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Drugs: Safe and Effective?
Nutrition: Surgery and
Healing
Supplements for Recovery
Vitamin A Safety
Ask Dr. J: Vitamin C Forms
In the Health News
Diet and Disease
Recipe of the Month: Cauliflower
Millet Casserole
References
Dear Friends,
While I believe that modern pharmaceuticals
have great value in treating disease when they
are administered properly, I am also aware that
properly administered medications are among
the leading causes of death in the United States
(they are far more damaging than illegal drugs,
other than the societal harm created by their
illegality). However, they are often used far
too frequently when safer alternatives are available.
Large drug companies have an enormous influence
on medical education and research. By funding
research in medical schools and hospitals, they
often determine what studies are done and what
gets published. They hire scientist spokespeople
(so-called “thought leaders”) to
tout their drugs at medical conferences, and
they send reps to doctors’ offices to
influence prescribing practices.
The drug companies advertise to both physicians
(most of the pages in many medical journals
are in fact drug ads) and to the public, in
all the major media. A recent analysis on National
Public Radio (NPR) was highly critical of the
drug companies because the “information”
they provide is often not backed by the weight
of the scientific evidence. They may find some
studies to support their claims, but they emphasize
these even when other studies contradict their
conclusions.
The FDA approves both the availability of drugs
and the uses for which they can be advertised.
But in some cases drugs can be valuable for
other conditions, and doctors have the flexibility
to prescribe them for “off-label”
uses. (Chelation therapy with EDTA for heart
disease is an example of a valuable off-label
use of a drug approved for lead toxicity.) However,
drug companies spend enormous amounts of money
to market their products to doctors for unapproved
(and unproven) uses that are not always beneficial,
and in many cases may be more harmful than other
treatments.
The NPR analysis criticized this practice,
and quoted a former editor of the New England
Journal of Medicine, who felt that the companies
were acting improperly when they offered PR
in the guise of education, and when they sent
drug salesmen to doctors saying “I know
“drug X” is not approved for “condition
Y” but a lot of your colleagues are finding
that it is a great treatment.” (The analysis
referred to the unscientific and unsuccessful
use of gabapentin (Neurontin), an epilepsy drug,
to treat manic depression.) These statements
are not scientific, but in a busy physician’s
office, they may be taken at face value, while
the drug rep is only trying to sell more product.
The smart patient asks the doctor in-depth
questions, and makes sure that the safest, most
effective option is the first choice in treatment,
even if it is another drug. My first choice,
if possible, is almost always natural therapy
with diet, exercise, stress management, nutritional
supplements, and herbs.
People who are admitted to hospitals are known
to have relatively poor nutritional status,
probably reflecting the poor diet of the population
at large. They have poor muscle mass as well
as vitamin and mineral deficiencies. Unfortunately,
their nutritional status tends to decline while
in the hospital, indicative of the low nutrient
value of typical hospital food.
A number of studies over the years have shown
that if you have any kind of trauma, including
surgery, or if you are hospitalized for non-surgical
health problems, you can improve your chances
of recovery and reduce your hospital stay by
enhancing your nutrition. You should not only
take dietary supplements, but also consider
having family or friends bring in healthier
food for you during your hospital stay.
In a study 15 years ago, doctors were unable
to recognize the nearly 50 percent of patients
who were malnourished on admission to a hospital.
As a result, they made no effort to correct
their nutritional status, which declined during
their hospital stay. After some basic training,
those same doctors were able to recognize every
patient who had malnutrition. Unfortunately,
doctors today are still not well trained in
nutrition.
Poor nutrition is one of the reasons that infections
are rampant in hospitals. Often the patients
don’t even receive enough food to maintain
their weight and muscle mass. I have recently
been visiting in a hospital, and I can tell
you that the food they served looked exactly
like the food I saw when I was in training 35
years ago (although I think it was reheated!).
Studies have shown that immune function is compromised
by poor nutrition, and a number of dietary supplements
help, including vitamins, minerals, essential
fatty acids, and amino acids. A Seattle medical
group did a randomized study of trauma and emergency
surgery patients. One group received extra vitamins
C and E, while the other received only “nutritionally
adequate” levels (so they were not technically
deficient).
These researchers reviewed almost 600 patients
who were at high risk of respiratory distress
and pneumonia, as well as multiple organ failure.
They administered 1000 IU of vitamin E and 1000
mg of intravenous vitamin C in half the patients,
and RDA levels in the other half. (They used
conservative levels to avoid having to change
the study protocol safety measures.) In the
supplemented group, they saw a 20 percent decline
in combined pneumonia and acute respiratory
distress syndrome. Even more impressive was
a 57 percent decline in multiple organ failure.
The supplemented group also had faster recovery,
shorter stays in intensive care, and less time
on mechanical respiratory support. This information
is not new, but it takes time for evidence to
accumulate to the degree that impresses physicians
enough to change practice.
In 1992, and again in 1999, researchers reported
on supplements, including L-arginine and omega-3
essential fatty acids, in surgical patients.
The subjects had fewer infections (70 percent
lower), improved immunity, hospital stays that
were 2 to 4 days shorter, and lower treatment
costs. These patients had non-emergency surgery,
so they were able to start their supplements
5 to 10 days before the operations.
A new study sheds some light on another mechanism
for help from supplements. Antioxidants and
L-arginine were added to human cells in a culture
dish. The cells were exposed to mechanical stress,
but nutrient pretreatment protected them from
damaging inflammatory compounds.
Antioxidants have other benefits. Coenzyme
Q10 protects the heart during surgery. Operations
on the heart lead to “reperfusion injury,”
or the damage from oxygen free radicals when
blood starts flowing back into oxygen-deprived
tissues. Pretreatment with coenzyme Q10 prevents
this damage. The information was published in
1996 in a heart surgery journal, but coQ10 is
still not commonly administered by surgeons.
In an animal study, vitamin C was helpful in
preventing reperfusion injury. The antioxidant
glutathione is another beneficial substance,
made in the body from the amino acids glycine,
glutamine and cysteine. These plus other vitamins,
minerals, and amimo acids, reduce inflammation,
protect from free-radical damage, and are important
for healing from trauma or surgery. Good nutrition
promotes healing, and will give you the best
chance of recovery.
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Recent analyses have suggested that excessive
levels of vitamin A in the blood may be associated
with an increased risk of osteoporosis and fractures.
The most recent population study in Sweden suggested
that men in the highest fifth of serum levels
had about twice the risk of hip fracture compared
to those in the middle range of vitamin A levels.
This was widely reported in the press, but
what they did not mention was that those in
the next to highest and middle ranges had a
significantly lower risk than those with lower
blood levels. The amounts in normal vitamin
supplements appear to be quite safe, but if
someone is also taking cod liver oil, eating
chicken or beef liver and dairy products with
added vitamin A, they may have some risk, so
I do recommend caution.
One problem with the latest study is that they
measured blood levels just once at the beginning
of the study 30 years ago. They assessed dietary
intake with a questionnaire in only half of
the subjects, when they were 20 years into the
study. While this study gives cause for some
concern, other studies are contradictory, so
we have to be careful before drawing firm conclusions.
Beta-carotene has not been associated with
any bone density risk, even though a portion
of it may be converted to vitamin A in the body.
Q. I heard that ascorbic acid is not the best
form of vitamin C. Is there another kind that
is better?
BG, via the Internet
A. A few forms of vitamin C are currently available
at health food stores and through mail order
companies. Ascorbic acid is the most basic form
of vitamin C, and it has been around for a long
time.
Ascorbic acid is mildly acidic, and it is generally
very well tolerated, although high doses of
any form of vitamin C can lead to loose bowels
or even diarrhea if you take enough at one time.
You can also find buffered ascorbate, in which
the acidity is eliminated by combining the ascorbic
acid with minerals, making a “salt.”
This combination may be with sodium, potassium,
calcium, magnesium, or a combination of these
minerals.
Some people report that they have some digestive
upset when they take plain ascorbic acid, although
this is not usually a problem. They may tolerate
the buffered form of vitamin C better.
You can also find a product called Ester-C,
a buffered form of vitamin C that the manufacturer
claims is better than plain vitamin C or other
buffered forms. Ester-C combines calcium ascorbate
with dehydroascorbate and calcium threonate,
both metabolites of ascorbic acid.
So far, I have seen no convincing evidence
that Ester-C is any better than other forms,
and some suggestive evidence that it may not
be as good. Linus Pauling took buffered ascorbate.
I take plain ascorbic acid. Although I take
about 9 grams a day, I usually recommend about
3 to 4 grams for most of my patients, or more
for specific health problems, such as viral
infections, cancer, heart disease, healing of
wounds, or surgery.
Ascorbyl palmitate is a lipid ester of vitamin
C used in pills, and also in skin creams as
an antioxidant and to help maintain skin collagen.
•Regular exercise has a new benefit for
cardiovascular disease: it appears to stimulate
the production of anti-inflammatory substances
by increasing blood flow and stress on the vessel
lining. Recurrent inflammation, leading to elevation
of markers such as C-reactive protein (CRP)
in the blood, appears to be one of the strongest
risk factors for heart disease. Reducing inflammation
through the local effect of exercise may be
one of the best defenses. (Ji JY, et al., Shear
Stress [...and]Endothelial Glucocorticoid Receptor
and Expression... Circulation Research 2003,
10.1161/01.RES.0000057753.57106.0B.)
•Costly modern drugs for hypertension
are not only more expensive than the older thiazide-type
diuretics, but also no better for treatment,
and far more risky. The study (ALLHAT…Research
Group, Major outcomes in high-risk hypertensive
patients.... JAMA 2002 Dec 18;288(23):2981-97.)
compared a thiazide with an ACE inhibitor (lisinopril)
and a calcium channel blocker (amlodipine, or
Norvasc). The diuretic controlled blood pressure
and mortality as well, but had fewer side effects.
The amlodipine had a 40 percent higher rate
of heart failure in five years. Still better:
try coenzyme Q10, essential fatty acids, magnesium,
garlic, and vitamins C and E as first treatments;
they all have side benefits, rather than toxic
side effects.
• Yet another study reports on the value
of whole grains (Liu S, Intake of refined carbohydrates
and whole grain foods in relation to risk of
type 2 diabetes mellitus and coronary heart
disease. J Am Coll Nutr 2002 Aug;21(4):298-306.)
Complex carbohydrates and fiber reduce the risk
of diabetes, obesity, and heart disease. They
lead to more favorable blood lipids and less
insulin resistance, a precursor to both diabetes
and heart disease. Refined carbohydrates (sugar
and white flour, for examples) increase those
risks.
Here is one way to add a tasty whole grain to
your diet. Bring1½ cups of millet in
3 cups of water (or diluted organic vegetable
broth) to a boil, then simmer until the liquid
is gone. Cut a cauliflower into 2-inch pieces.
Chop 1-2 onions plus fresh garlic and stir-fry
them in olive oil with cumin, thyme, dill, and
cayenne to taste. Add cubes of tofu (½
pound) and let it sizzle, then add the cauliflower,
cooking until it is almost soft, and add a pound
of chopped mushrooms. Next, fold in a bunch
of chopped spinach, 2-3 Tbsp of chopped parsley,
and the juice of one lemon, cook briefly, then
mix in the millet. Place it all in a casserole,
with or without a sprinkle of organic parmesan
cheese, and add some slices of tomato. Place
this in the oven at 350° for about 30 minutes,
or until the top is brown.
National Public Radio,
All Things Considered, January 16, 2003.
Macdonald KJ, Young LT, Newer antiepileptic
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Nathens AB, et al., Randomized...antioxidant
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Daly JM, et al., Enteral nutrition with supplemental
arginine, RNA, and omega-3 fatty acids... Surgery
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Gianotti L, et al., A...clinical trial on perioperative
feeding with an arginine-, omega-3 fatty acid-,
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among elderly hospitalized patients... JAMA
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and L-arginine .... Proc Natl Acad Sci USA 2003
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the improvement in cardiac tolerance to ischemia
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Demertzis S, et al., Ascorbic acid for amelioration
of reperfusion injury...in sheep. Ann Thorac
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Michaelsson K, et al.,
Serum retinol levels and the risk of fracture.
N Engl J Med 2003 Jan 23;348(4):287-94.
Ballew C, et al., High serum retinyl esters
are not associated with reduced bone mineral
density... J Bone Miner Res 2001 Dec;16(12):2306-12.
Wang S, et al., Pharmacokinetics
in dogs...of two different forms of ascorbic
acid. Res Vet Sci 2001 Aug;71(1):27-32.
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