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SEPTEMBER/OCTOBER 2015, VOL. 21, NO. 5

TABLE OF CONTENTS PERSPECTIVES 8

Nicholas Gonzalez, MD (1947–2015) Kelly Brogan, MD, ABIHM

12

A Statin for All Diabetics? Not So Fast …

Jonny Bowden, CNS; Drew Sinatra, ND; Stephen T. Sinatra, MD, FACC, FACN

ORIGINAL RESEARCH 16

The Effects of Musical Auditory Stimulation of Different Intensities on Geometric Indices of Heart Rate Variability Joice A. T. do Amaral, MSc; Heraldo L. Guida, PhD; Franciele M. Vanderlei, PhD; David M. Garner, MSc; Elaine Osório, MSc; Luiz Carlos de Abreu, PhD; Vitor E. Valenti, PhD

24

Smoking-related Alterations in Serum Levels of Thyroid Hormones and Insulin in Female and Male Students Ismail Meral, PhD; Ayse Arslan, PhD; Aydin Him, PhD; Harun Arslan, MD

30

Turkish Nurses’ Use of Nonpharmacological Methods for Relieving Children’s Postoperative Pain Ayda Çelebioğlu, PhD; Sibel Küçükoğlu, PhD; Emel Odabaşoğlu, MSci

PILOT STUDY 37

Oral Contraceptives Attenuate Cardiac Autonomic Responses to Musical Auditory Stimulation: Pilot Study Réveni Carmem Milan, PT; Bruna de Oliveira Plassa, PT; Heraldo L. Guida, PhD; Luiz Carlos de Abreu, PhD; Rayana L. Gomes, PT; David M. Garner, PhD; Vitor E. Valenti, PhD

44

Effect of Electroacupuncture on Transcutaneous Oxygen Partial Pressure During Hyperbaric Oxygen Therapy in Healthy Individuals Lan Qu, MD; Yong Ye, MD; Chunfeng Li, MM; Guangkai Gao, MD

52

A Prospective Trial of Ayurveda for Coronary Heart Disease: A Pilot Study Robert DuBroff, MD; Vasant Lad, BAMS, MASc; Cristina Murray-Krezan, BS, MS

review article 64

The Effectiveness of Dance Interventions to Improve Older Adults’ Health: A Systematic Literature Review Phoebe Woei-Ni Hwang, MS; Kathryn L. Braun, DrPH

73

Pilates Method for Lung Function and Functional Capacity in Obese Adults Janaina Rocha Niehues; Ana Inês Gonzáles, MSc; Robson R. Lemos, PhD; Patrícia Haas, PhD

x Table of Contents

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CONVERSATIONS 82

Michael Smith, MD: Treat the Underlying Causes of Weight Gain to Facilitate Successful Weight Loss Interview by Craig Gustafson

88

Tieraona Low Dog, MD: The Many Aspects of Greening Medicine Interview by Craig Gustafson

DEPARTMENTS 92

Conference Calendar

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Table of Contents

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editor in chief Andrew W. Campbell, MD CONTRIBUTING EDITORS

Michael Balick, PhD • Mark Hyman, MD • Jeffrey Bland, PhD, FACN, FACB • Roberta Lee, MD • Tieraona Low Dog, MD Editorial Board Sidney MacDonald Baker, MD ◆ Autism Research Institute

Rollin McCraty, PhD ◆ Institute of HeartMath

Brent A. Bauer, MD ◆ Mayo Clinic

Pamela Miles, Reiki Master ◆ New York, NY

Mark Blumenthal ◆ American Botanical Council

Daniel A. Monti, MD ◆ Thomas Jefferson University

Kelly Brogan, MD, ABIHM ◆ George Washington University

Gerard Mullin, MD ◆ Johns Hopkins University

Ian Coulter, PhD ◆ RAND/Samueli Chair in Integrative Medicine

John Neely, MD ◆ Pennsylvania State University

Jeffrey Dach, MD ◆ TrueMedMD, Davie, Florida

Paula J. Nenn, MD, ABIHM ◆ Optimal Health and Prevention Research Foundation Garth L. Nicolson, PhD ◆ The Institute for Molecular Medicine

James Dillard, MD, DC, LAc ◆ Integrative Pain Medicine Gloria F. Donnelly, PhD, RN, FAAN ◆ Drexel University

Joel S. Edman, DSc, FACN, CNS ◆ Thomas Jefferson University

Xie Ning, PhD ◆ Heilongjiang University of Traditional Chinese Medicine Thomas O’Bryan, DC, CCN, DACBN ◆ Adjunct Faculty, Institute for Functional Medicine, National Univ. of Health Sciences Dean Ornish, MD ◆ Preventive Medicine Research Institute

Karen Erickson, DC ◆ New York Chiropractic College

Nicole Pietschmann, PhD ◆ Cell Science Systems GmbH–Alcat Europe

Andrea Girman, MD, MPH ◆ Genova Diagnostics

Joseph E. Pizzorno, ND ◆ Seattle, WA

Ajay Goel, PhD ◆ Baylor Research Institute Garry F. Gordon, MD, DO ◆ Gordon Research Institute

Lawrence A. Plumlee, MD ◆ Chemical Sensitivity Disorders Association William J. Rea, MD ◆ Environmental Health Center – Dallas

Yuxin He, LAc, PhD ◆ Academy of Oriental Medicine at Austin

Sandeep Saluja, MD ◆ Saran Ashram Hospital, Dayalbagh

Elise Hewitt, DC ◆ Portland, OR

Eric R. Secor Jr, PhD, ND, MPH, MS, LAc ◆ Helen & Harry Gray Cancer Center, Hartford Hospital Stephen T. Sinatra, MD, FACC, FACN, CNS ◆ University of Connecticut School of Medicine Martha Stark, MD ◆ Harvard Medical School, Massachusetts Mental Health Center Alex Vasquez, DC, ND, DO ◆ University of Texas

Jeanne Drisko, MD ◆ University of Kansas

Alfred Johnson, DO ◆ Johnson Medical Associates Ellen Kamhi, PhD, RN, AHG, AHN-BC ◆ Stony Brook University Anup Kanodia, MD, MPH ◆ Ohio State University

Datis Kharrazian, DC, DHSc, MS, MNeuroSci ◆ Bastyr University of Aristo Vojdani, PhD, MSc, CLS ◆ Immunosciences Lab, Inc California; Institute for Functional Medicine Günver Kienle, DrMed ◆ Institute for Applied Epistemology Roeland van Wijk, PhD ◆ International Institute of Biophysics Lori, Knutson, RN, BSN, HN-BC ◆ Allina Hospitals & Clinics James B. Lago, EMT, DDS, BA ◆ Chicago Dental Health Lixing Lao, PhD, LAc ◆ University of Maryland Erqiang Li, PhD ◆ East West College of Natural Medicine

James M. Whedon, DC, MS ◆ Southern California University of Health Sciences Shi Xian, MD, PhD ◆ General Hospital of the Chinese People’s Liberation Army Qinhong Zhang, MD, PhD ◆ Stanford University Shun Zhongren, PhD ◆ Heilongjiang University of Traditional Chinese Medicine

Susan Luck, MS, RN ◆ University of Miami Cuauhtemoc Hernandez Maya, MD ◆ Tao Healing Arts Center Managing Editor, CRAIG GUSTAFSON • Creative Director, RANDY PALMER • Associate Editor, MICHAEL MILLER Editorial Assistant, KATIE THOLKES • Science Editor, PEGGY WRIGHT • E-mail: ATHM@innovisionhm.com Web: www.alternative-therapies.com

6 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

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Nicholas Gonzalez, MD (1947–2015) Kelly Brogan, MD, ABIHM

“L

et the current system exist in a parallel universe and start from scratch with a completely new system that’s based on nutrition, diet, psychology, and spirituality. We want a new medical model where prevention will be more important than treatment.”

These were the words of Nicholas Gonzalez, MD, whose untimely passing on July 21, 2015, has left thousands of patients, loved ones, followers, and colleagues breathless in despair. Here to shift the paradigm of health care as a teacher, author, and speaker, Dr Gonzalez devoted himself to this effort one patient at a time, every day, for 27 years of private practice.

As one of the clinicians deeply and irrevocably transformed by knowing Dr Gonzalez, I will share my perspective on his journey and the gifts that he has left for us.

THE MAKING OF THE MAN Nicholas Gonzalez, a proud American, born and raised in Queens, New York, by his Mexican father and Italian mother, graduated Phi Beta Kappa and magna cum laude from Brown University in 1970, where he majored in English literature. Never interested in science, it wasn’t until he began working as an investigative journalist assigned to interview some of the pioneers in nutritional and alternative medicine that he began to be inspired by geniuses such as 2-time noble laureate Linus Pauling. He decided to pursue medicine, turned down a book deal, and went to Cornell so that he could work with the then-president of Memorial Sloan Kettering, Robert Good, MD, a transplant pioneer with an expressed interest in nutrition. It was under Good’s wing that Gonzalez was able to pursue the work of William Donald Kelley, dentist and clinical genius, who was much maligned in his own time and today. Gonzalez lived in his house and told me about being woken up at 4:00 in the morning to discuss science with this most unusual specimen of humanity. He wrote: As part of my project, I eventually interviewed and evaluated more than 1000 of Kelley’s patients, concentrating on a group of some 455 patients diagnosed with cancer who had done well under his care. From this population, I wrote up in detail 50 cases, representing 26 different types of cancer. Even today, nearly 30 years later, I am still impressed by Kelley’s achievement.

8 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Kelley synthesized the works of neurophysiologists like Francis Pottenger, MD, and Ernst Gellhorn, MD, PhD, who both elucidated the relevance of the autonomic nervous system to disease, with nutritional anthropologists like Weston A. Price, DDS. He expanded and explored the relationship between ecological niches, ancestral nervous system dominance, the vulnerability to disease, and the role of specific diets for healing. Through Kelley’s own cancer recovery and self-experimentation, he intuited the work of John Beard, DSc,1 around the relevance of pancreatic enzymes to cancer treatment and also developed an appreciation for the role of detox and the infamous coffee enema.

He treated and saved thousands of lives before he closed his practice, potentially withering into obscurity.

Dr Gonzalez’s 5 years of research into Kelley’s cases allowed for a better understanding of the optimal manufacturing of pancreatic enzymes for anticancer effect. He describes this journey in his article, “The History of the Enzyme Treatment of Cancer,”2 complete with 2 poignantly moving cases of successful long-term treatment of stage IV lung cancer and Burkitt’s lymphoma. He greatly admired the work of Dr Beard (and was known to give 3-hour lectures on the subject) who first claimed that pancreatic enzymes (trypsin) have anticancer activity based on the trophoblast theory of cancer.3 This theory has been substantiated by others such as Max S. Wicha, MD, whose work has confirmed that cancer does not arise from rogue mature cells, but from stem cells that lose regulatory control in a hostile, toxic environment.

After completing a fellowship in immunology, Dr Gonzalez started out on his own in 1987, despite being asked to work with Bob Atkins, MD, the famed weight-loss doctor. He continued to care for a number of Kelley’s longterm survivors and he became a sought-after clinician even months into his private practice.

Today there are thousands of patients touched by the work of Dr Gonzalez and his associate, Linda Isaacs, MD, most of whom are long-term survivors of advanced cancer.

Quick-witted and frank, Gonzalez told Senator Arlen Specter of Pennsylvania (1980–2011): There is really only one truth. Either cancer patients get better with my treatment or they do not. And, if they do, I could not care less whether it involved moon dust or microbes from Pluto. What matters is that many—not all, by any means—of

Brogan—Tribute to Nicholas Gonzalez, MD

my patients are alive when they should be dead. And what has that made me in the eyes of the traditional cancer establishment?

Simple. I am Gonzalez, the quack, the fraud, the doctor who lies to cancer patients, steals their money, and kills them. If there was a signup sheet at NIH to run me down with a truck, people would stand in line for hours.

Often accused of selection bias skewing his unprecedented results, Gonzalez reframed the relevance of doctor-patient alchemy stating, “Patients have to do the treatment they believe in. Fear is an infectious disease. You can catch fear but you can’t catch faith. That has to come from within.” Requiring dietary adherence, daily enemas, and detox methods, as well as upwards of 150 capsules per day, his protocol would not have been a “cure” for a patient otherwise oriented toward a quick chemical fix. The consummate teacher, Dr Gonzalez worked to liberate patients, not just from their illnesses, but to find their life’s purpose, and to thrive.

Dr Gonzalez was an activist and a deep supporter of health freedom. He had amassed an important and deeply undermining knowledge of the flaws in conventional research designed to support the use of cancer diagnostics and associated chemical treatments. Always a seeker of independent evaluation of his results, acknowledgement, and validation by the medical establishment, Gonzalez was disillusioned by the mishandling of the Chabot trial, the details of which are discussed in a vindication recently published by a colleague, Colin Ross, MD.4 He nearly completed a compendium of 150 cases, meticulously documented, of patients made well by his protocol—a protocol he always attributed to his mentor, calling himself an “able technician.” The cases will be published and should, if they are to be properly acknowledged, change the course of modern medicine.

THE PROTOCOL All alternative practitioners know that food matters. But we are subject to the latest guru, some poorly designed study, or the lens of our own personal experience. Dr Gonzalez’s approach offers patients a personalization of diet for topdown regulation of all interconnected bodily systems.

He used a 3-tiered approach of a personalized diet, detox, and supplementation, much of which was glandulars tailored for growth factor stimulation of deficient areas in a given patient.

He said that “anyone who recommends one diet to everyone hasn’t studied the work of the great geniuses before us.” Kelley elucidated 10 dietary types on a map and also personally and clinically tested hundreds of nutrients for their properties in stimulating the para and sympathetic arms.

We have, as people, evolved in different ecological niches, with different relationships to the environment. The late microbiologist, René Dubos, PhD, was also an intellectual hero of Dr Gonzalez’s, who among many brilliant quotes, stated,

Brogan—Tribute to Nicholas Gonzalez, MD

Man himself has emerged from a line descent that began with microbial life, a line common to all plant and animal species … [he] is dependent not only on other human beings and on the physical world but also on other creatures—animals, plants, microbes—that have evolved together with him. Man will ultimately destroy himself if he thoughtlessly eliminates the organisms that constitute essential links in the complex and delicate web of life of which he is a part.

In these different niches, our nervous systems adapted to survive. Our ancestors interacted with the available food, the climate, and the microbes, and their bodies met and yielded to these forces like stone erodes from the waves. Those who survived, with time, had to be designed to complement the environment. From the Inuit to the Amazonians, the alkaline versus acidic nature of available foods selectively stimulated arms of the autonomic nervous system to perfectly balance a system’s native dominance.

There are those who thrive on a low-meat, high-leafy green and citrus diet, and those who thrive on a high-fat, meat 3-times-per-day regimen. Temperament and bodily habits can tell us a lot about where a given patient fit in this spectrum. In his time, Kelley subjected his patients to a 3200-question intake to help identify their type, but Gonzalez used specialized testing in his practice that served to support his clinical assessments.

A PERSONAL TRIBUTE I spent 7 months mentored by Dr Gonzalez, and I count it as the most formative window of intellectual growth in my life. To be in his presence, to hear him speak, was to tap into a wisdom that I can only attempt to transmit in my time as a clinician. Suffice it to say that his clinical outcomes are unmatched the world over, that his knowledge base spanned the esoteric arts, to biochemistry, to conventional cancer practice, and there has not been a clinician yet who is as able to synthesize this material with the level of meticulous, journalistic study he brought to each and every patient’s journey. He had the gift of inhabiting the role of the healer, of materializing a path to lasting wellness for his patients, while also being a true intellectual and a visionary.

A quick study, my intensive apprenticeship under Dr Gonzalez has inspired me anew. Case by case, I imagined the legions of patients who walked out of his office with the glorious lightness, and abiding gratitude, of those who have cheated death. Now, these patients contact me on a daily basis to share their deep sorrow at the loss of such a beacon of hope. They also, many of them, have already learned from him what they need to know to continue to survive and thrive even decades past their prognoses, but they know they will miss his companionship. He seemingly had an answer to every question in that otherworldly brain of his—every question except how we are meant to go on without him.

I dare say that my entire life has taken on a new meaning since knowing this man. His untimely and inexplicable death has forced me and his loved ones to bow down in surrender to the greater wisdom of our shared journeys.

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 9

For this moment, I am so deeply grateful to have stood in his light. To have heard the truth he channeled—it is a sound so sweet, I hope to continue to share it with the world.

He always told me, “Your only job is to continue to love the truth, every day.�(Altern Ther Health Med. 2015;21(5):8-10.)

REFERENCES 1. Gonzalez N. Enzyme therapy and alternative cancer treatment. Dr-Gonzalez. com Web site. http://www.dr-gonzalez.com/history_of_treatment.htm. Updated April 6, 2014. Accessed July 31, 2015.

2. Gonzalez NJ. The history of the enzyme treatment of cancer. Altern Ther Health Med. 2014;20(suppl 2):30-44.

3. Ross CA. The trophoblast model of cancer. Nutr Cancer. 2015;67(1):61-67.

4. Ross CA. Methodological flaws in the Chabot trial of pancreatic enzymes for cancer therapy. Int J Cancer Prevent Res. 2015;1(1):1-4.

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A Statin for All Diabetics? Not So Fast …

Jonny Bowden, CNS; Drew Sinatra, ND; Stephen T. Sinatra, MD, FACC, FACN

R

ecent guidelines from the American Diabetes Association (ADA) recommend giving statin drugs to almost all people with diabetes. This brings the ADA in line with the recommendations with the American College of Cardiology (ACC) and the American Heart Association (AHA), both of which recommend giving statins to most people at risk for heart disease.

Statins have become the most prescribed drug class, with 30 million people receiving these pharmaceuticals from 2005 to 20081 and an excess 56 million being eligible under the new guidelines of the ADA, AHA, and ACC.2 In a previous communication in this journal,3 we advocated choosing statins in patients using clinical diligence focusing on the patient with the most to gain and the least to lose: males younger than 75 years with coronary artery disease. We strongly suggested avoiding guidelines, standards, and algorithms that could cause a rush to judgement and overtreat many low-risk patients, who would not benefit from statins while being vulnerable to side effects at the same time.

Although the revised 2014 ADA guideline is an improvement of the 2008 mandate4 (standard of medical care in diabetes indicates that statin Rx may be initiated with a target lowdensity lipoprotein [LDL] cholesterol of <100 mg/dL), almost all diabetics will now receive statin Rx based on risk profile.5 Because diabetes in itself is the major risk factor for cardiovascular disease (CVD), on the surface it makes sense to go along with the following guidelines.

The ADA now recommends a moderate statin dose for people with diabetes and cardiovascular (CV) risk who are younger than 40 years, or 40 to 75 years old without any other risk for heart disease. A high statin dose is recommended for people with diabetes who have heart disease, and for those between 40 and 75 years old who have other risk factors for heart disease.5 However, we believe that this wholesale mandate to give statins to almost every diabetic patient is in need of re-examination.

That statins do some good is not in question. Statins have multiple pleotropic and antiatherogenic effects.6 They thin the blood, lower inflammation, and act as an antioxidant.

Yet these effects have been overshadowed by the action for which statins are most famous: lowering cholesterol. We 12 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

believe lowering cholesterol is actually the least important thing that statins do and that the mechanism by which they accomplish this—HMG coenzyme A reductase inhibition— is at least partially responsible for statin side effects.

Statins are neither innocent nor innocuous medications.

They have the potential for serious risks, and their side effects, which include cognitive loss, rhabdomyolysis, muscle pain, and peripheral neuropathy, are grossly underreported.7,8 Statin use is associated with accelerated coronary artery calcification among diabetics with atherosclerotic cardiovascular disease (ASCVD).9 Statins significantly increase the risk for cataracts10,11,12 and for age-related macular degeneration.13 Musculoskeletal conditions, joint problems, injuries, and pain are more common among statin users than among similar nonusers.14 Two small investigations have shown statin use is associated with a disturbing increase in the risk of cancer.

McDougall et al15 showed women who took statins for 10 or more years had an 83% higher risk for invasive ductal carcinoma (IDC) and a doubled risk of invasive lobular carcinoma (ILC) compared with nonstatin users. Another small study found that ever-use of any statin was associated with a significant increase in prostate cancer.16 In another study, statin use was actually associated with an increased risk of death.17 In that study, in a population of 300 adults diagnosed with heart failure and followed for an average of 3.7 years, those who were taking statins and had the lowest levels of LDL cholesterol were found to have the highest rates of mortality. (Conversely, those with the highest levels of cholesterol had a lower risk of death.)

There can be even more collateral damage resulting from indiscriminate cholesterol lowering. Depression runs much higher in people with low cholesterol.18 Elderly men with low cholesterol have a 300% higher risk of depression than their cohorts with high cholesterol.19 In a sample of 300 healthy women, depression was also significantly higher among those in the lowest cholesterol group.20 Lower cholesterol (<160) is associated with a significantly greater likelihood of suicide,21 with a significantly greater likelihood of external-cause mortality22 and with a 350% increase in the risk for Parkinson’s disease.23 Bowden—Statins and Diabetes

Although many other studies have shown deleterious effects of statins, the statin-diabetic connection has recently surfaced as a major issue suggesting that the routine use of statins in patients with prediabetes, family history of diabetes, and borderline insulin resistance may be antithetical. For example, observational studies have reported a higher risk of type 2 diabetes with statin Rx compared with those not taking statins.24 In addition, the popular Women’s Health Initiative Investigation suggests an age-adjusted increased risk—48% of diabetes in postmenopausal women receiving statins is unsettling.25 A meta-analysis of randomized, controlled trials of statins identified a higher risk of type 2 diabetes as opposed to patients taking placebo or being treated with standard of care26 In 2012,27 the US Food and Drug Administration Drug Safety Communication prompted a change in statin safety labeling. Most recently, in a 2015 large Finnish trial28 of white males taking cholesterollowering drugs, researchers found a 46% probability in the risk of developing diabetes. Almost 9000 men without diabetes, between 45 and 73 years of age, were evaluated during a 6-year period. One in 4 men were taking a statin, and 625 men were newly diagnosed with type 2 diabetes. The researchers commented that cholesterol lowering drugs can increase a person’s insulin resistance while impairing the ability of the pancreas to secrete insulin. However, the research found an association only between statin use and diabetes risk. Nevertheless, the investigators found statins decreased insulin sensitivity by 24% and insulin secretion by 12%. High-dose simvastatin was associated with a 44% increased risk of developing diabetes, whereas low-dose simvastatin increased the risk by 28%. In a previous metaanalysis, larger doses were compared with moderate doses indicating a dose-related effect.29 Thus, the higher the statin dose and the longer the patients took them, the greater the risk of diabetes. It is disconcerting that so many trials incriminate statins with an increased risk of diabetes.

In an investigation looking at the HMG coenzyme A reductase inhibition, researchers concluded that polymorphisms in the HMGCR gene may be responsible for HMGCR inhibition.30 Common single nucleotide polymorphism (SNPs) in the HMGCR gene were associated with body weight gain and a higher risk of insulin resistance leading to a higher risk of type 2 diabetes. Because other trials31,32,33 have demonstrated higher glycated hemoglobin (HbA1c), and lower insulin sensitivity, statins are working on a metabolic, biochemical, and probably genetic level resulting in an increased risk of diabetes.30 Mechanisms suggest insulin resistance, changes in body composition, or an increased body weight.

The paradox, therefore, is that stains increase the risk of diabetes and that type 2 diabetes is a major CV risk factor.

Although research has demonstrated a net benefit of statin treatment including patients with diabetes,34 an obvious dilemma for the physician is raised as when to use a statin medication in a patient who is prone to diabetes. If a patient’s risk of heart disease is high, especially among males with Bowden—Statins and Diabetes

coronary disease, the patient may be willing to incur the increased risk of diabetes in an attempt to possibly delay or prevent a secondary CV event.

However, the physician needs to counsel their patients with diabetes or insulin resistance with even more discernment. For example, if statins do increase the risk of cataracts, then when does a patient and physician choose the possibility of cataract verses perhaps the probability of a reduction in a subsequent CV event? And what about patients with a strong family history of diabetes who have overweight status, increase in abdominal girth, and higher blood pressure—characteristics that suggest an impending metabolic syndrome? For patients who may not yet be diabetic, but are vulnerable to developing diabetes, perhaps the physician should stress lifestyle changes, dietary considerations, exercise, and targeted nutritional supplements even more so if a statin is recommended.

Clearly, for any diabetic patient or prediabetic patient, it makes sense to use pharmaceutical therapies only when necessary and certainly to choose safer options to help assuage inflammation and overall risk profile. There are far more benevolent ways to accomplish the same goal, with far less potential for mischief. It is certainly worth exploring whether a greater anti-inflammatory effect could be obtained with omega-3 fatty acids, either as a stand-alone intervention or as part of a decidedly nontoxic cocktail of known antiinflammatories and antioxidants such as curcumin, resveratrol, and other natural substances such as citrus bergamot—all at considerably less economic cost and with none of the demonstrated side effects of statins.

Omega-3 fatty acids are anti-inflammatory and antithrombotic, lower blood pressure and heart rate, and improve heart rate variability.35,36 Insulin resistance is also improved with omega-3 supplementation and without significant changes in fasting glucose or HbA1c with longterm treatment.37 Citrus bergamot is an active flavanone polyphenol extract that originates from the coast of southern Italy. Citrus bergamot has been evaluated in several clinical prospective trails in humans. In doses of 1000 mg per day, this compound lowers LDL cholesterol up to 36% and triglycerides by 39%, and it increases high-density lipoprotein (HDL) cholesterol by 40% by inhibiting HMG coenzyme A reductase. Citrus bergamot also increases cholesterol and bile acid excretion, and it reduces reactive oxygen species, blood sugar, and oxLDL.38,39 The active ingredients in citrus bergamot include naringin, neroeriocitrin, neohesperidin, poncerin, rutin, neodesmin, rhoifolin, melitidine, and brutelidine.38,39 Pycnogenol40 and benfotiamine have also been popular in treating blood sugar and advanced glycation end products41,42 in addition to diabetic retinopathy.42 This very small sample of nutritional and nutraceutical supplements could represent a valid alternative for patients who are statin intolerant, patients without coronary artery disease who prefer not to take cholesterol-lowering drugs for the treatment dyslipidemia, and in those patients who prefer nonpharmaceutical ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 13

interventions. In addition, a Mediterranean dietary pattern, rich in extra-virgin olive oil, has been recently proven to significantly reduce new-onset cases of type 2 diabetes in the primary prevention PREDIMED randomized trial. This investigation clearly supports the beneficial effects of a highquality dietary pattern on insulin resistance.43 At the very least, including a Mediterranean diet and other alternative remedies in a treatment plan might allow the physician an alternative to prescribing a statin in patients who are prediabetic, vulnerable to diabetes, or have borderline insulin resistance.

In conclusion, statins can be a blessing or a curse.44 They need to be given to males with coronary disease with and without diabetes where efficacy is certain. Pragmatic guidelines given by organizations attempt to make treating the patient as an easy cookie-cutter entity, but the complex biochemical nature of statins—with all its pleotropic effects (good vs bad)—can create undesirable consequences in patients. In this modern era of medicine, physicians must think for themselves and use guidelines and algorithms only as a guide. They must carefully discuss statin options with their patients and especially in those who have a diabetic tendency. In the final analysis, placebo-controlled, doubleblind trials and large database meta-analyses are good to consider but nothing trumps the clinical experience of the physician. Physician’s must rely on their clinical acumen, discuss the varied options, and try to do the right thing for their patient—especially when selecting a statin Rx. Every patient is an individual and therapy must be carefully tailored to support the patient. We believe treating cholesterol numbers is not smart medicine, but treating the patient with all the conventional and alternative methodologies is. The challenge is to choose wisely while doing no harm. (Altern Ther Health Med. 2015;21(5):12-14.)

REFERENCES 1. National Center for Health Statistics. Health, United States. 2010: with special feature on death and dying. Hyattsville, MD: US Dept of Health and Human Services; 2011.

2. Pencina MJ, Navar-Boggan AM, D’Agostino RB Sr, et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med. 2014;370(15):1422-1431.

3. Sinatra ST, Teter BB, Bowden J, Houston MC, Martinez-Gonzalez MA. The cholesterol and statin controversy: the new 2013 statin-cholesterol guidelines.

Altern Ther Health Med. 2014;20(5):14-17.

4. American Diabetes Association. Standards of medical care in diabetes—2008.

Diabetes Care. 2008;31(suppl 1):S12-S54.

5. No authors listed. Introduction. Diabetes Care. 2015;38(suppl 1):S1-S2.

6. Davignon J. Beneficial cardiovascular pleiotropic effects of statins. Circulation.

2004;109(23)(suppl 1):lll39-lll43.

7. Golomb BA, McGraw JJ, Evans MA, Dimsdale JE. Physician response to patient reports of adverse drug effects: implications for patient-targeted surveillance.

Drug Saf. 2007;30(8):669-675.

8. Golomb BA, Evans MA. Statin adverse effects: a review of the literature and evidence for a mitochondrial mechanism. Am J Cardiovasc Drugs.

2008;8(6):373-418.

9. Saremi A, Bahn G, Reaven PD; VADT Investigators. Progression of vascular calcification is increased with statin use in the Veterans Affairs Diabetes Trial (VADT). Diabetes Care. 2012;35(11):2390-2392.

10. Machan CM, Hrynchak PK, Irving EL. Age-related cataract is associated with type 2 diabetes and statin use. Optom Vis Sci. 2012;89(8):1165-1171.

11. Li L, Wan XH, Zhao GH. Meta-analysis of the risk of cataract in type 2 diabetes.

BMC Ophthalmol. July 2014;14:94.

14 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

12. Leuschen J, Mortensen EM, Frei CR, Mansi EA, Panday V, Mansi I. Association of statin use with cataracts: a propensity score-matched analysis. JAMA Ophthalmol. 2013;131(11):1427-1434.

13. VanderBeek BL, Zacks DN, Talwar N, Nan B, Stein JD. Role of statins in the development and progression of age-related macular degeneration. Retina.

2013;33(2):414-422.

14. Mansi I, Frei CR, Pugh MJ, Makris U, Mortensen EM. Statins and musculoskeletal conditions, arthropathies, and injuries. JAMA Intern Med. 2013;173(14):1-10.

15. McDougall JA, Malone KE, Daling JR, Cushing-Haugen KL, Porter PL, Li CI. Long-term statin use and risk of ductal and lobular breast cancer among women 55 to 74 years of age. Cancer Epidemiol Biomarkers Prev. 2013;22(9):1529-1537.

16. Chang CC, Ho SC, Chiu HF, Yang CY. Statins increase the risk of prostate cancer: a population-based case-control study. Prostate. 2011;71(16):1818-1824.

17. Charach G, George J, Roth A, et al. Baseline low-density lipoprotein cholesterol levels and outcome in patients with heart failure. Am J Cardiol.

2010;105(1):100-104.

18. Shin JY, Suls J, Martin R. Are cholesterol and depression inversely related? A meta-analysis of the association between two cardiac risk factors. Ann Behav Med. 2008;36(1):33-43.

19. Morgan RE, Palinkas LA, Barrett-Connor EL, Wingard DL. Plasma cholesterol and depressive symptoms in older men. Lancet. 1993;341(8837):75-79.

20. Horsten M, Wamala SP, Vingerhoets A, Orth-Gomer K. Depressive symptoms, social support, and lipid profile in healthy middle-aged women. Psychosom Med. 1997;59(5):521-528.

21. Neaton JD, Blackburn H, Jacobs D, et al. Serum cholesterol level and mortality findings for men screened in the Multiple Risk Factor Intervention Trial: Multiple Risk Factor Intervention Trial Research Group. Arch Intern Med. 1992;152(7):1490-1500.

22. Boscarino JA, Erlich PM, Hoffman SN. Low serum cholesterol and externalcause mortality: potential implications for research and surveillance. J Psychiatr Res. 2009;43(9):848-854.

23. Huang X, Abbott RD, Petrovitch H, Mailman RB, Ross GW. Low LDL cholesterol and increased risk of Parkinson’s disease: prospective results from Honolulu-Asia Aging Study. Mov Disord. 2008;23(7):1013-1018.

24. Carter AA, Gomes T, Camacho X, Juurlink DN, Shah BR, Mamdani MM. Risk of incident diabetes among patients treated with statins: population based study.

BMJ. May 2013;346:f2610.

25. Culver AL, Ockene IS, Balasubramanian R, et al. Statin use and risk of diabetes mellitus in postmenopausal women in the Women’s Health Initiative. Arch Intern Med. 2012;172(2):144-152.

26. Sattar N, Preiss D, Murray HM, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet.

2010;375(9716):735-742.

27. FDA drug safety communication: important safety label changes to cholesterollowering statin drugs [news release]. Silver Spring, MD: US Food and Drug Administration; February 28, 2012. http://www.fda.gov/Drugs/DrugSafety/ ucm293101.htm. Accessed April 21, 2015.

28. Cederberg H, Stančáková A, Yaluri N, Modi S, Kuusisto J, Laakso M. Increased risk of diabetes with statin treatment is associated with impaired insulin sensitivity and insulin secretion: a 6 year follow-up study of the METSIM cohort [published online ahead of print March 10, 2015]. Diabetologia.

2015;58(5):1109-1117.

29. Preiss D, Seshasai SR, Welsh P, et al. Risk of incident diabetes with intensive-dose compared with moderate-dose statin therapy: a meta-analysis. JAMA. 2011;305(24):2556-2564.

30. Swerdlow DI, Preiss D, Kuchenbaecker KB, et al. HMG-coenzyme A reductase inhibition, type 2 diabetes, and bodyweight: evidence from genetic analysis and randomised trials. Lancet. 2015;385(9965):351-361.

31. Koh KK, Quon MJ, Han SH, Lee Y, Kim SJ, Shin EK. Atorvastatin causes insulin resistance and increases ambient glycemia in hypercholesterolemic patients. J Am Coll Cardiol. 2010;55(12):1209-1216.

32. Ridker PM, Danielson E, Fonseca FA, et al; JUPITER Study Group. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein.

N Engl J Med. 2008;359(21):2195-2207.

33. Sabatine MS, Wiviott SD, Morrow DA, McCabe CH, Cannon CP. High-dose atorvastatin associated with worse glycemic control: a PROVE-IT TIMI 22 substudy. Circulation. 2004;110(suppl III):834.

34. Kearney PM, Blackwell L, Collins R, et al; Cholesterol Treatment Trialists’ (CTT) Collaborators. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet.

2008;371(9607):117-125.

35. Houston MC, Fazio S, Chilton FH, et al. Nonpharmacologic treatment of dyslipidemia. Prog Cardiovasc Dis. 2009;52(2):61-94.

36. Saremi A, Arora R. The utility of omega-3 fatty acids in cardiovascular disease.

Am J Ther. 2009;16(5):421-436.

37. Mori TA, Burke V, Puddey IB, et al. Purified eicosapentaenoic and docosahexaenoic acids have differential effects on serum lipids and lipoproteins, LDL particle size, glucose, and insulin in mildly hyperlipidemic men. Am J Clin Nutr. 2000;71(5):1085-1094.

38. Di Donna L, De Luca G, Mazzotti F, et al. Statin-like principles of bergamot fruit (Citrus bergamia): isolation of 3-hydroxymethylglutaryl flavonoid glycosides. J Nat Prod. 2009;72(7):1352-1354.

Bowden—Statins and Diabetes

39. Mollace V, Sacco I, Janda E, et al. Hypolipemic and hypoglycaemic activity of bergamot polyphenols: from animal models to human studies. Fitoterapia.

2011;82(3):309-316.

40. Schäfer A, HÜgger P. Oligomeric procyanidins of French maritime pine bark extract (Pycnogenol) effectively inhibit alpha-glucosidase. Diabetes Res Clin Pract. 2007;77(1):41-46.

41. Lin J, Alt A, Liersch J, Bretzel RG, Brownlee M, Hammes HP. Benfotiamin inhibits formation of advanced glycation end products in vivo. Diabetes.

2000;49(suppl 1):A143(P583).

42. Hammes HP, Du X, Edelstein D, et al. Benfotiamine blocks three major pathways of hyperglycemic damage and prevents experimental diabetic retinopathy. Nat Med. 2003;9(3):294-299.

43. Salas-SalvadĂł J, BullĂł M, Estruch R, et al. Prevention of diabetes with Mediterranean diets: a subgroup analysis of a randomized trial. Ann Intern Med. 2014;160(1):1-10.

44. Sinatra ST, Teter BB, Bowden J, Houston MC, Martinez-Gonzalez MA. The saturated fat, cholesterol, and statin controversy: a commentary. J Am Coll Nutr.

2014;33(1):79-88.

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ORIGINAL RESEARCH

The Effects of Musical Auditory Stimulation of Different Intensities on Geometric Indices of Heart Rate Variability Joice A. T. do Amaral, MSc; Heraldo L. Guida, PhD; Franciele M. Vanderlei, PhD; David M. Garner, MSc; Elaine Osório, MSc; Luiz Carlos de Abreu, PhD; Vitor E. Valenti, PhD

ABSTRACT Background • Music has been proven to promote changes in cardiac autonomic modulation. However, it is not clear whether the effects of the auditory stimulation on heart rate variability (HRV) are dependent on its intensity.

Objective • The study intended to investigate the acute effects on the geometric HRV indices of auditory stimulation with heavy metal and baroque music using different intensities of auditory stimulation.

Design • The study was a nonrandomized, clinical trial.

Setting • The study was conducted at the facility of the Faculty of Sciences of the São Paulo State University, on the campus in Marilia, Brazil.

Participants • Participants were 24 healthy women aged between 18 and 27 y.

Intervention • HRV was recorded for each participant for 10 min at rest. Subsequently, participants were exposed to baroque or heavy metal music through an earphone. They were exposed to 3 equivalent sound levels—60-70 decibels (dB), 70-80 dB, and 80-90 dB—for 5 min in each intensity range. After the first session of baroque or heavy metal music, participants rested for an additional 5 min. Then they were exposed to the other musical style. The first style played for each musical period was randomly selected for all individuals and then the other style would be played automatically for the second session.

Joice A. T. do Amaral, MSc, is a postgraduate student; Heraldo L. Guida, PhD, is an assistant professor; Elaine Osório, MSc, is a postgraduate student; and Vitor E. Valenti, PhD, is an assistant professor at the Center for the Study of the Autonomic Nervous System (CESNA) in the Department of Speech Faculty of Philosophy and Science at São Paulo State University (UNESP) in Marília, SP, Brazil.

Franciele M. Vanderlei, PhD, is an assistant professor in the Department of Physiotherapy of the Faculty of Science and Technology at UNESP in Presidente Prudente, SP, Brazil.

David M. Garner, MSc, is a research associate in the Cardiorespiratory Research Group in the Department of 16 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Outcome Measures • The HRV analysis was performed using the following geometrical methods: (1) the triangular index (RRtri), (2) the triangular interpolation of the RR interval histogram (TINN), and (3) the Poincaré plot, using SD1—the standard deviation of the instantaneous variability of the beat-to beat heart rate (HR), SD2—the standard deviation of the long-term, continuous, RR interval variability, and the SD1/SD2 ratio—the ratio between the short- and long-term variations among the RR intervals.

Results • The classic baroque music by Johann Pachelbel, “Canon in D Major,” did not induce significant changes in the geometric indices of HRV at 60-70 dB, 70-80 dB, or 80-90 dB. However, auditory stimulation with heavy metal music, using “Heavy Metal Universe” by Gamma Ray, decreased the RRtri, TINN, and SD2 at 2 specific sound pressures (60-70 dB and 80-90 dB).

Conclusions • Auditory stimulation with the selected baroque music did not alter cardiac autonomic modulation, but the selected, heavy metal style of music in the lower and higher intensities reduced the global component of HRV acutely. (Altern Ther Health Med. 2015;21(5):16-23.)

Biological and Medical Sciences of the Faculty of Health and Life Sciences at Oxford Brookes University in Oxford, United Kingdom. Luiz Carlos de Abreu, PhD, is an assistant professor in the Department of Morphology and Physiology of the Faculty of Medicine of ABC in Santo André, SP, Brazil.

Corresponding author: Vitor E. Valenti, PhD E-mail address: vitor.valenti@marilia.unesp.br

Amaral—Heart and Auditory Stimulus Intensity

T

he effects that auditory stimulation with music provides in various organs and systems, particularly the cardiovascular system, have been studied by other researchers.1-3 Different physiological responses, such as changes in blood pressure, heart rate (HR), respiratory rate, body temperature, emotional response, and biochemical parameters, have been described on application of musical stimulation.4-6 Moreover, special attention has been drawn to using music in treating and preventing disease.7,8 Chuang et al7 illustrated that music therapy can promote a sense of relaxation and increase vagal modulation in individuals with cancer. The researchers concluded that the therapy may be an alternative in treating such patients. Okada et al8 found that music therapy can increase parasympathetic activity and decrease the likelihood of development of congestive heart failure in elderly patients with dementia and cerebrovascular disease.

Despite its importance in therapy, few studies exist in the literature that have sought to investigate the acute effects of music therapy on the autonomic nervous system (ANS).

Presently, a useful tool to evaluate the ANS is heart rate variability (HRV). Researchers obtain this measurement using an instrument that allows a noninvasive assessment and a selective evaluation of autonomic function. The ANS is determined by analyzing the time series of RR intervals (time between each heart beat) that are obtained from an electrocardiographic (ECG) signal, the variations of which provide information about sympathetic nerve activity (SNA) and its control over the heart.9,10 Among the methods used for analyzing HRV are the following geometric measures: the (1) triangular index (RRTri); (2) triangular interpolation of the RR interval histogram (TINN); and (3) Poincaré plot, which converts the RR intervals into geometric patterns and allows the analysis of HRV through the geometric properties or graphs of the resulting pattern. In that context, analysis of the Poincaré plot is considered to be based on nonlinear dynamics.

Nonlinear analysis has provided new insights into the abnormalities of HR behavior under various conditions. It provides more information for physiological interpretations and additional prognostics when compared with traditional linear methods.9,10 Some studies have revealed that acoustic stimulation with white noise above 50 decibels (dB) promotes changes in HRV that suggest increased sympathetic modulation.11 Further, a recent study reported that musical auditory stimulation with different intensities of auditory stimulation did not influence the HRV indices in the time and frequency domains in men.12 However, researchers possess little understanding as to whether different genders and different indices of HRV present different responses when induced by music in different but equivalent sound pressures. Therefore, the current research team aimed to investigate the acute effects of selected musical auditory stimulation using different intensities of auditory stimulation on the geometric HRV indices.

Amaral—Heart and Auditory Stimulus Intensity

METHODS Participants We selected 24 healthy female students from our institution after a previous interview, all nonsmokers, aged between 18 and 27 years.

The study excluded individuals who had reported the following conditions: (1) cardiopulmonary, psychological, or neurologically related disorders and other impairments that might prevent them from participating in the study; and (2) treatment with drugs that influence cardiac autonomic regulation. The volunteers were not evaluated during the 10 to 15 days or the 20 to 25 days after the first day of the menstrual cycle.13 Prior to the study, baseline criteria such as age, gender, weight, height, and body mass index (BMI) were obtained.

Weight was determined using a digital scale (W 200/5, Welmy, São Paulo, SP, Brazil) with a precision of 0.1 kg.

Height was determined using a stadiometer (ES 2020, Sanny, São Paulo, SP, Brazil) with a precision of 0.1 cm and 2.20 m of extension. BMI was calculated as weight/height2 with weight in kilograms and height in meters.

All volunteers were informed about the procedures and objectives of the study and gave written informed consent.

All of the study’s procedures were approved by the Ethics Committee in Research of the Faculty of Sciences at São Paulo State University on the university’s Marilia campus (No. CEP-2011-385) and were in accordance with Resolution 196/96 National Health 10/10/1996.

Procedures Measurement of Auditory Stimulation. The measurements of the equivalent sound levels were conducted in a soundproof room, using an SV 102 audiodosimeter (Svantek, Helsinki, Finland). The measurement was programmed into the “A” weighting circuit, providing a slow response.

The recordings were made during a session that lasted a total of 10 minutes for the relaxing, classical baroque music, of which the music lasted 4 minutes and 50 seconds. The length of the heavy-metal music was 5 minutes and 20 seconds. The research team used the insert-type microphone (MIRE, microphone in real ear), which was placed inside the auditory canal of the participant, immediately below the microphone, and was connected to a personal stereo. Before each measurement, the microphones were calibrated with the calibrator acoustic CR: 514 model (Cirrus Research, Hunmanby, North Yorkshire, UK).

In the analysis, the research team used the Leq (A), which is defined as the equivalent sound-pressure level and corresponds to a constant sound level in the same time interval. It contains the same total energy of sound. The team also analyzed the frequency spectrum of the sound stimulation (ie, the octave band).14,15 HRV Analysis. Data collection was undertaken in the same soundproof room for all volunteers. The temperature was between 21°C and 25°C, and relative humidity was ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 17

between 50% and 60%. Volunteers were instructed not to drink alcohol, caffeine, or other ANS stimulant for 24 hours before evaluation.

Datasets were collected on the same period of the day on an individual basis, between 18:00 and 21:00, to standardize the protocol and minimize circadian influences. All procedures necessary for the data collection were explained on an individual basis, and the participants were instructed to remain at rest and avoid talking during the collection.

The RR intervals were recorded by a portable HR monitor (Polar Electro, Helsinki, Finland), with a sampling rate of 1000 Hz, and were downloaded to the Polar Precision Performance program (Polar Electro, Helsinki, Finland). The software enabled the visualization of HR and the extraction of a cardiac period file (ie, an RR interval file, in .txt format).

After the recording, digital filtering occurred, complemented with manual filtering, to eliminate premature ectopic beats and artifacts. At least 256 RR intervals were used for the data analysis. Only series with more than a 95% sinus rhythm were included in the study.16 The research team evaluated the geometric indices of the HRV. For calculation of the indices, the research team used the HRV analysis software (Kubios HRV v1.1 for Windows, Biomedical Signal Analysis Group, Department of Applied Physics, University of Kuopio, Kuopio, Finland).

Intervention After the initial evaluation (ie, collection of height, weight, BMI, and arterial blood pressure) a heart monitor belt was placed over the participant’s thorax, aligned with the distal third of the sternum, and the Polar RS800CX heart rate receiver (Polar Electro, Helsinki, Finland) was placed on his or her wrist. To start the intervention, the participants were seated and remained at rest with spontaneous breathing for 10 minutes with the earphone turned off.

Participants were exposed to 3 equivalent sound levels—60 to 70 dB, 70 to 80 dB, and 80 to 90 dB—for 5 minutes in each intensity range for each type of music. The sequence of the songs’ intensities was randomized for each individual based on cards.

The musical pieces for the auditory stimulation were an exciting heavy metal piece, “Heavy Metal Universe” by Gamma Ray, and a classical baroque piece, “Canon in D Major” by Johann Pachelbel. After the initial rest period, the participants were exposed to the baroque or heavy metal music through the earphone. During analysis, their variables were compared at the following moments: (1) during the initial rest period, the rest control, (2) with the music at 60 to 70 dB, (3) with the music at 70 to 80 dB, and (4) with the music at 80 to 90 dB. After the first session of baroque or heavy metal music, participants rested for an additional 5 minutes. Then they were exposed to the other musical style. The style for the first musical period was randomly selected for all individuals, and then the other style was played automatically for the second session.

18 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Outcome Measures The HRV analysis was performed using the following geometrical methods: the (1) RRtri; (2) TINN; and (3) Poincaré plots, using the standard deviation of the instantaneous variability of the beat-to beat HR (SD1), the standard deviation of the long-term continuous RR interval variability (SD2), and the SD1/SD2 ratio.

The RRtri was calculated from the construction of a density histogram of RR intervals, which contained all possible RR intervals measured on a discrete scale on the horizontal axis, with 7.8125 millisecond boxes (1/128 s) and which contained the frequency with which each occurred on the vertical axis. The union of points of the histogram’s columns forms a triangle-like shape. The RRtri was obtained by dividing the number of RR intervals used to construct the histogram by their modal frequency (ie, the RR interval that appeared most frequently on RR-interval time series).10,16 For the TINN, the width of the distribution measurement at baseline forms the basis of a triangle that approximates the distribution of all RR intervals. The difference of least squares was used to determine the triangle.10,16 The Poincaré plot is a map of points in Cartesian coordinates that is constructed from the values of the RR intervals. Each point is represented on the x-axis by the previous normal RR interval and on the y-axis by the following RR interval.17 For the quantitative analysis of the plot, an ellipse was fitted to the points of the chart, with the center determined by the average RR interval. The SD1 indices were calculated to measure the standard deviation of the distances of the points from the diagonal y = x, and the SD2 was calculated to measure the standard deviation of the distances of points from the line y = -x + RRm, where RRm is the average RR interval. The SD1 is an index of the instantaneous recording of the variability from beat to beat and represents the parasympathetic activity, whereas the SD2 index represents the long-term HRV and reflects the overall variability. The SD1/SD2 shows the ratio between the short- and long-term variations among the RR intervals.17 The plot was qualitatively analyzed using HRV analysis software based on the figures formed by its attractor. The expected shapes have been described by Tulppo et al17 as (1) figures in which an increase in the dispersion of RR intervals is observed with increased intervals, characteristic of a normal plot; and (2) small figures with beat-to-beat global dispersion without increased long-term dispersion of RR intervals.

For analysis of geometric indices, the research team used the Kubios Software.

Statistical Analysis Standard statistical methods were applied for the calculation of means and standard deviations. Normal Gaussian distribution of the data was verified by the ShapiroWilks goodness-of-fit test, with the z value > 1.0. For parametric distributions, the research team applied the Amaral—Heart and Auditory Stimulus Intensity

Figure 1. Linear geometric indices of HRV before and after exposure to auditory stimulation with the classical baroque style of music.

11 9 8

TNN (ms)

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7 6 5 4 3 2 1 0

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Variable Age, y Height, m Weight, kg BMI, kg/m2 HR, BPM Mean RR, ms SAP, mm Hg DAP, mm Hg Control 60-70 dB 70-80 dB 80-90 dB

P = .53

P = .62

Abbreviations: HRV, heart rate variability; RR, time between beats; TINN, triangular interpolation of RR intervals.

Figure 2. Poincaré plot indices before and after exposure to auditory stimulation with the classical Baroque style of music.

24

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P = .87

0 Control 60-70 dB 70-80 dB 80-90 dB

P = .28

Abbreviations: SD1, standard deviation of the instantaneous variability of the beat-to beat heart rate; SD2, standard deviation of the long-term continuous RR interval variability; SD1/SD2 ratio, the ratio between the short- and long-term variations of RR intervals.

Amaral—Heart and Auditory Stimulus Intensity

Table 1. Baseline DAP, SAP, HR, Mean RR Interval, Age, Weight, Height, and BMI of the Volunteers Value Mean ± SD 20.1 ± 2.7 1.65 ± 0.4 58.6 ± 6.7 20.9 ± 3.1 81.2 ± 10.6 756.3 ± 132 111.3 ± 7.1 77.0 ± 9

Abbreviations: DAP, diastolic arterial pressure; SAP, systolic arterial pressure; HR, heart rate; BMI, body mass index; BPM, beats per minute.

analysis of variance (ANOVA) for repeated measures, followed by the Bonferroni posttest. For nonparametric distributions, the team used the Friedman test, followed by the Dunn’s posttest. Differences were considered significant when the probability of a type 1 error < 5% (P < .05). The team used the Software Biostat Professional version 5.8.4 for Windows for the analysis (AnalysisSoft, Walnut, CA, USA).

RESULTS Participants were 24 healthy women, all nonsmokers, aged between 18 and 27 years.

Data on baseline systolic (SAP) and diastolic arterial pressure (DAP), HR, mean RR interval, age, height, body weight, and BMI are presented in Table 1.

In relation to the time-linear geometric indices of HRV, the TINN and triangular index, the research team noted no significant differences between measurements during the control period and those during auditory stimulation with classical baroque music at the 3 equivalent sound levels (Figure 1).

In Figure 2, the research team observed that both the Poincaré plot indices, SD1 and SD2, were unchanged during exposure to the music in the classical baroque style at the 3 equivalent sound levels.

On the other hand, auditory stimulation with heavy metal music caused significant changes in HRV. The TINN and triangular

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 19

12 11

a

a

9 8

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a

a

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P = .018

P = .028

Abbreviations: HRV, heart rate variability; RR, time between beats; TINN, triangular interpolation of RR intervals. a

Significantly different from control period.

Figure 4. Poincaré plot indices before and after exposure to auditory stimulation with the heavy metal style of music.

24 22

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SD2 (ms)

DISCUSSION Considering that the intensity of musical auditory stimulation is a relevant point to be investigated, the current research team hoped to evaluate the effects of 2 musical styles in different intensities on cardiac autonomic regulation, using geometric analysis of HRV in healthy women. The team observed that the classical baroque music by Pachelbel, “Canon in D Major,” did not induce significant changes in the geometric indices of HRV at 60 to 70 dB, 70 to 80 dB, or 80 to 90 dB. In contrast, auditory stimulation with exciting, heavy metal music, “Heavy Metal Universe”

by Gamma Ray, decreased the TINN, triangular index, and SD2 at 2 specific sound pressures, 60 to 70 dB and 80 to 90 dB. In the current study, the research team investigated only women to avoid any genderdependent effects on cardiac autonomic responses that might be induced by auditory stimulation. The literature presents conflicting findings in relation to the physiological reactions induced by music between women and men. Kring and Gordon18 indicated that cardiac autonomic responses elicited by auditory stimulation depend on gender as a result of different gender-based experiences and forms emotional expression. A previous study found that women presented a more intensely stressful reaction to music when compared with men. It has also been suggested that gender-based differences in psychophysiological responses to auditory stimulation are significantly influenced by hormonal status.19

Figure 3. Linear geometric indices of HRV before and after exposure to auditory stimulation with the heavy metal style of music.

SD1 (ms)

indices were both significantly reduced during exposure to the heavy-metal music at 60 to 70 dB and 80 to 90 dB when compared with the control period (Figure 3). Further, the SD2 index was also significantly lower during auditory stimulation with heavymetal music at 60 to 70 dB and 80 to 90 dB when compared with the control period, whereas no significant difference was found for the SD1 index (Figure 4).

Figure 5A illustrates an example of the Poincaré plot patterns from 1 participant during the control period (ie, in the absence of music) and during auditory stimulation with the classical baroque music, whereas Figure 5B shows 1 participant during the control period (ie, in the absence of music) and during auditory stimulation with the heavy metal music.

12 10 8

a

35 30 25 20

6

15

4

10

2

5

0

a

0

Control 60-70 dB 70-80 dB 80-90 dB

Control 60-70 dB 70-80 dB 80-90 dB

P = .97

P = .003

Abbreviations: SD1, standard deviation of the instantaneous variability of the beat-to-beat heart rate; SD2, standard deviation of the long-term continuous RR interval variability; SD1/SD2 ratio, ratio between the shortand long-term variations of the RR intervals. a

Significantly different from control period.

20 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Amaral—Heart and Auditory Stimulus Intensity

Figure 5. Visual pattern of the Poincaré plot observed (A) in 1 participant before testing (ie, during the control period) and during musical auditory stimulation with the heavy metal style of music (80-90 dB) and (B) in 1 participant before testing (ie, during the control period) and during musical auditory stimulation with the classical Baroque style of music (80-90 dB).

Control

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ms Nevertheless, the literature lacks any analysis of differences between women and men concerning the cardiac autonomic responses to musical auditory stimulation.

Further, the menstrual cycle has further been reported to influence nonlinear indices of HRV.13 To exclude the interference of the follicular and luteal phases of the menstrual cycle on cardiac autonomic regulation, the current research team chose not to evaluate the volunteers during the 10 to 15 days or the 20 to 25 days after the first day of the menstrual cycle.

The current study found an absence of significant change in HRV during exposure to the selected baroque music. Previously, Roque et al14 had found that auditory stimulation with music from Pachelbel’s “Canon in D Major” in the frequency range of 60 to 70 dB caused a decrease in overall variability in healthy women, whereas Castro et al20 reported that the same music did not alter cardiac autonomic modulation during a postural-change maneuver in women.

Both studies analyzed the HRV indices in the time and frequency domains.

Amaral—Heart and Auditory Stimulus Intensity

0

200

400

ms In another study, anesthetized rats had shown that exposure to relaxing music (ie, “Träumerei” from the Kinderszenen Opus15-7 by Robert Schumann) promoted an increased activity of the gastric vagus nerve.21 In addition, another study, also performed on rats that were subjected to stimulation with the same music, found that it promoted a reduction in activity of the sympathetic nerve and a decrease in blood pressure.22 According to those researchers,21,22 the responses were dependent on an intact auditory cortex and cochlear. The variations between the studies may be explained, in part, by the divergence of the methods of study, such as the population involved and the exclusion criteria.

HRV fluctuations can indicate physiological health status. Reduced HRV is frequently a sign of poor adaptation of the ANS, which may indicate the presence of physiological failure in patients with cardiac disorders. Conversely, increased HRV represents good adaptation (ie, a healthy individual with efficient autonomic mechanisms).23,24 Correspondingly, the current research team reported that the heavy metal style of music decreased HRV, suggesting that ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 21

the musical style acutely overloads the ANS in healthy women. However, the team’s results cannot determine whether exposure to heavy metal music at 60 to 70 dB and 80 to 90 dB chronically impairs the ANS. The current research team has contemplated the idea that the heavy metal style of music is hazardous for patients with cardiac disorders, because the team observed that it reduces HRV. However, that hypothesis may be problematic because the overload in the ANS of the participants exposed to the heavy metal music, was not so intense as to induce a cardiac event. The team hypothesizes that the higher intensity levels of heavy metal music might induce cardiac events in patients with cardiovascular disorders.

Another important factor to be addressed is the influence of noise at the same dB levels as those of heavy metal music.

In a study by Roque et al,15 the researchers exposed women to white noise, and using an analysis of frequency domain indices, reported that it reduced HRV. Moreover, Lee et al11 found a significant correlation between white-noise intensity and the sympathetic component of HRV. The current research team suggests that auditory stimulation with the heavy metal style of music or with white noise presents similar effects on HRV. Nonetheless, further studies are necessary to identify additional mechanisms.

The significant, cardiac autonomic change that was induced by the selected heavy metal music in the current study may be explained by several physiological mechanisms.

The brain and brainstem are involved in cardiovascular25,26 and auditory information.27 In previous studies in which musicians were exposed to self-selected parts of music that elicited intensely pleasant emotional reactions, the current research team observed an increased, regional, cerebral blood flow in the left ventral striatum and dorsomedial midbrain, accompanied by a decrease in the blood flow in the right amygdala and left hippocampus/amygdale, indicating that music recruits dopaminergic neural mechanisms of recompense.28,29 Further, a recent study has suggested that dopamine release in the right caudate and the right nucleus accumbens, both brain areas related to reward mechanisms,30 increased during exposure to self-selected pleasurable music.31 Those physiological responses were hypothesized to be related to histaminergic H3 receptors in the suprachiasmatic nucleus of the hypothalamus, because that area has been reported to be involved in sympathetic and parasympathetic responses induced by relaxant music in rats.22 In that context, the style of music used in a study is an important question to be raised, because each the current research team’s previous studies used different music. Therefore, the current research team must be careful when interpreting data.

The investigation of the intensity of musical auditory stimulation is important to improve musical therapy for alternative treatments.32 A recent study reported that whitenoise stimulation above 50 dB heightened the sympathetic component of heart-rate regulation and also observed that a significant association existed between the LF/HF ratio and 22 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

the equivalent sound level; the higher the sound intensity, the higher was the sympathetic tone on the heart and the lower the HRV.11 In the current study, it was observed that the TINN, SD2, and triangular index, which represents overall variability, were decreased during exposure to heavy metal music in the frequency bands of 60 to 70 dB and 80 to 90 dB. These results might be explained by an increased sympathetic modulation and a consequent reduction in HRV due to the excitatory music profile associated with a high-intensity sound. Alternatively, the changes could be an autonomic response promoted by the acoustic startle reflex, characterized by the rapid response of blood pressure and HR that is induced by auditory stimulation with high intensity that occurs in an unexpected manner.11 A limitation of the current study should be noted. To avoid the effect of the sequence of music and sound intensity on the responses of cardiac-autonomic modulation, the sequence was randomized for each participant; hence, the research team cannot dismiss the possible effect of the influence of auditory accommodation in the volunteers.

Nevertheless, the results of the current study reinforce the need to study and interpret auditory stimulation in different intensities as a form of alternative adjuvant therapy for several typical treatments.

CONCLUSIONS Auditory stimulation with a selected baroque music did not change cardiac autonomic modulation, whereas the selected heavy metal style of music in lower and higher intensities acutely reduced the global component of geometric HRV indices. Further studies are essential to investigate whether patients who have had a cardiac event, should be given a warning about potential problems when listening to music in a high intensity that increases sympathetic drive or suppresses HRV. REFERENCES 1. Cervellin G, Lippi G. A journey with Euterpe: sinfonia concertante for music, heart and brain [in Italian]. Recenti Prog Med. 2011;102(9):352-358.

2. Phipps MA, Carroll DL, Tsiantoulas A. Music as a therapeutic intervention on an inpatient neuroscience unit. Complement Ther Clin Pract. 2010;16(3):138-142.

3. Lin LC, Lee MW, Wei RC, Mok HK, Yang RC. Mozart K.448 listening decreased seizure recurrence and epileptiform discharges in children with first unprovoked seizures: a randomized controlled study. BMC Complement Altern Med. January 2014;14:17.

4. Hatem TP, Lira PI, Mattos SS. The therapeutic effects of music in children following cardiac surgery. J Pediatr (Rio J). 2006;82(3):186-192.

5. Zanini CR, Jardim PC, Salgado CM, et al. Music therapy effects on the quality of life and the blood pressure of hypertensive patients. Arq Bras Cardiol.

2009;93(5):534-540.

6. Ferreira LL, Vanderlei LC, Abreu LC, Guida HL, Valenti VE. Neurophysiological aspects of musical auditory stimulation on the cardiovascular system [in Portuguese]. ABCS Health Sci. 2013;38(3):172-177.

7. Chuang CY, Han WR, Li PC, Young ST. Effects of music therapy on subjective sensations and heart rate variability in treated cancer survivors: a pilot study.

Complement Ther Med. 2010;18(5):224-226.

8. Okada K, Kurita A, Takase B, et al. Effects of music therapy on autonomic nervous system activity, incidence of heart failure events, and plasma cytokine and catecholamine levels in elderly patients with cerebrovascular disease and dementia. Int Heart J. 2009;50(1):95-110.

9. Fazan R Jr, Salgado HC. Analysis of heart rate and arterial pressure variability in the frequency domain as a tool to examine sympathetic modulation of cardiovascular system [in Portuguese]. Rev Bras Hipertens. 2005;12(4):242-244.

Amaral—Heart and Auditory Stimulus Intensity

10. Task Force of the European Society of Cardiology of the North American Society of Pacing and Electrophysiology. Heart rate variability: standards of measurement, physiological interpretation and clinical use. Circulation. 1996;93(5):1043-1065.

11. Lee GS, Chen ML, Wang GY. Evoked response of heart rate variability using short-duration white noise. Auton Neurosci. 2010;155(1-2):94-97.

12. Amaral JA, Nogueira ML, Roque AL, et al. Cardiac autonomic regulation during exposure to auditory stimulation with classical baroque or heavy metal music of different intensities. Turk Kardiyol Dern Ars. 2014;42(2):139-146.

13. Bai X, Li J, Zhou L, Li X. Influence of the menstrual cycle on nonlinear properties of heart rate variability in young women. Am J Physiol Heart Circ Physiol. 2009;297(2):H765-H774.

14. Roque AL, Valenti VE, Guida HL, et al. The effects of different styles of musical auditory stimulation on cardiac autonomic regulation in healthy women. Noise Health. 2013;15(65):281-287.

15. Roque AL, Valenti VE, Guida HL, et al. The effects of auditory stimulation with music on heart rate variability in healthy women. Clinics (Sao Paulo).

2013;68(7):960-967.

16. Vanderlei LC, Pastre CM, Hoshi RA, Carvalho TD, Godoy MF. Basic notions of heart rate variability and its clinical applicability. Rev Bras Cir Cardiovasc.

2009;24(2):205-217.

17. Tulppo MP, Mäkikallio TH, Seppänen T, Laukkanen RT, Huikuri HV. Vagal modulation of heart rate during exercise: effects of age and physical fitness. Am J Physiol. 1998;274(2, pt 2):H424-H429.

18. Kring AM, Gordon AH. Sex differences in emotion: expression, experience, and physiology. Journal of Personality and Social Psychology. 1998;74(3):686-703.

19. Nater UM, Abbruzzese E, Krebs M, Ehlert U. Sex differences in emotional and psychophysiological responses to musical stimuli. Int J Psychophysiol.

2006;62(2):300-308.

20. de Castro BC, Guida HL, Roque AL, et al. Previous exposure to musical auditory stimulation immediately influences the cardiac autonomic responses to the postural change maneuver in women. Int Arch Med. 2013;6(1):32.

21. Nakamura T, Tanida M, Niijima A, Nagai K. Effect of auditory stimulation on parasympathetic nerve activity in urethane-anesthetized rats. In Vivo.

2009;23(3):415-419.

22. Nakamura T, Tanida M, Niijima A, Hibino H, Shen J, Nagai K. Auditory stimulation affects renal sympathetic nerve activity and blood pressure in rats.

Neurosci Lett. 2007;416(2):107-112.

23. Abreu LC. Heart rate variability as a functional marker of development. J Hum Growth Dev. 2012;22(3):279-282.

24. Plassa BO, Milan RC, Guida HL, et al. Cardiac autonomic responses induced by auditory stimulation with music is influenced by affinity. Med Express.

2014;1(4):206-210.

25. Valenti VE, Abreu LC, Sato MA, Ferreira C. ATZ (3-amino-1,2,4-triazole) injected into the fourth cerebral ventricle influences the Bezold-Jarisch reflex in conscious rats. Clinics (Sao Paulo). 2010;65(12):1339-1343.

26. Valenti VE, De Abreu LC, Sato MA, Fonseca FL, Riera AR, Ferreira C. Catalase inhibition into the fourth cerebral ventricle affects bradycardic parasympathetic response to increase in arterial pressure without changing the baroreflex. J Integr Neurosci. 2011;10(1):1-14.

27. Schecklmann M, Landgrebe M, Kleinjung T, et al. State- and trait-related alterations of motor cortex excitability in tinnitus patients. PLoS One. 2014;9(1):e85015.

28. Salimpoor VN, van den Bosch I, Kovacevic N, McIntosh AR, Dagher A, Zatorre RJ. Interactions between the nucleus accumbens and auditory cortices predict music reward value. Science. 2013;340(6129):216-219.

29. Blood AJ, Zatorre RJ. Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. Proc Natl Acad Sci U S A. 2001;98(20):11818-11823.

30. Salimpoor VN, Benovoy M, Larcher K, Dagher A, Zatorre RJ. Anatomically distinct dopamine release during anticipation and experience of peak emotion to music. Nat Neurosci. 2011;14(2):257-262.

31. Leite-Morris KA, Kobrin KL, Guy MD, Young AJ, Heinrichs SC, Kaplan GB. Extinction of opiate reward reduces dendritic arborization and c-Fos expression in the nucleus accumbens core. Behav Brain Res. April 2014;263:51-59.

32. Valenti VE, Guida HL, Monteiro CB, et al. Relationship between cardiac autonomic regulation and auditory mechanisms: importance for growth and development. J Hum Growth Dev. 2013;23(1):94-98.

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Amaral—Heart and Auditory Stimulus Intensity

ORIGINAL RESEARCH

Smoking-related Alterations in Serum Levels of Thyroid Hormones and Insulin in Female and Male Students Ismail Meral, PhD; Ayse Arslan, PhD; Aydin Him, PhD; Harun Arslan, MD

ABSTRACT Context • Cigarette smoking has large-scale and complex effects on the endocrine system. Various studies related to cigarette smoking have provided differing results.

Therefore, more research is needed to determine the effects on the body that are created by cigarette smoking.

Objectives • The study was designed to investigate the effects of cigarette smoking, primarily on thyroid hormones in serum, such as on levels of total triiodothyronine (tT3), free triiodothyronine (fT3), total thyroxine (tT4), free thyroxine (fT4), thyroid-stimulating hormone (TSH) (ie, thyrotropin), and insulin of young students aged 18-25 y.

Design • This study was a randomized, controlled trial.

Setting • The study was performed in the Department of Physiology, School of Medicine, Yuzuncu Yil University (Van, Turkey).

Participants • Eighty healthy students, 40 females and 40 males, were included in the study.

Intervention • Of the 40 female participants, 25 were smokers, and 15 were nonsmokers. Of the 40 male participants, 25 were smokers, and 15 were nonsmokers.

Ismail Meral, PhD, is a professor in the Department of Physiology of the School of Medicine at Bezmialem Vakif University in Istanbul, Turkey. Ayse Arslan, PhD, is an assistant professor in the Department of Nursing of the School of Health at Yüzüncü Yil University in Van, Turkey.

Aydin Him, PhD, is an associate professor in the Department of Biophysics of the School of Medicine at Ondokuz Mayis University in Samsun, Turkey. Harun Arslan, MD, is a specialist in the Department of Radiology at Van Education and Research Hospital in Van, Turkey.

Corresponding author: Ismail Meral, PhD E-mail address: imeral@bezmialaem.edu.tr

24 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

The intervention (smoking) group, therefore, consisted of 50 participants, and the control (nonsmoking) group consisted of 30 participants.

Outcome Measures • Serum concentrations of thyroid hormones and insulin were determined by enzyme-linked immunesorbent assays (ELISAs), using monoclonal antibodies; and by measurement of blood glucose, using a glucometer.

Results • The study found that both female and male smokers had higher levels of serum tT3 and insulin hormone than nonsmokers had. A positive correlation was found between age and insulin resistance in male smokers. The study also found that male smokers had higher levels of serum tT3 and fT4 hormone than female smokers had.

Conclusions • Smoking may be associated with an increased secretion of thyroid hormones and the development of insulin resistance. With aging, insulin resistance may increase more in male smokers than in female smokers. (Altern Ther Health Med. 2015;21(5):24-29.)

A

ccording to the World Health Organization (WHO), the tobacco epidemic has led to the death of 6 million people worldwide each year and has become one of the most important public health problems the world faces today. Every 6 seconds, 1 person in the world dies from diseases related to cigarette smoking.1 Cigarettes and tobacco contain more than 4000 chemicals. Among them, at least 60 substances have been identified as toxic.

Polycyclic aromatic hydrocarbons, nitro compounds, and aromatic amines are only a few of them.2 Cigarette smoking has large-scale and complex effects on the endocrine system. It affects the functions of the pituitary, thyroid, and adrenal glands and of the testis and ovaries. Calcium metabolism and insulin activity are also affected by smoking. Cigarette smoking contributes to the Arslan—Smoking-related Alterations of Thyroid Hormone in Serum

METHODS Participants A total of 80 students, aged 18 to 25 years, Smoking Nonsmoking were included in the study. Forty of the Parameters Male Female Male Female participants were females, whereas 40 of them Gender, n 25 25 15 15 were male. The smoking group included 50 Age, y 22.60 22.60 21.13 21.93 smokers, 25 males and 25 females, whereas the control group included 30 nonsmokers, 15 Height, cm 174.24 165.12 172.86 165.60 males and 15 females. The characteristics of Weight, kg 68.24 55.96 66.66 56.66 the nonsmoking controls and the cigarette 2 22.43 20.48 22.28 20.66 BMI, kg/m smokers are given in Table 1.

Daily cigarette consumption 1 pack 1 pack — — The participants were students of the Duration of smoking, y 5-6 5-6 — — current second author, Ayse Arslan. Smokers and nonsmokers were chosen based on the listed exclusion criteria and matched for age, Abbreviation: BMI, body mass index. gender, body mass index (BMI), and health development of type 2 diabetes because it contributes to the status; both groups included healthy individuals. development of insulin resistance.3 It also has been shown to Students were excluded from the study if they (1) were have variable effects on thyroid functions due to an increase dieting; (2) were using medicine for any disease; (3) had or decrease in the concentrations of thyroid hormones, such hypertension, diabetes mellitus, or respiratory disease; or (4) had nodules in their thyroid glands, as determined by as thyroxine (T4) and triiodothyronine (T3).4,5 Cigarette smoking is a strong risk factor for the ultrasonographic examination. All participants were single development of thyroid disease and may inhibit or stimulate (ie, not married) and none of the females were pregnant.

Ethical approval was obtained from the Science and thyroid functions. Graves’ disease, Graves’ ophthalmopathy, Ethics Committee of Yüzüncü Yıl University (Van, Turkey). goiter, and abnormalities in thyroid hormones may occur in 3 The study was conducted only after voluntary consent was relation to cigarette smoking. Although the exact mechanism obtained from the participants. A full explanation of the is not understood, it is believed that nicotine leads to activation study’s protocol was provided to the students before their of the sympathetic nervous system and, thus, increases the consent was requested. total secretion of thyroid hormones. Further, some substances in cigarettes, such as thiocyanate and 2,3-hidroxypridine, may Procedures affect the normal physiology of the thyroid.6,7 For 1 month, blood samples were drawn from the Cigarette smoking can have multiple effects on thyroid students after an overnight fasting period. An average of function. In various studies, T4 levels in serum remained 8 9 5 mL of blood was taken from each participant. The blood was unchanged or were slightly elevated, whereas T3 levels 10 8 placed in biochemical tubes and allowed to clot for serum increased or remained unchanged. Levels of thyrotropinanalysis.

Serum samples were stored at -80°C until analysis. stimulating hormone (TSH) have been found to have 11 12 decreased or remained unaltered.

Those variable results may be due to the fact that the Outcome Measures The levels of total triiodothyronine (tT3), free various studies are not directly comparable. Although they were conducted among smokers and nonsmokers, significant triiodothyronine (fT3), total thyroxine (tT4), free thyroxine differences existed in ages, genders, body weights, cigarette (fT4), TSH, insulin, and fasting blood glucose were measured. smoking habits, and time of abstinence from smoking.

The hormone analyses were made using monoclonal Therefore, to investigate the effects of cigarette smoking, antibodies in an enzyme-linked immunosorbent assay the current study was designed to measure the levels of (ELISA-CHB ST-360 automatic, Shanghai Kehua Laboratory thyroid hormones, insulin, and fasting blood glucose in male System Co, Shanghai, China). Blood-glucose levels were and female university students, aged 18 to 25 years, who measured using a glucometer (Optium Xceed, Medisense, smoked cigarettes and to compare them with the levels in Abingdon, Oxon, UK) and blood-glucose testing strips healthy, nonsmoking students in the same age group. Several (Optium plus, Medisense). aspects of the study differed from previous investigations: (1) participants were younger (ie, aged 18-25 y), (2) the Statistical Analyses effects of smoking on the 2 genders were determined, (3) the Because the data were normally distributed according to effects on participants due to the daily quantity of cigarettes the Kolmogorov-Smirnov test, an analysis of variance (ANOVA) (ie, 20 cigarettes/d) and the duration of use (ie, for at least was performed to determine the differences in the parameters 5 y) were addressed, and (4) the correlation coefficiency in measured in the study between the smoking and nonsmoking the subgroups were determined to assess the relationships groups and also between female and male participants. The between the variables. results were expressed as mean ± standard error, and P < .05 was Table 1. Descriptive Characteristics of the Participants Included in the Study

Arslan—Smoking-related Alterations of Thyroid Hormone in Serum

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 25

considered statistically significant. In addition, Pearson’s correlation coefficients were calculated in the subgroups to determine whether a relationship existed between the variables. The SPSS statistical software package (SPSS for Windows version v13.0, SPSS Inc, Armonk, NY, USA) was used for the statistical analyses.

Table 2. Values of fT3, tT3, fT4, tT4, TSH, Insulin, and Glucose in Smoking and Nonsmoking Males and Females Nonsmoking Smoking Males Females Males Females Mean ± SE Mean ± SE Mean ± SE Mean ± SE Parameters (n = 15) (n = 15) (n = 25) (n = 25) 3.22 ± 0.17 3.27 ± 0.14 3.22 ± 0.13 3.50 ± 0.12 fT3 (pg/mL) 108.63 ± 6.22 102.25 ± 3.72 125.52 ± 4.97a 108.23 ± 4.96 tT3 (ng/dL) 1.48 ± 0.07 1.29 ± 0.04 1.56 ± 0.07 1.36 ± 0.04 fT4 (ng/dL) tT4 (μg/dL) 7.92 ± 0.44 7.50 ± 0.27 8.24 ± 0.28 7.46 ± 0.27 TSH (μIU/mL) 1.19 ± 0.21 1.53 ± 0.18 1.07 ± 0.13 1.09 ± 0.13 Insulin (μIU/mL) 9.80 ± 1.39 10.56 ± 2.31 17.94 ± 2.40a 14.26 ± 2.17b Glucose (mg/dL) 83.07 ± 2.25 79.75 ± 1.55 87.31 ± 2.57 82.77 ± 2.49

RESULTS The fT3, tT3, fT4, tT4, TSH, insulin, and glucose values of smoking and nonsmoking males and females are shown in Table 2. The fT3, fT4, tT4, TSH, and glucose levels were not Abbreviations: SE, standard error of the mean; fT3, free triiodothyronine; tT3, total statistically different between the triiodothyronine; fT4, free thyroxine; tT4, total thyroxine; TSH, thyrotropin smoking and nonsmoking males and stimulating hormone. females. The tT3 level was significantly a higher for smoking males, at P < .05, statistically significant differences between smoking and nonsmoking 125.52 ± 4.97 (P < .05) when compared male participants. b with that for nonsmoking males, at P < .05, statistically significant differences between smoking and nonsmoking 108.63 ± 6.22. However, no statistical female participants. difference existed between the tT3 levels of the smoking females and nonsmoking females. The Table 3. Values of fT3, tT3, fT4, tT4, TSH, Insulin, and Glucose insulin levels for smoking males, at 17.94 ± 2.40, were of Smoking and Nonsmoking Participants, Without significantly higher (P < .05) than those for nonsmoking Distinction Between Males and Females males, at 9.80 ± 1.39. The insulin levels for smoking females, at 14.26 ± 2.17, were also significantly higher (P < .05) than Nonsmoking Smoking those for nonsmoking females, at 10.56 ± 2.31.

Mean ± SE Mean ± SE The fT3, tT3, fT4, tT4, TSH, insulin, and glucose values of Parameters n = 30 n = 50 smoking and nonsmoking participants, without distinction between genders, are shown in Table 3. No statistically fT3 (pg/mL) 3.25 ± 0.11 3.36 ± 0.09 significant differences existed between the smoking and 105.44 ± 3.61 116.88 ± 3.69a tT3 (ng/dL) nonsmoking groups in terms of fT3, fT4, tT4, TSH, and glucose values. The tT3 and insulin values were statistically fT4 (ng/dL) 1.39 ± 0.04 1.47 ± 0.04 higher (P < .05) for the smoking group, at 116.88 ± 3.69 and 16.11 ± 1.62, respectively, versus the nonsmoking group, at 7.71 ± 0.26 7.85 ± 0.19 tT4 (μg/dL) 105.44 ± 3.61 and 10.19 ± 1.35, respectively.

TSH (μIU/mL) 1.37 ± 0.14 1.08 ± 0.09 When the Pearson’s correlation coefficients were analyzed in male smokers, it was found that a positive correlation (P < Insulin (μIU/mL) 10.19 ± 1.35 16.11 ± 1.62a .05) existed between the tT4 and tT3 levels (Table 4). When the tT4 level increased in the male smokers, the tT3 level also Glucose (mg/dL) 81.42 ± 1.38 85.05 ± 1.80 increased, by 77.5% (P < .01). In addition, a positive correlation (P < .05) was found between age and insulin level and also between the glucose and insulin levels in male smokers. As age Abbreviations: SE, standard error of the mean; fT3, free increased in the male smokers, the insulin levels also increased triiodothyronine; tT3, total triiodothyronine; fT4, free by 44.5%, whereas the glucose level increased by 43.7%. thyroxine; tT4, total thyroxine; TSH, thyrotropin stimulating When the Pearson’s correlation coefficients were hormone. analyzed in female smokers (Table 5), a positive correlation was found between (1) between age and glucose level, aP < .05, statistically significant differences between the 2 (2) tT4 and tT3, and (3) fT3 and TSH levels. Glucose levels groups. increased by 48.1% (P < .05) as age increased; tT3 increased by 56.7% (P < .01) as tT4 increased; and fT3 increased by 42.6% (P < .05) as TSH increased. A negative correlation increased in female smokers, the fT3 level decreased by 41.8%, existed between fT3 and age and between fT3 and fT4. As age and as the fT4 level increased, the fT3 level decreased by 49.1%.

26 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Arslan—Smoking-related Alterations of Thyroid Hormone in Serum

Table 4. Pearson’s Correlation Coefficients, by Characteristic, in Male Smokers (n = 25) Parameters

fT3

tT3

fT4

fT3 (pg/mL)

1

tT3 (ng/dL)

.213

1

fT4 (ng/dL)

-.290

.018

tT4

TSH

Insulin

1

tT4 (μg/dL)

.088

a

.181

1

TSH (μIU/mL)

-.243 -.351

.244

-.307

1

Insulin (μIU/mL)

-.031

.156

-.134

.036

-.339

1

Glucose (mg/dL)

.027

.306

-.032

.112

-.312

.437b b

.775

Glucose Age Height Weight BMI

1

Age

-.052

.104

.132

.027

-.395

.445

-.004

1

Height

.093

.035

.102

-.171 -.009

.246

-.109

.238

1

Weight

-.063

.042

.141

-.175 -.041

.337

-.068

.308

.917a

1

BMI

-.347

.029

.151

-.087 -.099

.334

.074

.296

.265

.626a

1

Abbreviations: fT3, free triiodothyronine; tT3, total triiodothyronine; fT4, free thyroxine; tT4, total thyroxine; TSH, thyrotropin stimulating hormone; BMI, body mass index. a

P < .01.

P < .05.

b

Table 5. Pearson’s Correlation Coefficients, by Characteristic, in Female Smokers (n = 25) Parameters

fT3

fT3 (pg/mL)

1

tT3 (ng/dL)

.209

1

fT4 (ng/dL)

-.491a

.066

1

tT4 (μg/dL)

.221

.567b

.260

TSH (μIU/mL)

.426a

.120 -.298 -.042

Insulin (μIU/mL)

.013

.256 -.127 -.137 -.316

Glucose (mg/dL)

.176

.178

.031

.130

.134

.313

1

-.418a

.092

.305

-.162

.026

.131

.481a

1

Age

tT3

fT4

tT4

TSH Insulin Glucose

Age

Height Weight

BMI

1 1 1

Height

.034

-.204 -.124 -.243

.327

-.194

-.116

-.032

1

Weight

.115

.005 -.162 -.108

.202

-.072

.144

.086

.769b

1

BMI

.132

.173 -.129

.041

.041

.268

.142

.373

.879b

.030

1

Abbreviations: fT3, free triiodothyronine; tT3, total triiodothyronine; fT4, free thyroxine; tT4, total thyroxine; TSH, thyrotropin stimulating hormone. a

P < .05 P < .01

b

Arslan—Smoking-related Alterations of Thyroid Hormone in Serum

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 27

DISCUSSION The current study was designed to investigate smokingrelated alterations on levels of tT3, fT3, tT4, fT4, TSH, insulin, and fasting blood glucose for young male and female students aged 18 to 25 years. The study found that no differences existed between the smoking and nonsmoking groups regarding values of fT3, fT4, tT4, TSH, and glucose, but the insulin and tT3 values were significantly higher in the smoking group.

In a previous study, Soldin et al13 found that active and passive smoke exposure produced a mild inhibitory effect on serum levels of tT3, tT4, and TSH in women of reproductive age (ie, from 18-44 y). That result is not consistent with the current study’s results because the research team found a significant increase in tT3 values for smokers. That finding may be due to the fact that the participants in the current study, compared with those in the prior study, were younger (ie, 18-25 y) and had a higher amount of daily cigarette inhalation (ie, 20 cigarettes/d).

In a study by Gulcu et al14 that was conducted to determine the relationship between cigarette smoking and hypothyroidism or hyperthyroidism, 31 males who smoked 12 to 18 cigarettes per day and 32 males who had never been smokers were included in the study. The researchers in that study observed that the tT3, tT4, and TSH levels of the smoking groups decreased significantly. They suggested that excessive smoking might have caused hypothyroidism. In a study by Asvold et al,15 the researchers suggested that smoking had an association with hyperthyroidism but not with hypothyroidism. The finding of a high level of serum tT3 in smokers in the current study is similar to the finding in the Asvold et al study.

It has been suggested that nicotine stimulates the sympathetic nervous system and ultimately increases the secretion of thyroid hormones.6,7 Two studies have found that nicotine can lead to the release of norepinephrine by binding to nicotinic cholinergic receptors, which are commonly found in the brain, and can stimulate the sympathetic nervous system.16,17 The current study also found that the tT3 level was significantly higher in smoking males than nonsmoking males. However, no difference existed between the smoking and nonsmoking females’ levels of tT3. Zeman et al18 have suggested that cigarettes preferred by females have lower levels of nicotine. In that study, the nicotine levels in the plasma and urine of females were lower than those of the males, and their nicotine metabolism was faster.

By the infusion of nicotine or cotinine, which is a metabolite of nicotine, another study has demonstrated that the plasma half-life of nicotine in females is shorter than in males.19 Benowitz et al20 have suggested that the clearance of nicotine or cotinine is slower in males compared with females. Those data suggest males are more affected by cigarettes and metabolites than females are, and, as a result, metabolic changes might emerge more significantly in males.

28 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Cigarette smoking is considered a major risk factor for cardiovascular disease.22 Some studies have shown that cigarette smoking decreases insulin sensitivity and leads to the development of insulin resistance.21,21 It has also been shown that cigarette smoking is associated with metabolic disorders and that the risk of the occurrence of metabolic syndrome increases in smokers.23,24 Eliasson25 has revealed that cigarette smoking increases the risk of developing diabetes, by 50% in females and males.

In the current study, insulin levels were found to be higher in smoking males and females compared with those who did not smoke. Despite that significant increase in the level of insulin in smokers, a significant difference was not found between smokers and nonsmokers in terms of the glucose level. That result indicates that insulin resistance can occur in smokers. That finding is consistent with the finding of a previous study that indicated that cigarette smoking contributed to the development of type 2 diabetes due to the development of insulin resistance.3 In the current study, it was also found that a positive correlation existed between age and insulin resistance in male smokers, but the same situation did not occur in female smokers. That finding showed development of insulin resistance may increase more with age in male smokers compared with female smokers.

It is not fully understood how cigarette smoking contributes to the development of insulin resistance. However, nicotine, carbon monoxide, and other toxic substances in cigarettes are believed to have a direct effect on the tissue formation of insulin resistance. According to other studies, continuous smoking can lead to vascular changes (eg, arterial spasm and atherosclerosis), thereby decreasing blood flow to skeletal muscles and decreasing the distribution of insulindependent glucose by impairing the endothelial function.26,27 Nicotine also contributes to the development of insulin resistance through increasing the release of corticosteroids and growth hormone, which are anti-insulin hormones.

Levels of free fatty acids and triglycerides are high in smokers and are associated with insulin resistance. Some studies have shown that increased plasma levels of free fatty acids can cause insulin resistance and impair the distribution of insulin-dependent glucose.26,28 In those studies, both insulin resistance and lipid intolerance have been found.

In another study,29 smokers were separated into 3 groups, according to their members’ annual cigarette consumption in terms of packages, as light (25), medium (20-39), and heavy (≥40) smokers. It was observed that metabolic disorders intensified when cigarette consumption increased (eg, high blood sugar, high triglycerides, and low high-density lipoprotein [HDL] cholesterol). Accordingly, it was concluded that the risk of the occurrence of metabolic syndrome was higher in smokers.

In another study,30 male and female smokers aged 18 to 92 years were investigated regarding metabolic disorders. The researchers found that males have higher risk factors for metabolic disorders; the mean ages and glucose concentrations were similar in both genders. Males tended Arslan—Smoking-related Alterations of Thyroid Hormone in Serum

to have a higher mean blood pressure (systolic and diastolic), a higher level of triglycerides, and a lower level of HDL cholesterol. The researchers also found that no significant relationship existed between smoking and metabolic syndrome in female participants.

In the current study, the research team concluded that the tT3 levels in male smokers and the insulin levels in male and female smokers increased, indicating that smoking was associated with the metabolism of thyroid hormones and insulin in healthy participants. Increased insulin secretion, without changes in glucose levels, indicated an insulin resistance in the participants.

In addition, tT3 values in males were found in the current study to be higher than those of females, which revealed the fact that cigarette smoking caused different effects in females and males and that the effects in males might be more severe. Further, the presence of a positive correlation between age and insulin resistance in male smokers and an absence of the same relationship in female smokers showed that insulin resistance may increase more with age in males compared with females.

The emergence of the effects of cigarette smoking in such an apparent way, even after 5 years of use, in a younger age group (18-25 y) of the current study, is remarkable. Insulin resistance, particularly when observed in young individuals who smoke, may increase the risk of developing type 2 diabetes in the future in those persons. Therefore, quitting smoking may have immediate benefits to health at any age.

For reductions in smoking among adults, effective interventions need to be augmented, such as smoke-free laws, tobacco price increases, and antitobacco media campaigns.

CONCLUSIONS Smoking may be associated with an increased secretion of thyroid hormones and the development of insulin resistance. With aging, insulin resistance may increase more in male smokers than in female smokers.

ACKNOWLEDGEMENTS This work was supported by the Research Fund of Yüzüncü Yil University.

7. Fisher CL, Mannino DM, Herman WH, Frumkin H. Cigarette smoking and thyroid hormone levels in males. Int J Epidemiol. 1997;26(5):972-977.

8. Hegedüs L, Bliddal H, Karstrup S, Bech K. Thyroid stimulating immunoglobulins are not influenced by smoking in healthy subjects.

Thyroidology. 1992;4(2):91-92.

9. Edén S, Jagenburg R, Lindstedt G, Lundberg PA, Mellström D. Thyroregulatory changes associated with smoking in 70-year-old men. Clin Endocrinol (Oxf).

1984;21(6):605-610.

10. Müller B, Zulewski H, Huber P, Ratcliffe JG, Staub JJ. Impaired action of thyroid hormone associated with smoking in women with hypothyroidism. N Engl J Med. 1995;333(15):964-969.

11. Melander A, Nordenskjöld E, Lundh B, Thorell J. Influence of smoking on thyroid activity. Acta Med Scand. 1981;209(1-2):41-43.

12. Sepkovic DW, Haley NJ, Wynder EL. Thyroid activity in cigarette smokers. Arch Intern Med. 1984;144(3):501-503.

13. Soldin OP, Goughenour BE, Gilbert SZ, Landy HJ, Soldin SJ. Thyroid hormone levels associated with active and passive cigarette smoking. Thyroid.

2009;19(8):817-823.

14. Gulcu F, Polat SF, Gursu MF. The effects of excessive tobacco use on levels of the trace element and thyroid function tests. Turkiye Klinikleri J Med Sci. 2003;23:386-391.

15. Asvold BO, Bjøro T, Nilsen TI, Vatten LJ. Tobacco smoking and thyroid function: a population-based study. Arch Intern Med. 2007;167(13):1428-1432.

16. Jones RT, Benowitz NL. Therapeutics for nicotine addiction. In: Davis KL, Charney D, Coyle JT, Nereoff C, eds. Neuropsychopharmacology: The Fifth Generation of Progress. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:1533-1543.

17. Tutka P, Mosiewicz J, Wielosz M. Pharmacokinetics and metabolism of nicotine.

Pharmacol Rep. 2005;57(2):143-153.

18. Zeman MV, Hiraki L, Sellers EM. Gender differences in tobacco smoking: higher relative exposure to smoke than nicotine in women. J Womens Health Gend Based Med. 2002;11(2):147-153.

19. Benowitz NL, Perez-Stable EJ, Fong I, Modin G, Herrera B, Jacob P III. Ethnic differences in N-glucuronidation of nicotine and cotinine. J Pharmacol Exp Ther.

1999;291(3):1196-1203.

20. Benowitz NL, Swan GL, Lessov CN, Jacob P. Oral contraceptives induce CYP2A6 activity and accelerate nicotine metabolism. Clin Pharmacol Ther.

February 2004;75:36.

21. Frati AC, Iniestra F, Ariza CR. Acute effect of cigarette smoking on glucose tolerance and other cardiovascular risk factors. Diabetes Care. 1996;19(2):112-118.

22. Wada T, Urashima M, Fukumoto T. Risk of metabolic syndrome persists twenty years after the cessation of smoking. Intern Med. 2007;46(14):1079-1082.

23. Nakanishi N, Takatorige T, Suzuki K. Cigarette smoking and the risk of the metabolic syndrome in middle-aged Japanese male office workers. Ind Health.

2005;43(2):295-301.

24. Geslain-Biquez C, Vol S, Tichet J, Caradec A, D’Hour A, Balkau B; DESIR Study Group. The metabolic syndrome in smokers: the DESIR study. Diabetes Metab. 2003;29(3):226-234.

25. Eliasson B. Cigarette smoking and diabetes. Prog Cardiovasc Dis. 2003;45(5):405-413.

26. Benowitz NL. Cigarette smoking and cardiovascular disease: pathophysiology and implications for treatment. Prog Cardiovasc Dis. 2003;46(1):91-111.

27. Facchini FS, Hollenbeck CB, Jeppesen J, Chen YD, Reaven GM. Insulin resistance and cigarette smoking. Lancet. 1992;339(8802):1128-1130.

28. Eliasson B, Mero N, Taskinen MR, Smith U. The insulin resistance syndrome and postprandial lipid intolerance in smokers. Atherosclerosis. 1997;129(1):79-88.

29. Cena H, Tesone A, Niniano R, Cerveri I, Roggi C, Turconi G. Prevalence rate of metabolic syndrome in a group of light and heavy smokers. Diabetol Metab Syndr. 2013;5(1):28.

30. Wang JW, Hu DY, Sun YH, Wang JH, Xie J. Gender difference in association between smoking and metabolic risks among community adults [in Chinese].

Zhonghua Yi Xue Za Zhi. 2011;91(12):805-809.

AUTHOR DISCLOSURE STATEMENT The authors report no conflicts of interest.

REFERENCES 1. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2013.

Geneva, Switzerland: World Health Organization; 2013.

2. Tziomalos K, Charsoulis F. Endocrine effects of tobacco smoking. Clin Endocrinol (Oxf). 2004;61(6):664-674.

3. Kapoor D, Jones TH. Smoking and hormones in health and endocrine disorders.

Eur J Endocrinol. 2005;152(4):491-499.

4. Burguet A, Kaminski M, Truffert P, et al; Epipage Study Group. Does smoking in pregnancy modify the impact of antenatal steroids on neonatal respiratory distress syndrome? Results of the Epipage study. Arch Dis Child Fetal Neonatal Ed. 2005;90(1):F41-F45.

5. Pontikides N, Krassas GE. Influence of cigarette smoking on thyroid function, goiter formation and autoimmune thyroid disorders. Hormones (Athens).

2002;1(2):91-98.

6. Christensen SB, Ericsson UB, Janzon L, Tibblin S, Melander A. Influence of cigarette smoking on goiter formation, thyroglobulin, and thyroid hormone levels in women. J Clin Endocrinol Metab. 1984;58(4):615-618.

Arslan—Smoking-related Alterations of Thyroid Hormone in Serum

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 29

ORIGINAL RESEARCH

Turkish Nurses’ Use of Nonpharmacological Methods for Relieving Children’s Postoperative Pain Ayda Çelebioğlu, PhD; Sibel Küçükoğlu, PhD; Emel Odabaşoğlu, MSci

ABSTRACT Context • The experience of pain is frequently observed among children undergoing surgery. Hospitalization and surgery are stressful experiences for those children.

Objective • The research was conducted to investigate and analyze Turkish nurses’ use of nonpharmacological methods to relieve postoperative pain in children.

Design • The study was cross-sectional and descriptive.

Setting • The study took place at 2 hospitals in eastern Turkey.

Participants • Participants were 143 nurses whose patients had undergone surgical procedures at the 2 hospitals.

Outcome Measures • The researchers used a questionnaire, a checklist of nonpharmacological methods, and a visual analogue scale (VAS) to collect the data. To assess the data, descriptive statistics and the χ2 test were used.

Results • Of the 143 nurses, 73.4% initially had applied medication when the children had pain. Most of the nurses (58.7%) stated the children generally experienced a middle level of postoperative pain. The most frequent practices that the nurses applied after the children’s

surgery were (1) “providing verbal encouragement” (90.2%), a cognitive–behavioral method; (2) “a change in the child’s position” (85.3%), a physical method; (3) “touch” (82.5%), a method of emotional support; and (4) “ventilation of the room” (79.7%), a regulation of the surroundings. Compared with participants with other educational levels, the cognitive–behavioral methods were the ones most commonly used by the more educated nurses (P < .05): (1) encouraging patients with rewards, (2) helping them think happy thoughts, (3) helping them use their imaginations, (4) providing music, and (5) reading books. Female nurses used the following methods more than the male nurses did (P < .05): (1) providing encouragement with rewards, (2) helping patients with deep breathing, (3) keeping a desired item beside them, (4) changing their positions, and (5) ventilating the room.

Conclusion • Undergoing surgery is generally a painful experience for children. Nurses most commonly use cognitive–behavioral methods in the postoperative care of their pediatric patients after surgery. (Altern Ther Health Med. 2015;21(5):30-35.)

Ayda Çelebioğlu, PhD, is an associate professor; and Sibel Küçükoğlu, PhD, is an assistant professor in the Department of Child Health and Disease Nursing, Faculty of Health Science, at Atatürk University, in Erzurum, Turkey. Emel Odabaşoğlu, MSci, is an expert nurse in the Department of Child Health and Disease Nursing, Samsun State Hospital, in Samsun, Turkey.

surgical intervention causes stress to an organism and significantly violates the normal functioning of organs and organic systems. Although treatment of chronic pain has become more common, for the past 2 decades, postoperative pain has remained an unresolved problem.1,2 Although evidence exists to guide available practice, children still have unrelieved moderate to severe postoperative pain.3-5 Effective control of postoperative pain can be performed by the individual caregiver or by a multidisciplinary team if both use a coordinated approach to patient care. Nurses in the team play an active role in identifying and controlling postoperative pain, implementing coping strategies, and teaching the strategies to patients.6 Pharmacological, surgical, and nonpharmacological methods are all used in postoperative pain management.

Corresponding author: Sibel Küçükoğlu, PhD E-mail address: sibel.kucukoglu@atauni.edu.tr

30 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

A

Çelebioğlu—Nonpharmacological Methods for Relieving Postoperative Pain

Pharmacological methods are medications ordered by physicians and are administered through a variety of routes.7 Meanwhile, nonpharmacological techniques constitute a significant portion of pediatric patient care that is associated with pain management, with an eye to ensuring adequate pain relief. Nonpharmacological methods are commonly considered additional strategies that are used alone or with medication.

To ensure correct and proper management of pain in the postoperative period, the existing pain should be evaluated using an appropriate method. Although the most reliable indicator in the assessment of pain is the pain expression of the patient, it should be noted that patients who have difficulty in reporting or identifying their pain must be evaluated by other means.

Regarding pain relief, the related literature has commonly reported on nonpharmacological methods, and some evidence indicates nurses use a more eclectic approach to pain management instead of relying on pharmacological methods alone.8 Moreover, recent studies have indicated postoperative pain is poorly managed in children.9-11 Using 3 classifications— cognitive–behavioral methods, physical methods, and emotional support strategies, Pölkki et al12 categorized nonpharmacological methods that help with the activities of daily living and those that create a comfortable environment.

The objectives of nonpharmacological interventions are (1) to decrease children’s fear, (2) to reduce their distress and pain, and (3) to give them a sense of control. To provide a comfortable environment for the child, both physical and cognitive–behavioral approaches are required.2 Further, nonpharmacological interventions performed during medical procedures reduce the stress experienced by parents, and nurses are able to carry out those practices independently and to encourage family members to engage in active participation in the patient’s care.13 The number of studies focusing on the use of nonpharmacological methods by nurses to relieve children’s pain has increased in recent years. However, it seems the results are inconsistent. Some researchers report nurses frequently use nonpharmacological methods to relieve the postoperative pain of children.12,14 On the other hand, research has revealed nurses rarely use those pain treatment methods for many reasons.15,16 In Turkey, several studies have investigated the knowledge and beliefs of nurses regarding the nature, assessment, and management of pain.2 However, only a limited number of studies on the subject have focused on pediatric surgical nurses in Turkey.17 The purpose of the current study was to assess the use of nonpharmacological methods by Turkish nurses to relieve postoperative pain experienced by children.

Those 4 wards included a pediatric surgical ward, an ear-nosethroat surgical ward, a brain surgical ward, and an orthopedic ward. The study excluded children who had different developmental characteristics, such as those in the infancy period of 0 to 1 year and in the adolescence period. Previously, the research team had observed some adolescent patients applying nonpharmacological methods themselves to control their pain, so this group was excluded from the study.

Ethical principles were considered during data collection.

Verbal and written informed consents were obtained from the related hospitals and participants. The aim of the study was explained to the nurses prior to administering the questionnaires, which were given only to nurses who had agreed to participate in the research. Ethics-committee approval was received from the Faculty of Health Science at Atatürk University.

Procedures Data collection lasted for approximately 3 months, from May 2011 to July 2011. The research team collected the data using a questionnaire, a checklist of nonpharmacological methods, and a visual analogue scale (VAS). The forms were filled out by the nurses in approximately 20 minutes. Because 10 clinical nurses who were interviewed before the study stated they had used a VAS to evaluate pain in toddlers—in whom it is still hard to identify pain exactly and accurately— the VAS was used in the current study for pain assessment.

Normally, VAS is a self-report tool, but in the present case, the research team considered it appropriate to use the tool with the nurses because the study looked at what they do when they perceive that a child is in pain.

MATERIAL AND METHODS Participants A total of 160 questionnaires were distributed to nurses in 4 wards at 2 hospitals in eastern Turkey. They received the questionnaires 1 day after their patients, who were between the ages of 1 and 12 years, had undergone surgical procedures.

OUTCOME MEASURES The questionnaire was divided into 2 parts. The first part measured the descriptive characteristics of the nurses (ie, gender, age, marital status, number of children, income level, educational level, professional mandate, the pediatric surgical clinics where they were working, and the first and second methods that they used to reduce postoperative pain). The second part collected information about nonpharmacological methods used by the nurses after a child’s surgery.

Nonpharmacological methods were established by reviewing the literature2,15,16,18 and by interviewing the 10 clinical nurses previously mentioned, and those methods were then incorporated into a checklist. To improve the reliability of the checklist, a pilot study was conducted with 25 nurses whose patients had undergone surgery in the pediatric surgical ward at a university hospital in Turkey. As a result of the pilot study, some minor revisions were made in terms of collection of data on the demographic characteristics of the nurses. Then, the nurses in the sample group were asked to fill out the checklist by considering nonpharmacological methods that they had used on children after surgery in the month prior to the study.

The nonpharmacological methods included (1) cognitive– behavioral methods—encouraging children verbally,

Çelebioğlu—Nonpharmacological Methods for Relieving Postoperative Pain

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 31

encouraging them using rewards, helping them think happy thoughts, helping them use their imaginations, providing them with music, relaxing them, helping them take deep breaths, and reading books to them; (2) physical methods— giving massages, keeping a desired item beside them, and changing their positions; (3) emotional support—constantly being nearby and touching them; and (4) regulating their surroundings—ventilating the room and providing a quiet environment.

The nurses assessed the postoperative pain their patients had after the surgeries, using a 10-cm scale on a VAS. The nurses defined the intensity of pain as no pain (0 cm), mild pain (0.5–3 cm), moderate pain (3.5–6.5 cm), and severe pain (7–10 cm).19 Because the VAS is methodologically sound, conceptually simple, easy to administer, and unobtrusive for respondents, it represented the most appropriate tool to measure the intensity of postoperative pain.

Table 1. Distribution of Sociodemographic Characteristics of Nurses Descriptive Characteristics Age (y) 18-30 31-40 >41 Gender Female Male Marital status Married Single Do you have children?

Yes No Education level High school University Master of science/doctorate Level of income

Data Analysis In the analyses, descriptive statistics were used to describe the demographic factors of the nurses and the children as well as the nurses’ uses of nonpharmacological methods for pain relief. Differences related to demographic factors and nurses’ uses of nonpharmacological methods were tested using a χ2 test, where P < .05 was considered statistically significant.

RESULTS Seventeen of the 160 nurses who received questionnaires refused to participate. Thus, participation in the study was determined to be 89.38% (n = 143).

The findings of the research established that (1) 66.4% of the nurses were 18 to 30 years old; (2) 93.7% were female; (3) 60.1% were married; (4) 70.6% were educated at the university level; (5) 49.7% had been working in their current clinic for 1 to 5 years, (6) 76.2% worked shifts; and (7) 73.4% initially had applied medication when the children were in pain (Table 1). It was determined that a greater number of the nurses used medication (62.2%) rather than nonpharmacological methods as a first option when controlling the pain 4 hours after the first application of pharmacological treatments, according to clinical procedure. Most nurses in this study (58.7%) stated the children generally experienced a middle level of postoperative pain (Figure 1).

The methods used by nurses for controlling the postoperative pain of the children were examined, and the results indicated that all of the nurses used at least 1 selfinitiated pain-relieving method. The most frequent cognitive– behavioral methods were (1) providing verbal encouragement (90.2%), (2) helping patients with deep breathing (60.8%), (3) providing encouragement with rewards (47.6%), and (4) helping them make relaxation movements (47.6%). The most frequent physical method was changing the children’s positions (85.3%). Touch (82.5%) was the most frequently used method of providing emotional support, and 79.7% of the nurses ventilated the room to provide regulation of the 32 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

n

%

95 43 5

66.4 30.1 3.5

134 9

93.7 6.3

86 57

60.1 39.9

70 73

49.0 51.0

34 101 8

23.8 70.6 5.6

Income lower than expenses

34

23.8

Income equal to expenses

103

72.0

6

4.2

71

49.7

Income lower than expenses Tenure in the clinic (y) 1-5 6-10

40

28.0

11-20

27

18.9

>21

5

3.5

Daytime

34

23.8

Shift

109

76.2

State hospital

49

34.3

University hospital

94

65.7

Medication

105

73.4

Nonpharmacological methods

38

26.6

When children had pain, the seconda application was: Medication 89 Nonpharmacological methods 54 Total 143

62.2 37.8 100

Mode of operation

Type of facility

When children had pain, the first application was:

a

Controlling the pain 4 h after the first application of pharmacological treatments.

Çelebioğlu—Nonpharmacological Methods for Relieving Postoperative Pain

Figure 1. Nurses’ assessment of patients’ worst postoperative pain using a visual analogue scale (VAS). Values are given as percentages (n = 143).

80 58.7%

60

39.9%

40 20 1.4% 0 Light

Middle

Severe

Table 2. Nurses’ Use of Nonpharmacological Methods for Children’s Postoperative Pain Relief (n = 143)a Nonpharmacological Methods Cognitive-behavioral methods Providing verbal encouragement Helping them with deep breathing Providing encouragement with reward Helping them make relaxation movements Helping them think happy thoughts Helping them use imagination Reading books Providing music Physical methods Changing their positions Keeping a desired item beside them Giving massages Emotional support Touching them Constantly being nearby Regulation of surroundings Ventilating the room Providing a quiet environment a More than 1 answer could be given.

n

%

129 87 68 68 62 41 20 16

90.2 60.8 47.6 47.6 43.4 28.7 14.0 11.2

122 85.3 109 76.2 63 44.1 118 82.5 28 19.6 114 79.7 84 58.7

Table 3. Relationship Between Nurses’ Demographic Factors and Their Uses of Nonpharmacological Methodsa

Nonpharmacological Methods Cognitive-behavioral methods Providing verbal encouragement Encouragement with reward Helping them think happy thoughts Helping them use imagination Providing music Helping them make relaxation movements Helping them with deep breathing Reading books Physical methods Giving massage Keeping a desired item beside them Changing their positions Emotional support Constantly being nearby Touching them Regulation of surroundings Ventilating the room a

Gender Female/ Male n

Age (y) 18-30/ 31-40 n

Education Type of Facility High School/ Working style State/ University/MS Daytime/Shift University n n n

122/7 97/4b 65/3 40/1 16/0 64/4 115/4b 20/0

87/42 42/26b 44/18 29/12 10/6 75/30b 84/85b 11/9

30/84/8 22/73/6b 24/75/5b 14/57/5b 7/38/2b 14/45/5 19/57/7 5/31/2b

27/102 19/49 20/84b 12/29 5/11 15/53 22/65 6/14

43/86 23/45 26/36b 14/27 5/11 32/36b 32/36b 33/54

60/3 123/6b 135/8b

41/22 72/37 79/43

13/4/15 25/72/7 28/79/8

19/79b 26/83 28/94

14/49b 38/71 42/80

26/2 110/8

18/10 76/42

7/19/1 31/91/8b

7/21 28/102b

7/21 37/81

119/6b

74/40

27/75/6

28/86

43/71

More than 2 answer could be given.

P < .05.

b

Çelebioğlu—Nonpharmacological Methods for Relieving Postoperative Pain

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 33

surroundings (Table 2). The nonpharmacological method that the nurses least preferred in the study was found to be providing music (11.2%).

Female nurses used the following methods significantly more than the male nurses did (P < .05): (1) providing encouragement with rewards, (2) helping patients with deep breathing, (3) keeping a desired item beside them, (4) changing their positions, and (5) ventilating the room (Table 3). The cognitive–behavioral methods that were used by more-educated nurses significantly more often compared with other nurses (P < .05) were (1) providing encouragement with rewards, (2) helping patients think happy thoughts, (3) helping them use their imaginations, (4) providing music, and (5) reading books.

It was established that nurses working in shifts used some techniques significantly more often than did nurses working during the daytime (P < .05): (1) helping patients think happy thoughts, (2) giving massages, and (3) touching patients. Meanwhile, nurses working in the university hospital used some techniques significantly more frequently than did nurses working in a state facility (P < .05): (1) helping patients think happy thoughts, (2) helping them perform relaxation movements, (3) helping them with deep breathing, and (4) giving them massages (Table 3).

DISCUSSION The term nonpharmacological pain management is comprehensive and includes all intervention methods for pain treatment that do not involve medications. A great majority of nurses in the current study assessed the postoperative pain of children as middle and severe in the study (Figure 1). In addition, related studies have demonstrated that children have various levels of postoperative pain. Kortesluoma et al1 and He et al2 have stated nonpharmacological methods are highly effective in reducing children’s pain. Cognitive–behavioral approaches, which actively engage children, assist patients to redirect their attention from fearful and painful procedures to something else.

The objectives of nonpharmacological interventions are to decrease children’s fear, reduce their distress and pain, and give them a sense of control. For the purpose of providing a comfortable environment for a child, both physical and cognitive–behavioral approaches are required.20,21 By actively engaging the children, cognitive–behavioral approaches enable them to move their attention away from fearful and painful operations. Music, guided imagery, distraction, hypnosis, relaxation techniques, controlled breathing, and biofeedback exercises are some examples of cognitive– behavioral interventions.20 The results of the current study revealed the participants used both physical and cognitive–behavioral, nonpharmacological methods for the purpose of treating children’s postoperative pain in the hospital. Examining practices used by nurses for children after surgery, the current study found that nurses most frequently used (1) providing verbal encouragement (90.2%), a cognitive–behavioral

method; (2) changing their positions (85.3%), a physical method; (3) touching them (82.5%), a method of providing emotional support; and (4) ventilating the room (79.7%), a method of regulation of the surroundings (Table 2). Effective pain management requires knowledge of both nonpharmacological and pharmacological methods. Although all of the nurses who participated in the current study had used nonpharmacological methods after the surgeries, it was determined that they had initially applied drug therapy when children had pain, which might be appropriate in a surgical population. On the other hand, only 37.8% nurses applied nonpharmacological methods when children expressed pain in the 4 hours after the first pharmacological application, which is an important result of the current study. That finding may suggest nurses did not have sufficient knowledge and skills related to nonpharmacological methods.

A study conducted by Efe et al17 demonstrated most of the nurses in the study had inadequate knowledge regarding physiological indicators that could be used to evaluate acute procedural pain in infants. As a result, pediatric surgical nurses had insufficient knowledge related to infant pain assessment. When pain assessment is performed poorly, that failure may result in an underestimation and undertreatment of pain in the pediatric population.22 However, numerous studies have emphasized that some barriers exist to the use of nonpharmacological methods, including institutional policies, the desire of physicians to get the pain under control in less time, and the problems experienced in communications with patients or their relatives that affect nurses’ use of nonpharmacological methods.15,23 In addition, the research team had observed that nurses’ heavy working conditions and the inadequate staffing of nurses, which are important problems in Turkey, might have prevented the nurses from systematically using nonpharmacological methods in postoperative pain management.

The results of the current study suggest some characteristics of nurses, such as their ages, educational levels, working styles, and institutions, can have an effect on their use of nonpharmacological methods (Table 3). In a study by Pöllki et al,12 the researchers indicated the nurses’ use of some nonpharmacological methods was affected by their demographic characteristics, such as age, educational level, work experience, status as a parent, and hospitalization experiences with their own children. Moreover, the study revealed nurses who had graduated from a university used cognitive and behavioral methods at a higher rate.

In another study by He et al,24 the researchers determined nurses’ educations were a significant factor. Nurses who specialized in pediatric nursing had greater knowledge regarding nonpharmacological pain management compared with other groups. The results are logical and demonstrate education has an effect on nursing practice. Those results are in line with those of Bandstra et al.25 Although the number of nurses with a master’s degree was limited in the current study, it was observed that those nurses tended to use nonpharmacological methods more

34 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 Çelebioğlu—Nonpharmacological Methods for Relieving Postoperative Pain

frequently (Table 3). Previous studies have demonstrated that training on pain management for nurses positively affects their knowledge, skills, and practices concerning postoperative pain control.26 It may be that nurses with master’s degrees used nonpharmacological methods more often because they had received training on pain management in their postgraduate educational programs.

Limitations The current study had some limitations. The total number of interviews was relatively small, and the results cannot be generalized to all pediatric surgical nurses in Turkey. Moreover, the fact that few participants were male or held a master’s or doctoral degrees may also have affected the results of the study. Despite those limitations, the results support the claim that nonpharmacological methods of pain management should be further considered. A need exists to develop systematic and evidence-based guidelines for pain management and the use of nonpharmacological methods in the postoperative period. Future studies should be carried out with a larger sample.

CONCLUSIONS Nonpharmacological interventions, an important part of child care in pediatric surgical departments, should be incorporated into clinical practice, either alone or in conjunction with pharmacological measures, according to an assessment of each child. To accomplish that goal, several recommendations can be made.

First, nurses’ knowledge and skills concerning the provision of postoperative care related to pain management should be increased through in-service training. Second, those nurses should then educate patients and their relatives on nonpharmacological pain management and encourage them to use the relevant methods. That practice means that children who have undergone operations should be actively involved in the planning and implementation of a regimen for pain management during their stays in the hospital, handled by nurses specialized in the field. Further, for children aged 1 to 12 years, nurses should more frequently use not only cognitive–behavioral methods for pain treatment, such as imagery, relaxation methods, and breathing techniques, but also some physical methods, including cold application and massage.

Further study is recommended on how nurses relieve children’s pain during the postoperative period. Future studies should examine the following elements: (1) what nonpharmacological methods nurses use for children suffering from pain after surgery at different ages, and (2) what factors obstruct or promote nurses’ use of different pain-relief methods in clinical practice.

Çelebioğlu—Nonpharmacological Methods for Relieving Postoperative Pain

AUTHOR DISCLOSURE STATEMENT The authors received no financial support for the current study and declare that they have no conflicts of interest related to the study.

REFERENCES 1. Kortesluoma RL, Nikkonen M, Serlo W. “You just have to make the pain go away”—children’s experiences of pain management. Pain Manag Nurs.

2008;9(4):143-149.

2. He HG, Jahja R, Lee TL, et al. Nurses’ use of nonpharmacological methods in children’s postoperative pain management: educational intervention study. J Adv Nurs. 2010;66(11):2398-2409.

3. Kotzer AM. Factors predicting postoperative pain in children and adolescents following spine fusion. Issues Compr Pediatr Nurs. 2000;23(2):83-102.

4. Swallow J, Briggs M, Semple P. Pain at home: children’s experience of tonsillectomy. J Child Health Care. 2000;4(3):93-98.

5. Pölkki T, Pietilä AM, Vehviläinen-Julkunen K. Hospitalized children’s descriptions of their experiences with postsurgical pain relieving methods. Int J Nurs Stud. 2003;40(1):33-44.

6. Eti Aslan F, Badır A. Reality about pain control: the knowledge and beliefs of nurses on the nature, assessment and management of pain [in Turkish]. Agri.

2005;17(2):44-51.

7. Arslan S, Çelebioğlu A. Postoperative pain management and alternative applications [in Turkish]. Int J Human Sci. 2004;1(1):1-7.

8. He HG, Lee TL, Jahja R, et al. The use of nonpharmacological methods for children’s postoperative pain relief: Singapore nurses’ perspectives. J Spec Pediatr Nurs. 2011;16(1):27-38.

9. He HG, Vehviläinen-Julkunen K, Pölkki T, Pietilä AM. Children’s perceptions on the implementation of methods for their postoperative pain alleviation: an interview study. Int J Nurs Pract. 2007;13(2):89-99.

10. Kankkunen P, Vehviläinen-Julkunen K, Pietilä AM, et al. Promoting children’s pharmacological post-operative pain alleviation at home. Pediatr Nurs.

2009;35(5):298-303.

11. Sutters KA, Savedra MC, Miaskowski C, et al. Children’s expectations of pain, perceptions of analgesic efficacy, and experiences with nonpharmacologic pain management strategies at home following tonsillectomy. J Spec Pediatr Nurs.

2007;12(3):139-148.

12. Pölkki T, Vehviläinen-Julkunen K, Pietilä AM. Nonpharmacological methods in relieving children’s postoperative pain: a survey on hospital nurses in Finland. J Adv Nurs. 2001;34(4):483-492.

13. Wente SJ. Nonpharmacologic pediatric pain management in emergency departments: a systematic review of the literature. J Emerg Nurs.

2013;39(2):140-150.

14. He HG, Pölkki T, Vehviläinen-Julkunen K, Pietilä AM. Chinese nurses’ use of nonpharmacological methods in children’s postoperative pain relief. J Adv Nurs.

2005;51(4):335-342.

15. Rejeh N, Ahmadi F, Mohammadi E, Anoosheh M, Kazemnejad A. Barriers to, and facilitators of post-operative pain management in Iranian nursing: a qualitative research study. Int Nurs Rev. 2008;55(4):468-475.

16. Twycross A. What is the impact of theoretical knowledge on children’s nurses’ post-operative pain management practices? An exploratory study. Nurse Educ Today. 2007;27(7):697-707.

17. Efe E, Dikmen S, Altaş N, Boneval C. Turkish pediatric surgical nurses’ knowledge and attitudes regarding pain assessment and nonpharmacological and environmental methods in newborns’ pain relief. Pain Manag Nurs.

2013;14(4):343-350.

18. Cürcani M, Celebioğlu A, Küçkoğlu S. Turkish mothers’ use of nonpharmacological methods for relieving children’s postoperative pain.

HealthMed. 2011;5(suppl 1):1902-1908.

19. Leong IY, Chong MS, Gibson SJ. The use of a self-reported pain measure, a nurse-reported pain measure and the PAINAD in nursing home residents with moderate and severe dementia: a validation study. Age Ageing.

2006;35(3): 252-256.

20. Khan KA, Weisman SJ. Nonpharmacologic pain management strategies in the pediatric emergency department. Clin Pediatr Emerg Med. 2007;8(4):240-247.

21. Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2004;114(5):1348-1356.

22. Merkel S, Malviya S. Pediatric pain, tools, and assessment. J Perianesth Nurs.

2000;15(6):408-414.

23. Simpson K, Kautzman L, Dodd S. The effects of a pain management education program on the knowledge level and attitudes of clinical staff. Pain Manag Nurs.

2002;3(3):87-93.

24. He HG, Vehviläinen-Julkunen K, Pietilä AM, Pölkki T. Increasing nurses’ knowledge and behavior changes in nonpharmacological pain management for children in China. J Nurs Care Qual. 2008;23(2):170-176.

25. Bandstra NF, Skinner L, Leblanc C, et al. The role of child life in pediatric pain management: a survey of child life specialists. J Pain. 2008;9(4):320-329.

26. Guardini I, Talamini, R, Lirutti M, Palese A. The effectiveness of continuing education in postoperative pain management: results from a follow-up study. J Contin Educ Nurs. 2008;39(6):281-288.

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 35

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PILOT STUDY

Oral Contraceptives Attenuate Cardiac Autonomic Responses to Musical Auditory Stimulation: Pilot Study Réveni Carmem Milan, PT; Bruna de Oliveira Plassa, PT; Heraldo L. Guida, PhD; Luiz Carlos de Abreu, PhD; Rayana L. Gomes, PT; David M. Garner, PhD; Vitor E. Valenti, PhD ABSTRACT Context • The literature presents contradictory results regarding the effects of contraceptives on cardiac autonomic regulation.

Objective • The research team aimed to evaluate the effects of musical auditory stimulation on cardiac autonomic regulation in women who use oral contraceptives.

Design • The research team designed a transversal observational pilot study.

Setting • The setting was the Centro de Estudos do Sistema Nervoso Autônomo (CESNA) in the Departamento de Fonoaudiologia at the Universidade Estadual Paulista (UNESP) in Marília, SP, Brazil.

Participants • Participants were 22 healthy nonathletic and nonsedentary females, all nonsmokers and aged between 18 and 27 y.

Interventions • Participants were divided into 2 groups: (1) 12 women who were not taking oral contraceptives, the control group; and (2) 10 women who were taking oral contraceptives, the oral contraceptive group. In the first stage, a rest control, the women sat with their earphones turned off for 20 min. After that period, the participants were exposed to 20 min of classical baroque music (ie, “Canon in D Major,” Johann Pachelbel), at 63-84 dB. Outcome Measures • Measurements of the equivalent sound levels were conducted in a soundproof room, and the

Réveni Carmem Milan, PT, is a physical therapist at the Centro de Estudos do Sistema Nervoso Autônomo (CESNA), Departamento de Fisioterapia e Terapia Ocupacional, Faculdade de Filosofia e Ciências, Universidade Estadual Paulista (UNESP), in Marília, SP, Brazil. Bruna de Oliveira Plassa, PT, is a physical therapist at CESNA, Departamento de Fisioterapia e Terapia Ocupacional, Faculdade de Filosofia e Ciências, at UNESP. Heraldo L. Guida, PhD, is a professor; and Vitor E. Valenti, PhD, is a professor at CESNA, Faculdade de Filosofia e Ciências, Departamento de Fonoaudiologia, at UNESP. Luiz Carlos de Abreu, PhD, is a professor in Departamento de Morfologia e Fisiologia, Faculdade de Medicina do Carmem Milan—Music and HRV

intervals between consecutive heartbeats (R-R intervals) were recorded, with a sampling rate of 1000 Hz. For calculation of the linear indices, the research team used software to perform an analysis of heart rate variability (HRV). Linear indices of HRV were analyzed in the time domain: (1) the standard deviation of normal-to-normal R-R intervals (SDNN), (2) the root-mean square of differences between adjacent normal R-R intervals in a time interval (RMSSD), and (3) the percentage of adjacent R-R intervals with a difference of duration greater than 50 ms (pNN50). The study also analyzed the frequency domain— low frequency (LF), high frequency (HF), and LF/HF ratio.

Results • For the control group, the musical auditory stimulation reduced (1) the SDNN from 52.2 ± 10 ms to 48.4 ± 16 ms (P = .0034); (2) the RMSSD from 45.8 ± 22 ms to 41.2 ± 19 ms (P = .0128); (3) the pNN50 from 25.5 ± 19 to 22.0 ± 18 (P = .0211); and (4) the LF (ms2) from 954.8 ± 457 ms2 to 686.2 ± 491 ms2 (P = .0024). In the oral contraceptive group, no significant changes occurred for the HRV indices during exposure to music.

Conclusions • Musical auditory stimulation had a greater influence on cardiac autonomic regulation in women who did not use oral contraceptives. (Altern Ther Health Med. 2015;21(5):37-43.)

ABC, in Santo André, SP, Brazil. Rayana L. Gomes, PT, is a physical therapist in the Programa de Pós-Graduação em Fisioetrapia, Faculdade de Ciências e Tecnologia, at UNESP, in Universidade Estadual Paulista (UNESP), in Presidente Prudente, SP, Brazil. David M. Garner, PhD, is a postdoctoral fellow in the Cardiorespiratory Research Group, Department of Biological and Medical Sciences, Faculty of Health and Life Sciences, at Oxford Brookes University in Gipsy Lane, Oxford, United Kingdom.

Corresponding author: Vitor E. Valenti, PhD E-mail address: vitor.valenti@marilia.unesp.br ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 37

A

uditory stimulation with music can affect physiological variables through activation of the autonomic nervous system.1 The auditory process, in its relationship to the cardiovascular and autonomic nervous systems, is involved in the cardiac responses induced by music.2 A very interesting study performed by Bernardi et al3 studied 24 healthy young adults. The researchers noted reduced activity of the sympathetic nervous system during different parts of the same music.

Heart rate variability (HRV) is a method for the evaluation of cardiac autonomic regulation. Noninvasive, the method investigates the fluctuations of the intervals between consecutive heartbeats. HRV is a conventionally accepted term to describe the fluctuations in the intervals between consecutive heartbeats (R-R intervals), which influence the sinus node.4 The acute effects on HRV of a specific classical baroque musical score by Johann Pachelbel, “Canon in D Major,” have been investigated, and the studies presented conflicting data.

In 2 studies, Roque et al5,6 observed a reduction of HRV during exposure to the mentioned music in healthy women.

However, 2 other studies found an absence of significant cardiac autonomic responses to the same music.7,8 One hypothesis to explain the variability in outcome data is that women who took oral contraceptives were not excluded in those studies.7,8 Evidence from previous studies has implied a significant effect of sex-steroid hormones on the autonomic nervous system.9 The role of exogenous estrogens on HRV is not well understood. A small uncontrolled study10 found that estrogen-containing replacement therapy beneficially modulates HRV, although opposite findings have also been reported, indicating the absence of a significant influence for oral contraceptives on cardiac autonomic regulation.11 Nevertheless, the role of oral contraceptives on cardiac autonomic responses that are elicited by music was not investigated. Therefore, the current study has aimed to evaluate the acute effects of musical auditory stimulation on the cardiac autonomic responses of women who were taking oral contraceptives. The information possibly could add new elements to complementary and alternative therapies based on music therapy, providing an interaction between music and oral contraceptives.

METHODS Participants The study took place at the Centro de Estudos do Sistema Nervoso Autônomo (CESNA) in the Departamento de Fonoaudiologia at the Universidade Estadual Paulista (UNESP) in Marília, SP, Brazil. Participants were 22 healthy students from our university selected after a previous interview. They were nonathletic and nonsedentary females, all nonsmokers and aged between 18 and 27 years.

All study procedures were approved by the Ethics Committee in Research of the Faculty of Sciences at UNESP, Campus of Marilia (No. CEP-2011-385), and were in accordance with Resolution 196/96 National Health 38 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

(10/10/1996). All individuals who met the study’s criteria were informed about the procedures and objectives of the study and gave written informed consent.

Participants were divided into 2 groups: (1) a control group composed of 12 women who were not taking oral contraceptives; and (2) an intervention group, the oral contraceptive group, composed of 10 women who were taking oral contraceptives (ie, combined ethinyl estradiol and progestin). All participants in the oral contraceptive group had been taking oral contraceptives for at least 6 months.

Only participants with consistent menstrual cycles were included in the study (ie, cycles of 26-30 d). All oral contraceptives included consistent doses of 20 to 50 mg of ethinyl estradiol, but they varied slightly in the type of progestin—norethindrone, drospirenone, and desogestrel. The women in the oral contraceptive group were given a card of oral contraceptives for use during the study. Use of the contraceptives started between the first and fifth day of a woman’s menstrual cycle. It ended when the contraceptives from the card were gone and the women stopped taking contraceptives for 7 days, as is usual with contraceptive practices.

The study did not include individuals with cardiopulmonary, auditory, psychological, or neurologically related disorders or other impairments that involved procedures and treatments with drugs that influenced the autonomic nervous system.

Procedures To avoid the influence of the follicular and luteal phases, participants were not evaluated during days 10 through 15 and days 20 through 25 of the cycle or during days 1 through 6.

Prior to the study, the research team collected baseline data that included participants’ demographics: age, gender, weight, height, and body mass index (BMI). Weight was determined using a digital scale (W 200/5, São Paulo, SP, Welmy, Brazil) with a precision of 0.1 kg. Height was determined using a stadiometer (ES 2020, São Paulo, SP, Sanny, Brazil) with a precision of 0.1 cm and 2.20 m of extension. BMI was calculated as weight/height2, with weight in kilograms and height in meters.

Measurements of equivalent sound levels were conducted in a soundproof room using a SV 102 audiodosimeter (Svantek, Warszawa, Poland). The device was programmed to take measurements in the A weighting circuit, with a slow response. A Microphone in Real Ear (MIRE), an insert-type microphone (Svantek, Warszawa, Poland) was placed inside the auditory canal of the participant, just below the speaker, which was connected to a personal stereo.

Data collection was carried out in the soundproofed room, with the temperature between 21°C and 25°C and the relative humidity between 50% and 60%. All participants were instructed not to drink alcohol and/or caffeine for 24 hours before evaluation, and all participants were not caffeine or alcohol dependent.

Data were collected on an individual basis, between 18:00 and 21:00, to standardize the protocol and avoid Carmem Milan—Music and HRV

Pressure (dB)

Figure 1. Equivalent sound level of auditory musical stimulation of Baroque style.

80.0 75.0 70.0 65.0

0

1

2 3 Time (minutes)

4

Pressure (dB)

Figure 2. Frequency spectrum of the sound stimulation (octave band).

70.0 60.0 50.0 40.0 30.0 20.0 63.0

500

4000

Total C

Frequency (Hz) circadian influences. All procedures necessary for the data collection were explained on an individual basis, and the participants were instructed to remain at rest and avoid talking during the collection.

Intervention After the collection of baseline data, participants in both groups had a heart monitor belt placed over their thoraxes and aligned with the distal third of the sternum, and the Polar RS800CX heart-rate receiver (Polar Electro, Helsinki, Finland) was placed on participants’ wrists. During the measurements, participants in both groups wore headphones and were instructed to keep their eyes open and to avoid tapping with their fingers or feet to prevent artifactual entrainment, which the research team confirmed by continuous visual monitoring.

Measurements were taken in 2 stages for both groups: (1) during a rest control period, during which the women sat with their earphones turned off for 20 minutes; and (2) during a test period, during which the women were exposed for 20 minutes to musical auditory stimulation, with a selected classical baroque musical score, Pachelbel’s “Canon in D Major,” at 63 to 84 dB. Before each measurement, the microphone was calibrated with an acoustic CR:514 model calibrator (Cirrus Research, Hunmanby, North Yorkshire, United Kingdom).

Carmem Milan—Music and HRV

Outcome Measures For the analyses, the research team used Leq (A), which is defined as the equivalent sound pressure level and which corresponds to the constant sound level in the same time interval. It contains the same total energy as the sound (Figure 1). The team also analyzed the frequency spectrum of the sound stimulation, octave band (Figure 2).5,6 HRV Analysis. The R-R intervals were recorded by the portable RS800CX heart rate (HR) monitor, with a sampling rate of 1000 Hz, and were downloaded to the Polar Precision Performance program (v3.0, Polar Electro, Helsinki, Finland).

The software enabled the visualization of HR and the extraction of a cardiac period (R-R interval) file in .txt format. Following digital filtering that was complemented with manual filtering for the elimination of premature ectopic beats and artifacts, at least 500 R-R intervals were used for the data analysis. Only series with more than a 95% sinus rhythm were included in the study.12 Linear Indices of HRV. For calculation of the linear indices, the research team used the HRV Analysis software (Kubios HRV v1.1 for Windows, Biomedical Signal Analysis Group, Department of Applied Physics, University of Eastern Finland, Kuopio, Finland).

The analysis in the time domain was performed in terms of (1) the standard deviation of normal-to-normal R-R intervals (SDNN), (2) the percentage of adjacent R-R intervals with a difference of duration greater than 50 ms (pNN50), and (3) the root-mean square of differences between adjacent normal R-R intervals in a time interval (RMSSD).13 To analyze HRV in the frequency domain, the lowfrequency (LF = 0.04-0.15 Hz) and high-frequency (HF = 0.15-0.40 Hz) spectral components were used in ms2 and normalized units (nu), representing a value relative to each spectral component in relationship to the total power minus the very low-frequency (VLF) components, and the ratio between these components (LF/HF) was also used. The spectral analysis was calculated using the Fast Fourier Transform algorithm.

Statistical Analysis Standard statistical methods were used to calculate the means and standard deviations. The normal Gaussian distribution of the data was verified by the Shapiro-Wilk goodness-of-fit test (z > 1.0). For parametric distributions, the research team applied the paired student t test and for nonparametric distributions, the team applied the paired Wilcoxon test to perform intragroup comparisons. For intergroup comparisons, the team applied the nonpaired student t test for parametric distributions and the nonpaired Mann-Whitney U test for nonparametric distributions.

Differences were considered significant when the probability of a type 1 error was less than 5% (P < .05). The research team used the Biostat 2009 Professional 5.8.4 software for the analyses (AnalysisSoft, Walnut, CA, USA).

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 39

Table 1. Mean Baseline SAPs and DAPs, RRs, HRs, Weights, Heights, and BMIs of the Participants Contraceptive Group Mean ± SD 108 ± 5 67 ± 6 785.8 ± 165 79 ± 14 1.61 ± 7 53 ± 6 20 ± 2

SDNN (ms)

Variable SAP (mm Hg) DAP (mm Hg) RR (ms) HR (BPM) Height (m) Weight (kg) BMI (kg/cm2)

Control Group Mean ± SD 101 ± 6 66 ± 6 768.2 ± 73 79 ± 6 1.63 ± 2 55 ± 9 20 ± 3

Figure 3. Mean values of the time domain indices of HRVa in the oral contraceptive and control groups during the rest-control period.

60 55 50 45 40 35 30 25 20 15 10 5 0

Abbreviations: SAP, systolic arterial pressure; DAP, diastolic arterial pressure; RR, R-R interval; HR, heart rate; BMI, body mass index; SD, standard deviation; BPM, beats per minute.

Oral Contraceptive

Control

Oral Contraceptive

Control

Oral Contraceptive

Control

50

40 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

RMSSD (ms)

45 40 35 30 25 20 15 10 5 0

pNN50

RESULTS Data on the mean baseline systolic (SAP) and diastolic (DAP) arterial pressures, HRs, R-R intervals, ages, heights, body weights, and BMIs for both groups are presented in Table 1.

Figure 3 displays the mean HRV indices in the time domain for the 2 groups during the rest-control period. The research team observed that the pNN50 index was significantly higher in the control group, and the RMMSD index also tended to be higher in the control group. However, no differences were observed in the SDNN index between the groups.

In relationship to the frequency-domain indices of HRV during the rest-control period, the research team noted that the mean HF index in absolute units and the mean HF index in normalized units were both higher than that of the oral contraceptive group, and the mean LF in normalized units was lower in the control group than in the oral contraceptive group. On the other hand, the team found no significant differences in the LF in absolute units or in the LF/HF ratio between the groups (Figure 4).

Table 2 indicates that musical auditory stimulation through a specific baroque music—Pachelbel, “Canon in D Major”—decreased all indices in the analysis of mean HRV in the time domain—SDNN, RMSSD, and pNN50—and 1 index in the frequency domain—LF in absolute units—in the control group. For the control group, the musical auditory stimulation reduced (1) the SDNN from 52.2 ± 10 ms to 48.4 ± 16 ms (P = .0034); (2) the RMSSD from 45.8 ± 22 ms to 41.2 ± 19 ms (P = .0128); and (3) the pNN50 from 25.5 ± 19 to 22.0 ± 18 (P = .0211). In the frequency domain, the musical auditory stimulation reduced the LF for the control group from 954.8 ± 457 ms2 compared with 686.2 ± 491 ms2 (P = .0024).

The group of women who were taking oral contraceptives did not present any significant changes in the HRV indices during exposure to musical auditory stimulation (Table 3).

30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 0

Abbreviations: HRV, heart rate variability; SDNN, standard deviation of normal-to-normal R-R intervals (intervals between consecutive heartbeats); RMSSD, root-mean square of differences between adjacent normal R-R intervals in a time interval; pNN50, percentage of adjacent R-R intervals with a difference of duration greater than 50 ms. a

SDNN: P = .16; RMSSD: P = .056; pNN50: P = .04.

Carmem Milan—Music and HRV

Control

1100 1000 900 800 700 600 500 400 300 200 100 0

Oral Contraceptive

1.8 1.6

Control

Rest Mean ± SD 52.2 ± 10 45.8 ± 22 25.5 ± 19 954.8 ± 457 53.4 ± 13 934.4 ± 796 46.4 ± 13 0.72 ± 0.2

Music Mean ± SD 48.4 ± 16 41.2 ± 19 22.0 ± 18 686.2 ± 491 49.1 ± 16 710.9 ± 629 50.6 ± 16 0.47 ± 0.1

1.0

0.4 0.2 0.0

Control

50 45 40 35 30 25 20 15 10 5 0

Oral Contraceptive

Control

Abbreviations: HRV, heart rate variability; LF, low frequency; nu, normalized units; HF, high frequency; LF/HF, low frequency/ high frequency ratio. a

Oral Contraceptive

P Value .0034 .0128 .0211 .0024 .1038 .0051 .1076 .1703

Abbreviations: HRV, heart rate variability; SD, standard deviation; SDNN, standard deviation of normal-to-normal R-R intervals (intervals between consecutive heartbeats); pNN50, percentage of adjacent R-R intervals with a difference of duration greater than 50 ms; RMSSD, root-mean square of differences between adjacent normal R-R intervals in a time interval; LF, low frequency; nu, normalized units; HF, high frequency; LF/HF, low frequency/high frequency ratio.

Carmem Milan—Music and HRV

1.2

0.6

Table 2. Indices of HRV for the Time and Frequency Domains During the Rest-Control Period and During Exposure to Musical Auditory Stimulation for the Control Group (No Oral Contraceptives)

Index SDNN RMSSD pNN50 LF (ms2) LF (nu) HF (ms2) HF (nu) LF/HF

1.4

0.8

Oral Contraceptive

HF (nu)

HF (ms2)

Oral Contraceptive

2.0

65 60 55 50 45 40 35 30 25 20 15 10 5 0

LF/HF

1200 1100 1000 900 800 700 600 500 400 300 200 100 0

LF (nu)

LF (ms2)

Figure 4. Mean values of the frequency domain indices of HRVa in the oral contraceptive and control groups during the rest-control period.

Control

LF-ms2: P = .49; LF-nu: P = .062; HF-ms2: P = .04; HF-nu: P = .06; LF/HF: P = .107.

Table 3. Indices of HRV for the Time and Frequency Domains During the Rest-Control Period and During Exposure to Musical Auditory Stimulation in the Oral Contraceptive Group

Index SDNN RMSSD pNN50 LF (ms2) LF (nu) HF (ms2) HF (nu) LF/HF

Rest Mean ± SD 49.4 ± 12 33.0 ± 9 12.8 ± 10 953.7 ± 1069 61.9 ± 11 469.3 ± 245 38 ± 11 1.860 ± 0.9

Music Mean ± SD 47.4 ± 10 33.8 ± 11 14.2 ± 12 703.2 ± 448 61.6 ± 12 527.2 ± 514 38.2 ± 12 1.864 ± 0.9

P Value .2062 .3383 .2535 .1713 .4686 .2884 .4707 .4957

Abbreviations: HRV, heart rate variability; SD, standard deviation; SDNN, standard deviation of normal-to-normal R-R intervals (intervals between consecutive heartbeats); pNN50, percentage of adjacent R-R intervals with a difference of duration greater than 50 ms; RMSSD, root-mean square of differences between adjacent normal R-R intervals in a time interval; LF, low frequency; nu, normalized units; HF, high frequency; LF/HF, low frequency/high frequency ratio.

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 41

DISCUSSION Previous studies have reported conflicting data regarding the HRV responses induced by a specific music in healthy women (ie, “Canon in D Major” by Pachelbel).5,6,7 In those studies, the role of sexual hormones in that response was not assessed. In that context, the literature has indicated a major impact for sex-steroid hormones on the cardiovascular system, mainly in rats.9 In view of the above considerations, the purpose of the current study was to evaluate the effects of musical auditory stimulation on cardiac autonomic regulation in women who took oral contraceptives. During the study, the research team observed that the women who were not taking oral contraceptives presented a reduced parasympathetic component of HRV and a decreased overall variability of HR during exposure to the selected music. However, the group composed of women who were taking oral contraceptives did not present significant changes in HRV. The most often used oral contraceptive is a combined pill that is composed of a combination of progestin and ethinyl estradiol. The oral contraceptives used by the participants in the current study was based on regular doses of ethinyl estradiol, but they varied slightly in the types of progestin—norethindrone, drospirenone, and desogestrel.

Those synthetic types of progesterone and estrogen avoid normal oscillations of endogenous progesterone and estrogen that have been observed in eumenorrheic women, leading to a suppression of ovulation.14 The current research team suggests that the different cardiac autonomic response to music observed in the oral contraceptive group in the current study was partially due to the steroid hormonal status of the participants. Based on the current study’s data, the team suggests that the parasympathetic component of cardiac autonomic control at rest was decreased in women who were taking oral contraceptives, because the pNN50 index and the HF indices were reduced in that group.

The effects of oral contraceptives on HRV have been contradictory in the literature; some studies have shown significant effects for oral contraceptives on HRV, and others have not. One study supports the research team’s results; the researchers in that study reported a lower baroreflex sensitivity during the follicular phase of the menstrual cycle in women taking oral contraceptives (23 ± 3 y old) compared with women who did not use hormonal contraception (24 ± 4 y old).15 Nonetheless, findings opposite to those of the current study were observed in that study.

In another study, oral contraceptives containing 20 μg ethinylestradiol and 150 μg gestodene did not influence the autonomic nervous system of women aged 24 ± 2 years old.11 Another study found that vagal baroreceptor sensitivity, plasma levels of catecholamines, and HRV were not different between users or nonusers of synthetic oral contraceptives in young healthy women of reproductive age.16 Reduced HRV in women taking oral contraceptives has been associated with unfavorable consequences, because 42 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

decreased HRV is frequently an indicator of inadequate or abnormal adjustment of the autonomic nervous system, which may or may not indicate the presence of physiological pathology in the individual.12 The exact mechanism related to reduced HRV in women who were taking oral contraceptives is unknown.

Some studies have shown that sex hormones influence the cardiovascular system. Intravenous injections of estrogen have been found to increase baroreflex function in ovariectomized female rats.17,18 On the other hand, another study reported that a contraceptive containing 20 μg of ethinyl estradiol and 3 mg of drospirenone did not cause significant changes in clinical, sympathovagal-modulation parameters in healthy women.19 It can be postulated that progesterone type and amount may also influence the response because it has a known effect on mood.20 According to the current research team’s findings, women who were not taking oral contraceptives presented more intense cardiac autonomic responses to musical auditory stimulation, although the group composed of women who were taking oral contraceptives did not present significant responses. The team has concluded that oral contraceptives attenuate cardiac autonomic responses to auditory stimulation with music. Endogenous estrogen and progesterone variations, combined with a regular menstrual cycle, have been hypothesized to affect sympathoexcitation during orthostatic stress.21,22 Nevertheless, the research team investigated women using an exogenous steroidal hormone.

Some mechanisms have been proposed to explain the more intense cardiac autonomic responses induced by music in women who are not taking oral contraceptives. A previous study evaluated the effects of auditory stimulation with the relaxing classical music “Träumerei” from Robert Schumann’s Kinderszenen, Opus 15, No. 77, on the autonomic nervous system of urethane-anesthetized rats.23 Even under anesthesia, the music’s style reduced renal sympathetic nerve activity as well as arterial blood pressure. Further, the researchers found that the effect depended on an intact cochlear and auditory cortex and that the autonomic response was regulated by the suprachiasmatic nucleus of the hypothalamus and histaminergic H3 receptors. The same group also has observed through evaluation of gastric vagal-nerve activity that “Träumerei” increased parasympathetic activity in anesthetized rats.24 As mentioned earlier, the hypothalamus influences autonomic responses elicited by music.24 A recent study revealed the relevance of neuroestradiol as a neurotransmitter in regulation of gonadotropin-releasing hormone (GnRH) from the medial basal hypothalamus.25 In that study, GnRH was reported to be a modulator of HRV responses that are related to cognitive function in the developing brain, and it differentially affected male and female sheep by its regulation.26 However, the current research team cannot extrapolate those results to all music styles, because the team selected a specific baroque music for the current study.

An important limitation of the current study is that the doses of ethinyl estradiol varied slightly in the type of Carmem Milan—Music and HRV

progestin—norethindrone, drospirenone, and desogestrel.

Therefore, the team suggests that further studies should investigate the specific effect of progestin types.

The current investigation has advanced the research team’s understanding of how oral contraceptives can affect cardiac autonomic regulation at rest and during a specific auditory stimulation. The team encourages further studies to investigate the effects in older adult women, because menopause induces a significant reduction in plasma levels of estrogen and progesterone.27 It could be helpful to clarify the mechanism that is involved in cardiac disorders related to those older women.

CONCLUSIONS Auditory stimulation with a specific music influences cardiac autonomic regulation with a higher intensity in women who do not take oral contraceptives.

AUTHOR DISCLOSURE STATEMENT The study received financial support from the São Paulo Research Foundation (FAPESP).

ACKNOWLEDGEMENTS

16. Schueller PO, Feuring M, Sharkova Y, Grimm W, Christ M. Effects of synthetic progestagens on autonomic tone, neurohormones and C-reactive protein levels in young healthy females in reproductive age. Int J Cardiol. 2006;111(1):42-48.

17. Saleh TM, Connell BJ. 17beta-estradiol modulates baroreflex sensitivity and autonomic tone of female rats. J Auton Nerv Syst. 2000;80(3):148-161.

18. Saleh TM, Connell BJ, Saleh MC. Acute injection of 17beta-estradiol enhances cardiovascular reflexes and autonomic tone in ovariectomized female rats. Auton Neurosci. 2000;84(1-2):78-88.

19. Nisenbaum MG, de Melo NR, Giribela CR, et al. Effects of a contraceptive containing drospirenone and ethinyl estradiol on blood pressure and autonomic tone: a prospective controlled clinical trial. Eur J Obstet Gynecol Reprod Biol.

April 2014;175:62-66.

20. Jae Jung S, Shin A, Kang D. Hormone-related factors and post-menopausal onset depression: results from KNHANES (2010-2012). J Affect Disord. January 2015;175C:176-183.

21. Carter JR, Lawrence JE, Klein JC. Menstrual cycle alters sympathetic neural responses to orthostatic stress in young, eumenorrheic women. Am J Physiol Endocrinol Metab. 2009;297(1):E85-E91.

22. Fu Q, Okazaki K, Shibata S, et al. Menstrual cycle effects on sympathetic neural responses to upright tilt. J Physiol. 2009;587(pt 9):2019-2031.

23. Nakamura T, Tanida M, Niijima A, Hibino H, Shen J, Nagai K. Auditory stimulation affects renal sympathetic nerve activity and blood pressure in rats.

Neurosci Lett. 2007;416(2):107-112.

24. Nakamura T, Tanida M, Niijima A, Nagai K. Effect of auditory stimulation on parasympathetic nerve activity in urethane-anesthetized rats. In Vivo.

2009;23(3):415-419.

25. Kenealy BP, Kapoor A, Guerriero KA, et al. Neuroestradiol in the hypothalamus contributes to the regulation of gonadotropin releasing hormone release. J Neurosci. 2013;33(49):19051-19059.

26. Wojniusz S, Vögele C, Ropstad E, et al. Prepubertal gonadotropin-releasing hormone analog leads to exaggerated behavioral and emotional sex differences in sheep. Horm Behav. 2011;59(1):22-27.

27. Pardini D. Hormone replacement therapy in menopause [in Portuguese]. Arq Bras Endocrinol Metabol. 2014;58(2):172-181.

The research team thanks FAPESP for financial support as well as the reviewers that kindly helped them with new ideas.

REFERENCES 1. Valenti VE, Guida HL, Frizzo AC, Cardoso AC, Vanderlei LC, Abreu LC. Auditory stimulation and cardiac autonomic regulation. Clinics (Sao Paulo).

2012;67(8):955-958.

2. Valenti VE, Guida HL, Mello Monteiro CB, et al. Relationship between cardiac autonomic regulation and auditory mechanisms: importance for growth and development. J Hum Growth Dev. 2013;23(1):94-98.

3. Bernardi L, Porta C, Sleight P. Cardiovascular, cerebrovascular, and respiratory changes induced by different types of music in musicians and non-musicians: the importance of silence. Heart. 2006;92(4):445-452.

4. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Heart rate variability: standards of measurement, physiological interpretation and clinical use. Circulation.

1996;93(5):1043-1065.

5. Roque AL, Valenti VE, Guida HL, et al. The effects of different styles of musical auditory stimulation on cardiac autonomic regulation in healthy women. Noise Health. 2013;15(65):281-287.

6. Roque AL, Valenti VE, Guida HL, et al.The effects of auditory stimulation with music on heart rate variability in healthy women. Clinics (Sao Paulo).

2013;68(7):960-967.

7. Amaral JA, Nogueira ML, Roque AL, et al. Cardiac autonomic regulation during exposure to auditory stimulation with classical baroque or heavy metal music of different intensities. Turk Kardiyol Dern Ars. 2014;42(2):139-146.

8. de Castro BC, Guida HL, Roque AL, et al. Auditory stimulation with music influences the geometric indices of heart rate variability in response to the postural change maneuver. Noise Health. 2014;16(68):57-62.

9. He XR, Wang W, Crofton JT, Share L. Effects of 17beta-estradiol on sympathetic activity and pressor response to phenylephrine in ovariectomized rats. Am J Physiol. 1998;275(4, pt 2):R1202-R1208.

10. Rosano GM, Patrizi R, Leonardo F, et al. Effect of estrogen replacement therapy on heart rate variability and heart rate in healthy postmenopausal women. Am J Cardiol. 1997;80(6):815-817.

11. Rebelo AC, Tamburús N, Salviati M, et al. Influence of third-generation oral contraceptives on the complexity analysis and symbolic dynamics of heart rate variability. Eur J Contracept Reprod Health Care. 2011;16(4):289-297.

12. Vanderlei LC, Pastre CM, Hoshi RA, Carvalho TD, Godoy MF. Basic notions of heart rate variability and its clinical applicability. Rev Bras Cir Cardiovasc.

2009;24(2):205-217.

13. Abreu LC. Heart rate variability as a functional marker of development. J Hum Growth Dev. 2012;22(3):279-281.

14. Shufelt CL, Bairey Merz CN. Contraceptive hormone use and cardiovascular disease. J Am Coll Cardiol. 2009;53(3):221-231.

15. Wilczak A, Marciniak K, Kłapciński M, Rydlewska A, Danel D, Jankowska EA. Relations between combined oral contraceptive therapy and indices of autonomic balance (baroreflex sensitivity and heart rate variability) in young healthy women. Ginekol Pol. 2013;84(11):915-921.

Carmem Milan—Music and HRV

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 43

PILOT STUDY

Effect of Electroacupuncture on Transcutaneous Oxygen Partial Pressure During Hyperbaric Oxygen Therapy in Healthy Individuals Lan Qu, MD; Yong Ye, MD; Chunfeng Li, MM; Guangkai Gao, MD

ABSTRACT Context • The goal of hyperbaric oxygen therapy (HBOT) is to increase the oxygen (O2) supply to the body significantly. Because of the toxic side effects and complications of hyperbaric oxygen (HBO2), the environmental pressure and treatment time must be restricted. The research team hypothesized that other therapies administered during HBOT could safely improve the value of the arterial oxygen partial pressure (PaO2) during HBOT and improve its therapeutic effect.

Objective • The study intended to investigate whether electroacupuncture (EA) while receiving HBOT had a greater effect for healthy individuals than HBOT or EA alone or EA combined with normobaric pure oxygen (pure O2).

Design • The research team designed a randomized, controlled trial.

Setting • The study was performed in the Department of Hyperbaric Medicine at the No. 401 Hospital of the People’s Liberation Army in Qingdao, China.

Participants • A total of 81 volunteers were recruited.

After thorough physical examination and laboratory testing, 21 volunteers were excluded from the study.

Participants included 60 healthy volunteers.

Intervention • Participants were randomly assigned to 1 of 4 groups of 15 participants each: (1) an HBOT group, (2) an EA group, (3) an EA During HBOT group, and (4) an EA Combined With Pure O2 group.

Lan Qu, MD, is a postdoctoral researcher at Jinan Military General Hospital in Jinan, China, and the associate chief physician in the Department of Hyperbaric Medicine, No. 401, Hospital of the People’s Liberation Army, in Qingdao, China. Yong Ye, MD, is deputy director of the Department of Medicine Affairs; Chunfeng Li, MM, is a senior engineer in the Department of Information; and Guangkai Gao, MD, is a chief physician and director of the Department of Hyperbaric Medicine, No. 401. All are located at the Hospital of the People’s Liberation Army in Qingdao.

Corresponding author: Guangkai Gao, MD E-mail address: 1102592256@qq.com 44 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Outcome Measures • Because at the current technology level a blood gas analyzer cannot test PaO2 during HBOT, transcutaneous oxygen partial pressure (PtcO2) of the participants was tested instead. Before, during, and after EA, variations in PtcO2 were monitored in each group.

Results • For the EA During HBOT group, (1) the increase in PtcO2 during EA was significantly greater than that observed for the other 3 groups (P < .01), and (2) the average PtcO2 level 15 min after EA remained significantly higher than that observed for the other 3 groups (P < .01).

For the EA During HBOT and the Pure O2 groups, the average PtcO2 levels during and after EA were significantly higher than that observed for the pre-EA period (P < .01).

For the EA group, the average PtcO2 level during EA was significantly higher than that observed for the pre-EA period (P < .01). For all 3 periods, the average PtcO2 level of the HBOT group showed small fluctuations (P > .05).

Conclusions • The EA During HBOT method provided improvements in the efficacy, safety, and tolerability of HBOT, and the study’s results partially demonstrated the accuracy of the research team’s hypothesis that EA therapy applied during HBOT could safely improve the value of PtcO2 (PaO2) during HBOT and produce a greater therapeutic effect. (Altern Ther Health Med. 2015;21(5):44-51.)

T

he goal of hyperbaric oxygen therapy (HBOT) is to increase the oxygen (O2) supply to the body significantly. During HBOT, O2 levels are increased to a greater extent than the normal pressure achieved using a manual method, and this increase in O2 is then delivered throughout the body to improve the anoxic state.

Arterial oxygen partial pressure (PaO2) is proportional to the environmental pressure. Because of the toxic side effects and complications of hyperbaric oxygen (HBO2), the environmental pressure and treatment time must be restricted. The common treatment pressure for HBOT in adults is generally 2.3 atmospheres absolute (ATA), although this value can range from 2.0 to 2.5 ATA. Therefore, the Qu—EA Therapy During HBOT

research team hypothesized that other therapies administered during HBOT could safely improve the value of PaO2 during HBOT and improve the therapeutic effect.

Transcutaneous oxygen partial pressure (PtcO2) is measured using a noninvasive diagnostic technique in which the partial pressure of O2 is recorded at the skin’s surface.

When special electrodes (Clark-type electrodes) are placed on heated skin, O2 diffuses from the capillaries into the subcutaneous tissue and skin, and electrodes monitor this value as the PtcO2. This measurement provides information regarding the functional status of capillaries and the O2 supply to the major circulation. Further, in adults, this measurement can be applied in wound evaluation, hyperbaric therapy, plastic surgery, determination of amputation level, and assessment of peripheral vascular disease, such as for limb revascularization procedures. The values of PtcO2 are approximately 10% lower than those of PaO2, although the coefficient of correlation is 0.99.1 Because in the current technology level of the world a blood gas analyzer cannot test PaO2 during HBOT, but the PtcO2 can be tested during HBOT, we can test only the PtcO2 of the participants instead of testing PaO2 of them during HBOT. Perfluorocarbon (PFC) is good O2 carrier. The quantities of O2 dissolved in PFC are 3 times greater than those in plasma.2 But due to the experimental conditions and cost of the current study, the research team did not adopt PFC to increase O2 content.

Acupuncture is a type of traditional Chinese medicine and has been used as a clinical treatment for 2000 years in China. According to the meridian acupoint, acupuncturists use different acupuncture needles and acupuncture manipulations to regulate the body’s function and prevent and treat disease. Electroacupuncture (EA) is a new method of therapy that combines electricity with acupuncture. After acupuncture of the acupoint, the acupuncture needle body is electrified via the specific electrical current in the retaining needle. Stimulation of the retaining needle is combined with the electrical current to strengthen the effects of the needle.

EA demonstrates a stimulatory effect similar to persistent needle manipulation, although the stimulus parameters can be objective.

The EA apparatus is the primary medical tool of EA therapy, and variations in the waveform, frequency, and intensity of the electrical current in the apparatus deliver different therapeutic effects. Acupuncture therapy has many advantages: (1) the ability to be used for a wide variety of indications, (2) the provision of improvements in therapeutic results that are delivered rapidly, (3) a lower treatment cost, (4) fewer side effects, and (5) an increased effectiveness compared with other therapies.3 During the current study, the selected acupoints were the commonly used acupoints that have demonstrated good efficacy in the treatment of cardiovascular diseases, can dredge the meridian, and can promote blood circulation.

Hong et al4 found that PtcO2 values increased significantly in regions surrounding acupoints. Further, other studies Qu—EA Therapy During HBOT

have shown that powerful stimulation acupuncture (ie, EA and reinforcement manipulation) or an increased needle retention time (≥ 20 min) can significantly increase the PtcO2 of acupoints along the same meridian.5-7 Therefore, the current research team hypothesized that EA therapy applied during HBOT could safely improve the value of PtcO2 and PaO2 during HBOT and produce a greater therapeutic effect. No similar studies regarding EA during HBOT have yet been published.

METHODS Participants We recruited the 81 volunteers via the Internet or by spreading leaflets in the hospital where the study was to take place. After a thorough physical examination and laboratory testing, the volunteers with active upper-respiratory tract infections, inflammation of the tympanic membrane, hematological disease, active lung disease, or pregnancy, as well as postpartum and menstruating individuals, were excluded from the study. A total of 21 volunteers were excluded from the study. Using computer-generated random numbers, participants numbering 60 healthy volunteers who did not smoke were randomly and equally divided into 4 groups of 15 participants each: (1) an HBOT group, (2) an EA group, (3) an EA During HBOT group, and (4) an EA Combined With Normobaric Pure Oxygen (Pure O2) group. We adopted an envelope method to hide the random allocation scheme. Participants in the current prospective, randomized controlled study were 31 males and 29 females between the ages of 16 and 75 years, with an average age of 37.0 years. No significant differences existed in gender, age, or body mass index (BMI) among the 4 groups according to a homogeneity test of variance and a χ2 test.

Table 1 shows the baseline characteristics of the 4 groups.

Written informed consent was obtained from all volunteers. The study was conducted after receiving approval from the institutional research and ethical committee of the 401st Hospital of the Chinese People’s Liberation Army.

Table 1. Participants’ Baseline Characteristics HBOT + EA Group

HBOT Group

EA Pure O2 Group Group

Males Females Age, y

8 7

6 9

7 8

10 5

mean Range BMI, mean

36.5 17-70 20.6

37.0 18-72 21.0

37.6 16-68 20.5

36.6 22-75 20.7

Gender, n

Abbreviations: BMI, body mass index; HBOT, hyperbaric oxygen therapy; EA, electroacupuncture; pure O2, normobaric pure oxygen.

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 45

According to the M. Kendall principle,8 the sample size estimations for multifactor analysis indicated that the number of each sample should be at least 10 times greater than the number of variables. The current study included only 1 variable, PtcO2, and 60 healthy adult volunteers.

Intervention EA Group (EA Only). Figures 1 and 2 show the stimulated acupoints, PC-6 (neiguan) and PC-4 (ximen), and the measured acupoint, PC-3 (quze), in the participants’ upper extremities. Figure 3 shows the stimulated acupoints, SP-6 (sanyinjiao) and SP-8 (diji), and the measured acupoint, SP-9 (yinlingquan), in the participants’ lower extremities.

The EA instrument used was the SDZ-II (SuzhouMedicine Instrumentation Inc, Suzhou, China), which has a maximum output current of ≤50 mA and a maximum output power of 0.3 VA. During therapy, participants were first placed in a supine position, and their homolateral PC-6 and PC-4 acupoints were perpendicularly pierced to a skin depth of 1 cm using HWATO acupuncture needles (0.25 × 25 mm, Suzhou Medicine Instrumentation Inc, Suzhou, China).

The wire clips of the EA instrument were then linked to the needles of the PC-6 and PC-4 acupoints. Next, using a selected continuous wave of 3 Hz and a pulse amplitude of 3 mA, the needles were retained in the skin for 15 minutes.

For acupuncture of the PC-6 and PC-4 acupoints, the PtcO2 microsensor (QSG-1000B Monitor, Beijing Qiumanshi Technology Inc, Beijing, China), was positioned above the skin of the PC-3 acupoint; the PtcO2 microsensor temperature was 44°C. For acupuncture of the SP-6 and SP-8 acupoints, the PtcO2 microsensor was positioned above the skin at the SP-9 acupoint. PtcO2 was recorded each minute using a matched electrochemical analyzer. Because only 1 PtcO2 sensor was used, each experiment tested only the PtcO2 on 1 side of the body. Testing was conducted from the left side to the right side and from the upper limbs to the lower limbs.

The PC-6, PC-4, and PC-3 represent an international standard code of acupoints.

The PtcO2 microsensor must be calibrated correctly under atmospheric pressure conditions first. When calibration was finished, the PtcO2 microsensor was positioned above the skin at the participant’s measured acupoint. When the reading of the PtcO2 value gradually stabilized after approximately 15 minutes, the research team continuously recorded the PtcO2 of the measured acupoint for 15 minutes to obtain the pre-EA data (Figure 4). Then, the EA was performed at the stimulated acupoints, with the needles retained for 15 minutes. At the same time, the team continuously recorded the PtcO2 of the measured acupoint to obtain the ongoing EA data. When the EA was completed, the team continuously recorded the PtcO2 of the measured acupoint for 15 minutes to obtain the post-EA data.

The HBOT group and EA During HBOT group needed to experience compression, but according to the product specifications of the manufacturer of the PtcO2 microsensor, 46 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Figure 1. Photograph of the stimulated and measured acupoints in participants’ upper extremities.

Figure 2. Diagram of the stimulated and measured acupoints in participants’ upper extremities.

neiguan PC-6 ximen PC-4

quze PC-3

stimulated (acupuntured) acupoints measured acupoints Figure 3. Diagram of the stimulated and measured acupoints in participants’ lower extremities.

yinlingquan SP-9 diji SP-8

sanyinjiao SP-6

stimulated (acupuntured) acupoints measured acupoints

Qu—EA Therapy During HBOT

Figure 4. Procedures for the upper extremities for the EA and the pure O2 groups.

PC-3 PtcO2 (started to inhale pure O2)

15 min

15 min

pre-EA

15 min

15 min

on-EA PC-6, PC-4

post-EA

Abbreviations: EA, electroacupuncture; pure O2, normobaric pure oxygen; PC-3 (quze), measured acupoint; PC-4 (ximen), stimulated acupoint; PC-6 (neiguan), stimulated acupoint; PtcO2, transcutaneous oxygen partial pressure.

Figure 5. Procedures for the upper extremities for the EA During HBO2 and the HBO2 groups. stabilizing pressure, started to inhale pure O2 PC-3 PtcO2 PC-3 PtcO2 PC-3 PtcO2 15 min 15 min 15 min 15 min 15 min

(as) pre-EA compressing

20 min

(as) post-EA

(as) on-EA PC-6, PC-4

decompressing

Abbreviations: EA, electroacupuncture; HBO2, hyperbaric oxygen; PC-3 (quze), measured acupoint; PC-4 (ximen), stimulated acupoint; PC-6 (neiguan), stimulated acupoint; PtcO2, transcutaneous oxygen partial pressure. the PtcO2 microsensor must be calibrated correctly under atmospheric pressure conditions first, and then it could start to compress. The EA group and Pure O2 group did not experience compression; the 2 groups were at atmospheric pressure. The EA group inhaled air and the Pure O2 group inhaled pure O2. When calibration was finished, the PtcO2 microsensor was positioned above the skin at the participantâ&#x20AC;&#x2122;s measured acupoint. When the reading of the PtcO2 value gradually stabilized after approximately 15 minutes, the research team closed the chamber door and started the compression. The environmental conditions of the laboratory for the HBOT group and EA During HBOT group were same. The environmental conditions of the laboratory for the EA group and the Pure O2 group were the same as those for Quâ&#x20AC;&#x201D;EA Therapy During HBOT

the HBOT group and EA During HBOT group, except for the high level of atmospheric pressure in the experimental hyperbaric chamber .

EA During HBOT Group. For the EA During HBOT group, the EA was administered in the same manner as for the EA group, and the HBOT was administered at 2.2 ATA in a hyperbaric chamber (Yantai Moon Co Ltd, Gas Compression Equipment Branch Company, Yantai, China).

The total duration in the chamber was 95 minutes, and the compression time was 15 minutes. When the pressure reached 2.2 ATA, that stabilizing pressure was maintained for 60 minutes, with the participants inhaling pure O2 for 60 minutes of that time. The decompression time was 20 minutes (Figure 5).

During the pressure stabilization period, the participants started to inhale pure O2. After approximately 15 minutes, the measured PtcO2 gradually reached a steady state, then the research team continuously recorded the PtcO2 value for the measured acupoint for 15 minutes, obtaining the pre-EA data. Then, the team initiated EA at the stimulated acupoints.

The needles were retained for 15 minutes, during which time the research team continuously recorded the PtcO2 of the measured acupoint, obtaining the ongoing EA data. When the EA was completed, the team continuously recorded the PtcO2 of the measured acupoint for 15 minutes, obtaining the post-EA data.

HBOT Group. During the pressure-stabilization period, participants in the HBOT group started to inhale pure O2.

After approximately 15 minutes, the measured PtcO2 gradually reached a steady state, and the research team continuously recorded the PtcO2 of the measured acupoint for 45 minutes. The PtcO2 data of the measured acupoint during the second 15-minute period corresponds to the pre-EA measurement. The PtcO2 data of the measured acupoint during the third 15-minute period corresponds to the ongoing EA measurement, and the PtcO2 data of the measured acupoint during the fourth 15-minute period corresponded to the post-EA measurement (Figure 5).

Pure O2 Group. Testing for the Pure O2 group was administered in the same manner as for the EA group. When calibration was finished, the participants started to inhale pure O2 for 15 minutes. The measured PtcO2 gradually reached a steady state, and the research team continuously recorded the PtcO2 value for the measured acupoint for 15 minutes to obtain the pre-EA data. Then, the team initiated EA with the stimulated acupoints. The needles were retained for 15 minutes, during which time the team continuously recorded the PtcO2 of the measured acupoint to obtain the ongoing EA data. When the EA was completed, the team continuously recorded the PtcO2 of the measured acupoint for 15 minutes to obtain the post-EA data (Figure 4).

Evaluation of Side Effects Side effects of the HBOT primarily included barotrauma to the otic, sinus, and pulmonary systems. The side effects of the EA included bent needles, stuck needles, broken needles, ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 47

fainting, and subcutaneous hemorrhage. During the study, the research team closely monitored the response of the participants. If any participant felt unwell, the team immediately stopped the study and took appropriate measures to ensure his or her safety.

Date Processing and Filtering During the study, abnormal data resulting from malfunction of an experimental instrument, sudden changes in the environmental conditions in the laboratory, interruption of O2 inhalation, EA or HBO2 intolerance of the participants, and side effects were rejected. Each acupoint was measured 3 times; the research team adopted the arithmetic mean values of the results of the multiple measurements to reduce random errors.

Statistical Analysis Two researchers entered the experimental data twice and checked the entries twice.

Because acupuncturists had to perform the needling, the research team performed a double-blind analysis of the participants and data. Descriptive data for the current study are presented as the mean ± standard deviation (SD). A control study for the pre-EA, ongoing EA, and post-EA data for each group was performed, and repeated measures and multivariate analysis of variance were performed using the SPSS statistical software package, version 17.0 (IBM, Armonk, NY, USA). P values < .05 were considered statistically significant.

Table 2. Comparison of PtcO2 (mm Hg) at Different Periods Among the 4 Groups

Group Case HBOT + EA 15 HBOT 15 EA 15 15 Pure O2

Pre-EA Mean ± SD 1108.5 ± 24.0a 1112.0 ± 23.8d 98.3 ± 8.3 489.0 ± 18.0

Ongoing-EA Mean ± SD 1370.6 ± 34.3b,c 1118.3 ± 28.7d,e 113.2 ± 12.8c 567.7 ± 20.8c

Post-EA Mean ± SD 1352.7 ± 31.4b,c 1115.7 ± 26.2d,e 105.2 ± 9.7 539.0 ± 19.9c

Abbreviations: PtcO2, transcutaneous oxygen partial pressure; SD, standard deviation; HBOT, hyperbaric oxygen therapy; EA, electroacupuncture; pure O2, normobaric pure oxygen. a

Compared with HBOT group, P > .05.

Compared with HBOT group, P < .01. c Compared with pre-EA period, P < .01. d Compared with Pure O2 group, P < .01. e Compared with pre-EA period, P > .05. b

Table 3. Comparison of PtcO2 (mm Hg) for the Same Periods Among the 4 Groupsa

Treatment Time Pre-EA

Ongoing-EA

Post-EA

Group 1

1

1

Group 2

3

P Value .64 .00

95% CI -18.34 to 11.41 995.33 to 1025.07

4 2

.00 .00

604.66 to 634.41 234.62 to 270.05

3

.00

1239.69 to 1275.11

4 2

.00 .00

785.15 to 820.58 219.37 to 254.50 1229.90 to 1265.03

3 .00 RESULTS 796.10 to 831.23 4 .00 Table 2, Table 3, Table 4, and Figure 6 show that the increase in PtcO2 during EA for the EA Abbreviations: PtcO2, transcutaneous oxygen partial pressure; During HBOT group was significantly greater than that observed among participants in the CI, confidence interval; EA, electroacupuncture; HBOT, hyperbaric other 3 groups (P < .01). After EA, the average oxygen therapy; pure O2, normobaric pure oxygen.

PtcO2 level in that group remained significantly a higher for 15 minutes than that observed in the Group 1, EA During HBOT group; group 2, HBOT group; group 3, EA other 3 groups (P < .01). group; group 4, Pure O2 group.

In the EA During HBOT and the Pure O2 groups, the average PtcO2 levels were significantly higher Seven of the 60 healthy volunteers terminated their during and after EA than those observed pre-EA (P < .01). In participation in the study: (1) 2 volunteers could not bear the the EA group, the average PtcO2 level was significantly otalgia (ear pain) during HBOT; (2) 3 volunteers suffered higher during EA than that observed pre-EA (P < .01). At all from an active, upper-respiratory tract infection during the 3 periods, the average PtcO2 level for the HBOT group study; (3) 1 volunteer was pregnant; and (4) 1 volunteer was showed small fluctuations (P > .05). Before, during, and after disturbed by other matters. After the 7 terminations, the EA, the average PtcO2 level in the HBOT group was research team recruited 7 new, healthy volunteers. A total of significantly greater than that measured for the Pure O2 3 volunteers felt slight earaches but remained in the study. group and the EA group (P < .01).

48 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Qu—EA Therapy During HBOT

Table 4. Comparison of PtcO2 (mm Hg) for Each Group at Different Periods Group HBOT + EA

Time

Time

P Value

Pre-EA

Ongoing-EA Post-EA Post-EA

.000 .000 .026

Ongoing-EA Post-EA Post-EA

1.000 1.000 1.000

Ongoing-EA Post-EA Post-EA

.000 .012 .000

Ongoing-EA Post-EA Post-EA

.000 .000 .000

Ongoing-EA HBOT

Pre-EA Ongoing-EA

EA

Pre-EA Ongoing-EA Pre-EA

Pure O2

Ongoing-EA

Abbreviations: PtcO2, transcutaneous oxygen partial pressure; HBOT, hyperbaric oxygen therapy; EA, electroacupuncture; pure O2, normobaric pure oxygen.

Figure 6. Comparison of PtcO2 at different periods among the 4 groups.

1600

b c

b c

PtcO2 (mm Hg)

1400 1200

a

a

a

1000 800 600 400 200 0

pre-EA

on-EA

HBOT + EA

EA

HBO2

Pure O2

Post-EA

Abbreviations: PtcO2, transcutaneous oxygen partial pressure; HBOT, hyperbaric oxygen therapy; EA, electroacupuncture; pure O2, normobaric pure oxygen. a

Compared with Pure O2 group, P < .01.

Compared with HBOT group, P < .01. c Compared with pre-EA period, P < .01. b

Qu—EA Therapy During HBOT

DISCUSSION The current study showed that HBOT only, EA only, and EA combined with pure O2 could increase the PtcO2 levels in treated participants, but the increase in PtcO2 among participants in the EA During HBOT group was significantly greater than those observed among participants in the other 3 groups. The total PtcO2 level of the EA During HBOT group also was significantly higher than those of the other 3 groups. These results illustrate the fact that the effects of simultaneous application of EA, high pressure, and pure O2 were significantly greater than that observed following HBOT only, EA only, or EA combined with pure O2.

HBOT aims to increase the levels of physically dissolved O2 and tissue O2 partial pressure to remedy hypoxia and promote aerobic metabolism. The current study showed that the increase in PtcO2 (PaO2) mediated by EA plus HBOT was significantly higher than that resulting from HBOT only, EA only, or EA combined with pure O2.Therefore, the therapeutic effects of EA during HBOT should be better than those of HBOT only, EA only, or EA combined with pure O2.

An increase in the therapy pressure increases the risk of injury to an organism caused by high pressure. However, the current study showed that a significantly increased PtcO2 (PaO2) in the EA During HBOT group, without an increase in therapy pressure, not only further increased the therapeutic effect of HBOT but also reduced the incidence of pressure injury caused by HBOT. According to Henry’s law, when the temperature is constant, the quantity of gas dissolved in a solution is proportionate to the partial pressure of the gas.

Further, within a certain pressure range of HBO2, higher PaO2 levels are associated with greater quantities of O2 dissolved in the plasma, which results in a superior therapeutic effect for HBOT, without an increase in the therapy pressure.

Although the increase in PaO2 increased the risk of O2 toxicity, this type of toxicity can also result from breathing O2 for too long. When a healthy individual with a PaO2 of 250 kPa (1875 mm Hg) breathes pure O2 for approximately 4 hours, his or her vital capacity will decrease by approximately 50%. When a person breathes pure O2 for more than 5 hours, 10% of individuals will demonstrate symptoms of O2 toxicity in the central nervous system. During the current study, the duration of O2 breathing was maintained at 60 minutes, and only 5 of 67 volunteers (7.5%) felt otalgia. These precautions minimized side effects observed in other studies9,10 and showed that the current study’s protocol was relatively safe.

The partial pressure of a gas can increase according to the ambient gas pressure, and each therapy pressure can be associated with a corresponding highest theoretical value of PaO2. For higher PaO2 values, greater quantities of O2 will be dissolved in the plasma, and when an increase in the O2 dissolved in the plasma occurs, the PaO2 level will be greater.

When the ambient temperature and gas pressure are kept constant, the quantity of O2 dissolved in the plasma will increase due to vasodilatation and increased blood flow.

According to previous reports, acupuncture can dilate the vascular system and increase blood flow,5-7,11 and it may ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 49

partially neutralize the vasoconstriction induced by HBO2, thereby dilating the vascular system and increasing the levels of blood flow and PaO2. Other research has demonstrated that superoxide anions can inactivate the nitric oxide (NO) synthesized by endothelial nitric oxide synthase (eNOS) and can cause the early induction of vasoconstriction following HBOT. Acupuncture can increase the NO level within the treatment region and increase local blood circulation. In particular, some researchers have found that EA can prevent the decrease in NO synthesis by eNOS and even stimulate the high expression of eNOS.12-14 Further, Kim et al15 found that acupuncture of the ST-36 (zusanli) acupoint can inhibit the increased expression of neuronal nitric oxide synthase (nNOS) and inducible nitric oxide synthase (iNOS), which are induced as a result of diabetes mellitus. EA has also been shown to decrease the expression of nNOS and iNOS,16-17 and another study reported that EA increased expression of eNOS during hypoxia.18 Those results may support the use of EA during HBOT. The major obstacles to EA in an HBOT chamber include percutaneous puncture and the power requirements of EA. However, for current HBO2 therapies, the technologies related to percutaneous puncture and the power- and pressure-retaining medical instruments in the HBOT chamber have improved. As a result, the treatment technology for EA during HBOT is practical and safe.

The EA for one group in the current study was done in a hyperbaric chamber while HBOT occurred. The study used many scientific methods that enabled the research team to reduce the danger caused by performing EA in the hyperbaric chamber while using HBOT and to ensure absolute safety.

First, the maximum output current of the EA instrument was less than or equal to 50 mA; the maximum output power was 0.3 VA. Second, only the wire and wire clips of the EA instrument were in the hyperbaric chamber; the EA instrument itself was outside the chamber. Third, the EA had a ground wire. Fourth, the research team started to electrify for EA only after the wire clips of the EA instrument were linked to the needles of the stimulated acupoint, thereby avoiding a spark induced when the clips were linked to the needle.

As long as researchers use those scientific procedures, they can perform EA safely in a hyperbaric chamber during HBOT. The current research team’s previous clinical trials have shown that participants’ PtcO2 levels can be gradually increased as long as they breathe pure O2 during the pressure-stabilization period of HBOT. After 10 to 15 minutes, the PtcO2 reaches a steady state, and PtcO2 fluctuates within a small range without interference. The team’s application of EA during HBOT was not initiated until the PtcO2 reached a steady state and the pressure stabilization period, during which pure O2 was breathed, was 60 minutes. Moreover, the application of EA during HBOT began after participants had breathed pure O2 for 15 minutes at the stabilizing pressure for standardization purposes. Before each experiment began, the PtcO2 test instrument was adjusted according to the regulations of the manufacturer to guarantee that it was working properly.

50 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Using the same therapy pressure, the increase in PtcO2 among participants in the EA During HBOT group was significantly greater than those observed among participants in the other 3 groups. This approach not only yielded better therapeutic effects without jeopardizing a patient’s safety but also could be very beneficial for patients with low tolerance for HBOT, such as (1) children; (2) older individuals; (3) individuals with conditions such as barotrauma, myopia, cataracts, and hypertension; and (4) patients who suffer from contraindications for HBOT (eg, severe upper-respiratory tract infections, severe emphysema, bronchiectasis, severe nasosinusitis, or ablatio retinae, and those who need to undergo HBOT treatment in cases of emergency).

One limitation of the present study was the use of only a single PtcO2 detection sensor and the measurement of PtcO2 only for the meridians of stimulated acupoints, as the acupoints of other meridians could not be measured. For EA during HBOT, if other research finds increased PtcO2 only at acupoints of the same meridian and not at other meridians, the results would demonstrate that EA during HBOT is similar to targeted therapy and does not affect the acupoints of other meridians, thus reducing the risk of O2 toxicity. The current research team plans to perform future research on the subject.

CONCLUSIONS The current results extend the range of HBOT and reduce its associated risks. Overall, the EA during HBOT method provided improvements in the efficacy, safety, and tolerability of HBOT, and the study’s results partly demonstrated the accuracy of the research team’s hypothesis that EA therapy applied during HBOT could safely improve the value of PtcO2 (PaO2) during HBOT and produce a greater therapeutic effect.

AUTHOR DISCLOSURE STATEMENT The authors have no financial or other relationship that might be perceived as leading to a conflict of interest.

REFERENCES 1. Weaver LK. Transcutaneous oxygen and carbon dioxide tensions compared to arterial blood gases in normals. Respir Care. 2007;52(11):1490-1496.

2. Mitsuno T, Ohyanagi H, Naito R. Clinical studies of a perfluorochemical whole blood substitute (Fluosol-DA): summar y of 186 cases. Ann Surg.

1982;195(1):60-69.

3. Sun GJ, Sheng CN, Yan J, et al. Acupuncturology. 7th ed. Shanghai, China: Science & Technology Press; 2005:1.

4. Hong M, Park SS, Ha Y, et al. Heterogeneity of skin surface oxygen level of wrist in relation to acupuncture point. Evid Based Complement Alternat Med. 2012;2012:106762.

5. Gong P, Zhang M, Huang G, Wang W. Influence of acupuncture at Hegu(LI 4) on transcutaneous oxygen partial pressure and transcutaneous carbon dioxide partial pressure of distal acupoints. J Tradit Chin Med. 2011;52(9):760-763.

6. Yu FL, Kong ES, Liu HA, et al. Effects of different acupuncture manipulation methods on partial pressure of oxygen at acupoints in healthy subjects [in Chinese]. Zhongguo Zhen Jiu. 1996;(10):15-17.

7. Wang H, Zhang H, Liu Y, et al. Effects of acupuncture on partial pressure of oxygen of the deeper tissue of acupoints, non-acupoints of meridian and nonacupoints [in Chinese]. Shanghai J Acupunct Moxibustion. 1997;16(1):3-5.

8. Wang JL. Clinical Epidemiology: Clinical Research Design, Measurement and Evaluation. 3rd ed. Shanghai, China: Science & Technology Press; 1996:177.

9. Fernau JL, Hirsch BE, Ramasastry S, et al. Hyperbaric oxygen therapy: effect on middle ear and eustachian tube function. Laryngoscope.1992;102(1):48-52.

Qu—EA Therapy During HBOT

10. Landolfi A, Autore A, Torchia F, et al. Ear pain after breathing oxygen at altitude: prevalence and prevention of delayed barotrauma. Aviat Space Environ Med. 2010;81(2):130-2.

11. Litscher G, Schwarz G, Sandner-Kiesling A, Hadolt I, Eger E. Effects of acupuncture on the oxygenation of cerebral tissue. Neurol Res. 1998;20(suppl 1):S28-S32.

12. Tsuchiya M, Sato EF, Inoue M, Asada A. Acupuncture enhances generation of nitric oxide and increases local circulation. Anesth Analg. 2007;104(2):301-307.

13. Jou NT, Ma SX. Responses of nitric oxide-cGMP releases in acupuncture point to electroacupuncture in human skin in vivo using dermal microdialysis.

Microcirculation. 2009;16(5):434-443.

14. Kimura K, Takeuchi H, Yuri K, Wakayama I. Effects of nitric oxide synthase inhibition on cutaneous vasodilation in response to acupuncture stimulation in humans. Acupunct Med. 2013;31(1):74-80.

15. Kim DD, Pica AM, Durán RG, Durán WN. Acupuncture reduces experimental renovascular hypertension through mechanisms involving nitric oxide synthases.

Microcirculation. 2006;13(7):577-585.

16. Jang MH, Shin MC, Lim BV, et al. Acupuncture increases nitric oxide synthase expression in hippocampus of streptozotocin-induced diabetic rats. Am J Chin Med. 2003;31(2):305-313.

17. Yang R, Huang ZN, Cheng JS. Anticonvulsion effect of acupuncture might be related to the decrease of neuronal and inducible nitric oxide synthases.

Acupunct Electrother Res. 2000;25(3-4):137-143.

18. Pan P, Zhang X, Qian H, et al. Effects of electro-acupuncture on endotheliumderived endothelin-1 and endothelial nitric oxide synthase of rats with hypoxiai n du c e d pu l m on ar y hy p e r te ns i on . E x p Bi ol Med ( May w o o d ) .

2010;235(5):642-648.

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PILOT STUDY

A Prospective Trial of Ayurveda for Coronary Heart Disease: A Pilot Study Robert DuBroff, MD; Vasant Lad, BAMS, MASc; Cristina Murray-Krezan, BS, MS

ABSTRACT Context • Coronary heart disease is the leading cause of death worldwide, and its incidence is rapidly accelerating in developing nations. Patients often search for therapies that are alternatives to traditional treatments, such as heart medicines, coronary bypass surgery, or coronary stenting.

Ayurveda is an ancient, East Indian, holistic approach to health care, and its use has never been formally evaluated for patients with coronary heart disease.

Objectives • The study intended to examine the feasibility and effectiveness of comprehensive ayurvedic therapy— incorporating diet, meditation, breathing exercises, yoga, and herbs—for patients with established coronary heart disease.

Design • The study was a prospective, single-group, pilot study.

Setting • The study took place at the University of New Mexico Cardiology Clinic and at the Ayurvedic Institute in Albuquerque, NM, USA. Participants • The participants were adults with a history of a prior heart attack, coronary bypass surgery, or a coronary intervention (ie, a coronary angioplasty and/or stent).

Intervention • All enrolled patients were evaluated by a single ayurvedic physician with >40 y of experience, and each received therapy consisting of a calorically unrestricted ayurvedic diet; instruction in yoga,

Robert DuBroff, MD, is an associate professor of medicine in the Division of Cardiology, School of Medicine, University of New Mexico, in Albuquerque, New Mexico.

Vasant Lad, BAMS, MASc, is an ayurvedic physician, as well as chairman of the board and president of the Ayurvedic Institute in Albuquerque. Cristina Murray-Krezan, BS, MS, is a research assistant professor in the Division of Epidemiology, Biostatistics, and Preventive Medicine, Department of Internal Medicine, Health Sciences Center, University of New Mexico.

Corresponding author: Robert DuBroff, MD E-mail address: rodubroff@unm.edu 52 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

meditation, and breathing; and use of ayurvedic herbs.

Outcome Measures • The primary endpoint was arterial pulse wave velocity, a marker of arterial function and vascular health. Secondary endpoints included the following measurements: (1) body mass index (BMI); (2) blood pressure (BP) and amount of reduction in BP medications; and (3) levels of total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides. All parameters were measured at baseline and after 90 d of therapy.

Results • Twenty-two patients were enrolled in the study, and 19 patients completed it. The research team observed significant improvements in arterial pulse wave velocity (P = .015), and favorable reductions in BMI (P < .0001), total cholesterol (P = .028), LDL cholesterol (P = .024), and triglycerides (P = .046). HDL cholesterol did not change significantly (P = .90). A majority of hypertensive patients were able to reduce or eliminate their antihypertensive medications (P = .0058).

Conclusions: The study’s results suggest a favorable effect for ayurveda on arterial function and multiple risk factors in patients with established coronary heart disease.(Altern Ther Health Med. 2015;21(5):52-62.)

A

ccording to the World Health Organization (WHO), cardiovascular disease is now the leading cause of death worldwide, and its incidence is rapidly accelerating in developing countries.1 The pandemic is largely due to unhealthy behaviors that include poor diet, smoking, lack of exercise, and resultant hypertension, obesity, and diabetes. Traditional therapies often include coronary bypass surgery; a coronary intervention (ie, a coronary angioplasty and/or stent); or medications. Alternative therapies are frequently sought by patients and may avoid many of the risks inherent in conventional treatments.

Ayurveda is an ancient, East Indian, holistic approach to health care that developed nearly 5000 years ago and focuses on the body, mind, and consciousness.2 Treatment is individualized DuBroff—Ayurveda and Coronary Heart Disease

to the patient rather than the disease and consists of diet, yoga, meditation, herbs, and other practices.3 Individual elements of ayurveda, such as specific herbs or yoga, have been tested in selected patients, but no studies investigating comprehensive ayurvedic therapy have been reported for patients with coronary heart disease. Single-modality ayurvedic therapies may not realize the synergistic or additive benefits of a comprehensive ayurvedic program. Therefore, the current research team developed a pilot study to assess the feasibility and effectiveness of a comprehensive ayurvedic program for patients with established coronary heart disease.

Optimal ayurvedic therapy requires a formal evaluation of each patient by an ayurvedic physician. The consultation establishes the constitution or dosha type of each patient (vata, pitta, kapha), both at conception (prakruti) and as related to the patient’s current status (vikruti). The assessment determines the appropriate therapy needed to rebalance the doshas.

Whereas prior ayurvedic research has tended to apply 1 standardized therapy for a particular disease, the current research team sought to maximize the efficacy of ayurveda by individualizing therapy and incorporating multiple modalities of treatment (ie, diet, meditation, yoga, breathing, and herbs).2 The team chose to measure the effectiveness of ayurveda by performing a simple, noninvasive assessment of vascular health (ie, measuring arterial pulse wave velocity) before and after 90 days of therapy.4 Arteries that are diseased are stiff and have rapid pulse wave velocities, whereas healthy arteries are more compliant and typically demonstrate slower pulse wave velocities. In addition, the team measured traditional cardiovascular risk factors such as blood pressure (BP), weight using body mass index (BMI), total cholesterol, triglycerides, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol.

METHODS Participants The study was a single-group, prospective, pilot. Englishspeaking men and women older than 18 years with known coronary artery disease were deemed eligible for participation.

Coronary artery disease was defined as a documented myocardial infarction, coronary bypass surgery, or coronary intervention (ie, an angioplasty and/or stent).

Patients were recruited between February 1, 2013, and June 1, 2013, from the University of New Mexico Cardiology Clinic and were followed for approximately 90 days. All eligible patients were screened by the principal investigator in the clinic.

All patients had to have stable health (ie, no hospitalizations, invasive cardiac procedures, or changes in medications for at least 30 d prior to enrollment). Exclusion criteria included (1) having a life expectancy of less than 6 months, (2) being pregnant or currently breastfeeding, (3) being unwilling or unable to complete a 90-day program of ayurveda, or (4) currently being on any form of ayurvedic therapy.

Prior studies of yoga and exercise have shown improvements in arterial function and reactivity.5 Based on DuBroff—Ayurveda and Coronary Heart Disease

the results of Duren et al,6 a sample size of 20 was identified as providing 81% power to detect a minimal, mean improvement in pulse wave velocity of 2.0 m/s (SD = 3.0).

Written informed consent was obtained after an investigator verified that a patient understood the study’s details. The study’s protocol and informed consent were reviewed and approved by the institutional review board of the University of New Mexico Human Research Protections Office.

Procedures After written informed consent was obtained, baseline assessments were completed, including each participant’s (1) demographics; (2) medical history; (3) current medications and dosages; (4) height; (5) weight; (6) BMI; (7) arterial pulse wave velocity; (8) automated, noninvasive, brachial-artery BP; and (9) blood samples for total cholesterol, triglycerides, HDL cholesterol, and LDL cholesterol.

Measurements of arterial pulse wave velocity and blood draws were performed at the cardiology clinic. Blood samples were processed by Atherotech (Birmingham, AL, USA).

Ayurvedic consultations; yoga, meditation, and breathing instructions; and follow-up were performed at the Ayurvedic Institute (Albuquerque, NM, USA). Herbs were prepared and dispensed from the institute pharmacy.

Patients were scheduled to see an ayurvedic physician for consultation and receipt of individualized instructions regarding (1) diet, (2) yoga, (3) breathing exercises, and (4) herbs. After 90 days, the research team repeated the assessments using the same measures. During the study, a systolic BP of less than 110 mm Hg was treated by the principal investigator through reducing and/or stopping BP medications Intervention Each patient consulted with a single ayurvedic physician, a member of the research team, who established the patient’s dosha score on a scale of 1 to 4, both at prakruti, the patient’s normal state at conception, and at vikruti, the patient’s current or diseased state (Table 1). These dosha scores were determined by the history and physical examination Table 1. Dosha Types Prakruti (scale 1-4)

Vikruti (scale 1-4)

Median (Q1-Q3)

Median (Q1-Q3)

Vata

1.0 (1.0-1.0)

1.0 (1.0-1.0)

Pitta

3.0 (3.0-3.0)

3.0 (3.0-3.0)

Kapha

2.5 (2.0-3.0)

3.0 (3.0-3.5)

Dosha

Abbreviations: Q1, 25th percentile; Q3, 75th percentile.

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 53

Table 2. Ayurvedic Herbs Sanskrit Punarnava Ashwagandha Arjuna Pushkaramula Chitrak Guduchi Triphala

Botanical Boerhaavia diffusa Withania somnifera Terminalia arjuna Inula racemosa Plumbago zeylanicum Tinospora cordifolia Amalaki, haritaki, bibhitaki

Table 3. Characteristics of Participants at Baseline (n =19) Dosage 500 mga 400 mga 300 mga 200 mga 200 mga 200 mga 2.5 mLb

a

Three times per day.

Every night at bedtime.

b

performed by the ayurvedic physician. The scale reflects the relative predominance of a particular dosha or constitution type. The predominant prakruti dosha of participants was pitta, whereas the greatest imbalance between prakruti and vikruti was kapha in all patients. Therefore, all patients received the same ayurvedic therapies designed to rebalance the kapha dosha.

The treatment recommendations included (1) a calorically unrestricted ayurvedic diet conforming to the patient handout included as Appendix 1, (2) a daily yoga practice using so’ham meditation described in the patient handout included as Appendix 2, (3) a pranayama breathing practice described in the patient handout included as Appendix 3, and (4) ayurvedic herbs (Table 2). Participants were instructed to perform each activity on a daily basis and were contacted weekly by telephone to encourage compliance.

Outcomes The primary outcome was arterial pulse wave velocity.

The velocity was measured noninvasively using a SphygmoCor unit, following standard techniques recommended by the manufacturer (AtCor Medical, Itasca, IL, USA). The tests were performed by a single ultrasonographer, certified in both cardiac and vascular ultrasound by the American Registry for Diagnostic Medical Sonography. Measurements were made at baseline and posttreatment in the fasting state, with patients having nothing to eat after midnight.

The prespecified secondary outcomes included (1) height and weight, to calculate BMI; (2) supine BP taken using a single, automatic, brachial-artery-BP machine (Welch Allyn, Skaneateles Falls, NY, USA); and (3) changes in BP medications, total cholesterol, triglycerides, LDL cholesterol, and HDL cholesterol. All secondary outcomes were also measured in the fasting state at baseline and posttreatment.

Statistical Analysis Descriptive statistics were calculated for baseline characteristics and are reported as means and standard deviations for continuous variables or as frequencies and percentages for categorical variables. Change scores were 54 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Characteristic Age, y, mean ± SD Male gender, n (%) Race or ethnic group, n (%) White Black Hispanic Asian BMI, mean ± SD Systolic BP (mm Hg), mean ± SD Diastolic BP (mm Hg), mean ± SD Medical history, n (%) Hypertension Diabetic on medication Prior myocardial infarction Coronary bypass surgery Percutaneous coronary intervention Current smoking COPD Baseline medications, n (%) ACEI or ARB Diuretic Calcium channel blocker β blocker Statin

Measure 71.6 ± 11.3 10 (53) 15 (79) 1 (5) 1 (5) 2 (10) 27.3 ± 4.4 138 ± 21 80 ± 7 15 (79) 4 (21) 8 (42) 9 (47) 7 (37) 1 (5) 2 (10) 8 (42) 2 (10) 6 (32) 12 (63) 18 (95)

Abbreviations: SD, standard deviation; BMI, body mass index; BP, blood pressure; COPD, chronic obstructive pulmonary disease; ACEI, angiotensin converting enzyme inhibitors; ARB, angiotensin receptor blockers. calculated as posttreatment values minus baseline values for the primary and secondary endpoints. Change scores were assessed for normality and were compared to the null hypothesis of no change by use of the paired t test. The exact binomial test was used to assess the significance of the decreases in dosage or stopping of antihypertensive medications during the study.

The proportion of patients in the study using antihypertensive medications at baseline was 15/19 (79%). The proportion of participants using those medications at the end of the study was compared with the proportion at baseline.

All analyses were performed in SAS 9.3 (SAS Institute Inc, Cary, NC, USA, 2011) and R 3.1 (R Foundation for Statistical Computing, http://www.r-project.org). P values were considered significant if they fell below the type 1 error rate of α = .05.

DuBroff—Ayurveda and Coronary Heart Disease

Table 4. Primary and Secondary Outcomes

Variable Pulse wave velocity (m/s) BMI Total cholesterol (mg/dL) Direct LDL holesterol (mg/dL) HDL cholesterol (mg/dL) Triglycerides (mg/dL)

BP

Figure 1. Flow diagram for participants.

Baseline Mean ± SD

Posttreatment Mean ± SD

Change Mean ± SD P Value

11.7 ± 3.5 27.3 ± 4.4

9.3 ± 3.5 26.6 ± 4.4

-2.4 ± 3.7 -0.7 ± 0.5

.015a <.0001a

171.6 ± 40.7

162.3 ± 38.0

-9.0 ± 16.3

.028a

97.8 ± 33.9

90.6 ± 27.4

-7.2 ± 12.6

.024a

52.2 ± 15.6

51.9 ± 19.3

-0.3 ± 8.9

.90a

112.6 ± 52.2

97.2 ± 37.1

-15.5 ± 31.5

.046a

Assessed for eligibility (N = 38)

Excluded (n = 16) • Ineligible (n = 3) • Declined (n = 13)

Enrolled (n = 22)

BP Reductionb in Medication BP Medication at Baseline Posttreatment n (%) n (%) 15/19 (79) 8/15 (53)

Received ayurvedic evaluation and treatment (n = 22)

--

.00582

Abbreviations: SD, standard deviation; BMI, body mass index; LDL, lowdensity lipoprotein; HDL, high-density lipoprotein; BP, blood pressure.

Dropped out (n = 3) • Distaste for herbs (n = 2) • Lost to follow-up (n = 1)

a

P value obtained from the paired t test.

Reduction or elimination. c P value obtained from the exact binomial test. b

RESULTS The trial was ended when the last patient completed the final 90-day assessment. Baseline characteristics are reported in Table 5. The average age of participants was 71.6 years, with a range of 51 to 83, and 53% of participants were male.

Twenty-two patients enrolled in the study; 1 patient was lost to follow-up, and 2 patients dropped out of the study due to distaste for the ayurvedic herbs. Nineteen patients completed the study. Participant flow is illustrated in Figure 2. The results are summarized in Table 6. No harms or adverse effects of treatment were reported or noted.

The primary endpoint, arterial pulse wave velocity, showed a favorable, statistically significant change from 11.7 ± 3.5 m/s to 9.3 m/s ± 3.5 (P = .015) after ayurvedic therapy. Statistically significant changes were also noted for BMI (P < .0001), total cholesterol (P = .028), direct LDL cholesterol (P = .024), and triglycerides (P = .046). HDL levels did not change significantly (P = .90). Among hypertensive patients (15), 53% were able to stop all antihypertensive medications or to reduce the dosage due to a systolic BP of less than 110 mm Hg (P = .0058).

DuBroff—Ayurveda and Coronary Heart Disease

Analyzed (n = 19)

DISCUSSION This study was a pilot intended to assess the feasibility and possible effectiveness of ayurveda in patients with established coronary heart disease. It was short in duration, modest in size, and neither blinded nor randomized. The advanced ages of the participants reflect the prevalence of coronary artery disease in the elderly and did not indicate an intention to exclude younger patients.

The research team did not measure compliance but instead relied on weekly phone calls to encourage each patient to be adherent. The team was surprised by the reduction in BMI because the ayurvedic diet that was prescribed had no caloric restrictions, only a list of foods to eat and foods to avoid based on the dosha type (Table 1).

However, it is possible that the weight loss may have contributed to the favorable effects seen on BP and lipid values. The trial design and results did not allow the team to investigate that possible relationship, but researchers may wish to explore the association further in future studies.

Despite of the limitations and caveats, the study’s findings do suggest a favorable effect for ayurveda on arterial pulse wave velocity, which is an established marker of arterial ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 55

AUTHOR DISCLOSURE STATEMENT

health and cardiovascular prognosis.7 Beneficial effects were also seen on many traditional cardiovascular risk factors. The research team failed to measure glucose levels, a lowering of which may have occurred given the weight loss observed.

The authors have no conflicts of interest to disclose. No external funding was received for the study.

REFERENCES

CONCLUSIONS To date, no clinical trials of comprehensive ayurvedic therapy with objective endpoints for coronary patients have been reported. The current research teamâ&#x20AC;&#x2122;s findings are not conclusive but suggest a salutary effect and provide support for further study of ayurveda in cardiovascular disease.

Future studies might include an assessment of compliance, an intention-to-treat analysis, and use of the methodology for a randomized, controlled trial.

1. Mendis S, Puska P, Norrving B, eds. Global Atlas on Cardiovascular Disease Prevention and Control. Geneva, Switzerland: World Health Organization; 2011.

2. Mamtani R, Mamtani R. Ayurveda and yoga in cardiovascular diseases. Cardiol Rev. 2005;13(3):155-162.

3. Lad V. Fundamental Principles of Ayurveda. Albuquerque, NM: The Ayurvedic Press; 2002. Textbook of Ayurveda; vol 1.

4. Nichols WW. Clinical measurement of arterial stiffness obtained from noninvasive pressure waveforms. Am J Hypertens. 2005;18(1, pt 2):3S-10S. 5. Sivasankaran S, Pollard-Quintner S, Sachdeva R, Pugeda J, Hoq SM, Zarich SW. The effect of a six-week program of yoga and meditation on brachial artery reactivity: do psychosocial interventions affect vascular tone? Clin Cardiol.

2006;29(9):393-398.

6. Duren CM, Cress ME, McCully KK. The influence of physical activity and yoga on central arterial stiffness. Dyn Med. January 2008;7:2.

7. Sakuragi S, Abhayaratna WP. Arterial stiffness: methods of measurement, physiologic determinants and prediction of cardiovascular outcomes. Int J Cardiol. 2010;138(2):112-118.

8. Lad U, Lad V. Ayurvedic Cooking for Self Healing. 2nd ed. Albuquerque, NM: The Ayurvedic Press; 2008.

9. Lad V. Applied Marma Therapy Cards. Albuquerque, NM: The Ayurvedic Press; 2013.

ACKNOWLEDGEMENTS The research team gratefully acknowledges the support of Atherotech for providing blood sample analyses. The SphygmoCor unit was provided by Dr Warren Laskey, chief of cardiology at the University of New Mexico. The team also wishes to acknowledge the generosity of the Ayurvedic Institute in supporting the project and donating personnel and resources for its conduct. The trial has been registered at http://ClinicalTrials.gov (identifier No. NCT02228343).

Appendix 1. Ayurvedic Food Guidelines Vata

Kapha

Favor

Avoid

Favor

Avoid

Favor

Generally most dried fruit Apples (raw) Cranberries Dates (dry) Figs (dry) Pears Persimmons Pomegranates Raisins (dry) Prunes (dry) Watermelon

Generally most sweet fruit Apples (cooked) Apricots Avocado Bananas Berries Cherries Coconut Dates (fresh) Figs (fresh) Grapefruit Kiwi Lemons Limes Mangoes Melons Oranges Papaya Peaches Pineapple Plums Prunes (soaked) Raisins (soaked) Rhubarb Strawberries Tamarind

Generally most sour fruits Apples (sour) Apricots (sour) Bananas Berries (sour) Cherries (sour) Cranberries Grapefruit Grapes (green) Kiwib Lemons Mangoes (green) Oranges (sour) Peaches Persimmons Pineapple (sour) Plums (sour) Rhubarb Tamarind

Generally most sweet fruit Apples (sweet) Applesauce Apricots (sweet) Avocado Berries (sweet) Cherries (sweet) Coconut Dates Figs Grapes (red & purple) Limesa Mangoes (ripe) Melons Oranges (sweet)a Papayaa Pears Pineapple (sweet)a Plums (sweet) Pomegranates Prunes Raisins Strawberriesa Watermelon

Generally most sweet & sour fruit Avocado Bananas Coconut Dates Figs (fresh) Grapefruit Kiwi Mangosb Melons Oranges Papaya Pineapple Plums Rhubarb Tamarind Watermelon

Generally most astringent fruit Apples Applesauce Apricots Berries Cherries Cranberries Figs (dry)a Grapesa Lemonsa Peachesa Pears Persimmons Pomegranates Prunes Raisins Strawberriesa

None

In moderation Almonds Black walnuts Brazil nuts Cashews Charole Coconut Filberts Hazelnuts Macadamia nuts Peanuts Pecans Pine nuts Pistachios Walnuts

Almonds (with skin) Black walnuts Brazil nuts Filberts Hazelnuts Macadmia nuts Peanuts Pecans Pine nuts Pistachios Walnuts

Almonds (soaked and peeled) Charole Coconut

Almonds (soaked and peeled)b Black walnuts Brazil nuts Cashews Coconuts Filberts Hazelnuts Macadamia nuts Peanuts Pecans Pine nuts Pistachios Walnuts

Charole

Fruits Nuts

Pitta

Avoid

56 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

DuBroffâ&#x20AC;&#x201D;Ayurveda and Coronary Heart Disease

Grains

Vegetables

Vata

Pitta

Kapha

Avoid

Favor

Avoid

Favor

Avoid

Favor

Generally frozen, raw, or dried vegetables Artichoke Beet greensb Bitter melon Broccoli Brussels sprouts Burdock root Cabbage (raw) Cauliflower (raw) Celery Corn (fresh)b Dandelion greens Eggplant Horseradishb Kale Kohlrabi Mushrooms Olives (green) Onions (raw) Peas (raw) Peppers (sweet & hot) Potatoes (white) Prickly pear (fruit & leaves) Radish (raw) Squash (winter) Tomatoes (cooked)b Tomatoes (raw) Turnips Wheat (grass & sprouts)

Generally vegetables should be cooked Asparagus Beets Cabbage (cooked)a Carrots Cauliflowera Cilantro Cucumber Daikon radisha Fennel (anise) Garlic Green beans Green chilies Jerusalem artichokea Leafy greensa Leeks Lettucea Mustard greensa Okra Olives (black) Onions (cooked)a Parsleya Parsnip Peas (cooked) Potatoes (sweet) Pumpkin Radishes (cooked)a

Generally pungent vegetables Beet greens Beets (raw) Burdock root Corn (fresh)b Daikon radish Eggplantb Garlic Green chilies Horseradish Kohlrabib Leeks (raw) Mustard greens Olives (green) Onions (raw) Peppers (hot) Turnip greensa Watercress Zucchini Prickly pear (fruit) Radishes (raw) Spinach (cooked)b Tomatoes Turnip greens Turnips

Generally sweet & bitter vegetables Artichoke Asparagus Beets (cooked) Bitter melon Broccoli Brussels sprouts Cabbage Carrots (raw)a Cauliflower Celery Cilantro Cucumber Dandelion greens Fennel (anise) Green Beans Jerusalem artichoke Kale Leafy greens Leeks (cooked) Lettuce Mushrooms Okra Olives (black) Onions (cooked) Parsley Parsnips Peas Peppers (sweet) Potatoes (sweet & white) Prickly pear (leaves) Pumpkin Radishes (cooked) Rutabaga Spaghetti squash Sprouts (not spicy) Squash (winter & summer) Taro root Watercressa Wheat grass (sprouts) Zucchini

Generally sweet & juicy vegetables Cucumber Olives (black or green) Parsnipsb Potatoes (sweet) Pumpkin Squash (summer) Taro root Tomatoes (raw) Zucchini

Generally most pungent & bitter vegetables Artichoke Asparagus Beet greens Beets Bitter melon Broccoli Brussels sprouts Burdock root Cabbage Carrots Cauliflower Celery Cilantro Corn Daikon radish Dandelion greens Eggplant Fennel (anise) Garlic Green beans Green chilis Horseradish Jerusalem artichoke Kale Kohlrabi Leafy greens Leeks Lettuce Mushrooms Mustard greens Okra Onions Parsley Peas Peppers (sweet & hot) Potatoes (white) Prickly pear (fruit & leaves) Radishes Rutabaga Spaghetti squasha Spinach Sprouts Squash (winter) Tomatoes (cooked) Turnip greens Turnips Watercress Wheat grass

Barley Bread (with yeast) Buckwheat Cereals (cold, dry, or puffed) Corn Couscous Crackers Granola Millet Muesli Oat bran Oats (dry) Pastab Polentab Rice cakesb Rye Sago Spelt Tapioca Wheat bran

Amarantha Durham flour Oats (cooked) Pancakes Quinoa Rice (all kinds) Seitan (wheat meat) Sprouted wheat bread (essene) Wheat

Bread (with yeast) Buckwheat Corn Millet Mueslib Oats (dry) Polentab Rice (brown)b Rye

Amaranth Barley Cereal (dry) Couscous Crackers Durham flour Granola Oat Bran Oats (cooked) Pancakes Pasta Quinoa Rice (basmati, white, wild) Rice cakes Seitan (wheat meat) Spelt Sprouted wheat bread (essene) Tapioca Wheat Wheat bran

Bread (with yeast) Oats (cooked) Pancakes Pastab Rice (brown & white) Rice cakesb Wheat

Amarantha Barley Buckwheat Cereal (cold, dry, or puffed) Corn Couscous Crackers Durham floura Granola Millet Muesli Oat bran Oats (dry) Polenta Quinoaa Rice (basmati, wild)a Rye Seitan (wheat meat) Sprouted wheat bread (essene) Tapioca Wheat bran

DuBroffâ&#x20AC;&#x201D;Ayurveda and Coronary Heart Disease

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 57

Animal Foods

Kapha

Avoid

Favor

Avoid

Favor

Aduki beans Black beans Black-eyed peas Chickpeas (garbanzo beans) Kidney beans Lentils (brown) Lima Beans Misob Navy beans Peas (dried) Pinto beans Soy beans Soy flour Soy powder Split peas Tempeh White beans

Lentils (red) Mung beans Mung dal Soy cheesea Soy milka Soy saucea Soy sausagesa Tofua Tur dal Urad dal

Miso Soy sauce Soy sausages Tur dal Urad dal

Aduki beans Black beans Black-eyed peas Chickpeas (garbanzo beans) Kidney beans Lentils (brown & red) Lima beans Mung beans Mung dal Navy beans Peas (dried) Pinto beans Soy beans Soy floura Soy milk Soy powdera Split peas Tempeh Tofu White beans

Kidney beans Soy beans Soy cheese Soy flour Soy powder Soy sauce Tofu (cold) Urad dal Miso

Aduki beans Black beans Black-eyed peas Chickpeas (garbanzo beans) Lentils (brown & red) Lima Beans Mung beansa Mung dala Navy beans Peas (dried) Pinto beans Soy milk Soy sausages Split peas Tempeh Tofu (hot) Tur dal White beans

Cow’s Milk (powdered) Goat’s Milk (powdered) Yogurt (plain, frozen, or with fruit)

Generally most dairy is good!

Butter Buttermilk Cheese (hard)a Cheese (soft) Cottage cheese Cow’s milk Ghee Goat’s milk Ice creama Sour creama Yogurt (diluted & spiced)a

Butter (salted) Buttermilk Cheese (hard) Sour cream Yogurt (plain, frozen, or with fruit)

Butter (unsalted) Cheese (soft, not aged, unsalted) Cottage cheese Cow’s milk Ghee Goat’s milk Goat’s cheese (soft, unsalted) Ice cream Yogurt (freshly made & diluted)a

Butter (salted) Butter (unsalted)b Cheese (soft & hard) Cow’s milk Ice cream Sour cream Yogurt (plain, frozen, or with fruit)

Buttermilka Cottage cheese (from skimmed goat’s milk) Gheea Goat’s cheese (unsalted & not aged) Goat’s milk (skim) Yogurt (diluted)

Lamb Pork Rabbit Venison Turkey (white)

Beef Buffalo Chicken (dark) Chicken (white)a Duck Eggs Fish (freshwater or sea) Salmon Sardines Seafood Shrimp Tuna fish Turkey (dark)

Beef Chicken (dark) Duck Eggs (yolk) Fish (sea) Lamb Pork Salmon Sardines Seafood Tuna fish Turkey (dark)

Buffalo Chicken (white) Eggs (albumen or white only) Fish (freshwater) Rabbit Shrimpa Turkey (white) Venison

Beef Buffalo Chicken (dark) Duck Fish (sea) Lamb Pork Salmon Sardines Seafood Tuna fish Turkey (dark)

Chicken (white) Eggs Fish (freshwater) Rabbit Shrimp Turkey (white) Venison

Chocolate Horseradish

Black peppera Chutney (mango sweet or spicy) Chili peppersa Coriander leavesa Dulse Gomasio Hijiki Kelp Ketchup Kombu Lemon Lime Lime pickle Mango pickle Mayonnaise Mustard Pickles Salt Scallions Seaweed Soy sauce Sproutsa Tamari Vinegar

Chili pepper Chocolate Chutney (mango spicy) Gomasio Horseradish Kelp Ketchup Lemon Lime pickle Mango pickle Mayonnaise Mustard Pickles Salt (in excess) Scallions Soy sauce Vinegar

Black peppera Chutney (mango sweet) Coriander leaves Dulsea Hijikia Kombua Limea Sprouts Salta Seaweeda Tamaria

Chocalate Chutney (mango sweet) Gomasio Kelp Ketchupb Lime Lime pickle Mango Pickle Mayonnaise Pickles Salt Soy sauce Tamari Vinegar

Black pepper Chili peppers Chutney (mango spicy) Coriander leaves Dulsea Hijikia Horseradish Lemona Mustard (without vinegar) Scallions Seaweeda Sprouts

Flax seed

For internal & external use (most suitable at top of list) Sesame Ghee Olive Most other oils

Almond Apricot Corn Safflower Sesame

For internal & external use (most suitable at top of list) Sunflower Ghee Canola Olive Soy Flax seed Primrose Walnut

Avocado Apricot Coconut Flax seedb Olive Primrose Safflower Sesame (internal) Soy Walnut

For internal & external use in small amounts (most suitable at top of list) Corn Canola Sesame (external) Sunflower Ghee Almond

Condiments Oils

Pitta

Favor

Dairy

Legumes

Vata Avoid

External use only Coconut Avocado

External use only Avocado Coconut

58 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

DuBroff—Ayurveda and Coronary Heart Disease

Seeds

Herbal Teas

Beverages

Vata

Pitta

Kapha

Avoid

Favor

Avoid

Favor

Avoid

Favor

Alcohol (hard; red wine) Apple juice Black tea Caffeinated beverages Carbonated drinks Chocolate milk Coffee Cold dairy drinks Cranberry juice Iced tea Icy cold drinks Pear juice Pomegranate juice Pune juiceb Soy milk (cold) Tomato juiceb V-8 Juice

Alcohol (beer; white wine) Almond milk Aloe vera juice Apple cider Apricot juice Berry juice (except for cranberry) Caroba Carrot juice Chai (hot spiced milk) Cherry juice Grain “coffee” Grape juice Grapefruit juice Lemonade Mango juice Miso broth Orange juice Peach nectar Pineapple juice Rice milk Sour juices Soy milk (hot & wellspiced)a Vegetable bouillion

Alcohol (hard; red & sweet wine) Apple cider Berry juice (sour) Caffeinated beverages Carbonated drinks Carrot juice Cherry juice (sour) Chocolate milk Coffee Cranberry juice Grapefruit juice Iced tea Icy cold drinks Lemonade Papaya juice Pineapple juice Tomato juice V-8 juice Sour juices

Alcohol (beer; dry white wine) Almond milk Aloe vera juice Apple juice Apricot juice Apple juice Berry juice (sweet) Black teaa Carob Chai (hot, spiced milk)a Cherry juice (sweet) Cool dairy drinks Grain “coffee” Grape juice Mango juice Miso brotha Mixed vegetable juice Orange juicea Peach nectar Pear juice Pomegranate juice Prune juice Rice milk Soy milk Vegetable bouillion

Alcohol (hard; beer, sweet wint) Almond milk Caffeinated beveragesb Carbonated drinks Cherry juice (sour) Chocolate milk Coffee Cold dairy drinks Lemonade Miso broth Orange juice Papaya juice Rice milk Sour juices Soy milk (cold) Tomato juice V-8 juice

Alcohol (dry wine red or white)a Aloe vera juice Apple cider Apple juicea Apricot juice Berry juice Black tea (spiced) Carob Carrot juice Chai (hot, spiced milk)a Cherry juice (sweet) Grain “coffee” Grape juice Mango juice Peach nectar Pear juice Pineapple juicea Pomegranate juice Prune juice Soy milk (hot & wellspiced)

Alfalfab Barleyb Basilb Blackberry Borageb Burdock Cinnamonb Cornsilk Dandelion Gingseng Hibiscus Hopsb Jasmineb Lemon balmb Mormon tea Nettleb Passion flowerb Red cloverb Red Zingerb Violetb Yarrowb Yerba Mate

Ajwan Bancha Catnipa Chamomile Chicorya Chrysanthemuma Clove Comfrey Elder flower Eucalyptus Fennel Fenugreek Ginger (fresh) Hawthorne Juniper berry Kukichaa Lavender Lemon grass Licorice Marshmallow Oat straw Orange peel Pennyroyal Peppermint Raspberrya Rosehips Saffron Sage Sarsaparilla Sassafras Spearmint Strawberrya Wintergreena

Ajwan Basilb Clove Eucalyptus Fenugreek Ginger (dry) Hawthorne Juniper berry Mormon tea Pennyroyal Red Zinger Rosehipb Sage Sassafras Yerba Mate

Alfalfa Bancha Barley Blackberry Borage Burdock Catnip Chamomile Chicory Comfrey Dandelion Fennel Ginger (fresh) Hibiscus Hops Jasmine Kukicha Lavender Lemon balm Lemon grass Licorice Marshmallow Nettle Oat Straw Passion flower Peppermint Raspberry Red clover Sarsaparilla Spearmint Strawberry Violet Wintergreen Yarrow

Licoriceb Marshmallow Red Zinger Rosehipb

Alfalfa Bancha Barley Blackberry Burdock Chamomile Chicory Cinnamon Clove Comfreya Dandelion Fennela Fenugreek Ginger Ginsenga Hibiscus Jasmine Juniper berry Kukicha Lavender Lemon balm Lemon grass Mormon tea Nettle Passion flower Peppermint Raspberry Red clover Sarsaparillaa Sassafras Spearmint Strawberry Wintergreen Yarrow Yerba Mate

Popcorn Psylliumb

Chia Flax Halva Pumpkin Sesame Sunflower Tahini

Chia Sesame Tahini

Flax Halva Popcorn (no salt or butter) Psyllium Pumpkina Sunflower

Halva Psylliumb Sesame Tahini

Chia Flaxa Popcorn (no salt or butter) Pumpkina Sunflower

DuBroff—Ayurveda and Coronary Heart Disease

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 59

Vata

Pitta

Kapha

Favor

Avoid

Favor

Avoid

Favor

All spices are good Ajwan Allspice Almond extract Anise Asafoetida (hing) Basil Bay leaf Black pepper Caraway Cardamom Cayennea Cinnamon Cloves Coriander Cumin Dill Fennel Fenugreeka Garlic Ginger Marjoram Mint Mustard seeds Nutmeg Orange peel Oregano Paprika Parsley Peppermint Pippali Poppy seeds Rosemary Saffron Salt Savory Spearmint Star anise Tarragon Thyme Tumeric Vanilla Wintergreen

Ajwan Allspice Almond extract Anise Asafoetida (hing) Basil (dry) Bay leaf Cayenne Cloves Fenugreek Garlic Ginger (dry) Mace Marjoram Mustard seeds Nutmeg Oregano Paprika Pippali Poppy seeds Rosemary Sage Salt Savory Star anise Thyme

Basil Black peppera Carawaya Cardamoma Cinnamon Coriander Cumin Dill Fennel Ginger (fresh) Mint Neem leavesa Orange peela Parsleya Peppermint Saffron Spearmint Tarragona Tumeric Vanillaa Wintergreen

Salt

All spices are good Ajwan Allspice Almond extract Anise Asafoetida (hing) Basil Bay leaf Black pepper Caraway Cardamom Cayenne Cinnamon Cloves Coriander Cumin Dill Fennela Fenugreek Garlic Ginger Marjoram Mint Mustard seeds Neem leaves Nutmeg Orange peel Oregano Paprika Parsley Peppermint Pippali Poppy seeds Rosemary Saffron Savory Spearmint Star anise Tarragon Thyme Tumeric Vanillaa Wintergreen

Maple syrupb White sugar

Barley malt Fructose Fruit juice concentrates Honey Jaggary Molasses Rice syrup Dried or fresh sugar cane juice Turbinado

White sugarb Honeyb Jaggary Molasses

Barley malt Fructose Fruit juice concentrates Maple syrup Rice syrup Dried or fresh sugar cane juice Turbinado

Barley malt Fructose Jaggary Maple syrup Molasses Rice syrup Dried or fresh sugar cane juice Turbinado White sugar

Fruit juice concentrates Honey (raw & not processed)

Barley green Brewer’s yeast

Aloe vera juicea Bee pollen Amino acids

Amino acids Bee pollenb Royal jellyb

Aloe vera juice Barley green Brewer’s yeast

Minerals: potassium

Minerals: calcium, copper, iron, magnesium, zinc

Minerals: copper, iron

Minerals: calcium, magnesium, zinc

Aloe vera juice Amino acids Barley green Bee pollen Brewer’s yeast

Vitamins; B2, B6, C, E, P (bioflavonoids), and folic acid

Spirolina Blue-green algae

Minerals: copper, calcium, iron, magnesium, zinc

Vitamins; A, B1, B12, D, and K

Vitamins; B6, C, P (bioflavonoids) and folic acid

Sweeteners

Spices

Avoid

Food Supplements

Vitamins: K

Royal jelly Spirolina Blue-green algae Vitamins; A, B1, B2, B6, B12, C, D, E, P (bioflavonoids) and folic acid

Vitamins; A, B1, B2, B12, D, and E

Note: Guidelines provided in this table are general. Specific adjustments for individual requirements may need to be made (eg, food allergies, strength of agni, season of the year, and degree of dosha predominance or aggravation). a

Okay in moderations.

Okay rarely.

b

Copyright © 1994, 2008 The Ayurvedic Institute and Vasant Lad, MASc. All Rights Reserved.

Excerpted from Ayurvedic Cooking for Self Healing, Usha and Vasant Lad, 2nd ed. Albuquerque: The Ayurvedic Press.8 Contact PO Box 23445, Albuquerque, NM 87192-1445, (505) 291-9698, http://www.ayurveda.com.

60 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

DuBroff—Ayurveda and Coronary Heart Disease

Appendix 2. Yoga Pranayama/Breathing Practice Name Kapalabhati Anuloma Viloma Utjayi Sheetali Utgeet

Sets Length/Time 2 30 s 2 1 min 1 7× 1 7× 1 7×

Notes Add 30 s/wk up to 2 min Add 30 s/wk up to 2 min 2 2 2

Yoga Practice (ujayi nostril breathing) Posture

Length Breath

Notes Tree Pose Stand near a wall and turn the right leg out, bending the knee and start with foot on the side of your ankle with toes on the floor.

Repeat other side.

7 Breaths

Tadasana Inhale, lift the arms, then exhale, lower the arms.

7 Breaths

Triangle Step your legs 4 feet apart (approx.) placing a chair next to your right leg, turn the right let out toward the chair, inhale to lift the arms out to the side and exhale to reach the right arm toward the chair and resting the arm on the chair.

Hold 7B and repeat other side (move the chair).

Maha Mudra Sit with both legs extended and then bend one knee toward your chest and turn the leg out, place that foot on the extended leg inner thigh as high up as possible.

Inhale lift the arms and exhale bend forward over the leg. Repeat other side.

Warrior I Step right leg back about 4 feet (3/4 of mat), turn the right leg out (external rotation back leg) while bending the front knee almost 90°. Inhale and lift the arms overhead. Try to keep your front hip bones and shoulder aligned to the front of the room. Repeat with the other leg. Rest between sides.

7 Breaths

7 Breaths

7 Breaths

Laying Spine Twist Lay down with arms out in a diagonal palms down. Bend only the right knee placing the right foot behind the left knee. Inhale. Exhale twist to the left side. It’s OK for your shoulder to lift up. Breathe into your back—watch the breath. Switch sides.

7 Breaths

Bridge Pose Lay down with knees bent and feet hip-width apart. Palms down and arms by the side pressing down.

Inhale to lift the chest up.

Cow Sit crossing the right leg over the left. Lift the left arm and bend the elbow behind the head and either use the right arm to support the arm or reach behind the back to catch the left arm. *Can also be done sitting on a chair and crossing the legs.

7 Breaths

Meditation Instructions So’Ham Meditation: 10 minutes in the morning and night. See handout. Add 5 minutes in length per week.

DuBroff—Ayurveda and Coronary Heart Disease

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 61

Appendix 3. So’Ham Meditation Inhale from 9 inches away from the nostrils and mentally say “so . . . ooo” as you inhale. Bring your awareness to the “so” as that “so” goes inward, into the center of the brain and center of your body, then stops. Stay there for a fraction of a second; then exhale as you feel and say “hammmm” throughout the phase of exhalation. You exhale out of the body and “ham” dissolves into the outer space. Within these 2 stops, “so” and “ham,” within that gap, a canvas of pure awareness exists. On that canvas, your whole life is painted. Be with that canvas, and then you will feel the pure essence of your being. Your being is god; your being is reality; your being is the love divine. Just stay there. With this practice, so’ham will unfold inner beauty, inner joy, and inner truth.

As this practice deepens, continue to expand this art of paying attention to the gap. While you are walking, walk, but be rooted in the gap. While eating food, you are in the gap. All activities of life are happening at the periphery, the circumference, but you are deeply rooted in the gap of the heart. Your whole life becomes a drama, a play, and you are simply the watcher of the drama. Every moment is then a moment of peace, love, and joy. a

Excerpted with permission from Applied Marma Therapy Cards.9

So’ham: The “a” is pronounced as the “a” in about, not the “a” in cat.

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25THCRBTAD2015, Version 1.0

REVIEW ARTICLE

The Effectiveness of Dance Interventions to Improve Older Adults’ Health: A Systematic Literature Review Phoebe Woei-Ni Hwang, MS; Kathryn L. Braun, DrPH

ABSTRACT Background • Physical inactivity is commonly observed among individuals aged ≥60 y. Identified barriers to sedentary older adults beginning activity include low selfefficacy, pre-existing medical conditions, physical limitations, time constraints, and culture. Dancing has the potential to be an attractive physical activity that can be adjusted to fit a target population’s age, physical limitations, and culture.

Objectives • This review examined the benefits to physical health of dance interventions among older adults.

Methods • Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search using the PubMed database was conducted. Eighteen studies met the inclusion and exclusion criteria and were analyzed for type of intervention, the study’s design, participants’ demographics, and outcomes, including attrition.

Results • The 18 articles reported on studies conducted in North America, South America, Europe, and Asia. Of the styles of dancing, 6 studies used ballroom, 5 used contemporary, 4 used cultural, 1 used pop, and 2 used jazz. Two studies targeted older adults with pre-existing

Phoebe Woei-Ni Hwang, MS, is a DrPH candidate. Kathryn L. Braun, DrPH, is a professor and chair of the Office of Public Health Studies. Both are located at the University of Hawai’i at Mānoa in Honolulu.

Corresponding author: Phoebe Woei-Ni Hwang, MS E-mail address: pwnhwang@hawaii.edu

P

hysical inactivity contributes to many health conditions, including obesity,1 cancer, coronary heart disease,2 sarcopenia,3 cerebrovascular disorders,4 circulatory diseases,5 and frailty.6 Fortunately, adding physical activity to one’s life is an effective method of preventing, controlling, and 64 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

medical conditions. The average age of participants ranged from 52-87 y. Researchers used a variety of measures to assess effectiveness: (1) 3 of 5 (60%) that used measures to assess flexibility showed significant positive results; (2) 23 of 28 (82%) that used measures of muscular strength and endurance showed significant positive changes; (3) 8 of 9 (89%) that used measures of balance showed significant positive changes; (4) 8 of 10 (80%) that used measures of cognitive ability showed significant positive changes; and (5) the one that measured cardiovascular endurance showed significant positive changes. Only 6 studies reported participation, and they found low attrition.

Conclusions • The findings suggest that dance, regardless of its style, can significantly improve muscular strength and endurance, balance, and other aspects of functional fitness in older adults. Future researchers may want to analyze the effects of dance on mental health and explore ways to make this intervention attractive to both genders.

Standardizing outcome measures for dance would facilitate meta-analysis. (Altern Ther Health Med. 2015;21(5):64-70.)

alleviating some health conditions. Studies have demonstrated that physical activity has positive effects on depression, anxiety,7 dementia,8 heart failure,9 stroke,10 cognition,11 and sleep.12,13 The harmful effects resulting from physical inactivity and the positive effects of physical activity suggest that further efforts are needed to encourage physical activity, with an emphasis on populations at high risk for inactivity.14 Physical inactivity is commonly observed among individuals aged 60 y and older.15 Although many older adults have positive attitudes toward physical activity and its benefits, factors such as the person who is recommending physical activity, the older adult’s environment, costs of activities, and safety concerns affect their behaviors regarding physical activity.16 Identified barriers to sedentary older adults beginning activity include low self-efficacy, Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health

pre-existing medical conditions, physical limitations, time constraints, and culture.17 The United States’ older adult population has been steadily increasing since the 1900s. It is predicted that 92 million older adults will live in the United States in 2060, compared with 30 million in 2000.18 Therefore, creative, appealing, and effective methods of physical activity need to be investigated to accommodate this growing population.

Dance therapy is a creative arts therapy that has been defined by the American Dance Therapy Association as “the psychotherapeutic use of movement to further the emotional, cognitive, physical, and social integration of the individual.”19 Cross-sectional studies have shown that older adults who dance on a regular basis have greater flexibility, postural stability, balance, physical reaction time, and cognitive performance than older adults who do not dance on a regular basis.20 Unlike other holistic approaches used to increase physical activity, dance includes an aesthetic form of artistic expression.21 Dancing can produce physical results comparable with those of formal exercise training, and it also has been found to improve social and behavioral factors, such as self-motivation.22 In addition, it can improve the emotional, psychological, and physical well-being of individuals.

Qualitative studies have shown that aesthetic forms of expression build passion and can contribute to older adults’ physical, intellectual, and social development.23,24 Dancing has the potential to be a versatile activity that can be adjusted to fit a target population’s age, physical limitations, and culture.

Two previously compiled literature reviews have examined the health benefits of dance.25,26 However, one review focused on the effectiveness of dance for healthy people regardless of age. The other specifically examined dance in older adults but excluded studies with elders who had health conditions as well as studies that did not specify the health status of the older adult. In addition, those 2 literature reviews focused on the effectiveness of dance as a substitute for physical activity rather than the feasibility of and adherence to the dance programs. Common reasons for the demise of interventions related to physical activity for older adults are poor adherence and high dropout rates.27 Therefore, additional research is needed to identify an intervention’s ability to be individualized and tailored to populations of older adults in ways that maintain participants’ involvement in the activity. The current study is meant to further scientific knowledge on this issue.

Given that many of older adults have cognitive and sensory motor impairments28 and that 45.3% of older adults aged 65 years and older have 2 or more chronic conditions,29 studies of interventions for older adults should not exclude those with chronic conditions. Thus, the purpose of the current review was to examine the effectiveness of dance programs in improving the physical health of all older adults, both those with health conditions and those considered healthy.

Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health

METHODS Databases Guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were used to develop the current systematic review.30 PubMed was searched using the keywords dance, aged, and older adults. In addition, the term dance therapy was used as a medical subject heading and used in searching as text words. The search was conducted from September 2013 through October 2013. Citation chasing was also used by searching the reference sections of other papers that pertain to the topic.

Inclusion and Exclusion Criteria To be included in the current review, a study had to evaluate the benefits of a dance intervention to the physical health of older adults lacking prior dance experience, within the age limits defined by a reviewed study’s authors. Studies had to present results in a quantitative format. Dance was defined as a form of artistic expression through rhythmic movement to music, which does not include aerobic fitness classes taught to music, such as Zumba and step-aerobics. The authors placed no limitations on the location of the research, intervention, or year the study was published. However, publications reviewed had to be peer reviewed and written in English.

Data Extraction and Coding Upon availability, the following information on each intervention and study was abstracted from each publication: (1) the mean age and gender of participants, (2) the dance style studied, (3) the program’s implementation strategy, (4) the study’s results, (5) the researchers’ decision about the effectiveness of the intervention, (6) the study’s attrition rates, and (7) the researchers’ conclusions. Effectiveness decisions were coded in the following manner: A plus (+) was used for significant results in positive health improvement, a 0 for null results, and a minus (-) for significance results in the negative direction.

Quality Analysis The scientific rigor of each study was evaluated using 6 criteria adapted from Sackett31 and Megens and Harris.32 Specifically, studies were assessed for the presence of (1) clearly stated inclusion and exclusion criteria for participants, (2) an adequate description of the dance program, (3) reliable outcome measures, (4) valid outcome measures, (5) assessors who were blinded to the participants’ groups, and (6) participants’ attendance, retention, and dropout rates.

RESULTS The article selection process is illustrated in Figure 1.

Specifically, 268 articles were identified based on search terms. Of those articles, 173 were excluded by title; 28 duplicates were removed; 51 were excluded based on the article’s content; and 2 were included from citation chasing.

Remaining were 18 articles published from 2004 to 2013.33-50 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 65

Figure 1. Article selection process.

Articles from initial search N = 268 Title appropriate articles n = 95

Full-text articles assessed for eligibility n = 67 Articles included from citation chasing n=2

Articles excluded by title n = 173

Duplicates removed n = 28

Full-text articles excluded n = 51

Articles reviewed n = 18

Intervention Designs Regarding styles of dancing, of the 18 interventions examined, 6 used ballroom, 5 used contemporary, 5 used cultural, and 2 used jazz (Table 1). Ballroom interventions included foxtrot, salsa, tango, bolero, swing, polka, cha-cha, waltz, and merengue. Two of the studies that used ballroom interventions used more than 1 style of ballroom dance in the program. Contemporary interventions included improvisation and the Lebed method. Cultural dance interventions included Greek, Turkish, Korean, Cantonese, and line dancing.

Eleven studies reported on the location of interventions.

Two were implemented in the United States; 6 were in Europe; 2 were in Asia; and 1 was in South America. The frequency of the interventions ranged from 1 to 4 times per week. The duration of the interventions ranged from 6 weeks to 8 months.

The length of each session ranged from 45 minutes to 2 hours.

Participants Two of the 18 studies examined the effectiveness of dance interventions for older adults who had been diagnosed with specific health conditions (Table 2). Those conditions included visual impairment33 and metabolic syndrome.48 The

Table 1. Intervention Design and Physical Outcomes

Study Hackney et al33 Granacher et al34 Ferrufino et al35

Location Atlanta, GA, USA Switzerland France

Krampe et al36 Coubard et al37

-Paris, France

Krampe et al38

--

Marmeleira et al39 Evora, Portugal Sofianidis et al40 Finland Las Vegas, Alpert et al41 Nevada, USA McKinley et al42 -Hui et al43

--

Eyigor et al44

--

Wallman et al45 Borges et al46

-Brazil

Holmerova et al47 Czech Republic Kim et al48

Korea

Song et al49 Young et al50

Korea --

Intervention Design Dosage—Frequency of Session, Duration of Style of Dance Program, and Session Flexibility Ballroom (tango) 2/wk, 11 wk, 1.5 h

Physical Outcomesa Muscular Strength/ Cardiovascular Body Endurance Balance Endurance Cognition Composition 0+ +

Ballroom (salsa) Contemporary (improvisation) Contemporary Contemporary (improvisation) Contemporary (Lebed method) Contemporary

2/wk, 8 wk, 1 h 1/wk, 4.4 mo, 1 h

+++00

Cultural (Greek) Jazz

2/wk, 10 wk, 2 h 15 wk

+

Ballroom (Argentine tango) Cultural (Cantonese pop) Cultural (Turkish folklore) Jazz Ballroom (foxtrot, bolero, swing, waltz, rumba) Ballroom (polka, foxtrot, waltz, cha-cha) Ballroom (cha-cha) Cultural (Korean) Cultural (line)

2/wk, 10 wk, 2 h

++

+0

3/wk, 6 wk, 45 min 1/wk, 5 mo, 1 h

0

3/wk, 6 wk, 45 min

+

0

0 +00

+

3/wk, 12 wk, 1.5 h

+++

+

2/wk, 12 wk, 50 min

1/wk, 15 wk, 1.5 h 3/wk, 8 mo, 50 min

+

+

+++0

+

+

+ +

+++

2/wk, 2 mo, 1 h 4/wk, 6 mo, 50 min 1/wk

+

+++

3/wk, 8 wk, 1 h

1/wk, 3 mo, 75 min

+++

+++ +++ ++

0000

00

a

+, significant positive change; 0, no significant change. Each represents the results of a specific measure used to indicate a physical outcome.

66 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health

Table 2. Studies’ Designs and Participants’ Demographicsa

Study

Experimental Participants

Study Design

Control Participants

Diagnosed Health Condition

Granacher et al34

RCT

N = 14 (y = 71)

N = 14 (y = 68.9)

--

Ferrufino et al35

RCT

N = 16 (f = 16, y = 73)

Fall prevention: N = 23 (f = 23, y = 72)

--

Krampe et al36

RCT

N = 15 (f = 11, y = 85)

N = 12 (f = 6, y = 85)

--

Marmeleira et al39 RCT

N = 19 (f = 15, y = 64)

N = 15 (f = 10, y = 66)

--

Sofianidis et al40

RCT

N = 14 (f = 13, y = 69)

N = 12 (f = 7, y = 72)

--

McKinley et al42

RCT

N = 14 (f = 11, y = 78)

Walking: N = 11 (f = 8, y = 74.6)

--

Eyigor et al44

RCT

N = 19 (f = 19, y = 73)

N = 18 (f = 18, y = 71.2)

--

Borges et al46

RCT

N = 39 (y = 67)

N = 36 (y = 67)

--

Holmerova et al47 RCT

N = 27 (f = 25, y = 81)

N = 25 (f = 21, y = 82)

--

Kim et al48

RCT

N = 26 (f = 19, y = 68)

N = 12 (f = 10, y = 68)

Metabolic syndrome

Coubard et al

Quasiexperimental

N = 16 (f = 16, y = 74)

Fall prevention: N = 67 (f = 64, y = 75), -Ta’i chi chuan: N = 27 (f = 24, y = 72)

Hui et al43

Quasiexperimental

N = 52 (f = 50, y = 52)

N = 45 (f = 44, y = 69)

--

Song et al49

Quasiexperimental

N = 46 (f = 43, y = 76)

N = 27 (f = 21, y = 74)b

65% diagnosed with chronic diseasec

Young et al50

Quasiexperimental

Line dance only: N = 15 (f = 15, y = 61) Line dance + squats: N = 15 (f = 15, y = 61) Line dance + squats + stomping: N = 15 (f = 15, y = 64)

--

Postmenopause

Hackney et al33

1 group, pre- and posttest

N = 13 (f = 7, y = 87)

--

Visual impairment

Krampe et al38

1 group, pre- and posttest

N = 11 (f = 7)

--

--

Alpert et al41

1 group, pre- and posttest

N = 13 (y = 68)

--

--

Wallman et al45

1 group, pre- and posttest

N = 12 (f = 12)

--

--

37

a

f , female; y, mean age.

The control group consisted of the program’s dropouts. c Although the study was not restricted to participants with chronic disease, the percentage of participants diagnosed with chronic disease was reported. b

remaining 16 studies targeted the general population of older adults. Groups ranged in size from 13 to 97 participants.

In 8 studies, more than one-half of the participants were females, and in 5 studies, all the participants were females.

The remaining 3 studies did not specify the gender of their participants. The average age of participants ranged from 52 to 87 years.

Study Designs Of the 18 interventions, 10 were randomized controlled trials (RCTs),34-36,39,40,42,44,46-48 4 used a quasiexperimental design,37,43,49,50 and 4 included only 1 group using pre- and posttest designs33,38,41,45 (Table 2). Of the 14 RCTs and quasiexperimental designs combined, 4 had control groups that engaged in another activity, such as walking,42 line dancing,50 t’ai chi,37 and a fall prevention program.35,37 The other 10 did not provide their control groups with alternate activities.

Quality Analysis Scientific rigor was assessed by the 6 criteria provided

by Sackett31 and Megens and Harris.32 As shown in Table 3, none met all 6 criteria; 10 met 5 criteria34,36,38,40-42,44,47-49; 6 met Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health

4 criteria33,35,43,45,46,50; and 2 met 3 criteria.37,39 All 18 studies specified the inclusion and exclusion criteria for participants and employed valid and reliable outcome measures in their evaluations. Fifteen studies adequately described the intervention. However, only 6 used blinded assessors, and only 6 provided information on participants’ attrition.

Outcomes The studies’ authors used a variety of measures of health outcomes. For the current review, each physical health outcome of dance measured by studies’ investigators was grouped into 1 of the 6 measurement categories: (1) flexibility—the flexibility of an older adult’s upper and lower body; (2) muscular strength and endurance measures— the general functional fitness of an older adult using tests such as get up and go, chair squats, or gait speed; (3) balance—the ability of an older adult to stand on 1 or 2 legs without swaying or with no center-of-pressure displacement; (4) cardiovascular endurance—the maximum volume of oxygen intake; (5) cognitive function—the older adult’s memory and organizational ability; and (6) body composition—the older adult’s body mass index and body fat percentage.

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 67

Table 3. Evaluative Criteria for Studies Inclusion and Intervention Reliable Outcome Valid Outcome Blind Assessment of Accounted Total No. Exclusion Criteria Adequately Described Measures Measures Outcome Measures for Attrition Criteria Met

Study Granacher et al34

✓

✓

✓

✓

✓

5

Krampe et al36

✓

✓

✓

✓

✓

5

✓

✓

✓

✓

✓

5

38

Krampe et al

40

Sofianidis et al

✓

✓

✓

✓

✓

5

Alpert et al41

✓

✓

✓

✓

✓

5

McKinley et al42

✓

✓

✓

✓

✓

5

Eyigor et al44

✓

✓

✓

✓

✓

5

Holmerova et al47

✓

✓

✓

✓

✓

Kim et al48

✓

✓

✓

✓

Song et al49

✓

✓

✓

✓

Hackney et al33

✓

✓

✓

✓

Ferrufino et al35

✓

✓

✓

✓

4

Hui et al43

✓

✓

✓

✓

4

Wallman et al45

✓

✓

✓

✓

4

Borges et al46

✓

✓

✓

✓

4

50

Young et al

✓

✓

✓

✓

4

Coubard et al37

✓

✓

✓

3

Marmeleira et al39

✓

✓

✓

3

5 ✓

✓

5 5 4

Note: ✓ indicates criteria were met; blank indicates criteria were not met.

Across the 18 studies, 59 measurements were reported (Table 1). These measurements include 5 measurements of flexibility, 28 of muscular strength and endurance, 9 of balance, 1 of cardiovascular endurance, 10 of cognitive ability, and 6 of body composition. Studies employed approximately 3 measures on average. Of the 18 studies, 6 used measurements from 1 category.35,37,39,41,45,49 All other studies used measurements from multiple categories.

All but 1 study showed significant improvement in at least 1 of their measures of physical health, and no change in measurement was significant in the negative direction.

Specifically, 3 of 5 (60%) measurements of flexibility showed significant positive results, and 2 showed no significant changes. Twenty-three of the 28 (82%) measurements of muscular strength and endurance showed significant positive changes, and 5 showed no significant changes. Eight of the 9 (89%) measurements of balance showed significant positive changes, and 1 showed no significant change. One study measured cardiovascular endurance, showing significant positive change. Eight of the 10 (80%) measurements of cognitive ability showed significant positive changes, and 2 showed no significant changes. Finally, for the 2 studies that used a measure of body composition, neither showed a significant change.

Attrition Only 6 of the 18 studies examined rates of attrition from their interventions (Table 3). Three reported completion rates of 100%34,38,40; 1 reported a completion rate of 81%48; 1 reported a completion rate of 93%41; and 1 reported a completion rate of 86%.36 The programs’ lengths for these 6 68 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

studies ranged from 6 weeks to 2 months. No correlation existed between a program’s length and the attrition rate.

Older Adults With Health Conditions Although most the 18 studies focused on improving health among older adults in general, 2 studies limited their interventions to older adults with specific health conditions or statuses (Table 2). Conditions examined were visual impairment33 and metabolic syndrome.48 Both studies demonstrated an improvement in the constructs measured.

For example, the dance program for visually impaired older adults used a self-reported visual function test, covering measures of muscular endurance, strength, and balance.

Significant positive increases were observed in all 3 tests. The study that examined older adults with metabolic syndrome found a significant positive increase in older adults’ cognitive functioning, although no change in body composition occurred.

DISCUSSION Eighteen studies that fit the search criteria were assessed on each study’s quality, its design, the intervention design, physical health outcomes, and attrition. The results for the current review have shown that dance is a promising method for improving older adults’ physical health. In addition, studies show that dance interventions may address older adult barriers to being physically active such as cultural preferences, pre-existing medical conditions, and physical limitations.

Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health

Dancing to Improve Overall Physical Health Every study except for 1 showed an improvement in a measure of physical health among older adults. With the exception of body composition, improvements were seen for 60% to 90% of measurements in the other categories of physical health measurement—flexibility, muscular strength and endurance, balance, cardiovascular endurance, and cognitive function. Lack of improvement in body composition is perhaps not surprising. Older adults on average increase 7.5% of their body fat mass and decrease 2% of the fat-free body mass per decade, even with moderate sports or recreational activity.51 In addition, dietary intake affects the lean mass of older adults and should be considered as a confounding factor when measuring body composition.52 However, because no significant negative changes were observed, perhaps dance can be seen as a method to maintain body composition. Body composition may not be a realistic evaluation measure for dance, because many variables contribute to body composition.

A majority of the studies tested muscular strength and endurance and balance, showing a significant positive effect for dance on older adults’ functional fitness. These measures are significant when identifying the physiological parameters that support physical mobility and independence in older adults53 and are also commonly used in basic tests of functional fitness for older adults. Therefore, dance interventions increase the functional fitness of older adults, which strengthens their bodies, allowing them to perform day-to-day tasks independently.

Intervention Design All types of dance reviewed in this article showed significant positive changes. Because the effectiveness of dance as an intervention was observed across a wide range of dosages, the dosage may be modifiable for participants as long as dance occurs at least once per week, for at least 6 weeks, with a minimum of 45-minute sessions.

The current review included a focus on attrition because a common downfall of physical activity interventions for older adults is poor adherence and high dropout rates.27 Unfortunately, only 6 of the 18 interventions reported program completion rates. However, these 6 reported low attrition rates.

Dancing to Improve Health Conditions Two studies specifically examined the effects of dance interventions on populations of older adults with health conditions. This preliminary evidence suggests that dance interventions should not automatically exclude older adults with pre-existing medical conditions from participating.

Rather, dance interventions can be offered to older adults with a variety of conditions. Additional research is needed to confirm the efficacy of dance to improve specific health conditions.

Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health

Limitations Limitations of this review of research studies include imbalanced demographics for participants, inconsistent outcome measures, and lack of process evaluations. More specifically, all examined studies reported samples with more than 50% female. In fact, several studies had only female participants. Future investigations should identify genderrelated barriers in recruitment, retention, program design, and study objectives. Further, research should explore if dance is a gender-oriented activity or can be used across all demographics.

The wide variety of measures used to test outcomes limited comparisons across studies and precluded a meta-analysis.

Finally, only 6 studies reported attrition data.

The review was limited in that the only database searched was PubMed. This choice was made because of the review’s focus on physical health outcomes. Researchers who want to examine mental health outcomes of dance should expand the search to databases such as PsycNET. Recommendations After reviewing the 18 studies that met the search criteria, the authors propose the following recommendations. First, dance interventions that aim to affect body composition should either incorporate a nutritional component into the intervention or document the participants’ dietary intakes.

Second, the research community should broaden study parameters to include dance styles other than the popularly used contemporary and ballroom styles. Third, dancing should be used as a medium to promote older adults’ physical health.

Dance programs should provide a minimum of 1 45-minute session per week for a total duration of 6 weeks. Program completion and reasons for attritions should be tracked.

Last, a majority of the studies in the current review tested muscular strength and endurance and balance. Those measures are useful in measuring physiological parameters that support physical mobility and independence in older adults.53 The measures are also commonly used in basic tests of functional fitness for older adults. Therefore, future studies should include measures that examine the functional fitness of older adults. Standardizing outcome measures for dance would facilitate future meta-analyses.

CONCLUSIONS To the authors’ knowledge, no systematic literature reviews have occurred that document how dance affects the physical health of older adults. Strong evidence suggests that dance, regardless of style and dosage, significantly improves older adults’ functional fitness. However, dance may not be sufficient to change body composition significantly. Although dance interventions have low attrition rates, a majority of the older adults participating in the dance interventions were female. Additional studies are needed to investigate the physical effects of dance coupled with nutritional education, the psychological impacts of dance, and rates of and reasons for adherence to dance as a physical activity.

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 69

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18. United States Census Bureau. Population Estimates, Vintage 1980-2012. In: Services DoHH, ed2012.

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21. Heber L. Dance movement: a therapeutic program for psychiatric clients.

Perspective Psychiatric Care. 1993;29(2):22-29.

22. Kaltsatou AC, Kouidi EI, Anifanti MA, Douka SI, Deligiannis AP. Functional and psychosocial effects of either a traditional dancing or formal exercising training program in patients with chronic heart failure: a comparative randomized controlled study. Clin Rehab. 2014;28(2):128-138.

23. Wikstrom BM. Older adults and the arts: The importance of aesthetic forms of expression in later life. Journal Gerontology Nursing. 2004;30(9):30-36.

24. Mullen R, Davis JA, Polatajko HJ. Passion in the performing arts: clarifying active occupational participation. Work. 2012;41(1):15-25.

25. Strassel JK, Cherkin DC, Steuten L, Sherman KJ, Vrijhoef HJM. A systematic review of the evidence for the effectiveness of dance therapy. Alternative Therapies. 2011;17(3):50-59.

26. Keogh JW, Kilding A, Pidgeon P, Ashley L, Gillis D. Physical benefits of dancing for healthy older adults: a review. J Aging Phys Act. 2009;17(4):479-500.

27. Brawley LR, Rejeski WJ, King AC. Promoting physical activity for older adults: the challenges for changing behavior. Am J of Prev Med. 2003;25(3):172-183.

28. Dodge HH, Kita Y, Takechi H, Hayakawa T, Ganguli M, Ueshima H. Healthy cognitive aging and leisure activities among the oldest old in Japan: Takashima study. J Geront 2008;63(11):1193-1200.

29. Freid VM, Bernstein AB, Bush MA. Mutliple chronic conditions among adults aged 45 and over: trends over the past 10 Years. National Center for Health Statistics Data Brief. 2012(100).

30. Moher D, Liberati A, Tetzlaff J, Altman DG, The Prisma Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. PLoS Med. 2009;6(7):1-6.

31. Sackett DL. How to read clinical journals: I. Why to read them and how to start reading them critically. Clinical Epidemiology Rounds. 1981;124:555-558.

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32. Megens A, Harris SR. Physical therapist management of lymphedema following treatment for breast cancer: a critical review of its effectiveness. Phys Ther.

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33. Hackney ME, Hall CD, Echt KV, Wolf SL. Dancing for balance: feasibility and efficacy in oldest-old adults with visual impairment. Nurs Res. 2013;62(2):138-143.

34. Granacher U, Muehlbauer T, Bridenbaugh SA, et al. Effects of salsa dance training on balance and strength performance in older adults. Geront.

2012;58:305-312.

35. Ferrufino L, Bril B, Dietrich G, Nonaka T, Coubard OA. Practice of contemporary dance promotes stochastic postural control in aging. Frontiers in Human Neuroscience. 2011;5(169):1-9.

36. Krampe J. Exploring the effects of dance-based therapy on balance and mobility in older adults. West J Nurs Res. 2011;35(1):39-56.

37. Coubard OA, Duretz S, Lefebvre V, Lapalus P, Ferrufino L. Practice of contmeporary dance improves congitive flexibility in aging. Front Aging Neurosci. 2011;3(13):1-12.

38. Krampe J, Rantz MJ, Dowell L, Schamp R, Skubic M, Abbott C. Dance-based therapy in a program of all-inclusive care for the elderly. Nurs Admin Quarterly.

2010;34(2):156-161.

39. Marmeleira JF, Pereira C, Cruz-Ferreira A, fretes V, Pisco R, Fernandes OM. Creative dance can enhance proprioception in older adults. J Sport Med Physi Fit. 2009;49(4):480-485.

40. Sofianidis G, Hatzitaki V, Douka S, Grouios G. Effect of a 10-week traditional dance program on static and dynamic balance control in elderly adults. J Aging Phys Act. 2009;17:167-180.

41. Alpert PT, Miller SK, Wallmann H, et al. The effect of modified jazz dance on balance, cognition, and mood in older adults. J Am Assoc Nurse Pract.

2009;21:108-115.

42. McKinley P, Jacobson A, Leroux A, Bednarczyk V, Rossignol M, Fung J. Effect of a community-based Argentine tango dance program on functional balance and confidence in older adults. J Aging Phys Act. 2008;16:435-453.

43. Hui E, Chui, B.T., Woo, J. Effects of dance in physical and psychological well being in older persons. Arch Gerontol Geriatr. 2008;49(2008):e45-e50.

44. Eyigor S, Karapolat H, Durmaz B, Ibisoglu U, Cakir S. A randomized controlled trial of Turkish folklore dance on the physical performance, balance, depression and quality of life in older women. Arch Gerontol Geriatr Suppl.

2009;48(2009):84-88.

45. Wallmann HW, Gillis, C.B., Alpert, P.T., Miller, S.K. The effect of a senior jazz dance class on static balance in healthy women over 50 years of age: a pilot study.

Biol Res Nurs. 2008;10(3):257-266.

46. Borges EG, Cader SA, Vale RG, et al. The effect of ballroom dance on balance and functional autonomy among the isolated elderly. Arch Gerontol Geriatr.

2012;55(2012):492-496.

47. Holmerova I, Machacova K, Vankova H, et al. Effect of Exercise Dance for Seniors (EXDASE) program on lower-body functioning among institutionalized older adults. J Aging Health. 2010;22(1):106-119.

48. Kim SH, Kim M, Ahn YB, et al. Effect of dance exercise on cognitive function in elderly patients with metabolic syndrome: A pilot study. J Sport Sci Med. 2011;10:671-678.

49. Song R, June KJ, Kim CG, Jeon MY. Comparisons of motivation, health behaviors and functional status among elders in residential homes in Korea.

Public Health Nurs. 2004;21(4):361-371.

50. Young CM, Weeks BK, Beck BR. Simple, novel physical activity maintains proximal femur bone mineral density, and improves muscle strength and balance in sedentary, postmenopausal Caucasian women. Osteoporos Int. 2007;18:1379-1387 51. Hughes VA, Frontera WR, Roubenoff R, Evans WJ, Fiatarone-Singh MA. Longitudinal changes in body composition in older men and women: role of body weight change and physical activity. Am Soc Clin Nutr. 2002;76(2):473-481.

52. Houston DK, Nicklas BJ, Ding J, et al. Dietary protein intake is associated with lean mass change in older, community-dwelling adults: the Health, Aging, and Body Composition (Health ABC) Study. Am Soc Clin Nutr. 2008;87(1):150-155.

53. Rikli RE, Jones CJ. Development and validation of a functional fitness test for community-residing older adults. J Aging Phys Act. 1999;7:129-116.

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REVIEW ARTICLE

Pilates Method for Lung Function and Functional Capacity in Obese Adults Janaina Rocha Niehues; Ana Inês Gonzáles, MSc; Robson R. Lemos, PhD; Patrícia Haas, PhD

ABSTRACT Obesity is defined as the condition in which the body mass index (BMI) is ≥ 30 kg/m2 and is responsible for decreased quality of life and functional limitations. The harmful effects on ventilatory function include reduced lung capacity and volume; diaphragmatic muscle weakness; decreased lung compliance and stiffness; and weakness of the abdominal muscles, among others. Pilates is a method of resistance training that works with low-impact muscle exercises and is based on isometric exercises. The current article is a review of the literature that aims to investigate the hypothesis that the Pilates method, as a complementary method of training, might be beneficial to pulmonary function and functional capacity in obese adults. The intent of the review was to evaluate the use of Pilates as an innovative intervention in the respiratory dysfunctions of obese adults.

In studies with other populations, it has been observed that Pilates can be effective in improving chest capacity and expansion and lung volume. That finding is due to the fact that Pilates works through the center of force, made

Janaina Rocha Niehues is an undergraduate student and laboratory assistant; Robson R. Lemos, PhD, is a faculty member; and Patrícia Haas, PhD, is a faculty member in the Division of Health Sciences, Núcleo de Pesquisa e Desenvolvimento da Saúde (NUPEDS), at Universidade Federal de Santa Catarina in Araranguá, Brazil. Ana Inês Gonzáles, MSc, is a research assistant in the Division of Health Sciences, NUPEDS, and she is a doctoral student in human movement sciences in the Division of Sport and Medicine, Núcleo de Cardiologia e Medicina do Exercício, at Universidade Estadual de Santa Catarina in Florianópolis, Brazil.

Corresponding author: Ana Inês Gonzáles, MSc E-mail address: anainesgonzales@gmail.com Niehues—Pilates for Lung Function and Functional Capacity

up of the abdominal muscles and gluteus muscles lumbar, which are responsible for the stabilization of the static and dynamic body that is associated with breath control. It has been observed that different Pilates exercises increase the activation and recruitment of the abdominal muscles.

Those muscles are important in respiration, both in expiration and inspiration, through the facilitation of diaphragmatic action. In that way, strengthening the abdominal muscles can help improve respiratory function, leading to improvements in lung volume and capacity. The results found in the current literature review support the authors’ observations that Pilates promotes the strengthening of the abdominal muscles and that improvements in diaphragmatic function may result in positive outcomes in respiratory function, thereby improving functional capacity. However, the authors did not find specific studies with obese people, justifying the need for future studies. (Altern Ther Health Med. 2015;21(5):73-80.)

O

besity is responsible for the manifestation of serious health problems and is currently seen as a public health problem, thus constituting a subject of worldwide interest and strong impact.1,2 Obesity is defined as a body mass index (BMI) greater than or equal to 30 kg/m2.

It is estimated that approximately 2.8 million annual deaths worldwide are related to the harmful effects of being overweight or obese.2,4,5,6 The accumulation of adipose tissue in the thorax and abdomen, evident in the obese population, causes increased stiffness of the chest and a reduction in lung compliance, favoring airway closure, microatelectasis, and increased pressure in static elastic retraction. As a result, a reduction in lung volume and capacity occurs.7 In addition, patients’ breathing requires increased effort to maintain adequate oxygenation, with an evident reduction in maximal oxygen ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 73

consumption (VO2max).7 Those changes lead to limitations in the activities of daily life and in functional capacity and to restrictions in the practice of physical exercise, all of which negatively affect quality of life.8 In that context, the aim of the current study was to investigate the hypothesis that the Pilates method, as a complementary method of training, might be beneficial to pulmonary function and functional capacity in obese adults.

RESPIRATORY CHANGES Respiratory Mechanics Obesity has been found to be directly related to changes in respiratory function and may lead to impairment of the chest and diaphragmatic muscles, with physiological changes being present even when the lungs are considered normal.9,10 Physiological changes that cause deleterious effects on respiratory function may be evident, such as changes in respiratory function, decreased strength in respiratory muscles, decreased endurance, reduction in the exchange of pulmonary gases, and less control of breathing, as well as limitations in tests of pulmonary function and exercise capacity. Those changes in lung function are caused by tissue accumulation in the chest wall and abdomen, compressing the chest wall, diaphragm, and lungs. Adipose tissue acts as a barrier and results in a reduction of diaphragm displacement and lung expansion, increased elastic recoil, and a decreased lung volume. As a result, an overload of the inspiratory muscles can occur.11 In many cases, lung compliance appears compromised and may result in small areas of atelectasis (ie, a complete or partial collapse of a lung or lobe of a lung) through an increased volume of pulmonary blood and the closing of dependent pathways. In addition, the increased elastic recoil, reduced distensibility of structures,12 and increased alveolar surface tension due to decreased functional residual capacity (FRC) are directly related to the values of the BMI.12,13,14 In a comparative trial with obese and nonobese individuals, a lower value for chest-wall compliance, 0.077 L/cm H2O, was found for the obese group when compared with the nonobese group at 0.224 L/cm H2O. In the same study, a significant correlation was observed between the values of vital capacity and total respiratory compliance.12 Other studies have found that another determining factor is the fact that the deposit of fatty tissue imposes a mechanical force that decreases the expansion of the rib cage,7,15 causing an evident hypertonia of the abdominal muscles.9,10 Lung Volume and Capacity In many cases of impaired respiratory mechanics, a reduction may occur in the expiratory reserve volume (ERV), and, consequently, in the FRC, which can result in a weakness of the respiratory muscles, leading to an imbalance in ventilation/perfusion.16,17 The reduction in FRC reflects an imbalance between lung inflation and deflation as a result of the overload of 74 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

adipose tissue around the rib cage, abdomen, and visceral cavity.14 Thus, an increase in respiratory effort occurs to try to meet the metabolic demands of the body, resulting in chronic hypercapnia and hypoxia.16,17 Studies have shown a direct correlation between BMI and FRC, demonstrating that individuals with higher BMIs had higher reductions in FRC.13,14 At the same time, the values of BMI have been shown to have a direct relationship to the degree of airway resistance and the work of breathing.13 With respect to total lung capacity and residual volume, the changes are modest. The reasons for a reduction in lung volume are still not well understood. Salome et al14 have proposed that the reduction is due to a mechanical effect in adipose tissue that is responsible for a reduction in the downward movement of the diaphragm due to the increase in abdominal mass, limiting the space for inflation of the lungs. Alternatively, the researchers have suggested that the reduction may be related to the deposition of fat in the subpleural spaces or to a combination of the 2 factors.

In a clinical trial, 96 adults were divided into 2 groups, obese (n = 48) and nonobese (n = 48), and they were studied with the objective of verifying spirometric changes.10 The results indicated that no significant spirometric changes were found when comparing obese and nonobese males. In women, the values of FCV and forced expiratory volume in 1 second (FEV1) were significantly lower in obese individuals when compared with those in nonobese individuals. For both genders, a negative correlation existed between spirometric values and waist circumference. Possible mechanisms of the effects of obesity on respiratory function are shown schematically in Figure 1.

Effect on Functional Capacity Obesity is a chronic disease that can lead to consequences for functional capacity, with limitations8 on the activities of basic daily living, such as rising from a chair, walking,19 or moving an object, as well as on professional tasks.20,21,22 The limitations occur due to a decline in lung function that leads to a progressive decline in maximal strength and VO2max, as well as to a reduction in exercise capacity, resulting in a negative cycle, with greater declines in lung function.23 That decrease is commonly related to feelings of dyspnea, which also ultimately limit the exercise capacity of individuals, negatively affecting their functional ability.24 In addition, being overweight imposes an abnormal mechanical force to the movements of the body, which can compromise joints and increase the risk of musculoskeletal overload, helping reduce exercise tolerance.8,25 With decreasing resilience and range of motion of major joints, a reduction in muscle strength occurs, leading obese individuals to maintain prolonged fixed postures; exacerbating sedentary activities; and having a direct negative effect on breathing capacity, work capacity, and quality of life.8,26 A recent study included 36 women with BMI greater than or equal to 30 kg/m2 and 10 women with normal weight (ie, a BMI between 18 kg/m2 and 25 kg/m2). In the Niehuesâ&#x20AC;&#x201D;Pilates for Lung Function and Functional Capacity

Figure 1. Likely mechanism of the effects of obesity on lung function. Adapted with permission from Dixon and Beaty.18 Ĺ Intra-abdominal & Pleural Pressures

Ļ Tidal Volume

Stiff Respiratory System

Ļ FRC Ĺ RSR at FRC Ĺ Risk of EFL Airway Closure During Tidal Breathing

Ļ Thoracic Volume

Ļ TLC

Ļ FCV

Dynamic Hyperinflation? Ļ Basal Ventilation Ļ PO2

Ļ FEV1

Abbreviations: FRC, functional residual capacity; RSR, respiratory system resistance; EFL, expiratory flow limitation; PO2, pressure of oxygen; TLC, total lung capacity; FVC, forced vital capacity; FEV1, forced expiratory volume in 1 sec .

Note: Ļ, reduction; Ĺ, increase. group of obese women, 12 individuals had a BMI greater than or equal to 30 but less than 35; 14 participants had a BMI greater than or equal to 35 but less than 40 (severely obese); and 10 women had a BMI greater than or equal to 40 kg/m2 (morbidly obese). All participants underwent (1) a clinical examination; (2) a walking test; (3) an endurance test (6-min walk); (4) a test of the power of the lower limbs (ie, getting up and down 5 times); and (5) a test of balance. Obese women had a significantly lower gait speed (P < .05) and reduced stride length. The results of the sitting and standing and strength tests were significantly lower (P < .05) for the obese group. In addition, major constraints were found for women with morbid obesity.27 Another study has demonstrated the negative effects of obesity on functional capacity and performance in carrying out activities. With a sample of 8 obese and 8 nonobese participants divided into 2 groups, the study sought to verify the strength of demands required by tasks, such as handshaking, shoulder flexion, and a task simulating assembly using the upper limbs. Measures of functional performance, including resistance, discomfort, motor control, and task performance were recorded for each of the task conditions. In the obese group, reduced muscle strength, increased discomfort, and decreased resistance were observed, resulting in a decline in the performance of tasks, particularly with regard to the ability to perform and the duration it took to complete the work.28

Niehues—Pilates for Lung Function and Functional Capacity

Effects of Physical Exercise Because of the high incidence of deaths per year due to the global obesity epidemic, national and international entities29,30 have emphasized the need for proper management of obesity, with effective interventions to prevent and/or minimize comorbidities from the disease.

In that context, interventions have been recommended to combat a sedentary lifestyle that can assist in bringing about changes in lifestyle and encourage physical activity in the population.29 Research has highlighted the benefits of physical exercise, taking into account different modalities, and has found (1) significant reductions in body weight, waist circumference, and BMI31; (2) improvements in 31% lean mass, VO2max,32 and glycemic regulation; (3) control of diabetes mellitus33; (4) improvements in lipid profiles, with decreased low-density lipoprotein (LDL) cholesterol and increased high-density lipoprotein (HDL) cholesterol34; (5) reductions in atherosclerotic events34; (6) decreases in cardiovascular events and improvements in hypertension control35; and (7) improvements in symptoms of depression, anxiety, and insomnia.36 Compared with individuals of normal weight, obese individuals have breathing at low volumes, with high respiratory pressures, increased workloads, and respiratory muscle weakness that is associated with limitations on the expiratory flow. Also, hyperinflation may present at the peak of physical activity, which may limit regular physical exercise of those individuals.37 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 75

Table 1. Exercise on Respiratory Function and Functional Capacity in Obese Adults Aadlam et al38

Sonehara et al39

Babb et al37

Study Type

Longitudinal study

Longitudinal study

Longitudinal study

Sample

N = 21

N = 20

N=9

Average Age (y)

42.6 ± 11.0 y

48.75 ± 13.71 y

37 ± 5 y

Intervention

Aerobic training, 5 ×/wk, lasting 45-60 min for 1 y; associated with diet.

Stretching exercises, strengthening and aerobic, 12 wk, 3 ×/wk lasting 60 min.

Aerobic training and weathered for 12 wk; associated with diet.

Evaluated Variables

VO2max 6MWT

MV CV SVC MaxIP MaxEP

Spirometric data MV Oxygen consumption CO2 output AsO2 Ventilatory threshold IC EV final TLC IV Respiratory pressures (pleural; TTP and GAP)

Anthropometric

Ļ Body weighta Ļ BMIa Ļ Waist circumferencea Ļ Fat massa

Ļ Body weighta Ļ Fat weighta

Ļ Body weighta Ļ Body fat with more evidence on abdominal regiona

Volumes, Lung Capacities, and Respiratory-muscle Strength

NE

Ĺ MVa Ĺ CVa Ĺ SVCa Ĺ MaxIPa Ĺ MaxEPa

Ĺ FRCa Ĺ FCVa Ĺ ERVa Ĺ EV finala Ļ Flow limitationa Ļ GAPa

Functional Capacity

Ĺ VO2maxa Time 6MWT

NE

NE

Results

Abbreviations: VO2max, maximal oxygen consumption; 6MWT, 6-min walk test; BMI, body mass index; NE, not evaluated; MV, minute volume; CV, current volume; SVC, slow vital capacity; MaxIP, maximal inspiratory pressure; MaxEP, maximal expiratory pressure; AsO2, arterial oxygen saturation; IC, inspiratory capacity; EV final, expiratory volume final; TLC, total lung capacity; IV, inspiratory lung volume; TPP, transpulmonary pressure; GAP, gastric pressure; FRC, functional residual capacity; ERV, expiratory reserve volume.

Note: Ļ, reduction; Ĺ, increase. a

Significant differences (P > .001).

76 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Niehues—Pilates for Lung Function and Functional Capacity

Only a few studies have been evaluated to date that take into account the effects of systematic programs of physical exercise on parameters related to respiratory function and functional capacity in obese adults (Table 1).

Although limited evidence is available to date, the authors have noted that performance of physical training programs can promote improvement in lung volumes and capacities, with positive changes in respiratory functions in obese adults37,39 and improved functional abilities.38 PILATES METHOD The Pilates method is a conditioning program of body and mind that is gaining popularity and acceptance worldwide.40 It is characterized by nonrepetitive or strenuous exercise and is able to suit the needs of each individual.40 The exercise program incorporates the use of special devices and equipment with movements that allow, among other benefits, improvements in flexibility, strength, coordination,41 blood circulation, fitness, range of motion, and postural alignment.42,43,44 The method works with low-impact muscle exercises that are based on isometric exercises of the abdominal muscles and that generate force without motion and stabilize the spine.45 The exercises are performed in different positions44-50 and have a low impact on the body’s structures, particularly on the spine, muscles, joints, and ligaments and particularly on the sacral lumbar region. Thus, people of any age can benefit from the method.46-48 The powerhouse or center of force is made up of (1) the abdominal muscles—the rectus abdominis, internal and external oblique, and transversus abdominis; (2) the gluteus; and (3) of the lumbar paraspinal region. It is responsible for the static and dynamic stabilization of the body.51-53 The center of force forms a structure that is responsible for supporting the spine and internal organs; stabilizing the trunk; and maintaining correct posture, with lower energy expenditure for movements.54,55 As a result, the risk of injury is decreased. The center of force should be in contraction during the execution of all exercises.56 In search of a complete fitness method, Joseph Pilates included the breathing mechanism, indicating that the performance of all exercises should be associated with an adequate and continuous breathing in rhythm.46,51,52,53,54,55 In the Pilates method, the respiratory style accentuates costal breathing, where the ribs ascend and descend during the respiratory flow, extending laterally and to the posterior. The transverse muscle must work to prevent abdominal distension, give greater support to the diaphragm to promote the movement of the lower ribs, and provide greater diaphragmatic excursion.44 The expiratory phase is also characterized by contraction of the transversus abdominis muscles that are associated with contraction of the multifidus muscles and the pelvic floor.52 In that way, the abdominal muscles are worked intensively during the exercises.50,56 Niehues—Pilates for Lung Function and Functional Capacity

The emphasis of the Pilates method on controlled breathing during exercise, which is associated with abdominal strengthening, can prevent or reverse the functional reductions resulting from a decline in pulmonary function.23 Respiratory Function and Functional Capacity Pilates has become a popular exercise method57 that has gained recognition in the area of rehabilitation for general orthopedic problems, neurological disorders, and chronic pain and in the treatment of cancer and cardiovascular disease, among other benefits. It has great acceptance worldwide and deserves attention for those benefits.43,46,55,58,59,60,61 Training through the Pilates method promotes an increase in the recruitment and activation of the abdominal muscles using the basic Pilates’ principle of centralization, especially in the concentric phase of the movement.62 Pilates can be recommended as an effective method of strengthening the muscles of the abdominal wall and of compensating for the development of asymmetries.63 Thus, Pilates exercises can be applied to clinical populations that need to strengthen those particular muscles as well as increase abdominal activation to perform functional activities.64 Different clinical studies have sought to evaluate the activation of the abdominal muscles during performance of the different exercises of Pilates. In those studies, the increased activity of the rectus abdominal,62,63,66 transversus abdominis,63,64,66 internal oblique, and external oblique64,65,66 have been observed. Those findings are shown in the Table 2.

The abdominal muscles—transverse abdominis, internal and external oblique, and rectus abdominis—are engaged primarily in forced expiration in relation to the expiratory muscles for ventilation. For those particular muscles, the muscle fibers during forced expiration exert traction on the ribs and the costal cartilage inferiorly, causing increased intra-abdominal pressure and displacing the diaphragm superiorly into the chest cavity to increase the expiration volume and speed.67 The abdominal muscles also exhibit 2 inspiratory functions: (1) during forced expiration, the increase of intraabdominal pressure performs a passive stretch of the diaphragm’s costal fibers, preparing it for the next inspiration; and (2) the increased pressure generated by the descent of the diaphragm in the inspiration must be countered by the tension of the abdominal muscles. Thus, without effective compliance of those muscles, the central tendon of the diaphragm is not effectively stabilized to perform the lateral expansion of the chest wall. Therefore, during the increased work of breathing, an increase in abdominal muscle activity occurs in both phases of respiration.67 In that way, strengthening the abdominal muscles can lead to a strengthening of diaphragmatic function. A randomized, clinical trial with 22 participants, who had decreased inspiratory and expiratory functions and whose forced expiratory flow rates were approximately 300 m/L, attempted to verify that hypothesis. The participants were randomly divided into (1) an experimental group with ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 77

Table 2. Activity of Abdominal Muscles During Pilates

Barbosa et al62 Sample N = 10 Average Age (y) 21.85 ± 3.34 Intervention Pilates with contractions and 6-sec interval of 3 min between contractions; single assessment.

Method of Electromyography Assessment Muscles RA Evaluated BB Results

Ĺ Recruitment of RA and BBa

Dorado et al63 N=9 35.7 ± 5.4 Pilates for 36 wk, 2 ×/wk, lasting 55 min.

Critchley et al64 N = 34 30 ± 7 Pilates for 8 wk, 2 ×/wk, lasting 45 min.

Silva et al65 N = 10 21.5 ± 0.64 Pilates, 3 sets of 8 repetitions; single assessment.

Endleman and Critchley66 N = 26 43 ± 14 Pilates for 6 mo at least 1 ×/wk, lasting 50 min.

Magnetic resonance RA OA TA Ĺ 8% in the OA and TA activitya Ĺ 21% in RA activitya Muscle hypertrophy

Ultrasound

Electromyography

Ultrasound

IO TA

RA EO

OI TA

Ĺ Activity TAa Ĺ Activity IO

Ĺ Recruitment of RA and EOa

Ĺ Activity TAa Ĺ Activity OI

Abbreviations: RA, rectus abdominis; BB, brachial biceps; OA, oblique abdominals; TA, transversus abdomen; IO, internal oblique; EO, external oblique.

Note: Ļ, reduction; Ĺ, increase. a

Significant differences (P > .001).

11 participants, 5 men and 6 women, that involved exercises to strengthen the deep abdominal muscles; and (2) a control group of 11 participants, 4 men and 7 women, who had no particular intervention. The training method was carried out once per day, 3 days per week, for 1 month. The intervention group’s FVC showed a 0.18-L increase between pre- and posttest, and forced expiratory volumes were found to have increased by 0.15 L between pre- and posttest. The control group also had an increase between pre- and posttest. The results of the study showed that strengthening the abdominal muscles was effective in improving respiratory parameters.68 In another study that included 50 sedentary females with a mean age of 60 years, the effects of Pilates on pulmonary function were investigated. The participants were randomly assigned either to a control group (n = 25) or an intervention group (n = 25). The control group maintained its usual activities without participating in any structured exercise, whereas the intervention group did the Pilates method for an 8-week period, with supervised progressive exercise. The program consisted of 3, nonconsecutive, 60-minute sessions per week, which were conducted by a qualified Pilates instructor. Sessions with Pilates exercises on the mat, which are associated with breath control, were performed. Groups underwent spirometry before and after the intervention.

78 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

After training with Pilates, significant improvements (P < .05) were found in forced expiratory flow at 25% of forced vital capacity (FVC), peak expiratory flow (PEF), FEV1, peak inspiratory flow, and mean forced expiratory flow. No significant changes were found in the values of FVC. Given those results, it was observed that physical training programs using Pilates can improve lung function in older, sedentary individuals and can thus improve impaired exercise capacity and physical function and minimize health consequences.23 A study including individuals with chronic obstructive pulmonary disease (COPD) compared the ventilatory, respiratory pattern of diaphragmatic breathing and of the Pilates’ method of breathing. Fifteen patients with COPD (COPD group) and 15 healthy patients (healthy group) were recruited, and they were asked to perform 3 types of breathing: natural, diaphragmatic, and Pilates. They were evaluated by respiratory inductive plethysmography.

Parameters regarding time, volume, and thoracoabdominal coordination were evaluated.

Diaphragmatic breathing promoted an increase in respiratory volumes and peripheral oxygen saturation, and respiratory rates decreased in both groups. The Pilates method of breathing increased respiratory volumes in the healthy group; no additional benefits for either breathing pattern were found for the COPD group. Regarding Niehues—Pilates for Lung Function and Functional Capacity

thoracoabdominal coordination, both groups showed greater asynchrony during diaphragmatic breathing. Although changes in volume and time measurements were not found during Pilates breathing for the COPD group, that pattern of breathing increased volume in healthy individuals and increased oxygenation in both groups.69 Another study analyzed the effects of the Pilates method in patients with cystic fibrosis (CF). A clinical trial was conducted with 19 patients with FC, 7 men and 12 women.

The patients underwent a weekly session of Pilates lasting 60 minutes, for 4 months. The variables studied before and after intervention were respiratory muscle strength (ie, maximal inspiratory pressure [MIP]) and maximal expiratory pressure (MEP), as well as FVC and FEV1. After the program, a significant increase in MIP was found in male patients, P = .017, whereas significant increases occurred in MIP and MEP for female patients, P = .005 and P = .007, respectively. After the intervention, no significant differences were found in FVC and FEV1. The results of that study showed the beneficial effects of application of the Pilates method for respiratory muscle strength in the studied patients.70 No specific studies exist regarding obese population, but from the information obtained from studies with other populations, it can be inferred that the Pilates method is an instrument that can assist positively in improving respiratory function in the obese population, consequently leading to improved functional capacity.

CONCLUSIONS Obesity is characterized as a serious public health problem with significant impact worldwide, as represented by high rates of death. Among the major comorbidities derived from obesity, changes in respiratory function can be highlighted. That condition can lead to respiratory muscle weakness, changes in lung volume and capacity, and disorders of respiratory mechanics, among other issues. The described conditions are closely related to a decreased functional capacity, limitation of daily activities, and reduction in physical exercise.

Thus, physical exercise is one effective means of therapeutic intervention for improving respiratory function. In that context, Pilates is considered to be a method of exercise that promotes overall physical and mental conditioning, improving flexibility, strength, and coordination. As a result, it has been gaining ground and is being popularized.

With the results found in the current literature review, the authors have observed that Pilates promotes the strengthening of abdominal muscles. That fact could possibly be related to improvement of the diaphragmatic function, which may result in positive outcomes in respiratory function, and, thereby, lead to improved functional capacity.

However, specific studies with obese people were not found through the review, justifying the need for future studies.

Niehues—Pilates for Lung Function and Functional Capacity

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Niehues—Pilates for Lung Function and Functional Capacity

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CONVERSATIONS

Michael Smith, MD: Treat the Underlying Causes of Weight Gain to Facilitate Successful Weight Loss Interview by Craig Gustafson

Part 4: Pillars 6 Through 9 and Clinical Application

Michael Smith, MD, is the senior health scientist and online personality for Life Extension, an organization dedicated to extending healthy human life span. He is author of the book The Supplement Pyramid, and he recently released an e-book detailing 9 pillars that underlie healthy weight management.

This article is the last in a 4-part series that has been published in various InnoVision Professional Media journals through September 2015, with the whole collection available at http://www.innovisionhm.com/9pillars (Altern Ther Health Med. 2015;21(5):82-86.)

Alternative Therapies in Health and Medicine (ATHM): We have talked about whether doctors are asking the right questions of their weight-loss patients and the first 5 pillars.

Let’s pick up again with pillar number 6.

Dr Smith: Sure, but first I do want to reiterate something about the pillars. They do not need to be considered in any particular order. The first pillar isn’t necessarily the most important pillar for everyone, although it is very important today because we are eating sugar like crazy in this country, so that is why I put it at number 1.

ATHM: So, on to pillar number 6.

Dr Smith: All right, number 6 is a slow resting metabolism.

I think most people recognize that a missing link for successful weight loss is failing to boost that resting energy expenditure—basically burning off stored fat while at rest. It is a significant issue for men and women, but it does seem to be more of an issue for postmenopausal women. It is also well established that aerobic exercise and resistance training can significantly improve RMR, or resting metabolic rate.

We want to help people burn more calories at rest. We are great at that as kids. Why can kids eat so much? They are more active, that is true. They are growing. They need more 82 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

sustained energy. Even when they are just sitting there watching TV or playing on their iPads or whatever, they are actually burning calories. Isn’t that awesome? To help somebody increase resting expenditure is going to help them to burn those calories at rest. They are going to get a bigger bang for their buck out of their exercise program.

I ask questions like: “Is it difficult to lose even a few pounds? Do you plateau quickly? Do you have thyroid issues? Are you over 50 and a woman?” That is a good indication she has a significant drop in metabolism. “Do you gain weight easily?” Even if you splurge for a couple days— go on a cruise—you can gain 8 pounds. That is a good sign that there is an issue with resting metabolism. Then, of course, loss of lean muscle mass is another indication.

Besides exercise, the research-supported nutrients that we use—and I say that because I think it is important—there are a lot of so-called metabolic boosters—thermogenic supplements on the market. Most of them have never been shown to actually boost resting expenditure. Green tea extract has; 7-keto-DHEA, or 7-keto-dehydroepiandrosterone has; capsaicin, or cayenne, from hot peppers has; and fucoxanthin, which is brown seaweed extract, has. Those 4 are, in my opinion, the best-supported, true thermogenic supplements. They do increase resting energy expenditure.

ATHM: What is pillar number 7?

Dr Smith: This one is an interesting one. Pillar number 7 is abnormal fat-cell signaling. This is new research. In the same way that brain cells make connections to each other so that they can fire their electrochemical impulses from one brain cell to the other—those connections are what we call the information highways, the synapses. That same concept, we do believe, happens in fat cells. Fat cells make connections to each other; maybe not in the same structural way, but they are not just a bag full of fat. The adipocyte is a metabolically active cell, which is Conversations With Michael Smith, MD

very different from what I learned back in medical school. We did not really talk much about the metabolic processes that occur inside a fat cell. The paradigm then was that you store fat; there are certain fat cells that just store fat and they sit there. We are now learning how that is not the case.

These fat cells, although one of their jobs is to store fat in case of future famines and starvation, regulate how much fat they store and how big they get by talking to other fat cells within their vicinity. There are certain gut hormones like CCK, or cholecystokinin, that probably have an influence on fat-cell production and fat-cell size. These cells are actually much more metabolically active than we ever thought, maybe not to the degree of a muscle cell, but they are active.

They use certain hormones to decide whether they need to store fat or burn fat. Leptin is one of them, for instance; adiponectin is another one. The glycerol-3-phosphate dehydrogenase enzyme is another one. These signals, some of them enzymes, some of them hormones, play a very important role in what happens to your stored fat. Does it get bigger or does it get smaller?

As you begin to gain weight and as you overwhelm your body, as you become engorged with potential energy and you start storing it, the fat cells become less and less active. You start seeing a mismanagement, an imbalance, between some of those signals, like leptin and adiponectin and glycerol-3phosphate dehydrogenase, which is the one that actually starts to activate in this instance. The fatter we get, the more fat we start to store, and those cells become less and less metabolically active, trying to conserve energy. Helping fat cells to regulate leptin, adiponectin, and glycerol-3-phosphate dehydrogenase actually helps them to stop making more fat cells and making less fat within a fat cell.

Questions I like to ask are: “Is it rare for you to feel satisfied after eating?” “Are you always hungry?” “Do you have fatty liver or nonalcoholic fatty liver?” “Do you have prediabetes issues or high blood-sugar issues?” “Do you have fat under the armpits, neck, or belly?” “Do you have high inflammation, high CR-P, a high sedimentation rate, or high levels of cortisol?”

If they answer yes to 3 of those, I consider that a mild case of abnormal signals. I start with Irvingia gabonensis, African mango extract. That has an effect on all 3 of those signals I mentioned. If they answer yes to 4 or more, that is a moderate case of abnormal signals; I add mangosteen and what is called Sphaeranthus indicus, which is an adaptogenic herb. Mangosteen and S indicus are found together in a product called Meratrim. I will do I gabonensis and Meratrim together if they answer yes to 4 of those questions. If they answer yes to all of these and I really do believe there is a fat-cell signaling problem, I add cyclic dextrin to it, which is a type of fiber that helps fat cells burn a little bit more and decrease the activity of glycerol-3-phosphate dehydrogenase.

ATHM: When it comes to the activity of adipose cells, a lot of the chemicals that we are exposed to are lipophilic, and so if they are not removed from the body they may end up getting sequestered in a fat cell. How could that affect fat-cell signaling?

Conversations With Michael Smith, MD

Dr Smith: It can interfere with the normal signaling process.

You are right, most of the toxins are lipophilic. As a matter of fact, they are not only lipophilic, they are xenoestrogens— estrogen-based fats, most of the toxins. Not only are you causing nonalcoholic fatty liver, not only are you causing some fat cell signaling issues, you also might be causing estrogen dominance in both men and women. Toxins, through a variety of mechanisms, could very much be a reason for people who are gaining weight.

I do not know if I am fully convinced yet about where these toxins go. I know there is this idea that they build up in fat cells. Maybe that is true, to what degree I don’t know. So to what degree that those toxins are disrupting these signals, we do not yet know. In theory, it does make sense. They are xenoestrogens, they are lipophilic, they are estrogen based, and all of those things can definitely make it tough to lose weight. I think there is more research that needs to go on there. How does the liver detoxify when it has an engorgement of fat? Where do these toxins go? Are they building up in bile? Are they building up in the biliary system? Do they really build up? I think those are questions that we have to answer still.

It is interesting, isn’t it, though, that most toxins are fat based and estrogen based?

ATHM: Yes. That is very interesting.

Dr Smith: I think it makes sense that there is definitely something going on there, but I think we just have to research that a little bit more. Notice that none of my pillars include toxins because I am not quite convinced yet. More research is needed.

ATHM: So, tell us about pillar number 8.

Dr Smith: Pillar number 8 is low AMPK, or AMP-activated protein kinase, activity. The best way to explain it is it’s really a master control switch or enzyme for the entire cell energy management process. It is adenosine monophosphateactivated protein, kinase. When you are young it is highly active, so you manage energy better when sugar comes into the cell—it undergoes glycolysis better, that then goes into the mitochondria. All the different phases of mitochondrial energy production are better when AMPK is more activated.

As a matter of fact, a lot of the pillars we just mentioned, even just insulin sensitivity issues, might all be linked to low AMPK activity. Metformin is a prescription drug that is an AMPK activator. We believe that one of the reasons that people who are diabetic that go on AMPK lose weight is because they are counteracting a lot of these pillars we just talked about: their fat-cell signaling issue or their insulin sensitivity issue.

AMPK brings everything together. We have covered 7 pillars so far. In my e-book, when it comes to pillar number 8, I only have 1 question: “Referring to pillars 1 through 7, did you answer yes to 3 or more of the questions for 4 of ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 83

more of the pillars? Meaning, are 4 or more of these pillars an issue for you?” If you answer yes, you know what this might really be? It could be a low-AMPK environment.

By focusing on AMPK, focusing on reactivating it, whether it is either through the prescription drug Metformin, or through the plant extracts berberine and Rosa canina— more known as dog rose extract or rose hips—those 2 plants, also like Metformin, reactivate AMPK. By reactivating AMPK, I might see an improvement on insulin sensitivity. I am going to manage cell energy better. It might help to manage those fat-cell signals better, the leptin, the adiponectin, and the glycerol-3-phosphate dehydrogenase.

We are really excited about where AMPK research might go. We are not calling it a weight-loss plan at this point, but we are excited to see people who are now taking the plant extracts.

If they really do see some weight loss with it, this could actually become in-and-of-itself a weight-loss program, because you are really just helping cells manage energy better.

When you do that, there is less fat storage, there is more burning of the energy, and your metabolic rate goes up. You can see the benefits of the other pillars we just discussed.

Look at abnormal fat-cell signals. I can explain to you all day long what we think the theory is behind that, and we can talk about leptin, but what does that really mean to the patient you are speaking to right now who needs to lose 20 pounds? How do you translate that awesome information, the awesome fat-cell signaling theory? How do you translate that into an everyday practice that is going to make sense to somebody? We believe it comes through those questions.

Your patients, and even you as a doctor, do not have to fully understand adiponectin if they just go through the 5 questions and see that they answered “yes” to 4 out of those 5; most likely they have some fat-cell signaling problems.

That is all you have got to know. You do not have to know the details of what adiponectin is actually doing.

ATHM: To play devil’s advocate, you have a patient who acts like he is completely allergic to eating anything that comes from a plant, and you are going to ask him 5 questions and give him some herbs. He is going to question the approach: “Just taking these herbs are going to burn weight off me?”

How do you motivate that patient to comply with the protocol?

ATHM: Then what is pillar number 9?

Dr Smith: This is just about eating a balanced diet. I talk about an 80% plant-based diet, versus a 20% lean animal protein diet. I think that is healthy for your heart, and your brain, but also for your metabolism. I talk about eating lean meat; if you juice, make sure you get a good ratio of 3 to 1—3 vegetables to 1 fruit—that is going to be better for fiber and sugars. Generally, eat more fiber, add fermented foods, and strive for more of that rainbow approach.

I am not one who is big on restrictive diets, where you lose texture and flavor. I think that leads to cheating and compliance issues. This pillar is about attaining a better balance to eating. There are suggestions that I give—lifestyle suggestions. There are no questions with this one.

ATHM: How do you go about putting this to work in a clinical setting?

Dr Smith: Remember, I said at the get-go that this was going to require a commitment. For most people, losing weight and keeping it off really is more of a lifestyle thing. To be committed to taking time to figure out why they are gaining weight in the first place, you need at least 2 or 3 visits. I actually think that is going to be more beneficial down the line, rather than just jumping right into Atkins or something like that.

What we have for each pillar are 5 simple yes-or-no questions. If you go through these questions and tally up the affirmative responses, more “yes” answers than “no” answers tells you that this person has a problem with that pillar.

People love quizzes, by the way. They enjoy doing them. So, I simplify it. I get into the nuts and bolts by asking the questions.

84 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Dr Smith: Remember, these 9 pillars are not about losing weight. They are about counteracting the reason you are gaining weight in the first place. In and of itself, when you correct these 9 pillars, or the 2 pillars you have issues with, is not the weight-loss program. You still need to find out what diet is going to be best for you and for your lifestyle. What exercise will work for you? That all still has to play a role.

What we are doing with these 9 pillars is identifying the likely reasons you have gained 30 pounds in the past 5 years.

By doing something to manage that better, now when you do decide on Atkins or whatever it is, you have a better chance of lasting success.

I am going to give them some of these herbs and I am going to improve how their fat cells respond to adiponectin, but that in and of itself is not going to burn the fat. We have still got to eat less and we have got to exercise. If you do correct the way adiponectin is working and how it interacts with the fat cells, whatever diet you do decide to do to lose weight has a better chance of working.

It is kind of like making your diet work by addressing why you are gaining weight in the first place. Instead of being in an uphill battle, I am leveling the playing field.

Now you actually can succeed on whatever program you want to go on.

ATHM: In one of our journals, we just published an article discussing intervention fidelity: Did the people participating in the study actually do the intervention, especially when it is self-delivered? That comes to mind, here. How do you motivate someone to do the intervention so that you can prove to them that the outcome actually happens?

Conversations With Michael Smith, MD

Dr Smith: You are right, that becomes difficult. Let’s say you have 3 pillars that look like you need to address. You start addressing them, but you may not lose weight initially. What do people want today?

ATHM: A silver bullet.

Dr Smith: Yes, they do. I think that is our opportunity as health care practitioners to re-educate. We have allowed the marketers to define the weight loss industry. We have allowed the promotion guys, the makeup artists, the people who want to sell things, to define how we are going to talk about weight loss and how you should look. Shame on us as doctors. We need to take back this whole weight-loss industry, and we need to start asking the right questions. We need to start asking why patients gain weight in the first place. We need to

start setting expectations better. We need to talk about lifestyle changes, not just losing weight for a wedding or some event.

Although, I am not saying that cannot be done. I think it is just our opportunity to re-educate—to re-establish the proper way to maintain healthy weight.

It is not the patient’s fault. Look at how many commercials are out there—how many ads in magazines: miracle weightloss this, miracle weight-loss that, or shed 5 pounds in 1 week with the yogurt diet—I just saw that. Of course they are going to look at that and say, “I’m going to try that. … Forget about my fat-cell signals.” When that person comes back to you after trying the yogurt diet and then trying the grapefruit diet, and they are still in that same place, that is where it is the health care practitioner’s job and duty to educate in the right way about weight-gaining mechanisms. It does not always have to be sexy. Sometimes we have got to say what is right.

Questions to Support Clinical Use of the 9 Pillars YES

No

Pillar 2A: Questions to Determine Women’s Level of Hormone Imbalance: Is your skin dry and itchy and/or do you have vaginal dryness?

Do you have night sweats?

Do you experience mood swings?

Is it hard to remember names and where you place things?

Do you have irregular and/or painful and/or heavy menstrual cycles or have you not had a cycle in more than 1 year?

YES

No

Pillar 2B: Questions to Determine Men’s Level of Hormone Imbalance: Do you fatigue easily and/or have trouble sleeping?

Do you lack motivation or feel depressed?

Have you lost muscle mass but gained belly fat?

Do you have low sex drive or suffer from erectile dysfunction (ED)?

Is it hard to remember names and where you place things?

YES

No

Pillar 3: Questions to Determine Your Carb & Starch Absorption: Do you eat 2 or more servings of white bread and/or white pasta per day?

Do you consume 1 sugary drink every day?

Do you eat more carbs in a day than protein?

Do you often feel shaky or have low energy after a meal?

Do you have a high level of fat in your blood (triglycerides >100)?

YES

No

Pillar 1: Questions Related to Insulin Resistance: Is your waist size 40 inches or more (men) or 35 inches or more (women)?

Do you have a history of high blood sugar (>110) or have you been diagnosed with prediabetes?

Is your blood pressure 130/80 or higher, or are you taking blood-pressure medication?

Do you have family members who have DM-2 (type 2 diabetes) or Latino, African American, Native American, or Asian American ancestry?

Are you overweight with a body mass index (BMI) of more than 25 (kg/m2)? Calculate your BMI by taking your weight (in kg) and dividing by twice your height (in m).

Conversations With Michael Smith, MD

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 85

Pillar 4: Questions to Determine Your Level of Physical Activity: Is it a rare moment for you to walk, jog, or swim?

Has it been several months or years since you last lifted weights?

Are you losing muscle mass in your arms, chest, and midsection?

Is it difficult for you to stretch and touch your toes?

Are you gaining fat around your midline, chin area, or under your arms?

YES

No

Pillar 5: Questions to Determine Your Level of Brain Serotonin: Do you crave sweets when under stress and/or in the afternoon?

Do you suffer from depression or feel “blue” and down more days than not?

Is your sleep restless, with waking up many times throughout the night or not feeling rested after waking up?

Would you describe your energy level as low?

Do you eat to feel better?

YES

No

Pillar 6: Questions to Determine the Level of Your Resting Metabolism: Is it difficult for you to lose even a few pounds and/or plateau quickly after losing just a few pounds?

Have you been diagnosed with low thyroid (hypothyroidism)?

Are you more than 50 years old?

Do you gain weight easily, such as 5 pounds or more after just a couple of days of splurging?

Have you lost muscle mass?

YES

No

Pillar 7: Questions to Determine the Status of Your Fat-cell Signaling: Is it rare for you to feel satisfied after eating, or are you always hungry?

Do you have nonalcoholic fatty liver?

Do you have diabetes, prediabetes, or consistently high blood sugar?

Do you carry most of your excess body fat around your waist and/or neck?

Have you ever been told you have high levels of inflammation (elevated CR-P and ESR) or cortisol (the stress hormone)?

YES

No

Pillar 8: Questions to Determine Your Level of AMPK Activity: Referring to pillars 1 through 7, did you answer “yes” to 3 or more of the questions for 4 or more of the pillars?

YES

No

Pillar 9: No Questions.

Incorporate more healthful dietary habits.

Visit the Web site http://www.innovisionhm.com/9pillars for the complete series of articles along with the patient version of the 9 pillars of weight loss program and other helpful resources.

86 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Conversations With Michael Smith, MD

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CONVERSATIONS

Tieraona Low Dog, MD: The Many Aspects of Greening Medicine Interview by Craig Gustafson

Tieraona Low Dog, MD, began studying natural medicine more than 35 years ago. She studied midwifery, massage therapy, and was a highly respected herbalist, serving as President of the American Herbalist Guild and running a teaching clinic in Albuquerque, New Mexico, before going on to receive her Doctor of Medicine degree from the University of New Mexico School of Medicine. Dr Low Dog opened and ran a successful integrative medical clinic in Albuquerque, before joining the faculty of the Arizona Center for Integrative Medicine at the University of Arizona where she served as the director of the fellowship from 2005-2014. On July 1, 2015, she was named fellowship director for the Academy of Integrative Health and Medicine (AIHM). In this interview, she discusses the topic of her upcoming presentation at the AIHM annual conference, “People, Planet, Purpose,” from October 25 through 29 in San Diego, California.

(Altern Ther Health Med. 2015;21(5):88-91.)

Alternative Therapies in Health and Medicine (ATHM): At the Academy of Integrative Health and Medicine conference in October, you will deliver an address on “The Greening of Medicine.” Please tell us about what that concept embodies.

Dr Low Dog: The greening of medicine is to actively turn and move towards a medicine that honors and acknowledges that human health is intrinsically connected to planetary health. As clinicians we must recognize that we are most human when we honor our place amidst the plants, animals, and earth—when we see our inner ecology as inseparable from our external ecology. And we must integrate the awareness that disharmony and disruption of that relationship can disturb our well-being and health. We are one thread in a multidimensional, complex web. Our health is tightly interwoven with the health of our planet.

Medicine must begin to think more broadly. We must consider the fullness of our actions in all of our decision making, whether on an individual, community, national, or global scale. While medication will always have an important role to play in the prevention and treatment of disease, to focus only on developing more pills to treat symptoms or 88 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

disease is shortsighted. Drugs have benefits. And they have consequences. Reactionary medicine is not sustainable. The tidal wave of chronic disease not far on the horizon will simply overwhelm our resources.

ATHM: The symptom-pill paradigm is often talked about by holistic practitioners as being shortsighted, but holistic practitioners also like to lean on Hippocrates’s statement, “Let your food be your medicine and your medicine be your food.” Looking at it from a different angle, could that statement be a little bit simplistic in that a holistic approach embodies more than eating and moving?

Dr Low Dog: “Let your food be your medicine and your medicine be your food.” How could anyone argue with that?

Of course food should nourish and sustain us. There are so many things to be grateful for when it comes to food in the 21st century. We have refrigeration and reliable ways to package and transport fresh food so that it is safe and accessible. Modern agricultural practices have increased crop yield and there is a global consciousness for caring for the hungry. I get all that. However, when I sit and listen to a patient describe what she typically eats, I also get that a lot of what we call food is junk. Pop-Tarts for breakfast, pasta and soda pop for lunch, and a Big Mac and fries for dinner is not my idea of medicine.

Let’s be honest. In 1980, we started creating dietary guidelines for the American public and if we’re honest, they haven’t been that useful. We were so focused on fat that we paid little attention to the dramatic increase in sugar in our diet. People ate low-fat potato chips with canola oil and sea salt and proclaimed them healthy. Food manufacturers threw out the sugar and loaded up on agave nectar so we could feel good about eating cookies and snacks. We ditched the yolk and ordered egg-white omelets, ditching the saltshaker along the way, thinking we were protecting our arteries and our hearts. What did that get us? Insulin resistance, diabetes, obesity, heart disease, and more cancer.

And for the first time since Morton’s put iodine in our salt in 1924, we now have reproductive-aged women who are Conversations With Tieraona Low Dog, MD

borderline iodine insufficient, a state that is extremely dangerous to the neurological development of a baby.

We tell people to eat 4 to 6 cups of vegetables and fruits every day. Who does that? Really? Yes, some do, but most fall far short of that goal. And because of modern agricultural practices, many of our fruits and vegetables are actually less nutritious than they were 40 years ago. Farmers can bring bigger produce to market faster, but they now contain 15% to 38% less iron, vitamin C, potassium, and calcium.

They are also lower in the strong protective phytochemicals necessary for helping us defend our cells against the increasing number of chemicals in our environment.

Many of these crops are also laden with pesticides and herbicides, which disrupt the microbiome of the soil and of our bodies. Scientists are only now developing tools that can truly assess the real risk that comes from being exposed to low doses of these chemicals on a daily basis for decades.

And while we continue to debate just how bad these chemicals might be, there is a growing body of evidence that suggests that they can be particularly dangerous during vulnerable periods, such as pregnancy and early childhood.

Pesticides, including insecticides and herbicides, are being linked to an increased risk for certain childhood cancers, which are on the rise; prostate and breast cancer; neurologic harm; and early puberty. While I am certainly an advocate for organic foods, how does this help the poorest amongst us who often live in areas where the soil, water, and air are the most polluted and have the least money to afford organic?

Worse, individual states have limited or restricted the purchase of organic milk and produce to participants in the Special Supplemental Nutrition Program for Women, Infants, and Children, or WIC. That is shameful. Who knows the long-term consequences of these chemicals in our blood and bones or to the pollinators, insects, soil, and environment?

What rational person would sit idly by and wait until someone says, “We have the answer”? We must decide if we are going to have a reactionary or a proactive approach to health.

ATHM: Is there a way to change the status quo?

Dr Low Dog: Like all social movements, it will take a groundswell of people becoming informed on the issues, voting with their pocketbooks, and putting pressure on politicians to do the right thing. Look at the crops that we subsidize. There is a reason that high-fructose corn syrup is everywhere. If you’re going to take my tax dollars, then at least subsidize healthy fruits and vegetables. This does not have to be an “antibusiness” movement. Look at all the “green” industries that are growing and thriving. But we are going to have to be honest about what kind of world we want to leave our great grandchildren. And health care professionals, like it or not, are going to have to be part of the groundswell that demands healthy food, a healthy environment, and greener medicine that produces less waste and is safer. It is going to take a vision of what we believe is Conversations With Tieraona Low Dog, MD

possible. And that vision is going to have to take a view that is longer than a 4-year presidential cycle.

ATHM: Individuals are constantly exposed to the environment—touching, breathing, and eating—and so you would think that it would simply be common sense that the environment affects the body. Why does conventional medicine not recognize that?

Dr Low Dog: It’s complex. Nature is frightening. This alienation and separation from the environment is deep. The Cartesian reductionist model that has been pervasive in both scientific thought and Western medicine is certainly a part of it. But, in truth, people having been battling Nature for a very long time. There’s been a need to conquer and control her. The more she can be controlled, the more secure we feel. We try to control our environment because, in many ways, we fear it.

On some level, I understand it. I live in a remote area of northern New Mexico. We get a couple days of rain and the small, dry streambed suddenly becomes a 10-foot-deep, 15-foot-wide raging river that takes up anything in its path.

The bears came, demolished our chicken coop, and killed all our hens. The coyotes took down a small doe and her baby.

The ravens ate the baby chickadees that were born in our barn. I’ve heard a rabbit scream. The wildfires came far too close to our land 2 years ago. I am constantly reminded of how raw and tenuous Nature can seem. I see it play out on a daily basis. However, I also feel a deep sense of calm and peace here in these mountains. The beauty and majesty of Life is on full display here amidst the Ponderosa and Douglas fir. I am overwhelmed with a sense of deep respect and love, knowing that I am part of this much larger community.

I have learned that the more we try to control Nature, the greater the unintended consequences. By not allowing periodic burns, the forests become overcrowded and unhealthy. By getting rid of predators and limiting hunting, deer populations have exploded in some areas of the country. More deer, more ticks. Lyme disease is dramatically on the rise.

Unfortunately, there are those who still believe we are at the top of the “food chain.” “Frack, dig, poison—it doesn’t matter, the environment is here for our use and for our pleasure.” That is such dangerous thinking. Life exists within a dynamic and interconnected web, not as a chain.

The US Geological Survey tested our freshwater and streams and found that the majority of large fish contained very high levels of mercury, primarily the result of coal emissions. When I was a kid, I used to go fishing with my grandparents all the time: eating the catfish and perch we caught in the creeks and little lakes of Kansas. My grandfather would have wept if he had been told that the fish were so toxic that they were not safe to feed his family. This is a dangerous sign of things to come. And talk about mixed messages. The medical community, conventional and integrative, keeps telling people to eat fish because it is good for our heart, brain, and eyes. We know that they are particularly important during pregnancy and early ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 89

childhood, which is why authorities recommend women eat 4 ounces of fish 3 times per week. Women are understandably concerned about exposing their unborn children to mercury.

While fish oil supplements can deliver omega-3 fatty acids that are free of mercury and toxins and can be made from sustainable sources, we continue to hear that we should get all our omega 3s from fish.

It is our duty and our privilege to act responsibly when it comes to the health of our planet. We must have a forwardthinking and reasoned approach to energy and agriculture.

We must be good and responsible stewards. Companies can be profitable and do the right thing. We must shift our thinking from either “the earth is dangerous and needs to be conquered” or “the earth is ours to exploit,” to a profound recognition that we are part of a large and complex community. And environmental medicine should never be limited to focusing only on environmental toxins. Nature itself is a healing force.

ATHM: Then, do you feel that health discussion needs to extend beyond environmental toxicology?

Dr Low Dog: Absolutely. Just as the environment can make someone sick, the environment can be used to heal. Think about the last time you walked at sunset along the ocean or took a long walk in the forest. The human mind is entrained for being in Nature. It did not evolve in concrete and steel.

Stress hormones are elevated when walking in downtown Chicago or New York City. While exhilarating, the sounds, traffic, people, congestion, smells, and concrete can overwhelm the ancient part of our brains that evolved in the savannah.

Space can be healing or harmful. Hospitals have always felt incredibly unhealthy to me. They smell bad and are filled with buzzers and people who wake you up in the middle of the night. We strip people of their clothes and jewelry, putting them in an uncomfortable and impersonal gown, taking away their dignity and their individuality. We feed them awful food and we expect healing to happen. Wow. We focus on stabilizing the patient, aggressively treating the disease, managing symptoms, and curing when possible.

We all want to be cured of what ails us. As someone with cancer, I can tell you that we want the best medicine has to offer. Yes, we need to make sure that we control infection and that we are able to easily clean the rooms. But healing is a multisensory experience. When we are in sympathetic overdrive—when adrenaline/epinephrine and cortisol are flooding our system because we’re scared, sleep-deprived, surrounded by bad smells, uncomfortable and feeling all alone—it’s hard to heal.

Thankfully, a small but growing number of hospitals are putting time, money, and vision into creating green and healing spaces. Farmers’ markets in the parking lot, healthy foods in the cafeteria, rooms with views of gardens or trees, massage instead of Haldol, acupuncture for nausea or pain, and soothing music on a channel on the television. Let’s face 90 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

it: If someone is sick enough to be in the hospital, we should be doing everything possible to enhance their innate healing.

And softer outcomes, like quality of life and happiness, should have a stronger place in our medical system.

ATHM: A healing environment: Hospitals have defined that as sterile, and while a sterile environment is a must for some aspects of medicine, is it desirable in all aspects? A while ago, I was looking at some studies that examined gardening as an activity that might benefit cardiovascular health. The studies looked at it only as a form of exercise. For me, it generated questions such as: “What about being in contact with the earth and grounding effects? What about the microbes in the soil that you are exposed to? What have they done in this study to allow for that?” These could play a role in the observed success of that activity.

Dr Low Dog: Many people have gone overboard when it comes to cleanliness. Now, don’t get me wrong. Cleanliness is important. Most animals have hygiene behaviors that help them prevent infection and human beings are no exception.

There was a reason that sewers were built, plumbing was installed, and soap was prized. But I have to say that like many things in life, the pendulum may have swung too far in the other direction. We have disrupted the microbial life within us and within the soil. Antibiotics definitely disrupt our inner ecology, with far-reaching consequences that we are unable to even fathom. While lifesaving, there is no question they are overprescribed. The average American has had 17 courses of antibiotics by their 21st birthday! We use antibiotics in livestock to help make them fat, and then we eat the animal.

All of this disrupts our microbiome, which may lead to an increase risk of allergies, asthma, autoimmunity, obesity, depression, anxiety, as well as a myriad of gut disorders.

Thankfully, nontherapeutic use of antibiotics in livestock is being phased out in the United States, and more and more people are becoming educated in how to treat minor ailments with natural, effective, and low-cost options.

While the microbes in our gut are vitally important, our skin plays host to billions of microbes that help keep us healthy. These microbes compete with harmful bacteria in many ways, including the secretion of antimicrobial proteins—proteins that keep bad bacteria from gaining a foothold. These healthy microbes help maintain one of our primary barriers to infection, our skin, so it’s not wise to be lathering up every day, in general, and with antibacterial soaps in particular. I object to the use of these in homes not only because they wipe out one of our skin’s natural forms of protection but also because most are laden with nasty chemicals. Triclosan, a compound found in the majority of antibacterial soaps, has been shown to be an endocrine disruptor that may interrupt thyroid function and possibly other hormones. I was relieved when the FDA finally came out and essentially said that there is no evidence these products are any better than just plain old soap and water for routine use in households.

Conversations With Tieraona Low Dog, MD

But when thinking of microbes, don’t forget to look down at the ground! There is more bacterial diversity in a teaspoon of dirt than there is diversity of animal life in the Amazon! However, modern agricultural practices that administer large amounts of herbicides and pesticides to crops and lawns to control weeds and insects disrupt the delicate balance of microbes in the soil. The soil’s microbial community is critical for protecting plants against disease, helping them uptake and digest nutrients, maintaining soil quality, and aiding in climate control.

Though invisible to our eyes, the health and balance of the microbial world is vital to human and planetary health.

The words of Leonardo da Vinci seem particularly prescient: “We know more about the movement of celestial bodies than we do the soil underfoot.”

the really up-close microscopic view and the 30 000-foot view. Medicine needs to think more in terms of systems biology. We must be cognizant of the unintended consequences of the many ways we have interrupted the natural, biological processes of the human body: from the way we are born, the way we live, the food we eat, the manner in which we treat disease, and even the way we die.

It will take the very best of science, medicine, politics, law, ethics, business, as well as citizen activism to address the many factors that affect our health and influence life on this planet. That we could hold as valuable as profit and expediency, the vision of creating a world that is healthy for all of her inhabitants—that is my prayer.

ATHM: What other practices might we also examine in this regard?

Dr Low Dog: The greening of medicine also asks us to look at practices like childbirth. In a healthy society, roughly 5% to 10% of pregnancies will end with a cesarean section to protect the health of the mom or the baby. The national average now hovers around 33% and in some hospital systems, it is closer to a 50% C-section rate. When born by cesarean, a child is already starting off at a disadvantage, as he/she neither ingests nor is covered by the microbes in the mother’s vaginal birth canal. For those who are born by C-section, the administration of particular strains of probiotics during the first year(s) of life might address this. Breastfeeding babies benefits them in innumerable ways, including encouraging and supporting the growth of healthy gut flora.

The American Academy of Pediatrics says, “We endorse and recommend exclusive breast feeding for the first 6 months of life.” But half of our babies are not breastfed at all at 6 months, let alone exclusively breastfed. Why? The reasons are complex but in no small part, our policies don’t support it. Many women are lucky to be working at a place that offers 6 weeks of maternity leave. This makes it much harder to exclusively breastfeed for 6 months. Breastfeeding can prevent ear infections, allergies, asthma, diarrhea, vomiting, urinary tract infections, obesity, and reduce the risk of sudden infant death syndrome, while boosting cognitive development! Fewer infections also mean fewer antibiotics. And mothers benefit, too. Women who breastfeed have less postpartum depression and may be protected against certain cancers.

There is a disconnection between policies and health, and we have this huge health burden that we are dealing with. Something as basic as breastfeeding for 6 months can be one of the best head starts we give an infant. I realize not all women are going to want to do this. But for those who do, it can be just too difficult to keep up a milk supply while working a full-time job.

Like looking at any ecosystem, we have to step back and ask ourselves, “How does this all fit together?” We need Conversations With Tieraona Low Dog, MD

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CONFERENCE CALENDAR The Gateway Foundation for Biological and Integrative Medicine: Curing the Incurables September 11-13, 2015—Hilton St Louis Frontenac, St Louis, Missouri Join the Gateway Foundation for Biological and Integrative Medicine as it presents “Curing the Incurables.” This conference will cover fibromyalgia, chronic fatigue syndrome, Lyme disease, autism spectrum disorders, and cancer. The 2015 Biological & Integrative Medicine Conference presenters represent: MD, DDS, ND, DO, DC, OMI, LAc, PhD, Chaplain, and Reverend. For more information, please visit http://www.iamconf.com/.

Mastering The Science of Integrative Blood Chemistry September 12-13, 2015—DoubleTree by Hilton-IAH, Houston, Texas Presented by Dr Abbas Qutab, this 2-day blood chemistry analysis seminar will dramatically improve your clinical outcomes. The seminar will allow practitioners to master, implement, and offer integrative blood chemistry analysis immediately in their practice. For more information, please contact Biotics Research at (800) 231-5777 or e-mail biotics@bioticsresearch.com.

Metabolic Medical Institute September 17-19, 2015—Sheraton New Orleans Hotel, New Orleans, Louisiana The American Academy of Anti-Aging (A4M) is excited to announce the redesigned Fellowship in Metabolic and Nutritional Medicine (formerly the Fellowship in Anti-Aging Medicine). This module will include neurology, inflammation and autoimmune disease, and using botanical medicines in women’s and men’s health. For more information, please call (866) 846-1107 or visit http://www.mmimedicine.com/.

6th Annual Integrative Medicine for Mental Health Conference September 17-20, 2015—Hyatt Regency Mission Bay Resort and Spa, San Diego, California This international conference will explore the field of integrative medicine in the treatment of mental health, autism, and related disorders. Research studies have revealed that many disorders such as depression, bipolar disorder, anxiety, obessive compulsive disorder, eating disorders, and autism spectrum disorders often have dietary and biological causes that contribute to symptoms. In keeping with our tradition of exploring the best and most cutting-edge research in the integrative field, this year we have even more new topics and speakers than ever before! For more information, please visit http://www.IMMH.org/.

Gut-Brain Relationship Conference September 18-19, 2015—DoubleTree Suites Hotel, Ft Lauderdale, Florida InnoVision Professional Media is sponsoring a unique health care symposium that will focus on the relationship between the gut and the brain.

The event will combine the latest research, testing techniques, and applications into a 2-day event with CMEs. Attendees will hear from leading health care thought leaders who will share their perspectives on this important relationship for your patients’ health. For registration and more information, visit http://www.innovisionhm.com/gutbrainconference or call (877) 904-7951.

Food as Medicine September 18-22, 2015—Kripalu Center for Yoga & Health, Stockbridge, Massachusetts This universally acclaimed professional training program provides health professionals with the foundation they need to effectively integrate nutrition into clinical practice. Food as Medicine’s remarkable faculty includes the country’s leading lifestyle medicine clinicians and researchers as well as some of our most gifted holistic nutritionists, mind-body practitioners, patient advocates, and chefs. Participants will leave grounded in the fundamentals of sound nutrition, knowledgeable about cutting-edge research, and prepared to confidently and compassionately guide their patients toward practical lifegiving healthy nutrition. For more information, please visit http://www.cmbm.org/professional-trainings/food-as-medicine/.

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The Brain: Nutritional Perspective & Considerations September 19, 2015—DoubleTree Suites-Time Square, New York, New York Presented by Court Vreeland, DC, DACNB. This educational seminar will focus on the latest research in nutrition and neurological health. Subjects to be included in this seminar include vital importance of blood brain barrier and gut barrier integrity in brain health, neuroinflammation and mechanisms through which diet may affect it, neurotransmitter physiology, neurodegenerative changes, and much more. Attendees will learn effective treatment strategies for a wide range of neurological conditions that are common but notoriously difficult to treat. For more information, please contact Biotics Research at (800) 231-5777 or e-mail biotics@bioticsresearch.com.

Mastering The Science of Integrative Blood Chemistry September 19-20, 2015—DoubleTree Suites, Boston, Massachusetts Presented by Dr Abbas Qutab, this 2-day blood chemistry analysis seminar will dramatically improve your clinical outcomes. The seminar will allow practitioners to master, implement, and offer integrative blood chemistry analysis immediately in their practice. For more information, please contact Biotics Research at (800) 231-5777 or e-mail biotics@bioticsresearch.com.

2015 Lifestyle Medicine Summit September 25-27, 2015—JW Marriott Phoenix Desert Ridge Resort and Spa, Phoenix, Arizona This year’s theme is “Healthy Aging—100% Vitality for Your First 100 years: Restoring and Maintaining Optimal Health.” Join leading experts who will be addressing the critical and most relevant issues related to health. This groundbreaking event is a unique opportunity to learn recent scientific advancements in prevention and treatment of common health issues from leading medical experts in the field of lifestyle medicine and other forward-thinking practitioners. For more information, please visit http://www.metagenics.com/education/.

The Institute for Functional Medicine Applying Functional Medicine in Clinical Practice (AFMCP) September 28-October 1, 2015—Hyatt Regency, Atlanta, Georgia Applying Functional Medicine in Clinical Practice (AFMCP) teaches health care practitioners to more effectively integrate science, research, and clinical insights to treat and prevent disease and maintain health.

Established and emerging diagnostics, therapeutics, and prevention strategies are extensively covered, including the use of diet, nutraceuticals, exercise, body/mind techniques, and the adaptation of lifestyle to an individual’s genetic risks and environmental exposures. For more information, please visit https://www.functionalmedicine.org/AFMCP or call (800) 228-0622.

13th Annual Restorative Medicine Conference October 1-4, 2015—Semiahmoo Resort, Blaine, Washington The 13th Annual International Restorative Medicine Conference is an extraordinary opportunity to hear expert speakers present emerging research and up-to-date protocols that empower you to effectively treat your patients.

The annual conference consistently lives up to its reputation for providing innovative educational opportunities for practitioners. For more information, please visit http://www.restorativemedicine.org/conference/2015/.

3rd Annual ILANP Conference October 3-4, 2015—National University of Health Sciences, Lombard, Illinois Join the Illinois Association of Naturopathic Physicians for its third annual conference. The title for this year’s event is “Special Populations: Naturopathic Medicine for Special Populations: Treating Every Individual.” For more information, please visit https://ilanp.org.

Conference Calendar

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Metabolic Medical Institute October 8-10, 2015—Chicago Marriott Downtown, Chicago, Illinois The American Academy of Anti-Aging (A4M) is excited to announce the redesigned Fellowship in Metabolic and Nutritional Medicine (formerly the Fellowship in Anti-Aging Medicine). This module will include gastroenterology, weight and lifestyle management, and prescription writing for compounded medications. For more information, please call (866) 846-1107 or visit http://www.mmimedicine.com/.

Integrative Healthcare Symposium Focus On: Microbiome October 9-10, 2015—Diplomat Resort & Spa, Hollywood, Florida Integrative Healthcare Symposium brings together multidisciplinary health care professionals dedicated to improving patient care and defining the future of integrative health care. For more information on this “Focus On” event, please visit http://www.ihsymposium.com/focus-event/.

Understanding, Evaluating & Addressing Autoimmune Disorders October 10, 2015—Dallas Marriott Las Colinas, Irving, Texas Presented by William M. Kleber, DC, DANCI. Rising rates of autoimmune conditions demand that the insightful practitioner not only have a keen knowledge of how the immune system functions, but must also understand what happens when the immune response is abnormal and communication mechanisms of the immune system are broken down. Before we can attempt to address autoimmune challenges, we must see the big picture. This presentation will focus on the cells involved with the immune system and how they communicate. We will evaluate the causes of the immune system aberrant communication and how the abnormal response results in pathology and illness. A 2-day blood chemistry analysis seminar will dramatically improve your clinical outcomes. The seminar will allow practitioners to master, implement, and offer integrative blood chemistry analysis immediately in their practice. For more information, please contact Biotics Research at (800) 231-5777 or e-mail biotics@bioticsresearch.com.

Mind-Body Medicine Professional Training Program October 10-14, 2015—Hyatt Regency Minneapolis, Minneapolis, Minnesota Mind-Body Medicine training program provides health professionals with the tools they need to become more effective clinicians and to find more meaning in their work. During the intensive 5-day training, faculty teaches the science of mind-body medicine in plenary sessions and techniques for self-awareness and self-expression in supportive small groups—the Center’s unique model for learning and support. For more information, please visit http://www.cmbm.org/.

ILADS Annual Lyme Disease Conference October 15-18, 2015—Marriott Resort Harbor Beach, Ft Lauderdale, Florida International Lyme and Associated Diseases Society is proud to bring its 2015 annual scientific conference to Ft Lauderdale, Florida. This is an underserved area for medical professionals who have an interest in treating tick-borne diseases. The program will consist of cutting-edge research presentations each morning followed by practical afternoon breakout sessions. For more information, please visit http://www.ilads.org/.

Heal Thy Practice October 16-18, 2015—Coronado Island Marriott Resort & Spa, Coronado Island, California Heal Thy Practice: Transforming Patient Care is an annual conference focused on practical strategies and effective practice models for implementing prevention-focused, patient-centered health care in real-world clinical settings. Heal Thy Practice is the only national continuing medical education conference focused exclusively on empowering doctors to make holistic and functional medicine a day-to-day reality in their communities. For more information and to register, please visit http://htpconference.com/.

94 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Douglas Laboratories Educational Live Seminar October 17, 2015—Atrium Hotel, Irvine, California Join Penny Kendall-Reed, ND, for a 1-day live seminar on neuroendocrine basis to stress and weight management. This 1-day seminar will discuss how stress causes neurotrophic and neuroendocrine dysfunction; alters DNA; and disrupts pathways involved in lipogenesis, food cravings, and metabolic rate.

Other topics will consist of ineffectiveness of diets, importance of eating more than 3 times per day, supplement protocols, and clinical takeaways to promote metabolic function and healthy sustained weight management. For more information, please visit http://www.douglaslabs.com/education/seminars. To register, please contact David Ross via e-mail at dross@douglaslabs.com or by phone at (800) 245-4440, extension 6191.

Douglas Laboratories Educational Live Seminar October 17, 2015—Monaco Hotel, Portland, Oregon Join Penny Kendall-Reed, ND, for a 1-day live seminar on neuroendocrine basis to stress and weight management. This 1-day seminar will discuss how stress causes neurotrophic and neuroendocrine dysfunction; alters DNA; and disrupts pathways involved in lipogenesis, food cravings, and metabolic rate. Other topics will consist of ineffectiveness of diets, importance of eating more than 3 times per day, supplement protocols, and clinical takeaways to promote metabolic function and healthy sustained weight management. For more information, please visit http://www.douglaslabs.com/education/seminars. To register, please contact David Ross via e-mail at dross@douglaslabs.com or by phone at (800) 245-4440, extension 6191.

World Conference on Regenerative Medicine 2015 October 21-23, 2015—Congress Center Leipzig, Leipzig, Germany The World Conference on Regenerative Medicine offers scientists, medical practitioners, and company representatives a perfect platform to gather and share information on the latest research trends and technology developments in regenerative medicine. The program covers a wide range of issues from stem cell technologies and tissue engineering, cell therapies and biomaterials, to regulatory requirements on ATMPs. For more information, please visit http://www.wcrm-leipzig.com/.

10th Annual Cardiometabolic Health Congress October 21-24, 2015—Sheraton Boston Hotel, Boston, Massachusetts Join the CMHC for a complete educational experience addressing today’s cardiometabolic disease epidemic. Interact with the leading experts in cardiometabolic health and take home practical strategies for managing your complex patients. For more information, please visit http://www.cardiometabolichealth.org/.

Douglas Laboratories Educational Live Seminar October 22, 2015—Renaissance Clubsport Walnut Creek Hotel, Walnut Creek, California Join Penny Kendall-Reed, ND, for a 1-day live seminar on neuroendocrine basis to stress and weight management. This 1-day seminar will discuss how stress causes neurotrophic and neuroendocrine dysfunction; alters DNA; and disrupts pathways involved in lipogenesis, food cravings, and metabolic rate. Other topics will consist of ineffectiveness of diets, importance of eating more than 3 times per day, supplement protocols, and clinical takeaways to promote metabolic function and healthy sustained weight management. For more information, please visit http://www.douglaslabs.com/education/seminars. To register, please contact David Ross via e-mail at dross@douglaslabs.com or by phone at (800) 245-4440, extension 6191.

Integrative Healthcare Symposium Canada October 23-24, 2015—Sheraton Parkway Toronto North Hotel & Suites, Richmond Hill, Ontario The Integrative Healthcare Symposium is a growing portfolio of educational conferences with a mission of bringing together multidisciplinary health care professionals who are focused on expanding their knowledge of integrative medicine and networking among like-minded peers. This event is looking to provide a platform for integrative health care education to practitioners in and around Toronto. For more information, please visit http://www.ihsymposium.com/canada/.

Conference Calendar

AIHM Annual Conference: People, Planet, Purpose: Global Practitioners United in Health & Healing October 24-29, 2015—Paradise Point Resort and Spa, San Diego, California The AIHM Annual Conference provides a unique combination of educational experience and sacred space, blending the art and science of integrative health and medicine with the most pressing global issues. The academy program is designed to give you clinically relevant information for your practice and tools to address the growing health issues humanity is facing. Interprofessional expert speakers will take us on a journey through evidence-informed, comprehensive, affordable, sustainable person-centered care. Faculty will explore cutting-edge research in integrative medicine and key global issues for the health of our planet. The event includes numerous opportunities for personal renewal and deep community connection. This educational course is for health care professionals seeking to expand their clinical competencies and advance their mind-body-spirit approach to healing. For more information, please visit http://www.aihm.org/events.

The Heart and Science of Yoga November 3-7, 2015—Cranwell Resort and Spa in Lenox, Massachusetts Join the American Meditation Institute’s (AMI) for its 7th annual mind/body medicine CME conference on meditation and yoga. This 30 CME mind/body medicine training is for physicians and other health care professionals. For more information, please visit http://www.americanmeditation.org/.

Energy Medicine: Paradox & Controversy October 30-November 1, 2015—The Murphy, Chicago, Illinois The International College of Integrative Medicine will be hosting its 60th congress meeting. This year’s fall conference theme is on energy and medicine. For more information, please visit http://www.icimed.com/.

The Institute for Functional Medicine Advanced Practice Module: GI November 6-8, 2015, Omni Hotel, Dallas, Texas “Restoring Gastrointestinal Equilibrium: Practical Applications for Understanding, Assessing, and Treating Gut Dysfunction.” This course will supply you with the foundational background, insight, and in-depth clinical thinking to confidently work up and treat patients who may present with conditions, signs, and symptoms indicative of gastrointestinal (GI) dysfunction. For more information, please visit https://www.functionalmedicine.org/GI/.

Lifestyle Medicine 2015 November 1-4, 2015—Renaissance Nashville Hotel, Nashville, Tennessee The American College of Lifestyle Medicine (ACLM) will host its 5th annual conference. The must-attend lifestyle medicine conference of the year will feature prominent keynote speakers, nearly 25 track sessions presented by world-renowned regional and international presenters, accompanied by 19.25 hours of CME credits. For more information, please visit http://www.lifestylemedicine.org/.

The Institute for Functional Medicine: Energy Regulation Advanced Practice Module November 6-8, 2015—Omni Hotel, Dallas, Texas “Illuminating the Energy Spectrum: Evidence and Emerging Clinical Solutions for Managing Pain, Fatigue, and Cognitive Dysfunction.” This program will help clinicians develop and refine their ability to assess and treat a variety of conditions involving energy regulation. We will investigate the science of mitochondrial function and dysfunction, as well as harness the power of intention and compassion within the therapeutic relationship. For more information, please visit https://www.functionalmedicine.org/Energy/.

Nutritional Interventions You Will Use Everyday November 7-8, 2015—SpringHill Suites by Marriot, Orlando, Florida Presented by Wally Schmitt, DC. To help take your interventions to the next level as you understand and integrate individualized nutritional protocols.

In this seminar you will acquire simple to use tools to increase compliance and provide successful patient outcomes. To register, contact Biotics Research at (800) 231-5777, or email biotics@bioticsresearch.com

Job Listing Complementary and Integrative Medicine Medical Director-Austin, TX Seton Healthcare Family is seeking a board certified Family Medicine or Internal Medicine physician, trained in complementary and integrative medicine to provide medical leadership and clinical services for a new integrative and complementary medicine center.

Candidates should be a highly skilled physician, preferably in primary care, who seeks to incorporate a holistic, patient centered team approach.

The Medical Director for Integrative Medicine reports to the CEO/ President of the Clinical Enterprise and is responsible for overseeing clinical standards, program growth and development, trainee exposure and education, research projects, quality of care, service excellence to patients, and professionalism by all staff and trainees as well as institutional goals set by the standards and mission of the Seton Healthcare Family.

Seton Healthcare Family is the leading provider of healthcare services in Central Texas, serving an 11-county population of 1.9 million. The organization operates 5 major medical centers, including the region's only Level I Trauma Centers for adult and pediatrics and dedicated children's hospital, 2 community hospitals, 3 rural hospitals, an inpatient mental health hospital, and 3 primary care clinics for the uninsured.

The Seton Healthcare Family is an Equal Opportunity/Affirmative Action/Equal Access Employer. Hiring is contingent upon obtaining medical licensure in the state of Texas. Interested applicants should submit a letter of interest and Curriculum Vitae to: Carrie Schumacher/Physician Recruitment/ CSchumacher@seton.org Conference Calendar

ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 95

American College of Nutrition’s 56th Annual Conference: November 11-14, 2015—B Resort & Spa, Orlando, Florida Join the American College of Nutrition (ACN) for its 56th annual conference titled “Translational Nutrition: Optimizing Brain Health.” Join world renowned researchers and clinicians as we learn to translate nutrition science into practice. This interactive educational event is a must-attend for anyone interested in the field of nutrition science. This year’s conference will focus on the impact of nutrition on the brain and cognitive health. For more information, please call (858) 652-5400 or visit http://www.americancollegeofnutrition.org/conference/.

AFNA Annual Functional Medicine Conference November 12-15, 2015—Georgia World Congress Center, Atlanta, Georgia The American Functional Medicine Association (AFMA) is an organization composed of scientists and health care practitioners from all specialties, ranging from physicians, pharmacists, naturopaths, and chiropractors to nurse practitioners, nurses, and physician assistants. AFMA is dedicated to the advancement of scientific knowledge to detect, prevent, and treat functional and aging related diseases. For more information, please visit http://www.AFMAssociation.com or call (855) 500-2362.

American College for Advancement in Medicine 2015 Annual Meeting November 12-15, 2015—Red Rock Resort, Las Vegas, Nevada Join ACAM for their annual conference titled “Integrative Medicine’s New Landscape: Practical Applications of New Technologies.” The world class faculty offer both practical and relevant applications practitioners can use today. With an all-new program format, the 2015 annual meeting format has changed to offer increased non-CME workshops and greater networking opportunities. For more information, please visit http://www.acam.org/ACAM2015/.

ICNITE Conference 2015: The Business of Better Medicine November 13-15, 2015—Omni La Costa Resort & Spa, San Diego, California Emerson Ecologics will host its first annual conference. The conference will provide integrative health care practitioners with the necessary business knowledge to develop a thriving and fulfilling practice. Workshops are designed to address key business challenges related to clinic operations, sales and marketing, and patient compliances, with a focus on providing valuable and actionable takeaways. For more information, please visit http://www.eeignite.com/.

Achieve Optimal Wellness with Detoxification November 14, 2015—Hilton Garden Inn Washington/ Bethesda, Bethesda, Maryland Presented by Dr. Abbas Qutab to more effectively help patients manage such conditions as: Chronic Fatigue Syndrome, Fibromyalgia, Polymyalgia, Rheumatoid Arthritis, Degenerative Joint Disease, Arthritis, and Acute and Chronic Pain. Topics will include basic concepts of pain/ inflammation, chronic disease disorders, understanding and restoring balance through detoxification, diagnostic strategies, and clinical protocols. To register, contact Biotics Research at (800) 231-5777, or email biotics@bioticsresearch.com 12th International Conference of the Society for Integrative Oncology November 14-16, 2015—Joseph B. Martin Conference Center, Boston, Massachusetts The first day will be a special joint program of the Society for Acupuncture Research, Fascia Research Society, and the Society for Integrative Oncology.

For more information, please visit http://www.integrativeonc.org/index. php/sio-international-conferences/.

Nutrition Pro 2015: Medical Nutrition Therapy in Practice November 15, 2015—B Resort & Spa, Orlando, Florida Immediately following The American College of Nutrition Conference 56th annual conference join the Board for Certification of Nutrition Specialists for Nutrition Pro 2015. Discussion topics will include nutritional practices influencing trends in 2015, clinical nutrition management of inflammation, digestive health, and much. For more information, please visit http://www.cbns.org/.

96 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5

Dr Roizen’s Preventive and Integrative Medicine Conference December 4-6, 2015—Encore Hotel, Las Vegas, Nevada Attend the Cleveland Clinic 12th Annual Dr Roizen’s Personalized, Preventive, and Integrative Medicine Conference. During the past decade, use of preventive and integrative medicines have greatly expanded along with the types of therapies, patient populations, and conditions treated. This conference will focus on discussing the most recent data, analyzing its impact, and assessing its best use in clinical practice. For more information, please visit http://www.clevelandclinicmeded.com/live/.

The American Academy of Anti-Aging Medicine (A4M) 23rd Annual Winter World Congress December 11-13, 2015—Venetian/Palazzo Hotel, Las Vegas, Nevada The American Academy of Anti-Aging Medicine (A4M) invites you to attend the 23rd Annual World Congress on Anti-Aging, Regenerative and Aesthetic Medicine. A4M is the largest Anti-Aging and Aesthetic event with more than 3000 health care practitioners, both domestic and international attendees. This event will include board certification exams, fellowship modules, general conference activities, and exhibition. For more information, visit http://www.a4m.com or call (888) 997-0112.

Labrix Advanced Workshop January 16-17, 2016—Platinum Hotel & Spa, Las Vegas, Nevada Labrix advanced training weekend offers an intimate and in-depth intensive on hormone balancing, the complex relationship between sex hormones, adrenal hormones and neurotransmitters, and the complicated symptom pictures that can result from these imbalances. This training is designed for the hormone-savvy practitioner, who is looking to elevate his or her practice through deeper understanding and additional clinical insight. Topics presented for discussion cover the gamut of clinical presentations and will be heavily case oriented. Also included are clinical pearls and pitfalls, gleaned from the decades of combined clinical experience of Labrix cofounders Jay Mead, MD, and Erin Lommen, ND, along with additional perspective offered from expert guest speakers and Labrix clinical staff. For more information, please visit https://www.labrix.com/law.

13th Annual Natural Supplements: An Evidence-Based Update January 28-31, 2016—Paradise Point Resort, San Diego, California This interactive educational event is a must-attend for anyone wanting to acquire a wide-range of knowledge and expertise for addressing and managing dietary supplement use. For more information, please visit http:// www.scripps.org/NaturalSupplements/.

Functional Medicine Advanced Practice Modules (APMs) February 4-6, 2016—Loews Atlanta Hotel, Atlanta, Georgia “Cardiometabolic—Transforming the Assessment, Prevention, and Management of Chronic Metabolic and Cardiovascular Disorders.” The module will help clinicians understand the physiology underlying cardiometabolic syndrome and cardiovascular disease, new approaches to effective assessments and treatments, and how to integrate these lifesaving tools into practice. For more information, please visit http://www.functionalmedicine.org/.

Functional Medicine Advanced Practice Modules (APMs) February 7-9, 2016—Loews Atlanta Hotel, Atlanta, Georgia “Immune—The Many faces of Immune Dysregulation and Chronic Inflammation: Chronic Infections, Atopy, and Autoimmune Disorders.”

This course will focus on chronic inflammation, systemic influences on the immune system, and the consequent dysfunction that may ensue. The Immune APM will supply you with an in-depth understanding of underlying immune mechanisms and enable you to develop effective interventions even in the absence of a conventional. For more information, please visit http://www.functionalmedicine.org/.

Integrative Healthcare Symposium February 25-27, 2016—New York Hilton Midtown, New York, New York Integrative Healthcare Symposium brings together multidisciplinary health care professionals dedicated to improving patient care and defining the future of integrative health care. For more information, visit http://www.ihsymposium.com/annual-conference/.

Conference Calendar

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