ARTHRITIS PAIN



Esterified Fatty Acids for Arthritis Pain

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By Kim Vanderlinden, ND, DTCM

Esterified fatty-acid complex (EFAC), which is not to be confused with essential fatty acids, may indeed be our most potent natural anti-inflammatory. Clinical trial results using EFAC, both as a topical agent and as an oral supplement, have been nothing short of spectacular. The results have been so dramatic that it appears to be a major breakthrough in arthritis and pain management. And as we know, genuine advancements are few and far between.

Esterified Fatty Acids vs. Essential Fatty Acids

Esterified fatty acids and essential fatty acids are very similar in the fact that they are both derived from oils. However, esterified oils are not essential oils, such as omega-3 and omega-6. Oils are considered to be healthy when they have anti-inflammatory properties. Omega-3 and fish oils are currently popular for this very reason. Esterified fatty acids are derived from beef tallow and appear to have far greater anti-inflammatory properties than current healthy oils, as shown in promising trial results.

Esterified fatty acids have another unique property: They are very well-absorbed topically, thereby reaching target tissues. This has major implications for chiropractic care. The active agent itself is the penetrating agent, versus trying to mix active ingredients and carriers in the same formula and hoping that some of the active agent passes through the skin along with the carrier.

EFAC for Knee Osteoarthritis

In 2007, researchers using EFAC as an oral supplement were awarded the best paper out of the 90 papers presented at the prestigious Scripps Integrated Medical Conference in San Diego.¹ The researchers were investigating knee osteoarthritis (OA). In this trial, as in previous trials using EFAC, pain scores dropped quickly and significantly. However, since pain is largely subjective, the researchers wanted objective measurements as well. The researchers decided to measure how far patients could go in a timed six-minute walk. Presumably patients with knee OA would walk slower due to pain and/or stiffness. The patients were tested prior to supplementation to establish a baseline and then again after two, four and eight weeks. In addition to less pain, the treated patients improved in just two weeks, as they were able walk an extra 233 feet. After four weeks they could travel an additional 330 feet. After eight weeks, they were able to walk a remarkable 537 feet farther than from baseline. Most importantly, the placebo patients did not improve, which makes the results that much more significant.

Two clinical trials using EFAC to treat osteoarthritis of the knees have been published in the very highly regarded Journal of Rheumatology. Once study tested an oral capsule, and the other tested atopical cream.^2,3 Osteoarthritic knees are often the subject of anti-inflammatory and joint health research because knee OA is prevalent and it provides a functional benchmark with which to compare previous research on other treatments.

In the topical cream trial, patients were tested at baseline, 30 minutes after the first application to the knees and after 30 days of applying the cream twice daily.³ Range of motion of their knees, ability to ascend and descend stairs, ease of getting up from a sitting position and balance while stepping down was tested. After only 30 minutes, the EFAC cream improved the ability of patients to perform the above tasks. There were also long-term benefits. After 30 days, the patients improved significantly.

What About Glucosamine and Chondroitin?

The NIH conducted the GAIT trial, which is the largest (1,583 patients) and most rigorous trial ever conducted on glucosamine and chondroitin.⁴ In 2006, the initial results of the trial were released: After six months of treatment, there was not a statistically significant reduction of knee pain compared to placebo. However, many physicians continued to recommend glucosamine and chondroitin despite the negative results in the NIH trial because even if they did not relieve pain, they still provided benefit for the cartilage.

GAIT trial patients were given the option to continue for an additional 18 months for a total treatment period of two years to determine whether glucosamine and/or chondroitin would benefit cartilage. The results: Glucosamine and/or chondroitin came up short again, as they did not prevent a statistically significant loss of cartilage.⁵

First, Do No Harm

Should we continue to recommend glucosamine and chondroitin to patients? Chiropractors need to be leaders, not followers, in the field of pain management. Taking the position that glucosamine and chondroitin likely won’t help, but won’t hurt, either, is simply not serving the best interests of our patients, especially if an safe, effective alternative is available.

As physicians primarily seeing patients presenting with pain, success largely depends on the reduction of that pain. It is generally acknowledged that a majority of pain is due to inflammation. Therefore, to effectively combat pain, we often need to address that inflammation. EFAC, both topically and orally, provides us with a clinically proven tool to do just that.

References

1. Udani JK, Singh B, Torreliza M, et al. Oral cetylated fatty acids for the improvement of functional ability and pain in patients with knee osteoarthritis. Presented at the Scripps Integrated Medical Conference, 2007
2. Hesslink R Jr, Armstrong D 3rd, Nagendran MV, et al. Cetylated fatty acids improve knee function in patients with osteoarthritis. J Rheumatol Aug 2002;29(8):1708-12.
3. Kraemer WJ, Ratamess NA, Anderson JM, et al. Effect of a cetylated fatty acid topical cream on functional mobility and quality of life of patients with osteoarthritis. J Rheumatol Apr 2004;31(4):767-74.
4. Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med, Feb. 23, 2006;354(8):795-808.
5. Sawitzke AD, Shi H, Finco MF, et al. The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial. Arthritis Rheumatism 2008;58(10):3181-91.

INFLAMMATION NATURALLY/FIGHTING

Fighting inflammation Naturally With Esterified Oils

By Kim Vanderlinden, ND, DTCM

Inflammation is a core pathology affecting everything from heart disease to cancer. Even the process of aging is greatly influenced by inflammation. And of course, most if not all pain is either made worse or in many cases is a direct result of inflammation.

The question is, what can be done to reduce inflammation in a safe and natural manner in order to enhance chiropractic care? The good news is that there is a new evidence based solution supported by outstanding clinical trial results. Researchers have discovered that esterified fatty acids or oils influence several pathways of the inflammatory cascade.

Please note that esterified fatty acids/oils are not the same thing as essential fatty acids or oils. Essential oils (omega-3 and omega-6) are "essential" by definition, as our body does not manufacture them. Esterified oils do not replace the need for omega-3 oils. Both omega-3 and esterified oils limit inflammation; however, clinical trials have shown esterified oils to be particularly potent.

Radio tagging of esterified oils has shown a very high concentration in white blood cell membranes.¹ With white blood cells (WBCs) being the mediators of inflammation, the high concentration of esterified oils in WBC membranes may explain why esterified oils have demonstrated such pronounced anti-inflammatory effects.

Esterified Oils vs. Glucosamine for Joint Health

The Cochrane Collaboration is an international, not-for-profit, independent organization that produces and disseminates systematic reviews of health care interventions. According to a February 2005 review of 20 studies involving 2,570 patients,² glucosamine failed to show benefit in pain and WOMAC function. In fact, only a specific brand of glucosamine appeared to have any benefit over placebo.

As reported in this publication several years ago,³ the GAIT or Glucosamine/Chondroitin Arthritis Intervention Trial, conducted by the National Institutes for Health, is the largest and most rigorous U.S. trial of glucosamine ever done with 1,583 patients. In GAIT, participants were randomly assigned to one of 10 treatment groups: 2 glucosamine alone, 2 chondroitin alone, 2 glucosamine and chondroitin in combination, 2 celecoxib, or 2 placebo. Five of the six glucosamine and/or chondroitin treatment groups failed to show a benefit in pain. Only the sixth group (one of the two glucosamine and chondroitin groups), which only had 72 patients representing less than 5 percent of the participants, showed a benefit in pain reduction after six months.

Patients were given the option to continue for two years to assess joint spacing. Again, there was no benefit over placebo. Ironically, the combination of glucosamine and chondroitin had slightly more cartilage loss than placebo; certainly not a benefit!

On the other hand, also as referred to previously in this publication, two clinical trials using esterified oils to treat osteoarthritis have been published in the Journal of Rheumatology,^4-5 one using esterified oils as an oral capsule and one using the oils as a topical cream. In the topical cream trial, patients improved after as little as 30 minutes and after a month of daily application.

Esterified Oils for Tissue Restoration

Non steroidal anti-inflammatories are the most common approach used to treat osteoarthritis. A concern about NSAIDs, besides the typical side effects (kidney and stomach problems, etc.) is that if used regularly, they inhibit healing. For example a non-steroidal anti-inflammatory will usually reduce knee pain for several hours; however, the time it takes for the knee to heal will be extended slightly due to NSAID use.

Ground-breaking research on esterified oils was published in 2009 in the Journal of Periodontology.⁶ Previous research had shown that esterified oils were effective, which is a major advancement because there really are very few, if any, options to treat periodontal disease. The new research, however, had a remarkable twist: connective and osseous tissue was restored!

The research showed that the bone density of the teeth was increased, osteoblast or bone-building cell activity was increased, osteoclast or bone-breaking cell activity was decreased, and the pocket depth between the gums and the teeth was reduced.

Basically, these findings change everything, as tissue regeneration is now a legitimate possibility. For chiropractic, the implication of this research is that our use of natural anti-inflammatories need not inhibit tissue regeneration and the innate ability of the body to heal itself.

Research on Safety

To assess safety, esterified oils were fed to animals at 1,300 times the regular dose.⁷ Basically they couldn't stuff any more in. That's the equivalent of a person taking 3,900 capsules per day (three per day x 1,300). Chances are we would be full, too. But even at this enormous dose, scientists did not detect any pathology.

At a time when chiropractic medicine is being highly scrutinized, it is important to know that we are using evidence-based solutions whenever available to complement our care. Research is demonstrating the value of esterified fatty acids and oils for treating inflammation and thus conditions in which inflammation is a hallmark symptom.

References

1. Islam A, Gallaher CM, Gallaher DD. Absorption and Metabolism of a Cetylated Fatty Acid. Technical Report, University of Minnesota, 2003.
2. Towheed T, Maxwell L, Anastassiades TP, Shea B, Houpt J, Welch V, Hochberg MC, Wells GA. Glucosamine therapy for treating osteoarthritis. Cochrane Database of Systematic Reviews, 2005;2.
3. Vanderlinden K. "Esterified Fatty Acids for Arthritis Pain." Nutritional Wellness, February 2009.
4. Kraemer WJ, Ratamess NA, Anderson JM, et al. Effect of a cetylated fatty acid topical cream on functional mobility and quality of life of patients with osteoarthritis. Journal of Rheumatology, Apr 2004;31(4):767-74.
5. Hesslink R Jr, Armstrong D III, Nagendren MV, et al. Cetylated fatty acids improve knee function in patients with osteoarthritis. Journal of Rheumatology, Aug 2002:29(8):1708-12.
6. Hasturk H, Goguet-Surmenian E et al. Tetradecanol complex: therapeutic actions in experimental periodontitis. J Periodontology, 2009;80(7):1103-13.
7. The Acute Toxicology of Oral Cetylated Fatty Acid Gavage CD-1 Mouse Model. Perry Scientific, Inc., 2001; Study No. 00-1075.

Nutrition for Prostate Cancer: Research Review

By James P. Meschino, DC, MS

Doctors encourage men over age 50 (and in cases of relevant family history or African-Americans, beginning at age 40) to have an annual prostate specific antigen (PSA) test for early detection of prostate cancer.

PSA is an enzyme released into the bloodstream at higher concentrations from prostate cells in cases of prostate inflammation, enlargement and prostate cancer. A PSA level above 4 ng/ml is cause for concern with respect to prostate cancer, as is a quickly rising PSA level from one year to the next even if the level is within the normal range (under 4 ng/ml).

If the PSA level arouses suspicion, then a transrectal ultrasound is scheduled to look for suspicious masses within the prostate gland. If such masses are detected, a needle biopsy is preformed and the suspicious tissue is assessed by a pathologist who gives the tissue samples a Gleason Score (from 1-10). The higher the score, the more malignant the cells are determined to be.

The good news is that if the cancer is detected early and is only confined to the prostate gland itself, then a surgical procedure (radical prostatectomy) results in a complete cure in most cases. However, if the cancer has extended through the prostate capsule to invade the bladder or the rectum, or cells find their way into the lymphatic system, the prognosis is not as encouraging. Metastasis of prostate cancer often involves invasion into bone and the liver. Thus, catching prostate cancer at an early stage is an important strategy considering it is the second leading cause of cancer death in North American men.

However, in some cases of localized prostate cancer, men refuse to have surgery because they know that they are likely to be left impotent and/or have urinary incontinence from nerve damage related to the surgical procedure. As well, statistics show that in the majority of cases, prostate cancer is a slow-growing tumor, which is usually not life-threatening. Thus, some men opt for watchful waiting, especially if they have a low Gleason Score and the tumor mass does not look very large upon transrectal ultrasound. If the PSA is rising very slowly, then they will often continue to refuse surgical intervention and/or radiation treatment.

Some doctors also recommend watchful waiting for men with localized prostate cancer who are at high risk for complications from surgery. For instance, men with pre-existing cardiovascular disease or who are morbidly obese and with uncontrolled diabetes fall into the category of non-surgical candidates.

In recent years, a number of clinical trials have been undertaken to see if specific dietary and lifestyle measures and/or nutritional supplements can slow the rise of PSA levels or possibly lower the PSA in men with localized prostate cancer. Other studies have included men with more advanced disease. A number of epidemiological studies and animal studies have suggested that certain nutrients can defend the prostate against prostate cancer and/or inhibit the growth of existing prostate cancer cells. With this knowledge, researchers have begun using some of these nutrients in supplementation trials with men with various stages of prostate cancer.

Soy Isoflavones

In a an intervention study, supplementation with 100 mg/day of soy isoflavones showed a favorable outcome in stabilizing PSA levels. Soy isoflavone supplementation was shown to decrease the rate of increase in serum PSA levels. These researchers concluded that their data suggests soy isoflavones may benefit some patients with prostate cancer by slowing the progression of the disease and therefore, potentially delaying the development of symptoms, improving quality of life, and perhaps even prolonging survival.¹

Vitamin D

The administration of cholecalciferol (vitamin D found in supplements) at physiological doses has been shown to decrease or slow the rise in PSA levels in men with prostate cancer without risk of vitamin D toxicity. In one study, 15 prostate cancer patients were given 2,000 IU (50 ug) of vitamin D daily and monitored every two to three months. In nine patients, the PSA level decreased or remained unchanged, and these results were sustained during the 21-month course of vitamin D administration.

Analysis also showed that there was a statistically significant decrease in the rate of PSA rise after administration of vitamin D compared with before vitamin D administration. The median PSA doubling time increased from 14.3 months prior to vitamin D administration to 25 months after commencing vitamin D supplementation. In fact, 14 of the 15 patients showed prolonged PSA doubling time after vitamin D supplementation. There were no side effects reported by any patient.²

The marked prolongation of PSA doubling time is an extremely important outcome. Partin, et al., showed that the risk of distal metastasis of prostate cancer (with respect to relapse after prostate cancer surgery) at five years was 65 percent to 75 percent when PSA doubling time was less than 10 months compared with 10 percent to 20 percent when PSA doubling time was greater than 10 months.³

Lycopene

In a Phase II clinical trial, researchers investigated the efficacy of lycopene alone or in combination with soy isoflavones on serum PSA levels. To be eligible for the study, men with prostate cancer had to have rising serum PSA following local therapy or while on hormone therapy. The study population included 71 patients with three successive rising PSA levels or a minimum PSA of 10 ng/ml at two successive evaluations prior to starting therapy.

Subjects were randomly assigned to receive a tomato-extract capsule containing 15 mg of lycopene alone (n: 38) or combined with a capsule containing 40 mg of a soy isoflavone mixture (n: 33) twice daily orally for six months. One patient on the lycopene arm did not receive therapy due to his inability to ingest the study pill.

There was no decline in serum PSA in either group. However, 35 of 37 (95 percent) patients in the lycopene group and 22 of 33 (67 percent) patients in the lycopene plus soy isoflavone group achieved stabilization in their serum PSA levels. The data suggest that lycopene and soy isoflavones have important adjunctive effects in PSA relapse and may delay progression of both hormone-refractory and hormone-sensitive prostate cancer.⁴

Antioxidants and Low-Animal-Fat Diet

Dr. Dean Ornish and colleagues conducted a study testing the effectiveness of an intensive dietary and lifestyle program as the sole treatment of prostate cancer in men with low to moderate Gleason Scores. The program consisted of a low-animal-fat diet (with the exception of some fish) and emphasis on fruits, vegetables, legumes, soy products and other vegetarian foods. He also supplemented these men with antioxidants (vitamin C, selenium and vitamin E) and included moderate aerobic exercise and stress management interventions in the treatment group. The daily antioxidant supplement dosages were: vitamin C, 2,000 mg; vitamin E, 400 IU; and selenium, 200 mcg.

Dr. Ornish, et al., studied 93 men who had chosen not to undergo conventional surgical or radiation treatment for prostate cancer. Half of these men were randomly allocated to the Ornish program, while the remainder served as a non-treated comparison group. After 12 months, PSA scores in the treated group decreased an average of 0.25 ng/ml or 4 percent, PSA scores in the non-treated group of men increased an average of 0.38 ng/ml or 6 percent.⁵

Ground Flaxseed

One hundred and sixty-one patients scheduled at least 21 days before prostatectomy were randomly assigned to one of the following arms: control (usual diet); flaxseed-supplemented diet (30 g/day); low-fat diet (<20 percent total energy); or ground flaxseed-supplement and low-fat diet. Blood was drawn at baseline and before surgery. Tumors were assessed for rates of proliferation and programmed cell death (apoptosis). The protocol was followed an average of 30 days.

Results showed that the men given the flaxseed supplement had a slower replication rate of their prostate cancer cells than did those not taking flaxseed supplementation and those only on a low-fat diet. The researchers concluded, "Findings suggest that flaxseed is safe and associated with biological alterations that may be protective for prostate cancer."⁶ These findings also suggest that ground flaxseed supplementation may slow the proliferation rate of existing prostate cancer cells.

Saw Palmetto

A 62-year-old man with androgen-independent metastatic prostate cancer that had failed to respond to multiple treatment regimens stopped all conventional therapy and began taking 10 mg/day lycopene and 300 mg of saw palmetto three times a day. The patient's PSA level decreased from 365 ng/ml to 140 ng/ml after one month and to dropped to 8.1 ng/ml after two months. A repeat bone scan revealed an improvement of bony metastases. He continued the lycopene and saw palmetto, and remained asymptomatic for an unspecified period of time.⁷Saw palmetto contains beta-sitosterol, which in experimental and animal studies, has shown an ability to induce apoptosis of certain prostate cancer cell lines. Most researchers attribute the dramatic disease-reversal effect in the above case to this biological process.

Pomegranate Juice

Researchers at the 104th Annual Meeting Scientific Meeting of the American Urology Association presented findings showing that men who had undergone prostate surgery or radiation treatment for localized prostate cancer benefited from drinking 8 ounces/day of pomegranate juice if their PSA levels were still continuing to rise.⁸ The doubling time of their PSA was extended to 60 months, compared to only 15.4 months prior to pomegranate juice administration. Previously, a study in the Journal of Clinical Cancer Research showed that men with established prostate cancer extended their PSA doubling time from 15 months to 54 months when they began drinking 8 ounces of pomegranate juice each day.

The body of evidence suggests that specific dietary and supplementation practices should be strongly considered in the adjunctive nutritional management of prostate cancer. Many medical doctors and oncologists are not familiar with the studies to support this approach. Thus, it falls to alternative health care practitioners to educate patients on this subject, including providing research to discuss with their attending physician.

References

1. Hussain M, Banerjee M, Sarkar FH, et al. Soy isoflavones in the treatment of prostate cancer. Nutr Cancer, 2003;42;2:111-7.
2. Woo TCS, Choo R, Jamieson M, et al. Pilot study: potential role of vitamin D (cholecalciferol) in patients with PSA relapse after definitive therapy. Nutr Cancer, 2005;5;1:32-6.
3. Partin AW, Pound CR, Rootselar CV. Natural history of progression after PSA elevation following radical prostatectomy: update. J Urol, 2003;169(4 suppl):935.
4. Vaishampayan U, Hussain M, Seren S, et al. Lycopene and soy isoflavones in the treatment of prostate cancer. Nutr Cancer, 2007;59(1):1-7.
5. Ornish D, Weidner G, Fair WR, et al. Intensive lifestyle changes may affect the progression of prostate cancer. J Urol, 2005;174:1065.
6. Demark-Wahnefried W. Flaxseed supplementation (not dietary fat restriction) reduces prostate cancer proliferation rates in men presurgery. Cancer Epidemiol Biomarkers Prev, 2008;17(12):3577-87.
7. Matlaga BR, Hall MC, Stindt D, Torti FM. Response of hormone refractory prostate cancer to lycopene. J Urol, 2001;166:613.
8. "Consumption of Pomegranate Juice May Benefit Men Treated for Localized Prostate Cancer." www.medicalnewstoday.com/articles/147647.php

Inflammatory Bowel Disease: Nutritional Considerations

Changing a Young Girl's Life

By Van Merkle, DC, CCN, DCBCN, DABCI

Dealing with a worried parent can sometimes be a little tricky. While they often would not even question recommendations for themselves or the side effects of the drugs they take, prescriptions for their tiny counterparts are subjected to rigorous research on the Internet, followed by endless questions to their doctor

I recently had a patient whose parents were so worried they were going to do the wrong thing and make their daughter's inflammatory bowel disease worse that they hesitated to follow my advice or any doctor's advice, for that matter. However, not taking action is an action in itself. No improvements can be made if we remain stagnant, too scared to accept the help we are given, and this child needed help.

At 10 years old, the patient was a good 4'11," but only 77 lbs and suffered from frequent loose stools (sometimes five or more per day) and was forced to get up at least twice a night to have bowel movements. She had an extremely sensitive stomach with bouts of abdominal pain and blood in her stool. A gastroenterologist checked her for bacteria, lactose intolerance, fructose intolerance and celiac's disease, and did an endoscopy and colonoscopy before finally diagnosing inflammation of the small intestine appearing to be early IBD, which two doctors said would likely become Crohn's disease.

They prescribed rifaximin to coat the lining of the intestines and promote healing, along with methotrexate and enteral nutritional therapy to rest the digestive system.¹ Her parents balked at these recommendations. Not only were they leery of giving their daughter drugs that are also used in chemotherapy treatment,² but, as her mother said, "It doesn't seem feasible to have a shy 10-year-old walking around with a feeding tube hanging from her nose."

After hearing that chemotherapy drugs were the best option for their daughter, her parents were a little anxious about what my recommendations would entail. One of the easiest ways to quell parental anxiety is with diagnostic testing. I explained that every disease, nutrient deficiency and inflammatory processes can be measured and diagnosed with various forms of laboratory testing, such as blood work, hair analysis, urinalysis and toxic element challenge. These findings give patients and their families a visual of what is going on in the body and how certain nutrients can improve those values. If a blood test reveals a high C-reactive protein (an inflammatory marker) and you recommend a natural anti-inflammatory like ginger/tumeric to be taken for three weeks, and then recheck that same marker, it will tell you whether those nutrients are working. If the C-reactive protein decreases, it is diagnostic proof that what you've been doing has worked.

We started by ordering some blood tests and a hair analysis to look at toxic elements and essential elements in her body. Because of the patient's weight and frequent bowel movements, malnutrition was a major concern. In the blood test, we saw low levels of things like chloride, sodium, magnesium, calcium and protein. These are indicators of nutrient-absorption problems and dehydration. We also found a low overall cholesterol level with an insufficient HDL level. This could be very dangerous and disruptive to her growth process because cholesterol is used to build and maintain cell membranes, produce sex hormones, aid in the manufacture of bile (which helps digest fats) and helps metabolize fat-soluble vitamins like A, D, E and K.³

Low iron levels suggested anemia and were likely causing the low red blood count. This reduces her ability to transport oxygen and other nutrients and can also affect her body's ability to heal and repair itself. The high CRP and ESR showed tissue inflammation, likely caused by the IBD while the low creatine kinase is a chronic wasting symptom common in patients with reduced muscle mass. On top of these issues, more problems appeared in the hair analysis with high levels of toxins, especially nickel, arsenic, aluminum, cadmium, uranium and copper. It's highly likely that the toxic elements were a primary cause of her IBD.^4-6 Copper in particular has been linked to gastrointestinal distress, and other toxins cause damage to organs such as the kidneys and liver, making expulsion of toxins even more difficult.

Each recommendation made to this patient was based on the test results seen above. For the first two weeks, I recommended vitamins to aid with digestion, heal the gut and replenish her vitamin and mineral stores. They included several digestive aids that each targeted a slightly different digestive issue, B12 to help with the anemia, egg-white protein powder and a green drink to boost her nutrient intake. After a few weeks, she was to add in some fish oil, a multimineral, vitamin C with ribose (which buffers the vitamin C, minimizing gastrointestinal distress), calcium, magnesium and a chelator, which would will help with the elimination of toxins.

Her mother's only complaint with my recommendations was that there were too many vitamins (16 total). She requested I give her a list of only what would be most beneficial for their daughter. I simply replied, "She will not feel better if she takes on this challenge half-heartedly. Doing only a portion of what is recommended will leave out vital nutrients and healing properties which are necessary for her recovery."

I asked them to retest the blood work in two months so we could re-evaluate the patient's status, but when I finally received her blood test almost four months later, I noticed that nothing had really changed. In fact, some areas were actually worse than before. When I sat down with the patient's mother, she confessed that after hearing completely opposite points of view from their gastroenterologist and me, she had been unsure of how to proceed. The gastroenterologist had told them to avoid vegetables because they were difficult to digest, while I had encouraged a whole-foods diet with lots of vegetables to get more nutrients into her body. They had decided to try a very bland, low-fiber diet in conjunction with a few digestive aids and the chelators.

Once her daughter started to feel better, she planned to add the remainder of the supplements recommended; however, her daughter got worse. So they stopped using any of the vitamins.

Seeing the numbers for their daughter's condition worsen kicked this family into gear. They started following my recommendations to the letter. Lo and behold, the anemia was better a few months later. She had more energy and no abdominal pain at all. She was playing softball, spent a week at camp and was sleeping great. Her mother said, "She gets to be a normal kid now." She was also up to a much healthier 93 lbs. One of the most significant changes was seen in the inflammation and wasting markers.

While it was great that this young girl felt better, it was also nice to have these diagnostic tests to give her parents a visual of their daughter's improved state of health. These markers will act as guideposts as she continues her treatment and works to reduce her body's levels of toxic elements.

References

1. Drugs.com: information about rifaximin. www.drugs.com/mtm/rifaximin.html
2. Drugs.com: information about methotrexate. www.drugs.com/methotrexate.html
3. Cholesterol: metabolism, biosynthesis, etc.http://themedicalbiochemistrypage.org/cholesterol.html
4. Mercury and food intolerances: common causes of chronic conditions related to leaky gut and intestinal dysfunction. www.flcv.com/leakyghg.html
5. Dartmouth Toxic Minerals Research Program.www.dartmouth.edu/~toxmetal/metals/questions/mercury.html
6. Safety and Health Topics: Toxic Metals. U.S. Department of Labor.www.osha.gov/SLTC/metalsheavy/index.html

Osteoporosis:             Primarily a Nutritional Issue?

By Deborah Pate, DC, DACBR

We have been relying on the theory that if we can prevent the rate of bone turnover and keep calcium available for absorption, osteoporosis can be avoided. This is the calcium theory of osteoporosis.

However, maintaining healthy bone is not that simple; if it were, then populations that consumed the most amounts of dairy and calcium supplements would have lower rates of osteoporotic fractures than the populations that consumed less dairy and calcium supplements. This has not been demonstrated; in fact, the opposite appears to be the case.

Countries that consume the most dairy and calcium supplements have the highest rates of hip fractures: the United States, Australia, New Zealand, and western European countries. The countries with the lowest rates of hip fractures (in Asia and Africa) consume little or no milk, dairy or calcium supplements. These data come from epidemiological surveys conducted worldwide by different research teams over the course of 20 years.

Osteoporosis is a complex, multi-factorial condition characterized by reduced bone mass and impaired micro-architectural structure, leading to an increased susceptibility to fractures. Bone strength is genetically determined, but other factors are involved, including environmental, nutritional and lifestyle factors.

Function of the Skeletal System  Support: The skeleton holds the body up, the mandible supports the teeth, all the bones provide support for the muscles, and many bones offer support for the organs directly or indirectly. Protection: The skeleton encloses the brain, spinal cord, lungs, heart, organs in the pelvis, the viscera, and bone marrow. Movement: The skeleton gives the skeletal muscles a platform for movement, locomotion, even respiration. Blood Formation: Red bone marrow is the major producer of blood cells and cells of the immune system. Electrolyte Balance: The skeleton is the body's main mineral reservoir, storing calcium and phosphate, and releasing them according to physiological needs. Acid-Base Balance: Bone buffers the blood against excessive pH changes by absorbing or releasing alkaline mineral salts.

Nutrition is an important modifiable factor in the development and maintenance of bone mass and the prevention and treatment of osteoporosis. Most of the bone mineral content is comprised of calcium and phosphorus. The other dietary components, such as protein, magnesium, zinc, copper, iron, fluoride, and vitamins D, A, C, and K, are required for normal bone metabolism.

Dietary Ca requirement is determined mostly by skeletal needs, and it exerts a threshold behavior. This means that the skeletal response (in this case, skeletal accretion) will occur only when Ca is increased from the deficiency level to a threshold zone. Adding more Ca when the level of dietary intake already exceeds the threshold will not likely improve bone mass.

The Ca threshold for adults is approximately 1,100 mg. Therefore, typical baseline Ca intake becomes important when evaluating the literature for efficacy of dietary Ca on bone. For example, if baseline intake is already at the threshold level, additional Ca would not be expected to improve bone.

Understanding the interaction between different factors associated with bone health is still a work in progress. Fortunately, enough information is available to make reasonable progress in the prevention and management of osteoporosis. Let's look some of the issues with regard to this condition:

• With prolonged life expectancy increasing the elderly population, predictions are that osteoporotic fractures will reach epidemic proportions.
• Osteoporosis is a multifactorial disorder. Besides the influence of heredity, bone health depends on a whole range of nutrients and foods as well as the environmental factors; understanding the interactions of these nutrients among themselves and interactions with pharmacological, environmental and lifestyle factors is crucial for prevention and management of osteoporosis.
• Prolonged deficiency or excess of one or a combination of several nutrients, as well as changes in requirements of some nutrients due to physiological and/or metabolic circumstances, need to be factored into the osteoporotic problem.

Nutrition is one of the important modifiable factors in the development and maintenance of bone, and the prevention and treatment of osteoporosis. The nutrients of most obvious importance to bone health are calcium and phosphorus; they compose 80 percent to 90 percent of the mineral content of bone. Protein is incorporated into the matrix of the bone for collagen structure upon which the mineralization occurs. Other minerals and nutrients are crucial in carrying out the reactions and metabolic processes in bone. It is beyond the scope of this article to discuss all the factors involved in bone health; but what is possible is to illuminate some the key issues involved in the maintenance of bone health.

We all know that bone is a dynamic structure and that it is continually remodeling. It has many functions, some of which are obvious: support for the body, protection of fragile organs and a platform for the attachment of muscles for locomotion. Of course, the bone marrow is the main source for blood cells and cells of the immune system; but it is also a reservoir for minerals that the body needs to regulate electrolytes, and buffers the blood against pH changes.

Let's consider the last two functions of bone, electrolyte balance and acid-base balance, which are very dynamic activities requiring constant monitoring and management for the survival of the organism. The main electrolytes in the blood are sodium, potassium, calcium, magnesium, chloride, phosphate, and carbonate. Most commonly, problems occur when the level of sodium, potassium, or calcium is abnormal.

The source for these electrolytes is from ingested food, but if they are not available when needed, bone is where the body will retrieve calcium and phosphate electrolytes. Similarly, the pH of the blood must be maintained in a narrow range between 7.35 pH to 7.45 pH. Chloride (Cl) and bicarbonate (HCO3) play a major role in maintaining acid-base balance, with bicarbonate being by far the most important buffer. Calcium forms an important blood buffer as ionized calcium bicarbonate. Again, if calcium is not found in sufficient amounts in food sources, bone is the body's resource for the needed calcium.

Because of these very important functions calcium plays in the balance of electrolytes and pH balance, osteoporosis appears to be more a problem of calcium homeostasis. This calcium homeostasis is of course affected by diet. It is known that increasing dietary protein increases urine calcium excretion. For every 50 g increment of protein consumed, an additional 60 mg of urinary calcium is excreted. It follows that the higher the protein intake, the more urine calcium is lost and the more negative calcium balance becomes.

Since 99 percent of the body's calcium is found in bone, with high consumption of protein there is an associated result of increased bone resorption. With increased bone resorption, increased prevalence of osteopenia results. But we also know that low-protein diets interfere with intestinal calcium absorption and IGF-1 levels. Epidemiological studies demonstrate a positive association between protein intake and BMD (bone mass density). On the other hand, there are many epidemiological studies that report higher fracture rates in groups consuming a high-protein diet. Overall, it appears that both low- and high-protein diets are detrimental to bone health.

With regard to whole foods containing multiple nutrients, the situation becomes even more complicated. The acid or alkali ash generated by the diet affects bone by altering acid-base status of the blood. It has been known since the late '60s that the skeleton serves as a buffering system for neutralizing acid or alkaline challenges from food and maintaining constant pH of blood.³ Bone undergoes increased resorption in order to release calcium to neutralize metabolic acidosis. Therefore, acid ash-producing foods like meats, especially when consumed over a long period of time, contribute to the depletion of calcium, increasing the risk of osteoporosis, as opposed to fruits and vegetables with an alkaline ash.

In summary, we know that osteoporosis is a multifactorial disorder and that nutrition plays an important role in bone health. Calcium homeostasis is adversely affected by high-acid-ash diets. Our understanding of nutrients and other components affecting bone health continues to improve, but this knowledge is far from complete. As the information becomes available, we need to continue to keep up to date. Osteoporosis is one disorder that can be managed with appropriate nutrition.

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Hip Fracture Incidence (HFI) by Country
HFI	Country	HFI per 100,000 Person-Years
Lowest	Nigeria	0.8
	China	2.9
	New Guinea	3.1
	Thailand	5.0
	South Africa	7.7
	Korea	11.5
	Singapore	21.6
	Malaysia	26.6
	Yugoslavia	33.5
	Saudi Arabia	47.3
	Chile	56.8
Middle	Italy	57.2
	Holland	60.7
	Spain	65.1
	Japan	67.3
	Hong Kong	69.2
	Israel	75.5
	Ireland	76.0
	France	77.0
	Finland	93.5
	Canada	110.3
	Crete	113.0
Highest	United Kingdom	116.5
	Portugal	119.8
	United States	120.3
	Australia	124.8
	Switzerland	129.4
	New Zealand	139.0
	Argentina	147.8
	Denmark	165.1
	Sweden	172.0
	Norway	186.7
	Germany	199.3
Lowest tertile	mean ± SD	19.7 ± 18.4
Middle tertile	mean ± SD	76.8 ± 18.1
Highest tertile	mean ± SD	147.3 ± 27.8

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SOURCE: Frassetto LA, Todd KM, Morris RC Jr, Sebastian AJ. Worldwide incidence of hip fracture in elderly women: relation to consumption of animal and vegetable foods. Gerontol A Biol Sci Med Sci, October 2000;55(10):M585-92.

References

1. Lanau AJ, Castleman M. Building Bone Vitality. McGraw Hill Companies Inc., 2009.
2. Kerstetter JE, Allen LH. Protein intake and calcium homeostasis. Adv Nutr Res, 1994;9:167-181.
3. Wachman A, Bernstein DS. Diet and osteoporosis. Lancet, 1968;1:958-961.

VITAMIN C

Vitamin C, Reflex Sympathetic Dystrophy and Complex Regional Pain Syndrome

By G. Douglas Andersen, DC, DACBSP, CCN

When I was in school, I remember being told that reflex sympathetic dystrophy (RSD) was the modern term for causalgia, a condition first described by doctors during the Civil War.

After graduation, I recall attending a seminar and learning that causalgia was the correct term to use if RSD was severe. Because of the confusion surrounding these two terms (as well as others), the condition was re-named in the mid 1990s to complex regional pain syndrome (CRPS), with CRPS Type 1 replacing RSD and CRPS Type 2 replacing causalgia. The differences were that the nerve dysfunction in CRPS Type 1 patients stemmed from traumas like sprains, fractures and surgeries, in which there was no direct nerve damage. The CRPS Type 2 label was reserved for those with a direct nerve injury. (However, due to the fact that the symptoms of the two classes do not differ, many doctors and therapists continue to call the condition RSD.)

Characteristics of CRPS

Table 1: Skin Changes in the Area of CRPS*

Thinning Shiny appearance Swelling Sweatiness or moistness Redness, white color, blue color Increased temperature or decreased temperature Increased hair growth or hair loss *Not all changes are seen in all patients.

CRPS is most likely to occur following trauma to an extremity that requires immobilization, such as a fracture, surgery or gunshot wound. However, it can even occur after a minor sprain or even a blood draw. The hallmark symptoms are intense burning pain and extreme skin sensitivity. A host of skin changes can also occur. (Table 1) Joint stiffness, muscle contractions, weakness and muscle atrophy can occur after three or more months.

Vitamin C for CRPS: What Recent Research Suggests

The authors of a 2009 study¹ called it a "quasi experiment" because it compared the outcomes of 392 patients in successive years who had foot and ankle surgeries. The first group (July 2002 - June 2003) numbered 177 patients; the second group (July 2003 - June 2004) included 215 patients. Patients in the second group only were given 1,000 mg of vitamin C a day for 46 consecutive days following their surgery. Study findings are shown in Table 2.

Table 2: Post-Op Vitamin C and CRPS Incidence No Vitamin C Vitamin C Number of Patients 177 215 CRPS Cases 18 4 % CRPS Cases 9.6% 1.7%

The results of this "quasi experiment"mirror an earlier study in 2007²involving wrist fractures, in which there was a 10 percent rate of CRPS in patients given placebo, a 1.8 percent rate of CRPS in patients given 500 mg of vitamin C and a 1.7 percent incidence of CRPS in a third group given 1,500 mg vitamin C for 50 days after  their wrist injuries.

Practice Recommendations

Based on these two studies, the simple addition of 500 mg of vitamin C a day for two months following extremity trauma appears to reduce of the incidence of CRPS by 80 percent. Whether you practice nutrition or not, anytime you have a patient who has a upper or lower limb injury requiring casting or surgical repair, remind them to take some extra vitamin C. Not only will it help healing by its well-recognized effect on collagen formation and free-radical reduction, but it also just may prevent CRPS. And as anyone who has had a CRPS patient will tell you, the best treatment is prevention.

References

1. Besse JL, Gadeyne S, Galand-Desme S, et al. Effect of vitamin C on prevention of complex regional pain syndrome type 1 in foot and ankle surgery. Foot and Ankle Surgery, 2009;(15)179-182.
2. Zollinger TE, Tuinebreijer WE, Breederveld RS, et al. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized controlled multicenter dose-response study. J Bone Joint Surg (U.S.), 2007;(89):1424-1431.