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Data Are No Longer Being Delivered A busy primary caregiver is not able to do as much research and reading as he or she would like buy fluconazole 200 mg cheap antifungal foot spray. Often buy fluconazole 200mg without a prescription xen fungus, new and interesting information is drawn to his or her attention by the marketing and sales staff of pharmaceutical compa- nies fluconazole 150 mg with visa fungus gnats rockwool. With rare examples order 150mg fluconazole free shipping fungi phylum, the counterpart of the pharmaceutical company, the vitamin company, generates a much larger proportion of its revenue from sales to the general public. The vitamin company’s marketing budget may not include detailing health care professionals. Vitamins and Minerals Are Not Patentable The hundreds of millions of dollars invested by a pharmaceutical company in research and development of a new drug can be recouped, because novel Chapter 5 / Supplements: Principles and Practice 105 substances can be patent-protected. A vitamin company has no incentive to invest in research for a widely available substance, because there is no safe- guard for the investment. The margin on a natural substance is much smaller than that on a pharmaceutical agent, because the competitive activity in the complementary health industry brings prices down. Although therapeutic claims for natural substances can be researched, patented, and registered (e. The next product on the shelf could also con- tain substance X, and the consumer’s buying decision would likely not rest on the claim. Individual Nature of Treatments In complementary medicine, the skill of the clinician and the suitability of his or her tools are paramount. In contrast to orthodox medicine, it is often simply not appropriate to give a large group of people exactly the same reg- imen to prevent or treat an illness. The decisions of the primary caregiver in complementary medicine are often more complex; for example, exactly how much of this substance is appropriate? Is there something about this patient’s physiology that requires a different substance all together? Will success be influenced by diet, stress level, sleep pattern, or other lifestyle factors? The one-size-fits-all stan- dard double-blind, placebo-controlled trial is not always the most appropri- ate means of providing good information about complementary medicines. The mineral ascorbates are not acids and are more suitable than ascorbic acid for subjects with sensitive stomachs and as chewable prepara- tions for children. Bioflavonoids Bioflavonoids are often considered with vitamin C, but they have a wider range of variations and indications than is often realized. Some examples of bioflavonoids are: 106 Part One / Principles of Nutritional Medicine ● Rutin, hesperidin, and quercetin. These include catechins, and oligomeric proanthocyanidins, which are pairs and triples (dimers and trimers) of catechin, and tannins, which are quadruples (tetramers) of catechins. Flavanols are found in grape seeds, tea, and pine bark, among other sources; and indications for use include antioxidant effects, hypoxia, inflammation, and ischemia. Anthocyanosides are used in ophthalmology and in the treatment of altered microcirculation and peripheral venous insufficiency, among other indications. Vitamin B Complex The vitamin B complex—comprising thiamin, riboflavin, niacin, pyridoxine, pantothenic acid, folic acid, biotin, and cyanocobalamin and the factors choline, inositol, and para-aminobenzoic acid—is also found in various forms. Controversially used in nonorthodox cancer therapies, laetrile is not considered part of the B complex. Although the use of the term international units was technically abandoned in 1981 in the ninth edition of the Recommended Dietary Allowances, it is still used in practice. Rather than weight, international units express the amount of work that a vitamin will perform. It is helpful to think of international units as expressing the distance a car will travel, whereas milligrams express the amount of gas in the tank. Natural vitamin E consists of one stereoisomer, which is highly Chapter 5 / Supplements: Principles and Practice 107 bioavailable. Because the d-form has a higher biopo- tency, the amounts required when given by weight vary for the same strength. This has been already included in the calculation to convert mil- ligrams to international units: the ratio is currently accepted as being 1. The difficulty lies in the uncertain conver- sion ratio, which can differ according to biochemical individuality, type and amount of fiber in the diet, and current vitamin A status, among other vari- ables. This binding to another substance, often an amino acid, makes the mineral more like a normal foodstuff. There are some specific rules about mineral absorption; for example, calcium citrate is about 25% better absorbed than calcium carbonate. Even in seemingly identical complexes such as mag- nesium oxide, there are light and heavy variations that alter the amount of available magnesium. There are many types, and it is important to be clear about their specific functions. Omega-6 fatty acid is generally supplied as evening primrose oil, a source of γ-linolenic acid. Evening primrose oil is commonly used to alleviate skin disorders and premenstrual syndrome, but other sources of ω-6 fatty acids include black currant seed oil and borage oil. However, for vegetarians, α-linolenic acid from flaxseed oil may be the only option. If this information is not on the label, the supplement is not necessarily reli- able. Standardized Versus Non-standardized Herbs Supporters of standardized herbs argue that guaranteeing the amount of a marker chemical provides assurance that the herb is of defined strength and quality. If the marker substance used is the active ingredient, the actual ther- apeutic potency of the herb is being controlled. It enables more accurate dos- ing, results that are more consistent, and a greater potential for scientific justification of herbal medicine. In fact, some herbal medicines, such as Ginkgo biloba leaf, have no history of traditional use. Those who disapprove of the use of standardized herbs argue that herbal medicine is not like conventional drug therapy and that there are many indi- vidual phytochemicals in the herb that exert a therapeutic effect. Standardizing the amount of a market chemical may have no relevance to therapeutic outcomes, because standardization does not guarantee stan- dardization of all phytochemicals—or even preservation of all of the herb’s relevant phytochemicals. Practitioners of traditional herbal medicine use a non-standardized extract, and they argue that standardized herbs are closer to drug therapy than herbal medicine. The rationale is that if disintegration takes place in less than 30 minutes in water, the time required would be considerably shorter in stom- ach acid. Often it is assumed that the use of the disks limits the amount of movement of the tablets to make disintegration more difficult; but when the disks are removed, disintegration times increase markedly. In a comparison of vitamin C tablets with mean disintegration times ranging from 9 to 120 minutes, it was demonstrated that tablets with a mean dis- integration time of 60 minutes had the highest bioavailability. These 110 Part One / Principles of Nutritional Medicine tablets would fail to meet the current United States Pharmacopeia requirement. It has been suggested that for a relatively unstable substance such as vitamin C, a formulation that is released more slowly would make a larger amount physiologically available. Although it is commonly believed that tablets are harder to digest, one indicator of digestion is disintegration time.

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On the Chapter 19 / Chronic Fatigue Syndrome 273 other hand generic fluconazole 200mg with amex antifungal nasal wash, treatment with some deficient nutrients discount fluconazole 50 mg without a prescription antifungal oral medication side effects, for example discount fluconazole 200mg otc antifungal for nails, essential fatty acids order 150mg fluconazole otc fungus killing plants, has more unpredictable results. Herbs that are tonics help to revitalize the patient and correct immune function (e. No stud- ies to support the use of ginseng, astragalus, licorice, echinacea, or St. Graham J: Chronic fatigue syndrome—a review, J Aust Coll Nutr Env Med 20: 19-28, 2001. Diefendorf D, Healey J, Kalyn W, editors: The healing power of vitamins, minerals and herbs, Surry Hills, Australia, 2000, Readers Digest. Developed Western nations have a higher incidence of colon cancer than Eastern and underdeveloped countries. The Western diet is associated with higher levels of fecal cholesterol, bile acids, and peroxidized fats. In colon cancer, constipation predominates, pain is colicky in nature, and patients often have anemia caused by occult blood loss. In rectal cancer, diarrhea is more common, tenesmus is prevalent, and the stool is often blood-stained. Consumption of fiber may reduce the risk of colon can- cer because it has all of these effects. Although no increased risk has been identified for the cis-form of the fatty acids, results of a case-control study confirmed that trans-fatty acids are car- cinogenic. The level of trans-fatty acids consumed had no influence on the risk of colon cancer in women who were estrogen-positive. Laboratory studies suggest that the enhancement of colon cell proliferation and carcinogenesis by a high-fat diet may be mediated through elevated serum leptin levels. Although this may be linked to an intake of animal fat, it may also be explained by the fact that red meat is a rich source of heme. Animal experiments showed that dietary heme increased colonic mucosal exposure to luminal irritants and enhanced proliferation of colonic epithelium. Although high levels of physical activity had the strongest inverse relationship, in a study that confirmed different lifestyle patterns have age-specific and tumor site–specific associations, a high intake of calcium was found to reduce the risk of colon cancer. A randomized study of patients with stage 1 or stage 2 colon cancer or adenomatous polyps suggested that 9 g of ω-3 fatty acid daily may be a useful chemopreventive agent in some cases. La Vecchia C: Mediterranean epidemiological evidence on tomatoes and the prevention of digestive-tract cancers. Liu Z, Uesaka T, Watanabe H, et al: High fat diet enhances colonic cell proliferation and carcinogenesis in rats by elevating serum leptin, Int J Oncol 19:1009-14, 2001. Schatzkin A, Lanza E, Corle D, et al: Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas, N Engl J Med 342:1149-55, 2000. Prinz-Langenohl R, Fohr I, Pietrzik K: Beneficial role for folate in the prevention of colorectal and breast cancer, Eur J Nutr 40:98-105, 2001. Pappalardo G, Guadalaxara A, Maiani G, et al: Antioxidant agents and colorectal carcinogenesis: role of beta-carotene, vitamin E and vitamin C, Tumori 82:6-11, 1996. Fukuda K, Hibiya Y, Mutoh M, et al: Inhibition by berberine of cyclooxygenase- 2 transcriptional activity in human colon cancer cells, J Ethnopharmacol 66: 227-33, 1999. Analysis of a cohort of smokers from the Alpha-Tocopherol Beta- Carotene Cancer Prevention Study showed that neither administration of dietary vitamins C and E and beta-carotene nor supplementation with vita- min E (50 mg/day) and beta-carotene (20 mg/day) had any meaningful association with the incidence of the common cold. Analysis of 23 studies suggested that vitamin C in daily doses of two or more grams was effective in managing the common cold. A randomized, double- blind, placebo-controlled trial demonstrated that zinc lozenges reduced the duration and severity of cold symptoms, especially cough. However, another randomized, double-blind, placebo-controlled clinical trial suggested that zinc gluconate lozenges reduced the duration of symp- toms by 42%. Successful therapy seemed most likely when the intervention was started within 48 hours and lozenges were sucked every 2 hours while subjects were awake. Perhaps the situation is best summarized by the Cochrane Project systematic review in which it was concluded that evidence of the effect of zinc lozenges for treating the common cold remains inconclusive. Furthermore, existing literature suggests that echinacea should be used as a treatment for illness, not as a means of prevention. A randomized, controlled trial showed that volunteers taking an allicin-containing garlic supplement (one capsule daily) were less likely to contract a cold and recovered faster if they were infected. For a sore throat, topical kava for its anesthetic effect and licorice for its soothing anti-inflammatory effect are useful. Hemila H, Kaprio J, Albanes D, et al: Vitamin C, vitamin E, and beta-carotene in relation to common cold incidence in male smokers, Epidemiology 13:32-7, 2002. Hemila H: Vitamin C supplementation and common cold symptoms: factors affecting the magnitude of the benefit, Med Hypotheses 52:171-8, 1999. A randomized, double-blind, placebo-controlled trial, Ann Intern Med 133:245-52, 2000. Zinc lozenges reduce the duration of common cold symptoms, Nutr Rev 55:82-5, 1997. Linde K, ter Riet G, Hondras M, et al: Systematic reviews of complementary therapies—an annotated bibliography. Henneicke-von Zepelin H, Hentschel C, Schnitker J, et al: Efficacy and safety of a fixed combination phytomedicine in the treatment of the common cold (acute viral respiratory tract infection): results of a randomised, double blind, placebo controlled, multicentre study, Curr Med Res Opin 15:214-27, 1999. Josling P: Preventing the common cold with a garlic supplement: a double- blind, placebo-controlled survey, Adv Ther 18:189-93, 2001. Mills S, Bone K: Principles and practice of phytotherapy, Edinburgh, 2000, Churchill Livingstone. It is character- ized by despondency, a lack of motivation, poor self-esteem, sleep distur- bance, and mental and physical slowness. Masked depression presents as flatness of mood, loss of interest, avoidance of people, lethargy, an inabil- ity to cope with stress, and pervasive anxiety. Increasing the cerebral level of serotonin and/or norepinephrine has an antidepressant effect. Effective antidepressants, such as the tricyclics and monoamine oxidase inhibitors, raise the concentration of the amines at the postsynaptic level. A frequent finding in endogenous depression is suppression of the normal hypothalamic-pituitary-adrenal axis characterized by hypersecretion of 285 286 Part Two / Disease Management corticotropin-releasing hormone, hypersensitivity of the adrenal cortex to corticotropin, and increased cortisol levels. Excess cortisol activates the enzyme tryptophan pyrrolase, shunting tryptophan away from the sero- tonin pathway into niacin production. Turkey, salmon, and milk are rich sources of tryptophan and may lighten depression. Some people who have started a caffeine-free and sugar-free diet report feeling less depressed, moody, and tired. In fact, depression may be one of the earliest signs of an incipient min- eral deficiency. Depression is also associated with iron deficiency anemia and may take months to resolve after the anemia has been corrected. Depression is the first symptom of experimental scurvy, and deficiency of vitamin B5 results in depression accompanied by fatigue and “burning feet. Correction of deficiency of vitamin C (500 mg daily), selenium (200 μg daily), iron (300 mg ferrous sul- fate three times daily), or folic acid (800 μg daily) has also been shown to be effective in clinical trials.