Exercise of Any Duration, Intensity Affects Weight Loss Significantly

Exercise

Exercise of Any Duration, Intensity Affects Weight Loss Significantly

Considerable evidence points to exercise as an important component of a behavioral weight loss program; however, the optimal amount of exercise needed to maximize long-term weight loss remains unclear.

The Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine recommend 30 minutes (minimum) of moderate-intensity activity on "most days of the week" to improve health; the Institute of Medicine (IOM) suggests 60 minutes minimum of exercise on most days to control body weight.






This study compared the effects of different durations and intensities of exercise on weight loss and overall cardiovascular fitness in 201 sedentary women (average age: 37) involved in a university-based weight control program. Participants were assigned to one of four exercise groups:

1) vigorous intensity/high duration
2) moderate intensity/high duration
3) moderate intensity/moderate duration
4) vigorous intensity/moderate duration

All women were also instructed to reduce energy intake to 1,200-15,00 kcal/day and to limit dietary fat to 20-30% of total daily energy intake. Each participant completed a detailed medical history and a physical activity readiness questionnaire prior to entry, and provided documentation from her physician indicating that the proposed 12-month intervention was not contraindicated. Main outcome measures were body weight, cardiorespiratory fitness, and exercise participation.

Following 12 months in the program (completed by 94% of the participants), weight loss and increased cardiovascular fitness was significant in all four groups, but with no significant differences noted between any of the groups.

"The results of this study have implications for prescription of exercise for sedentary, overweight adults engaging in weight loss efforts," conclude the study authors. "Moderate to high doses of exercise in combination with a decrease in energy intake resulted in 8% to 10% reductions in body weight following a 12-month intervention."

Recommending Exercise for Patients With Diabetes:

Diabetes mellitus affects an estimated 150 million people worldwide, including 16 million Americans; according to estimates, by the year 2025, the number of patients suffering from the condition will exceed 300 million.

Type 1 diabetes, which afflicts 10% of sufferers, is characterized by insulinopenia, requiring that patients take insulin for survival.
This overview of type I diabetes provides the clinician with an introduction to its etiology and how it is diagnosed, then explores the influence of exercise on patients with the condition, including the many general effects of a consistent exercise regimen:

* improving glucose tolerance by augmenting insulin sensitivity;
* decreasing muscle capillary basement membrane thickening and arterial pulse volume recordings;
* increasing lean body mass and work capacity;
* improving overall weight management;
* reducing serum total cholesterol, low-density lipoprotein (LDL) and very low-density lipoprotein levels (VLDL), while raising high-density lipoprotein (LDL) levels; and
* increasing cardiac function.

Numerous management strategies and guidelines for exercise are included and can be obtained from the Internet, along with steps clinicians should take in evaluating patients with type I diabetes (prior to recommending any exercise regimen); specific considerations in terms of diet, exercise intensity and duration, and energy requirements; and potential risks and complications.

The authors emphasize that caring for diabetes patients requires that all clinicians be responsible for education about blood glucose self-monitoring; proper exercise prescription; appropriate dietary and insulin management plans; pre-participation clearance; and ongoing education. With respect to exercise, they note: "Exercise has risks and benefits that must be understood so that participation yields a safe, enjoyable outcome. ..."

Is Aspartame Dangerous?

By Paul J. Toft, DC

Dear Editor:

I was happy that Dr. Lendon Smith wrote about aspartame (ASP, NutraSweetTM/EqualTM), in the November 22 issue of Dynamic Chiropractic.

Approximately 85% of the complaints registered with the FDA concern ASP reactions.

This represents 73 different symptoms and 5 deaths. It is estimated that 75 million Americans are experiencing reactions, but most of them are unaware of the relationship between ASP and their symptoms. According to research at MIT, ASP causes a drastic lowering of serotonin levels in the brain. Serotonin is a neurotransmitter that functions in the emotional centers of the brain. Low levels may cause headaches, chronic fatigue, anxiety attacks, nervousness, aggravation of phobias, loss of activities that were previously enjoyed, depression, suicidal tendencies, aggressive behavior, and an overall feeling of being "stressed out" or that life is much more of a struggle than it should be. According to the Northwestern Insurance Company, stress-related disability has doubled since 1981. Is it a coincidence that NutraSweet is celebrating its 10th anniversary this year? I don't think so.

All of us have patients that take anti-depressants. Do you tell your patients that NutraSweet can interfere with the anti-depressant's effectiveness? You can bet their MDs don't. Many of your patients are taking anti-depressants to counteract the imbalance in the brain caused by NutraSweet in the first place. Unless they stop using ASP products, these anti-depressants might not work.

ASP also breaks down into formic acid, formaldehyde, and diketopiperazine, know carcinogens. According the the National Cancer Institute, malignant brain tumors have risen dramatically each successive year following NutraSweet's approval for use in soft drinks in 1983. Is it a coincidence that similar tumors showed up in lab animals during testing? How many people have you heard about with brain tumors in the last 10 years?

ASP is also very detrimental to the immune system. Maybe someone should tell Magic Johnson about this as he fights for his life in the next several years. Nobody who is HIV positive should consume ASP products.

Did you know that a Public Board of Inquiry recommended that ASP not be approved until the brain tumor issue was resolved, only to be overturned by A.H. Hayes in 1983? Two months after Mr. Hayes approved ASP, he went to work for a NutraSweet public relations firm.

The media has totally avoided this issue because of offending sponsors and losing millions of dollars of advertising. Are chiropractors the only hope?

Mechanical Force, Manually Assisted Adjustments to the Temporomandibular Joint: Are They Safe?

By Darryl Curl

I was looking through the daily mail one day recently, and I ran across an interesting letter from a dentist, D.D. Sommers, who writes to me through the recommendation of his chiropractic friend, J.

Schuler, D.C. Both of these fine doctors are from Minot, North Dakota. Dr. Sommers writes: "As a practicing orthodontist, I have seen several patients on referral who have been undergoing chiropractic care for the management of craniomandibular disorders. Some of these patients have undergone mandibular 'adjustments.' Others have received 'activator' [sic] adjustments ... over the lateral aspect of the temporomandibular (TM) joint. I am concerned that such blows may result in sufficient insult to the capsular tissues to elicit inflammation ... compounding or exacerbating TM pain and dysfunction.

"Having had a limited exposure to chiropractic concepts, I am not clear as to the intent of the delivery of what appears to be a traumatic blow to the lateral aspect of the TM joint. Having experience in both dentistry and chiropractic care, I am interested in knowing your thoughts relating to this matter as well."

Dr. Sommers' letter points to a subject that I find most interesting; it's also one of the subjects I'm asked most often about. The subject, in this case, can be stated: "Is there a potential for injury to the TM joint when performing mechanical force, manually assisted adjustments?

The Delivery

First of all, we need to define the type of delivery of the adjustment being used in this situation. Dr. K.M. Bartol developed a model for the categorization of chiropractic treatment procedures used within the chiropractic profession.¹ In this model, which was used in the June 1991 Consensus Conference in Monterey, California, we find that there is a category for the chiropractic procedure that uses the piston device which Dr. Sommers refers to (i.e., an adjustment assisted by some form of mechanical device). This procedural category is titled, Mechanical Force, Manually Assisted.

The Anatomy

Before we can begin to address Dr. Sommers' estimable concern we need to establish some anatomical boundaries. In order to do so we will take the position of the tip of the mechanical piston as being over the lateral aspect of the TM joint. When this position is taken, it is important to ask, "What are all the tissues that are being impacted when the force from the mechanical device is delivered through the piston?

For the sake of brevity, let us leave out all those structures which may lie under the piston (e.g., preauricular lymph nodes, auriculotemporal nerve, portions of the facial nerve, and the superficial temporal artery and vein) and go directly to the joint itself. Here we can see that the lateral and second-most superficial structure is the articular capsule. (The most superficial structure is the TM ligament; not shown.) The fact that the capsule is situated as it is means that it is not designed to withstand "point-blank" insults.

Improperly delivered procedures, no matter what kind, always increase the patient's exposure to potential injury. This is particularly true for the TM joint when a mechanical device is used on it. Of particular concern is a crushing type injury to the lateral portion of the articular capsule as it crosses the lateral pole of the mandibular condyle.

Dr. Sommers' concern for insult injury to the capsular tissues is quite correct. The inflammation and edema he refers to are just two of the physiologic events that occur in capsulitis. Capsulitis has many causes (we saw one last month -- remember?) with one of the more common being trauma. Capsulitis can be a serious condition in-and-of itself and is formally classified as one of the many types of TM disorders. If a TM disorder was already present, capsulitis can compound the difficulty in treatment, and at a minimum it will exacerbate the symptom of pain and the signs of dysfunction.

The Prevention of Injury

Whenever possible, insult injury to the TM joint must be avoided during the deliver of mandibular adjustments. This is particularly true when a piston device is used over the joint. Fortunately, there are many ways in which the doctor can safeguard against crushing type injuries when using a piston device over the TM joint. In order to keep our discussion from getting too long, let's confine the safeguards for when the placement of the piston's tip is to the lateral aspect of the TM joint.

Insult injury to the tissues covering the TM joint can be prevented by using one of the following procedures: 1) Use a very soft tip on the end of the piston, preferably one that has a large flat surface. When using this method, the doctor should set the piston device to the lower amplitude setting. High settings or small tips should not be used when placing the piston in direct contact with the TM joint. 2) When a higher amplitude is needed, the piston should never be placed in direct contact over the TM joint. Instead, the doctor can place his thumb over the joint and then place the piston over the thumbnail. The piston's force is then delivered through the doctor's thumb.

Reference:

1. Bartol KM: A model for the categorization of chiropractic treatment procedures. J Chiro Tech., 3(2):78-80, May 1991.

Proteolytic Enzymes -- Part III

By G. Douglas Andersen, DC, DACBSP, CCN

This article is easily the most difficult and frustrating piece I have written for Dynamic Chiropractic. Although we have seen in the last two installments that proteolytic enzymes when consumed in adequate amounts orally demonstrate powerful nontoxic anti-inflammatory effects, I've stated I feel they are underutilized by DCs; the information presented here will further underscore this fact.

There are four main proteolytic enzymes used by DCs. Two are animal based, and two are vegetable based.

Chymotrypsin

Chymotrypsin is a proteolytic enzyme crystallized from an extract of the pancreas gland of the ox. One USP unit of chymotrypsin is the activity that causes a change in the absorption of 0.0075 of a substrate solution N acetyl L tyrosine ethyl ester under conditions specified in the United States Pharmacopeia Assay.¹

Trypsin

Trypsin is a proteolytic enzyme also crystallized from an extract of the pancreas gland of the ox. One USP unit of trypsin is the activity that causes a change in the absorption of a substrate solution of N benzoyl L arginine ethyl ester hydrochloride of 0.003 per minute, under the assay specified in the United States Pharmacopeia reference guide. 2500 USP units of trypsin may contain no more than 50 USP units of chymotrypsin.¹

Papain

Papain is a purified proteolytic substance derived from carica papaya. One USP unit of papain activity is that which releases an equivalent of 1 mg of tyrosine from a casein substrate solution as described in the United States Pharmacopeia reference guide.¹

Bromelain

There is no USP reference standard for bromelain. It is a proteolytic enzyme extracted from the pineapple. Its highest concentrations are in pineapple stems.^2,3 Bromelain is not a pure substance. In addition to a proteolytic enzyme, it also contains small amounts of acid phosphatase, peroxidase, several protease inhibitors, and a small amount of organically-bound calcium.⁴

In preparing this article, I contacted some of he nation's leading nutritional biochemists and nutritional orthomolecular medical and chiropractic physicians. As I stated last month, the weight and activity measure of proteolytic enzymes is totally convoluted. As an example, some of the units of enzyme measurement I found included Armor units, Roggin units, National Formulary units, caseinolytic units, milligrams, micrograms, gelatin-dissolving units, milk-clotting units, and United States Pharmacopeia, or USP units, which are not equal. It is impossible to convert a USP unit of trypsin chymotrypsin, and papain to a common denominator of enzymatic activity. This is because, if you notice, the United States Pharmacopeia uses different substrate solutions to calculate their USP value for each enzyme. I did, however, find the following conversions. These will be helpful in comparing the same type of proteolytic enzyme from company to company.

Chymotrypsin 1 mg = 1,000 USP units
Trypsin 1 mg - 25,000 USP units
Papain 1 mg = 6,000 USP units

The most common measures for bromelain I found were gelatin-dissolving units and milk-clotting units. When I contacted Dr. Roger Dabba, a biochemist at the United States Pharmacopeia, he stated that there is no conversion of gelatin-dissolving units to milk-clotting units. I recommend that you look to companies who list their activity unit to weight conversion factor on the label. Thus, with some simple mathematics, this will give doctors precise comparison of milligram amounts of products that are measured with the same units of activity, as well as a ballpark idea when you are comparing products based on GDU versus MCU. Note: Although pineapple and papaya do contain proteolytic enzymes, eating these fruits will not reduce inflammation. As we have reviewed, to have a physiological effect, enzymes must be enterically coated. The consumption of pineapple and papaya will help break down any protein that is present in the stomach, and in times of injury the body does require additional protein. Thus, there is nothing wrong with instructing your patients to increase their consumption of these fruits.

In my literature search, I did not find any peer-reviewed reference papers that attempted to compare the activity of equal weights of the various proteolytic enzymes. Again, based on personal experience, I feel that the vegetable-based enzymes (bromelain and papain) that are obtained from quality conscious companies who provide assays are fairly close in their activity. However, when comparing animal-based enzymes, a milligram of chymotrypsin is much more powerful than a milligram of trypsin. It is also much more expensive. Thus, many of the combination formulas will only contain very small amounts of chymotrypsin.

To summarize dosing, there is an extreme variant of units of measurement of proteolytic enzymes and formulas various companies offer. As the amount of enzyme needed to reduce inflammation will vary depending on the nature and extent of the injury as well as the size of the individual, I recommend that you contact the director of biochemistry of the company you are dealing with for dosing advice. This person should be able to instruct you on doses that are effective (remember, label instructions on proteolytic enzymes are extremely conservative mainly due to regulatory agencies).

Below are some hypothetical examples of the dosing amounts myself and nutritional-oriented doctors will use. This is not a cookbook and varies widely, depending on the nature and extent of the injury, as well as the size, age, activity, and general health of the patient. I have included this just to give doctors a general idea of the amounts of micronutrients needed to facilitate rapid healing and to stimulate the patients to make statements like, "That stuff really helps me." This is a hypothetical example of a grade III ankle sprain of a 200 pound male. For severe sprains, I will use separate vegetable and animal-based proteolytic enzyme products.

Grade III: Bromelain 400 mg per enterically-coated tablets (with activity measurement and conversion stated on the label), three tablets four times a day on an empty stomach for the first five days; two tablets four times a day on an empty stomach for the second five days; four tablets in the morning and four at night for the third five days. Chymotrypsin 7.5 mg per enterically-coated tablet with USP activity conversion on the label, three tablets four times a day for the first five days, and two tablets four times a day for the second five days. Additional nutritional support consists of 100 mg B complex, preferably 50 mg with breakfast and 50 mg with dinner; a minimum of 2,000 mg vitamin C with a minimum of 1,000 mg bioflavonoids; one and one-half times the RDA of calcium and magnesium; with three to five times the RDA of zinc and manganese; with 100 percent of the RDA of other minerals for two to three weeks. Patients are also instructed to try to consume at least an extra 40 ounces of fluid per day and to increase their protein intake to 1 gm per pound for three weeks.

Grade II: I will use either the bromelain or chymotrypsin formula mentioned above with a dose consisting of four tablets four times per day for the first five days, with four tablets in the morning and four tablets in the evening (again on an empty stomach) for the next five days. Additional micronutrient support: a 50 mg B-complex with a minimum of 1,500 mg per day of vitamin C; 750 mg per day of bioflavonoids; with 100 percent RDA of all minerals with the exception of zinc and manganese, which are increased two to three times the RDA.

Grade I: I will use lower potency combination formulas that also contain support factors. One enterically-coated tablet will usually contain approximately 100 mg of bromelain, 75 mg of papain, and 50 mg of trypsin, along with vitamin C, bioflavonoids, and zinc. Patients will take four tablets three times per day away from food for three to five days, and this will be backed by a multivitamin, multimineral formula that contains 100 percent of the RDA of all minerals with a B-complex of at least 10-25 mg, and vitamin C of 500 mg.

Should you have any questions concerning specific dosing protocols, feel free to contact me at my office. 

1. United States Pharmacopeia/National Formulary, USP 22/NF 17, 1990. The United States Pharmacopeia Convention, Inc., Rockville, Maryland 20852.
   
   
2. Taussig S, et al: Hiroshima Journal of Medical Science, 24(2): September 1975.
   
   
3. Miller J, et al: The administration of bromelain orally in the treatment of inflammation and edema. Exp. Med. Surg, 22(4): 1964.
   
   
4. Taussig S: The mechanism of the physiological action of bromelain. Medical Hypothesis, Vol 6, 1980.

Management of Herpes Zoster Infection

By R. Vincent Davis, DC, PT, DNBPM

Herpes zoster is an acute vesicular eruption of viral origin which has a propensity for tissue following the course of a sensory nerve pathway and usually occurs unilaterally. Although literature proposes one attack conferring lifelong immunity, this author has seen it occur more than once in the same patient. 
The most common location for the appearance of the vesicles is the thorax and the lumbar or trunk regions.

Pain usually precedes the eruptions for 48 hours or more. The pain may persist and increase in intensity following the disappearance of the vesicular lesions. With the appearance of superficial vesicles, cold quartz ultraviolet irradiation is recommended providing that the actinic light is not exposed to the eyes and only after performing a minimal erythematous dose (MED) test on some distant portion of the body not involved in the eruption. Two to three MEDs are recommended following appropriate procedures relative to distance and angle of body surface (cosine and inverse square laws). CQ-UV exposure is limited to once every other day and is only of value when the eruption is superficially exposed and thereby exposes the varicella virus to the direct CQ-UV rays.

To reduce or abolish the intensity of the pain, interferential current therapy is recommended using the Davis procedure (sequential triple dose intensity). To properly administer this current therapy, the electrodes must be placed carefully to encompass the neural pathway in an elliptical geometric configuration when treating the lumbar, abdominal or thoracic region. Upon presenting themselves for care the patient usually describes an exquisitely painful experience which otherwise may persist beyond the disappearance of the vesicular lesions. Scarring has not been a problem in the experience of this author, possibly due to the eradication of bacterial infection of the vesicles during CQ-UV irradiation.

Since herpes zoster infection of supraorbital or ocular distribution may lead to blindness, it may be prudent clinical judgment to secure an ophthalmological consult in the management of this form of herpes zoster, especially when present in the elderly. Otherwise, this author has had favorable experiences with the regimen outlined in this writing. Dimerization of the thymine base of the RNA/DNA of the involved pathogen by CQ-UV is an effective method of control and eradication.

References

Anderson, W.A.D. Pathology -- 3rd ed. Mosby Publishers

Davis, R.V. Therapeutic Modalities for the Clinical Health Sciences, 1st ed., 1983. Copyright -- Library of Congress TXU-389-661.

Griffin, J.E.; Karselis, T.C. Physical Agents for Physical Therapists, 2nd ed. Springfield: Charles C. Thomas 1982.

Krupp & Chatton. Current Medical Diagnosis & Treatment. Lang Publishers 1983.

Krusen; Kottke; Elwood. Handbook of Physical Medicine & Rehabilitation, 2nd ed. Philadelphia: W.B. Saunders company 1971.

Schriber, W.A. A Manual of Electrotherapy, 4th ed. Philadelphia: Lea & Feibiger 1975.

Proteolytic Enzymes -- Part I

By G. Douglas Andersen, DC, DACBSP, CCN

Proteolytic enzymes have been an important part of the chiropractor's arsenal for reducing inflammation for many years. Today, we will review the major types of proteolytic enzymes used as well as an explanation of weights, measures, and dosages.

There are four major types of proteolytic enzymes: trypsin, chymotrypsin, papain, and bromelain. Note: There are other substances available to the chiropractor that have anti-inflammatory properties, such as ascorbic acid, bioflavonoids, herbs, and certain fatty acids. This discussion will be limited to enzymes.

Although chiropractors have been getting good results from proteolytic enzymes for many years, there are still a surprising amount of health care professionals, especially non-chiropractors, who question their ability to produce the desired effect. Their argument is that since enzymes are proteins, they are digested like any other protein and, thus, have no effect other than protein in the diet. This argument is logical. This argument is also wrong.

My literature review yielded studies beginning with Brendel, et al., in 1956, who demonstrated that trypsin had an anti-inflammatory action when administered buccally.¹ In 1957 Martin, et al.,² showed that when trypsin, chymotrypsin, and papain were injected into the small intestines they were not denatured or digested but, in fact, absorbed with enough of the molecules intact to exert a marked systemic anti-inflammatory effect. They theorized that enterically coating these substances would enable them to be administered orally. Ambrus, et al.,³ showed that oral administration of enterically-coated trypsin and chymotrypsin resulted in increased specific blood activity changes that could occur only if these enzymes were absorbed intact. Vakians⁴ demonstrated that enterically-coated chymotrypsin was absorbed orally and remained functional in the blood stream for four hours after administration. Miller and Opher⁵showed in 1964 that enterically-coated bromelain given orally caused an increase in blood serum proteolytic activity. Innerfield and Wernick⁶ showed in 1961 that oral administration of papain produced a decreased clotting time.

There are so many examples in the literature of the unmistakable physiological and biochemical action of orally-administered, enterically-coated proteolytic enzymes that the classical theory of a protein-impermeable intestinal barrier is simply incorrect.⁷ Although this author has used proteolytic enzymes for many years, I was overwhelmed by the number of studies demonstrating their powerful anti-inflammatory effect.

The precise mechanism of absorption of proteolytic enzymes across the gastrointestinal barrier is not yet fully understood. Those interested in this topic should read Cichoke's review of the molecular absorption of protein molecules.⁸ What is clearly understood is that proteolytic enzymes are absorbed and thus beneficial for many inflammatory conditions, sports related or otherwise.

In part II we will address why proteolytic enzymes are not used more by chiropractors. Included in the discussion will be the very confusing weight and measure issue, label instruction, conversion factors, and tips on how to dose for maximum effect.

References 

1. Brendel R, Beiler JM, Martin GJ: American Journal of Pharmacology, 128:172, 1956.
   
   
2. Martin GJ, Brendel R, Beiler JM: Uptake of labeled chymotrypsin across the GI. American Journal of Pharmacology, 129:194-197, 1957.
   
   
3. Ambrus JC, Lassman HB, De Marchi JJ: Absorption of exogenous and endogenous proteolytic enzymes. Clinical Pharmacology and Therapeutics, 8(3):362-367, 1967.
   
   
4. Vakians A: Further studies on the absorption of chymotrypsin. Clinical Pharmacology and Therapeutics, 5(6):712-715, 1964.
   
   
5. Miller JM, Opher AW: The increased proteolytic activity of human blood serum after oral administration of bromelain. Exp. Med. Surg, 22:277-280, 1964.
   
   
6. Innerfield I, Wernick T: Plasma anti-thrombin alterations following oral papain. Proc. Soc. Ext. Biol. Med, (107):505-506, July 1961.
   
   
7. Miller JM: Absorption of proteolytic enzymes from the gastrointestinal tract. Clinical Medicine, pp 35-40, October 1968.
   
   
8. Cichoke AJ: Enteral absorption of intact protein molecules. Journal of the Council on Nutrition of the American Chiropractic Association, 14(2):19, April 1991.

Ayurveda: The Next Frontier in Healing -- Part II

By Abbas Qutab, MD, DC, FIACA

two-part series explaining ayurveda. Part I appeared in the September 1, 1991 issue of "DC."

Dr.

Qutab is a senior research assistant professor and senior research fellow in neurosciences at NYCC. He is a postgraduate professor of acupuncture with the International Academy of Clinical Acupuncture and co-founder and president of the American Academy of Ayurvedic Medicine.

Dr. Qutab describes ayurveda as the world's oldest system of natural medicine, with its heritage in ancient India. The word ayurveda comes from two Sanskrit words, ayur (life), and veda (sacred knowledge or science).

Ayurvedic medicine describes health as perfect balance. In this context, imbalance is seen as the basic cause of all disease. Ayurvedic medicine therefore strives to restore balance through eliminating imbalance from the most fundamental level of life -- pure consciousness. It can then focus on re-establishing the natural interconnectedness of the four fundamental approaches in ayurvedic science: mind, body, behavior, and environment. Health, in this context, is redefined as perfect balance and wholeness of life.

The basis of ayurveda lies in prevention of disease through strengthening the body's immune system and innate homeostatic self-repair mechanisms so that an individual naturally resists disease. Treatment of any particular imbalance generally includes a combination of therapies such as meditation, massage, yoga, aromas, colors, diet, herbal preparations, etc. These are natural approaches which work by enlivening nature's own inner intelligence within the individual for greater health and well-being, without harmful side effects. While medicine has made great advances in the treatment of disease, it is commonly recognized that a major gap still exists in treating disease at its source rather then merely pacifying symptoms.

All treatments of ayurvedic medicine are based upon one's individual body type or physiological constitution. Constitutional typing is based on three doshas or governing properties in the body. These doshas are vata, pitta, and kapha. They are the controllers of the physiology. When these three are in balance, health is optimal. The objective in treatment, therefore, is to establish balance among these three fundamental principles.

Vata is the property of movement and governs bodily functions concerning movement. Some vata indications include a small body frame, being a light sleeper, and having an aversion to cold weather. The proper balance of vata creates more energy, alertness, quickness, and creativity. Imbalance in vata can cause loss of sleep, high blood pressure, loss of weight, and constipation. Balance can be created through steadying, settling influences (food, spices, relationships, circumstances). The vata season is November-March or whenever the weather is cold and dry.

Pitta governs bodily functions concerned with heat, metabolism, and energy production. Pitta characteristics include thinning hair; sharp, aggressive intellect; a medium body frame and weight. When pitta is in balance, we enjoy good digestion and contentment. Too much pitta may cause loss of strength, skin problems, anger, and heart problems. Seek to cool and soothe body and emotions for pitta imbalance. The pitta season is July-September or whenever the weather is hot.

Kapha governs bodily functions concerned with physical structure and fluid balance. Some kapha indications include a pale, white complexion; an aversion to damp, cool weather; a large body frame; and good long-term memory. When kapha is balanced, we have strength, stamina, good immunity, stability, and good temperament. Imbalance in kapha can cause dullness, depression, joint problems, excess weight, high cholesterol, and coldness. Warm and energize the system for kapha imbalance. The kapha season is April-June or whenever the weather is cold and wet.

Each individual has a specific predominance or balance of one or more of these doshas which is natural and correct. This is what is referred to as one's constitution or body type.

If one of the doshas become aggravated, an imbalance results. This reduces agni -- the inner biological fire -- which is responsible for the proper digestion and absorption of foods. If a person's agni is thrown off, undigested food, or ama begins to accumulate in the intestines and produces toxins. These toxins then circulate through the body and accumulate at points of weakness. Then the condition of imbalance and toxicity begins to appear as the symptoms of disease.

The root cause of most diseases is toxicity and stagnation caused by low Agni, in turn caused by imbalance of the humors. This is true of infectious diseases, as well as of chronic and degenerative illnesses. Only when our immune system is weak, because of toxicity and dosha imbalance, will viruses and bacteria have an effect on us.

To determine one's dosha, or constitutional type, the ayurvedic physician conducts a detailed examination of factors such as body size, shape, structure, skin, hair distribution and color, pulse, tastes, habits, preferences, and many additional parameters.

Through pulse diagnosis, the ayurvedic physician analyzes the state of balance between the doshas to determine the extent to which it may be out of balance. Based on these diagnostic findings, the physician prescribes specific treatments to restore balance to the whole system. For example, if you have excessive kapha dosha, you may find it impossible to lost weight even when eating very little. The ayurvedic physician will first diagnose your body type and specific imbalances, then prescribe a special program to reduce kapha dosha. The program can include a specific diet, herbal treatments, daily and seasonal routines, rejuvenation therapy, and yoga exercise.

Next to stress reduction, diet is perhaps one of the most important changes one can make on the path to better health. Regularly eating the wrong types of food overloads the system and causes imbalance. Still, the wrong type of food for one person may be the right type of food for another. General guidelines like cutting back on fatty, high cholesterol foods, or favoring fresh high fiber foods are useful, but don't account for individual differences and needs. Different body types require different types of food. This knowledge has been part of ayurvedic medicine for thousands of years.

The personalized home health program prescribed by an ayurvedic physician is an essential component of ayurvedic medicine. In treating the disease at its source, while addressing its symptoms, a client is able to assume responsibility for his own personal well-being. In this way, ayurvedic is a path to promoting perfect health and longevity, creating a disease-free society.

Presently, courses in ayurvedic medicine are being offered by the American Academy of Ayurvedic Medicine in conjunction with the International Academy of Clinical Acupuncture. License renewal through New York Chiropractic College has been applied for all states.

Ayurveda, Part I

By John Amaro, LAc, DC, Dipl. Ac.(NCCAOM), Dipl.Med.Ac.(IAMA) and Abbas Qutab, MD, DC, FIACA

Introduction

Those of you who were around in the early days of the '70s are vitally aware of a phenomena which occurred, namely the adoption of a new healing art which spread rapidly throughout the entire North American continent.

I refer, of course, to acupuncture.

Today, with acupuncture being licensed in over half of the U.S., its practitioners being considered primary health care providers, and, in some states, physicians, acupuncture has earned a respected place alongside the conventional healing arts.

Given the fact there are more acupuncture colleges in California than there are chiropractic colleges in the world, is cause for alarm for a large proportion of our profession, especially for those DCs whose state law does not permit the use of acupuncture.

But as significant as acupuncture's growing popularity in the '70s, another healing art (which holds as much promise and was also born out of a foreign land, dating back thousands of years) looms on the horizon. It has already received very favorable press, been endorsed by the medical establishment, and is seeing thousands of patients heading for the doors of its practitioners. The science is ayurveda.

No, I don't feel it will replace acupuncture, but ayurveda holds a great deal of promise as being "the next frontier."

My very good friend and colleague, Abbas Qutab, M.D., D.C., F.I.A.C.A., has experience in ayurveda spanning nearly a quarter of a century. He has considerable expertise in ayurveda and has greatly contributed to its development as past house physician and surgeon for the district hospital in Bahawalnager, Pakistan. He is currently senior research assistant professor of New York Chiropractic College, as well as senior research fellow in neurosciences. He is also a postgraduate professor of acupuncture with the International Academy of Clinical Acupuncture.

I've asked Dr. Qutab to explain ayurveda in this two part series.

Ayurveda -- The Next Frontier in Healing, Part I

Ayurveda is the world's oldest scientific system of natural medicine, having its heritage in ancient India. It is formally recognized by the World Health Organization and is known to be a complete health care system, which emphasizes prevention of disease, as well as promotion of health and longevity.

The word ayurveda comes from two words in Sanskrit: ayur and veda. Ayur means life or life span, and veda means sacred knowledge or science. Ayurveda is therefore translated as "the science of life," which emphasizes its orientation toward prevention.

Ayurveda has several therapeutic and preventative approaches, which are based on the comprehensive understanding provided by the classical texts of the pathogenesis, symptomatology diagnosis, treatment, and prevention of disease.

Ayurveda holds that the primary force in the etiology of disease is imbalance resulting from disruption of homeostasis or immune mechanics. Ayurveda does not separate psyche from soma. It places equal importance on mental, emotional, and behavioral factors, which are seen as critical in the development of imbalances, hence disease.

Therapeutic modalities of ayurveda include: diet according to each person's individual psychophysiological constitution, herbs, neuromuscular and neurorespiratory integration programs, massage of specific points in the body, color therapy, and aromatherapy.

Ayurveda has captured the attention of physicians and scientists in the U.S. and all parts of the world, including the Soviet Union, where several thousand physicians have already been trained under the auspices of the USSR Center for Preventative Medicine, a division of the USSR Ministry of Health.

In the United States, ayurveda has been well received by the American Medical Association (AMA). Its recognition within allopathy is evident by a recent article on ayurveda published in the May 22, 1991 Journal of the American Medical Association (JAMA). Presently, courses in ayurveda are approved by the American College of Preventative Medicine and are accredited by the Accreditation Council for Continuing Medical Education, where medical doctors receive C.M.E. Category I credits for their license renewal.

Ayurveda has detailed scientific literature consisting of several classical medical texts including Treaties on Medical Ethics, and Physician-Patient Relationship. In addition, the ayurvedic pharmacopeia is vast, including thousands of plants and plant products, many of which are known therapeutic agents such as digitalis and rauwolfia.

Recently, The National Cancer institute funded 11 separate studies on ayurvedic herbal preparations, as agents to be investigated for their possible role in the prevention and treatment of cancer.

Ayurveda represents a newly found knowledge for the physician, which answers many questions raised from the increasing interest in fields such as psychoneuroimmunology and non-pharmacological approaches to disease.

Ayurveda can be perfectly blended in the scope of chiropractic, because, like chiropractic, ayurveda offers the knowledge to end the self-perpetuating tradition of sickness in the world. All diagnostic, therapeutic, or preventative procedures applied in ayurveda are completely non-invasive and natural.

In the ayurvedic framework, the body is viewed not merely as a sophisticated machine, but a physical expression on the self-interacting dynamics of an underlying field of intelligence. This concept is also the basis of chiropractic innate intelligence. These views by ayurvedic physicians and chiropractors are completely in accord with the recent unified field scientific theories of quantum physics. These theories describe the most fundamental level of nature as an underlying abstract field, which, through its own self-interacting dynamics, projects itself as matter. In fact, ayurveda identifies pure consciousness, the simplest form of human awareness as the unified field, and places it as the basis of the physiology rather than as an epiphenomenon of the nervous system. This view has also been articulated by the founders of quantum mechanics who felt that "mind stuff" underlies the physical universe and projects itself as matter.

In a quantum interpretation, a patient's thoughts, emotions, and memories are the fluctuations that give rise to cellular processes. From the chiropractic viewpoint, we tend to consider physiological and pathological processes as a neural phenomena. However, this concept cannot be unequivocally accepted, since the clinical results achieved in chiropractic do not totally fit into the known patterns of neural pathways. D.D. Palmer, the genius who founded the profession, seemed to clearly understand this when he wrote, "A subluxation does not restrain or liberate vital energy. Vital energy is expressed in functional activity. A subluxation may impinge against nerves; the transmitting channel may increase or decrease the momentum of impulses, not energy. Vital energy is not transmitted through the nervous system or any other, it is expressed in functional acts."

It appears the concepts of chiropractic conceived by D.D. Palmer were ahead of his time, and he clearly understood and wrote concepts which many within the profession are still struggling to understand. These concepts, however, were understood by the ayurvedic physicians 5,000 years ago and are being verified by the modern-day scientists and physicists.

The American Academy of Ayurvedic Medicine (AAAM) and The International Academy of Clinical Acupuncture are dedicated to the promotion of Ayurvedic Oriental Healing Arts, and also the concepts of D.D. Palmer, on which chiropractic was conceived, to all primary health care providers such as chiropractors, medical doctors, naturopaths, acupuncturists, etc.

Presently, courses in ayurveda are being offered by the AAAM, which are compatible with the international chiropractic licensing laws. License renewal through New York Chiropractic College has been applied for in all states.

How Dangerous Is Cervical Adjusting?

By John Gantner, DC, DABCO

Two years ago I attended a lecture by a medical doctor discussing ergonomics. After about an hour of pertinent material he drifted into the subject of treatment for back injuries. I noted with pleasure that he actually said that a chiropractor can really help a lot of back-injured claimants. 
He got my attention when he said, "But don't let the chiropractor work on your neck; it can cause a stroke." Wow!

At the close of his discussion I asked where he got the opinion that chiropractic adjustments to the neck can be so dangerous. He cited a study I did not know. I disagreed with him, indicating that I know hundreds of chiropractors who have treated thousands of patients over the past 30 years and none of them have ever had a lawsuit for anything. If there was such a problem with chiropractic treatment, it would be quite obvious to the chiropractors. That at least calmed the audience, but not me. Was I missing something?

I had been aware of literature discussing the problem and appreciated that such an accident could indeed occur. However, I knew it could not be frequent. Of the hundreds of DCs I have known over the past 31 years, none have had such an experience. Given this, I assumed that such an accident might happen if someone used unreasonable force or a poor choice of technique in adjusting the cervical spine. Nothing I have learned about the problem has caused me to change that opinion. Regardless, I think every DC should be interested in what follows:

Numerous articles in the chiropractic literature dealing with vascular injury resulting from chiropractic manipulation have put the fear of God into many of us. The truth is that there are a very few cases. In 1980 Jaskoviak¹ reported on 29 published reports involving 46 cases of complications arising from manipulation of the cervical spine, between 1947 and 1987, a span of 40 years. Terrett2 in 1990, discusses 113 documented cases of vertebrobasilar accidents following spinal manipulative therapy, from 1934 to 1987, a period of 53 years. Judging by the references to his article, it appears that Terrett has done literature searches in many countries, if not the entire world. Of the cases he discovered, 66 were chiropractic, 18 medical, 9 osteopathic, and 2 physiotherapist experiences. A remaining 13 cases were divided between "wife," "self," and "unknown."

Let's look at these statistics a bit harder. There were 66 chiropractic cases in the 53 years from 1934 to 1987. That's just a little over one incident per year. Let's compensate for the increase in our numbers over the past 25 years and take a position, for argument's sake, that 4 such accidents occur per year, instead of a little over one case per year that literature reveals. There are currently some 55,000 chiropractors in practice. Surveys state that the average DC sees 100 patients per week. That works out to some 5,500,000 adjustments per week given by chiropractors. That number of adjustments multiplied by 52 weeks in a year comes out to 286 million adjustments delivered per year. Four cases out of 286 million adjustments is not what we would call high exposure. That's one incident in 71,500,000 adjustments. The average chiropractor seeing 100 patient visits per week for 40 years will give a total of 208,000 adjustments in his entire career! It would take 340, 40-year-careers in chiropractic for one such incident to occur. If there are 4 cases out of 286 million adjustments, one would have to conclude the exposure is slim indeed.

Let's remember also that during that same 53-year period, 29 patients had the same experience at the hands of MDs, osteopaths, and physiotherapists.

Regardless, the problem exists and deserves attention. If the patient complains of vertigo, dizziness or light-headedness, determine exactly when such symptoms come on. Did they arise insidiously or after injury? Are they only present or brought on by certain head positions? Are they worsening or improving? If the patients state that they get dizzy each time they turn their head to the left, do not turn their head to the left during examination or treatment. If they get dizzy on lying supine, do not examine or give adjustments in the supine position.

Terrett² lists several signs and symptoms of vertebrobasilar ischemia:

Dizziness (vertigo, light-headedness)

Drop attacks

Diplopia

Dysarthria

Dysphagia

Ataxia of gait

Nausea with possible vomiting

Nystagmus and/or numbness

Seeing these symptoms should alert one to the potential of brainstem ischemia. Additional care must be taken with these patients. While some examination procedures may inadvertently produce dizziness, one should not purposely set out to reproduce the symptom simply to be satisfied of its presence. Take the patient's word for the time being at least.

The presence of any of these symptoms does not preclude chiropractic adjustments to the cervical spine. However, they should alert us to the possibility of vascular involvement. Accordingly, we should proceed with great caution simply because of the symptomatology.

Chiropractic clinical experience is that most dizziness, vertigo, or light-headedness responds to reasonable, low-force chiropractic measures. This must mean that such symptoms more often come about because of chiropractic subluxations with no vascular component. These subluxations can bring about dysfunction of the cervical mechanoreceptors (joint capsule stretch receptors) secondary to cervical spinal joint dysfunction.³ This is not an uncommon finding.

References 

1. Jaskoviak, P. "Complications arising from manipulation of the cervical spine." JMPT December 1980; 3(4).
   
   
2. Terrett, A. "It is more important to know when not to adjust." Chiropractic Technic February 1990; 2(1).
   
   
3. Gerhart, T. "Role of cervical joint dysfunction in balance and coordination." Success Express 1984; Spring.
   
   For additional information on treating these patients, please contact the author at 1406 South Main Street, Medina, New York 14103. I would appreciate your comments and/or a brief discussion of your personal/clinical experience on this subjec

Fibromyalgia Syndrome or Myofascial Pain Syndrome?

By Donald Murphy, DC, DACAN

There appears to be much confusion among many physicians of all types regarding the differential diagnosis of myofascial pain syndromes (MPS) and fibromyalgia syndrome (FS). There is also a great deal of misdiagnosis occurring, especially a tendency to use FS as a "wastebasket diagnosis." Anyone with widespread and/or poorly localized musculoskeletel pain without signs of overt pathology are just lumped into the general category of FS.^1,2 This is very unfortunate, and also very avoidable.

Each of these syndromes has clinical features which distinguishes it from the other. A patient with FS will experience widespread pain in all four body quadrants for at least three months duration.^1,3They will also have tender points (TePs) in at least eleven of the following eighteen locations: two cm below the lateral epicondyle at the elbow; the occiput; intertransverse ligaments of C5-C7; midpoint of the upper trapezius; medial aspect of the supraspinatus; pectoralis major at the level of the second rib two cm from the sternum; the upper gluteal area; the greater trochanter; and the medial condyle of the femur two cm above the joint line (these, of course, are bilateral locations).^2,3

Palpation of the TePs will cause local tenderness but no referred pain, and the patient's muscles in general will feel boggy or "mushy." Approximately 75 percent experience sleep disturbance which can range from insomnia to wakefulness to non-restorative sleep.^1,2,3 The discomfort will be aggravated by extremes in temperature as well as humidity. The patient will often experience chronic fatigue, tiring easily, and will often have poor aerobic fitness. FS patients often suffer from irritable bowel syndrome, morning stiffness, urinary urgency, anxiety, parasthesias, dysmenorrhea, and Raynaud's phenomenon.

In patients with MPS, the pain will more likely be localized to one region of the body and can be acute or chronic, the chronic cases frequently having active and latent stages, as opposed to the mostly constant pain for a prolonged period as seen in FS. MPS features trigger points (TrPs), which are primarily found in myofascial tissues as opposed to the TePs of FS, some of which are found at non-myofascial sites.⁴ TrPs, like TePs, will be locally tender but also characteristically produce referred pain and/or automatic symptoms upon palpation. They will be located along a palpable taut band of skeletal muscle.

This taut band is easily distinguished from the boggy feel of the FS patient by an experienced palpator. The MPS patient may experience some difficulty sleeping, and the pain can awaken them at night, but sleep disturbance is not a typical finding in MPS. Cold will tend to aggravate a MPS, but heat and humidity will not, in fact, these may be soothing to the patient. Although weakness and fatigueability of the muscle or muscles involved in the MPS is very commonly seen, generalized chronic fatigue is not characteristic, and MPS can affect the aerobically fit or unfit. Irritable bowel syndrome and dysmenorrhea are not typical of MPS in general, unless they involve specific areas in the rectus or oblique abdominis muscles. Anxiety is frequently seen in MPS,⁵ as is parasthesias. Raynaud's phenomenon is not typical.

FS must also be differentially diagnosed from, among other disorders, limbic system dysfunction^6,7 which features painful and tender muscles in the shoulder-neck, lower back, and pelvic floor. These patients may also experience dysmenorrhea and urinary urgency.

Understanding the differential diagnosis of these disorders is essential for the chiropractic physician, for most medical physicians are not trained to diagnose or treat them, even though most of the patients suffering from them are currently attending medical offices. The well-trained DCs, because of their superior palpatory skills and understanding of the integrated workings of the body, play an extremely important role in the evaluation and care of any individual suffering from pain in the locomotor system. It is our job to educate the scientific community and the public in this regard, to end some of the needless suffering that goes on, and take our rightful place as experts in locomotor system function/dysfunction and their relationship to health. 

1. Wolfe F. Diagnosis of fibromyalgia. J Musculoskel Med 1990: 7 (7):53-69.
   
   
2. Bennett RM. Myofascial pain syndromes and fibromyalgia syndrome: a comparative analysis. Man Med 1991; 6(1):34-45.
   
   
3. Duarte M. Primary fibromyalgia syndrome and myofascial pain syndrome: clinical features and criteria for diagnosis. Chiro Tech 1989; 1(3):97-100.
   
   
4. Simons DG. Muscle pain syndromes. Man Med 1991; 6(1):3-23.
   
   
5. Lowe JC. The purpose and practice of myofascial therapy. (Audio Cassette Album). 1989 McDowell, Houston.
   
   
6. Janda V Manipulation, Pain, and Locomotor System. Conference. New York Chiropractic College, May, 1990.
   
   
7. Murphy DM. The neglected muscular system: its role in the pathogenesis of the subluxation complex. J Chiro 1990:26(12):36-40.

Hydration -- Part III

By G. Douglas Andersen, DC, DACBSP, CCN

This month we will conclude our series on hydration with a discussion of the optimal amounts of carbohydrates and electrolytes that should be in fluid-replacement or carbohydrate electrolyte drinks. 
It is critical not to confuse a carbohydrate-loading beverage with a fluid-replacement beverage. Carbohydrate-loaded drinks have over twice as many carbohydrates than do fluid-replacement drinks. They are designed to increase the body's glycogen stores in the days preceding competition and should not be consumed just prior to or during an event for the following reasons: 

1. Ingesting solutions with high concentrations of carbohydrates can lead to osmotic imbalances in the stomach which causes the body to (a) increase fluid secretion for digestion, and (b) inhibit gastric emptying rate.¹ When this occurs, skeletal muscles do not receive the amount of fluid they require to function optimally (which is increased in times of exercise).
   
   
2. High carbohydrate beverages also cause a sharp increase in blood insulin levels. During exercise, skeletal muscles require smaller amounts of insulin than in the resting state. Therefore, this combination of increased quantity of insulin with a decreased requirement for insulin results in a powerful clearing of blood sugar leading to hypoglycemia.²Therefore, the consumption of carbohydrate-loading drinks should be terminated no later than four hours prior to competition.
   
   
3. When athletes consume beverages with large amounts of sugar right before or during competition, they will often have gastrointestinal complaints that may consist of nausea, vomiting, heartburn or a feeling of being "bloated."³ Beverages with high carbohydrate concentration will cause osmotic imbalances in the intestines and are contraindicated for exercising athletes. This is another example of something that chiropractors have known years before other health care providers.

There continues to be debate over the optimal ingredients for fluid-replacement drinks. After many hours of research coupled with my experience with professional beach volleyball players, marathon runners, and triathletes, the following is my personal opinion of ingredients for fluid-replacement drinks: 

1. Carbohydrates -- a good fluid-replacement drink should contain 6-7 percent carbohydrates which means approximately 14-17 gm. per 8 ounces or 55-70 calories per 8 ounces. I found one study where a 6 percent carbohydrate electrolyte solution was absorbed faster than distilled water.4 Glucose polymers, fructose, and glucose are the types of carbohydrate a good sports beverage should include. The ratio should be 4:2:1, glucose polymer to fructose to glucose. I know of no brand that gives the carbohydrate ratio breakdown on the label, but as interest in fluid-replacement drinks continues, I feel that you will see these ratios appear in the near future. Furthermore, a phone call to the manufacturer should result in your receiving the carbohydrate ratio.
   
   
2. Electrolytes/Minerals -- It is my opinion that electrolyte contents in milligrams per 8 ounces of fluid-replacement drinks should be sodium 35-120 mg., potassium 30-100 mg., chloride 35-120 mg., chromium 15-50 mcg., and magnesium 50-100 mg. The above electrolyte/mineral recommendations seemingly wide range is due to a lack of consensus upon my review of the literature. What I did find was that the above are the most important electrolytes/minerals to be included in sports drinks. I expect that continuing research over the next few years should reduce these ranges. Note: A good sports drink should also contain an antioxidant. I recommend 25 to 100 mg. of vitamin C per 8 fluid ounces.

There are also substances that should not be in a sports drink, such as sucrose, aspartame, artificial colors, artificial flavors, preservatives, protein, and fat. Various companies may have vitamins and minerals that were not mentioned in this article. As long as the amounts are not too high, your athletes should not get in trouble with the addition of other nutrients, assuming the substances mentioned in this article are included in the correct ranges.

In conclusion, the research clearly demonstrates that fluid-replacement drinks will optimize the performance of your patient athletes by stimulating additional amounts of fluid intake, thus, leading to enhanced endurance during activity, and shortening recovery time following activity. Fluid-replacement drinks can be safely consumed before, during, and after competition. Science hasn't replaced water, it has just improved it a little bit.

References 

1. Murray, R. "The effects of consuming carbohydrate-electrolyte beverages on gastric emptying and fluid absorption during and following exercise." Sports Medicine 1987; 4:322-351.
   
   
2. Evans, W.J.; Hughes, V.A. "Dietary carbohydrate and exercise endurance." American Journal of Clinical Nutrition May 1985; 41:1146-1154.
   
   
3. Davis, J.M.; Burgess, W.A., et al. "Effects of ingesting six percent and 12 percent glucose electrolyte beverages during prolonged intermittent cycling in the heat." European Journal of Applied Physiology 1988; 57:563-569.
   
   
4. Davis, J.M.; Lamb, D.R.; Burgess, W.A., et al. "Accumulation of deuterium oxide D2O in body fluids following ingestion of D2O-labeled beverages." Journal of Applied Physiology 1987.

Hydration -- Part II

By G. Douglas Andersen, DC, DACBSP, CCN

In this issue we will explore fluid-replacement drinks, also known as carbohydrate electrolyte drinks. They should not be confused with ergogenic-enhancement drinks, phosphate-buffering drinks, and carbohydrate-loading drinks, which will be discussed in future articles.

Fluid-replacement drinks are designed for three primary functions: hydration/rehydration; electrolyte/mineral replacement; and blood glucose/energy enhancements.

As we discussed last month, the athlete who is low on fluid has a distinct competitive disadvantage. Furthermore, the exercising athlete is only able to absorb one ounce of fluid every three or four minutes, while fluid losses can exceed one ounce per minute. Therefore, we must encourage our patient athletes to consume extra amounts of fluid before they become thirsty. Studies have shown that athletes will consume greater amounts of fluid if it tastes good. Fluid-replacement drinks contain various types of sugars and minerals that increase palatability.^1,2,3 A fluid-replacement drink with good balance will increase the absorption of carbohydrates, electrolytes, and water.⁴In my literature review, I came across exercise-induced hypotonic hyponatremias in athletes who are exercising vigorously and consuming only plain water or non-electrolyte solutions.⁵Consumption of a good fluid-replacement drink can avoid this unfortunate circumstance.

There are many reasons for the inclusion of minerals and electrolytes in fluid-replacement drinks: 

1. Activity-induced dehydration, whether frank or marginal, can result in electrolyte imbalances coupled with fluid shortages.⁶
   
   
2. The body's ability to absorb water is enhanced by the active transport of glucose and sodium in the small intestines, and by passive absorption of potassium and other solutes which displace and/or bind with osmotically active particles in the small intestine.⁷
   
   
3. Optimal glucose absorption can only occur when sodium is present in sufficient amounts intraluminally.⁸
   
   
4. Magnesium activates over 300 enzymes in the body. Among these are reactions involving the production of energy (ATP is bound to magnesium). Recent studies have shown that vigorous exercise results in magnesium depletion. Noted sports nutritionist Dr. Brian Leibovitz states that "Some evidence exists for a redistribution of magnesium (from blood to the muscle) during exercise, which could contribute to exercise-induced reduction in blood magnesium levels."⁹ Coupled with sweat losses, often times this can result in significant magnesium deficiency. Preliminary studies are showing that marginal magnesium deficiency can result in skeletal muscle mineral imbalances which, in turn, can decrease performance.
   
   
5. Chromium is a trace mineral that is currently receiving a great deal of attention. It enhances insulin's ability to deliver nutrients into the cells by increasing insulin sensitivity. Athletes require additional amounts of this vital trace mineral. Research has shown that athletes' urinary chromium levels are increased fourfold following continuous aerobic training of 45 minutes or longer.¹⁰
   
   
6. Chloride is an often overlooked electrolyte in exercise physiology. I came upon one study that showed that fluid-replacement drinks may slightly inhibit the body's ability to absorb chloride.¹¹ Thus, to maintain electrolyte hemostasis, a good fluid-replacement drink should contain chloride.

One of the most studied aspects of fluid-replacement drinks is carbohydrate source and amount. For many years, sports experts felt that plain water was the optimal sports drink, and the advent of the original sports drink, that contained sucrose and glucose only, did not change a lot of minds. Today you will find various combinations of glucose, fructose, sucrose, and maltodextrins in most sports drinks. The goals of carbohydrate inclusion in a sports drink are to contain the maximum level of carbohydrates that will: 

1. Not inhibit the rate of gastric emptying.
   
   
2. Provide a maximal amount of energy without causing a rebound hypoglycemia.
   
   
3. Not retard the absorption of water, carbohydrate and electrolytes in the small intestine.

We will now briefly review carbohydrates as they pertain to hydration.

Sucrose:

It is this author's opinion that sucrose or simple sugar is not the optimal source of carbohydrates for a sports drink. As most of you know, it causes a sharp rise in the blood plasma levels of insulin, which in turn leads to a rapid decrease in blood glucose levels. When intestinal fluid uptake of a 3.6 percent glucose polymer, 1.8 percent fructose, 1.6 percent sucrose solution (7 percent total) was compared to equal amounts of plain water, net fluid absorption from the small intestine was significantly reduced in those subjects who consumed the 7 percent carbohydrate solution.¹² In another study, a 7 percent solution consisting of 5 percent glucose polymer and 2 percent fructose emptied the stomach and was absorbed in the small intestine at rates very close to that of plain water.¹³ This is another example of the powerful affect even small amounts of sucrose can have on human physiology.

The obvious question is, what if sucrose is the only available source of carbohydrates for the athlete? Is sugar and water better than plain water? The answer depends on what the doctor needs to accomplish. When compared to an artificially-sweetened noncarbohydrate drink, the cycling athletes who consumed a dilute sucrose solution had increased endurance during their trial and a faster sprint performance at the end of the test.¹⁴ Thus, a dilute sucrose drink is better than plain water for energy enhancement. However, the athlete who is dehydrated or dehydrating should choose plain water over a water-sucrose combination.

Glucose

The stimulating effect of glucose on water absorption in the small intestine is a key mechanism in the advent of fluid-replacement drinks.¹⁵ Glucose also increases passive and active sodium transport in the small intestines.¹⁶ This is accomplished because free glucose can be used to generate energy in the gastrointestinal mucosal cells directly.¹⁷

Fructose

Fructose has many interesting effects in applications for fluid-replacement drinks. Fructose solutions leave the stomach faster than equal molar glucose solutions,¹⁸ but are absorbed more slowly than glucose from the small intestine.¹⁹ Fructose stimulates potassium absorption in the small intestine.²⁰ Fructose also increases water absorption in the small intestine, but not as much as glucose.²¹ It is non-insulogenic and spares glycogen.²² Finally, fructose is sweeter than glucose, glucose polymers or sucrose, and as previously-referenced studies have noted, athletes will consume greater amounts of beverages that are pleasing to the palate.

Glucose Polymer

Glucose polymer or maltodextrin are medium chains of the monosaccharide glucose. They are larger than mono- or disaccharides, but smaller than a starch. It, therefore, has some of the best properties of simple sugars and starches. Glucose polymers clear the stomach faster than glucose.²³ They also have a lower osmotic pressure than either fructose or glucose. This results in a decreased amount of intestinal secretion needed for its uptake. Glucose polymer ingestion maintains a greater plasma volume during exercise than simple carbohydrate drinks or plain water.²⁴ This means that beverages with the right amount of glucose polymer are absorbed by the body better than plain water. The thinking of many people (this author included) that nothing was better for hydrating the athlete than plain water is now becoming obsolete.

Next month in Hydration, Part III, we will continue this series with a discussion of the optimal ranges of carbohydrates and electrolytes a good fluid replacement drink should contain.

G. Andersen, D.C.
Brea, California

References 

1. Hargreaves, M.; Costill, D.; Coggan, A., et al. "Effect of carbohydrate feeding on muscle glycogen utilization and exercise performance." Medicine and Science in Sports and Exercise 1984; 16(3):219-222.
   
   
2. Murray, R. "The effects of consuming carbohydrate/electrolyte beverages on gastric emptying and fluid absorption during and following exercise." Sports Medicine 1986; 4:322-351.
   
   
3. Carter, J.E.; Gisolfi, C.V. "Fluid replacement during and after exercise in the heat." Medicine and Science in Sports and Exercise 1989; 25(5), 532-539.
   
   
4. Carter, J.E.; Gisolfi, C.V. Fluid replacement during and after exercise in the heat. Medicine and Science in Sports and Exercise 1989; 21(5):532-539.
   
   
5. Hiller, W.D.B.; O'Toole, M.L.; Laird, R.H., et al; "Electrolyte and glucose changes in endurance and ultraendurance exercise: results and medical implications." Abstract. Medicine and Science in Sports and Exercise 1986; 18(2) S62.
   
   
6. Wheeler, K.B.; Banwell, J.G. "Intestinal water and electrolyte flux of glucose-polymer electreolyte solutions." Medicine and Science in Sports and Exercise 1986; 19(4):436-439.
   
   
7. Murray, R. "The effects of consuming carbohydrate-electrolyte beverages on gastric emptying and fluid absorption during and following exercise." Sports Medicine 1987; 4:322-351.
   
   
8. Fisher, R.B.; Gardner, M.L.G. "Dependence of intestinal glucose absorption on sodium." Journal of Physiology 1974; 241:235.
   
   
9. Leibovitz, B.E. "Magnesium, the forgotten high performance mineral." Muscular Development 1990; 27(9).
   
   
10. Campbell, W.; Anderson, R.A. "Effects of aerobic exercise and training on trace minerals chromium, zinc, and copper." Sports Medicine 1987; 4:9-18.
    
    
11. Wheeler, K.B.; Banwell, J.G. "Intestinal water and electrolyte flux of glucose-polymer electrolyte solutions." Medicine and Science in Sports and Exercise 1986; 19(4):436-439.
    
    
12. Davenport, H.W. "Digestion and absorption -- physiology of digestive tract." Yearbook of Medical Publishers 1978; 4:187-210.
    
    
13. Costill, D.L.; Saltin, B. "Factors limiting gastric emptying during rest and exercise." Journal of Applied Physiology 1974; 37:679-683.
    
    
14. Hargreaves, M.; Costill, D.; Coggan, A., et al. "Effects of carbohydrate feeding on muscle glycogen utilization and exercise performance." Medicine and Science in Sports and Exercise 1984; 16(3)219-222.
    
    
15. Murray, R. "The effects of consuming carbohydrate-electrolyte beverages on gastric emptying and fluid absorption during and following exercise." Sports Medicine 1987; 4:322-351.
    
    
16. Fordtran, J.S. "Stimulation of acute and passive sodium absorption by sugars in the human jejunum." Journal of Clinical Investigation 1975; 55:728-737.
    
    
17. Leibovitz, B.E. "Ultimate sports drinks; a comparative analysis." Muscular Development 1990; 27:8.
    
    
18. Elias, E.; Gibson, G.J.; Greenwood, L.F., et al. "The slowing gastric emptying by monosaccharides and disaccharides in test meals. Journal of Physiology 1968; 194:317-326.
    
    
19. Hargreaves, M.; Costill, D.; Coggan, A., et al. "Effects of carbohydrate feeding on muscle glycogen utilization and exercise performance." Medicine and Science in Sports and Exercise 1984; 16(3):219-222.
    
    
20. Hargreaves, M., Costill, D.; Coggan, A., et al. "Effect of carbohydrate feeding on muscle glycogen utilization and exercise performance." Medicine and Science in Sports and Exercise 1984; 16(3):219-222.
    
    
21. Slader, G.E. Absorption of fluid and electrolytes in health and disease. Intestinal Absorption in Man. Academic Press, London 1975.
    
    
22. Levine, L.; Evans, W.J., et al. "Fructose and glucose ingestion in muscle glycogen use during submaximal exercise." Journal of Applied Physiology: Respiration in Environmental Exercise Physiology 1983; 55(6).
    
    
23. Murray, R. "The effects of consuming carbohydrate-electrolyte beverages on gastric emptying and fluid absorption during and following exercise." Sports Medicine 1987; 4:322-351.
    
    
24. Leibovitz, B.E. "Glucose Polymer." Muscular Development 1991; 28(4).