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Overview of naturopathic medicine and some common misconceptions
Assessment of fall risk in naturopathic practice
Nutritive status in older adults and the relationship to falls
Naturopathic treatment of medical conditions associated with increased fall risk
Options to reduce need for medications that increase fall risk
GOALS
NATUROPATHIC MEDICINE
Naturopathic Medicine is a
health care system that blends
modern medical knowledge
holistic and natural approach to the
assessment, diagnosis and treatment
of an individual
By focusing on prevention and
treating the cause of disease
NATUROPATHIC MEDICINE
NATUROPATHIC MEDICINE
6
Principles
of
Naturopathic
Medicine
NATUROAPTHIC MEDICINE
Misconceptions
Naturopathic Medicine….
Is not “Evidence Based”
Is “Alternative”
Is “Complementary”
Is about being “natural”
Is against prescription drugs
Is not regulated
Doesn’t refer / collaborate
Naturopathic Visits are very comprehensive
Complete medical history
Fall Risk Specific Assessment
o Fall risk checklists and algorithms (CDC)
o Orthostatic Blood Pressure
o Grip strength
o Gait speed
o Timed Get-up-and-GO (TUG)
o BERG Balance Scale
Refer to PT or OT for more in-depth assessment
ASSESSMENT OF FALL RISK
Lab testing Vitamin D (25-OH), Vitamin B12, Ferritin, CRP
Physical Exam related to fall risk o Blood pressure + Orthostatic Blood Pressure
o Weight, Hip/Waist ratio, BMI
o General assessment of muscle mass
o Hair Skin and Nail Exam
Nutritional Assessment & Diet Diary
Assess whole-person health and well-being: o Stress, mental health, spirituality, social
circumstances, finances, hobbies etc.
ASSESSMENT OF FALL RISK
Nutritional Risk: o34% of community dwelling older adults
over the age of 65 are at “Nutritional Risk” or risk of poor nutritional status
(Canadian Community Health Survey on Healthy Aging, 2008/2009)
Level of Nutritional risk is a significant indicator of fall risk (Johnson, 2003)
NUTRITION IN OLDER ADULTS
Risk Factors for Developing Malnutrition
Age Related
Physiological
Changes
•Loss of Appetite
•Change in senses
•Poor digestion
Medical conditions •Chronic Disease
•Polypharmacy
•Poor dentition
•Poor vision
•Depression, Isolation, Grief
•Altered cognition
Mobility •Poor Functional Status
•Availability and affordability of
transport
Social •Financial constraints
•Eating along / cooking for 1
•Lack of help preparing food
Physical Environment •Location of grocery stores
•Geographic isolation
Key Points about Nutrition & Fall Risk
• It is not about independent micronutrient deficiencies, rather overall nutritional
health
• Frailty & Weakness caused by malnutrition
• Effect of short term and lifetime diet on disease risk and fall prevention
NUTRITION AND FALL PREVENTION
This is NOT nutrition…
NATUROPATHIC NUTRITION
Drugs to reduce stomach acid
One of the top 5 most of the most prescribed drug
classes in Canada
Men: 5th most common drug (16% men 65-79)
Women: 2nd most common drug (22% women
65-79) • (Statistics Canada, 2014)
Some clinically relevant uses
Health Canada recommends lowest dose, for
shortest duration
PROTON PUMP INHIBITORS
Adverse effects Associated with PPIs (Schoenfield, 2016) (Climacteric, 2016) (Gomm, 2016)(Corleto, 2014, Jacob 2016)
Fracture
Osteoporosis (Decreased bone density & strength
Pneumonia
C. Difficile diarrhea (OR 1.69)
Hospital and community acquired pneumonia (OR 1.3)
Chronic Kidney Disease
Hypomagnesia, B12 Deficiency
Dementia (HR 1.44)
Reduce diversity of good gut bacteria
ALL of above may increase fall risk!
PROTON PUMP INHIBITORS
We will
review:
Naturopathic
Approaches
for select
conditions
that have a
high Odds
ratio (OR) of
Fall Risk
(Centre for Effective Practice, 2016)
Criteria 1:
The presence of low skeletal muscle mass
Plus at least one of Criteria 2 or 3:
Criteria 2: Low Muscle strength (e.g. handgrip)
Criteria 3: Or Low muscle performance (e.g. walking speed or muscle power)
When all three conditions are present, severe sarcopenia may be diagnosed
(Santilli, 2014)
SARCOPENIA OR
≈5
SARCOPENIA
Sarcopenia and Fall Risk Sarcopenia as a risk factor for falls in elderly
individuals: results from the ilSIRENTE study. (Landi, 2012)
oFall Risk Adjusted hazard ratio [HR], 3.23
Sarcopenic Obesity
Sarcopenia may be associated with concomitant increase in fat mass (central obesity)
Sarcopenic obesity associated with a significantly higher 2-year fall rate (vs sarcopenic non-obesity) (Scott, 2016)
OR
≈5
Society for Sarcopenia, Cachexia and Wasting Disease Expert Panel (Morley, 2010)
1. Exercise:
Resistance and Aerobic
In combination with adequate protein and energy
2. Protein:
Adequate protein supplementation alone only slows loss of muscle
mass.
Leucine-enriched balanced amino acids and possibly creatine may
enhance muscle strength.
3. Vitamin D:
Low 25(0H) vitamin D levels require vitamin D replacement
SARCOPENIA- Treatment OR
≈5
Treatment- Exercise
Min of 20 to 30 minutes
Resistance and aerobic exercise
3 times a week
TO slow muscle loss and prevent sarcopenia.
(Morley, 2010)
SARCOPENIA OR
≈5
Treatment- Protein Older persons produce less muscle protein than
younger persons from the same amount of dietary protein
In the Health, Aging, and Body Composition Study Persons in the highest quintile of protein intake lost nearly 40%
less appendicular lean mass than did those in the lowest quintile (Houston, 2008)
1.0 and 1.5 g of protein/kg/d to maintain muscle mass and to increase exercise-induced muscle hypertrophy in older persons (Morley, 2010)
SARCOPENIA OR
≈5
Treatment- Leucine Effects of leucine-rich protein supplements on
anthropometric parameter and muscle strength in the
elderly: a systematic review and meta-analysis. (J Nutr Health Aging, 2015)
Meta-analysis of 16 studies
Leucine supplementation significantly increased:
oBody weight (1.02kg)
oLean body mass (0.99kg)
oMore effective in subgroup of participants with
manifested sarcopenia
SARCOPENIA OR
≈5
Treatment- Vitamin D Levels of vitamin D decline with aging
Replacement of vitamin D in persons with low levels increases Strength and function
Decreases fall (as much as 20%)
Associated with lower mortality
Levels of 25(OH) vitamin D should be measured in ALL sarcopenic patients
Vitamin D should be supplemented in all persons with values less than 100nmol/L
(Bischoff-Ferrari, 2004)(Autier, 2004)(Morley, 2010)
SARCOPENIA OR
≈5
Treatment- Omega 3
6 Month DBRCT to evaluate the effect of fish oil derived n-3PUFA (omega 3) on muscle volume and strength.
Treatment group: 4x 1g pills of omega 3 =1.66g EPA, 1.5gDHA/day
Results:
o Increased thigh muscle volume by 3.6%
o Increased handgrip strength by 26%
o Increase 1-RM muscle strength 4%
These increases suggest omega 3 may prevent 2-3 years of normal age-associated losses in muscle mass (0.5-1%/year) and function (2-3% per year)
(Smith, 2015)
SARCOPENIA OR
≈5
SARCOPENIA- Example Treatment Plan
• Exercise:
• Encourage 20-30 minutes of exercise every day
• Mixture of aerobic, resistance, group, tai chi, etc.
• Refer to PT/OT
• Protein:
• 1.0-1.5g protein / kg/ day
• Educate on dietary protein sources
• Spread protein throughout the day from a variety of sources
• Leucine
• Whey protein powder (naturally high in Leucine)
• Vitamin D
• Test 25(OH) Vitamin D levels
• Supplement to obtain levels over 100nmol/L
• Omega 3
• 1-3g/day combined EPA+DHA
Risk of Falling
and sustaining a fall-
related injury increases
with the number and
type of chronic health
problems.
CHRONIC DISEASE
# chronic
conditions
OR Risk
of Falling
0
1 1.3
2 1.4
3 1.7
4 2.0
5 2.1
6 or more 2.7
(Sibley, 2014)
CHRONIC DISEASE
(World Economic Forum, 2012)
Naturopathic Approach to Chronic Disease
Treat the underlying cause!
CHRONIC DISEASE
Gut Microbiome & Intestinal Permeability
Insulin Resistance
Inflammation Oxidative
Stress
Number of lower-extremity symptomatic OA joints and Risk of Falling (Dore, 2015)
1 joint 53% higher odds
2 joints 74% higher odds
3-4 OA joints 85% higher odds.
OA of Knee (Smith, 2016)
54% greater chance of experiencing a fall
OA of Hip (Smith, 2016)
52% greater chance of experiencing a
RA may increase fall risk especially in ankle/foot
ARTHRITIS + FALL RISK
Underlying Causes Osteoarthritis:
o Degeneration and Inflammation
o Overweight
o Injury, Overuse, Manual labor
o Women > Men after age 55
Rheumatoid Arthritis o Autoimmune Disorder
o Genetic and environmental
o Gut Microbiome (beneficial flora)
o Intestinal permeability (Leaky Gut) (Bischoff, 2014)
o Infections
o Smoking
o Aging and Hormones
ARTHRITIS
(Taneja, 2014)
Mediterranean diet (Veronese, 2016)
Improve QOL, pain, disability and depression in OA Anti-
inflammatory diet:
Foods that promote inflammation:
Sugar and refined carbohydrates, trans fat,
excessive alcohol, processed meat,
Foods that reduce inflammation
Fruits and Vegetables (Colorful!), nuts, fish…
Prebiotic foods + Probiotic Supplement
Early trials of probiotic supplementation and RA promising
ARTHRITIS- Diet
ARTHRITIS
Nutritional
Therapeutic
Snapshot of Evidence
Curcumin Meta-analysis of 8 trials:
8-12 weeks of standardized curcumin extract reduced
joint arthritis symptoms similar to the effects of iburprofen
and diclofenac sodium (Daily, 2016)
SAM-E Meta-analysis of 11 trials:
As effective as NSAIDs for improving pain and functional
limitations in osteoarthritis (Soeken, 2002)
Boswellia
Serrata
90 day RCT
5-Loxin extract improved pain and function in
Osteoarthritis (Sengupta, 2008)
Omega 3 Meta-analysis: >2.7g/day omega-3 for >3 months
reduces NSAID consumption by rheumatoid arthritis
patients (Lee, 2012)
Acupuncture for OA
Meta-analysis of 12 trials:
oSignificant reductions in pain intensity
oImprovement in functional mobility
oImprovements in quality of life
(Manyanga, 2014)
ARTHRITIS- Acupuncture
Depression & Risk of Fall For older adults starting home health care
depressive symptoms doubled the risk of adverse fall event o This was independent of medical, medication,
environmental, and functional factors) (Contemp Clin Commun, 2016)
Depression screening in Naturopathic Practice Patient Health Screening tools
Lab testing to rule out underlying contributions:
o CBC, TSH, Vitamin B12, Ferritin, hormone testing
DEPRESSION OR
≈2
SSRI and TCA
antidepressants are
considered independent
risk factors for falls and
fracture due to falls (Dyks, 2015)
ANTIDEPRESSANT MEDICATION & FALL RISK OR≈ 1.3-1.6
Antidepressant Odds Ratio
(95%CI)
TCAs 1.30 (1.23-1.38)
SSRIs 1.66 (1.58-1.73)
Meta-analysis of 13 trials found SSRIs significantly
increased risk of fracture (RR 1.72) from falls
independent of depression and bone mineral density (Wu, 2012)
Nutrition
Dietary Fish intake associated with lower risk of
depression (Grosso, 2016)
Mediterranean diet pattern may have a protective
role in the prevention of depressive disorders.
o Inverse dose response with nuts, fruit, monounsaturated
to saturated fat ratio and legumes o (Majem, 2009)
“Healthy Dietary Pattern” (whole grains,
vegetables, fruits, fish, nuts and seeds) inversely
associated with depression scores (Kim, 2016)
OR
≈2 DEPRESSION
Probiotics
Gut brain axis! “psychobiotics”
8 week probiotic supplementation in patients with
MDD: o Decreased beck depression inventory scores
o Decreased serum insulin levels
o Decreased insulin resistance
o Decreased serum hs-cRP
o Increase in glutathione levels (Akkasheh, 2016)
Probiotics also have a positive effect on subclinical
depression, anxiety and perceived stress (McKean, 2016)
DEPRESSION OR
≈2
Saffron
Most expensive spice on earth
Saffron as effective as Citalopram for Major Depressive Disorder (Talaei, 2016)
Saffron as effective as fluoxetine in several trials o (Shahmansouri, 2014) (Salimi, 2016) ( Noorbala, 2005)
Meta-analysis (6 studies): Large treatment effect with similar activity to anti-depressant medication o (Lopresti, 2014)
DEPRESSION
Curcumin
Significant improvements in atypical
depression versus placebo (Lopresti, 2014)
Curcumin+Saffron combined
oSignificantly reduced depressive and
anxiety symptoms in major depressive
disorder (Lopresti, 2017)
DEPRESSION OR
≈2
Tai Chi
Positive studies for depression AND o hypertension, fall prevention, cognitive performance,
osteoarthritis, depression, COPD, pain, balance confidence and muscle strength (Solloway, 2016)
• ALL independent risk factors for FALLS!!!
Meditation and Mindfulness Based Programs Meta-analysis of 47 trials
Moderate evidence of improved anxiety, depression and pain (Goyal, 2014)
Yoga (Pilkington, 2005)
Refer: Counselling & CBT
DEPRESSION OR
≈2
Alzheimer’s Doubles Fall Risk Causes of Falls in Dementia:
Physical weakness, Gait change, Balance
Memory impairment
Fatigue
Medication
o Anti-psychotic medications
o Proton Pump Inhibitors may increase incidence of dementia 40% (Gomm, 2016)
Underlying causes of Dementia / Alzheimer’s / Cognitive Decline
Micronutrient deficiencies (Cardoso, 2013)
Oxidative stress, inflammation (Fusco, 2007)
“Diabetes of the Brain” ?
DEMENTIA OR
≈2
Strictly
Followed =
53% reduced risk
of Alzheimer’s
disease
Moderately
Followed =
35% reduced risk
of Alzheimer’s
disease
(Alzheimer's Dement,
2015)
Factors increasing fall risk in Diabetes: Peripheral neuropathy
Diabetic retinopathy
Diabetic Nephropathy
Wounds/ulcers
Medications: o Insulin
oMetformin
DIABETES & FALL RISK OR≈
1.6-2
DIABETES DIET OR≈
1.6-2
REDUCE: Refined Sugar, High GI/GL Carbohydrates,
Alcohol, Trans Fat, Food that’s not food!
Eat a diet full of:
Fiber
Low GI fruits and vegetables
Protein
Chromium food s(Broccoli!)
Unsaturated fatty acids (fish)
Monounsaturated fats (olive oil)
Nut & Seeds
Cinnamon, Turmeric
Resistant starch
DIABETES OR≈
1.6-2
Encourage weight loss
Exercise!
MBSR (Mindfulness Based Stress Reduction)
Helpful in many models of chronic disease
May reduce HbA1c levels and blood pressure
after 8 weeks (Rosenweig, 2007)
Acupuncture:
Limited RCTs, but show overall positive effect
Nutritional Therapeutics
PGX (PolyglycopleX) o Viscious fiber complex
o Reduces food cravings
o Supports weight loss
o Controls and balances blood sugar
o Lowers cholesterol levels
o Reduces glycemic index of a meal up to 50%
Treatment of Diabetic Neuropathy o Alpha lipoic acid
o Acupuncture
Nutritional
Therapeutic
Snapshot of Evidence
Alpha
Lipoic Acid
Improves insulin sensitivity and glucose disposal rates in T2DM
Particularly useful in diabetic neuropathy
600mg/day
PGX Reduces appetitie
Reduce blood glucose response regardless of food
berberine
Magnesiu
m
Optimizes insluin production, improves glucose metabolism, increases
insulin sensitivity (200-400mg/day)
DIABETES
Prescription sleep medications increase fall risk
Older age associated with sleep issues:
Advanced sleep phase: urge to sleep much
earlier
Many medical and mental health
comorbidities
Polypharmacy
May not require as many hours of sleep as
age
SLEEP
Benzodiazepines consistently found to be associated with falls (Dyks, 2015)
Nonbenzodiazepine Sedative Hypnotics (e.g. Zolpidem) also associated with increased fall risk (Tom, 2016)
Mechanism of Action: Activate GABA receptor, causing muscle weakness, dizziness, incoordination, somnolence, and confusion
Benzodiazepine use significantly associated with dementia (OR 1.78) Increase fall risk
(Masud, 2016)
SLEEP Rx
Ideally: Sleep hygiene coaching prior to being prescribed
Discontinue Medication With help from:
opharmacist and MD
owww.deprescribing.org
oSTOPP Protocols
Very slow taper
CBT: Tapering combined with CBT more effective at achieving long-term discontinuation than tapering alone
SLEEP
Educate on Sleep Hygiene: Regular sleep schedule
Restrict artificial light at night
Therapeutic therapy lamp in morning
Limit caffeine and alcohol
Eat more carbohydrates at dinner High GI meal 4h before bed shows a significant
shortening of sleep onset latency (Afaghi, 2007)
Keep bedroom dark and cool
Manage stress during the day
Exercise and light during the day
SLEEP HYGIENE
Stick to a regular sleep schedule – even on
weekends • Get regular exercise – avoid
exercising in the late evening9,10 • Go to
bed only when you feel tired • Use your
bedroom only for sleep and sexual activity
• Avoid large meals just before bedtime •
Limit caffeine, alcohol and nicotine • Keep
bedroom dark and quiet • Avoid daytime or
evening napping • Remove bedroom clock
from sight • Avoid light-emitting devices or
bright lights in the hours before bedtime
(e.g., e-books, cell phones)11
Cognitive Behavioral Therapy CBT more effective than medication for short and
long term management of insomnia in older adult
Find a Relaxation technique: Practice progressive muscle relaxation
Breathing exercises
Meditation
Being in nature
Try this throughout day, and 30-60 min before bedtime
Acupuncture, massage or other body therapy (Centre for Effective Practice- Management of chronic insomnia, 2017)
SLEEP & RELAXATION THERAPY
Exogenous Melatonin Supplementation
Studies mixed
Side Effects: vivid dreams, morning grogginess
My approach
oTry 0.5-5mg 30-60 min before bed
oProlonged release melatonin to help stay asleep
oTake 1 week to “reset” circadian rhythm then
discontinue
SLEEP- NUTRITIONAL THERAPEUTICS
Magnesium
DBRT: 46 older adults, 500mg magnesium versus placebo for 8 weeks o in sleep time, sleep efficiency, melatonin
concentration
o in insomnia severity index, sleep onset latency, and cortisol concentration, early morning waking
oWill also help with restless leg and muscle spasm
oNote: At higher doses may cause loose stool, reduce dose
• (Abbasi, 2012)
SLEEP- NUTRITIONAL THERAPEUTICS
Contribution Long visits, holistic approach to all areas of health
Focus on prevention of chronic disease
Focus on underlying causes of many conditions (inflammation, oxidative stress, gut health etc)
Empowering patients to pursue healthy habits
Barriers Cost
Integration with health system
Patient population skewed to proactive patients
NATUROAPTHIC FALL PREVENTION
The doctor of the future will give no medicine, but
will interest her or his patients in the care of the
human frame, in a proper diet, and in the cause and
prevention of disease.
-Thomas Edison
Dr. Kara Dionisio, ND
Naturopathic Doctor
Nature Med Naturopathic Clinic
1095 1st Ave West
Owen Sound, Ontario
(519) 416-9355
www.naturemed.ca
Questions? Or Say Hello….
