest that vitamin D status could affectcancer risk. Strong biological and mechanistic bases indicate that vitamin D plays a role in theprevention of colon, prostate, and breast cancers. Emerging epidemiologic data suggest that vitamin Dhas a protective effect against colon cancer, but the data are not as strong for a protective effect againstprostate and breast cancer.123


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Vitamin KVitamin K is a fat-soluble vitamin needed to produce blood-clotting factors, such as prothrombin, thatprevent excessive bleeding or hemorrhaging throughout the body. It also helps strengthen the body’sbones and capillaries.

Vitamin K comes in three forms: phylloquinone, menaquinone, and menadione. Phylloquinone, or K1, isfound in green leafy vegetables, and helps bones absorb and store calcium. One recent study showed thatincreased amounts of vitamin K in the diet might lower the risk of hip fracture; over time, a shortage ofvitamin K could lead to osteoporosis. Menaquinone, or K2, is manufactured in the body by naturallyoccurring intestinal bacteria. People that regularly take antibiotics or have a medical condition thatupsets the balance of bacteria in the intestine are at risk of developing a vitamin K deficiency.Menadione, or vitamin K3, is an artificial form of vitamin K, which is water-soluble and more easilyabsorbed by people who have problems with fat absorption.

Vitamin K is now being studied for its effectiveness as a cancer treatment. Initial laboratory studiesshowed that vitamin K might be as effective as some prescription drugs at slowing the growth ofcancerous tumors. Vitamin K is also be studied to see if it increases the effectiveness of standardanticancer drugs.

The Recommended Dietary Allowance (RDA) for vitamin K is based on an individual’s weight—about1 microgram for every 2 pounds. The RDA for the average male is about 80 micrograms, and the RDAfor the average female is about 65 micrograms. Greens, such as kale, spinach, broccoli, lettuce, andcabbage are good choices; cauliflower, soybeans, and strawberries are also high in vitamin K. High-protein foods, such as meats and eggs, have vitamin K. Vitamin K is also in green tea—this is the onlytype of tea that contains vitamin K.

Vitamin K deficiency is rare—most people get enough from food and from their own intestinal bacteria.One notable sign of vitamin K deficiency is abnormal bleeding and bruising as a result of minor injuries.Nosebleeds, blood in your urine, and intestinal bleeding are also signs of vitamin K deficiency.People at a higher risk of developing vitamin K deficiency include:Newborns do not have a supply of vitamin K in their system, so they are usually given an injection ofvitamin K at birth. Individuals with Crohn’s disease, colitis, or liver disease.Most multivitamin supplements do not contain vitamin K. Vitamin K supplements are available in 100-microgram capsules. Taking more than 100 micrograms of vitamin K each day could a day cause liverdamage, and people taking blood-thinning drugs should avoid this supplement altogether. 124

ZincZinc is an essential mineral that is naturally present in some foods and is available as a dietarysupplement.Common Uses of Zinc:

Zinc is involved in numerous aspects of cellular metabolism. It is required for the catalyticactivity of approximately 100 enzymes.

Plays a role in immune function. Protein synthesis.


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Wound healing. DNA synthesis. Cell division. Supports normal growth and development during pregnancy, childhood, and adolescence. Zinc is required for proper sense of taste and smell.

Recommended Dietary Allowances (RDAs) for Zinc

Age Male Female Pregnancy Lactation

Birth to 6 months 2 mg* 2 mg*

7 months to 3 years 3 mg 3 mg

4 to 8 years 5 mg 5 mg

9 to 13 years 8 mg 8 mg

14 to 18 years 11 mg 9 mg 13 mg 14 mg

19+ years 11 mg 8 mg 11 mg 12 mg125

Zinc Deficiency:

Zinc deficiency is characterized by growth retardation, loss of appetite, and impaired immune function.In more severe cases, zinc deficiency causes hair loss, diarrhea, delayed sexual maturation, impotence,hypogonadism in males, and eye and skin lesions. Weight loss, delayed healing of wounds, tasteabnormalities, and mental lethargy can also occur.The World Health Organization and UNICEF now recommend short-term zinc supplementation (20 mgof zinc per day, or 10 mg for infants under 6 months, for 10–14 days) to treat acute childhooddiarrhea.126

Health Risks from Excessive Zinc:Zinc toxicity can occur in both acute and chronic forms. Acute adverse effects of high zinc intakeinclude nausea, vomiting, loss of appetite, abdominal cramps, diarrhea, and headaches.The doses of zinc used in the AREDS study (80 mg per day of zinc in the form of zinc oxide for 6.3years, on average) have been associated with a significant increase in hospitalizations for genitourinarycauses, raising the possibility that chronically high intakes of zinc adversely affect some aspects ofurinary physiology.127

Keys to Prescribing Dietary SupplementsBefore prescribing dietary supplements, the Doctor of Chiropractic must be cognizant of the following:

The fact that most people do not inform their doctor when they are taking a supplement on theirown. The absence of communication between the doctor and patient can result in the patienthaving an adverse reaction due to "double–dosing" or combining supplements and certainmedications. The combined use of herbs with medicines can have an unpredictable, synergisticeffect.

The indications and contraindications for use of the supplement relative to the patient’s clinicalhistory and diagnosis.

An important consideration is that immunosuppression is a potential adverse effect of somedietary supplements. For example, long-term use of echinacea may cause immunosuppression.128


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Other problematic dietary supplements include green tea and ginger, which have demonstratedsuppression of lymphocyte proliferation. Clinicians should review dietary supplements on anindividual basis to assess their potential for immunosuppression or immunostimulation and thepotential benefits and risks to their patients.

Herbals can interact with drugs used for anesthesia. The American Society of Anesthesiologistsrecommends that all herbals be discontinued 2-3 weeks prior to a scheduled surgery.

Do not prescribe herbals to patient’s that are pregnant or breast-feeding. Do not prescribe herbals to patient’s taking the anticoagulant Coumadin. Some herbs can have an

affect on how long it takes your blood to clot. Do not prescribe herbal products containing ephedra. Many deaths have been associated with its

use. Avoid prescribing St. John’s Wort. Many drugs interact with St. John's Wort, prompting the US

Food and Drug Administration to issue a health advisory. The FDA advises against using St.John's Wort because it can cause some drugs to be eliminated from the body too quickly, makingthem less effective. 129

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Course Instructor: Dr. Louis Camilli - The Wise DC Folate Niacin Riboflavin Thiamine Vitamin B6 Vitamin B12 mg mcg mg mg mg mg mcg ... Males 15-18 1200/1300 1200/1250 150 18/12 400/410