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8/8/2019 Stephen Holt MD-Therapuetics With Natural Remedies_ FEB08
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THERAPEUTICS WITHNATURAL REMEDIES
Stephen Holt MD, LLD (Hon.) ChB., ND, FRCP (C), MRCP (UK), FACP, FACG, FACN, FACAM
Distinguished Professor of Medicine, NYCPM
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HISTORIC PERSPECTIVES
Pharmacognosy: the study of
natural products used in medicine
Ancient discipline of medicalscience
Pharmakon = drug, Gnosis =
knowledge
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CONCEPTS
Natural medicine cannot integrate intogeneral medical practice without ascientific base
Botanicals or herbs are drugs and
many drugs are botanicals or herbs, orsynthetic copies
Dietary supplement manufacturersexhibit widespread ignorance about
pharmaceutical science Hiding behind mythical and magical
thinking is no longer acceptable inintegrative medicine
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CONCEPTS
Some natural clinicians baulk at attemptsto explain the bioactivity of naturaltherapies within the framework of currentscientific knowledge
While sympathy exists for this position,our understanding of pharmacodynamiceffects of herbs, botanicals or nutrientsmust be based on scientific principles
Conversations about clinicalpharmacology among dietary supplementmanufacturers are rare and practicallynon-existent with their customer base
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DRUG OR NUTRACEUTICAL
DISPOSITION If dietary supplements are to be used astherapeutic agents, there must be somerespect for basic pharmacologic concepts.
The concepts are A, D, M and E One may look critically at some dietary
supplements by simply consideringfactors that influence absorption,
distribution, metabolism and excretion ofchemical compounds [drugs ornutraceuticals]
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ABSORPTION
Absorption is a complex function of routeof delivery, chemical characteristics,processes of movement across
absorption barriers and physiologicalevents such as gastric emptying, ormodified by presence of disease, age etc
Some nutraceuticals claim that they have
absorption and bioavailability that cannotbe present, based on simple scientificprinciples
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ABSORPTION [examples]
FISH OIL: Unstable in regularformulations, denatured by gastric acid,power is with EPA. Dosage requirements
high, compliance issues, triplebioavailability with enteric coat.Standard fish oil products passe
SHARK CARTILAGE: solid or extract,
enzymatic degradation of antiangiogenicproteins, buccal absorption a fairy tale,interesting facilitated absorption by aleaky gut
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DISTRIBUTION
Drug distribution is often uneven:different tissue binding, different PH orpermeability of tissues
Example: Antioxidant Therapy: Idealantioxidant has lipophilic and hydrophilicprofiles and acts in a wide REDOX range
Single high dosage antioxidants have
dangerous pro-oxidant effects eg vit.C, E Most antioxidant supplements do not use
the correct principles of formulation
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METABOLISM
The process of chemical alteration ofdrugs in the body
A primary but not exclusive function of
the liver Inactive and active metabolites are
produced, by synthetic or non-syntheticreactions
Example: Isoflavones: genistein/genistin,conjugation eg daidzein sulfate. Acomplicated story
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EXCRETION
Elimination from the body, primarily bythe kidneys
A real concern exists with age related
reduction in renal function andnutraceutical dosage adjustment
Some complex mechanisms exist egreabsorption transport mechanisms,
tubular secretion and biliary excretionwith enterohepatic cycling
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GENERAL ISSUES
Dietary Supplements are the main stay ofalternative and complementary medicine
Growth overall in OTC sales
Contemporary switch to natural remedies
The natural remedy first line option aswell as the last line option
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DSHEA- BASED MODEL
WEAK SUPPORTINGDATA
DIETARY SUPPLEMENT
?
CREATE PLATFORM
SELL WITH CLAIM
PEER ACCEPTANCE
SUCCESS FAILURE
STRONG R & D
PRODUCT AS A DIETARYSUPPLEMENT
BODY STRUCTURE FUNCTIONCLAIM
PEER ACCEPTANCE
SELL (PHASE IV AND V)
SUSTAINED
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A PEEK INTO THE INDUSTRY
The product of the month
The evidence based formula
Condition specific formulations CEO survey reveals scientific-
based, new formulations are of
major importance Who formulated the supplements
you use in your practice?
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KEY PUBLIC HEALTH
INITIATIVES Lifestyle medicine combined withnutritional interventions have
overshadowed allopathic approaches
for many public health problems First line options for disease
prevention are not rooted generally in
drugs or surgery
Many factors have moved consumersof health care to the new paradigm of
simple, gentle and more natural
interventions
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KEY PUBLIC HEALTH
INITIATIVES
Adult obesity
Childhood obesity (A Dead-Loss
Disorder) Cardiovascular health
Cancer
Arthritis Osteoporosis
THERE MUST BE A CONDITION SPECIFIC APPROACH
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THE KEY PUBLIC HEALTH
INITIATIVE The metabolic syndrome
(SYNDROME X)
A complex disorder rooted ingenetics, adverse lifestyle withprimary nutritional precipitation
Defining Syndrome X
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THE PUBLIC HEALTH RISK
Syndrome X increases risk for :
Maturity Onset Diabetes Mellitus
Cardiovascular DiseaseCardiovascular Deaths
Deaths from ALL CAUSES
Am.J.Epidemiol, 148, 958, 1998.
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SYNDROME X : THERAPEUTICS
Soluble fiber eg oat beta glucan hydrocolloid
Soy Protein 25 g/day
Omega 3 fatty acids (EPA)
Chromium
Alpha lipoic acid Vanadium
Antioxidants eg ellagic acid, bioflavonoids
Starch blockers
Cinnamon Maitake
Green coffee bean extract
Hoodia gordonii
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LOWERING CHOLESTEROL
When the treatment is worsethan the disease
Diet Exercise
Aggregate benefits of Soluble
Fiber, Soy Protein, Omega 3fatty acids, Garlic, and others[synergy]
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WEIGHT MANAGEMENT
A holistic management approach that isbest undertaken by a practitioner ofintegrative medicine
Multifactorial causes requiringmultipronged approaches
Weight loss must not be the sole target formanagement. HOODIACY?
The real issue is obesity related disease,disability and death
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DIETARY SUPPLEMENTS AS A
PROFIT CENTER
Declining revenue for cognitive activity inclinical practice
Dietary supplement dispensaries are a majorprofit center
Supplement sales promote return visits andprecipitate spontaneous demands frompatients for disease prevention
Margins on sales are high
Supporting literature saves consultation time
Avoid any unethical relationships withsupplement purveyors
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ETHICS
Physicians must not engage in selfreferral
Private labels with physician identity
are problematic [legal liabilities]
State licensing authorities have mixed
beliefs about supplement sales
At law, dietary supplements are not to
be used to prevent or treat any disease Medical practice should not be
legislated
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CONCLUSION The interface between alternative medicine
and allopathic medicine is increasingly
indistinct
At least three quarters of all patients in an
out-patient, hospital, clinic are takingsupplements, some of which are worthless
A doctor who sells a dietary supplement
that is available in retail will ruin their
practice [A HUGE ISSUE] Supplement dispensation by healthcare
professionals will lead to the responsible
use of dietary supplements