John D. Mark MD :John D. Mark MD Pediatric Pulmonary and Integrative Medicine University of Arizona


History of Medicine :History of Medicine TB: Hang cans of dog fat over your shoulder Ulcers: Goat dung Snake bite: Apply ½ of severed mouse Baldness: Drink Sea water Everything: Enemas (3/wk- Egypt) Galen: Blood letting- 1500 yrs!-1910


Health Expo :Health Expo Supplements, blue green algae, copper bracelets, vitamin sprays, juicers, foot massage dowels, water revitalizers, colloidal silver generators, aromatherapy, crystal kingdoms, gems for “balance”, copper embedded wristwatches, aura photos, diets, books, “dolphin energy” Are you a believer??????????


Complementary and Alternative Medicine (CAM) :Complementary and Alternative Medicine (CAM) Medical interventions not taught in medical school in the US or generally accepted at hospitals or routine clinics. Includes ideas from cultures or ethnic groups not considered to be part of conventional care 40-60% of adults use CAM Over $12 billion dollars spent-public!


Positive Motivation for CAM :Positive Motivation for CAM Perceived effectiveness and safety Philosophical congruence: “Zeitgeist”, holism, natural, active role of patient Good patient/therapist relationship Non-invasive, accessibility “High touch, low tech” Affluence, Control


Negative Motivation for CAM :Negative Motivation for CAM Dissatisfaction with aspects of conventional health care, adverse side effects Ineffective for certain condition, time “High tech, low touch” Rejection of science and technology Rejection of “the establishment” Desperation


Why is CAM use common in chronic illness? :Why is CAM use common in chronic illness? Chronic inflammatory illness Paradox: increasing despite advances Belief that “external” exposures as cause Belief that “emotions” can be important Meds: “like using a boulder to kill an ant” Holism and Empowerment of patients


The Integrative Approach :The Integrative Approach Whole person and family Healing oriented not Disease Patient/Physician partnership Mind/Body/Spirit Family and patient’s belief system Holistic in approach, multilevel, and multifactorial


Integrative Approach to Health :Integrative Approach to Health Conventional vs. Integrative Healing- restoration vs. evolution Disease-entity vs. aberrant organiz. pattern Study of health- linear causality vs. circular causality Study of healing-looks at single variables vs. looks at how all are linked to form a pattern


Medicine :Medicine Medicine is not merely a science but an art. The character of the physician may act more powerfully upon the patient than the drugs employed. Philippus Aureolus Paracelsus (1493-1541)


Chronic Respiratory Conditions :Chronic Respiratory Conditions Asthma Chronic Obstructive Pulmonary Disease (COPD) and Emphysema Cystic Fibrosis Other


Asthma in the United States :Asthma in the United States 17 million, over 5 million children Most common chronic illness in children 100 million restrictive activity days per year Over 470,000 hospitalizations per year Over 5,000 deaths per year-highest in Blacks and children (ages 15-24)


Paradox in Asthma Care :Paradox in Asthma Care NHLBI Expert Panel Guidelines (92’&97’) Understanding airway inflammation Early use of anti-inflammatory meds Home management/ peak flow monitors Practice Guidelines- both for ER & Outpts. Morbidity and Mortality- increased?


Asthma Education-MD’s :Asthma Education-MD’s Study of 108 MD’s and Guidelines Asthma Faculty-78% Asthma Fellows-69% Family Practice-55-60% Internal Medicine Residents-51% Just understanding classification-problem


Asthma Triggers :Asthma Triggers Imbalance of T-helper lymphocytes type-2 (Th2) system Respiratory viruses and Exercise Allergens and Irritants: grass, trees, molds, indoor and outdoor pollution, dust-mites, cockroach, animal dander Emotional (laughing/conflict) and Weather Shift in omega-6/omega-3 fatty acids in diet


Nutrition and Asthma :Nutrition and Asthma Dietary habits influence lung function Increased incidence in countries with PUSFA intake Allergen exposure to foods and additives Dietary intake of fruits, fresh fish and antioxidants decreased in asthmatics


Fat Classification :Fat Classification Saturated Fats Monounsaturated Fats Omega-9 family Polyunsaturated Fats Essential Fatty Acids (EFAs) Omega-6 Family Omega-3 Family Linoleic Acid (LA) Alpha linolenic acid (ALA) Gamma linolenic acid (GLA) Eicosapentaenoic acid (EPA) Arachidonic acid (AA) Docosahexaenoic acid (DHA)


Slide 18:Omega 6 Fatty Acid (Linoleic Acid) Omega 3 Fatty Acids (alpha-linolenic acid) ?6-Desaturase Gamma-linolenic acid (GLA) Evening Primrose Oil Borage Oil Black Current Oil Arachidonic Acid Leukotrienes Prostaglandins (PGE2) Inflammatory Lipoxygenase Cyclo-oxygenase (COX) Eicosapentaenoic Acid (EPA) Prostaglandins PGE1, PGE3 (Favorable) Less Inflammatory Leukotrienes Lipoxygenase Docosahexaenoic acid (DHA) COX ?5-Desaturase


Slide 19:Arachidonic Acid (in cell membrane) Free AA Phospholipase A-2 Cyclo-oxygenase Pathway Lipoxygenase Pathway Prostaglandins & Thromboxanes Leukotrienes Steroids Aspirin NSAIDs COX II Inhibitors: Celebrex, Vioxx, Mobic Colchicine Sulfasalazine Leukotriene Inhibitors: Accolate, Singulair, Zyflo


Slide 20:Omega 6:3 Ratio 0 5 10 15 20 25 Omega 6 Omega 3 1909 (4:1) 1985 (25:1)


Slide 21:30 year shelf life Polyunsaturated Partially Hydrogenated


Sources of Omega-3 Fatty Acids :Sources of Omega-3 Fatty Acids Cold Water Fish Salmon Mackerel Sardines Herring Fish Oils EPA & DHA


Sources of Omega-3 Fatty Acids :Sources of Omega-3 Fatty Acids Flax Seed Products Oil, ground seed. Walnuts/Oil Hemp seeds Soybeans/Oil* Dark Green Veges* algae


What to Recommend for chronic inflammation. :What to Recommend for chronic inflammation. Reduce saturated fats that contain arachidonic acid (Animal products, dairy) Reduce use of Omega 6 products (vegetable oils, crackers, things with a long shelf life) Increase use of Omega 3 products (cold water fish, flax, dark greens and nuts) Avoid low-carbohydrate (high fat) diets for prolonged periods of time (Atkins, Zone).


Dietary Supplements :Dietary Supplements Confusing more than any other area DSHEA Act of 1994 FDA lack of regulation Regulating nature? When, what, how much, how long, what form, interactions, who to ask? Botanicals, phytomedicine, Internet?


Dietary Supplements :Dietary Supplements Echinacea Coleus forskohlii (inhibits PAF) Ma huang (ephedra) (bronchodilator) Ginkgo biloba (PAF inhibitor) Licorice, coltsfoot, tumerac (anti-inflam.) Cordyceps (bronchodilator) Green tea (antioxidants)


Ma Huang (Ephedra sinica) :Ma Huang (Ephedra sinica) Used in China over 5,000 years Ephedrine- principle ingredient Commonly used with licorice (mucolytic) FDA-Over 600 complaints-22 deaths Tighter State regulations-esp diet claims Most problems stem from use with caffeine


Licorice (Glycyrrhiza glabra radix) :Licorice (Glycyrrhiza glabra radix) Folk medicine- treat cough Glycyrrhetinic acid and carbenoxolone-potent inhibitors of cortisol metabolism Enhances endogenous and exogenous steroids Also shown to elevate blood pressure, peripheral edema, headaches, low K+, lethargy , muscle weakness


Coleus forskohlii :Coleus forskohlii Ayurvedic medicine Acts like theophylline (increases cAMP) Another Ayurvedic herbal remedy seems to be an effective bronchodilator- Tylophora indica- No studies yet on children, some on adults


Ginkgo Biloba :Ginkgo Biloba Study of asthmatics using Ginkgo leaves concentrate showed decrease airway hyperactivity (p<0.05) and pulmonary function improved (p<0.05) Problem- 1997 study, in Chinese and do not specify the type of airway measurements used.


Ginkgo :Ginkgo Pilot data in this country has been described PAF antagonist Antioxidant Can interact with other drugs, esp coumadin type meds


Vitamins :Vitamins Vitamin B6 (pyridoxine)- RCT’s-helps for mild disease, 200 mg per day Vitamin C- RCT’s-mixed results -over 1 gm Selenium- no studies, antioxidant Fish oil (omega 3 Fatty Acids)-RCT’s- long term help


Case Presentation: Shannon :Case Presentation: Shannon 14 yr old with long standing asthma (moderate persistent), pets Meds: Albuterol, AeoBid (Singulair, Pulmocort)-followed peds clinic PFT’s- FEV1 (60/85), FEF25-75 (40/70) Treatment plan: Meds, Environment, Nutrition, Dietary Supplements, Exercise


Arizona Botanical Center :Arizona Botanical Center One of 4 (UCLA, Chicago, Purdue) Anti-inflammatories: Ginger, Tumeric, Boswellia Botanical to Chemical to Animal, to Human studies Ayruvedic- all used for asthma Leukotriene inhibitors (esp. Boswellia)


Boswellia serrata gum resin :Boswellia serrata gum resin European J Med Res 98’ Nov:3:511 40 patients with asthma (double blind and placebo study) 70% had improved symptoms, increase in FEV1/PEFR, decrease eosinophils Control group- had 27% improvement Boswellia serrata gum resin for asthma


Lung Support :Lung Support


“Lung Support” :“Lung Support” Retinol, Fructus,Salvia, Cordyceps, Astragalus, Prunus, Morus, Ophiopogon, Cynachum, Ginseng, Ginkgo, Magnesium No amounts listed SAFE NO DRUGS NO SIDE EFFECTS 100% NATURAL


Claims Made: :Claims Made: Ends..SOB, smoking damage, heart problems, sinus problems, emphysema, allergies, fatigue, asthma…. “Secrets to breathing disordered unlocked”, “End Bronchial disease” “Today’s Medicine is Harmful” “Dramatic improvement …few days” “100% SATISFACTION & RISK FREE “


Slide 41:Mind-Body Influences on health


Mind/Body Approach :Mind/Body Approach Placebo/Suggestion/Disclosure Hypnosis: Guided Imagery Pediatric study proposal Diaphragmatic breathing Exercise, Yoga, Martial arts


Accessing the Placebo Response :Accessing the Placebo Response Develop rapport and trust When able, recommend therapy based on the patient’s belief system Recommend any given therapy with enthusiasm and confidence Activate the patient’s expectation of the therapy with positive statements


Disclosure Chronic Illness :Disclosure Chronic Illness Smyth JM, et al. JAMA, 1999 Effects of Writing About Stressful Experiences on Symptom Reduction in Patients with Asthma and Rheumatoid Arthritis. Study Group: Wrote about a stressful life event for 20 mins/d for 3 days Control Group: Wrote about daily events 107 patients. Asthma: 20% improvement in lung function vs no improvement in control RA: 28% reduction in disease severity vs no change in control.


Hypnosis :Hypnosis Multidimensional Induces an altered state of consciousness Aids in developing a heightened concentration of an idea or image Studies- many in the behavioral literature, helps if subjects are “susceptible” to hypnosis


Tracy and the Laryngeal Warts :Tracy and the Laryngeal Warts


Massage/Manipulative :Massage/Manipulative Feels good, reduces stress and anxiety Recent Asthma study: 20 minutes at bedtime by parents helped Chiropractic- Osteopathic- Used with anecdotal success


Osteopathy :Osteopathy Manipulative Medicine-Dr Still Structure/Function relationship Over 100 different types Craniosacral, High-velocity-low-amplitude,muscle energy,counterstrain, myofascial release, lymphatic pump Spiritual Component- Dr Viola Fryman


Other Therapies: :Other Therapies: Mind/Body Medicine Massage Therapy Energy Medicine Healing touch Reiki Johrei Ethnocultural Medicine


Homeopathy :Homeopathy Law of Similars Potency Hahneman, homeopathy schools Acute versus Chronic remedies Classical versus “Modern” Who, When and for what problems


Traditional Chinese Medicine :Traditional Chinese Medicine 5 Elements 5 Branches Acupuncture, moxibustion Diet Herbal therapy Physical Therapy QiGong, Kung Fu Different Systems Approach


COPD :COPD Conventional Care?? Inhaled steroids/Bronchodilators/Atovent Pharmacoeconomic impact- Chest 2000 Regular use of Meds (albuterol?) Long-term Oxygen Therapy Home Ventilation Nutritional Intervention


COPD and CAM :COPD and CAM Ginseng and chronic bronchitis Clin Drug Invest Jan 2001, 75 patients Increased bacterial clearance Music therapy and dyspnea Holistic Nursing 1999, 24 patients Less anxiety and dyspnea, better energy Nutritional Chest Feb 2001, 21 report review


From Jerusalem to Jericho: a study of situational and dispositional variables in helping behavior. J Personality and Social Psychol. 1973;27:100-108 :From Jerusalem to Jericho: a study of situational and dispositional variables in helping behavior. J Personality and Social Psychol. 1973;27:100-108 Group #1 Group #2 Group #3


Healing :Healing People come together to form a healing circle, But the power lies in the empty center. A person’s chest rises and falls But the breath that fills it cannot be seen. Muscle and bone join to make a body But the life force within is invisible to the eye. A child’s laugher bursts with joy And the source of it cannot be touched. What can one be But the instrument of unseen bliss?- Lao Tzu