April 2002

Letter from Dr. Janson: Prescription Drug Advertising
Alternatives to Cholesterol Drugs
Cholesterol: Other Treatment Options
Octacosanol Beats Statins
Reflux Esophagitis: Ask Dr. J
In the Health News
Recipe of the Month: Marinated Grilled Tofu
References

Letter from Dr. Janson: Prescription Drug Advertising

Dear Friends,
It is unusual for me to agree with the U.S. Food and Drug Administration, but I have found one area of at least some common ground. I am referring to the television, magazine, and newspaper advertising of prescription drugs to the public, suggesting that they request a prescription from their doctors.

The FDA has said that some of these ads are misleading, and overstate the benefits of the drugs while underreporting the risks of side effects, or the chances that the drug will not work at all. However, it appears to me that the FDA is mostly paying lip-service to regulating such ads, judging by the ones that I have seen. I am all for an educated public, and ready access to drugs that are beneficial, as long as the education is not self-serving.

They often remind me of those Salem cigarette commercials where people filling their lungs with ashtray contents are seen as young, healthy, vibrant, and athletic, with beautiful skin, while lounging around in an environment of brilliant, cloudless skies, lush meadows, and pristine mountain streams. They just misrepresent the product, which would be more accurately portrayed by pictures of dirty, sweaty, exhausted men rising out of the coal mines covered in soot and grime.

The drug ads for allergy, ulcer, arthritis, cholesterol-lowering, sexual-dysfunction, and other medications often tell the viewer to "ask your doctor" for more information, but the end result is that people go to their doctors almost insisting on prescriptions for these products, and the doctors feel pressured to prescribe them. The doctor often thinks that the patient will go to another doctor if they leave the office without their desired medication. They might even wonder why the doctor is not up to date on the latest benefit afforded by the drug companies.

While the FDA has reprimanded companies, most of the ads that I have seen are still misleading, and the small print is usually ignored, even when it is a whole page on the back of the ad in the magazine. Perhaps the FDA is spending too much of its time, budget, and staff resources trying to prevent truthful and non-misleading advertising by dietary supplement companies, promoting products that are quite safe and beneficial. However, a few of the dietary supplement companies also promote their products with ads that are misleading, and I am opposed to that, too--it diminishes the reputation of alternative medicine, already struggling for respect against the medical juggernaut.

Prescription drugs are the fastest growing expense in medical care. Having semi-informed people, "educated" by advertising, pushing doctors to prescribe medications for them does not help. Fully informed people are more likely to choose alternatives, such as dietary supplements and complementary medicine, which are safe, effective, and relatively inexpensive.

Alternatives to Cholesterol Drugs
Speaking of drugs that are promoted directly to the public, cholesterol-lowering medications are among the most widely advertised. These drugs are hugely promoted because they are generating enormous profits for the manufacturers. Numerous studies show that they are effective in reducing cholesterol, heart disease, and coronary mortality, but this does not tell the whole story.

Such pervasive promotion diverts attention, not to mention resources, from dietary controls and natural substances that are even better than the drugs, but far less expensive. The ads offer drugs to control a problem that usually has its roots in lifestyle, so people may easily get the idea that they can ignore their diets, since the drugs will correct the effects of their poor choices. In addition, because these ads are paid promotion, rather than public education (although the companies often refer to their ads as informational), they minimize the potential drug side effects and costs.

For example, one of these drugs, Baycol (cerivastatin) was removed from the market when it was discovered that the side effect of muscle degeneration was far more frequent than expected. This side effect, called rhabdomyolysis, leads to muscle breakdown products passing through the kidneys and causing kidney failure and death. Other statins can also cause this side effect, as well as hepatitis, jaundice, other liver problems, gastrointestinal upsets, reduced platelet levels, anemia, joint pains, headache, sore throat, runny nose, and skin rashes. It is unfortunate that the public does not have the opportunity for balanced education about these products.

Cholesterol: Other Treatment Options
A study published in the Journal of the American Medical Association shows that even though statin drugs lower cholesterol, they also lower serum levels of valuable antioxidants. For example, they cause a 20 percent decline in beta-carotene, a 16 percent drop in vitamin E, and a 22 percent reduction of coenzyme Q10, all of which are important nutrients for the heart.

These researchers were actually studying how a diet rich in vegetables, fruits, nuts, and whole grains can lower cholesterol in addition to any lowering effect from the statins. What they found was that diet still plays an important role in managing cholesterol. In addition to its safety, it has many other benefits unrelated to the heart.

This study showed another damaging effect of the statins: an increase in serum insulin levels. Insulin is essential for maintaining a normal blood sugar, but high levels are associated with a condition called insulin resistance, a risk factor for heart disease and the development of diabetes. The diet reduced serum insulin levels, reversing some of the negative drug effects.

Octacosanol Beats Statins
While you may not have heard of it, a substance called octacosanol is more effective than the statin drugs in lowering cholesterol, and it has other benefits also. This is the main component of a complex called policosanol, and the research is impressive. In studies doing direct comparisons with statin drugs, the octacosanol was superior.

Octacosanol is a waxy alcohol derived from sugar cane or wheat germ. In a study of octacosanol and Pravachol (pravastatin), 10 mg daily of either product lowered LDL- cholesterol by 19.3 percent, the drug only 15.6 percent, it lowered total cholesterol by 13.9 percent (the drug only 11.8). The drug did not affect triglycerides or HDL, but octacosanol raised the good HDL by 18 percent, and lowered the triglycerides by 14 percent.

The change in the ratio of total cholesterol to HDL was lowered 25 percent by octacosanol, compared to only 15 percent by pravastatin. Inhibition of platelet aggregation reduces heart disease, and this effect was greater with octacosanol than the drug. Further, octacosanol protects the LDL from oxidative damage, and oxidized LDL is the most damaging form.

From all this information, octacosanol is clearly a superior choice: it is without side effects, and it is far less expensive than the medications.

These benefits have been known for more than ten years, but clearly the vast majority of people know of the drugs, while the natural and inexpensive alternative remains mired in obscurity.

Other dietary supplements also help maintain healthy cholesterol levels and reduce heart disease risk. Niacin, or vitamin B3, lowers cholesterol, and appears to have some of the same antiinflammatory effects as the statins, apparently a part of their benefit profile. Slow release niacin does not cause as much of a flush reaction as the plain niacin, but it has caused some liver function abnormalities in a few patients. Taking a non-flush form of niacin, inositol hexaniacinate, provides the same cholesterol effects without the liver changes, but it is more expensive. Effective niacin doses are 1500 to 3000 mg daily.

Vitamins E and C reduce total cholesterol and raise HDL levels, but not as much as octacosanol. They also protect the LDL from oxidation, and in clinical studies they reduce heart disease. It is impossible to get therapeutic levels of vitamin E (400 to 800 IU) from the diet. Vitamin C is easier to find in foods, and on a diet rich in raw fruits and vegetables it is possible to get over 2000 mg daily, but it is likely that you will need supplements to get this amount. The bioflavonoid quercetin is anti-inflammatory and inhibits oxidation of LDL.

Chromium supplements in the range of 200 to 400 mcg daily reduce total cholesterol and raise HDL levels, and up to 1000 mcg also help control blood sugar levels. As diabetes is a heart risk factor, this in itself is an important benefit.

In earlier issues, I have discussed the benefits of red yeast rice, pantethine, garlic, and L-carnitine, but octacosanol appears to be one of the best supplements for the heart, particularly when combined with exercise and a mostly vegetarian diet (plus fish with omega-3 oils), and soy foods such as tofu, tempeh, and soymilk.

Ask Dr. J
Q. My friend has chronic reflux. Are there any natural treatments? (C.N., Australia)

A. Gastroesophageal reflux disease, or GERD is a disorder of digestion with stomach acid backing up into the esophagus and causing irritation, heartburn, belching, and abdominal pain.

With chronic irritation and inflammation, the mucosa of the esophagus is damaged, and it is more prone to the development of cancer.

Sometimes the symptoms are due to hiatal hernia, in which a portion of the stomach slips above the diaphragm, or if the sphincter is not working properly to restrict stomach acid regurgitation. The same symptoms might be indicative of a gastric or peptic ulcer, so careful evaluation is essential for proper treatment. Most of the time, the symptoms are not due to excess stomach acid, but to poor diet, overweight, and food allergies.

While acid blocking drugs are often prescribed, it is usually better to avoid them unless an ulcer is present. Treatment involves reducing symptoms and preventing complications from esophageal irritation. Eating a high fiber diet helps to buffer the stomach acid, while low fiber foods, such as sugary, fatty snacks appear to increase symptoms, as do caffeine and alcohol.

Chewing a licorice extract, called deglycyrrhizinated licorice (DGL) can soothe the symptoms of heartburn by coating the mucosa. It also helps with ulcer disease. L-glutamine is an amino acid that helps heal the lining of the entire digestive tract, so it is useful for inflammatory bowel disease as well as esophagitis.

Folic acid helps to repair damaged mucous membranes. I also suggest high amounts of lutein, niacin, vitamin B6, zinc, and vitamin C, which have been shown to prevent esophageal cancer.

In The Health News
a. Polluted air is not only damaging to the lungs, but it also causes the arteries to constrict, reducing blood flow to tissues. (Experimental inhalation of pollutants causes acute arterial vasoconstriction. Circulation, 2002, March 12, as reported in Reuters Health). Researchers evaluated fine particulates and ozone, and found that even a two hour exposure to levels found in the air of many cities led to significant reduction in size of the brachial artery. Arterial constriction could be a trigger for heart attacks. To reduce the consequences of pollution, and arterial spasms, take antioxidants and arterial relaxants, such as vitamins C and E, magnesium, ginkgo biloba, and arginine, and exercise regularly.

Diet and Disease
a. Consuming soy isoflavones appears to modify estrogen hormones in premenopausal women, lengthening the time between menstrual cycles, and decreasing levels of estrone and estradiol, two strong estrogens that stimulate breast tissue, and lead to increased cancer risk. (Kumar NB, et al., The specific role of isoflavones on estrogen metabolism in premenopausal women. Cancer 2002;94(4):1166-1174.) The researchers gave 40 mg per day of genistein, and compared the results with placebo, in 68 women from 25 to 55 years old. This amount of genistein is found in a cup of tofu, a cup of soymilk, or supplements.

b. Eating omega-3 oils, particularly from fish, reduces the risk of heart disease. A new review shows that 1 to 2 fish meals a week lowers the incidence of heart attacks, and people who have had heart attacks have reduced overall mortality, as well as fewer recurrent heart attacks (Nordoy A, et al., n-3 polyunsaturated fatty acids and cardiovascular diseases. Lipids 2001;36 Suppl:S127-9.) Omega-3 oils are also in ground flaxseeds, flaxseed oil, and walnuts, and these foods also reduce cardiac risk.

Recipe of the Month: Marinated Grilled Tofu
Here is a good recipe for that healthy tofu. Cut half-inch slabs or 1 1/2 inch cubes of firm tofu. Marinate them for a few hours or overnight in a mixture of balsamic vinegar (or lemon if you prefer), crushed ginger and garlic, fresh-ground pepper (I use a mix of black, green, red, and white), thyme, and a small amount of soy sauce. Add other herbs and spices to taste, such as cumin, chili powder, or cayenne pepper. Put the slabs on a grill or a griddle, and cook on each side until brown. For the cubes, skewer them, alternating with mushrooms, onions, red peppers, cherry tomatoes, and zucchini, and grill these healthy shish kebabs. Serve either with brown rice or millet (try cooking these in vegetable broth--I buy an organic one from Imagine Foods), steamed broccoli, and a salad.

Note:
This month I'd like to recommend a link to a newsletter with valuable health articles. The newsletter is called Red Flags Weekly, and they ran a recent interesting article on coenzyme Q10 (www.redflagsweekly.com/features/Q10.html). I suggest that you visit and look for yourself. At the end of this newsletter, I have posted the philosophy of the site, whose editor is Nick Regush, who used to be with ABC News with Peter Jennings.

References

Editorial
Rosenthal MB, et al., Promotion of prescription drugs to consumers. N Engl J Med 2002 Feb 14;346(7):498-505.

Wolfe SM, N Engl J Med 2002 Feb 14;346(7):524-526

Statin Drugs and Octacosanol
Jula A, et al., Effects of diet and simvastatin on serum lipids, insulin, and antioxidants... JAMA 2002 Feb 6;287(5):598-605.

Abookire SA, et al., Use and monitoring of "statin" lipid-lowering drugs... Arch Intern Med 2001 Jan 8;161(1):53-8.

Castano G, et al., Effects of policosanol and pravastatin on lipid profile, platelet aggregation and endothelemia .... Int J Clin Pharmacol Res 1999;19(4):105-16.

Canetti M, et al., A two-year study on the efficacy and tolerability of policosanol... Int J Clin Pharmacol Res 1995;15(4):159-65.

Menendez R, et al., Effects of policosanol treatment on the susceptibility of ...(LDL) ... to oxidative modification in vitro. Br J Clin Pharmacol 2000 Sep;50(3):255-62.

Gouni-Berthold I, et al., Policosanol: clinical pharmacology and therapeutic significance...Am Heart J 2002 Feb;143(2):356-65.

Pryor WA Vitamin E and heart disease: basic science to clinical intervention trials. Free Radic Biol Med 2000 Jan 1;28(1):141-64.

Dwyer JH, et al., Oxygenated carotenoid lutein and progression of early atherosclerosis: the Los Angeles atherosclerosis study. Circulation 2001 Jun 19;103(24):2922-7.

Engelen W, et al., Effects of long-term supplementation with moderate pharmacologic doses of vitamin E .... Am J Clin Nutr 2000 Nov;72(5):1142-9.

Reflux Esophagitis
Goso Y, et al., Effects of traditional herbal medicine on gastric mucin against ethanol-induced gastric injury in rats. Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 1996 Jan;113(1):17-21.

Kolarski V, et al., Erosive gastritis and gastroduodenitis--clinical, diagnostic and therapeutic studies. Vutr Boles 1987;26(3):56-9.

Zhang ZF, et al., Adenocarcinomas of the esophagus and gastric cardia: the role of diet. Nutr Cancer 1997;27(3):298-309