Integrated Health Care:
Applying Best Practices
From Two Medical Models

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

From The May 2001 Issue of Nutrition Science News

By Raymond M. Lombardi, D.C., N.D., C.C.N.

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The transformation of U.S. health care is challenging and changing the way practitioners administer health care and the way patients receive it, as an aging population places greater demands on the traditional system for answers and options. A 1997 survey that found Americans made 629 million visits to alternative medical practitioners (more than the number of visits to all U.S. primary care physicians) is reason enough for allopathic practitioners to become skillful integrators of holistic care.

Allopathic medical practitioners have been ill-prepared to deal with the rapid proliferation of alternative medical therapies and natural supplements, many of which are being used by their patients in conjunction with traditional treatments. While practitioners are justifiably hesitant to begin an integrated practice, there are valid reasons for becoming more knowledgeable about alternative approaches to health care, and more willing to start adding select remedies to their practices.

Integrated medicine can provide a solid approach to numerous medical conditions, including osteoarthritis, elevated cholesterol levels, depression, and cancer. There are instances where supplements, herbs, homeopathic remedies, and energetic medicine protocols (clinical kinesiology, biomagnets and Reiki) are the preferred first line of treatment, prior to pharmaceuticals. Alternative remedies also can be used to reduce the side effects and nutrient depletions associated with conventional medications.

What follows are discussions of three common conditions for which alternative medical approaches can be used, either as a primary treatment model or in conjunction with conventional medical treatment.

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Treating Osteoarthritis

Osteoarthritis (OA), the age-related degeneration of joints, cartilage and bones, is nearly inevitable. The preferred conventional medical treatment for osteoarthritis has been nonsteroidal anti-inflammatory drugs (NSAIDs) that include over-the-counter aspirin, ibuprofen, and ketoprofen, as well as prescription drugs celecoxib (Celebrex), oxaprozin (Daypro) and rofecoxib (Vioxx).

NSAIDs reduce pain associated with osteoarthritis, but like most pharmacological approaches, do not address the underlying causes. These medications also have a history of significant side effects varying from gastrointestinal irritation to stomach bleeding, ulcers, and kidney and liver failure.

A few alternative approaches to osteoarthritis have been extensively studied and are demonstrating impressive track records. By far, glucosamine sulfate and chondroitin sulfate, substances found within normal joint cartilage, have received much attention for their effectiveness against OA.

In one recent study published in Lancet, researchers evaluated 1,500 mg/day glucosamine sulfate on the progression of osteoarthritic joint-structure changes and symptoms in 212 participants. The researchers found glucosamine sulfate improved both the symptoms and structural changes associated with OA. [2]Researchers at the University of Southern California reviewed the clinical efficacy and safety of glucosamine and chondroitin and found that they are effective and safe alternatives to NSAIDs for alleviating OA symptoms. [3]

Both glucosamine and chondroitin can be used concurrently with OA medications; however, further study is needed in this area.

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Taming Cholesterol

Elevated cholesterol levels, especially LDL (low-density lipoprotein) cholesterol, have been associated with increased cardiovascular disease risk. Conventional medical practitioners typically prescribe "statin" medications such as Lipitor (atorvastatin), Mevacor (levastatin), and Zocor (simvastatin) to lower cholesterol levels. In some cases, doctors may even prescribe niacin (vitamin B3), but pharmaceutical drugs are currently the first therapeutic choice.

However, prescription cholesterol-lowering medications can cause significant adverse side effects. The "statins" can cause liver dysfunction and failure, as well as cardiac events. [4] Alternative medicine, in conjunction with diet and exercise, has much to offer patients with elevated cholesterol. Three supplements and herbs that can effectively lower cholesterol levels are niacin, garlic, and fish oil.

NIACIN has been extensively studied over the past 45 years for its efficacy, safety, adverse effects, favorable effects on serum lipoprotein regulation, and containment of atherothrombotic cardiovascular diseases. [5] Niacin is so routinely used by mainstream practitioners that it is hardly considered alternative anymore.

In a recent multicenter trial conducted at Washington University School of Medicine in St. Louis, researchers evaluated 131 patients with primary hyperlipidemia, using an extended-release form of niacin for 25 weeks. The subjects experienced a dose-dependent response with significantly lowered LDL and triglyceride levels starting at 500 mg/day and 1,000 mg/day niacin, respectively. HDL cholesterol also showed significant reductions at 500 mg/day niacin. [6]

Extended-release niacin has been associated with liver toxicity, but this study reported no significant difference in liver function abnormalities compared to placebo. Niacin's other potential side effects include "flushing" of the body and gastrointestinal disturbances. [6] Many alternative care practitioners utilize a "non-flush" version of niacin, called inositol hexaniacinate, instead of regular niacin. This form of niacin does not have the flushing side effect of regular niacin (which can force patients to discontinue use) and is considered safer than niacin. Because of this, niacin use must be closely monitored.

GARLIC historically has been used for various conditions and demonstrates moderate value in lowering cholesterol levels. A recent meta-analysis performed by researchers in the department of complementary medicine at the University of Exeter, United Kingdom, surveyed 13 randomized, double-blind, placebo-controlled trials involving garlic and total cholesterol levels. The researchers concluded that garlic is superior to placebo in reducing total cholesterol levels, though the effects were modest. [7]

FISH OILS, predominantly from deep-sea fish, have been used in alternative medicine—and increasingly in mainstream practices—to lower cholesterol levels. The lipid-lowering effect of fish oil was recently studied in a group of 60 hemodialysis patients. The researchers found that 1.5 g/day fish oils for two months significantly lowered LDL cholesterol and triglyceride levels, while modestly raising HDL cholesterol levels. [8]

In many cases, combining conventional and alternative approaches can be the most beneficial treatment approach. In 1997, researchers at the College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, evaluated the combination of 1.5 g/day niacin and 20 mg/day pravastatin in 23 diabetic patients with high LDL cholesterol concentrations. They found that the low-dose niacin and pravastatin resulted in a significant reduction of LDL cholesterol levels compared to pravastatin alone. [9] Other studies involving niacin combined with cholesterol-lowering drugs also have illustrated the benefits of this approach. [10]

In addition to enhancing the effects of conventional drugs, alternative remedies can be used to replace nutrients that are depleted by pharmaceuticals. A side effect of "statins" is that they deplete the body of the nutrient Co-Q10, also known as ubiquinone. In a Danish double-blind study, 45 hypercholesterolemic patients taking increased doses of either 20-80 mg/day lovastatin or 10-40 mg/day pravastatin for 18 weeks experienced a dose-dependent decline of Co-Q10 levels. [11] These and other researchers support monitoring and supplementing Co-Q10 while on "statin" therapy.

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Lifting Depression

Clinical depression is another major ailment that can be treated with both conventional and alternative medicine. Conventional health care providers prescribe a number of antidepressant pharmaceutical drugs such as venlafarxine (Effexor), fluoxetine (Prozac), and sertraline (Zoloft). The side effects associated with these medications include gastrointestinal irritation, insomnia, sexual dysfunction, and weight gain. [12,13]

Alternative approaches to depression range from meditation to medications such as the herb St. John's wort (Hypericum perforatum), 5-hydroxytryptophan (5-HTP), and vitamin B12.

ST. JOHN'S WORT has been studied both as an individual treatment source and in combination with other antidepressant medications. [14-16] A recent six-week German study compared the efficacy and tolerability of 250 mg St. John's wort extract twice daily with 75 mg imipramine (Tofranil) twice daily in 324 patients with mild to moderate depression. The double-blind, randomized, multicenter, parallel-group trial found that the herbal extract was therapeutically equivalent to imipramine in treating mild to moderate depression, but patients tolerated St. John's wort better. [17]

VITAMIN B12 (cobalamine) deficiency can cause depression. In a study published in the American Journal of Psychiatry last year, researchers at the National Institute on Aging in Bethesda, Md., evaluated the vitamin B12 and folate levels of 700 disabled women older than 65. Metabolically significant vitamin B12 deficiencies were present in 14.9 percent of the 478 nondepressed subjects, 17.0 percent of the 100 mildly depressed subjects, and 27.0 percent of the 122 severely depressed subjects. The researchers concluded that metabolically significant vitamin B12 deficiency is associated with a two-fold risk of severe depression. [18]

5-HTP is a less known but effective treatment for depression. It is an intermediate metabolite of the essential amino acid L-tryptophan in the biosynthesis of serotonin. Low serotonin levels have been implicated as a primary cause of depression. Administering 5-HTP effectively increases serotonin synthesis in the central nervous system. [19] A Swiss study of 63 patients given either 100 mg 5-HTP three times daily, or 50 mg fluvoxamine three times daily, found both to be equally effective, but 5-HTP had fewer side effects. [20]

By themselves or as a group, St. John's wort, vitamin B12, and 5-HTP can be effective natural substances in treating depression.

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Beginning Integration

Central to an integrated approach to treatment is a proper foundation for health, beginning with an assessment of diet, nutrition, and followed by nutritional pharmacology, prior to using invasive therapies. Alternative practitioners begin patient care by helping a patient rebuild, repair, and restore his/her innate ability to heal from illness and disease, before turning to pharmaceuticals. Patients who suffer from mild to moderate forms of chronic conditions often benefit from the gentle relief alternative therapies offer.

For those allopathic medical practitioners uncertain about implementing integrative medicine, here are a few guidelines. A first step in an integrated treatment plan is to thoroughly evaluate a patient's specific problem. Next, the practitioner is obligated to outline for the patient a conventional treatment regimen, including the benefits and risks. At this point, the practitioner can discuss alternative care options, which will likely include lifestyle changes (nutrition, exercise, rest, fluid intake), supplements, mind-body medicine, and energy medicine. It is important to discuss with patients the reasons for integrating alternative therapies, whether as an adjunct to the conventional care or as a viable treatment option.

Depending on the nature and complexity of the problem (such as the common cold, flu or hyperlipidemia), a practitioner can simply ask if the patient prefers prescription medicine or natural alternatives.

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The Challenges of Alternative Medicine

Blending two completely different health care systems into a new health and wellness model provides opportunities for each system to complement the other. While the high-tech, science-, and research-based medical approach provides excellent emergency/surgical interventions in combination with medications for an array of conditions, it focuses on treating well-developed conditions. Allopathic medicine has a poor track record with chronic disease because of its primary mode of treatment with drugs, many of which generate adverse side effects.

Alternative medicine, which perceives health as a dynamic balance of highly sophisticated systems that integrate mind, body, emotions, and spirit, has been challenged by the lack of research needed to set standards of care. Many methodologies have been validated by the collective experience of generations of people around the world, over thousands of years. Many alternative methodologies involve multiple, simultaneous therapeutic interventions delivering synergistic effects, which are not easily validated with the single-variable nature of placebo-controlled trials. In addition, products may harbor unknown and unwanted contaminants, creating significant quality control issues.

An integrated approach with quality standards and more in-depth education for practitioners and consumers will ultimately enable all parties to access the best practices from each system for a more successful and cost-effective system of care.

Sidebars:

Cancer: The Alternative Care Leader

The New Integrative Pharmacy

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Raymond M. Lombardi, D.C., N.D., C.C.N., is a certified herbalist with a holistic practice in Redding, Calif. He is author of Aspirin Alternatives—The Top Natural Pain-Relieving Analgesics (BL Publications, 1999)

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References

2. Reginster JY, et al. Long-term effects of glucosamine sulfate on osteoarthritis progression: a randomized, placebo-controlled clinical trial. Lancet 2001 Jan 27;357(9252):251-6.

3. de los Reyes GC, et al. Glucosamine and chondroitin sulfate in the treatment of osteoarthritis: a survey. Prog Drug Res 2000;55(2):81-103.

4. Heuer T, et al. Toxic liver damage caused by HMG-CoA reductase inhibitor. Med Klin 2000 Nov 15;95(11):642-4.

5. Capuzzi DM, et al. Niacin dosing: relationship to benefits and adverse effects. Curr Atheroscler Rep 2000 Jan;2(1):64-71.

6. Goldberg A, et al. Am J Cardiol 2000 May 1;85(9):1100-5. Multiple-dose efficacy and safety of an extended-release form of niacin in the management of hyperlipdemia.

7. Stevinson C, et al. Garlic for treating hypercholesterolemia. A meta-analysis of randomized clinical trials. Ann Intern Med 2000 Sep 19;133(6):420-9.

8. Khajehdehi P. Lipid-lowering effect of polyunsaturated fatty acids in hemodialysis patients. J Ren Nutr 2000 Oct;10(4):191-5.

9. Gardner SF, et al. Combination of low-dose niacin and pravastatin improves the lipid profile in diabetic patients without compromising glycemic control. Ann Pharmacother 1997 Jun;31(6):677-82.

10. Brown BG, et al. Moderate dose, three-drug therapy with niacin, lovastatin, and colestipol to reduce low-density lipoprotein cholesterol <100 mg/dL in patients with hyperlipidemia and coronary artery disease. Am J Cardiol 1997 Jul 15;80(2):111-5.

11. Mortensen SA, et al. Dose-related decrease in serum coenzyme Q10 during treatment with HMG-CoA reductase inhibitors. Mol Aspects Med 1997;18(suppl):S137-S44.

12. Beasley CM, et al. Efficacy, adverse events, and treatment discontinuations in fluoxetine clinical studies of major depression: a meta-analysis of the 20 mg/day dose. J Clin Psychiatry 2000 Oct;61(10):722-8.

13. Fava M, et al. Fluoxetine versus sertraline and paroxetine in major depressive disorder: changes in weight with long-term treatment. J Clin Psychiatry 2000 Nov;61(11):863-7.

14. Linde K, Mulrow CD. St John's wort for depression. Cochrane Database Syst Rev 2000;(2):CD000448.

15. Miller AL. St. John's wort (Hypericum perforatum): clinical effects on depression and other conditions. Altern Med Rev 1998 Feb;3(1):18-26.

16. Schulte PF, et al. Saint John's wort as an antidepressant. Ned Tijdschr Geneeskd 2000 Sep 16;144(38):1820-5.

17. Woelk H. Comparison of St John's wort and imipramine for treating depression: randomized controlled trial. BMJ 2000 Sep 3;321(7260):536-9.

18. Penninx BW, et al. Vitamin B12 deficiency and depression in physically disabled older women: epidemiologic evidence from the Women's Health and Aging Study. Am J Psychiatry 2000 May;157(5):715-21.

19. Birdsall TC. 5-Hydroxytryptophan: a clinically effective serotonin precursor. Altern Med Rev 1998 Aug;3(4):271-80.

20. Poldinger W, et al. A functional-dimensional approach to depression: serotonin deficiency as a target syndrome in a comparison of 5-hydroxytryptophan and fluvoxamine. Psychopathology 1991;24(2):53-81

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