Childhood & Adolescent Nutrition Alternative & Integrative Nutrition

255 Pages·2012·4.6 MB·English

Alternative/Integrative Nutrition C o n tinuing
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Alternative &
Childhood &
Integrative Nutrition
Adolescent Nutrition
5th edition • Revised May 2011
by Leslie K. Kay-Getzinger, ,
8th edition • Revised Marchm 2s01r0d
by Kala Shipley, ,
rd ld
Formerly Alternative & Complementary Nutrition
Accredited Continuing Professional Education Course
7950 Jones Branch Driv7e9,5 70t Jho Fneloso Brr, aMncchL eDarinv,e ,V 7Ath 2 F2lo1o0r,7 McLean, VA 22107
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Alternative &
Integrative Nutrition
Formerly Alternative & Complementary Nutrition
5th edition • Revised May 2011
by Leslie K. Kay-Getzinger, MS, RD
About the Author:
Following her conventional training and education to become
an RD in 1982, Leslie has specialized in holistic nutrition. As production manager
for a nutraceutical manufacturer, she traveled to China to observe the manufactur-
ing of traditional botanical medicines. She has worked with conventionally trained
and integrative medical practitioners, served on an ADA task force developing
Complementary and Alternative Medicine competencies for dietetic practitioners,
and held positions in the Dietitians in Integrative and Functional Medicine (DIFM)
Practice Group. She completed postgraduate training and certification in integra-
tive and functional medicine and botanical medicine, and has worked as adjunct
faculty at community, state and private colleges throughout Southern California.
Leslie currently works as a consultant. Education: Southern Illinois Univ. (BS, Food
and Nutrition; MS, Human Development.)
EXPIRATION DATE: Students of all professions must submit this course for credit no later than
July 31, 2016. Credit will not be awarded for this course after that date.
Course Code: RD64, CHES64, FIT64, AT64
This course approved for
RD, DTR ................12 CPEU
CDM ...........12 Clock Hours
CHES .....................12 CECH
ACE .........................1.0 CEC
BOC...........................10 CEU
ABMP........................10 CEU
NSCA........................0.8 CEU
ACSM.......................10 CEU
CFCS.........................10 PDU
Edited by: Dale Ames Kline, MS, RD, CNSC
Copyediting/proofreading: Rich Kline
© 1999-2011 OnCourse Learning Corporation
No part of this course may be reproduced, duplicated or copied in any way without the written
permission of the copyright holder. (See note on Page ii)
Alternative/Integrative Nutrition ii
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Alternative/Integrative Nutrition iii
Table of Contents
Page # Chapter
1 Introduction
5 Chapter One: Alternative and Integrative Medicine
Consumer demand for CAM • Alternative (whole) medical systems • Traditional Chinese medicine • Ay
urvedic medicine • Homeopathic medicine • Functional Medicine • Biologically-based therapies • Herbal
medicine • Energy therapies • The placebo effect • Manipulative and body-based methods • Mind-body
medicine • Mind-body and the immune system
21 Chapter Two: Consumer Use of Dietary Supplements
Consumer use of dietary supplements • Consumer motivation • Rationale for supplementation • Rethinking
recommended dietary allowances • Dietary reference intake • The American diet • Biomarkers • Trade and
Professional organizations
35 Chapter Three: Dietary Supplements in Health Promotion & Disease Prevention
Calcium and osteoporosis • Vitamin D • Folic acid: benefits • Folic acid intake and supplementation •
Nutrition and cancer • Nutrition and cardiovascular disease • Nutrition and eye disease: Age-related macular
degeneration (AMD) • Cataracts • Glaucoma • Nutrition and infectious disease • Economic impact of
supplementation
63 Chapter Four: Introduction to Herbs & Botanicals
Plants as pharmaceuticals • Herbal medicine research • Forms of herbal preparations • Standardization • Plant
residues and other contamination • Policy, profits, and politics
75 Chapter Five: Rational Phytotherapy: Clinical Applications
Therapeutic uses of herbal remedies
103 Chapter Six: How Nutrition Supplements are Made
Formulation issues • Selecting raw materials • Formula design/manufacturing • Excipients: binders, fillers,
coatings • Disintegration vs dissolution: what's the difference? • Colloidal minerals • Bioavailability and
mineral interactions • Calcium absorption and bioavailability • Bioavailability: Selenium, Zinc • Natural vs
synthetic, is there a difference?
119 Chapter Seven: Understanding Supplement Regulations & Evaluating a Dietary Supplement
Dietary supplement legislation history • Label requirements for botanicals • Health versus therapeutic claims
Labeling regulations • Comparing 'Nutrition Facts' and 'Supplement Facts' labels • Quality issues •
Contamination • US regulatory process • Good manufacturing practices • FDA recalls • Adverse events
reporting • Quality assurance and certification programs • The European model • Toward stricter regulation

139 Chapter Eight: Evaluating a Supplement
Evaluating a supplement • Questions to ask supplement manufacturer • Evaluating probiotics
147 Chapter Nine: Supplements & Athletic Performance
Ergogenic aids • Supplement use among collage athletes • Recall • Liquid meals • Sports drinks • Risk/
benefit of ergogenic supplements
165 Chapter Ten: Specialty Dietary Supplements
Alpha-Lipoic Acid (ALA) • Bee Pollen (royal jelly)• Blue-green algae • Boron • Carnitine • Chitosan (Chitin) •
Choline • Chondroitin sulfate • CoQ10 • Conjugated Linoleic Acid (CLA)• DHEA• Fatty Acids • Evening
primrose oil • Flaxseed • EPA • Gamma oryzanol • Glandulars • Glucosamine • Glutamine • Glutathione
(GSH) • Green tea extract • Inositol • Melatonin • Methylsulfonylmethane (MSM) • N-Acetylcysteine (NAC)
Probiotics • Prebiotics • Inulin
195 Chapter Eleven: Foods as Medicine
Terminology • Diet and cancer • Nutraceuticals/Zooceuticals • Phytoestrogens in food
221 Chapter Twelve: Role & Responsibilities of Practitioners
CAM education and training for health professionals • Risk • Supplement sales by practitioners • Patients'
right to choose
227 Appendices
244 Examination
Alternative/Integrative Nutrition iv
Learning Objectives
Upon successful completion of this course, the student will be able to:
1. Describe the prevalence of consumer use of alternative medicine.
2. Describe the prevalence of consumer use of dietary supplements including herbs.
3. List the most popular dietary supplements used by Americans.
4. Explain the appropriate clinical use of dietary supplements in the treatment and pre-
vention of certain disease conditions.
5. Describe the therapeutic uses for the most commonly used herbal supplements.
6. List factors affecting the potency of herbal formulas.
7. Provide examples of harmful substances typically found in contaminated products.
8. Recognize an acceptable definition for structure/function claims as described by the
FDA.
9. List the names of herbs identified with “adaptogenic properties”.
10. Identify excipients associated with manufacturing of dietary supplement tablets.
11. Describe the implications of DSHEA of 1994 and current legislation regarding sup-
plements, label claims, and manufacturing practices as mandated by the FDA.
12. Explain the safety and risks from taking dietary supplements.
13. Describe some of the benefits of using probiotics for certain conditions.
14. Identify valid resources for checking efficacy and safety of nutritional supplements.
15. Explain how to read a dietary supplement label.
16. Describe counseling practices specific to patients who prefer alternative treatments.
17. Identify credible sources of information regarding alternative nutrition therapies.
Alternative/Integrative Nutrition 1
Introduction
C
omplementary and alternative medicine (CAM) encompasses a broad spectrum
of practices and beliefs, many of which include the use of functional lab tests, special
diets and nutritional supplements, including herbs. The title of this coursebook has been
changed to reflect terminology that better represents the approaches outlined in subse-
quent chapters.
The word Integrative includes patient-centered care, emphasizes the therapeutic
relationship between caregiver and patient and uses therapeutic approaches originating
from conventional and alternative medicine. This course focuses on nutritional supple-
ments and diets utilized in alternative and integrative medicine practice.
The National Center for Complementary and Alternative Medicine (NCCAM), cur-
rently subdivides CAM modalities into five categories:
• Alternative medical systems, which includes traditional Chinese medicine,
Ayurvedic medicine, homeopathy, and naturopathy;
• Mind-body interventions;
• Biologically based treatments, which includes specialized diets, herbal prod-
ucts, minerals, hormones, and biologicals. Specialized diets include vegan,
macrobiotic, organic, vegetarian, low glycemic, gluten-free, dairy-free, GMO-free,
and elimination diets, as well as diets which increase or add specific functional
foods to reduce disease risk or promote health.
• Manipulative and body-based methods; and
• Energy therapies
According to Dejun Su, a sociologist at the University of Texas, the rising cost of
health care is outpacing inflation and salaries, possibly contributing to increasing CAM
use (Su, 2011). A survey of 31,044 adults conducted by NCCAM and the National Center
for Health Statistics indicated that 62 percent of the population used some form of CAM.
Alternative/Integrative Nutrition 2
According to a 2004 report by the Centers for Disease Control and Prevention
(CDC) (Barnes, 2004), 36 percent of US adults had used some form of CAM, including
natural products and diet-based therapies, in the preceding 12 months. Some reports
and surveys indicate even higher usage of dietary supplements. Other researchers put
the figure nearer 40 percent, with the rate being higher among patients with serious ill-
nesses, such as cancer (Bell, 2010; Wargovich, 2010; Paisley, 2011).
Biologically based therapies are the second most frequently used form of CAM and
include the use of special diets and various forms of dietary supplements. The survey in-
dicated that most people used CAM to treat themselves, as only 12 percent of the survey
respondents sought care from a licensed CAM practitioner (CDC, 2004).
Earlier studies on the prevalence of alternative medicine served as a wake-up call to
the US healthcare industry and confirmed that a “cart-before-the-horse” situation existed
(in terms of safety and efficacy) regarding CAM therapies and products. That is, wide-
spread use occurred before complete scientific evidence was available.
Strategies have been implemented to improve research policies, practice guidelines
for practitioners and consumer protection mechanisms to ensure access to safe and effi-
cacious CAM therapies. However, major roadblocks to creating such policies and guide-
lines for CAM therapies make that task difficult. Some problems are:
• clinical significance for some CAM treatments may be lacking or are preliminary;
• no nationally recognized credentialing agency exists for herbal therapies;
• no firm agreement about how integrative medicine should be included in core
competencies at medical or allied health professional schools;
• credentialing of CAM practitioners varies from state to state;
• insurance benefits for CAM aren’t consistent nationally; and
• quality assurance standards for dietary supplements are not as stringent as for
pharmaceuticals.

However, major changes have taken place in the public and private sectors to
address these policy issue challenges. NCCAM’s mission is to conduct and support
research, train CAM researchers and disseminate information about CAM safety and effi-
cacy to the public and health professionals. NCCAM is one of the 27 institutes and cen-
ters that make up the National Institutes of Health (NIH) and supports research projects
and research training on CAM.
Examples of NCCAM-funded research for 2010 related to nutrition include:
• Clinical trial to test S-adenosyl-L-methionine (SAMe) for the treatment of depres-
sion in patients with Parkinson’s disease;
• research center grants to support basic and clinical research on botanicals;
• a clinical center for phase I/II trials of silymarin in chronic liver disease;
• colon cancer chemoprevention by grape seed extract;
• mechanisms underlying sex-specific effects of creatine on depression;
• rhodiola rosea therapy of major depressive disorder; and
• investigations of botanicals on food intake, satiety, weight loss, and oxidative.
Alternative/Integrative Nutrition 3
Medical institutions, practitioners and consumers are not necessarily waiting for
evidence-based results. Some forms of CAM are currently incorporated into services
provided by hospitals, are covered by health maintenance organizations, are delivered in
conventional medical practitioners’ offices, and are taught in medical, nursing, and other
health professions schools. Integrative medicine centers continue to increase across the
country; according to the American Hospital Association, survey results from 6,439 US
hospitals indicate that the percentage of hospitals that offer complementary therapies has
increased to 37 percent from 26 percent in 2005 (Ananth, 2008).
For conventional practitioners, one deterrent to CAM therapies is a lack of consistent
quality control standards for dietary supplements, especially herbs. Highly publicized
reports of dietary supplements failing to meet label claims is thought to have lowered
consumer confidence by contributing significantly to the decline in the growth of dietary
supplements.
To improve industry standards and public image, organizations associated with the
dietary supplement industry have been collaborating to develop appropriate standard-
ized test methods and product standards, improve quality assurance, help manufacturers
meet label claims, and boost consumer confidence.
The US Pharmacopeia, Natural Products Association, NSF International and
ConsumerLab.com have established quality standards and certification programs for
supplements, and provide seals or marks for labels indicating compliance (www.supple-
mentquality.com). The herbal industry and other trade organizations have partnered to
begin the process of developing a methods-validation program to authenticate analytical
methods for botanicals. Most significantly, the industry is proactive in regulating itself,
even blowing the whistle on fellow manufacturers with shoddy products or outrageous
label claims, especially relating to weight loss.
Progress also continues regarding implementing the good manufacturing practices
(GMP) standards specific for dietary supplements. In 2007, the FDA published GMP that
include requirements for establishing quality control procedures, designing and con-
structing manufacturing plants, and testing ingredients and finished products.
It also includes requirements for record-keeping and handling consumer complaints.
The FDA rules help prevent supplements from containing the wrong type or amount of
ingredients, or contamination with bacteria, pesticides, glass and heavy metals. The GMP
also help ensure products are properly labeled and packaged. Since June 2010, all dietary
supplement manufacturers are required to be compliant with GMP standards.
Credentialing regulations vary from state to state, as does education programs. Dr.
Andrew Weil’s first comprehensive curriculum in Integrative Medicine opened in 1994
and continues to attract health practitioners, serving as the nation’s first clinical fellow-
ship in Integrative Medicine and an educational model for physicians (www.drweil.org).
Graduates of the program believe that integrative medicine may be a potential solution
to the American healthcare crisis (Maizes, 2009).
Alternative/Integrative Nutrition 4
The public demand for information about the use of nutritional supplements, the
growing body of evidence supporting the use of supplements in disease prevention and
treatment, and the increasing popularity of supplements, makes it imperative for nutri-
tion and fitness practitioners to learn more about the safety, efficacy and appropriate use
of these products.
We hope this course will help practitioners properly guide and educate the public
by exploring this phenomenon from a non-judgmental yet evidence-based perspective.
Integrative medicine has the potential to accentuate, complement and enhance
what we commonly see as mainstream medical care. Perhaps the day will come when
complete agreement on just what works and what does not will eliminate the need for
classifications like “alternative.”
In the meantime, we’ll all continue to read, observe, collaborate and learn.

RefeRences
__________Institutes of Medicine of the National Academies. Complementary and Alternative Medicine in
the United States. Washington DC: The National Academies Press (2005).
Ananth, Sita. Health Forum Complementary and Alternative Medicine Survey Summary Report by Health
Forum, a subsidiary of the American Hospital Association (AHA). www.healthforumonlinestore.
com. Accessed March 24, 2011.
__________ Complementary and alternative medicine use among adults: United States, 2002. CDC Advance
Data Report #343. May 27, 2004.
Barnes PM, Powell-Griner E, McFann K, Nahin RL. 2004. Complementary and alternative medicine
use among adults: United States. Vital Health Stat 343:1–19, 2002 (advance data).
Maizes V, Rakel D, Niemiec C. Integrative medicine and patient-centered care. Explore (NY). 2009 Sep-
Oct;5(5):277-89.
Maizes V, Rakel D, et al. Integrative medicine and patient-centered care. Explore (NY), Sep-
Oct;5(5):277-89, 2009.
Paisley MA, Kang TI, Insogna IG, et al. Complementary and alternative therapy use in pediatric oncol-
ogy patients with failure of frontline chemotherapy. Pediatr Blood Cancer, Feb 25. doi: 10.1002/
pbc.22939, 2011. [Epub ahead of print]
Su D, Li L. Trends in the use of complementary and alternative medicine in the United States: 2002-
2007. J Health Care Poor Underserved, 22(1):296-310, 2001.
Wolsko PM, Eisenberg DM, Davis RB, et al. Insurance coverage, medical conditions, and visits to alter-
native medicine providers: Results of a national survey. Arch Intern Med 162(3):281–287, 2002.
Wootton JC, Sparber A. Surveys of complementary and alternative medicine: Part I. General trends
and demographic groups. J Altern Complement Med 7(2):195-208, 2001.
Wargovich MJ, Morris J, Brown V, et al. Nutraceutical use in late-stage cancer. Cancer Metastasis Rev,
Sep;29(3):503-10, 2010.
Alternative/Integrative Nutrition 5
Chapter One:
Alternative and
Integrative Medicine
A
merica’s continuing healthcare crisis is fueling debate over how to improve our
citizens’ health, and to what degree preventive complementary or alternative medicine
(CAM) should be part of the solution. In order to assess the role of alternative and inte-
grative therapies in health care, we need to discuss and define some of the terms used in
this course and in the professional and lay literature today.
• Complementary and alternative medicine (CAM) includes therapies not yet consid-
ered mainstream and, therefore, not normally offered by conventional medical person-
nel. They include, but are not limited to nutrition, herbal medicine, spinal manipulation,
bodywork medicine, “energy medicine,” spiritual attunement, relaxation training/stress
management, biofeedback and acupuncture. The list of what is considered “comple-
mentary” or “alternative” therapy is constantly changing; as they demonstrate efficacy
and safety, therapies become part of conventional medicine. CAM is a broad domain of
resources that encompasses health systems, modalities, and practices and their accompa-
nying theories and beliefs, other than those intrinsic to the dominant health system of a
particular society or culture in a given historical period.
The National Center for Complementary and Alternative Medicine (NCCAM), un-
der the National Institutes of Health (NIH), defines CAM as “..a group of diverse medi-
cal and health care systems, practices, and products that are not presently considered
part of conventional medicine” (IOM, 2005).
The chart on the next page lists some general characteristics of CAM.
• Integrative Medicine (IM), is a term used to represent the importance of the rela-
tionship between caregiver and patient. IM focuses on the whole person, and makes
use of evidenced-based therapeutic approaches; it starts with the conventional western
model of disease, but encompasses other healing methods and systems of treatment. The
term is often used interchangeably with CAM.