Showing posts with label research. Show all posts
Showing posts with label research. Show all posts

In Search of the Holy Grail

By Bill Benda, MD, FACEP, FAAEM

Photo by speckyfish2000 via Flickr, used under the Creative Commons License.
I sat on an NIH panel a couple of weeks ago in Washington, D.C. Our mandate: to determine which of a few dozen grant applications deserved, through purity of methodology and virtue of intent, to be awarded funding by a commercial enterprise whose name I cannot reveal.

In fact, I wish I could tell about you the subject of the grants, or the people who sat on the panel with me, or the amount of monies given away, or how we determined who got the cash. But the NIH is very, very adamant that nothing ever, ever leaks to the outside world on what transpired those two days. Non-disclosure forms are signed, warnings are given, and papers and discs are shredded after the proceedings are completed. I imagine there is a sophisticated surveillance system set up in Bethesda, MD, to watch our every step, and should I inadvertently write the wrong words in this blog, an alarm sounds on the east coast: NIH Central Alert! Reviewer violation! Activate liquidation team! And within the hour an ominous black Prius would pull up in front of my house and bespectacled men in trench coats would emerge.

But I digress from the topic of this article. My time on the panel did serve to reinforce one particular belief I have harbored over the past couple of decades as I have explored the world of scientific investigation – that research, for all of its academic and cultural value, is not health care’s Holy Grail. It is not representative of any irrefutable fact, it is not the courier of absolute truth, and it certainly is nothing close to purity of thought and action.

Now before those of you who spend most of your waking hours in academia start sharpening your ninja swords, let me state firmly that research itself is indeed the best tool we have at our disposal to differentiate reality from fiction in the clinical arena. But it is a fragile tool, and prone to breakage and misuse. And I do hold a touch of credibility on this particular topic - I have conducted and published two randomized control trials (one funded by NCCAM), and have been providing peer review to six medical journals over the past decade or so. So I can state with some authority one thing that I have never seen echoed in any journal, except perhaps on the editorial page or in a letter to the editor, and that is: All research is flawed, and likely quite badly flawed.

Lets take a look at the process of publishing a study, from the first inkling of an idea to the final inking on the journal page. Someone, somewhere, comes up with a hypothesis. After much thinking and mulling, the hypothesis transmogrifies into a research plan–usually in conjunction with other co-investigators–then into a methodology, complete with inclusion and exclusion criteria, plans for statistical analysis, recruitment, carrying out the study, collation of data, actual statistical analysis, final conclusions, writing of the paper, peer review by a journal, revisions as requested by said journal (and perhaps repetition of this step several times), publication of the article, reading and attempted understanding by the subscriber and, finally perhaps, incorporation into clinical use.

There are countless steps where bias and error can creep into the final findings, and this doesn’t take into account influence by industry if the piece happens to be on a pharmaceutical or other medical appliance. And speaking of pharmaceuticals (and supplements), the study usually recruits a narrow demographic of males between this age and that age with this clinical condition but not complicated by that clinical condition (exclusion criteria!) and then treats at a specified dose for a set period of time. And if the positive findings are somewhat higher than the placebo effect, that pharmaceutical (or supplement) is marketed to men and women from 18 to 88 with all sorts of confounding conditions and with each very diverse patient getting pretty much the same dosage. This is part of the reason why, say, hormone replacement therapy protected against heart disease last month, but increases heart attacks this month, while protecting against breast cancer last year, but thought to stimulate breast cancer next year, and on, and on.

OK, I’m going to back up once more and restate a very important point: Research is the best tool we have at our disposal to differentiate reality from fiction in the clinical arena! But it’s simply not as perfect as we, and our media, purport. As I tell my students, no research study, no matter how well done, is the truth; it is simply another finger pointing in the general direction of the truth.

So the next time that your organization wants to put research at the top of its priority list, consider… Wait a minute...

I need to go. A black Prius just pulled up in front of my house.

Homeopathic Treatment of Psychiatric Conditions and Emotional Imbalances

By Christopher Johnson, ND

Photo by Eggybird via Flickr, used under the Creative Commons License.
As a naturopathic physician I work regularly with patients who have emotional imbalances, sometimes as a chief complaint, and sometimes as simply one symptom amongst many. It seems that having some degree of anxiety and/or depression is simply a part of being human – most persons experience them at some point in their lives.

In practice, I have had significant success in treating clinical psychiatric conditions such as anxiety and depressive disorders, ADHD/behavioral disorders, PTSD, bipolar affective disorder and panic disorder using homeopathy. Most patients who come to me for help with these conditions are using psychotropic medications, but are often able to discontinue or reduce the dosage of these meds (under the supervision of whoever prescribed them) once they experience improvement.

In addition to treating clinically diagnosable psychiatric conditions, homeopathy is also extremely effective at treating everyday anxieties, irritabilities, moods, etc. Literally every day I see patients who come back for their first follow up visit to tell me they feel less anxious, irritable, etc. This, even though many of these patients did not come to me for help with emotional issues and in some cases were not even aware the issues were present until they took the homeopathic remedy, became healthy, and realized how good it feels to be without emotional imbalances.

Not only do many patients tell me they feel less anxious or depressed, I actually expect it from every patient. If it is not so, I have not given them the correct homeopathic remedy and they are not truly healing. A healthy body is an emotionally calm and happy body.

Homeopathy restores health quickly, gently and usually in a permanent fashion by stimulating the body’s own healing capacity.

People are often amazed to see that emotional issues can be resolved without years of psychotherapy, yet this is common with homeopathic treatment. In other cases, patients who are undergoing psychotherapy and are intellectually aware of their issues but unable to resolve them often have rapid progress upon initiating homeopathic treatment. I have seen patients suffering from anxiety for 30 years have it resolved within weeks of homeopathic treatment.

The fact that homeopathic remedies affect the body in this manner is not trivial. Two recent major studies demonstrated that anxiety is a very significant risk factor for heart disease – as much or more than hypertension, elevated cholesterol, etc. An anxious or depressed body is one out of balance and at risk for all manner of diseases.

Unlike conventional medical treatments, homeopathy has no side effects and the positive effects are curative (to the extent the body is capable of healing) – meaning that treatment need only proceed for a finite time period, after which the patient no longer need use the homeopathic remedy to remain healthy. This was demonstrated in a 2008 study which followed 3,709 patients for 8 years. It found, “Patients who seek homeopathic treatment are likely to improve considerably. These effects maintain for as long as 8 years.”

The following is a sampling of trials demonstrating homeopathy’s effectiveness in treating psychiatric disorders:

In a 2009 randomized, double-blind trial at a Brazilian state medical school, homeopathy outperformed Fluoxetine (Prozac) on all measured parameters in treatment of moderate to severe depression.

A 2006 study of 1,783 patients receiving homeopathic treatment for a variety of complaints found, “Strongly positive outcomes… were achieved most notably in the frequently treated conditions of anxiety, depression, and irritable bowel syndrome.”

A 2005 randomized, double-blind, placebo-controlled study published in the European Journal of Pediatrics found, “scientific evidence of the effectiveness of homeopathy in the treatment of ADHD, particularly in the areas of behavioral and cognitive functions.”

Where Do We Live?

By Jacob Schor, ND, FABNO

Photo by Liralen Li via Flickr, used under the Creative Commons License.
There’s a Hebrew expression that roughly translates as "Where do you live?" It’s not meant to ask the location of a person’s residence. Instead it expresses shock, dismay, or disbelief in the ideas held by the person being addressed. By implication, "Do you live on Mars?"

During the winter, I go skiing with my friend Jim every Wednesday. We have done this for almost two decades, from opening day in November to closing day in May. Given the many shared months of our lives spent shivering together, I guess it was fitting that when Jim came back from a business trip to Dublin last winter, he brought me a gift: a handmade wool sweater.

This beautiful sweater came with a brochure affixed to it with one of those plastic fasteners, which needs to be snipped off lest you leave a hole in the garment. The brochure informed me that because the sweater was made of Merino wool, it would be comfortable year round, winter, spring, summer and fall. It is a beautiful sweater and nice to wear outdoors with my vest when the temperature is in the twenties. It’s even wearable indoors when I’m writing, the heat is off and the temperature is below sixty. I’ve tried unsuccessfully to wear it a few times this spring. I joke about wearing it in the summer. We live in Colorado. It’s too hot here to even touch wool during the spring and summer. Though it makes for a good joke, "Oh, the temperature has dropped to 85. Shall I wear my sweater?"

I mention this sweater because I use it as an analogy. That information on that sweater tag teaches us two things. The first is obvious: you can’t believe everything you read. That certainly applies to a good many ‘miracle cancer cures’ my patients read about on the Internet and then expect me to believe in. I tell them about the sweater.

The second sweater lesson is less obvious. The statement that the sweater is wearable year round isn’t false. It’s probably true if you live in Ireland. The truth is relative. In the case of my sweater, to where you live.

My ruminations on the relativity of truth are triggered by Nathan Seppa’s article in last week’s Science News titled "The Sunshine Vitamin."i

Nathan Seppa and before him Janet Raloff have in their earlier Science News articles closely followed and reported on the growing vitamin D research over the last ten years. This article on the surface purports to cover both sides of the debate triggered by last year’s Institute of Medicine’s report on vitamin D.

Last November, an Institute of Medicine (IoM) panel of scientists announced new vitamin D recommendations. They recommended daily intakes of 200 to 600 IUs per day. For most of us who follow the growing data on vitamin D, and routinely prescribe doses ten times this high, these suggestions seemed absurd.

Seppa points out the argument on which most vitamin D proponents fall back: that "… these amounts still fall short of prehistoric people’s intakes by a Stone Age mile." Living outdoors with little clothing, these people manufactured thousands of international units, or IU, every day, perhaps getting three to five times as much as most people get now.

Seppa then goes on and writes a comprehensive review of the benefits associated with vitamin D. He reviews the many research studies that form the basis of our thinking that vitamin D can produce anti-viral, anti-cancer, anti-allergy (including asthma, allergies etc), anti-autoimmune (including DM, and especially MS), anti-neurodegnerative (Parkinson’s disease, Alzheimer’s disease), anti-hypertensive and anti-cardiovascular disease effects.

Seppa contrasts the IoM’s recommendations with those published this month by the Endocrine Society in the Journal of Clinical Endocrinology & Metabolism.ii "The society, the world’s oldest and largest group devoted to hormone research, called for vitamin D intake levels two to three times higher than the IOM’s recommendations."

The question in my mind isn’t which of these opinions to follow. For naturopathic physicians, this is a no brainer. The majority of us will follow the guidelines and thinking of the Endocrine Society over those of the IoM. The question is why varying groups of intelligent and well-meaning scholars see the world so differently.

I think our views are tainted by the day-to-day needs of clinical practice and the demands it places on us to make pragmatic decisions based on often incomplete data, while those of the IoM panel are made in the academic luxury of being able to stall until more data is available.

Seppa quotes Patsy Brannon, a molecular nutritionist at Cornell University and a member of the IoM panel, who expressed the need for more randomized to settle the question:
"We looked extensively at those areas," Brannon says. In non-bone research, she says, "We found very limited randomized controlled trials, and evidence for cause and effect was not present."
At this point, there is slim if any indication that vitamin D supplementation will be hurtful and ample suggestion that it will provide vast benefits. But that’s our point of view.

This brings to mind another recent article, this one in last Sunday’s New York Times by Siddartha Mukherjee, the author of 2010 book The Emperor of All Maladies: A Biography of Cancer, which won the Pulitzer Prize for General Nonfiction. In his Times article, he reviews the evidence behind the current fear that cell phones will cause brain cancer and compares it with the evidence that links formaldehyde exposure to leukemia and smoking with lung cancer.

Mukherjee points out that the link between formaldehyde and cancer was known in the 1970s. It wasn’t until recently that the National Toxicology Program actually announced the connection. He blames industry lobbyists, particularly plywood manufacturers, for delaying this official stance.

Mukherjee reminds us that "The human trials that established that tobacco smoke is a carcinogen were initially performed in the mid-1950s (some even earlier). The tobacco industry mounted an aggressive campaign to discredit the data, and continued marketing tobacco to the public. The landmark Surgeon General’s Report on smoking and cancer was released in 1964. And it took yet another decade of innovative strategies, including powerful anti-tobacco advertisements and tort cases against tobacco companies, to alter the trajectory of smoking behavior in America."iii

It can take a long time for knowledge to move from research publications to changes in public awareness and behavior. Let’s not even attempt to explain the recent trend toward increased smoking in young people in certain parts of the country.

Seppa sums up the arguments against the IoM’s desire for better evidence of vitamin D effect, and their desire for more randomized controlled trials by quoting Cedric Garland of the University of California, San Diego:
Besides, randomized controlled trials have never been the sole arbiter of medical thinking or policy, Garland says: "If they were, we would all still be smoking cigarettes and no one would be wearing seat belts."
We may never have randomized controlled trials on smoking because at this point it would be unethical to assign people to a ‘smoking arm’ of a trial. The weight of the evidence in support of vitamin D may soon bring us to a similar situation. How can we ethically tell people in a control group to not take vitamin D?

When it comes to wearing Merino wool sweaters in the summer, I don’t live in Ireland. What’s true in Ireland is not true in Denver.

We have to accept that the members of the IoM committee do not live in the same world we do. When it comes to encouraging higher intake of vitamin D, I want to think that we live in the real world, where our desire to improve patient health comes first in our list of priorities.

---

iNathan Seppa. The power of D: Sunshine vitamin’s potential health benefits stir up, split scientists. Science News / July 16th, 2011; Vol.180 #2 http://www.sciencenews.org/view/feature/id/332009/title/The_power_of_D_


iiHolick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM. Evaluation, treatment, and prevention of vitamin d deficiency: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911-30. PMID: 21646368


iiiMukherjee S. Times Patrolling Cancer’s Borderlines. New York Times. July 12, 2011. http://www.nytimes.com/2011/07/17/opinion/sunday/17Mukherjee.html

Order Matters

By Jacob Schor, ND
Photo by Kanko* via Flickr, used under the Creative Commons License.
If order matters, what comes first?

The implications of a study published way back in February in Clinical Cancer Research have been stewing around in the back of my mind. It’s one of a growing cascade of studies in which researchers at fairly mainstream medical institutions reveal that they’ve been playing with stuff that’s standard fare on a naturopathic doctor’s dispensary shelves.

In this instance we are talking about researchers from the Mayo Clinic in Minnesota playing with various combinations of curcumin, an extract of turmeric and green tea, and seeing how they affect lymphocytic leukemia cells.

As much as we still occasionally hear and read the myopic criticisms of our profession that claim our therapies are not backed by research, this study is just one of many. A PubMed search just now of the National Library of Medicine’s published scientific literature on curcumin and cancer yields a list of 1,265 articles. A search on green tea and cancer yields 1,338 published papers in the peer reviewed journals.

This particular study was similar to many others; cancer cells were grown in a laboratory, exposed to the ‘natural’ ingredient, and the degree to which growth was slowed down or that cancer cells were inspired to drop dead was measured. In this particular experiment, chronic lymphocytic leukemia B cells were the targets. Nothing unique about this setup.

And no surprise that the curcumin was found potentially useful. Here let me quote from the results in the abstract and then translate the interesting parts:

“Curcumin induced apoptosis in CLL B cells in a dose-dependent (5-20 micromol/L) manner ...”

‘Apoptosis’ is when a cell decides life isn’t worth living and self-destructs. Curcumin convinces these leukemia cells to commit suicide. The more curcumin added to the cells, the more died.

“Coculture of CLL B cells with stromal cells … decreased sensitivity to curcumin.”

Adding some other cells, stromal cells, into the mix decreased the curcumin effect; fewer cancer cells died.

“When curcumin was administered simultaneously with EGCG [green tea], antagonism was observed for most patient samples.”

Adding green tea extracts along with curcumin to the mix of leukemia and stromal cells caused, what these scientists called ‘antagonism.’ That’s an odd term and you need to view the full text article to get an idea of what they mean by antagonism. Put simply, the combination of the two natural substances, green tea and curcumin, didn’t work as well as predicted: “… simultaneous culture had a less than additive effect.” That is if you measure the anti-cancer effect of each substance separately, you can add the two ‘effects’ together to predict what should happen when both are used simultaneously. It turns out they don’t work as well as predicted; they antagonize each other.

“In contrast, sequential administration of these agents led to substantial increases in CLL B-cell death ...”

When instead of adding both curcumin and green tea to the culture at the same time, the cells are instead exposed to one agent and then the other, the story changes completely. They tried treating the cells first with curcumin followed by green tea, and vice versa. To quote the authors, “… sequential administration led to dramatically more leukemic cell death than simultaneous administration.”

Not only did exposing the cancer cells to these substances one at a time matter, but order mattered as well. Green tea first, followed by curcumin, worked much better than if the cells were exposed to curcumin first.

Think about the implications this brings to our practices. Sequential administration of treatments may work better than simultaneous treatments. Order matters. In this case green tea works better first.

Typically in practice we pile a bunch of different substances into a patient’s blood stream on the assumption that each has a specific action and these effects will add together. This reminds me of those combination locks that have four or five parallel numbered rings and to open the lock. You line up a number on each ring, get all the right numbers in a row at the same time, and the lock opens.

This leukemia study makes that image obsolete. If sequence matters, just knowing the combination is no longer enough. This is more like the dial lock on a safe. Sequence is essential. Three turns to the left and stop on the right number, then turn the dial to the right past your first number and stop on another specific number. And so on…

Think about this: our cancer patients often take a long list of supplements. This study suggests that, at least in chronic lymphocytic leukemia, we should start them on green tea for a period of time and then switch to curcumin. What if it is a similar story with quercetin, resveratrol, sulforaphane, vitamin D, melatonin and so on? What if there is a ‘best sequence’ for all of these? What if that combination were to vary by cancer? By patient? Or even by dose?

This is worth stewing about. It makes me think of certain patients who tell me they vary what supplements they take day-to-day based the way a pendulum held in their hand swings. Though this sounds less than ideal, it can’t work any worse than flipping a coin to decide on a sequence, which for the time being may still be of some utility.

Now that this study has been published, we shouldn’t be surprised to see other studies up asking this question: “If order matters, what comes first?”

Ghosh AK, Kay NE, Secreto CR, Shanafelt TD. Curcumin inhibits prosurvival pathways in chronic lymphocytic leukemia B cells and may overcome their stromal protection in combination with EGCG. Clin Cancer Res. 2009 Feb 15;15(4):1250-8.

Upcoming Convention – There is Hope!

By Sara Thyr, ND

I have the very time-consuming and honorable task of co-chairing the Convention committee and reviewing the talks before the conference to be sure that they are free of commercial bias. It can be a daunting task. We receive many really enticing abstracts, and have to work together to find the ones that will be the most interesting and educational to the most brilliant naturopathic doctors in the country.

As I look over the schedule and presentations for this upcoming Convention, I am filled with incredible pride, and–more mushy–a great sense of hope! There is a deep need for our medicine in the world and now is the right time.

I know first hand the incredible effort and time it takes to prepare a lecture for the AANP Convention. It is a daunting task to present to your peers. And what we will be able to listen to this year comes from some amazing and inspiring leaders in the field, and some doctors who have put together very well-researched and inspiring lectures.

What makes me so hopeful is knowing that we will come away with information about how a simple plant may help us deal with infections that are resistant to antibiotics. We will learn how epigenetics and preconception health affects health throughout our lives…the true heart of preventative medicine. We will have a chance to learn from some of the most practiced homeopaths in our profession – how to make homeopathic prescriptions as a naturopathic doctor that will increase our effectiveness with patients. We have a chance to hear about the importance of creativity in healing and actually learn how to help our patients implement this for the benefit of their lives. We can learn from someone who does more nutrition research in a week than most of us do all year about all of the myths and important research in the literature that most of us don’t find the time to look at. We can learn how genetically modified foods are dangerous and the interesting mechanism used to grow these foods that makes them so harmful (along with the shocking information about how our government, influenced by industry, continues to ignore the health risks involved).

Do you know how medicinal botanicals can help with neurodegenerative diseases? You will if you make it for the concurrent sessions on Wednesday. And if you are torn, as I am, about listening to that talk or learning about how to treat cancer patients if you are not a cancer specialist, have no fear. The AANP is making sure that you have the opportunity to hear every talk – even the ones that you can’t attend. I love this. I have always been torn in making a schedule where I’d get to see everything I am interested in. This year we can. We get to hear every lecture.

We have more keynote speakers this year, and more keynotes from naturopathic physicians, that will not only be educational, but also inspirational. The Convention theme is “Composing Effective Patient Care” and fitting this theme we will learn how tones and music affect our health.

I am so incredibly grateful to everyone who has put so much time, thought, and effort into making this Convention so incredible. I am more excited than ever to be attending. (Well, maybe I’ll be more excited next year when I won’t have any Board or Convention responsibilities. We’ll see.)

We are so lucky to get to meet again at the jewel of the desert, the Arizona Biltmore. All who have been there know that it is the perfect location for us to connect with friends and make new ones; to sit in on some great continuing education talks, and celebrate our profession.

I hope you will be there this year. It is not to be missed as a source of rejuvenation for your practice and your soul.

The Problem with Research

By Tim Birdsall, ND, FABNO
2009 AANP Physician of the Year

Photo by US Army Africa via Flickr, used under the Creative Commons License.
I’ve been out of the office for a few days, and was way too busy catching up on all of the countless things which don’t get done when you’re not there attending to them. So perhaps I can be forgiven for not seeing it immediately. But, at the end of the day, there it was in my Inbox, leering at me, daring me to open it up. “Selenium Does Not Benefit -- and May Harm -- Most Patients With Non-Small-Cell Lung Cancer.” What? Not again… Yet another study showing that antioxidants may do more harm than good. First it was beta-carotene. Then vitamin E. Now selenium. And that’s just the antioxidants.

To top it off, the reason I was out of the office last week was that I was attending the National Advisory Council for Complementary and Alternative Medicine, the advisory body to NIH’s NCCAM. On that council, we have talked about just this issue – why do therapies which seem to make biological and physiological sense, which have some epidemiologic data to support their use, and which naturopathic physicians (and other alternatively-minded practitioners) have been using for decades (or much longer), seem to fail in double blind, randomized clinical trials?

The reasons are multiple, complex, and often convoluted. And conventional medicine is all too willing to accept a negative study of a natural therapy, proclaim that “it doesn’t work,” and wash their hands of the entire mess, while leaving the public with the impression that alternative medicine isn’t really worth much. In reality, these therapies often fail in clinical trials because those trials are designed to answer simple, straightforward questions, and as anyone who has provided care to patients can attest, clinical medicine is anything but simple and straightforward. The typical randomized, placebo-controlled, double-blind study can only answer a limited set of very specific questions, and if the wrong question is being asked, or if it is being asked in the wrong patient population, the answer may be equivocal, confusing, or just plain wrong.

In the lung cancer study I saw today (J Clin Oncol 28:7s, 2010 (suppl; abstr CRA7004)), selenium actually appeared to show benefit in one sub-group – those who had never smoked. True, that finding did not reach statistical significance, but then neither did the finding of potential harm (P=0.15). But which one made the headline? You already know the answer.

And so I began to ponder the question, “What’s wrong with research?” A part of me becomes enraged at the reductionistic, allopathic, biomedical model, which breaks things down into components so small that all synergism, all interdependence is stripped away, and then declares those components to be ineffective. Another part argues that the wrong component was selected, or was a synthetic form (although in the lung cancer study, they used selenium yeast). But ultimately, I find myself becoming offended because I believe that these therapies work… Whoa! Believe? OK, but where is the role for evidence? I used to believe that stress caused gastric ulcers. And then along came Helicobacter pylori, and I had to change my belief to match the evidence.

For naturopathic medicine to survive and thrive in the 21st century climate of evidence-based medicine, I think at least three things must happen. First, we should be willing to judge ourselves critically and objectively, and subject our therapies (and ourselves) to scientific scrutiny. Scary and intimidating? Perhaps. Essential? Absolutely.

Second, we need to step up and recruit and train naturopathic physicians to be world-class researchers. We make great doctors – our patients tell us so every day. We have yet to prove that we can also make great researchers, although we have begun to lay the groundwork to create this success. We are playing catch-up with academic institutions that have a 50-60 year head start, but we have the advantages of being able to learn from their mistakes and of having a public who demands the type of care we provide. While the schools will bear much of this burden, it will require the concerted effort of the entire profession to create the infrastructure necessary to make this reality.

Third, we should collaborate with other professions and institutions to craft the research models necessary to adequately perform “whole systems” naturopathic research. There are examples of this type of approach already existing in the health systems research literature which can be adapted to our needs. In the end, we must create and validate the tools to dethrone the randomized controlled trial as the gold standard, and construct new ways to validate clinical approaches to health issues. Much as the homeopaths of 2+ centuries ago created the proving as a way to better understand and utilize their remedies, we must refuse to be limited by the way conventional medicine views health and disease.

We must boldly strike out to create the systems needed to transform both our research questions and the systems we use to generate the answers. Only then will we be able to use the tools of research to promote and defend naturopathic medicine, instead of feeling beaten over the head by them. Research as an advantage, instead of an impediment. Imagine that.

Two Schools

By Jacob Schor, ND, FABNO

Curcumin is the principal curcuminoid of the popular Indian spice turmeric, pictured above.
Photo by FootosVanRobin via Flickr, used under the Creative Commons License.


There were two distinct schools of thought regarding the dosing of herbal medicines when I was a student at National College of Naturopathic Medicine during the 1980s, a couple of decades ago. Most of our teachers in Portland thought in terms of what I now regard as low doses of botanical medicines. We would often prescribe doses of just several drops of tincture diluted in water.

Apparently those at Bastyr University held a different view. This was brought home when Dr. Silena Heron came down to Portland from Seattle one rainy day and lectured our class. She didn’t talk of drops but instead talked of doses in milliliters and teaspoons. She was dosing herbs to get pharmacological effect while we were looking for homeopathic effects.

These thoughts are on my mind because of a study I came across recently about curcumin and cholesterol. Over the years a number of papers have looked to see if curcumin or turmeric lowered cholesterol. Some report benefit, others not. But this paper reports something I would have not predicted. Let me tell you more about it.

The paper, authored by Alwi et al., was published in 2008 in an Indonesian medical journal and looked at the effect of curcumin on lipid levels in patients with acute coronary syndrome. This is a broad term, referring to most any situation in which the heart isn’t getting enough oxygen. For a year, between May 2005 and May 2006, the researchers enlisted patients at several hospitals to participate in a randomized double blind controlled trial. They administered curcumin in escalating doses that ranged from a low dose of just 15 mg/ 3 times per day, up to 60 mg/ three times a day, on the participathing patients’ lipid profiles. The researchers tracked total cholesterol, LDL, HDL, and triglycerides along with other common blood parameters in 63 patients who completed the study.

The researchers report that they saw lipid improvements stemming from the curcumin that varied with the doses and that in regard to, “… the effects of curcumin on total cholesterol level and LDL cholesterol level, there was a trend that the lower the dose of curcumin, the higher the effect of reduction. For HDL cholesterol level, there was also a trend that the lower the dose of curcumin, the higher the effect of increase in HDL cholesterol level.”

Let me make sure you are reading this right. They are telling us that 45 mg of curcumin per day worked better than 180 mg per day. Neither of these are particularly high doses. The smallest capsule we have on our pharmacy shelf contains 250 mg of curcumin and that product in particular claims enhanced absorption so that it is equivalent to a dose of 2,000 mg. Our standard curcumin product comes in 750 mg capsules. If we believe this Alwi study, we should divide those 750 mg capsules and spread it out over a two week period.

Perhaps we need to rethink our ‘more is better’ assumptions and even re-examine our earlier habits of using tiny doses when it comes to prescribing some botanical medicines.

The late William Mitchell would sometimes use a specific word to describe how a botanical extract affects an organism. He would say that it “informs” the body or the mind or the vital force. I don’t pretend to understand exactly what Dr. Mitchell meant by the word ‘inform,’ but I’ve taken it to mean that the particular molecules isolated from the plant bring information, that teaches or shows by example, a different pattern of behavior and function to the organism. Thus botanical medicine can act as a catalyst to change function.

We certainly have some unpleasant examples with which we might illustrate this idea. Certain addictive drugs appear to trigger permanent changes in brain chemistry after even a single exposure. Even if we aren’t talking about crack cocaine, it is not unreasonable to think that other more benign plant extracts will also cause lasting permanent changes in function. Botanical medicine, when well practiced, is perhaps more like the automatic software updates that my computer routinely downloads. They teach the system how to work better and update it so it understands how to respond to new challenges.

If we are using the analogy that herbs act like catalysts, then it makes sense that relatively small doses are all that’s needed to turn the trick. Maybe we only need the large doses when we are using herbs as drugs and not as information carriers. Perhaps drugs deliver orders to the body, while herbs deliver knowledge. [If I keep up this kind of train of thought I may have to move back to Oregon and eat granola again.]

These are the sorts of discussions we engaged in decades ago as naturopathic students. We hear these kinds of arguments less often these days. I often just reach for standardized plant extracts whose chemical actions have been multiplied by refining, distillation and concentration. More is better and stronger is better; these have become our quiet mantras. We once condescendingly attributed this type of thinking to medical doctors (especially those claiming to practice natural medicine) and considered it to be an inferior approach to treating the patient. We allowed that some one in our profession might out of necessity fall back and prescribe botanical medicine like this out of desperation but it wasn’t the preferred path of treatment, the way a real naturopathic doctor worked. We were such idealists.

Luckily many of us still are idealists and this paper on curcumin should serve as a reminder. Sometimes less is more. Sometimes what we need is a tiny nudge from something so small as to seem like magic. Or perhaps, in our rush to keep up with all the new science, we have to leave a little space in our understanding for the magic in our medicine to do its work.

Horsing Around at the NIH

By Bill Benda, MD, FACEP, FAAEM

Image by the NICHD via Wikipedia.org, used under the Fair Use Doctrine.

An interesting thing happened to me back in February – I received a request from the National Institutes of Health to serve on a panel that would determine how to dole out quite a few millions of dollars to fund research in what the NIH refers to as Human-Animal Interaction (HAI), usually referred to as animal-assisted therapy. Apparently the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Nursing Research, and the WALTHAM Center for Pet Nutrition (the pet food division of the Mars company) had entered into a public-private partnership to pursue research on this topic.

My invitation, I am sure, was the result of having published two prior research studies (one part of an NCCAM Center grant) investigating the effect of hippotherapy (physical therapy on horseback) on children with spastic cerebral palsy. It seems that all of the other “experts” in this relatively tiny field had in fact applied for the current grants, leaving yours truly as a rather singularly available authority. The rest of the 35-plus members on the March review panel consisted of sociologists, psychologists, and behavioral scientists, with one or two other MDs thrown in for good measure.

The rather impressive vows of confidentiality we were asked to give preclude me from mentioning who was at the table, the nature of the submissions, or any aspect of the ensuing discussions, but that is not relevant to the gist of this blog report. What was most surprising was that exploration of this rather unique arena did not come from NCCAM, or in fact from any realm associated with the practice of alternative, or complementary, or holistic, or integrative, or naturopathic, or whatever-shall-we-call-it medicine. It came from pediatrics, nursing, and a pet food company. Surprising, as it awoke me to the fact that we do not have dominion over unconventional therapies, as our marketing brochures and indeed last February’s Institute of Medicine Summit on Integrative Medicine or last May’s North American Research Conference on Complementary and Integrative Medicine would have us believe.

This is a very, very good thing, especially for naturopathic medicine, because it confirms that no medical field, conventional or other, is able to usurp any clinical or research field as some have feared – the realm of healthcare is simply too slippery to remain within the grasp of any one profession. It’s sort of like the power of the Internet in China, or even here in the U.S. No government, or industry, or social experiment will ever control any culture or country or endeavor as long as people can find a way to share information with each other. Like in a blog.

By the way, if you may be wondering why the NIH has a new-found interest in the human-animal bond as a healing modality, keep in mind that there are over 750 equine therapy centers and over 2000 canine therapy programs up and running in our hospitals, cancer centers, nursing home, prisons, et al. – each with certified therapists and each with a waiting list stretching around the proverbial block. In other words, it exists, people are using it and paying for it out of pocket, and so we might as well research it and give it our medical stamp of approval.

Sound familiar?

Remembering Daniel Leek

By Christine Girard, ND
AANP 2010 Physician of the Year

Daniel Leek, SCNM second year medical student. Photo courtesy of SCNM.
The Southwest College of Naturopathic Medicine mourns the loss of Daniel Leek, a second year medical student, in a tragic car crash that occurred Thanksgiving morning.

Dan grew up in Rockford, IL, and attended Southern Illinois University – Carbondale where he received three Bachelor’s of Arts Degrees: in psychology, physiology and biochemistry. He started his professional life as a senior research associate at the University of Chicago, conducting research in muscle physiology and molecular biology.

Dan started SCNM in the fall 2008 and made an immediate impression with his exuberance for experiential learning and his passion for research. Dan worked closely with Drs. Langland and Waters on research projects both at SCNM and at the ASU Biodesign Institute. He is an author on a recently submitted article, “Quantitative evaluation of the broad-spectrum anti-microbial activity of colloidal silver.”

In August 2010, Dan had the opportunity to speak before researchers and clinicians at the American Association of Naturopathic Physicians conference. He presented “The Regulation of Inflammatory Gene Expression by Immunostimulatory Botanicals” – and won the student research award which was presented at the formal awards ceremony that concludes the conference. He also presented research findings at the September 2010 SCNM Board of Trustees meeting – and wowed the Board members. Dr. Schwalm, the president of the Board, when informed of Dan’s passing extended his and the Board’s deepest sympathies for the loss our community has sustained.

Dan’s ultimate goal was to pursue a career in research, through an NIH post-doctoral fellowship, to expand knowledge in the area of naturopathic medicine.

Those who knew Dan, knew that he was a spiritual guy – and a guy with a big brain for big teachings whether the Bible, the Upanishads, Ram Dass, or quantum mechanics. Many of the stories about Dan involve hours-long conversations. He loved to talk about where we might go with a topic, be it spiritual or scientific.

Dan paraphrased Ram Dass by saying, “Moments of suffering in life are the fuel for bliss if interpreted spiritually.” Dan would want everyone to remember that.

Dan is well respected and well loved. He remains with us as an integral part of the fabric of the SCNM community. Memory Eternal!

Academia Translated into Plain English

By Bill Benda, MD

Hippocrates Statue and Dooley Hospital Door
Photo by taberandrew via Flickr, used under the Creative Commons License.

Ah, research. The bastion of Truth, the harbinger of new therapies, the gospel according to NCCAM, the Holy Grail of healthcare. Our research departments are at the heart of every medical center, pumping veracity through the veins of academia and bringing lifeblood to the marketing agencies.

But wait just one evidence-based minute. This particular journalist was actually a researcher for a few short years, a certified NCCAM principal investigator probing the effects of hippotherapy (physical therapy on horseback) on children with spastic cerebral palsy, resulting in two publications in peer-reviewed journals. And I am figuratively here to tell you that our collective, integrative research data is not holy, but in fact full of holes. Despite our truest of intentions, my fellow investigators and I walked into the studies brimming with bias (children and animals, for gosh sakes), and emerged no less partisan given our positive results. This does not mean the therapy did not benefit the kids; it simply means we found benefit despite our blinkered perspective.

Now please don’t get me wrong – as imperfect as it is, research is still one of our best tools in determining what arrows to place in our therapeutic quiver. But its conclusions are not the Truth, but simply one more finger pointing in the general direction of the Truth. And to help you, the clinician, to comprehend our particularly pedagogical dialect within the covers of your favorite journal, I have compiled a list of commonly utilized research phrases along with their more accessible vernacular to help in translating the next study you peruse in your living or other room. Plus, as an extra bonus and in the spirit of journalistic integrity, I am going to openly admit that I have plagiarized the following from an anonymous source within the pages of my monthly Funny Times subscription.

So without further ado, here is a translation of common academic phrases into plain old English:

  • “It has long been known” . . . I didn’t look up the original reference.
  • “A definite trend is evident” . . . These data are practically meaningless.
  • “While it has not been possible to provide definite answers to the questions” . . . An unsuccessful experiment but I still hope to get it published.
  • “Three of the samples were chosen for detailed study” . . . The other results didn’t make any sense.
  • “Typical results are shown” . . . This is the prettiest graph.
  • “These results will be in a subsequent report” . . . I might get around to this sometime, if pushed/funded.
  • “In my experience” . . . Once.
  • “In case after case” . . . Twice.
  • “In a series of cases” . . . Thrice.
  • “It is believed that” . . . I think.
  • “It is generally believed that” . . . A couple of others think so, too.
  • “Correct within an order of magnitude” . . . Wrong. Wrong. Wrong.
  • “According to statistical analysis” . . . Rumor has it.
  • “A statistically oriented projection of the significance of these findings” . . . A really wild guess.
  • “A careful analysis of obtainable data” . . . Three pages of notes were obliterated when I knocked over a beer glass.
  • “It is clear that much additional work will be required before a complete understanding of this phenomenon occurs” . . . I don’t understand it, and I never will.
  • “After additional study by my colleagues” . . . They don’t understand it either.
  • “A highly significant area for exploratory study” . . . A totally useless topic selected by my committee.
  • “It is hoped that this study will stimulate further investigation in this field” . . . I am pleased to feed you this B.S., and hope you will give me more funding.

So, future researchers, I hope this thesaurus will assist you in your lofty goal of saving humanity. Go get ‘em!

The Circle Game

By Bill Benda, MD, FACEP, FAAEM
2011 Naturopathic Champion Award Winner

Photo by Helen White via Flickr, used under the Creative Commons License.
So. It’s time to find a topic for the next edition of the Physicians Who Listen blog. I know because a week or so ago I received the gracefully worded request from Matthew Santoro, the Communications and Media Associate of the AANP, gently reminding me that Friday is the deadline.

And Friday came and went, bringing to my consciousness the fact that my Integrative Medicine: A Clinician's Journal editorial was also overdue by two weeks, and the Journal of the ACM deadline is only a week or so away, and that my mind is and has been a total blank. It’s not writer’s block—I could blather on for hours about various idiocies inherent to the conventional health-care system or how the emerging theory of basing physician pay on patient satisfaction would be the clinical kiss of death in the Emergency Room.

Nope. I’ve come to the sad conclusion that I really have nothing left to say about the field of integrative/holistic/naturopathic medicine that I haven’t said before, and others’ oft-employed editorial option of describing how the purity of our natural therapies reminds me of the first breath of Spring just isn’t my style. And of course I still do not have the courage to remark on Karen Howard’s leaving or how totally predictable our major conferences have become, as it may hurt some people I still like and admire (but stay tuned).

So I am stuck with nothing to say, and therefore have no choice but to talk about why there is nothing to say. Primarily because this grand experiment of ours is no longer grand or an experiment, at least to me, but simply another chapter in the Big Book of Health-care Tales. Not to sound a discouraging note—this conclusion is simply evidence of an inevitable step in the evolution of all great ideas. First the excitement and purity of discovery (this is so cool and makes so much sense), followed by the heady rise against all odds (from ridicule and ostracization (no, its not a word) to the emergence of Weil, Ornish, NCCAM, IOM reports, and countless billions spent out of pocket), all highly seasoned with the seductive flavor of danger (what if we can’t ever make a living doing this? What if we can’t even find a job?).

But then, with every “victory” comes the inevitable price.

“We can’t prove all of this because the reigning research paradigm was created for reductionistic trials” has become “we must make research a priority because it’s the only way the reigning paradigm will accept us.”

“Should we even consider accepting insurance reimbursement?” has transmogrified into “naturopaths are now on the federal CPT committee!”

Our pioneers are now not only writing even more books but also selling their household products online and hosting daily television shows that remind me of a cross between Oprah and Phil Donahue.

And if I get one more “Dear Bill, this is a personal note to you, and I hope you will join me in an exciting seven-day program to cure you patients and increase your income by 25%,” I’ll have to reach for the Nux Vomica.

It ain’t what it used to be, folks, and I guess that can be considered a good thing in today’s social media/newest/greatest culture. It means we’ve arrived. But it makes me want to leave again, to find whatever the next cutting edge is, the one that will challenge the integrative/holistic/naturopathic model I helped create. To feel the resistance rather than the acquiescence, to worry again that I may not really have a clue as to what I am doing.

I want some new paradigm, fresh idea, brilliant concept - one whose purity will remind me of the first breath of Spring . . .

President's Message: Science and Naturopathic Medicine

By Carl Hangee-Bauer, ND, LAc
AANP President

When I was a teenager, my first career choice was marine biology. Growing up along the coast in Florida, I spent much of my spare time in nature and in the water, enjoying the marvels of life and the natural world around me, and I still spend most of my vacations in natural settings and in the water. In school, I was a science geek and took every course in biology, chemistry, physics, etc., I could. When I went to college at Florida State University, my major was Biology, with dual minors in Chemistry and Physics. It was during my four-year stint in the United States Army that my attention was redirected to the medical field (I was a Medical Service Corps Officer), which eventually led me to naturopathic medicine and my true life career.

I tell you this to let you know that I am no stranger to science. I still find it fascinating and appreciate the many ways it helps us understand the workings of nature and the world, helping us separate what appears to be the truth of things from reality. Studying naturopathic medicine, and especially acupuncture, presented me with many challenges, and I learned along the way that our medicine, as well as all other systems of medicine, are really a combination of science and art. When we work with our patients, we draw from both in order to stimulate the vis and provide well-rounded care to our patients.

Thus it has become an increasing concern to me when I read articles and blogs on the Internet blasting naturopathic medicine for being “unscientific.” These frequently polemic articles, while professing to come from scientific logic, to my eye are biased misrepresentations of the truth. They often lambast our profession and philosophy as unscientific, yet I have yet to see any one of them provide a critical analysis of research done by naturopathic physicians and researchers. It is sad that science can be used in these political ways.

This is important. As a student at Bastyr University, I remember Dr. Joe Pizzorno saying that if our profession is to be taken seriously by the larger world of medicine, we must speak in a language that everyone can understand and appreciate. That language is the language of science, and few have done more over the past 25 years than Dr. Pizzorno to increase the credibility of the naturopathic profession using this approach. While I think we all can agree that we draw both from science as well as traditional practices and experiences when evaluating the efficacy of our therapies and approaches to practicing medicine, advancing the research and science agenda remains an important step for our profession to move forward, especially with the continued interest in evidence-based approaches to health care.

Fortunately there is now a great effort within the profession to advance our understanding of how science informs naturopathic practice, especially in the realm of whole practice approaches to health issues. Dr. Michael Cronin, the AANP’s President-Elect, has been a strong advocate on the AANP Board for promoting scientific affairs. The Naturopathic Physicians Research Institute (NPRI), headed by Dr. Carlo Calabrese, is a group of academic and community clinicians, clinical researchers and other health scientists whose aim is to increase the amount of original data and analysis on the practice of naturopathic medicine for the purposes of its documentation and improvement, the discovery of potentially generalizable health applications, and to inform policy. And, of course, there is active research going on presently at all of our naturopathic colleges by well-trained and experienced researchers who are testing the theories and practices of naturopathic medicine. Much of the discussion I’ve heard lately focuses on studies of whole practice approaches to health care versus single agent actions.

On August 16, 2011, the Tuesday before the start of the 2011 AANP Convention, the AANP will be sponsoring a scientific summit. While only in the early stages of planning, it promises to be a gathering for the different players in the naturopathic profession to connect and define how the AANP mission, naturopathic research, and evidence-informed health policy can join and result in healthier patients, a more effective health-care system, and a flourishing naturopathic profession. Core discussion points will include articulating policy and practice issues driving our research agenda, where the profession is now and what future possibilities exist, and defining the core research questions relating to safety, effectiveness, and costs.

The AANP Board and many in our profession agree that where possible providing a scientific basis for our therapies and for the naturopathic approach is an important step in growing our professions credibility and inclusion in the greater health care system. How we prioritize this and communicate to the public is of vital importance.

I hope to see many of you there.

Alley Jelly and Modern Chemistry

By Jacob Schor, ND, FABNO

Photo by Rachel Tayes via Flickr, used under the Creative Commons License.
There is a Hebrew prayer that expresses gratitude after tasting the first fruit of the season. This morning I am wondering whether there shouldn’t also be a prayer for the last taste of the season. I think this as I toss our last sprig of fresh basil into a pan of hot olive oil and the kitchen fills with the odor. The basil is in competition, though, with a pot of applesauce; I’d collected golden yellow apples that last night’s wind knocked off the tree around the corner. With the clock’s dropping back over just two weekends ago, there’s room in my morning schedule to make pack away a jar of applesauce before leaving for the office.

The weather here in Colorado collaborated to produce a bumper crop of fruit here in Denver. After watching cherries, apricots, plums and apples compost on the lawns of neighbors who have neglected to harvest their bounty, I’ve taken it upon myself to save what I can. Poppy also has taken advantage of the apples especially, and insists on eating a stomach full each day.

My wife Rena and I have been making grape jelly on weekends with some of the most flavor-filled Concord grapes I can even recall tasting. Thus the last few weekends have found me gathering the grapes hanging into an alley just off Montview Boulevard. This has led me to the grocery store, and to start experimenting with the new forms of pectin available. No doubt some reader will write to tell me that I shouldn’t use these modified pectins, but at this point, in my ignorance, they are very exciting. Traditional jelly-making required very high sugar concentrations to set. If I recall correctly, one heated the jelly ‘broth’ to about 220 degrees Fahrenheit, a temperature at which the mixture was about 65% sugar. Without the high sugar concentration, the jelly wouldn’t set. It had to be sugar; the pectin wouldn’t jell if you tried substituting honey.

Times have changed and food chemists have developed pectins that don’t require added sugar and will still jell if sweetened with honey. This is why you can buy sugar free jelly and preserves in the grocery store. We made our first batch of grape jelly the old fashioned way, making juice from the grapes and cooking it down with what seemed an enormous amount of sugar. Our second batch is still setting, but we made it without adding any sugar. I’m quite looking forward to opening the jar for my first taste in a few weeks.

An excellent discussion of how to make no sugar jellies is available from the University of Tennessee’s Agriculture Extension Service: www.utextension.utk.edu/publications/spfiles/SP325-F.pdf

This leads me to the point in this blog piece when I turn on my computer’s link to the National Library of Medicine and look up some current scientific data linked to whatever I am ruminating upon.

It so happens that there is a new paper looking at the effect of drinking Concord grape juice on blood pressure published a just over a week ago.

Researchers at the Boston University School of Medicine, almost within sight of Concord, the town where the grapes are originally from, conducted a placebo-controlled trial of grape juice in mildly hypertensive individuals. This was a double-blind cross over study. 64 otherwise healthy people participated and drank either grape juice or a placebo for two months, took a month off, and then switched beverages.

Although no statistically significant difference in average blood pressure was measured, several endpoints of interest did change during the grape juice portion of the study. Night-time blood pressures dropped 1.4% while drinking grape juice, while they increased 2.3% during the placebo phase. Blood sugar decreased 2 mg/dL while drinking grape juice, and increased 1 mg/dL during the placebo phase.i Interesting, but not fascinating.

These results are different from an earlier study from 2004. In this earlier study that was conducted in Korea, systolic blood pressure decreased an average of 7.2 mm Hg (p = 0.005) and diastolic blood pressure average by 6.2 mm Hg (p = 0.001) at the end of 8 weeks.ii In the new study. participants drank 7.5 ml /kg body weight, while in the older study, 5.5 ml/kg body weight was consumed.

Could the grape juice polyphenol content have varied, or could there be some genetic variant that differed between populations? It’s not clear.

Whatever the case with these studies, I remain enchanted with the idea of making sugarless jams and jellies, and look forward to next summer’s possibilities already. And as far as my pondering the lack of a prayer for the last of the season, well, it’s obvious that wiser ones than I understand that one never knows which taste will be our last so that all that we can mark is the first.
____________________________________________
i Dohadwala MM, Hamburg NM, Holbrook M, Kim BH, Duess MA, Levit A, Titas M, Chung WB, et al. Effects of Concord grape juice on ambulatory blood pressure in prehypertension and stage 1 hypertension. Am J Clin Nutr. 2010 Nov;92(5):1052-9.
ii Park YK, Kim JS, Kang MH. Concord grape juice supplementation reduces blood pressure in Korean hypertensive men: double-blind, placebo controlled intervention trial. Biofactors. 2004;22(1-4):145-7.

Red Leaves in Fall

By Jacob Schor, ND, FABNO

Photo by Mike Gifford via Flickr, used under the Creative Commons License.
We traveled to the east coast recently. Ostensibly we were going to a wedding and for Parents Weekend the following weekend at our daughter’s college, with the days between spent at the family cabin in Maine. In truth, we were going to see the leaves.

The leaves of deciduous trees change colors in autumn before they fall off the trees. Obviously this process gives name to the season. Less obviously, the Greek term for this leaf falling phenomenon is the etymologic base for the modern term ‘apoptosis,’ which describes the process of cellular suicide, an honorable and desirable decision when initiated in cancer cells. Why trees exhibit such a wide range of colors has been one of those unanswered questions for both the questioning mind and modern biologists.

A series of papers now provide an interesting answer to this question, and lead to an even greater appreciation of fall colors while forcing us toward some interesting ruminations.

Your basic, generic leaf is green. This is because chlorophyll is green and leaves contain lots of chlorophyll. Plants use chlorophyll to absorb energy from sunlight and convert it into sugars and starch, your basic elements of what we call food.

When leaves begin to die in the fall, the chlorophyll green fades away and no longer blocks out the underlying yellow pigments. Leaves turn yellow when they die. Yet some leaves turn brilliant red.

Red leaves are a different story. Chemicals called anthocyanins are responsible for this red color; they weren’t present in the leaves during the summer. Some trees actively make anthocyanins as their leaves start to die. Why would a tree go to the effort (expense) of filling leaves with anthocyanins just before they become ground litter? An even better question is, why are red leaves common in New England and rare in Western Europe?

Anthocyanins serve a number of functions in plants. The list gets longer every few years.

In 2003, William Hoch of Montana State University, reported that anthocyamins helped send nutrients to the plants roots.  Blocking anthocyanin production resulted in the plant sending fewer nutrients to the roots for winter storage.i

In 2007 Habineck reported that trees that grown in nitrogen-poor soils produced anthocyanins because the pigments protected the leaves and kept them alive a bit longer giving them the chance to store  more nutrients in their roots before winter set in. Thus the red hues in the fall are the sign of a stressed tree trying to squeeze out a few more days of photosynthesis, to make every last bit of food to survive..ii

Anthocyanins also protect leaves from freezing as the temperature gets colder in the fall and actually help the leaves absorb more warmth from sunlight postponing the inevitable.

Anthocyanin pigments also protect against damage caused by insects. This ‘insecticide action’ explains why autumn leaves are redder in the U.S. than in Western Europe.  Oddly enough this explanation comes from Simcha Lev-Yadun of the University of Haifa in Israel, a country not known for fall colors. While earlier theories focused on the red leaves serving as a warning to insects that ‘we don’t taste good,’ Lev-Yadun’s explanation focuses on the insecticidal properties of anthocyanins.  A carpet of anthocyanin rich leaves surrounding a tree through the winter decreases insect breeding and subsequent attack from insects the following year.

North America and Europe have underwent repeated eras of ice ages during which trees have evolved to become deciduous, adapting to fluctuating seasonal and climatic conditions. In adapting to both seasonal cold and dry periods, trees also learned to repel seasonal insect attacks. Many trees learned the value of seasonal anthocyanin production. (We should note that in the tropics, many plants produce anthocyanins year round.)

There is a key difference between the pressures put on trees in North America versus Europe. In North America, the challenge to trees during the ice ages was different; plants and insects could gradually migrate north and south as the ice fields waxed and waned. In Europe the trees were trapped, along with the insects that wanted to feast on them, between ice sheets that advanced from the north and from the Alps. According to Lev-Yadun’s thesis, these European insects largely died out: "The anti-herbivore component in red leaf coloration was relaxed, and northern Europe became dominated by trees with yellow autumn leaves." The European trees didn’t need to make anthocyanins, so they lost the habit. Thus European trees turn yellow with little red.iii

Here in Colorado, our thoughts quickly turn to Aspen leaves, which evolving high in the Rockies with reliable cold winters also had less need for insect defenses than trees in our eastern hardwood forests.

While solving this basic question of why leaves change colors just before they fall provides some relief, Lev-Yadun’s theory reminds us of a bigger question.

NDs often promote consumption of foods and nutritional supplements because of their high anthocyanin content.

Plants with high anthocyanin levels include the Vaccinium species (blueberry, cranberry and bilberry), the Rubus berries (black raspberry, red raspberry, blackberry, and blackcurrant), and a number of other plants including cherry, grape, red cabbage, violet petal, eggplant peel, black rice and black soybean.

Many nutritional proponents include these foods on their lists of the most beneficial things to eat.

Anthocyanins are but one example of chemicals that plants make that have insecticidal properties. When we start looking at other plant chemicals considered good for us, we eventually discover that the plant made them to be poisonous.

The yellow alkaloids in berberine and curcumin, the isoflavonoids in soybeans, the isocyanides in cruciferous vegetables and so on were all meant to be poisonous to bacteria, fungus, insects or animals.

Why is it desirable for us to swallow a botanical hodgepodge of poisons?

If we want to really understand this, we need to go back to basics. We need to view this question against an understanding of the basic laws of nature.

The first law of thermodynamics is often called the conservation of energy and says that, “Energy can be changed from one form to another, but it cannot be created or destroyed. The total amount of energy and matter in the Universe remains constant, merely changing from one form to another.”

The second law of thermodynamics tells us, “In all energy exchanges, if no energy enters or leaves the system, the potential energy of the state will always be less than that of the initial state." This is also referred to as the law of entropy. The universe always moves towards states of greater entropy or disorder. (I also refer to this as the Law of Socks, as in “Fewer pairs of sock will emerge from the dryer than I wore last week.”)

Everything in the universe moves toward states of greater entropy, except of course for things that are alive. Life is the opposite of entropy, always striving toward levels of greater complexity and order.

Things that are alive have the capacity to use energy and resist entropy. Living things react and adapt to forces that would drive them toward entropy.

The second law of thermodynamics: “if no energy enters or leaves the system…”
Living things are able to resist entropy because they constantly bring more energy into the system: they eat! Food contains stored energy. Resisting entropy takes energy; creating states of greater order takes energy. To do either takes food. We eat in order to resist entropy.

Thus, in a primal sense, we might define life as the ability to utilize the energy in food in order adapt, maintain order and resist entropy.

The stored energy in food all comes from sun, which at some point is stored through photosynthesis in plants.

Without food, living things lose their ability to resist the forces of entropy; they lose the ability to adapt.

How do you know if something is alive? You poke it. If it’s alive it moves. Living things respond to the world, to stimuli.

‘Poke it, see if it is alive’
Living things adapt and respond in someway to external forces; they adapt to maintain order, either to get out of harm’s way or to move toward food or less entropic environments.

These basic definitions of the universe lead us to a biological term called “adaptive response.” In its simplest definition, adaptive response means “an appropriate reaction to an environmental demand” (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier).

A fuller definition might read “The ability of a cell, tissue or organism to better resist stress damage because of prior exposure to a lesser amount of stress, observed in all organisms in response to a number of different cytotoxic agents.”

Adaptive response is now often applied to the ability to repair genetic damage and can be triggered by exposure to cytoxic exposure, to phytonutrients such as anthocyanins. Adaptive responses can also be triggered by whole organism stressors.

An example of whole body stressors is the Scandinavian habit of cold water swimming. Researchers there have done some interesting work on adaptive responses in individuals who enjoy this practice, which entails taking hot saunas and then leaping into holes cut into the winter ice of lakes for a swim.

One Finnish study tells us that this habit changes an individual’s response to cytokines: “These stresses appear to challenge both the neuro-endocrine and the immune systems and the results indicate that adaptive mechanisms occur in habitual winter swimmers.”iv

As an aside, as we look at the many traditional practices of nature cure that were and are promoted by members of the naturopathic profession, we can see how many of them trigger adaptive responses.

Coming back to red leaves in autumn and anthocyanins, if we view anthocyanins as elements that will trigger various adaptive responses, such as triggering DNA repair and preparing our bodies to adapt to stressors, we can see how and why these chemicals can be both poisonous to insects and health-promoting to humans at the same time.

As we watch leaves turn red this autumn, perhaps we can also find some pleasure in the understanding of these complex relationships that give rise to these leaf colors that our minds simply perceive as a thing of beauty.

--
iHoch W, Singsaas E, McCown B. Resorption Protection. Anthocyanins Facilitate Nutrient Recovery in Autumn by Shielding Leaves from Potentially Damaging Light Levels Plant Physiology 133:1296-1305 (2003)
iiHabineck, EM. Correlation of soil development and landscape position with fall leaf colors. Paper No. 81-15 2007 GSA Denver Annual Meeting (28–31 October 2007)
iiiLev-Yadun S. The shared and separate roles of aposematic (warning) coloration and the co-evolution hypothesis in defending autumn leaves. Plant Signal Behav. 2010 Aug;5(8):937-9.
ivDugué B, Leppänen E. Adaptation related to cytokines in man: effects of regular swimming in ice-cold water. Clin Physiol. 2000 Mar;20(2):114-21.

Valentine’s Day: Pistachio Nuts and Erectile Dysfunction

By Jacob Schor, ND, FABNO

Photo by theogeo via Flickr, used under the Creative Commons License.
Given the results of several recent studies, pistachio nuts should soon become the most prominent ingredient in Valentine’s Day meals. As our population of baby boomers age, they look less for aphrodisiacs and more for some sort of natural Viagra. Pistachios may fill this function.

Pistachios were likely the first nut to be cultivated. Remnants of pistachios found in archaeological digs in Jordan have been dated back to 6760 BCE, that’s close to 9,000 years ago. It’s thought that pistachio cultivation began in Iran, then spread through the Middle East to Turkey and then Italy. Immigrants from these areas began importing the nuts to the United States in the late 1880s. Trees were imported to the U.S. originally as ornamentals in 1854. Trees imported from France were planted in Sonoma, California, in 1875. In the early 1900s, the U.S. Department of Agriculture planted pistachio nut trees at the Plant Introduction Station in Chico, California. Still, few pistachios were grown in the U.S. Most were imported from Iran until the 1970s. It was when commercial exports from Iran became unavailable in the U.S. that significant commercial production of pistachio nuts began in the San Joaquin Valley of California.

It’s pretty well established that nuts improve lipid levels, lowering LDL and triglyceride levels and raising HDL, the good cholesterol. This is certainly true for pistachios.

Two papers on pistachio consumption and heart disease risk factors, Kay et al and Gebauer et al, published 2008 and 2010 respectively, are good examples. To briefly summarize, Kay reported in 2008 that eating two servings of pistachios per day dropped cholesterol by 8%, LDL by 11% and the non-HDL cholesterol/HDL cholesterol ratio by 10%.i In 2010, analyzing blood samples retained from Kay’s initial 2008 study, Gebauer reported that eating pistachios had had a significant impact on reducing levels of oxidized LDL.ii

An April 2010 paper by Sari et al was the first suggestion that pistachios might be useful for erectile dysfunction. This study reported that a diet high in pistachios improved lipid and blood glucose levels, but more importantly improved endothelial function. Endothelial function is important in relation to heart disease, and it’s also important in some other areas. The 32 participants in the Sari study followed a Mediterranean style diet for four weeks prior to instituting the pistachio phase. After the month of eating pistachios, low density lipoprotein had dropped by 23 % and total cholesterol by 21%. The pistachio diet significantly improved endothelium-dependent vasodilation (P=0.002, 30% relative increase).iii It should be noted that the participants followed a Mediterranean diet for a month prior to starting the pistachio phase of the study. Following a Mediterranean diet in itself might improve erectile dysfunction.iv

A recent study from just a few weeks ago, published in mid-January, focused directly on erectile dysfunction. Aldemir et al recruited 17 men with complaints of erectile dysfunction for at least a year. They were fed 100 grams (about four ounces) of pistachios each day for just three weeks. This was long enough to see a significant increase in function, a 51% increase in scores on the International Index of Erectile Function.v

Valentine’s Day is coming up fast. How many pistachio nuts do you think your patients will be willing to eat between now and then?
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i Gebauer SK, West SG, Kay CD, Alaupovic P, Bagshaw D, Kris-Etherton PM. Effects of pistachios on cardiovascular disease risk factors and potential mechanisms of action: a dose-response study. Am J Clin Nutr. 2008;88(3):651-659.


ii Kay CD, Gebauer SK, West SG, Kris-Etherton PM. Pistachios increase serum antioxidants and lower serum oxidized-LDL in hypercholesterolemic adults. J Nutr. 2010 Jun;140(6):1093-8. Epub 2010 Mar 31.


iii Sari I, Baltaci Y, Bagci C, Davutoglu V, Erel O, Celik H, et al. Effect of pistachio diet on lipid parameters, endothelial function, inflammation, and oxidative status: a prospective study. Nutrition. 2010 Apr;26(4):399-404. Epub 2009 Jul 31.


iv Esposito K, Giugliano F, Maiorino MI, Giugliano D. Dietary factors, Mediterranean diet and erectile dysfunction. J Sex Med. 2010 Jul;7(7):2338-45. Epub 2010 May 4.


v Aldemir M, Okulu E, Neşelioğlu S, Erel O, Kayıgil O. Pistachio diet improves erectile function parameters and serum lipid profiles in patients with erectile dysfunction. Int J Impot Res. 2011 Jan 13.