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Physicians remember: Mainstream-medicine haters are people tooMar 27, 2012 12:37 EDT
Dr Sara Warber of the University of Michigan, who specializes in integrative medicine, and Dr Dean Ornish, author of six best sellers on wellness, carried the remainder of the program on vitamins and supplements. As elite wellness experts, they handily cut through the skepticism, negativity, and charlatanistic gray zones that dance amid the neon world of alternative medicine.
Dr Warber began by defining integrative medicine as a practice that "reaffirms the relationship between the practitioner and the patient [and] is informed by evidence and makes use of all appropriate therapeutic approaches to achieve optimal health and healing . . . encompassing spirit, heart, mind, and body—the relational and emotional heart," she further explained.
Dr Warber presented an interesting case report of a 57-year-old female smoker with dyslipidemia, hypertension, and a family history of stroke and heart attack. She was referred by her primary-care physician because she declined mainstream medications to approach her risk-factor profile. Her diet was excellent, and although she claimed to exercise regularly, "she only exercised one day per week." Her BMI was 26—"that's a little over weight" she explained—"and her cholesterol was 260, HDL 45, and LDL 190. So, what to do with this patient?" Dr Warber asked, before venturing into some positive benefits of alternative therapies.
Making the point that smoking cessation delivers the biggest bang for the buck in the world of risk reduction, she always discusses the options of counseling, nicotine replacement, acupuncture, hypnosis, autogenic training, and even the mainstream option of antidepressants. "48% of patients prefer physician-directed counseling for smoking cessation and 35% prefer nicotine replacement; the remainder prefers acupuncture, hypnosis, or autogenic training, otherwise referred to as biofeedback." With regard to alternative options for blood-pressure control, she compared the 12- to 16-mm-Hg drop with pharmaceuticals with biofeedback, which can garner a 14/9 systolic/diastolic drop in blood pressure. Biofeedback requires the utilization of a device that directs controlled breathing at a rate of 10 breaths per minute or less. It "plays a little melody that helps to synchronize breathing," she said. "Micronutrients such as calcium supplementation in randomized controlled trials garner a 2.2-mm Hg drop in systolic BP. Magnesium, although [it has no impact] on systolic blood pressure, effects a 2.2-mm-Hg drop in diastolic numbers," she explained. Arginine, which she deems a "semiessential" amino, is a precursor to nitrous oxide, and at doses of 18 to 20 g per day in divided doses "has been associated with a 5.29/2.6-mm-Hg drop in systolic/diastolic pressure in a meta-analyses," Dr Warber explained." Co-Q 10 appears to reduce peripheral vascular resistance at a dose of 100 to 120 mg/day or 60 mg bid" and in a randomized controlled trial was associated with systolic reductions of up to 11 mm Hg. Although there are no adverse effects of Co-Q 10 reported in trials," there are negative interactions with warfarin" as alluded to in Dr Cooper-DeHoff's presentation, with significant reductions in INR. Fish-oil utilization at a dose of 3 g per day garners an up to 4.5-mm-Hg reduction in systolic pressure. "Adverse side effects such as belching, bad breath, a fishy aftertaste, and abdominal pain" are some of the downsides, points out Dr Warber. She also adds a specific red flag for warfarin users due to the known antiplatelet effects of fish oil.
Dr Warber then ventured into the world of lipids, stating that although statins are proven to be beneficial in secondary prevention, "Their role is not so clear for primary prevention." She alluded to stanols, which are "highly saturated derivatives of sterols that do not have to be taken with a meal." Two- to three-gram doses per day have been associated with an 11% reduction in cholesterol vs a 2.3% reduction seen with placebo. "My patients love Benecol chews," Dr Warber stated, a product that contains stanols at a cost of around $28 for 120 chews, with a recommended dose by product instruction of two to four chews per day. "Policosanol at a dose of 5 to 40 mg per day garners a 23% reduction in LDL cholesterol," she adds, "but studies conducted outside of Cuba demonstrated no effect at all." I felt a strong surge of caution here, because we have learned a hard lesson in mainstream medicine—that just because we are able to slide the cholesterol numbers into the normal range, with some entities like niacin and ezetimibe, their benefit remains to be proven, and in some realms, there are concerns about the possibility of harm with ezetimibe.
So, what did Dr. Warber do for her patient? She encouraged spiritual engagement, the exploration of her life's purpose, encouraged activities that promote good self-esteem, and suggested journaling for emotional expression. She encouraged healthy relationships, engaging in yoga or tai chi for 30 to 60 minutes per day, a diet of eight to 10 servings of fruits and veggies per day, fish oil or cold-water fish, and soy nuts. She counseled regarding smoking cessation, instructed relaxation techniques for BP lowering, and directed her to consider arginine, Co-Q 10, and plant stanols. It remains to be seen as to how these treatments affect the patient's blood pressure and lipid numbers, but the point is that a patient who was otherwise unwilling to consider mainstream medicine can still receive huge benefit from exercise and smoking cessation. It removed the barrier that stood between patient and physician and fostered an environment of consideration and possibilities.
One audience participant was not so convinced. "This isn't primary prevention as far as I'm concerned, this is secondary prevention," he said. "She could benefit from cholesterol-lowering medications and you might consider a calcium score." But he missed the point that she isn't willing to consider those things. Although we have pharmaceuticals that are known to reduce her risk of death, stroke, and heart attack, physicians are still bound to offer help to those who are unwilling to use them. We must somehow try to muster some understanding for patients who are okay with the most lethal of all entities in the world of cardiovascular risk—smoking and sedentary lifestyle—and who are afraid, no matter how illogical or ridiculous their ideas may seem to us, of mainstream solutions. We must try to find a common ground from which to start a conversation. Skeptical patients take more work, require more time, and can be very frustrating to deal with, but they deserve our time and our efforts; after all, as healers, we must never forget that mainstream-medicine haters, as our brothers and our sisters, are people too.
Dr Dean Ornish stepped to the microphone next.