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FODMAPs diet for IBS

Cognitive games for dementia

Hydrotherapy evidence review

By Erin Balodis, MSc, ND

By Maria Shapoval, ND

By Christopher Habib, ND and Janna Levanto, ND

Integrated Healthcare

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Dr Francesco Anello, â&#x20AC;&#x2030;MD Excellence in integrative medicine

Continuing Education

Acid- alkali balance and bone health By Jordan Robertson, ND, et al.

Pea Protein with the Power of Fruit Polyphenols

Genestra Brands Pro Pea protein powder combines pea protein with the power of fruit polyphenols in a dairy-free, soy-free vegetarian formula. Each scoop contains DL-alpha-lipoic acid, chromium, curcumin and lecithin in a delicious chocolate flavour.

EGETARIAN

Understanding the role of fruit polyphenols Our pre-clinical and clinical research in the development of fruit polyphenols has resulted in the introduction of specialized blends of blueberry, cranberry, and strawberry extracts targeted at specific health outcomes. Studies on the health benefits of small fruits are continuing in the areas of healthy aging, Metabolic Syndrome, and cognition. Ongoing studies include the effects of polyphenols on established biomarkers of health, as well as on inflammatory gene expression.

CANADA: 1-800-263ď&#x161;ş5861 | www.seroyal.com

GENESTRA BRANDS PRO PEA PRODUCT MONOGRAPH Genestra Pro Pea provides a highly available vegetable source of protein (pea) that helps control appetite by improving the feelings of satiety. The formulation combines pea protein, DL-alpha-lipoic acid, chromium, curcumin and lecithin with fruit polyphenols to help promote healthy metabolism and to help the body metabolize carbohydrates, fats and proteins. Pea Protein: There is convincing evidence that a higher protein intake increases thermogenesis and satiety compared to diets of lower protein content. The weight of evidence also suggests that high protein meals lead to a reduced subsequent energy intake. A clinical study, investigating an effect of different protein sources on satiation in healthy subjects, has demonstrated that 20 g of casein or pea protein has a stronger effect on lowering food intake 30 min later compared to whey protein, egg albumin and maltodextrin.1 DL-Alpha-Lipoic Acid: The metabolic syndrome is associated with increased angiotensin II activity, induction of a proinflammatory and oxidative state, and endothelial dysfunction.2 Administration of lipoic acid to patients with the metabolic syndrome improves endothelial function and reduces proinflammatory markers, factors that are implicated in the pathogenesis of atherosclerosis.3 Chromium: Chromium (Cr) is an essential element required for normal carbohydrate and lipid metabolism. Signs of Cr deficiency have been documented on numerous occasions, including elevated blood glucose, insulin, cholesterol and triglycerides, and decreased high-density lipoproteins (HDL) in humans consuming normal diets.4 Curcumin: Curcumin is used in Herbal Medicine to help relieve joint inflammation.5 Fruit Polyphenols: Strawberries have been reported to be potent antioxidants and reduce cardiovascular risk factors, such as hyperglycemia, dyslipidemia, and inflammation in limited studies.6 The authors of a study examined the effects of blueberry supplementation on features of metabolic syndrome, lipid peroxidation, and inflammation in obese men and women. This study shows blueberries may improve selected features of metabolic syndrome and related cardiovascular risk factors at dietary achievable doses. 7

EACH SCOOP (13.95 g) CONTAINS: Pea Proteins (from Pisum sativum seed) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.5 g DL-Alpha-Lipoic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 mg Vitamin D (cholecalciferol) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 IU / 5 mcg Vitamin B12 (methylcobalamin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 mcg Chromium (chromium nicotinate glycinate) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 mcg Curcumin (from Curcuma longa rhizome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.5 mg Lecithin (from Helianthus annuus seed) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 mg Strawberry (Fragaria x ananassa) Fruit Std. Extract (20:1) (2% Polyphenols / 5 g Dried Equivanent). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 mg Blueberry (Vaccinium angustifolium) Fruit Std. Extract (15:1) (4% Polyphenols / 3.75 g Dried Equivalent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 mg Other Ingredients: Cocoa powder, guar gum, natural chocolate flavour, natural cream flavour, natural vanilla cream flavour, rebaudioside A (stevia leaf extract), thaumatin

Recommended Adult Dose: In a glass, add 250 ml of water, juice or milk to two scoops of Pro Pea and mix. Take once daily or as recommended by your healthcare practitioner. Guaranteed to contain no added wheat, yeast, gluten, soy, artificial colouring or flavouring, antimicrobial preservatives or dairy products. Ideal for vegetarians.

1. Abou-Samra R, Keersmaekers L, Brienza D, Mukherjee R, MacĂŠ K. Effect of different protein sources on satiation and short-term satiety when consumed as a starter. Nutr J. 2011 Dec 23;10:139. 2. Sola S, Mir MQ, Cheema FA, Khan-Merchant N, Menon RG, Parthasarathy S, Khan BV. Irbesartan and lipoic acid improve endothelial function and reduce markers of inflammation in the metabolic syndrome: results of the Irbesartan and Lipoic Acid in Endothelial Dysfunction (ISLAND) study. Circulation. 2005 Jan 25;111(3):343-8. 3. NHPD AbLS on Alpha lipoic acid, DL-. September 2009. 4. Anderson RA. Chromium, glucose intolerance and diabetes. J Am Coll Nutr. 1998 Dec;17(6):548-55. 5. NHPD Monograph on Curcumin. February 2010. 6. Basu A, Wilkinson M, Penugonda K, Simmons B, Betts NM, Lyons TJ. Freeze-dried strawberry powder improves lipid profile and lipid peroxidation in women with metabolic syndrome: baseline and post intervention effects. Nutr J. 2009 Sep 28;8:43. 7. Basu A, Du M, Leyva MJ, Sanchez K, Betts NM, Wu M, Aston CE, Lyons TJ. Blueberries decrease cardiovascular risk factors in obese men and women with metabolic syndrome. J Nutr. 2010 Sep;140(9):1582-7.

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What’s new in the industry?

onference season is in full force – we have been noticing some interesting trends emerging in the health food and nutritional/ nutraceutical areas… Chia seed is taking over! We are seeing chia being delivered in every form imaginable… superfood or hype? We will be sure to cover it soon in IHP. Also, GMO has really emerged as a hot topic… North America is very behind many parts of the world regarding labeling of GMO foods. We agree labeling is a must, but at what expense? Are consumers willing to pay to be informed of the GMO content of a food? Who will establish what the criteria for labeling GMO free looks like? The organics category has shown us that these are real and legitimate concerns… You can have 55% organic ingredients in a product and label it as organic! That’s like getting an oil change and they put back 45% of the old oil??? Diligence is required as we create the standards the industry must abide by. Everyone looks bad when we allow companies to manipulate guidelines and mislead through labeling. Thankfully, the natural health products industry is working towards making things more clear, and obvious improvement in this area has been occurring… I would also like to take a moment to welcome the new Board of the OAND! Congratulations and welcome aboard! Looking forward to another excellent convention in November. Sanjiv Jagota Publisher

4 www.ihpmagazine.com l October 2013

Products Professionals Prefer®

2013 Celebrating 25 years!!

1988 FROM PAUL RIVETT-CARNAC AND THE STAFF AT ST. FRANCIS HERB FARM…

HAPPY 25TH!!

CONGRATULATIONS TO OUR FOUNDERS, JEREMY AND MONIQUE RIVETT-CARNAC, FOR THEIR PERSEVERANCE AND DEDICATION IN ACHIEVING YET ANOTHER GREAT MILESTONE: THEIR FIRST QUARTER CENTURY PROVIDING HIGH QUALITY NATURAL HEALTH PRODUCTS TO CANADIANS

This year we’re pleased to celebrate our founders and the magnitude of the work they have accomplished. Their commitment to key core values, has formed and shaped us into the company that we are today. From the beginning, the desire to help others and instill hope have been the driving forces behind St. Francis. Thanks to Jeremy and Monique, our name and our brand inspire wholehearted trust and have become synonymous with quality and effectiveness.

Health Canada Site License 300242

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Kinomai Cream ™

Topical Pain Relief

Kinomai Product Line Product Monograph for IHP, October 2013 By Terry Vanderheyden, ND

Joint Soothing Cream – now with either Capsaicin or Essential Oil of Eucalyptus Cayenne pepper has been used for centuries as a topical analgesic1. It is evident from years of use and positive clinical trials that the isolated capsaicin blocks pain significantly more effectively than crude cayenne.2 More recent research reveals that soft tissue pains and backaches also respond well to topical capsaicin creams.3 In traditional herbalism, cayenne is said to have rubefacient properties. Rubefacients increase the blood circulation to an area, thereby relieving pain and speeding healing. Eucalyptus is also a well-known rubefacient. However, while cayenne warms, eucalyptus oil produces a cooling sensation topically. Eucalyptus oil is official in the Indian Pharmacopoeia as a rubefacient for relieving joint pains.4 In addition to the capsaicin or eucalyptus, Kinomai cream contains MSM and other botanical ingredients, including mullein, meadowsweet, willow bark, St. John’s wort, and frankincense: MSM – An anti-inflammatory and source of the essential sulphur mineral for joints, MSM is well known in terms of its oral use. Topically, MSM and its precursor, DMSO, aid a penetrating healing of the skin, acting as carriers for other herbal or drug ingredients. Mullein – Although known more widely as a herb for coughs, mullein is also recognized as a topical anti-inflammatory and analgesic for pain. As herbalist Kiva Rose affirms, “I … find that a [mullein] salve or liniment … greatly lessens chronic, achy arthritis of the hands, hips, and other achy areas.”5 Meadowsweet & willow bark – Willow has been traditionally used by native North Americans for pain-relieving and fever-reducing purposes.6 In Europe it was used in antiquity for pain and fever. Willow bark is official in the German Pharmacopoeia, and the country’s Commission E herbal authority approves the use of willow bark for “rheumatic ailments.”7 Meadowsweet has a similar salicylate profile and thus a similar analgesic profile to that of willow. St. John’s wort – A dramatically illustrative in-vivo trial has determined that St. John’s wort has “profound analgesic activity”, twice the analgesic effect, in fact, of ibuprofen.8 Frankincense – The three wise men were definitely on to something here with this ancient and venerable medicament. Acknowledged for centuries as an antiinflammatory agent, modern Chinese pharmacopoeias confirm its traditional uses for pain, swelling, and inflammation. Herbalist Alan Tillotson adds strikingly that frankincense, “can often … be used as an alternative to NSAIDs and steroids” for pain and inflammation.9 Contra-indications and Cautions: For external use only. Avoid contact with eyes and mucous membranes. Do not apply to wounds or damaged skin. Wash hands after use. Do not bandage tightly. Headache, erythema, redness, rashes and/or burning discomfort have been known to occur; in which case, discontinue use. Do not apply with external heat, such as an electric heating pad, as this may result in excessive skin irritation or burn.

Terry Vanderheyden, ND (Research Consultant) Since graduating from the CCNM in 1994, Terry Vanderheyden, ND, has practiced in Ontario, specializing in homeopathic, nutritional, and botanical therapies. Terry lives in Barry’s Bay with his wife Laurie and their 7 children.

References: 1. Finley Ellingwood M.D., ed. “Some Good Things About Capsicum.” Ellingwood’s Therapeutist 1908, 2(10). 2. BM Fusco, M Giacovazzo. “Peppers and pain. The promise of capsaicin.” Drugs 1997 Jun; 53(6): 909-14. 3. S Chrubasik, T Weiser, B Beime. “Effectiveness and Safety of Topical Capsaicin Cream in the Treatment of Chronic Soft Tissue Pain.” Phytotherapy Research 2010; 24: 1877–1885. 4. Mark Blumenthal et al., ed. Expanded Commission E Monographs, Newton, MA: Integrative Medicine Communications, 2000, pp. 120-123. 5. Kiva Rose. A Golden Torch: Mullein’s Healing Light, accessed online from http:// bearmedicineherbals.com/ 6. DE Moerman. Native American Ethnobotany. Cambridge, UK: Timber Press; 1998, pp. 500-09. 7. Mark Blumenthal et al. Op cit, pp. 408-12. 8. IA Bukahri, A Dar and RA Khan. “Antinociceptive Activity of Methanolic Extracts of St. John’s Wort (Hypericum perforatum) Preparation.” Pakistan Journal of Pharmaceutical Sciences July 2004; 17(2): 13-19. 9. Alan Keith Tillotson. The One Earth Herbal Sourcebook. New York: Kensington, 2001.

Products Professionals Prefer® Contact us today to place an order. call: 1.866.562.9131 | Fax: 1.866.353.0427 info@stfrancisherbfarm.com www.stfrancisherbfarm.com

Integrated Healthcare

Mag-Matrix Liquid

President | Olivier Felicio (416) 203-7900 ext. 6107 CEO | Cory Boiselle (416) 203-7900 ext. 6114 Controller & Operations | Melanie Seth CMO | Zinnia Crawford (416) 203-7900 ext. 6135

Advertising Information Sanjiv Jagota | Tel: (416) 203-7900 ext 6125 Email: sanjiv@ihpmagazine.com Jeff Yamaguchi | Tel: (416) 203-7900 ext 6122 Email: jeff@gorgmgo.com Jason Cawley | Tel: (416) 203-7900 ext 6134 Email: jason@gorgmgo.com Erin Poredos | Tel: (416) 203-7900 ext 6128 Email: erin@gorgmgo.com Circulation Garth Atkinson | Publication Partners 345 Kingston Rd., Suite 101 Pickering, Ontario, L1V 1A1 Telephone: 1-877-547-2246 Fax: 905-509-0735 Email: ihp@publicationpartners.com

is a unique blend of highly absorbable magnesium sources — magnesium glycinate, malate and citrate — available in a format compatible for all patients, a delicious liquid.

Combining the most bioavailable forms of magnesium in a pleasant light tasting liquid format allows for prompt action in the body and maximum patient adherence. Mag-Matrix LiquidTM is ideal for both children and adults.

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Truly a benefit for your patients!

ihp magazine is pleased to review unsolicited submissions for editorial consideration under the following conditions: all material submitted for editorial consideration (photographs, illustrations, written text in electronic or hard copy format) may be used by ihr Media Inc. and their affiliates for editorial purposes in any media (whether printed, electronic, internet, disc, etc.) without the consent of, or the payment of compensation to, the party providing such material. Please direct submissions to the Editor, ihp magazine.

1 866 783-7504 www.cyto-matrix.com September 2013 l www.ihpmagazine.com 7

contents

This Issue: October 2013 • Vol. 6 • No. 5

34 Dr Francesco Anello, MD Cover Story

Excellence in integrative medicine

Clinic Profile

42 HealthSource Integrative Medical Centre

Leaders in the Community – providing results for patients

49 The Journal of IHP

Peer-reviewed articles on clinically revelant topics

Coming Next Issue ➜ In vivo metabolism of alpha linoleic acid (ALA) ➜ Chemotherapy- related cognitive impairment ➜ Comprehensive management of neurodegeneration

8 www.ihpmagazine.com l October 2013

Departments

4 Publisher’s Letter 11 Research News 20 Industry News 28 Calendar 31 Product Profiles 50 Editor’s Letter 54 Peer Review Board 58 Editorial Board 81 Continuing Education: Breaking it down:

The role of acid-base balance in the pathogenesis and treatment of osteoporosis

Fem Adapt R estore

M enopause

P hytoestrogen Empowered Health | Empowered You

ADVANCED

ORTHOMOLECULAR RESEARCH

IHP - Womens Health-FEM Adapt Oct 2013.indd 1

10/1/2013 8:56:21 AM

AOR Fem Adapt – Product Monograph General Overview Fem Adapt from AOR is formulated to help reduce the symptoms of menopause. The ingredients in Fem Adapt act to balance hormone levels and improve symptoms including hot flashes, night sweats and mood imbalances. Studies have shown that phytoestrogens such as lignans from flax and genistein from soy isoflavones have direct effects on some of the hormonal pathways that are involved in menopausal symptoms. The formula also protects against other potential health problems faced by menopausal women, including heart disease, osteoporosis and female cancers. Ingredients: Flax Lignans (from Linum usitatissimum L. extract) SDG or secoisolariciresinol diglucoside from flax (Linum usitatissimum) is a specialized lignan that has high bioavailability due to the monomers compared to the large polymers usually found in traditional flax supplements. Lignans are naturally occurring compounds found in the cell walls of plants such as fruits, vegetables, nuts and seeds such as flax (Linum usitatissimum). They are transformed in the colon to enterodiol and enterolactone which are then absorbed into the body via enterohepatic circulation. Studies show that enterolactone and enterodiol are helpful in conditions associated with estrogen deficiency (Wang C. et al, 1994; Adlercreutz H. et al, 1982). Studies with flax lignan extracts have demonstrated a variety of beneficial effects including a reduction in inflammatory markers, lowered cholesterol levels, and anticarcinogenic effects in animal studies of breast, ovary and colon cancers (Wang C. et al, 1994; Adlercreutz H. et al, 1982). Lignan supplementation has also been shown to increase the production of 2-hydroxyestrogen. (Haggans C. et al., 1999). Research shows having a higher ratio of 2-hydroxyestrogen to 16α-hydroxyestrogen is protective against estrogen dependent cancers. Enterolactone and enterodiol in clinical trials have been shown in both human and animal models to inhibit tumor growth (Adlercreutz H. et al, 1982). Genistein In Asia, only 10-20% of menopausal women experience hot flashes, while in North America 70-80% of women experience hot flashes (Messina M. et al., 2008; Cheng, G., 2007). Researchers have hypothesized that this difference is due to dietary factors, including the consumption of isoflavones found in soy. Genistein is one of the key isoflavones found in soy and has been researched in menopausal women due to its structural similarity to estrogen, making it a phytoestrogen. Several clinical trials have shown genistein supplementation to reduce the number and severity of hot flashes during menopause (Messina M. et al., 2008; Cheng, G., 2007; Williamson-Hughes et al., 2006). Genistein also appears to selectively bind to estrogen receptors, serving as a natural alternative to conventional hormonal therapy (HRT), which has been associated with an increased risk of breast cancer, stroke, venous thromboembolism and coronary heart disease. Additionally, subjects supplemented with genistein in a 2 year clinical trial experienced an improvement in bone mineral density (BMD), as well as a significant decrease in bone fracture risk (Marini H. et al., 2007). It binds more strongly to ER-β than ER-α, which then competes with estradiol for binding to these estrogen receptors. The β -estrogen receptor predominates in the heart, vasculature, bone, and bladder and may account for some of genistein’s beneficial effects. Genistein binds weaker to ERs than estradiol, and induces estrogenic effects with less potency than estradiol. This suggests that genistein selectively binds to estrogen receptors, serving as a natural alternative to conventional hormonal therapy, which has been associated with an increased risk of breast cancer, stroke, venous thromboembolism and coronary heart disease. Black Cohosh Black cohosh is a flowering plant native to North America originally used by the Native Americans. The effects of black cohosh on menopausal symptoms such as hot flashes and night sweats are under scrutiny, as are its traditional uses for pain related to PMS and its content of estrogen-like compounds. However, more recent research has revealed that black cohosh may have serotonin-like compounds that activate serotonin receptors (Burdette J. et al., 2003). This is important because low mood and depression can be secondary symptoms to menopause and PMS. In addition, newer clinical studies have shown that compounds in black cohosh may inhibit the formation of osteoclasts which are cells that break down bone (Qiu, S. 2007). Bone loss is one of the top concerns among post-menopausal women. For these reasons, black cohosh is still considered to be advantageous for menopausal women. Hops Lifenol® is a patented hops extract which has been clinically studied in France in menopausal women. Hops have been used in the beer industry for hundreds of years but in 1988 one of the active components of hops – 8-prenylnaringenin (8PN) was identified as having estrogenic properties; it is considered the most potent phytoestrogen. 8PN has been shown to have a higher affinity for estrogenic receptors than coumesterol from clover or genistein or dadzein from soy due to a unique side chain. Two studies have shown that 8PN reduced hot flashes and may be a good adjunct to other post-menopausal treatments (Heyerick A et al., 2006). SUPPLEMENT FACTS Serving size: 2 Capsules Linum usitatissimum L. extract (80-120:1) Soy Isoflavone Extract -Total isoflavones -Genistein/Genistin

168 mg 60 mg 14.2 -18.2 mg AIE* 8.4 -10.2 mg AIE*

Black Cohosh extract (15-20:1)

80 mg

LIFENOL® Hops extract (15-25:1)

120 mg

*AIE : Aglycone Isoflavone Equivalents Clinical Indications: Safety: The ingredients in this product have been extensively tested in human clinical trials and have been proven safe and effective at the recommended dosage. Caution: Ensure you are up-to-date on mammograms and gynecological evaluations prior to use. Consult a health care practitioner prior to use if you are breastfeeding, taking blood thinners, have a history of hormonal or gynecological disease including ovarian cancer, endometriosis or uterine fibroids, have a liver disorder or develop liver-related symptoms (e.g. abdominal pain, jaundice, dark urine), are taking hormone replacement therapy (HRT) including thyroid hormone replacement therapy or have depression or related diseases. Discontinue use and consult a health care practitioner if you experience breast pain, discomfort or tenderness or if you experience a recurrence of menstruation and/or uterine spotting. Do not use if you are pregnant, if you currently have or previously had breast cancer or breast tumours, have a predisposition to breast cancer as indicated by an abnormal mammogram, biopsy or have a family member with breast cancer. Consumption with alcohol, other medications or natural health products with sedative properties is not recommended. Some people may experience drowsiness. Exercise caution if operating heavy machinery, driving a motor vehicle or involved in activities requiring mental alertness. Hypersensitivity such as an allergy has been known to occur in rare cases, in which case discontinue use. Consult a health care practitioner if symptoms persist or worsen. This product contains soy. Dose and Administration: (menopausal and post-menopausal women): Take 2 capsules daily, or as directed by a qualified health care professional. Take a few hours before or after taking other medications or natural health products. Consult a health care practitioner for use beyond one year. References: Adlercreutz H. et al. Determination of urinary lignans and phytoestrogen metabolites, potential antiestrogens and anticarcinogens, in urine of women on various habitual diets. J Steroid Biochem 1986;25:791-7. Adlercreutz H. et al. Excretion of the lignans enterolactone and enterodiol and of equol in omnivorous and vegetarian postmenopausal women and in women with breast cancer. Lancet 1982;2:1295-9. Burdette J. et al. Black cohosh acts as a mixed competitive ligand and partial agonist of the serotonin receptor. J Agric Food Chem. 2003 Sep 10;51(19):5661-70. Cheng, G. et al. Isoflavone treatment for actue menopausal symptoms. Menopause. 2007; 13(3): 468-473. Erkkola R. et al. A randomized, double-blind, placebo-controlled, cross-over pilot study on the use of a standardized hop extract to alleviate menopausal discomforts. Phytomedicine. 2010 May;17(6):389-96. Haggans CJ. et al. Effect of flaxseed consumption on urinary estrogen metabolites in postmenopausal women. Nutr Cancer. 1999;33(2):188-95. Heyerick A. et al. first prospective, randomized, double-blind, placebo-controlled study on the use of a standardized hop extract to alleviate menopausal discomforts. Maturitas. 2006 May 20;54(2):164-75. Kapiotis S. et al. Genistein, the dietary-derived angiogenesis inhibitor, prevents LDL oxidation and protects endothelial cells from damage by atherogenic LDL. Arterioscler Thromb Vasc Biol 1997;17:2868-74. Marini H. et al. Effects of the phytoestrogen genistein on bone metabolism in osteopenic postmenopausal women. Ann Intern Med 2007: 146:839-847. Messina M. and Wood C. Soy Isoflavones, estrogen therapy, and breast cancer risk: Analysis and commentary. Nutrition Journal 2008, 7:17. Powell S et al. In vitro serotonergic activity of black cohosh and identification of N(omega)-methylserotonin as a potential active constituent. J Agric Food Chem. 2008 Dec 24;56(24):11718-26. Qiu SX et al. A triterpene glycoside from black cohosh that inhibits osteoclastogenesis by modulating RANKL and TNFalpha signaling pathways. Chem Biol. 2007 Jul;14(7):860-9. Wang C et al. Lignans and flavonoids inhibit aromatase enzyme in human preadipocytes. J Steroid Biochem Mol Biol 1994;50:205-12. Williamson-Hughes, P et al. Isoflavone supplements containing predominately genistein reduce hot flash symptoms: a critical review of published studies. Menopause. Vol 13, No 5, 831-839.

research news The role of Mediterranean diet on the risk of pancreatic cancer

Prophylactic probiotics to prevent Clostridium difficile

This study analyzed data from two case-control studies from Italy between 1983 and 2008, including 362 and 326 pancreatic cancer cases and 1552 and 652 hospital controls. A Mediterranean Diet Score (MDS) summarizing the major characteristics of the Mediterranean diet was used in the two studies separately and overall. Two further scores of adherence to the diet were applied in the second study, using the Mediterranean Dietary Pattern Adherence Index (MDP) and the Mediterranean Adequacy Index (MAI). The results showed that the odds ratios for increasing levels of scores (indicating increasing adherence) were estimated using multiple logistic regression models. Odds ratio for a MDS score of 6 compared with less than 3 was 0.57 in the first study, 0.51 in the second study, and 0.48 overall. A trend of decreasing risk was observed also for

This study was a prospective cohort study evaluating the effect on Clostridium difficile infections following antibiotic administration (CDIAA) of a probiotic added to existing C. difficile infection (CDI) standard preventative measure in 31,832 hospitalized patients receiving antibiotics. Phase I (1580) measured the impact of standard preventative measures alone. In Phase II, 50 to 60 × 109 cfu daily dose of oral Lactobacillus acidophilus CL1285 and L. casei LBC80R probiotic

the MDP and MAI the odds ratios for the highest versus the lowest quintile being 0.44 for MDP and 0.68 for the MAI. The results were consistent across strata of age, sex, education, body mass index, alcohol drinking, tobacco smoking, and diabetes. The authors conclude that the Mediterranean diet is favourably associated with decreased pancreatic cancer risk. Br J Cancer. 2013 August. PMID: 23928660

Efficiency and safety of electronic cigarette as tobacco cigarette substitute Electronic cigarettes (e-cigarettes) are becoming popular since their introduction a few years ago. This study was a prospective 12-month randomized, controlled trial that evaluated smoking reduction and abstinence in 300 smokers not intending to quit, experimenting two different nicotine strengths of a popular e-cigarette, compared to its non-nicotine choice. One group (n = 100) received 7.2mg nicotine cartridges for 12 weeks, the second group (n = 100) received 6 weeks of 7.2mg followed by 6 weeks of 5.4mg, and the third group (n = 100) received no-nicotine cartridges for 12 weeks. The study consisted of nine visits during which cig/day use and exhaled carbon monoxide levels were measured. Smoking reduction and abstinence rates were calculated. The results showed that there were declines in cig/day use and exhaled carbon monoxide in all three groups, with no consistent differences among study groups. Smoking reduction was documented in 22.3% and 10.3% at week-12 and week-52 respectively. Withdrawal symptoms were infrequently reported. The authors conclude that in smokers not intending to quit, the use of e-cigarettes, with or without nicotine, decrease cigarette consumption and elicited enduring tobacco abstinence with minimal side effects. PLoS One. June 2013. PMID: 23826093.

formula was administered to all patients receiving antibiotics. Phase III included the same intervention after a move to a new hospital facility. Phases II and III included 4968 patients. During Phase IV, 25,284 patients were submitted to the same regimen but outcome data were compared to those of similar hospitals in Quebec. At the end of Phase III, CDIAA had decreased from more than 18 cases per 1000 patient admissions in Phase I to less than 5 cases. Reductions of CDI cases (73%) were observed. CDI recurrence rate was reduced by 39%. During the following 6 years, the CDI rate averaged 2.71 cases per 10,000 patient-days compared to 8.50 cases per 10,000 patient-days in equivalent hospitals located in Quebec. Curr Med Res Opin. 2013 August. PMID: 23931498

October 2013 l www.ihpmagazine.com 11

research news Low CSF concentration of mitochondrial DNA in preclinical Alzheimer’s disease This study attempted to identify a novel biochemical marker that precedes clinical symptoms of Alzheimer’s disease (AD). Using quantitative PCR techniques, the authors measured circulating cell free mitochondrial DNA (mtDNA) in cerebrospinal fluid (CSF) from study participants, selected from a cohort of 282 subjects that were classified according to their concentrations of Aβ1-42, t-tau and p-tau and by the presence or absence of dementia, including asymptomatic subjects at risk of AD, symptomatic patients diagnosed with sporadic AD, pre-symptomatic subjects carrying pathogenic PSEN1 mutations and patients diagnoses with Fronto-temporal Lobar Degeneration (FTLD). They performed equivalent studies in a separate validation cohort of sporadic AD and FTLD patients. They measured mtDNA copy number in cultured cortical neurons from mutant Amyloid Precursor Protein/Presenilin1 transgenic mice. The results showed that asymptomatic patients at risk of AD and symptomatic AD patients, but not FTLD patients, exhibit a significant decrease in circulating cell free mtDNA in the CSF. The authors conclude that the low content of mtDNA in CSF may be a novel biomarker for the early detection of preclinical AD. These findings also support the hypothesis that mtDNA depletion is a characteristic pathophysiological factor of neurodegeneration in AD. Ann Neurol. 2013 Jun. PMID: 23794434

Exercise to improve sleep in insomnia: bidirectional effects Exercise improves sleep quality, mood, and quality of life among older adults with insomnia. This study evaluated the daily bidirectional relationships between exercise and sleep in a sample of women with insomnia. Participants included 11 women with insomnia who engaged in 30 minutes of aerobic exercise 3 times per week. Self-reported sleep quality was assessed at baseline and at 16 weeks. Sleep and exercise logs and wrist activity were collected continuously. The results showed that total sleep time, sleep efficiency, and self-reported global sleep quality improved from baseline to 16 weeks. Baseline ratings of sleepiness were negatively correlated with exercise session duration. Daily exercise was not associated with subjective or objective sleep variables during the corresponding night. However, participants had shorter exercise duration following nights with longer sleep onset latency. Total sleep time at baseline moderated the daily relationship between total sleep 12 www.ihpmagazine.com l October 2013

time and next day exercise duration. The relationship between shorter total sleep time and shorter next day exercise was stronger in participants who had shorter total sleep time at baseline. The authors conclude sleep influences next day exercise rather than exercise influencing sleep and that improving sleep encourages exercise participation. J Clin Sleep Med. 2013 August. PMID: 23946713

Effects of habitual coffee consumption on cardiovascular health and all-cause mortality The biological effects of coffee may be substantial and are not limited to the actions of caffeine. Coffee is a complex beverage containing hundreds of biologically-active compounds and the health effects of chronic coffee are wide-ranging. This review examined

the effects of coffee consumption on cardiovascular health and all-cause mortality. From a cardiovascular standpoint, coffee consumption may reduce the risks of type 2 diabetes mellitus and hypertension, as well as other conditions such as obesity and depression, but it may adversely affect lipid profiles depending on how the beverage is prepared. A growing body of data suggests that habitual coffee consumption is neutral to beneficial regarding the risks for a variety of adverse cardiovascular outcomes, including coronary heart disease, congestive heart failure, arrhythmias, and stroke. Large epidemiological studies suggest that regular coffee drinkers have reduced risks for mortality, both cardiovascular and all-cause. The potential benefits also include protection against neurodegenerative diseases, improved asthma control, and lower risk of select gastrointestinal diseases. Most of the data are based on observational data, with very few randomized controlled studies and an association does not prove causation. J Am Coll Cardiol. 2013 July. PMID: 23871889

research news ADHD associated with atopic diseases and skin infections

Gleason grade progression is uncommon The Gleason grade is used for pathological scoring of the differentiation of prostate cancer. This study examined 1207 Physicians’ Health Study and Professionals Follow-up Study participants diagnosed with prostate cancer from 1982 to 2004 and treated with prostatectomy. They compared the distribution of grade and clinical stage across the pre-PSA and PSA screening eras. The authors reviewed grade using the ISUP 2005 revised criteria. The proportion of advanced staged tumors dropped more than six-fold, from the earliest period, 19.9% stage ≥T3, to latest, 3% stage T3,

none T4. The proportion of Gleason score ≥8 decreased substantially less from 25.3% to 17.6%. A significant interaction between stage and diagnosis date predicting grade suggests that the relationship between grade and stage varies by time period. As the dramatic shift in stage since the introduction of PSA screening was accompanied by a more modest shift in Gleason grade, these findings suggest that grade may be established early in tumour pathogenesis. The authors conclude that this has implications for the understanding of tumour progression and prognosis and may help patients diagnosed with lower grade disease feel more comfortable choosing active surveillance. Cancer Res. 2013 August. PMID: 23946472

This study examined data to uncover whether there is a relationship between attention-deficit/hyperactivity disorder (ADHD) and allergies. In particular, the authors investigated if children with ADHD would be more likely to have a history of atopic disorders, skin infections, and medical prescriptions than those without ADHD. A nested case-control study among boys using the UK General Practice Research Database was conducted. Four controls who had neither ADHD nor ADHD drug prescriptions in their medical

Effects of caloric intake timing on insulin resistance in women with PCOS In women with polycystic ovarian syndrome (PCOS), hyperinsulinaemia stimulates ovarian cytochrome P450c17α activity that stimulates ovarian androgen production. The objective of this study was to compare whether timed caloric intake differentially influences insulin resistance and hyperandrogenism in lean PCOS women. A total of 60 lean PCOS women (BMI 23.5-24) were randomized into two isocaloric maintenance diets with different meal timing distribution: a breakfast diet of 980 kcal breakfast, 640 kcal lunch and 190 kcal dinner, or a dinner diet of 190 kcal breakfast, 640 kcal lunch and 980 kcal dinner for 90 days. In the breakfast diet group, a significant decrease was observed in both glucose area under the curse, insulin area under the curve by 7 and 54% respectively. In the breakfast group, free testosterone decreased by 50% and sex hormone-binding globulin increased by 105%. Gonadotropin-releasing hormone-stimulated peak serum 17OHP decreased by 39%. No change in these parameters was observed in the dinner group. Women in the breakfast group had an increased ovulation rate. In lean PCOS women, a high caloric intake at breakfast with reduced intake at dinner results in improved insulin sensitivity indices, which ameliorates hyperandrogenism and improves ovulation rate. Clin Sci (Lond). 2013 Nov. PMID: 23688334

records were matched to each case on age and general practice. 884 boys with a first-time diagnosis of drugtreated ADHD and 3536 controls were identified. The independent odds ratios adjusted for age and presence of low birth weight or preterm delivery were 1.4 for a medical history of asthma, 1.5 for impetigo, and 1.5 for any antihistamine drug prescriptions. Other exposures that were more common in cases than controls were cow’s milk intolerance and any prescriptions from the drug categories antiasthmatics, respiratory corticosteroids, topical steroids, antibacterials, or antifungals. The authors conclude that this study lends support to the emerging evidence that childhood ADHD is associated with atopic diseases and impetigo. Ann Allergy Asthma Immunol. 2013 August. PMID: 23886227

October 2013 l www.ihpmagazine.com 15

research news Decreased gut microbiota diversity in infants delivered by Caesarean section Early intestinal microbiota exerts important stimuli for immune development and a reduced microbial exposure and Caesarean section (CS) have been associated with the development of allergic disease. In this study, the authors addressed how microbiota development in infants is affected by mode of delivery, and relate differences in colonization patterns to the maturation of a balanced Th1/Th2 immune response. The study was designed such that the postnatal intestinal colonization patter was investigated in 24 infants, born vaginally (15) or by CS (9). The intestinal microbiota were characterized using pyrosequencing of 16S rRNA genes at 1 week, and 1, 3, 6, 12, and 24 months after birth. Venous blood levels of Th1- and Th2- associated chemokines were measured at 6, 12, and 24 months. The results showed that infants born through CS had lower total microbiota diversity during the first 2 years of life. CS delivered infants also had a lower abundance and diversity of the Bacteroidetes phylum and were less often colonized by the Bacteroidetes phylum. Infants born through CS had significantly lower levels of Th1- associated chemokines CXCL10 and CXCL11 found in the blood. Gut 2013 August. PMID: 23926244

Glucose levels and risk of dementia Diabetes is a risk factor for dementia, but it is unknown whether higher glucose levels increase the risk of dementia in people without diabetes. 35,264 clinical measurements of glucose levels and 10,208 measurements of glycated hemoglobin levels from 2067 participants without dementia were taken to examine the relationship between glucose levels and the risk of dementia. Participants were from the Adult Changes in Thought study and include 839 men and 1228 women whose mean age at baseline was 76 years, 232 participants had diabetes and 1835 did not. The authors fit Cox regression models, stratified according to diabetes status and adjusted for age, sex, study cohort, educational level, level of exercise, blood pressure, and other factors. The results showed that during a mean follow-up of 6.8 years, dementia developed in 524 participants. Among participants without diabetes, higher average glucose levels within

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the preceding 5 years were related to an increased risk of dementia. Among participants with diabetes, higher average glucose levels were also related to an increased risk of dementia. The authors conclude that higher glucose levels may be a risk factor for dementia, even among persons without diabetes. N Engl J Med. 2013 August. PMID: 23924004

High-dose Vitamin D treatment reduces blood pressure This randomized controlled trial examined the impact of 25-hydroxyvitamin D levels and high-dose vitamin D supplementation on isolated systolic hypertension. This was a parallel group, double-blind, placebo-controlled randomized trial. Primary care clinics and hospital clinics were utilized and participants were 70 years and older

with systolic hypertension, as well as baseline 25-hydroxyvitamin D levels less than 30 ng/mL. The intervention was 100,000 U of oral cholecalciferol or matching placebo every 3 months for 1 year. The measurements included office blood pressure, arterial stiffness, endothelial function, cholesterol level, insulin resistance, and b-type natriuretic peptide level during 12 months. 159 participants were randomized. Mean baseline office systolic blood pressure was 163/78 mmHg. Mean baseline 25-hydroxyvitamin D level was 18 ng/mL. 25-hydroxyvitamin D levels increased in the treatment group compared with the placebo group. No significant treatment effect was seen for mean office blood pressure. No significant treatment effect was evident for any secondary outcome, including arterial stiffness, cholesterol levels, and others. There was no excess of adverse events in the treatment group and the total number of falls was non-significantly lower in the group receiving vitamin D. JAMA Intern Med. 2013 August. PMID: 23939263

HairGrow Tech IHP FullPg.qxp:Educational ad

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testosterone to DHT (which is the primary molecule that causes hair loss). The SDG from flax lignans in both formulas also decreases excess cholesterol - the building block of testosterone. Based on new research on the rate of metabolism of SDG in flax lignans (8-12 hours on average), the dosage in both products has been revised from once a day to twice a day for optimum results.

Twice the Strength! Double the Power! Bio-Fen® Plus for Men: The mechanism that causes AGA in men follows the same pathway that results in benign prostatic hyperplasia (BPH). For example, the prescription drug finasteride also works by blocking the enzyme 5αreductase and is used as a treatment for both BPH and AGA. For AGA it is marketed under the brand name of Propecia, but the exact same molecule for BPH is sold under the name of Proscar. Hair Grow Technology’s Bio-Fen® product line is continually moving forward! We are introducing our two latest versions; Bio-Fen® Plus for Men and Bio-Fen® Plus for Women. These products have been assigned Natural Product Numbers (NPN’s) by the Natural Health Products Directorate (NHPD) of Health Canada. We recognize that both men and women experience androgenic alopecia (AGA, or male / female pattern baldness) and have made some improvements to the original formulation based on the latest science to address their specific needs. You will notice that we now have additional complementary (Health Canada Approved) health claims on each product.

What causes hereditary hair loss? Each hair grows from a pocket in the skin called the hair follicle. During its growing phase the follicle has a bulb-shaped bottom, the center of which is called the dermal papilla. The paplla is fed by very small blood vessels, which bring it food, oxygen and remove wastes. The papilla is highly sensitive to hormones and chemicals secreted by the body (or ingested as a medicine) which impacts hair growth It is believed that some individuals have a genetic predisposition to a receding hairline (most common in men) or hair (follicle) thinning over larger areas of the scalp (more common in women). These conditions result from hormonal changes caused by an enzyme in the dermal papilla called 5-alpha-reductase. This enzyme breaks down the hormone testosterone into dihyrotestosterone (DHT). Over a period of time, an over abundance of DHT causes the hair follicle to degrade and shortens the active phase of the hair, eventually leading to thinner hair and eventual hair loss.

How does Bio-Fen® PLUS work? We are bringing you two new products with double the number of capsules and triple the number of health claims for men and four times the number of health claims for women, As in the previous formulation, the fenugreek seed extract in both new formulas reduces excess blood lipid levels (hyperlipidemia). Fenugreek contains β-sitosterol, an active plant sterol, which has been shown to inhibit 5-alphareductase activity – the enzyme responsible for converting excess

As before, the saw palmetto extract inhibits the enzyme 5-alpha reductase, and this action slows down the conversion of testosterone to dihydrotestosterone (or DHT) – the overabundance of which causes the miniaturization of hair follicles. This activity of the saw palmetto also helps to relieve the urinary symptoms of mild to moderate BPH for men. The saw palmetto that originally was an extract standardized to 45% free fatty acids, esters, and sterols while the new formula is a 4:1 extract to support the BPH claim. The product still contains these molecules for hair loss, but they are now at proprietary amounts based on our research so that the competition cannot duplicate our formula.

Bio-Fen® Plus for Men will also help to: • Relieve the urologic symptoms associated with mild to moderate benign prostatic hyperplasia - BPH (e.g. weak urine flow, incomplete voiding, frequent daytime and night time urination). • Reduce elevated blood lipid levels / hyperlipidemia.

Bio-Fen® Plus for Women: The women’s formula is almost the same as the men’s formula. The mechanisms and results for the women formula is the same. The only difference is it contains silicon and iron instead of saw palmetto. Silicon has been shown to contribute to hair shaft strength and thus healthy hair growth. It also contains iron which helps prevent iron deficiency. A number of studies have related sub-clinical iron deficiency in women to diffuse hair loss/alopecia. The increased amount of SDG and other revisions to the regulations allow us to make some additional health claims for Bio-Fen® Plus for Women.

Available at Health Food Stores and Independent Pharmacies

Hair Grow Technology Inc.

•

Bio-Fen® Plus for Women will also help to: • Reduce elevated blood lipid levels/hyperlipidemia • Prevent iron deficiency. • Metabolize carbohydrates, fats and proteins.

How long must I use Bio-Fen® Plus? Bio-Fen® Plus for Men capsules are usually effective at stopping hair loss within the first two months. However, since healthy hair grows only about 1 cm each month, it may take up to three months before you notice that hair growth is increased or the rate of hair loss is decreased. Anyone experiencing new growth should see it within four months. In some people the original pigmentation may come back. Once you stop completely your hair growth pattern will slowly go back to the point where you started. However, some people may be able to go with a lower maintenance dose.

Why has the recommended dose doubled? Based on new research on the rate of metabolism of SDG in flax lignans (8-12 hours on average), the dosage in both products has been increased to twice a day for optimum results. The flax lignan extract in the original formulation was 100 mg standardized to 20% SDG x 1 capsule per day, which equaled to 20 mg/day of SDG. The new formulations have 200 mg per capsule of flax lignan extract standardized to 50% SDG x 2 caps/day equals 200 mg/day of SDG. As such, one is getting 10 times the amount of SDG per day!.

How safe is Bio-Fen® Plus? The ingredient combination in Bio-Fen® Plus is generally safe for most adults. However, the following cautions are advised: For Men: Consult a health care practitioner prior to use to exclude a diagnosis of prostate cancer, or if you have diabetes. For BPH or elevated blood lipid levels, consult a health care practitioner if symptoms persist or worsen. People sensitive to niacin may experience flushing of the skin that is generally mild and transient. Discontinue use if you experience hypersensitivity to flax, such as an allergy (may occur in rare cases). For Women: Consult a health care practitioner prior to use if you are pregnant or if you have diabetes. Consult a health care practitioner if elevated blood lipid levels persist or worsen. People sensitive to niacin may experience flushing of the skin that is generally mild and transient. Discontinue use if you experience hypersensitivity to flax, such as an allergy (may occur in rare cases). Because of the iron content, some people may experience constipation, diarrhea and/or vomiting. Keep out of the reach of children. There is enough iron in this package to seriously harm a child.

1-866-424-7745 • www.biofen.com

PRODUCT MONOGRAPH Bio-Fen Bio-Fen Plus is an oral natural health product used in the treatment of hereditary androgenic alopecia (AGA) for male or female pattern baldness. Without treatment, AGA is progressive, and causes social distress for in many men and women (Sinclair 1998). Bio-Fen Plus contains extracts BIO-FEN Menaffected and Women of fenugreek seeds, saw palmetto berries and flax lignans, as well as specific vitamins. Each ingredient is known to possess inhibitors of the enzyme 5α-reductase. are responsible for relieving symptoms associated withPlus hereditary AGA. Bio-Fen represents aThese line of inhibitors products approved by Health Canada for hair growth and restoration. Bio-Fen for Men and Bio-Fen Plus for Women are both oral natural health One of the primary causes hair loss is and a high level of hereditary the maleandrogenic hormonealopecia dihydrotestosterone (DHT) within the hair follicle (Vierhapper, 2001). products (NHPs) which support hairofgrowth in men women with (AGA), or female/male pattern baldness. Bio-Fen contains a combination of herb extracts andwith vitamins & minerals that are known inhibit the enzymeof 5 androgen -reductase (5AR), a keyto pathway in the progression of AGA. catalyzes the enzymatic For people AGA, their follicles have atogreater number receptors whichimplicated DHT attaches. 5-α-reductase conversion of testosterone to dihydrotestosterone, which binds to the receptor five-fold more avidly than the parent compound (Sinclair 1998). AGA Pathophysiology One of the primary causes of hair loss is a high level of the male hormone, dihydrotestosterone (DHT) within the hair follicle (Hoffmann 2002). DHT is produced from Saw palmetto repens) testosterone in the(Serenoa testes (males), the adrenal glands, and the follicle. After a period of time, anVitamins over abundance of DHT causes the hair follicle to degrade and shortens the active phase of the hair,(lipophillic) eventually leading to thinning hairbeen and eventual Thereinhibitor is a familial In tendency forstudy stepwise the hair follicle and an increase in the calcium ratio a Polish of miniaturization 46 women whoof had symptoms of diffuse alopecia, Standardized Serenoa extract has found tohair be loss. a potent of of telogen (resting phase) to anagen (growthtissue phase)DHT. hairs, which is promoteddose by systemic effects of was androgens. Althou gh everyone thosemg with pantothenate orally administered twiceproduces a day inDHT, dosesonly of 100 fora four to 5α-reductase, resulting in decreased An open-label, responseand local higher of androgen in their binding sitesof fora DHT, and greater five androgen sensitivity experience hairinjected loss (Prager 5AR forrepeated the 30 days and months, and vitamin B6 was every2002). day for 20istoresponsible studynumber was conducted onreceptors 42 healthy maleshair to follicles, determine the effect combination conversion of testosterone to dihydrotestosterone, binds to the sameon androgen but with five-fold greater(Brzezińska-Wcisło affinity. (Hoffmann 2001). 2002, Trueb again after six months It was2002) determined that vitamin of carotenoid astaxanthin and saw palmettowhich berry lipid extract DHT receptor, and

testosterone levels (Angwafor 2008). The men were divided into two groups:

B6 administered parenterally for a few weeks induces improvement in the hair

Flax condition in subset women and Flax reduces hair are loss. onelignans groupinhibit received 800 mg/day of the combination supplement the other Flax the enzyme 5AR, thus balancing formation of the maleand hormones that are responsible fora hair lossof(Evans 1995). lignans converted by the body to group received 2000 mg/daywith of the supplement for 14 days. ANOVA-RM enterolactones, which compete estrogen and testosterone for receptor binding,showed and increase sex hormone binding globulin (SHBG), resulting in lower levels of free (ie active) significant within-group increases in serum testeosterone significant estrogen and testosterone. Flaxseed has been shown total to reduce serum levelsand of 17-beta-estradiol and estrone sulfate (Hutchins 2001), and results in a shift in estrogen metabolism to Medicinal Ingredients Dose Per Capsule decreases serum DHT baseline in both favor the lessin biologically activefrom estrogens (Brooks 2004).dose groups (P=0.05). There

was no significant difference between dose groups with regard to the increase of

Fenugreek (Trigonella foenum graecum)

Fenugreek 260 mg testeosterone or the decrease of DHT; therefore both doses were effective (Angwafor seed extract 4:1 Fenugreek 2008). has been used traditionally as an oral and topical treatment for hair loss. Plant sterols contained in fenugreek such as -sitosterol have been shown to block DHT receptor sites (Prager 2002, see below).

Saw palmetto berry extract containing

160 mg

Another study tested liposterolic extract of Serenoa repens (LSESr) and beta45% free fatty acids Saw Palmetto (men’s product) sitosterol inextract the treatment of males (23-64 of age)resulting with mild to moderate AGA. Saw palmetto is a potent inhibitor of 5 years -reductase, in decreased tissue DHT (Prager 2002). In a pilot study of 26 men with mild to moderate AGA, treatment with Flax lignans, standardized toblinded 20% assessors (Prager 2002). In a meta Six of 10 (60%) subjectssaw were rated asextract improved at and the beta-sitosterol final visit, thus50mg establishing a combination of lipophilic palmetto 200mg improved symptoms by up to 60%, as scored by 100 mg diglucoside the effectiveness of 5α-reductase inhibitors AGA (Prager 2002). Chronic analysis by the Cochrane group, saw palmetto hasagainst also been found to be effective as a treatment secoisolariciresinol for symptoms of BPH (Wilt 2002). (SDG) inflammation of the hair follicle is considered to be a contributing factor for AGA. A

D-calcium pantothenate (Vitamin B5) 10.40 mg Silica (women’s product) study by Chittur et al sought to determine whether blockade of inflammation using Silica is a and tracetwo mineral that has been found to increase hydroxyproline in connective tissue (Barel 2005). In a randomized, double blind, placebo controlled study, 50 LSESr anti-inflammatory agents (carnitine and thiocticconcentration acid) could alter Niacinamide (Vitamin B3) 10.25 mg women with damaged skin weremarkers treated orally with 10mg silica as orthosilicic the expression of molecular of inflammation (Chittur 2009). It acid was (OSA) found daily for 20 weeks. The treatment group reported a significant decrease in visual analog scale ratings of hair brittleness (Barel 2005). A second randomized, double blind, placebo controlled trial conducted in 50 women with brittle hair found that 10mg silica as OSA Pyridoxine HCl (Vitamin B6) 2 mg that the combination suppressed lipopolysaccharide-activated gene expression of for 9 months significantly improved hair elasticity, breakage, and diameter (thickness) (Wickett 2007). chemokines associated with pathways involved in inflammation and apoptosis.

Riboflavin (Vitamin B2)

1.58 mg

Folic acid

0.095 mg

study thatcell 5-alpha inhibitors in combination withmetabolism. B The vitamins are concluded support healthy growthreductase and division, and facilitate optimal hormone

blockade of inflammatory processes could represent a new two-pronged approach Medicinal ingredients per capsule in both the men’s and women’s: in the treatment of AGA.

Fenugreek (Trigonella foenum graecum) seed extract 4:1 ....................................................260 mg Biotin 400 mcg equiv 1040mg) Fenugreek (dry Seeds Flax lignans, standardized to 50% SDG ...............................................................................100 mg Non-Medicinal Ingredients Fenugreek seeds contain 5% to 30% protein, steroid saponins, sterols, flavonoids d-calcium pantothenate (Vitamin B5) ..................................................................................10.4 mg and alkaloids (notably trigonelline and choline). Steroid saponins bind and Niacinamide (Vitamin B3) ...................................................................................................10.3 mg Inert microcrystalline cellulose and vegetable-based magnesium eliminateHCl extra cholesterol and hormones in the body; DHT is made from mg Pyridoxine (Vitamin B6) ...............................................................................................2.0 stearate in a veggie-based capsule testosterone, which in turn is made from cholesterol. Therefore, when excess mg Riboflavin (Vitamin B2)is.......................................................................................................1.6 cholesterol is eliminated, less DHT can be made (Stark 1993). In a study of 20 mcg Folic acid ..............................................................................................................................95 Recommended adult dose: One capsule per day adults....................................................................................................................................250 who consumed 12.5g and 18.0g of germinated fenugreek seed powder for Biotin mcg

one month, higher levels of consumption resulted in a significant reduction in total

Men’s also has: cholesterol and low-density lipoprotein (LDL) levels (Sowmya 1999). Saw palmetto berry extract 4:1 .............................................................................................125 mg (dry equiv. 500 mg) Flax lignans

Flax reduces the amount of DHT produced by reducing cholesterol levels in the

Women’s also has: body.(silicon A meta-analysis of 28 studies between 1990 and 2008 showed that flaxseed mg Silicon dioxide) ........................................................................................................40 significantly reduces circulating total and LDL-cholesterol concentrations (Pan mg Iron (ferric citrate) ................................................................................................................20

2009). Flaxseed interventions reduced total and LDL cholesterol by 0.10 mmol/L

Recommended use:0.00 one mmol/L) capsule twice capsules perCI: bottle). Bio-Fen® Plus capsules are usually effective (95% CI: -0.20, and daily 0.08 (60 mmol/L (95% -0.16, 0.00 mmol/L), at respectively. stopping hair Significant loss within the first two were months. Anyonewith experiencing new growth reductions observed whole flaxseed (-0.21should and see it within four months. Once Bio-Fen is stopped, the hairand growth pattern will and slowly return to its original point, however some people may -0.16 mmol/L, respectively) lignan (-0.28 -0.16 mmol/L, respectively) besupplements able to continue with a lower maintenance dose. (Pan 2009). Bio-Fen has been approved by Health Canada and has received a unique NPN number. In addition to being approved for hair growth applications, Bio-Fen has been approved for additional health benefits. Angwafor F III, Anderson ML. An open label, dose response study to determine the effect of a dietary supplement on dihydrotestosterone, testosterone and estradiol levels in healthy males. J Int Soc Sports Nutr 2008;5:12.

Contraindications: The ingredient combination in Bio-Fen Plus for Men/Women is generally safe for most adults. Bio-Fen should not be used by patients withB6 diabetes, or known hypersensitivity to any ingredients. Brzezińska-Wcisło L. Evaluation of vitamin and calcium pantothenate effectiveness on hair growth from clinical and trichographic aspects for treatment of diffuse alopecia in women. Wiad Lek 2001;54:11-8.

References Chittur S, Parr B, Marcovici G. Inhibition of inflammatory gene expression in keratinocytes using a composition containing carnitine, thioctic acid and saw palmetto extract. Evid Based Brooks JD, et al. Am J Clin Complement Alternat Med Nutr. 2009. 2004 Feb;79(2):318-25. Evans BA, et al. 1995 Nov;147(2):295-302. Pan A, Yu D, Demark-Wahnefried W, Franco OH, Lin X. Meta-analysis of the effects of flaxseed interventions on blood lipids. Am J Clin Nutr 2009;90:288-97. Hoffmann R. Clin Exp Dermatol. 2002 Jul;27(5):373-82. 2001;39(1):58-65. Hutchins AM,et al.K, Nutr Cancer. Prager N, Bickett French N, Marcovici G. A randomized, double-blind, placebo-controlled trial to determine the effectiveness of botanically derived inhibitors of 5-alpha-reductase in the Prager N, etof al.androgenetic 2002 Apr;8(2):143-52. treatment alopecia. J Altern Complement Med 2002;8:143-52. Trüeb RM. Exp Gerontol. 2002 Aug-Sep;37(8-9):981-90. Serenoa repens monograph. Alternative Medicine Review 1998;3:227-9. Wickett RR, et al Arch Dermatol Res. 2007 Dec;299(10):499-505. Wilt T et al. Database Syst Rev. 2002;(3):CD001423. Sinclair R. Cochrane Male pattern androgenetic alopecia. BMJ 1998;317:865-9. Sowmya P, Rajyalakshmi P. Hypocholesterolemic effect of germinated fenugreek seeds in human subjects. Plant Foods Hum Nutr 1999;53:359-65. Stark A, Madar Z. The effect of an ethanol extract derived from fenugreek (Trigonella foenum-graecum) on bile acid absorption and cholesterol levels in rats, Br J Nutr 1993;69:277-87. Vierpper H, Nowotny P, Maier H, Waldhausl W. Production rates of dihydrotestosterone in healthy men and women and in men with male pattern baldness: determination by stable isotope/ dilution and mass spectrometry. J Clin Endocrinol Metab 2001;86:5762-4.

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research news High caloric intake at breakfast vs. dinner and impact on weight loss This study examined time-of-day nutrient intake and its association with metabolic syndrome. The goal of the study was to compare a weight loss diet with high caloric intake during breakfast to an isocaloric diet with high caloric intake at dinner. Overweight and obese women (mean BMI 32.4) with metabolic syndrome were randomized into two isocaloric (1400 kcal) weight loss groups, a breakfast (700 kcal breakfast, 500 kcal lunch, 200 kcal dinner) or a dinner group (200 kcal breakfast, 500 kcal lunch, 700 kcal dinner) for 12 weeks. The results showed that the breakfast group showed greater weight loss and waist circumference reduction. Although fasting glucose, insulin, and ghrelin were reduced in both groups, fasting glucose, insulin, and HOMAIR decreased significantly to a greater extent in the breakfast group. Mean triglyceride levels decreased by 33.6%

Brain health and response to cocoa in older people

in the breakfast group, but increased by 14.6% in the dinner group. Oral glucose tolerance test led to a greater decrease of glucose and insulin in the breakfast group. In response to meal challenges, the overall daily glucose, insulin, ghrelin, and mean hunger scores were significantly lower, whereas mean satiety scores were significantly higher in the breakfast group. Obesity (Silver Spring). 2013 March. PMID: 23512957.

This study investigated the relationship between neurovascular coupling and cognitive function in elderly individuals with vascular risk factors to determine whether neurovascular coupling could be modified by cocoa consumption. Sixty older people were studied in a parallelarm, double-blind clinical trial of neurovascular coupling and cognition in response to 24 hours and 30 days of cocoa consumption. Measures included MiniMental State Examination and Trail Making Test A and B. Neurovascular coupling was measured from the beatto-beat blood flow velocity responses

Associations between active travel to work and overweight, hypertension, and diabetes Increasing active travel through walking, biking, and public transport, is promoted as a key strategy to increase physical activity and reduce the growing burden of noncommunicable diseases globally. However, not much is known about any associated cardiovascular health benefits in lowand middle-income countries. This was a cross-sectional study of 3902 participants in the Indian Migration Study. Associations between mode and duration of active travel and cardiovascular risk factors were assessed using random-effect logistic regression models adjusting for age, sex, caste, standard of living, occupation, factory location, leisure time physical activity, daily fat intake, smoking status, and alcohol use. The prevalence of overweight or obesity was 50.0%, 37.6%, 24.2%, 24.9%; hypertension was 17.7%, 11.8%, 6.5%, 9.8%; and diabetes was 10.8%, 7.4%, 3.8%, 7.3% in participants who travelled to work by private transport, public transport, bicycling, and walking respectively. Those walking or bicycling to work were significantly less likely to be overweight or obese and those travelling by private transport. Those bicycling to work were less likely to have hypertension or diabetes. There was a dose-response relationship between duration of bicycling to work and these health factors. PLoS Med. 2013 June. PMID: 23776412 PhotosÂŠiStockphoto.com

in the middle cerebral arteries to the N-Back Task. The results showed that neurovascular coupling was associated with Trails B scores and performance on the 2-Back Task. Higher coupling was also associated with significantly higher anisotropy in cerebral white matter hyperintensities. 30 days of cocoa consumption was associated with increased coupling and improved Trails B times in those with impaired neurovascular coupling at baseline. The authors conclude that there is a strong correlation between neurovascular coupling and cognitive function and that both can be improved by regular cocoa consumption in individuals with baseline impairments, and that better coupling is also associated with greater white matter structural integrity. Neurology. 2013 August. PMID: 23925758

October 2013 l www.ihpmagazine.com 19

industry news GeneDx Introduces Advanced Genetic Test Panels for Breast and Colon Cancer

GeneDx, one of the world’s foremost genetic testing laboratories and a wholly-owned subsidiary of Bio-Reference Laboratories, Inc. has announced the launch of a comprehensive suite of genetic tests for inherited cancer, including a 26-gene panel for breast and ovarian cancer that includes BRCA1 and BRCA2 and next generation sequencing based multi-gene panels for colorectal cancer, pancreatic cancer, and endometrial cancer. GeneDx, the first commercial laboratory to utilize next generation sequencing technologies in a CLIA-environment, is among only a handful of commercial labs currently offering testing for inherited cancer. The laboratory will begin accepting specimens immediately. The test offerings include a rapid turn-around test of the BRCA1 and BRCA2 genes combining sequencing and deletion/duplication analysis; an Ashkenazi Jewish panel for the three common Ashkenazi Jewish founder mutations in BRCA1 and BRCA2; a 26-gene panel for breast and ovarian cancer; an 18-gene panel for pancreatic cancer; an 18-gene panel for colorectal cancer; and an 11-gene panel for endometrial cancer. The test panels, which are marketed as OncoGeneDx, also include a Comprehensive Cancer Panel of 35 genes. All panels include deletion/duplication assessment.

Phase III Study of Investigational Vaccine in Canada to Prevent Clostridium difficile

Sanofi Pasteur, the vaccines division of Sanofi announced the initiation of its Phase III clinical program called Cdiffense to evaluate the safety, immunogenicity and efficacy of an investigational vaccine for the prevention of primary symptomatic Clostridium difficile infection (CDI). Clostridium difficile (C. diff) is a potentially life-threatening, spore-forming bacterium that causes intestinal disease. The risk of C. diff increases with age, antibiotic treatment and time spent in hospitals or nursing homes, where multiple cases can lead to outbreaks. The investigational C. diff vaccine is designed to produce an immune response that targets the toxins generated by C. diff bacteria, which can cause inflammation of the gut and lead to diarrhea. The investigational vaccine stimulates a person’s immune system to fight C. diff toxins upon exposure and ultimately may help prevent a future infection from occurring. The Cdiffense Phase III clinical program has just started recruiting volunteers in Canada for a randomized, observer-blind, placebo-controlled, multi-center, multi-national trial that will include up to 15,000 adults at 200 sites across 17 countries. Volunteers for the study should be age 50 or older and planning an upcoming hospitalization or have had at least two hospital stays and have received systemic antibiotics in the past year. For more information on the Cdiffense trial, please visit www.Cdiffense.org.

Dr. Louis Hugo Francescutti New President of the Canadian Medical Association

Dr. Louis Hugo Francescutti was installed as president of the Canadian Medical Association (CMA) during the association’s 146th annual meeting in Calgary. Dr. Francescutti succeeds Dr. Anna Reid, an emergency physician at Stanton Territorial Hospital in Yellowknife. “I feel strongly that Canada’s doctors can come together to transform our health care system into a system that will better serve our patients,” said Dr. Francescutti. “The evolving needs of Canada’s rapidly aging population mean there is no better time for the profession to shine.” Born in Montréal, Dr. Francescutti received his combined Doctor of Philosophy (Immunology) in 1985 and his Doctor of Medicine in 1987 from the University of Alberta. In 1994, he completed further studies in injury control while working toward a Masters of Public Health at Johns Hopkins University in Baltimore, Maryland. Dr. Francescutti currently works as an emergency physician at the Royal Alexandra Hospital and the Northeast Community Health Centre in Edmonton. As a professor in the School of Public Health at the University of Alberta, Dr. Francescutti has taught courses in injury control, public health and advocacy. Dr. Francescutti will serve as president of the CMA until August 2014.

Brain Cancer Lesion Treated with Precisely-Aimed Laser Catheter

IMRIS Inc. and MRI Interventions, Inc. announced that a surgical team at Brigham and Women’s Hospital (BWH) in Boston, MA, has performed the first laser ablation procedure to combine the use of MRI Interventions’ ClearPoint® Neuro Intervention System as the navigation platform with intraoperative MRI (iMRI) in an IMRIS VISIUS® Surgical Theatre. The combination of these two enabling technologies provided continuous visualization and guidance throughout a neurosurgical intervention to treat a right frontal brain tumor. “The combination of the two technologies made for a smooth and successful operation,” said Dr. Alexandra Golby, BWH neurosurgeon and associate professor of surgery at Harvard Medical School. “We had access to excellent real-time MR images within a hi-tech surgical suite and were able to use those images to guide and deliver the needed therapy to specific targets in the brain with a high degree of precision.” The ClearPoint navigation platform enables minimally-invasive neurosurgery under continuous MR guidance, and offers surgeons a direct view of the inside of a patient’s brain during a procedure. The VISIUS Surgical Theatre allows use of intraoperative MRI right inside the operating room and over the OR table. Using the ClearPoint system with VISIUS iMRI, Golby was able to see and select the lesion of the tumor in the brain, establish a safe trajectory, and visualize the laser catheter on MR images as it was inserted to the desired location. She was then able to utilize real-time MR thermometry to monitor progress as the laser catheter heated the target area to the desired temperature for therapeutic destruction of the malignant tissue, preserving surrounding healthy tissue in the process. MRI is the only imaging technology that will safely allow this continuous soft tissue visualization during surgery. Finally, Golby was able to confirm results of the procedure using the MRI before the patient was removed from the operating table. 20 www.ihpmagazine.com l October 2013

For Details, write #114 on Free Info Page, page 96.

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PRODUCT mOnOgRaPh

PRODUCT MONOGRAPH OIL OF OREGANO

Oil of Oregano is a hydrophobic extract of Origanum vulgare leaf. Major active constituents include the monoterpene phenolic compounds carvacrol and thymol. Carvacrol and thymol are potent antimicrobials with synergistic bactericidal, fungicidal, and antihelminthic activity.

Human studies

Oil of Mediterranean Oregano had antihelminthic effects when given at 600 mg emulsified oil per day in 14 adults who had tested positive for enteric parasites Blastocystis hominis, Entamoeba hartmanni, and Endolimax nana. After 6 weeks of treatment, there was complete resolution of parasitic infection in 8 cases, while Blastocystis hominis scores decreased in three more cases; gastrointestinal symptoms improved in 7 of the 11 subjects who had presented with Blastocystis hominis infection. (Force 2000)

Animal and In vitro studies

Carvacrol for oral candidiasis in immunocompromised rats was found to be as effective as treatment with Nystatin, reducing the number of colony forming units (CFU’s) and completely clearing hyphae from oral surfaces when given for 8 days (Chami 2004). In vitro, carvacrol was determined to exert an inhibitory effect against 6 different strains of Candida species primarily due to extensive lesion of the plasma membrane (Salgueiro 2003). Carvacrol has potent antimicrobial activity against several microbial species, including Staphylococcus aureus, Bacillus subtilis, Escherichia coli, Psuedomonas aeruginosa, Candida albicans, and Aspergillus niger; out of these, Candida albicans has been found most susceptible (Santoyo 2006). Carvacrol and thymol are thought to exert an additive effect by disrupting bacterial membrane integrity (Lambert 2001). Oregano has been shown to inhibit Methicillin resistant strains of Staph.

Figure 1: Structure of Carvacrol (left) and Thymol (right)

aureus and epidermis, and attenuates biofilm formation in vitro (Nostra 2004; 2007).

Toxicology

Essential oil extracts are categorically known to be toxic in high doses, and are therefore typically given in drop doses; essential oils should not be used internally by pregnant or breastfeeding women. Animal studies to date, however, indicate relative safety of Oregano oil. Carvacrol was shown to be hepatoprotective against ischemia and reperfusion injury in rats; both carvacrol and silymarin had similar beneficial effects on AST and ALT levels (Canbek 2007). Carvacrol also increased liver regeneration rate in rats after partial hepatectomy (Uyanoglu 2008). Mutagenicity studies of carvacrol show only weak activity; carvacrol is excreted in urine after 24 hours in large quantities, unchanged or as glucoronide and sulphate conjugates (De Vincenzi 2004).

References

Canbek M, Uyanoglu M, Bayramoglu G, Senturk H, Erkasap N, Koken T, Uslu S, Demirustu C, Aral E, Husnu Can Baser K. Effects of carvacrol on defects of ischemia-reperfusion in the rat liver. Phytomedicine. 2008 Jan. De Vincenzia M et al. Constituents of aromatic plants: carvacrol. Fitoterapia 2004; 75(7-8): 801-804. Force M et al. Inhibition of enteric parasites by emulsified oil of oregano in vivo. Phytother Res. 2000 May;14(3):213-4. Lambert RJ, Skandamis PN, Coote PJ, Nychas GJ. A study of the minimum inhibitory concentration and mode of action of oregano essential oil, thymol and carvacrol. J Appl Microbiol. 2001 Sep;91(3):453-62. Nostro A, Roccaro AS, Bisignano G, Marino A, Cannatelli MA, Pizzimenti FC, Cioni PL, Procopio F, Blanco AR. Effects of oregano, carvacrol and thymol on Staphylococcus aureus and Staphylococcus epidermidis biofilms. J Med Microbiol. 2007;56(Pt 4):519-23. Nostro A et al. Susceptibility of methicillin-resistant staphylococci to oregano essential oil, carvacrol and thymol. FEMS Microbiol Lett. 2004;230(2):191-5. Salgueiro LR et al. Chemical composition and antifungal activity of the essential oil of Origanum virens on Candida species. Planta Med. 2003 Sep;69(9):871-4. Santoyo S, Cavero S, Jaime L, Ibañez E, Señoráns FJ, Reglero G. Supercritical carbon dioxide extraction of compounds with antimicrobial activity from Origanum vulgare L.: determination of optimal extraction parameters. J Food Prot. 2006;69(2):369-75. Uyanoglu M, Canbed M, Aral E, Husnu Can Baser K. Effects of carvacrol upon the liver of rats undergoing partial hepatectomy. Phytomedicine 2008; 15(3): 226-9. ihpSept10_NAHS_Ad.indd 2 058.IHP NAHS mono.indd 1

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industry news Canadians Want a National Strategy for Seniors Health Care

Nine out of 10 (93%) Canadians believe Canada needs a pan-Canadian strategy for seniors health care at home, hospitals, hospices and long-term facilities, the Canadian Medical Association’s (CMA) 2013 National Report Card on health issues has found. In addition, an equal number believe a comprehensive strategy for seniors health care would improve the entire system by keeping elderly Canadians at home as long as possible, thereby lightening the load on hospitals and long-term care facilities, the Ipsos Reid poll found. Nine out of 10 respondents (89%) believe a national strategy for seniors should involve federal, provincial, territorial and municipal levels of government. And four in five (78%) believe the federal government has an important role to play in developing the strategy. Research shows that it costs $126 a day to provide care for a patient in a long-term care facility, versus $842 a day in a hospital. Of course, making it easier for elderly Canadians to stay at home while getting the care they need would be the preferred and most cost-effective option. “The results of this year’s CMA report card send a clear and direct message to policy-makers and public office holders that all levels of government need to act to address the demographic tsunami that is heading toward the health care system,’’ said past CMA President Dr. Anna Reid. The poll, conducted between July 17 and July 26 by phone with 1,000 Canadians 18 and over, found that four in five (83%) Canadians thought their health care in retirement years was a concern. The results show a majority (63%) believe home and community care should be the most important focus for governments when improving health care quality for senior citizens.

Super spice saffron for Canadians concerned about eye health

Saffron, one of the most esteemed spices in the world is now being used in an eye supplement approved by Health Canada and claimed to be a new hope for individuals affected by age-related macular degeneration (AMD) and cataracts, the two leading causes of vision impairment in Canada. Studies have shown the retinal protective effects and vision improvement properties of saffron in patients with AMD. Saffron 2020 is an eye supplement that combines saffron with other nutrients known to be important for eye health, and is the only saffron-containing supplement approved by Health Canada for macular degeneration and cataracts. Saffron 2020 was formulated following studies in Italy and Australia showing the benefits of saffron in patients with AMD. This natural health product helps to maintain our invaluable eyesight in AMD and cataracts, and also helps to reduce the risk of developing cataracts. Doctor Kim Julian, a top eye surgeon involved in the elaboration of Saffron 2020, stated: “At the moment, there is no cure for AMD, all we can do is aim to slow down its progression and make life as manageable as possible for this suffering. Saffron 2020 is the only supplement I’m aware of which combines saffron with important eye health nutrients like resveratrol, zinc, antioxidant vitamins (A, B2, C and E) and natural carotenoids lutein and zeaxanthin.” Saffron 2020 is a patent pending product provided by Groupe Persavita, a company located in Montreal, Canada.

Atrium Innovations Announces 2013 Second Quarter Financial Results

Atrium Innovations Inc., a globally recognized leader in the development, manufacturing and commercialization of innovative, science-based natural health products, today released its results for the quarter ended June 30, 2013. Highlights include: Revenue of $121.4 million, representing 10.9% year-over-year organic growth, EBITDA of $23.7 million or 19.6% of revenue, an increase of 10.2% over last year, adjusted diluted EPS of $0.45 for the quarter, an increase of 21.6% over last year, record operating cash flows before changes in non-cash working capital of $22.8 million, total net debt reduced by $19.7 million year-to-date. “We are very pleased by our solid performance during the quarter. Organic revenue growth of 10.2%, excluding foreign exchange impact, reflects strength in the Retail, Healthcare Practitioner (HCP) and Private Label channels. The EBITDA increase of 10.2% over last year and a margin of 19.6% was in line with our expectations and was supported by leveraging our extensive North American HCP platform,” said Pierre Fitzgibbon, President and CEO. “Operating cash flows before working capital reached a record level of $22.8 million for the quarter and enabled us to further reduce net debt by $10.1 million. Year-to-date, net debt was reduced by $19.7 million, further supporting our plan to deleverage the financial position.”

Canadian Association Of Interns And Residents: 6 Practical Steps To Better Care

According to new research conducted by the Canadian Association of Interns and Residents (CAIR), Canada needs a better way to anticipate the supply and demand of physicians if we are to meet patient needs in the future. Reliable data and better coordination between patient needs and residency training positions would also help residents with career decisions, ultimately resulting in better patient care. Based on the findings of its work, the CAIR Committee adopted six Principles that would bring about a more effective way of coordinating physician health human resources across the country: Effective, evidence-based workforce planning for Canadian patients and physicians, allocation of residency training positions that aligns with population needs and job availability, particularly in specialty areas, improvements to the work environment in rural areas to attract and retain new physicians in local communities, career counseling throughout medical training, promotion of a culture of social accountability in medical training and succession planning.

October 2013 l www.ihpmagazine.com 23

industry news Large-Scale Cost-Effectiveness Study of Non-Invasive Prenatal Testing in Canada

A team of researchers led by CHU de Quebec and Universite Laval, has received CAN$10.5 million from Genome Canada, the Canadian Institutes of Health Research (CIHR), Genome Quebec and other partners to conduct a large-scale comparative effectiveness study on non-invasive prenatal screening techniques. Dr. Francois Rousseau and his team will examine current prenatal screening practices for chromosomal conditions, such as Down syndrome, among pregnant women in Canada in order to improve screening approaches and avoid unnecessary procedures. Each year in Canada, about 450,000 women become pregnant and are offered Down syndrome prenatal screening using biochemical and ultrasound markers. The vast majority will be negative or low risk. However, for positive or high-risk results, those pregnant women are referred to amniocentesis, which is an invasive procedure done to confirm the screening result. Approximately 5% of all biochemical screening results are falsely positive, attributing to unnecessary invasive procedures that pose a 1 in 300 risk for miscarriage. The research project aims at independently comparing the performances of different such approaches that involve various combinations of the available tools for screening of chromosomal conditions, as well as to evaluate the cost-effectiveness, the ethical and social aspects of this new technology and to identify and adapt the best implementation tools for users in the health care system. The researchers will recruit 5600 pregnant women (3600 at high-risk of trisomy conditions and 2000 at low-risk). Samples from these women will be tested in parallel using different screening approaches that involve genomic-based NIPT, but also existing or new biochemical and ultrasound screening tools. The samples will be analyzed without knowledge of the true status of the pregnancy outcome. This will provide a comprehensive evaluation of the most efficient ways to improve the prenatal screening techniques widely used today.

CMA Recognizes Excellence in the Field of Medical Ethics

The Canadian Medical Association (CMA) announced that Dr. David McKnight of Toronto and Dr. Ian Mitchell of Calgary will receive the 2013 Dr. William Marsden Award in Medical Ethics. This award recognizes CMA members who have demonstrated exemplary leadership, commitment and dedication to the cause of advancing and promoting excellence in the field of medical ethics in Canada. Dr. David McKnight is widely admired for his leadership and dedication to excellence in the field of medical ethics. He began teaching ethics in anesthesia in 1990 and has won several awards for excellence in postgraduate education. Currently the associate dean of equity and professionalism for the faculty of medicine at the University of Toronto, he introduced the “Stethoscope Ceremony” during orientation for new medical students, symbolizing the importance of listening. He is also responsible for an empowering diversity statement for faculty recruitment. Dr. Ian Mitchell is a leader who enhances ethical and professional behaviour in physicians and displays excellence in his own ethics research and teaching initiatives. He is known as a meta-teacher who serves bioethics and the profession with insight, innovation and fearlessness. “I was honoured to be nominated and overwhelmed to be granted this award,” said Dr. Mitchell. “It is a privilege to work with children and families, and to encourage aspiring physicians to consider all aspects of care. Ethics are integral to the best health care.” After studying medicine at the University of Edinburgh, Dr. Mitchell pursued specialty training in pediatrics and pediatric lung disease. In 1982 he accepted a position at Alberta Children’s Hospital and joined the faculty of the University of Calgary’s department of paediatrics. Currently holding the rank of professor, he is director of the Respiratory Home Care Clinic.

Poverty the Greatest Barrier to Good Health, Canadians tell CMA Consultation

Poverty kills. That’s the key message in What Makes us Sick, a report released today by the Canadian Medical Association (CMA) based on what Canadians said during a series of town hall meetings and an online consultation held earlier this year. The national dialogue with Canadians asked them about their experiences with the social determinants of health - the factors that cause people to suffer poor health in the first place. “Many factors outside the health care system affect a person’s health, from inadequate housing to a lack of healthy food to sub-optimal early childhood experiences,” said Dr. Anna Reid, past CMA president. “What Canadians told us is that poverty is the recurring theme that underpins most of these social determinants of health.” The CMA report included recommendations for action, again, based on what Canadians said. However, Dr. Reid stressed that the report does not lay blame. “We aren’t pointing fingers,” she said. “We listened to Canadians and what we heard was that they want sincere, legitimate and real action. As a country we can do better in tackling issues around poverty, housing, early childhood development, food security and culture that can hinder a person’s chances to be healthy. There is no one sector responsible for making this happen. It has to be a joint effort, involving health care providers, governments, patients and Canadians from all backgrounds.”

24 www.ihpmagazine.com l October 2013

Full-Spectrum Longevity Support RevitalAge™ Ultra delivers longevity benefits with sustained-release coenzyme Q10, pure resveratrol, pterostilbene to offer enhanced antioxidant and mitochondrial support. RevitalAge™ Ultra Supports Youthful Gene Expression

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Resveratrol supports longevity by enhancing an epigenetic enzyme, SIRT1. It also works in concert with alpha lipoic acid and acetyl-l-carnitine to cooperatively support the synthesis of new mitochondria by promoting healthy activity of another enzyme known as AMP kinase (AMPK), a cellular longevity signal that directs a genetic program of mitochondrial renewal. Sustained-release CoQ10 provides 24-hour antioxidant protection with complementary support for mitochondrial bioenergetics. Pterostilbene supports healthy activation of PPARα, a genomic receptor involved in cardiometabolic health. †

Under license from

Inc.

This product contains resVida . resVida® is a registered trademark of DSM Nutritional Products, Inc. ®

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RevitalAge Ultra ™

What Is It? RevitalAge™ Ultra is a scientifically researched combination of acetyl-l-carnitine (ALC) and alpha lipoic acid (ALA) offered with PhytoLongevity, a polyphenol blend that supports inflammatory balance, cardiometabolic health and cognitive performance. The formula also includes a unique blend of sustained-release CoQ10, pure resVida® resveratrol and pterostilbene to promote healthy aging through maintaining youthful gene expression, mitochondrial function, cellular energy production and antioxidant protection.

Uses For RevitalAge™ Ultra Cellular Health and Longevity: Over a decade of research has associated healthy mitochondrial function with longevity. Preclinical research on aging conducted by an award-winning team of scientists at UC Berkley, including Dr. Bruce Ames, has revealed a combination of acetyl-l-carnitine, alpha lipoic acid and biotin can promote longevity. Dietary polyphenols from fruits and vegetables provide cellular protection by maintaining youthful patterns of gene expression in the heart, blood vessels and brain. Sustained-release CoQ10 provides 24-hour mitochondrial support. Pure resVida® resveratrol and pterostilbene target cellular pathways and genes involved in the aging process.

Special Features Patented Longevity Combination: • Patented, scientifically researched combination of acetyl-l-carnitine (ALC), alpha lipoic acid (ALA) and biotin, used under license from Juvenon, Inc. • Supports healthy gene expression and increases mitochondrial number for enhanced cellular energy production • In preclinical studies, this patented ratio of ALC and ALA has enabled elderly laboratory animals to function at a level characteristic of much younger animals • Clinical research indicates that the combination supports total plasma antioxidant capacity, cardiovascular health and psychological well-being PhytoLongevity: A Spectrum of Natural Polyphenols for Healthy Aging: • Polyphenols are active constituents of cardio- and neuroprotective fruits and vegetables; this proprietary blend contains cranberry, wild blueberry, strawberry and spinach leaf extracts • The unique ratio of blueberry and cranberry support healthy inflammatory balance by maintaining healthy activity of nuclear factor kappa-B (NFκB), a regulator of gene expression • Cranberry, strawberry and spinach polyphenols maintain healthy activity of prolyl endopeptidase (PEP), an enzyme that regulates neurotransmission; healthy PEP activity supports memory and cognition

MicroActive® sustained-release CoQ10 • Water-soluble • 24-hour sustained release with low inter-subject variability • Clinical research shows 300% greater peak plasma concentrations compared to standard CoQ10 resVida®: pure, clinically researched resveratrol • Pure trans-resveratrol with clinically proven bioavailability • Potent antioxidant that protects mitochondria from free radicals that contribute to cellular aging • Supports the expression of longevity genes in the cardiovascular system and brain associated with life span in preclinical studies pterostilbene: pure, methylated resveratrol • Pure, clinically researched pterostilbene, the methylated analog of resveratrol • Promotes cardiometabolic health by supporting healthy PPAR-alpha receptor activity • Provides synergistic antioxidant support when combined with resveratrol

What Is The Source? Acetyl-l-carnitine HCl†, alpha lipoic acid (thioctic acid), biotin, resVida® resveratrol and pterostilbene are synthetic. MicroActive® CoQ10-cyclodextrin complex containscoenzyme Q10 obtained naturally from fermentation and potato starch. PhytoLongevity proprietary blend is sourced from cranberry extract, wild blueberry extract, Orléans strawberry extract and spinach extract. RevitalAge™ Ultra three vegetable capsules contain

v 00

biotin† ...........................................................................................................................................2 mg acetyl-l-carnitine HCl† ......................................................................................................1,000 mg alpha lipoic acid (thioctic acid)† ...................................................................................... 400 mg resVida® resveratrol (as trans-resveratrol) ........................................................................30 mg CoQ10 (from MicroActive® Q10-cyclodextrin complex) .......................................................30 mg pterostilbene ..............................................................................................................................5 mg PhytoLongevity proprietary blend.......................................................................................200 mg providing cranberry (Vaccinium macrocarpon) extract (fruit), wild blueberry (Vaccinium angustifolium) extract (fruit), Orléans strawberry (Fragaria vesca var Orléans) extract (fruit) and spinach (Spinacia oleracea) extract (leaf) other ingredients: potato starch, maltodextrin

3 capsules daily, with meals. †Under

license from

Inc.

This product contains resVida®. resVida® is a registered trademark of DSM Nutritional Products, Inc.

866.856.9954 | Purecaps.ca The information contained herein is for informational purposes only and does not establish a doctor-patient relationship. Please be sure to consult your physician before taking this or any other product. Consult your physician for any health problems.

industry news Most Online Tests For Alzheimer’s Disease Fail On Scientific Validity, Reliability And Ethical Factors

An expert panel found that 16 freely accessible online tests for Alzheimer’s disease scored poorly on scales of overall scientific validity, reliability and ethical factors, according to new data reported at the Alzheimer’s Association International Conference® 2013 (AAIC® 2013) in Boston. “As many as 80 percent of Internet users, including a growing proportion of older adults, seek health information and diagnoses online,” said Julie Robillard, Ph.D., a postdoctoral fellow at the National Core for Neuroethics at the University of British Columbia in Vancouver, British Columbia, Canada, who presented the data at AAIC 2013. “Self-diagnosis behavior in particular is increasingly popular online, and freely accessible quizzes that call themselves ‘tests’ for Alzheimer’s are available on the Internet. However, little is known about the scientific validity and reliability of these offerings and ethics-related factors including research and commercial conflict of interest, confidentiality and consent. Frankly, what we found online was distressing and potentially harmful,” Robillard added. According to the Alzheimer’s Association 2013 Alzheimer’s Disease Facts and Figures report, more than five million Americans are living with Alzheimer’s disease. By 2050, the number of people with Alzheimer’s could reach 13.8 million. Other estimates suggest that number could be high as 16 million. “The number of people with Alzheimer’s is projected to rise significantly as more and more people age into greater risk for developing the disease,” said Maria Carrillo, Ph.D., Alzheimer’s Association vice president of medical and scientific Relations. “Especially in that context, active promotion of healthy aging is a priority for the Alzheimer’s Association, as is the delivery of accurate, reliable and ethical information and services.” All 16 tests scored “poor” or “very poor” on the evaluation criteria for ethical factors. According to Robillard, ethical issues with the tests included overly dense or absent confidentiality and privacy policies, failure to disclose commercial conflicts of interests, failure to meet the stated scope of the test and failure to word the test outcomes in an appropriate and ethical manner.

Royal College discusses national leadership approaches to Canadian health care with Federal Minister of Health

The Royal College welcomes recent efforts by the federal Minister of Health, Rona Ambrose, to engage and collaborate with Canada’s national health organizations and leaders. With growing illness complexity, budget limitations and an aging population challenging Canada’s health system, national leadership is vital. The Royal College’s senior leaders met with Minister Ambrose today at the Canadian Medical Association’s General Council meeting to discuss specialist employment issues, indigenous health, and the importance of innovation to the long-term sustainability of our health care system. “The Royal College agrees with the important role of innovation in health care,” said Royal College President, Cecil Rorabeck, MD, OC, FRCSC. “We believe leadership is needed to explore how our health care system can best benefit by employing technologies and innovation so Canadians can receive timely and high quality care. The federal government must also take the leadership to develop a national human resources for health strategy and a permanent agency to support ongoing health workforce planning.” The Royal College, along with its 44,000 members practising across Canada and abroad, looks forward to working with its government partners to enhance the efficiency, safety and quality of health and health care services. “Collaboration and open dialogue with the federal government are essential,” said Royal College CEO Andrew Padmos, MD, FRCPC. “To improve the effectiveness of the Canadian health care system, we urge the minister to lead an innovative approach to health workforce research and make national health human resources planning a top priority.” Moving forward, the Royal College encourages Minister Ambrose to continue this dialogue and engage in sustained collaborative efforts with health care providers to ensure that all Canadians have access to high quality health and care.

Data Published in the New England Journal of Medicine on Vedolizumab for IBD

Takeda Pharmaceutical Company Limited announced that results from two Phase three studies evaluating vedolizumab, an investigational humanized monoclonal antibody, for the treatment of adults with moderately to severely active ulcerative colitis (UC) and Crohn’s disease (CD), were published in the New England Journal of Medicine. Chronic and debilitating diseases, CD and UC are the two most common types of inflammatory bowel disease (IBD) and affect more than four million people worldwide, including approximately 233,000 Canadians, 1.4 million Americans, and 2.2 million Europeans. Vedolizumab is designed to specifically antagonize the alpha-4-beta-7 integrin, which is expressed on a subset of circulating white blood cells that have been shown to play a role in mediating the inflammatory process in CD and UC. In the publication, study results from GEMINI I, a placebo-controlled induction and maintenance study in patients with UC, showed that vedolizumab met primary endpoints of improvement in clinical response (reduction in the Mayo Clinic score of ≥3 points and ≥30 percent from baseline, along with a decrease of at least 1 point on the rectal bleeding subscale or an absolute rectal bleeding score of 0 or 1) at six weeks and clinical remission (Mayo score of 2 or lower and no subscore higher than 1) at 52 weeks. In addition, a significantly greater proportion of patients receiving vedolizumab achieved mucosal healing (Mayo endoscopic subscore of 0 or 1) at six and 52 weeks, and glucocorticoid-free remission at 52 weeks, compared with placebo.

October 2013 l www.ihpmagazine.com 27

calendar OCTOBER

October 3-6 CHFA East Conference Organized by: CHFA Toronto, ON For more information, please visit: https://www.chfa.ca/ tradeshows/chfa-east-2013/ October 4-6 The Evolution of Disease & Biotherapeutic Drainage Organized by: Seroyal Toronto, ON For more information, please visit http://www.seroyalseminars.com October 5-6 Nutrition for Docs, EBM Approach Part 1 Organized by: CSOM Toronto, ON For more information, please visit http://www.csom.ca October 7-9 2nd International Summit on Toxicology Organized by: OMICS Group Las Vegas, Nevada For more information, please visit http://www.omicsgroup.com/ conferences/toxicology-2013/ October 10-13 2nd International Congress on Controversies in Stem Cell Transplantation and Cellular Therapies (COSTEM) Organized by: FIGO Berlin, Germany For more information, visit http://www. comtecmed.com/cigi/2013/default.aspx October 16 Convallaria and Crataegus in the treatment of Cardiac Dysfunction Organized by: AARM Online Webinar For more information, visit http:// restorativemedicine.org/cme-webinars/ October 19-20 Successful Case Management of Chronic Disease Workshop Organized by: Seroyal Seattle, WA 28 www.ihpmagazine.com l October 2013

For more information, please visit http://www.seroyalseminars.com October 18-20 BCNA Conference Organized by: BCNA Vancouver, BC For more information, please visit http://www.bcna.ca October 20-22 10th International SIO Conference Organized by: Society for Integrative Oncology Vancouver, BC For more information, please visit http://www.integrativeonc.org October 24 Internal Medicine for Primary Care Organized by: MCE Conferences Sonoma, CA For more information, visit http:// www.mceconferences.com/ medical-conferences.php October 26 CHEST 2013 Organized by: CHEST Chicago, IL For more information, visit http:// www.chestnet.org/accp/events October 29-31 International Congress for Clinicians CIM (ICC-CIM 2013) Organized by: CAHCIM Chicago, IL For more information, visit http://www.icccim.org

NOVEMBER

November 2 Personalizing Nutritional Protocols Based on Lab Test Results Organized by: Metagenics Rogers, Arkansas For more information, please visit http://www.metagenics.com November 7-10 FirstLine Therapy Certification Organized by: Metagenics New York, NY For more information, please visit http://www.metagenics.com

November 9-10 Nutrition for Docs, EBM Approach Part 2 Organized by: CSOM Vancouver, BC For more information, please visit http://www.csom.ca November 15-17 OAND Convention Organized by: OAND Toronto, ON For more information, please visit http://www.oand.org November 20 Effective Herbal Therapies for Polycystic Ovarian Syndrome Organized by: AARM Online Webinar For more information, visit http:// restorativemedicine.org/cme-webinars/ November 30 Diabetes Boot Camp for Primary Care Organized by: MCE Conferences Florida For more information, visit http:// www.mceconferences.com/ medical-conferences.php November 30-Dec 1 Nutrition for Docs, EBM Approach Part 1 Organized by: CSOM Calgary, AB For more information, please visit http://www.csom.ca

DECEMBER

December 5-8 FirstLine Therapy Certification Organized by: Metagenics Austin, TX For more information, please visit http://www.metagenics.com December 18 Integrating Bio-Identical Hormones and Herbs for Menopausal Therapy Organized by: AARM Online Webinar For more information, visit http:// restorativemedicine.org/cme-webinars/

NPN(s): 80015104 and 80038453 (50 Billion bacteria)

Pharmacology Potential Mecanisms of Action It was shown that L. acidophilus CL1285® and L. casei LBC80R® strains have an excellent gastrointestinal survival rate. In fact, starter cultures resist to a pH of 2.5 and, when the strains are encapsulated with enteric coating, they can resist a pH of 1.5 for 2 hours (unpublished data). Both strains survived to a high concentration of bile salt. This resistance allows a safe delivery of the probiotics to the GI tract and results in a production of antimicrobial molecules such as organic acids or bacteriocins. These molecules have been shown to directly eliminate various pathogenic bacteria such as C. difficile, E. faecium, E. faecalis, E. coli O157:H7, L. monocytogenes and methicillin-resistant S. aureus (MRSA). Moreover, secretion of an unknown metabolite was shown to reduce the cytotoxicity of toxin A/B secreted by C. difficile. Finally, administration of the CL1285® starter culture modulates the fecal microbiota by increasing the total lactic acid bacteria and total anaerobe count and reducing the Staphylococcus sp. count.

Health Claim Helps to reduce the risk of Clostridium difficile associateddiarrhea in hospitalized patients. Helps to reduce the risk of antibiotic-associated diarrhea. Probiotic that forms part of a natural healthy gut flora. Provides live microorganisms that form part of a natural healthy gut flora. Probiotic that contributes to a natural healthy gut flora. Provides live microorganisms that contribute to a natural healthy gut flora. Probiotic to benefit health and/or confer a health benefit. Provides live microorganisms to benefit health and/or to confer a health benefit.

Supplied Bio-K+® guaranties a minimum of 50×109 L. acidophilus CL1285® and L. casei LBC80R® per capsule at expiration date. These bacteria are live and protected with an enteric coating. Lyophilized bacteria are the result of fermentation, concentration and freeze-dry processes. A mixture containing a predetermined concentration of lyophilized bacteria, cellulose, ascorbic acid, and magnesium stearate is prepared. This mixture is then added in a vegetable cellulose capsule pigmented with colloidal silicone dioxide. Then, the capsule is enteric coated. Each capsule contains: ≥50×109 live strains of L. acidophilus CL1285® and L. casei LBC80R®. Nonmedicinal ingredients: ascorbic acid, cellulose, ethylcellulose, hypromellose, magnesium stearate, medium chain triglycerides, silicone dioxide, sodium alginate and titanium dioxide. Bottles of 15 or 250. A box contains 10 or 100 groups of 10, individually wrapped capsules in blister aluminumsealed sheets. Refrigerate at 4°C for maximum activity.

(100 Billion bacteria)

Contra-indications • Do not use if you are experiencing nausea, fever, vomiting, bloody diarrhea or severe abdominal pain; • Do not use if you have an immune-compromised condition (e.g. AIDS, lymphoma, patients undergoing long-term corticosteroid treatment); • Discontinue use and consult a health care practitioner if symptoms of digestive upset (e.g. diarrhea, nausea and vomiting) occur, worsen, or persist beyond 3 days; • Do not use if you are taking streptomycin.

Warnings • May contain traces of milk solids. Do not use this product if you are allergic to milk; • Do not use if seal is broken; • Inform your health care practitioner if you are using this product; • Keep out of reach of children.

Precautions Bio-K+® capsules should be swallowed whole. To preserve the enteric coating properties, do not chew, crush or open the capsules. It is safe to take Bio-K+® capsules for a prolonged period of time.

Overdose For management of a suspected drug overdose, CPhA recommends that you contact your regional Poison Control Centre. See the eCPS Directory section for a list of Poison Control Centres.

Dosage Recommended Dosage During Antibiotic Therapy • 2 capsules per day for the duration of the antibiotic treatment, and for five days after the treatment is completed. • The capsule should be taken at least two hours after antibiotic administration.

product profiles

Legend

r y s s s g e h n h h al ine ine thy alt sur nce ete iatr tric tric itio alt alt tic llin c c a se ceu edi edi eop He res Ca iab ych edia eria utr e He s He n r N n ’ D Ps P P u a G ra n M l M om l n o t s d t u u C Nu a H or m me sc loo sia nic / et Sp Im Wo Va B Di nal . A ota io ad B r rt it T Nu

Estro Adapt Empowered Health | Empowered You. NEW from AOR! Estro Adapt balances estrogen levels and promotes healthy menstruation by supporting the detoxification of excess estrogen, carcinogens and toxins. DIM and the phytoestrogen 8-prenylaringenin reduce the risk of abnormal cellular growth, choline supports liver detoxification and d-glucarate and sulforaphane break down cancer causing compounds.

Femme Adapt Empowered Health | Empowered You. NEW from AOR! Fem Adapt naturally relieves menopausal symptoms. Powerful phytoestrogens from flax, black cohosh, soy isoflavones and hops reduce hot flashes, night sweats and promote healthy mood. Phytoestrogens affect hormonal pathways involved in menopausal symptoms and reduce risk of post-menopausal diseases including cancer, heart disease and osteoporosis.

New All in One Vegan Protein Introducing Progressive® VegEssential All in One! It combines the benefits of an entire cupboard full of supplements with the ease of consuming a single delicious smoothie. Each scoop provides 27g of vegan protein, 7g of fibre, 2g of omega-3 plant oils, 6-8 servings of fresh vegetables, over 100% RDA of 13 vitamins and minerals, and more!

ViraClear EPs 7630™ Clinically-Proven Extract Viraclear EPs 7630™ contains a proprietary extract, obtained from the roots of the Pelargonium sidoides plant, an herb long used to treat cough and respiratory ailments. It works differently, unlike conventional remedies that simply mask symptoms, Viraclear EPs 7630™ addresses the cause to help speed recovery and shorten the duration of upper respiratory tract infections. For more information please call 1.800.644.3211 or visit www.integrativeinc.com

Genuine Health – Whole Body

ThyroLife® Optima

greens+ whole body NUTRITION is designed for the person who is looking to supercharge their nutrition and optimize key body systems. With the over 70% fermented ingredients greens+ whole body NUTRITION, starts with nourishing the core of our health, our gut, priming the body for the absorption of other health promoting ingredients, including a full serving of Vegan greens+ O.

ThyroLife® Optima is a unique and complete, well-balanced multivitamin supplement for thyroid health. It contains a complete mix of vitamins, antioxidants, micronutrients, amino acids and herbs to help support thyroid function, energy, mood and the immune system.

October 2013 l www.ihpmagazine.com 31

product profiles

Legend

r y s s s g e h n h h al ine ine thy alt sur nce ete iatr tric tric itio alt alt tic llin c c a se ceu edi edi eop He res Ca iab ych edia eria utr e He s He n r N n â&#x20AC;&#x2122; D Ps P P u a G ra n M l M om l n o t s d t u u C Nu a H or m me sc loo sia nic / et Sp Im Wo Va B Di nal . A ota io ad B r rt it T Nu

HLC Immunity + Pro HLC Immunity + Pro combines 1000 mg of vitamin C, vitamins and minerals along with maintenance levels of HMF probiotics in great-tasting natural orange flavour. The soy free, dairy free, gluten free formula comes in convenient individualized sachets that easily mix into water or juice.

D3 K 2 Mulsion D3 K2 Mulsion combines vitamin D3 and vitamin K2 in a convenient liquid format that can be dropped directly in the mouth or mixed in drinks. Vitamin D is a factor in the maintenance of good health, helps in the development and maintenance of bones and teeth, and helps in the absorption and use of calcium and phosphorus.1 Vitamin K2 helps in the maintenance of bones.2

Grape Seed SAP Science-based antioxidant and anti-inflammatory The proanthocyanidins from grape seed extract (GSE) demonstrate anti-inflammatory mechanisms and exhibit cytotoxic behaviour towards human breast, lung and gastric adenocarcinoma cells. With superior free-radical scavenging ability to Vitamins C, E, and beta-carotene, GSE is a powerful antioxidant, which may protect organs and tissues from the toxic effects of pharmaceutical drugs and environmental stressors, while preventing the development of atherosclerotic plaques.

Cellular Detox EGCG SAP Science-based ultra-antioxidant from green tea Epigallocatechin gallate (EGCG) is a powerful natural antioxidant, and the major chemoprotective agent in green tea. Combined with anthocyanidins and lycopene, this standardized synergistic blend of antioxidants is supported by a wealth of scientific literature. A potent and popular choice of healthcare practitioners for combating oxidative stress; EGCG is designed to address the underlying process behind a myriad of chronic and degenerative conditions, including cancer and cardiovascular disease.

32 www.ihpmagazine.com l October 2013

Metagenics now offers PhytoMulti in easy-to-swallow vegetarian capsules. PhytoMulti is an entirely new class of daily foundation supplementation designed to help defy aging. This unique product defends cells from free radical damage and oxidative stress, recharges cellular health, and nourishes cells with a complex array of phytonutrients. PhytoMulti is the only multivitamin/ mineralsupplement providing a researchbased, broad spectrum of phytonutrients and plant extracts scientifically tested for antioxidant protection and DNA stability potential. PhytoMulti is also available in tablet form.

product profiles

Legend

r s y s s e g h n h h al ine ine thy alt sur nce ete iatr tric tric itio alt alt tic llin c c a se ceu edi edi eop He res Ca iab ych edia eria utr e He s He n r N n ’ D Ps P P u a G l ra n M l M om n o s t d t u u a C Nu H or m me sc loo sia nic / et Sp Im Wo Va B Di nal . A ota io B ad r rt it T Nu

Astaxanthin Powerful antioxidant for the skin, macula, joints, immune system and cardiovascular function Derived from Haematococcus pluvialis microalgae cultivated under pristine conditions, esterified astaxanthin is a stable, powerful, fat-soluble antioxidant from the carotenoid family. Astaxanthin protects the phospholipid membranes of cells from oxidative damage. Initial trials with astaxanthin suggest that it may boost the skin’s natural antioxidant defenses against free radicals induced by sun exposure. In a human clinical evaluation, supplementation with astaxanthin for two weeks provided enhanced antioxidant protection for the skin.

KLEAN Athlete™ Klean Athlete™ is a truly unique dietary supplement line formulated for the specific needs of athletes. Every product is NSF Certified for Sport® and tested clean of banned substances providing your patients with everything they need and nothing they don’t. Klean Athlete™ products are free of yeast, wheat, gluten, soy, corn, sugar and starch, they contain no artificial colouring, flavouring or preservatives. You can feel confident about offering safer nutritional supplements that support a healthy lifestyle and peak performance.

PASCOLEUCYN® – A Natural Flu Prevention PASCOLEUCYN® is a non-specific immune remedy that increases the body’s natural defenses in acute and chronic infections. It relieves symptoms due to colds and flu such as headaches, stuffy nose, sore throat, cough and fever. A prophylactic intake of PASCOLEUCYN® can give your patients broad protection against colds and flu. Recommend the ampoules once or twice per season for general defense, and the drops when others around your patient are starting to get sick. For complete dosing suggestions for all ages, visit www.pascoecanada.com. Made in Germany and quality assured, with 60 years of confidence.

Liposomal Glutathione – Enhanced Absorption The Liposomal form of glutathione offers an enhanced form for improved absorption. The liposomal form protects glutathione bonds from degradation that may occur during digestion. Glutathione is a powerful antioxidant key in cellular function and liver support.

NEURAPAS® balance – Vitality and Motivation NEURAPAS® balance is a well-tolerated herbal remedy that produces favorable results in the treatment of mental illnesses, particularly those with imbalanced mood, because of its wellbalanced composition and various pharmacological effects. In addition, because of the unique synergy – meaning smaller amounts of St. John’s wort achieve the same therapeutic effect NEURAPAS® balance has been shown to have no side effect on liver enzymes at therapeutic doses. Therefore the concern for side effects traditionally observed with St. John’s wort is not a problem with NEURAPAS® balance. October 2013 l www.ihpmagazine.com 33

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cover story

Excellence in Integrative Medicine by Philip Rouchotas, Msc, ND

The path taken by Dr Francesco Anello to arrive at the creation of the Complementary Healing Arts clinic in Cambridge, Ontario is indeed unique and influenced by several phenomena outside of any one individual’s control. Yet the story unfolds in a manner familiar to IHP readers: rigorous training in conventional therapeutics, considerable time spent applying the conventional medical model, a feeling of being “unfulfilled” by the care being delivered, and the inevitable search for better solutions to common, debilitating problems.

Francesco Anello, MD Dr Anello completed his undergraduate (HBSc genetics) and medical training at the University of Western, completing a family practice residency in 1984. He opened a family practice in Cambridge in 1986, providing a full- spectrum of care, yet with emphasis on obstetrics and neonatal/ pediatric care, and maintained emergency room rotations and surgical assisting at a local hospital. The healthcare crisis of the mid 1990’s and accompanying cutbacks left Dr Anello feeling the style of practice he was engaged in was no longer tenable. He closed down his private practice and undertook a role with the Woolwich Community Health Centre in 1995. At the same time, he began building what is known today as the Complementary Healing Arts clinic, which he fully transitioned to in 2002.

October 2013 l www.ihpmagazine.com 35

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cover story Dr Anello always maintained an active interest in integrative medicine. His original conventionally- focused facility in 1986 was seeing a lot of obstetrics patients, and quickly his clinic gained a reputation as being “midwife friendly”. In Dr Anello’s words, “a holistic perspective on birthing was required… people were wanting it, asking for it”. His work during a locum in the town of St Jacobs served as an excellent introduction to more holistic birthing practices, as he served a large Mennonite community within the town. The roots of Dr Anello’s interest in integrative medicine began much earlier, however. During his last year of medical school, Francesco spent six months in India completing a rotation in obstetrics and infectious disease. He met up with an individual he described as a “wandering healer” whom he spent the majority of the trip with, and was introduced to the art of meditation. Shortly after his return to Canada, Dr Anello continued his pursuit of training in integrative medicine through a channel familiar to most integrative MD’s; the seminars hosted by Jeffrey Bland and Alan Gaby. The clinic is situated in a stunning, large home on a main street in Cambridge, Ontario. An initial visit with Dr Anello is a one- hour intake, involving a complete medical history, a battery of common lab tests, and discussion of one or two relevant integrative diagnostic tests. Subsequent visits review relevant laboratory outcomes, an individualized treatment plan specific to the patient is created, and Dr Anello plus the impressive support staff of the facility implement recommendations as a team. The clinic performs a large number of IV therapies, used to address a wide array of patient concerns. Chief among them is the reputation the clinic has garnered as a facility of cardiovascular disease management, with IV EDTA emerging as among the most relied upon interventions. The team at the Complementary Healing Arts clinic is as diverse and skilled as the clinic’s founder. Marianne Anello brings a wealth of clinical experience as an RN in a broad array of hospital settings including ER and pediatric nursing. At the facility

Marianne oversees laboratory testing and IV therapies. Michael Reid is an ND graduated from CCNM. He describes Dr Anello as a gifted, selfless, and extremely knowledgeable practitioner of integrative medicine, citing his time with Dr. Anello as helping him advance his skill set as an ND. Alex Audette is an Asian- trained physician of traditional Chinese medicine. In addition to conventional TCM practices, Dr Audette delivers Japanese deep tissue lymphatic drainage at the facility, a labour- intensive, hands on form of acupuncture that may be time consuming yet delivers important outcomes quickly for patients. The clinic also boasts highly skilled and experienced practitioners in psychotherapy (Kristin Trotter, PhD), and registered nurse (Donna Rieck). Trudy Schneider rounds out the team by acting as office manager. Dr Anello did not let me spend much time getting to know about his style of practice. Instead, he would make a comment about some new happening in the world of medicine, and I would eagerly delve into the topic mostly out of personal interest. It began with a discussion of Dr Garth Nicolson, formerly Professor and Chairman of the Department of Tumor Biology at the University of Texas M.D. Anderson Cancer Center, who investigated the cause of Gulf War Syndrome with all the tools of molecular biology he had at his disposal. He hypothesized a mycoplasma organism was weaponized and used against US soldiers. The organism is believed to be responsible for chronic fatigue, chronic rheumatic pain type syndromes common among soldiers who served in the gulf war. Dr Nicolson has developed a private lab that tests for the mycoplasma organism, and advocates for the use of intermittent doxycycline for treatment of the disorder. Most astonishing to me, a handful of days before my interview with Dr Anello, a surgeon from the US was claiming 50%+ of individuals seeking back surgery for chronic pain can avoid the surgery entirely with an aggressive six month course of antibiotics. I asked Dr Anello about the CPSO, and whether or not he has faced controversy from them. He described a few inquiries, all of which occurred in his first 10 years October 2013 l www.ihpmagazine.com 37

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cover story

of practice. I was then immersed in a fascinating discussion of a well- known Ontario physician, Jozef Krop. Dr Krop practiced integrative medicine in Ontario for many years, and was cited as a major contributor to the modern integrative practices that define management of chemically sensitive patients. Dr Krop found himself in a lot of trouble with the CPSO, yet his patients rallied at Queen’s Park and not only vindicated Dr Krop, but also helped to pass the Kwinter Bill in Ontario. In brief, the Bill enshrined a patient’s freedom of choice in healthcare, and went a long way in preventing the stripping of a medical license for reasonable practice outside of conventional scope for physicians in Ontario. IHP is grateful to Dr Anello and the Complementary Healing Arts team for allowing us to showcase their efforts to

you. Dr Anello embodies everything one hopes to encounter in a practitioner of integrative medicine, and like a handful of others we have had the privilege to meet, he arrived at his current destination during a time when the path was much more difficult to follow than it is today. I am normally quite good at keeping an interview with integrative MD’s focused on the type of information gathered for a story. Dr Anello’s passion and knowledge simply made the task impossible in this case. Every side- bar, story, “hey did you hear this?” had me mesmerized and fascinated. Francesco truly is a wealth of knowledge and wisdom… Our profession will be richly rewarded if we can pry him from his clinic and get him delivering a lecture circuit of his own? Dr Anello, you are likely to serve as the “wandering healer” who inspires the next generation of physician to deliver the best system of medicine going… October 2013 l www.ihpmagazine.com 39

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METAGENICS PHYTOMULTI PhytoMulti by Metagenics is a robust multivitamin fortified with over 20 phytonutrient extracts, including lutein, greet tea extract, and resveratrol. As such, PhytoMulti is an ideal product for use in adults in order to optimize vitamin and mineral status, in lieu of poor dietary intake or increased physiological requirements, but also provides a broad spectrum of plant nutrients in order to mimic the many health effects of a plant-based diet. The USDA MyPlate recommendations include between 9-10 servings of fruits and vegetables per day, but less than 10% of adults achieve this target (Murphy 2011). The Mediterranean dietary pattern is an example of a well-researched diet that is very high in phytonutrients. The Mediterranean diet is associated with markedly lower risk of several chronic diseases, including cardiovascular disease and diabetes (Eustruch 2006, Interact Consortium 2011, Nordmann 2011), and a high fruit and vegetable diet has been shown to reduce risk of cancer (Block 1992), in large part due to high amounts of combined phytonutrients. Phytonutrients have been shown to confer beneficial health effects through numerous mechanisms, including modulation of signal transduction pathways, antioxidant properties, and through hormonal effects. PhytoMulti contains over 20 of these plant substances, including: lutein, zeaxanthin, acacia nilotica, and extracts of artichoke leaf, grape seed extract, green coffee, green tea, citrus bioflavonoids, resveratrol, prune skin, watercress, rosemary, pomegranate, lycopene, cinnamon, bitter melon, and blueberry. Multivitamin supplementation has been shown to benefit a variety of physical and cognitive parameters particularly in children, pregnant women or women who may become pregnant, individuals under increased stress, individuals with poor absorption, and the elderly. In pregnancy, supplementation with a folic acid containing multivitamin has been shown to reduce risk of complications such as placental abruption, preeclampsia, in addition to decreasing risk of congenital defects including neural tube defects, anencephaly, myelomeningocele, meningocele, oral facial cleft, structural heart defects, limb defects, urinary tract anomaly, and hydrocephalus when used prior to conception and during the first trimester (Wilson 2007). Periconceptional multivitamin use in lean women has been shown to decrease the risk of small-for-gestational-age (SGA) under the 5th percentile by up to 46% compared to non-users (OR=0.54, 95% CI), and has been associated with a 71% reduction in preeclampsia risk (OR=0.29, 95% CI) in lean women, users versus non-users (Catov 2007; Bodnar 2006). Periconceptional multivitamin use has also been associated with reduced risk of several pediatric cancers, including leukemia (OR=0.61) (39% reduced risk); pediatric brain tumors (OR=0.73) (27% reduced risk); and neuroblastoma (OR=0.53) (47% reduced risk) in a recent metaanalysis (Goh 2007). In patients under high levels of psychological stress, use of a multivitamin has been shown improve perceived levels of stress and psychometric parameters. Gruenwald et al (2002) found that use of a multivitamin for 6 months resulted in a 40.7% overall improvement in self rated stress levels using a psychologicalneurological questionnaire to assess “psycho-organic, central vegetative, and somatic discomforts.” Other outcomes included a 29% decrease in frequency of infections and 91% decrease in gastrointestinal discomfort. Schlebusch et al (2000) found similar benefit on various psychometric parameters in a 30 day trial (1997), and Harris found that multivitamin supplementation can improve measures of mood, stress, and alertness in older men (2011). Importantly, supplementation with a spectrum of B vitamins has also been shown to reduce ratings of workplace stress (Stough 2011). Several trials have shown increased cognitive performance in children taking a multivitamin supplement. Benton et al (1988) found a significant increase in nonverbal intelligence in children taking a multi versus those taking placebo after 8 months’ intervention. In a 14 month study of 608 children, Vazir et al (2006) found a significant increase in attention-concentration increment scores in those supplemented with a micronutrient-fortified beverage versus those receiving placebo. Additional benefits demonstrated in children include a reduced mean duration (5.0 versus 7.5 days, supplement versus placebo) of several common childhood illnesses including such as fever, cough and cold, diarrhea, and ear infections (Sarma 2006). In the elderly, multivitamin supplementation has been shown to significantly improve status of such nutrients as vitamin D, vitamin B6, vitamin B12, folate, vitamin C, vitamin E, zinc, and selenium (McKay 2000; Girodon 1997). In addition, supplementation has also been found to significantly reduce rates of infection in the elderly, as found a trial in 81 subjects given various supplemental combinations of micronutrients and followed over a 2 year period (Girodon 1997).

PhytoMulti: Active Ingredients* (per 1 tablet) Ingredient Vitamin A as retinyl acetate Vitamin A as carotenoids Vitamin E d-alpha tocopherol Vitamin C ascorbic acid Vitamin D3 cholecalciferol Vitamin K phytonadione Thiamine mononitrate

Dose 2500 2500 50 60 500 60 12.50

Unit IU IU IU mg IU mcg mg

Riboflavin 7.50 mg Niacin 6.25 mg Niacinamide 18.75 mg Pantothenic acid 37.5 mg Vitamin B6 pyridoxine HCl 12.50 mg Calcium L-Mefolinate 400 mcg Vitamin B12 cyanocobalamin 120 mcg Biotin 250 mg Magnesium citrate 20 mg Chromium polynicotinate 100 mcg Copper citrate 500 mcg Iodine potassium iodide 75 mcg Manganese citrate 250 mcg Molybdenum aspartate 25 mcg Selenium aspartate 50 mcg Zinc citrate 7.50 mg * In addition to extracts of over 20 phytonutrients.

References Benton D, Roberts G. Lancet. 1988 Jan 23;1(8578):140-3. Block G, et al. Fruit, vegetables, and cancer prevention: a review of the epidemiological evidence. Nutrition and cancer 1992;18(1):1-29. Bodnar LM, Tang G, Ness RB, Harger G, Roberts JM. Am J Epidemiol. 2006 Sep 1;164(5):470-7. Epub 2006 Jun 13. Catov JM, Bodnar LM, Ness RB, Markovic N, Roberts JM. Am J Epidemiol. 2007 Aug 1;166(3):296-303. Epub 2007 May 11. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Fertil Steril. 2008 Mar;89(3):668-76. Epub 2007 Jul 10. Eustruch R, Martínez-González MA, Corella D, et al. Ann Intern Med. 2006 Jul 4;145(1):1-11 Girodon F, Lombard M, Galan P, Brunet-Lecomte P, Monget AL, Arnaud J, Preziosi P, Hercberg S. Ann Nutr Metab. 1997;41(2):98-107. Goh YI, Bollano E, Einarson TR, Koren G. Clin Pharmacol Ther. 2007 May;81(5):685-91. Epub 2007 Feb 21. Grieger JA, Nowson CA, Jarman HF, Malon R, Ackland LM. Eur J Clin Nutr. 2007 Nov 28. Gruenwald J, Graubaum HJ, Harde A. Adv Ther. 2002 May-Jun;19(3):141-50. Harris E, Kirk J, Rowsell R, Vitetta L, Sali A, Scholey AB, Pipingas A. Hum Psychopharmacol. 2011 Dec;26(8):560-7. InterAct Consortium. Diabetes Care. 2011 Sep;34(9):1913-8. McKay DL, Perrone G, Rasmussen H, Dallal G, Hartman W, Cao G, Prior RL, Roubenoff R, Blumberg JB. J Am Coll Nutr. 2000 Oct;19(5):613-21. Murphy MM, et al. Journal of the American Dietetic Association 2011:in press. Nilsen RM, Vollset SE, Rasmussen SA, Ueland PM, Daltveit AK. Am J Epidemiol. 2008 Apr 1;167(7):867-74. Epub 2008 Jan 10. Nordmann AJ, Suter-Zimmermann K, Bucher HC, et al. Am J Med. 2011 Sep;124(9):841-51.e2. Ribeiro ML, Arçari DP, Squassoni AC, Pedrazzoli J Jr. Mech Ageing Dev. 2007 Oct;128(10):577-80. Epub 2007 Aug 15. Sarma KV, Udaykumar P, Balakrishna N, Vijayaraghavan K, Sivakumar B. Nutrition. 2006 Jan;22(1 Suppl):S8-14. Schlebusch L, Bosch BA, Polglase G, Kleinschmidt I, Pillay BJ, Cassimjee MH. S Afr Med J. 2000 Dec;90(12):1216-23. Stough C, Scholey A, Lloyd J, Spong J, Myers S, Downey LA. Hum Psychopharmacol. 2011 Oct;26(7):470-6. Tanvetyanon T, Bepler G. Cancer. 2008 Jul 1;113(1):150-7. Vazir S, Nagalla B, Thangiah V, Kamasamudram V, Bhattiprolu S. Nutrition. 2006 Jan;22(1 Suppl):S2632. Wilson RD, et al. J Obstet Gynaecol Can. 2007 Dec;29(12):1003.

clinic profile

HealthSource Integrative Medical Centre Leaders in the I Community – providing results for patients By Christopher Habib, ND Photographs by John Milios

42 www.ihpmagazine.com l October 2013

n this Clinic Profile, IHP is pleased to present the HealthSource Integrative Medical Centre. HealthSource is run by Dr. Michael Reid, ND and Dr. Som Thammasouk, ND. This husband and wife couple met in Naturopathic College. They started practicing together in a rehabilitation clinic, but their practices outgrew the space. They eventually purchased and moved their practices into a custom-built house that was designed and originally built specifically to be a medical office. They formed HealthSource Integrative Medical Centre at the end of 2011. Dr. Reid also works part-time with Dr. Anello, MD, who is also featured in

this issue of IHP. HealthSource now runs the second largest IV practice (Dr. Anello having the largest) in the Waterloo region and service approximately 100 patient visits a week. This clinic positions itself in the market as an integrative medical centre, where they bridge the gap between conventional and naturopathic medicine. The end result is that the community recognizes them as a location where both integrative care and naturopathic care can be obtained. They receive many referrals from other practitioners in the KitchenerWaterloo area, including complex and difficult cases.

clinic profile The full clinic team consists of the two Naturopathic Doctors, a Registered Practical Nurse, a Registered Massage Therapist, a Registered Holistic Nutritionist, and an Office Manager. The 2000 square foot clinic consists of six treatment rooms, one IV room, a preparatory IV/ lab room. The clinic provides on-site parking for patients. As a highly advanced centre, HealthSource utilizes numerous assessment tools. They do all blood draws directly in the clinic and local labs pick-up the samples. They developed their own panel of bloodwork with a laboratory and were able to offer it at a reduced rate that consists of nutrients, hormones, inflammatory markers and chemistry. Other common tests run at the centre include tumour markers, food intolerances, candida yeast testing, plasma amino acids, saliva hormones, and heavy metal testing. They utilize GDL, Doctor’s Data, Great Plains Lab, Rocky Mountain Analytical, Spectracell, Igenex, and Lifelabs. Their more advanced in-office testing includes arterial stiffness assessment to gage the risk of heart disease, live blood cell analysis/dark field microscopy, and bio-impedence analysis to assess body composition. Dr. Reid believes many patients see great results because of the clinical application of the functional markers. Their patients don’t simply focus on a reference range. For this reason, almost every patient will get some degree of lab work immediately at the start of their care.

and he receives referrals from other practitioners including Naturopathic Doctors, Pharmacists, Family Doctors and most recently a local Oncologist. He spends a good deal of his time focusing on difficult cases. As a result, the clinic has become known for its cancer program, but also its focus on treating autoimmune conditions, MS, ALS, cardiac conditions, chronic fatigue, and pain management. Highly advanced IV therapy is successfully used for numerous patient cases and is especially useful in helping many patients at once.When asked about his approach to treatment, Dr. Reid says “Using my knowledge-base, I always prescribe what is best for the individual patient. Patients are sometimes surprised that I will sometimes suggest the pharmaceutical approach, simply because I believe that might be the best approach.”

The clinic carries multiple reputable brands including NFH, Restorative Formulations, Douglas Labs, Pure Encapsulations, Thorne, MediHerb, AOR, Researched Nutritionals. The clinic also carries a tincture dispensary where the doctors perform customcompounding for patients and a small homeopathic dispensary. Dr. Reid and Dr. Thammasouk’s practices cover a broad range of health concerns and is open to all people. They are committed to continuing education and pride themselves on being at the forefront of medicine. Dr. Reid has an oncology-focused practice October 2013 l www.ihpmagazine.com 43

clinic profile

Dr. Thammasouk’s practice focuses on weight loss, pediatrics, female hormonal concerns, endocrinology, and dermatology. She has extensive experience with corporate wellness for companies including Canada Post and General Mills, usually by developing 12-month programs. She also creates customized health assessments and speaks at lunch and learns. She plans on bringing her corporate experiences to the Waterloo Region with local companies. She had a baby about a year ago and has been working hard maintaining a busy practice and home life. Dr. Reid and Dr. Thammasouk give their time to providing education to organizations within their community, including the public libraries, and special groups for Fibromyalgia, CFS/ME, arthritis, stroke recovery, Early Years Children’s Centres, YMCA, osteoporosis, and Alzheimer’s. They are passionate about educating people about different ways to approach healthcare, in particular about sharing the message of Naturopathic Medicine. This attitude has fueled and motivated the doctors. Since they started working, they’ve worked extremely hard to achieve what they’ve built. They were initially working 80-100 hours a week and now the majority of their practice is based on referrals. They believe that hard work and perseverance pays off and they want to be shining examples for other aspiring practitioners. One of the largest challenges faced by HealthSource is that in the Waterloo region, since it is outside the urban centre of Toronto, there is still a lack of understanding from other professionals and the public about everything Naturopathic Doctors can actually do and offer their patients. In an effort to bridge this gap, the clinic works closely with medical doctors in a collaborative manner. This allows the clinic to 44 www.ihpmagazine.com l October 2013

expand its scope of practice because it can provide more for its patients.When they initially began practicing, the doctors were practicing out of another clinic. They found that when they took the steps to go out on their own, their practices immediately grew substantially. In particular, they found the expanded space and more tailored support staff helped. They found that being able to customize the space also allowed them to create an environment that was accurately representing Naturopathic Medicine. The doctor’s next steps are to continue growing their clinic and to add practitioners to the team that will only enhance the health experience of the patients. When asked about the challenges of working with your spouse, Dr. Reid and Dr. Thammasouk both humourously suggest that it is especially difficult when the other partner is “strongly opinionated”. Their advice to others is to separate which role they are in, such as “spouse” versus “business” versus “doctor”. They also try to shut off work when they get home and focus on family. IHP wishes this incredible team much success in their future. ---------------------------------------Dr. Michael Reid, ND Dr. Som Thammasouk, ND Joyce Stanic, RPN, RNCP Ruth Thompson, RNCP, RHN, MSW Michael Stock, RMT Karen Keelan, Office Manager HealthSource Integrative Medical Centre 227 Dumfries Ave Kitchener, Ontario N2H 2E6 tel: 519.954.7950 fax: 519.954.7951 email: info@HealthSourceIMC.com web: www.HealthSourceIMC.com

clinic profile

October 2013 l www.ihpmagazine.com 45

Introducing...

Sereniten Plus

An effective solution consisting of Lactium®, L-Theanine and Vitamin D to reduce the symptoms of mental and physical stress.

A novel formula with anxiolytic activity • Bioactive decapeptide Lactium® with specific binding to GABA (A-1) receptors • Appropriate receptor binding without the side effects of drowsiness, memory loss, tolerance or addiction • Re-establishes the HPA feedback loop by increasing the sensitivity of the hypothalamus to cortisol • Decreases cortisol and CRH during chronic stress

Unregulated elevated levels of cortisol impair stage four delta wave sleep, destabilize mast cells, inhibit digestive enzyme production and increases endothelin and LDL levels. All of these effects contribute to increased cardiovascular disease, allergies, IBS and IBD. Balancing the hypothalamic-pituitary axis by re-establishing appropriate sensitivity within the feedback loop assists in mitigating these effects and normalizing cortisol levels. VISIT US @ DOUGLASLABS.CA OR CALL TOLL FREE @ 866.856.9954

Sereniten Plus

Anxiolytic effect reducing Mental and Physical Stress DESCRIPTION Sereniten Plus is a combination of Lactium®, L-Theanine and Vitamin D to support the HPA axis and feedback loop for stress management and cortisol regulation. FUNCTIONS The neurochemical and hormonal reactions to stress are regulated through the Hypothalamic-Pituitary-Adrenal axis (HPA axis) designed for acute stressors that resolve rapidly. Present day chronic, low-grade stress results in the continual release of CRH (Corticotropin Releasing Hormone) from the hypothalamus. This chronic secretion causes dysfunction in the HPA axis, desensitizing the hypothalamic and pituitary receptors to negative feedback from adrenaline, noradrenalin and particularly, cortisol. Loss of negative feedback within the neuro-hormonal system results in a multitude of health issues. It increases the production of ADH, aldosterone, and angiotensin increasing vascular vasoconstriction and sodium retention. It increases C-reactive protein and endothelin, promoting atherosclerosis and inflammation. It directly increases LDL production as well as glucocorticoid and mineralcorticoid release, further increasing cardiac risk. When the negative feedback loop within the HPA-axis is disrupted, chronic hormonal secretion becomes “normal” for that individual. In this state, they either fail to recognize they are stressed, or they may experience exaggerated emotional and physical response to every stressor including intolerance to noise or light, or feeling overwhelmed by simple tasks. Stress affects so many aspect of health that is becoming crucial to rebalance the HPA-axis. Lactium®, a bioactive decapeptide, alpha-1 sequence isolated from milk is effective in not only decreasing glucocorticoid secretion but will assist in rebalancing the HPA pathway. Lactium® works at three areas of the HPA-axis: 1) Lactium® binds specifically to the BZD site of the GABA-A receptor and does NOT bind to the PBR site of the GABA-A receptor responsible for the sedating effects seen with benzodiazepines. 2) Lactium® increases the sensitivity of the hypothalamus to cortisol, re-establishing receptor sensitivity feedback within the HPA-axis. It reduces the amount of CRH produced in response to stress. 3) Lactium® decreases the amount of cortisol released by the adrenal glands during acute and chronic stress. Studies in humans using alpha-S1-casein hydrolysate have resulted in anxiolytic-like effects, without side effects. Results showed a significant decrease in plasma cortisol throughout the combined stress tests and stable heart rate in the treatment group but not in the placebo group. Another study showed after 30 days of treatment a reduction in stress related symptoms including digestion, cardiovascular, intellectual, emotional, and social problems. L-Theanine is a unique amino acid derived from tea providing relaxation support without drowsiness. L-Theanine has been shown to increase alpha-wave production, an observed pattern considered to be an index of relaxation. Vitamin D has been included for additional support in reducing inflammation and supporting immune function. INDICATIONS Sereniten Plus is for individuals wanting to support their response to stress and reestablish HPA-axis to stress. FORMULA 201348 Each capsules contains: Casein decapeptide (milk)/ casein decapeptide (lait) (Lactium®) . . . . . . . . . . . . . . . . . . 175mg L-Theanine (Suntheanine®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50mg Vitamin D3/Vitamine D3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100IU

SUGGESTED USE Adults take 1 capsule daily or as directed by your health care professional. Characterization of α-casozepine, a tryptic peptide from bovine αs1-casein with benzodiazepine-like activity. Laurent Miclo, Emmanuel Perrin. The FASEB Journal June 2001 De Saint-Hilaire,Z; et al. Effects of Bovine αs1-Casein Tryptic Hydrolysate (CTH) on Sleep Disorder in Japanese General Population. The Open Sleep Journal, 2009,2,26-32 Kim, JH; Desor,D; et al. Efficacy of αs1-casein hydrolysate on stress-related symptoms in women. European Journal of Clinical Nutrition (2006),1-6 Messaoudi,M; et al. Effects of tryptic hydrolysate from bovine milk αs1-casein on hemodynamic responses in healthy human volunteers facings successive mental and physical stress situations. Eur J Nutr (2004,)534-537 VISIT US @ DOUGLASLABS.CA OR CALL TOLL FREE @ 866.856.9954

$250,000 2013 Dr. Rogers Prize awarded to Dr. Sunita Vohra, University of Alberta

The 2013 Dr. Rogers Prize for Excellence in Complementary and Alternative Medicine was awarded to Dr. Sunita Vohra of the University of Alberta at a gala award dinner on September 26th in Vancouver, BC. Dr. Vohra is the founding Director of Canada’s first academic pediatric integrative medicine program, CARE (Complementary and Alternative Research and Education), at the University of Alberta. She is currently evaluating the effectiveness and cost effectiveness of pediatric integrative medicine as an adjunct to usual care at the Stollery Children’s Hospital in Edmonton. She has led many high quality studies of the effectiveness of CAM including ginseng for pediatric upper respiratory tract infection and Mind Body Stress Reduction for at risk youth. With her background in pediatrics, clinical epidemiology and clinical pharmacology, Dr. Vohra is a respected leader in both CAM and conventional medicine, often working to help these two communities connect. She founded Canada’s national pediatric CAM network as well as helped found and now chairs the American Academy of Pediatrics’ Section on Integrative Medicine. Dr. Vohra initiated the use of N-of-1 studies (a multiple cross over trial performed in a single person) as an innovative and patient-centered solution to the limitations of randomized controlled trials for individualized therapies. At the beginning of her career, at the Hospital for Sick Children in Toronto, she recognized the importance of complementary and alternative medicine to her patients and their families and the lack of substantive information on the therapies and potential interactions with conventional care. She was recruited to the University of Alberta to implement her vision of the CARE program in 2003, a program which now trains the next generation of researchers, educators, and clinicians about pediatric integrative medicine.

CONGRATULATIONS! Dr. Sunita Vohra, University of Alberta

Winner of the 2013 $250,000 Dr. Rogers Prize for Excellence in Complementary and Alternative Medicine DR. VOHRA is the founding Director of Canada’s first academic pediatric integrative medicine program, CARE (Complementary and Alternative Medicine Research and Education) at Stollery Hospital in Edmonton. She has led many high-quality studies of the effectiveness of CAM therapies. With her background in pediatrics, clinical epidemiology and clinical pharmacology, Dr. Vohra is a well-respected leader in

Dr. Sunita Vohra University of Alberta

both CAM and conventional medicine, often bridging the two communities. For more information on Dr. Vohra’s achievements, see www.drrogersprize.org

The purpose of the Dr. Rogers Prize is to highlight the important contributions of Complementary and Alternative Medicine (CAM) to health care by recognizing and celebrating the pioneers who have made significant contributions to the field. The Dr. Rogers Prize was created in 2007 and is sponsored by the Lotte and John Hecht Memorial Foundation, Vancouver, BC.

www.drrogersprize.org

The Journal of

Integrated Healthcare

Practitioners 1

C ognitive health and new technologies Are you ready to prescribe videogames? by Maria Shaporal, ND

Integrated Healthcare Centre, Toronto, Ontario

Hydrotheraphy

Evidence for clinical applications by Christopher Habib, ND, and Janna Levantg, ND

Mahaya Forest Hill, Toronto, Ontario

FODMAP Diet

Implications in irritable bowel syndrone

by Erin Balodis, MSc, ND Kingswood Chiropractic Health Center, Hammonds Plains, Nova Scotia

it down CE p 81 BThereaking role of acid-base balance in the pathogenesis and treatment of osteoporosis

By Jordan Robertson, ND, Tina Behdinan, Alan Fung, Timothy Park, Emily Wilton, Mengchen Xi, Xin (Jennifer) Yin

McMaster University, Hamilton, Ontario

October 2013 l www.ihpmagazine.com 49

editor’s letter

Thanksgiving

lot of merit should be given to the concept of positive thinking, visualization of goals, and the notion that forward progress occurs much more readily when we adopt a “glass is half full” view as opposed to “glass is half empty”. In line with such a thought process, it should not go unrecognized that the only two countries on the planet that celebrate a Thanksgiving (Canada and the USA) are also two of the globes most affluent countries.

IHP is excited to introduce you to this issue’s cover story, Dr Francesco Anello. We have been extraordinarily privileged in 2013 to be afforded the opportunity to showcase the work of a large number of MD’s who have been practicing integrative medicine for decades. Dr Anello is a most esteemed member of this exclusive club. Each such physician travelled a path much less clearly defined, and much rockier, than the path physicians follow today to pursue interest in integrative medicine. Their pioneering efforts are a large part of the reason we are so readily able to take up the discipline today. The continuing education article for this issue is another excellent contribution from Jordan Robertson, ND, and her army of inquisitive and hard working students from McMaster University, addressing the topic of acid- alkali balance in bone health. The three feature articles in the issue all address very unique topics, likely to be our reader’s first introduction to the area (or at least the published science in the area). Erin Balodis, MSc, ND presents on the FODMAPs diet and its application in IBS. Maria Shapoval, ND presents on a surprisingly well- developed area of research focusing on video games and other cognitive challenges in the management of dementia. Chris Habib, ND and Janna Levanto, ND present an eloquent assimilation of the evidence- base surrounding hydrotherapy. Best Regards, Philip Rouchotas, MSc, ND Editor-in-Chief We invite questions or comments. philip@ihpmagazine.com

50 www.ihpmagazine.com l October 2013

section header

Integrated Healthcare

Practitioners Publisher | Sanjiv Jagota (416) 203-7900 ext 6125 Editor-in-Chief | Philip Rouchotas, MSc, ND (416) 203-7900 ext. 6109 Associate Editor | Christopher Habib, ND Art Director | Malcolm Brown Production Manager | Erin Booth (416) 203-7900 ext. 6110 Production Intern Ashanté Wright Contributors Christopher Habib, ND, Philip Rouchotas, MSc, ND Maria Shapoural, ND, Erin Balodis, MSc, ND, Janna Levanto, ND, Jordan Robertson, ND, Tina Behdian, Alan Fung, Timothy Park, Emily Wilton, Mengchen Xi, Xin Yin

President | Olivier Felicio (416) 203-7900 ext. 6107 CEO | Cory Boiselle (416) 203-7900 ext. 6114 Controller & Operations | Melanie Seth CMO | Zinnia Crawford (416) 203-7900 ext. 6135

Subscription Rates Canada $80 (gst included) for six issues | $120 International

Published by IHP Magazine

Canada Post Canadian Publication Mail Agreement Number 4067800 The publisher does not assume any responsibility for the contents of any advertisement and any and all representations or warranties made in such advertising are those of the advertiser and not of the publisher. The publisher is not liable to any advertiser for any misprints in advertising not the fault of the publisher and in such an event the limit of the publisher’s liability shall not exceed the amount of the publisher’s charge for such advertising. No portion of this publication may be reproduced, in all or part, without the express written permission of the publisher. ihp magazine is pleased to review unsolicited submissions for editorial consideration under the following conditions: all material submitted for editorial consideration (photographs, illustrations, written text in electronic or hard copy format) may be used by ihr Media Inc. and their affiliates for editorial purposes in any media (whether printed, electronic, internet, disc, etc.) without the consent of, or the payment of compensation to, the party providing such material. Please direct submissions to the Editor, ihp magazine.

September 2013 l www.ihpmagazine.com 51

Nutritional Fundamentals for Health Inositol SAP Myo-inositol powder for the treatment of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common cause of ovulatory disorders and female infertility. Signs and symptoms of PCOS may include anovulation or menstrual irregularities; ovarian cysts on ultrasound; hyperandrogenism including hirsutism, acne and alopecia; insulin resistance; and obesity. Insulin resistance and secondary hyperinsulinemia appear to play a causative role in the development of PCOS. myo-Inositol has been suggested as a first-line therapy in the treatment of PCOS, and has been shown to be effective in mitigating the symptoms of this syndrome and its associated comorbidities.

Each scoop contains:

ACTIVE INGREDIENTS

Inositol (myo-inositol) . . . . . . . . . . . . . . . . . . . . . . . . . . 4 g

Contains no: Preservatives, allergens, artificial flavor or color, sweeteners, wheat, gluten, soy, starch, yeast, citrus, egg or dairy.

DOSAGE

Adults: Mix 1 scoop to 8 oz. (250 ml) of water or juice one to three times daily mixed into juice or water or as directed by your health care practitioner. Consult a health care practitioner for use beyond 6 weeks.

INDICATIONS

Inositol SAP may be effective in the treatment of PCOS and its related morbidities—including hypercholesterolemia, hyperandrogenemia, hyperinsulinemia, hirsutism, acne, and menstrual irregularity—, and in the restoration of ovarian activity and infertility.

SAFETY

myo-Inositol is generally well-tolerated. At therapeutic doses up to 4 g/d, no significant adverse events have been reported for the oral supplementation of myo-inositol in studies for up to 6 months.

PURITY AND CLEANLINESS

Third-party testing is performed on finished product to ensure Inositol SAP is free of heavy metals, pesticides, solvents and other impurities.

Scientific Advisory Panel (SAP): adding nutraceutical research to achieve optimum health

Nutritional Fundamentals for Health • 3405 F.-X.-Tessier, Vaudreuil, QC J7V 5V5 • Tel. 1 866 510 3123 • Fax. 1 866 510 3130 • www.nfh.ca

IHP 2013-10,11 (Inositol SAP).indd 1

2013-10-02 11:18:21

Nutritional Fundamentals for Health Inositol SAP Product Monograph

POLYCYSTIC OVARY SYNDROME (PCOS)

HIRSUTISM, ACNE AND SKIN DISORDERS

Comorbidities, signs and symptoms of PCOS commonly include features of metabolic syndrome—including insulin resistance, obesity, and dyslipidemia—, in addition to hyperandrogenemia, reflected in hirsutism, alopecia, and acne. Insulin resistance appears in both obese and nonobese women diagnosed with PCOS.(3, 7)

FERTILITY

Polycystic ovary syndrome (PCOS) is the most common cause of ovulatory disorders and female infertility. It is estimated that this syndrome affects 6–10% of women of childbearing age. Increased insulin levels and impaired glucose tolerance may play causative roles in the development of hyperandrogenemia, the metabolic and reproductive changes in PCOS, through their synergism with luteinizing hormone (LH) to enhance androgen production.(1, 2, 3, 4, 5, 6)

Since the association of hyperinsulinemia, impaired glucose tolerance and insulin sensitivity with PCOS was realized, conventional treatments of this disorder have included pharmaceutical insulin-sensitizing drugs such as metformin, oral contraceptives for the regulation of menstruation, antiandrogenic agents such as spironolactone to address hirsutism, and clomiphene to induce ovulation if desired. Inositol-containing phosphoglycans (IPGs) have been discovered to play a role in activating enzymes that control glucose metabolism.(1, 2, 7) It is speculated that a decrease in the availability or utilization of IPG mediators may contribute to insulin resistance in the pathogenesis of PCOS. Up to 50–70% of women diagnosed with PCOS demonstrate insulin resistance and impaired glucose tolerance.(2, 3, 8)

METABOLIC, LIPID AND HORMONAL EFFECTS OF MYO-INOSITOL

myo-Inositol has been shown in multiple prospective studies to significantly reduce plasma LH, testosterone, free testosterone, HOMA index, and insulin levels within 3 months.(4, 9) Constantino et al. performed a randomized, double-blind, placebo-controlled trial using myo-inositol and found that myo-inositol supplementation at 4 g/d significantly reduced blood pressure, cholesterol, triglyceride, testosterone, and SHBG levels.(5) Minozzi et al. compared the effects of 4 g/d myo-inositol in combination with oral contraceptives versus oral contraceptives alone and found that combination therapy may be more effective than oral contraceptives alone at modulating pertinent hormone levels in PCOS.(10) For more information visit: www.nfh.ca

IHP 2013-10,11 (Inositol SAP).indd 2

myo-Inositol has been shown to reduce symptoms of hirsutism and acne associated with PCOS after 3 months. The decrease in the number of cases exhibiting hirsutism of all severities in this study was statistically significant at 3-month and 6-month follow-ups. 30 % of cases exhibited complete remission of hirsutism symptoms by the 6-month follow-up. The number of cases exhibiting acne also significantly decreased over the 6-month trial, with complete disappearance being reported in 53% of cases.(6) In a study by Genazzani et al., 2 g/d myo-inositol supplementation over 6 months restored menstrual cyclicity in all amenorrheic and oligomennorheic subjects.(9) 88% of amenorrheic subjects supplemented with 4 g/d myo-inositol in a study by Papaleo et al. achieved at least one spontaneous menstrual cycle within 6 months. 40% of subjects in the same study achieved clinical pregnancy, with no incidence of multiple pregnancy.(6) Raffone et al. compared the efficacy of 4 g/d myo-inositol and metformin in combination and alone and concluded that myo-inositol alone is more effective than metformin alone as first-line treatments for the restoration of normal menstrual cycles and in the treatment of infertility.(2) Furthermore, Morgante et al. establish that metformin alone, or in combination with clomiphene, has no advantage in inducing ovulation in patients with PCOS, and should be reserved for patients exhibiting glucose intolerance.(7) It is believed that myo-inositol may improve oocyte quality and ovarian function via modification of calcium signaling, required especially in the final stages of oocyte maturation.(2, 11, 12)

REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Unfer, V. “Polycystic ovary syndrome: a vitamin deficiency? Floating a new pathogenesis hypothesis”. European Review for Medical and Pharmacological Sciences 14, No. 12 (2010): 1101–1105. Raffone, E., P. Rizzo, and V. Benedetto. “Insulin sensitiser agents alone and in co-treatment with r-FSH for ovulation induction in PCOS women”. Gynecological Endocrinology 26, No. 4 (2010): 275–280. Fritz, H. “Polycystic ovary syndrome: Role of inositol in PCOS management”. Integrated Healthcare Practitioners Oct. 2009: 83–87. Zacchè, M.M., et al. “Efficacy of myo-inositol in the treatment of cutaneous disorders in young women with polycystic ovarian syndrome”. Gynecological Endocrinology 25, No. 8 (2009): 508–513. Costantino, D., et al. “Metabolic and hormonal effects of myo-inositol in women with polycystic ovary syndrome: a double-blind trial”. European Review for Medical and Pharmacological Sciences 13, No. 2 (2009): 105–110. Papaleo, E., et al. “myo-Inositol in patients with polycystic ovary syndrome: A novel method for ovulation induction”. Gynecological Endocrinology 23, No. 12 (2007): 700–703. Morgante, G., et al. “The role of inositol supplementation in patients with polycystic ovary syndrome, with insulin resistance, undergoing the low-dose gonadotropin ovulation induction regimen”. Fertility and Sterility 9, Issue 8, 2011: 2642–2644. Azziz, R., et al. “The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report”. Fertility and Sterility 91, Issue 2 (2009): 456–488. Genazzani, A.D., et al. “myo-Inositol administration positively affects hyperinsulinemia and hormonal parameters in overweight patients with polycystic ovary syndrome”. Gynecological Endocrinology 24, No. 3 (2008): 139–144. Minozzi, M., et al. “The effect of a combination therapy with myo-inositol and a combined oral contraceptive pill versus a combined oral contraceptive pill alone on metabolic, endocrine, and clinical parameters in polycystic ovary syndrome”. Gynecological Endocrinology 27, No. 11 (2011): 920–924. Papaleo, E., et al. “Contribution of myo-inositol to reproduction”. European Journal of Obstetrics & Gynecology and Reproductive Biology 147, No. 2 (2009): 120–123. Gerli, S., et al. “Randomized, double blind placebo-controlled trial: effects of myo-inositol on ovarian function and metabolic factors in women with PCOS”. European Review for Medical and Pharmacological Sciences 11, No. 5 (2007): 347–354.

2013-10-02 11:18:21

peer review

Peer Review Board Members Andrea Maxim, ND Healing Journey Naturopathic Clinic 25 Caithness St. W. Caledonia, Ontario N3W 1B7 andreamaximnd@gmail.com

Daniel Watters, BSc, ND Rosedale Wellness Centre 365 Bloor St East Toronto, Ontario M4W 3L4 dwatters@rosedalewellness.com

Anthony Moscar, ND Mahaya Forest Hill 73 Warren Road, Suite 102 Toronto, Ontario M4V 2R9 anthonymoscar@gmail.com

David W Lescheid, BSc, PhD, ND Lichtentaler Strasse 48 76530 Baden-Baden, Germany 20davidl20@gmail.com

Aoife Earls, MSc, ND Trafalgar Ridge Chiropractic and Acupuncture 2387 Trafalgar Road, Unit 7A Oakville, Ontario L6H 6K7 aearlsnd@gmail.com Berchman Wong, ND 718 - 33 Canniff St Toronto, Ontario M6K 3M5 berchman.nd@gmail.com Betty Rozendaal, BES, MA, ND Thornhill Naturopathic Health Clinic 12A Centre Street Thornhill, Ontario L4J 1E9 drbetty@thornhillnaturopathic.ca Brock McGregor, ND McGregor Naturopathic 220 St Clair Street Chatham, Ontario N7L 3J7 drbrock@mcgregornd.com

David Miller, BSc, ND 662 Gustavus Street Port Elgin, Ontario N0H2C0 drdavend@yahoo.ca Denisa Maruyama, ND Kona Wellness Center for Integrative Medicine 74-5565 Luhia Street Suite C-2 Kailua-Kona, Hawaii drmaruyama@konawellness.com Elaine Lewis, HBSc, ND Back to Play Chiropractic 592 Rathburn Road West Mississauga, Ontario L5B 3A4 elewis@ccnm.edu Elizabeth Cherevaty, BSc, ND Norfolk Chiropractic Wellness Centre 86 Norfolk Street, Suite 101 Guelph, Ontario N1H 4J2 elizabeth.cherevaty@gmail.com

Carol Morley, ND Zawada Health 201 City Centre Drive, Suite 404 Mississauga, Ontario L5B 2G6 info@zawadahealth.com

Erin Balodis, BSc, MSc, ND Kingswood Chiropractic Health Centre 1210 Hammonds Plains Road Hammonds Plains, Nova Scotia B4B 1B4 erinbalodis@gmail.com

Claire Girgis, ND Zawada Health 201 City Centre Drive, Suite 404 Mississauga, Ontario L5B 2G6 claire@zawadahealth.com

Erin Psota, BSc, ND King West Village Medical Centre 626 King St West, Suite 201 Toronto, Ontario M5V 1M7 drpsota@gmail.com

Colin MacLeod, ND Alderney Chiropractic 164 Ochterloney St. Dartmouth, Nova Scotia B2Y 1E1 info@drcolinmacleod.com

Faryal Luhar, ND Healthwise Wellness 4250 Weston Rd Toronto, Ontario M9L1W9 ndluhar@hotmail.com

54 www.ihpmagazine.com l October 2013

Heidi Fritz, MA, ND Canadian College of Naturopathic Medicine 1255 Sheppard Ave East Toronto, Ontario M2K 1E2 hfritz@ccnm.edu Isaac Eliaz, MD, MS, LAc Amitabha Medical Clinic & Healing Center 7064 Corline Ct #A Sebastopol, California 95472-4528 ieliaz@sonic.net Jacob Scheer, DC, ND, MHSc 2100 Finch Ave. W. #206 North York, Ontario M3N 2Z9 Jacob.Scheer@utoronto.ca Jiselle Griffith, BSc, ND The Health Hub Integrated Clinic 35 Hayden St, Suite 109 Toronto, Ontario M4Y 3C3 jiselle@healthhubclinic.com Jordan Robertson, BSc, ND Lakeshore Clinic 2159 Lakeshore Road Burlington, Ontario L7R 1A5 jordanrobertsonnd@gmail.com Judah Bunin, BSc, MSc, ND, DrAc Fredericton Naturopathic Clinic 10-150 Cliffe St Fredericton, New Brunswick E3A0A1 frednatclin@yahoo.ca Karam Bains, BSc, ND Inside Out Wellness 3650 Langstaff Road, Unit 12 Woodbridge, Ontario karam@elixirhealth.ca Kate Whimster, ND Kew Beach Naturopathic Clinic 2010 Queen Street East, 2nd floor Toronto, Ontario kwhimster@wavelengthwellness.com Kelly Brown, BSc, ND Clinic One 286 McDermont Avenue Winnipeg, Manitoba R3B 1H6 drkbrownnd@gmail.com

peer review

Leigh Arseneau, ND Centre for Advanced Medicine 670 Taunton Rd East Whitby, Ontario L1R 0K6 info@advancedmedicine.ca

Nicole Egenberger, BSc, ND Remede Naturopathics 214 Sullivan Street Suite 3B New York, New York 10012 info@remedenaturopathics.com

Lindsay Bast, BSc, ND Greenwood Wellness Clinic PO Box 189 1400 Greenwood Hill Rd. Wellesley, Ontario N0B 2T0 lindsay.bast@greenwoodclinic.ca

Nicole Sandilands, ND Durham Natural Health Centre 1550 Kingston Rd, Suite 318 Pickering, Ontario L1V 1C3 info@dnhc.ca

Louise Wilson, BSc, ND 320 Queen St S Bolton, Ontario L7E 4Z9 dr.louisewilsonnd@gmail.com

Raza Shah, BSc, ND St. Jacobs Naturopathic 1-9 Parkside Drive St. Jacobs, Ontario N0B 2NO stjacobs.nd@gmail.com

Maria Shapoval, ND Canadian College of Naturopathic Medicine 1255 Sheppard Ave East Toronto, Ontario M2K 1E2 mshapoval@ccnm.edu

Rochelle Wilcox, BA, ND Living Well Integrative Health Centre 2176 Windsor Street Halifax, Nova Scotia B3K 5B6 drwilcox@balancehealthcentre.ca

Makoto Trotter, ND Zen-tai Wellness Centre 120 Carlton Street, Suite 302 Toronto, Ontario M5A 4K2 makoto@zen-tai.com

Sarah Vadeboncoeur, ND Ottawa Integrative Health Centre 1129 Carling Ave Ottawa, Ontario K1Y 4G6 sarahmvadeboncoeur@gmail.com

Mandana Edalati, BA, ND Wellness Naturopathic Centre Suite 213-1940 Lonsdale Ave North Vancouver, British Columbia V7M 2K2 dredalati@gmail.com

Scott Clack, ND Touchstone Naturopathic Centre 950 Southdown Rd, Unit B5 Mississauga, Ontario L5J 2Y4 sclack.nd@touchstonecentre.com

Meghan MacKinnon, ND Armata Health Centre 126 Welling St. W, Unit 201B Aurora, Ontario L4G 2N9 drmeg.nd@gmail.com Melanie DesChatelets, BSc, ND True Health Studio 200-4255 Arbutus St Vancouver, British Columbia V6J 4R1 melanie@drdeschat.com Misa Kawasaki, BSc, ND Meridian Wellness 13085 Yonge Street, Suite 205 Richmond Hill, Ontario L4E 3S8 drkawasaki@meridianwellness.ca

Sylvi Martin, BScN, ND Fusion Chiropractic and Integrative Health 735 Danforth Avenue Toronto, Ontario M4J 1L2 info@fusionchiropractic.ca Tanya Lee, BSc, ND The Health Centre of Milton 400 Main St East Suite 210 Milton, Ontario L9T 1P7 tanyalee.nd@gmail.com Terry Vanderheyden, ND Bayside Naturopathic Medicine 118 Bay Street Barryâ&#x20AC;&#x2122;s Bay, Ontario KOJ 1B0 doctrv@gmail.com Theresa Jahn, BSc, ND Living Well Integrative Health Centre 2176 Windsor Street Halifax, Nova Scotia B3K 5B6 info@theresajahn.com

Shawna Clark, ND Forces of Nature Naturopathic Clinic 2447 1/2 Yonge St Toronto, Ontario M4P 2E7 info@shawnaclarknd.com Stephanie Swinkles, DDS Elmsdale Dental Clinic 4-269 Highway 214 Elmsdale, Nova Scotia N2S 1K1 steph_moroze@hotmail.com Susan Coulter, BSc, ND Roots of Health 2-497 Laurier Ave Milton, Ontario L9T 3K8 scoulter@rootsofhealth.ca October 2013 l www.ihpmagazine.com 55

PROGRESSIVE NUTRITIONAL THERAPIES VEGESSENTIAL ALL IN ONE VegEssential™ combines the benefit of an entire cupboard full of supplements with the ease of consuming a single smoothie. This simple to use all-in-one formula not only provides unmatched nutritional density, it also provides unmatched convenience. VegEssential™ embraces the wisdom of consuming an alkaline-forming, whole-food diet and draws on almost 100 plant-based ingredients to deliver an incredible spectrum of both micro and macro nutrients. Vegetable protein intake was inversely related to blood pressure. This finding is consistent with recommendations that a diet high in vegetable products be part of healthy lifestyle for prevention of high blood pressure and related diseases (Elliot, et al 2006). Elderly women with a high dietary ratio of animal to vegetable protein intake have more rapid femoral neck bone loss and a greater risk of hip fracture than do those with a low ratio. This suggests that an increase in vegetable protein intake and a decrease in animal protein intake may decrease bone loss and the risk of hip fracture (Sellmeyer, et al 2001). An elevated level of total plasma homocysteine (tHcy) is considered to be a predictor of the mortality risk for all diseases. Panunzio et al (2003) investigated whether supplementation of concentrated fruit and vegetables is able to decrease tHcy levels. Twenty-six subjects participated in a cross-over design intervention trial, receiving 2 capsules of fruits and 2 capsules of vegetables a day for 4 weeks, then acting as his/her own control for another 4 weeks. It was revealed that plasma tHcy concentration was decreased as a result of taking a powdered fruit and vegetable extract on a daily basis, reducing a risk factor causally linked to chronic disease. Cao et al (1998) examined whether a diet rich in fruit and vegetables would affect the antioxidant capacity of human plasma. Thirty-six healthy nonsmokers consumed 2 sets of control diets providing 10 servings of fruits and vegetables each day (for 15 days) with or without an additional 2 servings of broccoli each day on days 6-10. It was observed that increased consumption of fruit and vegetables could increase the plasma antioxidant capacity in humans. Vazir, et al (2006) evaluated the effect of a micronutrient supplement on mental function in children (aged 6 – 15 years). This double blind, placebo-controlled, matched-pair, cluster, randomized trial assessed a cohort of 608 children for intelligence, attention and concentration, memory, and school achievement, before and after 14 months of micronutrient supplementation. Results indicated that supplementation with a range of micronutrients significantly improved attention-concentration over the period of 14 months in children aged 6 – 15 years. The SHEEP study examined the association between the use a multivitamin supplements and the risk of myocardial infarction (MI). Results were based on data from a large population-based, case-control study of subjects aged 45 – 70 years. The study included 1296 cases (910 men, 386 women) with a first nonfatal MI and 1685 controls (1143 men, 542 women) frequency-matched to the cases by sex, age and hospital catchments area (Holmquist, et al 2003). The results from this study indicate that use of a multivitamin supplements may aid in the primary prevention of MI.

Dosage Indication: A factor in the maintenance of good health. Adults (≥ 18 years)

Suggested Use: Add 1 scoop of VegEssential™ into 350-400ml of the beverages of your choice.

Interactions There is insufficient research available regarding the safety of several of the herbal components in children, as a result the use of VegEssential is not recommended in children under 18 years of age (Jellin et al (2006)). Due to the potential of toxicity and adverse effects of some of the constituents, VegEssential is not recommended for use in pregnant or breastfeeding women (Jellin et al (2006)). Some the components in VegEssential may interact with medication, diseases and conditions, and/or lab test results. It is recommended that all ingredients be reviewed before use in an individual under medical supervision, taking prescription medication, suffering from a serious and/or pre-existing medical condition (Jellin et al (2006)).

Quality Assurance

Parameter Microbial Total Count Yeast & Mold Escherichia coli Salmonella sp Staphylococcus aureus Heavy Metal Arsenic Cadmium Lead Total Mercury Chemical Pesticides Solvents

Test

Specifications

USP USP USP USP USP

Less than 5,000 cfu/g Less than 100 cfu/g Negative Negative Negative

USEPA USEPA USEPA USEPA

< 1.0 ppm < 0.5 ppm < 1.0 ppm < 1.0 ppm

USP USP

Absent Conforms to limits

References Cao G, et al (1998). Increases in human plasma antioxidant capacity after consumption of controlled diets high in fruit and vegetables. Am J Clin Nutr, 68: 1081-1087. Elliott P, et al. Association Between Protein Intake and Blood Pressure: The INTERMAP Study. Arch Intern Med, Jan 2006; 166: 79 - 87

Holmquist C, et al (2003). Multivitamin Supplements Are Inversely Associated with Risk of Myocardial Infraction in Men and Women – Stockholm Heart Epidemiology Program (SHEEP). J Nutr, 133: 2650-2654. Jellin JM, et al (2006). Pharmacist’s Letter/Prescriber’s Letter th Natural Medicines Comprehensive Database.8 ed. Stockton, CA: Therapeutic Research Faculty. Sellmeyer, D. E., et al. 2001. A high ratio of dietary animal to vegetable protein increases the rate of bone loss and the risk of fracture in postmenopausal women. American Journal of Clinical Nutrition. 73(1): 118-122. Panunzio MF, et al (2003). Supplementation with fruit and vegetable concentrate decreases plasma homocysteine levels in a dietary controlled trial. Nutrition Research, 23: 1221-1228. Vazir S, et al (2006). Effect of micronutrient supplement on health and nutritional status of schoolchildren: mental function. Nutrition, 22: S26-S32.

editorial board

IHP Editorial Board Members The purpose of our Editorial Board is to help guide the direction of the publication, in a manner that A) improves academic quality and rigor, B) exerts a positive impact on patient outcomes, C) contributes to knowledge of integrative healthcare, and D) showcases evolving trends in the healthcare industry. We have appointed a dynamic mix of individuals representing integrative MD’s, profession-leading ND’s, and members of academia. This unique blend of minds comes together and has already provided

insight that is actively shaping the manner in which IHP is compiled. Our goal remains successful listing with the PubMed database of scientific literature, and the contributions of this incredible team are an important step in the right direction. IHP is grateful to the donation of time and expertise made by these incredible professionals. The best way we can think of honouring their contribution is to effectively implement their suggestions and thus continuously elevate the quality of delivery of this publication.

Jason Boxtart, ND

Dr Boxtart is currently serving as Chair to the Board of Directors for the Canadian Association of Naturopathic Doctors, the national association of naturopathic medicine in Canada. In that position he also chairs the Canadian Naturopathic Coordinating Council, the national stakeholder group in Canada. He also is a Board member of the Canadian Naturopathic Foundation, the national naturopathic charity. For the last eight years Dr Boxtart has held a Faculty of Medicine post with the University of Northern British Columbia. Jason, and his wife Dr Cher Boomhower, ND, share the role of Medical Director for the Northern Center for Integrative Medicine, a multi-practitioner clinic in Prince George, BC.

Ben Boucher, MD

Dr Boucher is a Nova Scotian of Acadian-Metis heritage who spent his early years in Havre Boucher, NS. He attended St. Francis Xavier University where he graduated in 1973. In 1978, he obtained a Doctor of Medicine degree from Dalhousie University, NS. Since 1979, he has practiced rural medicine in Cape Breton, NS. Although he has a very large general practice, he has special interests in chelation therapy and metal toxicity. In the past three years, he has been recognizing and treating vector- transmitted infections. Dr Ben does his best to help patients by following Sir William Osler’s approach whereby if one listens long enough to a patient, together the answer will be found.

58 www.ihpmagazine.com l October 2013

editorial board

Pardeep Nijhawan, MD, FRCP(C), FACG

Dr Nijhawan completed his medical school training at the University of Ottawa and proceeded to complete an internal medicine internship at Yale-Norwalk, CT. He completed his internal medicine residency and Gastroenterology and Hepatology fellowship at the Mayo Clinic in Rochester, MN. There he was awarded the Calgary fellowship for outstanding achievements. He is a member of the Royal College of Physicians and Surgeons of Canada, American Board of Gastroenterology, and American Board of Internal Medicine. In 2003, Dr Nijhawan established the Digestive Health Clinic to help bring leading edge technology to Canada. He specializes in therapeutic endoscopy, irritable bowel and celiac disease.

Gurdev Parmar, ND, FABNO

Dr Parmar is a respected leader in the field of Integrative Oncology. He and his wife, Dr Karen Parmar, launched the Integrated Health Clinic in 2000 and have since facilitated its growth to become one of the largest and most successful integrated health care facilities in Canada. Dr Parmar was the first Canadian naturopathic physician to hold a fellowship to the American Board of Naturopathic Oncology (FABNO), a board certification as a cancer specialist. Dr Parmar has been a consulting physician at the Lions Gate Hospital chemotherapy clinic since 2008, creating the first Integrative Oncology service in any chemotherapy hospital in the country.

Kristy Prouse, MD, FRCSC

Dr Prouse has practiced as an Obstetrician/Gynaecologist for over 10 years and currently holds the position of assistant professor at the University of Toronto and the Northern Ontario School of Medicine. Dr Prouse completed her medical degree at Queen’s University and residency training at the University of Calgary. Additionally, Dr Prouse has trained in bio-identical hormone replacement therapy and anti-aging and regenerative medicine through the University of Southern Florida-College of Medicine. She is the Founder and Chief Medical Officer at the Institute for Hormonal Health, an integrative medical practice in Oakville, Ontario that focuses on hormonal imbalances in both women and men. Kristy completed her residency training at the University of Calgary, while obtaining her medical degree from Queen’s.

Dugald Seely, ND, MSc

Dr Seely is a naturopathic doctor and director of research at the Canadian College of Naturopathic Medicine (CCNM). Dugald completed his masters of science in cancer research from the University of Toronto with a focus on interactions between chemotherapy and natural health products. In his current role as director of research, Dugald is the principal investigator for a number of clinical trials, and is actively pursuing relevant synthesis research in the production of systematic reviews and meta-analyses. Ongoing projects include three multi-centred randomized clinical trials and a comprehensive CIHR synthesis review of natural health products used for cancer. Dugald is currently a member of Health Canada’s Expert Advisory Committee for the Vigilance of Health Products and is a peer reviewer for the Canadian Adverse Reaction Newsletter.

October 2013 l www.ihpmagazine.com 59

Discover Calm Within the Storm

A swirling storm of worry and doubt leaves many patients struggling with occasional anxiety and restlessness. Lavela WS 1265™ contains Silexan™, an exclusive, clinically studied, lavender essential oil. Lavela WS 1265 has been shown to relieve occasional anxiety and promote relaxation in peer-reviewed, controlled trials.1,2 Lavela WS 1265™ - An Anxiously Awaited Solution - Clinically documented to relieve occasional anxiety - Convenient, once-daily dosing - Non-habit-forming, non-sedating relief

Silexan™ is a trademark of Dr. Willmar Schwabe 1. Woelk H, Schläfke S. A multi-center, double-blind, randomized study of the Lavender oil preparation Silexan in comparison to [drug name] for generalized anxiety disorder. Phytomedicine 2010;17:94–9. 2. Kasper S, Gastpar M, Müller WE, et al. Silexan, an orally administered Lavandula oil preparation, is eﬀective in the treatment of ‘subsyndromal’ anxiety disorder: a randomized, double-blind, placebo controlled trial. Int Clin Psychopharmacol 2010;25:277–87.

1.800.644.3211 • www.integrativeinc.com

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Cognitive health and new technologies Are you ready to prescribe videogames? By Maria Shapoval, ND Maria Shapoval, ND Integrated Healthcare Centre 1255 Sheppard Ave East Toronto ON M2K 1E2 416-738-4054 mshapoval@ccnm.edu

62 www.ihpmagazine.com l October 2013

Abstract In the face of a growing incidence of cognitive decline there is a need for sustainable lifestyle interventions to support, maintain and improve cognitive health. Perhaps serendipitously or intentionally technological evolution delivers a novel medium for cognitive training filled with promise and new potential. This medium is the realm of virtual reality, video games and mobile devices that allow for the development of individualized training regimes tailor made to suit the patientsâ&#x20AC;&#x2122; needs, not to mention a virtual intelligence that may be able to preserve that which the brain can no longer contain. This review explores the research behind the application of video games to cognitive exercise, rehabilitation programs encompassing virtual realities and smart phones dedicated to maintaining access to faculties challenged by the progression of Alzheimerâ&#x20AC;&#x2122;s disease. The limitations and challenges of these interventions will be explored as well.

The Journal of IHP Introduction

Photo©iStockphoto.com

As the baby boomers continue to age, the incidence of mild cognitive decline, as well as Alzheimer’s disease (AD) and dementia, is expected to rise (Park 2003). Currently the prevalence of Alzheimer’s disease is 1% in persons 60-70 years of age and 6-8% in those over 85 (Mayeux 2010), while the prevalence of mild cognitive impairment is 10-20% in the 65 and older population (Petersen 2011). There is a growing need for lifestyle interventions that are effective, economically sustainable and compliance-friendly. Some of the early signs of cognitive decline can include mild memory loss, mild reduction in reasoning, processing speed, and executive function, such as attention, language, and visuospatial skills (Deary 2009, Petersen 2011). These may be a result of normal aging (age-associated cognitive decline), mild cognitive impairment (slightly more significant cognitive decline than that of normal aging) as well as more serious causes such as Alzheimer’s disease, hypothyroidism, vitamin B12 deficiency, cerebrovascular disease (i.e. vascular dementia), central nervous system infection, hydrocephalus, cancer, substance abuse, adverse effects of medications, HIV related cognitive disorder and others (Mayeux 2010). A reduction in verbal memory and executive function, coupled with reduced retention of newly acquired information are more indicative of Alzheimer’s disease, while memory loss associated with psychosis is more characteristic of dementias (Mayeux 2010). As computers and mobile devices become more mainstream, their application to cognitive health may offer a novel intervention that is inexpensive and customizable, able to address individual needs of patients. Evidence from a recent prospective study correlates the use of daily computers with 30-40% lower risk of dementia (Almeida 2012). Healthy men, 5506 participants 69-87 years of age, were followed for six years, with the primary outcome documented being the diagnosis with dementia. Computer use included browsing

the internet, e-mail, word processing and playing games. Though there may be a range in the degree of benefit from computer use, potentially dependent on quality of content viewed, one simple factor that does seem to have an effect is experience. Comparing the functional MRI recordings of experienced users with those not familiar with the internet, Small et al (2009) found that the regular use correlated with activation of brain areas associated with decision making and complex reasoning, while naive internet browsing resulted in activation of areas associated with reading only. Thus there is some evidence to support the use of computers in the elderly population as a means to promote cognitive health. This review will examine a few computer based interventions and their impact on cognitive function as well as their respective limitations.

Video Games

A systematic review by Kueider et al (2012) provides an excellent overview of the terrain of video games and their current potential. Eight studies (participants ages 50-87) were examined and their impact on cognition compiled. Some of the games included were Nintendo Wii’s Big Brain Academy, Rise of

Nations, Medal of Honor, Pac Man, Donkey Kong, Tetris, Atari: Break out, Crystal Castles, Galazian, Frogger, and Kaboom. These were played between two to 11 weeks for two to October 2013 l www.ihpmagazine.com 63

The Journal of IHP

five hours each week. The biggest improvements were made in reaction time (effect size of 0.77; in this case the closer the effect size is to 1.0 the stronger the effect), processing speed (0.72) and global cognition (0.69). Global cognition was evaluated using the WAIS-R full IQ and ADAS-Cognition. A milder impact was made on executive function (0.25) and attention (0.21). The degree of impact varied across the different games examined. Except for Brain Academy, none of the above mentioned games focus on improving cognitive function. Contradictory to popular belief games stereotypically seen as â&#x20AC;&#x153;intellectualâ&#x20AC;? do not necessarily yield cognitive improvements, as demonstrated by study by Boot et al (2013). Healthy participants (mean age 74yo) randomized to play 60 hours of Brain Age 2 (intellectual game) or Mario Kart (action game) were assessed using a battery of cognitive tests including flanker test (selective attention), meaningful memory, Ravenâ&#x20AC;&#x2122;s matrices (reasoning), visual search (processing speed) and others. No significant changes were reported after 12 weeks for either game. 64 www.ihpmagazine.com l October 2013

To determine which game type offers the most cognitive benefit Oei et al (2013) compared several different types of games in the undergraduate student population. Seventyfive participants were randomly assigned to one of the five games: memory matrix (reproduce a sequence), The Sims (life simulation), action (first person shooter), match-3 (Bejewelled 2), or hidden-object (find object within a complex visual scene). They were instructed to play for one hour/day, five days per week for four weeks (20 hours total). They were assessed using a wide array of cognitive tests pre and post the games intervention. The tests included attentional blink, filter task, visual search/spatial memory and complex span. The action game resulted significant improvement in attentional blink (p<0.001). Authors speculate this to be due to the need to rapidly switch attention between targets, specific to the nature of action games, which results in improved attention switching transferrable to tasks outside the game. The action game also resulted in improvements in filter task, the ability to track multiple objects simultaneously, and complex span, a combination of arithmetic and verbal memory tasks, while

The Journal of IHP Bejewelled-2 yielded positive results on visual search/ spatial memory and complex span. Memory matrix and hidden-object were beneficial for visual search/spatial memory only, while the Sims did not make a significant impact on any of the four parameters. Thus it would seem that the action game offers to most broad benefit, though some cognitive benefit can be extracted from the other games as well.

Virtual Training

Though potentially less entertaining than video games, virtual reality (VR) training programs designed to improve specific skills are delivering effective interventions to both healthy elderly participants and those suffering with Alzheimer’s disease. A study by Optale et al (2010) demonstrated positive effect of VR training on several cognitive parameters in healthy elderly population. The randomized control trial enrolled 36 participants (mean age 80yo) with various degrees of impairment on the Verbal Story Recall (VSR) test into control (music therapy) and experimental groups. The experimental group received three training sessions every two weeks consisting of auditory training; listening to an audio recording of three different stories with three different musical backgrounds, and VR training; finding the correct path to a viewing location of a 15 second film clip, using a joystick and computer while listening to the same background music as used in the audio training. The training was delivered for three months. The training resulted in significant improvements in Mini Mental State Examination (MMSE) (p=0.014), Digit Span test (short term verbal memory; p=0.043), VSR (p<0.001), Phoenemic Verbal Fluency (p=0.005), Geriatric Depression Scale (p=0.025), while the control group either maintained or demonstrated loss of function. No changes were observed in visuospatial processing and activities of daily living. Using VR as a safe and controlled training environment, Hofmann et al (2003) created a shopping intervention to improve daily living function of patients with AD. The VR experience was created using digital photographs of the shopping route, which the participants were required to navigate in order to locate the shop, buy three items and answer 10 relevant multiple choice questions, such as “you will have to cross this road to get to the pharmacist. What do you have to keep in mind?”. After 12 sessions over four weeks, a significant reduction in the number of mistakes made (p<0.044) was documented, which was sustained for three weeks following the training. No impact on the MMSE was observed. While the study demonstrated ability to improve specific skills, it is difficult to conclude how generalizable these gains are to real-life shopping experience, as well as the duration of their perseverance past the three week follow up.

Other ways of applying new technologies

As the world of games and virtual realities continues to evolve, so does the world of applications. A case study by De Leo et al (2011) capitalized on the photographical capacity of the smart phone and developed what could be termed as virtual memory for a patient with Alzheimer’s disease. The participant was diagnosed with stage 4 Alzheimer’s disease (according to Functional Assessment Staging (FAST)) and was given a programmed smart phone, which he wore around his neck for four weeks. The phone was programmed to capture pictures every five minutes between 8:00am and 8:00pm. The images were uploaded automatically to a server at 2am each night. Redundant and poor quality images were discarded by the research team, and the rest were made into a slideshow, which the participant viewed once a week. A recent events memory recall test was administered before and immediately after viewing the video, along with a five-point Likert scale satisfaction questionnaire. Not surprisingly there were more events remembered

October 2013 l www.ihpmagazine.com 65

with the slideshow than without. Though the participant did not agree that the slideshow was a very useful tool as memory aid, he did agree that it made him feel less anxious knowing that it was keeping a record, especially in social situations where he was concerned about forgetting who he has met. Being able to share the experiences with family through the slideshow was an added pleasure. The device did not pose an inconvenience to the participant but did present with some technological problems and dependency on a video editor to

66 www.ihpmagazine.com l October 2013

sort through the slideshow. Another approach to creating a virtual memory is currently in the process of being piloted. Donnelly et al (2008) developed a Cell-Phone-Based-Video Streaming System to provide routinely scheduled reminders to patients with dementia as a way to assist with daily activities. By using familiar faces of relatives, the authors hope to achieve higher compliance. Another potential application of the smart phone is the use of the GPS component as way

PhotoÂŠiStockphoto.com

The Journal of IHP of locating patients with Alzheimer’s disease that become lost (De Leo 2011). The application of the Wii is another area that can be explored, as well as the social benefit and cognitive impact of the virtual online communities, such as Facebook, online dating and Skype.

Challenges and Limitations

There were two main obstacles identified in the literature with respect to these new technologies. The first and most familiar is the challenge of compliance. Boot et al (2013) explored participant preferences in a study comparing two different Nintendo DS game interventions. Participants (mean age 74yo) were randomized to play 60 hours of either an action game, Mario Kart DS, or a more intellectual game, Brain Age 2, which included choice of several different games including Sudoku. Participants rated the intellectual game more enjoyable and were more compliant with the prescription (56 hours on average were played of Brain Age 2 compared to 22 hours of the Mario Kart). They described the Mario Kart as “mindless” and “utterly boring”. Ironically, according to the research (Boot 2013, Oei 2013), it is the action games that offer the most benefit with respect to executive function and reaction speeds. The other concern is the adverse events associated with the ergonomics of computers. Some of the reported side effects of desktop monitors, joysticks and keyboard use included eye strain and arthritis (Boot 2013), while use of head-mounted visual displays, typically used to create virtual realities, resulted in nausea, vomiting, dizziness, headaches, disorientation and transient vestibular and psychomotor disturbances (Cherniak 2011). Another complication though not discussed in detail in the literature, but very familiar to us all, is the frustration of technological limitations in the forms of hardware and software malfunctions. Despite these challenges, a systematic review by Kueider et al (2012) reports that participants do not need to be technologically savvy in order to enjoy all the benefits that these intervention have to offer with respect to cognitive health.

Conclusion

As the technological world continues to evolve it may offer new tools and approaches that may aide in the maintenance of cognitive health and in the rehabilitation of various cognitive impairments. Individual needs and preferences will become crucial in the development of efficacious video games and virtual realities, which will not only need to stimulate the cognitive functioning but maintain interest and intrigue the participant, ideally while connecting them to a strong and supportive social network.

References:

Almeida OP, Yeap BB, Alfonso H, Hankey GJ, Flicker L, Norman PE. Older men who use computers have lower risk of dementia. PLoS One. 7(8) (2012) Basak C, Boot WR, Voss MW, Kramer AF. Can training in a realtime strategy video game attenuate cognitive decline in older adults? Psychology of Aging. 23(4) (2008); 765-77 Boot WR, Champion M, Blakely DP, Wright T, Souders DJ, Charness N. Video games as a means to reduce age-related cognitive decline: attitudes, compliance, and effectiveness. Front Psychology. 4(31) (2013) Cherniack EP. Not just fun and games: applications of virtual reality in the identification and rehabilitation of cognitive disorders of the elderly. Disabil Rehabil Assist Technology. 6(4) (2011); 283-9 Cohen GD, Firth KM, Biddle S, Lloyd Lewis MJ, Simmens S. The first therapeutic game specifically designed and evaluated for Alzheimer’s disease. Am J Alzheimer’s Dis Other Demen. 23(6) (2008): 540-51 De Leo G, Brivio E, Sautter SW. Supporting autobiographical memory in patients with Alzheimer’s disease using smart phones. Applied Neuropsychology. 18(1) (2011); 69-76 Deary IJ, Corley J, Gow AJ, Harris SE, Houlihan LM, Marioni RE, Penke L, Rafnsson SB, Starr JM. Age-associated cognitive decline. Br Med Bull. 92 (2009); 135-52 Donnelly MP, Nugent CD, Craig D, Passmore P, Mulvenna M. Development of a cell phone based video streaming system for persons with early stage Alzheimer’s disease. Conf Proc IEEE Eng Med Biol Soc. 2008; 5330-3 Hofmann M, Rosler A, Schwarz W, Muller-Spahn F, Krauchi K, Hock C, Seifritz E. Interactive computer-training as a therapeutic tool in Alzheimer’s disease. Compr Psychiatry. 44(3) (2003): 213-9 Kueider AM, Parisi JM, Gross AL, Rebok GW. Computerized cognitive training with older adults: a systematic review. PLoS One. 7(7) (2012) Mayeux R. Clinical practice. Early Alzheimer’s disease. New England Journal of Medicine. 362(23) (2010): 2194-201 Oei AC, Patterson MD. Enhancing cognition with video games: a multiple game training study. PLoS One. 8(3) (2013) Optale G, Urgesi C, Busato V, Marin S, Piron L, Priftis K, Gamberini L, Capodieci S, Bordin A. Controlling memory impairment in elderly adults using virtual reality memory training: a randomized controlled pilot study. Neurorehabilitation Neural Repair. 24(4) (2010); 348-57 Park HL, O’Connell JE, Thomson RG. A systematic review of cognitive decline in the general elderly population. Int J Geriatric Psychiatry. 18(12) (2003): 1121-34 Petersen RC. Clinical Practice. Mild Cognitive Impairment. New England Journal of Medicine. 364(23) (2011): 2227-34 Small GW, Moody TD, Siddarth P, Bookheimer SY. Your brain on Google: patterns of cerebral activation during internet searching. Am J Geriatr Psychiatry. 17(2) (2009); 116-26 October 2013 l www.ihpmagazine.com 67

The Journal of IHP

Hydrotherapy Evidence For Clinical Applications By Christopher Habib, ND and Janna Levanto, ND Christopher Habib, ND Clinic Director Mahaya Forest Hill 102-73 Warren Road Toronto, ON M4V 2R9 info@chrishabibnd.com Janna Levanto, ND Naturopathic Doctor jannalevanto@gmail.com

68 www.ihpmagazine.com l October 2013

Abstract Hydrotherapy is the use of water for therapeutic purposes. The mechanisms of action of hydrotherapy include local vasoconstriction followed by reflexive vasodilation which activates cutaneous circulation. The resulting therapeutic actions include muscle relaxation, enhanced collagen flexibility, pain reduction, and antiinflammatory effects. Many acute and chronic health conditions can benefit from these effects. The limited evidence available for the most common uses of hydrotherapy is reviewed. Hydrotherapy is effective for both rheumatoid arthritis and osteoarthritis, providing reductions in pain, increased mobility, and improved quality of life. The evidence shows that hydrotherapy is not effective in reducing the incidence, duration, or severity of the common cold in children. For patients suffering from chronic heart failure, hydrotherapy improves exercise tolerance and the hemodynamic profiles of patients, including beneficial reductions in blood pressure and heart rate. Considered together, the existing studies suggest that hydrotherapy is an extremely safe treatment option for a variety of health conditions.

Introduction

In general, hydrotherapy is the use of hot and cold water for the maintenance of good health and treatment of disease (Poorman 2001). It can also be used to describe exercise in warm water under supervision by utilizing the buoyancy, assistance and resistance of warm water to relieve pain, induce muscle relaxation, and promote more effective exercise. Hydrotherapy provides a safe and effective means of achieving exercise-related goals and is commonly used in rehabilitation programs (Al- Qubaeissy 2013). It has been utilized since ancient times in Greek medicine (Papavramidou 2003). Nowadays, hydrotherapy is used by numerous health care practitioners for various health conditions including rheumatoid arthritis (RA), osteoarthritis (OA), fibromyalgia, chronic heart failure (CHF), immune conditions, menopausal symptoms, exercise recovery, and for pain reduction (Geytenbeek 2002, Versey 2013). The mechanisms of action of hydrotherapy treatments depend on the type of protocol used. In general, hot treatments increase perspiration, metabolism, capillary pressure, and cell permeability. Heat causes an increased demand for nutrients as well as local vasodilation and hyperemia. In addition, collateral blood circulation is enhanced (Nadler 2004). The resulting therapeutic actions include muscle relaxation, enhanced collagen flexibility, pain reduction, and anti-inflammatory actions. The effects of cold temperatures generally include an analgesic effect due to acute anti-inflammatory actions as well as potentially decreasing muscle spasms (Nadler 2004). Hydrotherapy can also cause local vasoconstriction followed by reflexive vasodilation that activates cutaneous circulation. The byproducts of metabolically active cells are vasodilators such as carbon dioxide (Fathi 2011). There is a wide range in the quality of studies available for the varying uses of hydrotherapy treatments. In general the evidence is rather limited, rendering the interpretation of existing evidence even more important. This review article will outline the available evidence for the most common uses of hydrotherapy and highlight important clinical implications.

Rheumatoid Arthritis and Osteoarthritis

The effects of hydrotherapy for RA were investigated in 139 patients with chronic RA using a four category parallel design: hydrotherapy, seated immersion, land exercise or progressive relaxation (Hall 1996). For four consecutive weeks, twice a week, participants took part in 30 minutes of intervention under the supervision of physiotherapists. This study used a variety of assessment tools on three occasions including before and after the hydrotherapy treatment and at a 3-month follow up. Assessment parameters included physical abilities, pain, and health status measures using indices to assess joint tenderness, morning stiffness, grip strength, active range of motion, as well as C-reactive protein, the Beliefs in Pain Control Questionnaire, the McGill Pain Questionnaire, and the Arthritic Impact Measurements. It was found that regardless of the intervention all patients showed significant improvement in joint tenderness between pre and post-test, with the hydrotherapy group demonstrating the greatest reduction, with a mean decrease of 27% between pre and post-test. Females in the hydrotherapy group significantly increased knee range of motion by 6.6째. This improvement was maintained at follow up, but was no longer statistically significant. Other physical measures did not change significantly. All patients experienced a significant reduction in their evaluative and affective pain scores between pre and post-tests, however this was not maintained at follow up (Hall 1996). More recently, a systematic review examined the effectiveness of hydrotherapy in treating RA (Al- Qubaeissy 2013). In this systematic review, a total of 197 studies were identified and narrowed to six randomized controlled studies after applying specific inclusion and exclusion criteria. The reviewed studies included 419 participants both male and female with an age range of 18-80 who obtained some sort of waterbased treatment, including hydrotherapy pools and aquatic exercise routines. It was determined that patients who received hydrotherapy for treatment of RA gained some beneficial effects in improving their October 2013 l www.ihpmagazine.com 69

health status and reducing their pain scores compared to the control groups, as well as joint tenderness, mood and tension symptoms, and increasing grip strength. Benefits also included a substantial increase in the physical activity and emotional well-being of patients involved in the aquatic programs. However, the long-term benefits in this study were found to be inconclusive (Al-Qubaeissy 2013). In total, the evidence suggests that hydrotherapy can improve the quality of life of RA patients as well as multiple physical and emotional measures. The literature on hydrotherapy and OA tends to focus on treatments that include exercises in a body of water, part of the rationale being that the weight-relieving properties of water immersion allow for easier joint movement. One study compared two groups using hydrotherapy pool exercises versus similar exercises on land. This study showed that the hydrotherapy group experienced statistically significant improvements in their functional ability and had decreased pain, at least in the short-term (Sylvester 1990). A more recent randomized controlled trial included 152 older persons with chronic, symptomatic OA of the hip or knee. Participants were randomly allocated to hydrotherapy classes, Tai Chi classes, or a waiting list control group for twelve weeks. It was found that at twelve weeks, participants allocated to hydrotherapy classes demonstrated improvements for pain and physical function scores, compared with controls (Fransen 2007). Lastly, a pilot study has also been conducted comparing the effect of hydrotherapy versus conventional physiotherapy. In this particular study, thirty patients diagnosed with symptomatic OA of the hip or knees were randomly assigned to a hydrotherapy group, a physiotherapy group, or both, for two weeks. The hydrotherapy group received daily alternate thigh affusions (pouring water). The results showed that at a 10-week follow up, the hydrotherapy group had the most beneficial effects on pain intensity and mobility (Schencking 2013). Interestingly, hydrotherapy has strong evidence supporting its use in other musculoskeletal conditions with pain, including fibromyalgia (McVeigh 2008).

Immune-Stimulation

Hydrotherapy is often described as an immune-stimulating therapy and appears to have positive effects on immunoregulation, including increases in resistance and facilitated activation of cell-mediated immune reactions (Schencking 2013). The evidence available focuses on the effects of hydrotherapy for the common colds. An older study examined the immune effects of hydrotherapy, hyperthermic exposure in particular, on the incidence of common colds (Ernst 1990). Two groups of participants were utilized. The first group was submitted to sauna bathing consisting of a warm shower, drying, eight to 12 minutes of time spent in the sauna room, and 15 minutes of cooling with cold water and resting, repeated two or three times. The second group abstained from this procedure. In both groups, the frequency, duration, and severity of common colds were recorded for six months. The results showed that there were significantly fewer episodes of common cold in the sauna group, particularly in the last three months of the study period when the incidence was approximately half compared to controls. However, the mean duration and average severity did not differ significantly between groups and the authors concluded that further research is needed (Ernst 1990). A more recent and better designed, study examined whether or not hydrotherapy would be effective in the prevention and treatment of common colds in children (Gruber 2003). Children aged three to seven years with six or more common cold episodes during the previous year were randomized to receive daily inhalation of normal saline in the control group, or daily inhalation plus daily hydrotherapy in the experimental group for one year. The daily hydrotherapy treatment consisted of alternating warm (39Â°C over 10 minutes) and cold (15Â°C over 10 to 30 seconds). The main outcome measures were incidence, duration, and severity of common cold episodes as reported by the childrenâ&#x20AC;&#x2122;s parents in a daily symptom diary. The results showed that during the study period there were no significant differences in the incidence of colds or the average duration of episodes (Gruber 2003). This evidence suggests that hydrotherapy is therefore not an effective option for treating the common cold. 70 www.ihpmagazine.com l October 2013

The Journal of IHP

Although hydrotherapy may not be effective in treating the common cold, it may provide other immunological benefits. An in vivo study examined the immunological effects of warm and cold water exposure in mouse models (Kalenova 2005). When mice were exposed to warm or cold water, the activities of nonspecific resistance factors (peritoneal macrophages) increased upon first exposure, decreased for the following three exposures, and then increased after the fifth exposure. In particular, exposure to cold water activated cellular immunity, while warm water activated humoral immunity. The temperature alterations going from cold to warm led to the activation of cellular components and to the suppression of the humoral components of the immune system. However, the alteration of water temperature from warm to cold led to activation of nonspecific resistance

factors, cellular and humoral immunity (Kalenova 2005). Many practitioners who use contrast hydrotherapy advocate ending any treatment with cold exposure. For the purposes of immune-stimulation, the evidence also favours this protocol.

Heart Failure

Hydrotherapy as part of a rehabilitation program for patients with CHF has previously been thought to be potentially dangerous due to the increased venous return caused by the hydrostatic pressure, or the changes in circulation due to the changes in fluid dynamics. However, one study found that physical training in warm water was well tolerated, improved exercise capacity as well as muscle function, with no accompanying adverse effects (Cider 2003). The New York Heart Association (NYHA) assesses October 2013 l www.ihpmagazine.com 71

the stages of heart failure (I to IV or from mild to more severe) according to a functional classification based on patient symptoms. Twenty-five patients with stable CHF (NYHA grade II–III, age 72.1 +/- 6.1 years) were randomized to either eight weeks of hydrotherapy (n = 15) or into a control group (n = 10). The experimental group training program comprised of 45 minute sessions in a heated pool (33–34°C) three times a week, following a low to moderate exercise level (40-70% max heart rate). Patients in the hydrotherapy group showed a greater improvement in their maximal exercise capacity, maximal oxygen uptake, and six-minute walk test compared to the control group (Cider 2003). Specifically, they had improvements in isometric endurance in knee extension (+4 vs. -9, p=0.01) and improvement in the performance of heel-life (+4 vs. -3 n.o, p<0.01), shoulder abduction (+12 vs. -8 s, p=0.01) and shoulder flexion (+6 vs. +4, p=0.01) (Cider 2003). Another study looked at the addition of hydrotherapy to endurance training in elderly male patients with CHF and found a significant improvement in exercise tolerance and hemodynamic profiles (Caminiti 2011). Twenty-one male CHF patients (NYHA II-III, age 68 +/- 7 years) were randomized into two groups: 11 patients in the combined group of endurance training and hydrotherapy, and 10 patients in an endurance training only group. Hydrotherapy took place three times per week in an upright position in water at a temperature of 31°C. The treatment protocol involved callisthenic movements of the torso and both upper and lower limbs, gradually increasing from one to three sets of ten repetitions. The endurance training involved performing the same movements on land and also included 10 minutes of warm up and cool-down exercises and thirty minutes of aerobic exercise (60-70% VO2 max). At the initiation of the program and after 24 weeks all participants underwent a battery of tests including a sixminute walking test, assessment of blood pressure and heart rate, an echocardiogram, a noninvasive hemodynamic evaluation, and maximal voluntary contraction of quadriceps test. The results showed that distance in the six-minute walking test improved in both groups, but with significant intergroup differences in favour of hydrotherapy (hydrotherapy group: 150+/-32 m; control group: 105+/-28 m). Diastolic blood pressure and heart rate significantly decreased in the hydrotherapy group, but remained unchanged in the control group (−11 mm Hg+/−2, p = 0.04 and -12 beats per minute, p = 0.03; respectively). Overall, the exercise was well tolerated with no adverse effects reported (Caminiti 2011). In treating heart failure, hydrotherapy, at least delivered as exercise in warm water, appears to be a safe and effective conjunctive treatment.

Conclusion

Hydrotherapy is the use of water for therapeutic purposes, most commonly involving exposure to hot and cold temperatures. Though the exact mechanisms vary, there is usually an element of local vasoconstriction followed by reflexive vasodilation that activates cutaneous circulation. These physiological effects have therapeutic consequences including pain reduction and a reduction in inflammation. Hydrotherapy also appears to have positive effects on immunoregulation, including increases in resistance and facilitated activation of cell-mediated immune reactions. As discussed, many acute and chronic health conditions can potentially benefit from these effects. Since it is limited, the evidence available with regards to effectiveness must be interpreted with caution. Hydrotherapy was shown to be effective for both RA and OA, causing reductions in pain, increased mobility, and improved quality of life. The evidence reviewed here showed that hydrotherapy was not effective in reducing the incidence, duration, or severity of the common cold in children, but that it may have other immune-stimulating effects. For patients suffering from CHF, hydrotherapy improved exercise tolerance and the hemodynamic profiles of patients, including beneficial reductions in blood pressure and heart rate. The large majority of the studies available on hydrotherapy suggest that it is a safe and effective treatment option for various health conditions. 72 www.ihpmagazine.com l October 2013

The Journal of IHP

Al- Qubaeissy KY, Fatoye FA, Goodwin PC, Yohannes AM. The effectiveness of hydrotherapy in the management of rheumatoid arthritis: a systematic review. Musculoskeletal Care. 2013; 11(1):3-18. Caminiti G, Arisis A, Cerrito A, Marazzi G, Massaro R, Rosano G, Sposato B, Maurizio V. Hydrotherapy added to endurance training versus endurance training alone in elderly patients with chronic heart failure: A randomized pilot study. Int J Cardiol. 2011; 148(2):199-203.

Hall J, Skevington SM, Maddison PJ, Chapman K. A randomized and controlled trial of hydrotherapy in rheumatoid arthritis. Arthritis Care Res. 1996; 9(3):206-15. Kalenova LF, Sukhovei YG, Fisher TA. Specific and nonspecific reactions of mouse immune system under the effect of short-term exposure in warm and/or cold water. Bull Exp Biol Med. 2005; 140(6):720-2. McVeigh JG, McGaughey H, Hall M, Kane P. The effectiveness of hydrotherapy in the management of fibromyalgia syndrome: a systematic review. Rheumatoid Int. 2008; 29(2):119-30.

Cider A, Schaufelberger M, Sunnerhagen K, Anderson B. Hydrotherapy- a new approach to improve function in the older patient with chronic heart failure. Eur Heart J. 2003; 5(4):527-35.

Nadler SF, Weingand K, Kruse RJ. The physiological basis and clinical application of cryotherapy and thermotherapy for the pain practitioner. Pain Physician. 2004; 7(3):395-9.

Ernst E, Pecho E, Wirz P, Saradeth T. Regular sauna bathing and the incidence of common colds. Ann Med. 1990; 22(4):2257.

Papavramidou N, Christopoulou-Aletra H. Hydrotherapy: nineteenth century Greek scientific views. J Alt Compliment Med. 2003; 9(3):341â&#x20AC;&#x201C;4.

Fathi A, Yang C, Bakhtian K, Qi M, Lonser R, Pluta R. Carbon dioxide influence on nitric oxide production in endothelial cells and astrocytes: Cellular mechanisms. Brain Res. 2011; 1386:50-57.

Poorman D, Kim L, Mittman P. Naturopathic Medical Education: Where Conventional, Complementary, and Alternative Medicine Meet. Comp Health Prac Rev. 2001; 7(2):99-109.

Fransen M, Lam P, Nairn L, Winstanly J, Edmonds J. Physical activity for osteoarthritis management: a randomized controlled clinical trial evaluating hydrotherapy or Tai Chi classes. Arthritis Rheum. 2007; 57(3): 407-14.

Schencking M, Wilm S, Redaelli M. A comparison of Kneipp hydrotherapy with conventional physiotherapy in the treatment of osteoarthritis: a pilot trial. J Integr Med. 2013; 11(1):17-25.

Geytenbeek J. Evidence for Effective Hydrotherapy. Physiotherapy. 2002; 88(9):514-29.

Sylvester K. Investigation of the effect of hydrotherapy in the treatment of osteoarthritic hips. Clinical Rehab. 1990; 19890(4):223-28.

Gruber C, Riesberg A, Mansmann U, Knipschild P, Wahn U, Buhring M. The effect of hydrotherapy on the incidence of common cold episodes in children: a randomised clinical trial. Eur J Pediatr. 2003; 162(3):168-76.

Versey NG, Halso SL, Dawson BT. Water Immersion Recovery for Athletes: Effect on Exercise Performance and Practical Recommendations. Sports Med. 2013.

2 PhotosÂŠiStockphoto.com

References

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ÂŠiStockphoto.com

FODMAP diet

Implications in irritable bowel syndrone By Erin Balodis, MSc, ND Erin Balodis, MSc, ND Kingswood Chiropractic Health Centre 1210 Hammonds Plains Road, Hammonds Plains, Nova Scotia B4B 1B4 erinbalodis@gmail.com

74 www.ihpmagazine.com l October 2013

Abstract Most patients with IBS link their symptoms to food consumption. However, the current dietary recommendations for the management of IBS are inconsistent. FODMAPs, a group of short-chain carbohydrates have been identified as aggravating factors in patients with IBS. The constituents under the FODMAP umbrella are discussed. Research exploring the benefit of implementing a low FODMAP diet in patients with IBS is outlined. Recommending a reduction or an elimination of these specific carbohydrates in the diet may provide relief to those suffering with IBS.

ÂŠiStockphoto.com/geopaul

The Journal of IHP Introduction

Irritable bowel syndrome (IBS) is a common disease encountered worldwide (Morcos 2009), with a prevalence in Europe and North America between 10-15% (Hungin 2003, Quigley 2009). Typically characterized by either Rome or Manning criteria, irritable bowel syndrome is a chronic, recurring gastrointestinal problem, characterised by abdominal pain, bloating, and changes in bowel habit. Diagnosis is made by exclusion of other causes of organic bowel disease. IBS has a female predominance, often aggregating in families (Spiller 2007), with genetic studies show a connection (Hotoleanu 2008, Saito 2005). IBS is not associated with an increase in the development of any serious diseases, however patients with IBS suffer from a reduced quality of life, both physically and mentally (Li 2003). Kennedy and Jones (2000) showed that patients with IBS are more likely to undergo surgical operations, including hysterectomy (Kennedy 2000) and cholecystectomy (Kennedy 2000). The financial burden of IBS can be quite significant due to increased medical office visits, diagnostic testing, pharmacotherapy, and emergency room visits (Martin 2001). Many factors have been hypothesized as playing a role in the pathogenesis of IBS, including, but not limited to; gutbrain axis dysfunction (Bonaz 2009), impaired gut barrier, altered microflora, and low grade immune activation (Cremon 2009). Food intolerances are well known to play a role in the development of IBS symptoms, with patients indentifying a number of different categories of foods like those rich in carbohydrates, as well as fatty foods (Bohn 2013), coffee, alcohol, spicy food (Simren 2001), dairy (Vernia 2004), and gluten (Vazquez-Roque 2013), as common culprits. Between half and two thirds of patients with IBS associate symptoms with eating a meal (Ragnarsson 1998), with gas and abdominal pain as the most frequently reported symptoms (Simren 2001). Implementing elimination diets can be useful, but often patients donâ&#x20AC;&#x2122;t achieve a significant reduction in symptoms, or during the re-introduction or challenge phase, end up confused with some food reactions, due to the complex mixtures of foods, and timing (Barrett 2012). Since IBS is so widespread, with multi-factorial causes, and varying consequences, much interest has been paid to finding ways to reduce symptoms and improve the quality of life in sufferers. Despite the lack of conclusive findings of a link between food and IBS, encouraging evidence has prompted further study of dietary modifications.

FODMAP concept and constituents

FODMAP is a relatively new concept, with the phrase being coined by a group of Australian researchers who studied the effects of a seemingly unrelated group of carbohydrates on symptoms of IBS (Gibson 2005, Shepherd 2006). FODMAP stands for fermentable oligosacchardies, disaccharides, monosaccharies, and polyols. The included short chain carbohydrates are fructose, lactose, fructo- and galactooligosaccharides (fructans, and galactans), and polyols (such as sorbitol). The acronym includes short-chain carbohydrates that are poorly absorbed and rapidly fermented, as this is the mechanism by which these carbohydrates induce symptoms. FODMAPs have also been found to be osmotically active (Barrett 2010). The idea that fructose aggravates digestive system function is not new. Fructose is found in the diet as a free monosaccharide, hexose, as a constituent of the disaccharide sucrose, or in a polymerized form (fructan) (Gibson 2007). A study conducted in 1978 showed that fructose ingestion aggravated abdominal symptoms, and complete elimination of fructose improved symptoms of abdominal pain and colic (Andersson 1978) Absorptive capacity of fructose varies among individuals (Truswell 1988). Free fructose is absorbed by a different transport system than glucose, namely GLUT-5 (Burant 1992), which works more slowly and can be overwhelmed by large amounts of fructose (Truswell 1988). Malabsorption of fructose in healthy individuals, identified by a positive hydrogen breath test, was found in 53% of subjects given a dose of 25 grams, and in 73% of subjects given 50 grams (Beyer 2005). Despite positive breath tests, participants in the study experienced minimal gastrointestinal effects, however, studies have shown that the development of symptoms of fructose malabsorption occur much more readily in patients with IBS, and the use of fructose-free diets have dramatically reduced symptoms (FernandezBanares 1993, Goldstein 2000, Symons 1992). In 2008, Shepherd et al conducted a double-blinded, randomized, quadruple arm, placebo-controlled rechallenge trial. They found that symptoms of IBS were not adequately controlled in 70-79% of subjects who received fructose, fructans, or a mixture of the two carbohydrates in the context of diet. Aggravation of symptoms such as abdominal pain, bloating and flatulence occurred as patients were challenged with increasing doses of fructose and/or fructans. When subjects received the placebo, glucose alone, they experienced significantly less severe symptoms, which suggests that dietary restriction of fructose and/or fructans is likely to be responsible for symptomatic improvement.

October 2013 l www.ihpmagazine.com 75

The question of why a natural sugar found in fruit and other foods has more recently been found to cause digestive system symptoms relates to the increased intake of concentrated fructose. The development of high fructose corn syrup (containing on average 47-65% fructose (Ventura 2011)) and subsequent increase in consumption (Beyer 2005), is hypothesized to be a key factor involved in the increase in fructose malabsorption (Latulippe 2011). The average intake of fructose was thought to be approximately 37 g per day (Park 1993) but was then re-evaluated in 2004 to be 49 g/day (Marriott 2009). This increase in dietary fructose load may more commonly exceed the absorptive capacity of the intestines, exacerbating or unmasking IBS (Shepherd 2006). Interestingly, fructose absorption is altered depending on glucose presence. As previously mentioned, the absorption mechanism for fructose as a monosaccharide via the GLUT-5 transporter can become saturated. Studies have indicated that when glucose is present, either as free glucose, or when glucose and fructose are combined to form the disaccharide, sucrose, fructose absorptive capacity is increased (Riby 1993) by up-regulation of the GLUT-2 transporter and no malabsorptive state results (Shepherd 2006). This is clinically relevant, as researchers Barrett and Shepherd indicated, because it allows patients to choose foods that are fructose and glucose balanced (e.g. berries and stone fruits) or where glucose is in greater amounts, rather than completely eliminating all fructose containing foods. Another option is to consume glucose with high fructose containing foods, however this could present a problem for blood sugar control. Fructans are oligosaccharides and polysaccharides of fructose units with a glucose terminal end (Gibson 2007). They are referred to as inulins and fructooligosaccharides (FOS) and are found in foods such as wheat, onions, garlic, artichokes, and chicory. Fructans are completely unabsorbed by upper gastrointestinal tract, and are therefore rapidly fermentable (Rumessen 1998). Fructo-oligosaccharide is a well known prebiotic fibre, that has numerous health benefits, including its ability to increase populations of bacteria in the gut, specifically Bifidobacteria (Gibson 1995). However, research has shown that large amounts (14-20 g) of fructans can aggravate symptoms in people suffering from IBS (Olesen 2000), and can cause digestive upset (especially flatulence) even in healthy individuals (Pedersen 1997, Stone-Dorshow 1987). The average daily intake of fructans via the diet has been calculated to be as much as 10 g/day (van Loo 1995), but with the addition of inulin or FOS to food for its many health benefits, daily intake levels could be greater. Wheat, which accounts for 70% of the daily intake of 76 www.ihpmagazine.com l October 2013

fructans (Moshfegh 1999), could also be problematic, especially when consumed in large amounts. This may in part explain why gluten elimination has been found to decrease symptoms in individuals who suffer from IBS. Like fructans, galactans, polymers of galactose, more commonly known as raffinose and styachose, are almost completely unabsorbed in all people, leading to significant fermentation and therefore gas production. Galactans are found in large amounts in legumes, including lentils, chickpeas, kidney beans and have been found to aggravate symptoms of IBS (Chirila 2012), and are therefore included under the FODMAP umbrella. Lactose is the disaccharide included under the FODMAP umbrella. Lactose absorption depends on the activity of the hydrolase enzyme lactase, which is deficient in 2-100% of people in various populations worldwide (Swagerty 2002). Sixty-eight percent of people with IBS tested positive, via hydrogen breath test, for lactose malabsorption. After adhering to a lactose-free diet, symptoms subsided in nearly half of study participants. Other studies have found similar results (Bohmer 1996), and have suggested that the use of a hydrogen breath test could be used to identify lactose malabsorbers, thus allowing a less strict diet. Polyols, are sugar alcohols, including; sorbitol, xylitol, mannitol, maltitol, and isomalt, found naturally in some foods and added to many foods as artificial sweeteners. Polyols are incompletely absorbed, and it is well known that sorbitol specifically, has an osmotic laxative effect at high amounts (Hyams 1983). Unlike fructose, polyols do not have an associated active transport system in the small intestine and are probably absorbed by passive diffusion (Gibson 2010). The incomplete absorption of sugar alcohols has been found in healthy controls, at larger doses, indicating a dose response to malabsorption (Corazza 1988). Despite positive hydrogen breath tests, not all malabsorbers displayed symptoms, however, those with IBS experienced significantly more symptoms (Fernandez-Banares 1993, Nelis 1990, Symons 1992) As evident in the literature, each of the carbohydrate constituents of FODMAPs have been investigated individually. Tests of FODMAPs as a whole have also been conducted, not only by the Australian research group who originally grouped the short-chain carbohydrates together, but increasingly by other researchers worldwide and are showing promising results (Staudacher 2011, Ostgaard 2012, de Roest 2013).

The FODMAP diet in research

Mechanistically the FODMAP diet as a whole has been studied using an ileostomy model, which has been used to study the digestion and absorption of carbohydrates

The Journal of IHP in previous studies (Englyst 1985, Langkilde 1994). Barrett et al (2010) investigated the effect of dietary FODMAPs on the content of water and fermentable substrates of ileal effluent. Individuals with an ileostomy, but no evidence of small intestinal disease, undertook two 4-day dietary periods, comprising diets differing only in FODMAP content. Ileal effluent was collected every two hours on day four of each diet. The FODMAP content of the diet and effluent was measured and patients rated the effluent consistency on a visual analog scale. The effluent of the high FODMAP diet was found to be greater in dry weight and water content. Study participants perceived effluent consistency to be thicker with the low FODMAP diet. The researchers concluded that FODMAPs do increase delivery of water and fermentable substrates to the proximal colon (Barrett 2010). This study was the first mechanism type study that specifically addressed FODMAPs in the diet, as opposed to certain carbohydrates in isolation, confirming that FODMAPs as part of a diet are osmotically active and their poor absorption gives rise to potential fermentation and associated gas production. It is well known that people suffering from IBS often experience abdominal pain, bloating, and gas due to luminal distension. Ong et al (2010) demonstrated that dietary manipulation of FODMAPs can impact the total amount of gastrointestinal gas production and the spectrum of gas produced (hydrogen vs. methane) in healthy individuals and those with IBS. While an increase in gas was seen even in healthy individuals ingesting a high FODMAP diet, increased gastrointestinal symptoms as well as systemic symptoms, like fatigue, were seen in patients with IBS. A number of studies have linked the gut microenvironment with the pathophysiology of IBS (Simren 2013). Studies have identified inherent differences in the gut microﬂora and thus fermentation in IBS patients versus controls (Kassinen 2007, Madden 2002), which could explain the connection with FODMAPs, showing that FODMAPs don’t cause IBS, but could be aggravating symptoms by providing rapidly fermentable substrates to the intestines. Small intestine bacterial overgrowth (SIBO) has been found to be associated with IBS (Sachdeva 2011), and by nature of the FODMAP diet, a reduction in the intake of short-chain carbohydrates, and therefore fermentation, could be useful as dietary treatment. In a recent study, 90 patients with IBS received dietary advice regarding a low FODMAP diet and completed a hydrogen/methane breath testing for fructose and lactose malabsorption (deRoest 2013). Patients were then asked to complete a questionnaire approximately 15 months later. Results revealed a significant improvement in abdominal pain, bloating, flatulence. The authors concluded that breath testing was a good way to help

people understand and adhere to the diet (de Roest 2013). Breath testing has been used and recommended by other researchers as a clinical tool for assessing malabsorption (Barrett 2009, Gibson 2010). Gibson et al (2010) have suggested that breath testing for fructose and lactose malabsorption might be worthwhile because it would allow foods with negative results to be reintroduced back into the diet to a comfortable level, avoiding unnecessary restrictions(Gibson 2010), and providing a source of beneficial prebiotic fibre (Barrett 2012).

Clinical Utility

Table 1 (CCS 2012) outlines foods that are high in FODMAPs and suitable alternatives. Since food plays a large role in patient’s perception of symptom induction, many IBS sufferers are potentially already unknowingly avoiding FODMAP foods. The FODMAP diet has been shown to be fairly simple to implement, with limited instruction (Ostgaard 2012). A study by Ostgaard et al (2012) showed that after two hours of dietary guidance by a dietician, patients with IBS avoided all FODMAP‑rich food, consumed more food with probiotic supplements and did not avoid food sources that were crucial to their health. They had improved quality of life and reduced symptoms. Guidance on the management of diet improved their choice of a healthier diet, improved quality of life and reduced IBS symptoms. Gibson et al (2009) suggest a strict low FODMAP diet for a period of six to eight weeks, followed by a trial of foods to test tolerance, keeping total low FODMAP intake in mind. This would allow patients to occasionally consume foods deemed high FODMAP to a tolerable level, to ensure variety in the diet. A low FODMAP diet improved symptoms in at least 74% of patients with IBS (Barrett 2012). In the UK, The FODMAP diet was studied in comparison to the UK National Institute for Health and Clinical Excellence (NICE) dietary guidelines for symptom control in patients with IBS. Up to 86% of patients in the FODMAP group experienced overall symptom response, versus 49% in the standard group. Significantly more patients in the low FODMAP group reported improvements in bloating, abdominal pain, and flatulence. This drew the conclusion that a low FODMAP diet is more effective than the standard dietary advice in the UK, for symptom control in IBS (Staudacher 2011). With a continually growing body of evidence, both for the individual constituents of FODMAPs, as well as FODMAPs as a whole, the FODMAP diet seems a reasonable option for dietary management in patients suffering from IBS.

October 2013 l www.ihpmagazine.com 77

References

RICHEST SOURCES OF Food Group:

FODMAPs:

Suitable Alternatives

Fruit

Apples Apricots Cherries Blackberries Boysenberries Mango Nashi Pears Nectarines Peaches Pears Persimmon Plums Watermelon Artichokes Asparagus Cauliflower Garlic Mushrooms Onion Shallots Snow Peas Spring Onion

Banana Blueberry Cantaloupe Grapefruit Grapes Lemon Lime Mandarin Orange Passion fruit Raspberry Rhubarb Strawberry Carrot Chili Chives Cucumber Eggplant Ginger Green beans Lettuce Olives Parsnips Peppers Potato Spinach Tomato Zucchini All fresh Beef, Chicken, Lamb, Pork, Veal,

Vegetables

Protein Sources

Legumes Pistachio Nuts

Breads and cereals

Dairy

Other

Cashews Wheat Rye Barley

Condensed or Evaporated Milk Cottage or Ricotta Cheese Custard Ice Cream Milk Yogurt Honey Sorbitol or Mannitol High-fructose corn syrup Fructose

Macadamia, Peanut, Walnut, and Pine Nuts Eggs, Tempeh, Tofu Buckwheat Corn Oats Polenta Quinoa Rice Spelt Butter Lactose-free milk Lactose-free yogurt Other cheeses Rice milk

Golden syrup Maple syrup Regular sugar Glucose

Andersson DEH, Nygren A. Four Cases of Long-Standing Diarrhoea and Colic Pains Cured by Fructose-Free dietâ&#x20AC;&#x201D;A Pathogenetic Discussion. Acta Medica Scandinavica. 1978;203(16):87-92. Barrett JS. Extending our knowledge of fermentable, short- chain, carbohydrates for managing gastrointestinal symptoms. Nutrition in Clinical Practice. 2013;28(3):300-306. Barrett JS, Gearry RB, Muir JG, Irving PM, Rose R, Rosella O, Haines ML, Shepherd SJ, Gibson PR. Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon. Aliment Pharmacol Ther. 2010 Apr;31(8): 874-882. Barrett JS, Gibson PR. Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and nonallergic food intolerance: FODMAPs or food chemicals? Therap Adv Gastroenterol. 2012 Jul;5(4): 261-268. Barrett JS, Irving PM, Shepherd SJ, Muir JG, Gibson PR. Comparison of the prevalence of fructose and lactose malabsorption across chronic intestinal disorders. Aliment Pharmacol Ther. 2009 Jul;30(2): 165-174. Beyer PL, Caviar EM, McCallum RW. Fructose intake at current levels in the United States may cause gastrointestinal distress in normal adults. J Am Diet Assoc. 2005 Oct;105(10): 1559-1566. Bohmer CJ, Tuynman HA. The clinical relevance of lactose malabsorption in irritable bowel syndrome. Eur J Gastroenterol Hepatol. 1996 Oct;8(10): 1013-1016. Bohn L, Storsrud S, Tornblom H, Bengtsson U, Simren M. Self-reported food-related gastrointestinal symptoms in IBS are common and associated with more severe symptoms and reduced quality of life. Am J Gastroenterol. 2013 May;108(5): 634-641. Bonaz B, Sabate JM. Brain-gut axis dysfunction. Gastroenterol Clin Biol. 2009 Feb;33 Suppl 1: S48-58. Burant CF, Takeda J, Brot-Laroche E, Bell GI, Davidson NO. Fructose transporter in human spermatozoa and small intestine is GLUT5. J Biol Chem. 1992 Jul;267(21): 14523-14526. CCS, Monash University. The Monash University Low FODMAP Diet. 2012. Melbourne, Australia, Monash University. Chirila I, Petrariu FD, Ciortescu I, Mihai C, Drug VL. Diet and irritable bowel syndrome. J Gastrointestin Liver Dis. 2012 Dec;21(4): 357-362. Corazza GR, Strocchi A, Rossi R, Sirola D, Gasbarrini G. Sorbitol malabsorption in normal volunteers and in patients with coeliac disease. Gut. 1988 Jan;29(1): 44-48.

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The Journal of IHP Cremon C, Gargano L, Morselli-Labate AM, Santini D, Cogliandro RF, De Giorgio R, Stanghellini V, Corinaldesi R, Barbara G. Mucosal immune activation in irritable bowel syndrome: gender-dependence and association with digestive symptoms. Am J Gastroenterol. 2009 Feb;104(2): 392-400.

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de Roest RH, Dobbs BR, Chapman BA, Batman B, Oâ&#x20AC;&#x2122;Brien LA, Leeper JA, Hebblethwaite CR, Gearry RB. The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. Int J Clin Pract. 2013 May;epub.

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Kennedy TM, Jones RH. The epidemiology of hysterectomy and irritable bowel syndrome in a UK population. Int J Clin Pract. 2000 Dec;54(10): 647-650. Langkilde AM, Andersson H, Schweizer TF, Wursch P. Digestion and absorption of sorbitol, maltitol and isomalt from the small bowel. A study in ileostomy subjects. Eur J Clin Nutr. 1994 Nov;48(11): 768-775. Latulippe ME, Skoog SM. Fructose malabsorption and intolerance: effects of fructose with and without simultaneous glucose ingestion. Crit Rev Food Sci Nutr. 2011 Aug;51(7): 583592. Li FX, Patten SB, Hilsden RJ, Sutherland LR. Irritable bowel syndrome and health-related quality of life: a population-based study in Calgary, Alberta. Can J Gastroenterol . 2003 Apr;17(4): 259-263. Madden JA, Hunter JO. A review of the role of the gut microflora in irritable bowel syndrome and the effects of probiotics. Br J Nutr. 2002 Sep;88 Suppl 1:S67-72. Marriott BP, Cole N, Lee E. National estimates of dietary fructose intake increased from 1977 to 2004 in the United States. J Nutr. 2009 Jun;139(6): 1228S-1235S. Martin R, Barron JJ, Zacker C. Irritable bowel syndrome: toward a cost-effective management approach. Am J Manag Care. 2001 Jul;7(8 Suppl): S268-275. Morcos A, Dinan T, Quigley EM. Irritable bowel syndrome: role of food in pathogenesis and management. J Dig Dis. 2009 Nov;10(4): 237-246. Moshfegh AJ, Friday JE, Goldman JP, Ahuja JK. Presence of inulin and oligofructose in the diets of Americans. J Nutr. 1999 Jul;129(7 Suppl): 1407S-1411S. Nelis GF, Vermeeren MA, Jansen W. Role of fructose-sorbitol malabsorption in the irritable bowel syndrome. Gastroenterology. 1990 Oct;99(4): 1016-1020. Olesen M, Gudmand-Hoyer E. Efficacy, safety, and tolerability of fructooligosaccharides in the treatment of irritable bowel syndrome. Am J Clin Nutr. 2000 Dec;72(6): 1570-1575. October 2013 l www.ihpmagazine.com 79

Ong D, Mitchell S, Barrett J, Shepherd S, Irving P, Biesiekierski J, Smith S, Gibson P, Muir J. Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. J Gastroenterol Hepatol. 2010 Aug;25(8): 1366-1373. Ostgaard H, Hausken T, Gundersen D, El-Salhy M. Diet and effects of diet management on quality of life and symptoms in patients with irritable bowel syndrome. Mol Med Rep. 2012 Jun;5(6): 1382-1390. Park YK, Yetley EA. Intakes and food sources of fructose in the United States. Am J Clin Nutr. 1993 Nov;58(5 Suppl): 737S-747S. Pedersen A, Sandstrom B, Van Amelsvoort JM. The effect of ingestion of inulin on blood lipids and gastrointestinal symptoms in healthy females. Br J Nutr. 1997 Aug;78(2): 215-222. Quigley E, Fried M, Gwee KA, Olano C, Guarner F, Khalif I, Hungin P, Lindberg G, Abbas Z, Bustos- Fernandez L, Mearin F, Bhatia SJ, Hu PJ, Schmulson M, Krabshuis JH, Le Mair AW. Irritable bowel syndrome: a global perspective. 2009. W. G. O. G. Guideline. Ragnarsson G, Bodemar G. Pain is temporally related to eating but not to defaecation in the irritable bowel syndrome (IBS). Patientsâ&#x20AC;&#x2122; description of diarrhea, constipation and symptom variation during a prospective 6-week study. Eur J Gastroenterol Hepatol. 1998 May;10(5): 415-421. Riby JE, Fujisawa T, Kretchmer N. Fructose absorption. Am J Clin Nutr. 1993 Nov;58(5): 748S-753S. Rumessen JJ, Gudmand-Hoyer E. Fructans of chicory: intestinal transport and fermentation of different chain lengths and relation to fructose and sorbitol malabsorption. Am J Clin Nutr. 1998 Aug;68(2): 357-364. Sachdeva S, Rawat AK, Reddy RS, Puri AS. Small intestinal bacterial overgrowth (SIBO) in irritable bowel syndrome: frequency and predictors. J Gastroenterol Hepatol. 2011 Apr;26 Suppl 3: 135-138. Saito YA, Petersen GM, Locke GR, Talley NJ. The genetics of irritable bowel syndrome. Clin Gastroenterol Hepatol. 2005 Nov;3(11): 10571065. Shepherd S J, Gibson PR. Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management. J Am Diet Assoc. 2006 Oct;106(10): 1631-1639. Shepherd SJ, Parker FC, Muir JG, Gibson PR. Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo-controlled evidence. Clin Gastroenterol Hepatol. 2008 Jul;6(7): 765-771.

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Simren M, Barbara G, Flint HJ, Spiegel BM, Spiller RC, Vanner S, Verdu EF, Whorwell PJ, Zoetendal EG. Intestinal microbiota in functional bowel disorders: a Rome foundation report. Gut. 2013 Jan;62(1): 159-176. Simren M, Mansson A, Langkilde AM, Svedlund J, Abrahamsson H, Bengtsson U, Bjornsson ES. Food-related gastrointestinal symptoms in the irritable bowel syndrome. Digestion. 2001;63(2): 108-115. Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, Jones R, Kumar D, Rubin G, Trudgill N, Whorwell P. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut. 2007 Dec;56(12): 1770-1798. Staudacher HM, Whelan K, Irving PM, Lomer MC. Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. J Hum Nutr Diet. 2011 Oct;24(5): 487-495. Stone-Dorshow T, Levitt MD. Gaseous response to ingestion of a poorly absorbed fructo-oligosaccharide sweetener. Am J Clin Nutr. 1987 Jul;46(1): 61-65. Swagerty DL, Jr., Walling AD, Klein RM. Lactose intolerance. Am Fam Physician. 2002 May;65(9): 1845-1850. Symons P, Jones MP, Kellow JE. Symptom provocation in irritable bowel syndrome. Effects of differing doses of fructose-sorbitol. Scand J Gastroenterol. 1992 Nov;27(11): 940-944. Truswell AS, Seach JM, Thorburn AW. Incomplete absorption of pure fructose in healthy subjects and the facilitating effect of glucose. Am J Clin Nutr. 1988 Dec;48(6): 1424-1430. van Loo J, Coussement P, de Leenheer L, Hoebregs H, Smits G. On the presence of inulin and oligofructose as natural ingredients in the western diet. Crit Rev Food Sci Nutr. 1995 Nov;35(6): 525-552. Vazquez-Roque MI, Camilleri M, Smyrk T, Murray JA, Marietta E, Oâ&#x20AC;&#x2122;Neill J, Carlson P, Lamsam J, Janzow D, Eckert D, Burton D, Zinsmeister AR. A controlled trial of gluten-free diet in patients with irritable bowel syndrome-diarrhea: effects on bowel frequency and intestinal function. Gastroenterology. 2013 May;144(5): 903-911 e903. Ventura EE, Davis JN, Goran MI. Sugar content of popular sweetened beverages based on objective laboratory analysis: focus on fructose content. Obesity (Silver Spring). 2011 Apr;19(4): 868-874. Vernia P, Marinaro V, Argnani F, Di Camillo M, Caprilli R. Selfreported milk intolerance in irritable bowel syndrome: what should we believe? Clin Nutr. 2004 Oct;23(5): 996-1000.

The Journal of IHP â&#x20AC;&#x201C; Continuing Education successful completion of the questions at the end of this paper has been approved for continuing education by the bddt-n; 1.0 credit nutritional medicine and by the cnpbc; one ce hour.

Bachelor of Health Sciences (Honours), McMaster University. Naturopathic Doctor, Canadian College of Naturopathic Medicine 1

Bachelor of Health Sciences (Honours) Candidate, McMaster University 2

Breaking it down

The role of acid-base balance in the pathogenesis and treatment of osteoporosis

By Jordan Robertson, ND1, Tina Behdinan2, Alan Fung2, Timothy Park2, Emily Wilton2, Mengchen Xi2, Xin (Jennifer) Yin2

October 2013 l www.ihpmagazine.com 81

ABSTRACT Osteoporosis (OP) is a skeletal disorder characterized by low bone mineral density (BMD), which predisposes individuals to increased risk of skeletal fractures (Foundation 2010). In 2009, more than 22% of Canadians over the age of 50 were diagnosed with OP (Garriguet 2011). In 2010, OP accounted for $2.3 billion in Canadaâ&#x20AC;&#x2122;s healthcare expenditures of which over 50% were utilized for acute care of managing OP-related fractures (Tarride 2012). The etiology of OP is defined by elevated osteoclastic activity relative to osteoblastic activity, which induces bone resorption and deterioration of bone tissue (Duque 2008). OP is associated with multiple risk factors including advanced age, hormone imbalance, sedentary lifestyle, and hypocalcaemia (Tucker 2001). However, Kanis et al. (Kanis 2007) found that measuring BMD in addition to clinical risk factors provides the best fracture risk prediction. The standard first-line therapy for OP includes oral bisphosphonates combined with vitamin D and calcium (Ca) supplementation therapy, which are recommended from the age of 50 (Papaioannou 2010). However, bisphosphonates diminish in efficacy following three to five years of treatment and may cause severe adverse effects such as osteonecrosis of the jaw (Nase 2006, Rachner 2011). As such, investigation into alternative therapies is warranted. Furthermore, the role of Ca deficiency in the pathogenesis of OP fails to account for higher rates of hip fracture in Western countries with higher Ca intake relative to developing countries with lower Ca intake (FAO 2004, Poliquin 2009). As a result, alternative factors for disease progression, including those that influence the efficacy of Ca supplementation, have been investigated (FAO 2004). It has been suggested that a diet consisting of protein and grains is associated with an increased net acid load, which is buffered via bone dissolution (Fenton 2009a, Wachman 1968). The result is a decrease in BMD and a release of calcium from bone, which is subsequently excreted through urine (Fenton 2009a). It is posited that an alkaline diet consisting of a high intake of fruits and vegetables, which are metabolized to bicarbonate (HCO3), would buffer acidity and thereby preserve Ca levels and BMD (Fenton 2009a). The objective of this article is to explore the role of acid-base balance in OP pathogenesis, as well as its potential to drive alternative therapies. The validity of this hypothesis will be explored within the context of acidbase balance in OP, dietary effects of metabolic acidosis (specifically protein and minerals such as potassium (K) and sodium (Na)), and the role of physical activity on pH homeostasis.

ACID-BASE BALANCE IN OSTEOPOROSIS

Bone dissolution is a mechanistic phosphate-buffering response to low systemic pH as a result of increased dietary acid load and respiratory and/or renal acidosis (Fig. 1) (Bushinsky 2010). It was first suggested by Wachman and Bernstein (1968) that induced chronic metabolic acidosis and prolonged utilization of the phosphate-buffer system reduces skeletal buffering capacity over time, theoretically explaining age-associated osteoporotic risk. A Western diet high in grain and animal protein has been associated with increased calciuria and net urinary acid production (Jehle 2006, Maurer 2003). This is thought to represent elevated systemic acidity and would contribute towards OP pathogenesis (Jehle 2006). Figure 1. highlights the outcome of inadequate acid-base buffering in lungs and kidneys contributing to respiratory and renal acidosis, respectively. Although protein increases 82 www.ihpmagazine.com l October 2013

intestinal absorption of calcium, sulfur-containing amino acids in protein can also contribute towards acidosis. This systemic acid-base imbalance is in part alleviated by the skeletal system. Hydroxyapatite (HAP) typically stored in bone dissociates in response to low pH, releasing Ca, K, magnesium, and phosphate into the circulatory system. The release of phosphate ions neutralizes blood pH by forming H3PO4. Released K ions further alkalinizes systemic pH. This effect was further substantiated through NH4Cl loading in human subjects (n=14) where bone resorptive Ca loss, demonstrated by acidosis-induced calciuria, occurred in the absence of increased intestinal Ca absorption (Lemann 2003). Furthermore, acidosis has been associated with increased osteoclastic activity in human peripheral blood in vitro and inhibition of osteoblastic bone formation in rats in vitro (Arnett 2007, Brandao-Burch 2005). In a randomized prospective trial of

The Journal of IHP â&#x20AC;&#x201C; Continuing Education 161 postmenopausal women diagnosed with osteopenia, alkali treatment of 30 mEq/d oral potassium citrate was associated with 1.87%, 1.39%, and 1.98% increased BMD over one year in lumbar spine, femoral neck, and total hip, respectively (Jehle 2006).

PROTEIN

Figure 1. Release of Hydroxyapatite from bone to buffer acidosis

Although the link between metabolic acidosis and bone resorption has been previously established, there is significant debate over which acidogenic influences contribute to OP, as well as the extent of their impacts on systemic pH. Accumulation of acid load has been widely attributed to excessive protein intake and acid buildup via elevated metabolism of sulfur-containing amino acids (methionine and cysteine) found in higher quantities in animal protein (Fenton 2009a, Poupin 2012, Remer 2000). However, the basis of correlations between protein and systemic acidosis relies on the assumption that urinary Ca excretion induced by protein intake is representative of skeletal Ca loss. Instead, a report evaluating acid balance assessment techniques asserted that the quantification of acid balance requires direct evaluation of intestinal absorption and cannot be indirectly assessed through urinary composition (Lemann 2003). Recent theory proposes that the proteininduced calciuric effect may instead be a byproduct of increased intestinal Ca absorption (Bonjour 2009, Levis 2012). It is thought that dietary protein stimulates gastric acid production and increases Ca solubility and bioavailability, thus contributing towards urinary Ca excretion (Kerstetter 2005). Protein causes increased urinary Ca loss, although the source of the excreted Ca is uncertain. These confounding factors have not been recognized until recently. Population-based, protective effects of protein intake on BMD have been previously observed (Tucker 2001). In the Framingham Osteoporosis Study, dietary habits and BMD measurements of 615 elderly participants were analyzed in a longitudinal cohort study (Tucker 2001). Animal protein was associated with a stimulating or protective effect on bone mass, and participants with the greatest protein intake had the highest BMD (Tucker 2001). The highest quartile of protein intake consistently showed the lowest BMD loss over four years at the femoral neck and lumbar spine (Tucker 2001). Although study participants were mainly elderly, and one third of subjects had protein intake below the recommended daily allowance; protein was shown to be important in stimulating and maintaining bone growth in older adults (Tucker 2001). Although the mechanism of that effect remained identified, Gaffney-Stomberg et al. (2009) characterized the beneficial effects of protein intake on bone health through mechanisms involving insulin-like growth factor-1 (IGF-1) and parathyroid hormone (PTH) â&#x20AC;&#x201C; factors associated with bone growth and resorption, respectively. In a randomized controlled feeding study of 27 postmenopausal women, high protein intake (20% of daily energy intake) in low-Ca intake individuals (~675 mg/d) significantly increased Ca isotope absorption (29.5% vs. 26.0%) and compensated for the majority of a 0.5 mmol/d increase in calciuria (Hunt 2009). Additionally, in a randomized crossover study comparing (1) low protein and low-potential renal acid load (LPLP) to (2) high protein and high-potential renal acid load (HPHP) diets in 16 postmenopausal women, HPHP diet was associated with increased intestinal Ca October 2013 l www.ihpmagazine.com 83

absorption (26.5% vs 22.3%, p<0.05) (Cao 2011). Although neither dietary intervention (LPLP and HPHP) was found to influence markers of bone metabolism, upregulation of serum IGF-1, and downregulation of PTH substantiated proposed benefits of protein on bone even after accounting for renal acid load (Cao 2011). In the context of acid-base balance, it is important to recognize that the compensatory effect of increased intestinal Ca absorption does not completely counterbalance calciuric outcomes (Cao 2011, Hunt 2009). The minimal discrepancy in Ca absorption and excretion may yet contribute towards the etiology of OP through acidosis over time (New 2003). Nonetheless, substantial evidence demonstrating the beneficial effects of protein on bone health, especially in elderly and individuals with low Ca intake, cannot be ignored cannot be ignored. Furthermore, it has been suggested that the current recommended daily intake of 0.8g/kg prevents protein deficiency but is insufficient for optimization of bone health, especially in the elderly (Bushinsky 2010, GaffneyStomberg 2009).

POTASSIUM

Aside from high protein intake, the modern Western diet is characterized by energy-dense nutrient-poor foods, including fats, sugars, and Na (Frassetto 2008). It also involves decreased intake of K and HCO3-precursor-rich plants, since the most common plant food ingested is cultivated cereal grain, which yields a net acid load (Sebastian 2002). This diet was only adopted in the last 10 000 years, which is too recent for evolutionary mechanisms to have adjusted in terms of core metabolic machinery (Eaton 1988, Tobian 1988). Prior to the modern diet, humans ingested a higher ratio of K-to-Na and so the kidneys are programmed to excrete more K than Na (Frassetto 2008). However, this evolutionary mechanism has persisted despite the inversion of the dietary K-to-Na ratio (Eaton 1996). It has been demonstrated that interstitial fluid of bone contains higher concentrations of K and Na than Ca and phosphorus (Krieger 2004). K content is directly related to the amount of consumed and absorbed K and is used by the skeletal system to buffer metabolic acid load (Green 1991, Krieger 2004). Thus, it 84 www.ihpmagazine.com l October 2013

is important to maintain high levels of K, regardless of food source (Rafferty 2005). Fruits and vegetables may be dually helpful as they contain both K and HCO3 precursors (Frassetto 2005). It has been demonstrated that in postmenopausal women, higher intake of fruit were positively associated with increased BMD (Chen 2001). Furthermore, increased K content of plant protein relative to animal protein resulted in lowered risk for chronic metabolic acidosis (Deriemaeker 2010).

SODIUM

It has been postulated that high sodium chloride (NaCl) content and low proportion of plant foods in the Western diet induces metabolic acidosis (Frassetto 2008). This effect is compounded by age-related decrease in renal function (Frassetto 2008). It has been suggested that 50-100% of the dietâ&#x20AC;&#x2122;s net acid load can be attributed to high NaCl intake (Frassetto 2007). Therefore, decreasing the amount of NaCl intake or buffering NaCl with dietary base precursors could help maintain bone mass (Buehlmeier 2012). In a randomized crossover trial, eight male volunteers were randomized into two study campaigns: (1) the experimental group, receiving 90 mmol/d of potassium bicarbonate (KHCO3) to counteract a high NaCl diet (7.3 mmol/kg/d compared to the average NaCl diet of 2.6 mmol/kg/d) and (2) the control group, receiving only a NaCl-rich diet (7.3 mmol/kg/d) (Buehlmeier 2012). It was found that KHCO3 supplementation for ten days decreased NaCl-induced calciuria by 12% (p<0.05), indicating that intake of dietary base precursors may have a protective effect against bone mass loss (Buehlmeier 2012). The authors propose that decreased calciuria is attributed to increased Ca deposition in bone, though these results could be an indication of increased Ca utilization in other body systems(Buehlmeier 2012). Additionally, the adverse effects of NaCl were more persistent than the protective effects of KHCO3 (Buehlmeier 2012). The transient KHCO3 effect is thought to be due to relatively low amounts of KHCO3 (i.e. 90 mmol/d), suggesting that increased levels of KHCO3 may cause a stronger and more protective effect (Buehlmeier 2012). It has been previously shown that both dietary Ca and urinary Na excretion were significantly correlated with changes in

The Journal of IHP – Continuing Education Clinical Implications

Table 1. Clinical Considerations of Data Presented

Protein

● Dietary protein intake is demonstrated to have beneficial effects on bone health (i.e. BMD), especially in individuals with low calcium intake (Cao 2011, Tucker 2001) ● CurentCurrent recommended daily intake of 0.8g/kg prevents protein deficiency but is insufficient for optimiziationoptimization of bone health, especially in the elderly (Bushinsky 2010)

Potassium

● Increase daily K intake through fruits and vegetables and other K-rich foods (Frassetto 2005Chen 2001) ● Plant protein contains higher K content relative to animal protein and may reduce risk of metabolic acidosis while preserving bone health (Deriemaeker 2010)

Sodium

● KHCO3 has a protective effect in high NaCl diets (Buehlmeier 2012) ● Reduction of Na intake (recommended intake is 1000-1500 mg/d) ***may reduce risk of metabolic acidosis (Frassetto 2008, Health Canada 2012)

Physical Activity

● Engage in weight-bearing exercise, and practice yoga or tai chi to

decrease fracture risk (Borer 2005, Guadalupe-Grau 2009)

bone mass over a two-year period at the hip and ankle (Devine 1995). Furthermore, the reduction of Na intake has been reported to have beneficial skeletal effects on participants undergoing the Dietary Approaches to Stop Hypertension diet for a month (Lin 2003). In addition, higher dietary Na in young men and women led to increased 1,25-dihydroxyvitamin D and increased intestinal Ca absorption which accounted for Na-induced calciuria (Breslau 1982). It is interesting to note, however, that postmenopausal women did not demonstrate these increased 1,25-dihydroxyvitamin D levels, which may suggest that this population is unable to compensate for the calciuria caused by increased Na ingestion (Breslau 1985). Finally, Frassetto et al. (2008) conclusively demonstrated that dietary NaCl drives urinary Ca excretion, increases bone resorption, and increases the relative rates of bone resorption to bone formation.

PHYSICAL ACTIVITY

A lack of research surrounds the effects of physical activity on the body’s acid-base balance. Most research focuses on physical activity as a potential confounder instead of its role in maintaining acid-base homeostasis. Research on physical activity mainly centers on preventative measures rather than therapeutic options for OP (Borer 2005, Guadalupe-Grau 2009). Preventative treatment options include high-resistance physical activity to increase the peak BMD levels in youths, and yoga and tai chi to improve flexibility and reduce fractures among elderly persons (Borer 2005, Guadalupe-Grau 2009). There has been some discussion on the idea that deep breathing associated with yoga and other physical activities could be involved with acid-base balance within the body, as the body regulates

acid-base homeostasis through the exhalation of CO2 through the lungs (Horowitz 2009). However, there has not been rigorous research done on this topic, and in order to determine the effects of physical activity on the body’s acid-base homeostasis, further studies need to be conducted.

CONCLUSION

The physiochemical basis for acid-base balance in OP is founded upon sound principles but is not consistently supported by past studies, some of which used inadequate measures of systemic pH (Fenton 2009b, Lemann 2003, Poupin 2012, Remer 2000). Recent studies have found beneficial effects of protein intake on BMD and calcium absorption (Cao 2011, Tucker 2001). Furthermore, HCO3 and K derived from fruit and vegetable metabolism may be promising with regard to net acid load reduction and OP prevention, in addition to other beneficial effects on overall health (Frassetto 2005). However, as contended previously, the Western diet may not be solely responsible for OP pathogenesis since other countries with different dietary patterns exhibit similar patterns in OP prevalence (Fenton 2011). Promising alternative therapies that may aid in the prevention of OP include moderate aerobic exercises, weight-bearing activities, and balance exercises (Borer 2005, Fishman 2009, Guadalupe-Grau 2009, Maciaszek 2007). The clinical implications of findings reviewed in this paper are summarized below (Table 1). Additional etiologic factors may include sunlight exposure, physical labour, and genetic predisposition in these populations (Fenton 2011). Nonetheless, more primary research is needed to fully understand the role of acidbase balance in OP pathogenesis as well as its treatment potential. October 2013 l www.ihpmagazine.com 85

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Buehlmeier J, Frings-Meuthen P, Remer T, Maser-Gluth C, Stehle P, Biolo G, et al. Alkaline Salts to Counteract Bone Resorption and Protein Wasting Induced by High Salt Intake: Results of a Randomized Controlled Trial. Journal of Clinical Endocrinology & Metabolism. 2012;97(12):4789-97.

Fishman LM. Yoga for osteoporosis: A pilot study. Topics in Geriatric Rehabilitation. 2009;25(3):244-50.

Bushinsky DA. Acidosis and bone. Nutritional Influences on Bone Health: Springer; 2010. p. 161-6. Cao JJ, Johnson LK, Hunt JR. A diet high in meat protein and potential renal acid load increases fractional calcium absorption and urinary calcium excretion without affecting markers of bone resorption or formation in postmenopausal women. The Journal of nutrition. 2011;141(3):391-7. Chen Y, Ho S, Lee R, Lam S, Woo J. Fruit intake is associated with better bone mass among Hong Kong Chinese early postmenopausal women. J Bone Miner Res. 2001;16(suppl 1):S386.

Foundation NO.Clinician’s guide to prevention and treatment of osteoporosis.National Osteoporosis Foundation Washington DC; 2010. Frassetto L, Morris RC, Sebastian A. Long-term persistence of the urine calcium-lowering effect of potassium bicarbonate in postmenopausal women. Journal of Clinical Endocrinology & Metabolism. 2005;90(2):831-4. Frassetto LA, Morris RC, Sebastian A. Dietary sodium chloride intake independently predicts the degree of hyperchloremic metabolic acidosis in healthy humans consuming a net acidproducing diet. American Journal of Physiology-Renal Physiology. 2007;293(2):F521-F5.

Deriemaeker P, Aerenhouts D, Hebbelinck M, Clarys P. Nutrient Based Estimation of Acid-Base Balance in Vegetarians and Nonvegetarians. Plant foods for human nutrition. 2010;65(1):77-82.

Frassetto LA, Morris RC, Sellmeyer DE, Sebastian A. Adverse effects of sodium chloride on bone in the aging human population resulting from habitual consumption of typical American diets. The Journal of nutrition. 2008;138(2):419S-22S.

Devine A, Criddle RA, Dick IM, Kerr DA, Prince RL. A longitudinal study of the effect of sodium and calcium intakes on regional bone density in postmenopausal women.The American journal of clinical nutrition. 1995;62(4):740-5.

Gaffney-Stomberg E, Insogna KL, Rodriguez NR, Kerstetter JE. Increasing dietary protein requirements in elderly people for optical muscle and bone health. Journal of the American Geriatrics Society. 2009;57:1073-9.

Duque G, Kiel DP. Osteoporosis in Older Persons: Pathophysiology and Therapeutic Approach: Springer; 2008.

Garriguet D. Bone health: Osteoporosis, calcium and vitamin D. In: Canada S, editor. Health Reports 2011.

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The Journal of IHP – Continuing Education Guadalupe-Grau A, Fuentes T, Guerra B, Calbet JA. Exercise and bone mass in adults. Sports Medicine. 2009;39(6):439-68. Horowitz S. Acid–Base Balance, Health, and Diet.Alternative and Complimentary Therapies. 2009;15(6):292-7. Health Canada. (June 8, 2012). Sodium in Canada. In Health Canada – Food and Nutrition. Retrieved April 1, 2013, from http://www.hc-sc.gc.ca/fn-an/nutrition/sodium/index-eng.php. Hunt JR, Johnson LK, Roughead ZF. Dietary protein and calcium interact to influence calcium retention: a controlled feeding study. The American journal of clinical nutrition. 2009;89(5):135765. Jehle S, Zanetti A, Muser J, Hulter HN, Krapf R. Partial neutralization of the acidogenic Western diet with potassium citrate increases bone mass in postmenopausal women with osteopenia.Journal of the American Society of Nephrology. 2006;17(11):3213-22. Kanis J, Odén A, Johnell O, Johansson H, De Laet C, Brown J, et al. The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporosis International. 2007;18(8):1033-46. Kerstetter JE, O’Brien KO, Caseria DM, Wall DE, Insogna KL.The impact of dietary protein on calcium absorption and kinetic measures of bone turnover in women.Journal of Clinical Endocrinology & Metabolism. 2005;90(1):26-31.

Nase JB, Suzuki JB. Osteonecrosis of the jaw and oral bisphosphonate treatment. J Am Dent Assoc. 2006;137(8):11159. New SA. Intake of fruit and vegetables: Implications for bone health. Proceedings of the Nutrition Society. 2003; 52:889-99. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. Canadian Medical Association Journal. 2010;182(17):1864-73. Poliquin S, Joseph L, Gray-Donald K. Calcium and vitamin D intakes in an adult Canadian population.Canadian Journal of Dietetic Practice and Research. 2009;70(1):21-7. Poupin N, Calvez J, Lassale C, Chesneau C, Tomé D. Impact of the diet on net endogenous acid production and acid–base balance. Clinical Nutrition. 2012;31(3):313-21. Rachner TD, Khosla S, Hofbauer LC. Osteoporosis: now and the future. The Lancet. 2011;377(9773):1276-87. Rafferty K, Davies KM, Heaney RP. Potassium intake and the calcium economy.Journal of the American College of Nutrition. 2005;24(2):99-106. Remer T, editor. ACID‐BASE IN RENAL FAILURE: Influence of Diet on Acid‐Base Balance. Seminars in Dialysis; 2000: Wiley Online Library.

Krieger NS, Frick KK, Bushinsky DA.Mechanism of acidinduced bone resorption.Current opinion in nephrology and hypertension. 2004;13(4):423-36.

Sebastian A, Frassetto LA, Sellmeyer DE, Merriam RL, Morris RC. Estimation of the net acid load of the diet of ancestral preagricultural Homo sapiens and their hominid ancestors.The American journal of clinical nutrition. 2002;76(6):1308-16.

Lemann J, Bushinsky DA, Hamm LL. Bone buffering of acid and base in humans.American Journal of Physiology-Renal Physiology. 2003;285(5):F811-F32.

Tarride J-E, Hopkins R, Leslie W, Morin S, Adachi J, Papaioannou A, et al. The burden of illness of osteoporosis in Canada.Osteoporosis International. 2012;23(11):2591-600.

Levis S, Lagari VS. The Role of Diet in Osteoporosis Prevention and Management.Current osteoporosis reports. 2012;10(4):296302. Lin P-H, Ginty F, Appel LJ, Aickin M, Bohannon A, Garnero P, et al. The DASH diet and sodium reduction improve markers of bone turnover and calcium metabolism in adults. The Journal of nutrition. 2003;133(10):3130-6.

Tobian L.The Volhard lecture.Potassium and sodium in hypertension. Journal of hypertension Supplement: official journal of the International Society of Hypertension. 1988;6(4):S12.

Maciaszek J, Osiński W, Szeklicki R, Stemplewski R. Effect of Tai Chi on body balance: randomized controlled trial in men with osteopenia or osteoporosis. The American journal of Chinese medicine. 2007;35(01):1-9.

Wachman A, Bernstein DS. Diet and osteoporosis.The Lancet. 1968;291(7549):958-9.

Tucker KL, Hannan MT, Kiel DP. The acid-base hypothesis: diet and bone in the Framingham Osteoporosis Study. European journal of nutrition. 2001;40(5):231-7.

Maurer M, Riesen W, Muser J, Hulter HN, Krapf R. Neutralization of Western diet inhibits bone resorption independently of K intake and reduces cortisol secretion in humans. American Journal of Physiology-Renal Physiology. 2003;284(1):F32-F40. October 2013 l www.ihpmagazine.com 87

Questions 1. Standard first line therapy for osteoporosis is: a) Estrogen replacement therapy b) Bisphosphonates c) Bisphosphonates combined with vitamin D and calcium supplementation d) Bisphosphonates, estrogen replacement therapy, and calciummagnesium plus vitamin D supplementation 2. It has been proposed that a diet high in protein and grains is associated with an increased net alkaline load, which is buffered from calcium via bone dissolution. a) True b) False 3. A diet high in fruits and vegetables, which are metabolized to yield bicarbonate (HCO3), may buffer acidity and thereby preserve Ca levels and BMD. a) True b) False 4. The phosphate buffer system results in which of the following: a) Dissolution of hydroxyapatite (bone) releases Ca2+, K+, Mg, and phosphate into the circulation. b) Neutralization of blood pH by formation of H3PO4 and K+. c) Loss of BMD. d) All of the above 5. In a randomized prospective trial of 161 postmenopausal women diagnosed with osteopenia, alkali treatment of 30 mEq/d oral potassium citrate was associated with which of the following: a) 1.87% increase of lumbar BMD over one year b) -1.39% increase of femoral BMD over one year c) 1.98% decreased fracture rate over one year d) All of the above

6. Although, accumulation of acid load has been attributed to excessive protein intake and acid formation via elevated metabolism of sulfur-containing amino acids (methionine and cysteine) found in higher quantities in animal protein, large observational studies have shown bone-protecting effects from animal protein intake. a) True b) False 7. Increased animal protein intake has been associated with: a) Better intestinal calcium absorption b) Increased IGF-1 concentrations c) Decreased PTH levels d) All of the above 8. Which of the following is true about dietary components and potential risk of osteoporosis: a) Grains are thought to be acid forming and may contribute to chronic acidosis leading to BMD loss b) Fruits and vegetables contain K and HCO3 precursors which may help counter the systemic acid load c) Plant protein contains higher amounts of K relative to animal protein d) All of the above 9. In postmenopausal women, higher intake of fruit were positively associated with increased BMD. a) True b) False 10. Current recommended daily intake of 0.8g/kg prevents protein deficiency but is insufficient for optimiziation of bone health, especially in the elderly. a) True b) False

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fast joint care+

Introduction greens+ whole body NUTRITION fast joint care+ by Genuine Health is a novel, rapidly acting formulation designed to help alleviate joint pain and stiffness. fast joint care+ is a patented ingredient containing naturally occurring combination of molecules derived from natural eggshell membrane (NEM), whole Gallusbody gallus. These molecules includefrom fibrous proteins suchisasa superfood collagen type I, glycosaminoglycans (GAGs)nutritional such as chondroitin greens+ NUTRITION, a new offering Genuine Health, concentrate designed as an all-in-one formula for sulfate andsupport. dermatan sulfate, sulftated glycoproteins such as glucosamine, hyaluronic acid, and a host to ofsupport other related proteins (Ruff health total body This convenient, great-tasting, and allergen-free product helps rebalance body systems immune and digestive through 2009a). inclusion of a 70% fermented ingredient blend, alkalinize the body, provide a wide spectrum of plant-based antioxidants and anti-inflammatory ingredients, and support mood cognitive function.Unlike the most commonly used medications for the condition, such as NSAIDs, NEM is fast joint care+ is unique as and a joint care product. a disease-modifying agent, meaning that it not only improves the symptoms of arthritis but also helps repair damaged tissue. NSAIDs carry The key feature ofsuch this formula is the fermented blend, which contains sources of essentialthis fatty acids (flaxseed, purslane, black cumin, and significant risks, as development of peptic ulcer disease, renalfermented failure, and hemorrhage; underscores the importance of developing sea fermented whole foods (carrot, tomato, kale, cocoa, and rice bran); fermented plant based protein fromthat brown fermented safebuckthorn); treatment alternatives (Vangsness 2009). Unlike theolive, natural alternatives glucosamine and chondroitin sulfate can rice; takeand several fibre. Fermentation makes the nutrients from these sources more bioavailable; removes anti-nutrients such as phytic acid that inhibit nutrient absorption weeks to act, NEM works within 7-10 days. New research now indicates that fast joint care+ is also an effective treatment for non arthritic (Chen 2013); and introduces healthy bacteria to the gut, aiding digestion and immune function. Fermentation also improves the tolerability of foods joint pain and fibromyalgia. that otherwise trigger immune reactions, such as gluten (Calasso 2012).

Osteoarthritis The formula base is Vegan greens+ OTM, a combination of colorful plant-based antioxidants and alkalinizing nutrients that provides the equivalent of Osteoarthritis (OA)and is the most common musculoskeletal condition in Westernized approximately 27 million Americans TM six servings of fruits vegetables. A University of Toronto study has shown that greens+countries; significantly increases urine alkalinity after onlyare 14 days estimated to to placebo be clinically diagnosed with OA, while 46 millionhave are thought to bebeen affected bytoarthritis as a non-specific category compared (Berardi 2008). Plant-based foods upwards and their of antioxidants reproducibly shown be inversely associated with a host (Vangsness 2009, Lawrence 2008, Theis 2007). The impact of OA includes pain, loss of function and2012, mobility, physical and psychosocial of chronic diseases including cancer, cardiovascular disease, osteoporosis, and cognitive impairment (Bao Estruch 2013, Leenders 2013, Loef disability, of NSAID therapy, and financial costs to the healthcare system. Direct average annual per person medical 2012, Rivascomplications 2013). expenditures due to arthritis ranged from $1454- 2206 (Theis 2007).

Additional antioxidants in greens+ whole body NUTRITION include lutein from marigold, flavonoids from AuroraBlue® (a proprietary blend of wild Two initial pilot studies involving 11extract, and 26NeuroFactor subjects respectively with pre-existing joint disorders found in joint TM blueberries), a proprietary coffee bean that stimulates Brain-Derived Neurotrophic Factor significant (BDNF) andreductions protects against neuropain, joint stiffness, and pain on range of motion (ROM) compared to baseline (Ruff 2009a). After 7 days there was a 25% reduction in that degeneration, as well as a proprietary cantaloupe extract, Extramel®, that is particularly rich in the antioxidant Superoxide Dismutase (SOD) and pain, while at health. 30 days there was a 51% reduction. At 30 days, there was a 43% improvement in flexibility. Nearly 50% of the patients supports brain

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Adult dosage: Mixdouble 1-2 scoops (16.2-32.4g) of greens+ body NUTRITION in 1-1 ½ cup (250-375mL) purewas water or juice. Shake If you A more rigorous, blinded RCT involving 67 whole subjects with osteoarthritis found similar effects. of NEM given at 500 mg well. per day are a new user of greens+, begin with 1 scoop daily and gradually increase to 2 scoops daily over a 3 week period. Take 2 hours before or after taking for 2 months. Researchers found significant improvements in pain and stiffness as graded by WOMAC (a clinically relevant OA assessment other medications.

tool) both at 10 days and at 60 days. After 10 days, 54% of subjects in the treatment group had a 20-30% reduction in pain, compared to

24% in the placebo group; at 60 days, 32% vs to 12% ≥50% reductionbreastfeeding, in pain. Similar demonstrated for deficiency, stiffness, with Caution: Consult a health care practitioner prior use had if you are pregnant, havefindings any typewere of acute infection, iron hypoten25% reduction at 10 days, and 53% at 60 days. (Ruff 2009b) sion, liver disorder or develop symptoms of liver trouble (abdominal pain, dark urine, jaundice) or are taking medications for diabetes, blood pressure, or seizures. Do not use if you are taking health products that affect blood coagulation (eg. blood thinners, clotting factor replacements, acetylsalicylic Non Arthritic Pain acid, ibuprofen, Joint fish oils, vitamin E). Hypersensitivity, such as an allergy, has been known to occur; in which case discontinue use.

In addition to studies on NEM, fast joint care+ as a whole has been specifically assessed in subjects with non arthritic joint pain. In a randomized study, 60 unmedicated subjects with chronic (but non-arthritic) joint pain were given either 500mg of fast joint Non medicinal ingredients: Stevia rebaudiana: organic steviacare+ leaf or placebo1.for one month.per Those in the fast joint care+ group reported reduction in post-exercise pain ratings, phosphate, with four times less pain than Table Ingredients 34.2g (2 scoops) & astevia leaf extract, natural flavor, tricalcium ascorbyl Vegan greens+group OTM base formulaunpublished data). This the placebo (Berardi, exciting finding shows that fast joint care+ is an effective therapy for those “weekend ~7.5g palmitate, maltodextrin, silicon dioxide. warriors” suffering from joint pain, and not exclusively for those suffering from osteoarthritis. Oryza sativa: fermented, sprounted whole grain brown rice protein concentrate Fibromyalgia (non-GMO; 80% protein)

12.5g

References:

Bao PP, et al. Fruit, vegetable, and animal food intake and breast cancer risk

hormone Alison receptor Bested, status. Nutr Cancer. 2012 Aug;64(6):806-19. An open-label pilot study supervised by Toronto area fibromyalgiaby specialist MD investigated the effects of 500mg of fast jointblend: care+ among 15 patients when given daily for eight weeks. Outcomes were measured using the Fibromyalgia Impact Fermented 2308mg Berardi JM, Logan AC, Rao AV. Plant based dietary supplement increases Linum usitatissimum (Organic flaxseed); Questionnaire (FIQ) and Brief Pain Inventory (BPI) scales before and at the of Nutr. the study. Results 1154mg urinary pH. conclusion J Int Soc Sports 2008 Nov 6;5:20.showed that Oryza sativacare+ (Rice bran); fast joint significantly improved sleep, pain while working (i.e. performing activities), and overall pain ratings in FM. 692mg Portulaca oleracea (Purslane plant); 231mg M, et al.towards The sourdough fermentation may enhance the recovery “Enjoyment of Life”, “Everyday Work” and “Missed Work” scalesCalasso also trended improvement (Bested, unpublished data) Daucus corota (Purple carrot root);

231mg from intestinal inflammation of coeliac patients at the early stage of the Olea europaea (Olive fruit); 231mg gluten-free diet. Eur J Nutr. 2012 Jun;51(4):507-12. Recommended Use(Tomato fruit); Solanum lycopersicum 231mg Brassica oleracea viridis (Organic kale plant); 500 mg or one capsule per day. Contraindicated in persons with allergy toetegg or egg products. Noofknown adverse 231mg Chen L, al. High-efficiency removal phytic acid in soyeffects. meal using twoHippophae rhamnoides (Sea buckthorn fruit); 231mg stage temperature-induced Aspergillus oryzae solid-state fermentation. J Sci Nigella sativa (Black cumin seed); References 231mg Phyllanthus emblica amlaReduces fruit); Joint Pain. Unpublished Berardi J. Egg Shell(Organic Membrane data. Food Agric. 2013 Apr 30. doi: 10.1002/jsfa.6209. 231mg Theobroma cacao (Organic cocoa seed) 6g Estruch et al; in PREDIMED Study Investigators. Primary prevention of Bested A. Summary of aVitaFibreTM pilot, open-label, study of eggshell membrane (fast joint R, care+) fibromyalgia patients. Completed April 2012. Unpublished Isomaltooligosaccharides: cardiovascular disease with a Mediterranean diet. N Engl J Med. 2013 Apr data. (fermented; non-GMO) 4;368(14):1279-90. Lawrence RC, Felson DT, Helmick CG, Arnold LM, Choi H, Deyo RA, Gabriel S, Hirsch R, Hochberg MC, Hunder GG, Jordan JM, Katz JN, Kremers 800 IU/ Vegan Vitamin D (ergocalciferol from HM, Wolfe F; National Arthritis Data Workgroup. Estimates of arthritis other conditions in United States. Part II. 20mcg of the prevalence Leenders M, et al.and Fruit and rheumatic vegetable consumption andthe mortality: European Agaricus non-GMO, organic) Arthritis bisporus; Rheum. 2008 Jan;58(1):26-35. prospective investigation into cancer and nutrition. Am J Epidemiol. 2013 120mg Aug 15;178(4):590-602. Ruff KJ,erecta Winkler A, Jackson DeVore DP, Ritz BW. Eggshell membrane in the treatment of pain and stiffness from osteoarthritis of the knee: Tagetes (Marigold flowerRW, extract, 5% lutein)

a randomized, multicenter, double-blind, placebo-controlled clinical study. Clin Rheumatol. 2009 Aug;28(8):907-14.

100mg Loef M, et al. Fruit, vegetables and prevention of cognitive decline or Coffea arabica (NeuroFactoTM whole coffee fruit dementia: a systematic review of J Nutr Health Aging. 2012 Results Ruff KJ, DeVore DP, Leu MD, Robinson MA. Eggshell membrane: a possible new natural therapeutic forcohort joint studies. and connective tissue disorders. concentrate) Jul;16(7):626-30. from two open-label human clinical studies. Clin Interv Aging. 2009;4:235-40. 100mg Vaccinium & uliginosum Theis KA,ovalifolium Helmick CG, Hootman JM.Arthritis burden and impact are greater U.S. women than men: opportunities.J Womens Health Rivasamong A, et al. Mediterranean diet and intervention bone mineral density in two age TM (AuroraBlue wild Alaskan blueberry fruit) (Larchmt). 2007 May;16(4):441-53. 10mg groups of women. Int J Food Sci Nutr. 2013 Mar;64(2):155-61. Cucumis melo (Extramel® cantaloupe fruit juice Vangsness CT Jr, Spiker W, Erickson J. A review of evidence-based medicine for glucosamine and chondroitin sulfate use in knee osteoarthritis. concentrate)

Arthroscopy. 2009 Jan;25(1):86-94.

Vancouver | November 16, 2013, Hyatt Regency, 9:00am–4:30pm Dr. Tori Hudson, ND

Women’s Health Research Update: Natural Therapies & Controversial Issues A steady stream of research on diet, individual nutrients, and botanicals provides vital and relevant information for clinicians in everyday practice who are treating women for the plethora of primary care and/or gynecological issues they face. Staying up-to-date on this research can be challenging and even daunting. This lecture will highlight research from 2012 and 2013, and studies that can make a difference in the results and outcomes for your patients. In addition, this lecture will provide some depth of understanding into current controversies in screening mammography, calcium dosing, and menopausal hormone therapy.

Dr. Alana Shaw, MSc (c.), ND

Fertility & Aging: Exposing the Myths & Misconceptions Approximately one in six couples struggle with infertility, and delayed childbearing is believed to be one of the largest contributors to this statistic. This lecture will review the common myths and misconceptions about reproductive aging, and address the question of whether we can effectively “turn back the reproductive clock”. Practitioners will receive an update on current literature in the field of complementary medicine for the treatment of women with advanced maternal age, with a focus on how to integrate these treatments with reproductive technologies.

Dr. Cathy Carlson-Rink, ND, RM

Postpartum Care: Healing Traditions from Around the World The postpartum period is a particularly difficult period of adjustment for modern woman dealing with recovering from birth, the steep learning curve of how to care for an infant, body image concerns, and breast-feeding challenges. Added to this the lack of support, that historically women received during this time period, is leading to physical and mental exhaustion. Also known as the fourth stage of pregnancy, this sacred period needs to be re-embraced for the short- and long-term health of both the mother and baby. These healing traditions of the Baby Moon period are thousands of years old, common to all cultures, and are steeped in natural healing methods. In our fast-paced society, we have let this vital knowledge lapse and the mother-and-baby dyad is suffering because of it. This course will help the health-care provider learn holistic systems supporting the physical, emotional, and mental health of the mother and baby to aid and support the healthy transitions into life and to motherhood.

Dr. Tori Hudson, ND

Challenging Cases in Women’s Health: PCOS, Endometriosis, Interstitial Cystisis Women who have these chronic health conditions are frequent patients in our practice, and these conditions can result in significant limitations and quality of life issues for the patients. Whether it is the complex endocrinological and multiple manifestations of PCOS, the chronic pelvic pain of endometriosis, or the urinary frequency/urgency and pelvic pain of IC, these can be some of the most challenging cases in our practice. Many practitioners are not aware of the research that provides insight and guidance on more successful management of these chronic conditions. With this body of information, sample, comprehensive treatment plans can be used as a framework for a clinical approach. Case examples will also be utilized to demonstrate the challenges and treatment strategy options.

IHP 2013-10,11 (Women’s Health Symposium).indd 2

2013-09-18 14:30:59

Presents

Advances in

Women’s Health $40/practitioners • $20/students Pre-approved for CE credits Lunch will be provided Free products and samples

Vancouver | November 16, 2013, Hyatt Regency, 9:00am–4:30pm Dr. Tori Hudson, ND Women’s Health Research Update: Natural Therapies & Controversial Issues

Dr. Alana Shaw, MSc (c.), ND Fertility & Aging: Exposing the Myths & Misconceptions

Dr. Cathy Carlson-Rink, ND, RM Postpartum Care: Healing Traditions from Around the World

Dr. Tori Hudson, ND Challenging Cases in Women’s Health: PCOS, Endometriosis, Interstitial Cystisis

Dr. Tori Hudson, ND

Dr. Alana Shaw, MSc (c.), ND

Dr. Cathy Carlson-Rink, ND, RM

∙∙ Medical Director at A Woman’s Time in Portland (Oregon)

∙∙ Private practice at Grace Fertility Centre and Reproductive Medicine in Vancouver (British Columbia)

∙∙ Naturopathic Physician and Registered Midwife at the Family Health Clinic in Langley (British Columbia)

∙∙ Internationally renowned author of Women’s Encyclopedia of Natural Medicine ∙∙ In 2012, Dr. Hudson was inducted into the NCNM Hall of Fame

∙∙ Obtained her Masters degree at the University of British Columbia in the department of Reproductive Endocrinology and Infertility

∙∙ Instructor of Obstetrics and recently became Chair of Women’s and Children’s Health Programs at the Boucher Institute of Naturopathic Medicine

To register contact 1 866 510-3123 or info@nfh.ca — Limited space available

IHP 2013-10,11 (Women’s Health Symposium).indd 1

2013-09-18 14:30:55

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