Cutting-edge Nutrition

From the American Academy of Family Physicians’ 2008 Scientific Assembly, San Diego, CA

Educational Objectives

The goal of this program is to improve management of nutritional health, and of mild to moderate menopausal symp­toms. After hearing and assimilating this program, the clinician will be better able to:

1.   Recommend dietary sources of long-chain fatty acids.

2.   Prescribe effective dosing of vitamin D, vitamin B₁₂, and calcium supplementation.

3.   List benefits of and indications for probiotic use.

4.   Counsel patients with mild to moderate menopausal symptoms about lifestyle modification.

5.   Discuss safety and efficacy of soy and other natural products for treatment of menopausal symptoms.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Masley is President of Ten Years Younger. Dr. Larimore and the planning committee reported nothing to disclose.

Acknowledgements

Drs. Masley and Larimore spoke in San Diego, CA, at the American Academy of Family Physicians’ (AAFP) 2008 Sci­entific Assembly, presented September 17-21, 2008. The Audio-Digest Foundation thanks the speakers and the AAFP for their cooperation in the production of this program.

Nutrition and Health

Steven C. Masley, MD, Clinical Assistant Professor of Family Medicine, University of South Florida College of Medicine, Tampa, and President, Masley Optimal Health Center, St. Petersburg, FL

Introduction: in past 10 yr, more patients sought information about nutrition, lifestyle, and wellness from alternative health care providers (eg, nutritionists, chiropractors) than from allopathic physicians (eg, doctors of medicine [MDs] or doctors of osteopathy [DOs])

Supplements: daily multivitamins recommended for all patients; taken by 30% of children; likelihood of use in­creases with education level and age; 20% of patients in emergency department taking supplement that can ad­versely affect hospital stay; taken by 16% of patients undergoing elective surgery (may affect bleeding and anesthesia); top 20 supplements  —  multivitamins; meal replacements; sports nutrition products; calcium; B vita­mins; glucosamine and chondroitin; vitamin C; homeopathics; vitamin D; fish oil; coenzyme Q10 (CoQ10); vita­min A analogues; probiotics; noni juice; magnesium; iron; plant oils; digestive enzymes; garlic; sales increasing; quality  —sources vary; look for products assessed by United States Pharmacopoeia (USP) and products with good manufacturing practice (GMP) logo; many products not tested for safety; recommend safe, state-of-the-art products that meet patients’ needs; >80% of Americans nutritionally deficient; multivitamin, calcium, fish oil, and vitamin D supplementation recommended; multivitamins that contain excess retinol (vitamin A) decrease osteoblast activity and lead to more fractures later in life

Dietary intake: reducing caloric intake by 100 calories/day can result in 10-lb weight loss in 1 yr; corn syrup  —“metabolic toxin”; disrupts glucose and insulin pathways; converted to triglycerides in liver; affects insulin sensi­tivity and blood glucose regulation; hydrogenated fat  —biochemically similar to embalming fluid; worsens lipid profile, stiffens arteries, and disrupts insulin sensitivity; fiber  —  30 g/day recommended; insoluble fiber includes grains and husks that improve gastrointestinal (GI) function; soluble fiber associated with cholesterol and blood glucose benefits; may aid weight loss; associated with cardiovascular (CV) benefits; good sources include fruits, vegetables, oats, beans, and nuts

Long-chain fatty acids: sources include fish oil, algae, and seafood (eg, shellfish, seaweed); no proven anti-inflam­matory or anti-clotting benefits of medium-chain fatty acids (found in, eg, flaxseed, nuts [good sources of fiber and lignans]); associated benefits  —  enhanced insulin resistance; CV benefits; lower risk for clotting; improved endo­thelial function in arteries; decrease in platelet aggregation and cytokines; enhanced activity of peroxisome prolif­erator-activated receptor (PPAR) gamma in cells (can result in weight loss); enhanced cell membrane flexibility; decrease in triglycerides; decreased inflammation; decrease in CV events and mortality (1 g/day, or 3 servings of seafood per week recommended); associated with lower rates of Alzheimer’s disease and slower rates of cognitive decline; recommended dosing  —  1 g/day; look for 60% to 70% eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA); to improve triglycerides, 3 to 4 g/day; for inflammatory disease (eg, arthritis), 2 to 4 g/day; to decrease arrhythmias or obtain benefits for Alzheimer’s disease or metabolic syndrome, 1 to 2 g/day; least expensive source canned fish (eg, sardines, salmon); mercury content  —  associated with long-term neurologic disease; salmon, trout, sardines, herring, mussels, oysters, smaller whitefish (eg, cod) contain lower quantities; large halibut, tuna, grouper, snapper, and bass may be high in mercury; most fish oil supplements molecularly distilled; most studies done with high quality fish oils with low lipid peroxide levels; check quality by smelling and/or tasting drop of fish oil from capsule; side effects  —  >2 g/day may increase risk for bleeding, especially if undergoing procedure or on anticoag­ulant (patients on warfarin [Coumadin] should not take >2 g/day)

Vitamin D deficiency: affects 70% to 80% of Americans; may be related to multiple sclerosis (MS) and abnormal autoimmune response (eg, Crohn’s disease, psoriasis); vitamin D improves blood pressure (BP) control and CV death rates; 800 to 1000 IU/day helpful in reducing abnormal cell growth and proliferation; randomized trials show vitamin D lowers cancer rates over time; most multivitamins contain 200 to 500 IU; sources  —  cod liver oil; fish oil; salmon; fortified dairy products and soy milk; egg yolks; sun exposure; vitamin D₃ 5 times as potent as vitamin D₂; toxicity  —  no risks associated with £3000 IU/day; in randomized trials, 10,000 IU/day for 5 mo did not lead to toxicity; long-term use of high doses (eg, 50,000 IU/day) results in weakness, muscle loss, and electrocardio­graphic changes; measure 25-hydroxyvitamin D in patients with rickets, osteoporosis, osteopenia, MS, or autoim­mune disease; interpretation of laboratory results varies (eg, some laboratories consider 20 ng/mL  normal value, but <30 ng/mL low, and associated with increased cancer, osteoporosis, bone density loss, MS); clinical benefits seen with serum levels of 40 to 70 ng/mL; no good studies about optimal range; absorption varies between individ­uals and supplements

Vitamin B deficiency: elevated homocysteine level marker for disease states; 400 to 600 μg/day of B vitamins (eg, folic acid, vitamin B₆, vitamin B₁₂) recommended (especially for young women); most multivitamins contain 400 to 800 μg; multiple forms of folic acid studied; clear benefits of adding folic acid seen in randomized trials; high doses (eg, 1000 μg/day) in patients with elevated homocysteine levels or increased disease states (eg, CV disease, Alzheimer’s disease) not shown beneficial; patients with folic acid deficiency have greater number of colon polyps, but high doses of folic acid stimulate repair mechanisms and can increase polyp growth; women who take 400 μg/day before becoming pregnant at lower risk of having child with spina bifida; vitamin B₁₂ deficiency increasing due to use of acid-blocking agents (absorption requires acid in gut; deficiency likely in patients on proton pump in­hibitors [PPIs]); sources of vitamin B₁₂ include animal protein, GI bacteria, and supplements; signs  —  high mean corpusulcar volume (MCV); elevated homocysteine; tingling paresthesias; ataxia; neuropathy; cognitive dysfunc­tion; vitamin B₁₂ deficiency associated with increase in irreversible cognitive decline in Alzheimer’s disease; treat­ment for vitamin B₁₂ deficiency  —  aim for serum level of 300 to 800 pg/mL; for more accurate testing, check for elevated methylmevalonic acid in urine; supplementation recommended for vegans and patients on PPIs; 1000 to 2000 mg/day recommended for patients with deficiency

Calcium deficiency: common; calcium needs (eg, 800 mg/day, 1200 mg/day, or 1500 mg/day) dependent on life­style; optimal lifestyle  —  strength training and aerobic exercise 2 to 3 times per week; moderate animal protein, salt, phosphate, and caffeine intake; fewer than 2 servings of alcohol per day; sufficient calcium, magnesium, and vitamin D intake; adequate intake (eg, 4-5 c/day) of plant foods that alkalinize urine; 800 mg/day of calcium suffi­cient; average lifestyle  —  excessive caffeine, animal protein, and salt intake; low physical activity; 1000 to 1200 mg/day recommended; 1500 mg/day recommended for patients with osteopenia or osteoporosis; sources of calcium  —  dairy products; fortified drinks; green leafy vegetables (excluding wheat bran and spinach); since cot­tage cheese high in salt and animal protein, “you lose as much calcium as you gain”; yogurt, cow’s milk, or fortified soy milk provide 300 to 400 mg/c; green leafy vegetables provide 100 mg/c; whole grains provide 20 mg/c; calcu­late calcium intake from food sources and determine supplemental need; >2000 mg increases cancer risk; calcium carbonate  —  least expensive form; smallest pill size; associated with problems with heavy metals (eg, lead) and GI distress (eg, constipation); protein-bound calcium  —  chelated form; most expensive; best absorbed; no problems with heavy metals or GI distress; calcium citrate  —  well-tolerated by GI tract; no problems with heavy metals; nat­ural calcium  —  from, eg, coral, not recommended due to lead content

Magnesium deficiency: magnesium improves bowel function; deficiency may be associated with BP problems and risk for arrhythmia; magnesium associated with enzymes involved in antiaging processes; sources of magnesium include whole grains, green leafy vegetables, and legumes; magnesium oxide causes GI irritation; magnesium im­proves blood glucose control; 400 mg/day recommended; calcium to magnesium ratio  —  calcium blocks absorp­tion of magnesium, leading to cardiac, BP, and metabolic risks; giving calcium alone can worsen magnesium deficiency; giving calcium with magnesium can prevent GI distress associated with calcium supplementation; 2 to 1 or 3 to 1 ratio of calcium to magnesium recommended (no good clinical outcome studies available)

Iron deficiency: from clinical outcome perspective, excess iron more problematic than iron deficiency (eg, excess iron in men or postmenopausal women can lead to more rapid aging and death); iron deficiency common in chil­dren and menstruating women; sources of iron include green leafy vegetables, lean meats, beans, and whole grains; iron deficiency not more common in vegetarians; iron sulfate can cause GI irritation (consider protein-bound iron)

Selenium deficiency: multivitamins provide adequate selenium; in nursing homes, selenium supplementation shown to increase influenza antibody titers; influenza vaccine less effective in patients with selenium deficiency; adequate selenium associated with lower prostate cancer rates; optimal dose, 200 μg/day (difficult to obtain from food alone); >400 μg/day can cause toxicity (neurologic and GI symptoms)

Vitamin E: food sources recommended over supplements; many forms of vitamin E (eg, a-, g-, D-tocopherols and to­cotrienols); a-tocopherol  —  comprises 20% of vitamin E from food sources; used in most studies; blocks activity of g- and D-tocopherols (most efficient forms for CV benefits); identified in fasting serum as marker (rather than ac­tive agent; active agents found in food higher in g- and D-tocopherols); reduce high-density lipoprotein (HDL; par­ticularly HDL₂); increase in rate of plaque growth seen on carotid intima-media thickness (IMT), compared to placebo; increase in vascular events (eg, myocardial infarction, stroke); >800 IU/day associated with increased risk for bleeding; 200 to 400 IU/day reasonable (no clinical trials show benefit of vitamin E supplementation); 100 to 200 IU/day of mixed tocopherols may enhance immune function in people after chemotherapy, or raise titers of in­fluenza vaccines

Probiotics: benefits of healthy GI bacteria  —  reduce inflammation and cholesterol; enhance detoxification of drugs and nutrient metabolism; promote healthy GI function; common strains include Lactobacillus acidophilus, Bifido­bacterium, Saccharomyces boulardii; 5 billion to 10 billion per day for 1 to 3 mo can restore healthy GI function (especially after course of antibiotic); indications include diarrhea, gastroenteritis, inflammatory bowel disease, lactose intolerance, Helicobacter pylori infection, depressed immune function, allergy in infants, and hyperlipid­emia

Nutrients and Herbs for Menopausal Problems

Walter L. Larimore, MD, Clinical Associate Professor of Family Medicine, University of South Florida College of Medicine, Tampa, and Vice President of Medical Outreach, Focus on the Family, Colorado Springs, CO

Introduction: no therapy as effective as conventional hormone therapy for menopausal symptoms (eg, hot flushes); according to North American Menopause Society (NAMS), prescribed systemic estrogen-containing products re­main therapeutic standard for moderate to severe menopause-related hot flushes

Behavioral approaches: lifestyle changes effective; women who increase daily exercise, modify diet (eg, increase fruits and vegetables, decrease saturated fats), and stop tobacco smoking can 1) reduce menopausal symptoms, 2) increase sense of well-being, and/or 3) lower risk for CV disease, breast cancer, and osteoporosis; paced breathing and relaxation techniques (eg, meditation, journaling) for mild menopausal symptoms safe and somewhat effective; due to concerns about hormone therapy and difficulty changing lifestyle, many women turn to natural medicines (important to ask about use)

Management of mild to moderate symptoms: consider lifestyle modification with or without, eg, dietary isofla­vones, black cohosh, or vitamin E (not associated with serious side effects, but data inconclusive); little evidence of efficacy and safety available for most natural medicines used to treat menopausal symptoms; products not regulated in United States; American College of Obstetricians and Gynecologists states that, given lack of standardization of products, relatively short duration of therapy and follow-up in available data, and difficulty of interpreting data, few recommendations can be made with confidence; recent large systematic review concluded that frequency of vaso­motor symptoms in menopause not reduced in meta-analysis of trials of red clover isoflavone extracts, and results mixed for soy isoflavone extracts; evidence for efficacy of other therapies limited; relative efficacy difficult to de­termine; placebo rates in some studies 30% to 50% (some alternative medicine journals do not publish studies with placebo rates <30%)

Key points: soy  —  most evidence for effectiveness; soy foods preferred over soy supplements (concentrated isofla­vones; data shifting); black cohosh has less evidence than soy but might be helpful in some women; products with insufficient evidence for safety and efficacy  —  red clover; dehydroepiandrosterone (DHEA); flaxseed, chasteberry, kudzu, alfalfa, hops, licorice, evening primrose, Panax ginseng, wild yam, or vitamin E

Suggested Reading

Berger MM et al: Vitamins and trace elements: practical aspects of supplementation. Nutrition 22:952, 2006; Bur­nett-Hartman AN et al: Supplement use contributes to meeting recommended dietary intakes for calcium, magne­sium, and vitamin C in four ethnicities of middle-aged and older Americans: the Multi-Ethnic Study of Atherosclerosis. J Am Diet Assoc 109:422, 2009; Hu FB et al: Fish and omega-3 fatty acid intake and risk of coro­nary heart disease in women. JAMA 287:1815, 2002; Larimore WL et al: Herbal products should be regulated for quality control. Am Fam Physician 69:493, 2004; Masley SC: Dietary therapy for preventing and treating coronary artery disease. Am Fam Physician 57:1299, 1998; Masley SC et al: Efficacy of lifestyle changes in modifying practi­cal markers of wellness and aging. Altern Ther Health Med 14:24, 2008; McKelvey W et al: A biomonitoring study of lead, cadmium, and mercury in the blood of New York city adults. Environ Health Perspect 115:1435, 2007; Nel­son HD et al: Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis. JAMA 295:2057, 2006; Newton KM et al: Reprint of The Herbal Alternatives for Menopause (HALT) Study: background and study design. Maturitas 61:181, 2008; Rayman MP et al: Selenium and vitamin E supplementation for cancer prevention. JAMA 01:1876, 2009; Reiter E et al: Comparison of hormonal activity of isoflavone-containing supple­ments used to treat menopausal complaints. Menopause May 7, 2009 [Epub ahead of print]; Verdu EF: Probiotics ef­fects on gastrointestinal function: beyond the gut? Neurogastroenterol Motil 21:477, 2009.