Integrative Medicine — Holistic Medicine — with Georgia Tetlow, MD

The following post was brought to us by the Mesothelioma Center

When the body has all of the necessary nutrients to work with, it can function at its most optimum level.

Unfortunately, many diets do not provide adequate vitamins and minerals. In the case of mesothelioma patients, appetite loss or difficulty keeping food down can also prevent the patient from getting proper nutrition from their meals. For these people, dietary supplements can be an easy way to get cancer-fighting vitamins into their system!

Even for people who eat a balanced, nutrient-dense diet, supplements can be a natural way of relieving unpleasant conditions associated with mesothelioma treatment. Certain supplements can be used to reduce a patient’s need for drugs that counteract side effects of therapy.

Some of the most beneficial supplements for mesothelioma patients include:

• Vitamin C – protects the watery parts of healthy cells from cancer-causing free radical damage
• Vitamin A – inhibits the development of cancerous tumors
• Vitamin E – stimulates the immune system; protects healthy cells from damage during radiation therapy
• Garlic – reduce the risk of post-treatment infections
• Ginger – curbs nausea
• Nutmeg – helps limit diarrhea during or after chemotherapy.

Although whole foods are the best sources of nutrients, quality dietary supplements do exist. When looking for a supplement, be sure to check for fresh, filler-free supplements that are labeled “USP” in accordance with the U.S. Pharmacopeia’s standards. Be sure to follow the outlined dosing guidelines and remember to take them on a regular basis to reap the maximum benefits.

Alternative Therapies for Mesothelioma

In addition to supplements, many patients ask their doctors for other natural therapies they can use as part of their mesothelioma treatment plan.

Like vitamins, some of these alternative therapies can improve the body’s own ability to fight off the cancer. Homeopathy, massage and acupuncture have been thought to stimulate the body’s natural healing functions, and some cancer centers even offer these as complements to their traditional treatments.

Other alternative therapies can relieve symptoms of mesothelioma without the use of pharmaceuticals. Yoga can help relieve pain while stimulating a decreased appetite. Meditation can help relieve cancer-related anxiety and chiropractic care can help with stiffness and poor mobility.

Whether supplements, alternative therapies or both peak your interest, be sure to discuss all new treatment approaches with your oncologist before implementing them into your life.

Author bio: Faith Franz is a writer for the Mesothelioma Center. She combines her interests in whole-body health and medical research to educate the mesothelioma community about the newest developments in cancer care.

What Is The Best Amount Of Vitamin D3 For A Breast Cancer Survivor?

In my clinic, the way I dose vitamin D depends sun exposure, individual absorption and current co-morbidities/medical history, as well as other factors. Let’s discuss the breast cancer survivor population. As a general rule, I target a vitamin D3 range around 50, which is the lower to middle range of the 30-100 ng/ml “normal range” listed on lab results. This is also the general target range suggested during my two year fellowship in Integrative Medicine at the University of Arizona–I graduated a few years back and already had an established private integrative medicine practice in Philadelphia. The medical community needs well-designed studies to assess the cost benefit analysis of lower versus higher vitamin D levels in the breast cancer survivor and other populations. It takes funding to do longitudinal studies that look at secondary prevention of breast cancer, especially when so many factors are involved and it is challenging to accurately attribute cause to this single factor. New studies address a multipronged approach and its benefits, rather than seeking to isolate one factor to assess its involvement.

The Nurse’s Health Study first established by Dr. Frank Speizer in 1976 and later by Dr. Walter Willett in 1989 revealed that women who take in more calcium are statistically less likely to develop breast cancer to begin with. It’s established that higher vitamin D levels correlate with higher calcium absorption…so an indirect conclusion might be made here. Keep in mind that this correlation relates to primary cancer prevention, not prevention of a recurrence. Also calcium and vitamins D levels may matter more or even most when women are growing and developing, and there’s much more to learn here—the role of vitamin D during human development for prevention of later illness.

The reason that vitamin D may play a role in secondary prevention of breast cancer is that vitamin D acts as a hormone that affects proper immune function, and the immune system surveils the body and, ideally, destroys and recycles precancerous cells so that they do not develop into cancer. Again, much more research is needed to understand vitamin D’s extraordinary role in this and many other physiological functions.

In terms of how much daily vitamin D is needed to get to a specific target range, that varies widely. People absorb and metabolize vitamin D very differently. Many primary doctors recommend 2,000IU daily dose for maintenance, which I would say in the low end of the spectrum, especially if levels need to be repleted, but just maintained. For those with hypovitaminosis D, or low vitamin D, I may dose as much as 10,000IU daily for differing amounts of time to replete the D level. Vitamins A, D, E and K are fat soluble and need to be monitored for adequate but not excess repletion, so you need to work with your doctor. I do measure a serum or ionized calcium if I am concerned that levels are too high (this is a rare occasion), because higher levels of vitamin D translate to increased calcium absorption.

As a clinical anecdote, many with autoimmune disorders such as rheumatoid arthritis notice that higher serum vitamin D levels translate to improvements in range of motion, morning stiffness, pain and other parameters. Of course more research is needed here, too.

The Institute of Medicine has guidelines for dosing and target levels, so please research their recommendations as well: http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/DRI-Values.aspx

I always individualize vitamin D dosing and target range recommendations, and watch and learn how my patients absorb and metabolize water vs. fat soluble vitamins, as well as food in general.

Take care,

Dr. Georgia

Georgia Tetlow, MD, FAAPMR practices integrative medicine and specializes in wellness, chronic illness and cancer recovery. In support of a whole person approach, she addresses how conventional medicine can be infused with evidence-based approaches from a wide range of traditions to achieve balance and health. Addressing body mind and spirit, she takes the time to listen, educate and empower you. Dr. Tetlow works with your treatment team, and your recovery plan is personalized to your needs to address prevention, tolerance of conventional therapies, and wellness, not just the absence of disease. Trained in “alternative medicine” such as mindfulness and mind body medicine, biological therapies including supplements, alternative medical systems, hands on therapy and energy medicine, she also practices functional medicine, a more holistic conventional approach to care. She looks forward to seeing you in her Ambler, PA office.

Polycystic ovary syndrome was originally described as a syndrome including amenorrhea (lack of menses), hirsutism (excess body hair), and obesity in association with enlarged polycystic ovaries. The classic definition of PCOS includes women who have irregular periods, do not ovulate and have hyperandrogenism (excess testosterone and DHEA-s). It is a condition in which there is an imbalance of female sex hormones. This hormone imbalance causes changes in the menstrual cycle, skin changes, cysts in the ovaries, difficulty getting pregnant, and is often associated with type 2 diabetes and increased risk of developing cardiovascular disease.

In a typical menstrual cycle, follicles develop in the ovaries. These follicles contain eggs, and once an egg is sufficiently mature to be released, it travels into the fallopian tubes and this is referred to as ovulation. Polycystic ovaries are much larger than normal because there are multiple undeveloped follicles which become follicular cysts, thereby creating polycystic (multiple cysts) ovaries.

PCOS occurs most commonly in women during their reproductive years and its estimated that up to 10% of all women have PCOS. There is uncertainty as to the actual cause of PCOS but these factors are likely involved: genetic predisposition, insulin resistance, obesity, and/or environmental chemical pollution.

PCOS is most commonly treated with oral contraceptives to suppress the excess androgens (testosterone) and Metformin to treat insulin resistance by making insulin more efficient. But these treatments don’t address the underlying issue, the medications merely control the symptoms associated with PCOS.

Dr. Tetlow works with women with PCOS to make dietary and lifestyle changes in addition to focused nutrient supplementation. The right nutrition can make a big difference for women with PCOS, including an organic, whole foods diet with limited amounts of sugar and processed foods. A regular exercise program (30-45 minutes daily) is crucial to aid weight loss and improve insulin sensitivity. Supplements that can further aid PCOS include chromium, a mineral that helps to stabilize blood sugar and Chaste Tree Berry which is a herbal product that encourages ovarian production of progesterone. Dr. Tetlow has successfully worked with many women with PCOS using an approach that supports long-term, optimal health.

Vitamin D, a fat-soluble vitamin, is essential for homeostasis. Vitamin D is considered a hormone since it meets the basic definition: it can be synthesized in the body, it has specific target tissues, and it doesn’t have to be supplied by the diet. Vitamin D is also responsible for maintaining normal blood levels of calcium and phosphorus which are vital for normal neurological function and bone growth. Vitamin D works in concert with other vitamins, minerals and hormones to promote optimal bone mineralization, and to meet many physiological needs, as outlined below.

There are two ingested forms of vitamin D — D3 and D2. Vitamin D3 (cholecalciferol) can be produced in the skin after exposure to ultraviolet-B (UVB) radiation from sunlight, or it can be supplied by the diet. Plants also produce a form of vitamin D called vitamin D2 (or ergocalciferol), which also has activity in people. Both vitamin D3 and D2 are used to fortify foods and dietary supplements in the US. Cholecalciferol (D3) is the preferred form of vitamin D as it can be easily used by the body and doesn’t require additional hydroxylation. Ergocalciferol (D2) is the form added to most functional foods, such as cereals and milk, but requires the additional hydroxylation step by the kidneys and is not as bioavailable. Evidence shows that cholecalciferol (D3) seems to boost blood levels of usable vitamin D for a longer period of time than ergocalciferol (D2), and that D2 is 33% less potent than D3 (Armas LA et al. 2004). D2 (ergocalciferol) is made from yeast, while D3 is made from lanolin or fish oil.

Immune system

There is considerable scientific evidence that 1,25(OH)2D has a variety of effects on immune system function that may enhance innate immunity as well as inhibit the development of autoimmunity (Holick, 2005). Vitamin D in the form of 1,25(OH)2D is a powerful immune system modulator.

Insulin secretion

Pancreatic cells that secrete insulin also express the VDR, or vitamin D receptor. Although the data are limited, clinical studies suggests that suboptimal vitamin D levels may have an adverse effect on insulin secretion and glucose tolerance in individuals with type 2 diabetes (Holick, 2005).

Blood pressure

Vitamin D is also thought to play a major role in blood pressure regulation. Krause et al. (Krause et al., 1998) reported that hypertensive subjects exposed to UVB and UVA rays from tanning beds experienced a significant increase in circulating vitamin D and a decrease in both systolic and diastolic blood pressure compared to individual exposed to only UVA rays.

Heart failure

In cardiovascular patients, deficiency in vitamin D has been linked with an increased risk for heart failure (Zittermann et al., 2003 ). Also, a high incidence of vitamin D deficiency has also been reported in patients with peripheral vascular disease. While it is not fully understood how vitamin D may protect against cardiovascular disease, it is possible that it may be secondary to the role that vitamin D plays in maintaining blood pressure. It is known that 1,25(OH)2D is potently down-regulates the blood pressure hormone renin in the kidneys (Holick, 2005). Additionally, atherosclerosis is considered an inflammatory disease, and vitamin D has been shown to relax smooth muscles in the vascular system (Weishaar & Simpson, 1987).

Deficiency

Insufficient vitamin D impairs absorption of calcium. Subsequently, the parathyroid glands increase their production of parathyroid hormone (PTH) to mobilize calcium from the skeleton in order to maintain normal serum ionized calcium levels. In cases of severe vitamin D deficiency, rapidly growing bones fail to mineralize, resulting in rickets. Although the growth-plates continue to enlarge, in the absence of bone mineralization, weight-bearing limbs can bow, resulting in skeletal abnormalities. Although the bones of adults are no longer growing, another medical condition, known as osteomalacia, can occur as a result of severe vitamin D deficiency.

Though the fortification of foods with vitamin D (primarily milk) has practically eradicated rickets, there are a large number of children and adults worldwide who are vitamin D insufficient but not to the degree that skeletal or calcium metabolism abnormalities are apparent.

Assessing Vitamin D Status

Serum 25(OH)D level is the best indicator of vitamin D deficiency and sufficiency, but the cutoff values are debated. Severe deficiency, associated with rickets and osteomalacia, is generally associated with serum 25(OH)D values less than 20-25 nmol/L (Heaney, 2003; Glerup et al., 2000). Although 50 nmol/L has been suggested as the low end of the normal range (Malabanan et al., 1998), more recent research suggests that PTH levels (Chapuy et al., 1997; Thomas et al., 1998) and calcium absorption are not optimized until serum 25(OH)D levels reach approximately 80 nmol/L (Heaney et al., 2003).

Food Sources

Very few foods are naturally rich in vitamin D, therefore fortified foods are the most common sources of vitamin D. Although milk is fortified with vitamin D, other dairy products produced from milk, such as cheese and ice cream, are typically not fortified with vitamin D and therefore contain small amounts. Commercially-prepared fortified breakfast cereals generally provide 10-15% of the Daily Value defined for vitamin D. There is also some vitamin D in eggs, organ meats, and certain fish including salmon, sardines, and herring. The following table provides a listing of foods that provide vitamin D in varying amounts.

Disease Prevention and Intervention

Osteoporosis

It is estimated that over 28 million adults in the United States have, or are at risk of developing low bone density and osteoporosis. Prevention and early intervention is paramount.

Osteoporosis is most often associated with inadequate calcium intake, however, a deficiency of vitamin D contributes to the development of osteoporosis due to inadequate calcium and phosphorus absorption. While rickets and osteomalacia are extreme examples of vitamin D deficiency, osteopororsis is an example of a long-term effect of vitamin D deficiency. Adequate storage levels of vitamin D help keep bones strong and may help prevent osteoporosis in older individuals, non-ambulatory individuals (those who have difficulty walking and exercising), post-menopausal women, and individuals on chronic steroid and antiepileptic therapies.

Sufficient vitamin D intake is also associated with a reduction in falls (Graafsman et al., 1996). Vitamin D supplementation for the prevention and management of osteoporosis is considered an effective public health benefits due to its low costs, excellent tolerance, and overall health benefits.

Cancer

Laboratory, animal, and epidemiologic evidence suggests that vitamin D may be protective against some cancers. Epidemiologic studies suggest that a higher dietary intake of calcium and vitamin D, and/or sunlight-induced vitamin D synthesis, can correlate with lower incidence of cancer. In fact, for over 60 years researchers have observed an inverse association between sun exposure and cancer mortality, however, it wasn’t until the late 1980s that Garland and colleagues found that the mortality rate associated with colon cancer was higher in the Northeastern US compared to southern states (Garland et al., 1985). A wealth of accumulated data reveals that the risk of developing and dying of breast, colon, esophageal, non-Hodgkin’s Lymphoma, ovarian, and prostate cancers is associated with living at higher latitudes, associated with a greater risk for vitamin D deficiency (Holick, 2005; Hanchette & Schwartz, 1992; Grant, 2002). A meta-analysis showed reduction of cancer risk by up to 50% (for colon, breast, prostate and ovarian cancer) with adequate vitamin D intake and levels (Garland CF et al. 2006).

Alzheimer’s disease

Alzheimer’s disease has been associated with an increased risk of hip fractures. This is likely linked to the fact that many Alzheimer’s patients are older, homebound, and exposed less to sunlight. With aging, less vitamin D is converted to its active form. One study, which included elderly women with Alzheimer’s disease, found that decreased bone mineral density was associated with a low intake of vitamin D and inadequate exposure to sunlight (Sato et al., 2005). However, with regular sunlight exposure and calcium supplements, bone mineral density increased by 2.7% and serum 25(OH)D levels increased from 24 nmol/L to 52 (Sato et al., 2005). The need for vitamin D supplementation should be part of an overall treatment plan for those with Alzheimer’s disease.

Autoimmune Conditions

Components of the immune system, including macrophages, monocytes, and T and B lymphocytes, also have a VDR, thereby allowing vitamin D to have an impact on regulating cytokine synthesis, monocyte maturation, macrophage activity, and more (Holick, 2005). The risk of developing Type 1 diabetes and multiple sclerosis (MS) was significantly reduced or prevented in animals receiving vitamin D. Reportedly, living at a latitude greater than 37° increases the risk of developing MS >100% during one’s lifetime (Holick, 2005). The risk for both MS and rheumatoid arthritis was decreased by ~40% in women taking a multi-vitamin supplement with as little as 400 I.U. of vitamin D (Holick, 2005). Other studies have shown a role for vitamin D in modulating the immune system via regulation of T helper cell and dendritic cell function, with reduced risk of multiple sclerosis and rheumatoid arthritis with adequate vitamin D intake (Munger KL et al. 2004; Cantorna MT, Mahon BD 2004).

For individuals who have made positive lifestyle changes and may no longer need continued chronic acid suppression, it can often be difficult to come off of PPIs since this can cause rebound hyperacidity even if the underlying condition has resolved. ¹  Symptoms of dyspepsia in ASYMPTOMATIC people given 40 mg of pentoprazole for 6 weeks tend to reveal rebound dyspepsia that lasts 10-14 days. ¹

Some individuals slowly taper off the PPI over 2-4 weeks (the higher the dose, the longer the taper). While the taper is being completed, they might consider some form of “bridge therapy” to reduce the symptoms of rebound hyperacidity.

1.   Encourage regular aerobic exercise
2.   Encourage a relaxation technique such as deep breathing (this enhances vagal stimulation, encouraging digestion and aids peristalsis.
3.   Acupuncture 1-2 times weekly. ²
4.   Add one or more of the following:

• Deglycyrrhizinated Licorice (DGL), 2-4 380 mg tablets before meals or Sucralfate (Carafate) 1 gm before meals.
• Slippery Elm, 1-2 tbsp of powdered root in water or 400-500 mg capsules or 5 ml of a tincture three to four times daily.
• A combination botanical product, Iberogast® (Clown’s mustard, German chamomile, angelica root, caraway, milk thistle, lemon balm, calendine, licorice root and peppermint leaf). 1 ml three times daily.³

If acid reflux returns, some individuals work with positive lifestyle changes, or introduce an H2-Blocker. If symptoms are still difficult to control, consideration can be given to adding the PPI back.

It is beneficial to avoid long-term acid suppression if possible since this can be associated with malabsorption of vitamin B12 and iron,⁴ increased risk of community acquired pneumonia, ⁵ hip^{6, 7} and spine^{8, 9} fracture, and C. diff diarrhea.¹⁰

References

1.     Niklasson A, Lindstrom L, Simren M, Lindberg G, Bjornsson E. Dyspeptic symptom development after discontinuation of a proton pump inhibitor: A double-blind placebo-controlled trial. Am J Gastroenterol. 2010; .

2.     Dickman R, Schiff E, Holland A, et al. Clinical trial: Acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn. Aliment Pharmacol Ther. 2007; 26(10):1333-1344.

3.     Melzer J, Rosch W, Reichling J, Brignoli R, Saller R. Meta-analysis: Phytotherapy of functional dyspepsia with the herbal drug preparation STW 5 (iberogast). Aliment Pharmacol Ther. 2004; 20(11-12):1279-1287.

4.     Jensen RT. Consequences of long-term proton pump blockade: Insights from studies of patients with gastrinomas. Basic Clin Pharmacol Toxicol. 2006; 98(1):4-19.

5.     Laheij RJ, Sturkenboom MC, Hassing RJ, Dieleman J, Stricker BH, Jansen JB. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA. 2004; 292(16):1955-1960.

6.     Corley DA, Kubo A, Zhao W, Quesenberry C. Proton pump inhibitors and histamine-2 receptor antagonists are associated with hip fractures among at-risk patients. Gastroenterology. 2010; 139(1):93-101.

7.     Gray SL, LaCroix AZ, Larson J, et al. Proton pump inhibitor use, hip fracture, and change in bone mineral density in postmenopausal women: Results from the women’s health initiative. Arch Intern Med. 2010; 170(9):765-771.

8.     Kwok CS, Yeong JK, Loke YK. Meta-analysis: Risk of fractures with acid-suppressing medication. Bone. 2010; .

9.     Insogna KL. The effect of proton pump-inhibiting drugs on mineral metabolism. Am J Gastroenterol. 2009; 104 Suppl 2:S2-4.

10.     Cunningham R, Dale B, Undy B, Gaunt N. Proton pump inhibitors as a risk factor for clostridium difficile diarrhoea. J Hosp Infect. 2003; 54(3):243-245.