Monday, April 30, 2012

A Great Hydrotherapy/Travel Blog

This week I'm recommending that you spend some time reading the blog of my friend and colleague, Dr Marcus Coplin. Marcus is currently traveling through throughout Eastern Europe and the Near East visiting hot springs and medicinal spas in the area, learning about the cultural and medicinal history of springs, and talking with doctors and physiotherapists who currently staff the springs. Additionally, he's exploring cultures and countries that are currently off the beaten path, as well as reconnecting with his familial roots in Greece and Turkey. It's all being written from an iTouch, so you'll pardon some of the misspellings, but Marcus is adept at capturing the history and essence of the places he visits in a conversational but evocative style. I hope you enjoy it as much as I have.

Click here to see Dr Coplin's blog.

Thursday, April 26, 2012

Hawthorn And Hypertension

Because my blog entry a few weeks ago on olive leaf and blood pressure was so well-received, this week I’ve decided to examine the effect of hawthorn (Crataegus spp) on blood pressure. Call it an ongoing series if you like, but there will likely be further articles on hypertension as time goes on. Of course, as with most chronic disease, it’s not drugs, herbs or supplements that solve the problem, it’s diet and lifestyle that create and can resolve the problem. With a few exceptions, interventions don’t fix the problem, they help patients along while they are doing the work that will fix things in the long run. That said, let’s dive in.

Hawthorne is, of course, a well known herb used for heart problems, including congestive heart failure, angina, and mild arrhythmias, among others. Its main active constituents are antioxidant flavonoids, including quercetin, proanthocyanidins, and a number of other glycosides. Without going into the biochemistry of hawthorn, it acts primarily by increasing blood flow to the heart and improving its pumping action. For these reasons, it’s largely used for heart-specific pathology. Even so, evidence surrounding hawthorn’s effect on hypertension is interesting, though limited to say the least.

A study of lab rats found that an extract of Crataegus tanacetifolia leaf was effective in preventing artificially-induced hypertension. As in the animal study from the article I wrote on olive leaf, I find this study interesting, but not compelling. Artificially-induced hypertension in animals is very different from lifestyle-induced hypertension in humans, and so while this study warrants additional research, it shouldn’t be taken as warranting clinical advice. Additionally, most commercially available (or professionally available) hawthorn preparations are made from Crataegus monogyna, oxyacantha or laevigata, different species from the one used in this study, and most of those preparations are made primarily if not exclusively from berry, not leaf, extracts. While there’s undoubtedly some crossover in terms of active constituents, we can’t guarantee that.

Fortunately, human studies are out there, and I was able to find two randomized control trials in the literature. One was a small pilot study done in the UK, which had four study arms, one taking hawthorn alone, one taking magnesium alone, one taking hawthorn and magnesium, and one placebo arm. A trend towards lower diastolic blood pressure was noted in the hawthorn group, but no statistically significant findings were made. The authors noted that the dose of hawthorn was low (500 mg per day), and that as such it may have influenced the findings. The authors called for future studies to use higher doses in order to create more pronounced effects.

A second, larger study was done to follow up on the results from this first study, this time using a group of 79 diabetics, all of whom were taking other medications. This study used a higher dose of hawthorn (1200 mg per day) and found more statistically significant doses, although that effect was fairly small. A statistically significant reduction in diastolic blood pressure was noted, though only about 2-3 mmHg; changes in systolic blood pressure were similarly small, and this was only a trend, not a statistically significant finding.

Even though the effect of Crataegus was limited in these studies, I think further research into this herb as a potential treatment for hypertension is warranted. As noted, the first study was performed using a dose of hawthorn that was very low – only 500 mg – and that higher doses are necessary to achieve a therapeutic effect. In the second study, significant changes were noted, but the effect was still small, despite larger doses. I don’t think that this means we should dismiss hawthorn as only mildly effective – the study was done on diabetic patients, many of whom were on antihypertensive medications (an average of 2.5 antihypertensive medications each), and Crataegus’ mechanism of action would likely have overlapped with these medications. Hawthorn is known to block the ACE enzyme, influence calcium activity in heart cells, and have a mild diuretic action – three of the primary mechanisms of antihypertensive medications. Hawthorn’s action would therefore have been a light push against biochemical pathways that were already being forcibly opened. I’d like to see future studies done using high doses of hawthorn as a primary treatment for hypertension, to see if stronger effects can be observed.

One final piece before I sign off for the day, and the one that really has me thinking about the therapeutic benefit of hawthorn – in my searching, I was pleased to find a great article on the use of hawthorn in hypertension that was published in the British Medical Journal in November of 1939. Not only is the article full of great archaic medical terms (‘morbid conditions of the chest’ being one), but it harkens back to a time when herbal medicines were used to treat conditions now seen rarely by naturopathic physicians or other CAM practitioners. The article discusses the use of Crataegus in 10 cases of hypertension – severe hypertension, which would make many docs on both sides of the aisle whimper – and notes changes in systolic blood pressures of 50+ mmHg, and changes in diastolic blood pressure of 30+ mmHg. It’s easy to dismiss these old articles as being the subject of selective reporting, or poor testing procedures, but I for one think that there’s something behind these findings that deserves attention. The dose of hawthorn used is quite high, something that’s perhaps been missing from the more recent studies.

The take home message for me is this: we need more research. The more recent studies have been fairly lackluster, though intriguing, but we also have this older case series that really makes your head turn. Under no circumstances should patients discontinue current medications and place all of their stock in hawthorn, especially not without supervision from a physician, but we may yet find evidence that hawthorn has an important role to play in hypertension. Stay tuned.

Monday, April 23, 2012

My 100th Blog Post

Happy Monday everyone! Today marks my 100th blog post over the past 18 months, and I'd like to start today's short little post by thanking all of you for reading, whether you read weekly, monthly, or just every once in a while. Readership of my blog has exploded in recent months, and it gives me great happiness to know that natural and preventive health can generate such interest - it's what keeps me working, so as long as you keep reading, I'll keep writing!

It being a Monday, I'm bringing to light an article or chart made by someone else - in this case, I'm including a link to an article that appeared in the New York Times back in September. The article addresses the commonly held misconception that junk food and fast food is cheaper. Anyone who's eaten beans and rice consistently knows how inexpensive a meal can be, but even so, the idea that bad food is cheaper is still pervasive. The article includes a great graphic which illustrates this point, showing how much a meal for four would cost, whether purchased at a fast food restaurant like McDonald's or made at home (examples include roast chicken with salad, and a bean and rice dish).

The article also addresses important social factors at play - economic realities in dual-income households often leave little time to cook, and the stresses of work often leave little motivation to cook. Additionally, there's simply the force of habit, and a certain behavioral inertia that prevents people from making changes, even when they know and understand the benefit they'll gain. However, instead of succumbing to these forces and taking the easiest, least healthy solution, the article encourages readers to rise to the challenge, at least as much as they can. In the same way that some exercise is better than no exercise, some home-cooked food is better than no home-cooked food.

Fifty years ago, there was a lot of allure to the idea that we could all live in single-family homes, eat sumptuous meals with minimal effort put in to cooking, and watch television in air-conditioned comfort. Unfortunately, we've found that that way of living has lead us down a rabbit hole - but there's no wonderland at the other end. Instead, we live in social isolation and eat without enjoyment or health benefit. Cooking, as the author argues, is part of larger social change that will bring us back into contact with one another, improve our health, and save us money. This Monday, I'm asking you readers to complete a little assignment - cook at least one meal this week (no matter how simple), and invite someone over to eat with you. It's time for us to be in touch with each other and what we eat.

Thursday, April 19, 2012

Is Depression An Inflammatory Disease?

This past weekend, I had the opportunity to hear Dr Andrew Weil speak at a conference put on by the University of Maryland’s Center for Integrative Medicine. Dr Weil deserves a lot of credit for recognizing the importance of mind-body medicine and nutrition at a time (the early 70’s) when it was almost entirely unheard of, and when the naturopathic profession was only beginning to wake out of several decades of slumber. Additionally, he’s become a focal point that has helped to bring shape to a diverse group of healthcare practitioners who would otherwise be practicing in isolation. His role in encouraging the evolution of medicine would be hard to understate.

Towards the end of his talk, Dr Weil discussed the possibility that the root cause of depression might not be, as is often suspected, a serotonin imbalance (for which the ‘solutions’ are Paxil, Prozac, Zoloft, etc), but rather an inflammatory process. In the discussion, he mentioned a study in which NSAIDs (non-steroidal anti-inflammatory drugs, such as aspirin or ibuprofen) showed the same effect as traditional anti-depressants, and that, by extension, turmeric or ginger might be effective anti-depressants. Fascinating stuff, right? Needless to say, I was intrigued, and spent much of the next day trying to pull articles.

After a few hours, I found that Dr Weil had probably overstated things a bit in his presentation. There IS increasing evidence that some forms of depression are linked to inflammatory disease markers, but there AREN’T many studies that have looked at the therapeutic value of anti-inflammatories on depression.

So, here’s what I was able to find. Many inflammatory cytokines (chemical messengers) have been documented to be elevated among depressed people, including several interleukins, and it appears that many pro-inflammatory enzymes are up-regulated in patients suffering from major depression (1, 2, 3, 4, 5, 6). Interestingly, some of the body's compensatory anti-inflammatory markers are similarly elevated. This body of evidence is growing steadily, and while there is some variability in which biomarkers are elevated, there is consistent evidence that certain pro-inflammatory cytokines are elevated in patients with depressive symptoms.

These observations have lead to the publication of many articles that suggest that researchers investigate the use of anti-inflammatories in the treatment of depression. Indeed, the number of articles I was able to find advocating for research into this as a potential treatment for depression far exceeds the number of articles I was able to find which either document the effects of inflammatory cytokines on depression or the effects of anti-inflammatory drugs on depression. I found a number of such articles, from researchers all over the US and all over the world, but I’m only going to provide links to a few of them, because many essentially say the same thing and draw on the same sources (1, 2, 3). Researchers are writing about their interest in this potential treatment, but few are actually researching the use of anti-inflammatories as part of treatment.

What few clinical trials I was able to find mainly focus on the use of celecoxib (Celebrex) as an adjunct treatment in depression. Two articles I found supported the hypothesis that the combination of celecoxib and an antidepressant provided greater relief from depression than an anti-depressant alone (1, 2). An additional trial found that celecoxib provided significant relief from depressive episodes as an adjunct treatment in bipolar disorder. These were all fairly small trials, but they certainly make us think, and as a naturopathic physician, I find this information extremely useful – celecoxib is nothing special, pharmacologically speaking, and it’s action can easily be performed by a natural substance, such as turmeric or ginger.

However, the largest study I was able to find found no benefit. It was a re-evaluation of data from a study investigating the use of anti-inflammatory drugs to prevent Alzheimer’s progression, and among the 500 participants who also had major depressive symptoms, no relief was gained from either celecoxib or naproxen. While the study methods weren’t ideal, it’s still an important piece of information. The take-home message from these studies, I believe, is that anti-inflammatories may have a beneficial effect on depression in conjunction with an anti-depressant.

At the end of the day, though, what this whole line of thinking actually indicates is that we really have very little understanding of depression. On an individual level, practitioners can help people quite a lot with depression, but it takes time and work, and above all, a deep understanding of what is causing that person to be depressed. However, on a large scale, we don’t understand depression – we don’t understand why so many people are depressed, we don’t understand what’s making them depressed, and we don’t understand how to fix them. Again, I underline that this is on a large scale – on an individual scale, we can change lives, because depression is individual in its origin and similarly unique in its resolution. It’s a result of a combination of biochemical, environmental, and social factors, and treatment must take into account all of these factors.

I think the reason we don’t understand depression on a large scale is that, in some ways, there is no such disease as depression. A disease has a clear etiology or can be diagnosed using a specific marker – iron-deficiency anemia, lupus, strep throat, etc are examples of diseases. ‘Depression’, as we call it, is many, many diseases all masquerading around with the same major symptom. These dis-eases arise from a variety of causes, and vary significantly between patients. Though a variety of practitioners can help work through depression, including MDs, psychologists, and therapists, I believe that the individualized treatment that is a hallmark of naturopathic medicine offers the personalized approach necessitated in depression.

Monday, April 16, 2012

Some Monday Morning Reading On Parenting

In the wake of the book 'Battle Hymn of the Tiger Mother', cross-cultural parenting analysis has become suddenly fashionable, and the culture du jour has become the French. Pamela Druckerman's 'Bringing Up Bébé' brought praise and criticism from both sides of the Atlantic, with some arguing that French parents ought to be role models for our overwhelmed, confused American parents, and others pointing out that French disciplinary behaviors stifle creativity and self-expression. Not being a parent myself, I can't argue one way or another, but in this debate, I've been most interested in the eating habits that French parents apparently instill in their children - eschewing sugar, simple carbs, and snacking, French parents encourage vegetables, and even fish. Without discussing how this is achieved, the results are impressive - American children are three times more likely to be overweight than French children, a statistic that ought to inspire both terror and adulation in the minds of epidemiologists. Needless to say, there's already been a book written on the topic, 'French Kids Eat Everything'. It's Monday, and if you're feeling a bit Continental, peruse these articles and get interested.

Thursday, April 12, 2012

Olive Leaf and Hypertension

Recently, I found myself leafing through a freebie natural health magazine – if you read this blog, you probably know the type – and came across an article about the use of olive leaf in hypertension. The article was a bit alarmist, and suggested that medical doctors were playing a dangerous game by allowing elevated blood pressure to go untreated. On the contrary, anyone familiar with the creation of ‘prehypertension’ as a diagnostic category or with updates in cholesterol treatment guidelines, knows that when it comes to cardiac risk factors, MDs are nothing if not aggressive. So I walked into the article with a bit of skepticism. However, given that I’d just blogged last week about using magnesium in hypertension, I thought I’d do some investigation into olive leaf and hypertension.

Olive leaf is a little-known herb, but one which has interested me since I read an article stating that it had been shown to inhibit viral reverse transcriptase – one of the enzymes that is crucial to HIV’s ability to infect humans. It’s been variously lauded as an antioxidant, an antimicrobial, and anti-inflammatory. I, however, am primarily interested in its activity as an antihypertensive.

As always, research starts with animal studies. About a decade ago, researchers found that olive leaf extract could reverse hypertension in lab rats who had been made hypertensive through administration of a nitric oxide-synthase inhibitor. While this information is interesting, there exist too many variables to consider this for application to humans – human hypertension arises from a variety of causes and mechanisms, and nitric oxide inhibition is not a common cause – had the rats been hypertensive due to obesity or dietary factors, I would have given the study more consideration, but given the experimental design, it could have easily been inferred that the olive leaf extract merely inhibited the inhibitor, and wouldn’t be useful in humans.

As if noting the limitations of the prior research, a subsequent article addressed this exact question, and found that an extract of olive leaf was effective in preventing severe hypertension in salt-sensitive, insulin-resistant lab rats. This is much more compelling information – these rats have metabolic problems which more closely resemble the ones plaguing Americans, and their hypertension arises from similar causes. This study had me more interested. That said, a more recently published article found that olive leaf extract, when included in the diet of rats fed a high-carbohydrate, high-fat diet, improved a number of markers of cardiac and metabolic markers, including blood lipids, glucose tolerance, and organ changes, but without affecting blood pressure. This study used a model that even more closely mimicked human hypertension, and found no effect on blood pressure. Taken together, these animal studies are interesting, but equivocal.

Eventually, human studies were performed. A 2008 study found that an olive leaf extract did reduce blood pressure in humans, with the greatest changes being a 9 mmHg drop in systolic hypertension, and 4 mmHg drop in diastolic. The study was small, and included only 40 participants, who were assigned to one of three study arms, so this isn’t earth-shattering evidence. Additionally, the evidence only shows a modest reduction in blood pressure, an amount that could be also achieved by diet and lifestyle changes, and the data comes from patients with borderline hypertension, not more severe disease, so it’s hard to tell how useful olive leaf would be in patients with a greater need for aggressive treatment.

The only other human study I was able to find was a 2012 study, which showed that olive leaf extract produced blood pressure decreases of 11.5 mmHg systolic and 4.8 mmHg diastolic in patients with Stage I hypertension. Again, this information does make me pay attention, as it satisfies some of the qualms I had with the earlier study, and the changes in blood pressure are closer to clinically important changes. Even so, there are significant problems with this study, including its being sponsored by makers of the olive leaf extract and a lack of ‘p-values’ or confidence intervals (tools used by researchers as measures of a study’s validity). An interesting study, to be sure, but not the piece of rock-solid evidence that would nail it for olive leaf and hypertension.

The obvious conclusion to all of this is that olive leaf is not yet ready for prime time when it comes to hypertension. The animal studies are intriguing, but the human studies are too small and too unreliable to make clinical judgments on them. Additionally, there is such great number of scientifically-validated ways of reducing blood pressure naturally, that it’s not necessary to turn to something with a less-established track record.

The additional moral to this story is that you can’t always trust what you read in ‘grey’ literature, especially when they are trying to sell you something. Results are overstated and limitations often go unmentioned in these reviews, and without direct access to the studies they are citing, it can be hard to sort out truths. Olive leaf may yet hold promise for the future, but dealing with a chronic condition is never as simple as taking a supplement a couple of times and being done with it – these conditions often require years of work to manage, and the therapeutic benefit of working with a qualified practitioner is crucial to successful outcomes.

Monday, April 9, 2012

How 'Super' Is This Fruit?

Over the past several years, we've been bombarded with hype about 'superfruits' - but what is a 'superfruit', exactly, and are they really better than our native fruits? Is eating an expensive superfruit more beneficial to your health than eating a balanced, vegetable-rich diet? Are they worth the ecological and social cost, as compared with locally-produced fruit and vegetables?

These are all questions I've been asking myself for the past several years, and have been thinking all over again as a result of this recent article in the LA Times on the topic. The article doesn't go into extreme detail, but it's worth a read to get you thinking on a Monday - perhaps the next time you reach for a mangosteen-goji juice, you'll ask if it's really the best option.

Speaking of mangosteens, I'm including this picture to make a point. Only the milky-white interior of the fruit is traditionally edible, yet mangosteen juice is purple - because the indigestible exterior skin has been included. True, the exterior is full of antioxidants (produced to protect the fruit from environmental stresses), but should we really be eating it?

Thursday, April 5, 2012

Magnesium and Hypertension

When it comes to calcium and osteoporosis, everyone is agreed – NDs, MDs, acupuncturists, NPs, and chiropractors all recommend 1200 mg of calcium a day to help ward off the onset of osteoporosis. By contrast, there’s not as much discussion of magnesium when it comes to high blood pressure, despite an overwhelming amount of research into the topic, a fact at least partly explainable by inconsistent results in clinical studies. This week, I’m going to write on this topic, referencing select articles from the medical literature – there are thousands of articles on the topic of magnesium and hypertension, and it’s easy to get lost in the sea of literature.

Let me start by discussing briefly the epidemiological information on the topic. I won’t present studies here, though there are many, but in general, the research indicates that people who consume higher amounts of magnesium have, in general, a lower prevalence of hypertension, lower blood pressure in general, and lower incidence of stroke. Of course there are studies that have found no association, as is the case when you have enough studies devoted to a given topic, but a greater number of studies indicate that there is a relationship present, and the evidence is quite compelling.

One of the reasons that I’m inclined to believe the link is because there exist plausible mechanisms for magnesium’s ability to reduce blood pressure. A recent article published in the Journal of Clinical Hypertension elaborates on the biochemistry behind magnesium’s role in hypertension, indicating multiple pathways by which it acts to lower blood pressure, but primarily likening its action to that of a calcium channel blocker (a class of medication used for hypertension and chronic heart failure). Much like a calcium channel blocker, magnesium induces vasodilatation of arteries and regulates cardiac contractility, thus lowering blood pressure and improving the function of the heart. It’s also been suggested that the role that magnesium plays in reducing blood pressure is in part due to the action its presence exerts on other minerals in the body, including sodium, potassium and calcium.

As always, none of this should be taken without evidence that it actually lowers blood pressure in a clinical setting. A 2002 meta-analysis, which looked at 22 trials, including 1220 patients, found that magnesium provided mild benefit to hypertensive patients, although this benefit was dose-dependent, which suggests that greater benefit might be derived from higher doses of magnesium. Since then, further studies have been published that indicate benefit, albeit mild, from magnesium supplementation (1, 2). Taken together, these studies indicate that there is some benefit to be had from magnesium in regards to hypertension. However, all authors more or less agree that the benefit is somewhat inconsistent in clinical trials. The authors of the previously mentioned meta-analysis indicated that small studies and variable study design was a likely factor in the inconsistencies, and called for larger studies in order to more clearly define the benefit and role of magnesium in hypertension.

One piece of the puzzle that has as yet not been fully fleshed out, but which I believe is likely to answer many questions is that of magnesium deficiency. As early as 1983, a study published in the British Medical Journal showed that magnesium could reduce blood pressure significantly, and postulated that it was due to a correction of magnesium deficiency. However, this hasn’t been a major area of research in the intervening period, although a recent study showed that magnesium did produce surprisingly large decreases in blood pressure among a collection of hypertensive diabetics who also had low serum magnesium. This piece of information may give us clinical guidelines regarding when to prescribe magnesium for hypertension, and when to resort to other measures. There’s been some dispute in the past as to the best way to measure a patient’s magnesium status, but I think the clinical correlation here points the way forward.

So what’s the take home message? In all, magnesium does appear to provide some mild benefit in cases of hypertension, a benefit even more marked if the patient is demonstrably low in magnesium. As always, be in consultation with a healthcare provider about using nutritional supplements to help combat disease, especially one with consequences as serious as hypertension – additionally, magnesium is not without side effects, and it takes an experienced provider to help guide you through that.

Monday, April 2, 2012

A Graphic to Explain Snacking

It's Monday again. How about a good, old-fashioned graphic?

This one gives some information about understanding how a food's glycemic index influences whether or not it's a good snack choice. Unfortunately, they don't include nuts or seeds (my favorite snack foods), but this is still a great tool. Many thanks to the people at Massive Health for putting this together.