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INTEGRATIVE, COMPLEMENTARY, AND ALTERNATIVE MEDICINE FOR PROVIDERS OF PRIMARY CARE
This pocket handbook was created by AMSAs Humanistic Medicine Action Committee HuMed, 2006-2007 Many thanks to our contributors for helping in the creation of this handbook, including the EDCAM advisory panel For more information on AMSA and HuMed, visit wwwamsaorg/humed
COMPLEMENTARY AND ALTERNATIVE MEDICINE: DEFINITIONS From the National Institutes of Health, National Center for Complementary and Alternative Medicine NCCAM website at wwwnccamnihgov Complementary medicine is used together with conventional medicine An example of a complementary therapy is using aromatherapy to help lessen a patients discomfort following surgery Alternative medicine is used in place of conventional medicine An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor Integrative medicine, as
defined by NCCAM, combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness
A model for using CAM in the office setting Family Practice Vol 20, No 3, 324-332
Integrative, Complementary, and Alternative Medical Systems Acupuncture Acupuncture is a form of traditional Chinese medicine, although other forms Japanese, Korean, and classical Chinese are practiced and taught throughout the world Acupuncture relies on the idea that the flow of energy, called Qi, pronounced chi affects a patients health By inserting thin, sterile needles through various points in a patients body, acupuncturists seek to correct or regulate the flow of Qi These points have been defined and standardized by the World Health Organization Indications for acupuncture are wide-ranging, with documented effects for post-surgical nausea, dental pain, blood pressure, anxiety, and a wide range of disorders A typical treatment costs
between 30 - 100, and is covered by some insurance carriers Ayurveda Ayurvedic medicine is a form of traditional Indian medicine, which focuses on balancing an individuals body, spirit, and mind to produce health, rather than treating individual symptoms At the initial office visit, an eightfold examination is used to determine the balance of the three doshas, which are believed to govern all bodily processes Each person has a dominant dosha, which determines his/her constitution type Doshas include Vata space and air elements, Pitta fire element, and Kapha combination of water and earth elements The main aspects of Ayurveda are Panchakarma cleansing, Abhiyanga oil massage, and Samana herbal remedies Cost widely ranges from 100 for a first-time office visit, to greater for follow-up visits Not generally covered by insurance Homeopathy The foundation of homeopathy comes from Hahnemanns supposition that like treats like Practitioners use small amounts of a substance with similar
properties as the illness to treat that illness Homeopathic remedies are used to treat a number of conditions including headaches, migraines, diabetes, heartburn, indigestion, irritable bowel syndrome, asthma, fibromyalgia, infertility, PMS, menopausal issues, and hypertension The remedies use ingredients derived from plants, animals, and minerals Homeopathy is very costeffective over the long term Currently, most insurance carriers do not cover homeopathy Native American Healing - Native American healing encompasses a broad spectrum of belief systems practiced by members of over 500 indigenous tribes of North America Specific practices vary among tribes, but an overarching theme is maintaining respectful, harmonious relationships between man, nature and the spiritual world Practices consist of counseling, healing ceremony and communication with nature Exact practices, medicines and rituals differ according to tribe and geographic location, although there are four commonalities:
involvement of a healer, use of herbal remedies, use of ritual purging and purification, as well as the observance of symbolic rituals and ceremonies http://wwwhealing-artsorg/nativelinkshtm Naturopathy - Naturopaths have been called the generalists of alternative treatments The American Association of Naturopathic Physicians defines naturopathic medicine as a distinct system of primary health care - an art, science, philosophy and practice of diagnosis, treatment and prevention of illness Treatments used in naturopathic practice include clinical nutrition and dietary changes, counseling for lifestyle modification, herbal medicine, homeopathy, physical medicine, and Asian medicine wwwnaturopathicorg Osteopathy - Osteopathic medicine is a distinctive, equivalent form of medicine to allopathic medicine in the United States Osteopathic medicine provides all of the benefits of modern medicine including prescription drugs, surgery, and the use of technology to diagnose disease and evaluate
injury; in addition, osteopathic training emphasizes healing the whole individual, preventive care, and the musculoskeletal system more than allopathic schools Osteopaths are trained to use Osteopathic Manipulative Medicine OMT Most if not all insurance carriers cover DO services Traditional Chinese Medicine - Traditional Chinese medicine views disease as a result of internal imbalance that either causes disease or allows outside agents to cause disease Concepts in TCM include ideas of Yin and Yang oppositional forces which mediate balance within the body, Qi the bodys vital energy, Zang and Fu organs system classified as solid and hollow, respectively TCM practices include acupuncture, herbs, massage, and the use of external salves or ointments Some TCM practices may be covered by insurance, notably acupuncture
Tibetan Medicine Disease in Tibetan Medicine is described as disturbances or disharmonies in one or more of seven components: milk, blood, meat, fat, bone, marrow, and
essence; three excreta: excrement, urine, and perspiration; and three principles of energy: wind, bile, and phlegm The three principles of energy are used to describe the constitution of a person, much like Ayurvedic medicine Tibetan medicine is very preventive based, as it is meant to address unhealthy tendencies before disease occurs Types of therapy include behavioral, diet, and herbal treatments In addition, practitioners use acupuncture, moxibustion use of burning moxa herb directly or indirectly on body to stimulate circulation, bloodletting, cupping, massage, and inhalation therapies Traditional Mexican Therapy - Mexican traditional medicine encompasses native Indian folk practices, Western European medicine, and religious-spiritual beliefs Health is believed to be a balance of ones physical, emotional, psychological, and spiritual elements For example, Illnesses can be attributable to an imbalance between hot and cold elements, which can be treated with food and herbs to return
balance to the body In general, health advice from elders is highly respected, and there is a great reliance on herbal medicine to treat a variety of ailments Specific Therapies in CAM Energy Therapies Polarity therapy - A comprehensive health system involving energy-based bodywork, diet, exercise and selfawareness to balance and restore the natural flow of energy, resulting in improved health and fitness on all levels Reiki - Energy therapy where practitioners lay their hands on specific areas on a patients body to transmit ki, believed to be a life-force energy, to improve the flow and balance of energy in a beneficial way Body-based therapies Aikido A modern Japanese martial art, which consists of striking, body throw and joint locking techniques It is known for its fluidity and blending motions Students cite they experience mind-body co-ordination and an increase in spiritual awareness from practicing this non-violent art Alexander Technique - Teaches individuals how to recognize
and overcome habituated limitations within their manner of movement and thinking This is most often addressed by alleviating unnecessary muscular tension in the body Alexander technique is taught individually and in supportive group settings Breema - Described as a cross between partner yoga and Thai massage Benefits include an enhanced sense of mindfulness and experience of presence The Breema practitioner helps students realize a sense of peace, calm energy, and clarity Chiropractic - Chiropractics premise is that spinal joint misalignments, which chiropractors call vertebral subluxations, can interfere with the nervous system and result in many different conditions of diminished health Their treatments consist of a variety of techniques and methods which chiropractors refer to as spinal adjustments Most PCPs refer patients to chiropractors for lower-back pain Covered by some insurance providers Massage - Practice of applying structured or unstructured pressure, tension, motion, or
vibration — manually or with mechanical aids — to the soft tissues of the body, including muscles, connective tissue, tendons, ligaments, joints and lymphatic vessels, to achieve a beneficial response Proven benefit for patients with subacute and chronic nonspecific low-back pain, especially when combined with exercises and education Evidence may suggest that acupressure massage is more effective than classic/Swedish massage Cochrane 2006 Reflexology - Practice of stimulating points on the feet and hands, to bring positive effects to other areas of the body, or to improve general health The most common form is foot reflexology Tai Chi - A form of moving meditation, intended to teach awareness of ones own balance and what affects it Students gain an ability to mediate extremes of behavior and attitude at both mental and physical levels Yoga A form of moving mediation that incorporates the practice of asanas postures and breathing techniques to promote strength, balance, mental
clarity and calmness Biologically-based Therapies Fasting - Seen as a way of cleansing the body of toxins, dead or diseased tissues, and giving the gastrointestinal system a rest Some fasts are either water-only, or consist of fruit and vegetable juices Herbal Medicine A folk and traditional method of using indigenous plants and plant extracts for treatment of various ailments Vitamins Contained in daily foods or as supplements Dietary supplements, often containing vitamins, are used to ensure that adequate amounts of nutrients are obtained on a daily basis Used when optimal amounts of nutrients cannot be obtained through a varied diet Scientific evidence supporting the benefits of some dietary supplements is well established for certain health conditions
Mind-Body Medicine Art Therapy - Based on the belief that the creative process is healing and life-enhancing Through creating and talking about art with an art therapist, one can increase awareness of self, cope with symptoms,
stress, and traumatic experiences Biofeedback Biofeedback involves measuring a persons bodily processes such as blood pressure, heart rate, skin temperature, galvanic skin response sweating, and muscle tension This information is conveyed to the individual in real-time to raise his or her awareness and conscious control of related physiological activities EMDR Short for eye movement desensitization and reprocessing It is a form of psychotherapy best known for treating patients with PTSD It relies on the theory that traumatic events, and our unique responses to them, are stored in memory networks EMDR is an 8-phase treatment In Phase I, the patient identifies targets for densensitization and reprocessing, including etiological traumatic incidents and current situations that cause emotional distress In Phase 2, the therapist assesses the patients readiness for imaginal exposure to disturbing material and works with the patient to develop adequate coping skills and behaviors The actual
desensitization and reprocessing of traumatic memories and stimuli occur in Phases 3 through 6 Mindfulness Based Stress Reduction Developed by Dr Jon Kabat-Zinn in 1979, MBSR involves mindful meditation conducted in a participatory group setting The instructor guides the group in a mindfulness meditation focusing on sensations in the body, the breath, or slow mindful movement Later, students discuss challenges and insights they experienced as they practiced meditation Modern Medical Hypnosis Describes hypnosis as a state of inner absorption, concentration and focused attention When an individual reaches this state, he/she may be able to access unknown functions for self-improvement Most commonly used to modify a subjects behavior, emotional content and attitudes, as well as a wide range of conditions including obesity, substance abuse, pain, ego, anxiety, stress, amnesia, phobias, and matters of performance It may also be used to assist with functional disorders like Irritable Bowel
Syndrome Spiritual Healing Spiritual healing takes on many forms, including healing touch and intercessory prayer Many studies have suggested that prayer can reduce physical stress, while uplifting patient morale, thus aiding recovery Some studies show that the psychological benefits of prayer may help reduce stress and anxiety, promote a more positive outlook, and strengthen the will to live Derived from the CAM Handbook 2006 Integrative Medicine Network of UCSF NOTES
CAM Therapies for Everyday Use RX Gingko biloba 120 mg/day, taken in 2-3 divided doses, or 05 ml extract taken 3 times a day Uses: Some evidence for efficacy in cognitive impairment and dementia with little side effects 2006 Cochrane collaborationl Early-stage Alzheimers, vascular dementia, peripheral claudication, tinnitus PDR for Herbal Medicines, Third Edition Suggested brands: Gingkgold/Natures Way, Ginkoba/Pharmaton, Quanterra/Warner Lambert, Ginkai/Lchtwer Mechanism of action: Anti-inflammatory effects have
been demonstrated with reduced eosinophil infiltration; antioxidant activity has been demonstrated through free scavenger action and prevention of lipid peroxidation PDR for Herbal Medicines, Third Ed Side effects/Interactions: Mild: abdominal upset, nausea, headache, dizziness, allergic skin reactions NCCAM, Can increase risk of bleeding if used with warfarin and antiplatelet meds AAFP Glucosamine sulfate 1500 mg/day, up to three times a day Results seen after a minimum of 4 weeks and up to 3 years later PDR for Herbal Medicines, Third Ed Uses: Short and long-term benefits for osteoarthritis and symptoms have been shown with little side effects compared to placebo 2006 Cochrane Mechanism of action: Preclinical studies have shown glucosamine has a tropism for cartilage and bone; seems to enhance cartilage proteoglycan synthesis, inhibiting deterioration of cartilage brought about by osteoarthritis, maintaining equilibrium between cartilage catabolic and anabolic actions; an
anti-inflammatory action of glucosamine has also been proposed PDR for Herbal Medicines, Third Ed Side effects/interactions: Rare 2006 Cochrane Collaboration; use with caution in patients with shellfish allergies as supplements are usually derived from crab shells, although corn-derived supplements are available PDR for Herbal Medicines, Third Ed Saint Johns Wort Hypericum perforatum L 300 mg three times a day of standard extract, or St Johns wort tea single dose 2-3 g dried herb placed in boiling water Uses: Treatment for mild to moderate depressive symptoms Minimal effects for treating major depression 2006 Cochrane Collaboration For depressive moods, it is recommended the herb be administered for 4-6 weeks; if no improvement is apparent, a different therapy should be initiated PDR for Herbal Medicines, Third Ed Suggested brands: Jarsin/Lichter Pharma; Quanterra Emotional Balance/Warner Lambert; Perika/Natures Way; Movana/Pharmaton Mechanism of action: Hypericin was originally
thought to be the major active component for St Johns wort in depression; however, it is now believed that hyperforin and related compounds are mostly responsible for St Johns worts effect on mood Hyperforin extracts have been shown to modulate neurotransmitter levels including serotonin, norepinephrine, and dopamine 2006 UpToDate Side effects: Fewer than pharmaceutical antidepressants 2006 Cochrane Photosensitivity AAFP Interactions: Can cause serotonin syndrome when taken with MAO-Is, SSRI, and TCAs Inducer of CYP3A4; may reduce effectiveness of oral contraceptive pills, as well as amitriptyline, carbamazepine, cyclosporine, digoxin, indinavir, irinotecan, midazolam, nevirapine, sertraline, simvastatin, tacrolimus, theophylline, warfarin AAFP Echinacea Echinaceae species 300 mg three times a day or 3-4 cups of tea daily Uses: Upper respiratory tract treatment and prevention; Aerial parts of Echinacea purpurea might be effective for the early treatment of colds in adults; more
evidence exists for reducing duration and severity of symptoms than in preventing URI Cochrane 2006 Suggested brands: Echinagard/Natures Way, Echinacea Standardized, Echinacea Root Herbal Mechanism of Action: Evidence for stimulation of phagocytic but not specifically acquired immune system Biochem Pharm 2000 June 15; Causes the release of tumor necrosis factor, interleukin 1, interleukin 6, and interferon in vitro; has been noted to have antiviral activity against influenza, herpes, and poliovirus; phenolic compounds present in echinacea demonstrate antioxidant activity; evidence for anti-inflammatory activity through inhibition of LOX and COX pathways; evidence for stimulation of anterior pituitary-adrenal cortex UpToDate 2006 Side effects: Extensive studies have shown no toxicity in both children and adults in acute as well as long-term administration PDR for Herbal Medicines, Third Ed Rash has been reported in children Cochrane 2006 Interactions: Inhibits cytochrome P450 in vitro
PDR for Herbal Medicines, Third Ed; however, no cases of interaction have been reported in clinical use AAFP Use with caution when administered with drugs metabolized by this enzyme
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Saw palmetto Serenoa repens 160 mg capsule twice daily Uses: Mild to moderate improvement in urinary symptoms and flow measures for men with BPH 2006 Cochrane Collaboration Approved by Commission E for use for irritable bladder and prostate complaints PDR for Herbal Medicines, Third Ed Suggested brands: Elusan Prostate/PlantesMedicines, ProstActive/Natures Way Mechanism of action: Some of the mechanisms proposed include anti-inflammatory activity, blocked conversion of testosterone to dihydrotestosterone DHT,3,4 and prostate epithelial involution similar to effects noted with the use of finasteride AAFP Side effects: Adverse effects due to Serenoa repens were mild and infrequent 2006 Cochrane Collaboration Mild; less compared to finasterides, GI upset AAFP Interactions: No known drug
interactions with saw palmetto AAFP Concurrent use may result in increased risk of bleeding Patients with hormone-dependant cancers should observe caution and speak to a physician regarding use because of its antiestrogenic, estrogenic, and antiandrogenic effects PDR for Herbal Medicines, Third Ed Horse chestnut Aesculus hippocastanum 35-70 mg daily of aescin from encapsulated standardized extracts, or as Horse Chestnut leaf tea 1 tsp finely cut leaves steeped in boiling water PDR for Herbal Medicine, Third Ed Uses: Approved by Commission E for treatment of venous conditions chronic venous insufficiency, including symptoms of leg pain and heaviness PDR for Herbal Medicines, Third Ed Suggested brands Venastat/Pharmaton Mechanism of action: The principal ingredient of Horse Chestnut seed extract, aescin, has an anti-exudative, vascular tightening effect, and reduction of vascular permeability which results in an anti-edema effect; also demonstrates improvement of venous flow PDR for
Herbal Medicines, Third Ed Side effects: Health risks or side effects when used as directed are not recorded Horse Chestnut leaf has a coumarin component, which may interact with warfarin, salicylates, and other anti-coagulants; Nausea with some pts has been demonstrated with horse chestnut seeds PDR for Herbal Medicines, Third Ed
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Derived from Dr Victor Sierpina, Integrative Medicine for the Office, available at camutmbedu NOTES
Common Herbal Remedies HERB COMMON USES Black Menstrual Cohosh symptoms, menopausal dysfunction
BENEFITS Has been used for up to 6 months in treating sleep/mood disturbances and hot flashes associated with menopause B 3 UTI prevention–B; UTI treatment–D 3 Migraine prevention–C 1 Small, short term lipidlowering–A Antithrombotic and association with lower incidence of laryngeal, endometrial, colorectal and gastric cancers–B Claudication-C; lowering BP, insulin sensitivity, glucose–D; 2 Mental functioning, diabetes–B; physical performance–D
3
ADVERSE EFFECTS Contraindicated during pregnancy: can stimulate uterine contraction; controversy on risks for women with family history of breast cancer 3 May increase urinary oxalate levels 3 Mild and transient 1 Can prolong bleeding time prudent to stop taking high doses 7-10days before surgery: C Possible abdominal symptoms, dermatitis, flatulence 2
DRUG INTERACTIONS Increases inhibitory effect of Tamoxifen on breast cancer cell lines 3 None known 3 No significant interactions 1 Caution with anticoagulants; unclear effects on protease inhibitor pharmacokinetics 3
Cranberry Feverfew Garlic
UTI prevention and treatment Headaches Arthritis Wide General health promotion Postulated cardiovascular, antineoplastic, antimicrobial properties Antiinflammatory, improved wellbeing and physical performance Sleep disorders
Ginseng
Melatonin
Milk thistle
Liver and gall bladder disease
Valerian
Insomnia; anxiety less commonly
Delayed sleep syndrome-B Jet leg, shift work disorder-C
Primary and secondary sleep disorders-D,2 B–Improvement in aminotransferases in alcoholic liver disease, chronic liver disease, viral hepatitis-C,2 Insufficient evidence of improved symptoms 2 Improved subjective experiences of sleep most notably sleep latency among selfdescribed poor sleepers-A No benefit among self-described good sleepers 1
2: Agency for Healthcare Research and Quality AHRQ B: promising evidence of safety and efficacy; more research needs to be done
Nausea, diarrhea, euphoria, insomnia, headaches, hypertension, hypotension, mastalgia, vaginal bleeding 3 Safe in short term and at moderate-to-high doses Reported adverse effects nausea, headache, drowsiness were statistically insig 2 Few and mild Causality not clearly established Include GI,headache,arthralgias, impotence, anaphylaxis 2 Sudden cessation of long-term high dose therapy can induce withdrawal syndrome similar to benzodiazepenes 1; rarely, dizziness 2
Caution with warfarin, oral hypoglycemics, phenelzine,
insulin 3 Insufficient data to report 2
Insufficient data to report 2
Can potentiate other CNS depressants Avoid using with alcohol 3
COMMON HERBAL REMEDIES KEY: Databases 1: The Cochrane cited: Collaboration Strength of Evidence: A:solid evidence of safety and efficacy
3: American Academy of Family Physicians AAFP C: insufficient or equivocal evidence of efficacy; no evidence of harm
4: National Cener for Complementary and Alternative Medicine NCCAM D: evidence shows no efficacy X:evidence of harm
Table provided by Catherine Jones, Tulane School of Medicine Class of 2008
DIET NUTRITION
Community Nutrition Resources: Local and community-based national food and nutrition resource programs Women, Infants, and Childrens Supplemental Food Program WIC http://wwwfnsusdagov/fns/ Lactation consultants, other support groups such as Le Leche League http://wwwlalecheleagueorg/ National School Lunch and Breakfast Program http://wwwfnsusdagov/fns/ Food Stamps and local emergency
food assistance programs providing meals or groceries http://wwwfnsusdagov/fns/ Weight loss programs that are based on sound nutrition principles such as Weight Watchers or programs offered by hospitals or clinics or private practice Registered Dietitians Nutrition Program for the Elderly, which includes mobile meals and congregate meals at community locations http://wwwfnsusdagov/fdd/programs/nsip/nsiphomehtm Cooperative Extension Service Home care programs for in-home assistance with meal preparation Other local community nutrition resources and food programs including local or state cooperative extension service From Physicians Curriculum in Clinical Nutrition: Primary Care, Second Edition The Group on Nutrition, Society of Teachers of Family Medicine
GLYCEMIC INDEX - Glycemic index GI describes how certain carbohydrates affect blood sugar and insulin The lower a foods glycemic index, the less it affects blood sugar and insulin levels Clinical trials in normal, diabetic and
hyperlipidemic subjects show that low-GI diets reduce mean blood glucose concentrations, reduce insulin secretion and reduce serum triglycerides in individuals with hypertriglyceridemia GLYCEMIC INDEX OF COMMON FOODS Low Glycemic Index 50 Moderate Glycemic Index 50-70 High Glycemic Index 70-100
Remember that glycemic index can only be measured on foods that contain carbohydrate Glycemic index values have not been determined on all foods, however more extensive lists can be found at http://wwwglycemicindexcom/ University of Sidneys Web Site The reference food for this table is glucose BREADS Bagel 72 Kaiser roll 73 White bread 70 Whole wheat bread 69 Sourdough bread 52 Whole grain pumpernickel CEREALS Corn flakes 83 Rice Krispies 82 Grapenuts flakes 80 Total 76 Cheerios 74 Puffed wheat 74 Shredded wheat 69 Grapenuts 67 Cream of wheat 66 Oatmeal 61 Special K 54 All bran 42 GRAINS Instant rice 87 Millet 71 White rice 56 Brown rice 55 Bulgur 48 Converted rice 47 Barley 25 SNACKS Rice
cakes 82 Jelly beans 80 Soda crackers 74 Corn chips 72 Chocolate bar 68 Rye crisp bread 63 Power Bar 57 Popcorn 55 Potato chips 54 Peanuts 14 PASTA Spaghetti 41 Whole wheat spaghetti BEANS Baked beans 48 Chickpeas 33 Cooked beans 29 Lentils 29 Soy beans 18 VEGETABLES Baked potato 85 Beats 64 New potato 62 Sweet corn 55 Sweet potato 54 Carrots 49 Green peas 48 FRUIT Watermelon 72 Pineapple 66 Raisins 64 Mango 55 Orange juice 52 Canned peach 47 Orange 43 Unsweetened apple juice Apple 36 Pear 36 Peach 28 Grapefruit 25 MILK AND YOGURT Chocolate milk 34 Low fat fruit yogurt 33 Skim milk 32 Whole milk 27 SUGARS Glucose 100 Honey 58 Sucrose table sugar Fructose 43
37
46
41
65
Information from University of Wisconsin Hospital and Clinics, Center for Integrative Medicine
NUTRIENT GUIDE Nutrient Incidence of Deficiency Biotin 16 overall Calcium Average diet contains 40 to 50 of RDA
Typical Sx and Diseases Dermatitis, eye inflammation, hair loss, loss of muscle control, insomnia, muscle
weakness Brittle nails, cramps, delusions, depression, insomnia, irritability, osteoporosis, palpitations, periodontal disease, rickets, tooth decay Anxiety, fatigue, glucose intolerance, adultonset diabetes Anemia, arterial damage, depression, diarrhea, fatigue, fragile bones, hair loss, hyperthyroidism, weakness Diarrhea, dry skin and hair, hair loss, immune impairment, infertility, poor wound healing, premenstrual syndrome, acne, eczema, gallstones, liver degeneration Anemia, apathy, diarrhea, fatigue, headaches, insomnia, loss of appetite, neural tube defects, paranoia, shortness of breath, weakness Cretinism, fatigue, hypothyroidism, weight gain Anemia, brittle nails, confusion, constipation, depression, dizziness, fatigue, headaches, inflamed tongue, mouth lesions Anxiety, confusion, heart attack, hyperactivity, insomnia, nervousness, muscular irritability, restlessness, weakness Atherosclerosis, dizziness, elevated cholesterol, glucose intolerance, hearing loss, loss of muscle
control, ringing in ears Bad breath, canker sores, confusion, depression, insomnia, dermatitis, diarrhea, emotional instability, fatigue, irritability, loss of appetite, memory impairment, muscle weakness, nausea, skin eruptions and inflammation Abdominal pains, burning feet, depression, eczema, fatigue, hair loss, immune impairment, insomnia, irritability, low blood pressure, muscle spasms, nausea, poor coordination Acne, constipation, depression, edema, excessive water consumption, fatigue, glucose intolerance, high cholesterol levels, insomnia, mental impairment, muscle weakness, nervousness, poor reflexes
Chromium Copper
90 of diets deficient 75 of diets deficient; average diet contains 50 RDA Very common
Essential fatty acids
Folic acid
Iodine Iron Magnesium
Manganese Niacin
Average diet contains 60 of RDA; requirement doubles in pregnancy; 183 deficient in US Uncommon since the supplementation of salt with iodine Most common mineral deficiency; also 5 with excess 75 to 85
of diets deficient: average diet contains 50 to 60 of RDA Unknown, may be common in women Commonly deficient in elderly, 137 general population
Dosing 1-5mg/d; safe up to 10g/d 800-1200 citrate; check formulation for alternative dosing 200-400ug/d; can be toxic 600ug/d 1mg /d gluconate; 60mg causes emesis and blocks Zn absoption 1-9g/d; limited by bleeding risk 3g/d, immune suppression 6g/d 400ug-10mg/d
100-200 ug/d Na salt 15-45mg/d 200-400mg citrate; can be toxic greater than 500mg/day 1-5mg/d chelate; 500-1000mg/d; Note: inositol hexaniacinate reduces flushing 250-500mg/d; safe up to 10g/d 1000-3000mg/d, monitor Na; toxicity rare except in renal failure
Pantothenic acid B5 Potassium
Average elderly diet contains 60 of RDA; deficiency in 26 overall Commonly deficient in elderly
Pyridoxine B6, P5P
71 of male and 90 of female diets deficient; 227 deficient overall Deficient in 30 of elderly Britons; 8 overall US
Riboflavin B2
Selenium
Average diet contains 50 of RDA
Thiamin
B1
Commonly deficient in elderly; 33
Vitamin A Vitamin B12 cyanocobalamin
20 of diets deficient, overall deficiency 109 Serum levels low in 25 of hospital patients; 159 general population
Vitamin C
20 to 50 of diets deficient, 195 deficient serum levels 82 of elderly womens diets deficient, 42 of US adolescents worse in Af Am and winter 23 of male and 15 of female diets deficient; overall deficiency 341 Deficiency in pregnant women 68 of diets deficient
Acne, anemia, arthritis, eye inflammation, depression, dizziness, facial oiliness, fatigue, impaired wound healing, irritability, loss of appetite, loss of hair, mouth lesions, nausea Blurred vision, cataracts, depression, dermatitis, dizziness, hair loss, inflamed eyes, mouth lesions, nervousness, neurological symptoms numbness, loss of sensation, electric shock sensations, seizures, sensitivity to light, sleepiness, weakness Growth impairment, high cholesterol levels, increased incidence of cancer, pancreatic insufficiency
inability to secrete adequate amounts of digestive enzymes, immune impairment, liver impairment, male sterility Confusion, constipation, digestive problems, irritability, loss of appetite, memory loss, nervousness, numbness of hands and feet, pain sensitivity, poor coordination, weakness, alcoholism, dementia Acne, dry hair, fatigue, growth impairment, insomnia, hyperkeratosis, immune impairment, night blindness, weight loss Anemia, constipation, depression, dizziness, fatigue, intestinal disturbances, headaches, irritability, loss of vibration sensation, low stomach acid, mental disturbances, moodiness, mouth lesions, numbness, spinal cord degeneration, psychosis,epilepsy,ataxia,tinnitus, infertility Bleeding gums, depression, easy bruising, impaired wound healing, irritability, joint pains, loose teeth, malaise, tiredness Burning sensation in mouth, diarrhea, insomnia, myopia, neuvousness, osteomalacia, osteoporosis, rickets, scalp sweating Gait disturbances, poor reflexes, loss of
position sense, loss of vibration sense, shortened red blood cell life Bleeding disorders
30-250mg/d; neurotoxic above 500mg; suppresses lactation 150mg 10-50mg/d; toxic above 13 mg/day but is rapidly excreted
200-400ug/d selenomethionine; toxic 600ug/d 50-100mg/d; toxic 8g
5-10000 IU/d short term; limit to RDA in pregnancy 1-5g/d; no known toxic dose
Vitamin D
1-5 g/d; limited by gastritis, low Ca, Mg, G6PD, hemochromatosis 800-2000 IU/d; toxic at greater than 24000IU/d 100-1200 IU/d mixed tocopherols not alpha 100-500 ug/d 15-50mg/d picolinate; toxic 75mg/d causes Cu deficiency
Vitamin E
Vitamin K Zinc
Acne, amnesia, apathy, brittle nails, delayed maturity, depression, diarrhea, eczema, fatigue, growth impairment, hair loss, immune impairment, impotence, irritability, lethargy, loss of appetite, loss of sense of taste, low stomach acid, male infertility, impaired memory, night blindness, paranoia, white spots on nails, impaired healing Table provided by Julie Skapnik Johns
Hopkins School of Medicine Class of 2007
PROGRESSIVE MUSCLE RELAXATION SCRIPT Progressive muscle relaxation is a technique that involves tensing specific muscle groups and then relaxing them to create awareness of tension and relaxation It is termed progressive because it proceeds through all major muscle groups, relaxing them one at a time, and eventually leads to total muscle relaxation Instructions: Step 1 Assume a comfortable position You may lie down; loosen any tight clothing, close your eyes and be quiet Step 2 Assume a passive attitude Focus on yourself and on achieving relaxation in specific body muscles Tune out all other thoughts Step 3 Tense and relax each muscle group as follows: Forehead - Wrinkle your forehead, try to make your eyebrows touch your hairline for five seconds Relax Eyes and nose - Close your eyes as tightly as you can for five seconds Relax Lips, cheeks and jaw - Draw the centers of your mouth back and grimace for five seconds Relax Feel the warmth and
calmness in your face Hands - Extend your arms in front of you Clench your fists tightly for five seconds Relax Feel the warmth and calmness in your hands Forearms - Extend your arms out against an invisible wall and push forward with your hands for five seconds Relax Upper arms - Bend your elbows Tense your biceps for five seconds Relax Feel the tension leave your arms Shoulders - Shrug your shoulders up to your ears for five seconds Relax Back - Arch your back off the floor for five seconds Relax Feel the anxiety and tension disappearing Stomach - Tighten your stomach muscles for five seconds Relax Hips and buttocks - Tighten your hip and buttock muscles for five seconds Relax Thighs - Tighten your thigh muscles by pressing your legs together as tightly as you can for five seconds Relax Feet - Bend your ankles toward your body as far as you can for five seconds Relax Toes - Curl your toes as tightly as you can for five seconds Relax Step 4 Focus on any muscles which may
still be tense If any muscle remains tense, tighten and relax that specific muscle three or four times Step 5 Fix the feeling of relaxation in your mind Resolve to repeat the process again Remember, people respond differently to various activities Some feel pleasant or refreshed, and others feel calm and relaxed after an activity like this one Some people notice little change the first time, but with practice, their control increases - as well as the benefits If you practice this activity, your relaxation should increase Dennis SA, Kennedy R Techniques for Managing Stress PDF University of Arkansas Division of Agriculture NOTES
Source:amsa.org
