9/21/2015

1

What is Integrative Medicine Comprehensive prevention-based approach to enhance

health promotion and manage chronic disease Multi-disciplinary, evidence based team approach to care:

Doctor Nutrition counseling Health coaching Exercise Massage Acupuncture Chiropractic Aromatherapy Supplements & herbal therapies

US Health Sad state of affairs:

>50% of US population has 1 or more chronic illness Today’s children are predicted to have a shorter life span

than their grandparents Only 43% of Americans are at a healthy body weight <15% of US population meets 4/5 health promotion

goals: optimal BMI, nonsmoker, high quality diet, regular exercise activity and minimal alcohol consumption. American Journal of Preventive Medicine, 27:2 Suppl. 25-33

9/21/2015

2

Integrative Medicine Treating the whole person: body, mind and spirit fosters

resiliency. Resilient people weather life’s up’s and down’s with less

illness 73% of CAM users surveyed for a study reported behavior

change such as eating healthier or instituting regular exercise: 53% reported motivation to make a change was result of

feeling better with prescribed therapy 53% indicated motivator was the provider suggesting the

change Altern Ther Health Med. 2011 Jan-Feb; 17(1):22-30.

Integrative Medicine Patients working with IM practitioners:

Healthier Lower health care costs Survey high level of satisfaction

IM Cost Savings Ornish Lifestyle Program: plant based diet, exercise,

yoga based mindfulness, group support Participants followed 30yrs

Outcome reversal of heart disease and prostate cancer 80% of participants who changed lifestyle avoided heart

surgery or angioplasty $30,000 calculated per patient

Explore (NY). 2010 Sep-Oct; 6(5):308-12

9/21/2015

3

IM Cost Savings Employee Resilience Training @ Allina Hospitals and

Clinics: Instruction mind-body techniques, exercise direction

and nutrition counseling 60% participants experienced remission of depression

without prescription drug therapy Improved production and activity (fewer sick days) Value $2181 per employee per year

Duskek, J (2010). Penny George Institute for Health and Healing Outcomes Report.

Integrative Medicine Oncology Patient Autonomy: taking control over your personal

destiny Personal contribution to minimize side effects of

treatment thereby improving quality of life Better tolerance of treatment higher chance of

completing prescribed treatment and improving survival

Survivorship plan maintain remission & prevent recurrence

Stress Management

Crucial in chronic disease management Stress may contribute to poor nutrition, nausea, appetite

reduction (weight loss), carbohydrate cravings (weight gain)

Stress exacerbates pain, mood disorders, sleep disruption, co-morbid conditions such as HTN , DMII, CAD, Chron’s, Irritable Bowel…thereby impeding the patient’s healing

9/21/2015

4

Stress Management

Feeling of control decreases stress Support team: family, friends, coworkers, community,

professional caregivers Motivational forces: concerns, beliefs, values, goals Integrative therapies: nutrition, exercise,

acupuncture, massage, aromatherapy, meditation, counseling

Aromatherapy Autonomy for management of nausea, pain, anxiety,

sleep, hot flashes

9/21/2015

5

Nutrition & Exercise Core therapy First line for most chronic illnesses: HTN,

Hyperlipidemia, CAD, DMII, COPD, Back Pain, Osteoarthritis, Fibromyalgia, Eczema

Nutrition & Exercise important component of cancer treatment and post treatment survivorship

Exercise

Largest number of studies supporting its benefits of any of the integrative therapies Benefits response to cancer treatment = higher remission rates, longer survival Benefits post cancer treatment = decreased recurrence rates Exercise prescription tailored to the patients needs

Nutrition

Prevention is best Population studies show reduced cancer risk

associated with high consumption of vegetables and fruits

Several dietary botanical compounds are in preclinical or clinical trials for cancer chemoprevention: genistein (soybeans), lycopene(tomatoes), brassinin (cruciferous vegetables), sulforaphane (asparagus), indole-3-carbinol (broccoli), resveratrol (grapes & peanuts)

• Gullett NP, et al. Demin Oncol. 2010 Jun

9/21/2015

6

Nutrition Phytochemicals are likely to reduce the risk of acquiring

cancers by acting on cellular pathways: Suppress cancer cell proliferation Inhibit angiogenesis Suppress expression of anti-apoptotic proteins (enhance

apoptosis) Inhibit cyclooxygenase-2 Inhibit growth factor signaling pathways Induce apoptosis Inhibit nuclear factor-kB, AP-1, MAPK, p53, and JAK-STAT

activation pathways• Rajput S, Mandal MEur J Cancer Prev. 2012 Mar

Nutrition Recommendations Increase intake:

Phytoestrogens: isoflavenoids (soy, beans, legumes), lignans(cereal brans, beans, flaxseeds), & coumestans (beans-pinto, lima, split peas, alfalfa, clover sprouts)

Cruciferous vegetables “cabbage family”: cabbage, broccoli, cauliflower, brussel sprouts, kale, bok choy

Garlic and onions Tumeric and ginger Mushrooms Green tea Coffee Omega 3 fatty acids Vitamin D

Nutrition Recommendations Mediterranean diet = anti-inflammatory diet High intake of omega-3 fats and antioxidants Avoid omega-6 fats and simple sugars=Avoid

processed foods Helps prevent cachexia in combination with medical

treatment of the tumor Cachexia results from cytokines (inflammatory

biochemicals) that are produced and secreted by the cancer cells

9/21/2015

7

Mediterranean Diet Studies Mediterranean Diet w olive oil may lower risk of breast ca

by >50% JAMA Internal Medicine 2015 Sept 14: 1-9 (Toledo E et al.)

Mediterranean Diet Decreases Risk of Endometrial Ca British Journal Ca 2015 May 26; 112 (11): 1816-21 (Filomeno et al.)

Eating Fish May Prevent Depression Journal Epidemiology & Community Health 2015 Sept 10, pii; jech-2015-206278(Li Fu et al.)

Primary Prevention CAD-Mediterranean Diet N Engl J Med 2013; 368:1279-90 4/4/2013

Mediterranean Diet Improves Blood Sugar Control & Cholesterol Nutrition & Diabetes 2015 July 20; 5:e172 (Violi F. et al)

Lower Birth Defects Linked w Moms who eat Mediterranean Diet Archives of Disease in Childhood 2015 August 24. pii:fetal neonatal-2014-3908013 (Botto LD et al)

Mediterranean Diet Preserve Brain Structure, Delay Cognitive Aging Alzheimer's & Dementia 2015 July 16 Pelletier A et al

Nutrition Recommendations

Nutrition Weight Loss Overwhelming # Diets to choose from: Mayo clinic,

Atkins, LA weight loss, Weight Watchers, Jenny Craig, ABO Blood Type, YOLI, Body By Vi, Ideal Protein, Profile diet, Southbeach, Thrive, Alkaline Diet, HCG diet, Baby food diet, Paleo, Chewing diet, Tapeworm diet

# attempts at wt loss prior to success

9/21/2015

8

Nutrition Recommendations Supplements will not make up for a poor diet. Dietary botanicals are safe, cost less and have superior

oral bioavailability It is unlikely that one compound such as indole-3-

carbinol as found in broccoli is solely responsible for its benefits; it is more likely that it is a harmony of multiple compounds in the plant that provide benefits for the body & its superior bioavailability

Coffee

National Cancer Institute >500,000 Americans Over 15 years >4 cups coffee daily (reg or decaf) attributed to 15%

decreased risk colon cancer Effect maintained adjusting for exercise, BMI, family

history, alcohol intake and smoking

Green Tea EGCG is a major constituent in green tea that has been

shown to inhibit cell proliferation and induce apoptosis in several types of human tumors

EGCG is a potent antioxidant • Maruyama T, Oncol Rep. 2014 Feb

9/21/2015

9

Mushrooms and Green Tea 2,018 pre and postmenopausal Chinese women 10 g fresh mushroom or 4 g dried mushrooms Women who consumed fresh mushrooms daily were

64% less likely to develop beast ca Mushroom intake with regular green tea consumption

reduced the risk of breast cancer by about 90%• Zhang, M, et al: International Journal of Cancer March 2009

American Cancer Society “…strong evidence that a diet rich in vegetables, fruits

and other plant-based foods may reduce the risk of cancer…there is no evidence at this time that supplements can reduce cancer risk…some evidence exists that indicates that high dose supplements can increase cancer risk.”

• Kushi et al, Cancer 2006

Supplements

Supplement use by patients is widespread and underreported

A few supplements have good evidence for prevention of cancer

Very few supplements have good evidence for efficacy in treating patients with cancer

Indiscriminate use of supplements may result in interactions with therapy by induction or inhibition of metabolism enzymes effecting therapeutic levels of drugs

9/21/2015

10

Curcumin Diverse mechanisms affecting multiple levels of cell

pathways for tumorigenesis….anticarinogenic, antimetastatic, antiangogenic, proapoptotic and antioxidant

Omega 3 Fatty Acids

Breast cancer patients with higher fat tissue levels of DHA showed improved response to chemotherapy compared to patients with lower levels of fat tissue DHA

Mechanisms: Increase chemo drug accumulation within cancer cells Reduce cancer cell proliferation by inhibiting protein

kinase C activity Bougnoux, P, et al. Br J Cancer 1999 Apr;

Omega 3 Fatty Acids Non-small cell lung cancer O3FA + standard care compared to standard care 60% vs 25.8% noted increased response rate and

clinical benefit One year survival greater w O3FA group 60% vs 38.7%

Murphy et al, Cancer 2011

9/21/2015

11

Vitamin D Studies show patients w/ new cancer dx have lower

vitamin D levels than healthy age matched controls Higher vitamin D levels at dx correlates w/ better

survival

Vitamin D

Men w/ higher vitamin D levels: 17% overall decreased cancer incidence 29% decreased cancer mortality 43% decreased GI cancer incidence 45% decreased GI cancer mortality

• Giovannucci et al J Natl Cancer Inst 2006

Astragalus Meta analysis 34 studies – 2815 pts w/ advanced non

small cell lung cancer and platinum based chemo 12 studies – decreased risk death @12mo 30 studies – improved tumor response to chemo

9/21/2015

12

Chinese Herbal Formulas Prescribed based on meridian diagnosis Support the body: energy, immune system, nutrition

(appetite, digestion & absorption) during chemo or radiation therapies for the cancer

Chinese Herbal Formulas San Francisco Study demonstrated dramatically superior

survival rates in colon cancer patients at any stage –comparing Conventional Western Txt alone vs. Conventional + Asian Holistic txt (Acupuncture + Chinese Herbs) 1yr: 100% combo alive vs. 40-95% conventional alive dep on

stage 5yr: 60%-82% survival rate combo group vs 7%-8%

conventional group Additional studies to come Dana Farber Ca Center Harvard;

Cleveland Clinic Integrative Cancer Therapy 2011 Sep; 10(3):240-59.doiu

Mushrooms Stimulate patient’s immune response to the cancer

Uptake into macrophages & turning on enzymes involved in tumor inhibition

Stimulate T cells & Natural Killer cells

9/21/2015

13

Mushrooms NIH funded 7 year study Univ of MN and Bastyr Univ

Women stage I – III breast cancer Daily turkey tail mushroom supplement Added support for immune function No patients w adverse effects adding mushrooms to the

treatment regimen

Shiitake Lentinan Patients advanced stage 3-4 unresectable cancers 1-2mg 1-2 x weekly x 1 yr Increased survival time by 6-9mo

• Matsuoka H et al Anticancer Res 1997

White Button Mushrooms Inhibits aromatase activity and breast cancer cell

proliferation

Enhances NK cell activity in mice

• Biaba J et al J Nutrition 2007• Wu D J Nutrition 2001

9/21/2015

14

Reishi Stimulates immune function in patients w advanced

cancers Increased CD56 & NK cells

• Gao Y et al Immunol Invest 2003

Chemotherapy + Antioxidants Glutathione, melatonin, vit A, C, E, L-Carnitine,

CoQ10 15 human studies 3738 pts on nutritional antioxidant

supplements showed increased survival 50 human studies 8521 pts taking nutritional

antioxidant supplements Enhanced medical cancer treatment Decreased side effects on treatment

• Simone CB et al Alt Ther Health Med 2007

Chemotherapy & Antioxidants 33 articles 2446 patients

24/33 benefits decreased toxicity 1 study Vit A showed increased toxicity 5 studies antioxidant group completed more full dose

chemo in comparison to the non supplement group

• Block K et al Int J Cancer 2008 Sept 15

9/21/2015

15

Antioxidants – Melatonin Melatonin + Chemo in patients w/ metastatic solid

tumor 50% increase regression & 1 yr survival rates vs chemo alone Favorable studies for melatonin in breast, lung, kidney, liver,

pancreas, stomach, and colon cancer

• Lissoni P et al Eur J Cancer 1999

Antioxidants & Chemotherapy Unfavorable interaction antioxidant and alkylating

chemo agents such as bleomycin, anthrocyclines, etoposide, mitomycin

Supplement Guideline Hold day before, day of and day after radiation or

chemotherapy treatment

Stop supplements 7-10 days prior to any surgery or invasive proceedure

9/21/2015

16

Integrative Medicine Enhance the patient’s quality of

life emphasizing natural healing with complimentary evidence based integrative therapies

Active partnership with the patient – teaching wellness and encouraging the patient’s active role in good health

We work in partnership with the patient’s team of caregivers