Complementary and Alternative Medicine Sourcebook

Health Reference Series
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Helping the Layperson Understand, Manage, Fourth Edition

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Complementary and alternative medicine (CAM) therapies play a key role in _____________________________________________________________________________________________________________________
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the health care of many Americans. The National Center for Complementary
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and Alternative Medicine reports that in the United States, about four in _________________________________________________________________________________________________________________ ___
10 adults and about one in nine children use some form of CAM, such as _____________________________________________________________________________________________________________________
deep breathing, dietary supplements, massage, meditation, or yoga. CAM, _____________________________________________________________________________________________________________________
alone or in conjunction with mainstream medicine, is often used to treat an
increasing variety of diseases and conditions, such as arthritis, anxiety, back

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pain, cancer, diabetes, heart disease, and sleep problems. _____________________________________________________________________________________________________________________
Basic Consumer Health Information about
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Complementary and Alternative Medicine Sourcebook, Fourth Edition _____________________________________________________________________________________________________________________
Ayurveda, Acupuncture, Aromatherapy, Chiropractic
provides updated information for people considering these therapies for Health _____________________________________________________________________________________________________________________
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Care, Diet-Based Therapies, Guided Imagery, Herbal
general well-being or specific health conditions. It discusses how to select a
CAM practitioner, talk with a primary health care provider about using CAM,
Reference _____________________________________________________________________________________________________________________
and Vitamin Supplements, Homeopathy, Hypnosis, Massage,
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evaluate information on the internet, and pay for CAM therapies. It describes Series _____________________________________________________________________________________________________________________
Meditation, Naturopathy, Pilates, Reflexology, Reiki, Shiatsu,
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whole medical systems, such as Ayurveda, traditional Chinese medicine, Na-
tive American medicine, acupuncture, homeopathy, and naturopathy. It also
4th Edition _____________________________________________________________________________________________________________________
Tai Chi, Traditional Chinese Medicine, Yoga, and Other
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talks about the safe use of dietary supplements, including vitamins, minerals, Complementary and Alternative Medical Therapies
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and herbs. Information on biologically based therapies, mind-body medicine,
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manipulative and body-based therapies, and energy-based therapies is also Along with Statistics, Tips for Selecting a Practitioner,
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included. A glossary of related terms and a directory of additional resources _____________________________________________________________________________________________________________________
provide additional help and information.
Treatments for Specific Health Conditions, a Glossary
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Omnigraphics _____________________________________________________________________________________________________________________
of Related Terms, and a Directory of Resources for
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ISBN 978-0-7808-1082-2 Additional Help and Information
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Edited by
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P.O. Box 31-1640 Amy L. Sutton
Detroit, MI 48231
Phone: 800-234-1340
Fax: 800-875-1340
www.omnigraphics.com
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Basic Consumer Health Information about Ayurveda,
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Based Therapies, Guided Imagery, Herbal and Vitamin
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Along with Statistics, Tips for Selecting a Practitioner,
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Treatments for Specic Health Conditions, a Glossary
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of Related Terms, and a Directory of Resources for
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Bibliographic Note
Because this page cannot legibly accommodate all the copyright notices, the Bibliographic
Note portion of the Preface constitutes an extension of the copyright notice.
Edited by Amy L. Sutton
Karen Bellenir, Managing Editor
David A. Cooke, MD, FACP, Medical Consultant
Elizabeth Collins, Research and Permissions Coordinator
Cherry Edwards, Permissions Assistant
EdIndex, Services for Publishers, Indexers
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Omnigraphics, Inc.
Matthew P. Barbour, Senior Vice President
Kevin M. Hayes, Operations Manager
***
Peter E. Ruffner, Publisher
Copyright 2010 Omnigraphics, Inc.
ISBN 978-0-7808-1082-2
Library of Congress Cataloging-in-Publication Data

Complementary and alternative medicine sourcebook : basic consumer health
information about ayurveda, acupuncture, aromatherapy, chiropractic care,
diet-based therapies, guided imagery, herbal and vitamin supplements,
homeopathy, hypnosis, massage, meditation, naturopathy, pilates,
reexology, reiki, shiatsu, tai chi, traditional chinese medicine, yoga,
and other complementary and alternative medical therapies ; along with
statistics, tips for selecting a practitioner, treatments for specic
health conditions, a glossary of related terms, and a directory of resources
for additional help and information / edited by Amy L. Sutton. -- 4th ed.
p. cm. -- (Health reference series)
Includes bibliographical references and index.
Summary: Provides basic consumer health information about alternative and
complementary medical therapies, including treatments for specic diseases
and conditions. Includes index, glossary of related terms, and other
resources--Provided by publisher.
ISBN 978-0-7808-1082-2 (hardcover : alk. paper) 1. Alternative
medicine--Popular works. I. Sutton, Amy L.
R735.C66 2010
610--dc22
2010013183
Electronic or mechanical reproduction, including photography, recording, or any other infor-

mation storage and retrieval system for the purpose of resale is strictly prohibited without
permission in writing from the publisher.
The information in this publication was compiled from the sources cited and from other sources
considered reliable. While every possible effort has been made to ensure reliability, the pub-
lisher will not assume liability for damages caused by inaccuracies in the data, and makes no
warranty, express or implied, on the accuracy of the information contained herein.
This book is printed on acid-free paper meeting the ANSI Z39.48 Standard. The innity
symbol that appears above indicates that the paper in this book meets that standard.
Printed in the United States

Table of Contents
Visit www.healthreferenceseries.com to view A Contents Guide to the
Health Reference Series, a listing of more than 15,000 topics and the
volumes in which they are covered.
Preface ............................................................................................ xi
Part I: An Overview of Complementary and Alternative

Medicine (CAM)
Chapter 1What Is Complementary and Alternative
Medicine (CAM)?....................................................... 3
Chapter 2Common Questions and Answers about CAM .......... 7
Chapter 3The Use of CAM in the United States ..................... 13
Chapter 4CAM Use and Children ............................................ 17
Chapter 5CAM Use in Older Adults......................................... 21
Chapter 6Health Care Providers and CAM ............................. 31
Section 6.1Selecting a CAM Practitioner......... 32
Section 6.2Tips for Talking with Your
Health Care Providers
about CAM...................................... 37
Chapter 7Insurance Issues and Paying
for CAM Treatment ................................................ 39
Chapter 8Health Fraud Awareness.......................................... 45
Chapter 9Use Caution Buying Medical Products Online ....... 51
v
Part II: Alternative Medicine Systems
Chapter 10What Are Whole Medical Systems? ....................... 59
Chapter 11Ayurvedic Medicine ................................................ 65
Chapter 12Other Indigenous Medical Systems ....................... 73
Section 12.1Traditional Chinese
Medicine...................................... 74
Section 12.2Native American Medicine ........ 78
Chapter 13Acupuncture............................................................ 81
Chapter 14Homeopathy ............................................................ 85
Chapter 15Naturopathy............................................................ 91
Part III: Dietary Supplements

Chapter 16Questions and Answers about
Dietary Supplements............................................ 101
Chapter 17Botanical Dietary Supplements ........................... 107
Chapter 18Using Dietary Supplements Wisely ..................... 111
Chapter 19Adolescents and Supplement Use........................ 117
Chapter 20Tips for Older Dietary Supplement Users........... 121
Chapter 21Vitamin A and Carotenoids .................................. 129
Chapter 22Vitamin B6 ............................................................ 137
Chapter 23Vitamin B12 ........................................................... 143
Chapter 24Vitamin D.............................................................. 147
Chapter 25Vitamin E .............................................................. 153
Chapter 26Folate (Folic Acid) ................................................. 161
Chapter 27Magnesium............................................................ 169
Chapter 28Omega-3 Fatty Acid Supplements ....................... 175
Section 28.1Fish Oils.................................... 176
Section 28.2Flaxseed and Flaxseed Oils ..... 190
Chapter 29Selenium................................................................ 193
Chapter 30Bone and Joint Health Supplements................... 197
Section 30.1Calcium Supplements
and Bone Health....................... 198
vi
Section 30.2Glucosamine/Chondroitin
Supplements and Joint
Health ....................................... 201
Chapter 31Immune System Support Supplements............... 205
Section 31.1Echinacea.................................. 206
Section 31.2Zinc............................................ 208
Chapter 32Mood and Brain Health Supplements ................. 213
Section 32.1Ginkgo Biloba ........................... 214
Section 32.2St. Johns Wort.......................... 216
Chapter 33Probiotics: Supplements for
Gastrointestinal Health ....................................... 219
Chapter 34Sports and Energy Supplements ......................... 225
Section 34.1Sports Supplements ................. 226
Section 34.2Energy Drinks .......................... 231
Chapter 35Supplements Used for Weight Loss ..................... 235
Section 35.1Green Tea.................................. 236
Section 35.2Hoodia ....................................... 238
Part IV: Biologically Based Therapies

Chapter 36Biologically Based Therapies: An Overview ........ 243
Chapter 37Apitherapy ............................................................ 253
Chapter 38Aromatherapy and Essential Oils........................ 257
Chapter 39Diet-Based Therapies ........................................... 263
Section 39.1Detoxication Diets.................. 264
Section 39.2Fasting ...................................... 267
Section 39.3Gerson Therapy ........................ 269
Section 39.4Macrobiotics.............................. 273
Section 39.5Veganism .................................. 275
Section 39.6Vegetarianism........................... 279
Chapter 40Oxygen Therapy.................................................... 285
Part V: Mind-Body Medicine

Chapter 41Mind-Body Medicine: An Overview ..................... 293
Chapter 42Art Therapy........................................................... 299
vii
Chapter 43Biofeedback ........................................................... 303
Chapter 44Deep Breathing Exercises .................................... 311
Chapter 45Feng Shui .............................................................. 317
Chapter 46Guided Imagery and Hypnosis............................. 321
Section 46.1Guided Imagery........................ 322
Section 46.2Hypnosis ................................... 324
Chapter 47Meditation ............................................................. 329
Chapter 48Music Therapy ...................................................... 335
Chapter 49Prayer and Spirituality ........................................ 341
Chapter 50Relaxation Training.............................................. 345
Chapter 51Tai Chi ................................................................... 349
Chapter 52Yoga ....................................................................... 353
Chapter 53Other Mind-Body Medicine
Therapies............................................................... 357
Section 53.1Color Therapy ........................... 358
Section 53.2Dance Therapy.......................... 359
Part VI: Manipulative and Body-Based Therapies

Chapter 54Manipulative and Body-Based Therapies:
An Overview.......................................................... 363
Chapter 55Alexander Technique ............................................ 371
Chapter 56Aquatic Therapy (Hydrotherapy)......................... 383
Chapter 57Chiropractic Care and Osteopathic
Manipulation......................................................... 399
Chapter 58Craniosacral Therapy ........................................... 403
Chapter 59Feldenkrais Method .............................................. 407
Chapter 60Massage Therapy .................................................. 413
Section 60.1Massage Therapy Overview..... 414
Section 60.2Lymphatic Drainage
Massage .................................... 419
Section 60.3Tui Na: Chinese Massage ........ 421
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Chapter 61Pilates.................................................................... 423
Chapter 62Qigong ................................................................... 427
Chapter 63Reexology ............................................................ 431
Chapter 64Structural Integration Techniques ...................... 435
Section 64.1Hellerwork Structural
Integration................................ 436
Section 64.2Rolng....................................... 438
Chapter 65Other Manipulative and Body-Based
Therapies............................................................... 447
Section 65.1Applied Kinesiology.................. 448
Section 65.2Bowen Technique...................... 449
Section 65.3Trager Approach....................... 450
Part VII: Energy-Based Therapies

Chapter 66Energy Medicine: An Overview............................ 455
Chapter 67Magnet Therapy.................................................... 463
Chapter 68Polarity Therapy ................................................... 467
Chapter 69Reiki ...................................................................... 471
Chapter 70Shiatsu .................................................................. 475
Chapter 71Therapeutic Touch ................................................ 479
Chapter 72Other Energy-Based Therapies............................ 483
Section 72.1Bioresonance Therapy.............. 484
Section 72.2Crystal and Gem Therapy........ 486
Section 72.3Zero Balancing.......................... 487
Part VIII: Alternative Treatments for Specic Diseases

and Conditions
Chapter 73Arthritis and CAM................................................ 491
Chapter 74Asthma, Allergies, and CAM ................................ 503
Chapter 75Cancer and CAM................................................... 507
Chapter 76Cognitive Decline and CAM ................................. 517
Chapter 77Diabetes and CAM ................................................ 523
ix
Chapter 78Fibromyalgia and CAM ........................................ 529
Chapter 79Headache and CAM .............................................. 533
Chapter 80Heart Disease and Chelation Therapy ................ 537
Chapter 81Hepatitis C and CAM ........................................... 541
Chapter 82Hormones, CAM, and Aging ................................. 547
Chapter 83Infertility and CAM .............................................. 559
Section 83.1Herbal Remedies for
Infertility .................................. 560
Section 83.2Infertility and CAM.................. 561
Chapter 84Low Back Pain and CAM...................................... 563
Chapter 85Menopausal Symptoms and CAM........................ 567
Chapter 86Mental Health Care and CAM ............................. 573
Section 86.1Overview of CAM Used in
Mental Health Care ................. 574
Section 86.2Alcohol Addiction and
Electroacupuncture .................. 579
Section 86.3Attention Decit
Hyperactivity Disorder
(ADHD) and CAM .................... 580
Section 86.4Anxiety and Self-Hypnosis ...... 582
Section 86.5Posttraumatic Stress Disorder
and Acupuncture ...................... 583
Chapter 87Sleep Disorders and CAM .................................... 585
Part IX: Additional Help and Information

Chapter 88Glossary of Terms Related to Alternative
and Complementary Medicine ............................. 593
Chapter 89Directory of Organizations That Provide
Information about Alternative and
Complementary Medicine .................................... 599
Index........................................................................................... 615
x
Preface
About This Book

Complementary and alternative medicine (CAM) therapies play a
key role in the health care of many Americans. The National Center for
Complementary and Alternative Medicine reports that in the United
States, about four in 10 adults and about one in nine children use some
form of CAM, such as deep breathing, dietary supplements, massage,
meditation, or yoga. CAM, alone or in conjunction with mainstream
medicine, is often used to treat an increasing variety of diseases and
conditions, such as arthritis, anxiety, back pain, cancer, diabetes, heart
disease, and sleep problems.
Complementary and Alternative Medicine Sourcebook, Fourth Edi-
tion provides updated information for people considering these thera-
pies for general well-being or specic health conditions. It discusses
how to select a CAM practitioner, talk with a primary health care
provider about using CAM, evaluate information on the internet, and
pay for CAM therapies. It describes whole medical systems, such as
Ayurveda, traditional Chinese medicine, Native American medicine,
acupuncture, homeopathy, and naturopathy. It also talks about the safe
use of dietary supplements, including vitamins, minerals, and herbs.
Information on biologically based therapies, mind-body medicine, ma-
nipulative and body-based therapies, and energy-based therapies is
also included. A glossary of related terms and a directory of additional
resources provide additional help and information.
xi
How to Use This Book
This book is divided into parts and chapters. Parts focus on broad
areas of interest. Chapters are devoted to single topics within a part.
Part I: An Overview of Complementary and Alternative Medicine (CAM)
denes CAM, identies common therapies, and answers questions
consumers often have about choosing a CAM practitioner and pay-
ing for treatments. Information and statistics on CAM use in specic
populations, including children and the elderly, is also included, along
with tips on avoiding health fraud and spotting internet scams.
Part II: Alternative Medicine Systems describes whole medical systems
practiced in cultures throughout the world that evolved separately
from conventional medicine as it is practiced in the United States.
These include Ayurvedic medicine, traditional Chinese medicine, Na-
tive American medicine, acupuncture, homeopathy, and naturopathy.
Part III: Dietary Supplements identies vitamins, minerals, herbs and
botanicals, and other food and dietary substances taken to improve
health or nutrition. Readers will also nd tips on ensuring supple-
ment safety and selecting specic products to support bone and joint
health, immune system functioning, mood regulation, and weight loss
efforts.
Part IV: Biologically Based Therapies discusses CAM practices that
strive to enhance or improve health using substances found in nature.
This part highlights biologically based techniques including apitherapy,
aromatherapy and essential oils, and diet-based therapies such as de-
toxication diets, fasting, macrobiotics, and vegetarianism.
Part V: Mind-Body Medicine describes CAM techniques that focus on
using the mind to improve health or reduce unwanted symptoms, such
as biofeedback, deep breathing, guided imagery and hypnosis, medi-
tation, prayer and spirituality, relaxation training, tai chi, and yoga.
In addition, readers will nd information about practices focused on
healing via creative expression in art, music, and dance.
Part VI: Manipulative and Body-Based Therapies offers information
about massage therapy, chiropractic care and osteopathic manipula-
tion, hydrotherapy, Pilates, reexology, qigong, and other CAM thera-
pies that involve movement or manipulation of one or more parts of
the body.
Part VII: Energy-Based Therapies discusses CAM therapies that encour-
age healing through the manipulation of energy elds. CAM practitioners
xii
of reiki, shiatsu, polarity therapy, and therapeutic touch use pressure
and touch to manipulate the energy elds in and around a persons
body. With magnet and bioresonance therapies, practitioners inuence
electromagnetic elds, which purports to increase energy and vitality
in the patient.
Part VIII: Alternative Treatments for Specic Diseases and Conditions
highlights scientic research of CAM therapies for treating arthritis,
asthma and allergies, cancer, dementia, diabetes, bromyalgia, head-
ache, heart disease, hepatitis, and sleep disorders. The use of CAM for
treating mental health problems, including anxiety and addiction, is
also discussed.
Part IX: Additional Help and Information provides a glossary of im-
portant terms related to complementary and alternative medicine. A
directory of organizations that provide information to consumers about
complementary and alternative therapies is also included.
Bibliographic Note
This volume contains documents and excerpts from publications is-
sued by the following U.S. government agencies: Agency for Healthcare
Research and Quality (AHRQ); National Cancer Institute (NCI); Na-
tional Center for Complementary and Alternative Medicine (NCCAM);
National Institute of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS); National Institute of Neurological Disorders and Stroke
(NINDS); National Institute on Aging (NIA); National Institutes of
Health (NIH); Ofce of Dietary Supplements (ODS); Substance Abuse
and Mental Health Services Administration (SAMHSA); and the U.S.
Food and Drug Administration (FDA).
In addition, this volume contains copyrighted documents from the
following organizations: A.D.A.M., Inc.; American Apitherapy Society;
American Art Therapy Association; American Dance Therapy Associa-
tion; American Music Therapy Association; American Polarity Therapy
Association; American Pregnancy Association; American Psychological
Association; American Reexology Certication Board; American Soci-
ety for the Alexander Technique; Association for Applied Psychophysi-
ology and Biofeedback; Asthma and Allergy Foundation of America;
Center for Integrative Health and Healing; ChiEnergy; Feldenkrais
Educational Foundation of North America; Gannett Company, Inc.;
Hellerwork International; National Center on Physical Activity and
Disability; National Headache Foundation; National Qigong Associa-
tion; Natural Medicines Comprehensive Database; Natural Standard;
xiii
The Nemours Foundation; Rolf Institute of Structural Integration;
Trager International; University of CaliforniaSan Diego; Vegetarian
Resource Group; and the Zero Balancing Health Association.
Full citation information is provided on the rst page of each chap-
ter or section. Every effort has been made to secure all necessary rights
to reprint the copyrighted material. If any omissions have been made,
please contact Omnigraphics to make corrections for future editions.
Acknowledgements
Thanks go to the many organizations, agencies, and individuals
who have contributed materials for this Sourcebook and to medical
consultant Dr. David Cooke and document engineer Bruce Bellenir.
Special thanks go to managing editor Karen Bellenir and research and
permissions coordinator Liz Collins for their help and support.
About the Health Reference Series

The Health Reference Series is designed to provide basic medical
information for patients, families, caregivers, and the general public.
Each volume takes a particular topic and provides comprehensive cov-
erage. This is especially important for people who may be dealing with
a newly diagnosed disease or a chronic disorder in themselves or in a
family member. People looking for preventive guidance, information
about disease warning signs, medical statistics, and risk factors for
health problems will also nd answers to their questions in the Health
Reference Series. The Series, however, is not intended to serve as a tool
for diagnosing illness, in prescribing treatments, or as a substitute for
the physician/patient relationship. All people concerned about medical
symptoms or the possibility of disease are encouraged to seek profes-
sional care from an appropriate health care provider.
A Note about Spelling and Style

Health Reference Series editors use Stedmans Medical Dictionary
as an authority for questions related to the spelling of medical terms
and the Chicago Manual of Style for questions related to grammati-
cal structures, punctuation, and other editorial concerns. Consistent
adherence is not always possible, however, because the individual vol-
umes within the Series include many documents from a wide variety
of different producers and copyright holders, and the editors primary
goal is to present material from each source as accurately as is possible
xiv
following the terms specied by each documents producer. This some-
times means that information in different chapters or sections may
follow other guidelines and alternate spelling authorities. For example,
occasionally a copyright holder may require that eponymous terms be
shown in possessive forms (Crohns disease vs. Crohn disease) or that
British spelling norms be retained (leukaemia vs. leukemia).
Locating Information within the Health Reference Series

The Health Reference Series contains a wealth of information about
a wide variety of medical topics. Ensuring easy access to all the fact
sheets, research reports, in-depth discussions, and other material con-
tained within the individual books of the Series remains one of our
highest priorities. As the Series continues to grow in size and scope,
however, locating the precise information needed by a reader may
become more challenging.
A Contents Guide to the Health Reference Series was developed to
direct readers to the specic volumes that address their concerns. It
presents an extensive list of diseases, treatments, and other topics of
general interest compiled from the Tables of Contents and major index
headings. To access A Contents Guide to the Health Reference Series,
visit www.healthreferenceseries.com.
Medical Consultant
Medical consultation services are provided to the Health Reference
Series editors by David A. Cooke, MD, FACP. Dr. Cooke is a graduate of
Brandeis University, and he received his M.D. degree from the Univer-
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s $R,YNDA"AKER!SSOCIATE0ROFESSOROF,IBRARYAND
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Royal Oak, MI
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s +AREN-ORGAN-ARDIGIAN,IBRARY5NIVERSITYOF-ICHIGAN
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s 2OSEMARY/RLANDO3T#LAIR3HORES0UBLIC,IBRARY
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xvi
Part One
An Overview of
Complementary and
Alternative Medicine (CAM)
Chapter 1
What Is Complementary and

Alternative Medicine (CAM)?
There are many terms used to describe approaches to health care

that are outside the realm of conventional medicine as practiced in
the United States. This text explains how the National Center for
Complementary and Alternative Medicine (NCCAM), a component
of the National Institutes of Health, denes some of the key terms
used in the eld of complementary and alternative medicine (CAM).
Complementary medicine is used together with conventional medicine,
and alternative medicine is used in place of conventional medicine.
What is CAM?
CAM is a group of diverse medical and health care systems, practices,
and products that are not generally considered to be part of conventional
medicine. While scientic evidence exists regarding some CAM therapies,
for most there are key questions that are yet to be answered through well-
designed scientic studiesquestions such as whether these therapies are
safe and whether they work for the purposes for which they are used.
Are complementary medicine and alternative medicine dif-

ferent from each other?
Yes, they are different. Complementary medicine is used together
with conventional medicine. An example of a complementary therapy
From What is CAM? by the National Center for Complementary and Al-
ternative Medicine (NCCAM, nccam.nih.gov), part of the National Institutes of
Health, February 2007.
3
Complementary and Alternative Medicine Sourcebook, Fourth Edition
is using aromatherapy to help lessen a patients discomfort following

surgery. Alternative medicine is used in place of conventional medi-
cine. An example of an alternative therapy is using a special diet to
treat cancer instead of undergoing surgery, radiation, or chemotherapy
that has been recommended by a conventional doctor.
What is integrative medicine?

Integrative medicine combines treatments from conventional medi-
cine and CAM for which there is evidence of safety and effectiveness.
It is also called integrated medicine.
What are the major types of complementary and alterna-

tive medicine?
NCCAM groups CAM practices into four domains, recognizing there
can be some overlap. In addition, NCCAM studies CAM whole medical
systems, which cut across all domains.
Whole medical systems: Whole medical systems are built upon
complete systems of theory and practice. Often, these systems have
evolved apart from and earlier than the conventional medical approach
used in the United States. Examples of whole medical systems that
have developed in Western cultures include homeopathic medicine and
naturopathic medicine. Examples of systems that have developed in non-
Western cultures include traditional Chinese medicine and Ayurveda.
Mind-body medicine: Mind-body medicine uses a variety of tech-
niques designed to enhance the minds capacity to affect bodily function
and symptoms. Some techniques that were considered CAM in the past
have become mainstream (for example, patient support groups and
cognitive-behavioral therapy). Other mind-body techniques are still
considered CAM, including meditation, prayer, mental healing, and
therapies that use creative outlets such as art, music, or dance.
Biologically based practices: Biologically based practices in
CAM use substances found in nature, such as herbs, foods, and vita-
mins. Some examples include dietary supplements, herbal products,
and the use of other so-called natural but as yet scientically unproven
therapies (for example, using shark cartilage to treat cancer).
Manipulative and body-based practices: Manipulative and
body-based practices in CAM are based on manipulation and/or move-
ment of one or more parts of the body. Some examples include chiro-
practic or osteopathic manipulation.
4
What Is Complementary and Alternative Medicine (CAM)?
Energy medicine: Energy therapies involve the use of energy

elds. They are of two types:
s "IOlELDTHERAPIESAREINTENDEDTOAFFECTENERGYlELDSTHATPUR-
portedly surround and penetrate the human body. The existence
of such elds has not yet been scientically proven. Some forms of
energy therapy manipulate bioelds by applying pressure and/or
manipulating the body by placing the hands in, or through, these
elds. Examples include qi gong, Reiki, and therapeutic touch.
s "IOELECTROMAGNETIC BASEDTHERAPIESINVOLVETHEUNCONVENTIONAL
use of electromagnetic elds, such as pulsed elds, magnetic
elds, or alternating-current or direct-current elds.
What is NCCAMs role in the eld of CAM?

NCCAM is the Federal Governments lead agency for scientic re-
search on CAM. NCCAMs mission is to explore complementary and
alternative healing practices in the context of rigorous science, train
CAM researchers, and disseminate authoritative information to the
public and professionals.
5
Chapter 2
Common Questions and

Answers about CAM
For thousands of Americans, health care includes some form of

complementary and alternative medicine (CAM). Like any decision
concerning your health, decisions about whether to use CAM are im-
portant.
What is CAM?
CAM is a group of diverse medical and health care systems, prac-
tices, and products that are not generally considered part of conven-
tional medicine. Conventional medicine is medicine as practiced by
holders of MD (medical doctor) or DO (doctor of osteopathy) degrees
and by their allied health professionals, such as physical therapists,
psychologists, and registered nurses. Integrative medicine combines
conventional and CAM treatments for which there is evidence of safety
and effectiveness.
How can I get reliable information about a CAM therapy?

It is important to learn what scientic studies have discovered
about the CAM therapy you are considering. Making a decision based
on the facts is a better idea than using a therapy simply because of
something you have seen in an advertisement or on a website or be-
cause someone has told you that it worked for them.
From Are You Considering CAM? by the National Center for Complemen-
tary and Alternative Medicine (NCCAM, nccam.nih.gov), part of the National
Institutes of Health, April 2009.
7
Understanding a therapys potential benets, risks, and scientic

evidence is critical to your health and safety. Scientic research on
many CAM therapies is relatively new, so this kind of information
may not be available for every therapy. However, many studies are
under way, including those that NCCAM supports, and knowledge and
understanding of CAM are increasing all the time.
Here are some ways to nd reliable information:
s Talk with your doctor or other health care providers.
Tell them about the therapy you are considering and ask any
questions you may have about safety, effectiveness, or interac-
tions with medications (prescription or nonprescription) or
other dietary supplements. They may know about the therapy
and be able to advise you on its safety and use.
s Visit the NCCAM website (nccam.nih.gov). The Health
Information page has information on specic CAM therapies,
and links to other online sources of information. It also has
contact information for the NCCAM Clearinghouse, where in-
formation specialists are available to assist you in searching
the peer-reviewed literature and to suggest useful NCCAM
publications.
s Visit your local library or a medical library. Ask the refer-
ence librarian to help you nd books and scientic journals with
information on the therapy that interests you.
Are CAM therapies safe? How can I minimize risks in using

CAM therapies?
As with any medical treatment, there can be risks with CAM thera-
pies. These risks depend on the specic therapy. Each CAM therapy
needs to be considered on its own. However, if you are considering a
CAM therapy, the following general suggestions can help you think
about safety and minimize risks.
s 4AKECHARGEOFYOURHEALTHBYBEINGANINFORMEDCONSUMER&IND
out what the scientic evidence is about any therapys safety
and whether it works.
s "EAWARETHATINDIVIDUALSRESPONDDIFFERENTLYTOTREATMENTS
whether conventional or CAM. How a person might respond to
a CAM therapy depends on many things, including the persons
state of health, how the therapy is used, or the persons belief in
the therapy.
8
Common Questions and Answers about CAM
s +EEPINMINDTHAThNATURALvDOESNOTNECESSARILYMEANhSAFEv
(Think of mushrooms that grow in the wild: some are safe to eat,
while others are not.)
s ,EARNABOUTFACTORSTHATAFFECTSAFETY&ORA#!-THERAPYTHAT
is administered by a practitioner, these factors include the train-
ing, skill, and experience of the practitioner. For a CAM product
such as a dietary supplement, the specic ingredients and the
quality of the manufacturing process are important factors.
s )FYOUDECIDETOUSEA#!-THERAPYTHATWOULDBEGIVENBYA
practitioner, choose the practitioner carefully.
s )FYOUDECIDETOUSEADIETARYSUPPLEMENTSUCHASANHERBAL
product, be aware that some products may interact with medica-
tions (prescription or over-the-counter) or other dietary supple-
ments, and some may have side effects on their own.
s 4ELLALLYOURHEALTHCAREPROVIDERSABOUTANYCOMPLEMENTARY
and alternative practices you use. Give them a full picture of
what you do to manage your health. This will help ensure coordi-
nated and safe care.
How can I determine whether statements made about the

effectiveness of a CAM therapy are true?
Statements that manufacturers and providers of CAM therapies
may make about effectiveness and benets can sound reasonable and
promising. However, the statements may not be backed up by scientic
evidence. Before you begin using a CAM therapy, it is a good idea to
ask the following questions:
s )STHERESCIENTIlCEVIDENCENOTJUSTPERSONALSTORIES TOBACKUP
the statements?
s $OESTHEFEDERALGOVERNMENTHAVEANYTHINGTOREPORTABOUTTHE
therapy?
s 6ISITTHE.##!-WEBSITEORCONTACTTHE.##!-#LEARING-
house to see if NCCAM has information about the therapy.
s 6ISITTHE&$!;53&OODAND$RUG!DMINISTRATIONWWW
fda.gov] online to see if there is any information available
about the product or practice. Information specically about
dietary supplements can be found on FDAs Center for Food
Safety and Applied Nutrition website. Or visit the FDAs
page on recalls and safety alerts.
9
s #HECKWITHTHE&EDERAL4RADE#OMMISSION&4#WWWFTC
.gov) to see if there are any enforcement actions for deceptive
advertising regarding the therapy. Also, visit the sites Diet,
Health, and Fitness Consumer Information section.
s (OWDOESTHEPROVIDERORMANUFACTURERDESCRIBETHETHERAPY
s 1UESTIONTERMSLIKEhSCIENTIlCBREAKTHROUGHvhMIRACLECUREv
secret ingredient, or ancient remedy.
s )FYOUENCOUNTERCLAIMSOFAhQUICKlXvTHATDEPARTSFROMPREVI-
ous research, keep in mind that science usually advances over
time by small steps, slowly building toward an evidence base.
s 2EMEMBER)FITSOUNDSTOOGOODTOBETRUEFOREXAMPLE
claims that a therapy can cure a disease or works for a wide
variety of ailmentsit usually is.
Are CAM therapies tested to see if they work?

While some scientic evidence exists regarding the effectiveness of
some CAM therapies, for most there are key questions that are yet to
be answered through well-designed scientic studiesquestions such
as how the therapies work, and whether they work for the diseases
or medical conditions for which they are used. As the federal govern-
ments lead agency for scientic research on CAM, NCCAM supports
studies to answer these questions and determine who might benet
most from the use of specic therapies.
I am interested in a CAM therapy that involves treatment from

a practitioner. How do I go about selecting a practitioner?
Your health care provider or local hospital may be able to recom-
mend a practitioner. The professional organization for the type of
practitioner you are seeking may have helpful information, such as
licensing and training requirements. Many states have regulatory
agencies or licensing boards for certain types of practitioners; they
may be able to help you locate practitioners in your area.
Can I receive treatment or a referral to a practitioner from

NCCAM?
NCCAM does not provide CAM treatments or referrals to practi-
tioners. NCCAMs mission is to explore CAM practices using rigorous
scientic methods and build an evidence base for the safety and ef-
fectiveness of these practices.
10
Common Questions and Answers about CAM
Can I participate in a CAM clinical trial?

NCCAM supports clinical trials (research studies in people) on
CAM therapies. Clinical trials on CAM are taking place in many loca-
tions worldwide, and study participants are needed. To nd trials that
are recruiting participants, go to the website nccam.nih.gov/research/
clinicaltrials. You can search this site by type of therapy or by disease
or condition.
11
Chapter 3
The Use of CAM in the

United States
In December 2008, the National Center for Complementary and

Alternative Medicine (NCCAM) and the National Center for Health
Statistics (part of the Centers for Disease Control and Prevention) re-
leased new ndings on Americans use of complementary and alterna-
tive medicine (CAM). The ndings are from the 2007 National Health
Interview Survey (NHIS), an annual in-person survey of Americans
regarding their health- and illness-related experiences. The CAM sec-
tion gathered information on 23,393 adults aged 18 years or older
and 9,417 children aged 17 years and under. A similar CAM section
was included in the 2002 NHIS, providing the opportunity to examine
trends in CAM use, too.
About CAM
CAM is a group of diverse medical and health care systems, practic-
es, and products that are not generally considered part of conventional
medicine. Complementary medicine is used together with conventional
medicine, and alternative medicine is used in place of conventional
medicine. Integrative medicine combines conventional and CAM treat-
ments for which there is evidence of safety and effectiveness. While
scientic evidence exists regarding some CAM therapies, for most there
are key questions that are yet to be answered through well-designed
Excerpted from The Use of Complementary and Alternative Medicine in
the United States, by the National Center for Complementary and Alternative
Medicine (NCCAM, nccam.nih.gov), December 2008.
13
scientic studiesquestions such as whether these therapies are safe

and whether they work for the purposes for which they are used. NC-
CAMs mission is to explore CAM practices using rigorous scientic
methods and build an evidence base for the safety and effectiveness
of these practices.
Figure 3.1. CAM Use by U.S. Adults and Children
How Many People Use CAM

In the United States, approximately 38 percent of adults (about 4 in
10) and approximately 12 percent of children (about 1 in 9) are using
some form of CAM, shown in Figure 3.1.
Who Uses CAM Most

People of all backgrounds use CAM. However, CAM use among
adults is greater among women and those with higher levels of educa-
tion and higher incomes.
14
The Use of CAM in the United States
CAM Therapies Used the Most

Nonvitamin, nonmineral natural products are the most commonly
used CAM therapy among adults. Use has increased for several thera-
pies, including deep breathing exercises, meditation, massage therapy,
and yoga.
CAM therapies included in the 2007 NHIS:
s !CUPUNCTURE

s !YURVEDA

s "IOFEEDBACK
s #HELATIONTHERAPY
s #HIROPRACTICOROSTEOPATHICMANIPULATION
s $EEPBREATHINGEXERCISES
s $IET BASEDTHERAPIES
s !TKINSDIET s -ACROBIOTICDIET s /RNISHDIET
s 0RITIKINDIET s 3OUTH"EACHDIET s 6EGETARIANDIET
s :ONEDIET
s %NERGYHEALINGTHERAPY2EIKI
s 'UIDEDIMAGERY
s (OMEOPATHICTREATMENT
s (YPNOSIS
s -ASSAGE
s -EDITATION
s -OVEMENTTHERAPIES
s !LEXANDERTECHNIQUE s &ELDENKRAIS s 0ILATES
s 4RAGERPSYCHOPHYSICALINTEGRATION
s .ATURALPRODUCTSNONVITAMINANDNONMINERALSUCHASHERBS
and other products from plants, enzymes, etc.)
s .ATUROPATHY
s 0ROGRESSIVERELAXATION
s 1IGONG
s 4AICHI
15
s 4RADITIONALHEALERS
s "OTANICA s #URANDERO s %SPIRITISTA

s (IERBEROOR9ERBERA s .ATIVE!MERICANHEALER-EDICINEMAN
s 3HAMAN s 3OBADOR
s 9OGA
.OTE!NASTERISK
INDICATESAPRACTITIONER BASEDTHERAPY
Use of Natural Products

The most popular natural products are sh oil/omega-3 fatty acids,
glucosamine, echinacea, and axseed.
Health Conditions Prompting CAM Use

People use CAM for an array of diseases and conditions. American
adults are most likely to use CAM for musculoskeletal problems such
as back, neck, or joint pain. The use of CAM therapies for head or chest
colds showed a substantial decrease from 2002 to 2007.
CAM Use among Children

The 2007 NHIS asked selected adult respondents about CAM use by
children in their households. Overall, approximately 12 percent of children
use some form of CAM. Use is greater among the following groups:
s #HILDRENWHOSEPARENTSUSED#!-
s !DOLESCENTSAGEDn COMPAREDTOYOUNGERCHILDREN
s 7HITECHILDREN COMPAREDTO(ISPANICCHILDREN
ANDBLACKCHILDREN
s #HILDRENWHOSEPARENTSHADHIGHEREDUCATIONLEVELSMORETHAN
HIGHSCHOOL
s #HILDRENWITHSIXORMOREHEALTHCONDITIONS
s #HILDRENWHOSEFAMILIESDELAYEDCONVENTIONALCAREBECAUSEOF
COST
16
Chapter 4
CAM Use and Children
A wide range of complementary and alternative medicine (CAM)

therapies are used in children, including herbs and dietary supple-
ments, massage, acupuncture, chiropractic care, naturopathy, and ho-
meopathy. This text offers information for parents who are thinking
about using a CAM therapy for their child.
Patterns of CAM Use in Children

The 2007 National Health Interview Survey gathered information
on CAM use among more than 9,000 children aged 17 and under.
Nearly 12 percent of the children had used some form of CAM during
the past 12 months. CAM use was much more likely among children
WHOSEPARENTSALSOUSED#!-!DOLESCENTSAGEDnCHILDRENWITH
multiple health conditions, and those whose families delayed or did
not use conventional medical care because of cost were also more likely
to use CAM.
In addition, a 2001 survey of 745 members of the American Acad-
emy of Pediatrics found that 87 percent of pediatricians had been asked
about CAM therapies by a patient or a parent in the 3 months prior to
the survey. The pediatricians were asked most often about herbs and
dietary supplements.
From CAM Use and Children, by the National Center for Complementary
and Alternative Medicine (NCCAM, nccam.nih.gov), part of the National Insti-
tutes of Health, February 2009.
17
Safety of Childhood CAM Use

Few high-quality studies have examined how CAM therapies may
affect young people, and results from studies in adults do not neces-
sarily apply to children. Children are not small adults. Their immune
and central nervous systems are not fully developed, which can make
them respond to treatments differently from adults. This is especially
true for infants and young children.
Herbs and other dietary supplements may interact with medicines
or other supplements, or they may cause problems during surgery,
such as bleeding-related complications. In addition, natural does
not necessarily mean safe. CAM therapies can have side effects, and
these may be different in children than in adults.
Parents should seek information from scientic studies about how
safe and effective a specic CAM therapy is in children. However,
since few, if any, rigorous studies in young people exist, additional
scientic studies are needed. Anecdotes and testimonials (personal
stories) about CAM therapies are common and can be compelling, but
they are not evidence.
Discussing CAM with Your Pediatrician

Parents often do not tell pediatricians or other health care provid-
ers that their child is receiving CAM. It is important, however, that
families speak with their childs health care provider about any CAM
therapy being used or considered. Providing a full picture of what is
being done to manage your childs health will help ensure coordinated
and safe care.
When seeking care from a CAM practitioner, it is important to ask
about the practitioners qualications, including the following:
s %DUCATIONANDTRAINING
s %XPERIENCEINDELIVERINGCARETOCHILDREN
s %XPERIENCEWORKINGWITHOTHERPROVIDERSINCLUDINGPHYSICIANS
to ensure coordinated care
s ,ICENSINGSOMESTATESHAVELICENSINGREQUIREMENTSFORCERTAIN
CAM practitioners, such as chiropractors, naturopathic doctors,
massage therapists, and acupuncturists)
In addition to asking your childs physician what is known about

whether a therapy works and is safe for children, consider these points
when making decisions about using CAM in children:
18
CAM Use and Children
s %NSURETHATYOURCHILDHASRECEIVEDANACCURATEDIAGNOSISFROM
a licensed health care provider and that CAM use does not re-
place or delay conventional medical care.
s )FYOUDECIDETOUSE#!-FORYOURCHILDDONOTINCREASETHEDOSE
or length of treatment beyond what is recommended. More is not
necessarily better.
s )FYOURCHILDEXPERIENCESANEFFECTFROMA#!-THERAPYTHATCON-
cerns you, contact your childs health care provider.
s 3TOREHERBALANDOTHERDIETARYSUPPLEMENTSOUTOFTHESIGHTAND
reach of children.
s )FYOUAREAWOMANWHOISPREGNANTORBREASTFEEDINGREMEMBER
that some CAM therapies may affect your fetus or nursing infant.
19
Chapter 5
CAM Use in Older Adults
What is CAM?
Today, many people use complementary and alternative medicine,
or CAM, for a wide variety of diseases or conditions, and use of CAM
has increased in recent years. But what exactly is CAM, and how is it
different from standard medical care?
Denition of CAM
Complementary medicine is used together with standard medical
care. An example is using acupuncture to help with side effects of
cancer treatment.
Alternative medicine is used in place of standard medical care. An
example is treating heart disease with chelation therapy (which seeks
to remove excess metals from the blood) instead of using a standard
approach.
A related concept, integrative medicine, is a total approach to care
that involves the patients mind, body, and spirit. It combines standard
medical treatments with CAM practices that have shown the most
promise. An example is taking an omega-3 fatty acid supplement in
addition to a prescription statin medication to reduce cholesterol.
Experts group CAM practices into four major categories. These
include the following:
Excerpted from Complementary and Alternative Medicine (CAM), by the
National Institute on Aging (NIA, nihseniorhealth.gov), part of the National In-
stitutes of Health, December 2008.
21
s "IOLOGICALLYBASEDPRACTICES
s %NERGYMEDICINE
s -ANIPULATIVEANDBODY BASEDPRACTICES
s -IND BODYMEDICINE
These four categories sometimes overlap.

Another term, whole medical systems, refers to complete systems
of care that have evolved over time in different cultures and parts of
the world. Whole medical systems may include practices from the four
major CAM categories.
CAM Practices
The four major categories of complementary and alternative medi-
cine include biologically based practices, energy medicine, manipulative
and body-based practices, and mind-body medicine. These categories
sometimes overlap.
Biologically Based Practices

Biologically based practices involve adding dietary supplements,
functional foods, and other products found in nature to ones diet. A
dietary supplement is a product that contains vitamins, minerals, herbs
or botanicals, amino acids, enzymes, probiotics, or other ingredients that
supplement the diet. Examples of dietary supplements include vitamin
B12, St. Johns wort (a botanical), and acidophilus (a probiotic).
Energy Medicine
Energy medicine uses energy elds with the intent to affect health.
Some elds, such as magnetic elds, have been measured. Others,
such as bioelds, have not. Therapies involving bioelds are based on
the idea that people have a subtle form of energy; energy medicine
practitioners believe that illness results from disturbances of these
subtle energies.
Examples of energy medicine include magnet therapy, healing
touch, and Reiki.
Magnet therapy uses magnets or magnetic devices to treat or ease
the symptoms of various diseases and conditions, including pain.
Healing touch practitioners pass their hands over or gently touch a
persons body to try to identify imbalances in the bodys energy eld.
22
Reiki is based on the idea that there is a universal (or source) en-
ergy that supports the bodys innate healing abilities. Practitioners
seek to access the energy and allow it to ow to the body to help with
healing. In a Reiki session, the practitioners hands are placed lightly
on or just above the clients body.
Manipulative and Body-Based Practices

Manipulative and body-based practices focus mainly on the struc-
tures and systems of the body, including the bones and joints, the soft
tissues, and the circulatory and lymphatic systems. Some practices
come from traditional systems of medicine, such as those from China
and India, while others, like spinal manipulation, were developed
within the last 150 years.
Examples of manipulative and body-based practices are massage,
spinal manipulation, and reexology. Spinal manipulation is performed
by chiropractors and other health professionals such as physical thera-
pists and osteopaths.
There are over 80 types of massage therapy. In all of them, thera-
pists press, rub, and otherwise manipulate the muscles and other soft
tissues of the body, often varying pressure and movement. They most
often use their hands and ngers, but may also use their forearms,
elbows, or feet. The goal of the therapy is usually to relax the soft
tissues, increase delivery of blood and oxygen to the massaged areas,
warm them, and decrease pain.
The goal of chiropractic medicine is to help the body heal by cor-
recting its alignment.
Doctors of chiropractic, who are also called chiropractors or chiroprac-
tic physicians, use a type of hands-on therapy called manipulation, or
adjustment, as their main type of procedure. Adjustments are done to
increase the range and quality of motion in the area being treated.
Conditions commonly treated by chiropractors include back pain,
neck pain, headaches, sports injuries, and repetitive strains. Patients
also seek treatment of pain associated with other conditions, such
as arthritis.
In reexology, pressure points on the feet or hands are used to help
other parts of the body relax and heal.
Mind-Body Medicine
Mind-body medicine, which focuses on how the mind and body in-
teract, uses a variety of techniques designed to enhance the minds
capacity to affect bodily function and symptoms.
23
Examples of mind-body medicine are meditation, yoga, tai chi, qi

gong, imagery, and creative outlets.
The term meditation refers to a group of techniques, most of which
started in Eastern religious or spiritual traditions. These techniques have
been used by many different cultures throughout the world for thousands
of years. Today, many people use meditation outside of its traditional
religious or cultural settings for health and wellness purposes.
In meditation, people learn to focus their attention and suspend
the stream of thoughts that normally occupy the mind. This practice
is believed to result in a state of greater calmness, physical relaxation,
and psychological balance. Practicing meditation can change how a
person relates to the ow of emotions and thoughts in the mind.
Yoga is an ancient system of exercise, breathing, and relaxation
that originated in India.
In yoga, people use stretches and poses and pay special attention
to their breathing to balance the mind, body, and spirit.
Tai chi is a practice that uses a series of slow, gentle movements co-
ordinated with breathing and meditation. The goal is to enhance physi-
cal functioning, improve balance and concentration, and reduce stress.
1IGONGISALSOAPRACTICETHATCOMBINESMOVEMENTMEDITATIONAND
controlled breathing.
In imagery, people imagine scenes, pictures, or experiences to
achieve a desired physical response such as stress reduction.
Creative outlets such as art, music, or dance are also sometimes
used for health purposes.
Whole Medical Systems

Whole medical systems are built upon complete systems of theory
and practice. Often, these systems have evolved apart from, and earlier
than, the standard medical approach used in the United States. Ex-
amples of whole medical systems that have developed in non-Western
cultures include traditional Chinese medicine and Ayurvedic medicine.
Examples of systems that have developed in Western cultures include
homeopathic medicine and naturopathic medicine.
Traditional Chinese Medicine (TCM)

Traditional Chinese medicine, or TCM, is a healing system that
dates back more than 2,000 years. It is based on the concept that
disease results from disruption in the ow of vital energy, or qi in the
body. The ow of qi is maintained by keeping a balance in the two
forces known as yin and yang.
24
TCM uses three main therapeutic approaches: acupuncture and

moxibustion, herbs and other natural products, and massage and ma-
nipulation.
Acupuncture is the stimulation of specic points on the body by a
variety of techniques, including the insertion of thin metal needles
through the skin. It is intended to remove blockages in the ow of qi
and restore and maintain health.
Moxibustion is the application of heat from the burning of the herb
moxa at the acupuncture point.
Herbs and botanicals used in TCM are usually used together in for-
mulas, and the formulas are usually adjusted to t a persons specic
diagnosis. TCM is an example of personalized medicine.
Ayurvedic Medicine
Ayurveda, which means the science of life in Sanskrit, originated
in India and evolved there over thousands of years. Its goal is to prevent
and treat disease by bringing the body, mind, and spirit into balance.
Ayurveda also proposes treatments for specic health problems.
Three qualities called doshas are believed to form important charac-
teristics of each persons body constitution and to control bodily activities.
Imbalances in the doshas, which can be caused by an unhealthy lifestyle,
diet, stress, the weather, chemicals, or germs, can lead to illness.
Ayurvedic medicine relies on therapies such as diet, exercise, medi-
tation, herbs, massage, exposure to sunlight, and controlled breathing.
The goals of treatment are to eliminate impurities, reduce symptoms,
reduce worry, increase harmony in a persons life, and help resolve
both physical and psychological problems.
Homeopathy
Homeopathy originated in Europe and has been practiced in the
United States since the early 19th century. Its goal is to help the body
heal itself by using very small doses of highly diluted substances that
in larger doses would produce illness or symptoms. Most homeopathic
remedies are derived from natural substances that come from plants,
minerals, or animals.
A homeopathic practitioner will select treatments based upon a
total picture of a persons symptoms, not solely upon the symptoms of
a disease. Homeopaths evaluate not only a persons physical symptoms
but emotions, psychological state, lifestyle, nutrition, and other aspects.
In homeopathy, different people with the same symptoms may receive
different homeopathic remedies.
25
Naturopathy
Like homeopathy, naturopathy originated in Europe, but it also
includes ancient and modern therapies from other traditions. Natur-
opathy attempts to help the body heal itself, and naturopaths consider
a persons physical, emotional, genetic, environmental, and social cir-
cumstances when evaluating treatment. The emphasis is on supporting
health rather than ghting disease.
Practitioners of naturopathy prefer to use treatment approaches
that they consider to be the most natural and least invasive, relying
on methods other than standard medications and surgery. They focus
on changes in diet and lifestyle and on preventing disease, together
with CAM therapies such as herbs and massage.
CAM Research and Diseases Affecting Older Adults

The National Institutes of Health (NIH) funds research into the
safety and effectiveness of complementary and alternative medicine
(CAM) therapies. Much of the research looks at CAM for medical condi-
tions that are common in older people, such as heart disease, cancer,
arthritis, and Alzheimers disease.
NIH supports many studies of CAM and heart disease, including
studies of chelation therapy, meditation, and garlic.
NIH is leading a large, nationwide study to nd out whether chela-
tion therapy is safe and effective for people with heart disease. Chela-
TIONUSESACHEMICALCALLED%$4!;ETHYLENE DIAMINE TETRA ACETICACID=
to remove heavy metals from the body.
Researchers are also conducting studies of how meditation and re-
lated practices affect heart disease. One study is looking at whether a
technique called mindfulness-based stress reduction can help patients
who have decreased blood ow to the heart.
In another study, researchers are focusing on ways that garlic
might prevent blood clots, which can lead to a heart attack. Re-
search shows that garlic can thin the blood in a manner similar to
aspirin. An earlier study found that garlic does not seem to lower
LDL (low-density lipoprotein), the bad cholesterol that increases
heart disease risk.
NIH-supported research into CAM therapies for cancer includes
studies of acupuncture, massage, and vitamin E and selenium.
Researchers have found evidence that acupuncture can reduce nau-
sea and vomiting caused by cancer chemotherapy. Other researchers
are currently studying whether acupuncture can improve quality of
life in patients with advanced ovarian and colorectal cancers.
26
Acupuncture is one of many CAM therapies that people with cancer

seek outnot as cures, but as complementary therapies that may help
them feel better and recover faster.
Studies are evaluating whether massage can help people who have
cancer cope with various physical and emotional challenges. Research-
ers are looking at whether massage can reduce pain and swelling
related to cancer.
6ITAMIN%ANDSELENIUMAREDIETARYSUPPLEMENTSTHATWERETESTED
in a large study for prostate cancer prevention. The study, known as
3%,%#4THE3ELENIUMAND6ITAMIN%#ANCER0REVENTION4RIAL FOUND
that the supplements, taken either alone or together, did not prevent
prostate cancer. Over 35,000 men age 50 and over participated in this
study. The researchers will continue to monitor the volunteers health
for another 3 years to learn more about prostate cancer and other
diseases faced by older men.
NIH-supported research into CAM therapies for osteoarthritis, the
most common kind of arthritis, include studies of acupuncture and
glucosamine and chondroitin.
A study of acupuncture in people with osteoarthritis of the knee
recently found that the therapy can reduce pain and improve ability
to function in people with this condition. The study was the largest,
lengthiest acupuncture study of its kind.
In a study of the dietary supplements glucosamine and chondroitin
in people with pain from osteoarthritis of the knee, the combination
did not help the participants as a whole, but it did help a small group
of people with moderate to severe pain. A follow-up study, showed that
the supplements, together or alone, also appeared to fare no better than
placebo in slowing the loss of cartilage in knee osteoarthritis.
NIH-supported research into CAM therapies for Alzheimer disease
and other kinds of dementia (age-related changes in memory, thinking
ability, and personality) includes studies of ginkgo biloba, antioxidants,
B vitamins, and omega-3 fatty acids.
Although researchers had hoped that extracts from the leaves of the
ginkgo biloba tree might be of some help in preventing dementia, a large
study called the Ginkgo Evaluation in Memory study (GEM) recently
found that the ginkgo product researched was not effective in delaying
or preventing Alzheimers disease or other types of dementia. This study,
which recruited more than 3,000 volunteers age 75 and over, was the
largest study ever to investigate ginkgos effect on dementia.
Some studies are considering whether antioxidantssuch as vita-
min E and Ccan slow Alzheimer disease. One clinical trial is exam-
ining whether vitamin E and/or selenium supplements can prevent
27
Alzheimer disease or stop mental decline. More studies on other anti-

oxidants are ongoing or being planned.
Studies have shown that people with Alzheimer disease often have
higher levels of an amino acid called homocysteine in their blood. High
levels of homocysteine are known to increase the risk of heart disease.
Folic acid and vitamins B6 and B12 can reduce levels of homocysteine
in the blood, and scientists are conducting clinical trials to see whether
these substances can also slow rates of mental decline.
Omega-3 fatty acids are found in the oil of certain sh. One study is
LOOKINGATWHETHERANOMEGA FATTYACIDCALLED$(!;DOCOSAHEXAENOIC
acid] can slow the progression of Alzheimer disease.
Be an Informed Consumer
Take charge of your health by being an informed consumer.
Talk with your health care providers when making any decisions
about using complementary and alternative medicine (CAM). Your health
care providers can give you advice based on your medical needs.
If you are thinking about using a CAM therapy, learn the facts. Is
it safe? Does it work?
Find out what scientic studies have been done. It is not a good
idea to use a CAM therapy simply because you have seen it in an
advertisement or on a website or because people have told you that it
worked for them.
+EEPINMINDTHATTHENUMBEROFWEBSITESOFFERINGHEALTH RELATED
resources grows every day. Many sites provide valuable information,
while others may have information that is unreliable or misleading.
To evaluate the quality of a website, take a look at who runs the site,
who pays for it, and the purpose of the site. Also, check out where the
information comes from, how it is selected, and how current it is.
Scientic research on many CAM therapies is relatively new, so
information about safety and effectiveness may not be available for
every therapy. However, many studies of CAM treatments are under-
way, and researchers are always learning more about CAM.
You can nd reliable information on CAM through the National
Institutes of Healths National Center for Complementary and Alterna-
tive Medicine (NCCAM). The NCCAM website (nccam.nih.gov) provides
a variety of useful information as well as links to other trustworthy
SOURCES9OUCANALSOCONTACTTHE.##!-#LEARINGHOUSESTAFF;CALL
toll-free at: 888-644-6226 or e-mail [email protected]] for help).
Your health care providers and pharmacist are also good resources
for learning about CAM. If you are considering a new CAM therapy,
28
ask them about its safety, effectiveness, and possible interactions with
medications (both prescription and over-the-counter). Your health care
team can nd the latest scientic studies or help you to understand
the results of studies you have found.
Dietary supplementssuch as vitamins, minerals, and herbs and
other botanicalscan be a form of CAM. Some dietary supplements
can interact with your prescription medicines. Supplements may also
have side effects if not used correctly, if taken in large amounts, or
sometimes even if taken according to the instructions on the label.
While many supplements come from natural sources, natural does
not always mean safe. Natural supplements may have active ingredi-
ents that cause strong biological effects in the body. Some supplements
will affect how your medicines work.
Also, if you are considering or using dietary supplements, it is
important to know that they are not regulated in the same way as
drugs. The federal government does not review supplements for safety
and effectiveness before they are sold. However, in 2007 the U.S.
Food and Drug Administration (FDA) established a rule requiring
current good manufacturing practices for dietary supplements. The
rule will help ensure that dietary supplements are produced in a
quality manner, do not contain contaminants or impurities, and are
accurately labeled.
For CAM therapies provided by a practitioner, such as acupuncture
or chiropractic treatments, choose a practitioner with care.
Tell Your Health Care Providers

Almost two thirds of people aged 50 and older use some form of
complementary and alternative medicine (CAM). But less than one
third of those who use CAM talk with their doctors about it, according
TOARECENTSURVEYBY!!20;!MERICAN!SSOCIATIONOF2ETIRED0ERSONS=
and the National Institutes of Health (NIH). If you use CAM, it is
important to tell your health care providers.
Giving your health care providers a full picture of what you do to
manage your health helps you stay in control. Some CAM approaches
can have an effect on standard medicine. For example, certain supple-
ments can interact with over-the-counter or prescription medicines.
Also, some supplementssuch as garlic or ginkgocan increase the
risk of bleeding problems during surgery. Talking with your health care
providers about CAM use will help ensure coordinated and safe care.
Your pharmacist may also have information on any dietary supple-
ments you are considering or using.
29
Be proactivedont wait for your health care providers to ask about

your CAM use. Tell them about all of the therapies you usestandard
and CAM. Talking to your providers about your CAM use helps them
to be your fully informed partners in health care. Similarly, it is im-
portant to tell your CAM practitioners about the conventional medica-
tions you use.
When lling out the patient history form at a medical ofce or hos-
pital, list all over-the-counter and prescription medicines, as well as
dietary supplements. Tell your health care provider about other CAM
therapies that you use, as well. It may help to make a list in advance
and bring it with you.
If you are considering a new CAM therapy, ask your health care
providers about its safety, effectiveness, and possible interactions with
medicines (both prescription and over-the-counter).
It is especially important to talk with your health care providers
if you are:
s THINKINGABOUTREPLACINGYOURREGULARMEDICALCAREWITHONEOR
more supplements;
s TAKINGOTHERMEDICATIONSFORACHRONICMEDICALCONDITIONOR
s PLANNINGTOHAVESURGERY
30
Chapter 6
Health Care
Providers and CAM
Chapter Contents
Section 6.1Selecting a CAM Practitioner ................................. 32
Section 6.2Tips for Talking with Your Health
Care Providers about CAM..................................... 37
31
Section 6.1
Selecting a CAM Practitioner

Excerpted from text by the National Center for Complementary and Al-
ternative Medicine (NCCAM, nccam.nih.gov), part of the National Insti-
tutes of Health, February 2007.
Selecting a health care practitionerof conventional or complemen-

tary and alternative medicine (CAM)is an important decision and
can be key to ensuring that you are receiving the best health care.
What is CAM?
CAM is a group of diverse medical and health care systems, prac-
tices, and products that are not presently considered to be part of
conventional medicine. Complementary medicine is used together with
conventional medicine, and alternative medicine is used in place of
conventional medicine. Some health care providers practice both CAM
and conventional medicine. The list of what is considered to be CAM
changes continually as those therapies that are proven to be safe and
effective become adopted into conventional health care and as new
approaches to health care emerge.
I am interested in a CAM therapy that involves treatment

from a practitioner. How do I go about nding a practitioner?
Before selecting a CAM therapy or practitioner, talk with your pri-
mary health care provider(s). Tell them about the therapy you are
considering and ask any questions you may have. They may know
about the therapy and be able to advise you on its safety, use, and ef-
fectiveness, or possible interactions with medications. Here are some
suggestions for nding a practitioner:
s !SKYOURDOCTOROROTHERHEALTHPROFESSIONALSWHETHERTHEYHAVE
recommendations or are willing to make a referral.
s #ONTACTANEARBYHOSPITALORAMEDICALSCHOOLANDASKIFTHEY
maintain a list of area CAM practitioners or could make a rec-
ommendation. Some regional medical centers may have CAM
centers or CAM practitioners on staff.
32
Health Care Providers and CAM
s !SKIFYOURTHERAPYWILLBECOVEREDBYINSURANCEFOREXAMPLESOME
insurers cover visits to a chiropractor. If the therapy will be covered,
ask for a list of CAM practitioners who accept your insurance.
s #ONTACTAPROFESSIONALORGANIZATIONFORTHETYPEOFPRACTITIONER
you are seeking. Often, professional organizations have standards
of practice, provide referrals to practitioners, have publications
explaining the therapy (or therapies) that their members provide,
and may offer information on the type of training needed and
whether practitioners of a therapy must be licensed or certied in
your state. Professional organizations can be located by searching
the internet or directories in libraries (ask the librarian). One direc-
tory is the Directory of Information Resources Online (DIRLINE)
compiled by the National Library of Medicine (dirline.nlm.nih.gov).
It contains locations and descriptive information about a variety
of health organizations, including CAM associations and organiza-
tions. You may nd more than one member organization for some
CAM professions; this may be because there are different schools
of practice within the profession or for other reasons.
s -ANYSTATESHAVEREGULATORYAGENCIESORLICENSINGBOARDSFOR
certain types of practitioners. They may be able to provide you
with information regarding practitioners in your area. Your state,
county, or city health department may be able to refer you to such
agencies or boards. Licensing, accreditation, and regulatory laws
for CAM practices are becoming more common to help ensure
that practitioners are competent and provide quality services.
Will insurance cover the cost of a CAM practitioner?

Few CAM therapies are covered by insurance, and the amount of
coverage offered varies depending on the insurer. Before agreeing to
a treatment that a CAM practitioner suggests, you should check with
your insurer to see if they will cover any portion of the therapys cost.
If insurance does cover a portion of the cost, you will want to ask if the
practitioner accepts your insurance or participates in your insurers
network. Even with insurance, you may be responsible for a percent-
age of the cost of therapy.
I have located the names of several practitioners. How do I

select one?
Begin by contacting the practitioners on your list and gathering
information.
33
s !SKWHATTRAININGOROTHERQUALIlCATIONSTHEPRACTITIONERSHAVE
Ask about their education, additional training, licenses, and cer-
tications. If you have contacted a professional organization, see
if the practitioners qualications meet the standards for train-
ing and licensing for that profession.
s !SKIFITISPOSSIBLETOHAVEABRIEFCONSULTATIONINPERSONORBYPHONE
with the practitioners. This will give you a chance to speak with
them directly. The consultation may or may not involve a charge.
s !SKIFTHEREAREDISEASESHEALTHCONDITIONSINWHICHTHEPRACTI-
tioners specialize and how frequently they treat patients with
problems similar to yours.
s !SKIFTHEPRACTITIONERSBELIEVETHETHERAPYCANEFFECTIVELYAD-
dress your complaint and if there is any scientic research sup-
porting the treatments use for your condition.
s !SKHOWMANYPATIENTSTHEPRACTITIONERSTYPICALLYSEEINADAY
and how much time they spend with each patient.
s !SKWHETHERTHEREISABROCHUREORWEBSITETOTELLYOUMORE
about the practice.
s !SKABOUTCHARGESANDPAYMENTOPTIONS(OWMUCHDOTREATMENTS
cost? If you have insurance, do the practitioners accept your insur-
ance or participate in your insurers network? Even with insurance,
you may be responsible for a percentage of the cost.
s !SKABOUTTHEHOURSAPPOINTMENTSAREOFFERED(OWLONGISTHE
wait for an appointment? Consider whether this will be conve-
nient for your schedule.
s !SKABOUTOFlCELOCATION)FYOUNEEDABUILDINGWITHANELEVATOR
or a wheelchair ramp, ask about it.
s !SKWHATWILLBEINVOLVEDINTHElRSTVISITORASSESSMENT
Observe how comfortable you feel during these rst interactions.
Once you have gathered the information, assess the answers and
determine which practitioner was best able to respond to your ques-
tions and best suits your needs.
I have selected a practitioner. What questions should I ask

at my rst visit?
The rst visit is very important. Come prepared to answer questions
about your health history, such as surgeries, injuries, and major illnesses,
34
as well as prescriptions, vitamins, and other supplements you take. Not

only will the practitioner wish to gather information from you, but you
will want to ask questions, too. Write down ahead of time the questions
you want to ask, or take a family member or friend with you to help you
remember the questions and answers. Some people bring a tape recorder
to record the appointment. (Ask the practitioner for permission to do
this in advance.) Here are some questions you may want to ask:
s 7HATBENElTSCAN)EXPECTFROMTHISTHERAPY
s 7HATARETHERISKSASSOCIATEDWITHTHISTHERAPY
s $OTHEBENElTSOUTWEIGHTHERISKSFORMYDISEASEORCONDITION
s 7HATSIDEEFFECTSCANBEEXPECTED
s 7ILLTHETHERAPYINTERFEREWITHANYOFMYDAILYACTIVITIES
s (OWLONGWILL)NEEDTOUNDERGOTREATMENT(OWOFTENWILLMY
progress or plan of treatment be assessed?
s 7ILL)NEEDTOBUYANYEQUIPMENTORSUPPLIES
s $OYOUHAVESCIENTIlCARTICLESORREFERENCESABOUTUSINGTHE
treatment for my condition?
s #OULDTHETHERAPYINTERACTWITHCONVENTIONALTREATMENTS
s !RETHEREANYCONDITIONSFORWHICHTHISTREATMENTSHOULDNOTBE
used?
How do I know if the practitioner I have selected is right

for me?
After your rst visit with a practitioner, evaluate the visit. Ask
yourself:
s 7ASTHEPRACTITIONEREASYTOTALKTO$IDTHEPRACTITIONERMAKE
me feel comfortable?
s 7AS)COMFORTABLEASKINGQUESTIONS$IDTHEPRACTITIONERAPPEAR
willing to answer them, and were they answered to my satisfaction?
s 7ASTHEPRACTITIONEROPENTOHOWBOTH#!-THERAPYANDCONVEN-
tional medicine might work together for my benet?
s $IDTHEPRACTITIONERGETTOKNOWMEANDASKMEABOUTMY
condition?
s $IDTHEPRACTITIONERSEEMKNOWLEDGEABLEABOUTMYSPECIlC
health condition?
35
s $OESTHETREATMENTRECOMMENDEDSEEMREASONABLEANDACCEPT-
able to me?
s 7ASTHEPRACTITIONERCLEARABOUTTHETIMEANDCOSTSASSOCIATED
with treatment?
Can I change my mind about the treatment or the practi-

tioner?
Yes, if you are not satised or comfortable, you can look for a differ-
ent practitioner or stop treatment. However, as with any conventional
treatment, talk with your practitioner before stopping to make sure
that it is safe to simply stop treatmentit may not be advisable to stop
some therapies midway through a course of treatment.
Discuss with your practitioner the reasons you are not satised or
comfortable with treatment. If you decide to stop a therapy or seek
another practitioner, make sure that you share this information with
any other health care practitioners you may have, as this will help
them make decisions about your care. Communicating with your
practitioner(s) can be key to ensuring the best possible health care.
Can I receive treatment or a referral to a practitioner from

NCCAM?
NCCAM is the federal governments lead agency for scientic re-
search on CAM. NCCAMs mission is to explore CAM healing practices
in the context of rigorous science, train CAM researchers, and dissemi-
nate authoritative information to the public and professionals. NCCAM
does not provide CAM therapies or referrals to practitioners.
Can I receive CAM treatment through a clinical trial?

NCCAM supports clinical trials (research studies in people) on CAM
therapies. Clinical trials on CAM are taking place in many locations
worldwide, and study participants are needed. To nd trials that are
recruiting participants, go to the website nccam.nih.gov/clinicaltrials.
You can search this site by the type of therapy being studied or by
disease or condition.
36
Section 6.2
Tips for Talking with Your

Health Care Providers about CAM
From text by the National Center for Complementary and Alternative
Medicine (NCCAM, nccam.nih.gov), part of the National Institutes of
Health, October 2008.
Like many Americans, you may be using or considering some form

of complementary and alternative medicine (CAM). If so, it is a good
idea to talk with your health care providers about your CAM use.
About CAM
CAM refers to health-related products and practices that are not pres-
ently considered part of conventional medicine. Examples include herbal
supplements, acupuncture, chiropractic manipulation, and many others.
Reasons for Talking with Your Health Care Providers

about CAM Use
Some CAM approaches can have an effect on conventional medi-
cines. Talking with your health care providers about your CAM use
will help ensure coordinated and safe care.
Doctors, nurses, pharmacists, and other health care providers can
help you decide whether a particular CAM therapy is right for you.
They can answer questions, suggest reliable sources of information,
and point out potential benets and risks.
You are an important part of a team that includes all of the health
care providers you rely on to manage your health. Giving your team
a complete picture of everything you do to take care of your health
makes them your fully informed partnersand it helps you stay in
control of your own health care.
Tips for Talking with Your Health Care Providers about CAM
s $ONTWAITFORYOURHEALTHCAREPROVIDERSTOASKABOUTYOUR#!-
use. Be proactivestart the conversation.
37
s +EEPACURRENTLISTOFALLOFYOURTHERAPIESANDTREATMENTSIN-
cluding over-the-counter and prescription medicines as well as
any CAM products such as herbal and dietary supplements. Also
note any medical specialists or CAM practitioners you see. Take
the list with you whenever you visit a health care provider. Be sure
to tell your health care providers about all of your therapies and
treatments. Also include all therapies and treatments on any
patient history forms you ll out.
s 'ATHERINFORMATIONONTHE#!-THERAPYYOUREINTERESTEDIN
You may want to take copies with you; that way, you and your
health care provider can refer to them as you talk, and your
health care provider can help you evaluate the information.
s -AKEALISTOFTHETHINGSYOUWANTTOTALKABOUT&OREXAMPLEIF
youre considering taking an herbal supplement, you might want
to talk about the following topics:
s 7HY)WANTTOTAKETHESUPPLEMENT
s (OW)FOUNDOUTABOUTIT
s )SITSAFEFORMETOTAKE7ILLITINTERACTWITHANYOFMYMEDI-
cations?
s )SITLIKELYTOHELPME
s 7HATELSESHOULD)KNOWABOUTIT7HERECAN)lNDMOREIN-
formation?
s 3HOULD)TRYTHIS)FNOTWHYNOT-IGHTSOMETHINGELSEBE
better?
s 4AKEANOTEPADORTAPERECORDERWITHYOU,ISTENCAREFULLYAND
keep a record of what you nd out. You may want to ask a family
member or friend to accompany you, so you can compare notes
after your visit.
s )FSOMETHINGISUNCLEARTOYOUORIFYOUWANTMOREINFORMATION
dont be afraid to ask. Your health care providers may not be able
to answer every question, but they can help you nd the answers.
38
Chapter 7
Insurance Issues and

Paying for CAM Treatment
If you are using (or thinking about using) complementary and al-
ternative medicine (CAM), you may have nancial questions about
paying for treatment.
How do people pay for CAM treatments?

They pay for CAM treatments in one or both of these ways:
s Out-of-pocket: Most people must pay for CAM services and
products themselves.
s Insurance: Not all health insurance plans offer CAM coverage,
however. When they do, the coverage varies by state and is often
limited. Examples of CAM therapies that are sometimes covered
by insurance are chiropractic, acupuncture, massage therapy,
biofeedback, and naturopathy. Consumers interest in CAM cov-
erage is prompting more insurance companies and managed care
organizations to consider offering this coverage as an option.
What are some questions to ask about paying for CAM

treatment?
Some questions to ask a CAM practitioner or his ofce staff include
the following:
Excerpted from Paying for CAM Treatment, by the National Center for
Complementary and Alternative Medicine (NCCAM, nccam.nih.gov), part of the
National Institutes of Health, August 2008.
39
s 7HATDOESTHElRSTAPPOINTMENTCOST
s 7HATDOFOLLOWUPAPPOINTMENTSCOST
s (OWMANYAPPOINTMENTSDOESSOMEONEWITHMYCONDITIONTYPI-
cally need?
s !RETHEREANYADDITIONALCOSTSSUCHASFORTESTSEQUIPMENTOR
supplements)?
If you have a health insurance plan, some other questions might

include the following:
s $OYOUACCEPTTHISINSURANCE
s 7HATHASYOUREXPERIENCEBEENWITHCOVERAGEBYTHISINSURANCE
company for my condition?
s $O)lLETHECLAIMFORMSORDOYOUTAKECAREOFTHAT
If it would be difcult for you to pay the full fee at each visit, you
can ask these questions:
s #OULDYOUARRANGEAPAYMENTPLANOVERTIME
s $OYOUOFFERASLIDING SCALEFEE3LIDING SCALEFEESAREDETER-
mined by peoples income and ability to pay.)
What types of CAM coverage do employers offer?

If an employer offers CAM coverage, it usually has one or more of
the following aspects:
s Deductibles that may be higher than those for convention-
al care: A deductible is a total dollar amount that you must pay
before the insurer begins making any payment for treatment.
s Policy riders: A rider is an amendment that modies the policys
coverage in some way (for example, by increasing or decreasing its
benets). You may be able to purchase a rider for CAM coverage.
s A contracted network of providers: Some insurers contract
with a group of CAM providers who agree to offer their services
at a lower rate to members than to nonmembers. You pay out-of-
pocket, but at a discounted rate.
Employers negotiate with insurance companies for their rates and

services, usually once a year. The Agency for Healthcare Research and
1UALITYPARTOFTHEFEDERALGOVERNMENTHASPUBLICATIONSONCHOOSING
and using a health insurance plan.
40
Insurance Issues and Paying for CAM Treatment
What are some important things to nd out about my

plans coverage of CAM?
First, it is important to read your plan to nd out whether it dis-
cusses coverage of the therapy in which you are interested. If anything
about the coverage is not clear or you have questions, contact the insur-
ance company before you decide about having treatment. Examples
of questions that people often ask company representatives include
the following:
s )STHISTREATMENTCOVEREDFORMYHEALTHCONDITION
s $OESTHISCARENEEDTOBE
s PREAUTHORIZEDORPREAPPROVED
s ORDEREDBYAPRESCRIPTIONOR
s ORDEREDTHROUGHAREFERRALFROMMYPRIMARYCAREPROVIDER
s $O)HAVETOSEEAPRACTITIONERINYOURNETWORKINORDERTOBE
covered?
s $O)HAVEANYCOVERAGEIF)GOOUT OF NETWORK
s !RETHEREANYLIMITSANDREQUIREMENTSFOREXAMPLEONTHE
number of visits or the amount you will pay?
s 7HATDO)HAVETOPAYOUT OF POCKET
It is a good idea to keep detailed records about all contacts you have
with the insurance company, including notes on calls and copies of bills,
claims, and letters. This will help you if a dispute arises about a claim.
Does my state have any laws about CAM coverage?

Each state and U.S. territory, as well as the District of Columbia,
has a department of insurance (check the government pages, or blue
pages, of your phone book). This department regulates the insurance
industry within its region, enforces pertinent laws, and assists consum-
ers. The services vary, but every ofce responds to consumer inquiries
on insurance.
If you are seeking CAM treatment from a practitioner, there is
likely to be at least one professional association for the specialty
for example, associations for chiropractors. Many of these associa-
tions monitor insurance coverage and reimbursement in their eld.
You can search for them on the internet or ask a reference librarian
for help.
41
Which insurance companies cover CAM?

Your state insurance department may be able to help you with
this question. Many of these departments provide consumer publica-
tions, such as proles and ratings of companies. (They do not provide
recommendations or advice on specic companies.) An insurance
broker (an agent who sells policies for a variety of companies) may
also be a resource.
My insurance company denied my claim for CAM treat-

ment. Is there anything I can do?
Yes, there are some things you can do:
s +NOWYOURPLANINCLUDINGWHATITDOESANDDOESNOTCOVER
s #HECKWHETHERTHE#!-PRACTITIONERSOFlCEORYOURINSURANCE
company has made a coding error. To do this, compare the codes
on the practitioners bill with the codes on the document you re-
ceived from the insurance company.
s )FYOUTHINKYOURINSURERMAYHAVEMADEAMISTAKEPROCESSING
your claim, you can request a review.
s 4HEINSURANCECOMPANYSHOULDALSOHAVEAPROCESSFORAPPEALING
coverage decisions.
s 9OUCANASKTHE#!-PRACTITIONERIFTHEREISANYTHINGSHECAN
do, such as writing a letter on your behalf.
If the problem is still not resolved, contact your state insurance

department.
What are FSAs and HSAs, and can they help me with CAM
expenses?
An FSA (short for exible spending arrangement or exible spend-
ing account) is a benet offered by some employers. An FSA allows you
to set aside pretax dollars each pay period for health-related expenses
(some employers also make contributions). You submit receipts for
yourself, your spouse, and/or your dependents to the FSA administra-
tor for health-related expenses that were not covered some other way
(for example, by insurance). You are then reimbursed for qualifying
expenses (check your plans language on this), such as deductibles,
medical appointments, tests, and medicines.
42
Insurance Issues and Paying for CAM Treatment
An HSA (short for health savings account) is another type of tax-

exempt account. It is for people who participate in a high-deductible
health plan (also called a catastrophic health plan). In an HSA, you
not your employerestablish and maintain the account (although
some employers make contributions). You can also invest your HSA
funds to earn tax-deductible interest.
The Internal Revenue Service (IRS) has further information on
these accounts. The IRS does not allow the same expenses to be reim-
bursed through an FSA or HSA and also claimed as tax deductions.
Can I deduct CAM treatments on my income tax return?

In tax year 2007, the IRS allowed taxpayers to deduct medical expenses
for a limited number of CAM services and products, such as acupuncture
and chiropractic care. These expenses were generally allowed for taxpay-
ers and their spouses and dependents. Note that people cannot deduct the
same medical expenses from their taxes and an FSA or HSA.
Can the federal government help me with expenses for CAM?

The federal government helps with at least some of the health ex-
penses of people who are eligible for federal health benet programs
usually because they meet one or more of the following conditions:
s 4HEYHAVEALOWINCOMEANDLIMITEDRESOURCES
s 4HEYDONOTHAVEOTHERMEDICALINSURANCE
s 4HEYHAVEADISABILITYORCERTAINMEDICALCONDITIONS
s 4HEYAREPARTOFAPOPULATIONTHATHASDIFlCULTYOBTAININGMEDI-
cal care.
s 4HEYAREATLEASTYEARSOLD
s 4HEYHAVESERVEDINTHEMILITARY
That assistance may be direct (through payments) or indirect

(through benets like medical care at public clinics). Examples of
programs that may provide some CAM coverage under some circum-
stances (as of July 2008) include the following:
s 4HE$EPARTMENTOF6ETERANS!FFAIRSFORCHIROPRACTICCAREAND
acupuncture)
s -EDICAREWHICHCOVERSCHIROPRACTICBUTDOESNOTCOVERWHATIT
calls alternative therapies, giving as examples acupuncture,
chelation therapy, biofeedback, and holistic medicine
43
s -EDICAIDDEPENDINGONYOURSTATESGUIDELINES
GovBenets and USA.gov are two internet resources that explain

federal health benet programs. GovBenets has a test you can take
about qualifying for programs. State and local departments of health
or social services also have nancial assistance programs for eligible
residents, and you can contact them directly to inquire.
Does NCCAM provide nancial help for CAM treatment?

Financial help for treatment does not t under NCCAMs mission.
NCCAM does sponsor clinical trials (research studies in people) of
some CAM treatments. To nd out what therapies are being studied
and whether you might qualify to participate, go to nccam.nih.gov/
clinicaltrials, or contact the NCCAM Clearinghouse.
Are there any other potential sources of nancial assistance?

If treatment (whether CAM or conventional) for a disease or condi-
tion is creating a nancial crisis for you and your family, you might nd
it helpful to contact nonprot organizations that focus on the disease
or condition. To locate them, try an internet search or check directories
at your local library.
If you are receiving care at a hospital or clinic, ask if a social worker
or patient advocate could advise you.
44
Chapter 8
Health Fraud Awareness
Health fraud is the deceptive sale or advertising of products that

claim to be effective against medical conditions or otherwise benecial
to health, but which have not been proven safe and effective for those
purposes.
In addition to wasting billions of consumers dollars each year,
health scams can lead patients to delay proper treatment and cause
seriousand even fatalinjuries.
Since the 1990s, peddlers of fraudulent health products have used
the internet as a primary tool to hawk their wares. This has kept the
U.S. Food and Drug Administration (FDA) and other agencies busier
than ever in protecting the public from health fraud.
Since June 2008, FDA has warned consumers not to use bogus
cancer-treatment products marketed online by 28 U.S. companies.
These products include tablets, teas, tonics, salves, and creams sold
under more than 180 different brand names.
And since December 2008, FDA has warned about more than 70
weight loss products containing unapproved pharmaceutical ingredi-
ents and chemicals not listed on the labels. Some of these ingredients
present serious health risks when taken in dosages recommended on
the product label.
From FDA 101: Health Fraud Awareness, by the U.S. Food and Drug Ad-
ministration (FDA, www.fda.gov), May 2009.
45
Common Types of Health Fraud

Cancer fraud: Among the many long-running cancer scams is
the Hoxsey Cancer Treatment, an herbal regimen that has no proven
benet. Another scam involves products called black salves. These are
offered with the false promise of drawing cancer out from the skin, but
they are potentially corrosive to tissues.
Cancer requires individualized treatment by a specialized physician.
No single device, remedy, or treatment can treat all types of cancer.
Patients looking to try an experimental cancer treatment should enroll
in a legitimate clinical study. For more information, visit the National Can-
cer Institute Clinical Trials website www.cancer.gov/CLINICALTRIALS.
HIV/AIDS fraud: There are legitimate treatments that can help

PEOPLEWITHTHEHUMANIMMUNODElCIENCYVIRUS()6 7HILEEARLY
TREATMENTOF()6CANDELAYPROGRESSIONTO!)$3;ACQUIREDIMMUNO-
deciency syndrome], there is currently no cure for the disease.
Relying on unproven products and treatments can be dangerous
and cause delays in seeking legitimate medical treatments that have
been proven in clinical trials to improve quality of life.
3AFERELIABLETESTINGTODETERMINEWHETHERYOUHAVE()6CANBE
done by a medical professional.
To date, there is one FDA-approved testing system that allows
INDIVIDUALSTOTESTTHEMSELVESATHOME)TISAN()6COLLECTIONSYSTEM
THATTESTSONLYFOR()6 WHICHISTHECAUSEOFTHEMAJORITYOFTHE
WORLDS()6INFECTIONS
4HETESTSOLDEITHERAS4HE(OME!CCESS()6 4EST3YSTEMOR4HE
(OME!CCESS%XPRESS()6 4EST3YSTEMALLOWSBLOODSAMPLESTOBE
SENTTOALABORATORYFORTESTINGWITHAN&$!APPROVED()6 TEST
Arthritis fraud: The U.S. Federal Trade Commission says consum-

ers spend about $2 billion annually on unproven arthritis remedies
that are not backed by adequate science.
For current, accurate information on arthritis treatments and al-
ternative therapies, visit the Arthritis Foundation website at www
.arthritis.org.
Fraudulent diagnostic tests: Doctors often use in vitro di-

AGNOSTIC)6$ TESTSINTANDEMWITHAPHYSICALEXAMINATIONANDA
medical historyto get a picture of a patients overall health.
These tests involve blood, urine, or other specimen samples taken
from the body. They help diagnose or measure many conditions, includ-
INGPREGNANCYHEPATITISFERTILITY()6CHOLESTEROLANDBLOODSUGAR
46
Its rare that the use of only one of these tests can provide a meaning-
FULDIAGNOSIS9OUCANBUY)6$TESTSINSTORESTHROUGHTHEMAILORON-
line. Many of these tests are regulated by FDA and sold legally. However,
many others are marketed illegally and do not meet FDAs regulatory
requirements. These tests may not work or may be harmful.
4OlNDOUTWHETHER&$!HASCLEAREDORAPPROVEDAN)6$TESTFORA
particular purpose, call FDA at 888-463-6332, or your local FDA dis-
trict ofce www.fda.gov/Safety/ReportaProblem/ConsumerComplaint-
Coordinators/default.htm.
Bogus dietary supplements: The array of dietary supplements

including vitamins and minerals, amino acids, enzymes, herbs, animal
extracts, and othershas grown tremendously.
Although the benets of some of these have been documented, the ad-
vantages of others are unproven. For example, claims that a supplement
allows you to eat all you want and lose weight effortlessly are false.
Claims to treat diseases cause products to be considered drugs.
Firms wanting to make such claims legally must follow FDAs pre-
market New Drug Approval process to show that the products are
safe and effective.
Weight loss fraud: Since 2003, FDA has worked with national and
international partners to take hundreds of compliance actions against
companies pushing bogus and misleading weight loss schemes.
FDA has recently enhanced efforts to stop sales and importation of
and to warn consumers aboutweight loss products that contain dan-
gerous prescription drug ingredients that are not listed on the label.
Sexual enhancement product fraud: FDA has warned consum-

ers about numerous illegal drugs promoted and sold online for treating
erectile dysfunction and for enhancing sexual performance.
Although they are marketed as dietary supplements, these prod-
ucts are really illegal drugs that contain potentially harmful ingredi-
ents that are not listed on the label.
Diabetes fraud: FDA has taken numerous compliance actions

against sales of fraudulent diabetes treatments promoted with bogus
claims such as the following:
s h$ROPYOURBLOODSUGARPOINTSINDAYSv
s h%LIMINATEINSULINRESISTANCEv
s h0REVENTTHEDEVELOPMENTOFTYPEDIABETESv
s h2EDUCEORELIMINATETHENEEDFORDIABETESDRUGSORINSULINv
47
Inuenza (u) scams: Federal agencies have come across con-

taminated, counterfeit, and subpotent inuenza products.
FDA, with U.S. Customs and Border Protection, has intercepted
products claimed to be generic versions of the inuenza drug Tamiu,
but which actually contained vitamin C and other substances not
shown to be effective in treating or preventing inuenza.
Dont Be a Victim
Its ultimately up to the buyer to beware of potential health fraud.
+NOWOFTHEPOTENTIALFORHEALTHFRAUDANDLEARNABOUTTHECOMMON
techniques and gimmicks that fraudulent marketers use to gain your
attention and trust.
For instance, testimonials from people who say they have used the
product may sound convincing, but these can easily be made up. These
testimonials are not a substitute for scientic proof.
Also, never diagnose or treat yourself with questionable products.
Always check with your health care professional before using new
medical products.
Be wary of these red ags:
s #LAIMSTHATAPRODUCTISAQUICKEFFECTIVECURE ALLORADIAGNOSTIC
tool for a wide variety of ailments
s 3UGGESTIONSTHATAPRODUCTCANTREATORCUREDISEASES
s 0ROMOTIONSUSINGWORDSSUCHAShSCIENTIlCBREAKTHROUGHv
miraculous cure, secret ingredient, and ancient remedy
s 4EXTWITHIMPRESSIVE SOUNDINGTERMSSUCHAShHUNGERSTIMULA-
tion point and thermogenesis for a weight loss product
s 5NDOCUMENTEDCASEHISTORIESBYCONSUMERSORDOCTORSCLAIMING
amazing results
s ,IMITEDAVAILABILITYANDADVANCEPAYMENTREQUIREMENTS
s 0ROMISESOFNO RISKMONEY BACKGUARANTEES
s 0ROMISESOFANhEASYvlX
s #LAIMSTHATTHEPRODUCTIShNATURALvORhNON TOXICvWHICHDOESNT
necessarily mean safe)
Dont be fooled by professional-looking websites. Avoid websites that

fail to list the companys name, physical address, phone number, or
other contact information. For more tips for online buying, visit www
.fda.gov/buyonlineguide.
48
Report Problems
If you nd a person or company that you think is illegally selling
human drugs, animal drugs, medical devices, biological products, foods,
dietary supplements, or cosmetics, report it to FDA.
To report problems with FDA-regulated products, visit www.fda
.gov/opacom/backgrounders/complain.html.
To report unlawful sales of medical products on the internet, visit
www.fda.gov/oc/buyonline/buyonlineform.htm.
49
Chapter 9
Use Caution Buying

Medical Products Online
Get prescription drugs fastno doctor needed! Cure cancer with

HERBS:APYOURPAINAWAYWITHANAMAZINGDEVICE!BSOLUTELYSAFE
pull out your credit card now, and get rock-bottom prices.
Its not hard to nd statements like these oating around in cyber-
space. And if they sound too good to be true, its because they usually
are, says Rich Cleland, assistant director of the Division of Advertising
Practices at the Federal Trade Commission (FTC).
Many legitimate websites bring customers health products with
the benets of convenience, privacy and, sometimes, cheaper prices.
But consumers need to be aware that the internet has also created
a marketplace for unapproved medical products, illegal prescribing,
and products marketed with fraudulent health claims, says William
Hubbard, former associate commissioner for policy and planning at
the Food and Drug Administration.
And the unique qualities of the internet, including its broad reach,
relative anonymity, and the ease of creating and removing websites,
pose challenges for enforcing federal and state laws, Hubbard says.
Many sites are connected to other sites and have multiple links, which
makes investigations more complex. And there are jurisdictional chal-
lenges because the regulatory and enforcement issues cross state,
federal, and international lines.
Excerpted from Use Caution Buying Medical Products Online, by the U.S.
Food and Drug Administration (FDA, www.fda.gov), May 1, 2009.
51
Government agencies work together to shut down illegal websites

and prosecute criminals, but enforcement resources are limited. Con-
sumers need to take some responsibility for recognizing suspicious
sites and turning the other way, Hubbard says. So how can you spot
the red ags? Heres a guide to help you protect your health and
your wallet.
Dietary Supplements
Dietary supplements are products taken as a supplement to the
diet. Examples are vitamins, minerals, herbs, botanicals, and amino
acids, the individual building blocks of proteins needed for all life.
Dietary supplements are classied as foods and not drugs.
Problem sites: Websites cannot claim that dietary supplements

will prevent, treat, or cure any disease. This would make the product
an unapproved and illegal drug. Also, websites cant make claims that
a dietary supplement will have an effect on any structure or function
of the body when the claims are not substantiated.
Websites selling dietary supplements with false or unsubstantiated
claims sometimes use testimonials and advertisements touting a quick,
miracle cure, says the FTCs Cleland. And some sites claim a product
will cure it allheart disease, cancer, arthritis, you name it.
Cleland says he sees a lot of miracle claims for major diseases and
weight loss. Criminals also prey on peoples fears about terrorism,
he adds. After the anthrax attacks in 2001, some sites falsely claimed
that dietary supplements such as colloidal silver and oregano oil could
protect against biological and chemical contamination.
Risks: In promoting some products, companies are telling patients

not to undergo surgery, chemotherapy, or other needed treatment,
says Cleland. So we are concerned about people forgoing legitimate
medical treatment.
Consumers also have to worry about ingesting harmful substances.
Companies may call a product natural, but that doesnt mean its
safe. And dietary supplements are intended to supplement diets, not
replace them. Too much of some nutrients can cause problems. There
is also a danger of dietary supplements interacting with other drugs
you may be taking. The prescription medicine warfarin, the herbal
supplement gingko biloba, aspirin, and vitamin E all can thin the
blood, so taking any of them together can increase the potential for
internal bleeding.
52
Use Caution Buying Medical Products Online
Regulation: Under the Dietary Supplement Health and Educa-

tion Act of 1994 (DSHEA), dietary supplements are products that are
intended to supplement the diet and that contain one or more of the
following dietary ingredients: a vitamin, a mineral, an herb or other
botanical, an amino acid, a dietary substance that supplements the
diet by increasing the total daily intake, or a concentrate, metabolite,
constituent, extract, or combination of these ingredients.
Dietary supplement manufacturers must notify the FDA at least
75 days before marketing products containing some new dietary in-
gredients. This includes providing the agency with safety information
about the supplement. New dietary ingredients are those that were
not marketed as dietary supplements before Oct. 15, 1994.
Except for those dietary supplements containing new dietary ingre-
dients, the safety and labeling of most dietary supplements is moni-
tored only after they reach the marketplace. The FDA evaluates the
safety of dietary supplements after they are on the market, overseeing
safety, manufacturing, and product information on the labeling. The
FTC regulates the advertising of dietary supplements under the FTC
Act, which prohibits deceptive claims in advertising.
Under DSHEA, the FDA generally has responsibility for showing
a dietary supplement is unsafe before it can take action to restrict the
products use. For example, in 2004, the FDA banned the use of ephed-
rine alkaloids in dietary supplements because the substances pose an
unreasonable risk of illness or injury. Ephedrine alkaloids in dietary
supplements have been linked to cardiovascular problems.
If the FDA can establish that claims are false or misleading, or
if a rm is making drug claims for a dietary supplement, the agency
can take action using any of our enforcement tools, such as warning
letters, cyber letters, seizure of products, and criminal prosecution,
says Jennifer Thomas, who leads the dietary supplement and labeling
enforcement team in the FDAs Center for Food Safety and Applied
Nutrition, Ofce of Compliance.
Consumers should be wary of claims related to diseases or con-
ditions that are prominent in the news. For example, when severe
acute respiratory syndrome (SARS) was in the news in 2003, the FDA
found several dietary supplement products promoted on the internet
for treating or preventing SARS. The FDA took action against 10 of
these rms, as there was no evidence of safety or effectiveness of the
products for use against SARS.
Enforcement examples: Since 2003, the FDA has taken action

against street drug alternative products called Black Beauties and Yel-
53
low Jackets, seizing millions of dollars worth of these products. Although

labeled and marketed as dietary supplements, such products are actually
unapproved drugs and cannot be sold as dietary supplements.
In February 2004, the FDA warned consumers against purchasing a
liquid product called Green Hornet. Although it was promoted on the
internet and sold in stores as a dietary supplement, the product was
actually an illegal drug because it was promoted as an herbal version
of Ecstasy. After taking the product, four teenagers were rushed to the
hospital with seizures, excessive heart rates, severe body rashes, and
high blood pressure.
In March 2004, the FDA and the FTC announced that SeaSil-
ver USA Inc. and Americaloe Inc. of Carlsbad, California, signed a
consent decree of permanent injunction and agreed to stop manu-
facturing a bogus cure-all liquid supplement called SeaSilver and
other products.
In June 2004, the FDA announced the sentencing of a man who
swindled cancer patients by heavily advertising and selling Laetrile,
also known as vitamin B-17 or apricot pits. Although he purported it
to be a dietary supplement, Laetrile is actually an unapproved drug.
The highly toxic product hasnt shown any effect on treating cancer.
The FDA issued a warning letter to Cellular Wellness Foundation
in September 2004, citing claims made on its website that the product
Cellular Tea was effective in treating serious diseases such as cancer.
In 2004, the FDA issued warning letters to 25 rms that promote
their products on the internet with claims that the products are useful
for weight loss. The claims are not supported by scientic evidence.
In July 2004, the U.S. District Court for the District of New Jersey
found that three products sold as dietary supplements and a cosmetic
by Lane Labs-USA Inc. and its president Andrew J. Lane are in fact
unapproved new drugs because they were being marketed as treat-
MENTSFORCANCER()6ANDSKINCANCERWITHOUT&$!APPROVAL4HE
court permanently enjoined Lane and the company from distributing
the productsBenen, MGN-3, and SkinAnswerunless they are rst
either approved for marketing by the FDA or distributed pursuant to
an investigational new drug application for purposes of conducting a
clinical trial. The court also ordered the defendants to pay restitution to
purchasers of the three products since Sept. 22, 1999. The defendants
appealed the courts decision.
Tips: Consumers who choose to buy dietary supplements on the

internet should consider who operates the website and what evidence
is provided to substantiate claims.
54
Use Caution Buying Medical Products Online
Dietary supplement makers are responsible for making sure that

their products are safe before they go on the market and that claims
on labels are accurate, truthful, and substantiated with adequate sci-
entic evidence. By law, supplement manufacturers are allowed to use
these types of claims, when appropriate:
s .UTRIENT CONTENTCLAIMSSUCHAShHIGHINCALCIUMvORhEXCELLENT
source of vitamin C may be used.
s (EALTHCLAIMSTHATSHOWALINKBETWEENTHESUPPLEMENTAND
reduced risk of a disease or health condition, when the use of the
claim has been approved by the FDA, may be used. For example,
women who get adequate amounts of the B vitamin folic acid dur-
ing pregnancy have a decreased risk of having a baby with a
neural tube defect.
s 1UALIFIEDHEALTHCLAIMSWHICHAREFORDIETARYSUPPLEMENTS
only, may be used. This type of claim came about as a result
of a 1999 decision by the U.S. Court of Appeals for the Dis-
trict of Columbia Circuit in the case of Pearson v. Shalala.
The courts ruling requires the FDA to allow appropriately
qualified health claims that would be misleading without
such qualification. These qualified claims are based on the
weight of the scientific evidence. An example of this type of
claim is Supportive but not conclusive research shows that
consumption of EPA (eicosapentaenoic acid) and DHA (doco-
sahexaenoic acid) omega-3 fatty acids may reduce the risk of
coronary heart disease.
s #LAIMSREGARDINGABENElTRELATEDTOACLASSICALNUTRIENTDEl-
ciency disease, such as vitamin C and scurvy, may be used.
s #LAIMSTHATADIETARYSUPPLEMENTHASANEFFECTONTHESTRUC-
ture or function of the body, when such claims are supported
by scientic evidence, may be used. An example of such a
claim is calcium builds strong bones for a supplement that
contains calcium.
s #LAIMSTHATDESCRIBEGENERALWELL BEINGFROMCONSUMPTIONOFTHE
product may be used.
The FDA recommends that consumers contact their health care pro-
viders before using dietary supplements. This is especially important for
people who are pregnant or breast-feeding, chronically ill, older, younger
than 18, or taking prescription or over-the-counter medicines.
55
Reporting Problems
To report a problem with a website selling human drugs, animal
drugs, medical devices, biological products, foods, dietary supplements,
or cosmetics, see the following:
s )FTHEPROBLEMINVOLVESASERIOUSORLIFE THREATENINGSITUATION
call your health care professional immediately for medical ad-
vice. To report the situation to the FDA, call 301-443-1240.
s )FTHEPROBLEMINVOLVESASERIOUSREACTIONORPROBLEMCONTACT
your health care professional for advice. To ll out the FDAs
MedWatch reporting form, go to www.fda.gov/medwatch.
s &ORPROBLEMSTHATDONOTINVOLVEASERIOUSORLIFE THREATENING
reaction, ll out the form at www.fda.gov/oc/buyonline/
buyonlineform.htm.
s 4OREPORTE MAILSORWEBSITESPROMOTINGMEDICALPRODUCTS
that might be illegal, forward the material to webcomplaints
@ora.fda.gov.
s 4OREPORTFALSECLAIMSTOTHE&EDERAL4RADE#OMMISSIONCALL
877-382-4357. If you lose your money, contact the credit card
company, your state attorney generals ofce, or the Better
Business Bureau.
56
Part Two
Alternative
Medicine Systems
Chapter 10
What Are Whole

Medical Systems?
Whole medical systems involve complete systems of theory and prac-

tice that have evolved independently from or parallel to allopathic (con-
ventional) medicine. Many are traditional systems of medicine that are
practiced by individual cultures throughout the world. Major Eastern
whole medical systems include traditional Chinese medicine (TCM),
and Ayurveda, one of Indias traditional systems of medicine. Major
Western whole medical systems include homeopathy and naturopathy.
Other systems have been developed by Native American, African, Middle
Eastern, Tibetan, and Central and South American cultures.
Traditional Chinese Medicine

TCM is a complete system of healing that dates back to 200 B.C. in
written form. Korea, Japan, and Vietnam have all developed their own
unique versions of traditional medicine based on practices originating
in China. In the TCM view, the body is a delicate balance of two oppos-
ing and inseparable forces: yin and yang. Yin represents the cold, slow,
or passive principle, while yang represents the hot, excited, or active
principle. Among the major assumptions in TCM are that health is
achieved by maintaining the body in a balanced state and that dis-
ease is due to an internal imbalance of yin and yang. This imbalance
leads to blockage in the ow of qi (or vital energy) and of blood along
Excerpted from Whole Medical Systems: An Overview, by the National
Center for Complementary and Alternative Medicine (NCCAM, nccam.nih.gov),
part of the National Institutes of Health, March 2007.
59
pathways known as meridians. TCM practitioners typically use herbs,

acupuncture, and massage to help unblock qi and blood in patients in
an attempt to bring the body back into harmony and wellness.
Treatments in TCM are typically tailored to the subtle patterns of
disharmony in each patient and are based on an individualized diag-
nosis. The diagnostic tools differ from those of conventional medicine.
There are three main therapeutic modalities:
1. Acupuncture and moxibustion (moxibustion is the application
of heat from the burning of the moxa at the acupuncture point)
2. Chinese Materia Medica (the catalogue of natural products
used in TCM)
3. Massage and manipulation
Although TCM proposes that natural products catalogued in Chinese

Materia Medica or acupuncture can be used alone to treat virtually any ill-
ness, quite often they are used together and sometimes in combination with
other modalities (e.g., massage, moxibustion, diet changes, or exercise).
Acupuncture
The report from a Consensus Development Conference on Acupunc-
ture held at the National Institutes of Health (NIH) in 1997 states that
acupuncture is being widely practicedby thousands of acupuncturists,
physicians, dentists, and other practitionersfor relief or prevention of
pain and for various other health conditions. In terms of the evidence at
that time, acupuncture was considered to have potential clinical value for
nausea/vomiting and dental pain, and limited evidence suggested its po-
tential in the treatment of other pain disorders, paralysis and numbness,
movement disorders, depression, insomnia, breathlessness, and asthma.
Preclinical studies have documented acupunctures effects, but they
have not been able to fully explain how acupuncture works within the
framework of the Western system of medicine.
It is proposed that acupuncture produces its effects by the conduction
of electromagnetic signals at a greater-than-normal rate, thus aiding the
activity of pain-killing biochemicals, such as endorphins and immune
system cells at specic sites in the body. In addition, studies have shown
that acupuncture may alter brain chemistry by changing the release of
neurotransmitters and neurohormones and affecting the parts of the
central nervous system related to sensation and involuntary body func-
tions, such as immune reactions and processes whereby a persons blood
pressure, blood ow, and body temperature are regulated.
60
What Are Whole Medical Systems?
Chinese Materia Medica

Chinese Materia Medica is a standard reference book of information
on medicinal substances that are used in Chinese herbal medicine.
Herbs or botanicals usually contain dozens of bioactive compounds.
Many factorssuch as geographic location, harvest season, post-harvest
processing, and storagecould have a signicant impact on the con-
centration of bioactive compounds. In many cases, it is not clear which
of these compounds underlie an herbs medical use. Moreover, multiple
herbs are usually used in combinations called formulas in TCM, which
makes the standardization of herbal preparations very difcult. Fur-
ther complicating research on TCM herbs, herbal compositions and the
quantity of individual herbs in a classic formula are usually adjusted
in TCM practice according to individualized diagnoses.
In the past decades, major efforts have been made to study the effects
and effectiveness of single herbs and of combinations of herbs used in
classic TCM formulas. The following are examples of such work:
s Artemisia annua: Ancient Chinese physicians identied that
this herb controls fevers. In the 1970s, scientists extracted the
chemical artemisinin from Artemisia annua. Artemisinin is the
starting material for the semi-synthetic artemisinins that are
proven to treat malaria and are widely used.
s Tripterygium wilfordii Hook F (Chinese Thunder God

vine): Thunder God vine has been used in TCM for the treatment
of autoimmune and inammatory diseases. The rst small ran-
domized, placebo-controlled trial of a Thunder God vine extract in
the United States showed a signicant dose-dependent response
in patients with rheumatoid arthritis. In larger, uncontrolled stud-
ies, however, renal, cardiac, hematopoietic, and reproductive tox-
icities of Thunder God vine extracts have been observed.
Ayurvedic Medicine
Ayurveda, which literally means the science of life, is a natural
healing system developed in India. Ayurvedic texts claim that the
sages who developed Indias original systems of meditation and yoga
developed the foundations of this medical system. It is a comprehen-
sive system of medicine that places equal emphasis on the body, mind,
and spirit, and strives to restore the innate harmony of the individual.
Some of the primary Ayurvedic treatments include diet, exercise, medi-
tation, herbs, massage, exposure to sunlight, and controlled breathing. In
61
India, Ayurvedic treatments have been developed for various diseases

(e.g., diabetes, cardiovascular conditions, and neurological disorders).
However, a survey of the Indian medical literature indicates that the
quality of the published clinical trials generally falls short of contem-
porary methodological standards with regard to criteria for random-
ization, sample size, and adequate controls.
Naturopathy
Naturopathy is a system of healing, originating from Europe, that
views disease as a manifestation of alterations in the processes by
which the body naturally heals itself. It emphasizes health restora-
tion as well as disease treatment. The term naturopathy literally
translates as nature disease. Today naturopathy, or naturopathic
medicine, is practiced throughout Europe, Australia, New Zealand,
Canada, and the United States. There are six principles that form the
basis of naturopathic practice in North America (not all are unique
to naturopathy):
1. The healing power of nature
2. Identication and treatment of the cause of disease
3. The concept of rst do no harm
4. The doctor as teacher
5. Treatment of the whole person
6. Prevention
The core modalities supporting these principles include diet modi-

cation and nutritional supplements, herbal medicine, acupuncture and
Chinese medicine, hydrotherapy, massage and joint manipulation, and
lifestyle counseling. Treatment protocols combine what the practitioner
deems to be the most suitable therapies for the individual patient.
As of this writing, virtually no research studies on naturopathy as a
complete system of medicine have been published. A limited number of
studies on botanicals in the context of use as naturopathic treatments
have been published. For example, in a study of 524 children, echinacea
did not prove effective in treating colds. In contrast, a smaller, double-
blind trial of an herbal extract solution containing echinacea, propolis
(a resinous product collected from beehives), and vitamin C for ear
pain in 171 children concluded that the extract may be benecial for
ear pain associated with acute otitis media. A naturopathic extract
known as Otikon Otic Solution (containing Allium sativum, Verbascum
62
What Are Whole Medical Systems?
thapsus, Calendula ores, and Hypericum perforatum in olive oil) was

found as effective as anesthetic ear drops and was proven appropriate
for the management of acute otitis media-associated ear pain. An-
other study looked at the clinical effectiveness and cost-effectiveness
of naturopathic cranberry tabletsversus cranberry juice and versus
a placeboas prophylaxis against urinary tract infections (UTIs).
Compared with the placebo, both cranberry juice and cranberry tablets
decreased the number of UTIs. Cranberry tablets proved to be the most
cost-effective prevention for UTIs.
Homeopathy
Homeopathy is a complete system of medical theory and practice. Its
founder, German physician Samuel Christian Hahnemann (17551843),
hypothesized that one can select therapies on the basis of how closely
symptoms produced by a remedy match the symptoms of the patients
disease. He called this the principle of similars. Hahnemann proceeded
to give repeated doses of many common remedies to healthy volunteers
and carefully record the symptoms they produced. This procedure is
called a proving or, in modern homeopathy, a human pathogenic trial.
As a result of this experience, Hahnemann developed his treatments for
sick patients by matching the symptoms produced by a drug to symptoms
in sick patients. Hahnemann emphasized from the beginning carefully
examining all aspects of a persons health status, including emotional
and mental states, and tiny idiosyncratic characteristics.
Since homeopathy is administered in minute or potentially nonex-
istent material dosages, there is an a priori skepticism in the scientic
community about its efcacy. Nonetheless, the medical literature pro-
vides evidence of ongoing research in the eld. Studies of homeopathys
effectiveness involve three areas of research:
1. Comparisons of homeopathic remedies and placebos
2. Studies of homeopathys effectiveness for particular clinical
conditions
3. Studies of the biological effects of potencies, especially ultra-
high dilutions
Five systematic reviews and meta-analyses evaluated clinical trials

of the effectiveness of homeopathic remedies as compared with pla-
cebo. The reviews found that, overall, the quality of clinical research
in homeopathy is low. But when high-quality studies were selected for
analysis, a surprising number showed positive results.
63
Overall, clinical trial results are contradictory, and systematic re-

views and meta-analyses have not found homeopathy to be a deni-
tively proven treatment for any medical conditions.
Summary
While whole medical systems differ in their philosophical approach-
es to the prevention and treatment of disease, they share a number
of common elements. These systems are based on the belief that ones
body has the power to heal itself. Healing often involves marshalling
multiple techniques that involve the mind, body, and spirit. Treatment
is often individualized and dependent on the presenting symptoms. To
date, NCCAMs research efforts have focused on individual therapies
with adequate experimental rationale and not on evaluating whole
systems of medicine as they are commonly practiced.
64
Chapter 11
Ayurvedic Medicine
Ayurvedic medicine (also called Ayurveda) is one of the worlds

oldest medical systems. It originated in India and has evolved there
over thousands of years. In the United States, Ayurvedic medicine is
considered complementary and alternative medicine (CAM)more
specically, a CAM whole medical system. Many therapies used in
Ayurvedic medicine are also used on their own as CAMfor example,
herbs, massage, and specialized diets.
Background
Ayurvedic medicine, also called Ayurveda, originated in India sev-
eral thousand years ago. The term Ayurveda combines the Sanskrit
words ayur (life) and veda (science or knowledge). Thus, Ayurveda
means the science of life.
In the United States, Ayurvedic medicine is considered a type of
CAM and a whole medical system. As with other such systems, it is
based on theories of health and illness and on ways to prevent, man-
age, or treat health problems.
Ayurvedic medicine aims to integrate and balance the body, mind,
and spirit; thus, some view it as holistic. This balance is believed to lead
to happiness and health, and to help prevent illness. Ayurvedic medicine
also treats specic physical and mental health problems. A chief aim of
From Ayurvedic Medicine: An Introduction, by the National Center for
National Institutes of Health, July 2009.
65
Ayurvedic practices is to cleanse the body of substances that can cause

disease, thus helping to reestablish harmony and balance.
Ayurvedic Medicine in India

Ayurvedic medicine, as practiced in India, is one of the oldest sys-
tems of medicine in the world. Many Ayurvedic practices predate writ-
ten records and were handed down by word of mouth. Two ancient
books, written in Sanskrit more than 2,000 years ago, are considered
the main texts on Ayurvedic medicineCaraka Samhita and Sushruta
Samhita. The texts describe eight branches of Ayurvedic medicine:
s )NTERNALMEDICINE
s 3URGERY
s 4REATMENTOFHEADANDNECKDISEASE
s 'YNECOLOGYOBSTETRICSANDPEDIATRICS
s 4OXICOLOGY
s 0SYCHIATRY
s #AREOFTHEELDERLYANDREJUVENATION
s 3EXUALVITALITY
Ayurvedic medicine continues to be practiced in India, where nearly

80 percent of the population uses it exclusively or combined with con-
ventional (Western) medicine. It is also practiced in Bangladesh, Sri
Lanka, Nepal, and Pakistan.
Most major cities in India have an Ayurvedic college and hospital.
The Indian government began systematic research on Ayurvedic prac-
tices in 1969, and that work continues.
Use in the United States

According to the 2007 National Health Interview Survey, which in-
cluded a comprehensive survey of CAM use by Americans, more than
200,000 U.S. adults had used Ayurvedic medicine in the previous year.
Underlying Concepts
Ayurvedic medicine has several key foundations that pertain to
health and disease. These concepts have to do with universal intercon-
nectedness, the bodys constitution (prakriti), and life forces (doshas).
66
Ayurvedic Medicine
Interconnectedness: Ideas about the relationships among people,

their health, and the universe form the basis for how Ayurvedic prac-
titioners think about problems that affect health. Ayurvedic medicine
holds that the following statements are true:
s !LLTHINGSINTHEUNIVERSEBOTHLIVINGANDNONLIVING AREJOINED
together.
s %VERYHUMANBEINGCONTAINSELEMENTSTHATCANBEFOUNDINTHE
universe.
s (EALTHWILLBEGOODIFONESMINDANDBODYAREINHARMONYAND
ones interaction with the universe is natural and wholesome.
s $ISEASEARISESWHENAPERSONISOUTOFHARMONYWITHTHEUNI-
verse. Disruptions can be physical, emotional, spiritual, or a
combination of these.
Constitution (prakriti): Ayurvedic medicine also has specic

beliefs about the bodys constitution. Constitution refers to a persons
general health, the likelihood of becoming out of balance, and the abil-
ity to resist and recover from disease or other health problems.
The constitution is called the prakriti. The prakriti is a persons
unique combination of physical and psychological characteristics and
the way the body functions to maintain health. It is inuenced by such
factors as digestion and how the body deals with waste products. The
prakriti is believed to be unchanged over a persons lifetime.
Life forces (doshas): Important characteristics of the prakriti

are the three life forces or energies called doshas, which control the
activities of the body. A persons chances of developing certain types
of diseases are thought to be related to the way doshas are balanced,
the state of the physical body, and mental or lifestyle factors.
Ayurvedic medicine holds the following beliefs about the three
doshas:
s %ACHDOSHAISMADEUPOFTWOOFlVEBASICELEMENTSETHERTHE
upper regions of space), air, re, water, and earth.
s %ACHDOSHAHASAPARTICULARRELATIONSHIPTOBODILYFUNCTIONSAND
can be upset for different reasons.
s %ACHPERSONHASAUNIQUECOMBINATIONOFTHETHREEDOSHASAL-
though one dosha is usually prominent. Doshas are constantly be-
ing formed and reformed by food, activity, and bodily processes.
s %ACHDOSHAHASITSOWNPHYSICALANDPSYCHOLOGICALCHARACTERISTICS
67
s !NIMBALANCEOFADOSHAWILLPRODUCESYMPTOMSTHATAREUNIQUE
to that dosha. Imbalances may be caused by a persons age,
unhealthy lifestyle, or diet; too much or too little mental and
physical exertion; the seasons; or inadequate protection from the
weather, chemicals, or germs.
The doshas are known by their original Sanskrit names: vata, pitta,
and kapha.
The vata dosha combines the elements ether and air. It is considered
the most powerful dosha because it controls very basic body processes
such as cell division, the heart, breathing, discharge of waste, and
the mind. Vata can be aggravated by, for example, fear, grief, staying
up late at night, eating dry fruit, or eating before the previous meal
is digested. People with vata as their main dosha are thought to be
especially susceptible to skin and neurological conditions, rheumatoid
arthritis, heart disease, anxiety, and insomnia.
The pitta dosha represents the elements re and water. Pitta controls
hormones and the digestive system. A person with a pitta imbalance
may experience negative emotions such as anger and may have physi-
cal symptoms such as heartburn within 2 or 3 hours of eating. Pitta is
upset by, for example, eating spicy or sour food, fatigue, or spending too
much time in the sun. People with a predominantly pitta constitution
are thought to be susceptible to hypertension, heart disease, infectious
diseases, and digestive conditions such as Crohn disease.
The kapha dosha combines the elements water and earth. Kapha
helps to maintain strength and immunity and to control growth. An
imbalance of the kapha dosha may cause nausea immediately after
eating. Kapha is aggravated by, for example, greed, sleeping during
the daytime, eating too many sweet foods, eating after one is full, and
eating and drinking foods and beverages with too much salt and water
(especially in the springtime). Those with a predominant kapha dosha
are thought to be vulnerable to diabetes, cancer, obesity, and respira-
tory illnesses such as asthma.
Treatment
Ayurvedic treatment is tailored to each persons constitution.
Practitioners expect patients to be active participants because many
Ayurvedic treatments require changes in diet, lifestyle, and habits.
The patients dosha balance: Ayurvedic practitioners rst de-
termine the patients primary dosha and the balance among the three
doshas by doing the following:
68
Ayurvedic Medicine
s !SKINGABOUTDIETBEHAVIORLIFESTYLEPRACTICESRECENTILLNESSES

(including reasons and symptoms), and resilience (ability to re-
cover quickly from illness or setbacks)
s /BSERVINGSUCHPHYSICALCHARACTERISTICSASTEETHANDTONGUE
skin, eyes, weight, and overall appearance
s #HECKINGTHEPATIENTSURINESTOOLSPEECHANDVOICEANDPULSE
(each dosha is thought to make a particular kind of pulse)
Treatment practices: Ayurvedic treatment goals include eliminat-

ing impurities, reducing symptoms, increasing resistance to disease,
and reducing worry and increasing harmony in the patients life. The
practitioner uses a variety of methods to achieve these goals:
s %LIMINATINGIMPURITIES!PROCESSCALLEDPANCHAKARMAISIN-
tended to cleanse the body by eliminating ama. Ama is described
as an undigested food that sticks to tissues, interferes with nor-
mal functioning of the body, and leads to disease. Panchakarma
focuses on eliminating ama through the digestive tract and the
respiratory system. Enemas, massage, medical oils administered
in a nasal spray, and other methods may be used.
s 2EDUCINGSYMPTOMS4HEPRACTITIONERMAYSUGGESTVARIOUSOP-
tions, including physical exercises, stretching, breathing exercis-
es, meditation, massage, lying in the sun, and changing the diet.
The patient may take certain herbsoften with honey, to make
them easier to digest. Sometimes diets are restricted to certain
foods. Very small amounts of metal and mineral preparations,
such as gold or iron, also may be given.
s )NCREASINGRESISTANCETODISEASE4HEPRACTITIONERMAYCOMBINE
several herbs, proteins, minerals, and vitamins in tonics to improve
digestion and increase appetite and immunity. These tonics are
based on formulas from ancient texts.
s 2EDUCINGWORRYANDINCREASINGHARMONY!YURVEDICMEDICINE
emphasizes mental nurturing and spiritual healing. Practitio-
ners may recommend avoiding situations that cause worry and
using techniques that promote release of negative emotions.
Use of plants: Ayurvedic treatments rely heavily on herbs and

other plantsincluding oils and common spices. Currently, more than
600 herbal formulas and 250 single plant drugs are included in the
pharmacy of Ayurvedic treatments. Historically, Ayurvedic medicine
has grouped plant compounds into categories according to their effects
69
(for example, healing, promoting vitality, or relieving pain). The com-

pounds are described in texts issued by national medical agencies in
India. Sometimes, botanicals are mixed with metals or other naturally
occurring substances to make formulas prepared according to specic
Ayurvedic text procedures; such preparations involve several herbs
and herbal extracts and precise heat treatment.
Practitioner Training and Certication

Many practitioners study in India, where there are more than
150 undergraduate and 30 postgraduate colleges for Ayurvedic medi-
cine. Training can take 5 years or longer. Students who receive their
Ayurvedic training in India can earn either a bachelors degree (Bach-
elor of Ayurvedic Medicine and Surgery, BAMS) or doctoral degree
(Doctor of Ayurvedic Medicine and Surgery, DAMS) there. After gradu-
ation, some Ayurvedic practitioners choose to provide services in the
United States or other countries.
The United States has no national standard for training or certi-
fying Ayurvedic practitioners, although a few states have approved
Ayurvedic schools as educational institutions.
Concerns about Ayurvedic Medications

Ayurvedic practice involves the use of medications that typically
contain herbs, metals, minerals, or other materials. Health ofcials in
India and other countries have taken steps to address some concerns
about these medications. Concerns relate to toxicity, formulations,
interactions, and scientic evidence.
Toxicity: Ayurvedic medications have the potential to be toxic.
Many materials used in them have not been thoroughly studied in
either Western or Indian research. In the United States, Ayurvedic
medications are regulated as dietary supplements. As such, they are
not required to meet the safety and efcacy standards for conventional
medicines. An NCCAM-funded study published in 2004 found that of
70 Ayurvedic remedies purchased over-the-counter (all manufactured
in South Asia), 14 contained lead, mercury, and/or arsenic at levels that
could be harmful. Also in 2004, the Centers for Disease Control and
Prevention reported that 12 cases of lead poisoning occurring over a re-
cent 3-year period were linked to the use of Ayurvedic medications.
Formulations: Most Ayurvedic medications consist of combina-

tions of herbs and other medicines. It can be challenging to know which
components are having an effect and why.
70
Ayurvedic Medicine
Interactions: Whenever two or more medications are used, there

is the potential for them to interact with each other. As a result, the
effectiveness of at least one may increase or decrease in the body.
Scientic evidence: Most clinical trials (i.e., studies in people) of

Ayurvedic approaches have been small, had problems with research
designs, lacked appropriate control groups, or had other issues that af-
fected how meaningful the results were. Therefore, scientic evidence
for the effectiveness of Ayurvedic practices varies, and more rigorous
research is needed to determine which practices are safe and effective.
Other Points to Consider about Using Ayurvedic

Medicine
s 4ELLYOURHEALTHCAREPROVIDERSABOUTANYCOMPLEMENTARYAND
alternative practices you use, including Ayurvedic medicine.
Give them a full picture of what you do to manage your health.
This will help to ensure coordinated and safe care.
s 7OMENWHOAREPREGNANTORNURSINGORPEOPLEWHOARETHINKING
of using Ayurvedic therapy to treat a child, should be especially
sure to consult their health care provider.
s )TISIMPORTANTTOMAKESURETHATANYDIAGNOSISOFADISEASEOR
condition has been made by a provider who has substantial con-
ventional medical training and experience with managing that
disease or condition.
s 0ROVENCONVENTIONALTREATMENTSSHOULDNOTBEREPLACEDWITHAN
unproven CAM treatment.
s )TISBETTERTOUSE!YURVEDICREMEDIESUNDERTHESUPERVISIONOF
an Ayurvedic medicine practitioner than to try to treat yourself.
s "EFOREUSING!YURVEDICTREATMENTASKABOUTTHEPRACTITIONERS
training and experience.
s &INDOUTWHETHERANYRIGOROUSSCIENTIlCSTUDIESHAVEBEENDONE
on the therapies in which you are interested.
71
Chapter 12
Other Indigenous
Medical Systems
Chapter Contents
Section 12.1Traditional Chinese Medicine .............................. 74
Section 12.2Native American Medicine ................................... 78
73
Section 12.1
Traditional Chinese Medicine

From Traditional Chinese Medicine: An Introduction, from the Na-
tional Center for Complementary and Alternative Medicine (NCCAM,
nccam.nih.gov), part of the National Institutes of Health, March 2009.
Traditional Chinese medicine (TCM) originated in ancient China

and has evolved over thousands of years. TCM practitioners use herbs,
acupuncture, and other methods to treat a wide range of conditions.
In the United States, TCM is considered part of complementary and
alternative medicine (CAM).
Background
Traditional Chinese medicine, which encompasses many different
practices, is rooted in the ancient philosophy of Taoism and dates
back more than 5,000 years. Today, TCM is practiced side by side with
Western medicine in many of Chinas hospitals and clinics.
TCM is widely used in the United States. Although the exact num-
ber of people who use TCM in the United States is unknown, it was
estimated in 1997 that some 10,000 practitioners served more than
1 million patients each year. According to the 2007 National Health
Interview Survey, which included questions on the use of various CAM
therapies, an estimated 3.1 million U.S. adults had used acupuncture
in the previous year. In addition, according to this same survey, ap-
proximately 17 percent of adults use natural products, including herbs,
making it the most commonly used therapy. In another survey, more
than one third of the patients at six large acupuncture clinics said they
also received Chinese herbal treatments at the clinics.
Underlying Concepts
Underlying the practice of TCM is a unique view of the world and
the human body that is different from Western medicine concepts.
This view is based on the ancient Chinese perception of humans as
microcosms of the larger, surrounding universeinterconnected with
nature and subject to its forces. The human body is regarded as an
74
Other Indigenous Medical Systems
organic entity in which the various organs, tissues, and other parts
have distinct functions but are all interdependent. In this view, health
and disease relate to balance of the functions.
The theoretical framework of TCM has a number of key compo-
nents:
s 9IN YANGTHEORYTHECONCEPTOFTWOOPPOSINGYETCOMPLEMEN-
tary, forces that shape the world and all lifeis central to TCM.
s )NTHE4#-VIEWAVITALENERGYORLIFEFORCECALLEDQICIRCULATES
in the body through a system of pathways called meridians.
Health is an ongoing process of maintaining balance and har-
mony in the circulation of qi.
s 4HE4#-APPROACHUSESEIGHTPRINCIPLESTOANALYZESYMPTOMS
and categorize conditions: cold/heat, interior/exterior, excess/
deciency, and yin/yang (the chief principles). TCM also uses the
theory of ve elementsre, earth, metal, water, and woodto
explain how the body works; these elements correspond to par-
ticular organs and tissues in the body.
These concepts are documented in the Huang Di Nei Jing (Inner

Canon of the Yellow Emperor), the classic Chinese medicine text.
Treatment
TCM emphasizes individualized treatment. Practitioners tradition-
ally used four methods to evaluate a patients condition: observing
(especially the tongue), hearing/smelling, asking/interviewing, and
touching/palpating (especially the pulse).
TCM practitioners use a variety of therapies in an effort to promote
health and treat disease. The most commonly used are Chinese herbal
medicine and acupuncture.
s Chinese herbal medicine: The Chinese materia medica (a
pharmacological reference book used by TCM practitioners) con-
tains hundreds of medicinal substancesprimarily plants, but also
some minerals and animal productsclassied by their perceived
action in the body. Different parts of plants such as the leaves,
roots, stems, owers, and seeds are used. Usually, herbs are com-
bined in formulas and given as teas, capsules, tinctures, or powders.
s Acupuncture: By stimulating specic points on the body, most
often by inserting thin metal needles through the skin, practitio-
ners seek to remove blockages in the ow of qi.
75
Other TCM therapies include moxibustion (burning moxaa cone

or stick of dried herb, usually mugworton or near the skin, some-
times in conjunction with acupuncture); cupping (applying a heated
cup to the skin to create a slight suction); Chinese massage; mind-body
therapies such as qi gong and tai chi; and dietary therapy.
Status of TCM Research

In spite of the widespread use of TCM in China and its use in the
West, scientic evidence of its effectiveness is, for the most part, lim-
ited. TCMs complexity and underlying conceptual foundations pres-
ent challenges for researchers seeking evidence on whether and how
it works. Most research has focused on specic modalities, primarily
acupuncture and Chinese herbal remedies.
Acupuncture research has produced a large body of scientic evi-
dence. Studies suggest that it may be useful for a number of different
conditions, but additional research is still needed.
Chinese herbal medicine has also been studied for a wide range
of conditions. Most of the research has been done in China. Although
there is evidence that herbs may be effective for some conditions, most
studies have been methodologically awed, and additional, better de-
signed research is needed before any conclusions can be drawn.
Examples of TCM Uses and Studies

Both acupuncture and Chinese herbal medicine have been used
and studied for a wide range of conditions:
s !CUPUNCTURE
s "ACKPAIN s #HEMOTHERAPY INDUCEDNAUSEA
s $EPRESSION s /STEOARTHRITIS
s #HINESEHERBALMEDICINE
s #ANCER s (EARTDISEASE s $IABETES
s ()6!)$3;HUMANIMMUNODElCIENCYVIRUSACQUIREDIMMU-
nodeciency syndrome]
Safety
The U.S. Food and Drug Administration (FDA) regulations for di-
etary supplements (including manufactured herbal products) are not
the same as those for prescription or over-the-counter drugs; in general,
the regulations for dietary supplements are less strict. Some Chinese
76
herbal treatments may be safe, but others may not. There have been
reports of products being contaminated with drugs, toxins, or heavy
metals or not containing the listed ingredients. Some of the herbs are
very powerful, can interact with drugs, and may have serious side
effects. For example, the Chinese herb ephedra (ma huang) has been
linked to serious health complications, including heart attack and
stroke. In 2004, the FDA banned the sale of ephedra-containing dietary
supplements used for weight loss and performance enhancement, but
the ban does not apply to TCM remedies or to herbal teas.
Acupuncture is considered safe when performed by an experienced
practitioner using sterile needles.
Training, Licensing, and Certication

Most states license acupuncture, but states vary in their inclu-
sion of other TCM components (e.g., herbal medicine) in the licenses
they issue. The federally recognized Accreditation Commission for
Acupuncture and Oriental Medicine (ACAOM) accredits schools that
teach acupuncture and TCM, and about one third of the states that
license acupuncture require graduation from an ACAOM-accredited
school. The National Certication Commission for Acupuncture and
Oriental Medicine (NCCAOM) offers separate certication programs
in acupuncture, Chinese herbology, and Oriental bodywork. Almost
all licensing states require completion of NCCAOMs national written
exam; some states also require a practical exam.
If You Are Thinking about Using TCM

s ,OOKFORPUBLISHEDRESEARCHSTUDIESON4#-FORTHEHEALTHCON-
dition that interests you.
s )FYOUARETHINKINGABOUTTRYING4#-HERBALREMEDIESITISBET-
ter to use these products under the supervision of a medical pro-
fessional trained in herbal medicine than to try to treat yourself.
s !SKABOUTTHETRAININGANDEXPERIENCEOFTHE4#-PRACTITIONER
you are considering.
s $ONOTUSE4#-ASAREPLACEMENTFOREFFECTIVECONVENTIONALCAREOR
as a reason to postpone seeing a doctor about a medical problem.
s )FYOUAREPREGNANTORNURSINGORARETHINKINGOFUSING4#-TO
treat a child, you should be especially sure to consult your health
care provider.
77
s 4ELLALLYOURHEALTHCAREPROVIDERSABOUTANYCOMPLEMENTARYAND
alternative practices you use. Give them a full picture of what
you do to manage your health. This will help ensure coordinated
and safe care.
NCCAM-Funded Research
2ECENT.##!- SUPPORTEDSTUDIESHAVEBEENINVESTIGATINGTHEFOL-
lowing:
s 4#-FORENDOMETRIOSIS RELATEDPELVICPAINIRRITABLEBOWELSYN-
drome, and temporomandibular (jaw) disorders
s #HINESEHERBALMEDICINESFORFOODALLERGIESANDFOROSTEOARTHRITIS
of the knee
s #ONSISTENCYOF4#-PRACTITIONERSDIAGNOSISANDHERBALPRESCRIP-
tions for rheumatoid arthritis patients
Section 12.2
Native American Medicine

2EPRINTEDWITHPERMISSIONFROMTHEWEBSITEOFTHE*OHN-OORES5NIVER-
sity of CaliforniaSan Diego Cancer Center, http://cancer.ucsd.edu. 2002
5NIVERSITYOF#ALIFORNIAn3AN$IEGO!LLRIGHTSRESERVED2EVIEWEDBY$AVID
A. Cooke, MD, FACP, December 25, 2009.
This treatment modality is thought to manage symptoms of cancer, side

effects from conventional therapies, and/or control pain. Native American
healing should be used with, not in place of, standard cancer therapy.
What does Native American healing involve?

Native American healing combines religion, community ritual,
spirituality, and herbal medicine to treat illness. Because of their
Eurasian ancestry, many of the beliefs of Native Americans have their
roots in ancient Indian (Ayurvedic) and Chinese medicine. Native
American tribes share a common belief in the interconnectedness
of people, the community, the environment and the spiritual world.
78
Harmony must exist amongst them for good health to dominant a

community. Native American healers believe that illness results from
spiritual imbalances within the individual and the community. The
community relies upon medicine men and women, or shamanic heal-
ers, who are thought to be able to contact the spiritual world to heal
illness and ght disease. Native American tradition focuses on four
elements of healing:
1. Symbolic ritualto communicate with the spiritual world and
enlist its aid in healing
2. Shamanic healersoffer prayers to appease spirits so that
they will treat illness and restore health
3. Purication of the bodyto rid the body of impurities and re-
store a spiritually pure state
4. Use of herbs as medicine
How is Native American healing thought to manage specic

symptoms of cancer, side effects of conventional therapies,
and/or control pain?
The heavy dependence on spiritual communication and meditation
may reduce stress and anxiety, bring about peace of mind, and pro-
duce a sense of wholeness among patients. Native American knowl-
edge of herbs is extensive and many have value in treating a variety
of ills, symptoms of disease, side effects of conventional treatment,
and reduction of pain.
What has been proven about the benet of Native American

healing?
Formal research of the healing ceremonies and traditions of Native
Americans is almost nonexistent even though claims have been made
regarding cures of a variety of ailments, including cancer. However,
the community-based approach to health care may provide comfort
to patients who enjoy the sense of sharing a common purpose and
history with a large group of people. Other health benets may be
the result of the placebo response. According to the American Cancer
Society, although Native American healing has not been shown to cure
disease, anecdotal reports suggest that it can reduce pain and stress,
and improve quality of life. However, it should not be relied on to cure
cancer, or used instead of modern, science-based treatment.
79
What is the potential risk or harm of Native American

healing?
Many purication rituals have side effects. Sweat lodges may cause
patients to become dehydrated. An herbal tea called Black Drink
causes patients to vomit.
How much does Native American healing cost?

Information on cost is unavailable.
For Additional Information

Association of American Indian Physicians
3OVEREIGN2OW3UITE
Oklahoma City, OK 73108
Phone: 405-946-7072
Website: www.aaip.org
Institute for Traditional Medicine

2017 SE Hawthorne Boulevard
0ORTLAND/2
Phone: 503-233-4907
Website: www.itmonline.org
80
Chapter 13
Acupuncture
Acupuncture is among the oldest healing practices in the world. As

part of traditional Chinese medicine, acupuncture aims to restore and
maintain health through the stimulation of specic points on the body.
In the United States, where practitioners incorporate healing tradi-
tions from China, Japan, Korea, and other countries, acupuncture is
considered part of complementary and alternative medicine (CAM).
About Acupuncture
The term acupuncture describes a family of procedures involving
the stimulation of anatomical points on the body using a variety of tech-
niques. The acupuncture technique that has been most often studied sci-
entically involves penetrating the skin with thin, solid, metallic needles
that are manipulated by the hands or by electrical stimulation.
Practiced in China and other Asian countries for thousands of years,
acupuncture is one of the key components of traditional Chinese medi-
cine. In TCM, the body is seen as a delicate balance of two opposing
and inseparable forces: yin and yang. Yin represents the cold, slow, or
passive principle, while yang represents the hot, excited, or active prin-
ciple. According to TCM, health is achieved by maintaining the body in
a balanced state; disease is due to an internal imbalance of yin and
Excerpted from Acupuncture: An Introduction, by the National Center for

National Institutes of Health, December 2007.
81
yang. This imbalance leads to blockage in the ow of qi (vital energy)

along pathways known as meridians. Qi can be unblocked, according to
TCM, by using acupuncture at certain points on the body that connect
with these meridians. Sources vary on the number of meridians, with
numbers ranging from 14 to 20. One commonly cited source describes
meridians as 14 main channels connecting the body in a weblike in-
terconnecting matrix of at least 2,000 acupuncture points.
Acupuncture became better known in the United States in 1971,
when New York TimesREPORTER*AMES2ESTONWROTEABOUTHOWDOC-
tors in China used needles to ease his pain after surgery. American
practices of acupuncture incorporate medical traditions from China,
Japan, Korea, and other countries.
Acupuncture Use in the United States

The report from a Consensus Development Conference on Acupunc-
ture held at the National Institutes of Health (NIH) in 1997 stated that
acupuncture is being widely practicedby thousands of physicians,
dentists, acupuncturists, and other practitionersfor relief or prevention
of pain and for various other health conditions. According to the 2007
National Health Interview Survey, which included a comprehensive sur-
vey of CAM use by Americans, an estimated 3.1 million U.S. adults and
150,000 children had used acupuncture in the previous year. Between
the 2002 and 2007 NHIS, acupuncture use among adults increased by
three-tenths of 1 percent (approximately 1 million people).
Acupuncture Side Effects and Risks

The U.S. Food and Drug Administration (FDA) regulates acupunc-
ture needles for use by licensed practitioners, requiring that needles
be manufactured and labeled according to certain standards. For ex-
ample, the FDA requires that needles be sterile, nontoxic, and labeled
for single use by qualied practitioners only.
2ELATIVELYFEWCOMPLICATIONSFROMTHEUSEOFACUPUNCTUREHAVEBEEN
reported to the FDA, in light of the millions of people treated each year
and the number of acupuncture needles used. Still, complications have
resulted from inadequate sterilization of needles and from improper
delivery of treatments. Practitioners should use a new set of disposable
needles taken from a sealed package for each patient and should swab
treatment sites with alcohol or another disinfectant before inserting
needles. When not delivered properly, acupuncture can cause serious
adverse effects, including infections and punctured organs.
82
Acupuncture
Status of Acupuncture Research

There have been many studies on acupunctures potential health
benets for a wide range of conditions. Summarizing earlier research,
the 1997 NIH Consensus Statement on Acupuncture found that, over-
all, results were hard to interpret because of problems with the size
and design of the studies.
In the years since the Consensus Statement was issued, the Na-
tional Center for Complementary and Alternative Medicine (NCCAM)
has funded extensive research to advance scientic understanding of
acupuncture. Some recent NCCAM-supported studies have looked at
the following:
s 7HETHERACUPUNCTUREWORKSFORSPECIlCHEALTHCONDITIONS
such as chronic low-back pain, headache, and osteoarthritis of
the knee
s (OWACUPUNCTUREMIGHTWORKSUCHASWHATHAPPENSINTHE
brain during acupuncture treatment
s 7AYSTOBETTERIDENTIFYANDUNDERSTANDTHEPOTENTIALNEUROLOGI-
cal properties of meridians and acupuncture points
s -ETHODSANDINSTRUMENTSFORIMPROVINGTHEQUALITYOFACUPUNC-
ture research
Finding a Qualied Practitioner

Health care providers can be a resource for referral to acupunctur-
ists, and some conventional medical practitionersincluding phy-
sicians and dentistspractice acupuncture. In addition, national
acupuncture organizations (which can be found through libraries or
search engines) may provide referrals to acupuncturists.
s #HECKAPRACTITIONERSCREDENTIALS-OSTSTATESREQUIREALICENSE
to practice acupuncture; however, education and training stan-
dards and requirements for obtaining a license to practice vary
from state to state. Although a license does not ensure quality
of care, it does indicate that the practitioner meets certain stan-
dards regarding the knowledge and use of acupuncture.
s $ONOTRELYONADIAGNOSISOFDISEASEBYANACUPUNCTUREPRACTI-
tioner who does not have substantial conventional medical train-
ing. If you have received a diagnosis from a doctor, you may wish
to ask your doctor whether acupuncture might help.
83
What to Expect from Acupuncture Visits

During your rst ofce visit, the practitioner may ask you at length
about your health condition, lifestyle, and behavior. The practitioner
will want to obtain a complete picture of your treatment needs and be-
haviors that may contribute to your condition. Inform the acupunctur-
ist about all treatments or medications you are taking and all medical
conditions you have.
Acupuncture needles are metallic, solid, and hair-thin. People ex-
perience acupuncture differently, but most feel no or minimal pain as
the needles are inserted. Some people feel energized by treatment,
while others feel relaxed. Improper needle placement, movement of
the patient, or a defect in the needle can cause soreness and pain dur-
ing treatment. This is why it is important to seek treatment from a
qualied acupuncture practitioner.
Treatment may take place over a period of several weeks or more.
Treatment Costs
Ask the practitioner about the estimated number of treatments need-
ed and how much each treatment will cost. Some insurance companies
may cover the costs of acupuncture, while others may not. It is important
to check with your insurer before you start treatment to see whether
acupuncture is covered for your condition and, if so, to what extent.
84
Chapter 14
Homeopathy
Homeopathy, also known as homeopathic medicine, is a whole medi-

cal system that was developed in Germany more than 200 years ago
and has been practiced in the United States since the early 19th cen-
tury. Homeopathy is used for wellness and prevention and to treat
many diseases and conditions.
Overview
The term homeopathy comes from the Greek words homeo, meaning
similar, and pathos, meaning suffering or disease. Homeopathy seeks
to stimulate the bodys ability to heal itself by giving very small doses
of highly diluted substances. This therapeutic method was developed
by German physician Samuel Christian Hahnemann at the end of the
18th century. Hahnemann articulated two main principles:
s The principle of similars (or like cures like) states that a dis-
ease can be cured by a substance that produces similar symptoms in
healthy people. This idea, which can be traced back to Hippocrates,
was further developed by Hahnemann after he repeatedly ingested
cinchona bark, a popular treatment for malaria, and found that he
developed the symptoms of the disease. Hahnemann theorized that
if a substance could cause disease symptoms in a healthy person,
small amounts could cure a sick person who had similar symptoms.
Excerpted from Homeopathy: An Introduction, by the National Center for

National Institutes of Health, July 2009.
85
s The principle of dilutions (or law of minimum dose) states that

the lower the dose of the medication, the greater its effectiveness.
In homeopathy, substances are diluted in a stepwise fashion and
shaken vigorously between each dilution. This process, referred to as
potentization, is believed to transmit some form of information or
energy from the original substance to the nal diluted remedy. Most
homeopathic remedies are so dilute that no molecules of the heal-
ing substance remain; however, in homeopathy, it is believed that
the substance has left its imprint or essence, which stimulates the
body to heal itself (this theory is called the memory of water).
Homeopaths treat people based on genetic and personal health his-

tory, body type, and current physical, emotional, and mental symptoms.
Patient visits tend to be lengthy. Treatments are individualized or
tailored to each personit is not uncommon for different people with
the same condition to receive different treatments.
Homeopathic remedies are derived from natural substances that
come from plants, minerals, or animals. Common remedies include red
onion, arnica (mountain herb), and stinging nettle plant.

According to the 2007 National Health Interview Survey, which in-
cluded a comprehensive survey of complementary and alternative medi-
cine (CAM) use by Americans, an estimated 3.9 million U.S. adults and
approximately 900,000 children used homeopathy in the previous year.
People use homeopathy for a range of health concerns, from well-
ness and prevention, to the treatment of diseases and conditions such
as allergies, asthma, chronic fatigue syndrome, depression, digestive
disorders, ear infections, headaches, and skin rashes.
Regulation of Homeopathic Treatments

Homeopathic remedies are prepared according to the guidelines of
the Homeopathic Pharmacopeia of the United States (HPUS), which was
written into law in the Federal Food, Drug, and Cosmetic Act in 1938. Ho-
meopathic remedies are regulated in the same manner as nonprescription,
over-the-counter (OTC) drugs. However, because homeopathic products
contain little or no active ingredients, they do not have to undergo the
same safety and efcacy testing as prescription and new OTC drugs.
The U.S. Food and Drug Administration (FDA) does require that ho-
meopathic remedies meet certain legal standards for strength, purity,
and packaging. The labels on the remedies must include at least one
86
Homeopathy
major indication (i.e., medical problem to be treated), a list of ingredi-

ents, the dilution, and safety instructions. In addition, if a homeopathic
remedy claims to treat a serious disease such as cancer, it needs to be
sold by prescription. Only products for self-limiting conditions (minor
health problems like a cold or headache that go away on their own)
can be sold without a prescription.
The Status of Homeopathy Research

Most analyses of the research on homeopathy have concluded that
there is little evidence to support homeopathy as an effective treat-
ment for any specic condition, and that many of the studies have
been awed. However, there are some individual observational stud-
ies, randomized placebo-controlled trials, and laboratory research that
report positive effects or unique physical and chemical properties of
homeopathic remedies.
Research Challenges
Homeopathy is difcult to study using current scientic methods
because highly diluted substances (known as ultra-high dilutions or
UHDs) cannot be readily measured, making it difcult to design or
replicate studies. In addition, homeopathic treatments are highly in-
dividualized and there is no uniform prescribing standard for homeo-
paths. There are hundreds of different homeopathic remedies, which
can be prescribed in a variety of different dilutions to treat thousands
of symptoms. On the other hand, many aspects of the interactions
between the homeopathic practitioner and his or her patients may be
quite benecial, and can be studied more easily.
Controversies Regarding Homeopathy

Homeopathy is a controversial area of CAM because a number of
its key concepts are not consistent with established laws of science
(particularly chemistry and physics). Critics think it is implausible
that a remedy containing a miniscule amount of an active ingredient
(sometimes not a single molecule of the original compound) can have
any biological effectbenecial or otherwise. For these reasons, crit-
ics argue that continuing the scientic study of homeopathy is not
worthwhile. Others point to observational and anecdotal evidence that
homeopathy does work and argue that it should not be rejected just
because science has not been able to explain it.
87
Side Effects and Risks

Although the side effects and risks of homeopathic treatments are
not well researched outside of observational studies, some general
points can be made about the safety of these treatments:
s !SYSTEMATICREVIEWFOUNDTHATHOMEOPATHICREMEDIESINHIGH
dilution, taken under the supervision of trained professionals,
are generally considered safe and unlikely to cause severe ad-
verse reactions.
s ,IQUIDHOMEOPATHICREMEDIESMAYCONTAINALCOHOL4HE&$!AL-
lows higher levels of alcohol in these remedies than it allows in
conventional drugs. However, no adverse effects from alcohol lev-
els have been reported to the FDA.
s Homeopaths expect some of their patients to experience homeo-
pathic aggravation (a temporary worsening of existing symp-
TOMSAFTERTAKINGAHOMEOPATHICPRESCRIPTION 2ESEARCHERSHAVE
not found much evidence of this reaction in clinical studies; how-
ever, research on homeopathic aggravations is scarce.
s (OMEOPATHICREMEDIESARENOTKNOWNTOINTERFEREWITHCONVENTION-
al drugs; however, if you are considering using homeopathic rem-
edies, you should discuss this with your health care provider rst.
Licensing and Certication

There are currently no uniform licensing or professional standards
for the practice of homeopathy in the United States; the licensing of
homeopaths varies from state to state. Usually, a homeopathic prac-
titioner is licensed in a medical profession, such as conventional or
osteopathic medicine. Homeopathy is also part of the medical educa-
tion for naturopathy.
Licensure as a homeopathic physician is available only to medical
doctors and doctors of osteopathy in Arizona, Connecticut, and Nevada.
Arizona and Nevada also license homeopathic assistants, who are al-
lowed to perform medical services under the supervision of a homeo-
pathic physician. Some states explicitly include homeopathy within
the scope of practice of chiropractic, naturopathy, physical therapy,
dentistry, nursing, and veterinary medicine.
National certication may be obtained through organizations such
as the Council for Homeopathic Certication, American Board of
Homeotherapeutics, and the Homeopathic Academy of Naturopathic
88
Homeopathy
Physicians. The U.S. Department of Education, which ofcially rec-

ognizes some CAM organizations for certication purposes, has not
recognized these organizations; however, members of the homeopathic
community consider certication a way to help set education and com-
petency standards for practicing homeopathy.
If You Are Thinking about Using Homeopathy
s $ONOTUSEHOMEOPATHYASAREPLACEMENTFORPROVENCONVENTIONAL
care or to postpone seeing a doctor about a medical problem.
s ,OOKFORPUBLISHEDRESEARCHSTUDIESONHOMEOPATHYFORTHE
health condition you are interested in.
s )FYOUARECONSIDERINGUSINGHOMEOPATHYANDDECIDETOSEEK
treatment from a homeopath, ask about the training and experi-
ence of the practitioner you are considering.
of using homeopathy to treat a child, should consult their health
care provider.
Tell your health care providers about any complementary and al-
ternative practices you use. Give them a full picture of all you do to
manage your health. This will ensure coordinated and safe care.
NCCAM-supported exploratory grants have sought to understand
patient and provider perspectives on homeopathic treatment and have
explored the effectiveness of homeopathic remedies with various suc-
cussions (vigorous shaking) and dilutions.
89
Chapter 15
Naturopathy
Naturopathy, also called naturopathic medicine, is a whole medical

systemone of the systems of healing and beliefs that have evolved
over time in different cultures and parts of the world. Naturopathy is
rooted in health care approaches that were popular in Europe, espe-
cially in Germany, in the 19th century, but it also includes therapies
(both ancient and modern) from other traditions. In naturopathy, the
emphasis is on supporting health rather than combating disease.
A Brief Description of Naturopathy

Naturopathy is a whole medical system that has its roots in Ger-
many. It was developed further in the late 19th and early 20th centu-
ries in the United States, where today it is part of complementary and
alternative medicine (CAM). The word naturopathy comes from Greek
and Latin and literally translates as nature disease.
A central belief in naturopathy is that nature has a healing power
(a principle called vis medicatrix naturae). Another belief is that living
organisms (including the human body) have the power to maintain
(or return to) a state of balance and health, and to heal themselves.
Practitioners of naturopathy prefer to use treatment approaches that
they consider to be the most natural and least invasive, instead of us-
ing drugs and more invasive procedures.
Excerpted from An Introduction to Naturopathy, by the National Center
for Complementary and Alternative Medicine (NCCAM, nccam.nih.gov), part of
the National Institutes of Health, April 2007.
91
Naturopathy was named and popularized in the United States by

Benedict Lust, who was born in Germany in the late 1800s. When Lust
became seriously ill with what he believed was tuberculosis, he was
treated by a priest and healer in Germany named Sebastian Kneipp.
Kneipps treatment was based on various healing approaches and
philosophies that were popular in Europe, including the following:
s (YDROTHERAPYWATERTREATMENTS
s 4HEhNATURECUREvMOVEMENTWHICHFOCUSEDONRESTORINGHEALTH
through a return to nature
This movement advocated therapies such as gentle exercise,

herbal medications, wholesome dietary approaches, and exposure
to sun and air.
Lust found his health much improved from Kneipps treatment,
and when he immigrated to the United States at the turn of the 20th
century, he was dedicated to popularizing it. He gave it the name
naturopathy, led the way in developing it as a medical system in the
United States, and founded the rst naturopathic college and profes-
sional association. In naturopathys early years, other therapies were
added to its practicefor example, homeopathy and manipulation (a
hands-on therapy).
Naturopathys popularity reached its peak in the United States in
the 1920s and 1930s. However, its use began to decline when drugs
(such as antibiotics) and other developments in conventional medicine
moved to the forefront of health care. Naturopathy began to reemerge
in the 1970s, with increased consumer interest in holistic health ap-
proaches and the founding of new naturopathic medical colleges. Today,
naturopathy is practiced in a number of countries, including the United
States, Canada, Great Britain, Australia, and New Zealand.
Americans Use of Naturopathy

In a national survey on Americans use of CAM, published in 2004,
just under 1 percent of the 31,000 survey respondents had used natur-
opathy. These respondents reported that they used it because of the
following reasons:
s 4HEYBELIEVEDTHATNATUROPATHYCOMBINEDWITHCONVENTIONAL
medicine would help (62 percent).
s 4HEYBELIEVEDTHATCONVENTIONALMEDICALTREATMENTSWOULDNOT
help (53 percent).
92
Naturopathy
s 4HEYTHOUGHTNATUROPATHYWOULDBEINTERESTINGTOTRYPERCENT
s 4HEYTHOUGHTTHATCONVENTIONALMEDICINEWASTOOEXPENSIVE
percent).
s 4HEYWEREREFERREDTONATUROPATHYBYACONVENTIONALMEDICAL
professional (17 percent).
3OURCE"ARNES0-0OWELL 'RINER%-C&ANN+.AHIN2,#OMPLE-

mentary and alternative medicine use among adults: United States,
#$#!DVANCE$ATA2EPORT
Key Principles
The practice of naturopathy is based on six key principles:
1. Promote the healing power of nature.
2. First do no harm. Naturopathic practitioners choose therapies
with the intent to keep harmful side effects to a minimum and
not suppress symptoms.
3. Treat the whole person. Practitioners believe a persons
health is affected by many factors, such as physical, mental,
emotional, genetic, environmental, and social ones. Practitio-
ners consider all these factors when choosing therapies and
tailor treatment to each patient.
4. Treat the cause. Practitioners seek to identify and treat the
causes of a disease or condition, rather than its symptoms.
They believe that symptoms are signs that the body is trying
to ght disease, adapt to it, or recover from it.
5. Prevention is the best cure. Practitioners teach ways of living that
they consider most healthy and most likely to prevent illness.
6. The physician is a teacher. Practitioners consider it impor-
tant to educate their patients in taking responsibility for
their own health.
Who Provides Naturopathy?

In the United States, professionals who practice naturopathy gener-
ally fall into one of several groups. (The terms used by some practitio-
ners vary and may depend on the legal situation in the states where
they practice.)
93
Naturopathic Physicians
Naturopathic physicians are educated and trained in a 4-year,
graduate-level program at one of the four U.S. naturopathic medical
schools accredited by the Council on Naturopathic Medical Education.
Admission requirements include a bachelors degree and standard
premedical courses. The study program includes basic sciences, natur-
opathic therapies and techniques, diagnostic techniques and tests,
specialty courses, clinical sciences, and clinical training. Graduates
receive the degree of N.D. (Doctor of Naturopathic Medicine). Post-
doctoral training is not required, but graduates may pursue it.
Depending on where they wish to practice, naturopathic physicians
may also need to be licensed. A number of states, the District of Colum-
bia, and two U.S. territories have such licensing requirements, most of-
ten consisting of graduation from a 4-year naturopathic medical college
and passing the national standardized board examination (known as the
.0,%8;.ATUROPATHIC0HYSICIANS,ICENSING%XAMINATIONS= 4HESCOPEOF
practice varies by state and jurisdiction. For example, some states allow
naturopathic physicians with special training to prescribe drugs, perform
minor surgery, practice acupuncture, and/or assist in childbirth.
Traditional Naturopaths
The second major group of practitioners are traditional naturopaths,
or simply naturopaths. They emphasize education in naturopathic ap-
proaches to a healthy lifestyle, strengthening and cleansing the body,
and noninvasive treatments. Prescription drugs, x-rays, and surgery
are several of the practices that traditional naturopaths do not use.
Education and training for these practitioners typically consists of
correspondence courses, an apprenticeship, and/or self-teaching. Ad-
mission requirements for schools can range from none, to a high school
diploma, to specic degrees and coursework. Programs vary in length
and content. They are not accredited by agencies recognized for ac-
creditation purposes by the U.S. Department of Education. Traditional
naturopaths are not subject to licensing.
Conventional Providers with Naturopathic Training

This group consists of licensed conventional medical providers (such
as doctors of medicine, doctors of osteopathy, dentists, and nurses) who
pursue additional training in naturopathic treatments, and possibly
other holistic therapies. Education and training programs for this
purpose also vary.
94
Naturopathy
What Practitioners Do in Treating Patients

A rst visit to a naturopathic practitioner is usually an extended
appointment. The practitioner will interview the patient at length
about his health history, reasons for the visit, and lifestyle (such as
diet, stress, alcohol and tobacco use, sleep, and exercise). The practi-
tioner may perform examinations and, if in her scope of practice, order
diagnostic and screening tests. Toward the end of the appointment, a
management plan is set up to address the patients general health and
PROBLEMSWITHILLNESS2EFERRALSTOOTHERHEALTHCAREPROVIDERSMAY
be made, if appropriate. Practitioners may deliver some naturopathic
treatments in their ofces, such as hydrotherapy or manipulation.
Examples of additional treatments include the following:
s $IETARYCHANGESFOREXAMPLEEATINGMOREWHOLEAND
unprocessed foods)
s 6ITAMINSMINERALSANDOTHERDIETARYSUPPLEMENTS
s (ERBALMEDICINE
s #OUNSELINGANDEDUCATIONONLIFESTYLECHANGES
s (OMEOPATHY
s (YDROTHERAPYFOREXAMPLEAPPLYINGHOTWATERTHENCOLDWATER
s -ANUALANDBODY BASEDTHERAPIESSUCHASMANIPULATIONAND
mobilization
s %XERCISETHERAPY
s -IND BODYTHERAPIESSUCHASYOGAANDMEDITATION
Some practitioners use other treatments as well.

Naturopathy appears to be a generally safe health care approach,
especially if used as complementary (rather than alternative) medicine,
but several qualifying points are important:
s .ATUROPATHYISNOTACOMPLETESUBSTITUTEFORCONVENTIONALMEDI-
cal care.
s 3OMETHERAPIESUSEDINNATUROPATHYHAVETHEPOTENTIALTOBEHARM-
ful if not used properly or under the direction of a trained practi-
tioner. For example, herbs can cause side effects on their own and
INTERACTWITHPRESCRIPTIONOROVER THE COUNTERMEDICINES2ESTRICTIVE
or other unconventional diets can be unsafe for some people.
95
s 3OMEPRACTITIONERSOFNATUROPATHYDONOTRECOMMENDUSINGALL
or some of the childhood vaccinations that are standard practice
in conventional medicine.
s 4HEEDUCATIONANDTRAININGOFPRACTITIONERSOFNATUROPATHYVARY
widely.
Naturopathy as a whole medical system is challenging to study.

2IGOROUSRESEARCHONTHISWHOLEMEDICALSYSTEMISTAKINGPLACEBUTIS
at an early stage.
Some Other Points to Consider

and safe care.
s .ATUROPATHICPHYSICIANSARETRAINEDTOKNOWTHATHERBSAND
some dietary supplements can potentially interact with drugs,
and to avoid those combinations. To do so, they need to be in-
formed of all drugs (whether prescription or over-the-counter)
and supplements that you are taking.
s 4ALKTOTHEPRACTITIONERABOUTTHEFOLLOWING
s (ISEDUCATIONANDTRAININGANDANYLICENSINGORCERTIlCATION
s !NYSPECIALMEDICALCONDITIONSYOUHAVEANDWHETHERTHE
practitioner has had any specialized training or experience
in them
s #OSTSANDWHETHERTHESERVICESARECOVEREDBYYOURMEDICAL
insurance plan
Some Points of Controversy

As in other elds of CAM, there are some controversies in natur-
opathy.
s 0RACTITIONERSOFNATUROPATHYDONOTALWAYSAGREEONEDUCATIONALRE-
quirements or how naturopathy should be practiced and regulated.
s !NUMBEROFBELIEFSANDPRACTICESINNATUROPATHYDONOTFOLLOW
the scientic approach of conventional medicine.
s 0RACTITIONERSAREDIVIDEDONWHETHERTHISSYSTEMOFMEDICINE
should be studied using conventional medical research approaches.
96
Naturopathy
NCCAM-Funded Research in Naturopathy

Some recent NCCAM-supported projects have been studying the
following:
s #!-APPROACHESINCLUDINGNATUROPATHICTREATMENTSFORWOMEN
with temporomandibular disorder, a condition in which the
joints connecting the skull to the lower jaw become inamed
s !NATUROPATHICDIETARYAPPROACHASACOMPLEMENTARYTREATMENT
for type 2 diabetes
s 4HEMUSHROOMTrametes versicolor, for its effects as a comple-
mentary immune therapy in women with breast cancer
s 4HECOSTSANDEFFECTSOFNATUROPATHICCARECOMPAREDWITHCON-
ventional care, for low-back pain
s (ERBALANDDIETARYAPPROACHESFORMENOPAUSALSYMPTOMS
97
Part Three
Dietary Supplements
Chapter 16
Questions and Answers

about Dietary Supplements
What is a dietary supplement?

As dened by Congress in the Dietary Supplement Health and
Education Act, which became law in 1994, a dietary supplement is a
product (other than tobacco) that:
s ISINTENDEDTOSUPPLEMENTTHEDIET
s CONTAINSONEORMOREDIETARYINGREDIENTSINCLUDINGVITAMINS
MINERALSHERBSOROTHERBOTANICALSAMINOACIDSANDOTHERSUB-
STANCES ORTHEIRCONSTITUENTS
s ISINTENDEDTOBETAKENBYMOUTHASAPILLCAPSULETABLETOR
LIQUIDAND
s ISLABELEDONTHEFRONTPANELASBEINGADIETARYSUPPLEMENT
What is a new dietary ingredient?

A new dietary ingredient is a dietary ingredient that was not
sold in the United States in a dietary supplement before October
15, 1994.
Excerpted from Dietary Supplements: Background Information, by the

Ofce of Dietary Supplements (ODS, ods.od.nih.gov), part of the National Insti-
tutes of Health, July 9, 2009.
101
Are dietary supplements different from foods and drugs?

Although dietary supplements are regulated by the U.S. Food and
Drug Administration (FDA) as foods, they are regulated differently
from other foods and from drugs. Whether a product is classied
as a dietary supplement, conventional food, or drug is based on its
intended use. Most often, classication as a dietary supplement is
determined by the information that the manufacturer provides on
the product label or in accompanying literature, although many
food and dietary supplement product labels do not include this
information.
What claims can manufacturers make for dietary supple-

ments and drugs?
The types of claims that can be made on the labels of dietary supple-
ments and drugs differ. Drug manufacturers may claim that their
product will diagnose, cure, mitigate, treat, or prevent a disease. Such
claims may not legally be made for dietary supplements.
The label of a dietary supplement or food product may contain one of
three types of claims: a health claim, nutrient content claim, or struc-
ture/function claim. Health claims describe a relationship between a
food, food component, or dietary supplement ingredient, and reducing
risk of a disease or health-related condition. Nutrient content claims
describe the relative amount of a nutrient or dietary substance in a
product. A structure/function claim is a statement describing how a
product may affect the organs or systems of the body and it can not
mention any specic disease.
Structure/function claims do not require FDA approval but the
manufacturer must provide FDA with the text of the claim within 30
days of putting the product on the market. Product labels containing
such claims must also include a disclaimer that reads, This statement
has not been evaluated by the FDA. This product is not intended to
diagnose, treat, cure, or prevent any disease.
How does FDA regulate dietary supplements?

In addition to regulating label claims, FDA regulates dietary sup-
plements in other ways. Supplement ingredients sold in the United
States before October 15, 1994, are not required to be reviewed by
FDA for their safety before they are marketed because they are pre-
sumed to be safe based on their history of use by humans. For a new
dietary ingredient (one not sold as a dietary supplement before 1994)
102
Questions and Answers about Dietary Supplements
the manufacturer must notify FDA of its intent to market a dietary

supplement containing the new dietary ingredient and provide in-
formation on how it determined that reasonable evidence exists for
safe human use of the product. FDA can either refuse to allow new
ingredients into or remove existing ingredients from the marketplace
for safety reasons.
Manufacturers do not have to provide FDA with evidence that di-
ETARYSUPPLEMENTSAREEFFECTIVEORSAFEHOWEVERTHEYARENOTPERMITTED
to market unsafe or ineffective products. Once a dietary supplement
is marketed, FDA has to prove that the product is not safe in order
to restrict its use or remove it from the market. In contrast, before
being allowed to market a drug product, manufacturers must obtain
FDA approval by providing convincing evidence that it is both safe
and effective.
The label of a dietary supplement product is required to be truth-
ful and not misleading. If the label does not meet this requirement,
FDA may remove the product from the marketplace or take other
appropriate actions.
What information is required on a dietary supplement label?

FDA requires that certain information appear on the dietary sup-
plement label. General information includes the following:
s .AMEOFPRODUCTINCLUDINGTHEWORDhSUPPLEMENTvORASTATE-
ment that the product is a supplement)
s .ETQUANTITYOFCONTENTS
s .AMEANDPLACEOFBUSINESSOFMANUFACTURERPACKERORDISTRIBUTOR
s $IRECTIONSFORUSE
The Supplement Facts panel includes the following information:

s 3ERVINGSIZELISTOFDIETARYINGREDIENTSAMOUNTPERSERVINGSIZE
(by weight), percent of Daily Value (%DV), if established
s )FTHEDIETARYINGREDIENTISABOTANICALTHESCIENTIlCNAMEOFTHE
PLANTORTHECOMMONORUSUALNAMESTANDARDIZEDINTHEREFER-
ence Herbs of Commerce, 2nd Edition (2000 edition) and the
name of the plant part used
s )FTHEDIETARYINGREDIENTISAPROPRIETARYBLENDIEABLENDEX-
clusive to the manufacturer), the total weight of the blend and
the components of the blend in order of predominance by weight
103
Other ingredients that must be listed include nondietary ingredi-

ENTSSUCHASlLLERSARTIlCIALCOLORSSWEETENERSmAVORSORBINDERS
listed by weight in descending order of predominance and by common
name or proprietary blend.
The label of the supplement may contain a cautionary statement
but the lack of a cautionary statement does not mean that no adverse
effects are associated with the product.
Does a label indicate the quality of a dietary supplement

product?
It is difcult to determine the quality of a dietary supplement prod-
uct from its label. The degree of quality control depends on the manu-
facturer, the supplier, and others in the production process.
In 2007, the FDA issued Good Manufacturing Practices (GMPs) for
dietary supplements, a set of requirements and expectations by which
dietary supplements must be manufactured, prepared, and stored to
ensure quality. Manufacturers are expected to guarantee the identity,
purity, strength, and composition of their dietary supplements. For
example, the GMPs aim to prevent the inclusion of the wrong ingredi-
ents, the addition of too much or too little of a dietary ingredient, the
possibility of contamination (by pesticides, heavy metals such as lead,
bacteria, etc.), and the improper packaging and labeling of a product.
Large companies are required to comply with FDAs dietary supple-
ment GMPs now, and the smallest companies by June 2010.
Are dietary supplements standardized?

3TANDARDIZATIONISAPROCESSTHATMANUFACTURERSMAYUSETOENSURE
batch-to-batch consistency of their products. In some cases, standard-
IZATIONINVOLVESIDENTIFYINGSPECIlCCHEMICALSKNOWNASMARKERS THAT
CANBEUSEDTOMANUFACTUREACONSISTENTPRODUCT4HESTANDARDIZATION
process can also provide a measure of quality control.
$IETARYSUPPLEMENTSARENOTREQUIREDTOBESTANDARDIZEDINTHE
United States. In fact, no legal or regulatory denition exists in the
5NITED3TATESFORSTANDARDIZATIONASITAPPLIESTODIETARYSUPPLEMENTS
"ECAUSEOFTHISTHETERMhSTANDARDIZATIONvMAYMEANMANYDIFFERENT
THINGS3OMEMANUFACTURERSUSETHETERMSTANDARDIZATIONINCORRECTLY
TOREFERTOUNIFORMMANUFACTURINGPRACTICESFOLLOWINGARECIPEISNOT
SUFlCIENTFORAPRODUCTTOBECALLEDSTANDARDIZED4HEREFORETHEPRES-
ENCEOFTHEWORDhSTANDARDIZEDvONASUPPLEMENTLABELDOESNOTNECES-
sarily indicate product quality.
104
Questions and Answers about Dietary Supplements
What methods are used to evaluate the health benets and

safety of a dietary supplement?
Scientists use several approaches to evaluate dietary supplements
for their potential health benets and safety risks, including their his-
tory of use and laboratory studies using cell or animal studies. Studies
involving people (individual case reports, observational studies, and
clinical trials) can provide information that is relevant to how dietary
supplements are used. Researchers may conduct a systematic review
TOSUMMARIZEANDEVALUATEAGROUPOFCLINICALTRIALSTHATMEETCERTAIN
criteria. A meta-analysis is a review that includes a statistical analysis
of data combined from many studies.
What safety advice should people know about dietary sup-

plements?
s 4HEINFORMATIONINTHISTEXTDOESNOTREPLACEMEDICALADVICE
s "EFORETAKINGADIETARYSUPPLEMENTCONSULTADOCTOROROTHER
health care providerespecially if you have a disease or medical
condition, take any medications, are pregnant or nursing, or are
planning to have an operation.
s "EFORETREATINGACHILDWITHADIETARYSUPPLEMENTCONSULTWITHA
doctor or other health care provider.
s ,IKEDRUGSDIETARYSUPPLEMENTSHAVECHEMICALANDBIOLOGICAL
activity. They may have side effects. They may interact with cer-
tain medications. These interactions can cause problems and can
even be dangerous.
s )FYOUHAVEANYUNEXPECTEDREACTIONSTOADIETARYSUPPLEMENT
inform your doctor or other health care provider.
105
Chapter 17
Botanical Dietary
Supplements
What is a botanical?
A botanical is a plant or plant part valued for its medicinal or
therapeutic properties, avor, and/or scent. Herbs are a subset of bo-
tanicals. Products made from botanicals that are used to maintain or
improve health may be called herbal products, botanical products, or
phytomedicines.
In naming botanicals, botanists use a Latin name made up of the
genus and species of the plant. Under this system the botanical black
cohosh is known as Actaea racemosa L., where L stands for Linneaus,
who rst described the type of plant specimen. In this text, we do not
include such initials because they do not appear on most products
used by consumers.
Can botanicals be dietary supplements?

To be classied as a dietary supplement, a botanical must meet the def-
inition given below. Many botanical preparations meet the denition.
As dened by Congress in the Dietary Supplement Health and
Education Act, which became law in 1994, a dietary supplement is a
product (other than tobacco) that:
Excerpted from Botanical Dietary Supplements: Background Information,

by the Ofce of Dietary Supplements (ODS, ods.od.nih.gov), part of the National
Institutes of Health, July 9, 2009.
107
MINERALSHERBSOROTHERBOTANICALSAMINOACIDSANDOTHERSUB-
STANCES ORTHEIRCONSTITUENTS
s ISINTENDEDTOBETAKENBYMOUTHASAPILLCAPSULETABLETOR
LIQUIDAND
s ISLABELEDONTHEFRONTPANELASBEINGADIETARYSUPPLEMENT
How are botanicals commonly sold and prepared?

"OTANICALSARESOLDINMANYFORMSASFRESHORDRIEDPRODUCTSLIQ-
UIDORSOLIDEXTRACTSANDTABLETSCAPSULESPOWDERSANDTEABAGS&OR
example, fresh ginger root is often found in the produce section of
FOODSTORESDRIEDGINGERROOTISSOLDPACKAGEDINTEABAGSCAPSULESOR
TABLETSANDLIQUIDPREPARATIONSMADEFROMGINGERROOTAREALSOSOLD
A particular group of chemicals or a single chemical may be isolated
from a botanical and sold as a dietary supplement, usually in tablet or
capsule form. An example is phytoestrogens from soy products.
Common preparations include teas, decoctions, tinctures, and ex-
tracts:
s !TEAALSOKNOWNASANINFUSIONISMADEBYADDINGBOILINGWA-
ter to fresh or dried botanicals and steeping them. The tea may
be drunk either hot or cold.
s 3OMEROOTSBARKANDBERRIESREQUIREMOREFORCEFULTREATMENTTO
extract their desired ingredients. They are simmered in boiling
water for longer periods than teas, making a decoction, which
also may be drunk hot or cold.
s !TINCTUREISMADEBYSOAKINGABOTANICALINASOLUTIONOFAL-
cohol and water. Tinctures are sold as liquids and are used for
concentrating and preserving a botanical. They are made in dif-
ferent strengths that are expressed as botanical-to-extract ratios
(i.e., ratios of the weight of the dried botanical to the volume or
weight of the nished product).
s !NEXTRACTISMADEBYSOAKINGTHEBOTANICALINALIQUIDTHATRE-
moves specic types of chemicals. The liquid can be used as is or
evaporated to make a dry extract for use in capsules or tablets.
Are botanical dietary supplements standardized?

3TANDARDIZATIONISAPROCESSTHATMANUFACTURERSMAYUSETOEN-
sure batch-to-batch consistency of their products. In some cases,
108
Botanical Dietary Supplements
S TANDARDIZATIONINVOLVESIDENTIFYINGSPECIlCCHEMICALSALSOKNOWNAS
markers) that can be used to manufacture a consistent product. The
STANDARDIZATIONPROCESSCANALSOPROVIDEAMEASUREOFQUALITYCONTROL
$IETARYSUPPLEMENTSARENOTREQUIREDTOBESTANDARDIZEDINTHE
United States. In fact, no legal or regulatory denition exists for stan-
DARDIZATIONINTHE5NITED3TATESASITAPPLIESTOBOTANICALDIETARY
SUPPLEMENTS"ECAUSEOFTHISTHETERMhSTANDARDIZATIONvMAYMEAN
MANYDIFFERENTTHINGS3OMEMANUFACTURERSUSETHETERMSTANDARDIZA-
TIONINCORRECTLYTOREFERTOUNIFORMMANUFACTURINGPRACTICESFOLLOW-
INGARECIPEISNOTSUFlCIENTFORAPRODUCTTOBECALLEDSTANDARDIZED
4HEREFORETHEPRESENCEOFTHEWORDhSTANDARDIZEDvONASUPPLEMENT
label does not necessarily indicate product quality.
)DEALLYTHECHEMICALMARKERSCHOSENFORSTANDARDIZATIONWOULDALSO
be the compounds that are responsible for a botanicals effect in the
body. In this way, each lot of the product would have a consistent health
effect. However, the components responsible for the effects of most bo-
tanicals have not been identied or clearly dened. For example, the
sennosides in the botanical senna are known to be responsible for the
laxative effect of the plant, but many compounds may be responsible
for valerians relaxing effect.
Are botanical dietary supplements safe?

Many people believe that products labeled natural are safe and
good for them. This is not necessarily true because the safety of a bo-
tanical depends on many things, such as its chemical makeup, how it
works in the body, how it is prepared, and the dose used.
The action of botanicals range from mild to powerful (potent). A
botanical with mild action may have subtle effects. Chamomile and
peppermint, both mild botanicals, are usually taken as teas to aid di-
gestion and are generally considered safe for self-administration. Some
mild botanicals may have to be taken for weeks or months before their
full effects are achieved. For example, valerian may be effective as a
sleep aid after 14 days of use but it is rarely effective after just one
dose. In contrast a powerful botanical produces a fast result. Kava, as
one example, is reported to have an immediate and powerful action
affecting anxiety and muscle relaxation.
The dose and form of a botanical preparation also play important
roles in its safety. Teas, tinctures, and extracts have different strengths.
The same amount of a botanical may be contained in a cup of tea, a few
teaspoons of tincture, or an even smaller quantity of an extract. Also,
different preparations vary in the relative amounts and concentrations
109
of chemical removed from the whole botanical. For example, peppermint

tea is generally considered safe to drink but peppermint oil is much
more concentrated and can be toxic if used incorrectly. It is important
to follow the manufacturers suggested directions for using a botanical
and not exceed the recommended dose without the advice of a health
care provider.
Does a label indicate the quality of a botanical dietary

supplement product?
It is difcult to determine the quality of a botanical dietary supple-
ment product from its label. The degree of quality control depends on
the manufacturer, the supplier, and others in the production process.
In 2007, the FDA issued Good Manufacturing Practices (GMPs) for
dietary supplements, a set of requirements and expectations by which
dietary supplements must be manufactured, prepared, and stored to
ensure quality. Manufacturers are expected to guarantee the identity,
purity, strength, and composition of their dietary supplements. For
example, the GMPs aim to prevent the inclusion of the wrong ingredi-
ents, the addition of too much or too little of a dietary ingredient, the
possibility of contamination (by pesticides, heavy metals such as lead,
bacteria, etc.), and the improper packaging and labeling of a product.
Large companies are required to comply with FDAs dietary supple-
ment GMPs now, and the smallest companies by June 2010.
What methods are used to evaluate the health benets and

safety of a botanical dietary supplement?
Scientists use several approaches to evaluate botanical dietary sup-
plements for their potential health benets and safety risks, including
their history of use and laboratory studies using cell or animal studies.
Studies involving people (individual case reports, observational stud-
ies, and clinical trials) can provide information that is relevant to how
botanical dietary supplements are used.
2ESEARCHERSMAYCONDUCTASYSTEMATICREVIEWTOSUMMARIZEAND
evaluate a group of clinical trials that meet certain criteria. A meta-
analysis is a review that includes a statistical analysis of data com-
bined from many studies.
110
Chapter 18
Using Dietary
Supplements Wisely
Many people take dietary supplements in an effort to be well and

stay healthy. With so many dietary supplements available and so many
claims made about their health benets, how can a consumer decide
whats safe and effective? This text provides a general overview of
dietary supplements, discusses safety considerations, and suggests
sources for additional information.
About Dietary Supplements

Dietary supplements were dened in a law passed by Congress in
1994 called the Dietary Supplement Health and Education Act (DSHEA).
According to DSHEA, a dietary supplement is a product that:
minerals, herbs or other botanicals, amino acids, and certain
OTHERSUBSTANCES ORTHEIRCONSTITUENTS
s ISINTENDEDTOBETAKENBYMOUTHINFORMSSUCHASTABLETCAP-
SULEPOWDERSOFTGELGELCAPORLIQUID
s ISLABELEDASBEINGADIETARYSUPPLEMENT
Excerpted from text by the National Center for Complementary and Alter-
native Medicine (NCCAM, nccam.nih.gov), part of the National Institutes of
Health, February 2009.
111
Herbal supplements are one type of dietary supplement. An herb

is a plant or plant part (such as leaves, owers, or seeds) that is used
for its avor, scent, and/or therapeutic properties. Botanical is often
used as a synonym for herb. An herbal supplement may contain a
single herb or mixtures of herbs.
Research has shown that some uses of dietary supplements are
effective in preventing or treating diseases. For example, scientists
have found that folic acid (a vitamin) prevents certain birth defects,
ANDAREGIMENOFVITAMINSANDZINCCANSLOWTHEPROGRESSIONOFTHE
age-related eye disease macular degeneration. Also, calcium and vi-
tamin D supplements can be helpful in preventing and treating bone
loss and osteoporosis (thinning of bone tissue).
Research has also produced some promising results suggesting that
other dietary supplements may be helpful for other health conditions
(e.g., omega-3 fatty acids for coronary disease), but in most cases, ad-
ditional research is needed before rm conclusions can be drawn.
Dietary Supplement Use in the United States

A national survey conducted in 2007 found that 17.7 percent of Amer-
ican adults had used natural products (i.e., dietary supplements other
than vitamins and minerals) in the past 12 months. The most popular
products used by adults for health reasons in the past 30 days were sh
oil/omega 3/DHA [docosahexaenoic acid] (37.4%), glucosamine (19.9%),
echinacea (19.8%), axseed oil or pills (15.9%), and ginseng (14.1%). In
another, earlier national survey covering all types of dietary supple-
ments, approximately 52 percent of adult respondents said they had
USEDSOMETYPEOFSUPPLEMENTINTHELASTDAYSTHEMOSTCOMMONLY
reported were multivitamins/multiminerals (35%), vitamins E and C
(1213%), calcium (10%), and B-complex vitamins (5%).
Federal Regulation of Dietary Supplements

The federal government regulates dietary supplements through the
U.S. Food and Drug Administration (FDA). The regulations for dietary
supplements are not the same as those for prescription or over-the-
counter drugs. In general, the regulations for dietary supplements
are less strict.
s !MANUFACTURERDOESNOTHAVETOPROVETHESAFETYANDEFFECTIVENESS
of a dietary supplement before it is marketed. A manufacturer is
permitted to say that a dietary supplement addresses a nutrient
deciency, supports health, or is linked to a particular body function
112
Using Dietary Supplements Wisely
(e.g., immunity), if there is research to support the claim. Such a

claim must be followed by the words This statement has not been
evaluated by the Food and Drug Administration. This product is
not intended to diagnose, treat, cure, or prevent any disease.
s -ANUFACTURERSAREEXPECTEDTOFOLLOWCERTAINhGOODMANUFAC-
turing practices (GMPs) to ensure that dietary supplements
are processed consistently and meet quality standards. Require-
ments for GMPs went into effect in 2008 for large manufacturers
and are being phased in for small manufacturers through 2010.
s /NCEADIETARYSUPPLEMENTISONTHEMARKETTHE&$!MONITORS
safety. If it nds a product to be unsafe, it can take action against
the manufacturer and/or distributor, and may issue a warning or
require that the product be removed from the marketplace.
Also, once a dietary supplement is on the market, the FDA moni-

tors product information, such as label claims and package inserts.
The Federal Trade Commission (FTC) is responsible for regulating
PRODUCTADVERTISINGITREQUIRESTHATALLINFORMATIONBETRUTHFULAND
not misleading.
The federal government has taken legal action against a number of
dietary supplement promoters or websites that promote or sell dietary
supplements because they have made false or deceptive statements about
their products or because marketed products have proven to be unsafe.
Sources of Science-Based Information

Its important to look for reliable sources of information on dietary
supplements so you can evaluate the claims that are made about them.
The most reliable information on dietary supplements is based on the
results of rigorous scientic testing.
To get reliable information on a particular dietary supplement, try
the following:
s !SKYOURHEALTHCAREPROVIDERS%VENIFTHEYDONOTKNOWABOUTA
specic dietary supplement, they may be able to access the latest
medical guidance about its uses and risks.
s ,OOKFORSCIENTIlCRESEARCHlNDINGSONTHEDIETARYSUPPLEMENT
The National Center for Complementary and Alternative Medi-
cine (NCCAM) and the NIH Ofce of Dietary Supplements, as
well as other federal agencies, have free publications, clearing-
houses, and information on their websites.
113
Safety Considerations
If you are thinking about or are using a dietary supplement, here
are some points to keep in mind.
ternative practices you use, including dietary supplements. Give them
a full picture of what you do to manage your health. This will help
ensure coordinated and safe care. It is especially important to talk to
your health care provider if you are considering the following:
s 4ALKTOYOURPROVIDERIFYOUARETHINKINGABOUTREPLACINGYOUR
regular medication with one or more dietary supplements.
s 4ALKTOYOURPROVIDERIFYOUARETHINKINGABOUTTAKINGANYMEDI-
cations (whether prescription or over-the-counter), as some di-
etary supplements have been found to interact with medications.
s 4ALKTOYOURPROVIDERIFYOUAREPLANNINGTOHAVESURGERY#ER-
tain dietary supplements may increase the risk of bleeding or
affect the response to anesthesia.
s 4ALKTOYOURPROVIDERIFYOUAREPREGNANTORNURSINGABABYOR
are considering giving a child a dietary supplement. Most dietary
supplements have not been tested in pregnant women, nursing
mothers, or children.
If you are taking a dietary supplement, read the label instructions.

Talk to your health care provider if you have any questions, particu-
larly about the best dosage for you to take. If you experience any side
effects that concern you, stop taking the dietary supplement, and con-
tact your health care provider. You can also report your experience to
the FDAs MedWatch program. Consumer safety reports on dietary
supplements are an important source of information for the FDA.
Keep in mind that although many dietary supplements (and some
prescription drugs) come from natural sources, natural does not al-
ways mean safe. For example, the herbs comfrey and kava can cause
serious harm to the liver. Also, a manufacturers use of the term stan-
DARDIZEDvORhVERIlEDvORhCERTIlEDv DOESNOTNECESSARILYGUARANTEE
product quality or consistency.
"EAWARETHATANHERBALSUPPLEMENTMAYCONTAINDOZENSOFCOM-
pounds and that its active ingredients may not be known. Research-
ers are studying many of these products in an effort to identify active
ingredients and understand their effects in the body. Also consider the
possibility that whats on the label may not be whats in the bottle.
Analyses of dietary supplements sometimes nd differences between
labeled and actual ingredients. Here are some examples:
114
Using Dietary Supplements Wisely
s !NHERBALSUPPLEMENTMAYNOTCONTAINTHECORRECTPLANTSPECIES
s 4HEAMOUNTOFTHEACTIVEINGREDIENTMAYBELOWERORHIGHERTHAN
the label states. That means you may be taking lessor more
OFTHEDIETARYSUPPLEMENTTHANYOUREALIZE
s 4HEDIETARYSUPPLEMENTMAYBECONTAMINATEDWITHOTHERHERBS
pesticides, or metals, or even adulterated with unlabeled ingredi-
ents such as prescription drugs.
For current information from the federal government on the safety of

particular dietary supplements, check the Dietary Supplements: Warn-
ings and Safety Information section of the FDA website at www.fda.gov/
Food/DietarySupplements/Alerts/default.htm or the Alerts and Adviso-
ries section of the NCCAM website at nccam.nih.gov/news/alerts.
Dietary Supplements Research at the National Institutes

of Health
NCCAM, which is part of the National Institutes of Health (NIH), is
the federal governments lead agency for studying all types of CAM. As
part of that role, the Center sponsors a wide array of research to see how
dietary supplements might affect the body and tests their use in clinical
trials. In scal year 2007, NCCAM supported more than 200 research
projects studying dietary supplements, including herbs and botanicals.
Also within NIH, the Ofce of Dietary Supplements (ODS) focuses
specically on dietary supplements, seeking to strengthen knowledge
by supporting and evaluating research, disseminating results, and
educating the public.
NCCAM and ODS collaborate to fund dietary supplement research
centers focused on botanicals, known collectively as the NIH Botani-
cal Research Centers Program. Scientists at the centers conduct basic
research and other studies on botanicals and help to select products to
be tested in clinical trials. The centers are advancing the scientic base
of knowledge about botanicals, making it possible to better evaluate
their safety and effectiveness.
NCCAM also sponsors a number of Centers of Excellence for Re-
search on CAM, including centers studying antioxidant therapies,
botanicals for autoimmune and inammatory diseases, grape-derived
POLYPHENOLSFOR!LZHEIMERDISEASEANDBOTANICALSFORPANCREATICDIS-
eases and for colorectal cancer.
115
Chapter 19
Adolescents and
Supplement Use
Teens striving to shape their bodies or improve their athletic per-

formance may be tempted to use dietary or sports supplements. These
products, readily available and often touted as natural, may seem like
perfector at least harmlesssolutions. Yet, supplements can cause prob-
lems. While some simply fail to deliver what they promise, supplements
also can actually be dangerous. So, monitor your teens use of supplements
and guide her toward safe ways to boost her physical tness.
Wide Variety
Vitamins and minerals may be the most familiar dietary supple-
ments. However, they include many other substances such as herbals,
BOTANICALSAMINOACIDSANDENZYMES$IETARYANDNUTRITIONALSUPPLE-
ments also come in many forms such as tablets, capsules, powders,
energy bars, or drinks.
Sports and bodybuilding supplements promise more power, im-
proved performance, and better health. While your teen may know
better than to take steroids, which are illegal, he may think it is okay to
use other legal substances. However, most supplements have not been
studied thoroughly, especially for the effects on teenage athletes.
From Supplements: Added Risk, Doubtful Benet, by the Substance Abuse

and Mental Health Services Administration (SAMHSA, samhsa.gov), part of the
U.S. Department of Health and Human Services, February 26, 2007.
117
Little Control
The U.S. Food and Drug Administration (FDA) does not approve
dietary supplements as safe and effective. Manufacturers and dis-
tributors are responsible for making sure that their products are
safe and that claims about them are correct. The FDA acts only
when it nds that a dietary supplement product carries a high risk
of illness or injury. Some problems become clear over time through
reports of tragedies or through the results of studies that often take
years to conduct.
In 2004, the FDA banned the supplement ephedra, also known
as ephedrine or ma huang. Ephedra was labeled as a fat burner
because it acts as a stimulant, speeding up the nervous system
and increasing metabolism. The FDA found that ephedra is risky,
especially for people suffering from heart disease and high blood
pressure.
Ephedra had been controversial before the FDA declared it illegal.
"EGINNINGINTHESSEVERALORGANIZATIONSGOVERNINGSPORTSBANNED
the drug. The United States military banned ephedra from commis-
saries and military exchanges in 2002 after the deaths of military
personnel who were taking the drug. Ephedra drew added attention
when the drug was linked to the death of 23-year-old Baltimore Orioles
pitcher Steve Bechler in 2003.
Uncertain Effects
Because many supplements have not been studied scientically, we
cannot be sure how well they work or if they are dangerous. Supple-
ments that are safe for most people who use them may be risky for
others. Groups at increased risk include women who are pregnant or
nursing a baby and people who have medical conditions such as dia-
betes, hypertension, or heart disease.
Likewise, a supplement that is safe when taken by itself may cause
problems if combined with other medications. Even well-known prod-
ucts such as vitamin supplements, which are widely used and generally
considered safe for teens and children, can cause problems under cer-
tain conditions. For example, combining supplements and medications
that thin the blood can increase the potential for internal bleeding.
In addition, vitamins, minerals, herbals, or other supplements can be
dangerous for people having surgery. To avoid harmful drug reactions,
doctors may ask patients to stop taking these substances 2 or 3 weeks
before surgery.
118
Adolescents and Supplement Use
Need for Caution

With so many supplements on the market, each claiming to be
effective, knowing which products are safe for a teen to take is dif-
cult. So, if you have a teenager who is driven to win or who frets
about her shape, talk with a doctor or pharmacist before she takes
a supplement. Including your teen in the discussion will help her
understand the seriousness of protecting her health.
Better yet, urge him to hit the gym and reach for those fruits and
veggies. Keep nutritious food on hand and plan well-balanced meals.
By denition, a supplement is an add-on, which cannot take the
place of making healthy choices related to diet and exercise.
119
Chapter 20
Tips for Older Dietary

Supplement Users
Can dietary supplements help older consumers?

Even if you eat a wide variety of foods, how can you be sure that
you are getting all the vitamins, minerals, and other nutrients you
need as you get older? If you are over 50, your nutritional needs may
change. Informed food choices are the rst place to start, making sure
you get a variety of foods while watching your calorie intake. Supple-
ments and fortied foods may also help you get appropriate amounts
of nutrients. To help you make informed decisions, talk to your doctor
and/or registered dietitian. They can work together with you to deter-
mine if your intake of a specic nutrient might be too low or too high
and then decide how you can achieve a balance between the foods and
nutrients you personally need.
What are dietary supplements?

Todays dietary supplements are not only vitamins and minerals.
They also include other less-familiar substances, such as herbals, bo-
TANICALSAMINOACIDSENZYMESANDANIMALEXTRACTS3OMEDIETARY
supplements are well understood and established, but others need
further study. Whatever your choice, supplements should not replace
the variety of foods important to a healthful diet.
Excerpted from text by the U.S. Food and Drug Administration (FDA, www.fda
.gov), May 7, 2009.
121
Unlike drugs, dietary supplements are not preapproved by the

government for safety or effectiveness before marketing. Also, unlike
drugs, supplements are not intended to treat, diagnose, prevent, or
cure diseases. But some supplements can help assure that you get
ANADEQUATEDIETARYINTAKEOFESSENTIALNUTRIENTSOTHERSMAYHELP
you reduce your risk of disease. Some older people, for example, are
tired due to low iron levels. In that case, their doctor may recommend
an iron supplement.
At times, it can be confusing to tell the difference between a dietary
supplement, a food, or over-the-counter (OTC) medicines. This is be-
cause supplements, by law, come in a variety of forms that resemble
these products, such as tablets, capsules, powders, energy bars, or
drinks. One way to know if a product is a dietary supplement is to look
for the Supplement Facts label on the product.
Are there any risks, especially to older consumers?

While certain products may be helpful to some older individuals,
there may be circumstances when these products may not benet your
health or when they may create unexpected risks. Many supplements
contain active ingredients that have strong biological effects in the
body. This could make them unsafe in some situations and hurt or
complicate your health. For example:
s Are you taking both medicines and supplements? Are you
substituting one for the other? Taking a combination of sup-
plements, using these products together with medications (wheth-
er prescription or over-the-counter), or substituting them in place
of medicines your doctor prescribes could lead to harmful, even
life-threatening results. Be alert to any advisories about these
products. Coumadin (a prescription medicine), ginkgo biloba (an
herbal supplement), aspirin (an over-the-counter drug), and vi-
tamin E (a vitamin supplement) can each thin the blood. Taking
any of these products alone or together can increase the poten-
tial for internal bleeding or stroke. Another example is St. Johns
wort that may reduce the effectiveness of prescription drugs
FORHEARTDISEASEDEPRESSIONSEIZURESCERTAINCANCERSOR()6
[human immunodeciency virus].
s Are you planning surgery? Some supplements can have

unwanted effects before, during, and after surgery. It is impor-
tant to fully inform your healthcare professional, including your
pharmacist, about the vitamins, minerals, herbals, and any
122
Tips for Older Dietary Supplement Users
other supplements you are taking, especially before surgery.

You may be asked to stop taking these products at least 23
weeks ahead of the procedure to avoid potentially dangerous
supplement/drug interactionssuch as changes in heart rate,
blood pressure, or bleeding risk that could adversely affect the
outcome of your surgery.
s Is taking more of a good thing better? Some people might
think that if a little is good, taking a lot is even better. But taking
too much of some nutrients, even vitamins and minerals, can
also cause problems. Depending on the supplement, your age,
and the status of your health, taking more than 100% of the
Daily Value (DV) of certain vitamins and minerals, e.g., vita-
min A, vitamin D, and iron (from supplements and food sources
like vitamin-fortied cereals and drinks) may actually harm
your health. Large amounts can also interfere with how your
medicines work.
Remember: Your combined intake from all supplements (including

multivitamins, single supplements, and combination products) plus forti-
ed foods, like some cereals and drinks, could cause health problems.
Why speak to my healthcare provider about dietary

supplements?
You and your health professionals (doctors, nurses, registered di-
etitians, pharmacists, and other caregivers) are a team working to-
WARDACOMMONGOALTODEVELOPAPERSONALIZEDHEALTHPLANFORYOU
Your doctor and other members of the health team can help monitor
your medical condition and overall health, especially if any problems
develop. Although they may not immediately have answers to your
questions, these health professionals have access to the most current
research on dietary supplements.
There are numerous resources that provide information about di-
ETARYSUPPLEMENTS4HESEINCLUDE46RADIONEWSPAPERSMAGAZINES
store clerks, friends, family, or the internet. It is important to question
recommendations from people who have no formal training in nutrition,
botanicals, or medicine. While some of these sources, like the web, may
seem to offer a wealth of accurate information, these same sources may
contain misinformation that may not be obvious. Given the abundance
and conicting nature of information now available about supplements,
it is more important than ever to partner with your healthcare team to
sort the reliable information from the questionable.
123
How will I be able to spot false claims?

Be savvy! Although the benets of some dietary supplements have been
documented, the claims of others may be unproven. If something sounds
too good to be true, it usually is. Here are some signs of a false claim:
s )TMAKESSTATEMENTSTHATTHEPRODUCTISAQUICKANDEFFECTIVE
cure-all. For example: Extremely benecial in treatment of
rheumatism, arthritis, infections, prostate problems, ulcers,
cancer, heart trouble, hardening of the arteries, and more.
s )TMAKESSTATEMENTSTHATSUGGESTTHEPRODUCTCANTREATORCURE
diseases. For example: shrinks tumors or cures impotency. Ac-
tually, these are drug claims and should not be made for dietary
supplements.
s )TMAKESSTATEMENTSTHATCLAIMTHEPRODUCTIShTOTALLYSAFEvhALL
natural, or has denitely no side effects.
s )TINCLUDESPROMOTIONSTHATUSEWORDSLIKEhSCIENTIlCBREAKTHROUGHv
miraculous cure, exclusive product, secret ingredient, or an-
cient remedy. For example: A scientic breakthrough formulated
by using proven principles of natural health-based medical science.
s )TINCLUDESTEXTTHATUSESOVERLYIMPRESSIVE SOUNDINGTERMS
like those for a weight-loss product: hunger stimulation point
and thermogenesis.
s )TUSESPERSONALTESTIMONIALSBYCONSUMERSORDOCTORSCLAIMING
AMAZINGRESULTS&OREXAMPLEh-YHUSBANDHAS!LZHEIMERDISEASE
He began eating a teaspoonful of this product each day. And now in
just 22 days, he mowed the grass, cleaned out the garage, and weed-
EDTHEmOWERBEDSWETAKEOURMORNINGWALKTOGETHERAGAINv
s )THASLIMITEDAVAILABILITYANDREQUIRESADVANCEPAYMENT&OR
example: Hurry. This offer will not last. Send us a check now to
reserve your supply.
s )TPROMISESNO RISKhMONEY BACKGUARANTEESv&OREXAMPLEh)F
after 30 days you have not lost at least 4 pounds each week, your
uncashed check will be returned to you.
What are the key points to ponder before I buy?

s Think twice about chasing the latest headline. Sound
health advice is generally based on research over time, not a
single study. Be wary of results claiming a quick x that depart
from scientic research and established dietary guidance. Keep
124
in mind that science does not generally proceed by dramatic

breakthroughs, but rather by taking many small steps, slowly
building toward scientic agreement.
s We may think, Even if a product may not help me, it at
least wont hurt me. Its best not to assume that this will al-
ways be true. Some product ingredients, including nutrients and
plant components, can be toxic based on their activity in your body.
Some products may become harmful when consumed in high
enough amounts, for a long enough time, or in combination with
certain other substances.
s The term natural does not always mean safe. Do not as-
sume this term assures wholesomeness or that these products
have milder effects, making them safer to use than prescribed
drugs. For example, many weight-loss products claim to be nat-
ural or herbal but this doesnt necessarily make them safe. The
products ingredients may interact with drugs or may be dan-
gerous for people with certain medical conditions.
s Spend your money wisely. Some supplement products may
be expensive and may not work, given your specic condition.
Be wary of substituting a product or therapy for prescription
medicines. Be sure to talk with your healthcare team to help
you determine what is best for your overall health.
Remember: Safety rst. Resist the pressure to decide on the spot

about trying an untested product or treatment. Ask for more information
and consult your doctor, nurse, dietitian, pharmacist, and/or caregiver
about whether the product is right for you and safe for you to use.
Who is responsible for ensuring the safety and efcacy of

dietary supplements?
Unlike prescription and over-the-counter medicines, dietary supple-
ment products are not reviewed by the government before they are
marketed. Under the law, manufacturers of dietary supplements are
responsible for making sure their products are safe before they go to
market. If you want to know more about the product you are purchas-
ing, check with the manufacturer to nd out if the rm can provide
the following information:
s )NFORMATIONTOSUPPORTTHECLAIMSFORTHEIRPRODUCTS
s )NFORMATIONONTHESAFETYOREFlCACYOFTHEINGREDIENTSINTHEPRODUCT
s !DVERSEEVENTREPORTSFROMCONSUMERSUSINGTHEIRPRODUCTS
125
What is FDAs responsibility?

FDA has the responsibility to take action against unsafe dietary sup-
plement products after they reach the market. The agency may also take
legal action against dietary supplement manufacturers if FDA can prove
that claims on marketed dietary supplements are false and misleading.
What if I think I have had a reaction to a dietary supplement?

Adverse effects from the use of dietary supplements should be re-
ported to the FDAs MedWatch Program. You, your healthcare provider,
or anyone should report a serious adverse event or illness directly to
FDA if you believe it is related to the use of any dietary supplement
product by calling FDA at 800-FDA-1088, faxing to 800-FDA-0178,
or reporting online. FDA would like to know whenever you think a
product caused you a serious problem, even if you are not sure that the
product was the cause, and even if you do not visit a doctor or clinic.
Whats the bottom line?

s $IETARYSUPPLEMENTSAREINTENDEDTOSUPPLEMENTTHEDIETNOT
to cure, prevent, or treat diseases or replace the variety of foods
important to a healthful diet.
s 3UPPLEMENTSCANHELPYOUMEETDAILYREQUIREMENTSFORCERTAIN
nutrients, but when you combine drugs and foods, too much of
some nutrients can also cause problems.
s -ANYFACTORSPLAYAROLEINDECIDINGIFASUPPLEMENTISRIGHTFOR
you, including possible drug interactions and side effects.
s $ONOTSELF DIAGNOSEANYHEALTHCONDITION4OGETHERYOUANDYOUR
healthcare team can make the best decision for optimal health.
Ask yourself the following questions and talk to your doctor, nurse,
dietitian, pharmacist, and/or caregiver about dietary supplements.
s )STAKINGADIETARYSUPPLEMENTANIMPORTANTPARTOFMYTOTALDIET
s !RETHEREANYPRECAUTIONSORWARNINGS)SHOULDKNOWABOUTEG
is there an amount or upper limit I should not go above)?
s !RETHEREANYKNOWNSIDEEFFECTSEGLOSSOFAPPETITENAUSEA
headaches, etc.)? Do they apply to me?
s !RETHEREANYFOODSMEDICINESPRESCRIPTIONOROVER THECOUNTER
or other supplements I should avoid while taking this product?
126
s )F)AMSCHEDULEDFORSURGERYSHOULD)BECONCERNEDABOUTTHE
dietary supplements I am taking?
s 7HATISTHISPRODUCTFOR
s 7HATAREITSINTENDEDBENElTS
s (OWWHENANDFORHOWLONGSHOULD)TAKEIT
What are some examples of products marketed as

dietary supplements?
Because many products are marketed as dietary supplements, it is
important to remember that supplements include botanical/herbal as
well as vitamin/mineral products. The list* in the following text gives
some examples of products you may see sold as dietary supplements.
It is not possible to list them all here. Note: the examples provided
do not represent either an endorsement or approval by FDA or any
coalition members.
Vitamins, minerals, and nutrients include the following:
s -ULTIPLEVITAMINMINERAL s 6ITAMIN"COMPLEX
s 6ITAMIN# s 6ITAMIN$
s 6ITAMIN% s #ALCIUM
s &IBER s &OLICACID
s :INC s )RON
s "ETA CAROTENE s /MEGA FATTYACIDS
Botanicals and other substances include the following:

s !CIDOPHILUS s "LACKCOHOSH
s 'INGER s %VENINGPRIMROSEOIL
s %CHINACEA s 'ARLIC
s Ginkgo biloba s &ISHOIL
s 3T*OHNSWORT s 3AWPALMETTO
s 'LUCOSAMINEANDORCHONDROITINSULFATE
*Adapted from A Healthcare Professionals Guide to Evaluating Dietary

Supplements, the American Dietetic Association & American Pharma-
ceutical Association Special Report. (2000).
127
Chapter 21
Vitamin A and Carotenoids
Vitamin A: What is it?

Vitamin A is a group of compounds that play an important role in
vision, bone growth, reproduction, cell division, and cell differentiation
(in which a cell becomes part of the brain, muscle, lungs, blood, or other
SPECIALIZEDTISSUE 6ITAMIN!HELPSREGULATETHEIMMUNESYSTEMWHICH
helps prevent or ght off infections by making white blood cells that
destroy harmful bacteria and viruses. Vitamin A also may help lympho-
cytes (a type of white blood cell) ght infections more effectively.
Vitamin A promotes healthy surface linings of the eyes and the
respiratory, urinary, and intestinal tracts. When those linings break
down, it becomes easier for bacteria to enter the body and cause infec-
tion. Vitamin A also helps the skin and mucous membranes function
as a barrier to bacteria and viruses.
In general, there are two categories of vitamin A, depending on
whether the food source is an animal or a plant.
Vitamin A found in foods that come from animals is called pre-
formed vitamin A. It is absorbed in the form of retinol, one of the most
usable (active) forms of vitamin A. Sources include liver, whole milk,
and some fortied food products. Retinol can be made into retinal and
retinoic acid (other active forms of vitamin A) in the body.
Vitamin A that is found in colorful fruits and vegetables is called
provitamin A carotenoid. They can be made into retinol in the body. In
Excerpted from text by the Ofce of Dietary Supplements (ODS, ods.od.nih.gov),
part of the National Institutes of Health, April 23, 2006.
129
the United States, approximately 26% of vitamin A consumed by men

and 34% of vitamin A consumed by women is in the form of provita-
min A carotenoids. Common provitamin A carotenoids found in foods
that come from plants are beta-carotene, alpha-carotene, and beta-
cryptoxanthin. Among these, beta-carotene is most efciently made
into retinol. Alpha-carotene and beta-cryptoxanthin are also converted
to vitamin A, but only half as efciently as beta-carotene.
Of the 563 identied carotenoids, fewer than 10% can be made into vi-
TAMIN!INTHEBODY,YCOPENELUTEINANDZEAXANTHINARECAROTENOIDSTHAT
do not have vitamin A activity but have other health promoting properties.
The Institute of Medicine (IOM) encourages consumption of all carotenoid-
rich fruits and vegetables for their health-promoting benets.
Some provitamin A carotenoids have been shown to function as
ANTIOXIDANTSINLABORATORYSTUDIESHOWEVERTHISROLEHASNOTBEEN
consistently demonstrated in humans. Antioxidants protect cells
from free radicals, which are potentially damaging by-products of
oxygen metabolism that may contribute to the development of some
chronic diseases.
What foods provide vitamin A?

Retinol is found in foods that come from animals such as whole eggs,
milk, and liver. Most fat-free milk and dried nonfat milk solids sold in
the United States are fortied with vitamin A to replace the amount
lost when the fat is removed. Fortied foods such as fortied breakfast
cereals also provide vitamin A. Provitamin A carotenoids are abundant
in darkly colored fruits and vegetables. The 2000 National Health and
Nutrition Examination Survey (NHANES) indicated that major dietary
contributors of retinol are milk, margarine, eggs, beef liver and fortied
breakfast cereals, whereas major contributors of provitamin A carote-
noids are carrots, cantaloupes, sweet potatoes, and spinach.
Vitamin A in foods that come from animals is well absorbed and
used efciently by the body. Vitamin A in foods that come from plants
is not as well absorbed as animal sources of vitamin A.
What are recommended intakes of vitamin A?

Recommendations for vitamin A are provided in the Dietary Refer-
ence Intakes (DRIs) developed by the Institute of Medicine (IOM). DRI
is the general term for a set of reference values used for planning and
assessing nutrient intake in healthy people. Three important types of
reference values included in the DRIs are Recommended Dietary Al-
lowances (RDA), Adequate Intakes (AI), and Tolerable Upper Intake
130
Levels (UL). The RDA recommends the average daily dietary intake
level that is sufcient to meet the nutrient requirements of nearly
all (97% to 98%) healthy individuals in each age and gender group.
An AI is set when there are insufcient scientic data to establish an
RDA. AIs meet or exceed the amount needed to maintain nutritional
adequacy in nearly all people. The UL, on the other hand, is the maxi-
mum daily intake unlikely to result in adverse health effects.
The NHANES III survey (19881994) found that most Americans
consume recommended amounts of vitamin A. More recent NHANES
data (19992000) show average adult intakes to be about 3,300 IU per
day, which also suggests that most Americans get enough vitamin A.
There is no RDA for beta-carotene or other provitamin A carote-
noids. The IOM states that consuming 3 mg to 6 mg of beta-carotene
daily (equivalent to 833 IU to 1,667 IU vitamin A) will maintain blood
levels of beta-carotene in the range associated with a lower risk of
chronic diseases. A diet that provides ve or more servings of fruits and
vegetables per day and includes some dark green and leafy vegetables
and deep yellow or orange fruits should provide sufcient beta-carotene
and other carotenoids.
What are some current issues and controversies about

vitamin A?
Vitamin A, beta carotene, and cancer: Dietary intake studies
suggest an association between diets rich in beta-carotene and vitamin
A and a lower risk of many types of cancer. A higher intake of green and
yellow vegetables or other food sources of beta carotene and/or vitamin
A may decrease the risk of lung cancer. However, a number of studies
that tested the role of beta-carotene supplements in cancer prevention
did not nd them to protect against the disease. In the Alpha-Tocopherol
Beta-Carotene (ATBC) Cancer Prevention Study, more than 29,000 men
WHOREGULARLYSMOKEDCIGARETTESWERERANDOMIZEDTORECEIVEMGBETA
carotene alone, 50 mg alpha-tocopherol alone, supplements of both, or a
placebo for 5 to 8 years. Incidence of lung cancer was 18% higher among
men who took the beta-carotene supplement. Eight percent more men
in this group died, as compared to those receiving other treatments or
placebo. Similar results were seen in the Carotene and Retinol Efcacy
Trial (CARET), a lung cancer chemoprevention study that provided
subjects with supplements of 30 mg beta-carotene and 25,000 IU retinyl
palmitate (a form of vitamin A) or a placebo. This study was stopped
after researchers discovered that subjects receiving beta-carotene had
a 46% higher risk of dying from lung cancer.
131
The IOM states that beta-carotene supplements are not advisable

for the general population, although they also state that this advice
does not pertain to the possible use of supplemental beta-carotene
as a provitamin A source for the prevention of vitamin A deciency in
populations with inadequate vitamin A.
Vitamin A and osteoporosis:/STEOPOROSISADISORDERCHARACTERIZED

by porous and weak bones, is a serious health problem for more than 10
million Americans, 80% of whom are women. Another 18 million Ameri-
cans have decreased bone density which precedes the development of
osteoporosis. Many factors increase the risk for developing osteoporosis,
including being female, thin, inactive, at advanced age, and having a fam-
ily history of osteoporosis. An inadequate dietary intake of calcium, ciga-
rette smoking, and excessive intake of alcohol also increase the risk.
Researchers are now examining a potential new risk factor for osteo-
porosis: an excess intake of vitamin A. Animal, human, and laboratory
research suggests an association between greater vitamin A intake and
weaker bones. Worldwide, the highest incidence of osteoporosis occurs in
northern Europe, a population with a high intake of vitamin A. However,
decreased biosynthesis of vitamin D associated with lower levels of sun
exposure in this population may also contribute to this nding.
One small study of nine healthy individuals in Sweden found that
the amount of vitamin A in one serving of liver may impair the ability of
vitamin D to promote calcium absorption. To further test the association
between excess dietary intakes of vitamin A and increased risk for hip
fractures, researchers in Sweden compared bone mineral density and
retinol intake in approximately 250 women with a rst hip fracture to 875
age-matched controls. They found that a dietary retinol intake greater than
1,500 mcg/day (more than twice the recommended intake for women) was
associated with reduced bone mineral density and increased risk of hip
fracture as compared to women who consumed less than 500 mcg/day.
This issue was also examined by researchers with the Nurses
Health Study, who looked at the association between vitamin A intake
and hip fractures in over 72,000 postmenopausal women. Women who
consumed the most vitamin A in foods and supplements (3,000 mcg
or more per day as retinol equivalents, which is over three times the
recommended intake) had a signicantly increased risk of experiencing
a hip fracture as compared to those consuming the least amount (less
than 1,250 mcg/day). The effect was lessened by use of estrogens. These
observations raise questions about the effect of retinol because retinol
intakes greater than 2,000 mcg/day were associated with an increased
risk of hip fracture as compared to intakes less than 500 mcg.
132
A longitudinal study in more than 2,000 Swedish men compared

blood levels of retinol to the incidence of fractures in men. The in-
vestigators found that the risk of fractures was greatest in men with
the highest blood levels of retinol (more than 75 mcg per deciliter
[dL]). Men with blood retinol levels in the 99th percentile (greater
than 103 mcg per dL) had an overall risk of fracture that exceeded
the risk among men with lower levels of retinol by a factor of seven.
High vitamin A intake, however, does not necessarily equate to high
blood levels of retinol. Age, gender, hormones, and genetics also inu-
ence these levels. Researchers did not nd any association between
blood levels of beta-carotene and risk of hip fracture. Researchers
ndings, which are consistent with the results of animal, in vitro
(laboratory), and epidemiologic studies, suggest that intakes above
the UL, or approximately two times that of the RDA for vitamin A,
may pose subtle risks to bone health that require further study.
The Centers for Disease Control and Prevention (CDC) reviewed
data from NHANES III (198894) to determine whether there was any
association between bone mineral density and blood levels of retinyl
esters, a form of vitamin A. No signicant associations between blood
levels of retinyl esters and bone mineral density in 5,800 subjects
were found.
There is no evidence of an association between beta-carotene intake,
especially from fruits and vegetables, and increased risk of osteoporo-
sis. Current evidence points to a possible association with vitamin A
as retinol only. If you have specic questions regarding your intake of
vitamin A and risk of osteoporosis, discuss this information with your
physician or other qualied healthcare provider to determine whats
best for your personal health.
What are the health risks of too much vitamin A?

Hypervitaminosis A refers to high storage levels of vitamin A in the
body that can lead to toxic symptoms. There are four major adverse ef-
fects of hypervitaminosis A: birth defects, liver abnormalities, reduced
bone mineral density that may result in osteoporosis (see the previous
section), and central nervous system disorders.
Toxic symptoms can also arise after consuming very large amounts
of preformed vitamin A over a short period of time. Signs of acute toxic-
ITYINCLUDENAUSEAANDVOMITINGHEADACHEDIZZINESSBLURREDVISION
and muscular uncoordination. Although hypervitaminosis A can occur
when large amounts of liver are regularly consumed, most cases result
from taking excess amounts of the nutrient in supplements.
133
The IOM has established Tolerable Upper Intake Levels (ULs) for
vitamin A that apply to healthy populations. The UL was established
to help prevent the risk of vitamin A toxicity. The risk of adverse health
effects increases at intakes greater than the UL. The UL does not apply
to malnourished individuals receiving vitamin A either periodically or
through fortication programs as a means of preventing vitamin A de-
ciency. It also does not apply to individuals being treated with vitamin
A by medical doctors for diseases such as retinitis pigmentosa.
Retinoids are compounds that are chemically similar to vitamin A.
Over the past 15 years, synthetic retinoids have been prescribed for
acne, psoriasis, and other skin disorders. Isotretinoin (Roaccutane
or Accutane) is considered an effective anti-acne therapy. At very
high doses, however, it can be toxic, which is why this medication is
usually saved for the most severe forms of acne. The most serious con-
sequence of this medication is birth defects. It is extremely important
for sexually active females who may become pregnant and who take
these medications to use an effective method of birth control. Women
of childbearing age who take these medications are advised to undergo
monthly pregnancy tests to make sure they are not pregnant.
What are the health risks of too many carotenoids?

Provitamin A carotenoids such as beta-carotene are generally con-
sidered safe because they are not associated with specic adverse
health effects. Their conversion to vitamin A decreases when body
stores are full. A high intake of provitamin A carotenoids can turn the
skin yellow, but this is not considered dangerous to health.
Clinical trials that associated beta-carotene supplements with a
greater incidence of lung cancer and death in current smokers raise
concerns about the effects of beta-carotene supplements on long-term
HEALTHHOWEVERCONmICTINGSTUDIESMAKEITDIFlCULTTOINTERPRETTHE
health risk. For example, the Physicians Health Study compared the
effects of taking 50 mg beta-carotene every other day to a placebo in
over 22,000 male physicians and found no adverse health effects. Also,
a trial that tested the ability of four different nutrient combinations
to help prevent the development of esophageal and gastric cancers in
30,000 men and women in China suggested that after ve years those
participants who took a combination of beta-carotene, selenium, and vi-
tamin E had a 13% reduction in cancer deaths. In one lung cancer trial,
men who consumed more than 11 grams/day of alcohol (approximately
one drink per day) were more likely to show an adverse response to
beta-carotene supplements, which may suggest a potential relationship
between alcohol and beta-carotene.
134
The IOM did not set ULs for carotene or other carotenoids. Instead,
it concluded that beta-carotene supplements are not advisable for the
general population. As stated earlier, however, they may be appropriate
as a provitamin A source for the prevention of vitamin A deciency in
specic populations.
Vitamin A intakes and healthful diets: According to the 2005

Dietary Guidelines for Americans, Nutrient needs should be met pri-
marily through consuming foods. Foods provide an array of nutrients
and other compounds that may have benecial effects on health. In
certain cases, fortied foods and dietary supplements may be useful
sources of one or more nutrients that otherwise might be consumed in
less than recommended amounts. However, dietary supplements, while
recommended in some cases, cannot replace a healthful diet. For more
information about building a healthful diet, refer to the Dietary Guide-
lines for Americans (http://www.health.gov/dietaryguidelines/dga2005/
document/pdf/DGA2005.pdf) and the U.S. Department of Agricultures
FOODGUIDANCESYSTEM-Y0YRAMIDHTTPWWWMYPYRAMIDGOV
135
Chapter 22
Vitamin B6
Vitamin B6 : What is it?

Vitamin B6 is a water-soluble vitamin that exists in three major
chemical forms: pyridoxine, pyridoxal, and pyridoxamine. It performs
a wide variety of functions in your body and is essential for your good
health. For example, vitamin B6ISNEEDEDFORMORETHANENZYMES
involved in protein metabolism. It is also essential for red blood cell
metabolism. The nervous and immune systems need vitamin B6 to
function efciently, and it is also needed for the conversion of trypto-
phan (an amino acid) to niacin (a vitamin).
Hemoglobin within red blood cells carries oxygen to tissues. Your body
needs vitamin B6 to make hemoglobin. Vitamin B6 also helps increase
the amount of oxygen carried by hemoglobin. A vitamin B6 deciency can
result in a form of anemia that is similar to iron deciency anemia.
An immune response is a broad term that describes a variety of
biochemical changes that occur in an effort to ght off infections. Calo-
ries, protein, vitamins, and minerals are important to your immune
defenses because they promote the growth of white blood cells that
directly ght infections. Vitamin B6, through its involvement in protein
metabolism and cellular growth, is important to the immune system.
It helps maintain the health of lymphoid organs (thymus, spleen, and
lymph nodes) that make your white blood cells. Animal studies show
that a vitamin B6 deciency can decrease your antibody production
and suppress your immune response.
part of the National Institutes of Health, August 24, 2007.
137
Vitamin B6 also helps maintain your blood glucose (sugar) within

a normal range. When caloric intake is low your body needs vitamin
B6 to help convert stored carbohydrate or other nutrients to glucose
to maintain normal blood sugar levels. While a shortage of vitamin B6
will limit these functions, supplements of this vitamin do not enhance
them in well-nourished individuals.
What foods provide vitamin B6?

Vitamin B6 is found in a wide variety of foods including fortied
cereals, beans, meat, poultry, sh, and some fruits and vegetables.
What is the Recommended Dietary Allowance for vitamin

B6 for adults?
The Recommended Dietary Allowance (RDA) is the average daily
dietary intake level that is sufcient to meet the nutrient requirements
of nearly all (97 to 98 percent) healthy individuals in each life-stage
and gender group.
The 1998 RDAs for vitamin B6 for adults, in milligrams, are 1.3 mg
for men and women 1950. Men 51 and older should get 1.7 mg and
women 51 and older should get 1.5 mg. Pregnant women should get
1.9 mg and lactating women need 2.0 mg of this vitamin.
Results of two national surveys, the National Health and Nutrition
Examination Survey (NHANES III 198894) and the Continuing Survey
of Food Intakes by Individuals (199496 CSFII), indicated that diets of
most Americans meet current intake recommendations for vitamin B6.

vitamin B6?
Vitamin B6 and the nervous system: Vitamin B6 is needed for the
synthesis of neurotransmitters such as serotonin and dopamine. These
neurotransmitters are required for normal nerve cell communication.
Researchers have been investigating the relationship between vitamin
B6STATUSANDAWIDEVARIETYOFNEUROLOGICCONDITIONSSUCHASSEIZURES
chronic pain, depression, headache, and Parkinson disease.
Lower levels of serotonin have been found in individuals suffering
from depression and migraine headaches. So far, however, vitamin B6
supplements have not proved effective for relieving these symptoms.
One study found that a sugar pill was just as likely as vitamin B6 to
relieve headaches and depression associated with low dose oral con-
traceptives.
138
Vitamin B6
Alcohol abuse can result in neuropathy, abnormal nerve sensations

in the arms and legs. A poor dietary intake contributes to this neuropa-
thy and dietary supplements that include vitamin B6 may prevent or
decrease its incidence.
Vitamin B6 and carpal tunnel syndrome: Vitamin B6 was rst

recommended for carpal tunnel syndrome almost 30 years ago. Several
popular books still recommend taking 100 to 200 milligrams (mg) of
vitamin B6 daily to treat carpal tunnel syndrome, even though scien-
tic studies do not indicate it is effective. Anyone taking large doses of
vitamin B6 supplements for carpal tunnel syndrome needs to be aware
that the Institute of Medicine recently established an upper tolerable
limit of 100 mg per day for adults. There are documented cases in the
literature of neuropathy caused by excessive vitamin B6 taken for
treatment of carpal tunnel syndrome.
Vitamin B6 and premenstrual syndrome: Vitamin B6 has be-

come a popular remedy for treating the discomforts associated with
premenstrual syndrome (PMS). Unfortunately, clinical trials have
failed to support any signicant benet. One recent study indicated
that a sugar pill was as likely to relieve symptoms of PMS as vitamin
B6. In addition, vitamin B6 toxicity has been seen in increasing num-
bers of women taking vitamin B6 supplements for PMS. One review
indicated that neuropathy was present in 23 of 58 women taking daily
vitamin B6 supplements for PMS whose blood levels of B6 were above
normal. There is no convincing scientic evidence to support recom-
mending vitamin B6 supplements for PMS.
Vitamin B6 and interactions with medications: There are many

drugs that interfere with the metabolism of vitamin B6)SONIAZID
which is used to treat tuberculosis, and L-DOPA [L-3,4-dihydroxyphe-
nylalanine], which is used to treat a variety of neurologic problems
such as Parkinson disease, alter the activity of vitamin B6. There is
disagreement about the need for routine vitamin B6 supplementation
WHENTAKINGISONIAZID!CUTEISONIAZIDTOXICITYCANRESULTINCOMAAND
SEIZURESTHATAREREVERSEDBYVITAMIN"6, but in a group of children
RECEIVINGISONIAZIDNOCASESOFNEUROLOGICALORNEUROPSYCHIATRICPROB-
lems were observed regardless of whether or not they took a vitamin
B6 supplement. Some doctors recommend taking a supplement that
provides 100% of the RDA for B6WHENISONIAZIDISPRESCRIBEDWHICH
is usually enough to prevent symptoms of vitamin B6 deciency. It is
important to consult with a physician about the need for a vitamin B6
SUPPLEMENTWHENTAKINGISONIAZID
139
What is the relationship between vitamin B6 , homocysteine,

and heart disease?
A deciency of vitamin B6, folic acid, or vitamin B12 may increase
your level of homocysteine, an amino acid normally found in your blood.
There is evidence that an elevated homocysteine level is an independent
risk factor for heart disease and stroke. The evidence suggests that high
levels of homocysteine may damage coronary arteries or make it easier
for blood clotting cells called platelets to clump together and form a
clot. However, there is currently no evidence available to suggest that
lowering homocysteine level with vitamins will reduce your risk of heart
disease. Clinical intervention trials are needed to determine whether
supplementation with vitamin B6, folic acid, or vitamin B12 can help
protect you against developing coronary heart disease.
What is the health risk of too much vitamin B6?

Too much vitamin B6 can result in nerve damage to the arms and
legs. This neuropathy is usually related to high intake of vitamin B6 from
supplements, and is reversible when supplementation is stopped.
According to the Institute of Medicine, Several reports show sen-
sory neuropathy at doses lower than 500 mg per day. As previously
mentioned, the Food and Nutrition Board of the Institute of Medicine
has established an upper tolerable intake level (UL) for vitamin B6 of
100 mg per day for all adults. As intake increases above the UL, the
risk of adverse effects increases.
Vitamin B6 intakes and healthful diets: Vitamin B6 is found in
a wide variety of foods. Foods such as fortied breakfast cereals, sh
including salmon and tuna sh, meats such as pork and chicken, ba-
nanas, beans and peanut butter, and many vegetables will contribute
to your vitamin B6 intake.
According to the 2005 Dietary Guidelines for Americans, Nutrient
needs should be met primarily through consuming foods. Foods provide an
array of nutrients and other compounds that may have benecial effects
on health. In certain cases, fortied foods and dietary supplements may be
useful sources of one or more nutrients that otherwise might be consumed
in less than recommended amounts. However, dietary supplements, while
recommended in some cases, cannot replace a healthful diet.
The Dietary Guidelines for Americans describes a healthy diet as
one that does the following:
s %MPHASIZESAVARIETYOFFRUITSVEGETABLESWHOLEGRAINSANDFAT
free or low-fat milk and milk products
140
Vitamin B6
s )NCLUDESLEANMEATSPOULTRYlSHBEANSEGGSANDNUTS

s )SLOWINSATURATEDFATSTRANSFATSCHOLESTEROLSALTSODIUM AND
added sugars
s 3TAYSWITHINYOURDAILYCALORIENEEDS
For more information about building a healthful diet, refer to the

Dietary Guidelines for Americans and the U.S. Department of Agri-
cultures food guidance system, MyPyramid.
141
Chapter 23
Vitamin B12
Vitamin B12 is a water-soluble vitamin that is naturally present in

some foods, added to others, and available as a dietary supplement and a
prescription medication. Vitamin B12 exists in several forms and contains
the mineral cobalt, so compounds with vitamin B12 activity are collective-
ly called cobalamins. Methylcobalamin and 5-deoxyadenosylcobalamin
are the forms of vitamin B12 that are active in human metabolism.
Vitamin B12 is required for proper red blood cell formation, neurologi-
cal function, and DNA [deoxyribonucleic acid] synthesis. Vitamin B12
functions as a cofactor for methionine synthase and L-methylmalonyl-
#O!MUTASE-ETHIONINESYNTHASECATALYZESTHECONVERSIONOFHOMO-
cysteine to methionine. Methionine is required for the formation of
S-adenosylmethionine, a universal methyl donor for almost 100 different
substrates, including DNA, RNA [ribonucleic acid], hormones, proteins,
and lipids. L-methylmalonyl-CoA mutase converts L-methylmalonyl-
CoA to succinyl-CoA in the degradation of propionate, an essential
biochemical reaction in fat and protein metabolism. Succinyl-CoA is
also required for hemoglobin synthesis.
Vitamin B12, bound to protein in food, is released by the activity of
hydrochloric acid and gastric protease in the stomach. When synthetic
vitamin B12 is added to fortied foods and dietary supplements, it is
already in free form and, thus, does not require this separation step.
Free vitamin B12 then combines with intrinsic factor, a glycoprotein
secreted by the stomachs parietal cells, and the resulting complex
part of the National Institutes of Health, October 12, 2009.
143
undergoes absorption within the distal ileum by receptor-mediated

endocytosis. Approximately 56% of a 1 mcg oral dose of vitamin B12 is
absorbed, but absorption decreases drastically when the capacity of
intrinsic factor is exceeded (at 12 mcg of vitamin B12).
Pernicious anemia is an autoimmune disease that affects the gastric
mucosa and results in gastric atrophy. This leads to the destruction
of parietal cells, achlorhydria, and failure to produce intrinsic factor,
resulting in vitamin B12 malabsorption. If pernicious anemia is left
untreated, it causes vitamin B12 deciency, leading to megaloblastic
anemia and neurological disorders, even in the presence of adequate
dietary intake of vitamin B12.
Dietary Supplements
In dietary supplements, vitamin B12 is usually present as cyano-
cobalamin, a form that the body readily converts to the active forms
methylcobalamin and 5-deoxyadenosylcobalamin. Dietary supplements
can also contain methylcobalamin and other forms of vitamin B12.
Existing evidence does not suggest any differences among forms
with respect to absorption or bioavailability. However the bodys abil-
ity to absorb vitamin B12 from dietary supplements is largely limited
by the capacity of intrinsic factor. For example, only about 10 mcg of a
500 mcg oral supplement is actually absorbed in healthy people.
In addition to oral dietary supplements, vitamin B12 is available in
SUBLINGUALPREPARATIONSASTABLETSORLOZENGES4HESEPREPARATIONSARE
frequently marketed as having superior bioavailability, although evidence
suggests no difference in efcacy between oral and sublingual forms.
Vitamin B12 and Health

Cardiovascular Disease
Cardiovascular disease is the most common cause of death in in-
DUSTRIALIZEDCOUNTRIESSUCHASTHE5NITED3TATESANDISONTHERISEIN
developing countries. Risk factors for cardiovascular disease include
elevated low-density lipoprotein (LDL) levels, high blood pressure, low
high-density lipoprotein (HDL) levels, obesity, and diabetes.
Elevated homocysteine levels have also been identied as an in-
dependent risk factor for cardiovascular disease. Homocysteine is a
sulfur-containing amino acid derived from methionine that is normally
present in blood. Elevated homocysteine levels are thought to promote
thrombogenesis, impair endothelial vasomotor function, promote lipid
peroxidation, and induce vascular smooth muscle proliferation. Evidence
144
Vitamin B12
from retrospective, cross-sectional, and prospective studies links el-

evated homocysteine levels with coronary heart disease and stroke.
Vitamin B12, folate, and vitamin B6 are involved in homocysteine
metabolism. In the presence of insufcient vitamin B12, homocysteine
levels can rise due to inadequate function of methionine synthase. Re-
SULTSFROMSEVERALRANDOMIZEDCONTROLLEDTRIALSINDICATETHATCOMBINA-
tions of vitamin B12 and folic acid supplements with or without vitamin
B6 decrease homocysteine levels in people with vascular disease or
diabetes and in young adult women. In another study, older men and
women who took a multivitamin/multimineral supplement for 8 weeks
experienced a signicant decrease in homocysteine levels.
Evidence supports a role for folic acid and vitamin B12 supplements
in lowering homocysteine levels, but results from several large prospec-
tive studies have not shown that these supplements decrease the risk
of cardiovascular disease. In the Womens Antioxidant and Folic Acid
Cardiovascular Study, women at high risk of cardiovascular disease who
took daily supplements containing 1 mg vitamin B12, 2.5 mg folic acid,
and 50 mg vitamin B6 for 7.3 years did not have a reduced risk of major
cardiovascular events, despite lowered homocysteine levels. The Heart
Outcomes Prevention Evaluation (HOPE) 2 trial, which included 5,522
patients older than 54 years with vascular disease or diabetes, found
that daily treatment with 2.5 mg folic acid, 50 mg vitamin B6, and 1 mg
vitamin B12 for an average of 5 years reduced homocysteine levels and
the risk of stroke but did not reduce the risk of major cardiovascular
events. In the Western Norway B Vitamin Intervention Trial, which
included 3,096 patients undergoing coronary angiography, daily supple-
ments of 0.4 mg vitamin B12 and 0.8 mg folic acid with or without 40 mg
vitamin B6 for 1 year reduced homocysteine levels by 30% but did not
affect total mortality or the risk of major cardiovascular events during
38 months of follow-up. The Norwegian Vitamin (NORVIT) trial and the
Vitamin Intervention for Stroke Prevention trial had similar results.
The American Heart Association has concluded that the available
evidence is inadequate to support a role for B vitamins in reducing
cardiovascular risk.
Dementia and Cognitive Function

Researchers have long been interested in the potential connection
between vitamin B12 deciency and dementia. A deciency in vitamin
B12 causes an accumulation of homocysteine in the blood and might
DECREASELEVELSOFSUBSTANCESNEEDEDTOMETABOLIZENEUROTRANSMITTERS
Observational studies show positive associations between elevated
HOMOCYSTEINELEVELSANDTHEINCIDENCEOFBOTH!LZHEIMERDISEASEAND
145
dementia. Low vitamin B12 status has also been positively associated
with cognitive decline.
Despite evidence that vitamin B12 lowers homocysteine levels and cor-
relations between low vitamin B12 levels and cognitive decline, research
has not shown that vitamin B12 has an independent effect on cognition.
)NONERANDOMIZEDDOUBLE BLINDPLACEBO CONTROLLEDTRIALSUBJECTS
aged 70 years or older with no or moderate cognitive impairment received
1,000 mcg vitamin B12, 1,000 mcg vitamin B12 plus 400 mcg folic acid, or
placebo for 24 weeks. Treatment with vitamin B12 plus folic acid reduced
homocysteine concentrations by 36%, but neither vitamin B12 treatment
nor vitamin B12 plus folic acid treatment improved cognitive function.
Women at high risk of cardiovascular disease who participated in the
Womens Antioxidant and Folic Acid Cardiovascular Study were ran-
domly assigned to receive daily supplements containing 1 mg vitamin
B12, 2.5 mg folic acid and 50 mg vitamin B6, or placebo. After a mean
of 1.2 years, B-vitamin supplementation did not affect mean cognitive
change from baseline compared with placebo. However, in a subset of
women with low baseline dietary intake of B vitamins, supplementation
signicantly slowed the rate of cognitive decline. In a trial conducted
BYTHE!LZHEIMERS$ISEASE#OOPERATIVE3TUDYCONSORTIUMTHATINCLUDED
INDIVIDUALSWITHMILD TO MODERATE!LZHEIMERDISEASEDAILYSUPPLEMENTS
of 1 mg vitamin B12, 5 mg folic acid, and 25 mg vitamin B6 for 18 months
did not slow cognitive decline compared with placebo. Another study
found similar results in 142 individuals at risk of dementia who received
supplements of 2 mg folic acid and 1 mg vitamin B12 for 12 weeks.
The authors of two Cochrane reviews and a systematic review of
RANDOMIZEDTRIALSOFTHEEFFECTSOF"VITAMINSONCOGNITIVEFUNCTIONCON-
cluded that insufcient evidence is available to show whether vitamin
B12 alone or in combination with vitamin B6 or folic acid has an effect
on cognitive function or dementia. Additional large clinical trials of
vitamin B12 supplementation are needed to assess whether vitamin
B12 has a direct effect on cognitive function and dementia.
Energy and Endurance

Due to its role in energy metabolism, vitamin B12 is frequently
promoted as an energy enhancer and an athletic performance and
endurance booster. These claims are based on the fact that correcting
the megaloblastic anemia caused by vitamin B12 deciency should
improve the associated symptoms of fatigue and weakness. However,
vitamin B12 supplementation appears to have no benecial effect on
performance in the absence of a nutritional decit.
146
Chapter 24
Vitamin D
Vitamin D is a fat-soluble vitamin that is naturally present in very

few foods, added to others, and available as a dietary supplement. It
is also produced endogenously when ultraviolet rays from sunlight
strike the skin and trigger vitamin D synthesis. Vitamin D obtained
from sun exposure, food, and supplements is biologically inert and
must undergo two hydroxylations in the body for activation. The rst
occurs in the liver and converts vitamin D to 25-hydroxyvitamin D
[25(OH)D], also known as calcidiol. The second occurs primarily in the
kidney and forms the physiologically active 1,25-dihydroxyvitamin D
[1,25(OH)2D], also known as calcitriol.
Vitamin D is essential for promoting calcium absorption in the
gut and maintaining adequate serum calcium and phosphate concen-
TRATIONSTOENABLENORMALMINERALIZATIONOFBONEANDPREVENTHYPO
calcemic tetany. It is also needed for bone growth and bone remodeling
by osteoblasts and osteoclasts. Without sufcient vitamin D, bones can
become thin, brittle, or misshapen. Vitamin D sufciency prevents
rickets in children and osteomalacia in adults. Together with calcium,
vitamin D also helps protect older adults from osteoporosis.
Vitamin D has other roles in human health, including modulation of
neuromuscular and immune function and reduction of inammation.
Many genes encoding proteins that regulate cell proliferation, differ-
entiation, and apoptosis are modulated in part by vitamin D. Many
Excerpted from text by the Ofce of Dietary Supplements (ODS, ods.od.nih

.gov), part of the National Institutes of Health, November 13, 2009.
147
laboratory-cultured human cells have vitamin D receptors and some con-

vert 25(OH)D to 1,25(OH)2D. It remains to be determined whether cells
with vitamin D receptors in the intact human carry out this conversion.
Dietary Supplements
In supplements and fortied foods, vitamin D is available in two
forms, D2 (ergocalciferol) and D3 (cholecalciferol). Vitamin D2 is manu-
factured by the UV irradiation of ergosterol in yeast, and vitamin D3 is
manufactured by the irradiation of 7-dehydrocholesterol from lanolin
and the chemical conversion of cholesterol. The two forms have tradition-
ally been regarded as equivalent based on their ability to cure rickets,
BUTEVIDENCEHASBEENOFFEREDTHATTHEYAREMETABOLIZEDDIFFERENTLY
Vitamin D3 could be more than three times as effective as vitamin D2
in raising serum 25(OH)D concentrations and maintaining those levels
for a longer time, and its metabolites have superior afnity for vitamin
D-binding proteins in plasma. Because metabolite receptor afnity is not
a functional assessment, as the earlier results for the healing of rickets
were, further research is needed on the comparative physiological effects
of both forms. Many supplements are being reformulated to contain
vitamin D3 instead of vitamin D2. Both forms (as well as vitamin D in
foods and from cutaneous synthesis) effectively raise serum 25(OH)D
levels. According to NHANES (National Health and Nutrition Survey)
data from 2005-2006, only 29% of adult men and 17% of adult women
(ages 19 and older) had intakes of vitamin D from food alone that ex-
ceeded their AIs. Overall in the U.S. population, only about one third
of individuals 1 year of age and older had vitamin D intakes from food
exceeding their respective AIs. However, dietary supplements as well as
foods contribute vitamin D, so both sources must be included to obtain a
true picture of total intakes. In 20052006, 37% of people in the United
States reported the use of a dietary supplement containing vitamin D.
Total intake estimates of vitamin D from both food and supplements are
currently being tabulated by the Ofce of Dietary Supplements.
Vitamin D and Health

Optimal serum concentrations of 25(OH)D for bone and general health
throughout life have not been established and are likely to vary at each
stage of life, depending on the physiological measures selected. The three-
fold range of cut points that have been proposed by various experts, from
16 to 48 ng/mL (40 to 120 nmol/L), reect differences in the functional
endpoints chosen (e.g., serum concentrations of parathyroid hormone or
bone fractures), as well as differences in the analytical methods used.
148
Vitamin D
In March 2007, a group of vitamin D and nutrition researchers

published a controversial and provocative editorial contending that the
desirable concentration of 25(OH)D is greater than or equal to ng/mL
(greater than or equal to 75 nmol/L). They noted that supplemental
intakes of 400 IU/day of vitamin D increase 25(OH)D concentrations
by only 2.84.8 ng/mL (712 nmol/L) and that daily intakes of approxi-
mately 1,700 IU are needed to raise these concentrations from 20 to
32 ng/mL (50 to 80 nmol/L).
Osteoporosis: More than 25 million adults in the United States

HAVEORAREATRISKOFDEVELOPINGOSTEOPOROSISADISEASECHARACTERIZED
by fragile bones that signicantly increases the risk of bone fractures.
Osteoporosis is most often associated with inadequate calcium intakes
(generally <1,000-1,200 mg/day), but insufcient vitamin D contributes
to osteoporosis by reducing calcium absorption. Although rickets and
osteomalacia are extreme examples of the effects of vitamin D de-
ciency, osteoporosis is an example of a long-term effect of calcium and
vitamin D insufciency. Adequate storage levels of vitamin D maintain
bone strength and might help prevent osteoporosis in older adults,
nonambulatory individuals who have difculty exercising, postmeno-
pausal women, and individuals on chronic steroid therapy.
Normal bone is constantly being remodeled. During menopause, the
balance between these processes changes, resulting in more bone being
resorbed than rebuilt. Hormone therapy with estrogen and progesterone
might be able to delay the onset of osteoporosis. However, some medi-
cal groups and professional societies recommend that postmenopausal
women consider using other agents to slow or stop bone resorption be-
cause of the potential adverse health effects of hormone therapy.
Most supplementation trials of the effects of vitamin D on bone
health also include calcium, so it is not possible to isolate the effects
of each nutrient. The authors of a recent evidence-based review of
research concluded that supplements of both vitamin D3 (at 700800
IU/day) and calcium (5001,200 mg/day) decreased the risk of falls,
fractures, and bone loss in elderly individuals aged 6285 years. The
decreased risk of fractures occurred primarily in elderly women aged
85 years, on average, and living in a nursing home. Women should
consult their healthcare providers about their needs for vitamin D (and
calcium) as part of an overall plan to prevent or treat osteoporosis.
African Americans have lower levels of 25(OH)D than Caucasians,
yet they develop fewer osteoporotic fractures. This suggests that
factors other than vitamin D provide protection. African Americans
have an advantage in bone density from early childhood, a function of
149
their more efcient calcium economy, and have a lower risk of fracture
even when they have the same bone density as Caucasians. They also
have a higher prevalence of obesity, and the resulting higher estrogen
levels in obese women might protect them from bone loss. Further
reducing the risk of osteoporosis in African Americans are their lower
levels of bone-turnover markers, shorter hip-axis length, and superior
renal calcium conservation. However, despite this advantage in bone
density, osteoporosis is a signicant health problem among African
Americans as they age.
Cancer: Laboratory and animal evidence as well as epidemiologic

data suggest that vitamin D status could affect cancer risk. Strong
biological and mechanistic bases indicate that vitamin D plays a role
in the prevention of colon, prostate, and breast cancers. Emerging epi-
demiologic data suggest that vitamin D has a protective effect against
colon cancer, but the data are not as strong for a protective effect
against prostate and breast cancer, and are variable for cancers at
other sites. Studies do not consistently show a protective effect or no
effect, however. One study of Finnish smokers, for example, found that
subjects in the highest quintile of baseline vitamin D status have a
three-fold higher risk of developing pancreatic cancer.
Vitamin D emerged as a protective factor in a prospective, cross-
sectional study of 3,121 adults aged greater than or equal to 50 years
(96% men) who underwent a colonoscopy. The study found that 10%
had at least one advanced cancerous lesion. Those with the high-
est vitamin D intakes (>645 IU/day) had a signicantly lower risk
of these lesions. However, the Womens Health Initiative, in which
36,282 postmenopausal women of various races and ethnicities were
randomly assigned to receive 400 IU vitamin D plus 1,000 mg cal-
cium daily or a placebo, found no signicant differences between the
groups in the incidence of colorectal cancers over 7 years. More re-
cently, a clinical trial focused on bone health in 1,179 postmenopausal
women residing in rural Nebraska found that subjects supplemented
daily with calcium (1,4001,500 mg) and vitamin D3 (1,100 IU) had
a signicantly lower incidence of cancer over 4 years compared to
women taking a placebo. The small number of cancers reported (50)
PRECLUDESGENERALIZINGABOUTAPROTECTIVEEFFECTFROMEITHERORBOTH
nutrients or for cancers at different sites. This caution is supported
by an analysis of 16,618 participants in NHANES III, where total
cancer mortality was found to be unrelated to baseline vitamin D
status. However, colorectal cancer mortality was inversely related
to serum 25(OH)D concentrations.
150
Vitamin D
Further research is needed to determine whether vitamin D inad-

equacy in particular increases cancer risk, whether greater exposure
to the nutrient is protective, and whether some individuals could be
at increased risk of cancer because of vitamin D exposure.
Other conditions: A growing body of research suggests that vita-

min D might play some role in the prevention and treatment of type 1
and type 2 diabetes, hypertension, glucose intolerance, multiple scle-
rosis, and other medical conditions. However, most evidence for these
roles comes from in vitro, animal, and epidemiological studies, not the
RANDOMIZEDCLINICALTRIALSCONSIDEREDTOBEMOREDElNITIVE5NTILSUCH
trials are conducted, the implications of the available evidence for
public health and patient care will be debated. A systematic review of
health outcomes related to vitamin D and calcium intakes, both alone
and in combination, was published in August 2009.
A recent meta-analysis found that use of vitamin D supplements
was associated with a reduction in overall mortality from any cause by
a statistically signicant 7%. The subjects in these trials were primar-
ILYHEALTHYMIDDLEAGEDORELDERLYANDATHIGHRISKOFFRACTURESTHEY
took 3002,000 IU/day of vitamin D supplements.
151
Chapter 25
Vitamin E
Vitamin E is found naturally in some foods, added to others, and avail-

able as a dietary supplement. Vitamin E is the collective name for a
group of fat-soluble compounds with distinctive antioxidant activities.
Naturally occurring vitamin E exists in eight chemical forms (al-
pha-, beta-, gamma-, and delta-tocopherol and alpha-, beta-, gamma-,
and delta-tocotrienol) that have varying levels of biological activity.
!LPHA TOCOPHEROLISTHEONLYFORMTHATISRECOGNIZEDTOMEETHUMAN
requirements.
Serum concentrations of vitamin E (alpha-tocopherol) depend on the
liver, which takes up the nutrient after the various forms are absorbed
from the small intestine. The liver preferentially resecretes only alpha-
TOCOPHEROLVIATHEHEPATICALPHA TOCOPHEROLTRANSFERPROTEINTHELIVER
METABOLIZESANDEXCRETESTHEOTHERVITAMIN%FORMS!SARESULTBLOOD
and cellular concentrations of other forms of vitamin E are lower than
those of alpha-tocopherol and have been the subjects of less research.
Antioxidants protect cells from the damaging effects of free radicals,
which are molecules that contain an unshared electron. Free radicals
damage cells and might contribute to the development of cardiovas-
cular disease and cancer. Unshared electrons are highly energetic and
react rapidly with oxygen to form reactive oxygen species (ROS). The
body forms ROS endogenously when it converts food to energy, and
antioxidants might protect cells from the damaging effects of ROS. The
Excerpted from Vitamin E Fact Sheet, by the Ofce of Dietary Supplements

(ODS, ods.od.nih.gov), December 15, 2009.
153
body is also exposed to free radicals from environmental exposures,

such as cigarette smoke, air pollution, and ultraviolet radiation from
the sun. ROS are part of signaling mechanisms among cells.
Vitamin E is a fat-soluble antioxidant that stops the production of
ROS formed when fat undergoes oxidation. Scientists are investigat-
ing whether, by limiting free-radical production and possibly through
other mechanisms, vitamin E might help prevent or delay the chronic
diseases associated with free radicals.
In addition to its activities as an antioxidant, vitamin E is involved in
immune function and, as shown primarily by in vitro studies of cells, cell
signaling, regulation of gene expression, and other metabolic processes.
!LPHA TOCOPHEROLINHIBITSTHEACTIVITYOFPROTEINKINASE#ANENZYME
involved in cell proliferation and differentiation in smooth muscle cells,
platelets, and monocytes. Vitamin-Ereplete endothelial cells lining the
interior surface of blood vessels are better able to resist blood-cell compo-
nents adhering to this surface. Vitamin E also increases the expression
OFTWOENZYMESTHATSUPPRESSARACHIDONICACIDMETABOLISMTHEREBY
increasing the release of prostacyclin from the endothelium, which, in
turn, dilates blood vessels and inhibits platelet aggregation.
Vitamin E and Health

Many claims have been made about vitamin Es potential to pro-
mote health and prevent and treat disease. The mechanisms by which
vitamin E might provide this protection include its function as an
antioxidant and its roles in anti-inammatory processes, inhibition
of platelet aggregation, and immune enhancement.
!PRIMARYBARRIERTOCHARACTERIZINGTHEROLESOFVITAMIN%INHEALTH
is the lack of validated biomarkers for vitamin E intake and status to
help relate intakes to valid predictors of clinical outcomes. This section
focuses on four diseases and disorders in which vitamin E might be
involved: heart disease, cancer, eye disorders, and cognitive decline.
Coronary Heart Disease

Evidence that vitamin E could help prevent or delay coronary heart
disease (CHD) comes from several sources. In vitro studies have found
that the nutrient inhibits oxidation of low-density lipoprotein (LDL)
cholesterol, thought to be a crucial initiating step for atherosclerosis.
Vitamin E might also help prevent the formation of blood clots that
could lead to a heart attack or venous thromboembolism.
Several observational studies have associated lower rates of heart
disease with higher vitamin E intakes. One study of approximately
154
Vitamin E
90,000 nurses found that the incidence of heart disease was 30% to
40% lower in those with the highest intakes of vitamin E, primarily
from supplements. Among a group of 5,133 Finnish men and women
followed for a mean of 14 years, higher vitamin E intakes from food
were associated with decreased mortality from CHD.
(OWEVERRANDOMIZEDCLINICALTRIALSCASTDOUBTONTHEEFlCACYOFVITA-
min E supplements to prevent CHD. For example, the Heart Outcomes
Prevention Evaluation (HOPE) study, which followed almost 10,000
patients at high risk of heart attack or stroke for 4.5 years, found
that participants taking 400 IU/day of natural vitamin E experienced
NOFEWERCARDIOVASCULAREVENTSORHOSPITALIZATIONSFORHEARTFAILURE
or chest pain than participants taking a placebo. In the HOPE-TOO
followup study, almost 4,000 of the original participants continued
to take vitamin E or placebo for an additional 2.5 years. HOPE-TOO
found that vitamin E provided no signicant protection against heart
attacks, strokes, unstable angina, or deaths from cardiovascular dis-
ease or other causes after 7 years of treatment. Participants taking
vitamin E, however, were 13% more likely to experience, and 21% more
LIKELYTOBEHOSPITALIZEDFORHEARTFAILUREASTATISTICALLYSIGNIlCANTBUT
unexpected nding not reported in other large studies.
The HOPE and HOPE-TOO trials provide compelling evidence that
moderately high doses of vitamin E supplements do not reduce the risk
of serious cardiovascular events among men and women >50 years of
age with established heart disease or diabetes. These ndings are sup-
ported by evidence from the Womens Angiographic Vitamin and Estrogen
study, in which 423 postmenopausal women with some degree of coronary
stenosis took supplements with 400 IU vitamin E (type not specied) and
500 mg vitamin C twice a day or placebo for >4 years. Not only did the
supplements provide no cardiovascular benets, but all-cause mortality
was signicantly higher in the women taking the supplements.
The latest published clinical trial of vitamin Es effects on the heart
and blood vessels of women included almost 40,000 healthy women
greater than or equal to 45 years of age who were randomly assigned
to receive either 600 IU of natural vitamin E on alternate days or pla-
cebo and who were followed for an average of 10 years. The investiga-
tors found no signicant differences in rates of overall cardiovascular
events (combined nonfatal heart attacks, strokes, and cardiovascular
deaths) or all-cause mortality between the groups. However, the study
did nd two positive and signicant results for women taking vitamin
E: they had a 24% reduction in cardiovascular death rates, and those
greater than or equal to 65 years of age had a 26% decrease in nonfatal
heart attack and a 49% decrease in cardiovascular death rates.
155
The most recent published clinical trial of vitamin E and mens car-
diovascular health included almost 15,000 healthy physicians greater
than or equal to 50 years of age who were randomly assigned to receive
400 IU synthetic alpha-tocopherol every other day, 500 mg vitamin C
daily, both vitamins, or placebo. During a mean followup period of 8
years, intake of vitamin E (and/or vitamin C) had no effect on the inci-
dence of major cardiovascular events, myocardial infarction, stroke, or
cardiovascular morality. Furthermore, use of vitamin E was associated
with a signicantly increased risk of hemorrhagic stroke.
In general, clinical trials have not provided evidence that routine
use of vitamin E supplements prevents cardiovascular disease or
reduces its morbidity and mortality. However, participants in these
studies have been largely middle-aged or elderly individuals with
demonstrated heart disease or risk factors for heart disease. Some
researchers have suggested that understanding the potential utility of
vitamin E in preventing CHD might require longer studies in younger
participants taking higher doses of the supplement. Further research is
needed to determine whether supplemental vitamin E has any protec-
tive value for younger, healthier people at no obvious risk of CHD.
Cancer
Antioxidant nutrients like vitamin E protect cell constituents from
the damaging effects of free radicals that, if unchecked, might contrib-
ute to cancer development. Vitamin E might also block the formation
of carcinogenic nitrosamines formed in the stomach from nitrites in
foods and protect against cancer by enhancing immune function. Hu-
man trials and surveys that attempted to associate vitamin E intake
with cancer incidence have generally been inconclusive.
Some research links higher intakes of vitamin E with a decreased
incidence of breast and prostate cancers, but the evidence is incon-
sistent. For example, an examination of the impact of dietary factors,
including vitamin E, on the incidence of postmenopausal breast can-
cer in >18,000 women found no benet from the vitamin. Similarly, a
prospective cohort study of >29,000 men found no association between
dietary or supplemental vitamin E intake and prostate cancer risk,
with one exception: among current smokers and men who had quit,
vitamin E intakes of more than 400 IU/day were associated with a
statistically signicant 71% reduction in the risk of advanced prostate
CANCER!LARGERANDOMIZEDCLINICALTRIALBEGANINTODETERMINE
whether 712 years of daily supplementation with synthetic vitamin
E (400 IU), with or without selenium (200 mcg), reduces the number
of new prostate cancers in healthy men. The trial was discontinued
156
Vitamin E
in October 2008 when an analysis found that the supplements, taken

alone or together for an average of 5 years, did not prevent prostate
cancer. Study staff members will continue to monitor participants
health for an additional 3 years.
One study of women in Iowa provides evidence that higher intakes
of vitamin E from foods and supplements could decrease the risk of
colon cancer, especially in women <65 years of age. The overall rela-
tive risk for the highest quintile of intake (>35.7 IU/day) compared
to the lowest quintile (<5.7 IU/day) was 0.32. However, prospective
cohort studies of 87,998 women in the Nurses Health Study and
47,344 men in the Health Professionals Follow-up Study failed to
replicate these results.
The American Cancer Society conducted an epidemiologic study
examining the association between use of vitamin C and vitamin E
supplements and bladder cancer mortality. Of the almost one million
adults followed between 1982 and 1998, adults who took supplemental
vitamin E for 10 years or longer had a reduced risk of death from blad-
DERCANCERVITAMIN#SUPPLEMENTATIONPROVIDEDNOPROTECTION
Both the recently published HOPE-TOO Trial and Womens Health
Study evaluated whether vitamin E supplements might protect people
from cancer. HOPE-TOO, which followed men and women greater than
or equal to 55 years of age with heart disease or diabetes for 7 years,
found no signicant differences in the number of new cancers or cancer
deaths between the groups taking 400 IU/day vitamin E or a placebo.
In the Womens Health Study, in which healthy women greater than or
equal to 45 years of age received either 600 IU vitamin E every other
day or a placebo for 10 years, the supplement did not reduce the risk
of developing any form of cancer.
The inconsistent and limited evidence precludes any recommenda-
tions about using vitamin E supplements to prevent cancer.
Eye Disorders
Age-related macular degeneration (AMD) and cataracts are among
the most common causes of signicant vision loss in older people. Their
etiologies are usually unknown, but the cumulative effects of oxida-
tive stress have been postulated to play a role. If so, nutrients with
antioxidant functions, such as vitamin E, could be used to prevent or
treat these conditions.
Prospective cohort studies have found that people with relatively high
dietary intakes of vitamin E (e.g., 30 IU/day) have an approximately 20%
lower risk of developing AMD than people with low intakes (e.g., <15 IU/
DAY (OWEVERTWORANDOMIZEDCONTROLLEDTRIALSINWHICHPARTICIPANTSTOOK
157
supplements of vitamin E (500 IU/day d-alpha-tocopherol in one study

and 111 IU/day dl-alpha-tocopheryl acetate combined with 20 mg/day
beta-carotene in the other) or a placebo failed to show a protective effect
for vitamin E on AMD. The Age-Related Eye Disease Study (AREDS),
ALARGERANDOMIZEDCLINICALTRIALREVEALEDTHATPARTICIPANTSWITHEARLY
stage AMD could slow the progression of their disease by taking a daily
supplement of vitamin E (400 IU dl-alpha-tocopheryl acetate), vitamin
#MG BETA CAROTENEMG ZINCMG ANDCOPPERMG FORAN
average of 6.3 years compared to participants taking a placebo.
Several observational studies have revealed a potential relationship
between vitamin E supplements and the risk of cataract formation.
One prospective cohort study found that lens clarity was superior in
participants who took vitamin E supplements and those with higher
blood levels of the vitamin. In another study, long-term use of vitamin
E supplements was associated with slower progression of age-related
LENSOPACIlCATION(OWEVERINTHERANDOMIZED!2%$3STUDYTHEUSEOF
the vitamin E-containing supplement package had no apparent effect
on the development or progression of cataracts over 7 years.
Overall, the available evidence is inconsistent with respect to
whether vitamin E supplements, taken alone or in combination with
other antioxidants, can reduce the risk of developing AMD or cataracts.
(OWEVERTHEFORMULATIONOFVITAMIN%OTHERANTIOXIDANTSZINCAND
copper used in AREDS holds promise for slowing the progression of
AMD in people with early-stage disease. AREDS 2, a followup study,
will determine whether a modied combination of dietary supplements
can further slow the progression of vision loss from AMD.
Cognitive Decline
The brain has a high oxygen consumption rate and abundant poly-
unsaturated fatty acids in the neuronal cell membranes. Researchers
HYPOTHESIZETHATIFCUMULATIVEFREE RADICALDAMAGETONEURONSOVER
time contributes to cognitive decline and neurodegenerative diseases,
SUCHAS!LZHEIMERDISEASETHENINGESTIONOFSUFlCIENTORSUPPLEMEN-
tal antioxidants (such as vitamin E) might provide some protection.
This hypothesis was supported by the results of a clinical trial in 341
PATIENTSWITH!LZHEIMERDISEASEOFMODERATESEVERITYWHOWERERAN-
domly assigned to receive a placebo, vitamin E (2,000 IU/day dl-alpha-
tocopherol), a monoamine oxidase inhibitor (selegiline), or vitamin E
and selegiline. Over 2 years, treatment with vitamin E and selegiline,
separately or together, signicantly delayed functional deterioration
ANDTHENEEDFORINSTITUTIONALIZATIONCOMPAREDTOPLACEBO(OWEVER
participants taking vitamin E experienced signicantly more falls.
158
Vitamin E
Vitamin E consumption from foods or supplements was associated

with less cognitive decline over 3 years in a prospective cohort study of
elderly, free-living individuals aged 65102 years. However, a clinical
trial in primarily healthy older women who were randomly assigned to
receive 600 IU d-alpha-tocopherol every other day or a placebo for less
than or equal to 4 years found that the supplements provided no appar-
ent cognitive benets. Another trial in which 769 men and women with
mild cognitive impairment were randomly assigned to receive 2,000 IU/
DAYVITAMIN%TYPENOTSPECIlED ACHOLINESTERASEINHIBITORDONEPEZIL
or placebo found no signicant differences in the progression rate of
!LZHEIMERDISEASEBETWEENTHEVITAMIN%ANDPLACEBOGROUPS
In summary, most research results do not support the use of vi-
tamin E supplements by healthy or mildly impaired individuals to
maintain cognitive performance or slow its decline with normal aging.
More research is needed to identify the role of vitamin E, if any, in the
management of cognitive impairment.
159
Chapter 26
Folate (Folic Acid)
Folate: What is it?

Folate is a water-soluble B vitamin that occurs naturally in food.
Folic acid is the synthetic form of folate that is found in supplements
and added to fortied foods.
Folate gets its name from the Latin word folium for leaf. A key obser-
vation of researcher Lucy Wills nearly 70 years ago led to the identication
of folate as the nutrient needed to prevent the anemia of pregnancy. Dr.
Wills demonstrated that the anemia could be corrected by a yeast extract.
Folate was identied as the corrective substance in yeast extract in the
late 1930s, and was extracted from spinach leaves in 1941.
Folate helps produce and maintain new cells. This is especially
important during periods of rapid cell division and growth such as in-
fancy and pregnancy. Folate is needed to make DNA [deoxyribonucleic
acid] and RNA [ribonucleic acid], the building blocks of cells. It also
helps prevent changes to DNA that may lead to cancer. Both adults
and children need folate to make normal red blood cells and prevent
anemia. Folate is also essential for the metabolism of homocysteine,
and helps maintain normal levels of this amino acid.
What foods provide folate?

Leafy green vegetables (like spinach and turnip greens), fruits
(like citrus fruits and juices), and dried beans and peas are all natu-
ral sources of folate.
Excerpted from Folate, by the Ofce of Dietary Supplements (ODS, ods.od.nih
.gov), part of the National Institutes of Health, April 15, 2009.
161
In 1996, the Food and Drug Administration (FDA) published regula-

tions requiring the addition of folic acid to enriched breads, cereals, ours,
corn meals, pastas, rice, and other grain products. Since cereals and grains
are widely consumed in the United States, these products have become a
very important contributor of folic acid to the American diet.
What are the Dietary Reference Intakes for folate?

Recommendations for folate are given in the Dietary Reference In-
takes (DRIs) developed by the Institute of Medicine of the National
Academy of Sciences. Dietary Reference Intakes is the general term for
a set of reference values used for planning and assessing nutrient intake
for healthy people. Three important types of reference values included
in the DRIs are Recommended Dietary Allowances (RDA), Adequate
Intakes (AI), and Tolerable Upper Intake Levels (UL). The RDA recom-
mends the average daily intake that is sufcient to meet the nutrient
requirements of nearly all (9798%) healthy individuals in each age
and gender group. An AI is set when there is insufcient scientic data
available to establish a RDA. AIs meet or exceed the amount needed to
maintain a nutritional state of adequacy in nearly all members of a spe-
cic age and gender group. The UL, on the other hand, is the maximum
daily intake unlikely to result in adverse health effects.
The RDAs for folate are expressed in a term called the Dietary Fo-
late Equivalent. The Dietary Folate Equivalent (DFE) was developed
to help account for the differences in absorption of naturally occurring
dietary folate and the more bioavailable synthetic folic acid. Table 26.1
lists the RDAs for folate, expressed in micrograms (mcg) of DFE, for
children and adults.
Table 26.1. Recommended Dietary Allowances for Folate for Chil-

dren and Adults
Males and Females Pregnancy Lactation
Age (years) (mcg/day) (mcg/day) (mcg/day)
13 150 N/A N/A
48 200 N/A N/A
913 300 N/A N/A
1418 400 600 500
19+ 400 600 500
Note: 1 DFE = 1 mcg food folate = 0.6 mcg folic acid from supplements and
fortied foods.
162
Folate (Folic Acid)
The National Health and Nutrition Examination Survey (NHANES

III 198894) and the Continuing Survey of Food Intakes by Individuals
(199496 CSFII) indicated that most individuals surveyed did not con-
sume adequate folate. However, the folic acid fortication program, which
was initiated in 1998, has increased folic acid content of commonly eaten
foods such as cereals and grains, and as a result most diets in the United
States now provide recommended amounts of folate equivalents.
When can folate deciency occur?

A deciency of folate can occur when an increased need for folate is
not matched by an increased intake, when dietary folate intake does
not meet recommended needs, and when folate loss increases. Medica-
tions that interfere with the metabolism of folate may also increase
the need for this vitamin and risk of deciency.
Medical conditions that increase the need for folate or result in
increased loss of folate include the following:
s 0REGNANCYANDLACTATIONBREASTFEEDING
s !LCOHOLABUSE
s -ALABSORPTION
s +IDNEYDIALYSIS
s ,IVERDISEASE
s #ERTAINANEMIAS
-EDICATIONSTHATINTERFEREWITHFOLATEUTILIZATIONINCLUDETHEFOL-
lowing:
s !NTICONVULSANTMEDICATIONSSUCHAS$ILANTINPHENYTOINAND
primidone)
s -ETFORMINSOMETIMESPRESCRIBEDTOCONTROLBLOODSUGARINTYPE
2 diabetes)
s 3ULFASALAZINEUSEDTOCONTROLINmAMMATIONASSOCIATEDWITH
Crohn disease and ulcerative colitis)
s 4RIAMTERENEADIURETIC
s -ETHOTREXATEUSEDFORCANCERANDOTHERDISEASESSUCHASRHEU-
matoid arthritis)
s "ARBITURATESUSEDASSEDATIVES
163
What are some current issues and controversies about folate?

Folic acid and cardiovascular disease: Cardiovascular disease
involves any disorder of the heart and blood vessels that make up the
cardiovascular system. Coronary heart disease occurs when blood ves-
sels which supply the heart become clogged or blocked, increasing the
risk of a heart attack. Vascular damage can also occur to blood vessels
supplying the brain, and can result in a stroke.
Cardiovascular disease is the most common cause of death in in-
DUSTRIALIZEDCOUNTRIESSUCHASTHE5NITED3TATESANDISONTHERISEIN
developing countries. The National Heart, Lung, and Blood Institute
of the National Institutes of Health has identied many risk factors
for cardiovascular disease, including an elevated LDL [low-density
lipoprotein]-cholesterol level, high blood pressure, a low HDL [high-
density lipoprotein]-cholesterol level, obesity, and diabetes. In recent
years, researchers have identied another risk factor for cardiovascular
disease, an elevated homocysteine level. Homocysteine is an amino
acid normally found in blood, but elevated levels have been linked with
coronary heart disease and stroke. Elevated homocysteine levels may
impair endothelial vasomotor function, which determines how easily
blood ows through blood vessels. High levels of homocysteine also
may damage coronary arteries and make it easier for blood clotting
cells called platelets to clump together and form a clot, which may
lead to a heart attack.
A deciency of folate, vitamin B12, or vitamin B6 may increase blood
levels of homocysteine, and folate supplementation has been shown
to decrease homocysteine levels and to improve endothelial function.
At least one study has linked low dietary folate intake with an in-
creased risk of coronary events. The folic acid fortication program in
the United States has decreased the prevalence of low levels of folate
and high levels of homocysteine in the blood in middle-aged and older
adults. Daily consumption of folic-acid fortied breakfast cereal and
the use of folic acid supplements has been shown to be an effective
strategy for reducing homocysteine concentrations.
Evidence supports a role for supplemental folic acid for lowering ho-
mocysteine levels, however this does not mean that folic acid supplements
will decrease the risk of cardiovascular disease. Clinical intervention tri-
als are underway to determine whether supplementation with folic acid,
vitamin B12, and vitamin B6 can lower risk of coronary heart disease. It is
premature to recommend folic acid supplementation for the prevention
OFHEARTDISEASEUNTILRESULTSOFONGOINGRANDOMIZEDCONTROLLEDCLINICAL
trials positively link increased folic acid intake with decreased homo-
cysteine levels and decreased risk of cardiovascular disease.
164
Folate (Folic Acid)
Folic acid and cancer: Some evidence associates low blood levels
of folate with a greater risk of cancer. Folate is involved in the synthe-
sis, repair, and function of DNA, our genetic map, and there is some
evidence that a deciency of folate can cause damage to DNA that may
lead to cancer. Several studies have associated diets low in folate with
increased risk of breast, pancreatic, and colon cancer.
Over 88,000 women enrolled in the Nurses Health Study who were
free of cancer in 1980 were followed from 1980 through 1994. Researchers
found that women ages 55 to 69 years in this study who took multivitamins
containing folic acid for more than 15 years had a markedly lower risk of
developing colon cancer. Findings from over 14,000 subjects followed for
20 years suggest that men who do not consume alcohol and whose diets
provide the recommended intake of folate are less likely to develop colon
cancer. However, associations between diet and disease do not indicate a
direct cause. Researchers are continuing to investigate whether enhanced
folate intake from foods or folic acid supplements may reduce the risk of
cancer. Until results from such clinical trials are available, folic acid supple-
ments should not be recommended to reduce the risk of cancer.
Folic acid and methotrexate for cancer: Folate is important for
cells and tissues that rapidly divide. Cancer cells divide rapidly, and
drugs that interfere with folate metabolism are used to treat cancer.
Methotrexate is a drug often used to treat cancer because it limits the
ACTIVITYOFENZYMESTHATNEEDFOLATE
Unfortunately, methotrexate can be toxic, producing side effects
such as inammation in the digestive tract that may make it difcult
to eat normally. Leucovorin is a form of folate that can help rescue
or reverse the toxic effects of methotrexate. There are many studies
underway to determine if folic acid supplements can help control the
side effects of methotrexate without decreasing its effectiveness in
chemotherapy. It is important for anyone receiving methotrexate to
follow a medical doctors advice on the use of folic acid supplements.
Folic acid and methotrexate for non-cancerous diseases: Low
dose methotrexate is used to treat a wide variety of non-cancerous
diseases such as rheumatoid arthritis, lupus, psoriasis, asthma, sar-
coidosis, primary biliary cirrhosis, and inammatory bowel disease.
Low doses of methotrexate can deplete folate stores and cause side
effects that are similar to folate deciency. Both high folate diets and
supplemental folic acid may help reduce the toxic side effects of low
dose methotrexate without decreasing its effectiveness. Anyone taking
low dose methotrexate for the health problems listed should consult
with a physician about the need for a folic acid supplement.
165
What cautions should I take with folic acid supplements?

Beware of the interaction between vitamin B12 and folic acid. Intake
of supplemental folic acid should not exceed 1,000 micrograms (mcg)
per day to prevent folic acid from triggering symptoms of vitamin B12
deciency. Folic acid supplements can correct the anemia associated with
vitamin B12 deciency. Unfortunately, folic acid will not correct changes
in the nervous system that result from vitamin B12 deciency. Permanent
nerve damage can occur if vitamin B12 deciency is not treated.
It is very important for older adults to be aware of the relationship
between folic acid and vitamin B12 because they are at greater risk of
having a vitamin B12 deciency. If you are 50 years of age or older, ask
your physician to check your B12 status before you take a supplement
that contains folic acid. If you are taking a supplement containing folic
acid, read the label to make sure it also contains B12 or speak with a
physician about the need for a B12 supplement.
What is the health risk of too much folic acid?

Folate intake from food is not associated with any health risk. The
risk of toxicity from folic acid intake from supplements and/or fortied
foods is also low. It is a water soluble vitamin, so any excess intake
is usually lost in the urine. There is some evidence that high levels
OFFOLICACIDCANPROVOKESEIZURESINPATIENTSTAKINGANTICONVULSANT
medications. Anyone taking such medications should consult with a
medical doctor before taking a folic acid supplement.
The Institute of Medicine has established a tolerable upper in-
take level (UL) for folate from fortied foods or supplements (i.e., folic
acid) for ages 1 and above. Intakes above this level increase the risk
of adverse health effects. In adults, supplemental folic acid should
not exceed the UL to prevent folic acid from triggering symptoms of
vitamin B12DElCIENCY)TISIMPORTANTTORECOGNIZETHATTHE5,REFERS
to the amount of synthetic folate (i.e., folic acid) being consumed per
day from fortied foods and/or supplements. There is no health risk,
and no UL, for natural sources of folate found in food.
As the 2000 Dietary Guidelines for Americans states, Different foods
contain different nutrients and other healthful substances. No single
food can supply all the nutrients in the amounts you need. Green leafy
vegetables, dried beans and peas, and many other types of vegetables
and fruits provide folate. In addition, fortied foods are a major source
of folic acid. It is not unusual to nd foods such as some ready-to-eat
cereals fortied with 100% of the RDA for folate. The variety of fortied
foods available has made it easier for women of childbearing age in the
166
Folate (Folic Acid)
United States to consume the recommended 400 mcg of folic acid per day
from fortied foods and/or supplements. The large numbers of fortied
foods on the market, however, also raises the risk of exceeding the UL.
This is especially important for anyone at risk of vitamin B12 deciency,
which can be triggered by too much folic acid. It is important for any-
one who is considering taking a folic acid supplement to rst consider
whether their diet already includes adequate sources of dietary folate
and fortied food sources of folic acid.
167
Chapter 27
Magnesium
Magnesium: What is it?

Magnesium is the fourth most abundant mineral in the body and is
essential to good health. Approximately 50% of total body magnesium
is found in bone. The other half is found predominantly inside cells of
body tissues and organs. Only 1% of magnesium is found in blood, but
the body works very hard to keep blood levels of magnesium constant.
Magnesium is needed for more than 300 biochemical reactions in the
body. It helps maintain normal muscle and nerve function, keeps heart
rhythm steady, supports a healthy immune system, and keeps bones
strong. Magnesium also helps regulate blood sugar levels, promotes
normal blood pressure, and is known to be involved in energy metabo-
lism and protein synthesis. There is an increased interest in the role of
magnesium in preventing and managing disorders such as hypertension,
cardiovascular disease, and diabetes. Dietary magnesium is absorbed in
the small intestines. Magnesium is excreted through the kidneys.

magnesium?
Magnesium and blood pressure: Epidemiologic evidence sug-
gests that magnesium may play an important role in regulating blood
pressure. Diets that provide plenty of fruits and vegetables, which are

.gov), part of the National Institutes of Health, July 13, 2009.
169
good sources of potassium and magnesium, are consistently associated

with lower blood pressure. The DASH study (Dietary Approaches to
Stop Hypertension), a human clinical trial, suggested that high blood
PRESSURECOULDBESIGNIlCANTLYLOWEREDBYADIETTHATEMPHASIZESFRUITS
vegetables, and low-fat dairy foods. Such a diet will be high in magne-
sium, potassium, and calcium, and low in sodium and fat.
An observational study examined the effect of various nutritional
factors on incidence of high blood pressure in over 30,000 U.S. male
health professionals. After 4 years of follow-up, it was found that a
lower risk of hypertension was associated with dietary patterns that
provided more magnesium, potassium, and dietary ber. For 6 years,
the Atherosclerosis Risk in Communities (ARIC) Study followed ap-
proximately 8,000 men and women who were initially free of hyperten-
sion. In this study, the risk of developing hypertension decreased as
dietary magnesium intake increased in women, but not in men.
Foods high in magnesium are frequently high in potassium and di-
etary ber. This makes it difcult to evaluate the independent effect of
magnesium on blood pressure. However, newer scientic evidence from
DASH clinical trials is strong enough that the Joint National Com-
mittee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure states that diets that provide plenty of magnesium
are positive lifestyle modications for individuals with hypertension.
This group recommends the DASH diet as a benecial eating plan for
people with hypertension and for those with prehypertension who
desire to prevent high blood pressure http://www.nhlbi.nih.gov/health/
public/heart/hbp/dash.
Magnesium and diabetes: Diabetes is a disease resulting in insuf-

cient production and/or inefcient use of insulin. Insulin is a hormone
made by the pancreas. Insulin helps convert sugar and starches in food
into energy to sustain life. There are two types of diabetes: type 1 and type
2. Type 1 diabetes is most often diagnosed in children and adolescents, and
results from the bodys inability to make insulin. Type 2 diabetes, which
is sometimes referred to as adult-onset diabetes, is the most common
form of diabetes. It is usually seen in adults and is most often associated
with an inability to use the insulin made by the pancreas. Obesity is a
risk factor for developing type 2 diabetes. In recent years, rates of type 2
diabetes have increased along with the rising rates of obesity.
Magnesium plays an important role in carbohydrate metabolism.
It may inuence the release and activity of insulin, the hormone that
helps control blood glucose (sugar) levels. Low blood levels of magne-
sium (hypomagnesemia) are frequently seen in individuals with type 2
170
Magnesium
diabetes. Hypomagnesemia may worsen insulin resistance, a condition

that often precedes diabetes, or may be a consequence of insulin resis-
tance. Individuals with insulin resistance do not use insulin efciently
and require greater amounts of insulin to maintain blood sugar within
normal levels. The kidneys possibly lose their ability to retain magne-
sium during periods of severe hyperglycemia (signicantly elevated
blood glucose). The increased loss of magnesium in urine may then
result in lower blood levels of magnesium. In older adults, correcting
magnesium depletion may improve insulin response and action.
The Nurses Health Study (NHS) and the Health Professionals
Follow-up Study (HFS) follow more than 170,000 health professionals
through questionnaires the participants complete every 2 years. Diet
was rst evaluated in 1980 in the NHS and in 1986 in the HFS, and
dietary assessments have been completed every 2 to 4 years since. In-
formation on the use of dietary supplements, including multivitamins,
is also collected. As part of these studies, over 127,000 participants
(85,060 women and 42,872 men) with no history of diabetes, cardio-
vascular disease, or cancer at baseline were followed to examine risk
factors for developing type 2 diabetes. Women were followed for 18
YEARSMENWEREFOLLOWEDFORYEARS/VERTIMETHERISKFORDEVEL-
oping type 2 diabetes was greater in men and women with a lower
magnesium intake. This study supports the dietary recommendation
to increase consumption of major food sources of magnesium, such as
whole grains, nuts, and green leafy vegetables.
The Iowa Womens Health Study has followed a group of older wom-
en since 1986. Researchers from this study examined the association
between womens risk of developing type 2 diabetes and intake of car-
bohydrates, dietary ber, and dietary magnesium. Dietary intake was
estimated by a food frequency questionnaire, and incidence of diabetes
throughout 6 years of follow-up was determined by asking participants
if they had been diagnosed by a doctor as having diabetes. Based on
baseline dietary intake assessment only, researchers ndings suggest-
ed that a greater intake of whole grains, dietary ber, and magnesium
decreased the risk of developing diabetes in older women.
The Womens Health Study was originally designed to evaluate the
benets versus risks of low-dose aspirin and vitamin E supplementa-
tion in the primary prevention of cardiovascular disease and cancer in
women 45 years of age and older. In an examination of almost 40,000
women participating in this study, researchers also examined the as-
sociation between magnesium intake and incidence of type 2 diabetes
over an average of 6 years. Among women who were overweight, the
risk of developing type 2 diabetes was signicantly greater among
171
those with lower magnesium intake. This study also supports the di-
etary recommendation to increase consumption of major food sources of
magnesium, such as whole grains, nuts, and green leafy vegetables.
On the other hand, the Atherosclerosis Risk in Communities
(ARIC) study did not nd any association between dietary magne-
sium intake and the risk for type 2 diabetes. During 6 years of follow-
up, ARIC researchers examined the risk for type 2 diabetes in over
12,000 middle-aged adults without diabetes at baseline examination.
In this study, there was no association between dietary magnesium
intake and incidence of type 2 diabetes in either black or white par-
ticipants. It can be confusing to read about studies that examine the
same issue but have different results. Before reaching a conclusion
on a health issue, scientists conduct and evaluate many studies. Over
time, they determine when results are consistent enough to suggest
a conclusion. They want to be sure they are providing correct recom-
mendations to the public.
Several clinical studies have examined the potential benet of supple-
mental magnesium on control of type 2 diabetes. In one such study, 63
subjects with below normal serum magnesium levels received either
2.5 grams of oral magnesium chloride daily in liquid form (providing
300 mg elemental magnesium per day) or a placebo. At the end of the
16-week study period, those who received the magnesium supplement
had higher blood levels of magnesium and improved control of diabetes,
as suggested by lower hemoglobin A1C levels, than those who received
a placebo. Hemoglobin A1C is a test that measures overall control of
blood glucose over the previous 2 to 3 months, and is considered by many
doctors to be the single most important blood test for diabetics.
In another study, 128 patients with poorly controlled type 2 diabetes
WERERANDOMIZEDTORECEIVEAPLACEBOORASUPPLEMENTWITHEITHER
mg or 1000 mg of magnesium oxide (MgO) for 30 days. All patients
were also treated with diet or diet plus oral medication to control blood
glucose levels. Magnesium levels increased in the group receiving 1000
mg magnesium oxide per day (equal to 600 mg elemental magnesium
per day) but did not signicantly change in the placebo group or the
group receiving 500 mg of magnesium oxide per day (equal to 300 mg
elemental magnesium per day). However, neither level of magnesium
supplementation signicantly improved blood glucose control.
These studies provide intriguing results but also suggest that ad-
ditional research is needed to better explain the association between
blood magnesium levels, dietary magnesium intake, and type 2 diabe-
tes. In 1999, the American Diabetes Association (ADA) issued nutri-
tion recommendations for diabetics stating that routine evaluation of
172
Magnesium
blood magnesium level is recommended only in patients at high risk

for magnesium deciency. Levels of magnesium should be [replaced]
only if hypomagnesemia can be demonstrated.
Magnesium and cardiovascular disease: Magnesium metabolism

is very important to insulin sensitivity and blood pressure regulation,
and magnesium deciency is common in individuals with diabetes. The
observed associations between magnesium metabolism, diabetes, and
high blood pressure increase the likelihood that magnesium metabo-
lism may inuence cardiovascular disease.
Some observational surveys have associated higher blood levels
of magnesium with lower risk of coronary heart disease. In addition,
some dietary surveys have suggested that a higher magnesium intake
may reduce the risk of having a stroke. There is also evidence that
low body stores of magnesium increase the risk of abnormal heart
rhythms, which may increase the risk of complications after a heart
attack. These studies suggest that consuming recommended amounts
of magnesium may be benecial to the cardiovascular system. They
have also prompted interest in clinical trials to determine the effect
of magnesium supplements on cardiovascular disease.
Several small studies suggest that magnesium supplementation
may improve clinical outcomes in individuals with coronary disease.
In one of these studies, the effect of magnesium supplementation on
exercise tolerance (the ability to walk on a treadmill or ride a bicycle),
chest pain caused by exercise, and quality of life was examined in 187
patients. Patients received either a placebo or a supplement providing
365 milligrams of magnesium citrate twice daily for 6 months. At the
end of the study period researchers found that magnesium therapy
signicantly increased magnesium levels. Patients receiving magne-
sium had a 14 percent improvement in exercise duration as compared
to no change in the placebo group. Those receiving magnesium were
also less likely to experience chest pain caused by exercise.
In another study, 50 men and women with stable coronary dis-
EASEWERERANDOMIZEDTORECEIVEEITHERAPLACEBOORAMAGNESIUM
supplement that provided 342 mg magnesium oxide twice daily. After
6 months, those who received the oral magnesium supplement were
found to have improved exercise tolerance.
In a third study, researchers examined whether magnesium sup-
plementation would add to the anti-thrombotic (anti-clotting) effects
of aspirin in 42 coronary patients. For 3 months, each patient received
either a placebo or a supplement with 400 mg of magnesium oxide
two to three times daily. After a 4-week break without any treatment,
173
treatment groups were reversed so that each person in the study

then received the alternate treatment for 3 months. Researchers
found that supplemental magnesium did provide an additional anti-
thrombotic effect.
These studies are encouraging, but involved small numbers. Addi-
tional studies are needed to better understand the complex relation-
ships between magnesium intake, indicators of magnesium status, and
heart disease. Doctors can evaluate magnesium status when above-
mentioned medical problems occur, and determine the need for mag-
nesium supplementation.
Magnesium and osteoporosis: Bone health is supported by many

factors, most notably calcium and vitamin D. However, some evidence
suggests that magnesium deciency may be an additional risk factor
for postmenopausal osteoporosis. This may be due to the fact that
magnesium deciency alters calcium metabolism and the hormones
that regulate calcium. Several human studies have suggested that
magnesium supplementation may improve bone mineral density. In
a study of older adults, a greater magnesium intake maintained bone
mineral density to a greater degree than a lower magnesium intake.
Diets that provide recommended levels of magnesium are benecial
for bone health, but further investigation on the role of magnesium in
bone metabolism and osteoporosis is needed.
174
Chapter 28
Omega-3 Fatty
Acid Supplements
Chapter Contents
Section 28.1Fish Oils............................................................... 176
Section 28.2Flaxseed and Flaxseed Oils ................................ 190
175
Section 28.1
Fish Oils
Omega-3 Fatty Acids, Fish Oil, Alpha-Linolenic Acid Copy-
right 2009 Natural Standard (www.naturalstandard.com).
All rights reserved.
Background
Dietary sources of omega-3 fatty acids include sh oil and certain
plant/nut oils. Fish oil contains both docosahexaenoic acid (DHA) and
eicosapentaenoic acid (EPA), while some nuts (English walnuts) and
vegetable oils (canola, soybean, axseed/linseed, olive) contain alpha-
linolenic acid (ALA).
There is evidence from multiple studies supporting intake of recom-
mended amounts of DHA and EPA in the form of dietary sh or sh
oil supplements lowers triglycerides, reduces the risk of death, heart
attack, dangerous abnormal heart rhythms, and strokes in people
with known cardiovascular disease, slows the buildup of atheroscle-
rotic plaques (hardening of the arteries), and lowers blood pressure
slightly. However, high doses may have harmful effects, such as an
increased risk of bleeding. Although similar benets are proposed for
alpha-linolenic acid, scientic evidence is less compelling, and bene-
cial effects may be less pronounced.
Some species of sh carry a higher risk of environmental contami-
nation, such as with methylmercury.
Synonyms
Alpha-linolenic acid (ALA, C18:3n-3), cod liver oil, coldwater sh,
docosahexaenoic acid (DHA, C22:6n-3), eicosapentaenoic acid (EPA,
C20:5n-3), sh oil fatty acids, sh body oil, sh extract, sh liver oil,
halibut oil, long chain polyunsaturated fatty acids, mackerel oil, ma-
rine oil, menhaden oil, n-3 fatty acids, n-3 polyunsaturated fatty acids,
omega fatty acids, omega-3 oils, polyunsaturated fatty acids (PUFA),
salmon oil, shark liver oil, w-3 fatty acids.
Note: Should not be confused with omega-6 fatty acids.
176
Omega-3 Fatty Acid Supplements
Evidence
These uses have been tested in humans or animals. Safety and ef-
fectiveness have not always been proven. Some of these conditions are
potentially serious, and should be evaluated by a qualied healthcare
PROVIDER+EYTOGRADES!3TRONGSCIENTIlCEVIDENCEFORTHISUSE "
'OODSCIENTIlCEVIDENCEFORTHISUSE #5NCLEARSCIENTIlCEVIDENCE
FORTHISUSE $&AIRSCIENTIlCEVIDENCEAGAINSTTHISUSE &3TRONG
scientic evidence against this use).
Uses Based on Scientic Evidence

High Blood Pressure
Multiple human trials report small reductions in blood pressure with
intake of omega-3 fatty acid. DHA may have greater benets than EPA.
However, high intakes of omega-3 fatty acids per day may be necessary
to obtain clinically relevant effects, and at this dose level, there is an in-
creased risk of bleeding. Therefore, a qualied healthcare provider should
be consulted prior to starting treatment with supplements. Grade: A.
Hypertriglyceridemia (Fish Oil/EPA plus DHA)

There is strong scientic evidence from human trials that omega-3
fatty acids from sh or sh oil supplements (EPA + DHA) signicantly
reduce blood triglyceride levels. Benets appear to be dose-dependent.
Fish oil supplements also appear to cause small improvements in
HIGH DENSITYLIPOPROTEINhGOODCHOLESTEROLv HOWEVERINCREASESWORS-
ening) in low-density lipoprotein levels (LDL/bad cholesterol) are
also observed. It is not clear if alpha-linolenic acid signicantly af-
fects triglyceride levels, and there is conicting evidence in this area.
The American Heart Association has published recommendations for
EPA + DHA. Because of the risk of bleeding from omega-3 fatty acids,
a qualied healthcare provider should be consulted prior to starting
treatment with supplements. There is growing evidence that reducing
C-reactive protein (CRP) is benecial toward favorable cardiovascular
outcomes, although additional research is pending in this area. The
data on sh oils and CRP levels is mixed. Grade: A.
Secondary Cardiovascular Disease Prevention (Fish Oil/

EPA plus DHA)
3EVERALWELL CONDUCTEDRANDOMIZEDCONTROLLEDTRIALSREPORTTHATIN
people with a history of heart attack, regular consumption of oily sh or
177
sh oil/omega-3 supplements reduces the risk of non-fatal heart attack,

fatal heart attack, sudden death, and all-cause mortality (death due to
any cause). Most patients in these studies were also using conventional
heart drugs, suggesting that the benets of sh oils may add to the
effects of other therapies. Grade: A.
Primary Cardiovascular Disease Prevention (Fish Intake)

Several large studies of populations (epidemiologic studies) re-
port a signicantly lower rate of death from heart disease in men and
women who regularly eat sh. Other epidemiologic research reports no
such benets. It is not clear if reported benets only occur in certain
groups of people, such as those at risk of developing heart disease.
Overall, the evidence suggests benets of regular consumption of sh
OIL(OWEVERWELL DESIGNEDRANDOMIZEDCONTROLLEDTRIALSWHICHCLASSIFY
people by their risk of developing heart disease are necessary before
a rm conclusion can be drawn. Grade: B.
Protection from Cyclosporine Toxicity in Organ Trans-

plant Patients
There are multiple studies of heart transplant and kidney transplant pa-
tients taking cyclosporine (Neoral), who were administered sh oil supple-
ments. The majority of trials report improvements in kidney function, and
less high blood pressure compared to patients not taking sh oil. Although
several recent studies report no benets on kidney function, the weight of
scientic evidence favors the benecial effects of sh oil. Grade: B.
Rheumatoid Arthritis (Fish Oil)

-ULTIPLE RANDOMIZED CONTROLLED TRIALS REPORT IMPROVEMENTS IN
morning stiffness and joint tenderness with the regular intake of sh
oil supplements for up to 3 months. Benets have been reported as
additive with anti-inammatory medications such as NSAIDs (like
ibuprofen or aspirin). However, because of weaknesses in study designs
and reporting, better research is necessary before a strong favorable
recommendation can be made. Effects beyond three months of treat-
ment have not been well evaluated. Grade: B.
Angina Pectoris
Preliminary studies report reductions in angina associated with
sh oil intake. Better research is necessary before a rm conclusion
can be drawn. Grade: C.
178
Asthma
Several studies in this area do not provide enough reliable evidence
to form a clear conclusion, with some studies reporting no effects, and
others nding benets. Because most studies have been small without
clear descriptions of design or results, the results cannot be considered
conclusive. Grade: C.
Atherosclerosis
Some research reports that regular intake of sh or sh oil supplements
reduces the risk of developing atherosclerotic plaques in the arteries of
the heart, while other research reports no effects. Additional evidence is
necessary before a rm conclusion can be drawn in this area. Grade: C.
Bipolar Disorder
to form a clear conclusion. Grade: C.
Cancer Prevention
Several population (epidemiologic) studies report that dietary omega-3
fatty acids or sh oil may reduce the risk of developing breast, colon,
ORPROSTATECANCER2ANDOMIZEDCONTROLLEDTRIALSARENECESSARYBEFORE
a clear conclusion can be drawn. Grade: C.
Cardiac Arrhythmias (Abnormal Heart Rhythms)

There is promising evidence that omega-3 fatty acids may decrease
the risk of cardiac arrhythmias. This is one proposed mechanism be-
hind the reduced number of heart attacks in people who regularly
ingest sh oil or EPA + DHA. Additional research is needed in this area
specically before a rm conclusion can be reached. Grade: C.
Colon Cancer
Omega-3 fatty acids are commonly taken by cancer patients. Al-
though preliminary studies report that growth of colon cancer cells
may be reduced by taking sh oil, effects on survival or remission have
not been measured adequately. Grade: C.
Crohns Disease
It has been suggested that effects of omega-3 fatty acids on inam-
mation may be benecial in patients with Crohns disease when added
to standard therapy, and several studies have been conducted in this
179
area. Results are conicting, and no clear conclusion can be drawn at

this time. Grade: C.
Cystic Fibrosis
A small amount of research in this area does not provide enough
reliable evidence to form a clear conclusion. Grade: C.
Dementia
Well-designed clinical trials are needed before omega-3 fatty acids
can be recommended for the prevention of cognitive impairment or
dementia. Grade: C.
Depression
Several studies on the use of omega 3 fatty acids in depression, in-
cluding positive results in postpartum depression, do not provide enough
reliable evidence to form a clear conclusion or replace standard treat-
ments. However, based on one recent study, omega-3 fatty acids may have
therapeutic benets in childhood depression. Promising initial evidence
requires conrmation with larger, well-designed trials. Grade: C.
Dysmenorrhea (Painful Menstruation)

There is preliminary evidence suggesting possible benets of sh oil/
omega-3 fatty acids in patients with dysmenorrhea. Additional research
is necessary before a rm conclusion can be reached. Grade: C.
Eczema
3EVERALSTUDIESOF%0!FORECZEMADONOTPROVIDEENOUGHRELIABLE
evidence to form a clear conclusion. Grade: C.
IgA Nephropathy
There are conicting results from several trials in this area. Grade: C.
Infant Eye/Brain Development

Well-designed research is necessary before a clear conclusion can
be reached. Grade: C.
Lupus Erythematosus
There is not enough reliable evidence to form a clear conclusion in
this area. Grade: C.
180
Nephrotic Syndrome
There is not enough reliable evidence to form a clear conclusion in
this area. Grade: C.
Preeclampsia
Several studies of sh oil do not provide enough reliable evidence
to form a clear conclusion in this area. Grade: C.
Prevention of Graft Failure after Heart Bypass Surgery

There is limited study of the use of sh oils in patients after under-
going coronary artery bypass grafting (CABG). Additional evidence is
necessary before a rm conclusion can be drawn in this area. Grade: C.
Prevention of Restenosis after Coronary Angioplasty (PTCA)

3EVERALRANDOMIZEDCONTROLLEDTRIALSHAVEEVALUATEDWHETHEROMEGA
fatty acid intake reduces blockage of arteries in the heart following
balloon angioplasty (percutaneous transluminal coronary angioplasty/
PTCA). The evidence in this area remains inconclusive. Grade: C.
Primary Cardiovascular Disease Prevention (Alpha-Lino-

lenic Acid [ALA])
Additional research is necessary before a conclusion can be drawn
in this area. Grade: C.
Psoriasis
to form a clear conclusion. Grade: C.
Schizophrenia
4HEREISPROMISINGPRELIMINARYEVIDENCEFROMSEVERALRANDOMIZED
controlled trials in this area. Additional research is necessary before
a rm conclusion can be reached. Grade: C.
Secondary Cardiovascular Disease Prevention (Alpha-

Linolenic Acid [ALA])
3EVERALRANDOMIZEDCONTROLLEDTRIALSHAVEEXAMINEDTHEEFFECTSOF
alpha-linolenic acid in people with a history of heart attack. Although
some studies suggest benets, others do not. Additional research is
necessary before a conclusion can be drawn in this area. Grade: C.
181
Stroke Prevention
Several large studies of populations (epidemiologic studies) have
examined the effects of omega-3 fatty acid intake on stroke risk. Some
studies suggest benets, while others do not. Effects are likely on isch-
emic or thrombotic stroke risk, and very large intakes of omega-3 fatty
acids (Eskimo amounts) may actually increase the risk of hemor-
rhagic (bleeding) stroke. At this time, it is unclear if there are benets
in people with or without a history of stroke, or if effects of sh oil are
comparable to other treatment strategies. Grade: C.
Ulcerative Colitis
It has been suggested that effects of omega-3 fatty acids on inam-
mation may be benecial in patients with ulcerative colitis when added
to standard therapy, and several studies have been conducted in this
area. Better research is necessary before a clear conclusion can be
drawn. Grade: C.
Appetite/Weight Loss in Cancer Patients

There is preliminary evidence that sh oil supplementation does
not improve appetite or prevent weight loss in cancer patients. Further
study is warranted. Grade: D.
Diabetes
The available scientic evidence suggests that there are no signi-
cant long-term effects of sh oil in patients with diabetes. Most studies
in this area are not well designed. Grade: D.
Hypercholesterolemia
Although sh oil is able to reduce triglycerides, benecial effects on
blood cholesterol levels have not been demonstrated. Fish oil supple-
ments appear to cause small improvements in high-density lipoprotein
hGOODCHOLESTEROLv HOWEVERINCREASESWORSENING INLOW DENSITY
lipoprotein levels (bad cholesterol) are also observed. Fish oil does
not appear to affect C-reactive protein (CRP) levels. Grade: D.
Transplant Rejection Prevention (Kidney and Heart)

There are multiple studies of heart transplant and kidney transplant
patients taking cyclosporine (Neoral), who were administered sh oil
supplements. The majority of trials report improvements in kidney func-
tion (glomerular ltration rate, serum creatinine), and less hypertension
182
(high blood pressure) compared to patients not taking sh oil. However,

several recent studies report no benets on kidney function, and no chang-
es have been found in rates of rejection or graft survival. Grade D.
Uses Based on Tradition or Theory

The below uses are based on tradition or scientic theories. They often
have not been thoroughly tested in humans, and safety and effectiveness
have not always been proven. Some of these conditions are potentially
serious, and should be evaluated by a qualied healthcare provider: Acute
myocardial infarction (heart attack), acute respiratory distress syndrome
(ARDS), age related macular degeneration, aggressive behavior, agorapho-
BIA!)$3;ACQUIREDIMMUNODElCIENCYSYNDROME=ALLERGIES!LZHEIMERS
disease, anticoagulation, antiphospholipid syndrome, attention decit
hyperactivity disorder (ADHD), anthracycline-induced cardiac toxicity,
bacterial infections, psychological disorders (borderline personality disor-
der), breast cysts, breast tenderness, chronic fatigue syndrome (postviral
fatigue syndrome), chronic obstructive pulmonary disease, cirrhosis, com-
mon cold, congestive heart failure, critical illness, deciency (omega-3 fatty
acid), dermatomyositis, diabetic nephropathy, diabetic neuropathy, dys-
lexia, dyspraxia, endocrine disorders (glycogen storage diseases), exercise
performance enhancement, bromyalgia, gallstones, gingivitis, glaucoma,
glomerulonephritis, gout, hay fever, headache, hepatorenal syndrome,
hypoxia, ichthyosis (skin disorder), immunosuppression, inammatory
conditions (Behets syndrome), joint problems (cartilage repair), kid-
ney disease prevention, kidney stones, leprosy, leukemia, malaria, male
infertility, mastalgia (breast pain), memory enhancement, menopausal
symptoms, menstrual cramps, methotrexate toxicity, multiple sclerosis,
myopathy, nephritis (autoimmune), neuropathy, night vision enhance-
ment, obesity, osteoarthritis, osteoporosis, otitis media (ear infection),
panic disorder, peripheral vascular disease, pregnancy nutritional sup-
plement, premature birth prevention, premenstrual syndrome, prostate
cancer prevention, protection from isotretinoin drug toxicity, Raynauds
phenomenon, Refsums syndrome, retinitis pigmentosa, Reyes syndrome,
SEIZUREDISORDER3JGRENSSYNDROMESUICIDEPREVENTIONSYSTEMICLUPUS
erythematosus, tardive dyskinesia, tennis elbow, ulcerative colitis, uro-
lithiasis (bladder stones), vision enhancement, weight loss.
Dosing
The below doses are based on scientic research, publications, tra-
ditional use, or expert opinion. Many herbs and supplements have
not been thoroughly tested, and safety and effectiveness may not be
183
proven. Brands may be made differently, with variable ingredients,

even within the same brand. The below doses may not apply to all
products. You should read product labels, and discuss doses with a
qualied healthcare provider before starting therapy.
Adults (18 years and older): Average dietary intake of omega-3/

omega-6 fatty acidsAverage Americans consume approximately
1.6 grams of omega-3 fatty acids each day, of which about 1.4 grams
(~90%) comes from alpha-linolenic acid, and only 0.10.2 grams (~10%)
from EPA and DHA. In Western diets, people consume roughly 10
times more omega-6 fatty acids than omega-3 fatty acids. These large
amounts of omega-6 fatty acids come from the common use of vegetable
oils containing linoleic acid (for example: corn oil, evening primrose
oil, pumpkin oil, safower oil, sesame oil, soybean oil, sunower oil,
walnut oil, wheat germ oil). Because omega-6 and omega-3 fatty acids
compete with each other to be converted to active metabolites in the
body, benets can be reached either by decreasing intake of omega-6
fatty acids, or by increasing omega-3 fatty acids.
Recommended daily intake of omega-3 fatty acids (healthy adults)
For healthy adults with no history of heart disease, the American Heart
Association recommends eating sh at least two times per week. In
particular, fatty sh are recommended, such as anchovies, bluesh,
carp, catsh, halibut, herring, lake trout, mackerel, pompano, salmon,
striped sea bass, tuna (albacore), and whitesh. It is also recommended
to consume plant-derived sources of alpha-linolenic acid, such as tofu/
soybeans, walnuts, axseed oil, and canola oil. The World Health Or-
GANIZATIONANDGOVERNMENTALHEALTHAGENCIESOFSEVERALCOUNTRIES
recommend consuming 0.30.5 grams of daily EPA + DHA and 0.81.1
grams of daily alpha-linolenic acid. A doctor and pharmacist should
be consulted for dosing for other conditions.
Children (younger than 18 years): Omega-3 fatty acids are used

in some infant formulas, although effective doses are not clearly estab-
lished. Ingestion of fresh sh should be limited in young children due
to the presence of potentially harmful environmental contaminants.
Fish oil capsules should not be used in children except under the di-
rection of a physician.
Safety
The U.S. Food and Drug Administration does not strictly regulate
herbs and supplements. There is no guarantee of strength, purity or
safety of products, and effects may vary. You should always read product
184
labels. If you have a medical condition, or are taking other drugs, herbs,
or supplements, you should speak with a qualied healthcare provider
before starting a new therapy. Consult a healthcare provider immedi-
ately if you experience side effects.
Allergies
People with allergy or hypersensitivity to sh should avoid sh oil
or omega-3 fatty acid products derived from sh. Skin rash has been
reported rarely. People with allergy or hypersensitivity to nuts should
avoid alpha linolenic acid or omega-3 fatty acid products that are de-
rived from the types of nuts to which they react.
Side Effects and Warnings

The U.S. Food and Drug Administration classies intake of up to
3 grams per day of omega-3 fatty acids from sh as GRAS (Generally
Regarded as Safe). Caution may be warranted, however, in diabetic pa-
tients due to potential (albeit unlikely) increases in blood sugar levels,
patients at risk of bleeding, or in those with high levels of low-density
lipoprotein (LDL). Fish meat may contain methylmercury and caution
is warranted in young children and pregnant/breastfeeding women.
Omega-3 fatty acids may increase the risk of bleeding, although there is
little evidence of signicant bleeding risk at lower doses. Very large intakes
of sh oil/omega-3 fatty acids (Eskimo amounts) may increase the risk of
hemorrhagic (bleeding) stroke. High doses have also been associated with
nosebleed and blood in the urine. Fish oils appear to decrease platelet ag-
gregation and prolong bleeding time, increase brinolysis (breaking down
of blood clots), and may reduce von Willebrand factor.
Potentially harmful contaminants such as dioxins, methylmercury,
and polychlorinated biphenyls (PCBs) are found in some species of sh.
Methylmercury accumulates in sh meat more than in sh oil, and
sh oil supplements appear to contain almost no mercury. Therefore,
safety concerns apply to eating sh but likely not to ingesting sh oil
supplements. Heavy metals are most harmful in young children and
pregnant/nursing women.
Gastrointestinal upset is common with the use of sh oil supple-
ments. Diarrhea may also occur, with potentially severe diarrhea at
very high doses. There are also reports of increased burping, acid re-
ux/heartburn/indigestion, abdominal bloating, and abdominal pain.
Fishy aftertaste is a common effect. Gastrointestinal side effects can
BEMINIMIZEDIFlSHOILSARETAKENWITHMEALSANDIFDOSESARESTARTED
low and gradually increased.
185
Multiple human trials report small reductions in blood pressure

with intake of omega-3 fatty acids. Reductions of 25 mmHg have been
observed, and effects appear to be dose-responsive (higher doses have
greater effects). DHA may have greater effects than EPA. Caution
is warranted in patients with low blood pressure or in those taking
blood-pressure lowering medications.
Although slight increases in fasting blood glucose levels have been
noted in patients with type 2 (adult onset) diabetes, the available
scientic evidence suggests that there are no signicant long-term
effects of sh oil in patients with diabetes, including no changes in he-
moglobin A1C levels. Limited reports in the 1980s of increased insulin
needs in diabetic patients taking long-term sh oils may be related to
other dietary changes or weight gain.
Fish oil taken for many months may cause a deciency of vitamin E,
and therefore vitamin E is added to many commercial sh oil products.
As a result, regular use of vitamin E-enriched products may lead to
elevated levels of this fat-soluble vitamin. Fish liver oil contains the
fat-soluble vitamins A and D, and therefore sh liver oil products (such
as cod liver oil) may increase the risk of vitamin A or D toxicity.
Increases (worsening) in low-density lipoprotein levels (bad cho-
lesterol) by 510% are observed with intake of omega-3 fatty acids.
Effects are dose-dependent.
Mild elevations in liver function tests (alanine aminotransferase)
have been reported rarely.
Skin rashes have been reported rarely.
There are rare reports of mania in patients with bipolar disorder
or major depression. Restlessness and formication (the sensation of
ants crawling on the skin) have also been reported.
Pregnancy and Breastfeeding

Potentially harmful contaminants such as dioxins, methylmer-
cury, and polychlorinated biphenyls (PCBs) are found in some
species of sh, and may be harmful in pregnant/nursing women.
Methylmercury accumulates in sh meat more than in sh oil, and
sh oil supplements appear to contain almost no mercury. Therefore,
these safety concerns apply to eating sh but likely not to ingesting
sh oil supplements. However, unrened sh oil preparations may
contain pesticides.
It is not known if omega-3 fatty acid supplementation of women
during pregnancy or breastfeeding is benecial to infants. It has been
suggested that high intake of omega-3 fatty acids during pregnancy,
186
particularly DHA, may increase birth weight and gestational length.

However, higher doses may not be advisable due to the potential risk
of bleeding. Fatty acids are added to some infant formulas.
Interactions
Most herbs and supplements have not been thoroughly tested for
interactions with other herbs, supplements, drugs, or foods. The inter-
actions listed in the following text are based on reports in scientic
publications, laboratory experiments, or traditional use. You should
always read product labels. If you have a medical condition, or are
taking other drugs, herbs, or supplements, you should speak with a
qualied healthcare provider before starting a new therapy.
Interactions with Drugs

In theory, omega-3 fatty acids may increase the risk of bleeding
when taken with drugs that increase the risk of bleeding. Some exam-
ples include aspirin, anticoagulants (blood thinners) such as warfarin
(Coumadin) or heparin, anti-platelet drugs such as clopidogrel (Pla-
vix), and non-steroidal anti-inammatory drugs such as ibuprofen
(Motrin, Advil) or naproxen (Naprosyn, Aleve).
Based on human studies, omega-3 fatty acids may lower blood pressure
and add to the effects of drugs that may also affect blood pressure.
Fish oil supplements may lower blood sugar levels a small amount.
Caution is advised when using medications that may also lower blood
sugar. Patients taking drugs for diabetes by mouth or insulin should
be monitored closely by a qualied healthcare provider. Medication
adjustments may be necessary.
Omega-3 fatty acids lower triglyceride levels, but can actually in-
crease (worsen) low-density lipoprotein (LDL/bad cholesterol) levels
by a small amount. Therefore, omega-3 fatty acids may add to the
triglyceride-lowering effects of agents like niacin/nicotinic acid, -
BRATESSUCHASGEMlBROZIL,OPID ORRESINSSUCHASCHOLESTYRAMINE
(Questran). However, omega-3 fatty acids may work against the LDL-
lowering properties of statin drugs like atorvastatin (Lipitor) and
lovastatin (Mevacor).
Interactions with Herbs and Dietary Supplements

In theory, omega-3 fatty acids may increase the risk of bleeding
when taken with herbs and supplements that are believed to increase
the risk of bleeding. Multiple cases of bleeding have been reported with
187
the use of Ginkgo biloba, and fewer cases with garlic and saw palmetto.
Numerous other agents may theoretically increase the risk of bleeding,
although this has not been proven in most cases.
Based on human studies, omega-3 fatty acids may lower blood pres-
sure, and theoretically may add to the effects of agents that may also
affect blood pressure.
Fish oil supplements may lower blood sugar levels a small amount.
Caution is advised when using herbs or supplements that may also
lower blood sugar. Blood glucose levels may require monitoring, and
doses may need adjustment.
Omega-3 fatty acids lower triglyceride levels, but can actually in-
crease (worsen) low-density lipoprotein (LDL/bad cholesterol) levels
by a small amount. Therefore, omega-3 fatty acids may add to the
triglyceride-lowering effects of agents like niacin/nicotinic acid, but
may work against the potential LDL-lowering properties of agents like
barley, garlic, guggul, psyllium, soy, or sweet almond.
Fish oil taken for many months may cause a deciency of vitamin
E, and therefore vitamin E is added to many commercial sh oil prod-
ucts. As a result, regular use of vitamin E-enriched products may lead
to elevated levels of this fat-soluble vitamin. Fish liver oil contains
the fat-soluble vitamins A and D, and therefore sh liver oil products
(such as cod liver oil) may increase the risk of vitamin A or D toxicity.
Since fat-soluble vitamins can build up in the body and cause toxicity,
patients taking multiple vitamins regularly or in high doses should
discuss this risk with their healthcare practitioners.
Methodology
This information is based on a professional level monograph edited
and peer-reviewed by contributors to the Natural Standard Research
Collaboration (www.naturalstandard.com).
Selected References
1. Berbert AA, Kondo CR, Almendra CL, et al. Supplementation
of sh oil and olive oil in patients with rheumatoid arthritis.
Nutrition n
2. Bittiner SB, Tucker WF, Cartwright I, et al. A double-blind,
randomised, placebo-controlled trial of sh oil in psoriasis.
Lancet n
3. Bjorneboe A, Smith AK, Bjorneboe GE, et al. Effect of dietary
supplementation with n-3 fatty acids on clinical manifesta-
tions of psoriasis. Br J Dermatol n
188
"ROUWER)!:OCK0,#AMM!*ETAL%FFECTOFlSHOILONVEN-

tricular tachyarrhythmia and death in patients with implant-
able cardioverter debrillators: the Study on Omega-3 Fatty
!CIDSAND6ENTRICULAR!RRHYTHMIA3/&! RANDOMIZEDTRIAL
JAMA.*UN n
5. Burns CP, Halabi S, Clamon G, et al. Phase II study of high-
dose sh oil capsules for patients with cancer-related cachexia.
Cancer n
6. Chan JK, McDonald BE, Gerrard JM, et al. Effect of di-
etary alpha-linolenic acid and its ratio to linoleic acid on
platelet and plasma fatty acids and thrombogenesis. Lipids
n
7. Dry J, Vincent D. Effect of a sh oil diet on asthma: results of
a 1-year double-blind study. Int Arch Allergy Appl Immunol.
n n
8. Duffy EM, Meenagh GK, McMillan SA, et al. The clinical ef-
fect of dietary supplementation with omega-3 sh oils and/
or copper in systemic lupus erythematosus. J Rheumatol.
n
%RKKILA!4,ICHTENSTEIN!(-OZAFFARIAN$ETAL&ISHIN-
take is associated with a reduced progression of coronary ar-
tery atherosclerosis in postmenopausal women with coronary
artery disease. Am J Clin Nutr. n
10. Fenton WS, Dickerson F, Boronow J, et al. A placebo-controlled
trial of omega-3 Fatty Acid (ethyl eicosapentaenoic Acid) sup-
plementation for residual symptoms and cognitive impairment
INSCHIZOPHRENIAAm J Psychiatry n
11. Lim WS, Gammack JK, Van Niekerk J, et al. Omega 3 fatty
acid for the prevention of dementia. Cochrane Database Syst
Rev.*AN #$
12. Mostad IL, Bjerve KS, Bjorgaas MR, et al. Effects of n-3 fatty
acids in subjects with type 2 diabetes: reduction of insulin sen-
sitivity and time-dependent alteration from carbohydrate to
fat oxidation. Am J Clin Nutr.3EP n
13. Olsen SF, Secher NJ, Tabor A, et al. Randomised clinical
trials of sh oil supplementation in high risk pregnancies.
Fish Oil Trials In Pregnancy (FOTIP) Team. BJOG.
n
189
14. Stoll AL, Severus WE, Freeman MP, et al. Omega 3 fatty acids
in bipolar disorder: a preliminary double-blind, placebo-controlled
trial. Arch Gen. Psychiatry n
15. Su KP, Huang SY, Chiu CC, et al. Omega-3 fatty acids in major
depressive disorder. A preliminary double-blind, placebo-controlled
trial. Eur. Neuropsychopharmacol. n
Section 28.2
Flaxseed and Flaxseed Oils

Excerpted from Flaxseed and Flaxseed Oil, by the National Center for
Complementary and Alternative Medicine (NCCAM, nccam.nih.gov),
part of the National Institutes of Health, April 2008.
Flaxseed is the seed of the ax plant, which is believed to have

originated in Egypt. It grows throughout Canada and the northwest-
ern United States. Flaxseed oil comes from axseeds. Common names
for axseed are axseed and linseed. The Latin name for axseed is
Linum usitatissimum.
What Flaxseed Is Used For

s &LAXSEEDISMOSTCOMMONLYUSEDASALAXATIVE
s &LAXSEEDISALSOUSEDFORHOTmASHESANDBREASTPAIN
s &LAXSEEDOILISUSEDFORDIFFERENTCONDITIONSTHANmAXSEEDINCLUD-
ing arthritis.
s "OTHmAXSEEDANDmAXSEEDOILHAVEBEENUSEDFORHIGHCHOLES-
terol levels and in an effort to prevent cancer.
How Flaxseed Is Used

Whole or crushed axseed can be mixed with water or juice and taken
by mouth. Flaxseed is also available in powder form. Flaxseed oil is avail-
able in liquid and capsule form. Flaxseed contains lignans (phytoestro-
gens, or plant estrogens), while axseed oil preparations lack lignans.
190
What the Science Says

s &LAXSEEDCONTAINSSOLUBLElBERLIKETHATFOUNDINOATBRANAND
is an effective laxative.
s 3TUDIESOFmAXSEEDPREPARATIONSTOLOWERCHOLESTEROLLEVELS
report mixed results.
s 3OMESTUDIESSUGGESTTHATALPHA LINOLENICACIDASUBSTANCE
found in axseed and axseed oil) may benet people with heart
disease. But not enough reliable data are available to determine
whether axseed is effective for heart conditions.
s 3TUDYRESULTSAREMIXEDONWHETHERmAXSEEDDECREASESHOTmASHES
s .##!-ISFUNDINGSTUDIESONmAXSEED2ECENTSTUDIESHAVE
looked at the effects of axseed on high cholesterol levels, as well
as its possible role in preventing conditions such as heart dis-
ease and osteoporosis.
Side Effects and Cautions

s &LAXSEEDANDmAXSEEDOILSUPPLEMENTSSEEMTOBEWELLTOLERATED
Few side effects have been reported.
s &LAXSEEDLIKEANYSUPPLEMENTALlBERSOURCESHOULDBETAKEN
WITHPLENTYOFWATEROTHERWISEITCOULDWORSENCONSTIPATIONOR
in rare cases, even cause intestinal blockage.
s 4HElBERINmAXSEEDMAYLOWERTHEBODYSABILITYTOABSORB
medications that are taken by mouth. Flaxseed should not be
taken at the same time as any conventional oral medications or
other dietary supplements.
alternative practices you use. Give them a full picture of what you
do to manage your health. This will help ensure coordinated and
safe care.
191
Chapter 29
Selenium
What is selenium?
Selenium is a trace mineral that is essential to good health but re-
quired only in small amounts. Selenium is incorporated into proteins
TOMAKESELENOPROTEINSWHICHAREIMPORTANTANTIOXIDANTENZYMES4HE
antioxidant properties of selenoproteins help prevent cellular damage
from free radicals. Free radicals are natural by-products of oxygen me-
tabolism that may contribute to the development of chronic diseases
such as cancer and heart disease. Other selenoproteins help regulate
thyroid function and play a role in the immune system.

selenium?
Selenium and cancer: Observational studies indicate that death
from cancer, including lung, colorectal, and prostate cancers, is lower
among people with higher blood levels or intake of selenium. In addi-
tion, the incidence of nonmelanoma skin cancer is signicantly higher
in areas of the United States with low soil selenium content. The effect
of selenium supplementation on the recurrence of different types of
skin cancers was studied in seven dermatology clinics in the United
States from 1983 through the early 1990s. Taking a daily supplement
containing 200 mcg of selenium did not affect recurrence of skin cancer,

.gov), part of the National Institutes of Health, November 12, 2009.
193
but signicantly reduced the occurrence and death from total cancers.
The incidence of prostate cancer, colorectal cancer, and lung cancer was
notably lower in the group given selenium supplements.
Research suggests that selenium affects cancer risk in two ways. As
an antioxidant, selenium can help protect the body from damaging ef-
fects of free radicals. Selenium may also prevent or slow tumor growth.
Certain breakdown products of selenium are believed to prevent tumor
growth by enhancing immune cell activity and suppressing develop-
ment of blood vessels to the tumor.
However, not all studies have shown a relationship between seleni-
um status and cancer. In 1982, over 60,000 participants of the Nurses
Health Study with no history of cancer submitted toenail clippings for
selenium analysis. Toenails are thought to reect selenium status over
the previous year. After three and a half years of data collection, re-
searchers compared toenail selenium levels of nurses with and without
cancer. Those nurses with higher levels of selenium in their toenails
did not have a reduced risk of cancer.
Two long-term studies, the SU.VI.MAX study in France and the
Selenium and Vitamin E Cancer Prevention Trial (SELECT) in the
United States and Canada, investigated whether selenium combined
with at least one other dietary supplement could reduce the risk of
prostate cancer in men.
The SU.VI.MAX study examined the effects of a supplement pack-
age containing moderate doses of vitamins E and C, beta-carotene,
ZINCANDSELENIUMMCGDAY VERSUSPLACEBOONTHERISKOFCHRONIC
diseases such as cancer and cardiovascular disease. Among the 5,141
MENENROLLEDTHOSERANDOMIZEDTOTHESUPPLEMENTSWHOBEGANTHE
study with a normal (<3 ng/ml) PSA (prostate specic antigen) level at
baseline had their risk of prostate cancer reduced by half. Among the
men whose PSA levels were elevated at baseline, however, use of the
supplements was associated with an increased incidence of prostate
cancer of borderline statistical signicance compared to placebo.
The Selenium and Vitamin E Cancer Prevention Trial (SELECT)
WASAVERYLARGERANDOMIZEDCLINICALTRIALBEGUNINSPECIlCALLY
designed to determine whether 712 years of daily supplementation
with selenium (200 mcg), with or without synthetic vitamin E (400
IU), reduces the number of new prostate cancers in healthy men (PSA
less than or equal to 4 ng/ml at baseline). The trial, which had enrolled
>35,000 men, was discontinued in October 2008 when an analysis
found that the supplements, taken alone or together for an average of
5.5 years, did not prevent prostate cancer. Study staff members will
continue to monitor participants health for an additional 3 years.
194
Selenium
Selenium and heart disease: Some population surveys have sug-

gested an association between lower antioxidant intake and a greater
incidence of heart disease. Evidence also suggests that oxidative stress
from free radicals, which are natural by-products of oxygen metabo-
LISMMAYPROMOTEHEARTDISEASE&OREXAMPLEITISTHEOXIDIZEDFORMOF
low-density lipoproteins (LDL, often called bad cholesterol) that pro-
motes plaque build-up in coronary arteries. Selenium is one of a group
of antioxidants that may help limit the oxidation of LDL cholesterol
and thereby help to prevent coronary artery disease. Currently there
is insufcient evidence available to recommend selenium supplements
for the prevention of coronary heart disease.
Selenium and arthritis: Surveys indicate that individuals with

rheumatoid arthritis, a chronic disease that causes pain, stiffness,
swelling, and loss of function in joints, have reduced selenium levels
in their blood. In addition, some individuals with arthritis have a low
selenium intake.
The bodys immune system naturally makes free radicals that can help
destroy invading organisms and damaged tissue, but that can also harm
healthy tissue. Selenium, as an antioxidant, may help to relieve symptoms
of arthritis by controlling levels of free radicals. Current ndings are
considered preliminary, and further research is needed before selenium
supplements can be recommended for individuals with arthritis.
Selenium and HIV: HIV/AIDS [human immunodeciency virus/

acquired immunodeciency syndrome] malabsorption can deplete
levels of many nutrients, including selenium. Selenium deciency
is associated with decreased immune cell counts, increased disease
progression, and high risk of death in the HIV/AIDS population. HIV/
AIDS gradually destroys the immune system, and oxidative stress
may contribute to further damage of immune cells. Antioxidant nu-
trients such as selenium help protect cells from oxidative stress, thus
potentially slowing progression of the disease. Selenium also may
be needed for the replication of the HIV virus, which could further
deplete levels of selenium.
An examination of 125 HIV-positive men and women linked sele-
nium deciency with a higher rate of death from HIV. In a small study
of 24 children with HIV who were observed for ve years, those with
low selenium levels died at a younger age, which may indicate faster
disease progression. Results of research studies have led experts to
suggest that selenium status may be a signicant predictor of survival
for those infected with HIV.
195
Researchers continue to investigate the relationship between sele-

nium and HIV/AIDS, including the effect of selenium levels on disease
progression and mortality. There is insufcient evidence to routinely
recommend selenium supplements for individuals with HIV/AIDS,
but physicians may prescribe such supplements as part of an overall
treatment plan. It is also important for HIV-positive individuals to
consume recommended amounts of selenium in their diet.
196
Chapter 30
Bone and Joint

Health Supplements
Chapter Contents
Section 30.1Calcium Supplements and Bone Health..................198
Section 30.2Glucosamine/Chondroitin Supplements ..................201
and Joint Health
197
Section 30.1
Calcium Supplements and Bone Health

From Calcium Supplements: What to Look for, by the National In-
stitute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS,
niams.nih.gov), part of the National Institutes of Health, May 2009.
Calcium is essential for many functions in the body, including the

following:
s 2EGULATINGTHEHEARTBEAT
s #ONDUCTINGNERVEIMPULSES
s 3TIMULATINGHORMONESECRETIONS
s #LOTTINGBLOOD
s "UILDINGANDMAINTAININGHEALTHYBONES
Calcium is a mineral found in many foods. Getting enough of this

nutrient is important because the human body cannot make it. Even
after you are fully grown, adequate calcium intake is important be-
cause the body loses calcium every day through the skin, nails, hair,
and sweat, as well as through urine and feces. This lost calcium must
be replaced daily through the diet. Otherwise, the body takes calcium
from the bones to perform other functions, which makes the bones
weaker and more likely to break over time.
Experts recommend that adults get 1,000 to 1,200 mg (milligrams)
of calcium each day. Although food is the best source of calcium, most
Americans do not get enough of it from food sources. Calcium-fortied
foods (such as orange juice, bread, cereals, and many others on grocery
shelves) and calcium supplements can ll the gap by ensuring that
you meet your daily calcium requirement.
What to Look for in a Calcium Supplement

Calcium exists in nature only in combination with other substances.
These substances are called compounds. Several different calcium
compounds are used in supplements, including the following:
198
Bone and Joint Health Supplements
s #ALCIUMCARBONATE
s #ALCIUMPHOSPHATE
s #ALCIUMCITRATE
These compounds contain different amounts of elemental calcium,

which is the actual amount of calcium in the supplement. Read the
label carefully to determine how much elemental calcium is in the
supplement and how many doses or pills to take.
Calcium supplements are available without a prescription in a wide
range of preparations and strengths, which can make selecting one a
confusing experience. Many people ask which calcium supplement they
should take. The best supplement is the one that meets your needs.
Ask yourself these questions:
s (OWWELLDOESMYBODYTOLERATETHISKINDOFSUPPLEMENT$OES
it cause any side effects (such as gas or constipation)? If so, you
may want to try a different type or brand.
s )STHISKINDOFSUPPLEMENTCONVENIENT#AN)REMEMBERTOTAKE
it as often as recommended each day?
s )STHECOSTOFTHISSUPPLEMENTWITHINMYBUDGET
s )SITWIDELYAVAILABLE#AN)BUYITATASTORENEARME
Other Important Things to Consider

Purity: Choose calcium supplements with familiar brand names.
Look for labels that state puried or have the USP (United States
Pharmacopeia) symbol. Avoid supplements made from unrened oyster
shell, bone meal, or dolomite that dont have the USP symbol because
they may contain high levels of lead or other toxic metals.
Absorbability: The body easily absorbs most brand-name calcium

products. If you arent sure about your product, you can nd out how
well it dissolves by placing it in a small amount of warm water for 30
minutes and stirring it occasionally. If it hasnt dissolved within this
time, it probably will not dissolve in your stomach. Chewable and liq-
uid calcium supplements dissolve well because they are broken down
before they enter the stomach.
The body best absorbs calcium, whether from food or supplements,
when its taken several times a day in amounts of not more than 500
mg, but taking it all at once is better than not taking it at all. Calcium
carbonate is absorbed best when taken with food. Calcium citrate can
be taken anytime.
199
Tolerance: Some calcium supplements may cause side effects, such

as gas or constipation, for some people. If simple measures (such as
increasing your intake of uids and high-ber foods) do not solve the
problem, you should try another form of calcium. Also, it is important to
increase the dose of your supplement gradually: take just 500 mg a day
for a week, and then slowly add more calcium. Do not take more than
the recommended amount of calcium without your doctors approval.
Calcium interactions: Its important to talk with a doctor or phar-

macist about possible interactions between calcium supplements and
your over-the-counter and prescription medications. For example, calci-
um supplements may reduce the absorption of the antibiotic tetracycline.
Calcium also interferes with iron absorption. So you should not take a
calcium supplement at the same time as an iron supplementunless the
calcium supplement is calcium citrate or the iron supplement is taken
with vitamin C. Any medications that need to be taken on an empty
stomach should not be taken with calcium supplements.
Combination Products
Calcium supplements are available in a bewildering array of com-
binations with vitamins and other minerals. Calcium supplements
often come in combination with vitamin D, which is necessary for the
absorption of calcium. However, calcium and vitamin D do not need
to be taken together or in the same preparation to be absorbed by the
body. Minerals such as magnesium and phosphorus also are important
but usually are obtained through food or multivitamins. Most experts
recommend that nutrients come from a balanced diet, with multivita-
mins used to supplement dietary deciencies.
Getting enough calciumwhether through your diet or with the help
of supplementswill help to protect the health of your bones. However,
this is only one of the steps you need to take for bone health. Exercise, a
healthy lifestyle, and, for some people, medication are also important.
200
Section 30.2
Glucosamine/Chondroitin
Supplements and Joint Health
Excerpted from Dietary Supplements Glucosamine and/or Chondroitin
Fare No Better than Placebo in Slowing Structural Damage of Knee Os-
teoarthritis, by the National Institutes of Health (NIH, www.nih.gov),
September 29, 2008.
The dietary supplements glucosamine and chondroitin sulfate, to-

gether or alone, appeared to fare no better than placebo in slowing loss of
cartilage in osteoarthritis of the knee, researchers from the Glucosamine/
chondroitin Arthritis Intervention Trial (GAIT) team report in the Octo-
ber issue of Arthritis & Rheumatism.1 Interpreting the study results is
complicated, however, because participants taking placebo had a smaller
loss of cartilage, or joint space width, than predicted. Loss of cartilage, the
slippery material that cushions the joints, is a hallmark of osteoarthritis
and its loss is typically measured as a reduction in joint space widththe
distance between the ends of bones in a joint as seen on an x-ray.
While these results are of interest, we cannot draw denitive con-
clusions about the utility of glucosamine or chondroitin in reducing
joint space width loss, in part because the placebo group fared better
than anticipated based on prior research results, said Josephine P.
Briggs, MD, director of the National Center for Complementary and
Alternative Medicine, at the National Institutes of Health (NIH), one
of the studys funders. The results of the study provide interesting
insights for future research.
The NIH-supported study was led by University of Utah School of
-EDICINES!LLEN$3AWITZKE-$AND$ANIEL/#LEGG-$4HISSTUDY
was an ancillary, or additional, trial conducted by the GAIT team with a
subset of participants from the original GAIT study. The original GAIT
study sought to determine whether these dietary supplements could treat
the pain of knee osteoarthritis and found that overall the combination of
glucosamine plus chondroitin sulfate did not provide signicant relief from
osteoarthritis pain among all participants. However, a smaller subgroup of
study participants with moderate-to-severe pain showed signicant relief
with the combined supplements. These results were reported in 2006.2
201
To study whether the dietary supplements could diminish the struc-

tural damage of osteoarthritis, interested GAIT patients were offered the
opportunity to continue their original study treatment in the ancillary
trial for an additional 18 months, for a total of 2 years. The randomly
assigned study treatments were 500 milligrams glucosamine hydrochlo-
ride three times daily, sodium chondroitin sulfate 400 milligrams three
times daily, the combination of glucosamine plus chondroitin sulfate,
placebo, or celecoxib 200 milligrams daily. The research team enrolled
572 GAIT participants for the ancillary study. Participants entering the
ancillary study had x-ray evidence of moderate (grade 2) or severe (grade
3) knee osteoarthritis in one or both knees using a scale that measures
osteoarthritis severity called the Kellgren-Lawrence scale. At the end of
the ancillary study, the team had gathered data on 581 knees.
At 2 years, no treatment showed what we determined to be a clinically
IMPORTANTREDUCTIONINJOINTSPACEWIDTHLOSSvSAID$R3AWITZKEASSOCIATE
professor of medicine and lead investigator for the ancillary study. While
we found a trend toward improvement among those with milder, Kellgren-
Lawrence grade 2 osteoarthritis of the knee in those taking glucosamine
alone, we were not able to draw any denitive conclusions.
The joint space width in the knee, or knees, of the patients was
measured with a specic x-ray protocol on entering the ancillary study
and at 1 and 2 years to determine any loss in joint width. The x-ray
TECHNIQUEREQUIREDIMAGESOFTHEKNEESBETAKENINASTANDARDIZED
weight-bearing position.
The GAIT researchers expected patients in the placebo group to
have a joint space width loss of approximately 0.4 millimeters over 2
years, based on results of previously published large studies. The study
TEAMHYPOTHESIZEDTHATALOSSOFMILLIMETERSORLESSWOULDSHOW
a slowed rate of cartilage loss. The nal results, adjusted for baseline
joint space width, gender, and other factors, showed the following:
s 4HEGLUCOSAMINEALONEGROUPHADTHELEASTAVERAGEJOINTSPACE
width loss of 0.013 millimeters.
s 4HECHONDROITINALONEGROUPHADANAVERAGELOSSOFMILLI-
meters.
s 4HEGLUCOSAMINEPLUSCHONDROITINGROUPHADANAVERAGELOSSOF
0.194 millimeters.
s 4HECELECOXIBGROUPHADANAVERAGELOSSOFMILLIMETERS
s 4HEPLACEBOGROUPHADANAVERAGELOSSOFMILLIMETERS
In addition to measuring average loss of joint space width, the study

also measured the percentage of participants with progression (worsening)
202
of their osteoarthritisdened as a joint space width loss of more than

0.48 millimeters over the 2 years. Overall, those with grade 2 (moderate)
knee osteoarthritis were least likely to have progression of osteoarthritis
compared to those with more severe disease. Approximately 24 percent
of participants taking the combination of glucosamine plus chondroi-
tin sulfate showed disease progression, which was similar to placebo,
but greater than either glucosamine or chondroitin sulfate alone. The
RESEARCHERSTHEORIZETHATTHISMAYREmECTINTERFERENCEINABSORPTIONOF
the two supplements when taken together.
Research continues to reveal that osteoarthritis, the most common
form of arthritis, appears to be the result of an array of factors including
AGEGENDERGENETICSOBESITYANDJOINTINJURIESvSAID3TEPHEN)+ATZ
MD, director of the National Institute of Arthritis and Musculoskeletal
and Skin Diseases, co-funder of the study. Because osteoarthritis affects
an estimated 27 million Americans, we are seeking ways to not only treat
pain, but also address the structural effects of the condition.
The researchers note that the study has limitations, such as a
greater-than-expected variability in measurement of joint space width
loss and a less-than-expected loss of joint space width in the placebo
group. However, the team also notes that not only was the study de-
signed to investigate whether glucosamine and chondroitin sulfate, ei-
ther together or alone, may have an effect on structural damage, it was
also designed to test the method of measuring joint space width loss
and learning more about the natural progression of osteoarthritis.
Despite the ancillary studys limitations, it has provided us with
new insights on osteoarthritis progression, the techniques to use to
more reliably measure loss of joint space width, the possible effects of
these dietary supplements, and the characteristics of osteoarthritis
patients that may best respond, all of which will assist investigators
in future studies, said Dr. Clegg, professor of medicine and chief of
rheumatology and principal investigator for GAIT.
References
3AWITZKE!$3HI(&INCO-&ETAL4HE%FFECTOF'LUCOSAMINE
and/or Chondroitin Sulfate on the Progression of Knee Os-
teoarthritis: A Report from the Glucosamine/Chondroitin
Arthritis Intervention Trial. Arthritis & Rheumatism,
58(10):31833191.
2. Clegg D, Reda DJ, Harris CL, et al. Glucosamine, Chondroitin
Sulfate, and the Two in Combination for Painful Knee Osteoar-
thritis. New England Journal of Medicine,n
203
Chapter 31
Immune System
Support Supplements
Chapter Contents
Section 31.1Echinacea............................................................. 206
3ECTION:INC....................................................................... 208
205
Section 31.1
Echinacea
Excerpted from text by the National Center for Complementary and
Alternative Medicine (NCCAM, nccam.nih.gov), part of the National
Institutes of Health, March 2008.
This text provides basic information about the herb echinacea.

There are nine known species of echinacea, all of which are native to
the United States and southern Canada. The most commonly used,
Echinacea purpurea, is believed to be the most potent. Common names
include echinacea, purple coneower, coneower, and American cone-
ower. Latin names include Echinacea purpurea, Echinacea angusti-
folia, and Echinacea pallida.
What Echinacea Is Used For

s %CHINACEAHASTRADITIONALLYBEENUSEDTOTREATORPREVENTCOLDS
u, and other infections.
s %CHINACEAISBELIEVEDTOSTIMULATETHEIMMUNESYSTEMTOHELP
ght infections.
s ,ESSCOMMONLYECHINACEAHASBEENUSEDFORWOUNDSANDSKIN
problems, such as acne or boils.
How Echinacea Is Used

The aboveground parts of the plant and roots of echinacea are used
FRESHORDRIEDTOMAKETEASSQUEEZEDEXPRESSED JUICEEXTRACTSOR
preparations for external use.

s 3TUDYRESULTSAREMIXEDONWHETHERECHINACEAEFFECTIVELYTREATS
colds or u. For example, two NCCAM-funded studies did not
nd a benet from echinacea, either as Echinacea purpurea
fresh-pressed juice for treating colds in children, or as an un-
rened mixture of Echinacea angustifolia root and Echinacea
206
Immune System Support Supplements
purpurea root and herb in adults. However, other studies have

shown that echinacea may be benecial in treating upper respi-
ratory infections.
s -OSTSTUDIESTODATEINDICATETHATECHINACEADOESNOTAPPEARTO
prevent colds or other infections.
s .##!-ISCONTINUINGTOSUPPORTTHESTUDYOFECHINACEAFORTHE
treatment of upper respiratory infections. NCCAM is also study-
ing echinacea for its potential effects on the immune system.

s 7HENTAKENBYMOUTHECHINACEAUSUALLYDOESNOTCAUSESIDEEF-
fects. However, some people experience allergic reactions, includ-
ing rashes, increased asthma, and anaphylaxis (a life-threatening
allergic reaction). In clinical trials, gastrointestinal side effects
were most common.
s 0EOPLEAREMORELIKELYTOEXPERIENCEALLERGICREACTIONSTOECHINA-
cea if they are allergic to related plants in the daisy family, which
includes ragweed, chrysanthemums, marigolds, and daisies. Also,
people with asthma or atopy (a genetic tendency toward allergic
reactions) may be more likely to have an allergic reaction when
taking echinacea.
alternative practices you use. Give them a full picture of what you
safe care.
207
Section 31.2
Zinc
%XCERPTEDFROMh:INCvBYTHE/FlCEOF$IETARY3UPPLEMENTS/$3
ods.od.nih.gov), part of the National Institutes of Health, June 30, 2009.
:INCISANESSENTIALMINERALTHATISNATURALLYPRESENTINSOMEFOODS
ADDEDTOOTHERSANDAVAILABLEASADIETARYSUPPLEMENT:INCISALSO
FOUNDINMANYCOLDLOZENGESANDSOMEOVER THE COUNTERDRUGSSOLDAS
cold remedies.
:INCISINVOLVEDINNUMEROUSASPECTSOFCELLULARMETABOLISM)TIS
REQUIREDFORTHECATALYTICACTIVITYOFAPPROXIMATELYENZYMESAND
it plays a role in immune function, protein synthesis, wound healing,
$.!;DEOXYRIBONUCLEICACID=SYNTHESISANDCELLDIVISION:INCALSOSUP-
ports normal growth and development during pregnancy, childhood,
and adolescence and is required for proper sense of taste and smell. A
DAILYINTAKEOFZINCISREQUIREDTOMAINTAINASTEADYSTATEBECAUSETHE
BODYHASNOSPECIALIZEDZINCSTORAGESYSTEM
Immune Function
3EVEREZINCDElCIENCYDEPRESSESIMMUNEFUNCTIONANDEVENMILDTO
MODERATEDEGREESOFZINCDElCIENCYCANIMPAIRMACROPHAGEANDNEUTRO-
phil functions, natural killer cell activity, and complement activity. The
BODYREQUIRESZINCTODEVELOPANDACTIVATE4 LYMPHOCYTES)NDIVIDUALS
WITHLOWZINCLEVELSHAVESHOWNREDUCEDLYMPHOCYTEPROLIFERATION
response to mitogens and other adverse alterations in immunity that
CANBECORRECTEDBYZINCSUPPLEMENTATION4HESEALTERATIONSINIMMUNE
FUNCTIONMIGHTEXPLAINWHYLOWZINCSTATUSHASBEENASSOCIATEDWITH
increased susceptibility to pneumonia and other infections in children
in developing countries and the elderly.
Wound Healing
:INCHELPSMAINTAINTHEINTEGRITYOFSKINANDMUCOSALMEMBRANES
0ATIENTSWITHCHRONICLEGULCERSHAVEABNORMALZINCMETABOLISMAND
LOWSERUMZINCLEVELSANDCLINICIANSFREQUENTLYTREATSKINULCERSWITH
208
ZINCSUPPLEMENTS4HEAUTHORSOFASYSTEMATICREVIEWCONCLUDEDTHAT
ZINCSULFATEMIGHTBEEFFECTIVEFORTREATINGLEGULCERSINSOMEPATIENTS
WHOHAVELOWSERUMZINCLEVELS(OWEVERRESEARCHHASNOTSHOWNTHAT
THEGENERALUSEOFZINCSULFATEINPATIENTSWITHCHRONICLEGULCERSOR
arterial or venous ulcers is effective.
Diarrhea
Acute diarrhea is associated with high rates of mortality among
CHILDRENINDEVELOPINGCOUNTRIES:INCDElCIENCYCAUSESALTERATIONSIN
immune response that probably contribute to increased susceptibility to
infections, such as those that cause diarrhea, especially in children.
Studies show that poor, malnourished children in India, Africa,
South America, and Southeast Asia experience shorter courses of in-
FECTIOUSDIARRHEAAFTERTAKINGZINCSUPPLEMENTS4HECHILDRENINTHESE
STUDIESRECEIVEDnMGOFZINCADAYINTHEFORMOFZINCACETATEZINC
GLUCONATEORZINCSULFATE
)NADDITIONRESULTSFROMAPOOLEDANALYSISOFRANDOMIZEDCONTROLLED
TRIALSOFZINCSUPPLEMENTATIONINDEVELOPINGCOUNTRIESSUGGESTTHATZINC
HELPSREDUCETHEDURATIONANDSEVERITYOFDIARRHEAINZINC DElCIENTOR
otherwise malnourished children. Similar ndings were reported in
AMETA ANALYSISPUBLISHEDINANDAREVIEWOFZINCSUPPLE-
MENTATIONFORPREVENTINGANDTREATINGDIARRHEA4HEEFFECTSOFZINC
SUPPLEMENTATIONONDIARRHEAINCHILDRENWITHADEQUATEZINCSTATUS
such as most children in the United States, are not clear.
4HE7ORLD(EALTH/RGANIZATIONAND5.)#%&;5NITED.ATIONS#HIL-
DRENS&UND=NOWRECOMMENDSHORT TERMZINCSUPPLEMENTATIONMG
OFZINCPERDAYORMGFORINFANTSUNDERMONTHSFORnDAYS
to treat acute childhood diarrhea.
The Common Cold

4HEEFFECTOFZINCTREATMENTONTHESEVERITYORDURATIONOFCOLD
SYMPTOMSISCONTROVERSIAL2ESEARCHERSHAVEHYPOTHESIZEDTHATZINC
directly inhibits rhinovirus binding and replication in the nasal mu-
cosa and suppresses inammation. However, no data are available to
support this hypothesis.
)NARANDOMIZEDDOUBLE BLINDPLACEBO CONTROLLEDCLINICALTRIAL
SUBJECTSWITHINHOURSOFDEVELOPINGTHECOMMONCOLD TOOKAZINC
ACETATELOZENGEMGZINC ORPLACEBOEVERYnWAKEFULHOURS
#OMPAREDWITHPLACEBOTHEZINCLOZENGESSIGNIlCANTLYREDUCEDTHEDU-
ration of cold symptoms (cough, nasal discharge, and muscle aches).
209
In another clinical trial involving 273 participants with experimen-

TALLYINDUCEDCOLDSZINCGLUCONATELOZENGESPROVIDINGMGZINC
signicantly reduced the duration of illness compared with placebo but
HADNOEFFECTONSYMPTOMSEVERITY(OWEVERTREATMENTWITHZINCAC-
ETATELOZENGESPROVIDINGORMGZINC HADNOEFFECTONEITHERCOLD
DURATIONORSEVERITY.EITHERZINCGLUCONATENORZINCACETATELOZENGES
affected the duration or severity of cold symptoms in 281 subjects with
natural (not experimentally induced) colds in another trial.
)NPARTICIPANTSWITHNATURALCOLDSACOMBINATIONOFZINCGLU-
CONATENASALSPRAYANDZINCOROTATELOZENGESMGZINCEVERYn
wakeful hours) was also found to have no effect on the number of
asymptomatic patients after 7 days of treatment.
In September of 2007, Caruso and colleagues published a structured
REVIEWOFTHEEFFECTSOFZINCLOZENGESNASALSPRAYSANDNASALGELSON
THECOMMONCOLD/FTHERANDOMIZEDPLACEBO CONTROLLEDSTUDIES
INCLUDEDUSINGZINCLOZENGESUSINGANASALGEL SHOWEDTHATTHE
ZINCTREATMENTHADABENElCIALEFFECTANDUSINGZINCLOZENGES
USINGANASALSPRAYANDUSINGLOZENGESANDANASALSPRAY SHOWED
NOEFFECT!#OCHRANEREVIEWOFTHEEFFECTSOFZINCLOZENGESONCOLD
symptoms also reported inconclusive ndings, although the author
OFANOTHERREVIEWCONCLUDEDTHATZINCCANREDUCETHEDURATIONAND
severity of cold symptoms.
The available data are therefore inconclusive regarding the use of
ZINCLOZENGESNASALGELSANDSPRAYSTOTREATTHECOMMONCOLD
!SPREVIOUSLYNOTEDTHESAFETYOFINTRANASALZINCHASBEENCALLED
into question because of numerous reports of anosmia (loss of smell), in
SOMECASESLONG LASTINGORPERMANENTFROMTHEUSEOFZINC CONTAINING
nasal gels or sprays.
Age-Related Macular Degeneration

2ESEARCHERSHAVESUGGESTEDTHATBOTHZINCANDANTIOXIDANTSDELAY
the progression of age-related macular degeneration (AMD) and vi-
sion loss, possibly by preventing cellular damage in the retina. In a
population-based cohort study in the Netherlands, high dietary intake
OFZINCASWELLASBETACAROTENEVITAMIN#ANDVITAMIN%WASASSOCIATED
with reduced risk of AMD in elderly subjects. However, the authors of a
systematic review and meta-analysis published in 2007 concluded that
ZINCISNOTEFFECTIVEFORTHEPRIMARYPREVENTIONOFEARLY!-$ALTHOUGH
ZINCMIGHTREDUCETHERISKOFPROGRESSIONTOADVANCED!-$
4HE!GE 2ELATED%YE$ISEASE3TUDY!2%$3 ALARGERANDOMIZED
placebo-controlled, clinical trial (n = 3,597), evaluated the effect of high
210
doses of selected antioxidants (500 mg vitamin C, 400 IU vitamin E, and

MGBETA CAROTENE WITHORWITHOUTZINCMGASZINCOXIDE ONTHE
development of advanced AMD in older individuals with varying degrees
of AMD. Participants also received 2 mg copper to prevent the copper
DElCIENCYASSOCIATEDWITHHIGHZINCINTAKES!FTERANAVERAGEFOLLOW UP
PERIODOFYEARSSUPPLEMENTATIONWITHANTIOXIDANTSPLUSZINCBUT
not antioxidants alone) signicantly reduced the risk of developing ad-
VANCED!-$ANDREDUCEDVISUALACUITYLOSS:INCSUPPLEMENTATIONALONE
signicantly reduced the risk of developing advanced AMD in subjects
at higher risk but not in the total study population. Visual acuity loss
WASNOTSIGNIlCANTLYAFFECTEDBYZINCSUPPLEMENTATIONALONE
Two other small clinical trials evaluated the effects of supplemen-
TATIONWITHMGZINCSULFATEPROVIDINGMGZINC FORYEARSIN
SUBJECTSWITHDRUSENORMACULARDEGENERATION:INCSUPPLEMENTATION
signicantly reduced visual acuity loss in one of the studies but had
no effect in the other.
A Cochrane review concluded that the evidence supporting the
USEOFANTIOXIDANTVITAMINSANDZINCFOR!-$COMESPRIMARILYFROM
the AREDS study. Further research is required before public health
recommendations can be made, but individuals who have or are devel-
oping AMD might wish to talk to their physician about using dietary
supplements.
211
Chapter 32
Mood and Brain

Health Supplements
Chapter Contents
Section 32.1Ginkgo Biloba ...................................................... 214
Section 32.2St. Johns Wort..................................................... 216
213
Section 32.1
Ginkgo Biloba
Excerpted from Ginkgo, by the National Center for Complementary
and Alternative Medicine (NCCAM, nccam.nih.gov), part of the National
Institutes of Health, November 2008.
This text provides basic information about the herb ginkgo. The
ginkgo tree is one of the oldest types of trees in the world. Ginkgo
seeds have been used in traditional Chinese medicine for thousands
of years, and cooked seeds are occasionally eaten. Common names
include ginkgo, Ginkgo biloba, fossil tree, maidenhair tree, Japanese
silver apricot, baiguo, bai guo ye, kew tree, and yinhsing (yin-hsing).
The Latin name is Ginkgo biloba.
What Ginkgo Biloba Is Used For

s 'INKGOLEAFEXTRACTHASBEENUSEDTOTREATAVARIETYOFAILMENTS
and conditions, including asthma, bronchitis, fatigue, and tinni-
tus (ringing or roaring sounds in the ears).
s 4ODAYPEOPLEUSEGINKGOLEAFEXTRACTSHOPINGTOIMPROVEMEMO-
RYTOTREATORHELPPREVENT!LZHEIMERDISEASEANDOTHERTYPESOF
DEMENTIATODECREASEINTERMITTENTCLAUDICATIONLEGPAINCAUSED
BYNARROWINGARTERIES ANDTOTREATSEXUALDYSFUNCTIONMULTIPLE
sclerosis, tinnitus, and other health conditions.
How Ginkgo Biloba Is Used

Extracts are usually taken from the ginkgo leaf and are used to
make tablets, capsules, or teas. Occasionally, ginkgo extracts are used
in skin products.

s .UMEROUSSTUDIESOFGINKGOHAVEBEENDONEFORAVARIETYOFCONDI-
tions. Some promising results have been seen for intermittent clau-
dication, but larger, well-designed research studies are needed.
214
Mood and Brain Health Supplements
s !N.##!- FUNDEDSTUDYOFTHEWELL CHARACTERIZEDGINKGO

product, EGb-761, found it ineffective in lowering the overall
INCIDENCEOFDEMENTIAAND!LZHEIMERDISEASEINTHEELDERLY&UR-
ther analysis of the same data also found ginkgo to be ineffective
in slowing cognitive decline. In this clinical trial, known as the
Ginkgo Evaluation of Memory study, researchers recruited more
than 3,000 volunteers age 75 and over who took 240 mg of gink-
go daily. Participants were followed for an average of approxi-
mately 6 years.
s 3OMESMALLERSTUDIESFORMEMORYENHANCEMENTHAVEHADPROMIS-
ing results, but a trial sponsored by the National Institute on Aging
of more than 200 healthy adults over age 60 found that ginkgo
taken for 6 weeks did not improve memory.
s /THER.##!- FUNDEDRESEARCHINCLUDESSTUDIESONGINKGOFOR
asthma, symptoms of multiple sclerosis, vascular function (inter-
mittent claudication), cognitive decline, sexual dysfunction due to
antidepressants, and insulin resistance. NCCAM is also looking at
potential interactions between ginkgo and prescription drugs.
s 3IDEEFFECTSOFGINKGOMAYINCLUDEHEADACHENAUSEAGASTRO-

INTESTINALUPSETDIARRHEADIZZINESSORALLERGICSKINREACTIONS
More severe allergic reactions have occasionally been reported.
s 4HEREARESOMEDATATOSUGGESTTHATGINKGOCANINCREASEBLEED-
ing risk, so people who take anticoagulant drugs, have bleeding
disorders, or have scheduled surgery or dental procedures should
use caution and talk to a health care provider if using ginkgo.
s 5NCOOKEDGINKGOSEEDSCONTAINACHEMICALKNOWNASGINKGO-
TOXINWHICHCANCAUSESEIZURES#ONSUMINGLARGEQUANTITIESOF
seeds over time can cause death. Ginkgo leaf and ginkgo leaf
extracts appear to contain little ginkgotoxin.
and safe care.
215
Section 32.2
St. Johns Wort

Excerpted from St. Johns Wort, by the National Center for Comple-
mentary and Alternative Medicine (NCCAM, nccam.nih.gov), part of the
National Institutes of Health, March 2008.
This text provides basic information about the herb St. Johns wort.
St. Johns wort is a plant with yellow owers whose medicinal uses
were rst recorded in ancient Greece. The name St. Johns wort appar-
ently refers to John the Baptist, as the plant blooms around the time of
the feast of St. John the Baptist in late June. Common names include
St. Johns wort, hypericum, Klamath weed, and goat weed. The Latin
name for St. Johns wort is Hypericum perforatum.
What St. Johns Wort Is Used For

s 3T*OHNSWORTHASBEENUSEDFORCENTURIESTOTREATMENTALDISOR-
ders and nerve pain.
s 3T*OHNSWORTHASALSOBEENUSEDASASEDATIVEANDATREATMENT
for malaria, as well as a balm for wounds, burns, and insect bites.
s 4ODAY3T*OHNSWORTISUSEDBYSOMEFORDEPRESSIONANXIETY
and/or sleep disorders.
How St. Johns Wort Is Used

The owering tops of St. Johns wort are used to prepare teas and
tablets containing concentrated extracts.

s 4HEREISSOMESCIENTIlCEVIDENCETHAT3T*OHNSWORTISUSEFULFOR
treating mild to moderate depression. However, two large studies,
one sponsored by NCCAM, showed that the herb was no more effec-
tive than placebo in treating major depression of moderate severity.
s .##!-ISSTUDYINGTHEUSEOF3T*OHNSWORTINAWIDERSPEC-
trum of mood disorders, including minor depression.
216
Mood and Brain Health Supplements

St. Johns wort may cause increased sensitivity to sunlight. Other
SIDEEFFECTSCANINCLUDEANXIETYDRYMOUTHDIZZINESSGASTROINTESTINAL
symptoms, fatigue, headache, or sexual dysfunction.
Research shows that St. Johns wort interacts with some drugs. The
HERBAFFECTSTHEWAYTHEBODYPROCESSESORBREAKSDOWNMANYDRUGS
in some cases, it may speed or slow a drugs breakdown. Drugs that
can be affected include the following:
s !NTIDEPRESSANTS
s "IRTHCONTROLPILLS
s #YCLOSPORINEWHICHPREVENTSTHEBODYFROMREJECTINGTRANSPLANT-
ed organs
s $IGOXINWHICHSTRENGTHENSHEARTMUSCLECONTRACTIONS
s )NDINAVIRANDPOSSIBLYOTHERDRUGSUSEDTOCONTROL()6;HUMAN
immunodeciency virus] infection
s )RINOTECANANDPOSSIBLYOTHERDRUGSUSEDTOTREATCANCER
s 7ARFARINANDRELATEDANTICOAGULANTS
When combined with certain antidepressants, St. Johns wort may

increase side effects such as nausea, anxiety, headache, and confusion.
St. Johns wort is not a proven therapy for depression. If depres-
sion is not adequately treated, it can become severe. Anyone who may
have depression should see a health care provider. There are effective
proven therapies available.
ternative practices you use. Give them a full picture of what you do to
manage your health. This will help ensure coordinated and safe care.
217
Chapter 33
Probiotics: Supplements
for Gastrointestinal Health
Probiotics are live microorganisms (in most cases, bacteria) that are
similar to benecial microorganisms found in the human gut. They are
also called friendly bacteria or good bacteria. Probiotics are available to
consumers mainly in the form of dietary supplements and foods. They
can be used as complementary and alternative medicine (CAM).
What Probiotics Are

Experts have debated how to dene probiotics. One widely used
DElNITIONDEVELOPEDBYTHE7ORLD(EALTH/RGANIZATIONANDTHE&OOD
AND!GRICULTURE/RGANIZATIONOFTHE5NITED.ATIONSISTHATPROBIOT-
ics are live microorganisms, which, when administered in adequate
amounts, confer a health benet on the host. (Microorganisms are tiny
living organismssuch as bacteria, viruses, and yeaststhat can be
seen only under a microscope.)
Probiotics are not the same thing as prebioticsnondigestible food
ingredients that selectively stimulate the growth and/or activity of
benecial microorganisms already in peoples colons. When probiotics
and prebiotics are mixed together, they form a synbiotic.
Probiotics are available in foods and dietary supplements (for ex-
ample, capsules, tablets, and powders) and in some other forms as
well. Examples of foods containing probiotics are yogurt, fermented
Excerpted from An Introduction to Probiotics, by the National Center for

National Institutes of Health, August 1, 2008.
219
and unfermented milk, miso, tempeh, and some juices and soy bever-
ages. In probiotic foods and supplements, the bacteria may have been
present originally or added during preparation.
Most probiotics are bacteria similar to those naturally found in
peoples guts, especially in those of breastfed infants (who have natu-
ral protection against many diseases). Most often, the bacteria come
from two groups, Lactobacillus or Bidobacterium. Within each group,
there are different species (for example, Lactobacillus acidophilus and
Bidobacterium bidus), and within each species, different strains (or
varieties). A few common probiotics, such as Saccharomyces boulardii,
are yeasts, which are different from bacteria.
Some probiotic foods date back to ancient times, such as fermented
foods and cultured milk products. Interest in probiotics in general
HASBEENGROWING!MERICANSSPENDINGONPROBIOTICSUPPLEMENTSFOR
example, nearly tripled from 1994 to 2003.
Uses for Health Purposes

There are several reasons that people are interested in probiotics
for health purposes.
First, the world is full of microorganisms (including bacteria), and
so are peoples bodiesin and on the skin, in the gut, and in other
orices. Friendly bacteria are vital to proper development of the im-
mune system, to protection against microorganisms that could cause
disease, and to the digestion and absorption of food and nutrients.
Each persons mix of bacteria varies. Interactions between a person
and the microorganisms in his body, and among the microorganisms
themselves, can be crucial to the persons health and well-being.
This bacterial balancing act can be thrown off in two major ways:
1. It can be thrown off by antibiotics, when they kill friendly bac-
teria in the gut along with unfriendly bacteria. Some people use
probiotics to try to offset side effects from antibiotics like gas,
cramping, or diarrhea. Similarly, some use them to ease symp-
toms of lactose intolerancea condition in which the gut lacks
THEENZYMENEEDEDTODIGESTSIGNIlCANTAMOUNTSOFTHEMAJOR
sugar in milk, and which also causes gastrointestinal symptoms.
2. Unfriendly microorganisms such as disease-causing bac-
teria, yeasts, fungi, and parasites can also upset the balance.
Researchers are exploring whether probiotics could halt these
unfriendly agents in the rst place and/or suppress their
growth and activity in conditions like the following:
220
Probiotics: Supplements for Gastrointestinal Health
s )NFECTIOUSDIARRHEA
s )RRITABLEBOWELSYNDROME
s )NmAMMATORYBOWELDISEASEEGULCERATIVECOLITISAND#ROHN
disease)
s )NFECTIONWITHHelicobacter pylori (H. pylori), a bacterium
that causes most ulcers and many types of chronic stomach
inammation
s 4OOTHDECAYANDPERIODONTALDISEASE
s 6AGINALINFECTIONS
s 3TOMACHANDRESPIRATORYINFECTIONSTHATCHILDRENACQUIREIN
daycare
s 3KININFECTIONS
Another part of the interest in probiotics stems from the fact there
are cells in the digestive tract connected with the immune system. One
theory is that if you alter the microorganisms in a persons intestinal
tract (as by introducing probiotic bacteria), you can affect the immune
systems defenses.

Scientic understanding of probiotics and their potential for prevent-
ing and treating health conditions is at an early stage, but moving ahead.
In November 2005, a conference that was cofunded by the National Center
for Complementary and Alternative Medicine (NCCAM) and convened by
the American Society for Microbiology explored this topic.
According to the conference report, some uses of probiotics for which
there is some encouraging evidence from the study of specic probiotic
formulations are as follows:
s 4OTREATDIARRHEATHISISTHESTRONGESTAREAOFEVIDENCEESPE-
cially for diarrhea from rotavirus)
s 4OPREVENTANDTREATINFECTIONSOFTHEURINARYTRACTORFEMALE
genital tract
s 4OTREATIRRITABLEBOWELSYNDROME
s 4OREDUCERECURRENCEOFBLADDERCANCER
s 4OSHORTENHOWLONGANINTESTINALINFECTIONLASTSTHATISCAUSED
by a bacterium called Clostridium difcile
221
s 4OPREVENTANDTREATPOUCHITISACONDITIONTHATCANFOLLOWSUR-
gery to remove the colon)
s 4OPREVENTANDMANAGEATOPICDERMATITISECZEMA INCHILDREN
The conference panel also noted that in studies of probiotics as

CURESANYBENElCIALEFFECTWASUSUALLYLOWASTRONGPLACEBOEFFECTOFTEN
OCCURSANDMORERESEARCHESPECIALLYINTHEFORMOFLARGECAREFULLYDE-
signed clinical trials) is needed in order to draw rmer conclusions.
Some other areas of interest to researchers on probiotics include
the following:
s !NAREAOFINTERESTISWHATISGOINGONATTHEMOLECULARLEVEL
with the bacteria themselves and how they may interact with
the body (such as the gut and its bacteria) to prevent and treat
diseases. Advances in technology and medicine are making it
possible to study these areas much better than in the past.
s )SSUESOFQUALITYAREALSOOFINTEREST&OREXAMPLEWHATHAPPENS
when probiotic bacteria are treated or are added to foodsis their
ability to survive, grow, and have a therapeutic effect altered?
s 3CIENTISTSWANTTOUNDERSTANDTHEBESTWAYSTOADMINISTERPRO-
biotics for therapeutic purposes, as well as the best doses and
schedules.
s 3CIENTISTSWANTTOUNDERSTANDPROBIOTICSPOTENTIALTOHELPWITH
the problem of antibiotic-resistant bacteria in the gut.
s !NOTHERAREAOFINTERESTISWHETHERTHEYCANPREVENTUNFRIENDLY
bacteria from getting through the skin or mucous membranes
and traveling through the body (e.g., which can happen with
burns, shock, trauma, or suppressed immunity).

Some live microorganisms have a long history of use as probiotics
without causing illness in people. Probiotics safety has not been thor-
oughly studied scientically, however. More information is especially
needed on how safe they are for young children, elderly people, and
people with compromised immune systems.
Probiotics side effects, if they occur, tend to be mild and digestive
(such as gas or bloating). More serious effects have been seen in some
people. Probiotics might theoretically cause infections that need to be
treated with antibiotics, especially in people with underlying health
222
Probiotics: Supplements for Gastrointestinal Health
conditions. They could also cause unhealthy metabolic activities, too

much stimulation of the immune system, or gene transfer (insertion
of genetic material into a cell).
Probiotic products taken by mouth as a dietary supplement are
manufactured and regulated as foods, not drugs.
Some Other Points to Consider

s )FYOUARETHINKINGABOUTUSINGAPROBIOTICPRODUCTAS#!-
consult your health care provider rst. No CAM therapy should
be used in place of conventional medical care or to delay seeking
that care.
s %FFECTSFROMONESPECIESORSTRAINOFPROBIOTICSDONOTNECESSAR-
ily hold true for others, or even for different preparations of the
same species or strain.
s )FYOUUSEAPROBIOTICPRODUCTANDEXPERIENCEANEFFECTTHATCON-
cerns you, contact your health care provider.
223
Chapter 34
Sports and
Energy Supplements
Chapter Contents
Section 34.1Sports Supplements ............................................ 226
Section 34.2Energy Drinks ..................................................... 231
225
Section 34.1
Sports Supplements
Sports Supplements, May 2008, reprinted with permission from
www.kidshealth.org. Copyright 2008 The Nemours Foundation. This informa-
tion was provided by KidsHealth, one of the largest resources online for medi-
cally reviewed health information written for parents, kids, and teens. For more
articles like this one, visit www.KidsHealth.org, or www.TeensHealth.org.
If youre a competitive athlete or a tness buff, improving your sports

performance is probably on your mind. Lots of people wonder if taking
sports supplements could offer fast, effective results without so much hard
work. But do sports supplements really work? And are they safe?
What Are Sports Supplements?

Sports supplements (also called ergogenic aids) are products used
to enhance athletic performance that may include vitamins, minerals,
amino acids, herbs, or botanicals (plants)or any concentration, ex-
tract, or combination of these. These products are generally available
over the counter without a prescription.
Sports supplements are considered a dietary supplement. Dietary
supplements do not require U.S. Food and Drug Administration (FDA)
approval before they come on the market. Supplement manufacturers
do have to follow the FDAs current good manufacturing practices to
ensure quality and safety of their product, though. And the FDA is
responsible for taking action if a product is found to be unsafe after it
has gone on the market.
Critics of the supplement industry point out cases where manu-
facturers havent done a good job of following standards. They also
mention instances where the FDA hasnt enforced regulations. Both
of these can mean that supplements contain variable amounts of in-
gredients or even ingredients not listed on the label.
Some over-the-counter medicines and prescription medications,
including anabolic steroids, are used to enhance performance but they
are not considered supplements. Although medications are FDA ap-
proved, using medicineseven over-the-counter onesin ways other
than their intended purpose puts the user at risk of serious side effects.
226
Sports and Energy Supplements
For example, teen athletes who use medications like human growth
hormone (hGH) that havent been prescribed for them may have prob-
lems with development and hormone levels.
,OTS OF SPORTS ORGANIZATIONS HAVE DEVELOPED POLICIES ON SPORTS
supplements. The National Football League (NFL), the National Col-
legiate Athletic Association (NCAA), and the International Olympic
Committee (IOC) have banned the use of steroids, ephedra, and an-
drostenedione by their athletes, and competitors who use them face
nes, ineligibility, and suspension from their sports.
The National Federation of State High School Associations (NFHS)
strongly recommends that student athletes consult with their doctor
before taking any supplement.
Common Supplements and How They Affect the Body

Whether you hear about sports supplements from your teammates
in the locker room or the sales clerk at your local vitamin store, chances
are youre not getting the whole story about how supplements work, if
they are really effective, and the risks you take by using them.
Androstenedione and DHEA

Androstenedione (also known as andro) and dehydroepiandros-
terone (also known as DHEA) are prohormones or natural steroids
that can be broken down into testosterone. When researchers studied
these prohormones in adult athletes, DHEA and andro did not increase
MUSCLESIZEIMPROVESTRENGTHORENHANCEPERFORMANCE
The side effects of these natural steroid supplements like DHEA
and andro arent well known. But experts believe that, when taken in
large doses, they cause effects similar to stronger anabolic steroids.
What is known is that andro and DHEA can cause hormone imbal-
ances in people who use them. Both may have the same effects as taking
anabolic steroids and may lead to dangerous side effects like testicular
cancer, infertility, stroke, and an increased risk of heart disease. As with
anabolic steroids, teens who use andro while they are still growing may
not reach their full adult height. Natural steroid supplements can also
cause breast development and shrinking of testicles in guys.
Creatine
Creatine is already manufactured by the body in the liver, kidneys,
and pancreas. It also occurs naturally in foods such as meat and sh.
Creatine supplements are available over the counter, and teens make
up a large portion of the supplements users.
227
People who take creatine usually take it to improve strength, but

the long-term and short-term effects of creatine use havent been stud-
ied in teens and kids. Research in adults found that creatine is most
effective for athletes doing intermittent high-intensity exercise with
short recovery intervals, such as sprinting and power lifting. However,
researchers found no effect on athletic performance in nearly a third
of athletes studied. Creatine has not been found to increase endurance
or improve aerobic performance.
The most common side effects of creatine supplements include
weight gain, diarrhea, abdominal pain, and muscle cramps. People
with kidney problems should not use creatine because it may affect
kidney function. The American College of Sports Medicine recommends
that people younger than 18 years old do not use creatine. If you are
considering using creatine, talk with your doctor about the risks and
benets, as well as appropriate dosing.
Fat Burners
Fat burners (sometimes known as thermogenics) were often made with
an herb called ephedra, also known as ephedrine or ma huang, which acts
as a stimulant and increases metabolism. Some athletes use fat burners
to lose weight or to increase energybut ephedra-based products can be
one of the most dangerous supplements. Evidence has shown that it can
cause heart problems, stroke, and occasionally even death.
Because athletes and others have died using this supplement,
ephedra has been taken off the market. Since the ban, ephedra-
free products have emerged, but they often contain ingredients with
ephedra-like properties, including bitter orange or country mallow.
Similar to ephedra, these supplements can cause high blood pressure,
HEARTATTACKSTROKEANDSEIZURES
Many of these products also contain caffeine, along with other caf-
feine sources (such as yerba mate and guarana). This combination may
lead to restlessness, anxiety, racing heart, irregular heart beat, and
increases the chance of having a life-threatening side effect.
Will Supplements Make Me a Better Athlete?

Sports supplements havent been tested on teens and kids. But stud-
ies on adults show that the claims of many supplements are weak at
best. Most wont make you any stronger, and none will make you any
faster or more skillful.
Many factors go into your abilities as an athleteincluding your
diet, how much sleep you get, genetics and heredity, and your training
228
program. But the fact is that using sports supplements may put you at
risk for serious health conditions. So instead of turning to supplements
to improve your performance, concentrate on nutrition and follow a
weight-training and aerobic-conditioning program.
Tips for Dealing with Athletic Pressure and Competition

Advertisements for sports supplements often use persuasive before
and after pictures that make it look easy to get a muscular, toned body.
But the goal of supplement advertisers is to make money by selling more
supplements, and many claims may be misleading. Teens and kids may
seem like an easy sell on supplements because they may feel dissatised
or uncomfortable with their still-developing bodies, and many supplement
companies try to convince teens that supplements are an easy solution.
Dont waste your money on expensive and dangerous supplements.
Instead, try these tips for getting better game:
s Make downtime a priority. Studies show that teens need
more than 8 hours of sleep a night, and sleep is important for
ATHLETES/RGANIZETIMEFORSLEEPINTOYOURSCHEDULEBYDOINGAS
much homework as possible on the weekend or consider cutting
back on after-school job hours during your sports season.
s Try to relax. Your school, work, and sports schedules may
have you sprinting from one activity to the next, but taking a
FEWMINUTESTORELAXCANBEHELPFUL-EDITATINGORVISUALIZING
your success during the next game may improve your perfor-
MANCESITTINGQUIETLYANDFOCUSINGONYOURBREATHINGCANGIVE
you a brief break and prepare you for your next activity.
s Choose good eats. Fried, fatty, or sugary foods will interfere
with your performance. Instead, focus on eating foods such as
lean meats, whole grains, vegetables, fruits, and low-fat dairy
PRODUCTS#ELEBRATINGWITHTHETEAMATTHELOCALPIZZAPLACEAF-
ter a big game is ne once in a while. But for most meals and
snacks, choose healthy foods to keep your weight in a healthy
range and your performance at its best.
s Eat often. Sometimes people skip breakfast or have an early
lunch, then try to play a late afternoon game. Not getting enough
food to fuel an activity can quickly wear you outand even place
you at risk for injury or muscle fatigue. Be sure to eat lunch on
practice and game days. If you feel hungry before the game, pack
easy-to-carry, healthy snacks in your bag, such as fruit, trail mix,
or string cheese. Its important to eat well after a workout.
229
s Avoid harmful substances. Smoking will diminish your lung

capacity and your ability to breathe, alcohol can make you slug-
gish and tired, and can impair your hand-eye coordination and
reduce your alertness. And you can kiss your team good-bye if
you get caught using drugs or alcoholmany schools have a no-
tolerance policy for harmful substances.
s Train harder and smarter. If you get out of breath easily dur-
ing your basketball game and you want to increase your endur-
ance, work on improving your cardiovascular conditioning. If you
think more leg strength will help you excel on the soccer eld,
consider weight training to increase your muscle strength. Before
changing your program, though, get advice from your doctor.
s Consult a professional. If youre concerned about your
weight or whether your diet is helping your performance, talk
to your doctor or a registered dietitian who can evaluate your
nutrition and steer you in the right direction. Coaches can help
too. And if youre still convinced that supplements will help you,
talk to your doctor or a sports medicine specialist. The doc will
be able to offer alternatives to supplements based on your body
and sport.
230
Section 34.2
Energy Drinks
Excerpted from Energy Drinks: Power Boosts or Empty Boasts? by the
Substance Abuse and Mental Health Services Administration (SAMHSA,
family.samhsa.gov), part of the U.S. Department of Health and Human
Services, April 30, 2007.
Slick packaging, edgy themes, exotic ingredients, and special for-

mulas are all part of the hype about energy drinks. A growing num-
ber of beverages promise quick energy as well as performance and
nutritional benets to athletes, students, partygoersanyone who
wants a pick-me-up. Yet, claims about these products often are in-
ated while health risks such as dehydration, overstimulation, and
the double danger of combining energy drinks with alcohol receive
little attention.
Do you know what your child drinks between meals and when he
works out or plays sports? Make sure both of you understand which
ingredients energy drinks contain and the effects they produce.
Looking for a Liquid Lift

The energy drink market is hot. With names that suggest extreme
power, a growing number of beverages are aimed at anyone who wants
to improve athletic performance, study late, dance all night, or just
counter a mid-afternoon slump.
These products are sold with claims that include boosting energy,
raising alertness, lowering reaction time, improving concentration,
speeding up metabolism, increasing stamina, and enhancing nutrition.
Perhaps the most powerful energy drink is named after an illegal drug.
Although this product does not contain the drug, it promises a high
FOLLOWEDBYALONG LASTINGENERGYBUZZ
Whats behind these claims? Although the makers of energy drinks
tout mixtures of vitamins, minerals, and tropical extracts, the main
ingredient is caffeine. The difference between the caffeine in energy
drinks and other beverages is the amountthey have at least as much
caffeine as coffee and much more than soft drinks.
231
Caffeine Concerns
Caffeine perks up the central nervous system and provides the lift
that energy drinks are all about. The central nervous system, which
includes the brain and the spinal cord, is the main processing center
that controls all of the bodys organs and systems.
However, the high levels of caffeine in energy drinks can cause prob-
lems. Because caffeine can send you to the bathroom more often, it can
dehydrate your bodymeaning that you do not have as much water and
uids as you shouldwhen you are also sweating during exercise.
Caffeine also can speed up a persons heart and raise blood pres-
sure. The amount of caffeine in energy drinks is not good for children.
Caffeine may cause a child to become agitated, irritable, or nervous.
In addition, caffeine is a concern for pregnant women as well as the
children they carry. The Food and Drug Administration advises preg-
nant women to use caffeine in moderation.
How much caffeine is too much? It dependsthe effects of caffeine
VARYFROMONEPERSONTOANOTHERACCORDINGTOTRAITSSUCHASAGESIZE
and health. For most people, three 8-ounce cups of coffee per day is
considered a moderate amount of caffeine.
Mixing energy drinks with alcohol poses a special risk. The stimu-
lation from a caffeine-heavy energy drink can make a person feel less
intoxicated than she really is. As a result, she may keep drinking or
TAKEARISKSUCHASDRIVINGWITHOUTREALIZINGTHEDANGER)NADDITION
because caffeine dehydrates the body, alcohol becomes harder to ab-
sorb, which makes its toxic effects much more damaging to the body.
School starts early, activities and jobs create tight schedules, and
nighttime often nds todays youth up late doing homework, listening
to music, playing computer games, and instant messaging their friends.
As a result, kids often do not get the sleep they need, leaving them
more likely to reach for a caffeine jolt. In fact, the more caffeine kids
consume, the less sleep they get. So, work with your child to adjust his
schedule so he has enough time for sleep and offer him noncaffeinated
drinks such as juice, milk, and water after dinner.
Whats in the Mix?

Other energy drink ingredients add to the possible problems. Guar-
ana, or guarine, is a caffeine-like substance. Taurine is an amino acid
that the body produces naturally, but exactly how it works or how
much is too much is not known. Vitamins, minerals, and herbs added
to energy drinks are not risky by themselves, but they could upset ones
nutritional balance and could cause a bad reaction to medication.
232
Finally, energy drinks contain carbohydratescarbs for shortthat

we need to fuel long exercise sessions. However, energy drinks provide
more carbs than most people need for exercise. The resultexcess
caloriesis just what we are trying to avoid or burn off. And because
carbs make it harder for the body to absorb uids, they can cause de-
hydration, especially in hot weather.
Choosing Wisely
While an energy drink every so often will not be a problem for most
people, make sure that your child knows the real deal about these
products. Talk with him about situations in which sports drinks could
have unexpected effects. Remind him that many other products or just
plain water can give him the lift he is looking for, often at a much lower
cost than an energy drink. Making careful choices when he wants to
kick it up a notch will pay off in safety and results. As a bonus, hell
end up with more money in his pocket.
233
Chapter 35
Supplements Used
for Weight Loss
Chapter Contents
Section 35.1Green Tea............................................................. 236
Section 35.2Hoodia .................................................................. 238
235
Section 35.1
Green Tea
Excerpted from text by the National Center for Complementary and Al-
ternative Medicine (NCCAM, nccam.nih.gov), part of the National Insti-
tutes of Health, November 2008.
This text provides basic information about green tea. All types of
tea (green, black, and oolong) are produced from the Camellia sinensis
plant using different methods. Fresh leaves from the Camellia sinensis
plant are steamed to produce green tea. Common names include green
tea, Chinese tea, and Japanese tea. The Latin name for green tea is
Camellia sinensis.
What Green Tea Is Used For

s 'REENTEAANDGREENTEAEXTRACTSSUCHASITSCOMPONENT
EGCG [epigallocatechin gallate], have been used to prevent
and treat a variety of cancers, including breast, stomach, and
skin cancers.
s 'REENTEAANDGREENTEAEXTRACTSHAVEALSOBEENUSEDFORIM-
proving mental alertness, aiding in weight loss, lowering choles-
terol levels, and protecting skin from sun damage.
How Green Tea Is Used

Green tea is usually brewed and drunk as a beverage. Green tea extracts
can be taken in capsules and are sometimes used in skin products.

s ,ABORATORYSTUDIESSUGGESTTHATGREENTEAMAYHELPPROTECT
against or slow the growth of certain cancers, but studies in
people have shown mixed results.
s 3OMEEVIDENCESUGGESTSTHATTHEUSEOFGREENTEAPREPARA-
tions improves mental alertness, most likely because of its caf-
feine content. There are not enough reliable data to determine
236
Supplements Used for Weight Loss
whether green tea can aid in weight loss, lower blood cholesterol
levels, or protect the skin from sun damage.
s .##!-ISSUPPORTINGSTUDIESTOLEARNMOREABOUTTHECOMPO-
nents in green tea and their effects on conditions such as cancer,
diabetes, and heart disease.

s 'REENTEAISSAFEFORMOSTADULTSWHENUSEDINMODERATE
amounts.
s 4HEREHAVEBEENSOMECASEREPORTSOFLIVERPROBLEMSINPEOPLE
taking concentrated green tea extracts. This problem does not
seem to be connected with green tea infusions or beverages.
Although these cases are very rare and the evidence is not deni-
tive, experts suggest that concentrated green tea extracts be tak-
en with food, and that people should discontinue use and consult
a heath care practitioner if they have a liver disorder or develop
symptoms of liver trouble, such as abdominal pain, dark urine,
or jaundice.
s 'REENTEAANDGREENTEAEXTRACTSCONTAINCAFFEINE#AFFEINECAN
cause insomnia, anxiety, irritability, upset stomach, nausea, diar-
rhea, or frequent urination in some people.
s 'REENTEACONTAINSSMALLAMOUNTSOFVITAMIN+WHICHCANMAKE
anticoagulant drugs, such as warfarin, less effective.
and safe care.
237
Section 35.2
Hoodia
Excerpted from text by the National Center for Complementary and
Alternative Medicine (NCCAM, nccam.nih.gov), part of the National
Institutes of Health, June 2008.
This text provides basic information about the herb hoodia. Hoo-
dia is a owering, cactus-like plant native to the Kalahari Desert in
southern Africa. Its harvest is protected by conservation laws. Common
names include hoodia, Kalahari cactus, and Xhoba. The Latin name
for it is Hoodia gordonii.
What Hoodia Is Used For

s Kalahari Bushmen have traditionally eaten hoodia stems to re-
duce their hunger and thirst during long hunts.
s 4ODAYHOODIAISMARKETEDASANAPPETITESUPPRESSANTFORWEIGHTLOSS
How Hoodia Is Used

Dried extracts of hoodia stems and roots are used to make capsules,
powders, and chewable tablets. Hoodia can also be used in liquid ex-
tracts and teas. Hoodia products often contain other herbs or minerals,
such as green tea or chromium picolinate.

There is no reliable scientic evidence to support hoodias use. No
studies of the herb in people have been published.

s (OODIASSAFETYISUNKNOWN)TSPOTENTIALRISKSSIDEEFFECTSAND
interactions with medicines and other supplements have not
been studied.
s 4HEQUALITYOFHOODIAPRODUCTSVARIESWIDELY.EWSREPORTSSUG-
gest that some products sold as hoodia do not contain any hoodia.
238
Supplements Used for Weight Loss
and safe care.
239
Part Four
Biologically
Based Therapies
Chapter 36
Biologically Based
Therapies: An Overview
Denition of Scope of Field

The complementary and alternative medicine (CAM) domain of
biologically based practices includes, but is not limited to, botanicals,
animal-derived extracts, vitamins, minerals, fatty acids, amino acids,
proteins, prebiotics and probiotics, whole diets, and functional foods.
Dietary supplements are a subset of this CAM domain. In the
Dietary Supplement Health and Education Act (DSHEA) of 1994,
Congress dened a dietary supplement as a product taken by mouth
that contains a dietary ingredient intended to supplement the diet.
The dietary ingredients in these products may include vitamins,
minerals, herbs or other botanicals, amino acids, and substances
such as enzymes, organ tissues, glandulars, and metabolites. Dietary
supplements can also be extracts or concentrates, and they can occur
in many forms, such as tablets, capsules, softgels, gelcaps, liquids,
or powders.
The Food and Drug Administration (FDA) regulates dietary supple-
ments differently than drug products (either prescription or over-the-
counter). First, drugs are required to follow dened good manufacturing
practices (GMPs). The FDA is developing GMPs for dietary supple-
ments. However, until they are issued, companies must follow existing
manufacturing requirements for foods. Second, drug products must
Excerpted from Biologically Based Practices: An Overview, by the National

Center for Complementary and Alternative Medicine (NCCAM, nccam.nih.gov),
part of the National Institutes of Health, March 2007.
243
be approved by the FDA as safe and efcacious prior to marketing.

In contrast, manufacturers of dietary supplements are responsible
for ensuring that their products are safe. While the FDA monitors
adverse effects after dietary supplement products are on the market,
newly marketed dietary supplements are not subject to premarket
approval or a specic postmarket surveillance period. Third, while
DSHEA requires companies to substantiate claims of benet, citation
of existing literature is considered sufcient to validate such claims.
Manufacturers are not required, as they are for drugs, to submit such
substantiation data to the FDA; instead, it is the Federal Trade Com-
mission that has primary responsibility for monitoring dietary supple-
ments for truth in advertising. A 2004 Institute of Medicine (IOM)
report on the safety of dietary supplements recommends a framework
for cost-effective and science-based evaluation by the FDA.
History and Demographic Use of Biologically Based

Practices
Dietary supplements reect some of humankinds rst attempts to
improve the human condition. The personal effects of the mummied
prehistoric Ice Man found in the Italian Alps in 1991 included me-
dicinal herbs. By the Middle Ages, thousands of botanical products had
been inventoried for their medicinal effects. Many of these, including
digitalis and quinine, form the basis of modern drugs.
Interest in and use of dietary supplements have grown considerably
in the past two decades. Consumers state that their primary reason for
using herbal supplements is to promote overall health and wellness,
but they also report using supplements to improve performance and
energy, to treat and prevent illnesses (e.g., colds and u), and to allevi-
ate depression. According to a 2002 national survey on Americans use
of CAM, use of supplements may be more frequent among Americans
who have one or more health problems, who have specic diseases such
as breast cancer, who consume high amounts of alcohol, or who are
obese. Supplement use differs by ethnicity and across income strata.
On average, users tend to be women, older, better educated, live in
one- or two-person households, have slightly higher incomes, and live
in metropolitan areas.
Use of vitamin and mineral supplements, a subset of dietary supple-
ments, by the U.S. population has been a growing trend since the 1970s.
National surveyssuch as the Third National Health and Nutrition
Examination Survey (NHANES III, 19881994); NHANES, 19992000;
and the 1987 and 1992 National Health Interview Surveysindicate
244
Biologically Based Therapies: An Overview
that 40 to 46 percent of Americans reported taking at least one

vitamin or mineral supplement at some time within the month sur-
veyed. Data from national surveys collected before the enactment
of DSHEA in 1994, however, may not reect current supplement
consumption patterns.
In 2002, sales of dietary supplements increased to an estimated
$18.7 billion per year, with herbs/botanical supplements account-
ing for an estimated $4.3 billion in sales. Consumers consider the
proposed benets of herbal supplements less believable than those
of vitamins and minerals. From 2001 to 2003, sales of herbs expe-
rienced negative growth. This was attributed to consumers wither-
ing condence and confusion. Within the herbal category, however,
formulas led single herbs in sales; products became increasingly
condition-specic; and sales of womens products actually increased
by approximately 25 percent.
In contrast to dietary supplements, functional foods are compo-
nents of the usual diet that may have biologically active components
(e.g., polyphenols, phytoestrogens, sh oils, carotenoids) that may
provide health benets beyond basic nutrition. Examples of func-
tional foods include soy, nuts, chocolate, and cranberries. These foods
bioactive constituents are appearing with increasing frequency as
ingredients in dietary supplements. Functional foods are marketed
directly to consumers. Sales increased from $11.3 billion in 1995 to
about $16.2 billion in 1999. Unlike dietary supplements, functional
foods may claim specic health benets. The Nutrition Labeling and
Education Act (NLEA) of 1990 delineates the permissible labeling of
these foods for health claims.
Whole diet therapy has become an accepted practice for some
health conditions. However, the popularity of unproven diets, espe-
cially for the treatment of obesity, has risen to a new level as the
prevalence of obesity and metabolic syndrome among Americans
has increased and traditional exercise and diet prescriptions have
failed. Popular diets today include the Atkins, Zone, and Ornish diets,
Sugar Busters, and others. The range of macronutrient distributions
of these popular diets is very wide. The proliferation of diet books
is phenomenal. Recently, food producers and restaurants have been
targeting their marketing messages to reect commercially success-
ful low-carbohydrate diets.
Public need for information about dietary supplements, functional
foods, and selected strict dietary regimens has driven research on the
effectiveness and safety of these interventions and the dissemination
of research ndings.
245
Scope of the Research

Range of Studies
Research on dietary supplements spans the spectrum of basic to
clinical research and includes ethnobotanical investigations, analyti-
cal research, and method development/validation, as well as bioavail-
ability, pharmacokinetic, and pharmacodynamic studies. However, the
basic and preclinical research is better delineated for supplements
composed of single chemical constituents (e.g., vitamins and minerals)
than for the more complex products (e.g., botanical extracts). There is
an abundance of clinical research for all types of dietary supplements.
Most of this research involves small phase II studies.
The literature on functional foods is vast and growing; it includes
clinical trials, animal studies, experimental in vitro laboratory studies,
and epidemiological studies. Much of the current evidence for function-
al foods is preliminary or not based on well-designed trials. However,
the foundational evidence gained through other types of investigations
is signicant for some functional foods and their health-promoting
constituents. The strongest evidence for effectiveness is that developed
in accordance with the NLEA guidelines for preapproved health claims
(e.g., oat bran or psyllium).
An important gap in knowledge concerns the role of diet composi-
tion in energy balance. Popular diets low in carbohydrates have been
purported to enhance weight loss. Shorter-term clinical studies show
equivocal results. In addition, mechanisms by which popular diets affect
energy balance, if at all, are not well understood. Although numerous
animal studies assessing the impact of diet composition on appetite and
body weight have been conducted, these studies have been limited by
availability and use of well-dened and standardized diets. The research
on weight loss is more abundant than that on weight maintenance.
Primary Challenges
Many clinical studies of dietary supplements are awed because
of inadequate sample size, poor design, limited preliminary dosing
data, lack of blinding even when feasible, and/or failure to incorporate
objective or standardized outcome instruments. In addition, the lack
of reliable data on the absorption, disposition, metabolism, and excre-
tion of these entities in living systems has complicated the selection
of products to be used in clinical trials. This is more problematic for
complex preparations (e.g., botanicals) than for products composed of
single chemical moieties (e.g., zinc).
246
The lack of consistent and reliable botanical products represents

a formidable challenge both in clinical trials and in basic research.
Most have not been sufciently characterized or standardized for the
conduct of clinical trials capable of adequately demonstrating safety
or efcacy, or predicting that similarly prepared products would also
be safe and effective in wider public use. Consequently, obtaining suf-
cient quantities of well-characterized products for evaluation in clinical
trials would be advantageous. Several issues regarding the choice of
clinical trial material require special attention, for example:
s )NmUENCESOFCLIMATEANDSOIL
s 5SEOFDIFFERENTPARTSOFTHEPLANTS
s 5SEOFDIFFERENTCULTIVARSANDSPECIES
s /PTIMALGROWINGHARVESTINGANDSTORAGECONDITIONS
s 5SEOFTHEWHOLEEXTRACTORASPECIlCFRACTION
s -ETHODOFEXTRACTION
s #HEMICALSTANDARDIZATIONOFTHEPRODUCT
s "IOAVAILABILITYOFTHEFORMULATION
s $OSEANDLENGTHOFADMINISTRATION
Some nonbotanical dietary supplements, such as vitamins, car-

nitine, glucosamine, and melatonin, are single chemical entities.
Botanicals, however, are complex mixtures. Their putative active in-
gredients may be identied, but are rarely known for certain. Usu-
ally, there is more than one of these ingredients, often dozens. When
active compounds are unknown, it is necessary to identify marker or
reference compounds, even though they may be unrelated to biological
effects. Qualitative and quantitative determinations of the active and
marker compounds, as well as the presence of product contaminants,
can be assessed by capillary electrophoresis, gas chromatography, liq-
uid chromatography-mass spectrometry, gas chromatography-mass
spectrometry, high-performance liquid chromatography, and liquid
chromatography-multidimensional nuclear magnetic resonance. Fin-
gerprinting techniques can map out the spectrum of compounds in a
plant extract. New applications of older techniques and new analyti-
cal methods continue to be developed and validated. However, there
remains a paucity of analytical tools that are precise, accurate, spe-
cic, and robust. Steps are currently being taken to apply molecular
tools, such as DNA ngerprinting, to verify species in products, while
247
transient expression systems, and microarray and proteomic analyses,

are beginning to be used to dene the cellular and biological activities
of dietary supplements.
Particular attention should be paid to the issues of complex botani-
cals and clinical dosing. Quality control of complex botanicals is dif-
cult, but must be accomplished, because it is not ethical to administer
an unknown product to patients. The use of a suboptimal dose that
is safe but ineffective does not serve the larger goals of NCCAM, the
CAM community, or public health. Although the trial would indicate
only that the tested dose of the intervention was ineffective, the public
might conclude that all doses of the intervention are ineffective, and
patients would be denied a possible benet from the intervention.
Overdosing, on the other hand, might produce unnecessary adverse
effects. Phase I/II studies should be conducted rst to determine the
safety of various doses, and the optimal dose should then be tested in
a phase III trial. As a result, maximum benet would be seen in the
trial; also, any negative result would be denitive.
To a great extent, the difference between a dietary supplement
and a drug lies in the use of the agent, not in the nature of the agent
itself. If an herb, vitamin, mineral, or amino acid is used to resolve a
nutritional deciency or to improve or sustain the structure or func-
tion of the body, the agent is considered a dietary supplement. If the
agent is used to diagnose, prevent, treat, or cure a disease, the agent
is considered a drug. This distinction is key when the FDA determines
whether proposed research on a product requires an investigational
new drug (IND) exemption. If the proposed investigation of a law-
fully marketed botanical dietary supplement is to study its effects on
diseases (i.e., to cure, treat, mitigate, prevent, or diagnose a disease
and its associated symptoms), then the supplement is more likely to
be subject to IND requirements. The FDA has worked with NCCAM
to provide direction to investigators and created a Botanical Review
Team to ensure consistent interpretation of the document Guidance
for IndustryBotanical Drug Products.
Similarly, little attention has been paid to the quality of probiotics.
Quality issues for probiotic supplements may include the following:
s 6IABILITYOFBACTERIAINTHEPRODUCT
s 4YPESANDTITEROFBACTERIAINTHEPRODUCT
s 3TABILITYOFDIFFERENTSTRAINSUNDERDIFFERENTSTORAGECONDITIONS
and in different product formats
s %NTERICPROTECTIONOFTHEPRODUCT
248
Therefore, for optimal studies, documentation of the type of bacte-

ria (genus and species), potency (number of viable bacteria per dose),
purity (presence of contaminating or ineffective microorganisms), and
disintegration properties must be provided for any strain to be consid-
ered for use as a probiotic product. Speciation of the bacteria must be
established by means of the most current, valid methodology.
Many of the challenges identied for research on dietary supple-
ments, including issues of composition and characterization, are ap-
plicable to research on functional foods and whole diets. In addition,
challenges of popular diet research include adherence to the protocol
for longer-term studies, inability to blind participants to intervention
assignment, and efcacy versus effectiveness.
Summary of the Major Threads of Evidence

Over the past few decades, thousands of studies of various dietary
supplements have been performed. To date, however, no single supple-
ment has been proven effective in a compelling way. Nevertheless, there
are several supplements for which early studies yielded positive, or at
least encouraging, data. Good sources of information on some of them
can be found at the Natural Medicines Comprehensive Database and a
number of National Institutes of Health (NIH) websites. The NIH Of-
ce of Dietary Supplements (ODS) annually publishes a bibliography
of resources on signicant advances in dietary supplement research.
Finally, the ClinicalTrials.gov database lists all NIH-supported clinical
studies of dietary supplements that are actively accruing patients.
For a few dietary supplements, data have been deemed sufcient
to warrant large-scale trials. For example, multicenter trials have
concluded or are in progress on ginkgo (Ginkgo biloba) for preven-
tion of dementia, glucosamine hydrochloride and chondroitin sulfate
for osteoarthritis of the knee, saw palmetto (Serenoa repens)/African
plum (Prunus africana) for benign prostatic hypertrophy, vitamin E/
selenium for prevention of prostate cancer, shark cartilage for lung
cancer, and St. Johns wort (Hypericum perforatum) for major and
minor depression. The results of one of the depression studies showed
that St. Johns wort is no more effective for treating major depression
of moderate severity than placebo. Other studies of this herb, including
its possible value in treatment of minor depression, are under way.
Reviews of the data regarding some dietary supplements have been
conducted, including some by the members of the Cochrane Collabora-
tion. The Agency for Healthcare Research and Quality has produced a
number of evidence-based reviews of dietary supplements, including
249
garlic, antioxidants, milk thistle, omega-3 fatty acids, ephedra, and

S-adenosyl-L-methionine (SAMe). The following are examples of nd-
ings from some of these reviews:
s !NALYSISOFTHELITERATURESHOWSGENERALLYDISAPPOINTINGRESULTS
for the efcacy of antioxidant supplementation (vitamins C and
E, and coenzyme Q10) to prevent or treat cancer. Because this
nding contrasts with the benets reported from observational
studies, additional research is needed to understand why these
two sources of evidence disagree.
s 3IMILARLYTHELITERATUREONTHEROLESOFTHEANTIOXIDANTSVITAMINS
C and E and coenzyme Q10 for cardiovascular disease also shows
discordance between observational and experimental data. There-
fore, the thrust of new research into antioxidants and cardiovas-
cular disease should be randomized trials.
s 4HECLINICALEFlCACYOFMILKTHISTLETOIMPROVELIVERFUNCTIONISNOT
clearly established. Interpretation of the evidence is hampered by
poor study methods or poor quality of reporting in publications.
Possible benet has been shown most frequently, but not consis-
tently, for improvement in aminotransferase levels. Liver func-
tion tests are overwhelmingly the most common outcome measure
studied. Available evidence is not sufcient to suggest whether
milk thistle is more effective for some liver diseases than others.
Available evidence does suggest that milk thistle is associated
with few, and generally minor, adverse effects. Despite substantial
in vitro and animal research, the mechanism of action of milk
thistle is not well dened and may be multifactorial.
s 4HEREVIEWOF3!-EFORTHETREATMENTOFDEPRESSIONOSTEOARTHRI-
tis, and liver disease identied a number of promising areas for
future research. For example, it would be helpful to conduct (1)
additional review studies, studies elucidating the pharmacology
of SAMe, and clinical trials; (2) studies that would lead to a bet-
ter understanding of the risk-benet ratio of SAMe compared to
that of conventional therapy; (3) good dose-escalation studies us-
ing the oral formulation of SAMe for depression, osteoarthritis,
or liver disease; and (4) larger clinical trials once the efcacy of
the most effective oral dose of SAMe has been demonstrated.
s 4WOHIGH QUALITYRANDOMIZEDCONTROLLEDTRIALSPROVIDEGOODEVI-
dence that cranberry juice may decrease the number of symptom-
atic urinary tract infections in women over a 12-month period. It
250
is not clear if it is effective in other groups. The fact that a large

number of women dropped out of these studies indicates that
cranberry juice may not be acceptable over long periods of time.
Finally, the optimal dosage or method of administration of cran-
berry products (e.g., juice or tablets) is not clear.
There has been some study of other popular dietary supplements.

For example, valerian is an herb often consumed as a tea for improved
sleep, and melatonin is a pineal hormone touted for the same pur-
pose. Small studies suggest that these two supplements may relieve
insomnia, and there may be little harm in a trial course of either one.
Echinacea has long been taken to treat or prevent colds; other supple-
ments currently used for colds include zinc lozenges and high doses of
vitamin C. As yet, only moderate-sized studies have been conducted
with echinacea or zinc, and their outcomes have been conicting. Large
trials of high doses of oral vitamin C showed little, if any, benet in
preventing or treating the common cold.
Because of widespread use, often for centuries, and because the
products are natural, many people assume dietary supplements to be
inert or at least innocuous. Yet, recent studies show clearly that inter-
actions between these products and drugs do occur. For example, the
active ingredients in ginkgo extract are reported to have antioxidant
properties and to inhibit platelet aggregation. Several cases have been
reported of increased bleeding associated with ginkgos use with drugs
that have anticoagulant or antiplatelet effects. St. Johns wort induces
a broad range of enzymes that metabolize drugs and transport them
out of the body. It has been shown to interact with a number of drugs
that serve as substrates for the cytochrome P450 CYP3A enzymes
responsible for metabolism of approximately 60 percent of current
pharmaceutical agents. Other dietary supplements shown to potenti-
ate or interfere with prescription drugs include garlic, glucosamine,
ginseng (Panax), saw palmetto, soy, valerian, and yohimbe.
In addition to interacting with other agents, some herbal supple-
ments can be toxic. Misidentication, contamination, and adulteration
may contribute to some of the toxicities. But other toxicities may result
from the products themselves. For example, in 2001, extracts of kava
were associated with fulminant liver failure. More recently, the FDA
banned the sale of ephedra after it was shown to be associated with
an increased risk of adverse events.
The FDA lists warnings and safety information on dietary supple-
ments (e.g., androstenedione, aristolochic acid, comfrey, kava, and PC
SPES) as they become available.
251
Chapter 37
Apitherapy
What is apitherapy?
As a technique, it is the medical use of the products of the honeybee
hive often used with essential oils.
As a philosophy, it is a form of harmony between the individual and
the environment.
As a medical principle, it is primarily the cultivation of health and
its re-establishment when sickness interferes.
What products are used in apitherapy?

They are: honey, pollen, propolis, royal jelly, and bee venom. These
products can be used individually. More frequently, several of those
are used together.
Essential oils, already present in honey and propolis, are often used
in conjunction with the products of the hive.
What kinds of conditions are treated with apitherapy?

Currently the most popular and well-known uses of honeybee ven-
om in the United States are for people suffering from MS [multiple
sclerosis] and many forms of arthritis. Now, the only condition that
has actual scientic data supporting the use of apitherapy for treat-
ment is post-herpetic neuralgia. There were several articles written
Frequently Asked Questions about Apitherapy, 2009 American Apitherapy
Association (www.apitherapy.org). Reprinted with permission.
253
in the rst half of the 1900s about using bee venom in the treatment
of osteoarthritis and rheumatoid arthritis and there is some ongoing
research now looking at its effect in multiple sclerosis. Anecdotal re-
ports suggest that it might have some usefulness in the treatment of
infectious, autoimmune, cardiovascular, pulmonary, gastrointestinal,
neuropathic pain, and other chronic pain conditions.
How are MS and arthritis treated?

Bee venom, in synergy with other bee products, is the major thera-
peutic agent. Live bee stings or a commercially available venom extract
which can be injected by doctors are used in conjunction with one or
more of the products of the bee hive mentioned above.
Where can I nd someone who can help me with apitherapy?

The American Apitherapy Society (AAS) has information on its
database of practitioners and of people ready to give information and
assistance. This information is available to society members.
Who practices apitherapy?

Practitioners include physicians, nurses, acupuncturists, and natur-
opaths, as well as interested laypersons including bee keepers who can
provide persons who want bee venom therapy with bees and instruct
them how to treat themselves.
Is apitherapy covered by insurance?

No, however, many AAS members practitioners do not charge for
the procedure but some do charge for their time. A donation to AAS
is appreciated to support the dissemination of information about and
education about apitherapy. The amount of the donation can vary and
can be discussed with the practitioner. Joining the AAS is another way
to support the organization and you get an informative and entertain-
ing newsletter quarterly as part of the membership.
Is apitherapy a recognized therapy in the United States?

No ofcial body in the United States has sanctioned apitherapy as
a recognized treatment modality. Bee venom has been approved by the
FDA [U.S. Food and Drug Administration] for desensitization purposes
only. Apitherapy is considered, from both the legal and medical view-
point, an experimental approach.
254
Apitherapy
What about bee sting allergy?

Contrary to popular belief allergy to honeybee sting is relatively
rare: About seven in 1,000 persons are allergic. Of this proportion only
a small percentage risks anaphylactic shock. Nevertheless bee venom
treatment is always to be preceded by a test of sensitivity. A sensitive
person can be d-sensitized to bee venom, thus allowing apitherapy
to proceed. AAS recommends that anyone that uses or administers
bee venom have readily available an epinephrine kit to be used in
case of anaphylactic response and know how to use it. Many people
erroneously consider swelling after a sting to be an allergic reaction.
Swelling is a normal response of the body as are localized redness,
swelling, and itching.
255
Chapter 38
Aromatherapy and
Essential Oils
What is aromatherapy?
Aromatherapy is the use of essential oils from plants to support and
balance the mind, body, and spirit. It is used by patients with cancer
mainly as a form of supportive care that may improve quality of life
and reduce stress and anxiety. Aromatherapy may be combined with
other complementary treatments like massage therapy and acupunc-
ture, as well as with standard treatments.
Essential oils (also known as volatile oils) are the basic materials of
aromatherapy. They are made from fragrant essences found in many
plants. These essences are made in special plant cells, often under the
surface of leaves, bark, or peel, using energy from the sun and elements
from the air, soil, and water. If the plant material is crushed, the es-
sence and its unique fragrance are released.
When essences are extracted from plants in natural ways, they
become essential oils. They may be distilled with steam and/or water,
or mechanically pressed. Oils that are made with chemical processes
are not considered true essential oils.
There are many essential oils used in aromatherapy, including Ro-
man chamomile, geranium, lavender, tea tree, lemon, cedarwood, and
bergamot. Each type of essential oil has a different chemical structure
that affects how it smells, how it is absorbed, and how it is used by
PDQ Cancer Information Summary. National Cancer Institute; Bethesda,

MD. Aromatherapy and Essential Oils (PDQ): CAMPatient. Updated
01/2010. Available at http://cancer.gov. Accessed January 13, 2009.
257
the body. Even varieties of plants within the same species may have
chemical structures different from each other because they are grown
or harvested in different ways or locations.
Essential oils are very concentrated. For example, it takes about
220 pounds of lavender owers to make about 1 pound of essential oil.
Essential oils are very volatile, evaporating quickly when they come
in contact with air.
What is the history of the discovery and use of aromatherapy

as a complementary and alternative treatment for cancer?
Fragrant plants have been used in healing practices for thousands
of years across many cultures, including ancient China, India, and
Egypt. Ways to extract essential oils from plants were rst discovered
during the Middle Ages.
The history of modern aromatherapy began in the early 20th cen-
tury, when French chemist Rene Gattefosse coined the term aro-
matherapie and studied the effects of essential oils on many kinds
of diseases. In the 1980s and 1990s, aromatherapy was rediscovered
in Western countries as interest in complementary and alternative
medicine (CAM) began to grow.
What is the theory behind the claim that aromatherapy is

useful in treating cancer?
Aromatherapy is generally not suggested as a treatment for can-
cer, but as a form of supportive care to manage symptoms of cancer
or side effects of cancer treatment. There are different theories about
how aromatherapy and essential oils work. One theory is that smell
receptors in the nose may respond to the smells of essential oils by
sending chemical messages along nerve pathways to the brains limbic
system, which affects moods and emotions. Imaging studies in humans
help show the effects of smells on the limbic system and its emotional
pathways. Another theory suggests that because essential oils are
extracted from whole aromatic plants, they have a life force or vitality
that can affect the body in unique ways.
How is aromatherapy administered?

Aromatherapy is most often used in one of two ways:
s Inhalation (taking into the body by breathing): This can
be done by using a diffuser or placing drops of essential oils near
the patient.
258
Aromatherapy and Essential Oils
s Topical treatment (applied to the surface of the body),

usually in a diluted form: This can be done by massaging
with essential oils diluted in a carrier oil, or by using essential
oils in bath water, lotions, or dressings.
Aromatherapy is rarely taken by mouth.

There are some essential oils commonly chosen to treat specic
conditions. However, the types of oils used and the ways they are
combined may vary, depending on the experience and training of the
aromatherapist. This lack of standard methods has led to conicting
research on the effects of aromatherapy.
Have any preclinical (laboratory or animal) studies been

conducted using aromatherapy?
Many studies of essential oils have found that they have antibacte-
rial effects when applied to the skin. In addition, studies in rats have
shown that different essential oils can be calming or energizing. When
rats were exposed to certain fragrances under stressful conditions,
their behavior and immune responses were improved.
One study showed that after essential oils were inhaled, markers of
the fragrance compounds were found in the bloodstream, suggesting
that aromatherapy affects the body directly like a drug, rather than
indirectly through the central nervous system.
Have any clinical trials (research studies with people) of

aromatherapy been conducted?
Clinical trials of aromatherapy have mainly studied its use in the
treatment of stress, anxiety, and other health-related conditions in se-
riously ill patients. Several clinical trials of aromatherapy in patients
with cancer have been published with mixed results.
A few early studies have shown that aromatherapy may improve
quality of life in patients with cancer. Some patients receiving aro-
matherapy have reported improvement in symptoms such as nau-
sea or pain, and have lower blood pressure, pulse, and respiratory
rates.
A small study of tea tree oil as a topical treatment to clear antibiotic
-resistant MRSA [methicillin-resistant Staphylococcus aureus] bacte-
ria from the skin of hospital patients found that it was as effective as
the standard treatment. No studies in scientic or medical literature
discuss aromatherapy as a treatment for cancer.
259
Have any side effects or risks been reported from

aromatherapy?
Safety testing on essential oils shows very few bad side effects
or risks when they are used as directed. Some essential oils have
been approved as ingredients in food and are classified as GRAS
(generally recognized as safe) by the U.S. Food and Drug Admin-
istration, within specific limits. Eating large amounts of essential
oils is not recommended.
Allergic reactions and skin irritation may occur in aromathera-
pists or in patients, especially when essential oils are in contact with
the skin for long periods of time. Sun sensitivity may develop when
citrus or other oils are applied to the skin before sun exposure.
Lavender and tea tree oils have been found to have some
hormone-like effects. They have effects similar to estrogen (female
sex hormone) and also block or decrease the effect of androgens
(male sex hormones). Applying lavender and tea tree oils to the
skin over a long period of time has been linked to breast enlarge-
ment in boys who have not yet reached puberty. It is not known if
the use of lavender and tea tree oils is safe for women who have a
high risk for breast cancer that is estrogen-receptive.
Is aromatherapy approved by the U.S. Food and Drug Ad-

ministration (FDA) for use as a cancer treatment in the
United States?
Aromatherapy products do not need approval by the Food and Drug
Administration because no specic claims are made for the treatment
of cancer or other diseases.
Aromatherapy is not regulated by state law, and there is no licens-
ing required to practice aromatherapy in the United States. Profession-
als often combine aromatherapy training with another eld in which
they are licensed, for example, massage therapy, registered nursing,
acupuncture, or naturopathy.
The National Association for Holistic Aromatherapy (www.naha.
org) and the Alliance of International Aromatherapists (www.alliance-
aromatherapists.org) are two organizations that have national edu-
cational standards for aromatherapists. The National Association for
Holistic Aromatherapy (NAHA) plans to have a standard aromathera-
py certication in the United States. At this time, there are 19 schools
that offer certicate programs approved by NAHA. National exams in
aromatherapy are held twice a year.
260
Aromatherapy and Essential Oils
The Canadian Federation of Aromatherapists (www.cfacanada.com)

certies aromatherapists in Canada. See the International Federation
of Aromatherapists website (www.ifaroma.org) for a list of interna-
tional aromatherapy programs.
261
Chapter 39
Diet-Based Therapies
Chapter Contents
Section 39.1Detoxication Diets............................................. 264
Section 39.2Fasting ................................................................. 267
Section 39.3Gerson Therapy ................................................... 269
Section 39.4Macrobiotics......................................................... 273
3ECTION6EGANISM ............................................................. 275
3ECTION6EGETARIANISM...................................................... 279
263
Section 39.1
Detoxication Diets
Are Detox Diets Safe? January 2009, reprinted with permission from www
.kidshealth.org. Copyright 2009 The Nemours Foundation. This information
was provided by KidsHealth, one of the largest resources online for medically
reviewed health information written for parents, kids, and teens. For more
What Is a Detox Diet?

The name sounds reassuringeveryone knows that anything toxic
is bad for you. Plus these diets encourage you to eat natural foods and
involve lots of water and veggiesall stuff you know is good for you.
You hear about celebrities going on detox diets, and people who go into
drug or alcohol rehabs are said to be detoxing. So shouldnt a detox
diet be a good bet?
Not really. Like many other fad diets, detox diets can have harmful
side effects, especially for teens.
A toxin is a chemical or poison that is known to have harmful effects
on the body. Toxins can come from food or water, from chemicals used
to grow or prepare food, and even from the air that we breathe. Our
bodies process those toxins through organs like the liver and kidneys
and eliminate them in the form of sweat, urine, and feces.
Although detox diet theories have not been proven scientically, the
people who support them believe that toxins dont always leave our
bodies properly during the elimination of waste. Instead, they think
toxins hang around in our digestive, lymph, and gastrointestinal sys-
tems as well as in our skin and hair causing problems like tiredness,
headaches, and nausea.
The basic idea behind detox diets is to temporarily give up certain
kinds of foods that are thought to contain toxins. The idea is to purify
and purge the body of all the bad stuff. But the truth is, the human
body is designed to purify itself.
Detox diets vary. Most involve some version of a fast: that is, giving
up food for a couple of days and then gradually reintroducing certain
foods into the diet. Many of these diets also encourage people to have
colonic irrigation or enemas to clean out the colon. (An enema ushes
264
out the rectum and colon using water.) Others recommend that you
take special teas or supplements to help the purication process.
There are lots of claims about what a detox diet can do, from pre-
venting and curing disease to giving people more energy or focus. Of
course, eating a diet lower in fat and higher in ber can help many
people feel healthier. But people who support detox diets claim that
this is because of the elimination of toxins. Theres no scientic proof
that these diets help rid the body of toxins faster or that the elimina-
tion of toxins will make you a healthier, more energetic person.
What Should You Watch out For?

Detox diets are supposedly to help clean out the system but many peo-
ple think they will lose weight if they try these diets. Heres the truth:
Detox diets are not recommended for teens. Normal teenag-

ers need lots of nutritional goodies; like enough calories and protein to
support rapid growth and development. So diets that involve fasting
and severe restriction of food are not a good idea. For teens who are
involved in sports and physical activities that require ample food, fast-
ing does not provide enough fuel to support these activities. For these
reasons, detox diets can be especially risky for teenagers.
Detox diets arent for people with health conditions. Theyre

not recommended for people with diabetes, heart disease, or other
chronic medical conditions. Detox diets should be avoided if you are
pregnant or have an eating disorder.
Detox diets can be addicting. Thats because theres a certain

feeling that comes from going without food or having an enema
almost like the high other people get from nicotine or alcohol. This can
become a dangerous addiction that leads to health problems, including
serious eating disorders, heart problems, and even death.
Detox supplements can have side effects. Many of the supple-

ments used during detox diets are actually laxatives, which are designed
to make people go to the bathroom more often, and that can get messy.
Laxative supplements are never a good idea because they can cause dehy-
dration, mineral imbalances, and problems with the digestive system.
Detox diets dont help people lose fat. Finally, people who fast
for several days may drop pounds, but most of it will be water and some
of it may be muscle. Most people regain the weight they lost soon after
completing the program.
265
Detox diets are for short-term purposes only. In addition to

causing other health problems, fasting for long periods can slow down
a persons metabolism, making it harder to keep the weight off or to
lose weight later.
Eat Right and Your Body Does the Rest

Of course, its a great idea to eat lots of fruits and veggies, get lots
of ber, and drink water. But you also need to make sure youre getting
all of the nutrients you need from other foods, including protein (from
sources such as lean meats, eggs, beans, or peas) and calcium (from
foods like low-fat or fat-free milk or yogurt). You denitely shouldnt
start a detox diet or stop eating from any major food group without
talking to your doctor or a registered dietitian.
The human body is designed to purify itself. Your liver and kidneys
will do the job theyre supposed to do if you eat a healthy diet that
includes ber, fruits, veggies, and plenty of water. If youre feeling tired
or run down, or if youre concerned that youre overweight, talk with
a doctor who can help you determine the cause and recommend ways
to address the problem.
266
Section 39.2
Fasting
Reprinted with permission from the website of the John Moores Univer-
University of CaliforniaSan Diego. All rights reserved. Reviewed by David
This treatment modality is used in place of conventional therapies

to treat cancer. Seek advice from a qualied physician before replacing
standard cancer therapy with fasting and juice therapies.
What do fasting and juice therapies involve?

Fasting, or voluntarily abstaining from food, and juice therapy, the
consumption of certain fruit and vegetable juices instead of food, are
believed by supporters to cleanse and detoxify the body internally.
Fasting has long been practiced around the world as a part of religious
beliefs to purify the soul. Only recently has fasting been thought to
purify the physical body.
How are fasting and juice therapies thought to treat cancer?

Proponents believe that fasting or just consuming certain juices
aids the body in cleansing itself of toxins and impurities. The immune
system is believed by its supporters to work better, heal the body, and
get rid of poisons when the bodys physiologic systems have a chance
to rest. Juice can also provide nutrients and calories if a patient is
unable to keep solid food down.
What has been proven about the benet of fasting and

juice therapies?
The American Cancer Society does not believe that detoxication
by fasting is based on scientic fact, nor does it cure cancer. While
short-term fasting does aid weight loss in the severely obese, there
is no evidence that it can rid the body of toxins or aid in treatment
of disease. The mainstream medical community states the denying
267
the body of necessary nutrients and calories actually weakens the

immune system, resulting in the deterioration, not improvement, of
health. Patients with advanced cancer are encouraged to avoid fasting.
While not a magic cure-all, juice can serve as a valuable nutritional
supplement for cancer patients. Juice does not contain ber, fat, and
protein and these need to be ingested as well to maintain energy and
reach optimum health.
What is the potential risk or harm of fasting and juice

therapies?
Fasting and juice therapies can cause fatigue, anemia, dizziness, and
an irregular heartbeat. Supporters do not believe these are harmful
symptoms. In fact, they view them as indicators of movement towards
well-being and mental sharpness. Certain medical conditions such as
diabetes can be aggravated by the ingestion of juices. Acidic citrus and
tomato juices can irritate the stomach of sensitive patients.
How much do fasting and juice therapies cost?

Eating nothing or just juice is sure to cut back on ones grocery bill.
Most treatments are self-help remedies and are performed at home.
Occasionally, a physician might oversee the patient to ensure no ad-
ditional health problems develop as a result of the therapy.
For Additional Information

American Association of Naturopathic Physicians
8201 Greensboro Drive, Suite 300
-C,EAN6!
Phone: 877-969-2267
Website: www.naturopathic.org
268
Section 39.3
Gerson Therapy
PDQ Cancer Information Summary. National Cancer Institute; Bethes-
da, MD. Gerson Therapy (PDQ): CAMPatient. Updated 06/2009.
Available at http://cancer.gov. Accessed December 10, 2009.
What is the Gerson therapy?

The Gerson therapy has been used by some people to treat cancer
and other diseases. It is based on the role of minerals, enzymes, and
other dietary factors. There are three key parts to the therapy:
s Diet: Organic fruits, vegetables, and whole grains to give the body
plenty of vitamins, minerals, enzymes, and other nutrients. The
fruits and vegetables are low in sodium (salt) and high in potassium.
s Supplementation: The addition of certain substances to the
diet to help correct cell metabolism (the chemical changes that
take place in a cell to make energy and basic materials needed
for the bodys life processes).
s Detoxication: Treatments, including enemas, to remove toxic
(harmful) substances from the body.
What is the history of the discovery and use of the Gerson ther-
apy as a complementary or alternative treatment for cancer?
The Gerson therapy was named after Dr. Max B. Gerson (1881
1959), who rst used it to treat his migraine headaches. In the 1930s,
Dr. Gersons therapy became known to the public as a treatment for a
type of tuberculosis (TB). The Gerson therapy was later used to treat
other conditions, including cancer.
What is the theory behind the claim that the Gerson thera-
py is useful in treating cancer?
The Gerson therapy is based on the idea that cancer develops when
there are changes in cell metabolism because of the buildup of toxic sub-
stances in the body. Dr. Gerson said the disease process makes more toxins
269
and the liver becomes overworked. According to Dr. Gerson, people with
cancer also have too much sodium and too little potassium in the cells in
their bodies, which causes tissue damage and weakened organs.
The goal of the Gerson therapy is to restore the body to health by
repairing the liver and returning the metabolism to its normal state.
According to Dr. Gerson, this can be done by removing toxins from
the body and building up the immune system with diet and supple-
ments. The enemas are said to widen the bile ducts of the liver so
toxins can be released. According to Dr. Gerson, the liver is further
overworked as the treatment regimen breaks down cancer cells and
rids the body of toxins. Pancreatic enzymes are given to decrease the
demands on the weakened liver and pancreas to make enzymes for
digestion. An organic diet and nutritional supplements are used to
boost the immune system and support the body as the regimen cleans
the body of toxins. Foods low in sodium and high in potassium are
said to help correct the tissue damage caused by having too much
sodium in the cells.
How is the Gerson therapy administered?

The Gerson therapy requires that the many details of its treatment
plan be followed exactly. Some key parts of the regimen include the
following:
s !PERSONMUSTDRINKGLASSESOFJUICEADAY4HEJUICEMUSTBE
freshly made from organic fruits and vegetables and be taken
once every hour.
s !PERSONMUSTEATVEGETARIANMEALSOFORGANICALLYGROWNFRUITS
vegetables, and whole grains.
s !PERSONMUSTTAKEANUMBEROFSUPPLEMENTSINCLUDINGTHE
following:
s 0OTASSIUM
s ,UGOLS3OLUTIONPOTASSIUMIODIDEIODINEANDWATER
s #OENZYME1INJECTEDWITHVITAMIN"12 (The original regi-
men used crude liver extract instead of coenzyme Q10.)
s 6ITAMINS!#AND"3 (niacin)
s &LAXSEEDOIL
s 0ANCREATICENZYMES
s 0EPSINASTOMACHENZYME
270
s !PERSONMUSTTAKECOFFEEORCHAMOMILEENEMASREGULARLYTORE-
move toxins from the body.
s !PERSONMUSTPREPAREFOODWITHOUTSALTSPICESOROILSAND
without using aluminum cookware or utensils.

conducted using the Gerson therapy?
No results of laboratory or animal studies have been published in
scientic journals.

the Gerson therapy been conducted?
Most of the published information on the use of the Gerson therapy
reports on retrospective studies (reviews of past cases). Dr. Gerson
published case histories (detailed reports of the diagnosis, treatment,
and follow-up of individual patients) of 50 of his patients. He treated
several different types of cancer in his practice. The reports include Dr.
Gersons notes, with some X-rays of the patients over time. The follow-
up was contact with patients by mail or phone and included anecdotal
reports (incomplete descriptions of the medical and treatment histories
of one or more patients).
In 1947 and 1959, the National Cancer Institute (NCI) reviewed the
cases of a total of 60 patients treated by Dr. Gerson. The NCI found that
the available information did not prove the regimen had benet.
The following studies of the Gerson therapy were published:
s In 19831984, a retrospective study of 38 patients treated with
the Gerson therapy was done. Medical records were not available
to the authors of the study; information came from patient inter-
views. These case reviews did not provide information that sup-
ports the usefulness of the Gerson therapy for treating cancer.
s )NASTUDYOFADIETREGIMENSIMILARTOTHE'ERSONTHERAPY
was done in Austria. The patients received standard treatment
along with the special diet. The authors of the study reported that
the diet appeared to help patients live longer than usual and have
fewer side effects. The authors said it needed further study.
s )NTHE'ERSON2ESEARCH/RGANIZATIONDIDARETROSPECTIVE
study of their melanoma patients who were treated with the
Gerson therapy. The study reported that patients who had stage
271
)))ORSTAGE)6MELANOMALIVEDLONGERTHANUSUALFORPATIENTS
with these stages of melanoma. There have been no clinical tri-
als that support the ndings of this retrospective study.
s !CASEREVIEWOFSIXPATIENTSWITHMETASTATICCANCERWHOUSED
the Gerson therapy reported that the regimen helped patients in
some ways, both physically and psychologically. Based on these
results, the reviewers recommended that clinical trials of the
Gerson therapy be conducted.
Have any side effects or risks been reported from use of the
Gerson therapy?
Reports of three deaths that may be related to coffee enemas have
been published. Taking too many enemas of any kind can cause changes
in normal blood chemistry, chemicals that occur naturally in the body
and keep the muscles, heart, and other organs working properly.
Is the Gerson therapy approved by the U.S. Food and Drug

Administration (FDA) for use as a cancer treatment in the
United States?
The Gerson therapy has not been approved by the FDA for use as
a treatment for cancer or any other disease.
For most cancer patients, nutrition guidelines include eating a
well-balanced diet with plenty of fruits, vegetables, and whole-grain
products. However, general guidelines such as these may have to be
changed to meet the specic needs of an individual patient. Patients
should talk with their health care providers about an appropriate
diet to follow. Information about diet during cancer treatment is also
available from the Cancer Information Service (800-4-CANCER [TTY:
800-332-8615]).
272
Section 39.4
Macrobiotics
Reprinted with permission from the website of the John Moores Univer-
University of CaliforniaSan Diego. All rights reserved. Reviewed by David
This treatment modality is thought to promote wellness and opti-

mize overall health. Macrobiotics should be used with, not in place of,
standard cancer therapy.
What does macrobiotics therapy involve?

Macrobiotics therapy is a combination of diet, spiritual, and social
philosophy and a way of healthful living. The macrobiotics philosophy
combines elements of Buddhism with dietary principles based on sim-
plicity and avoidance of toxic animal products. Although a relatively
new therapy, macrobiotics teaches that it is necessary to maintain
balance and harmony between two antagonistic but complementary
forces, Yin and Yang, a traditional Chinese medicine concept. The diet,
originally termed the Zen macrobiotic diet, was very restrictive and
has since been modied by other practitioners in the macrobiotic move-
ment. The diet consists mainly of whole grains, vegetables, and beans
with the occasional use of sh and some fruits. Foods not allowed in
the diet include coffee, dairy products, eggs, sugar, meats, and pro-
cessed foods. The macrobiotics diet also requires special methods of
food preparation such as using only pots, pans, and utensils made of
certain materials. There is not a single diet for everyone, but rather
a diet principle that considers different climates, ages, sex, level of
activity, and changing personal needs.
How is macrobiotics thought to promote wellness and opti-

mize overall health?
Traditional Chinese medicine believes that imbalances of Yin and
Yang lead to illness. Therefore, macrobiotics attempts to rebalance
Yin and Yang and regain health through diet and a change in lifestyle
273
and life philosophy. The macrobiotics diet can lower fat and cholesterol
and, like other fat-reducing diets, may help prevent some cancers that
appear to be related to higher fat intake, such as colon cancer. This
fat-free diet can also lower blood pressure and reduce the chance of
heart disease. Other aspects of the macrobiotics therapy may promote
a reduction in stress.
What has been proven about the benet of macrobiotics?

According to the University of Texas MD Anderson Cancer Center,
peer-reviewed research concerning the ability of the macrobiotics diet to
cure cancer is currently limited. After an extensive search only three hu-
man studies on macrobiotics applicable to cancer were found. None dem-
onstrated beyond a reasonable doubt that macrobiotics therapy should be
viewed as a curative therapy. Macrobiotics is a lifestyle approach that
can help prevent cancer, promote wellness, and optimize health.
What is the potential risk or harm of macrobiotics therapy?

A nutrient, vitamin, and calorie restrictive diet can be dangerous
for frail cancer patients. The most serious effects occur when the diet
is decient in calories, vitamin D, vitamin B12, protein, and iron. In-
creased caloric needs to ght illness and recover from treatment may
not be met with the macrobiotics diet, which is high in bulk and low
in fat. Children on the macrobiotics diet tend to have growth and nu-
trient deciencies.
How much does macrobiotics therapy cost?

The cost of consuming a macrobiotics diet is probably comparable
to consumption of a typical American diet when all factors are taken
into consideration. Higher costs for macrobiotics include the initial
setup of a macrobiotics kitchen and special foods. However, eating a
macrobiotic diet can decrease costs because of the elimination of meat
and poultry and the tendency to dine outside the home.
274
Section 39.5
Veganism
h6EGAN$IETSINA.UTSHELLv6EGETARIAN2ESOURCE'ROUP
(www.vrg.org). Reprinted with permission.
What Is a Vegan?
6EGETARIANSDONOTEATMEATlSHORPOULTRY6EGANSINADDITIONTO
being vegetarian, do not use other animal products and by-products
such as eggs, dairy products, honey, leather, fur, silk, wool, and cosmet-
ics and soaps derived from animal products.
Why Veganism?
People choose to be vegan for health, environmental, and/or ethical
reasons. For example, some vegans feel that one promotes the meat
industry by consuming eggs and dairy products. That is, once dairy
cows or egg laying chickens are too old to be productive, they are often
sold as meat. Some people avoid these items because of conditions as-
sociated with their production.
Many vegans chose this lifestyle in order to promote a more humane
and caring world. They know they are not perfect, but believe they have
a responsibility to try to do their best, while not being judgmental of
others.
Common Vegan Foods

[Common vegan foods include]: Oatmeal, stir-fried vegetables, ce-
real, toast, orange juice, peanut butter on whole wheat bread, frozen
fruit desserts, lentil soup, salad bar items like chickpeas and three
bean salad, dates, apples, macaroni, fruit smoothies, popcorn, spaghetti,
vegetarian baked beans, guacamole, chili.
6EGANSALSOEAT4OFULASAGNAHOMEMADEPANCAKESWITHOUTEGGS
hummus, eggless cookies, soy ice cream, tempeh, corn chowder, soy
yogurt, rice pudding, fava beans, banana mufns, spinach pies, oat nut
burgers, seitan, corn fritters, French toast made with soy milk, soy hot
dogs, vegetable burgers, pumpkin casserole, scrambled tofu, falafel.
275
When Eating Out

Try these foods: Pizza without cheese, Chinese moo shu vegetables,
Indian curries and dahl, eggplant dishes without the cheese, bean
tacos without the lard and cheese (available from Taco Bell and other
Mexican restaurants), Middle Eastern hummus and tabouli, Ethiopian
injera (at bread) and lentil stew, Thai vegetable curries.
Egg and Dairy Replacers

As a binder substitute for each egg:
s CUPOUNCES SOFTTOFUBLENDEDWITHTHELIQUIDINGREDIENTSOF
the recipe
s SMALLBANANAMASHED
s CUPAPPLESAUCE
s TABLESPOONSCORNSTARCHORARROWROOTSTARCH
s %NER '%GG2EPLACERORANOTHERCOMMERCIALMIXFOUNDINHEALTH
food stores.
Dairy substitutes:
s 3OYMILKRICEMILKPOTATOMILKNUTMILKORWATERINSOMERECI-
pes) may be used.
s "UTTERMILKCANBEREPLACEDWITHSOUREDSOYORRICEMILK&OR
each cup of buttermilk, use 1 cup soy milk plus 1 tablespoon of
vinegar.
s 3OYCHEESEAVAILABLEINHEALTHFOODSTORES"EAWARETHATMANY
soy cheeses contain casein, which is a dairy product.)
s #RUMBLEDTOFUCANBESUBSTITUTEDFORCOTTAGECHEESEORRICOTTA
cheese in lasagna and similar dishes.
s 3EVERALBRANDSOFNONDAIRYCREAMCHEESEAREAVAILABLEINSUPER-
markets and kosher stores.
Vegan Nutrition
The key to a nutritionally sound vegan diet is variety. A healthy
and varied vegan diet includes fruits, vegetables, plenty of leafy greens,
whole grain products, nuts, seeds, and legumes.
276
Protein
It is very easy for a vegan diet to meet the recommendations for
protein as long as calorie intake is adequate. Strict protein planning
or combining is not necessary. The key is to eat a varied diet.
Sources of protein: Almost all foods except for alcohol, sugar, and
FATSPROVIDESOMEPROTEIN6EGANSOURCESINCLUDELENTILSCHICKPEAS
tofu, peas, peanut butter, soy milk, almonds, spinach, rice, whole wheat
bread, potatoes, broccoli, and kale.
For example, if part of a days menu included the following foods,
you would meet the Recommended Dietary Allowance (RDA) for pro-
tein for an adult male:
s CUPOATMEAL
s CUPSOYMILK
s SLICESWHOLEWHEATBREAD
s BAGEL
s 4ABLESPOONSPEANUTBUTTER
s CUPVEGETARIANBAKEDBEANS
s OUNCESTOFU
s TABLESPOONSALMONDS
s CUPBROCCOLI
s CUPBROWNRICE
Fat
6EGANDIETSAREFREEOFCHOLESTEROLANDAREGENERALLYLOWINSATU-
rated fat. Thus eating a vegan diet makes it easy to conform to recom-
mendations given to reduce the risk of major chronic diseases such as
heart disease and cancer. High-fat foods, which should be used spar-
ingly, include oils, margarine, nuts, nut butters, seed butters, avocado,
and coconut.
Vitamin D
6ITAMIN$ISNOTFOUNDINTHEVEGANDIETBUTCANBEMADEBYHUMANS
following exposure to sunlight. At least 10 to 15 minutes of summer
sun on hands and face two to three times a week is recommended for
adults so that vitamin D production can occur. Food sources of vitamin
D include vitamin D-fortied orange juice and vitamin D-fortied soy
milk and rice milk.
277
Calcium
Calcium, needed for strong bones, is found in dark green leafy vegetables,
tofu made with calcium sulfate, calcium-fortied soy milk and orange juice,
and many other foods commonly eaten by vegans. Although lower animal
protein intake may reduce calcium losses, there is currently not enough
EVIDENCETOSUGGESTTHATVEGANSHAVELOWERCALCIUMNEEDS6EGANSSHOULD
eat foods that are high in calcium and/or use a calcium supplement.
Other good sources of calcium include: okra, turnip greens, soybeans,
tempeh, almond butter, broccoli, bok choy, calcium-fortied soy yogurt.
The recommended intake for calcium for adults 19 through 50 years
is 1,000 milligrams/day.
Note: It appears that oxalic acid, which is found in spinach, rhubarb,
chard, and beet greens, binds with calcium and reduces calcium absorp-
tion. Calcium is well absorbed from other dark green vegetables.
Zinc
6EGANDIETSCANPROVIDEZINCATLEVELSCLOSETOOREVENHIGHERTHAN
the RDA. Zinc is found in grains, legumes, and nuts.
Iron
Dried beans and dark green leafy vegetables are especially good
sources of iron, better on a per calorie basis than meat. Iron absorption
is increased markedly by eating foods containing vitamin C along with
foods containing iron.
Sources of iron: Soybeans, lentils, blackstrap molasses, kidney
beans, chickpeas, black-eyed peas, Swiss chard, tempeh, black beans,
prune juice, beet greens, tahini, peas, bulghur, bok choy, raisins, wa-
termelon, millet, kale.
Omega-3 Fatty Acids

In order to maximize production of DHA and EPA ([docosahexaenoic
acid and eicosapentaenoic acid] omega-3 fatty acids), vegans should
include good sources of alpha-linolenic acid in their diet such as ax-
seed, axseed oil, canola oil, tofu, soybeans, and walnuts.
Vitamin B12
The requirement for vitamin B12 is very low but it is an essential
nutrient. It is especially important for pregnant and lactating women,
infants, and children to have reliable sources of vitamin B12 in their
diets. Non-animal sources include cereals, soy milk, rice milk, and meat
278
analogues that have been fortied with vitamin B12. Also, around 2
TEASPOONSOF2ED3TARNUTRITIONALYEAST4OFTENLABELEDAS6EG-
etarian Support Formula, supplies the adult RDA.
Read labels carefully or contact companies since fortication levels
CANCHANGE6ITAMIN"12 supplements are another option. There are
supplements which do not contain animal products. Claims of a high
vitamin B12 content in fermented soy foods (miso and tempeh) and for
sea vegetables and Spirulina are unfounded. Unless fortied, no plant
food contains signicant amounts of active vitamin B12.
Section 39.6
Vegetarianism
h6EGETARIANISMv/CTOBERREPRINTEDWITHPERMISSIONFROMWWWKID-
shealth.org. Copyright 2008 The Nemours Foundation. This information
was provided by KidsHealth, one of the largest resources online for medically
reviewed health information written for parents, kids, and teens. For more
6EGETARIANISMISAPOPULARCHOICEFORMANYINDIVIDUALSANDFAMI-
lies. But parents may wonder if kids can safely follow a vegetarian
diet and still get all necessary nutrients. Most dietary and medical
experts agree that a well-planned vegetarian diet can actually be a
very healthy way to eat.
But special care must be taken when serving kids and teens a veg-
etarian diet, especially if it doesnt include dairy and egg products. And
as with any diet, youll need to understand that the nutritional needs
of kids change as they grow.
Types of Vegetarian Diets

Before your child or family switches to a vegetarian diet, its impor-
tant to note that all vegetarian diets are not alike. Major vegetarian
categories include:
s Ovo-vegetarian: Eats eggs; no meat
s Lacto-ovo vegetarian: Eats dairy and egg products; no meat
279
s Lacto-vegetarian: Eats dairy products; no eggs or meat

s Vegan: Eats only food from plant sources
And many other people are semi-vegetarians who have eliminated

red meat, but may eat poultry or sh.
The Choice of Vegetarianism

Kids or families may follow a vegetarian diet for a variety of reasons.
Younger vegetarians are usually part of a family that eats vegetarian
meals for health, cultural, or other reasons. Older kids may decide to
become vegetarians because of concern for animals, the environment,
or their own health.
In most cases, you shouldnt be alarmed if your child chooses veg-
etarianism. Discuss what it means and how to implement it, ensuring
your child makes healthy and nutritious food choices.
Nutrition for All Ages

Your doctor or a registered dietitian can help you plan and monitor
a healthy vegetarian diet. Parents should give their kids a variety of
foods that provide enough calories and nutrients to enable them to
grow normally.
A well-planned vegetarian diet can meet kids nutritional needs and
has some health benets. For example, a diet rich in fruits and veggies will
be high in ber and low in fat, factors known to improve cardiovascular
health by reducing blood cholesterol and maintaining a healthy weight.
However, kids and teens on a vegetarian diet may need to be careful that
they get an adequate amount of certain vitamins and minerals.
Here are nutrients that vegetarians should get and some of their
best food sources:
s Vitamin B12: Dairy products, eggs, and vitamin-fortied prod-
ucts, such as cereals, breads, and soy and rice drinks, and nutri-
tional yeast
s Vitamin D: Milk, vitamin D-fortied orange juice, and other
vitamin D-fortied products
s Calcium: Dairy products, dark green leafy vegetables, broccoli,
dried beans, and calcium-fortied products, including orange
juice, soy and rice drinks, and cereals
s Protein: Dairy products, eggs, tofu and other soy products, dried
beans, and nuts
280
s Iron: Eggs, dried beans, dried fruits, whole grains, leafy green
vegetables, and iron-fortied cereals and bread
s Zinc: Wheat germ, nuts, fortied cereal, dried beans, and pump-
kin seeds
Depending on the type of vegetarian diet chosen, kids may miss

out on some of these important nutrients if the diet isnt monitored
by the parents. The less restrictive the vegetarian diet, the easier
it will be for your child to get enough of the necessary nutrients.
In some cases, fortified foods or supplements can help meet nutri-
tional needs.
Vegetarian Infants
The main sources of protein and nutrients for infants are breast
milk and formula (soy formula for vegan infants), especially in the
rst 6 months of life. Breastfed infant vegans should receive a source
of vitamin B12, if the mothers diet isnt supplemented, and breastfed
infants and infants drinking less than 32 ounces (1 liter) of formula
should get vitamin D supplements.
Guidelines for the introduction of solid foods are the same for veg-
etarian and nonvegetarian infants. Breastfed infants 6 months and
older should receive iron from complementary foods, such as iron-
fortied infant cereal.
Once an infant is introduced to solids, protein-rich vegetarian foods
can include pureed tofu, cottage cheese, yogurt or soy yogurt, and pu-
reed and strained legumes (legumes include beans, peas, chickpeas,
and lentils).
Vegetarian Toddlers
Toddlers are already a challenge when it comes to eating. As they
come off of breast milk or formula, kids are at risk for nutritional de-
ciencies. After the age of 1, strict vegan diets may not offer growing
toddlers enough essential vitamins and minerals, such as vitamin D,
vitamin B12, iron, calcium, and zinc. So its important to serve fortied
CEREALSANDNUTRIENT DENSEFOODS6ITAMINSUPPLEMENTATIONISRECOM-
mended for young children whose diets may not provide adequate
nutrients.
Toddlers are typically picky about which foods theyll eat and,
as a result, some may not get enough calories from a vegetarian
diet to thrive. For vegan toddlers, the amount of vegetables needed
for proper nutrition and calories may be too bulky for their tiny
281
stomachs. During the picky toddler stage, its important for vegetar-
ian parents to make sure their young child eats enough calories.
You can get enough fat and calories in a vegan childs diet, but you
have to plan carefully.
Older Vegetarian Kids and Teens

Preteens and teens often voice their independence through the foods
they choose to eat. One strong statement is the decision to stop eating
meat. This is common among teens, who may decide to embrace veg-
etarianism in support of animal rights, for health reasons, or because
friends are doing it.
If its done right, a meat-free diet can actually be a good choice for
adolescents, especially considering that vegetarians often eat more of
the foods that most teens dont get enough offruits and vegetables.
A vegetarian diet that includes dairy products and eggs (lacto-ovo)
is the best choice for growing teens. A more strict vegetarian diet may
fail to meet a teens need for certain nutrients, such as iron, zinc, cal-
cium, and vitamins D and B12. If youre concerned that your child is
not getting enough of these important nutrients, talk to your doctor,
who may recommend a vitamin and mineral supplement.
The good news for young vegetariansand their parentsis that
many schools are offering vegetarian fare, including salad bars and
other healthy vegetarian choices. Schools publish lists of upcoming
lunch menus; be sure to scan them to see if your child will have a veg-
etarian choice. If not, you can pack lunch. That old standbya peanut
butter and jelly sandwichis a great fast vegetarian lunch.
If your vegetarian preteen or teen would rather make his or her
own school lunch or opts to buy lunch, keep in mind that your childs
idea of a healthy vegetarian meal may be much different from yours
(e.g., french fries and a soda). Talk to your child about the importance
of eating right, especially when following a vegetarian diet.
Also be wary if your child has self-imposed a very restrictive diet.
A teen with an eating disorder may drastically reduce calories or cut
out all fat or carbohydrates and call it vegetarianism because its
considered socially acceptable and healthy.
Even if preteens or teens are approaching vegetarianism in a healthy
way, its still important for them to understand which nutrients might
be missing in their diet. To support your childs dietary decision and
promote awareness of the kinds of foods your preteen or teen should
be eating, consider having the whole family eat a vegetarian meal at
least one night a week.
282
A Healthy Lifestyle
A vegetarian diet can be a healthy choice for all kids, as long as its
properly planned.
The principles of planning a vegetarian diet are the same as plan-
ning any healthy dietprovide a variety of foods and include foods
from all of the food groups. A balanced diet will provide the right com-
binations to meet nutritional needs. But be aware of potential nutrient
deciencies in your childs diet and gure out how youll account for
them. With a little exploration, you may nd more vegetarian options
than you realized.
If you arent sure your child is getting all necessary nutrients or
if you have any questions about vegetarian diets, check in with your
family doctor, pediatrician, or a registered dietitian.
283
Chapter 40
Oxygen Therapy
Overview
Hyperbaric oxygen therapy (HBOT) is the inhalation of 100 percent
oxygen inside a hyperbaric chamber that is pressurized to greater than
1 atmosphere (atm). HBOT causes both mechanical and physiologic
effects by inducing a state of increased pressure and hyperoxia.
HBOT is typically administered at 1 to 3 atm. While the duration of
an HBOT session is typically 90 to 120 minutes, the duration, frequen-
cy, and cumulative number of sessions have not been standardized.
HBOT is administered in two primary ways, using a monoplace cham-
ber or a multiplace chamber. The monoplace chamber is the less-costly
option for initial setup and operation but provides less opportunity for
patient interaction while in the chamber. Multiplace chambers allow
medical personnel to work in the chamber and care for acute patients
to some extent. The entire multiplace chamber is pressurized, so medi-
cal personnel may require a controlled decompression, depending on
how long they were exposed to the hyperbaric air environment.
The purpose of this text is to provide a guide to the strengths and
limitations of the evidence about the use of HBOT to treat patients who
have brain injury, cerebral palsy, and stroke. Brain injury can be caused by
an external physical force (also known as traumatic brain injury, or TBI);
Excerpted from Hyperbaric Oxygen Therapy for Brain Injury, Cerebral Palsy,
and Stroke. Summary, Evidence Report/Technology Assessment: Number 85.
AHRQ Publication Number 03-E049, September 2003. Agency for Healthcare Re-
search and Quality, Rockville, MD. http://www.ahrq.gov/clinic/epcsums/hypoxsum
.htm. Reviewed by David A. Cooke, MD, FACP, January 23, 2010.
285
rapid acceleration or deceleration of the head; bleeding within or around

the brain; lack of sufcient oxygen to the brain; or toxic substances passing
through the blood-brain barrier. Brain injury results in temporary or per-
manent impairment of cognitive, emotional, and/or physical functioning.
Cerebral palsy refers to a motor decit that usually manifests itself by 2
years of age and is secondary to an abnormality of at least the part of the
brain that relates to motor function. Stroke refers to a sudden interruption
of the blood supply to the brain, usually caused by a blocked artery or a
ruptured blood vessel, leading to an interruption of homeostasis of cells,
and symptoms such as loss of speech and loss of motor function.
While these conditions have different etiologies, prognostic factors,
and outcomes, they also have important similarities. Each condition
represents a broad spectrum, from barely perceptible or mild disabilities
to devastating ones. All three are characterized by acute and chronic
phases and by changes over time in the type and degree of disability.
Another similarity is that the outcome of conventional treatment is often
unsatisfactory. For brain injury in particular, there is a strong sense that
conventional treatment has made little impact on outcomes.
Predicting the outcome of brain injury, cerebral palsy, and stroke
is difcult. Prognostic instruments, such as the Glasgow Coma Scale
(GCS) for brain injury, are not precise enough to reliably predict an
INDIVIDUALPATIENTSMORTALITYANDLONG TERMFUNCTIONALSTATUS6ARI-
ous prognostic criteria for the cerebral palsy patients function have
been developed over the years. For example, if a patient is not sitting
independently when placed by age 2, then one can predict with ap-
proximately 95 percent condence that he/she never will be able to
walk. However, it is not possible to predict precisely when an individual
patient is likely to acquire a particular ability, such as smiling, recog-
nizing other individuals, or saying or understanding a new word.
Mortality and morbidity from a stroke are related to older age, his-
tory of myocardial infarction, cardiac arrhythmias, diabetes mellitus,
and the number of stroke decits. Functional recovery is dependent
on numerous variables, including age, neurologic decit, comorbidities,
psychosocial factors, educational level, vocational status, and charac-
teristics of the stroke survivors environment.
Reporting the Evidence

This text addresses the following questions:
s $OES("/4IMPROVEMORTALITYANDMORBIDITYINPATIENTSWHO
have traumatic brain injury or nontraumatic brain injury, such
as anoxic ischemic encephalopathy?
286
Oxygen Therapy
s $OES("/4IMPROVEFUNCTIONALOUTCOMESINPATIENTSWHO
have cerebral palsy? (Examples of improved functional out-
comes are decreased spasticity, improved speech, increased
alertness, increased cognitive abilities, and improved
visual functioning.)
s $OES("/4IMPROVEMORTALITYANDMORBIDITYINPATIENTSWHO
have suffered a stroke?
s 7HATARETHEADVERSEEFFECTSOFUSING("/4INTHESECONDITIONS
Findings
Brain Injury
s &ORTRAUMATICBRAININJURYONERANDOMIZEDTRIALPROVIDEDFAIR
evidence that HBOT might reduce mortality or the duration of
coma in severely injured TBI (traumatic brain injuries) patients.
However, in this trial, HBOT also increased the chance of a poor
functional outcome. A second fair quality randomized trial found
no difference in mortality or morbidity overall, but a signicant
reduction in mortality in one subgroup. Therefore, they provide
insufcient evidence to determine whether the benets of
HBOT outweigh the potential harms.
s 4HEQUALITYOFTHECONTROLLEDTRIALSWASFAIRMEANINGTHATDEl-
ciencies in the design add to uncertainty about the validity of
results.
s $UETOmAWSINDESIGNORSMALLSIZETHEOBSERVATIONALSTUDIESOF
HBOT in TBI do not establish a clear, consistent relationship be-
tween physiologic changes after HBOT sessions and measures of
clinical improvement.
s 4HEEVIDENCEFORUSEOF("/4INOTHERTYPESOFBRAININJURYIS
inconclusive. No good- or fair-quality studies were found.
Cerebral Palsy
s 4HEREISINSUFlCIENTEVIDENCETODETERMINEWHETHERTHEUSEOF
HBOT improves functional outcomes in children with cerebral
palsy. The results of the only truly randomized trial were dif-
cult to interpret because of the use of pressurized room air in the
control group. As both groups improved, the benet of pressur-
ized air and of HBOT at 1.3 to 1.5 atm should both be examined
in future studies.
287
s 4HEONLYOTHERCONTROLLEDSTUDYCOMPARED("/4TREATMENTS
with 1.5 atm to delaying treatment for 6 months. As in the
placebo-controlled study, signicant improvements were seen,
but there was not a signicant difference between groups.
s 4WOFAIR QUALITYUNCONTROLLEDSTUDIESONETIME SERIESONE
before-after) found improvements in functional status compa-
rable to the degree of improvement seen in both groups in the
controlled trial.
s !LTHOUGHNONEOFTHESTUDIESADEQUATELYMEASUREDCAREGIVER
burden, study participants often noted meaningful reductions in
caregiver burden as an outcome of treatment.
Stroke
s !LTHOUGHALARGENUMBEROFSTUDIESADDRESS("/4FORTHE
treatment of stroke, the evidence is insufcient to determine
whether HBOT reduces mortality in any subgroup of stroke
patients because no controlled trial assessed was designed to
assess mortality.
s !MONGCONTROLLEDTRIALSTHEEVIDENCEABOUTMORBIDITYISCONmICT-
ing. The three best-quality trials found no difference in neuro-
logical measures in patients treated with HBOT versus patients
treated with pressurized room air.
s 4WOOTHERCONTROLLEDTRIALSONERANDOMIZEDANDONENONRANDOM-
ized, found that HBOT improved neurological outcomes on some
measures. However, both were rated poor-quality.
s -OSTOBSERVATIONALSTUDIESREPORTEDFAVORABLEANDSOMETIMES
dramatic, results, but failed to prove that these results can be at-
tributed to HBOT. For example, one retrospective study found
better mortality rates in patients who received HBOT than a com-
parison group of patients from a different hospital who did not. The
study did not provide information on mortality rates from other
causes in each hospital; this information would have made it easier
to judge whether the improved survival was due to HBOT or to
differences in overall quality of care at the HBOT hospital.
s 4HEOBSERVATIONALSTUDIESOF("/4PROVIDEDINSUFlCIENTEVIDENCE
to establish a clear relationship between physiologic changes after
HBOT sessions and measures of clinical improvement. Few stud-
ies established that patients were stable at baseline.
288
Oxygen Therapy
Adverse Events
s %VIDENCEABOUTTHETYPEFREQUENCYANDSEVERITYOFADVERSE
events in actual practice is inadequate. Reporting of adverse ef-
fects was limited, and no study was designed specically to as-
sess adverse effects.
s 4HEFEWDATATHATAREAVAILABLEFROMCONTROLLEDTRIALSANDCOHORT
studies of TBI suggest that the risk of seizure may be higher in
patients with brain injuries treated with HBOT.
s .OSTUDYOF("/4FORBRAININJURYCEREBRALPALSYORSTROKEHAS
been designed to identify the chronic neurologic complications.
s 0ULMONARYCOMPLICATIONSWERERELATIVELYCOMMONINTHETRIALS
of brain-injured patients. There are no reliable data on the in-
cidence of aspiration in children treated for cerebral palsy with
hyperbaric oxygen.
s %ARPROBLEMSAREAKNOWNPOTENTIALADVERSEEFFECTOF("/4
While ear problems were reported in brain injury, cerebral palsy,
and stroke studies the incidence, severity, and effect on outcome
are not clear. However, the rates reported among cerebral palsy
patients were higher (up to 47 percent experiencing a problem)
than reported with brain injury or stroke. However, the data in
brain injury are limited by the use of prophylactic myringotomies.
Supplemental Qualitative Analysis

s /PINIONSABOUTTHEFREQUENCYANDSEVERITYOFRISKSOF("/4
vary widely.
s 3EVERALPARTICIPANTSEMPHASIZEDTHEIMPORTANCEOFCONTINUED
treatments to maximize results.
s 0ATIENTSANDCAREGIVERSVALUEANYDEGREEOFBENElTFROM("/4
highly. An improvement that may appear small on a standard
measure of motor, language, or cognitive function can have a
very large impact on caregiver burden and quality of life.
289
Part Five
Mind-Body Medicine
Chapter 41
Mind-Body Medicine:
An Overview
Mind-body medicine focuses on the interactions among the brain,

mind, body, and behavior, and the powerful ways in which emotional,
mental, social, spiritual, and behavioral factors can directly affect
health. It regards as fundamental an approach that respects and en-
hances each persons capacity for self-knowledge and self-care, and it
emphasizes techniques that are grounded in this approach.
Denition of Scope of Field

Mind-body medicine typically focuses on intervention strate-
gies that are thought to promote health, such as relaxation, hypno-
sis, visual imagery, meditation, yoga, biofeedback, tai chi, qi gong,
cognitive-behavioral therapies, group support, autogenic training,
and spirituality. The eld views illness as an opportunity for personal
growth and transformation, and health care providers as catalysts and
guides in this process.
Mind-body interventions constitute a major portion of the overall
use of CAM by the public. In 2002, ve relaxation techniques and im-
agery, biofeedback, and hypnosis, taken together, were used by more
than 30 percent of the adult U.S. population. Prayer was used by more
than 50 percent of the population.
Excerpted from Mind-Body Medicine: An Overview, by the National Center

the National Institutes of Health, May 2007.
293
Background
The concept that the mind is important in the treatment of illness is
integral to the healing approaches of traditional Chinese and Ayurvedic
medicine, dating back more than 2,000 years. It was also noted by Hip-
pocrates, who recognized the moral and spiritual aspects of healing, and
believed that treatment could occur only with consideration of attitude,
environmental inuences, and natural remedies (ca. 400 BC). While this
integrated approach was maintained in traditional healing systems in the
East, developments in the Western world by the 16th and 17th centuries
led to a separation of human spiritual or emotional dimensions from the
physical body. This separation began with the redirection of science, dur-
ing the Renaissance and Enlightenment eras, to the purpose of enhancing
humankinds control over nature. Technological advances (e.g., microscopy,
the stethoscope, the blood pressure cuff, and rened surgical techniques)
demonstrated a cellular world that seemed far apart from the world of
belief and emotion. The discovery of bacteria and, later, antibiotics further
dispelled the notion of belief inuencing health. Fixing or curing an illness
became a matter of science (i.e., technology) and took precedence over, not
a place beside, healing of the soul. As medicine separated the mind and
the body, scientists of the mind (neurologists) formulated concepts, such
as the unconscious, emotional impulses, and cognitive delusions, that
solidied the perception that diseases of the mind were not real, that
is, not based in physiology and biochemistry.
In the 1920s, Walter Cannons work revealed the direct relation-
ship between stress and neuroendocrine responses in animals. Coining
the phrase ght or ight, Cannon described the primitive reexes of
sympathetic and adrenal activation in response to perceived danger
and other environmental pressures (e.g., cold, heat). Hans Selye fur-
ther dened the deleterious effects of stress and distress on health. At
the same time, technological advances in medicine that could identify
specic pathological changes, and new discoveries in pharmaceuticals,
were occurring at a very rapid pace. The disease-based model, the search
for a specic pathology, and the identication of external cures were
paramount, even in psychiatry.
During World War II, the importance of belief reentered the web of
health care. On the beaches of Anzio, morphine for the wounded soldiers
was in short supply, and Henry Beecher, MD, discovered that much of the
pain could be controlled by saline injections. He coined the term placebo
effect, and his subsequent research showed that up to 35 percent of a
therapeutic response to any medical treatment could be the result of belief.
Investigation into the placebo effect and debate about it are ongoing.
294
Mind-Body Medicine: An Overview
Since the 1960s, mind-body interactions have become an exten-

sively researched eld. The evidence for benets for certain indications
from biofeedback, cognitive-behavioral interventions, and hypnosis is
quite good, while there is emerging evidence regarding their physi-
ological effects.
Less research supports the use of CAM approaches like meditation
and yoga. The following is a summary of relevant studies.
Mind-Body Interventions and Disease Outcomes

Over the past 20 years, mind-body medicine has provided consider-
able evidence that psychological factors can play a substantive role in
the development and progression of coronary artery disease. There is
evidence that mind-body interventions can be effective in the treat-
ment of coronary artery disease, enhancing the effect of standard car-
diac rehabilitation in reducing all-cause mortality and cardiac event
recurrences for up to 2 years.
Mind-body interventions have also been applied to various types of
pain. Clinical trials indicate that these interventions may be a particu-
larly effective adjunct in the management of arthritis, with reductions
in pain maintained for up to 4 years and reductions in the number of
physician visits. When applied to more general acute and chronic pain
management, headache, and low-back pain, mind-body interventions
show some evidence of effects, although results vary based on the
patient population and type of intervention studied.
Evidence from multiple studies with various types of cancer patients
suggests that mind-body interventions can improve mood, quality of
life, and coping, as well as ameliorate disease- and treatment-related
symptoms, such as chemotherapy-induced nausea, vomiting, and pain.
Some studies have suggested that mind-body interventions can alter
various immune parameters, but it is unclear whether these altera-
tions are of sufcient magnitude to have an impact on disease progres-
sion or prognosis.
Mind-Body Inuences on Immunity

There is considerable evidence that emotional traits, both negative
and positive, inuence peoples susceptibility to infection. Following
systematic exposure to a respiratory virus in the laboratory, individu-
als who report higher levels of stress or negative moods have been
shown to develop more severe illness than those who report less stress
or more positive moods. Recent studies suggest that the tendency to
295
report positive, as opposed to negative, emotions may be associated

with greater resistance to objectively veried colds. These laboratory
studies are supported by longitudinal studies pointing to associations
between psychological or emotional traits and the incidence of respi-
ratory infections.
Meditation and Imaging

Meditation, one of the most common mind-body interventions, is
a conscious mental process that induces a set of integrated physi-
ological changes termed the relaxation response. Functional magnetic
resonance imaging (fMRI) has been used to identify and characterize
the brain regions that are active during meditation. This research
suggests that various parts of the brain known to be involved in
attention and in the control of the autonomic nervous system are
activated, providing a neurochemical and anatomical basis for the
effects of meditation on various physiological activities. Recent stud-
ies involving imaging are advancing the understanding of mind-body
mechanisms. For example, meditation has been shown in one study
to produce signicant increases in left-sided anterior brain activ-
ity, which is associated with positive emotional states. Moreover, in
this same study, meditation was associated with increases in anti-
body titers to inuenza vaccine, suggesting potential linkages among
meditation, positive emotional states, localized brain responses, and
improved immune function.
Physiology of Expectancy (Placebo Response)

Placebo effects are believed to be mediated by both cognitive and
conditioning mechanisms. Until recently, little was known about the
role of these mechanisms in different circumstances. Now, research
has shown that placebo responses are mediated by conditioning when
unconscious physiological functions such as hormonal secretion are
involved, whereas they are mediated by expectation when conscious
physiological processes such as pain and motor performance come into
play, even though a conditioning procedure is carried out.
Positron emission tomography (PET) scanning of the brain is pro-
viding evidence of the release of the endogenous neurotransmitter
dopamine in the brain of Parkinson disease patients in response to
placebo. Evidence indicates that the placebo effect in these patients
is powerful and is mediated through activation of the nigrostriatal
dopamine system, the system that is damaged in Parkinson disease.
296
Mind-Body Medicine: An Overview
This result suggests that the placebo response involves the secretion
of dopamine, which is known to be important in a number of other re-
inforcing and rewarding conditions, and that there may be mind-body
strategies that could be used in patients with Parkinson disease in lieu
of or in addition to treatment with dopamine-releasing drugs.
Stress and Wound Healing

Individual differences in wound healing have long been recognized.
Clinical observation has suggested that negative mood or stress is as-
sociated with slow wound healing. Basic mind-body research is now
conrming this observation. Matrix metalloproteinases (MMPs) and
the tissue inhibitors of metalloproteinases (TIMPs), whose expression
can be controlled by cytokines, play a role in wound healing. Using a
blister chamber wound model on human forearm skin exposed to ul-
traviolet light, researchers have demonstrated that stress or a change
in mood is sufcient to modulate MMP and TIMP expression and,
presumably, wound healing. Activation of the hypothalamic-pituitary-
adrenal (HPA) and sympathetic-adrenal medullary (SAM) systems can
modulate levels of MMPs, providing a physiological link among mood,
stress, hormones, and wound healing. This line of basic research sug-
gests that activation of the HPA and SAM axes, even in individuals
within the normal range of depressive symptoms, could alter MMP
levels and change the course of wound healing in blister wounds.
Surgical Preparation
Mind-body interventions are being tested to determine whether
they can help prepare patients for the stress associated with surgery.
Initial randomized controlled trialsin which some patients received
audiotapes with mind-body techniques (guided imagery, music, and
instructions for improved outcomes) and some patients received con-
trol tapesfound that subjects receiving the mind-body intervention
recovered more quickly and spent fewer days in the hospital.
Behavioral interventions have been shown to be an efcient means
of reducing discomfort and adverse effects during percutaneous vas-
cular and renal procedures. Pain increased linearly with procedure
time in a control group and in a group practicing structured attention,
but remained at in a group practicing a self-hypnosis technique. The
self-administration of analgesic drugs was signicantly higher in the
control group than in the attention and hypnosis groups. Hypnosis
also improved hemodynamic stability.
297
Conclusion
Evidence from randomized controlled trials and, in many cases,
systematic reviews of the literature, suggest the following:
s -ECHANISMSMAYEXISTBYWHICHTHEBRAINANDCENTRALNERVOUS
system inuence immune, endocrine, and autonomic functioning,
which is known to have an impact on health.
s -ULTICOMPONENTMIND BODYINTERVENTIONSTHATINCLUDE
some combination of stress management, coping skills train-
ing, cognitive-behavioral interventions, and relaxation therapy
may be appropriate adjunctive treatments for coronary artery
disease and certain pain-related disorders, such as arthritis.
s -ULTIMODALMIND BODYAPPROACHESSUCHASCOGNITIVE BEHAVIORAL
therapy, particularly when combined with an educational/infor-
mational component, can be effective adjuncts in the manage-
ment of a variety of chronic conditions.
s !NARRAYOFMIND BODYTHERAPIESEGIMAGERYHYPNOSISRELAX-
ation), when employed presurgically, may improve recovery time
and reduce pain following surgical procedures.
s .EUROCHEMICALANDANATOMICALBASESMAYEXISTFORSOMEOFTHE
effects of mind-body approaches.
Mind-body approaches have potential benets and advantages. In

particular, the physical and emotional risks of using these interventions
are minimal. Moreover, once tested and standardized, most mind-body
interventions can be taught easily. Finally, future research focusing on
basic mind-body mechanisms and individual differences in responses
is likely to yield new insights that may enhance the effectiveness and
individual tailoring of mind-body interventions. In the meantime, there
is considerable evidence that mind-body interventions, even as they are
being studied today, have positive effects on psychological functioning
and quality of life, and may be particularly helpful for patients coping
with chronic illness and in need of palliative care.
298
Chapter 42
Art Therapy
Art therapy is the therapeutic use of art making, within a pro-

fessional relationship, by people who experience illness, trauma, or
challenges in living, and by people who seek personal development.
Through creating art and reecting on the art products and processes,
people can increase awareness of self and others; cope with symptoms,
stress, and traumatic experiences; enhance cognitive abilities; and
enjoy the life-afrming pleasures of making art.
Art therapists are professionals trained in both art and therapy.
They are knowledgeable about human development, psychological the-
ories, clinical practice, spiritual, multicultural, and artistic traditions,
and the healing potential of art. They use art in treatment, assess-
ment, and research, and provide consultations to allied profession-
als. Art therapists work with people of all ages: individuals, couples,
families, groups, and communities. They provide services, individually
and as part of clinical teams, in settings that include mental health,
rehabilitation, medical, and forensic institutions; community outreach
programs; wellness centers; schools; nursing homes; corporate struc-
tures; open studios and independent practices.
The American Art Therapy Association encourages educational,
professional, and ethical standards for its members. The Art Therapy
Credentials Board, Inc. (ATCB), an independent organization, grants
art therapy credentials based on educational attainment.
About Art Therapy, 2009 American Art Therapy Association (www.american

arttherapyassociation.org). Reprinted with permission.
299
s 2EGISTRATION!42;2EGISTERED!RT4HERAPIST= ISGRANTEDUPON
completion of graduate education and post-graduate supervised
experience.
s "OARD#ERTIlCATION!42 "# ISGRANTEDTO2EGISTERED!RT
Therapists who pass a written examination, and is maintained
through continuing education.
s 3OMESTATESREGULATETHEPRACTICEOFARTTHERAPYANDINMANY
states art therapists can become licensed as counselors or men-
tal health therapists.
Dening Art Therapy

Art therapy is a mental health profession that uses the creative
process of art making to improve and enhance the physical, mental,
and emotional well-being of individuals of all ages. It is based on the
belief that the creative process involved in artistic self-expression
helps people to resolve conicts and problems, develop interpersonal
skills, manage behavior, reduce stress, increase self-esteem and self-
awareness, and achieve insight.
Art therapy integrates the elds of human development, visual art
(drawing, painting, sculpture, and other art forms), and the creative
process with models of counseling and psychotherapy. Art therapy is
used with children, adolescents, adults, older adults, groups, and fami-
lies to assess and treat the following: anxiety, depression, and other
mental and emotional problems and disorders; substance abuse and
other addictions; family and relationship issues; abuse and domestic
violence; social and emotional difculties related to disability and ill-
ness; trauma and loss; physical, cognitive, and neurological problems;
and psychosocial difculties related to medical illness. Art therapy
programs are found in a number of settings including hospitals, clinics,
public and community agencies, wellness centers, educational institu-
tions, businesses, and private practices.
Art therapists are masters level professionals who hold a degree
in art therapy or a related eld. Educational requirements include:
theories of art therapy, counseling, and psychotherapy; ethics and
standards of practice; assessment and evaluation; individual, group,
and family techniques; human and creative development; multicul-
tural issues; research methods; and practicum experiences in clinical,
community, and/or other settings. Art therapists are skilled in the ap-
plication of a variety of art modalities (drawing, painting, sculpture,
and other media) for assessment and treatment.
300
Art Therapy
Frequently Asked Questions

How did art therapy begin?
Visual expression has been used for healing throughout history, but
art therapy did not emerge as a distinct profession until the 1940s. In
the early 20th century, psychiatrists became interested in the artwork
created by their patients with mental illness. At around the same time,
educators were discovering that childrens art expressions reected
developmental, emotional, and cognitive growth. By mid-century, hos-
pitals, clinics, and rehabilitation centers increasingly began to in-
clude art therapy programs along with traditional talk therapies,
underscoring the recognition that the creative process of art making
enhanced recovery, health, and wellness. As a result, the profession
of art therapy grew into an effective and important method of com-
munication, assessment, and treatment with children and adults in a
variety of settings. Currently, the eld of art therapy has gained atten-
tion in health-care facilities throughout the United States and within
psychiatry, psychology, counseling, education, and the arts.
Where do art therapists work?

Art therapists work in a wide variety of settings, including, but not
limited to, the following:
s (OSPITALSANDCLINICSBOTHMEDICALANDPSYCHIATRIC
s /UTPATIENTMENTALHEALTHAGENCIESANDDAYTREATMENTFACILITIES
s 2ESIDENTIALTREATMENTCENTERS
s (ALFWAYHOUSES
s $OMESTICVIOLENCEANDHOMELESSSHELTERS
s #OMMUNITYAGENCIESANDNON PROlTSETTINGS
s 3HELTEREDWORKSHOPS
s 3CHOOLSCOLLEGESANDUNIVERSITIES
s #ORRECTIONALFACILITIES
s %LDERCAREFACILITIES
s !RTSTUDIOS
s 0RIVATEPRACTICE
An art therapist may work as part of a team that includes physi-

cians, psychologists, nurses, mental health counselors, marriage and
family therapists, rehabilitation counselors, social workers, and teachers.
301
Together, they determine and implement a clients therapeutic goals

and objectives. Other art therapists work independently and maintain
private practices with children, adolescents, adults, groups, and/or
families.
What are the requirements to become an art therapist?

Personal qualications: An art therapist must have sensitivity, em-
pathy, emotional stability, patience, interpersonal skills, insight into hu-
man behavior, and an understanding of art media. An art therapist must
also be an attentive listener and a keen observer. Flexibility and a sense
of humor are important in adapting to client needs and work setting.
Educational requirements: One must complete the required

core curriculum as outlined in the American Art Therapy Associations
Education Standards to qualify as a professional art therapist. Entry
into the profession of art therapy is at the masters level. Graduate
level art therapy programs include:
s MASTERSDEGREEINARTTHERAPY
s MASTERSDEGREEWITHANEMPHASISINARTTHERAPY
s TWENTY FOUR SEMESTERUNITSINARTTHERAPYCOURSEWORKWITH
a masters degree in a related eld.
Contact the National Ofce for more information concerning current

educational requirements and programs.
;3EEWWWAMERICANARTTHERAPYASSOCIATIONORGFORCONTACTINFORMATION=
Registration and Board Certication Requirements: The ATR and
ATR-BC are the recognized standards for the eld of art therapy, and
are conferred by the Art Therapy Credentials Board (ATCB). In order
to qualify as a registered art therapist (ATR), in addition to the educa-
tional requirements, an individual must complete a minimum of 1,000
direct client contact hours after graduation. One hour of supervision
is required for every 10 hours of client contact.
302
Chapter 43
Biofeedback
What is biofeedback?
Biofeedback is a mind-body technique using electronic instruments
to help individuals gain awareness and control over their body and
mind. Biofeedback instruments measure muscle activity, skin tem-
perature, electrodermal activity, respiration, heart rate, blood pressure,
brain electrical activity, and brain blood ow. Biofeedback is useful
in medical care, mental health treatment, physical and occupational
therapy, dental care, and education.
When is biofeedback appropriate? Who should seek it and

when?
Biofeedback is a useful self-help tool that can benet almost every
living human being. Biofeedback is a pathway to learning important vol-
untary control skills that are useful throughout life. Biofeedback enables
individuals to increase bodily awareness, acquire relaxation skills, and
gain control over a variety of organ systems in the body. Many persons feel
encouraged and empowered by biofeedback. After gaining control over
their body they feel more capable of gaining control over their lives.
Biofeedback: Consumer Questions Answered, by Donald Moss, PhD, 2002. As-

sociation for Applied Psychophysiology and Biofeedback (www.aapb.org). Reprinted
with permission. The text that follows this document under the heading Health
Reference Series Medical Advisors Notes and Updates was provided to Omnigraph-
ics, Inc. by David A. Cooke, MD, FACP, January 23, 2010. Dr. Cooke is not afliated
with the Association for Applied Psychophysiology and Biofeedback.
303
Anyone who is suffering from life stress and anxiety can benet
from biofeedback strategies for physical and mental relaxation. Any-
one suffering from medical problems that are caused or aggravated
by stress will benet from biofeedback. In addition, individuals with
many organic medical problems, such as spinal injury related motor
control problems, may nd that biofeedback helps them compensate
for their medical condition and function better.
What are some of the most common uses for biofeedback?

Research shows that biofeedback can benet individuals with a
broad range of mental health and medical problems, including:
s ALCOHOLISMANDADDICTIONS
s ANXIETY
s ASTHMA
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s CLOSEDHEADINJURY
s DEPRESSION
s DIABETESMELLITUS
s ENURESIS
s EPILEPSY
s ESSENTIALHYPERTENSION
s HEADACHEMIGRAINE
s HEADACHETENSION
s INCONTINENCEFECALANDURINARY
s INSOMNIA
s IRRITABLEBOWELSYNDROME
s LEARNINGDISABILITIES
s MOTIONSICKNESS
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tendon transfers, torticollis, cerebral palsy, peripheral nerve
problems, spasm);
s PAINMYOFASCIAL
s PAINRHEUMATOIDARTHRITIS
s PAINTEMPOROMANDIBULARDYSFUNCTION
304
Biofeedback
s 2AYNAUDSSYNDROMEANDDISEASE
s SLEEPDISORDERS
s STROKE
How does it work and what are the benets?

Biofeedback teaches human beings to recognize the link between
their bodies and minds. The biofeedback instrument monitors one
bodily system (like a muscle) and gives the individual immediate feed-
back when the body changes. This increases personal awareness of the
bodily process, which leads to control over the body.
The rst level of benet most people encounter is improved relax-
ation of the entire bodyreversing the effects of stress on the body.
The second level of benet is ongoing reduction in everyday ten-
sions and anxieties.
The third level of benet is relief from specic medical and mental
health problems. There are biofeedback treatments for the emotional disor-
ders, attention decit, alcoholism, and a wide range of medical problems.
The fourth level of benet is a growing sense of personal power and
condence, a feeling that I can learn skills which make a difference
in my life.
What do people need to know about biofeedback before

pursuing it? What information do they need?
It helps to learn about the idea of biofeedback, and to understand
how it works, by reading a book chapter about biofeedback, such as those
listed in the References portion of text. Then the individual should care-
fully identify a competent well-trained biofeedback professional.
What are some of the misconceptions that people have

about biofeedback that need to be cleared up?
Some persons are afraid that biofeedback will do something harm-
ful to them. Biofeedback is only a tool to enable the individual to gain
control over his or her own body and mind. The instruments measure
your bodily processes, and provide feedback to you. The instruments
do not actively do anything to your body.
The second myth is that biofeedback will replace all need for medi-
cal treatment or medication. Many medical problems are complex, and
a combination of traditional medical care with biofeedback is often
more effective than biofeedback alone. This is true for headaches and
hypertension, for instance.
305
How should a person select a biofeedback practitioner?

What criteria should a person use in the selection process?
I recommend asking the biofeedback practitioner several questions,
before committing to the treatment process:
s Are you certied by the Biofeedback Certication In-
stitute of America (BCIA)? BCIA has excellent standards
for the knowledge and skills a biofeedback practitioner should
have. Therapists must accumulate educational credit, practical
supervised experience, and pass an exam. Therapists should
learn about biofeedback through college classes, approved train-
ing workshops, extensive reading, and supervised training and
practice. The BCIA certication tells the patient that this thera-
pist has done all of these things.
s What state and national biofeedback organizations do
you belong to, and what state and national conferences
or biofeedback training workshops have you attended in
the past two years? Competent professionals belong to profes-
sional societies and attend meetings in order to keep their skills
and knowledge current.
s What journals and newsmagazines do you subscribe to in
order to keep up with progress in biofeedback treatment?
Again, competent professionals keep their knowledge current by
reading current reports.
s Are you licensed or certied for independent practice as
a health care provider in this state? Biofeedback profession-
als usually are also licensed within a profession, such as medi-
cine, psychology, nursing, or physical therapy.
Once biofeedback is used for the control of migraine

headaches or some other health problem does the person
need maintenance sessions of any kind, or will they need to
repeat the entire treatment process again and again?
Most patients learn skills that continue to work for them for a
lifetime. That is the beauty of biofeedback. Medicines for psychiatric
or medical problems often work only until you stop them. Biofeedback
teaches self-control skills that one can use over and over for new prob-
lems that arise in life.
Some persons periodically return for additional biofeedback sessions
to brush up their skills. Dr. Joel Lubar, who developed the biofeedback
306
Biofeedback
treatment for ADHD, reports that most of his patients function for
years with improved attention, and only occasionally come back for a
short refresher course. Some problems, like migraine headache, may
require extensive additional treatment at various times in life.
Is biofeedback something people can do on their own? If so,

how is it best learned?
It is easier to learn biofeedback through treatment with a qualied
professional. There are many related self-help skills that one can learn
on ones own, such as progressive muscle relaxation, autogenic training,
and meditation. Relaxation and meditation classes and workbooks are
inexpensive ways to gain these skills.
There are several biofeedback systems being developed for patient
self-education or for home training in between biofeedback therapy ses-
sions. For example, the Heart Math company has a trainer unit that
patients can use to train themselves in cardiovascular relaxation. The
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trainer, for patients to use with children with attention problems.
What is a visit to a biofeedback practitioner like? What

should a person expect and should they do anything to
prepare?
The treatment should begin with a clinical interview, in which the
therapist learns all about the patients life, family, work, sources of
stress, coping skills, and medical and emotional problems. Biofeedback
is a holistic mind-body therapy, meaning that biofeedback practitio-
ners see any illness or problem as involving the whole person. So one
must begin by getting to know the person who has the illness.
Next the therapist will do a biofeedback evaluation (also called a
psychophysiological stress prole), to identify the patients unique
stress response. The interview and biofeedback evaluation are used
to design the treatment.
No preparation is necessary prior to the rst interview, although
it helps to prepare a written timeline showing the onset and progres-
sion of ones symptoms, along with important life events in the same
time period.
How many sessions are needed and generally what is the cost?
The length of treatment varies depending on the presenting prob-
lem. For most mental health problems and many medical problems
307
eight to 12 sessions can provide excellent results. For some prob-

lems like epilepsy, alcoholism, or attention decit, frequent and
lengthy treatment is necessary: two to three sessions a week for
3060 sessions.
Costs vary around the country, and are higher in urban areas. Half-
hour training sessions can cost from $30 to $75. One-hour sessions
range from $60 to $150.
Has there been any scientic research to support the use of

biofeedback as a treatment method? If so, how can one nd
such research?
Yes, there is extensive scientic evidence proving the effectiveness
of biofeedback. See the References portion of text for books and book
chapters reviewing research on biofeedback treatment. AAPB also
publishes a booklet summarizing the research showing that biofeed-
back is effective for many disorders (Shellenberger, Amar, Schneider,
& Turner, 1994).
References
Lawlis, G.F. (2001). Biofeedback (pp. 196224). In L.W. Freeman, &
G.F. Lawlis (2001). Mosbys Complementary and alternative medi-
cine: A research based approach. St. Louis, MO: Mosby.
Moss, D. (2001). Biofeedback. In S. Shannon (Ed.), Handbook of

complementary medicine in mental health. San Diego, CA: Academic
Press.
Moss, D., Wickramasekera, I., McGrady, A., & Davies, T. (Eds.).

(2003). Handbook of mind-body medicine in primary care: Be-
havioral and physiological tools. Thousand Oaks, CA: Sage
Publications.
Schwartz, M. & Associates. (2nd edition, 1995). Biofeedback: A prac-

titioners guide. NY: Guilford.
Schwartz, M., & Andrasik, F. (3rd edition, 2003). Biofeedback: A

practitioners guide. NY: Guilford.
Shellenberger, R., Amar, P., Schneider., P., & Turner, J. (1994). Clini-
cal efcacy and cost effectiveness of biofeedback therapy. Guidelines
for third party reimbursement. Wheat Ridge, Co.: Association for Ap-
plied Psychophysiology and Biofeedback.
308
Biofeedback
Health Reference Series Medical Advisors Notes and

Updates
There is a great deal of variation in the strength and quality of
the evidence supporting the use of biofeedback for the above listed
disorders. While there is fairly good scientic support for some uses,
the data supporting others are questionable. Additional research is
needed to fairly evaluate which disorders benet from biofeedback
and to what degree.
309
Chapter 44
Deep Breathing Exercises
Cancer pain can be managed effectively in most patients with can-

cer or with a history of cancer. Although cancer pain cannot always
be relieved completely, therapy can lessen pain in most patients. Pain
management improves the patients quality of life throughout all stag-
es of the disease.
Flexibility is important in managing cancer pain. As patients vary
in diagnosis, stage of disease, responses to pain and treatments, and
personal likes and dislikes, management of cancer pain must be in-
dividualized. Patients, their families, and their health care providers
must work together closely to manage a patients pain effectively.
Physical and Psychosocial Interventions

Noninvasive physical and psychological methods can be used along
with drugs and other treatments to manage pain during all phases of
cancer treatment. The effectiveness of the pain interventions depends
on the patients participation in treatment and his or her ability to tell
the health care provider which methods work best to relieve pain.
Physical Interventions
Weakness, muscle wasting, and muscle/bone pain may be treated
with heat (a hot pack or heating pad); cold (exible ice packs); massage,
Excerpted from PDQ Cancer Information Summary. National Cancer Insti-

tute; Bethesda, MD. Pain (PDQ): Supportive CarePatient. Updated 02/2009.
Available at http://cancer.gov. Accessed January 7, 2009.
311
pressure, and vibration (to improve relaxation); exercise (to strengthen

weak muscles, loosen stiff joints, help restore coordination and bal-
ance, and strengthen the heart); changing the position of the patient;
restricting the movement of painful areas or broken bones; stimulation;
controlled low-voltage electrical stimulation; or acupuncture.
Thinking and Behavioral Interventions

Thinking and behavior interventions are also important in treating
pain. These interventions help give patients a sense of control and help
them develop coping skills to deal with the disease and its symptoms.
Beginning these interventions early in the course of the disease is use-
ful so that patients can learn and practice the skills while they have
enough strength and energy. Several methods should be tried, and one
or more should be used regularly.
s Relaxation and imagery: Simple relaxation techniques may
be used for episodes of brief pain (for example, during cancer
treatment procedures). Brief, simple techniques are suitable for
periods when the patients ability to concentrate is limited by
severe pain, high anxiety, or fatigue.
s Hypnosis: Hypnotic techniques may be used to encourage relax-
ation and may be combined with other thinking/behavior meth-
ods. Hypnosis is effective in relieving pain in people who are able
to concentrate and use imagery and who are willing to practice
the technique.
s Redirecting thinking: Focusing attention on triggers other than
pain or negative emotions that come with pain may involve distrac-
tions that are internal (for example, counting, praying, or saying
things like I can cope) or external (for example, music, television,
talking, listening to someone read, or looking at something specic).
Patients can also learn to monitor and evaluate negative thoughts
and replace them with more positive thoughts and images.
s Patient education: Health care providers can give patients
and their families information and instructions about pain and
pain management and assure them that most pain can be con-
trolled effectively. Health care providers should also discuss the
major barriers that interfere with effective pain management.
s Psychological support: Short-term psychological therapy
helps some patients. Patients who develop clinical depression or
adjustment disorder may see a psychiatrist for diagnosis.
312
s Support groups and religious counseling: Support groups

help many patients. Religious counseling may also help by pro-
viding spiritual care and social support.
Relaxation Exercises
The following relaxation exercises may be helpful in relieving pain.
Exercise 1: Slow Rhythmic Breathing for Relaxation*

1. Breathe in slowly and deeply, keeping your stomach and
shoulders relaxed.
2. As you breathe out slowly, feel yourself beginning to relax; feel
the tension leaving your body.
3. Breathe in and out slowly and regularly at a comfortable rate.
Let the breath come all the way down to your stomach, as it
completely relaxes.
4. To help you focus on your breathing and to breathe slowly
and rhythmically: Breathe in as you say silently to yourself,
in, two, three or each time you breathe out, say silently to
yourself a word such as peace or relax.
5. Do steps 1 through 4 only once or repeat steps 3 and 4 for up
to 20 minutes.
6. End with a slow deep breath. As you breathe out say to
yourself, I feel alert and relaxed.
Exercise 2: Simple Touch, Massage, or Warmth for

Relaxation*
Touch and massage are traditional methods of helping others relax.
Some examples include the following:
s "RIEFTOUCHORMASSAGESUCHASHANDHOLDINGORBRIEmYTOUCHING
or rubbing a persons shoulders, can help relax the patient.
s 3OAKINGFEETINABASINOFWARMWATERORWRAPPINGTHEFEETINA
warm, wet towel can be relaxing.
s -ASSAGETOMINUTES OFTHEWHOLEBODYORJUSTTHEBACK
feet, or hands. If the patient is modest or cannot move or turn
easily in bed, consider massage of the hands and feet.
313
s 5SEAWARMLUBRICANT!SMALLBOWLOFHANDLOTIONMAYBE
warmed in the microwave oven or a bottle of lotion may be
warmed in a sink of hot water for about 10 minutes.
s -ASSAGEFORRELAXATIONISUSUALLYDONEWITHSMOOTHLONGSLOW
strokes. Try several degrees of pressure along with different types
of massage, such as kneading and stroking, to determine which
is preferred.
Especially for the elderly person, a back rub that effectively pro-
duces relaxation may consist of no more than 3 minutes of slow,
rhythmic stroking (about 60 strokes per minute) on both sides of the
spine, from the crown of the head to the lower back. Continuous hand
contact is maintained by starting one hand down the back as the
other hand stops at the lower back and is raised. Set aside a regular
time for the massage. This gives the patient something pleasant to
anticipate.
Exercise 3: Peaceful Past Experiences*

Something may have happened to you a while ago that brought you
peace or comfort. You may be able to draw on that experience to bring
you peace or comfort now. Think about these questions:
s #ANYOUREMEMBERANYSITUATIONEVENWHENYOUWEREACHILD
when you felt calm, peaceful, secure, hopeful, or comfortable?
s (AVEYOUEVERDAYDREAMEDABOUTSOMETHINGPEACEFUL7HAT
were you thinking?
s $OYOUGETADREAMYFEELINGWHENYOULISTENTOMUSIC$OYOU
have any favorite music?
s $OYOUHAVEANYFAVORITEPOETRYTHATYOUlNDUPLIFTINGOR
reassuring?
s Have you ever been active religiously? Do you have favorite
readings, hymns, or prayers? Even if you havent heard or thought
of them for many years, childhood religious experiences may still
be very soothing.
Additional points: Some of the things that may comfort you, such as
your favorite music or a prayer, can probably be recorded for you. Then
you can listen to the tape whenever you wish. Or, if your memory is
strong, you may simply close your eyes and recall the events or words.
314
Exercise 4: Active Listening to Recorded Music*

1. Obtain the following:
s !N-0#$ORTAPEPLAYER3MALLBATTERY OPERATEDONES
are more convenient.)
s %ARPHONESORAHEADSET(ELPSFOCUSTHEATTENTIONBETTERTHAN
a speaker a few feet away, and avoids disturbing others.)
s -USICYOULIKE-OSTPEOPLEPREFERFASTLIVELYMUSICBUT
some select relaxing music. Other options are comedy rou-
tines, sporting events, old radio shows, or stories.)
2. Mark time to the music; for example, tap out the rhythm with
your nger or nod your head. This helps you concentrate on
the music rather than on your discomfort.
3. Keep your eyes open and focus on a xed spot or object. If you
wish to close your eyes, picture something about the music.
4. Listen to the music at a comfortable volume. If the discomfort
increases, try increasing the volume; decrease the volume
when the discomfort decreases.
5. If this is not effective enough, try adding or changing one or
more of the following: Massage your body in rhythm to the mu-
sic; try other music; or mark time to the music in more than one
manner, such as tapping your foot and nger at the same time.
Additional points: Many patients have found this technique to be

helpful. It tends to be very popular, probably because the equipment is
usually readily available and is a part of daily life. Other advantages
are that it is easy to learn and not physically or mentally demanding.
If you are very tired, you may simply listen to the music and omit
marking time or focusing on a spot.
*Note: Adapted and reprinted with permission from McCaffery M,
Beebe A: Pain: Clinical Manual for Nursing Practice. St. Louis, Mo:
CV Mosby: 1989.
315
Chapter 45
Feng Shui
What Is It?
Feng shui is the study of how humans interact with their environ-
ment. More specically feng shui is all about creating an atmosphere
in buildings in which the people who use them can best succeed. Feng
shui is based on the premise that human beings contain and are sur-
rounded by a subtle eld of electromagnetic energy known as chi in
China. This can be photographed using Kirlian Photography and looks
like a multi colored gas ame around any living creature. In humans
the color and shape changes depending on emotional responses, so this
energy can be said to contain some of a persons emotional energy.
In China this energy is called chi and chi is widely used in most
traditional oriental humanistic pursuits; including acupuncture, chi
GONG;QIGONG=SHIATSU2EIKIMARTIALARTSANDFENGSHUI4HEIDEAIN
feng shui is that each building has its own atmospheric chi and that
this energy will inuence the chi energy eld around the human body.
Once a person interacts with the energy of a building he or she will
begin to feel different.
How Does It Work?

The principle behind feng shui is that your own chi carries your
thoughts and emotions around and through your body and that if
Feng Shui Principles, 2006 ChiEnergy (http://chienergy.co.uk). Re-
printed with permission. For additional information about feng shui, visit http://
chienergy.co.uk/freeinformation_fs.htm.
317
something changes your chi you will nd that you feel and think differ-
ently. Each building has its own atmosphere and this energy will inuence
your own chi energy eld. For example you will feel different standing in
a large empty cathedral and sitting in a small crowded cafe.
The aim of modern feng shui is to create buildings in which people
will be able to best succeed in that environment. Therefore the only
question a feng shui consultant will be interested in is how will people
who use the space feel whilst they are there and what kind of human
feelings will best help each person succeed.
What Do You Want?

When using feng shui it is helpful to know what you want from
life, what you could change about yourself to achieve it more easily
and then how you can set up your home or work space so that you feel
better able to make those changes. For example if you wanted to get a
promotion but felt you needed to be more outgoing and expressive to
achieve that you would need to set up the spaces you spent most time
so that the atmosphere brought out those aspects of your character
more. In this feng shui example bright colors, mirrors, plants, up light-
ing, and sunshine would help.
In addition to looking at the way people react with their buildings
feng shui examines the relationship between buildings and their en-
vironment. The way a building is exposed to sunlight is a prime factor
as the suns solar radiation alters the atmosphere in different parts of
a building. The local terrain, water, earths magnetic eld, earth ener-
gies, and nearby buildings will all contribute to dening how a new
building can best harmonize with its environment and harness this
to improve the internal feng shui atmosphere.
Feng Shui at Work

To give people the best opportunity to fulll their potential it is
important to look at the kind of work that is done and think through
what atmosphere would encourage the kind of emotions that bring
success. For example someone who is dealing with complaints will
need to be patient, sensitive, diplomatic, and understanding. So here
a softer feng shui work environment with pastel colors and curved
forms would be ideal.
Ofce environments can be set up so that people feel empowered
and best able to master the work required. Most important in this situ-
ation is the seating position relative to the room. Feng shui principles
suggest staff would sit facing into the room in a way that he or she can
318
Feng Shui
see the door to the ofce and any windows. This means most of what
is happening in an ofce is going on in front of the person and he or
she can feel protected from behind by a wall.
Pollution, EMF (Electromagnetic Fields), and Noise

Potentially toxic fumes given off by the synthetic surface materials
and paints often pollute the modern ofce. In addition the electronic
equipment, computers, fax machines, and copiers tend to emit electro-
magnetic elds and this makes it harder to maintain good health and
concentration from a feng shui perspective. One way to combat ofce
pollution is to ll the space with plants. Healthy plants will clean the
air and reduce the inuence of the electrical equipment. In addition
plants have excellent properties for reducing sound.
319
Chapter 46
Guided Imagery
and Hypnosis
Chapter Contents
Section 46.1Guided Imagery................................................... 322
Section 46.2Hypnosis .............................................................. 324
321
Section 46.1
Guided Imagery
Guided Imagery, Center for Integrative Health and Healing. Reprinted with
permission. For additional information, visit www.cihh.net. The date of this
document is unknown. The text that follows this document under the heading
Health Reference Series Medical Advisors Notes and Updates was provided to
Omnigraphics, Inc. by David A. Cooke, MD, FACP, January 23, 2010. Dr. Cooke
is not afliated with the Center for Integrative Health and Healing.
Train your brain to improve your health. While that may sound
funny, its a powerful technique you can use to heal your body and
even prevent the onset of disease. Its called guided imagery and its a
remarkable trend in holistic medicine.
Who can benet?

Research has proven guided imagery to be helpful with the follow-
ing and more:
s 0OSTTRAUMATICSTRESSDISORDER043$
s ,OWERBLOODPRESSURE
s 2EDUCECHOLESTEROL
s 2EDUCEANXIETYANDDEPRESSION
s 3PEEDUPHEALINGFROMCUTSFRACTURESANDBURNS
s %NHANCEIMMUNEFUNCTION
s #ANCERPATIENTSUPPORT
s )RRITABLEBOWELSYNDROME)"3
s 2EDUCECHRONICPAINANDlBROMYALGIA
s 2EDUCELENGTHOFHOSPITALSTAYINPOSTOPERATIVEPATIENTS
s 2EDUCEALLERGICREACTIONS
What is guided imagery?

Guided imagery is a form of deliberate daydreaming; a mixture of
guided hypnosis and guided meditation. It utilizes both the power of
322
Guided Imagery and Hypnosis
ones imagination and suggestive words and phrases to evoke ones

memory and multi-sensory fantasies for the purpose of healing or
the development of a management strategy in the face of adverse
situations.
A meditative styled hypnosis, guided imagery is a gentle yet pow-
erful practice which is easy for most people to do and produces very
effective results. The only prerequisite is motivation.
How does guided imagery work?

Imagery works by sending healing images straight into ones brain
and nervous system by way of primitive, sensory pathways. Because
the route of travel of these messages goes to the right brain (non-
dominant brain) which feels, perceives, and senses as opposed to the
left brain which is busy judging, deciding, and analyzing, healing imag-
ery can be a very effective intervention tool for many diseases, stress,
and traumatic conditions.
Guided imagery easily supports other ongoing therapies and also
provides the patient his own powerful tool which grows more effective
with continued use.
Whats a guided imagery session like?

Initially, you will meet with the practitioner to discuss the personal
issues you wish to overcome using guided imagery before the actual
session occurs.
The 1-hour session takes place in a warm and tranquil room
where you can chose between sitting in a comfortable chair or ly-
ing down on a soft massage table. The practitioner dims the lights
and sits nearby.
Carefully selected music serves to enhance the imagery work by
subtly falling into the background of the therapeutic session while at
the same time promoting momentum for it.
The practitioner begins meditation and breath work to prepare you
for a relaxed state. The rst part of your session involves discovering
your sacred place from which you can feel utter safety. This sacred
place can be from a real or imagined memory. From this inner protec-
tive sanctuary, healing images are evoked.
With the practitioners guidance, these powerful healing images
interact with the symptom image to reduce or eliminate its effects.
The second and third sessions further develop and attune these skills
for continued independent use.
323

Updates
Use of guided imagery for problems listed in the Who can ben-
et? section and others remains quite controversial. Different studies
have produced conicting results, some showing benets and others
no effect. Many of these conditions are difcult to measure and may
naturally vary over time, so the reliability of the data is questionable.
Many experts feel that the effectiveness of guided imagery is neither
proven nor disproved at this point.
Section 46.2
Hypnosis
Hypnosis Today: Looking beyond the media portrayal, American Psycho-
logical Association Position Paper (2008), http://www.apa.org/releases/
hypnosis.html. Copyright 2008 by the American Psychological As-
sociation. Reproduced with permission. No further reproduction or dis-
tribution is permitted without written permission from the American
Psychological Association.
While you may think of hypnosis as something you see only in the
movies or novels, hypnosis is used in real life as part of the treatment
plan for people with numerous health ailments ranging from depres-
sion to gastrointestinal disorders. Based on research showing that
hypnosis can help people manageand in some cases recover from
illness, hypnosis is becoming a more common part of many patients
recommended health treatment.
Denition
According to the American Psychological Association (APA)s Divi-
sion of Psychological Hypnosis, hypnosis is a procedure during which a
health professional or researcher suggests while treating someone that
he or she experience changes in sensations, perceptions, thoughts, or
behavior. Although some hypnosis is used to make people more alert,
324
most hypnosis includes suggestions for relaxation, calmness, and well-

being. Instructions to imagine or think about pleasant experiences are
also commonly included during hypnosis. People respond to hypnosis
in different ways. Some describe hypnosis as a state of focused atten-
tion, in which they feel very calm and relaxed. Most people describe
the experience as pleasant.
Is There Evidence That Hypnosis Works?

Yes. While there are plenty of examples in the scientific lit-
erature attesting to the usefulness of clinical hypnosis, a study
published in the journal Gut is noteworthy. The study involved
204 people suffering from Irritable Bowel Syndrome (IBS). Treat-
ment consisted of 12 weekly sessions of hypnosis (lasting about 1
hour each). Fifty-eight percent of the men and 75 percent of the
women reported signicant symptom relief immediately after nish-
ing treatment. More than 80 percent of those who reported initial
relief were still improved up to 6 years later. Fewer than 10 percent
of the participants tried other treatments after hypnotherapy. (Gut,
November 2003).
Can Everyone Be Hypnotized?

People differ in the degree to which they respond to hypnosis. A
persons ability to experience hypnosis can be inhibited by fears and
concerns arising from some common misconceptions. Contrary to some
depictions of hypnosis in books, movies, or television, people who have
been hypnotized do not lose control over their behavior. Unless amne-
sia has specically been suggested, people remain aware of who they
are, where they are, and remember what transpired during hypnosis.
Hypnosis makes it easier for people to experience suggestions, but it
does not force them to have these experiences.
Is Hypnosis Therapy?
Hypnosis is not a type of psychotherapy. It also is not a treatment
in and of itself; rather, it is a procedure that can be used to facilitate
other types of therapies and treatments. Clinical hypnosis should
be conducted only by properly trained and credentialed health care
professionals (e.g., psychologists) who also have been trained in the
use of hypnosis and who are working within the limits of their pro-
fessional expertise.
325
Practical Uses for Hypnosis

Hypnosis has been used in the treatment of pain; depression; anxi-
ety and phobias; stress; habit disorders; gastrointestinal disorders;
skin conditions; post-surgical recovery; relief from nausea and vomit-
ing; childbirth; treatment of hemophilia; and many other conditions.
However, it may not be useful for all psychological and/or medical
problems or for all patients or clients. The decision to use hypnosis
as an adjunct to treatment should only be made in consultation with
a qualied health care provider who has been trained in the use and
limitations of clinical hypnosis. In addition to its use in clinical settings,
hypnosis is used in research and forensic settings. Researchers study
the value of hypnosis in the treatment of physical and psychological
problems and examine the impact of hypnosis on sensation, perception,
learning, and memory.
Professional Hypnosis Organizations

APA Division 30, Society of Psychological Hypnosis: http://www.apa
.org/divisions/div30 (Executive Committee of the American Psychologi-
cal Association, Division of Psychological Hypnosispromotes profes-
sional education and exchange of scientic information and develops
standards of care).
American Board of Psychological Hypnosis (ABPH)

c/o Gary R. Elkins, PhD, ABPH
Scott & White Clinic
Department of Psychiatry
2401 South 31st Street
Temple, TX 76508
E-mail:
[email protected]
American Society of Clinical Hypnosis (ASCH)

140 North Bloomingdale Road
Bloomingdale, IL 60108-1017
Phone: 630-980-4740
Fax: 630-351-8490
E-mail:
[email protected]
Website:
http://www.asch.net
326
The International Society of Hypnosis (ISH)

c/o Dr. E. Vermetten
University Medical Center Utrecht
P.O. Box 342
4000 AH TIEL
The Netherlands
Tel. + 31 344 615 427
Fax + 31 344 655 260
E-mail:
[email protected]
Society for Clinical and Experimental Hypnosis (SCEH)

2201 Haeder Road, Suite 1
Pullman, WA 99163
Phone: 509-332-7555
Fax: 509-332-5907
E-mail:
[email protected]
327
Chapter 47
Meditation
Meditation is a mind-body practice in complementary and alter-

native medicine (CAM). There are many types of meditation, most of
which originated in ancient religious and spiritual traditions. Gener-
ally, a person who is meditating uses certain techniques, such as a
specic posture, focused attention, and an open attitude toward dis-
tractions. Meditation may be practiced for many reasons, such as to
increase calmness and physical relaxation, to improve psychological
balance, to cope with illness, or to enhance overall wellness.
Overview
The term meditation refers to a group of techniques, such as man-
tra meditation, relaxation response, mindfulness meditation, and Zen
Buddhist meditation. Most meditative techniques started in Eastern
religious or spiritual traditions. These techniques have been used by
many different cultures throughout the world for thousands of years.
Today, many people use meditation outside of its traditional religious
or cultural settings, for health and wellness purposes.
In meditation, a person learns to focus attention. Some forms of
meditation instruct the practitioner to become mindful of thoughts,
feelings, and sensations and to observe them in a nonjudgmental way.
This practice is believed to result in a state of greater calmness and
From Meditation: An Introduction, by the National Center for Complemen-
tary and Alternative Medicine (NCCAM, nccam.nih.gov), part of the National
Institutes of Health, February 2009.
329
physical relaxation, and psychological balance. Practicing meditation

can change how a person relates to the ow of emotions and thoughts
in the mind.
Most types of meditation have four elements in common:
s A quiet location: Meditation is usually practiced in a quiet
place with as few distractions as possible. This can be particu-
larly helpful for beginners.
s A specic, comfortable posture: Depending on the type be-
ing practiced, meditation can be done while sitting, lying down,
standing, walking, or in other positions.
s A focus of attention: Focusing ones attention is usually a part
of meditation. For example, the meditator may focus on a mantra
(a specially chosen word or set of words), an object, or the sensa-
tions of the breath. Some forms of meditation involve paying at-
tention to whatever is the dominant content of consciousness.
s An open attitude: Having an open attitude during meditation
means letting distractions come and go naturally without judging
them. When the attention goes to distracting or wandering thoughts,
they are not suppressed; instead, the meditator gently brings atten-
tion back to the focus. In some types of meditation, the meditator
learns to observe thoughts and emotions while meditating.
Meditation used as CAM is a type of mind-body medicine. Generally,

mind-body medicine focuses on the following:
s 4HEINTERACTIONSAMONGTHEBRAINMINDTHERESTOFTHEBODYAND
behavior
s 4HEWAYSINWHICHEMOTIONALMENTALSOCIALSPIRITUALAND
behavioral factors can directly affect health
Uses of Meditation for Health in the United States

A 2007 national government survey that asked about CAM use in
a sample of 23,393 U.S. adults found that 9.4 percent of respondents
(representing more than 20 million people) had used meditation in
the past 12 monthscompared with 7.6 percent of respondents (rep-
resenting more than 15 million people) in a similar survey conducted
in 2002. The 2007 survey also asked about CAM use in a sample of
9,417 children; 1 percent (representing 725,000 children) had used
meditation in the past 12 months.
330
Meditation
People use meditation for various health problems, such as the

following:
s !NXIETY
s 0AIN
s $EPRESSION
s 3TRESS
s )NSOMNIA
s 0HYSICALOREMOTIONALSYMPTOMSTHATMAYBEASSOCIATEDWITH
CHRONICILLNESSESSUCHASHEARTDISEASE()6!)$3;HUMAN
immunodeciency syndrome/acquired immunodeciency syn-
DROME=ANDCANCER ANDTHEIRTREATMENT
Meditation is also used for overall wellness.
Examples of Meditation Practices

Mindfulness meditation and Transcendental Meditation (also known
as TM) are two common forms of meditation. NCCAM-sponsored re-
search projects are studying both of these types of meditation.
Mindfulness meditation is an essential component of Buddhism. In
one common form of mindfulness meditation, the meditator is taught
to bring attention to the sensation of the ow of the breath in and out
of the body. The meditator learns to focus attention on what is being
experienced, without reacting to or judging that experience. This is
seen as helping the meditator learn to experience thoughts and emo-
tions in normal daily life with greater balance and acceptance.
The TM technique is derived from Hindu traditions. It uses a man-
tra (a word, sound, or phrase repeated silently) to prevent distracting
thoughts from entering the mind. The goal of TM is to achieve a state
of relaxed awareness.
How Meditation Might Work

Practicing meditation has been shown to induce some changes in
the body. By learning more about what goes on in the body during
meditation, researchers hope to be able to identify diseases or condi-
tions for which meditation might be useful.
Some types of meditation might work by affecting the autonomic
(involuntary) nervous system. This system regulates many organs
and muscles, controlling functions such as the heartbeat, sweating,
breathing, and digestion. It has two major parts:
331
s 4HESYMPATHETICNERVOUSSYSTEMHELPSMOBILIZETHEBODYFOR
action. When a person is under stress, it produces the ght-or-
ight response: The heart rate and breathing rate go up and
blood vessels narrow (restricting the ow of blood).
s 4HEPARASYMPATHETICNERVOUSSYSTEMCAUSESTHEHEARTRATEAND
breathing rate to slow down, the blood vessels to dilate (improv-
ing blood ow), and digestive juices to increase.
It is thought that some types of meditation might work by reducing

activity in the sympathetic nervous system and increasing activity in
the parasympathetic nervous system.
In one area of research, scientists are using sophisticated tools to
determine whether meditation is associated with signicant changes
in brain function. A number of researchers believe that these changes
account for many of meditations effects.
It is also possible that practicing meditation may work by improv-
ing the minds ability to pay attention. Since attention is involved in
performing everyday tasks and regulating mood, meditation might
lead to other benets.
A 2007 NCCAM-funded review of the scientic literature found
some evidence suggesting that meditation is associated with poten-
tially benecial health effects. However, the overall evidence was in-
conclusive. The reviewers concluded that future research needs to be
more rigorous before rm conclusions can be drawn.

Meditation is considered to be safe for healthy people. There have
been rare reports that meditation could cause or worsen symptoms in
people who have certain psychiatric problems, but this question has
not been fully researched.
People with physical limitations may not be able to participate in
certain meditative practices involving physical movement. Individuals
with existing mental or physical health conditions should speak with
their health care providers prior to starting a meditative practice and
make their meditation instructor aware of their condition.
If You Are Thinking about Using Meditation Practices
s $ONOTUSEMEDITATIONASAREPLACEMENTFORCONVENTIONALCAREOR
as a reason to postpone seeing a doctor about a medical problem.
332
Meditation
s !SKABOUTTHETRAININGANDEXPERIENCEOFTHEMEDITATIONINSTRUC-
tor you are considering.
s ,OOKFORPUBLISHEDRESEARCHSTUDIESONMEDITATIONFORTHEHEALTH
condition in which you are interested.
and safe care.
NCCAM-Supported Research
Some recent NCCAM-supported studies have been investigating
meditation for the following:
s 2ELIEVINGSTRESSINCAREGIVERSFORELDERLYPATIENTSWITHDEMENTIA
s 2EDUCINGTHEFREQUENCYANDINTENSITYOFHOTmASHESINMENO-
pausal women
s 2ELIEVINGSYMPTOMSOFCHRONICBACKPAIN
s )MPROVINGATTENTION RELATEDABILITIESALERTINGFOCUSINGAND
prioritizing)
s 2ELIEVINGASTHMASYMPTOMS
333
Chapter 48
Music Therapy
What is music therapy?

Music therapy is the clinical and evidence-based use of music in-
terventions to accomplish individualized goals within a therapeutic
relationship by a credentialed professional who has completed an ap-
proved music therapy program. (American Music Therapy Association
denition, 2005)
What do music therapists do?

Music therapists assess emotional well-being, physical health, social
functioning, communication abilities, and cognitive skills through mu-
sical responses; design music sessions for individuals and groups based
on client needs using music improvisation, receptive music listening,
song writing, lyric discussion, music and imagery, music performance,
and learning through music; participate in interdisciplinary treatment
planning, ongoing evaluation, and follow up.
Who can benet from music therapy?

Children, adolescents, adults, and the elderly with mental health needs,
developmental and learning disabilities, Alzheimers disease and other ag-
ing related conditions, substance abuse problems, brain injuries, physical
disabilities, and acute and chronic pain, including mothers in labor.
Frequently Asked Questions About Music Therapy, 2009 American Mu-

sic Therapy Association (www.musictherapy.org). Reprinted with permission.
335
Where do music therapists work?

Music therapists work in psychiatric hospitals, rehabilitative facili-
ties, medical hospitals, outpatient clinics, day care treatment centers,
agencies serving developmentally disabled persons, community men-
tal health centers, drug and alcohol programs, senior centers, nurs-
ing homes, hospice programs, correctional facilities, halfway houses,
schools, and private practice.
What is the history of music therapy as a health care

profession?
The idea of music as a healing inuence which could affect health
and behavior is at least as old as the writings of Aristotle and Plato.
The 20th century discipline began after World War I and World War
II when community musicians of all types, both amateur and pro-
fessional, went to veterans hospitals around the country to play for
the thousands of veterans suffering both physical and emotional
trauma from the wars. The patients notable physical and emotional
responses to music led the doctors and nurses to request the hiring
of musicians by the hospitals. It was soon evident that the hospital
musicians needed some prior training before entering the facility and
so the demand grew for a college curriculum. The rst music therapy
degree program in the world, founded at Michigan State University
in 1944, celebrated its 50th anniversary in 1994. The American Music
Therapy Association was founded in 1998 as a union of the National
Association for Music Therapy and the American Association for
Music Therapy.
Who is qualied to practice music therapy?

Persons who complete one of the approved college music therapy
curricula (including an internship) are then eligible to sit for the na-
tional examination offered by the Certication Board for Music Thera-
pists. Music therapists who successfully complete the independently
administered examination hold the music therapist-board certied
credential (MT-BC).
The National Music Therapy Registry (NMTR) serves qualied
music therapy professionals with the following designations: RMT
;2EGISTERED-USIC4HERAPIST=#-4;#ERTIlED-USIC4HERAPIST=!#-4
;!DVANCED#ERTIlED-USIC4HERAPIST=4HESEINDIVIDUALSHAVEMETAC-
cepted educational and clinical training standards and are qualied
to practice music therapy.
336
Music Therapy
Is there research to support music therapy?

AMTA promotes a vast amount of research exploring the benets of
music as therapy through publication of the Journal of Music Therapy,
Music Therapy Perspectives, and other sources. A substantial body of
literature exists to support the effectiveness of music therapy.
What are some misconceptions about music therapy?

That the client or patient has to have some particular music ability
to benet from music therapythey do not. That there is one particular
style of music that is more therapeutic than all the restthis is not
the case. All styles of music can be useful in effecting change in a client
or patients life. The individuals preferences, circumstances and need
for treatment, and the client or patients goals help to determine the
types of music a music therapist may use.
How can music therapy techniques be applied by healthy

individuals?
Healthy individuals can use music for stress reduction via active
music making, such as drumming, as well as passive listening for relax-
ation. Music is often a vital support for physical exercise. Music therapy
assisted labor and delivery may also be included in this category since
pregnancy is regarded as a normal part of womens life cycles.
How is music therapy utilized in hospitals?

Music is used in general hospitals to: alleviate pain in conjunc-
tion with anesthesia or pain medication; elevate patients mood and
counteract depression; promote movement for physical rehabilitation;
calm or sedate, often to induce sleep; counteract apprehension or fear;
and lessen muscle tension for the purpose of relaxation, including the
autonomic nervous system.
How is music therapy utilized in nursing homes?

Music is used with elderly persons to increase or maintain their
level of physical, mental, and social/emotional functioning. The sensory
and intellectual stimulation of music can help maintain a persons
quality of life.
How is music therapy utilized in schools?

Music therapists are often hired in schools to provide music therapy
services listed on the Individualized Education Plan for mainstreamed
337
special learners. Music learning is used to strengthen nonmusical

areas such as communication skills and physical coordination skills
which are important for daily life.
How is music therapy utilized in psychiatric facilities?

Music therapy allows persons with mental health needs to: explore
personal feelings, make positive changes in mood and emotional states,
have a sense of control over life through successful experiences, prac-
tice problem solving, and resolve conicts leading to stronger family
and peer relationships.
Is music therapy a reimbursable service?

Medicare: Since 1994, music therapy has been identied as a re-
imbursable service under benets for Partial Hospitalization Programs
(PHP). Falling under the heading of Activity Therapy, the interventions
cannot be purely recreational or diversionary in nature and must be
individualized and based on goals specied in the treatment plan. The
CURRENT(#0#3;(EALTHCARE#OMMON0ROCEDURE#ODING3YSTEM=#ODE
for PHP is G0176.
The music therapy must be considered an active treatment by meet-
ing the following criteria:
s BEPRESCRIBEDBYAPHYSICIAN
s BEREASONABLEANDNECESSARYFORTHETREATMENTOFTHE
individuals illness or injury;
s BEGOALDIRECTEDANDBASEDONADOCUMENTEDTREATMENT
plan;
s THEGOALOFTREATMENTCANNOTBETOMERELYMAINTAIN
current level of functioningthe individual must exhibit
some level of improvement.
Medicaid: As Medicaid programs vary from state-to-state, so do the

Medicaid coverage avenues for music therapy services. Some private
practice music therapists have successfully applied for Medicaid pro-
vider numbers within their states. Some states offer waiver programs
in which music therapy can be covered. In some situations, although
music therapy is not specically listed as a covered service, due to
functional outcomes achieved, music therapy interventions can fall
under an existing treatment category such as community support,
rehabilitation, or habilitation.
338
Music Therapy
Examples:
s Arizona: Medicaid coverage for music therapy provided to indi-
viduals with developmental disabilities; originally recognized as a
habilitation service but also considered as a socialization service.
s Minnesota: Individual music therapist received provider
number to service clients with mental illness and developmental
disabilities. Waiver program for children with developmental
disabilities provides coverage for music therapy.
s Pennsylvania: Department of Aging Waiver program allows
Medicaid payment for music therapy provided in a community
based setting. Music therapy is listed under health and mental
health related counseling services.
s North Carolina: Medicaid reimbursement is available for
music therapy services through the Community Alternatives
Program (CAP) for clients with developmental disabilities.
s Indiana: Waiver program for children with developmental
disabilities offers coverage for music therapy.
s Michigan: Music therapy is a covered service under the states
Medicaid Childrens Waiver Program.
Private insurance: The number of success stories involving third

party reimbursement for the provision of music therapy services con-
tinues to grow. Over the past 12 years a growing public demand for
music therapy services has been accompanied by a demand for third
party reimbursement. In response to the increasing demand the music
therapy profession has worked to facilitate the reimbursement process
for clients of music therapy services.
The American Music Therapy Association now estimates that at least
20% of music therapists receive third party reimbursement for the ser-
vices they provide. This number is expected to increase exponentially as
music therapy occupies a strong position in the health care industry.
Insurance companies are recognizing the advantages of including
music therapy as a benet as they respond to the increasing market
demand for greater patient choice of health care services. Companies
like Blue Cross/Blue Shield, Humana, Great West Life, Aetna, Metro-
politan, and Provident have reimbursed for music therapy services on
a case-by-case basis, based on medical necessity.
Music therapy is comparable to other health professions like oc-
cupational therapy and physical therapy in that individual assess-
ments are provided for each client, service must be found reasonable
339
and necessary for the individuals illness or injury, and interventions

include a goal-directed documented treatment plan.
Like other therapies, music therapy is typically preapproved for
coverage or reimbursement, and is found to be reimbursable when
deemed medically necessary to reach the treatment goals of the indi-
vidual patient. Therefore, reimbursement for services is determined on
a case-by-case basis and is available in a large variety of health care
settings, with patients with varying diagnoses.
Other sources: Additional sources for reimbursement and nanc-

ing of music therapy services include: many state departments of men-
tal health, state departments of mental retardation/developmental
disabilities, state adoption subsidy programs, private auto insurance,
employee workers compensation, county boards of mental retarda-
tion/developmental disabilities, IDEA Part B related services funds,
foundations, grants, and private pay.
What is the American Music Therapy Association?

The American Music Therapy Association is the largest professional
association which represents over 5,000 music therapists, corporate
members, and related associations worldwide. Founded in 1998, its
mission is the progressive development of the therapeutic use of music
in rehabilitation, special education, and community settings. AMTA
sets the education and clinical training standards for music therapists.
Predecessors to the American Music Therapy Association included
the National Association for Music Therapy founded in 1950 and the
American Association for Music Therapy founded in 1971.
What is a typical music therapy session like?

Since music therapists serve a wide variety of persons with many
different types of needs there is no such thing as an overall typical ses-
sion. Sessions are designed and music selected based on the individual
clients treatment plan.
What is the future of music therapy?

The future of music therapy is promising because state of the art
music therapy research in physical rehabilitation, Alzheimers disease,
and psychoneuroimmunology is documenting the effectiveness of mu-
sic therapy in terms that are important in the context of a biological
medical model.
340
Chapter 49
Prayer and Spirituality
General Information about Spirituality

Religious and spiritual values are important to patients
coping with cancer.
The terms spirituality and religion are often used in place of each other,
but for many people they have different meanings. Religion may be dened
as a specic set of beliefs and practices, usually within an organized group.
Spirituality may be dened as an individuals sense of peace, purpose, and
connection to others, and beliefs about the meaning of life. Spirituality
may be found and expressed through an organized religion or in other
ways. Patients may think of themselves as spiritual or religious or both.
Spirituality and religion may have different meanings.

Studies have shown that religious and spiritual values are impor-
tant to Americans. Most American adults say that they believe in God
and that their religious beliefs affect how they live their lives. However,
people have different ideas about life after death, belief in miracles, and
other religious beliefs. Such beliefs may be based on gender, education,
and ethnic background.
Many patients with cancer rely on spiritual or religious beliefs and
practices to help them cope with their disease. This is called spiritual
PDQ Cancer Information Summary. National Cancer Institute; Bethesda,

MD. Spirituality in Cancer Care (PDQ): Supportive CarePatient. Updated
03/2009. Available at http://cancer.gov. Accessed December 9, 2009.
341
coping. Many caregivers also rely on spiritual coping. Each person may
have different spiritual needs, depending on cultural and religious
traditions. Some patients and their family caregivers may want doc-
tors to talk about spiritual concerns, but may feel unsure about how
to bring up the subject.
There is a growing understanding that doctors support of spiritual
well-being in very ill patients helps improve their quality of life. Health
care providers who treat patients coping with cancer are looking at
new ways to help them with religious and spiritual concerns. Doctors
may ask patients which spiritual issues are important to them, not
only for end-of-life issues but also during treatment.
Serious illness, such as cancer, may cause spiritual distress.

Serious illnesses like cancer may cause patients or family caregiv-
ers to have doubts about their beliefs or religious values and cause
much spiritual distress. Some studies show that patients with cancer
may feel that they are being punished by God or may have a loss of
faith after being diagnosed. Other patients may have mild feelings of
spiritual distress when coping with cancer.
Spirituality and Quality of Life

Spiritual and religious well-being may help improve
quality of life.
It is not known for sure how spirituality and religion are related to
health. Some studies show that spiritual or religious beliefs and practices
create a positive mental attitude that may help a patient feel better and
improve the well-being of family caregivers. Spiritual and religious well-
being may help improve health and quality of life in the following ways:
s 4HEYMAYHELPDECREASEANXIETYDEPRESSIONANGERANDDISCOMFORT
s 4HEYMAYHELPDECREASETHESENSEOFISOLATIONFEELINGALONE AND
the risk of suicide.
s 4HEYMAYHELPDECREASEALCOHOLANDDRUGABUSE
s 4HEYMAYLOWERBLOODPRESSUREANDTHERISKOFHEARTDISEASE
s 4HEYMAYHELPTHEPATIENTADJUSTTOTHEEFFECTSOFCANCERANDITS
treatment.
s 4HEYMAYINCREASETHEABILITYTOENJOYLIFEDURINGCANCERTREATMENT
s 4HEYMAYGIVEAFEELINGOFPERSONALGROWTHASARESULTOFLIVING
with cancer.
342
Prayer and Spirituality
s 4HEYMAYINCREASEPOSITIVEFEELINGSINCLUDINGTHEFOLLOWING
s (OPEANDOPTIMISM
s &REEDOMFROMREGRET
s 3ATISFACTIONWITHLIFE
s !SENSEOFINNERPEACE
Spiritual and religious well-being may also help a patient

live longer.
Spiritual distress may also affect health. Spiritual distress may make
it harder for patients to cope with cancer and cancer treatment. Health
care providers may encourage patients to meet with experienced spiri-
tual or religious leaders to help deal with their spiritual issues. This
may improve their health, quality of life, and ability to cope.
Spiritual Assessment
A spiritual assessment may help the doctor understand
how religious or spiritual beliefs will affect the way a
patient copes with cancer.
A spiritual assessment is a method or tool used by doctors to under-
stand the role that religious and spiritual beliefs have in the patients
life. This may help the doctor understand how these beliefs affect the way
the patient responds to the cancer diagnosis and decisions about cancer
treatment. Some doctors or caregivers may wait for the patient to bring
up spiritual concerns. Others may use an interview or a questionnaire.
A spiritual assessment explores religious beliefs and

spiritual practices.
A spiritual assessment may include questions about the following:
s 2ELIGIOUSDENOMINATIONIFANY
s "ELIEFSORPHILOSOPHYOFLIFE
s )MPORTANTSPIRITUALPRACTICESORRITUALS
s 5SINGSPIRITUALITYORRELIGIONASASOURCEOFSTRENGTH
s "EINGPARTOFACOMMUNITYOFSUPPORT
s 5SINGPRAYERORMEDITATION
s ,OSSOFFAITH
s #ONmICTSBETWEENSPIRITUALORRELIGIOUSBELIEFSANDCANCERTREATMENTS
s 7AYSTHATHEALTHCAREPROVIDERSANDCAREGIVERSMAYHELPWITH
the patients spiritual needs
343
s #ONCERNSABOUTDEATHANDAFTERLIFE
s 0LANNINGFORTHEENDOFLIFE
The health care team may not ask about every issue the patient
feels is important. Patients should bring up other spiritual or religious
issues that they think may affect their cancer care.
Meeting the Patients Spiritual and Religious Needs

To help patients with spiritual needs during cancer care,
medical staff will listen to the wishes of the patient.
Spirituality and religion are very personal issues. Patients should
expect doctors and caregivers to respect their religious and spiritual
beliefs and concerns. Patients with cancer who rely on spirituality to
cope with the disease should be able to count on the health care team to
give them support. This may include giving patients information about
people or groups that can help with spiritual or religious needs. Most
hospitals have chaplains, but not all outpatient settings do. Patients
who do not want to discuss spirituality during cancer care should also
be able to count on the health care team to respect their wishes.
Doctors and caregivers will try to respond to their patients con-
cerns, but may not take part in patients religious practices or discuss
specic religious beliefs.
The health care team will help with a patients spiritual

needs when setting goals and planning treatment.
The health care team may help with a patients spiritual needs in
the following ways:
s 4HEYMAYSUGGESTGOALSANDOPTIONSFORCARETHATHONORTHE
patients spiritual and/or religious views.
s 4HEYMAYSUPPORTTHEPATIENTSUSEOFSPIRITUALCOPINGDURING
the illness.
s 4HEYMAYENCOURAGETHEPATIENTTOSPEAKWITHHISHERRELIGIOUS
or spiritual leader.
s 4HEYMAYREFERTHEPATIENTTOAHOSPITALCHAPLAINORSUPPORT
group that can help with spiritual issues during illness.
s 4HEYMAYREFERTHEPATIENTTOOTHERTHERAPIESTHATHAVEBEEN
shown to increase spiritual well-being. These include mindful-
ness relaxation, such as yoga or meditation, or creative arts pro-
grams, such as writing, drawing, or music therapy.
344
Chapter 50
Relaxation Training
One of the most powerful tools a psychologist can use is actually

nothing new, said Herbert Benson, MD, at APAs Annual Convention.
In fact, its an approach thats been around for millennia, yet its full
potential remains untapped.
Benson was referring to the relaxation response, a physical state of deep
rest that changes a persons physical and emotional responses to stress.
Benson, of Harvard Medical School and the Benson-Henry Institute
for Mind Body Medicine at Massachusetts General Hospital, discovered
the relaxation responses power to reduce stress in the 1960s. But his
subsequent research found that the approach is really no different
from what people have done for centuries through prayer, chanting,
and repetitive motion.
Today, scientists have shown that such practices lower heart rates,
blood pressure, and oxygen consumption, and they alleviate the symp-
toms associated with a vast array of conditions, including hypertension,
arthritis, insomnia, depression, infertility, cancer, anxiety, even aging.
You as psychologists can use the mind like you would use a drug,
he said. This should empower you in your practices.
His latest research, published in the online journal Public Library
of Science ONE*ULY;= SUGGESTSTHATPRACTICINGTHERELAXATION
The power of the relaxation response, Monitor on Psychology, Volume 39,

No. 9, October 2008, p. 32, http://www.apa.org/monitor/2008/10/relaxation.html.
Copyright 2008 by the American Psychological Association. Reproduced with
permission. No further reproduction or distribution is permitted without written
permission from the American Psychological Association.
345
response can actually lead to genomic activity changes. In the study,

his team of researchers looked at how the relaxation response affected
each of the bodys 40,000 genes and found that, compared with a con-
trol group, those who regularly used the relaxation response induced
anti-oxidation and anti-inammatory changes that counteracted the
effects of stress on the body.
Everyday Meditation
Eliciting the relaxation response is simple, he explained: Once
or twice a day for 10 to 20 minutes, sit in a relaxed position, eyes
closed, and repeat a word or sound as you breathe. Some people use
such words as love or peace. Others say traditional prayers. If your
thoughts straywhich is normal and expectedjust refocus on the
word repetition.
There are scores of other ways to summon the relaxation response,
as well, said Benson. Anything that breaks the train of everyday
thought will evoke this physiological state.
That includes participating in repetitive sports such as running, let-
ting go of tension through progressive muscular relaxation, practicing
yoga, knitting, crocheting, even playing musical instruments.
You know how when you play an instrument and you become one
with that instrument and the time its away? That is the relaxation
response, he said. You know the high you get from running? That
is the relaxation response coming about by the repetitive motion of
your footfall.
Research into Practice

Benson recommended that psychology practitioners learn a vari-
ety of techniques so they can introduce their clients to the practice
theyll be comfortable with. Catholics might want to try the Hail Mary
prayer. Athletes can use repetitive sports.
Keep your mind open about the practice that will work for your
clients, he said. The damning thing about these techniques is that
when you use them regularly, you come to believe that the one that was
successful for you will be successful for everyone. Let your client nd
the technique that she or he believes in and encourage daily practice.
You cant simply save this for when they are under stress, he said.
With regular practice, clients develop quieter minds. So its particu-
larly benecial when a client elicits the relaxation response before a
therapy session.
346
Relaxation Training
With less static, less noise, traditional cognitive restructuring en-

ters, said Benson. People listen better. Its a more fertile environment,
so you can do what you are so well trained to dothe cognitive work,
the positive ideation. Its a door opening to allow you to help change
peoples lives.
Given that 60 percent to 90 percent of health-care professional
visits are stress-related, the potential of the relaxation response to
help people is enormous, he said. I believe this is going to change
medicine.
Bensons invited address was sponsored by Div. 12 (Society of Clinical
Psychology) and Div. 38 (Health).
Further Reading
For more information on Bensons work and the relaxation response,
visit the Massachusetts General Hospital Benson-Henry Institute
for Mind Body Medicine at www.massgeneral.org/bhi.
Bensons newest research, Genomic Counter-Stress Changes In-
DUCEDBYTHE2ELAXATION2ESPONSEvAPPEARSINTHE*ULY;=EDI-
tion of PLoS One at www.plosone.org.
347
Chapter 51
Tai Chi
Tai chi, which originated in China as a martial art, is a mind-body

practice in complementary and alternative medicine (CAM). Tai chi is
sometimes referred to as moving meditationpractitioners move their
bodies slowly, gently, and with awareness, while breathing deeply.
Overview
Tai chi developed in ancient China. It started as a martial art and
a means of self-defense. Over time, people began to use it for health
purposes as well.
Accounts of the history of tai chi vary. A popular legend credits its
origins to Chang San-Feng, a Taoist monk, who developed a set of 13 ex-
ercises that imitate the movements of animals. He also emphasized medi-
tation and the concept of internal force (in contrast to the external force
emphasized in other martial arts, such as kung fu and tae kwon do).
The term tai chi (shortened from tai chi chuan) has been trans-
lated in various ways, such as internal martial art and supreme
ultimate st. It is sometimes called taiji or taijiquan.
Tai chi incorporates the Chinese concepts of yin and yang (opposing
forces within the body) and qi (a vital energy or life force). Practicing
tai chi is said to support a healthy balance of yin and yang, thereby
aiding the ow of qi.
Excerpted from Tai Chi: An Introduction, by the National Center for
National Institutes of Health, April 2009.
349
People practice tai chi by themselves or in groups. In the Chinese

community, people commonly practice tai chi in nearby parksoften
in early morning before going to work. There are many different styles,
but all involve slow, relaxed, graceful movements, each owing into
the next. The body is in constant motion, and posture is important.
The names of some of the movements evoke nature (e.g., Embrace
Tiger, Return to Mountain). Individuals practicing tai chi must also
concentrate, putting aside distracting thoughts; and they must breathe
in a deep and relaxed, but focused manner.

A 2007 survey by the National Center for Health Statistics and
the National Center for Complementary and Alternative Medicine
(NCCAM) on Americans use of CAM found that 1 percent of the more
than 23,300 adults surveyed had used tai chi in the past 12 months.
Adjusted to nationally representative numbers, this means more than
2.3 million adults.
People practice tai chi for various health-related purposes, such as
the following:
s &ORBENElTSASSOCIATEDWITHLOW IMPACTWEIGHT BEARINGAEROBIC
exercise
s 4OIMPROVEPHYSICALCONDITIONMUSCLESTRENGTHCOORDINATION
and exibility
s 4OIMPROVEBALANCEANDDECREASETHERISKOFFALLSESPECIALLYIN
elderly people
s 4OEASEPAINANDSTIFFNESSFOREXAMPLEFROMOSTEOARTHRITIS
s 4OIMPROVESLEEP
s &OROVERALLWELLNESS
The Status of Tai Chi Research

Scientic research on the health benets of tai chi is ongoing. Sev-
eral studies have focused on the elderly, including tai chis potential
for preventing falls and improving cardiovascular tness and overall
well-being. A 2007 NCCAM-funded study on the immune response to
varicella-zoster virus (the virus that causes shingles) suggested that tai
chi may enhance the immune system and improve overall well-being
in older adults. Tai chi has also been studied for improving functional
capacity in breast cancer patients and quality of life in people with HIV
350
Tai Chi
;HUMANIMMUNODElCIENCYVIRUS=INFECTION3TUDIESHAVEALSOLOOKED
at tai chis possible benets for a variety of other conditions, including
cardiovascular disease, hypertension, and osteoarthritis. In 2008, a
review of published research, also funded by NCCAM, found that tai
chi reduced participants blood pressure in 22 (of 26) studies.
In general, studies of tai chi have been small, or they have had
design limitations that may limit their conclusions. The cumulative
evidence suggests that additional research is warranted and needed
before tai chi can be widely recommended as an effective therapy.

Tai chi is a relatively safe practice. However, there are some cautions:
s !SWITHANYEXERCISEREGIMENIFYOUOVERDOPRACTICEYOUMAY
have sore muscles or sprains.
s 4AICHIINSTRUCTORSOFTENRECOMMENDTHATYOUDONOTPRACTICETAI
chi right after a meal, or when you are very tired, or if you have
an active infection.
s )FYOUAREPREGNANTORIFYOUHAVEAHERNIAJOINTPROBLEMSBACK
pain, fractures, or severe osteoporosis, your health care provider
may advise you to modify or avoid certain postures in tai chi.

Tai chi instructors do not have to be licensed, and the practice is not
regulated by the federal government or individual states. In traditional
tai chi instruction, a student learns from a master teacher. To become
an instructor, an experienced student of tai chi must obtain a master
teachers approval. Currently, training programs vary. Some training
programs award certicates; some offer weekend workshops. There is
no standard training for instructors.
If You Are Thinking about Practicing Tai Chi

s $ONOTUSETAICHIASAREPLACEMENTFORCONVENTIONALCAREORTO
postpone seeing a doctor about a medical problem.
s )FYOUHAVEAMEDICALCONDITIONORHAVENOTEXERCISEDINAWHILE
consult with your health care provider before starting tai chi.
s +EEPINMINDTHATLEARNINGTAICHIFROMAVIDEOORBOOKDOESNOT
ensure that you are doing the movements correctly and safely.
351
s )FYOUARECONSIDERINGATAICHIINSTRUCTORASKABOUTTHE
individuals training and experience.
s ,OOKFORPUBLISHEDRESEARCHSTUDIESONTAICHIFORTHEHEALTH
condition you are interested in.
and safe care.
NCCAM has supported studies of tai chis effects on the following:
s "ONELOSSINPOSTMENOPAUSALWOMEN
s #ANCERSURVIVORS
s $EPRESSIONINELDERLYPATIENTS
s &IBROMYALGIASYMPTOMSSUCHASMUSCLEPAINFATIGUEAND
insomnia
s /STEOARTHRITISOFTHEKNEE
s 0ATIENTSWITHCHRONICHEARTFAILURE
s 2HEUMATOIDARTHRITIS
352
Chapter 52
Yoga
Yoga is a mind-body practice in complementary and alternative

medicine with origins in ancient Indian philosophy. The various styles
of yoga that people use for health purposes typically combine physical
postures, breathing techniques, and meditation or relaxation.
Overview
Yoga in its full form combines physical postures, breathing exercis-
es, meditation, and a distinct philosophy. Yoga is intended to increase
relaxation and balance the mind, body, and the spirit.
Early written descriptions of yoga are in Sanskrit, the classical
language of India. The word yoga comes from the Sanskrit word yuj,
which means yoke or union. It is believed that this describes the
union between the mind and the body. The rst known text, The Yoga
Sutras, was written more than 2,000 years ago, although yoga may
have been practiced as early as 5,000 years ago. Yoga was originally
developed as a method of discipline and attitudes to help people reach
spiritual enlightenment. The Sutras outline eight limbs or foundations
of yoga practice that serve as spiritual guidelines:
s 9AMAMORALBEHAVIOR
s .IYAMAHEALTHYHABITS
Excerpted from Yoga for Health: An Introduction, by the National Center
the National Institutes of Health, May 2008.
353
s !SANAPHYSICALPOSTURES
s 0RANAYAMABREATHINGEXERCISES
s 0RATYAHARASENSEWITHDRAWAL
s $HARANACONCENTRATION
s $HYANACONTEMPLATION
s 3AMADHIHIGHERCONSCIOUSNESS
The numerous schools of yoga incorporate these eight limbs in

varying proportions. Hatha yoga, the most commonly practiced in the
United States and Europe, emphasizes two of the eight limbs: postures
(asanas) and breathing exercises (pranayama). Some of the major
styles of hatha yoga include Ananda, Anusara, Ashtanga, Bikram,
Iyengar, Kripalu, Kundalini, and Viniyoga.
Use of Yoga for Health in the United States

According to the 2007 National Health Interview Survey (NHIS),
which included a comprehensive survey of CAM use by Americans,
yoga is one of the top 10 CAM modalities used. More than 13 million
adults had used yoga in the previous year, and between the 2002 and
2007 NHIS, use of yoga among adults increased by 1 percent (or ap-
proximately 3 million people). The 2007 survey also found that more
than 1.5 million children used yoga in the previous year.
People use yoga for a variety of health conditions including anxi-
ety disorders or stress, asthma, high blood pressure, and depression.
People also use yoga as part of a general health regimento achieve
physical tness and to relax.
The Status of Yoga Research

Research suggests that yoga might help with the following:
s )MPROVEMOODANDSENSEOFWELL BEING
s #OUNTERACTSTRESS
s 2EDUCEHEARTRATEANDBLOODPRESSURE
s )NCREASELUNGCAPACITY
s )MPROVEMUSCLERELAXATIONANDBODYCOMPOSITION
s (ELPWITHCONDITIONSSUCHASANXIETYDEPRESSIONANDINSOMNIA
s )MPROVEOVERALLPHYSICALlTNESSSTRENGTHANDmEXIBILITY
s 0OSITIVELYAFFECTLEVELSOFCERTAINBRAINORBLOODCHEMICALS
354
Yoga
More well-designed studies are needed before denitive conclusions

can be drawn about yogas use for specic health conditions.

s 9OGAISGENERALLYCONSIDEREDTOBESAFEINHEALTHYPEOPLEWHEN
practiced appropriately. Studies have found it to be well toler-
ated, with few side effects.
s 0EOPLEWITHCERTAINMEDICALCONDITIONSSHOULDNOTUSESOME
yoga practices. For example, people with disk disease of the
spine, extremely high or low blood pressure, glaucoma, retinal
detachment, fragile or atherosclerotic arteries, a risk of blood
clots, ear problems, severe osteoporosis, or cervical spondylitis
should avoid some inverted poses.
s !LTHOUGHYOGADURINGPREGNANCYISSAFEIFPRACTICEDUNDEREX-
pert guidance, pregnant women should avoid certain poses that
may be problematic.

There are many training programs for yoga teachers throughout the
country. These programs range from a few days to more than 2 years.
Standards for teacher training and certication differ depending on
the style of yoga.
There are organizations that register yoga teachers and training
programs that have complied with minimum educational standards.
For example, one nonprot group requires at least 200 hours of train-
ing, with a specied number of hours in areas including techniques,
teaching methodology, anatomy, physiology, and philosophy. However,
there are currently no ofcial or well-accepted licensing requirements
for yoga teachers in the United States.
If You Are Thinking about Yoga

s $ONOTUSEYOGAASAREPLACEMENTFORCONVENTIONALCAREORTO
postpone seeing a doctor about a medical problem.
s )FYOUHAVEAMEDICALCONDITIONCONSULTWITHYOURHEALTHCARE
provider before starting yoga.
s !SKABOUTTHEPHYSICALDEMANDSOFTHETYPEOFYOGAINWHICHYOU
are interested, as well as the training and experience of the yoga
teacher you are considering.
355
s ,OOKFORPUBLISHEDRESEARCHSTUDIESONYOGAFORTHEHEALTH
condition you are interested in.
and safe care.
Recent studies supported by NCCAM have been investigating yogas
effects on the following:
s "LOODPRESSURE
s #HRONICLOW BACKPAIN
s #HRONICOBSTRUCTIVEPULMONARYDISEASE
s $EPRESSION
s $IABETESRISK
s ()6;HUMANIMMUNODElCIENCYVIRUS=
s )MMUNEFUNCTION
s )NmAMMATORYARTHRITISANDKNEEOSTEOARTHRITIS
s )NSOMNIA
s -ULTIPLESCLEROSIS
s 3MOKINGCESSATION
356
Chapter 53
Other Mind-Body
Medicine Therapies
Chapter Contents
Section 53.1Color Therapy ...................................................... 358
Section 53.2Dance Therapy .................................................... 359
357
Section 53.1
Color Therapy
From Chromotherapy, 2009 Natural Medicines Comprehensive
Database (www.naturaldatabase.com). Reprinted with permission.
www.naturaldatabase.com.
What other names is the therapy known by?

Chromotherapist, color medicine, color therapy, colorology
What is it?
Chromotherapy, or color therapy, is the use of color to treat medical
conditions.
Is it effective?
Natural Medicines Comprehensive Database rates effectiveness
based on scientic evidence according to the following scale: effective,
likely effective, possibly effective, possibly ineffective, likely ineffective,
and insufcient evidence to rate.
The effectiveness ratings for chromotherapy are as follows:
s )NSUFlCIENTEVIDENCETORATEEFFECTIVENESSFOR
s DEPRESSIONANXIETYSTRESSFATIGUEPAINCRAMPSHEADACHE
migraine headache, diabetes, hypertension, asthma, cough,
and many other conditions.
How does it work?

Chromotherapy practitioners believe that color can be used to correct
energy imbalances which are the cause of disease. A chromotherapist ap-
plies specic colors or lights to specic points on the body called chakras.
Different colors have different effects. For example, red is thought to in-
crease pulse rate, blood pressure, and breathing rate. Therefore, it is often
used for circulatory conditions. Blue is believed to cause relaxation and
calm. Therefore, blue is used for headaches, pain, cramping, stress, and
other conditions. There is no reliable scientic support for these beliefs.
358
Other Mind-Body Medicine Therapies
Are there safety concerns?

There is not enough reliable information available to know if chro-
motherapy is safe or if there are any safety concerns.
Are there any interactions with medications?

It is not known if chromotherapy interacts with any medicines.
Before using chromotherapy, talk with your healthcare professional
if you take any medications.
Section 53.2
Dance Therapy
What Is Dance/Movement Therapy? 2009 American Dance Therapy
Association (www.adta.org). Reprinted with permission.
Based on the understanding that the body and mind are interrelated,
THE!MERICAN$ANCE4HERAPY!SSOCIATION;!$4!=DElNESDANCEMOVE-
ment therapy as the psychotherapeutic use of movement to further the
emotional, cognitive, physical, and social integration of the individual.
Dance/movement therapy is practiced in mental health, rehabilita-
tion, medical, educational, and forensic settings, and in nursing home,
day care center, disease prevention, private practice, and health pro-
motion programs.
The dance/movement therapist focuses on movement behavior as it
emerges in the therapeutic relationship. Expressive, communicative,
and adaptive behaviors are all considered for both group and individual
treatment. Body movement as the core component of dance simultane-
ously provides the means of assessment and the mode of intervention
for dance/movement therapy.
Board Certied
The Dance/Movement Therapy Certication Board, Inc. follows
standards of the National Organization for Competency Assurance,
and awards the R-DMT (Registered-Dance/Movement Therapist) to
359
individuals who have completed a masters degree in dance/movement

therapy or a masters degree in a related eld plus 45 credits of specic
dance/movement therapy curriculum. All candidates must complete a
700-hour supervised clinical internship in dance/movement therapy.
BC-DMT (Board Certied-Dance/Movement Therapist) is awarded only
after the R-DMT has completed 3,640 hours of supervised, professional
clinical work and passed a certication exam. BC-DMTs are qualied
to teach, provide supervision, and engage in private practice. Many
BC-DMTs hold state licenses, National Certied Counselor (NCC)
status, and doctoral degrees.
Professional Training
Professional training of dance/movement therapists occurs on the
graduate level. ADTA has established an approval procedure for grant-
ing recognition to those institutions that fulll the guidelines for mas-
ters degree programs in dance/movement therapy. Prerequisite study
includes Psychology, Anatomy and Kinesiology, and extensive dance
experience.
Course content includes: Dance/Movement Therapy Theory; Devel-
opment, Expressive, and Communicative Aspects of Verbal and Non-
verbal Behavior; Methods for Observation, Analysis, and Assessment;
Psychopathology and Diagnosis; Group Processes; Human Growth, De-
velopment, and Behavior; Research in Dance/Movement Therapy and
Human Behavior; Clinical Applications of Dance/Movement Therapy
and Related Psychological Theories; Clinical Fieldwork; Supervised
Clinical Internship.
360
Part Six
Manipulative and
Body-Based Therapies
Chapter 54
Manipulative and
Body-Based Therapies:
An Overview
Under the umbrella of manipulative and body-based practices is

a heterogeneous group of CAM interventions and therapies. These
include chiropractic and osteopathic manipulation, massage therapy,
Tui Na, reexology, Rolng, Bowen technique, Trager bodywork, Alex-
ander technique, Feldenkrais method, and a host of others. Surveys of
the U.S. population suggest that between 3 percent and 16 percent of
adults receive chiropractic manipulation in a given year, while between
2 percent and 14 percent receive some form of massage therapy. In
1997, U.S. adults made an estimated 192 million visits to chiroprac-
tors and 114 million visits to massage therapists. Visits to chiroprac-
tors and massage therapists combined represented 50 percent of all
visits to CAM practitioners. Data on the remaining manipulative and
body-based practices are sparser, but it can be estimated that they are
collectively used by less than 7 percent of the adult population.
Manipulative and body-based practices focus primarily on the struc-
tures and systems of the body, including the bones and joints, the soft
tissues, and the circulatory and lymphatic systems. Some practices were
derived from traditional systems of medicine, such as those from China,
India, or Egypt, while others were developed within the last 150 years
(e.g., chiropractic and osteopathic manipulation). Although many provid-
ers have formal training in the anatomy and physiology of humans, there
is considerable variation in the training and the approaches of these
Excerpted from Manipulative and Body-Based Practices: An Overview by
the National Center for Complementary and Alternative Medicine (NCCAM,
nccam.nih.gov), part of the National Institutes of Health, March 2007.
363
providers both across and within modalities. For example, osteopathic

and chiropractic practitioners, who use primarily manipulations that
involve rapid movements, may have a very different treatment approach
than massage therapists, whose techniques involve slower applications
of force, or than craniosacral therapists. Despite this heterogeneity,
manipulative and body-based practices share some common character-
istics, such as the principles that the human body is self-regulating and
has the ability to heal itself and that the parts of the human body are
interdependent. Practitioners in all these therapies also tend to tailor
their treatments to the specic needs of each patient.

Range of Studies
The majority of research on manipulative and body-based practices
has been clinical in nature, encompassing case reports, mechanistic
studies, biomechanical studies, and clinical trials. A cursory search
in PubMed for research published in the last 10 years identied 537
clinical trials, of which 422 were randomized and controlled. Similarly,
526 trials were identied in the Cochrane database of clinical trials.
PubMed also contains 314 case reports or series, 122 biomechanical
studies, 26 health services studies, and 248 listings for all other types
of clinical research published in the last 10 years. On the other hand,
for this same time period, there have been only 33 published articles
of research involving in vitro assays or employing animal models.
Primary Challenges
Different challenges face investigators studying mechanisms of ac-
tion than those studying efcacy and safety. The primary challenges
that have impeded research on the underlying biology of manual thera-
pies include the following:
s ,ACKOFAPPROPRIATEANIMALMODELS
s ,ACKOFCROSS DISCIPLINARYCOLLABORATIONS
s ,ACKOFRESEARCHTRADITIONANDINFRASTRUCTUREATSCHOOLSTHAT
teach manual therapies
s )NADEQUATEUSEOFSTATE OF THE ARTSCIENTIlCTECHNOLOGIES
Clinical trials of CAM manual therapies face the same general

challenges as trials of procedure-based interventions such as surgery,
psychotherapy, or more conventional physical manipulative techniques
(e.g., physical therapy). These include the following:
364
Manipulative and Body-Based Therapies: An Overview
s )DENTIFYINGANAPPROPRIATEREPRODUCIBLEINTERVENTIONINCLUD-

ing dose and frequency is a difculty. This may be more difcult
than in standard drug trials, given the variability in practice
patterns and training of practitioners.
s )DENTIFYINGANAPPROPRIATECONTROLGROUPS ISDIFlCULT)NTHIS
regard, the development of valid sham manipulation techniques
has proven difcult.
s 2ANDOMIZINGSUBJECTSTOTREATMENTGROUPSINANUNBIASEDMAN-
ner is difcult. Randomization may prove more difcult than in
a drug trial, because manual therapies are already available to
the public; thus, it is more likely that participants will have a
preexisting preference for a given therapy.
s -AINTAININGINVESTIGATORANDSUBJECTCOMPLIANCETOTHEPROTOCOL
is difcult. Group contamination (which occurs when patients
in a clinical study seek additional treatments outside the study,
usually without telling the investigators; this will affect the
accuracy of the study results) may be more problematic than
in standard drug trials, because subjects have easy access to
manual therapy providers.
s 2EDUCINGBIASBYBLINDINGSUBJECTSANDINVESTIGATORSTOGROUP
assignment can be problematic. Blinding of subjects and inves-
tigators may prove difcult or impossible for certain types of
manual therapies. However, the person collecting the outcome
data should always be blinded.
s )DENTIFYINGANDEMPLOYINGAPPROPRIATEVALIDATEDSTANDARDIZED
outcome measures can be a problem.
s %MPLOYINGAPPROPRIATEANALYSESINCLUDINGTHEINTENT TO TREAT
paradigm, can be difcult.
Summary of the Major Threads of Evidence

Preclinical Studies
The most abundant data regarding the possible mechanisms under-
lying chiropractic manipulation have been derived from studies in ani-
mals, especially studies on the ways in which manipulation may affect
the nervous system. For example, it has been shown, by means of stan-
dard neurophysiological techniques, that spinal manipulation evokes
changes in the activity of proprioceptive primary afferent neurons in
365
paraspinal tissues. Sensory input from these tissues has the capacity
to reexively alter the neural outow to the autonomic nervous system.
Studies are under way to determine whether input from the paraspinal
tissue also modulates pain processing in the spinal cord.
Animal models have also been used to study the mechanisms of
massage-like stimulation. It has been found that antinociceptive and
cardiovascular effects of massage may be mediated by endogenous opi-
oids and oxytocin at the level of the midbrain. However, it is not clear
that the massage-like stimulation is equivalent to massage therapy.
Although animal models of chiropractic manipulation and mas-
sage have been established, no such models exist for other body-based
practices. Such models could be critical if researchers are to evaluate
the underlying anatomical and physiological changes accompanying
these therapies.
Clinical Studies: Mechanisms

Biomechanical studies have characterized the force applied by a
practitioner during chiropractic manipulation, as well as the force
transferred to the vertebral column, both in cadavers and in normal
volunteers. In most cases, however, a single practitioner provided the
manipulation, limiting generalizability. Additional work is required
to examine interpractitioner variability, patient characteristics, and
their relation to clinical outcomes.
Studies using magnetic resonance imaging (MRI) have suggested
that spinal manipulation has a direct effect on the structure of spinal
joints; it remains to be seen if this structural change relates to clini-
cal efcacy.
Clinical studies of selected physiological parameters suggest that
massage therapy can alter various neurochemical, hormonal, and im-
mune markers, such as substance P in patients who have chronic pain,
serotonin levels in women who have breast cancer, cortisol levels in
patients who have rheumatoid arthritis, and natural killer (NK) cell
numbers and CD4+ T-cell counts in patients who are HIV [human im-
munodeciency virus]-positive. However, most of these studies have
come from one research group, so replication at independent sites is
necessary. It is also important to determine the mechanisms by which
these changes are elicited.
Despite these many interesting experimental observations, the
underlying mechanisms of manipulative and body-based practices are
POORLYUNDERSTOOD,ITTLEISKNOWNFROMAQUANTITATIVEPERSPECTIVE
Important gaps in the eld, as revealed by a review of the relevant
scientic literature, include the following:
366
s ,ACKOFBIOMECHANICALCHARACTERIZATIONFROMBOTHPRACTITIONER
and participant perspectives
s ,ITTLEUSEOFSTATE OF THE ARTIMAGINGTECHNIQUES
s &EWDATAONTHEPHYSIOLOGICALANATOMICALANDBIOMECHANICAL
changes that occur with treatment
s )NADEQUATEDATAONTHEEFFECTSOFTHESETHERAPIESATTHE
biochemical and cellular levels
s /NLYPRELIMINARYDATAONTHEPHYSIOLOGICALMEDIATORSINVOLVED
with the clinical outcomes
Clinical Studies: Trials

Forty-three clinical trials have been conducted on the use of spinal
manipulation for low-back pain, and there are numerous systematic
reviews and meta-analyses of the efcacy of spinal manipulation for
both acute and chronic low-back pain. These trials employed a variety
of manipulative techniques. Overall, manipulation studies of varying
quality show minimal to moderate evidence of short-term relief of
back pain. Information on cost-effectiveness, dosing, and long-term
benet is scant. Although clinical trials have found no evidence that
spinal manipulation is an effective treatment for asthma, hyperten-
sion, or dysmenorrhea, spinal manipulation may be as effective as
some medications for both migraine and tension headaches and may
offer short-term benets to those suffering from neck pain. Studies
have not compared the relative effectiveness of different manipula-
tive techniques.
Although there have been numerous published reports of clinical
trials evaluating the effects of various types of massage for a variety
of medical conditions (most with positive results), these trials were
almost all small, poorly designed, inadequately controlled, or lacking
adequate statistical analyses. For example, many trials included co-
interventions that made it impossible to evaluate the specic effects of
massage, while others evaluated massage delivered by individuals who
were not fully trained massage therapists or followed treatment pro-
tocols that did not reect common (or adequate) massage practice.
There have been very few well-designed controlled clinical trials
evaluating the effectiveness of massage for any condition, and only
three randomized controlled trials have specically evaluated massage
for the condition most frequently treated with massageback pain.
All three trials found massage to be effective, but two of these trials
were very small. More evidence is needed.
367
Risks
There are some risks associated with manipulation of the spine,
but most reported side effects have been mild and of short duration.
Although rare, incidents of stroke and vertebral artery dissection have
been reported following manipulation of the cervical spine. Despite the
fact that some forms of massage involve substantial force, massage is
generally considered to have few adverse effects. Contraindications for
massage include deep vein thrombosis, burns, skin infections, eczema,
open wounds, bone fractures, and advanced osteoporosis.
Utilization/Integration
In the United States, manipulative therapy is practiced primarily
by doctors of chiropractic, some osteopathic physicians, physical thera-
pists, and physiatrists. Doctors of chiropractic perform more than 90
percent of the spinal manipulations in the United States, and the vast
majority of the studies that have examined the cost and utilization of
spinal manipulation have focused on chiropractic.
Individual provider experience, traditional use, or arbitrary payer
capitation decisionsrather than the results of controlled clinical trials
determine many patient care decisions involving spinal manipulation.
More than 75 percent of private payers and 50 percent of managed care
organizations provide at least some reimbursement for chiropractic care.
Congress has mandated that the Department of Defense (DOD) and the
Department of Veterans Affairs provide chiropractic services to their
beneciaries, and there are DOD medical clinics offering manipulative
services by osteopathic physicians and physical therapists. The State of
Washington has mandated coverage of CAM services for medical condi-
tions normally covered by insurance. The integration of manipulative ser-
vices into health care has reached this level despite a dearth of evidence
about long-term effects, appropriate dosing, and cost-effectiveness.
Although the numbers of Americans using chiropractic and massage
are similar, massage therapists are licensed in fewer than 40 states,
and massage is much less likely than chiropractic to be covered by
HEALTHINSURANCE,IKESPINALMANIPULATIONMASSAGEISMOSTCOM-
monly used for musculoskeletal problems. However, a signicant frac-
tion of patients seek massage care for relaxation and stress relief.
Cost
A number of observational studies have looked at the costs as-
sociated with chiropractic spinal manipulation in comparison with
368
the costs of conventional medical care, with conicting results. Smith

and Stano found that overall health care expenditures were lower
for patients who received chiropractic treatment than for those who
received medical care in a fee-for-service environment. Carey and col-
leagues found chiropractic spinal manipulation to be more expensive
than primary medical care, but less expensive than specialty medical
care. Two randomized trials comparing the costs of chiropractic care
with the costs of physical therapy failed to nd evidence of cost sav-
ings through chiropractic treatment. The only study of massage that
measured costs found that the costs for subsequent back care following
massage were 40 percent lower than those following acupuncture or
self-care, but these differences were not statistically signicant.
Patient Satisfaction
Although there are no studies of patient satisfaction with manip-
ulation in general, numerous investigators have looked at patient
satisfaction with chiropractic care. Patients report very high levels of
satisfaction with chiropractic care. Satisfaction with massage treat-
ment has also been found to be very high.
369
Chapter 55
Alexander Technique
Why do I need the Alexander Technique?

You may be mystied by your back pain, excess tension, or lack of co-
ordination. You might have a chronic physical problem youd like to solve.
Perhaps you see your problem as hereditary, structural, unchangeable.
You may be unaware that how you move could be creating or compound-
ing your problem. You may not realize that how you go through your
daily activities needlessly strains your joints and muscles.
How can the Alexander Technique help me?

The Technique offers you a way to streamline what you do, mak-
ing your activities less stressful and more pleasurable. You come to
understand how your body can move most efciently. As you learn to
move more easily, you make surprising improvements in how you look
and feel. As you learn to apply Alexanders principles, you practice an
effective, lasting method of self-care.
What is the Alexander Technique?

The Alexander Technique is an intelligent way to solve the common
movement problems that cause chronic pain and stress. It is a way to
notice your movement habits, release compression, and move with ease
Frequently Asked Questions, by Joan Arnold and Hope Gillerman, Certi-
ed Teachers of the Alexander Technique, 2009. For additional information,
visit the website of the American Society for the Alexander Technique, www
.alexandertech.org.
371
and expansion. A proven self-care method, it is a set of skills that you

learn to relieve pain, prevent injury, and enhance performance.
How is the Alexander Technique different from other

approaches?
It is not a treatment, such as chiropractic or massage. Any treat-
ment has its own unique benets. The Alexander Techniques unique
contribution is a mode of self-management that gives you independence
in maintaining your health. Rather than being solely a recipient, you
learn to soothe your own nervous system, release your own muscles,
and balance your own structure. Alexander skills also make you a more
informed, receptive patient when you do need any kind of treatment.
It is not a set of exercises such as those you might learn in yoga,
physical therapy, Feldenkrais, Pilates, or the gym. Because the Alex-
ander Technique is a way to heighten awareness of how you move and
to better coordinate your body during activity, it helps you do specic
postures, procedures, or exercises with less strain and more comfort.
Since it is a tool to improve your overall coordination, you become a
more intelligent exerciser who can focus effort during a strenuous
challenge. You learn more about the body, and bring that rened un-
derstanding to a class or set of stretches.
What are the Alexander Techniques benets?

People who learn the Alexander Technique can better handle daily
stress and develop a long-term solution to chronic pain and muscular
tension. They acquire an enduring way to perceive tensions as they
arise and to restore their own balance.
s Self-careAs the premiere form of self-care, the Alexander
Technique helps people prevent injury and recover from chronic
back, hip and neck disorders, traumatic or repetitive strain in-
juries, balance and coordination disorders, arthritis, and muscle
spasms. It can also be helpful for people with asthma and stress-
related disorders, such as migraine headaches, sleep disorders,
and panic attacks.
s Skill enhancementAthletes use the Technique to help them
improve strength, endurance, exibility, and responsiveness. Per-
forming artists use it to lessen performance anxiety while im-
proving concentration and stage presence. Public speakers use it
to improve vocal projection and voice quality. Those in business
nd it enhances presentation skills and increases condence.
372
Alexander Technique
s Mental healthAs your posture and movement style im-

prove, you look and feel better. As your breathing capacity expands,
you have a greater resource of energy. Physicians recommend the
Alexander Technique to lessen the depression and anxiety asso-
ciated with chronic conditions. Psychotherapists also refer their
patients to Alexander Technique teachers. While you unravel
muscular tensions, you may perceive an emotional link to your
physical symptom. Study of the Alexander Technique can help
release emotion, can provoke deeper understanding of the self,
and can complement psychotherapy.
Who studies the Alexander Technique?

People of all types are Alexander students. They might come to re-
cuperate from an injury or surgery or for relief from chronic pain. They
may hear of the Technique from friends, physicians, or other health
professionals. Here are some examples of the many who have used
the Alexander Technique to improve their comfort level, professional
achievement, and their lives:
s 0ERFORMINGARTISTS
s 0ARENTS
s %XECUTIVES
s #OMPUTERUSERS
s 4HEWHEELCHAIRBOUND
What problems and conditions can the Alexander Tech-

nique help me resolve?
s Stress in daily lifeBecause the Alexander Technique helps
you change your response to stress, it can help you relieve or elim-
inate stress-related conditions. The bodys reaction to threata
fear reex marked by a tight neck and contracted bodyis a nat-
ural, adaptive response. But if the body does not unwind from
this contraction and stays in a constant state of emergency, we
pay a physical price. You can learn to restabilize and recuperate
from stress with the Alexander Technique: A set of body/mind
skills that helps you release contracted muscles, calm the ner-
vous system, and handle stressors more easily.
s Chronic painChronic pain can be the result of injury,
disease, structural abnormality, or muscular tension. Though
the Technique is not a miracle cure for medical conditions, by
373
reducing the stress response it can often provide a surprising degree

of relief. For conditions that cannot be changedsuch as rheuma-
toid arthritisit can still help the individual release the muscular
tension and fear response that accompany injury or disease.
s Back problemsOne of the most effective approaches to
chronic back problems, the Technique can address the under-
lying cause and often relieve the condition completely. When
there are unchangeable factors of disease or structure, the Al-
exander teachers soothing hands and helpful guidance enables
youwhatever your limitationto reach your full potential for
function. A 2008 British Medical Journal study reported a ran-
domized trial that showed Alexander Technique to be the most
effective tool in reducing or eliminating back pain (http://www
.bmj.com/cgi/content/full/337/aug19_2/a884).
s ArthritisStudying the Alexander Technique will help you
relieve pain, retain mobility, and increase range of motion. The
Alexander Technique teacher helps you see what in your move-
ment style causes joint compression and might exacerbate your
condition. As you re-educate your overall coordination, the torso
muscles support rather than compress the spine. Reduced com-
pression allows your body to expand during daily activities and
can help reduce pain.
s Postural problemsMany people develop unhealthy pos-
ture and movement habits that become deep-seated patterns of
strain. These habits are typically expressed by tight back and neck
muscles and collapsed stature. With the hands-on guidance of a
trained Alexander Technique teacher, you learn to elicit the pri-
mary controlan easy, dynamic relationship between the head
and spine. You gain access to the bodys elegant power steering.
You learn that nding poise can help to ease discomfort and
streamline movement. With greater uidity and stability, you
gain condence and a more positive self-image.
s Asthma and other breathing disordersAsthma is the
bodys respiratory reex gone awry. Neck muscles tighten, shoul-
ders yank up to the ears, and the abdominal muscles contract.
Sufferers say the greatest problem is rising panic at an attacks
onsetthe fear that they wont win the ght for the next breath.
These responses are elements of the startle pattern. With the Al-
exander Technique, asthmatics can halt the startle pattern and
calm the nervous system, inviting an easier balance in body and
374
Alexander Technique
mind. They can control or conquer their symptoms. Expanded

space in the torso and information about how to breathe can help
anyone who wants to improve breathing capacity and, with it,
overall vitality.
s Repetitive strain injury and carpal tunnel syndrome
The Alexander Technique addresses the cause of these wide-
SPREADINJURIES,ACKOFPOSTURALSUPPORTANDEXCESSJOINT
compression while working. With the Alexander Technique, you
learn to eliminate strain and perform repetitive movements with
ease and comfort. Much of our current epidemic of repetitive strain
injury and carpal tunnel syndrome could be alleviated if more
people learned how to:
s SITUPRIGHTEASILY
s DOREPEATEDMOTIONSWITHLESSMUSCULARTENSIONINTHE
shoulders, arms, and wrists;
s TAPTHEKEYBOARDANDMOUSELIGHTLY
s ATTUNETOTHEIRBODIESSIGNALS
How do I learn the Alexander Technique?

You learn the Technique from a highly trained professional in a
series of one-on-one sessions. Some teachers offer group classes, but
the Technique is most commonly offered privately. The teacher gives
you expert coaching tailored to your specic needs.
What happens in an Alexander Technique session?

In an Alexander Technique session, your teacher instructs you
with words and touchto approach movement differently. Using a
mirror, s/he helps you recognize your ingrained patterns and highlights
how your movement style relates to your symptoms. Your teacher uses
a specialized hands-on method to help you release areas of tension and
elicit your bodys capacity for dynamic expansion. With this expert
guidance, you learn the skills to replicate that ease and expansion on
your own. Over a course of sessions, you strip away the movement hab-
its at the root of your discomfort. You acquire a way to guide yourself
through daily activities that stays with you for the rest of your life.
What do I wear?
You come to your Alexander lesson wearing loose, comfortable
clothing.
375
What is an Alexander studio like?

The Alexander teachers studio is a low-tech environment with a
chair, bodywork table, and a mirror.
How long are sessions?

Usually 4560 minutes, the Alexander lesson is instruction tailored
to your needs.
Whats the point of a lesson?

An Alexander Technique session is an opportunity for you to unwind
and observe how your mind and body work. Your teacher gives you
focused, supportive coaching on how to use your increased awareness
to calm your system and raise your level of functioning.
What will we do?

Your Alexander teacher observes you doing simple actions, such as
sitting, standing, or walking. Using a mirror, s/he helps you see and
sense how your movement style relates to your problem. There are two
aspects to an Alexander lesson:
s Table workWhile you lie clothed on a bodywork table and
settle into restful state, the teacher gently moves your head and
limbs, encouraging expansion. S/he guides you with a unique,
informative touch that does not intrude or manipulate, but sug-
gests soothing release and an enlivened kinesthetic sense.
s Guidance during activityWhile you perform ordinary move-
ments, the teacher gives you verbal, visual, and conceptual cues
to help you sit, stand, walk, or reach more comfortably. You con-
sider activities you would like to enhance, such as public speaking,
lifting and carrying, computer work, practicing yoga or a martial
art, playing your favorite sport, or even sleeping comfortably.
Performers can choose to work on a monologue, an aria, or a dance
movement. If you would like to rene a specialized activity
such as how you swing a tennis racket, lift a child, or play an
instrumentthe teacher can help you reduce compression and
increase overall physical support as you do it.
How can an Alexander Technique teacher help me?

Your Alexander Technique teacher offers personally tailored instruc-
tion with a unique hands-on approach, helping you see what in your
376
Alexander Technique
individual movement style contributes to your recurring problem. As

he or she helps you to release muscular tension and restore your bodys
original poise, you learn to sit, stand, and move with safety, balance,
and ease. Your teacher can point out the source of your problem. With
anatomical pictures s/he helps you to better understand the bodys
functioning. S/he considers your entire bodynot just segmentsand
looks at you as the dynamic creature you are.
Who can benet from learning the Alexander Technique?

s Computer usersIn the current epidemic of repetitive strain
injury, carpal tunnel syndrome, chronic back pain, headaches,
and stress-related disorders, many computer users suffer. While
ergonomic design can improve the work stationchair design,
monitor, and keyboard placementthe Alexander Technique
enables you to use your own bodys design, even when the work
station is not ideal. By understanding the Techniques basic al-
phabet of movement, you can avoid injury and often relieve the
agonizing symptoms associated with computer use.
Your Alexander Technique teacher guides you to:
s SITUPRIGHTWITHOUTSTRAIN
s PREVENTSPINALCOMPRESSIONANDMUSCULARTENSIONINTHE
neck, shoulders, and upper back;
s ENCOURAGEFREERRANGEOFMOTIONINTHEJOINTSANDMUSCLES
s TAPTHEKEYBOARDANDMOUSELIGHTLYTOREDUCESTRESSONTHE
wrist and carpal tunnel;
s ATTUNETOYOURBODYSSIGNALSHEEDEARLYWARNINGSTRESS
signs, and ward off pain before it escalates;
s BREATHEPROPERLYTOPREVENTFATIGUEANDSOOTHETHENERVOUS
system;
s RESTOREBALANCEINYOURBACKDURINGANDAFTERWORKEACHDAY
s Singers, dancers, actors, and musiciansPerforming art-
ists study the Technique to reduce performance anxiety, lessen the
likelihood of injury, and enhance stage presence. The Alexander
Technique gives them sharp focus, a highly rened sensory
awareness, efcient use of their energy, excellent balance and
coordination and an inner sense of calm. Some of the renowned
actors and musicians who have been using the Alexander Tech-
nique since the beginning of this century are: Julie Andrews,
377
William Hurt, Jeremy Irons, James Earl Jones, Paul McCartney,

+ELLEY-C'ILLIS0ATTI,UPONE0AUL.EWMAN3TING-AGGIE
Smith, Mary Steenbergen, Robin Williams, Joanne Woodward,
and members of the New York Philharmonic.
s Athletes and tness enthusiastsThough the Technique is
a wonderful stress reducer, you can also use it during vigorous
activities. If you work out, proper form and degree of muscular
tension are just as important as how strenuously or how often
you exercise. By demonstrating principles of efcient movement,
the Alexander teacher offers the tness enthusiast a way to
prevent injury and gain better results. Studying the Technique
gives you the skills to prevent pain while you improve breathing,
balance, and posture. Together, you and your Alexander teacher
can explore how to solve movement problems and optimize your
performance, adding to your achievement and enjoyment. You
can apply the Technique to any activitytennis, golf, skiing,
baseball, horseback riding, basketball, etc.
s Pregnant womenThe Alexander Technique has much to offer
women before, during, and after childbirth.
s "EFOREPREGNANCYYOUCANUSETHE4ECHNIQUETOUNLEARN
harmful postural habits while improving balance and coor-
dination. This enables you to manage your body during the
changes pregnancy brings.
s $URINGPREGNANCYTHE!LEXANDERTEACHERCANHELPELIMINATE
lower back pain caused by increased weight in front of the
body. The babys growth limits the mothers internal space
and her organs become compressed. This can result in diges-
tive problems and shortness of breath. Use of the Alexander
Technique will allow more internal space for both mother
and baby. With more breath and mobility, the mother can
stay active. To help the mother prepare for labor and deliv-
ery, Alexander Technique lessons coordinate breathing and
strengthen pelvic muscles.
s $URINGCHILDBIRTHTHE!LEXANDER4ECHNIQUECANHELPTHE
mother manage the physical challenges.
s !FTERCHILDBIRTHAMOTHERCANCONTINUETOUSETHE4ECHNIQUE
to help focus on her own self care while nourishing and car-
ing for her child. Both parents can learn how to manage the
constant lifting and carrying that come with parenthood.
378
Alexander Technique
How did the Alexander Technique begin?

The Alexander Technique was developed by F.M. Alexander (1869
1955). As a young Australian actor, he suffered from a vocal problem
that interrupted his burgeoning career as a Shakespearean actor.
Frustrated by this limitation, he studied his own movement for the
cause of his problem. Through a long process of self-observation and ex-
periment, he evolved a way to restore full use of his voice. In exploring
how to help himself and others, he discovered the crucial importance
of the relationship between the head, neck, and spine. He named this
relationship the primary control because he perceived it as primary
in controlling posture, breath, and movement. He developed a way to
teach people how to elicit the primary control in their daily lives.
What are the Alexander Techniques basic ideas?

Though your body is much more elaborate and subtle than any
machine, you can understand the Alexander Techniques basic ideas
by comparing it to driving a car. You use the mirrors (awareness), the
brake (inhibition), and the gas (direction). As you develop each of these
skills and learn to use them all together, you gain access to your bodys
power steeringthe primary control. Just as you dont have to focus on
every detail of a cars operation, you learn about your bodys capacity
to respond and coordinate each of its systems to work together, as an
integrated whole.
s Primary controlThe primary control is the relationship
between the head, neck, and spine. The quality of that relation-
shipcompressed or freedetermines the quality of our overall
movement and functioning. When the neck is not overworking,
the head balances lightly atop the spine, the torso expands and
breath comes more easily. We restore the efcacy of the postural
reexa natural, dynamic force that counters gravity and easily
guides the torso upward. You elicit your bodys primary control
by developing three interlocking skills:
s !WARENESS-ANYPEOPLEDONTREALIZETHESOURCEOFTHEIR
limitation, aches, or chronic pain. You acquire a powerful tool
when you rene awareness of your habitual tendencies, ob-
serve how you operate moment to moment, and understand
how your body works best.
s )NHIBITION4HOUGHWEOFTENTENDTOTHINKWERENOTDO-
ing enough, Alexander found that our habits of tension and
compression interfere with our bodys ingenious design. By
379
catching ourselves as we move with compression and reduc-

ing excess muscular effort, we can inhibit (or stop) compres-
sive habits and stress responses. We can actually accomplish
more by doing less.
s $IRECTION%ACHOFUSHASTHECAPACITYTOVISUALIZEMOVE-
ment and mentally guide the ow of force through the body.
Rather than gunning the motor and muscling our way through
an activity, we can use the mind to director envision
dynamic expansion while moving. By doing so, the bodys
reexive coordination seems to handle the action by itself,
gracefully and effortlessly.
How long will it be before I see results?

Each lesson will bring new insights that you can apply immediately,
and you will probably feel the effects of your Alexander Technique work
within the rst 610 lessons. As you continue and your understanding
grows, you will be able to apply what youve learned to a wider range of
activities. Instead of a quick x with a eeting effect, you will experi-
ence a gradual change and long-term results.
How long should I take lessons to get the full benet?

,IKEANYSKILLITTAKESPRACTICE!SERIESOFLESSONSONCEORTWICEA
week for 3 to 6 months, is the best way for you to learn the Technique.
Does everyone need the same number of lessons?

The number of lessons you need depends upon your goals, interests,
and physical condition. Some students study for 35 months, others
continue taking lessons after reaching their initial goals and continue
for years. Duration of study is up to you.
Do the Alexander Techniques benets wear off when I stop

taking lessons?
Not if you continue to use what you have learned! While taking les-
sons, you reclaim your bodys natural sense of ease and increase your
understanding of how you function. This practice enables you to take
the mind/body process wherever you go and apply it to anything you
do, such as riding a bike, sitting through a long meeting, playing an
instrument, swinging a racket, or carrying luggage. You can continue
to build your skills on your own after you stop taking lessons.
380
Alexander Technique
Since F.M. Alexander was not a physician, why should the

medical eld take the Alexander Technique seriously?
Because it works! The Alexander Technique is a proven, safe, self-
care method to stop pain, muscle tension, and stress cause by everyday
misuse of the body.
s Endorsed by physicians and health care professionalsThe
Alexander Technique is offered in wellness centers and health edu-
cation programs. Medical professionals of every kind recommend
the Alexander Technique for chronic back pain, migraines, repetitive
stress injuries, balance and coordination problems, and for the de-
pression and anxiety that often accompanies chronic pain and stress.
s Endorsed by scientistsAlexanders ndings are supported
by behavioral scientists and physiologists including Nobel laure-
ate Sir Charles Sherrington, Dr. Rudolph Magnus, G.E. Coghill,
Frank Pierce Jones, and Nikolaus Tinbergen, who noted Alexan-
ders discoveries in his Nobel Prize acceptance speech.
s An established record of successClinical studies have
shown that the Technique modies stress responses while im-
proving breathing capacity and posture. In a 1988 study of
chronic pain sufferers, the Alexander Technique was chosen as
patients preferred method of reducing pain.
Is the Alexander Technique just another health fad?

Now over 100 years old, the Alexander Technique has a long track
record of helping people with back problems, chronic pain and tension,
posture and movement disorders, asthma, migraines, and whiplash. As
its wide applications are understood and its successes continue to mul-
tiply, the reputation of the Technique is growing. Today there are about
2,500 teachers worldwide, with about 700 in the United States.
What are Alexander Technique teachers like?

Many have come from the performing arts, such as dance, theater,
or music. Some are physical therapists, massage therapists, or teach-
ers in another eld.
What training is required to be an Alexander Technique

teacher?
AmSAT-certied Alexander Technique teachers must complete 1,600
hours of training over a minimum of 3 years in an AmSAT-approved
381
training program. To assure quality instruction, each Alexander Teach-

ing Training Program maintains a ve-to-one student/teacher ratio.
Alexander teachers must practice what they teach: the ability to in-
tegrate and streamline their own movement while guiding their clients
toward improved functioning. They acquire this ability from expert
mentors through long hours of intense, focused hands-on training.
Alexander practitioners are trained in careful visual observation to
spot the source of movement problems. They are schooled in teaching
skills that encourage learning in a non-judgmental, supportive atmo-
sphere. And they are trained in the unique Alexander touch, a com-
plex combination of kinesthetic receptivity and the subtle suggestion
of expansion and lightness in movement. Additional studies include
anatomy, study of F.M. Alexanders theoretical writings, literature, and
research by Alexander scholars and those in related elds.
What is AmSAT?
The American Society of the Alexander Technique is the largest pro-
fessional association of certied Alexander Technique teachers in the
United States. Its mission is to maintain the integrity of the Alexander
Technique as developed by F.M. Alexander (18691955). AmSAT main-
tains the nations highest standards for teacher training, certication,
and membership and maintains afliations with similar credentialing
bodies worldwide. Since its formation in 1987, over 1,200 teachers have
completed a rigorous training process to earn AmSAT certication.
382
Chapter 56
Aquatic Therapy
(Hydrotherapy)
The Standards and Steering Committees of the Aquatic Therapy

and Rehabilitation Industry Certication dene aquatic therapy and
rehabilitation as: The use of water and specically designed activity
by qualied personnel to aid in the restoration, extension, maintenance
and quality of function for persons with acute, transient, or chronic
disabilities, syndromes or diseases.
Denition of Hydrotherapy
Hydrotherapy is the use of water by external applications, either
for its pressure effect or as a means of applying physical energy to a
tissue. The term often refers to the use of water in wound manage-
ment, such as whirlpool baths, but can be used interchangeably with
the term, aquatic therapy.
Denition of Adapted Aquatics

Adapted aquatics are techniques that emphasize swimming skills
modied or adapted to accommodate individual abilities. Usually
used with people with disabilities, adapted aquatics focuses on skills
Aquatic Therapy, 2006 National Center on Physical Activity and Dis-

ability. This copyrighted article is reproduced from the National Center on
Physical Activity and Disability at www.ncpad.org. It may be freely distributed
in its entirety as long as it includes this notice but cannot be edited, modied,
or otherwise altered without the express written permission of NCPAD. Contact
NCPAD at 1-800-900-8086 for additional details.
383
including pool entry and exit and swimming skill development, and
should also encompass community referral.
Indications for Aquatic Therapy

s 3ENSORYDISORDERS
s ,IMITEDRANGEOFMOTION
s 7EAKNESS
s 0OORMOTORCOORDINATION
s 0AIN
s 3PASTICITY
s 0ERCEPTUALSPATIALPROBLEMS
s "ALANCEDElCITS
s 2ESPIRATORYPROBLEMS
s #IRCULATORYPROBLEMS
s $EPRESSIONPOORSELF ESTEEM
s #ARDIACDISEASES
s *OINTREPLACEMENT
s -OTORLEARNING
s /RTHOPEDICINJURIESTRAUMA
s /BESITY
s 0RENATAL
s .EUROLOGICAL-3;MULTIPLESCLEROSIS=
s /STEOPOROSIS
s 2HEUMATOLOGYARTHRITISlBROMYALGIA
Aquatic Therapy Techniques

Ai Chi
Created by Jun Konno of Japan, ai chi is a combination of deep
breathing and slow broad movements of the arms, legs, and torso,
using concepts of Tai Chi, Shiatsu, and Qigong. Ai Chi is performed
standing in shoulder-depth water with an ideal pool temperature of
88 degrees Fahrenheit to 96 degrees Fahrenheit.
384
Aquatic Therapy (Hydrotherapy)
Ai Chi Ne
Ai Chi Ne (pronounced Eye Chee Knee) is a partner stretching pro-
gram. Ne is the Japanese word for two. Ai Chi Ne involves breathing
techniques to increase relaxation and therefore enhance the stretch
abilities. Using the breathing techniques decreases stress, joint ten-
sion, muscular tension, and the stretch reex response.
BackHab
This is an integrated program that the individual can do on his or
her own. It was developed for people with back problems but is now
being used by group programs for people with disabilities. Rather than
focusing on healing one part of the body, all the body parts coordinate
to work on healing and xing the affected area. BackHab is an aquatic
walking program using various strides to accomplish a variety of ben-
ets. It is excellent for gait re-training.
Bad Ragaz
This technique originated in Germany in 1957 and was introduced
by a German therapist to the therapeutic thermal pools of Bad Ragaz
in Switzerland. The technique has since become more clearly dened
as the Bad Ragaz Ring Method. Bad Ragaz is a method of muscle re-
education utilizing specic patterns of resistance, endurance, elonga-
tion, relaxation, range of motion, and tonal reduction.
The Burdenko Method

The Burdenko Method is used for athletic training and as a thera-
peutic method for people with disabilities. The basic concepts include
integrating land and water therapy, using a vertical position, focusing
on the whole body, and homework.
Feldenkrais
Developed by Dr. Moshe Feldenkrais, this method uses gentle move-
ment and directed attention to improve movement and enhance human
functioning. This method aims to increase ease and range of motion,
improve exibility and coordination, and encourage the individual
to rediscover innate capacity for graceful, efcient movement. These
improvements will often generalize to enhance functioning in other
aspects of life.
385
Halliwick
The Halliwick concept is an approach to teaching people with physi-
cal and/or learning difculties to participate in water activities, to move
independently in water, and to swim. The practice utilizes the Ten Point
Program, which includes essential components of motor learning, and even-
tually leads to independence in the water. The Ten Point Program includes
the concepts of mental adjustment, balance control, and movement.
Lyu Ki Dou
,YU+I$OUDEVELOPEDFROMSTUDIESOFVARIOUSHANDS ONHEALING
modalities, along with Ai Chi, Tai Chi, and Qi Gong. The name was
DERIVEDFROMTHE*APANESETRANSLATIONOFh&LOATING,IFE%NERGY0ATH-
WAYSv,YU+I$OUEMPHASIZESTHEFACILITATORSSELF CAREWHICHINTURN
will benet the clients/patients that are receiving any type of therapy
or exercise programming from an individual who has literally turned
on this vital life-giving energy source that is inside each of us.
Massage
Massage therapists have moved their practice to the water to ex-
pand the benets and applications of massage. Water massage, the use
of soft tissue manipulation and body mobilization techniques in water
warmer than skin temperature (92 degrees Fahrenheit93 degrees
Fahrenheit), is evolving as a therapeutic method. Practitioners nd
that the use of massage in water is creative, innovative, and individu-
alized, and no two practitioners have the same approach.
Proprioceptive Neuromuscular Facilitation (PNF)

PNF is an approach to therapeutic exercise which aims to improve
motor skill through positive motor transfer, using the principles of
facilitation/inhibition, irradiation/reinforcement, and reciprocal in-
nervation. Exercises consist of spiral and diagonal patterns and must
incorporate three components of motion: exion or extension, adduction
or abduction, and rotation.
Water Pilates
Pilates exercises have been adapted for the pool. Created by Joseph
Pilates, this body conditioning program is designed to improve strength,
exibility, and range of motion, and also encourages musculoskeletal
alignment. The main tenets are resisting your own weight, controlled
breathing, spine alignment, and abdominal strengthening.
386
Unpredictable Command Technique (UCT)

Created by David Ogden, a PT [physical therapist] from Phoenix,
AZ, UCT has a goal of progressing the client(s) so that two or more
motor movements are done simultaneously. Improved somatic aware-
ness and motor control can be achieved through the challenge to do
a variety of constantly-changing familiar and unfamiliar activities.
Using the UCT, the author and others have observed client(s) dem-
onstrating improved voluntary control, awareness of movement and
body in space, and enhanced mental concentration.
Wassertanzen
Wassertanzen is a dynamic movement therapy that includes work below
the water surface with the aid of nose clips. Wassertanzen means water
dance and was created in 1987 by Swiss-Germans Arjana Brunschwiler
and Aman Schroter. Wassertanzen is very different from watsu because
of the challenge it presents for a person to surrender control of his breath
to go underwater, says Harold Dull, creator of Watsu.
Water Yoga
Hatha yoga poses performed in warm, waist- to chest-depth water
develop strength and static balance simultaneously. In addition, range
of motion increases in coordination with diaphragmatic breathing and
long exhalations.
Watsu
Developed by Harold Dull, watsu (water + shiatsu) is a cradling, one-
on-one program that is experienced in a very warm (approx. 94 degrees
Fahrenheit) pool. The client is held in the water by the practitioner and
moved using the water to massage the body. Shiatsu (acupressure) points
are stimulated along the meridians of the body during the massage. Watsu
is used for pain reduction, increased range of motion, increased circulation,
psychological problems, relaxation, and reduction of stress. It has been
used in rehabilitation programs for people with orthopedic problems or
physical disabilities, for pregnant mothers, and the elderly.
Yogalates
Fluid Yogalates, developed by Dr. Mary Wykle, combines Iyengar
Yoga, Pilates, and Ai Chi. Static poses and core stabilization exercises are
transitioned with circular movements and emphasis on deep breathing
387
to create a continual uid program. The objectives are increased body

awareness, strength, range of motion, relaxation, and an inward focus.
Adaptations and Modications

s %QUIPMENT
s "EGINSLOWLY
s 5SEPROGRESSIVEOVERLOADPUSHINGAMUSCLEPASTITSNORMAL
capacity. This is a basic principle of exercise and is necessary to
increase strength, exibility, and conditioning.)
s "EGINWITHCONSERVATIVE2/-;RANGEOFMOTION=
s #ONSIDERWEARINGAQUA SHOESFORPROTECTIONANDSLIPRESISTANCE
s 5SEGOODTECHNIQUEASTOLERATEDSTOPWITHPOORTECHNIQUE
Exercise Session Format

s 3TARTWITHTOMINUTESANDINCREASEIN MINUTEINTERVALS
s 5SEDEEPBREATHINGTOINCREASEVITALCAPACITY
s 5SEGRADUALPROGRESSIVEOVERLOAD
s 7ORKONBALANCE
s 7ORKONSTRENGTH
s 7ORKONmEXIBILITY
s ,ONGERCOOLDOWN
Program Modications
s 5SEFEWERREPSOFTHESAMEMUSCLEGROUPWHENBEGINNING
s #ENTERTHEBODYBETWEENTRANSITIONS
s 2EACHACROSSTHEMIDLINEANDOVERHEADACROSS
s 5SEHANDSBEHINDHEADANDBODY
s -OVEBACKWARDASWELLASFORWARD
s %XERCISETOIMPROVEPOSTURE
s 5SESLOWCONTROLLEDMOVEMENT
s "EGINWEIGHT BEARINGISSUESINDEEPERWATERANDPROGRESSTO
shallower.
s %NTERWATERSLOWLYSOALLSYSTEMSHAVEANOPPORTUNITYTO
gradually accommodate the environment.
s +EEPMEDICATIONSATPOOLEDGE
388
Sample Aquatic Therapy Exercise Program I

Begin at pool edge with spinal alignment and postural awareness
with Water Pilates.
Exercise: The Hundred

1. In waist-deep water at the side of the pool, sit in an imaginary
chair. Thighs are parallel to the bottom of the pool and knees
align over the ankles. The back is against the pool wall and re-
mains immobile throughout the exercise. Arms are at the sides
with palms facing backward and shoulders are relaxed. The
head faces straight ahead.
2. Begin pumping the arms forward and back about 6 inches.
3. Inhale for ve counts and exhale for ve counts.
4. Keep the back against the pool wall.
#HALLENGES,EARNINGTOhSCOOPvTHESTOMACHINTOSETTHEBACKTO
the wall is the main concern. Encourage full breaths.
Progression: Gradually increase the pumping action with the arms
coordinated with the breath until you count to 100.
Exercise: Single Leg Circles

1. In waist-deep water at the side of the pool, sit in an imaginary
chair. Thighs are parallel to the bottom of the pool and knees
align over the ankles. The back is against the pool wall and re-
mains immobile throughout the exercise. Arms are at the sides
with palms facing backward and against the wall. Shoulders
should be relaxed. The head looks straight ahead.
,IFTTHERIGHTLEGABOUTINCHESANDSTRAIGHTEN4URNTHELEG
out slightly from the hip socket.
3. Begin the leg circle by moving the leg across the body, then cir-
cling it down, around, and back to the starting position. The back
does not move from the wall. Complete ve circles. Inhale as you
begin the motion and exhale to return to the starting position.
4. Reverse the direction of the circle starting outward, continuing
down, then across the body, and return to the starting position.
5. Repeat the leg circles with the left leg.
Challenges: Emphasize that only the leg moves with the back, hips,
and arms staying stable against the pool wall.
389
Progression: Gradually increase the size of the circles while main-

taining control throughout the movement.
Sample Aquatic Therapy Exercise Program II

Use BackHab exercises for integrating cardio, mobility, coordina-
tion, balance, ROM, and motor skills.
Exercise: On Toes
s 'OAL"ALANCECOORDINATIONEXPERIENCEOFAXIALELONGATION
s #ONSIDERATIONS%LIMINATELEANINGFORWARDKEEPmOWINGNOTJERKY
s 0ROGRESSION,ENGTHENSTRIDE
Exercise: On Heels
s 'OAL"ALANCESTRETCHOFCALFMUSCLESGASTROCNEMIUS
endurance of tibialis anterior
s #ONSIDERATIONS+EEPTORSOUPRIGHTKEEPmOWINGNOTJERKY
s 0ROGRESSION.OARMS
Exercise: High Knee

s 'OAL'LUTEALANDHAMSTRINGENDURANCEmEXIBILITY
s #ONSIDERATIONS,IFTBOTHKNEESEQUALLYPRESSFOOTBACKWHEN
moving backward
s 0ROGRESSION(EAVYADDPAUSEORSTOP
Exercise: Side Lifts (Hip Abduction)

s 'OAL3TRENGTHENABDUCTORSANDADDUCTORSBALANCESTRUCTURAL
stability for knee
s #ONSIDERATIONS%LIMINATEEXTERNALHIPROTATIONEQUALLIFTAND
stride length
s 0ROGRESSION0AUSEORSTOP
Exercise: Dips (Lunge)

s 'OAL"ENDINGSKILLSINCREASEMUSCLETONEANDmEXIBILITY
s #ONSIDERATIONS-AINTAINUPRIGHTSTANCEONLUNGELUNGEWITHOUT
slamming
s 0ROGRESSION5SEEXPLOSIVEPOWERONABDUCTION
390
Sample Aquatic Therapy Exercise Program III

Use Fluid Yogalates and Ai Chi for re-patterning and to further
develop coordination, balance, ROM, and pain-free movement. These
can also be used for relaxation unless a trained practitioner is avail-
able to offer Watsu.
Fluid Yogalates
PoseWarrior II:
1. In waist- to chest-deep water, separate legs approximately 4 feet.
2. Turn the right foot to the side and come into a lunge position.
The right ankle and knee align. The right thigh should be al-
most parallel to the bottom of the pool. The back leg (left) con-
tinues to bear weight, pushing the energy ow up to the torso.
3. The torso remains upright and facing forward. It does not rotate.
4. The arms extend out from the shoulders. Extension continues
through the ngertips. The shoulders remain relaxed and down.
5. The head turns to look through the ngers of the leading arm.
Maintain this position for ve or more slow breaths.
6. Repeat to the left side.
Challenges: It is difcult to adequately separate the legs and main-
tain balance. The leading knee has a tendency to rotate inward. The
body leans forward or backward if the weight is not distributed be-
tween the legs.
Progression: Hold for longer periods. Add variations such as Side
Angle Pose.
PoseWarrior I:
1. In waist- to chest-deep water, separate legs approximately 4 feet.
2. Turn the right foot and leg to the side. Rotate the entire body
to the same side. The left leg and foot also turn in the same
direction. Insure the pelvis is squared to the side.
3. Bend the right knee, aligning the knee over the ankle. The left
leg remains straight.
4. Extend the arms above the head with palm facing each other
and hold for approximately ve breaths.
5. Repeat to the left side.
391
Challenges: Maintaining balance in the water with the arms ex-

tended out of the water. Caution to limit extension of the back and
discourage hyperextension.
Progression: Extend the left (back) heel to the bottom of the pool.
Progress to other poses such as Warrior III.
PoseTree:
3TANDERECTINWAIST TOCHEST DEEPWATER,OOKSTRAIGHTAHEAD
2. Balancing on one leg, ex the knee of the opposite leg and lift
that foot to the inside of the supporting leg.
3. Arms bend into prayer position at chest level.
4. Gradually extend the arms overhead, keeping the palms
together. Body stays straight and appears to lengthen.
5. Begin by trying to hold the position for ve breaths. Repeat on
the other side.
Challenges: Do not place the foot of the bent leg against the sup-
porting knee. Extend the arms overhead only when balance is secure.
Watch the body position because of a tendency to shift one hip to the
side to assist with balance.
0ROGRESSION (OLD FOR LONGER PERIODS ,ENGTHEN BODY AND ARMS
upward.
Ai Chi
Accepting:
1. Exhale easily through your mouth, turn your palms down,
bring the right arm over to the left so the thumbs of both hands
touch each other, while pivoting both feet 90 degrees left so youre
facing the left side. Your weight is evenly balanced between
both legs.
2. While still facing left, inhale through your nose, turn your
palms up, and pull both arms back so that your rib cage feels
fully opened. At the same time, shift your weight back on the
right leg so that youre leaning back slightly. The trunk must
be stable.
3. While still facing left, exhale through your mouth, turn your
palms down, and bring both arms together so the thumbs of
both hands touch each other. At the same time, shift your weight
forward onto the left leg so youre leaning forward slightly.
392
4. Repeat steps two and three, owing smoothly 5 to 10 times.

5. Inhale through your nose, turn your palms up, bring the right
arm back to the right side, while pivoting both feet 90 degrees
right so youre facing front.
bring the left arm over to the right so the thumbs of both
hands touch each other, while pivoting both feet 90 degrees
right so youre facing the right side. Your weight is evenly
balanced between both legs.
7. While still facing right, inhale through your nose, turn your
palms up, and pull both arms back so that your rib cage feels
fully opened. At the same time, shift your weight back on the
left leg so that youre leaning back slightly.
8. While still facing right, exhale through your mouth, turn your
both hands touch each other. At the same time, shift your weight
forward onto the right leg so youre leaning forward slightly.
9. Repeat steps seven and eight, owing smoothly 5 to 10 times.
10. Inhale through your nose, turn your palms up, bring the left arm
back to the left side, while pivoting both feet 90 degrees left so
youre facing front.
Rounding:
touch each other, while pivoting both feet 90 degrees left so
youre facing the left side. Your weight is evenly balanced be-
tween both legs.
palms up, pull arms back so that your rib cage feels fully
opened. At the same time, step your right leg back and shift
your weight back so youre leaning back slightly.
both hands touch each other. At the same time, lift your right
leg straight in front of you and lean forward slightly. Bring
toes to ngertips.
4. Repeat steps two and three, owing smoothly 5 to 10 times.
393
5. Inhale through your nose, turn your palms up, bring the right
arm back to the right side, while pivoting both feet 90 degrees
right so youre facing front.
palms up, pull arms back so that your rib cage feels fully opened.
At the same time step your left leg back and shift your weight
back so youre leaning back slightly.
8. While still facing right, exhale through your mouth, turn your
both hands touch each other. At the same time, lift your left leg
straight in front of you and lean forward slightly. Bring toes
and ngertips together.
9. Repeat steps seven and eight, owing smoothly 5 to 10 times.
10. Inhale through your nose, turn your palms up, bring the left arm
back to the left side, while pivoting both feet 90 degrees left so
youre facing front.
Balancing:
touch each other, while pivoting both feet 90 degrees left so
youre facing the left side. Your weight is evenly balanced be-
tween both legs.
palms up, and press both arms down and back (bilateral shoulder
extension) with hands supinated. At the same time, lift your
right (back) leg forward and lean forward slightly.
palms down, and lift both arms forward and up (bilateral shoul-
der exion with hands pronated). At the same time, stretch the
RIGHTLEGBACKBUTDONOTSTEPITDOWN,EANFORWARD2EPEAT
steps two and three, owing smoothly 5 to 10 times without
stepping the right leg down. Inhale through your nose, turn
your palms up, bring the right arm back to the right side,
394
while stepping the right foot down and pivoting both feet 90
degrees right so youre facing front.
palms up, and press both arms down and back (bilateral shoul-
der extension with hands supinated). At the same time, lift
your left (back) leg forward and lean forward slightly.
6. While still facing right, exhale through your mouth, turn
your palms down, and lift both arms forward and up (bilat-
eral shoulder exion with hands pronated). At the same time,
STRETCHTHELEFTLEGBACKBUTDONOTSTEPITDOWN,EANFORWARD
7. Repeat steps seven and eight, owing smoothly 5 to 10 times
without stepping the left leg down.
8. Inhale through your nose, turn your palms up, bring the left
arm back to the left side, while pivoting both feet 90 degrees
left so youre facing front.
About the Author

An internationally recognized leader in the health and tness
industry, Ruth Sova is dedicated to the growth and betterment of
the industry through her tireless research and development efforts.
She has founded eight successful businesses and holds numerous
honors and awards in the industry. She educates and energizes
audiences with her presentations on personal growth, entrepre-
neurship, health, tness, wellness, running a business, and aquatic
rehab and tness.
In 1994, she founded the Aquatic Therapy and Rehab Institute, Inc.
(ATRI), a non-prot educational organization dedicated to the profes-
sional development of health care professionals involved with aquatic
therapy. ATRI, with headquarters in Chassell, MI, offers continuing
education courses at conferences and workshops that advance the
knowledge and skills of the aquatic therapist. She is also the founder
and past president of the Aquatic Exercise Association (AEA), a non-
prot international association serving as a clearinghouse for all as-
pects of the aquatics industry.
395
Organizations
1. American Alliance for Health, Physical Education, Recreation,
and Dance [http://www.ncpad.org/organizations/index.php?id=
1056&state=Virginia&city=Reston], Reston, Virginia
2. American Red Cross [http://www.ncpad.org/organizations/index
.php?id=974&state=District of Columbia&city=Washington],
Washington, District of Columbia
3. Aquatic Exercise Association (AEA) [http://www.ncpad.org/
organizations/index.php?id=876&state=Florida&city=North
Venice], North Venice, Florida
4. Aquatic Resources Network [http://www.ncpad.org/organizations/
index.php?id=1517&state=Wisconsin&city=Amery], Amery,
Wisconsin
5. Aquatic Therapy and Rehab Institute (ATRI) [http://www
.ncpad.org/organizations/index.php?id=877&state=Florida&cit
y=West Palm Beach], West Palm Beach, Florida
6. International Council for Aquatic Therapy and Rehabilitation
[http://www.ncpad.org/organizations/index.php?id=1518&state
=Washington&city=Spokane], Spokane, Washington
7. Jeff Ellis & Associates [http://www.ncpad.org/organizations/index
.php?id=1058&state=Texas&city=Kingwood], Kingwood, Texas
8. National Therapeutic Recreation Society [http://www.ncpad
.org/organizations/index.php?id=920&state=Virginia&city=As
hburn], Ashburn, Virginia
9. Worldwide Aquatic Bodywork Association [http://www.ncpad
.org/organizations/index.php?id=1520&state=California&city=
Middletown], Middletown, California
10. Aquatic Consulting & Education Resource Services [http://www
.ncpad.org/organizations/index.php?id=1521&state=Wisconsin&ci
ty=Milwaukee], Milwaukee, Wisconsin
11. Aquatic Consulting Services [http://www.ncpad.org/organizations/
index.php?id=1522&state=California&city=San Diego], San Di-
ego, California
12. Aquatic Healing Services [http://www.ncpad.org/organizations/
index.php?id=1523&state=Virginia&city=Charlottesville],
Charlottesville, Virginia
396
13. Burdenko Water and Sports Therapy Institute [http://www.ncpad

.org/organizations/index.php?id=1525&state=Massachusetts&cit
y=Wayland], Wayland, Massachusetts
14. Essert AssociatesAquatic Therapy [http://www.ncpad.org/
organizations/index.php?id=1527&state=Arkansas&city=Conwa
y], Conway, Arkansas
15. MW Aquatics [http://www.ncpad.org/organizations/index.php?id=
1530&state=Virginia&city=Burke], Burke, Virginia
16. Therapeutic Aquatics, Inc. [http://www.ncpad.org/organizations/
index.php?id=1534&state=Wyoming&city=Jackson], Jackson,
Wyoming
Suppliers
1. Adolf Kiefer and Associates [http://www.ncpad.org/suppliers/
index.php?id=651&state=Illinois&city=Zion], Zion, Illinois
2. Aqua Gear, Inc. [http://www.ncpad.org/suppliers/index.php?id=
752&state=Florida&city=West Palm Beach], West Palm Beach,
Florida
3. Blue Moon Aqua Products, TRMN Enterprises, Inc. [http://
www.ncpad.org/suppliers/index.php?id=753&state=Ohio&city=
Columbus], Columbus, Ohio
4. Danmar Products, Inc. [http://www.ncpad.org/suppliers/index
.php?id=351&state=Michigan&city=Ann Arbor], Ann Arbor,
Michigan
5. Ferno-Washington, Inc. [http://www.ncpad.org/suppliers/index
.php?id=754&state=Ohio&city=Wilmington], Wilmington, Ohio
6. Fitness Mart Country Technology, Inc. [http://www.ncpad.org/
suppliers/index.php?id=755&state=Wisconsin&city=Gays
Mills], Gays Mills, Wisconsin
7. Hydro-Fit, Inc. [http://www.ncpad.org/suppliers/index.php?id=6
54&state=Oregon&city=Eugene], Eugene, Oregon
8. Orthopedic Physical Therapy Products (OPTP) [http://www
.ncpad.org/suppliers/index.php?id=756&state=Minnesota&city
=Minneapolis], Minneapolis, Minnesota
9. Recreonics, Inc. [http://www.ncpad.org/suppliers/index.php?id=
STATE+ENTUCKYCITY,OUISVILLE=,OUISVILLE+ENTUCKY
397
10. Water Gear [http://www.ncpad.org/suppliers/index.php?id=758&

state=California&city=Pismo Beach], Pismo Beach, California
11. WaterWear, Inc. [http://www.ncpad.org/suppliers/index.
php?id=759&state=New Hampshire&city=Wilton], Wilton, New
Hampshire
12. Water Warm-Ups [http://www.ncpad.org/suppliers/index.php?id
=760&state=California&city=Corona del Mar], Corona del Mar,
California
13. The Wet Wrap DK Douglas Company, Inc. [http://www.ncpad.org/
SUPPLIERSINDEXPHPIDSTATE-ASSACHUSETTSCITY,ONGME
ADOW=,ONGMEADOW-ASSACHUSETTS
Books
1. Sova, R. Ai Chi: Balance, Harmony and Healing.
2. Sova, R. & Harpt, S. (1996). BACKHAB: The Water Way to Mo-
bility and Pain Free Living.7ASHINGTON7ISCONSIN$3,,TD
3. Wykle, M. Transitioning Yoga and Pilates to the Water.
4. Grosse, Susan J. The Halliwick Method: Water Freedom for
Individuals with Disabilities.
5. Grosse, Susan. Sponges, Splashes, and Sprinkles.
398
Chapter 57
Chiropractic Care and

Osteopathic Manipulation
Chiropractic is a health care approach that focuses on the relation-

ship between the bodys structuremainly the spineand its function-
ing. Although practitioners may use a variety of treatment approaches,
they primarily perform adjustments to the spine or other parts of the
body with the goal of correcting alignment problems and supporting
the bodys natural ability to heal itself.
Overview and History

The term chiropractic combines the Greek words cheir (hand)
and praxis (action) to describe a treatment done by hand. Hands-on
therapyespecially adjustment of the spineis central to chiroprac-
tic care. Chiropractic, which in the United States is considered part
of complementary and alternative medicine (CAM), is based on these
key concepts:
s 4HEBODYHASAPOWERFULSELF HEALINGABILITY
s 4HEBODYSSTRUCTUREPRIMARILYTHATOFTHESPINE ANDITSFUNC-
tion are closely related, and this relationship affects health.
s 4HERAPYAIMSTONORMALIZETHISRELATIONSHIPBETWEENSTRUCTURE
and function and assist the body as it heals.
Excerpted from Chiropractic: An Introduction, by the National Center for

National Institutes of Health, November 2007.
399
While some procedures associated with chiropractic care can be

traced back to ancient times, the modern profession of chiropractic was
founded by Daniel David Palmer in 1895 in Davenport, Iowa. Palmer, a
self-taught healer, believed that the body has a natural healing ability.
Misalignments of the spine can interfere with the ow of energy needed
to support health, Palmer theorized, and the key to health is to normal-
ize the function of the nervous system, especially the spinal cord.
Patterns of Use
According to the 2007 National Health Interview Survey, which
included a comprehensive survey of CAM use by Americans, about 8
percent of American adults and nearly 3 percent of children had re-
ceived chiropractic or osteopathic manipulation in the past 12 months.
Adjusted to nationally representative numbers, these percentages
mean that more than 18 million adults and 2 million children received
chiropractic or osteopathic manipulation in the previous year.
Many people who seek chiropractic care have chronic, pain-related
HEALTHCONDITIONS,OW BACKPAINNECKPAINANDHEADACHEARECOMMON
conditions for which people seek chiropractic treatment.
What to Expect from Chiropractic Visits

During the initial visit, chiropractors typically take a health his-
tory and perform a physical examination, with a special emphasis
on the spine. Other examinations or tests such as x-rays may also
be performed. If chiropractic treatment is considered appropriate, a
treatment plan will be developed.
During followup visits, practitioners may perform one or more of the
many different types of adjustments used in chiropractic care. Given
mainly to the spine, a chiropractic adjustment (sometimes referred
to as a manipulation) involves using the hands or a device to apply a
controlled, sudden force to a joint, moving it beyond its passive range
of motion. The goal is to increase the range and quality of motion in
the area being treated and to aid in restoring health. Other hands-on
therapies such as mobilization (movement of a joint within its usual
range of motion) also may be used.
Chiropractors may combine the use of spinal adjustments with
several other treatments and approaches such as the following:
s (EATANDICE
s %LECTRICALSTIMULATION
s 2EST
400
Chiropractic Care and Osteopathic Manipulation
s 2EHABILITATIVEEXERCISE
s #OUNSELINGABOUTDIETWEIGHTLOSSANDOTHERLIFESTYLEFACTORS
s $IETARYSUPPLEMENTS

Side effects and risks depend on the specic type of chiropractic
treatment used. For example, side effects from chiropractic adjust-
ments can include temporary headaches, tiredness, or discomfort in
parts of the body that were treated. The likelihood of serious complica-
tions, such as stroke, appears to be extremely low and related to the
type of adjustment performed and the part of the body treated.
If dietary supplements are a part of the chiropractic treatment plan,
they may interact with medicines and cause side effects. It is impor-
tant that people inform their chiropractors of all medicines (whether
prescription or over-the-counter) and supplements they are taking.
Qualications to Practice
To practice chiropractic care in the United States, a practitioner
must earn a Doctor of Chiropractic (D.C.) degree from a college ac-
credited by the Council on Chiropractic Education (CCE). CCE is the
agency certied by the U.S. Department of Education to accredit chi-
ropractic colleges in the United States. Admission to a chiropractic
college requires a minimum of 90 semester hour credits (approximately
3 years) of undergraduate study, mostly in the sciences.
Chiropractic training is a 4-year academic program that includes
both classroom work and direct experience caring for patients. Course-
work typically includes instruction in the biomedical sciences, as well
as in public health and research methods. Some chiropractors pursue
a 2- to 3-year residency for training in specialized elds.
Regulation
Chiropractic is regulated individually by each state and the Dis-
trict of Columbia. Board examinations are required for licensing and
include a mock patient encounter. Most states require chiropractors to
earn annual continuing education credits to maintain their licenses.
Chiropractors scope of practice varies by state in areas such as labora-
tory tests or diagnostic procedures, the dispensing or selling of dietary
supplements, and the use of other CAM therapies such as acupuncture
or homeopathy.
401
Insurance Coverage
Compared with other CAM therapies, insurance coverage for chiro-
practic services is extensive. Many HMOs (health maintenance orga-
nizations) and private health care plans cover chiropractic treatment,
as do all state workers compensation systems. Chiropractors can bill
Medicare, and many states cover chiropractic treatment under Medic-
aid. If you have health insurance, check whether chiropractic services
are covered before you seek treatment.
Other Points to Consider

Research to expand the scientic understanding of chiropractic
treatment is ongoing. If you decide to seek chiropractic care, talk to
your chiropractor about the following:
s (ISEDUCATIONTRAININGANDLICENSING
s 7HETHERHEHASEXPERIENCETREATINGTHEHEALTHCONDITIONSFOR
which you are seeking care
s !NYSPECIALMEDICALCONCERNSYOUHAVEANDANYMEDICINESOR
dietary supplements you are taking
Tell all of your health care providers about any complementary

and alternative practices you use. Give them a full picture of what
you do to manage your health. This will help ensure coordinated and
safe care.
Recent research projects on chiropractic care supported by the Na-
tional Center for Complementary and Alternative Medicine (NCCAM)
have focused on the following:
s %FFECTIVENESSOFCHIROPRACTICTREATMENTSFORBACKPAINNECKPAIN
and headache, as well as for other health conditions such as tem-
poromandibular disorders
s $EVELOPMENTOFACURRICULUMTOINCREASETHENUMBEROF
chiropractors involved in research
s )NmUENCEOFPEOPLESSATISFACTIONWITHCHIROPRACTICCAREONTHEIR
response to treatment
402
Chapter 58
Craniosacral Therapy
Discovering the best form of therapy for your condition can be an

enlightening moment. That aha moment for many of our patients
comes when we introduce craniosacral therapy.
Craniosacral therapy is an effective treatment for:
s HEADACHESANDMIGRAINES
s CHRONICNECKANDBACKPAIN
s ANXIETYANDNERVOUSNESS
s INSOMNIA
s DEPRESSION
s 4-*;TEMPOROMANDIBULARJOINTDISORDER=
s DIZZINESSANDTINNITUS
Craniosacral therapy is a powerful alternative in cases where other

therapies have not provided relief. In addition, craniosacral therapy
promotes relaxation and immune system function, thereby enhancing
healing throughout your body.
Craniosacral Therapy, Center for Integrative Health and Healing. Re-
printed with permission. For additional information, visit www.cihh.net. The text
that follows this document under the heading Health Reference Series Medical
Advisors Notes and Updates was provided to Omnigraphics, Inc. by David A.
Cooke, MD, FACP, January 23, 2010. Dr. Cooke is not afliated with the Center
for Integrative Health and Healing.
403
How It Works
The craniosacral system consists of the brain, spinal cord, mem-
branes, and the uid within it. This uid has a pulse or rhythm not
unlike the pulse of the circulatory or respiratory systems.
After the body experiences a trauma such as a fall or accident or has
been in a cycle of repeated stress, the rhythm within the craniosacral
system can be disrupted and a restriction can occur in the natural ow
of this uid. Because the system that is affected is the central nervous
system, a variety of different symptoms can occur from headaches to
chronic pain and many other neurological complaints.
Through light touch and gentle manipulation of areas on the head
and throughout the body including the spine, a trained practitioner
can detect where the natural ow is restricted and facilitate a release
where ow is then restored. The natural healing ability of the body is
the key to the effectiveness of this therapy.
This complementary therapy is gaining popularity due to its gentle
and non-invasive treatment of a variety of symptoms. In addition, cran-
iosacral therapy works well in conjunction with other therapeutic tech-
niques to promote balance and recovery for a variety of symptoms.
Case Study #1
A woman in her 50s came for an appointment with allergies that
developed into ear infections several months ago. The ear infections
cleared up but one ear remained plugged and lled with uid and the
patient stated that she couldnt hear out of it.
The patients ear, nose, and throat specialist recommended surgery but
the patient wanted to try an alternative approach instead. Our therapist
saw her a total of three times for craniosacral therapy. On the third visit
the patient stated that she could hear out of her ear and it was no longer
plugged. She also stated that she had her energy back as well.
Case Study #2
A female patient in her 50s came for an appointment complaining
of chronic low back pain that kept her from being able to sit for long
periods of time. This was difcult for her as she had a desk job. The
pain had been with her for many years. She had a history of several
falls on her tailbone as well as fractures to the tailbone.
After two sessions of craniosacral therapy, the client reported that
the pain was gone and she could sit at her desk for the length of her
shift. A monthly follow-up was recommended and the client continues
to be pain free.
404
Craniosacral Therapy
What a Session Is Like

In a typical session the patient lies on a padded table on their
BACKFULLYCLOTHEDANDUSUALLYCOVEREDWITHABLANKET,IGHTTOUCH
no heavier than the weight of a nickel is used to detect the rhythm of
the craniosacral system and gentle techniques are used on the head,
spine, and throughout the body to release a restriction.
A client can expect to feel relaxed, sleepy, or even energized. Some
clients report that they become more aware of their body and the
restrictions within it. A typical craniosacral therapy session lasts ap-
proximately 1 hour.

Updates
The effectiveness of craniosacral therapy for the disorders listed
remains controversial. Few good-quality scientic trials have been
performed, and there have been conicting results. Additional research
is needed to determine whether the effects of craniosacral therapy are
unique or can be attributed to other factors.
In the How It Works section, the explanations for the effects of
craniosacral therapy are those stated by its practitioners. Scientic
study of the underlying assumptions has produced mixed results.
405
Chapter 59
Feldenkrais Method
What is the Feldenkrais Method?

The Feldenkrais Method is named after its originator, Dr. Moshe
Feldenkrais, D.Sc. (19041984) [about], a Russian born physicist, judo
expert, mechanical engineer, and educator.
The Feldenkrais Method is a form of somatic education that uses
gentle movement and directed attention to improve movement and en-
hance human functioning. Through this method, you can increase your
ease and range of motion, improve your exibility and coordination,
and rediscover your innate capacity for graceful, efcient movement.
These improvements will often generalize to enhance functioning in
other aspects of your life.
The Feldenkrais Method is based on principles of physics, biome-
chanics, and an empirical understanding of learning and human de-
velopment. By expanding the self-image through movement sequences
that bring attention to the parts of the self that are out of awareness,
the method enables you to include more of yourself in your functioning
movements. Students become more aware of their habitual neuro-
muscular patterns and rigidities and expand options for new ways of
moving. By increasing sensitivity the Feldenkrais Method assists you
to live your life more fully, efciently, and comfortably.
Frequently Asked Questions, 2009 Feldenkrais Educational Foundation

of North America (www.feldenkrais.com). Reprinted with permission.
407
The improvement of physical functioning is not necessarily an end

in itself. Such improvement is based on developing a broader functional
awareness which is often a gateway to more generalized enhancement
of physical functioning in the context of your environment and life.
Who benets from the Feldenkrais Method?

Anyoneyoung or old, physically challenged or physically tcan
benet from the method. Feldenkrais is benecial for those experienc-
ing chronic or acute pain of the back, neck, shoulder, hip, legs, or knee,
as well as for healthy individuals who wish to enhance their self-image.
The method has been very helpful in dealing with central nervous sys-
tem conditions such as multiple sclerosis, cerebral palsy, and stroke.
Musicians, actors, and artists can extend their abilities and enhance
creativity. Many seniors enjoy using it to retain or regain their ability
to move without strain or discomfort.
Through lessons in this method you can enjoy greater ease of move-
ment, an increased sense of vitality, and feelings of peaceful relaxation.
After a session you often feel taller and lighter, breathe more freely,
and nd that your discomforts have eased. You experience relaxation,
and feel more centered and balanced.
Successful Students: Here are examples of recent successes stu-
dents have accomplished after work with the Feldenkrais Method:
s ! YEAR OLDCOMPUTERPROGRAMMERWITHINCIPIENTWRISTPROB-
lems is able to increase his speed on the keyboard after learning
how to use his arms and hands more efciently.
s ! YEAR OLDWOMANGOESTHROUGHHERTHIRDPREGNANCYBUTTHE
rst one without back pain.
s ! YEAR OLDWOMANISABLETOLIFTHERAFFECTIONATE YEAR OLD
granddaughter without straining her back.
s ! YEAR OLDCELLISTBECOMESSOCREATIVEINDEVELOPINGNEW
less strained positions to play in that she is able to extend her
musical repertoire.
s ! YEAR OLDWITHLEARNINGDISABILITIESCANREADAFULLPAGE
competently and gains self-condence in his intelligence.
s ! YEAR OLDDIVERISABLETOVISUALIZEANDPERFORMTHECOMPLEX
series of movements needed to accomplish an intricate endeavor
more prociently.
s ! YEAR OLDMANWALKSAMILEDAILYFREEOFCHRONICKNEEPAIN
hes had for 30 years.
408
Feldenkrais Method
s ! YEAR OLDMANLEARNSTOREUSEHISHANDSAFTERACRIPPLING

auto accident.
Professional athletes who have enjoyed the benets of Feldenkrais

include basketball star Julius Erving and PGA golfers Rick Acton and
Duffy Waldorf. Celebrities who have used Feldenkrais include Nor-
man Cousins, Margaret Mead, former Israeli Prime Minister David
Ben-Gurion, Helen Hayes, and Whoopi Goldberg. Famous musicians
include violinist Yehudi Menuhin and cellist Yo Yo Ma.
What happens in a Feldenkrais Method session?

Feldenkrais work is done in two formats.
In group classes, called Awareness Through Movement, the Feldenk-
rais teacher verbally leads you through a sequence of movements in ba-
sic positions: sitting or lying on the oor, standing or sitting in a chair.
Private Feldenkrais lessons, called Functional Integration, are tai-
lored to each students individual learning needs; the teacher guides
your movements through touch.
People learning the Feldenkrais Method are usually referred to as
students rather than clients or patients. This reinforces our view of
the work as primarily being an educational process.
What happens in an Awareness Through Movement lesson?

Awareness Through Movement (ATM) consists of verbally directed
movement sequences presented primarily to groups. A lesson generally
lasts from 30 to 60 minutes. The lessons consist of comfortable, easy
movements that gradually evolve into movements of greater range
and complexity. These precisely structured movement explorations
involve thinking, sensing, moving, and imagining. Many are based on
developmental movements and ordinary functional activities (reaching,
standing, lying to sitting, looking behind yourself, etc.); some are based
on more abstract explorations of joint, muscle, and postural relation-
ships. There are hundreds of ATM lessons, varying in difculty and
complexity, for all levels of movement ability.
The emphasis is on learning which movements work better and noticing
the quality of these changes in your body. Through increased awareness,
you will learn to abandon habitual patterns of movement and develop new
alternatives, resulting in improved exibility and coordination.
How do you learn in an Awareness Through Movement lesson?
s 5SINGSLOWGENTLEMOVEMENTANDDIRECTINGSTUDENTSTOMOVE
within the limits of safety by avoiding pain and strain
409
s /RIENTINGTOTHEPROCESSOFLEARNINGANDDOINGRATHERTHAN
working toward a goal
s $IRECTINGAWARENESSTOWARDSENSINGDIFFERENCESANDPERCEIVING
whole interconnected patterns in movement
s !LLOWINGTHESTUDENTTOlNDHISHEROWNWAYWITHALESSON
What happens in a Functional Integration lesson?

As Feldenkrais practitioners guide you through movement sequenc-
es verbally in Awareness Through Movement lessons, they also guide
you through movement in Functional Integration lessons with gentle
non-invasive touching.
Functional Integration is performed with the student fully clothed,
usually lying on a table or with the student in sitting or standing posi-
tions. At times, various props (pillows, rollers, blankets ) are used in an
effort to support the persons body conguration or to facilitate certain
movements. The learning process is carried out without the use of any
invasive or forceful procedure.
Functional Integration is a hands-on form of tactile, kinesthetic
communication. The practitioner communicates how you organize
your body and, through gentle touching and movement, conveys the
experience of comfort, pleasure, and ease of movement while you learn
how to reorganize your body and behavior in new and more expanded
functional motor patterns.
In Functional Integration the practitioner/teacher develops a lesson
for you, custom-tailored to your unique conguration at that particular
moment, relating to a desire, intention, or need you have. Through rapport
and respect for your abilities, qualities, and integrity, the practitioner/
teacher creates an environment in which you can learn comfortably.
How does the Feldenkrais Method differ from massage and

chiropractic?
The similarity is that both practices touch people, but beyond that
our method is very different. In massage, the practitioner is working
directly with the muscles, in chiropractic, with the bones. These are
structural approaches that seek to affect change through changes in
structure (muscles and spine). The Feldenkrais Method works with
your ability to regulate and coordinate your movement; which means
working with the nervous system. We refer to this as a functional ap-
proach wherein you can improve your use of self inclusive of whatever
structural considerations are present.
410
Feldenkrais Method
How can I nd a certied Feldenkrais practitioner?

The Feldenkrais Guild of North America can refer you to a practitio-
ner in your area, or see the online directory [http://www.feldenkrais.com/
practitioners/nd]. Visit the International Feldenkrais Federation [http://
feldenkrais-method.org/en/node/580] for international associations.
How are Feldenkrais practitioners trained?

All Feldenkrais practitioners must complete 740800 hours of
training over a 3- to 4-year period. Trainees participate in Awareness
Through Movement and Functional Integration lessons, lectures, dis-
cussions, group process, and videos of Dr. Feldenkrais teaching. Even-
tually students teach Awareness Through Movement and Functional
Integration under supervision. Trainees gradually acquire knowledge
of how movement and function are formed and organized. This exten-
sive subjective experience forms the basis from which she/he will learn
to work with others.
The main purpose of the training is for the trainees to acquire for
themselves a deep understanding of movement and its formation, to
become aware of their own movement, to become astute observers of
movement in others, and to be able to teach other people to enlarge
their awareness and movement skills.
The training process is based upon the vast body of knowledge Dr.
Feldenkrais introduced. Since he integrated into his body of learning theo-
ry aspects from a variety of scientic elds such as Newtonian mechanics,
physics, neurophysiology, movement development, biology, and learning
theories, we present some of these aspects in the training program for the
trainee to comprehend the theoretical background of the method.
Who was Moshe Feldenkrais?

Feldenkrais was born in Russia. At the age of 13 he left his home
and travelled alone for a year until he reached Palestine, where he
worked as a laborer, cartographer, and tutor in mathematics. He also
became active in sports (gymnastics, soccer) and the martial arts (jiujit-
su). During his mid twenties he left for France and eventually became
a graduate of lEcole des Travaux Publiques de Paris, in Mechanical
AND%LECTRICAL%NGINEERING,ATERHEEARNEDHIS$OCTOROF3CIENCEIN
Physics from the Sorbonne in Paris, where he assisted Nobel Prize
winner Joliot-Curie in early nuclear research.
In Paris, Feldenkrais also met Jigaro Kano, the creator of modern
Judo, and Feldenkrais became one of the rst Europeans to earn a
411
Black Belt in Judo (1936) and to introduce Judo in the West through
his teaching and books on the subject. In the early 1940s, while work-
ing in anti-submarine warfare for the British Admiralty, he patented
a number of sonar devices.
After suffering crippling knee injuries, Feldenkrais used his own
body as his laboratory and merged his acquired knowledge with his
deep curiosity about biology, perinatal development, cybernetics, lin-
guistics, and systems theory. He taught himself to walk again and in
the process developed an extraordinary system for accessing the power
of the central nervous system to improve human functioning.
Feldenkrais studied intensively in psychology, neurophysiology,
and other health-related disciplines, and in 1949 he returned to Israel
where he continued to integrate and rene his ideas into the system
known as the Feldenkrais Method.
412
Chapter 60
Massage Therapy
Chapter Contents
Section 60.1Massage Therapy Overview................................ 414
3ECTION,YMPHATIC$RAINAGE-ASSAGE ............................ 419
Section 60.3Tui Na: Chinese Massage ................................... 421
413
Section 60.1
Massage Therapy Overview

Excerpted from Massage Therapy: An Introduction, by the Na-
tional Center for Complementary and Alternative Medicine
(NCCAM, nccam.nih.gov), June 2009.
Massage therapy has a long history in cultures around the world.

Today, people use many different types of massage therapy for a vari-
ety of health-related purposes. In the United States, massage therapy
is often considered part of complementary and alternative medicine
(CAM), although it does have some conventional uses.
History of Massage
Massage therapy dates back thousands of years. References to
massage appear in writings from ancient China, Japan, India, Arabic
nations, Egypt, Greece (Hippocrates dened medicine as the art of
rubbing), and Rome.
Massage became widely used in Europe during the Renaissance. In
the 1850s, two American physicians who had studied in Sweden intro-
duced massage therapy in the United States, where it became popular
and was promoted for a variety of health purposes. With scientic and
technological advances in medical treatment during the 1930s and
1940s, massage fell out of favor in the United States. Interest in mas-
sage revived in the 1970s, especially among athletes.
Use of Massage Therapy in the United States

According to the 2007 National Health Interview Survey, which
included a comprehensive survey of CAM use by Americans, an esti-
mated 18 million U.S. adults and 700,000 children had received mas-
sage therapy in the previous year.
People use massage for a variety of health-related purposes, in-
cluding to relieve pain, rehabilitate sports injuries, reduce stress, in-
crease relaxation, address anxiety and depression, and aid general
wellness.
414
Massage Therapy
Dening Massage Therapy

The term massage therapy encompasses many different tech-
niques. In general, therapists press, rub, and otherwise manipulate the
muscles and other soft tissues of the body. They most often use their
hands and ngers, but may use their forearms, elbows, or feet.
In Swedish massage, the therapist uses long strokes, kneading, deep
circular movements, vibration, and tapping. Sports massage is similar to
Swedish massage, adapted specically to the needs of athletes. Among
the many other examples are deep tissue massage; trigger point massage,
which focuses on myofascial trigger pointsmuscle knots that are pain-
ful when pressed and can cause symptoms elsewhere in the body; and
reexology, which applies pressure to the feet (or sometimes the hands
or ears), to promote relaxation or healing in other parts of the body.
The Practice of Massage Therapy

Massage therapists work in a variety of settings, including private
ofces, hospitals, nursing homes, studios, and sport and tness facili-
ties. Some also travel to patients homes or workplaces. They usually
try to provide a calm, soothing environment.
Therapists usually ask new patients about symptoms, medical his-
tory, and desired results. They may also perform an evaluation through
touch, to locate painful or tense areas and determine how much pres-
sure to apply.
Typically, the patient lies on a table, either in loose-tting clothing
or undressed (covered with a sheet, except for the area being mas-
saged). The therapist may use oil or lotion to reduce friction on the
skin. Sometimes, people receive massage therapy while sitting in a
chair. A massage session may be fairly brief, but may also last an hour
or even longer.
Research Status
Although scientic research on massage therapywhether it works
and, if so, howis limited, there is evidence that massage may benet
some patients. Conclusions generally cannot yet be drawn about its
effectiveness for specic health conditions.
According to one analysis, however, research supports the general
conclusion that massage therapy is effective. The studies included in the
analysis suggest that a single session of massage therapy can reduce
state anxiety (a reaction to a particular situation), blood pressure, and
heart rate, and multiple sessions can reduce trait anxiety (general
415
anxiety-proneness), depression, and pain. In addition, recent studies

suggest that massage may benet certain conditions, for example:
s !REVIEWOFCLINICALTRIALSFOUNDEVIDENCETHATMAS-
sage might be useful for chronic low-back pain. Clinical practice
guidelines issued in 2007 by the American Pain Society and the
American College of Physicians recommend that physicians con-
sider using certain CAM therapies, including massage (as well
as acupuncture, chiropractic, progressive relaxation, and yoga),
when patients with chronic low-back pain do not respond to
conventional treatment.
s !MULTISITESTUDYOFMORETHANHOSPICEPATIENTSWITHAD-
vanced cancer concluded that massage may help to relieve pain
and improve mood for these patients.
s !STUDYOFPATIENTSWITHCHRONICNECKPAINFOUNDTHATTHERA-
peutic massage was more benecial than a self-care book, in
terms of improving function and relieving symptoms.
There are numerous theories about how massage therapy may affect
the body. For example, the gate control theory suggests that massage
may provide stimulation that helps to block pain signals sent to the
brain. Other examples include theories suggesting that massage might
stimulate the release of certain chemicals in the body, such as serotonin
or endorphins, or cause benecial mechanical changes in the body. How-
ever, additional studies are needed to test the various theories.
Safety
Massage therapy appears to have few serious risksif it is per-
formed by a properly trained therapist and if appropriate cautions are
followed. The number of serious injuries reported is very small. Side
effects of massage therapy may include temporary pain or discomfort,
bruising, swelling, and a sensitivity or allergy to massage oils.
Cautions about massage therapy include the following:
s 6IGOROUSMASSAGESHOULDBEAVOIDEDBYPEOPLEWITHBLEEDING
disorders or low blood platelet counts, and by people taking
blood-thinning medications such as warfarin.
s -ASSAGESHOULDNOTBEDONEINANYAREAOFTHEBODYWITHBLOOD
clots, fractures, open or healing wounds, skin infections, or weak-
ened bones (such as from osteoporosis or cancer), or where there
has been a recent surgery.
416
Massage Therapy
s !LTHOUGHMASSAGETHERAPYAPPEARSTOBEGENERALLYSAFEFORCANCER
patients, they should consult their oncologist before having a mas-
sage that involves deep or intense pressure. Any direct pressure
over a tumor usually is discouraged. Cancer patients should dis-
cuss any concerns about massage therapy with their oncologist.
s 0REGNANTWOMENSHOULDCONSULTTHEIRHEALTHCAREPROVIDER
before using massage therapy.

There are approximately 1,500 massage therapy schools and train-
ing programs in the United States. In addition to hands-on practice of
massage techniques, students generally learn about the body and how
it works, business practices, and ethics. Massage training programs
generally are approved by a state board. Some may also be accred-
ited by an independent agency, such as the Commission on Massage
Therapy Accreditation (COMTA).
As of 2007, 38 states and the District of Columbia had laws regulating
massage therapy. In some states, regulation is by town ordinance.
The National Certication Board for Therapeutic Massage and
Bodywork (NCBTMB) certies practitioners who pass a national ex-
amination. Increasingly, states that license massage therapists require
them to have a minimum of 500 hours of training at an accredited
institution, pass the NCBTMB exam, meet specic continuing educa-
tion requirements, and carry malpractice insurance.
In addition to massage therapists, health care providers such as
chiropractors and physical therapists may have training in massage.
Some common licenses or certications for massage therapists in-
clude the following:
s ,-4,ICENSED-ASSAGE4HERAPIST
s ,-0,ICENSED-ASSAGE0RACTITIONER
s #-4#ERTIlED-ASSAGE4HERAPIST
s .#4-"(ASMETTHECREDENTIALINGREQUIREMENTSINCLUD-
ing passing an exam) of the National Certication Board for
Therapeutic Massage and Bodywork, for practicing therapeutic
massage and bodywork
s .#4-(ASMETTHECREDENTIALINGREQUIREMENTSINCLUDINGPASS-
ing an exam) of the National Certication Board for Therapeutic
Massage and Bodywork, for practicing therapeutic massage
417
If You Are Thinking about Using Massage Therapy

s $ONOTUSEMASSAGETHERAPYTOREPLACEYOURREGULARMEDICALCARE
or as a reason to postpone seeing a health care provider about a
medical problem.
s )FYOUHAVEAMEDICALCONDITIONANDAREUNSUREWHETHERMAS-
sage therapy would be appropriate for you, discuss your concerns
with your health care provider. Your health care provider may also
be able to help you select a massage therapist. You might also
look for published research articles on massage therapy for
your condition.
s "EFOREDECIDINGTOBEGINMASSAGETHERAPYASKABOUTTHETHERA-
pists training, experience, and credentials. Also ask about the
number of treatments that might be needed, the cost, and insur-
ance coverage.
s )FAMASSAGETHERAPISTSUGGESTSUSINGOTHER#!-PRACTICESFOR
example, herbs or other supplements, or a special diet), discuss it
rst with your regular health care provider.
you do to manage your health. This will ensure coordinated
and safe care.
418
Massage Therapy
Section 60.2
Lymphatic Drainage Massage

h,YMPHATIC$RAINAGE-ASSAGEv#ENTERFOR)NTEGRATIVE(EALTHAND
Healing. Reprinted with permission. For additional information, visit
www.cihh.net. The date of this document is unknown. Reviewed by
David A. Cooke, MD, FACP, January 23, 2010.
What Is Lymphatic Drainage Massage?

,YMPHATICDRAINAGEMASSAGEISASPECIALIZEDMASSAGETECHNIQUE
for the purpose of reducing swelling in the body and increasing the
mOWOFLYMPH,YMPHISTHEmUIDTHATSEEPSOUTOFTHECELLSANDMUST
be returned to the bloodstream. It ows through vessels very similar
to blood vessels. In the process, the lymph nodes lter and purify the
lymph. The lymphatic system is an integral part of the immune sys-
tem, so in stimulating the ow of lymph, you are also stimulating the
immune system, leading to better overall health.
Swelling in the body often occurs because there is an imbalance,
injury, or disease that reduces, overloads, or blocks the ow of lymph.
,YMPHATICDRAINAGEMASSAGEVERYGENTLYOPENSANDSTRETCHESTHE
initial lymphatic vessels just under the skin, facilitating the ow of
the lymph and reducing the swelling. It also very lightly ushes the
lymph nodes, encouraging a smoother, more effective ow of the lymph
through them. It can also speed the healing of injuries and reduce the
size of scar tissue.
Benets of Lymphatic Drainage Massage

s 2EDUCESSWELLINGANDEDEMA
s %NHANCESIMMUNEFUNCTION
s 3PEEDSHEALINGOFINJURIESANDSURGERIES
s 2EDUCESSCARRING
s 2EDUCESSTRESSANDTENSION
s 2ELIEVESHEADACHES
419
s 2ELIEVESSINUSPROBLEMS
s )MPROVESTHECONDITIONOFTHESKIN
s 2EJUVENATESTHESKINONTHEFACEANDNECK
s )MPROVESTHECLIENTSOVERALLENERGYLEVEL
The Technique
,YMPHATICDRAINAGEMASSAGEUSESVERYLIGHTPRESSUREOFTHElNGERS
and hands, just slightly moving the skin, a technique quite different
from the long deeper owing strokes of regular massages. The pattern
of strokes in lymphatic drainage massage is very small and precise,
moving very slowly and rhythmically, and repeating over and over.
Because of this, lymphatic drainage massage is very relaxing and
therefore excellent for reducing the effects of stress and tension.
What Is a Session of Lymphatic Drainage Massage Like?

A session of lymphatic drainage massage is very restful. The client
lies comfortably on a massage table under a sheet while the therapist
very lightly massages the skin, working one area thoroughly before
moving to another area.
Sessions can involve massaging all the major areas of the body,
which take an hour and a half or more. They can also be shorter ses-
sions, between 30 to 60 minutes, focusing on one particular area of the
body. For example, if someone has an injured arm, the therapist could
massage just the arm and torso.
Facial Lymphatic Drainage

Facial lymphatic drainage sessions are very popular. Facial lym-
phatic drainage reduces swelling in the face and neck as well as im-
proving and rejuvenating the skin. This helps the skin look younger.
Facial lymphatic drainage works very well in conjunction with facial
rejuvenation acupuncture, improving skin tone and reducing the signs
of aging. This combination of therapies has proven successful results.
Facial lymphatic drainage is also very benecial in relieving headaches
and sinus problems.
420
Massage Therapy
Section 60.3
Tui Na: Chinese Massage

Tui NaChinese Massage, Center for Integrative Health and
Healing. Reprinted with permission. For additional information, visit
www.cihh.net. The date of this document is unknown. Reviewed by
David A. Cooke, MD, FACP, January 23, 2010.
The mind, the spirit, and the hands are the most fundamental
tools of healing we possess. Tui Na makes use of all three to promote
health and well being through the individuals muscular, skeletal, and
ENERGETICSYSTEMSv#HRISTOPHER2EILLY,!C-3!
Tui Na is perhaps the oldest branch of traditional Chinese medi-
cine (TCM). The rst written record of Tui Na dates to 2700 BCE
[Before the Common Era], and the ofcial Tui Na department was
established in the State Ofce of Imperial Physicians in Chinas Sui
AND4ANG$YNASTIESn#%;#OMMON%RA= ,ITERALLYTRANS-
lated as pushing and grasping, Tui Na encompasses an extremely
broad set of hands-on techniques whose applications are guided by
the same theory and physiological concepts that govern acupuncture
and herbal therapy. Throughout the past 5,000 years, Tui Na experts
have developed methods of bone-setting, joint manipulation, trauma
therapy, massage therapy, pediatric therapy, preventive therapy, and
topical herbal applications.
The Tui Na form of bodywork differs from most Swedish and west-
ern styles in the speed and vigor with which certain techniques are
applied, the TCM theory and philosophy embedded within the Tui Na,
and an emphasis on the stimulation of acupuncture points and merid-
ians. There are a variety of techniques, such as dragon and phoenix
rolling, zhens single nger pushing, and trembling that are unique to
Tui Na. In modern terms, Tui Na as it is practiced in America can be
understood as a hands-on form of bodywork which uses acupressure
and traditional Chinese medical theory to achieve a variety of wellness
goals, including pain relief and muscular health.
Tui Na is often the treatment of choice for TCM practitioners, and
is used in place of acupuncture in children. The rst treatise on pe-
diatric Tui Na in China dates to 1601 CE. Areas of the body that are
421
of particular relevance to pediatric sessions have been documented

over hundreds of years with names such as sky river, wood gate, the
three fences, and the six fu. During very brief sessions (about 5 to 10
minutes), gentle techniques are applied to the extremities and trunk
to relieve poor appetite, loose stools, low-grade fevers, etc. Very simple
techniques are taught to the childs caregivers, who can perform them
at home to enhance and boost the effectiveness of the Tui Na. In the
case of children and adults, Tui Na provides a non-invasive and well-
tolerated means to apply traditional Chinese medical theory to con-
temporary health challenges.
422
Chapter 61
Pilates
Pilates (pronounced: puh-lah-teez) improves your mental and physi-

cal well-being, increases exibility, and strengthens muscles. Pilates
uses controlled movements in the form of mat exercises or equipment
to tone and strengthen the body. For decades, its been the exercise
of choice for dancers and gymnasts (and now Hollywood actors), but
it was originally used to rehabilitate bedridden or immobile patients
during World War I.
What Is Pilates?
Pilates is a body conditioning routine that seeks to build exibility,
strength, endurance, and coordination without adding muscle bulk.
In addition, Pilates increases circulation and helps to sculpt the body
and strengthen the bodys core or powerhouse (torso). People who
do Pilates regularly feel they have better posture, are less prone to
injury, and experience better overall health.
Joseph H. Pilates, the founder of the Pilates exercise method, was
born in Germany. As a child he was frail, living with asthma in addition
to other childhood conditions. To build his body and grow stronger, he
took up several different sports, eventually becoming an accomplished
Pilates, April 2007, reprinted with permission from www.kidshealth.org.

Copyright 2007 The Nemours Foundation. This information was provided by
KidsHealth, one of the largest resources online for medically reviewed health
information written for parents, kids, and teens. For more articles like this one,
visit www.KidsHealth.org, or www.TeensHealth.org.
423
athlete. As a nurse in Great Britain during World War I, he designed ex-

ercise methods and equipment for immobilized patients and soldiers.
In addition to his equipment, Pilates developed a series of mat
exercises that focus on the torso. He based these on various exercise
methods from around the world, among them the mind-body formats
of yoga and Chinese martial arts.
Joseph Pilates believed that our physical and mental health are
intertwined. He designed his exercise program around principles that
support this philosophy, including concentration, precision, control,
breathing, and owing movements.
There are two ways to exercise in Pilates. Today, most people focus
on the mat exercises, which require only a oor mat and training. These
exercises are designed so that your body uses its own weight as resis-
tance. The other method of Pilates uses a variety of machines to tone
and strengthen the body, again using the principle of resistance.
Getting Started
The great thing about Pilates is that just about everyonefrom
couch potatoes to tness buffscan do it. Because Pilates has gained
lots of attention recently, there are lots of classes available. Youll
probably nd that many tness centers and YMCAs offer Pilates
classes, mostly in mat work. Some Pilates instructors also offer pri-
vate classes that can be purchased class by class or in blocks of
classes; these may combine mat work with machine work. If your
health club makes Pilates machines available to members, make sure
theres a qualied Pilates instructor on duty to teach and supervise
you during the exercises.
The fact that Pilates is hot and classes are springing up everywhere
does have a downside, though: inadequate instruction. As with any
form of exercise, it is possible to injure yourself if you have a health
condition or dont know exactly how to do the moves. Some gyms send
their personal trainers to weekend-long courses and then claim theyre
qualied to teach Pilates (theyre not!), and this can lead to injury.
So look for an instructor who is certied by a group that has a
rigorous training program. These instructors have completed several
hundred hours of training just in Pilates and know the different ways
to modify the exercises so new students dont get hurt.
The Pilates mat program follows a set sequence, with exercises fol-
lowing on from one another in a natural progression, just as Joseph
Pilates designed them. Beginners start with basic exercises and build
up to include additional exercises and more advanced positioning.
424
Pilates
Keep these tips in mind so that you can get the most out of your
Pilates workout.
s Stay focused. Pilates is designed to combine your breathing
rhythm with your body movements. Qualied instructors teach
ways to keep your breathing working in conjunction with the
exercises. You will also be taught to concentrate on your muscles
and what you are doing. The goal of Pilates is to unite your mind
and body, which relieves stress and anxiety.
s Be comfortable. Wear comfortable clothes (as you would for
yogashorts or tights and a T-shirt or tank top are good choic-
es), and keep in mind that Pilates is usually done without shoes.
If you start feeling uncomfortable, strained, or experience pain,
you should stop.
s Let it ow. When you perform your exercises, avoid quick, jerky
movements. Every movement should be slow, but still strong and
exible. Joseph Pilates worked with dancers and designed his
movements to ow like a dance.
s Dont leave out the heart. The nice thing about Pilates is
you dont have to break a sweat if you dont want tobut you
can also work the exercises quickly (bearing in mind uidity, of
course!) to get your heart rate going. Or, because Pilates is pri-
marily about strength and exibility, pair your Pilates workout
with a form of aerobic exercise like swimming or brisk walking.
Most fans of Pilates say they stick with the program because its
diverse and interesting. Joseph Pilates designed his program for
varietypeople do fewer repetitions of a number of exercises rather
than lots of repetitions of only a few. He also intended his exercises
to be something people could do on their own once theyve had proper
instruction, cutting down the need to remain dependent on a trainer.
Before you begin any type of exercise program, its a good idea to
talk to your doctor, especially if you have a health problem.
425
Chapter 62
Qigong
Qigong is an ancient Chinese health care system that

integrates physical postures, breathing techniques, and
focused intention.
The word Qigong (Chi Kung) is made up of two Chinese words. Qi
is pronounced chee and is usually translated to mean the life force or
vital energy that ows through all things in the universe.
The second word, Gong, pronounced gung, means accomplishment,
or skill that is cultivated through steady practice. Together, Qigong
(Chi Kung) means cultivating energy; it is a system practiced for health
maintenance, healing, and increasing vitality.
Qigong is an integration of physical postures, breathing

techniques, and focused intentions.
Qigong practices can be classied as martial, medical, or spiritual.
All styles have three things in common: They all involve a posture
(whether moving or stationary), breathing techniques, and mental fo-
cus. Some practices increase the Qi; others circulate it, use it to cleanse
and heal the body, store it, or emit Qi to help heal others. Practices vary
from the soft internal styles such as Tai Chi; to the external, vigorous
styles such as Kung Fu. However, the slow gentle movements of most
Qigong forms can be easily adapted, even for the physically challenged
and can be practiced by all age groups.
What is Qigong? 2009 National Qigong Association (www.nqa.org).
Reprinted with permission.
427
,IKEANYOTHERSYSTEMOFHEALTHCARE1IGONGISNOTAPANACEABUT

it is certainly a highly effective health care practice. Many health care
professionals recommend Qigong as an important form of alternative
complementary medicine.
Qigong creates an awareness of and inuences dimensions of our
being that are not part of traditional exercise programs. Most exer-
cises do not involve the meridian system used in acupuncture nor do
they emphasize the importance of adding mind intent and breathing
techniques to physical movements. When these dimensions are added,
the benets of exercise increase exponentially.
The gentle, rhythmic movements of Qigong reduce stress, build
stamina, increase vitality, and enhance the immune system. It has
also been found to improve cardiovascular, respiratory, circulatory,
lymphatic, and digestive functions.
Those who maintain a consistent practice of Qigong nd that it
helps one regain a youthful vitality, maintain health even into old
age, and helps speed recovery from illness. Western scientic research
conrms that Qigong reduces hypertension and the incidence of falling
in the aged population. One of the more important long-term effects is
that Qigong reestablishes the body/mind/soul connection.
People do Qigong to maintain health, heal their bodies,

calm their minds, and reconnect with their spirit.
When these three aspects of our being are integrated, it encourages
a positive outlook on life and helps eliminate harmful attitudes and
behaviors. It also creates a balanced life style, which brings greater
harmony, stability, and enjoyment.
There are a wide variety of Qigong practices. They vary from the
simple, internal forms to the more complex and challenging external
styles. They can interest and benet everyone, from the most physically
challenged to the super athlete. There are Qigong classes for children,
senior citizens, and every age group in between. Since Qigong can be
practiced anywhere or at any time, there is no need to buy special
clothing or to join a health club.
Qigongs great appeal is that everyone can benet, regard-

less of ability, age, belief system, or life circumstances.
Anyone can enrich their lives by adding Qigong to their daily rou-
tine: Children learning to channel their energy and develop increased
concentration; ofce workers learning Qigong to reduce stress; seniors
participating in gentle movements to enhance balance and their quality
428
Qigong
of life; caregivers embracing a practice to develop their ability to help

others; prisons instituting Qigong programs to restore balance in in-
mates lives; midwives using Qigong techniques to ease childbirth.
When an individual or group assumes responsibility and takes
action for their health and healing, we all benet. It is best to get
referrals from people whose judgment you have condence in. Check
the Yellow Pages for Tai Chi schools, acupuncturists, or martial art
academies. The National Qigong Association (NQA) directory is also
an excellent source for nding instructors.
Keep in mind the following criteria for choosing a qualied in-
structor: What is their background and experience; are they of good
character; do they treat everyone fairly and with respect; do they live
what they teach; do they refrain from making wild, unsubstantiated
claims; do they encourage and bring out a students highest potential?
While keeping these points in mind, remember to trust your intuition
in nding an instructor who is right for you.
How can I learn if there arent any teachers near me?

If there are no instructors in your area, many teachers regularly
travel to give workshops in all regions of the country. Many excellent
instructional books and videos are also available.
Begin by familiarizing yourself with the many resources available
for learning Qigong. The internet is one of the best tools today for
learning about Qigong.
Seek referrals in your area and visit local classes. Attending the
annual NQA conference also provides an introduction to many styles
of Qigong and practitioners from around the world.
After you have looked into some of these resources, nd a style
you feel comfortable with, and develop a consistent daily practice. It
is recommended by experienced teachers to stay with a form for at
least 100 days. A consistent practice is the most important asset you
can develop.
When beginners ask, What is the most important aspect of practic-
ing Qigong? The answer is always just do it.
429
Chapter 63
Reexology
A Brief History of Foot Reexology

Modern Reexology is based on the work of two American physi-
cians, Dr. William Fitzgerald and Dr. Joe Shelby Riley of the 1920s, and
on that of physiotherapist Eunice D. Ingham who developed Fitzgerald
and Rileys knowledge into a usable therapy, calling it Foot Reexology
and took it to the public in the late 1930s through the early 70s.
The scientic basis to Reexology begins in the last century. In the
1890s knighted research scientist and medical doctor, Sir Henry Head,
demonstrated the neurological relationship that exists between the
skin and the internal organs. Nobel prizewinner, Sir Charles Sher-
rington, proved that the whole nervous system and body adjusts to a
stimulus when it is applied to any part of the body. Around the same
time in Germany, Dr. Alfons Cornelius observed that pressure to cer-
tain spots triggered muscle contractions, changes in blood pressure,
variation in warmth and moisture in the body as well as directly affect-
ing the psychic processes, or mental state of the patient. The Russians,
beginning with Drs. Ivan Pavlov and Vladimir Bekhterev, have also
been exploring reex responses in the body for nearly a century.
In the last 30 years, because of Eunice Inghams traveling around
the country teaching groups of people her method of Reexology, a
grassroots following of Reexology emerged in the United States. In
This chapter contains text from A Brief History of Foot Reexology and The
Differences between Reexology and Massage, 2008 American Reexology
Certication Board (www.arcb.net). Reprinted with permission.
431
that time practicing Reexologists have emerged, more than 40 Reex-

ology books have been published, and the number of magazine articles
published has risen by 500 percent since 1982. Television appearances
by Reexologists have increased by 500 percent since 1988.
Today recent research studies have been conducted around the
world, including in the United States, which are validating the ef-
fectiveness of Reexology on a wide variety of conditions. Chronic
conditions seem to respond especially well to Reexology. In China,
where Reexology is accepted by the central government as a means
of preventing and curing diseases and preserving health, over 300
research studies have shown Reexology provided some improvement
to 95 percent of the over 18,000 cases covering 64 illnesses studied.
In Japan and Denmark, Reexology has been incorporated into the
employee health programs of several large corporations saving each
company thousands of dollars annually in paid sick leave benets.
Many of our health problems can be linked to stress. It is an acknowl-
edged fact by the medical community that a body trying to function while
under the inuence of prolonged stress is less capable of organizing its
defenses against illnesses and repair damage caused by injury. Stress
can be mentally, emotionally, physically, or environmentally induced.
Reexology is primarily a relaxation technique. Reexology can negate
the effects of stress while it helps the body relax and balance. Through
the relaxation process the body is more capable of dealing with the
stresses placed on it by daily living and those associated with illness.
Reexology gently nudges the body toward better functioning by improv-
ing lymphatic drainage and venous circulation, stimulation to the nerve
pathways, and muscle relaxation, helping the body to balance itself.
While historically Reexology has anecdotally been found to have
a positive effect on the body suffering from a wide variety of chronic
problems, it is not a panacea for all ills. Reexology is not a substitute
for medical treatment, but can be used as a complement to any type of
medical approach or therapy. Reexology can also be incorporated into
an overall healthy lifestyle, which includes attention to diet, moderate
exercise, and different forms of stress reduction and relaxation.
The Differences between Reexology and Massage

Some people confuse Reexology with massage, but they are two dif-
ferent modalitieseach with its own strengths. Both, like many other
therapies, such as chiropractics, osteopathy, and other somatic practices,
involve the use of the hands to apply their techniques. The aim with both
Reexology and massage is to enhance the well-being of the client. [See
Table 63.1 for a comparison of reexology and massage.]
432
Reexology
Table 63.1. Comparison of Reexology and Massage

Reexology Massage
Application
Applied to specic areas (usually Applied to the whole body; mus-
feet, hands and ears); to promote a cles and connective tissue locally
response from an area far removed for local benet, or when applied
from the tissue stimulated via the to muscles located all over the
nervous systems and acupuncture body, benets the entire body.
meridians.
All the clothing comes off, as
Only the footwear comes off, as
most of the body is touched.
only the feet, hands, and ears are
touched.
Techniques
Uses small muscle movements; pri- Uses large muscle movement;
marily thumbs and ngers are used. hands (either opened or closed),
and sometimes feet, arms, and
elbows.
Purpose
To improve the function of organs Primarily to change the soft tis-
and glands and all systems of the sue directly stimulated. Works
body. Works with the function of the with the structure of the body.
body.
Benet
Total body relaxation leading to the Local muscle relaxation or if the
balancing of all internal and external entire body is massaged then to
body systems; improving circulation muscular system improving cir-
via stimulation to the nervous and culation and reducing muscular
subtly, energy systems. tension.
It is not necessary for Reexology practitioners to study working

on a naked body when all they work on are the feet, hands, and ears
of a fully clothed person.
433
Chapter 64
Structural
Integration Techniques
Chapter Contents
Section 64.1Hellerwork Structural Integration..................... 436
Section 64.2Rolng.................................................................. 438
435
Section 64.1
Hellerwork Structural Integration

What Hellerwork Structural Integration Is, 2009
Hellerwork International (www.hellerwork.com).
Reprinted with permission.
Hellerwork Structural Integration (SI) is a powerful system of so-

matic education and structural bodywork, based on the inseparability
of body, mind, and spirit. Following Ida Rolfs lineage of Structural In-
tegration bodywork, Joseph Heller incorporated movement education/
awareness and body-centered human development processes creating
Hellerwork.
Deep tissue bodywork combined with movement education and
dialogue of the mind/body connection guides you to new options, both
physically and emotionally. Hellerwork SI encourages you to make
the connection between movement and body alignment. Hellerwork
restores your bodys natural balance from the inside out.
During the 11 section series, the structural balance of your body
is realized through the systematic release and reorganization of
muscle and connective tissue using a variety of deep-tissue bodywork
techniques. When your body comes into alignment within the eld
of gravity chronic pain and tension dissipate. A comfortable sense of
support replaces the stress and strain of carrying your body through
life. Movement education is incorporated to enhance uidity and ease
of motion and helps you develop a deeper awareness of your body and
its expression in the world.
Self-awareness facilitated through dialogue is an important com-
ponent of the Hellerwork SI series. As your body releases patterns of
tension and stress, new options of support and uidity become avail-
able. Emotionally, new options also become available. Guided dialogue
enhances a deeper awareness of your emotional and cultural patterns
allowing for choice and change.
Hellerwork Structural Integration is based on the assumption that
every person is innately healthy. Your results are maximized by creat-
ing a deeper experience of the integrity in your body, your movement,
and in your relationship with yourself and the world around you.
436
Structural Integration Techniques
What to Expect in a Hellerwork SI Session

A session starts with a check-in to discuss how your body has been as-
similating the work, what changes you have noticed, and what is getting
your attention in the moment. This followed by an assessment of your
structure and movement patterns. The practitioner utilizes this informa-
tion to individualize the session to address your particular needs.
The bodywork is received primarily while lying on a massage table,
although seated and standing work may be included. Hellerwork gen-
erally feels like slow deep pressure followed by a pleasant sense of ease
and release. As a client you may be asked to make slow movements
while the practitioner guides the tissue, releasing patterns of strain
and tension. Sensations may range from pleasure to temporary discom-
fort depending on the condition of the tissue. Hellerwork practitioners
are skilled in working sensitively with you to determine an appropriate
level of pressure, depth, and speed.
An important part of the session involves movement education and
body/mind awareness. The Dialogue component of a Hellerwork ses-
sion helps to enhance your awareness of the inseparable connection
of mind, body, emotion, and spirit. Movement exercises are designed
and taught to meet your individual needs. Proper mechanics involved
in walking, sitting, and standing are emphasized.
In general, clients report feeling a sense of lightness, length, and
well-being upon completion of a session. The release and rebalancing
of your structure will continue between sessions. Your body continues
to integrate your newfound awareness, new relationship with gravity,
new way of being, and new sense of excellence with ease.
437
Section 64.2
Rolng
Frequently Asked Questions, 2009 Rolf Institute of Structural
Integration (www.rolf.org). Reprinted with permission.
Who should consider Rolng?

According to Dr. Rolf, all bodies have some degree of disorder and
compensation in their structure; therefore she believed that everyone
should receive Rolng structural integration. In fact, in her global vi-
sion, she imagined a more evolved and structurally efcient human
species as a result of Rolng. However, we realize that most potential
clients need more compelling reasons to undergo this powerful trans-
formative sequence of session. It is possible to divide those who come
to Rolng into two groups.
The rst and largest group who should consider Rolng are those
who have a history of injury or trauma and notice that the effects of
their often minor injuries are beginning to interfere with their ev-
eryday lives. In many cases these individuals have tried traditional
medical treatments or exercise to reduce or counteract the long-term
effects of old injuries with varying degrees of success. This group might
include former and current athletes, musicians, performers, or those
engaged in physically demanding jobs who choose not to accept the
notion that the quality of their lives must suffer simply because they
are aging. In fact, all adults of any age who suffer from any limiting
physical discomfort can absolutely benet from Rolng as long as
the pains themselves are in the neuromuscular system and not signs
of a nervous disorder or a deeper pathology. For most of us, Rolng
combined with appropriate movement therapy and exercise offers a
long-lasting solution for connective tissue problems.
The second group are those who are on a spiritual path and who
nd that their physical limitations prevent them from attaining a
higher level of spiritual or emotional peace. Frequently, many on this
path assume that the body is something to be transcended rather
than something to be honored and loved. For these individuals, Rolf-
ing can serve as an educational resource which allows them a more
438
intimate and comfortable relationship with their physical body, which

in turn allows a greater ability to experience greater serenity. Interest-
ingly enough, as the body transforms physically it transforms on other
planes as well, so that, while Rolngs primary focus is the muscular
and connective tissue system, it frequently has an even more dramatic
effect in seemingly unrelated areas such as the spiritual. Exactly how
this happens is still a matter of much debate and speculation. However,
the results of the work were of much greater importance than the how
or why for Dr. Rolf. The genius of Rolng is that it can affect so many
people in so many ways and continue to reveal new possibilities for
such a rich diversity of individuals.
Does Rolng hurt?

When most people think of Rolng, one of the rst words that come to
their mind is pain. Often, this perception is based on anecdotal accounts
of sessions performed during Rolngs infancy, when it tended to be often
a less subtle and more intense discipline, frequently linked to popular
emotionally intense types of therapies in the late 1960s and early 70s.
Part of this reputation can be attributed to an often-quoted complaint
of Dr. Rolf during her training classes that her students failed to work
deep enough. Apparently, many assumed that what she meant was that
they needed to work harder and deeper. However, we now realize that
deep work is not necessarily synonymous with physical intensity.
Several factors determine the level of comfort or discomfort during
a Rolng session. One is the degree of trauma in the system; the other
ISHOWLONGFASCIALDISTORTIONSHAVEBEENINTHECLIENTSBODY,ONG TERM
distortions create more tenacious and widespread compensatory pat-
terns, which may require more sustained pressure to release.
Another factor is the degree of emotional charge associated with an
area of injury or strain. Dr. Rolf made the point that during the thera-
peutic process, emotional pain is often experienced when deeply held
emotional traumas and memories are brought to surface and processed.
Similarly, she reasoned, deep touch can result in transitory experience
of pain that is healing and transformative. However, there is actually a
fair amount of variation in the level of intensity. Various practitioners
feel it is appropriate to affect the necessary level of change. It is recom-
mended that the potential Rolng client speak to all Rolfers about this
issue and try the various work of practitioners, judging both the level
of intensity and the quality of the results you experience.
A general guideline for the vast majority of Rolng clients is that
the intensity experienced is transitory, moving quickly from brief inten-
sity to a decrease in sensation and nally to an easing of long-standing
439
holdings which can prove both profound and transformative. To para-

phrase Peter Schwind, a Certied Advanced Rolfer from Munich, Ger-
many, The art of Rolng is to master a wide range of styles of touch
and know when a lighter and more intense touch is required. Continu-
ous communication with the client and pacing the level of intensity are
essential, profoundly affecting the clients reaction to the transitory
discomfort when seriously restricted tissue is softened, discriminated,
and reintegrated.
What is the difference between massage and Rolng?

One of the most common misconceptions about Rolng is that it
is a nothing more than a type of very deep massage. There are many
varieties of massage, which are particularly effective for loosening
tight tissue, reducing stress, detoxing the body, and an increased
feeling of relaxation and well-being. Since these benets are also
a byproduct of Rolng, the general public experience confusion as
to the precise difference between our work and the proliferation of
effective touch modalities currently available. Ray McCall, an Ad-
vanced Rolfer in Boulder and former student of Dr. Rolf, once said
that what Rolfers do can be summed up in three words: palpation,
discrimination, and integration. We palpate, or touch the tissue,
feeling for imbalances in tissue texture, quality, and temperature
to determine where we need to work. We discriminate, or separate
fascial layers that adhere and muscles that have been pulled out of
position by strain or injury. Finally, we integrate the body, relating
its segments in an improved relationship, bringing physical balance
in the gravitational eld. Other soft-tissue manipulation methods,
including massage, are quite good at the rst two, but do not balance
the body in gravity. As Dr. Rolf used to say: Anyone can take a body
apart, very few know how to put it back together. The true genius
of her method is the art and science of reshaping and reorganizing
human structure according to clearly dened principles in a system-
atic and consistent manner.
In addition to our skill as structural integrators, we are also edu-
cators, a point Dr. Rolf stressed frequently in her training classes.
The role of teacher is something every Rolfer takes seriously. In each
session, Rolfers seek to impart insights to clients to increase their
awareness and understanding, to help the client make the work we
do their own. Our job is to make ourselves obsolete, by empowering
our clients to take charge of their own physical and emotional health.
Inuencing the structural evolution of man on a global level was Dr.
Rolfs fondest dream.
440
How does Rolng work?

Rolng strives to align and balance the bodys components until
the entire system is a smoothly functioning coordinated whole. For
example, the legs are aligned to the hips, shoulders to rib cage, the
body is positioned over the feet, and then all of these joints and related
tissue are integrated to one another. A few of the many benets people
experience are reduced pain, increased exibility, an enhanced sense
of body awareness, and improved posture.
These wonderful transformations are possible because Rolng ad-
dresses the bodys internal system of exible support, otherwise known
as fascia. These connective tissues surround every muscle ber, encase
all joints, and even have a role in the nervous system. Think of the fascial
system as an intricate internal guide wire network for the body. And if one
set of support wires becomes tight or out of place, the excess tension may
appear as nagging joint pain, muscle soreness, or a postural shift.
To correct internal misalignments, a Rolng practitioner uses mild,
direct pressure to melt or release facial holdings and allow the body to nd
health through the reestablishment of balance. It is currently believed
that the slow, deep strokes of Rolng stimulate intra-fascial mechanore-
ceptors (sensory neurons of the muscle nerve), which in turn triggers the
nervous system to reduce the tension of the related muscles and fascia.
Put another way, Rolng allows the brain and nervous system to
re-boot areas of the body that are receiving too much electrical stimu-
lation (chronically tight or sore muscles). And once a healthy level of
muscle contraction is established, someones entire structure is free
to express a pain-free form.
What is the Rolng Ten Series?

The hallmark of Rolng Structural Integration is a standardized
recipe known as the Ten Series, the goal of which is to systematically
balance and optimize both the structure (shape) and function (move-
ment) of the entire body over the course of 10 Rolng sessions.
Each session focuses on freeing restrictions or holdings trapped in
a particular region of the body. A practitioner also maintains a holistic
view of the clients entire system during each session, thus ensuring the
transformational process evolves in a comfortable and harmonious way.
The Ten Series can be divided into three distinct units.
Sessions 13: Called the sleeve sessions, numbers one through
three strive to loosen and balance surface layers of connective tissue.
Specically, the rst session is devoted to enhancing the quality of
breath with work on the arms, ribcage, and diaphragm. Opening is also
441
started along the upper leg, hamstrings, neck, and spine. The second ses-
sion helps give the body a stable foundation by balancing the foot and
muscles of the lower leg. Number three typically involves a side view for
an understanding of how the head, shoulder girdle, and hips are position-
ally related to one another when standing under the inuence of gravity.
Then, the body is addressed within the context of this new vision.
Sessions 47: Four through seven are referred to as core sessions
and examine terrain found between the bottom of the pelvis and top
of the head. The idea of core also includes the deep tissue of the legs
for its role in support.
Session four begins this journey; its territory extends from the in-
side arch of the foot and up the leg, to the bottom of the pelvis. The
fth session is concerned with balancing surface and deep abdominal
muscles to the curve of the back. Number six seeks to enlist more sup-
port and momentum from the legs, pelvis, and lower back, while the
seventh session turns its sole attention to the neck and head.
Session 810: Integration is emphasized throughout the remain-
ing three sessions, as eight, nine, and ten provide an opportunity for
the practitioner to blend previously established advancements, and
ones yet to be made, into the body in a way that encourages smooth
movement and natural coordination.
During sessions eight and nine, the practitioner is free to decide
how best to achieve this integration, as the protocol is unique for each
individual. The tenth and nal session is also one of integration, but
more importantly, serves to inspire a sense of order and balance. Once
completed, the wisdom of the Rolng Ten Series will drive and support
the body with health for years to come.
Does Rolng relieve stress?

When people come to Rolfers, they frequently complain about their
high level of stress and how it affects their everyday life. They are seeking
some means of reducing their stress. Often, they have explored allopathic
means such as muscle relaxants, painkillers, liniments, balms, and other
topical treatments. When these treatments fail to achieve a satisfactory
level of improvement, those still suffering seek other forms of relief such
as exercise, meditation, yoga, visualization, and chanting.
They may also seek a myofascial (neuromuscular) solution and start
receiving regular massages or some other similar soft tissue therapy. In
many cases, these therapies are good at providing transitory relief of
the physical causes of chronic stress. Those seeking a more permanent
solution to the problem are more likely to have success with Rolng.
442
What most potential clients fail to understand is that Rolng is not

a method which focuses on stress reduction. What the Rolng method
does is create a higher level of integration in the body, balancing and
educating the body and the psyche. As the body approaches balance,
it is more comfortable in the gravitational eld. As the body becomes
more comfortable, physical and emotional stress diminish. This chain
of events is a more typical sequence of events as a body changes during
the Rolng process. Ultimately, however, the results as experienced by
the client are more important than the process. All clients experience
benets from Rolng, an important one for most is that they are less
stressed and more at ease in their bodies.
What about the emotional and psychological effects of Rolng?

It is impossible to touch the physical body without touching the
emotional body. All individuals develop compensatory patterns, ways
of holding and defending against a variety of physical and emotional
insults to form.
During the Rolng process, we offer options and new modes of physi-
cal expression. Resultant emotional changes are quite common. There
is a well-documented cellular memory, a memory of experience stored
in the tissue at a cellular level. Touching the body will frequently help
the client access these physical memories encoded in the fascial (or
connective tissue) matrix. Anecdotal reports of major cathartic releases
during Rolng sessions are very common and often act as an impedi-
ment to some individuals entering into the Rolng process.
For most Rolfers, this catharsis is not something consciously de-
sired nor intended. Rather, the person is approached with reverence
and compassion. When emotionally charged areas of the body have
been identied by the client, or intuited by the practitioner, they are
normally accessed slowly and with constant communication between
the Rolfer and the client.
Sometimes, however, repressed memories or experiences will arise
for which the client and the Rolfer may not have any advanced warn-
ing. In this situation, the goal of the Rolfer is to provide a safe container
for the release and take the requisite time to integrate the experience
into the physical and emotional body in a way that promotes maximum
resolution and minimal trauma to the system.
Rolfers are trained to ease a client through such an experience but
not always trained as therapists. The nature and quality of access-
ing and resolution of emotionally charged material may be the most
profound portion of a clients Rolng experience. However, the client
443
should not enter the Rolng process anticipating such a major release
but should remember that a Rolfers actual expertise is integrating and
balancing connective tissue. The emotional component, as attractive
or dreaded as it may be, remains an ancillary aspect of the Rolng
process and not its primary intention.
Where can I nd a Rolfer in my area?

Call 800-530-8875 to receive a list in the mail, or go to Find a Rolfer
at http://www.rolf.org/nd/locate.asp.
What are some books I can read to learn about Rolng?

Selected annotated bibliography on Rolng:
Anson, Briah. Rolng: Stories of Personal Empowerment (Berkeley, CA:
North Atlantic Press, 1998). Inspiring and insightful accounts of the Rolf-
ing experience as reported by numerous former Rolng clients.
Bond, Mary. Balancing Your Body: A Self-Help Approach to Rolng to
Balancing the Body (Rochester, VT: Healing Arts Press, 1993).
Cottingham, John T. Healing Through Touch (Boulder, CO, The Rolf
Institute, 1985). Exploration of methods of healing going back 5,000
years.
Fahey, Brian W., PhD. The Power of Balance: A Rolng View of Health
(Portland, OR: Metamorphous Press, 1995). A very accessible summary
of the basic Rolng theory and movement.
Feitus, Rosemary, ed. Remembering Ida Rolf (Berkeley, CA, North Atlantic
Books, 1996). Collection of stories from people who knew Dr. Rolf.
Maitland, Jeffrey, PhD. Spacious Body: Explorations in Somatic Ontol-
ogy (Berkeley, CA: North Atlantic Books, 1995). Philosophical consid-
eration of embodiment, Buddhism, and the Rolng experience.
Ida Rolf Talks about Rolng and Physical Reality. Rosemary Feitis,
ed. Reprinted ed. (Boulder, CO, The Rolf Institute, 1978). A collection
of quotes on bodywork and a variety of topics of interest to Dr. Rolf.
Rolf, Ida. Rolng: Reestablishing the Natural Alignment and Structural
Integration of the Human Body for Vitality and Well-being. Reprinted
Ed. (Rochester, VT: Healing Arts Press, 1989). The bible of Rolng
completed late in Dr. Rolf s long career.
3CHULTZ2,OUIS0H$Out in the Open: The Complete Male Pelvis
(Berkeley, CA: North Atlantic Books, 1999). A unique look at the struc-
tural and psychological issues involved in the male pelvis from a Rolf-
ing perspective.
444
What is Rolf Movement?

Toward the end of her life, Dr. Rolf felt that a movement training
component would be a valuable adjunct to her structural Ten Series.
In her lifetime, Dr. Rolf collaborated with rst Dorothy Nolte and
then Judith Aston to develop this aspect of Rolng. Since Dr. Rolf s
death in 1979, others, including Jane Harrington, Heather Starsong,
Gael Ohlgren, and Vivian Jaye have elevated this less familiar style
of Rolng to a level of high art with tremendous transformative value.
Currently, approximately 25% of all Rolfers have been certied in Rolf
Movement and employ their training as a way of enriching their work.
The purpose of Rolng Movement is to work with the client to help
her identify movement patterns that promote strain and asymmetry
in her system. Once the patterns are identied, the Rolf Movement
practitioner does not seek to change those patterns, which have served
the client well, but rather to offer more economical solutions which
promote greater balance and efciency in the gravitational eld.
,IKETHESTRUCTURAL4EN3ERIES2OLlNG-OVEMENTISTAUGHTASASE-
quence of sessions devoted to specic structural and movement themes. In
a classic movement series, the rst session is devoted to exploring breath-
ing patterns and using the breath to promote ease and release holdings in
the ribs, lungs, and respiratory diaphragm. Subsequent sessions address
movement patterns in the foot, ankle, and knee joints, the hip joint, the
arms, and head and neck. These sessions are normally repeated to access
deeper holding patterns and achieve higher levels of order just as struc-
tural Rolfers return to the extremities and upper and lower girdles (the
shoulder and pelvis) in the latter sessions to more fully integrate structure
and function. Rolng movement can be explored by clients who have com-
pleted a structural series and can serve equally well as an autonomous
tool for achieving higher levels of self-awareness and coherence.
Is Rolng helpful to musicians?

Musicians often face a number of unique physical challenges brought
on by years of diligent practice and performing. Sometimes, even the
best musicians develop habits which lead to chronic pain, mostly in their
hands and wrists, forearms, neck and shoulders and lower back. Rolng
and Rolng movement can help in a number of ways. Physical adapta-
tions to a musicians chosen instrument, including the voice, which often
lead to discomfort and imbalance, are normalized in a traditional Rolng
Ten Series. The Rolng Ten Series can be specically adapted to address
such patterns as carpal tunnel, chronic muscle imbalances, and long-
term effects of odd stances and body position caused by the exigencies of
445
playing a given instrument. Musicians who have experienced the basic

series have consistently noticed profound changes in their level of physi-
cal comfort, energy level, and internal awareness. This increased freedom
of movement noticeably impacts the performers pleasure in performing
and often leads to greater creative abilities. Another tool many Rolfers
employ is movement work. Those trained in this modality observe you
in the act of playing and call your attention to subtle ways you hold or
translate force through your body which reinforce strain patterns that
interfere with your performance. The movement teachers intention is
not to change how you play or to inhibit your unique approach to the
instrument. Rather, they help you nd creative alternatives to stressful
patterns in your current mode of performance.
Is Rolng suitable for children?

A common misunderstanding about Rolng is that its main value is
in correcting long-standing structural patterns. Rolng can also serve
as a prophylactic measure to reverse potentially problematic patterns
in the young. One of the things children learn from watching us is how
we carry ourselves and they will naturally imitate their parents lan-
guage, movement, and other modes of expression. These patterns can
be seen in family photos and are as much a part of a childs makeup
as his hair color, height, and predisposition to certain hereditary ill-
nesses. Rolng can begin to correct patterns, such as hip imbalances
which may limit the childs development and mobility.
Also, when children are injured from falls or minor accidents, they
may seem to be ne on the outside since the cut or bruise healed.
However, as Dr. Rolf pointed out, they are not really the same. Minor
changes have taken place in the connective tissue, in their joints, and in
the muscles that were injured. Small tears or pulls cause the tissue to
thicken. Soon, muscles begin to adhere to each other and are less able
to function as discrete entities. These changes may express themselves
as a slight limp, lower energy, a decrease in range of motion or strength.
Early intervention by a Rolfer aware of the unique needs of children
can make a profound difference in a childs awareness, comfort level,
and self-esteem. The importance of receiving loving supportive touch
in and of itself is of immeasurable value to a developing child. Rolng,
however, can accomplish so much more, creating palpable change in
the childs connective tissue matrix. We have also found that Rolng
adolescents during and after puberty, a time of great insecurity and
emotional turmoil for most of us, besides the obvious structural ben-
ets, frequently has a profound effect on the developing childs aware-
ness and comfort in his or her rapidly changing body and mind.
446
Chapter 65
Other Manipulative and

Body-Based Therapies
Chapter Contents
Section 65.1Applied Kinesiology............................................. 448
Section 65.2Bowen Technique................................................. 449
Section 65.3Trager Approach.................................................. 450
447
Section 65.1
Applied Kinesiology
From Applied Kinesiology, 2009 Natural Medicines Comprehensive
Database (www.naturaldatabase.com). Reprinted with permission.

AK, applied kinesiology, educational kinesiology, health kinesiology,
kinesiology muscle test
What is it?
Kinesiology is an alternative medicine system used to diagnose and
treat medical conditions.
Is it effective?
The effectiveness ratings for kinesiology are as follows:
s ,IKELYINEFFECTIVEFOR
s DISEASEDIAGNOSIS
s LEARNINGDISABILITIES
s MASTALGIABREASTPAIN
How does it work?

Kinesiology is an alternative medicine system used to diagnose
and treat conditions based on the belief that build up of toxins around
muscles results in weakness in that area. By identifying muscle weak-
ness, the practitioner is able to identify areas of disease. However,
there is no reliable scientic evidence that kinesiology is an accurate
indicator of medical conditions or disease.
448
Other Manipulative and Body-Based Therapies

There are no known safety concerns; however, this technique should
not be relied upon to identify or diagnose medical conditions in place
of modern diagnostic techniques.

It is not known if kinesiology interacts with any medicines. Before
using kinesiology, talk with your healthcare professional if you take
any medications.
Section 65.2
Bowen Technique
From Bowen Technique, 2009 Natural Medicines Comprehensive Da-
tabase (www.naturaldatabase.com). Reprinted with permission.

Bowen manipulative therapy, Bowen therapist, Bowen therapy, BT
What is it?
The Bowen technique is a manipulative technique.
Is it effective?
The effectiveness ratings for the Bowen technique are as follows:
s PAINFATIGUERELAXATIONFROZENSHOULDERANDOTHERCONDITIONS
449
How does it work?

The Bowen technique is a manipulative therapy that uses light
pressure applied to specic locations throughout the body. Practitio-
ners of the Bowen technique believe that applying pressure in these
areas can stimulate the bodys own healing ability. However, there is
no reliable scientic support for this belief.

There is not enough reliable information available to know if the
Bowen technique is safe or if there are any safety concerns.

It is not known if the Bowen technique interacts with any medicines.
Before using the Bowen technique, talk with your healthcare pro-
fessional if you take any medications.
Section 65.3
Trager Approach
What Is the Trager Approach? 2005 Trager International (www.trag-
er.com). Reprinted with permission. Reviewed by David A. Cooke, MD,
FACP, December 25, 2009.
The Trager Approach is the innovative approach to movement education,

created and developed over a period of 65 years by Milton Trager, MD.
There are two aspects of the Trager Approach; one in which you, the
client, are passive and the other in which you are active. The passive
aspect is usually referred to as the table work, and the active aspect
is called Mentastics.
Utilizing gentle, non-intrusive, natural movements, the Trager Ap-
proach helps release deep-seated physical and mental patterns and
facilitates deep relaxation, increased physical mobility, and mental
clarity. These patterns may have developed in response to accidents,
illnesses, or any kind of physical or emotional trauma, including the
stress of everyday life.
450
Other Manipulative and Body-Based Therapies
A session usually lasts from 60 to 90 minutes. No oils or lotions are

used and the client is dressed for their comfort, with a minimum of
swimwear or briefs, and are additionally draped appropriately.
During the table work session the client is passive and lying on a
comfortably padded table. The practitioner moves the client in ways
they naturally move, and with a quality of touch and movement such
that the recipient experiences the feeling of moving that effortlessly
and freely on his/her own.
The movements are never forced so that there is no induced pain
or discomfort to the client.
This quality of effortless movement is maintained and reinforced
by Mentastics. These are simple, active, self-induced movements which
you, the client, can do on your own, during your daily activities. They
have the same intent as the table work in terms of releasing deep-
seated patterns.
For many people, Mentastics becomes a part of their life in taking
care of themselves, and relieving themselves of stress and tension.
Because many of the effects of the Trager Approach are cumu-
lative, clients most often appreciate and will benet most from a
series of sessions.
One of the most potent aspects of the Trager Approach is the abil-
ity to recall the feeling of deep relaxation, and how it feels to move
freely and easily.
Who does it?

Certied Practitioners of the Trager Approach have successfully
completed the certication program provided by Trager International,
and have maintained continuing education, and other requirements
of Trager International. Trager International maintains a database
of Certied Practitioners worldwide. If you have any question about
someones credentials, you are advised to contact Trager International
for verication.
451
Part Seven
Energy-Based Therapies
Chapter 66
Energy Medicine:
An Overview
Energy medicine is a domain in CAM that deals with energy elds

of two types:
s 6ERITABLEWHICHCANBEMEASURED
s 0UTATIVEWHICHHAVEYETTOBEMEASURED
The veritable energies employ mechanical vibrations (such as

sound) and electromagnetic forces, including visible light, magnetism,
monochromatic radiation (such as laser beams), and rays from other
parts of the electromagnetic spectrum. They involve the use of specic,
measurable wavelengths and frequencies to treat patients.
In contrast, putative energy elds (also called bioelds) have deed
measurement to date by reproducible methods. Therapies involving
putative energy elds are based on the concept that human beings
are infused with a subtle form of energy. This vital energy or life force
is known under different names in different cultures, such as qi in
traditional Chinese medicine (TCM), ki in the Japanese Kampo sys-
tem, doshas in Ayurvedic medicine, and elsewhere as prana, etheric
energy, fohat, orgone, odic force, mana, and homeopathic resonance.
6ITALENERGYISBELIEVEDTOmOWTHROUGHOUTTHEMATERIALHUMANBODY
but it has not been unequivocally measured by means of conventional
instrumentation. Nonetheless, therapists claim that they can work
Excerpted from text by the National Center for Complementary and Alter-
native Medicine (NCCAM, nccam.nih.gov), part of the National Institutes of
Health, March 2007.
455
with this subtle energy, see it with their own eyes, and use it to effect
CHANGESINTHEPHYSICALBODYANDINmUENCEHEALTH
0RACTITIONERSOFENERGYMEDICINEBELIEVETHATILLNESSRESULTSFROM
disturbances of these subtle energies (the bioeld). For example, more
THANYEARSAGO!SIANPRACTITIONERSPOSTULATEDTHATTHEmOWAND
balance of life energies are necessary for maintaining health and de-
scribed tools to restore them. Herbal medicine, acupuncture, acupres-
sure, moxibustion, and cupping, for example, are all believed to act by
correcting imbalances in the internal bioeld, such as by restoring the
mOWOFQITHROUGHMERIDIANSTOREINSTATEHEALTH3OMETHERAPISTSARE
believed to emit or transmit the vital energy (external qi) to a recipi-
ent to restore health.
Examples of practices involving putative energy elds include the
following:
s 2EIKIAND*OHREIBOTHOF*APANESEORIGIN
s 1IGONGA#HINESEPRACTICE
s (EALINGTOUCHINWHICHTHETHERAPISTISPURPORTEDTOIDENTIFY
imbalances and correct a clients energy by passing his or her
hands over the patient
s )NTERCESSORYPRAYERINWHICHAPERSONINTERCEDESTHROUGHPRAYER
on behalf of another
In the aggregate, these approaches are among the most controver-

sial of CAM practices because neither the external energy elds nor
their therapeutic effects have been demonstrated convincingly by any
biophysical means. Yet, energy medicine is gaining popularity in the
American marketplace and has become a subject of investigations at
some academic medical centers. A recent National Center for Health
3TATISTICSSURVEYINDICATEDTHATAPPROXIMATELYPERCENTOFTHEPAR-
TICIPANTSHADUSED2EIKIPERCENTHADUSEDQIGONGANDPERCENT
had used some kind of healing ritual.

Veritable Energy Medicine
There are many well-established uses for the application of measur-
able energy elds to diagnose or treat diseases: electromagnetic elds in
magnetic resonance imaging, cardiac pacemakers, radiation therapy, ul-
traviolet light for psoriasis, laser keratoplasty, and more. There are many
other claimed uses as well. The ability to deliver quantiable amounts of
456
Energy Medicine: An Overview
energies across the electromagnetic spectrum is an advantage to studies

of their mechanisms and clinical effects. For example, both static and
pulsating electromagnetic therapies have been employed.
Magnetic therapy:3TATICMAGNETSHAVEBEENUSEDFORCENTURIESIN
efforts to relieve pain or to obtain other alleged benets (e.g., increased
energy). Numerous anecdotal reports have indicated that individuals
have experienced signicant, and at times dramatic, relief of pain after
the application of static magnets over a painful area. Although the lit-
erature on the biological effects of magnetic elds is growing, there is a
paucity of data from well-structured, clinically sound studies. However,
THEREISGROWINGEVIDENCETHATMAGNETIClELDSCANINmUENCEPHYSIOLOGICAL
processes. It has recently been shown that static magnetic elds affect
the microvasculature of skeletal muscle. Microvessels that are initially
dilated respond to a magnetic eld by constricting, and microvessels
that are initially constricted respond by dilating. These results suggest
that static magnetic elds may have a benecial role in treating edema
or ischemic conditions, but there is no proof that they do.
0ULSATINGELECTROMAGNETICTHERAPYHASBEENINUSEFORTHEPAST
years. A well-recognized and standard use is to enhance the healing of
nonunion fractures. It also has been claimed that this therapy is effective
in treating osteoarthritis, migraine headaches, multiple sclerosis, and
SLEEPDISORDERS3OMEANIMALANDCELLCULTURESTUDIESHAVEBEENCONDUCTED
to elucidate the basic mechanism of the pulsating electromagnetic therapy
effect, such as cell proliferation and cell-surface binding for growth factors.
However, detailed data on the mechanisms of action are still lacking.
Millimeter wave therapy: Low-power millimeter wave (MW) ir-
RADIATIONELICITSBIOLOGICALEFFECTSANDCLINICIANSIN2USSIAANDOTHER
parts of Eastern Europe have used it in past decades to treat a variety
of conditions, ranging from skin diseases and wound healing to vari-
ous types of cancer, gastrointestinal and cardiovascular diseases, and
psychiatric illnesses. In spite of an increasing number of in vivo and
in vitro studies, the nature of MW action is not well understood. It
has been shown, for example, that MW irradiation can augment T-cell
mediated immunity in vitro. However, the mechanisms by which MW
IRRADIATIONENHANCES4 CELLFUNCTIONSARENOTKNOWN3OMESTUDIESIN-
dicate that pretreating mice with naloxone may block the hypoalgesic
and antipruritic effects of MW irradiation, suggesting that endogenous
opioids are involved in MW therapy-induced hypoalgesia. Theoreti-
cal and experimental data show that nearly all the MW energy is
absorbed in the supercial layers of skin, but it is not clear how the
energy absorbed by keratinocytes, the main constituents of epidermis,
457
is transmitted to elicit the therapeutic effect. It is also unclear whether

MW yields clinical effects beyond a placebo response.
Sound energy therapy:3OUNDENERGYTHERAPYSOMETIMESRE-

ferred to as vibrational or frequency therapy, includes music therapy
as well as wind chime and tuning fork therapy. The presumptive basis
of its effect is that specic sound frequencies resonate with specic or-
gans of the body to heal and support the body. Music therapy has been
the most studied among these interventions, with studies dating back
TOTHESWHENITWASREPORTEDTHATMUSICAFFECTEDBLOODPRESSURE
Other studies have suggested that music can help reduce pain and
anxiety. Music and imagery, alone and in combination, have been used
to entrain mood states, reduce acute or chronic pain, and alter certain
biochemicals, such as plasma beta-endorphin levels. These uses of en-
ergy elds truly overlap with the domain of mind-body medicine.
Light therapy: Light therapy is the use of natural or articial light

to treat various ailments, but unproven uses of light extend to lasers,
colors, and monochromatic lights. High-intensity light therapy has
been documented to be useful for seasonal affective disorder, with less
evidence for its usefulness in the treatment of more general forms of
depression and sleep disorders. Hormonal changes have been detected
after treatment. Although low-level laser therapy is claimed to be
USEFULFORRELIEVINGPAINREDUCINGINmAMMATIONANDHELPINGTOHEAL
wounds, strong scientic proof of these effects is still needed.
Energy Medicine Involving Putative Energy Fields

The concept that sickness and disease arise from imbalances in
the vital energy eld of the body has led to many forms of therapy. In
4#-ASERIESOFAPPROACHESARETAKENTORECTIFYTHEmOWOFQISUCHAS
herbal medicine, acupuncture (and its various versions), qi gong, diet,
and behavior changes.
Acupuncture: Of these approaches, acupuncture is the most promi-
NENTTHERAPYTOPROMOTEQImOWALONGTHEMERIDIANS!CUPUNCTUREHAS
been extensively studied and has been shown to be effective in treating
some conditions, particularly certain forms of pain. However, its mecha-
nism of action remains to be elucidated. The main threads of research on
acupuncture have shown regional effects on neurotransmitter expres-
sion, but have not validated the existence of an energy per se.
Qi gong:1IGONGANOTHERENERGYMODALITYTHATPURPORTEDLYCAN
restore health, is practiced widely in the clinics and hospitals of China.
458
Most of the reports were published as abstracts in Chinese, which

MAKESACCESSINGTHEINFORMATIONDIFlCULT"UT3ANCIERHASCOLLECTED
more than 2,000 records in his qi gong database which indicates that
qi gong has extensive health benets on conditions ranging from blood
pressure to asthma. The reported studies, however, are largely anec-
dotal case series and not randomized controlled trials. Few studies
have been conducted outside China and reported in peer-reviewed
journals in English. There have been no large clinical trials.
Whole medical systems and energy medicine: Although mo-
dalities such as acupuncture and qi gong have been studied separately,
TCM uses combinations of treatments (e.g., herbs, acupuncture, and
QIGONG INPRACTICE3IMILARLY!YURVEDICMEDICINEUSESCOMBINATIONS
of herbal medicine, yoga, meditation, and other approaches to restore
vital energy, particularly at the chakra energy centers.
Homeopathy: One Western approach with implications for energy
medicine is homeopathy. Homeopaths believe that their remedies mobi-
lize the bodys vital force to orchestrate coordinated healing responses
throughout the organism. The body translates the information on the
vital force into local physical changes that lead to recovery from acute
and chronic diseases. Homeopaths use their assessment of the decits in
vital force to guide dose (potency) selection and treatment pace, and to
judge the likely clinical course and prognosis. Homeopathic medicine is
based on the principle of similars, and remedies are often prescribed in
high dilutions. In most cases, the dilution may not contain any molecules
of the original agents at all. As a consequence, homeopathic remedies,
at least when applied in high dilutions, cannot act by pharmacological
means. Theories for a potential mechanism of action invoke the homeo-
pathic solution, therefore, postulating that information is stored in the
dilution process by physical means. Other than a study reported by the
Benveniste laboratory and other smaller studies, this hypothesis has
not been supported by scientic research. There have been numerous
clinical studies of homeopathic approaches, but systematic reviews point
out the overall poor quality and inconsistency of these studies.
Therapeutic touch and related practices: Numerous other
practices have evolved over the years to promote or maintain the bal-
ance of vital energy elds in the body. Examples of these modalities
INCLUDE4HERAPEUTIC4OUCHHEALINGTOUCH2EIKI*OHREIVORTEXHEALING
and polarity therapy. All these modalities involve movement of the
practitioners hands over the patients body to become attuned to the
condition of the patient, with the idea that by so doing, the practitioner
is able to strengthen and reorient the patients energies.

Many small studies of Therapeutic Touch have suggested its effective-

ness in a wide variety of conditions, including wound healing, osteoarthritis,
migraine headaches, and anxiety in burn patients. In a recent meta-analysis
OFCONTROLLED4HERAPEUTIC4OUCHSTUDIESCONTROLLEDSTUDIESHADPOSITIVE
outcomes, and 3 showed no effect; in one study, the control group healed
FASTERTHANTHE4HERAPEUTIC4OUCHGROUP3IMILARLY2EIKIAND*OHREIPRAC-
titioners claim that the therapies boost the bodys immune system, en-
hance the bodys ability to heal itself, and are benecial for a wide range
of problems, such as stress-related conditions, allergies, heart conditions,
high blood pressure, and chronic pain. However, there has been little rigor-
ous scientic research. Overall, these therapies have impressive anecdotal
evidence, but none has been proven scientically to be effective.
Distant healing:0ROPONENTSOFENERGYlELDTHERAPIESALSOCLAIM
that some of these therapies can act across long distances. For example,
the long-distance effects of external qi gong have been studied in China
and summarized in the book Scientic Qigong Exploration, which has
been translated into English. The studies reported various healing
cases and described the nature of qi as bidirectional, multifunctional,
adaptable to targets, and capable of effects over long distances. But
none of these claims has been independently veried. Another form of
distant healing is intercessory prayer, in which a person prays for the
healing of another person who is a great distance away, with or without
THATPERSONSKNOWLEDGE2EVIEWOFEIGHTNONRANDOMIZEDANDNINERAN-
domized clinical trials published between 2000 and 2002 showed that
the majority of the more rigorous trials do not support the hypothesis
that distant intercessory prayer has specic therapeutic effects.
Physical properties of putative energy elds: There has always
been an interest in detecting and describing the physical properties
of putative energy elds. Kirlian photography, aura imaging, and gas
discharge visualization are approaches for which dramatic and unique
differences before and after therapeutic energy attunements or treat-
ments have been claimed. However, it is not clear what is being detected
or photographed. Early results demonstrated that gamma radiation
LEVELSMARKEDLYDECREASEDDURINGTHERAPYSESSIONSINPERCENTOF
subjects and at every body site tested, regardless of which therapist
PERFORMEDTHETREATMENT2ECENTLYREPLICATEDSTUDIESIDENTIlEDSTATISTI-
cally signicant decreases in gamma rays emitted from patients during
alternative healing sessions with trained practitioners.
It has been hypothesized that the bodys primary gamma emitter, potas-
sium-40 (K40), represents a self-regulation of energy within the body and
the surrounding electromagnetic eld. The bodys energy adjustment may
460
result, in part, from the increased electromagnetic elds surrounding the

hands of the healers. Furthermore, an extremely sensitive magnetometer
CALLEDASUPERCONDUCTINGQUANTUMINTERFERENCEDEVICE315)$ HASBEEN
claimed to measure large frequency-pulsing biomagnetic elds emanating
from the hands of Therapeutic Touch practitioners during therapy. In one
study, a simple magnetometer measured and quantied similar frequency-
pulsing biomagnetic elds from the hands of meditators and practitioners
OFYOGAANDQIGONG4HESElELDSWERETIMESGREATERTHANTHESTRON-
gest human biomagnetic eld and were in the same frequency range as
those being tested in medical research laboratories for use in speeding the
healing process of certain biological tissues. This range is low energy and
extremely low frequency, spanning from 2 Hz to 50 Hz. However, there are
CONSIDERABLETECHNICALPROBLEMSINSUCHRESEARCH&OREXAMPLE315)$
measurement must be conducted under a special shielded environment,
and the connection between electromagnetic eld increases and observed
healing benets reported in the current literature is missing.
Other studies of putative energies suggested that energy elds from
one person can overlap and interact with energy elds of other people.
For example, when individuals touch, one persons electrocardiographic
signal is registered in the other persons electroencephalogram (EEG)
and elsewhere on the other persons body. In addition, one individuals
cardiac signal can be registered in anothers EEG recording when two
people sit quietly opposite one another.
Additional theories: Thus far, electromagnetic energy has been dem-
onstrated and postulated to be the energy between bioenergy healers and
patients. However, the exact nature of this energy is not clear. Among the
RANGEOFIDEASEMERGINGINTHISlELDISTHETHEORYOFA2USSIANRESEARCHER
who recently hypothesized that torsion elds exist and that they can be
PROPAGATEDTHROUGHSPACEATNOLESSTHANTIMESTHESPEEDOFLIGHTIN
vacuum; that they convey information without transmitting energy; and
that they are not required to obey the superposition principle.
There are other extraordinary claims and observations recorded
in the literature. For example, one report claimed that accomplished
meditators were able to imprint their intentions on electrical devices
))%$ WHICHWHENPLACEDINAROOMFORMONTHSWOULDELICITTHESE
intentions, such as changes in pH and temperature, in the room even
WHENTHE))%$WASREMOVEDFROMTHEROOM!NOTHERCLAIMISTHAT
water will crystallize into different forms and appearances under the
INmUENCEOFWRITTENINTENTIONSORTYPESOFMUSIC
For research, questions remain about which of the above theories
and approaches can be and should be addressed using existing tech-
nologies, and how.

Chapter 67
Magnet Therapy
-AGNETSHAVEBEENUSEDFORHEALTHPURPOSESFORCENTURIES3TATIC
or permanent, magnets are widely marketed for pain control and are
considered part of complementary and alternative medicine (CAM).
About Magnets
!MAGNETPRODUCESAMEASURABLEFORCECALLEDAMAGNETIClELD3TATIC
magnets have magnetic elds that do not change (unlike another type
called electromagnets, which generate magnetic elds only when elec-
TRICALCURRENTmOWSTHROUGHTHEM -AGNETSAREUSUALLYMADEFROM
metals (such as iron) or alloys (mixtures of metals, or of a metal and
a nonmetal).
Magnets come in different strengths, often measured in units called
GAUSS' ORALTERNATIVELYUNITSCALLEDTESLATESLA' -AG-
nets marketed for pain usually claim strengths of 300 to 5,000 G
many times stronger than the Earths magnetic eld (about 0.5 G) and
MUCHWEAKERTHANTHEMAGNETSUSEDFOR-2);MAGNETICRESONANCE
IMAGING=MACHINESAPPROXIMATELY'ORHIGHER
6ARIOUSPRODUCTSWITHMAGNETSINTHEMAREMARKETEDFORHEALTHPUR-
poses, including shoe insoles, bracelets and other jewelry, mattress pads,
bandages, headbands, and belts. These products are often placed in contact
with painful areas of the body with the goal of providing relief.
&ROMh-AGNETSFOR0AINvBYTHE.ATIONAL#ENTERFOR#OMPLEMENTARYAND
Alternative Medicine (NCCAM, nccam.nih.gov), part of the National Institutes
OF(EALTH-ARCH
463
History of Magnets for Health Uses

Magnets have been used for many centuries for a variety of health
purposes. By various accounts, magnets were discovered when people
rst noticed the presence of naturally magnetized stones, also called
LODESTONES"YTHETHIRDCENTURY!$;!NNO$OMINI='REEKPHYSICIANS
were using magnetic rings to treat arthritis and magnetized pills made
of amber to stop bleeding. In the Middle Ages, doctors used magnets to
treat gout, arthritis, poisoning, and baldness; to clean wounds; and to
retrieve arrowheads and other iron-containing objects from the body.
)NTHE5NITED3TATESMAGNETICDEVICESSUCHASHAIRBRUSHESAND
insoles), magnetic ointments, and clothes with magnets attached came
into wide use after the Civil War, especially in some rural areas where
few doctors were available. Healers claimed that magnetic elds ex-
isted in the blood, and that people became ill when their magnetic
elds were depleted. Thus, healers marketed magnets as a means of
replenishing these magnetic elds. Magnets were promoted as cures for
a wide range of health conditions, including paralysis, headache, back-
ache, sleeplessness, upset stomach, and liver and kidney problems.
The use of magnets to treat medical problems remained popular
well into the 20th century. Today, magnets are used for many different
types of pain, including foot pain and back pain from conditions such
as arthritis and bromyalgia.

What Studies Have Shown
Overall, the scientic evidence does not support the use of magnets
FORPAINRELIEF0RELIMINARYSTUDIESLOOKINGATDIFFERENTTYPESOFPAIN
such as knee, hip, wrist, foot, back, and pelvic painhave had mixed
RESULTS3OMEOFTHESESTUDIESINCLUDINGARECENT.)(;.ATIONAL)NSTI-
tutes of Health]-sponsored clinical trial that looked at back pain in a
small group of people, have suggested a benet from using magnets. The
majority of rigorous trials, however, have found no effect on pain.
3OMERESEARCHRESULTSSUGGESTTHATEFFECTSMAYDEPENDONTHETYPE
of pain treated. For example, results from a few studies suggest that
magnets might provide some relief specically from osteoarthritis pain.
Effects may also depend on the type and strength of the magnets used,
the frequency of use, and the length of time the magnet was applied
during the study.
Many studies were not high-quality because they included a small
number of participants, were too short, and/or were poorly designed.
464
Magnet Therapy
More rigorous research is needed before reaching any rm conclusions

about the effectiveness of magnets for pain.
Challenges Facing Researchers

2ESEARCHERSFACECHALLENGESWHENSTUDYINGMAGNETSINCLINICAL
trials:
s 3OMETHINGOTHERTHANTHEMAGNETMAYRELIEVEASTUDYPARTICI-
pants pain. For example, relief could come from a placebo effect
or from a warm bandage or cushioned insole that holds the mag-
net in place.
s )TCANBEDIFlCULTTODESIGNASHAMMAGNETTHATPARTICIPANTS
cannot distinguish from an active magnet. If participants know
whether they are using an active magnet, study ndings may be
less reliable.
s )TISPOSSIBLETHATTHEMAGNETICPROPERTIESOFLOW STRENGTHMAG-
nets, which are sometimes used as shams, can actually have a
therapeutic effect.
s /PINIONSDIFFERABOUTHOWTOADMINISTERMAGNETTHERAPYINCLUD-
ing what strength magnet to use, where to place the magnets on
the body, and how long to use them. These factors have not been
fully studied in humans. Clinical trials that look at these factors
are needed.
How Magnets Might Work

No scientic theory or manufacturer claim about how magnets
might work has been conclusively proven. Although some preliminary
research has been conducted in animals and in small clinical trials,
the mechanisms by which magnets might affect the human body are
not yet known.
3CIENTIlCRESEARCHERSANDMAGNETMANUFACTURERSHAVEPROPOSED
that magnets might work by the following methods:
s #HANGINGHOWNERVECELLSFUNCTIONANDBLOCKINGPAINSIGNALSTO
the brain
s 2ESTORINGTHEBALANCEBETWEENCELLDEATHANDGROWTH
s )NCREASINGTHEmOWOFBLOODANDTHEDELIVERYOFOXYGENAND
nutrients to tissues
s )NCREASINGTHETEMPERATUREOFTHEAREAOFTHEBODYBEINGTREATED
465
Findings from preliminary studies in healthy peopleincluding

one study funded by NIHsuggest that magnets may not affect blood
mOWORNERVEFUNCTION

Magnets may not be safe for some people to use, including those
who meet the following conditions:
s 5SEAMEDICALDEVICESUCHASAPACEMAKERDElBRILLATORORINSU-
lin pump, because magnets may interfere with the functioning of
the medical device
s (AVEAWOUNDTHATHASNOTHEALED
Otherwise, magnets are generally considered safe when applied to

THESKIN2EPORTSOFSIDEEFFECTSORCOMPLICATIONSHAVEBEENRARE
It is important not to use magnets in place of proven treatments
for serious medical conditions. Tell your health care providers about
any complementary and alternative practices you use. Give them a full
picture of what you do to manage your health. This will help ensure
coordinated and safe care.
466
Chapter 68
Polarity Therapy
What Is Polarity Therapy?

%NERGYlELDSANDCURRENTSEXISTEVERYWHEREINNATURE0OLARITY
4HERAPYASSERTSTHATTHEmOWANDBALANCEOFENERGYINTHEHUMAN
body is the foundation of good health.
)NTHE0OLARITYMODELHEALTHISEXPERIENCEDWHEN
ENERGYSYSTEMSFUNCTIONINTHEIRNATURALSTATEAND
ENERGYmOWSSMOOTHLYWITHOUTSIGNIlCANTBLOCKAGEORlXATION
When energy is unbalanced, blocked or xed due to stress or other
factors, pain and disease arise.
Blockages generally manifest in sequence from the subtle to the
DENSELEVELSOFTHElELD0OLARITY4HERAPYSEEKSTOlNDTHEBLOCKAGES
ANDRELEASEENERGYTONORMALmOWPATTERNSANDTOMAINTAINTHE%N-
ERGY&IELDINANOPENmEXIBLECONDITION
!BLENDOFMODERNSCIENCEANDCOMPLEMENTARYMEDICINE0OLARITY
Therapy is a comprehensive health system involving energy-based
BODYWORKDIETEXERCISEANDSELF AWARENESS3CIENTIlCALLYITWORKS
with the Human Energy Field, electromagnetic patterns expressed
INMENTALEMOTIONALANDPHYSICALEXPERIENCE)N0OLARITY4HERAPY
HEALTHISVIEWEDASAREmECTIONOFTHECONDITIONOFTHEENERGYlELD
4HISCHAPTERINCLUDESh7HATIS0OLARITY4HERAPYvANDh7HATCAN)EXPECTIN
ATYPICAL0OLARITY4HERAPYSESSIONvREPRINTEDWITHPERMISSIONFROMTHE!MERICAN
0OLARITY4HERAPY!SSOCIATION!MERICAN0OLARITY4HERAPY!SSOCIATION!LL
rights reserved. For additional information visit www.polaritytherapy.org.
467
and therapeutic methods are designed to balance the eld for health
benet. There are three types of energy elds in the human body: long
line currents that run north to south on the body; transverse currents
that run east-west in the body; and spiral currents that start at the
navel and expand outward.
)NTHEHEALINGARTS0OLARITY4HERAPYISSPECIALINITSCOMPREHENSIVE
exploration of the different dimensions of the human condition (physi-
CALMENTALANDEMOTIONAL 0OLARITY4HERAPYSEEKSTOBRIDGETHEFULL
spectrum of body, mind, and spirit: The body is designed by nature to
HEALITSELF0OLARITY4HERAPYASSISTSINTHISNATURALOCCURRENCE!PPLY-
INGTHE0OLARITY4HERAPYSYSTEMCANTAKEDIVERSEFORMSALWAYSBASED
on the underlying intention to support the clients inherent self-healing
intelligence as expressed in its energetic patterns.
0OLARITY4HERAPYWASDEVELOPEDBY$R2ANDOLPH3TONE$/$#.$
n WHOCONDUCTEDATHOROUGHINVESTIGATIONOFENERGYINTHE
HEALINGARTSOVERTHECOURSEOFHIS YEARMEDICALCAREER$RAWINGON
information from a wide range of sources, he found that the Human
Energy Field is affected by touch, diet, movement, sound, attitudes,
RELATIONSHIPSLIFEEXPERIENCETRAUMAANDENVIRONMENTALFACTORS3INCE
0OLARITY4HERAPYLENDSANENERGY BASEDPERSPECTIVETOALLTHESESUB-
JECTSTHESCOPEOF0OLARITYPRACTICEISOFTENVERYBROADWITHIMPLICA-
tions for health professionals in many therapeutic disciplines.
!SARESULT0OLARITYSUPPORTSSTRONGCONNECTIONSTOMANYOTHER
healing and holistic health systems. For example, basic characteristics
of the Human Energy Field are described in many sources, both ancient
ANDMODERN&ROMTHE!YURVEDICTRADITION0OLARITYINTEGRATESTHE
h4HREE0RINCIPLESAND&IVE#HAKRASvANDHASBEENCALLEDTHEMODERN
MANIFESTATIONOFANCIENT(ERMETIC0HILOSOPHY0OLARITYISEXPERIENCED
as the universal pulsation of expansion/contraction or repulsion/attrac-
tion known as Yang and Yin in Oriental therapies. Energy moves out
from a central sourcewhich is repulsion, then back to the source
WHICHISATTRACTION0OLARITYPRACTITIONERSUSETHISNATURALPHENOMENON
ASAWAYOFTRACKINGENERGYmOW
What Can I Expect in a Typical Polarity Therapy Session?

In a typical session, the practitioner assesses energetic attributes
USINGPALPATIONOBSERVATIONANDINTERVIEWMETHODS3ESSIONSUSUALLY
TAKEnMINUTESDONOTREQUIREDISROBINGANDINVOLVESOFTTOUCH
some rocking, as well as point specic touch.
%NERGETIC4OUCHISTHEWORK0OLARITYPRACTITIONERSPERFORMWITH
clientsverbal interaction is energetic communication which has
to do with reading the energy in peoples words and staying neutral
468
Polarity Therapy
vs. engaging in the emotions of the patient and verbal interaction.

Contact may be light, medium, or rm. In the session, the practitioner
supports the client in increasing self-awareness of subtle energetic
sensations, which are often experienced as tingling, warmth, expan-
SIONORWAVELIKEMOVEMENT4HERESULTSOF0OLARITY4HERAPYSESSIONS
vary, and may include profound relaxation, an understanding of en-
ergetic patterns and their implications, and relief from numerous
specic problematic situations such as hypertension, anxiety attacks,
and breathing disorders.

Chapter 69
Reiki
2EIKIISAHEALINGPRACTICETHATORIGINATEDIN*APAN2EIKIPRACTI-
tioners place their hands lightly on or just above the person receiv-
ing treatment, with the goal of facilitating the persons own healing
RESPONSE)NTHE5NITED3TATES2EIKIISPARTOFCOMPLEMENTARYAND
alternative medicine (CAM).
History
4HEWORDh2EIKIvISDERIVEDFROMTWO*APANESEWORDSREIORUNI-
VERSALANDKIORLIFEENERGY#URRENT2EIKIPRACTICECANBETRACED
TOTHESPIRITUALTEACHINGSOF-IKAO5SUIIN*APANDURINGTHEEARLY
THCENTURY5SUISTEACHINGSINCLUDEDMEDITATIVETECHNIQUESAND
HEALINGPRACTICES/NEOF5SUISSTUDENTS#HUJIRO(AYASHIFURTHER
developed the healing practices, placing less emphasis on the medita-
TIVETECHNIQUES!N!MERICANNAMED(AWAYO4AKATALEARNED2EIKI
from Hayashi in Japan and introduced it to Western cultures in the
LATES
4HETYPEOF2EIKIPRACTICEDANDTAUGHTBY(AYASHIAND4AKATAMAY
BECONSIDEREDTRADITIONAL2EIKI.UMEROUSVARIATIONSORSCHOOLS OF
2EIKIHAVESINCEBEENDEVELOPEDANDARECURRENTLYPRACTICED
&ROMh2EIKI!N)NTRODUCTIONvBYTHE.ATIONAL#ENTERFOR#OMPLEMENTARY
TUTESOF(EALTH*ULY

Practice
2EIKIISBASEDONTHEIDEATHATTHEREISAUNIVERSALORSOURCE ENERGY
THATSUPPORTSTHEBODYSINNATEHEALINGABILITIES0RACTITIONERSSEEKTOAC-
CESSTHISENERGYALLOWINGITTOmOWTOTHEBODYANDFACILITATEHEALING
!LTHOUGHGENERALLYPRACTICEDASAFORMOFSELF CARE2EIKICANBE
received from someone else and may be offered in a variety of health
care settings, including medical ofces, hospitals, and clinics. It can be
practiced on its own or along with other CAM therapies or conventional
medical treatments.
)NA2EIKISESSIONTHECLIENTLIESDOWNORSITSCOMFORTABLYFULLY
clothed. The practitioners hands are placed lightly on or just above
THECLIENTSBODYPALMSDOWNUSINGASERIESOFTODIFFERENTHAND
positions. Each position is held for about 2 to 5 minutes, or until the
PRACTITIONERFEELSTHATTHEmOWOFENERGYEXPERIENCEDASSENSATIONS
such as heat or tingling in the handshas slowed or stopped. The
number of sessions depends on the health needs of the client. Typically,
THEPRACTITIONERDELIVERSATLEASTFOURSESSIONSOFTOMINUTESEACH
4HEDURATIONOF2EIKISESSIONSMAYBESHORTERINCERTAINHEALTHCARE
settings (for example, during surgery).
0RACTITIONERSWITHAPPROPRIATETRAININGMAYPERFORM2EIKIFROM
a distance, that is, on clients who are not physically present in the
ofce or clinic.
Uses
!CCORDINGTOTHE.ATIONAL(EALTH)NTERVIEW3URVEYWHICH
included a comprehensive survey of CAM use by Americans, more than
MILLIONADULTSHADUSEDANENERGYHEALINGTHERAPYSUCHAS2EIKI
INTHEPREVIOUSYEAR4HESURVEYALSOFOUNDTHATAPPROXIMATELY
children had used an energy healing therapy in the previous year.
0EOPLEUSE2EIKIFORRELAXATIONSTRESSREDUCTIONANDSYMPTOM
RELIEFINEFFORTSTOIMPROVEOVERALLHEALTHANDWELL BEING2EIKIHAS
BEENUSEDBYPEOPLEWITHANXIETYCHRONICPAIN()6!)$3;HUMAN
immunodeciency virus/acquired immunodeciency syndrome], and
other health conditions, as well as by people recovering from surgery
OREXPERIENCINGSIDEEFFECTSFROMCANCERTREATMENTS2EIKIHASALSOBEEN
given to people who are dying (and to their families and caregivers) to
help impart a sense of peace.
Effects and Safety

#LIENTSMAYEXPERIENCEADEEPSTATEOFRELAXATIONDURINGA2EIKI
session. They might also feel warm, tingly, sleepy, or refreshed.
472
Reiki
2EIKIAPPEARSTOBEGENERALLYSAFEANDNOSERIOUSSIDEEFFECTSHAVE
been reported.

No special background or credentials are needed to receive train-
ING(OWEVER2EIKIMUSTBELEARNEDFROMANEXPERIENCEDTEACHEROR
a Master; it cannot be self-taught. The specic techniques taught can
vary greatly.
4RAININGINTRADITIONAL2EIKIHASTHREEDEGREESLEVELS EACHFOCUS-
ing on a different aspect of practice. Each degree includes one or more
INITIATIONSALSOCALLEDATTUNEMENTSOREMPOWERMENTS 2ECEIVINGAN
INITIATIONISBELIEVEDTOACTIVATETHEABILITYTOACCESS2EIKIENERGY
Training for rst- and second-degree practice is typically given in 8 to
CLASSHOURSOVERABOUTDAYS)NlRST DEGREETRAININGSTUDENTSLEARN
TOPERFORM2EIKIONTHEMSELVESANDONOTHERS)NSECOND DEGREETRAIN-
INGSTUDENTSLEARNTOPERFORM2EIKIONOTHERSFROMADISTANCE3OME
STUDENTSSEEKMASTER LEVELTHIRD DEGREE TRAINING!2EIKI-ASTERCAN
teach and initiate students. Becoming a Master can take years.
2EIKI PRACTITIONERS TRAINING AND EXPERTISE VARY )NCREASINGLY
many people who seek training are licensed health care profession-
als. However, no licensing or professional standards exist for the
PRACTICEOF2EIKI
If You Are Thinking about Using Reiki

s $ONOTUSE2EIKIASAREPLACEMENTFORPROVENCONVENTIONALCARE
or to postpone seeing a doctor about a medical problem.
s &INDOUTABOUTTHE2EIKIPRACTITIONERSBACKGROUNDINCLUDING
training and experience treating clients.
s "EAWARETHAT2EIKIHASNOTBEENWELLSTUDIEDSCIENTIlCALLYBUT
RESEARCHONWHETHERANDHOW2EIKIMAYWORKISUNDERWAY
3OMERECENT.##!- SUPPORTEDSTUDIESHAVEBEENINVESTIGATING
the following areas:
s (OW2EIKIMIGHTWORK
473
s 7HETHER2EIKIISEFFECTIVEANDSAFEFORTREATINGTHESYMPTOMSOF
bromyalgia
s 2EIKISPOSSIBLEIMPACTONTHEWELL BEINGANDQUALITYOFLIFEIN
PEOPLEWITHADVANCED!)$3
s 4HEPOSSIBLEEFFECTSOF2EIKIONDISEASEPROGRESSIONANDOR
anxiety in people with prostate cancer
s 7HETHER2EIKICANHELPREDUCENERVEPAINANDCARDIOVASCULAR
risk in people with type 2 diabetes
474
Chapter 70
Shiatsu
Are You Searching for the Answers to These Questions?

Is there a way to relieve my health problems with a gentle and
NON INVASIVEAPPROACH3OMETHINGNOURISHINGFORMYBODYANDSOUL
3OMETHINGTHAT)CANLOOKFORWARDTORECEIVINGWHICHLEAVESMERE-
LAXEDBUTENERGIZED3OMETHINGTHATADDRESSESMYHEALTHCONCERNS
INALLTHESEWAYSANDISHIGHLYEFFECTIVE
3HIATSUMAYBEYOURANSWER
What Is Shiatsu?
3HIATSUISAMODERNBODYWORKTHERAPYWITHITSORIGINSINANCIENT
Oriental medical philosophy. It is a form of acupressure, originating
in Japan, that uses nger pressure to stimulate acupoints (tsubos),
which are the same points used in acupuncture. It also uses the hands,
sts, elbows, and feet to apply pressure to larger areas of the body.
3HIATSUINCORPORATESGENTLEASSISTEDSTRETCHINGANDMANIPULATIONTECH-
niques to relax the joints.
3HIATSUWORKSWITHTHELIFEFORCEENERGYCALLEDCHIORQIKI
ENCOURAGINGITTOmOWMORESMOOTHLYALONGTHEENERGYPATHWAYSTHE
h3HIATSUv#ENTERFOR)NTEGRATIVE(EALTHAND(EALING2EPRINTEDWITHPERMIS-
sion. For additional information, visit www.cihh.net. The date of this document is
unknown. The text that follows this document under the heading Health Reference
Series-EDICAL!DVISORS.OTESAND5PDATESvWASPROVIDEDTO/MNIGRAPHICS)NC
BY$AVID!#OOKE-$&!#0*ANUARY$R#OOKEISNOTAFlLIATEDWITH
the Center for Integrative Health and Healing.
475
MERIDIANSOFTHEBODY3HIATSUSTIMULATESTHEBODYSOWNHEALINGSYS-
tems and brings the body into balance, energetically and physically.
Benets of Shiatsu
s 2ELIEVESPAINCHRONICANDACUTE
s 2ELEASESSTRESSANDITSEFFECTS
s )NCREASESTHECIRCULATIONOFBLOODANDLYMPH
s "OOSTSTHEIMMUNESYSTEM
s 2ELAXESTIGHTMUSCLES
s 2ELIEVESHEADACHESANDMIGRAINES
s %ASESANDBALANCESDIGESTION
s %ASESANXIETYANDDEPRESSION
s "ALANCESHORMONES
s )NCREASESENERGYVITALITYSTAMINAANDWELL BEING
How Does Shiatsu Work?

3HIATSUUSESTHESAME/RIENTALMEDICALPHILOSOPHIESTHATAREUSED
in acupuncture, but hands and ngers are used instead of needles, with
gentle practitioner-assisted stretches and light massage incorporated
into the session. While each therapist has his or her own style and
EMPHASIS3HIATSUALWAYSINVOLVESACUPRESSUREWORKANDSTRETCHING
Oriental medical philosophy is based on the belief that life force energy
CALLEDCHImOWSTHROUGHTHEBODYALONGENERGYCHANNELSCALLEDMERIDIANS
!SLONGASTHISENERGYISmOWINGSMOOTHLYAPERSONREMAINSWELL(OW-
EVERTHEmOWOFCHICANBECOMEWEAKSLUGGISHSTAGNANTORBLOCKEDDUE
to stress, injury, poor diet and exercise habits, etc. An imbalance in the
mOWOFCHICANCONSEQUENTLYCONTRIBUTETOPAINILLNESSANDDYSFUNCTION
4HE3HIATSUTHERAPISTEVALUATESTHECLIENTINANIN DEPTHINTERVIEW
and decides which meridians need attention to help address the prob-
lems that are present.
Case Studies
Osteoarthritis: A 57-year-old female presented with osteoarthri-
TISINHERKNEEANKLESANDTOES&OURSESSIONSOF3HIATSURESULTEDIN
signicant improvement of her medical condition allowing the client to
awake without morning stiffness and to be signicantly less dependent
on medication.
476
Shiatsu
Multiple sclerosis (MS):! YEAR OLDFEMALEWITH-3PRESENTED

with pain and weakness on one side of her body requiring the use of
ACANETOWALK4HREEWEEKLYSESSIONSOF3HIATSUREDUCEDDEPENDENCY
on the cane and lessened pain signicantly.
What Is a Shiatsu Session Like?

3HIATSUSESSIONSAREDONEWITHTHECLIENTDRESSEDINCOMFORTABLECLOTH-
ing that will allow for the gentle stretching. The sessions are usually done
WITHTHECLIENTLYINGONATHICKCOMFORTABLEMATONTHEmOORTHOUGHITIS
ne to have the session done on a massage table if that is more comfort-
ABLEFORTHECLIENT4HE3HIATSUTHERAPISTDOESANIN DEPTHINTERVIEWTO
learn what the health problems are and to determine which meridians
need addressing. The therapist then uses palm and nger pressure along
the appropriate meridians and acupoints of the arms, legs and back.
Gentle stretches and massage are interspersed throughout the session to
HELPRELEASERESTRICTIONSINTHEJOINTSTHATMAYHAMPERTHEmOWOFCHI
A shiatsu session lasts about an hour and leaves the client feeling
very relaxed, yet energized at the same time.
History of Shiatsu
3HIATSUISABLENDOFANCIENT%ASTERNMEDICALPHILOSOPHYANDMODERN
Western science. China has always held high regard for the effectiveness
of massage and acupressure for the treatment of a wide variety of health
PROBLEMSFOROVERYEARS3HIATSUHASITSROOTSINATRADITIONAL
form of massage and acupressure called Anma Therapy. Anma Therapy
originated in China hundreds of years ago and was then brought to
Japan. It was used to treat pain and many common ailments as well as
SERIOUSDISEASESANDISSTILLPRACTICEDTODAY3HIATSUISTHECULMINATION
OF%ASTERNAND7ESTERNINmUENCEONTHISANCIENTHEALINGART
3HIATSUCONTINUESTOEVOLVE)N*APANWHERETHEREARECURRENTLY
OVERREGISTERED3HIATSUPRACTITIONERS3HIATSUHASBEENHIGHLY
respected for its effectiveness in the treatment and prevention of dis-
ease for hundreds of years.

Updates
4HEMANNERINWHICH3HIATSUTHERAPYMAYBENElTPATIENTSREMAINS
subject to interpretation. Oriental medical philosophies provide one
interpretation, but Western scientists have suggested other biological
explanations for benets. The subject can be viewed through more than
477
one lens; perhaps the most important factor is whether the patient
improves, whatever the mechanism.
478
Chapter 71
Therapeutic Touch
What is therapeutic touch?

Therapeutic touch is a form of healing that uses a practice called laying
on of hands to correct or balance energy elds. The word touch is mislead-
ing because there is generally no direct physical touch involved. Instead,
the hands are moved just over the body. Therapeutic touch is based on the
theory that the body, mind, and emotions form a complex energy eld. Ac-
cording to therapeutic touch, health is an indication of a balanced energy
lELDANDILLNESSREPRESENTSIMBALANCE3TUDIESSUGGESTTHATTHERAPEUTIC
touch can help to heal wounds, reduce pain, and promote relaxation.
What is the energy eld?

Although scientists differ on the nature and relevance of the human
energy eld, the concept of an energy eld is also a part of other types of
healing. In the ancient medical systems of India and China, the energy
eld is described as life energy. It is thought to exist throughout the body
and is responsible for maintaining normal physiological, psychological, and
spiritual functions. In Traditional Chinese Medicine, this energy is called
qi (pronounced chee); in Indias ayurvedic medicine it is called prana.
What is the history of therapeutic touch?

$OLORES+RIEGERAPROFESSORAT.EW9ORK5NIVERSITY3CHOOLOF.URS-
INGAND$ORA+UNZANATURALHEALERDEVELOPEDTHERAPEUTICTOUCHIN
!$!-)NC2EPRINTEDWITHPERMISSION

THEEARLYS!TlRST+RIEGERAND+UNZONLYTAUGHTTHETECHNIQUES
to Kriegers graduate school nursing students, but Kriegers profes-
sional research and writing increased the popularity of the technique,
particularly among nurses. The practice grew primarily through a
GRASSROOTSEFFORTOFNURSESTHROUGHOUTTHE5NITED3TATES4ODAYTHERA-
peutic touch is taught at hospitals and health centers worldwide and
is most commonly practiced by nurses.
How does therapeutic touch work?

3CIENTISTSARENOTCERTAINHOWTHERAPEUTICTOUCHWORKS4HEREARE
few studies, and scientic investigators have so far not detected the
HUMANENERGYlELDDISCUSSEDBY4HERAPEUTIC4OUCHPRACTITIONERS3TILL
two theories have been put forward.
One theory is that the actual pain associated with a physically or
emotionally painful experience (such as infection, injury, or a difcult
relationship) remains in the bodys cells. The pain stored in the cells is
disruptive, and prevents some cells from working properly with other
cells in the body. This results in disease. Therapeutic touch is thought
to restore health by restoring communication between cells.
The other theory is based on the principles of quantum physics. As
blood, which contains iron, circulates in our bodies an electromagnetic
eld is produced. According to this theory, at one time we could all
easily see this eld (called an aura), but now only certain individuals,
such as those who practice therapeutic touch, develop this ability.
More generally, therapeutic touch is based on the idea that optimal
HEALTHREQUIRESABALANCEDmOWOFLIFEENERGY0RACTITIONERSOFTHERAPEUTIC
touch, by their own description, sense your energy through their hands and
then send healthy energy back to you. When receiving therapeutic touch
you usually feel such things as warmth, relaxation, and pain relief. The
practitioner describes your energy as hot or cold, active or passive, blocked
or free. There are eight general regions of the body above which energy is
sensedhead, throat, heart, stomach, lower abdomen, sacral region, knees,
ANDFEET5LTIMATELYYOUTHERECIPIENTOFTHERAPEUTICTOUCHARETHEHEALER
The practitioner simply allows your bodys own healing mechanisms to
emerge. The role of the practitioner is to facilitate this process.
What should I expect on my rst visit?

Before the session begins, you will be asked to sit or lie down. No un-
DRESSINGISNECESSARY3ESSIONSCANBEBROKENDOWNINTOFOURSTEPS
s (1) CenteringThe therapist becomes centered by using
breathing, imagery, and meditation to achieve an altered state of
consciousness for himself or herself.
480
Therapeutic Touch
s (2) Assessment4HETHERAPISTHOLDSTHEIRHANDSnINCHES
away from your body while moving from your head to your feet.
This is done to assess the energy eld surrounding your body.
Therapists often describe feelings of warmth, coolness, static,
and tingling over the areas of energy congestion or blockage.
s (3) InterventionOnce a congested or blocked area is located,
the therapist will move their hands in a rhythmic motion,
starting at the top of the blocked area and moving down and
AWAYFROMYOURBODY4HISACTIONKNOWNASUNRUFmINGISRE-
peated until the therapist no longer senses congestion or until
you begin to sense relief. The therapist will also visualize and
transmit life energy to specic areas of your body, also intended
to correct imbalances.
s (4) Evaluation/ClosureOnce youve had a few minutes to relax,
the therapist will ask you how you feel. The therapist may recheck
your energy eld to be sure that no blockages were overlooked.
What is therapeutic touch good for?

Most studies indicate that therapeutic touch can relieve tension
headaches and reduce pain, such as pain associated with burns, os-
teoarthritis, or following surgery. It may also speed the healing of
wounds and improve function in those with arthritis.
Therapeutic touch also promotes relaxation. Cancer, heart disease,
and burn patients have reported that therapeutic touch signicantly
lessens their anxiety. Generally, the deep relaxation associated with
therapeutic touch reduces stress, lowers blood pressure, and improves
breathing. Being relaxed may also lead to lower cholesterol levels and
ALSOMAYIMPROVEIMMUNEANDBOWELFUNCTIONS$IFlCULTPREGNANCIES
may also be made a little easier with the help of therapeutic touch.
Together with medical treatment, therapeutic touch can help with
many additional conditions, including:
s lBROMYALGIA
s SLEEPAPNEA
s RESTLESSLEGSYNDROMEADISORDERTHATCAUSESINSOMNIA
s ALLERGIES
s BRONCHITIS
s ADDICTIONS
s LUPUSAND
s !LZHEIMERDISEASEANDPOSSIBLYOTHERFORMSOFDEMENTIA

3OMEPEOPLEINDICATETHATTHEYEXPERIENCEEMOTIONALANDSPIRITUAL
changes after receiving therapeutic touch. These may include greater
self-condence, self-control, and self-understanding.
There is still controversy, however, as to whether the healing power
of therapeutic touch has anything to do with the laying on of hands.
Critics suggest that the healing observed after therapeutic touch may
be the result of the relaxing nature of the therapy itself and not the
energy transfer that is believed to occur between the therapists hands
and the individuals body.
Is there anything I should watch out for?

You may feel thirsty, lightheaded, and a need to urinate. Light-
HEADEDNESSGENERALLYLASTSONLYFORMINUTESAFTERASESSIONBUT
you may feel thirsty for days. According to some practitioners, if you
WEREmOODEDWITHTOOMUCHENERGYYOUMIGHTFEELINCREASEDPAINAND
be irritable, restless, anxious, or even nauseated. Therapeutic touch
MAYALSOWORSENFEVERSANDACTIVEINmAMMATIONTHEREFOREITISBEST
not to obtain therapeutic touch when you have either a fever or active
INmAMMATIONSUCHASASWOLLENJOINTFROMARTHRITIS
3OMETHERAPEUTICTOUCHPRACTITIONERSRECOMMENDTHATCHILDRENTHE
elderly, and very sick people be treated for only a short time. Although
there is no actual touching involved with therapeutic touch, talk with
your practitioner about what to expect from a session, particularly if
you have been physically or sexually abused in your past.
How can I nd a qualied practitioner?

4HEREISNOFORMALCERTIlCATIONPROGRAMINTHE5NITED3TATESFOR
therapeutic touch. Most therapeutic touch practitioners are in the
nursing profession (although some massage therapists, physical thera-
pists, chiropractors, acupuncturists, and others practice therapeutic
TOUCHASWELL .URSE(EALERS 0ROFESSIONAL!SSOCIATES)NTERNATIONAL
.( 0!) RECOMMENDSTHATPEOPLELOOKFORTHERAPISTSWHOPRACTICE
regularly (at least an average of two times per week), have at least 5
YEARSOFEXPERIENCEANDHAVECOMPLETEDATLEASTHOURSOFTHERAPEU-
tic touch workshops. To locate a qualied practitioner near you, visit
THE.( 0!)WEBSITEATWWWTHERAPEUTIC TOUCHORG
What is the future of therapeutic touch?

While there seem to be many potential uses for therapeutic touch,
particularly for chronically ill people, measuring the effectiveness of the
technique is very difcult. Because of this, much of the research that exists
has been criticized. Improved studies may lead to wider acceptance.
482
Chapter 72
Other Energy-Based
Therapies
Chapter Contents
3ECTION"IORESONANCE4HERAPY......................................... 484
3ECTION#RYSTALAND'EM4HERAPY................................... 486
3ECTION:ERO"ALANCING..................................................... 487
483
Section 72.1
Bioresonance Therapy
Turn off Allergies, by Nanci Bompey, Asheville Citizen-Times
!SHEVILLE.#'ANNETT#OMPANY)NC2EPRODUCEDWITHPERMIS-
sion of the Gannett Company, via Copyright Clearance Center.
*ULIA2OSAHASSUFFEREDFROMSEASONALALLERGIESANDASTHMAHER
whole life, but after undergoing allergy desensitization at her natur-
OPATHSOFlCETHE#ANDLER;.ORTH#AROLINA=RESIDENTSAIDSHEHASNT
sneezed this allergy season.
h(ANDSDOWNTHEREREALLYISNOCOMPARISONv2OSASAID
Asheville naturopath Eric Lewis is one of the few practitioners
in the region using electrodermal screening and acupressure to help
desensitize patients to potential allergens.
The goal of this is to change the way the body perceives a substance,
Lewis said of the process. The goal is to reverse sensitivity to these
things so that a patient can tolerate these things in the future.
4HETECHNIQUEWHICHISNOTAPPROVEDBYTHE&OODAND$RUG!DMIN-
istration, rst uses an electrodermal screening machine to determine
what substances cause a person to have an allergic reaction.
$URINGTHEPROCESSTHEPATIENTHOLDSARODCONTAININGTHENEGATIVE
end of a circuit while Lewis uses another rod, the positive end, to touch
different acupuncture points on the patients body. These points corre-
spond to different substances that could trigger an allergic reaction.
The machine then measures the electrical conductivity, or current,
THROUGHTHECIRCUITTHATHASBEENCREATED!DROPINCURRENTmOWIN-
dicates a resistance to electrical conductance, indicating a persons
sensitivity to a particular substance, Lewis said.
h!CHANGEINTHEENERGYmOW MEANSTHATSHEISLIKELYSENSITIVETO
THATALLERGENv,EWISSAIDASHEDEMONSTRATEDTHETECHNIQUEON2OSA
It shows her bodys energy is reacting negatively to that substance.
Thats when we know that we have a problem.
Lewis said the machine he uses can screen for thousands of aller-
gens that are environmental, like pollen, chemical, perfume or from
food. He said because each substance has its own electromagnetic
eld, the machine is able to screen down to specic substances to
484
Other Energy-Based Therapies
determine if a persons sensitivity to dairy is from Cheddar cheese or

cottage cheese.
While many people with allergies know what they are allergic to,
Lewis said the machine can help those patients who have symptoms
but dont know what causes them.
It gives an objective reading, Lewis said. Its a numerical presen-
tation of what is going on.
The desensitization part of the process comes next. Once Lewis has
determined what a patient is allergic to, he places a small vial contain-
ing water and alcohol into the machine, which imprints the electric
signal from the substances that a person has sensitivity to into the
mixture. Lewis calls this a remedy.
The patient then holds the remedy while Lewis presses on various
acupressure points on the patients back. The procedure simulates the
person being in the presence of the allergen, Lewis said.
The body is learning to not attack these allergens, he said.
2OSAHASBEENTHROUGHALLFOURSESSIONSFORTHEALLERGYDESENSITIZA-
TIONPROCESSASHASHER YEAR OLDSON#ONOR3HESAIDTHETECHNIQUE
identied that her son was allergic to several foods, including dairy,
which may have been causing his ear infections.
3HESAIDTHATSINCE#ONORHADTHEDESENSITIZATIONPROCEDUREDONE
he hasnt had an ear infection.
h(EHASNOEXCUSENOWTOMISSSCHOOLv2OSASAID
$R(AL*ENKINSADOCTORAT!SHEVILLES2EGIONAL!LLERGYSAIDHEHAS
not heard of the technique. He said that immunotherapy, or allergy
shots, is the only proven way to build up a resistance to allergens.
It is tried and true, he said. None of the other modalities have
been.
485
Section 72.2
Crystal and Gem Therapy

2EPRINTEDWITHPERMISSIONFROMTHEWEBSITEOFTHE*OHN-OORES5NIVER-
SITYOF#ALIFORNIAn3AN$IEGO#ANCER#ENTERHTTPCANCERUCSDEDU
5NIVERSITYOF#ALIFORNIAn3AN$IEGO!LLRIGHTSRESERVED2EVIEWEDBY$AVID
!#OOKE-$&!#0$ECEMBER
This treatment modality is thought to promote wellness and opti-

mize overall health. Crystal healing should be used with, not in place
of, standard cancer therapy.
What does crystal healing involve?

Crystal healing is the belief that certain stones and crystals contain
special healing energy that can be transferred into people to provide
protection against illness and disease and provide spiritual guidance.
This healing energy is transferred by touching, wearing, or placing
the crystal on ailing parts of the body. Crystal healing also involves
placing stones around the home, carrying them in a pocket, wearing
them around the neck, and touching them as the need arises. A visit to
a crystal healer involves the placement of various stones and crystals
on acupoints or chakras, as identied by acupuncture and Ayurvedic
medicine respectively, to restore vital energy within the patient.
How is crystal healing thought to promote wellness and

optimize overall health?
0ROPONENTSOFCRYSTALHEALINGBELIEVETHATCRYSTALSANDSTONESOF
different colors have different properties. These properties include the
ability to purify the blood, calm the mind, and revive energy. The main
value of crystals is the ability for those who believe in their healing pow-
ers to let go of negative emotions, reduce stress, and calm anxieties.
What has been proven about the benet of crystal healing?

While formal research on the healing power of crystals has never
been performed, there is no evidence or rationale that a crystal or stone
can treat illness or aid healing. The placebo response may account for
the benets that do occur.
486
Other Energy-Based Therapies
What is the potential risk or harm of crystal healing?

There is no intrinsic harm in using crystal healing to boost spirits
and improve well-being.
How much does crystal healing cost?

6ISITSTOCRYSTALHEALERSANDTHEPURCHASEOFSTONESANDCRYSTALSWILL
vary with the practitioner and crystal shop owner, respectively.
Section 72.3
Zero Balancing
h!BOUT:ERO"ALANCINGv:ERO"ALANCING(EALTH!SSOCIATION
WWWZEROBALANCINGCOM 2EPRINTEDWITHPERMISSION
:ERO"ALANCING:" ISANADVANCEDSTUDIESPROGRAMFORTHEHEALTH
care professional. It is a non-diagnostic system of healing which clari-
es and coordinates energy elds in the body, and balances body energy
with body structure. It is holistic in nature and is based on natural law.
A typical session is done through clothing and lasts 30 to 45 minutes.
A clear state of balancing helps to relive pain and suffering, provides a
foundation for health and happiness, and brings a person closer to his
ORHERTRUENATURE:ERO"ALANCINGPROMOTESTHISBALANCEDSTATE
:ERO"ALANCINGISAHANDS ONBODYMINDTHERAPYTHATCOMBINESTHE
Western view of medicine and science with the Eastern view of energy
and healing. It is based on the quantum physics notion that the par-
ticle and the wave are the two fundamental aspects that comprise our
universe, and, in terms of the human being, comprise our structural
and our energy bodies. Consciousness is the organizing principle that
coordinates these foundations into one functioning whole and allows
us to experience that process. Emotions are the vibratory frequencies
that bring this process into awareness.
:ERO"ALANCINGUSESENERGYASITSWORKINGTOOLINTHEFORMOFAFUL-
crum. A fulcrum is a eld of tension which we create through touch.
It serves as a catalyst to promote change. There are three, sometimes
overlapping, classes of fulcrums: those that work as points of reference
487
to promote balance and local change; those which work as elds to re-
lease weaker, or less organized vibration; and those which engage the
clients own energy to promote change. The fulcrums in the rst group
are held stationary for brief periods; the second group utilizes the form
of a curve or so-called half moon vector; and the third are moving foci
of energy. In all cases the fulcrum is performed at interface of touch
to ensure clear boundaries, and contacts both the energy body and the
structural body of the person.
:ERO"ALANCINGTEACHESTHATTHEDEEPESTCURRENTSOFENERGYAREIN
bone, that memory can be held in tissue, that energy elds in the body
underlie mind, body, and emotions, and that imbalances in the eld
precede pathology.
488
Part Eight
Alternative Treatments
for Specic Diseases and
Conditions
Chapter 73
Arthritis and CAM
Rheumatoid Arthritis and CAM

Rheumatoid arthritis (RA) is a chronic disease that affects the
joints, often those in a persons wrists, ngers, and feet. The common
symptoms of RA are pain, stiffness, fatigue, sleep disturbances, and
fever. There are treatments for RA in conventional medicine, but some
people also try complementary and alternative medicine (CAM).
Scientic Research on CAM Treatments for RA

Botanical supplements and other dietary supplements: Overall,
there is not much rigorous research available on the effectiveness and
safety of botanical and other supplements that people try for RA. It is
also important to know that while supplements are regulated by the U.S.
Food and Drug Administration (FDA) as a category of foods, supplements
made from plants and used for medicinal purposes (sometimes referred
to as herbal medicines) can have effects as powerful as those of drugs. In
fact, many conventional drugs rst came from plants, such as digitalis
(from the foxglove plant), used to treat heart failure and heart rhythm,
and paclitaxel (from the yew tree), a cancer chemotherapy drug.
This chapter includes text excerpted from Rheumatoid Arthritis and Comple-
mentary and Alternative Medicine, from the National Center for Complementary
and Alternative Medicine (NCCAM, nccam.nih.gov), September 2005, and text
from Acupuncture Relieves Pain and Improves Function in Knee Osteoarthritis,
by the NCCAM, December 20, 2004. Reviewed by David A. Cooke, MD, FACP,
January 23, 2010.
491
It is important to be as informed as possible about the safety of any

supplement you are considering or using. Some information already ex-
ists from a long history of botanical use outside conventional medicine.
This knowledge is being strengthened as NCCAM supports rigorous
studies on botanicals and other supplements that have shown promise
in early studies to nd out more about their molecular structure, their
safety, how they may work, and for what diseases or conditions.
Thunder God vine: Thunder God vine (TGV for short; botanical
name Tripterygium wilfordii Hook F) is a perennial vine native to
China, Japan, and Korea. Preparations made from the skinned root of
TGV have been used in traditional Chinese medicine to treat inam-
matory and autoimmune diseases. Interestingly, TGV also has a history
of use to kill insects in farm elds.
Some anti-inammatory and immune-system-suppressing activ-
ity for TGV has been seen in laboratory and animal studies. The rst
clinical trial on TGV in the United States (the earlier ones were done
in China) was carried out at the University of Texas Southwestern
Medical Center and the National Institutes of Health (NIH). Its results
were published in 2002. Twenty-one patients for whom conventional
RA treatment had not worked completed the trial. Eighty percent of
those who received a high-dose TGV extract and 40 percent of those
who received a low-dose TGV extract experienced improvement in
RA symptoms and physical functioning. No one in the placebo group
improved. Longer and larger studies are needed to conrm these nd-
ings and to nd out more about TGV.
Parts of the TGV plant are dangerous. The leaves, the owers, the
main stem, and the skin covering the root are poisonous, to a point
that they could cause death. People should never try to make TGV
medications themselves.
Currently, there are no consistent, high-quality TGV products being
manufactured in the United States. Preparations of TGV made outside
the United States (for example, in China) can sometimes be obtained,
but it is not possible to verify whether they are safe and effective. An
expert from the University of Texas/NIH study advises that consumers
not use TGV until reliable TGV preparations become available.
If taken for a long time (according to one study, for more than 5
years), TGV may decrease the density of the minerals in womens
bones, which would be of special concern for women who have osteo-
porosis or are at risk for it. If taken at high doses, TGV could suppress
the immune system and increase the effects of immune-suppressing
drugs.
492
Arthritis and CAM
The TGV extract made for the NIH study discussed in the previous
text was well tolerated by study participants. However, side effects can
occur and may include stomach upset, diarrhea, skin rash, changes in
menstrual periods, and hair loss.
Gamma-linolenic acid (GLA): GLA is an omega-6 fatty acid that

is found in the oils of some plant seeds, including evening primrose
(Oenothera biennis L.), borage (Borago ofcinalis L.), and black currant
(Ribes nigrum L.). GLA can be used by the body to make substances
that reduce inammation.
A 2000 Cochrane Collaboration review analyzed seven placebo-
controlled studies of GLA (from evening primrose, borage, and black
currant oils) for RA. The authors noted there were issues with these
studies that made it difcult to draw conclusions. However, they
thought the better studies indicated potential relief for RA pain, morn-
ing stiffness, and joint tenderness.
There are potential side effects and risks to know about with GLA.
First, these plant seed oils may affect certain medical conditions and
interact with prescription medications:
s 3OMEBORAGESEEDOILPREPARATIONSCONTAININGREDIENTSCALLED
PAs (for pyrrolizidine alkaloids) that can harm the liver or worsen
liver disease. Only preparations that are certied and labeled as
PA-free should be used.
s "ORAGEOILANDEVENINGPRIMROSEOILMIGHTINCREASETHERISKOF
bleeding and bruising, especially in people taking blood-thinning
drugs, such as aspirin, clopidogrel, NSAIDs, or warfarin.
s %VENINGPRIMROSEOILMAYCAUSEPROBLEMSFORPEOPLETAKINGA
class of psychiatric drugs called phenothiazines, such as chlor-
promazine or prochlorperazine.
s 3IDEEFFECTSOFTHESEOILSCANINCLUDENAUSEADIARRHEASOFTSTOOL
intestinal gas, burping, and stomach bloating.
Fish oil: Fish oil contains high amounts of two omega-3 fatty ac-
ids: EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid). As
with GLA, the body can use omega-3s to make substances that reduce
inammation.
There is some encouraging evidence from a number of laboratory
studies, animal studies, and clinical trials about the potential useful-
ness of sh oil or omega-3 supplementation for various aspects of
RAsuch as the number of tender joints, morning stiffness, and the
493
need for NSAIDs. However, more research is needed to denitively

answer various questions, including what the most effective dosage
or length of treatment would be, which patients would benet most,
and whether a placebo effect is at work.
In some people, the high amounts of omega-3s that are present in
sh oil can increase the risk of bleeding or affect the time it takes blood
to clot. If a person is taking drugs that affect bleeding or is going to
have surgery, this is of special concern. Fish oil supplements interact
with medicines for high blood pressure, so taking them together might
lower a persons blood pressure too much.
Certain species of sh can contain high levels of contaminants, such
as mercury, from the environment. Thus, their oils could pose a health
risk, especially for pregnant or nursing women and for children. The
sh that the federal government has found to have the highest levels
of mercury are shark, swordsh, king mackerel, and tile sh. People
who decide to use sh oil should look for products made from sh with
lower mercury levels. Government information on this topic is avail-
able. You may have to contact the manufacturer to nd out the type(s)
of sh used in a product. Also, it is desirable to nd out whether the
manufacturer tests the product for contaminating substances and if
the results of those tests are available.
Another point to note about safety is that a product called sh liver
oil can contain more vitamin A than the recommended daily dosage,
which could cause problems.
Generally, for low doses of sh oil supplements, the side effects are
mild and can include a shy aftertaste, belching, stomach disturbances,
and nausea.
Valerian: The herb valerian has a history of use for sleep problems
and anxiety disorders. Disrupted sleep has been called a common and
often neglected symptom of arthritis. A large, nationally representative
survey of people over 65 with arthritis in 2000 found that disruption of
sleep, among all the disruptions of arthritis, was the main reason that
people sought a variety of CAM, self-care, and conventional medical
treatments. Valerian has also been taken for other reasons, such as the
intent to relieve muscle and joint pain. The species of valerian most
used in American supplements is Valeriana ofcinalis.
The evidence suggests that valerian has at least mild benets for
sleep problems in the general population, including insomnia. It has
been theorized that valerian may have benet for people with sleep
problems from RA. However, research on valerian for RA specically
has not been done to answer this question.
494
Arthritis and CAM
There is not much evidence on how long it is safe to take valerian

and which dose to use.
There is not enough reliable evidence to declare whether valerian is
effective for muscle and joint pain, including pain from RA. There may
be some biological basis for the theory that valerian could be benecial
for musculoskeletal pain.
Valerian is considered generally safe. However, it should not be
taken with sedative drugs (for example, alcohol, benzodiazepines,
or narcotics) or other sedative herbs (such as melatonin, SAMe
[S-adenosyl-L-Methionine], or St. Johns wort). Valerian will increase
sedative effects. People who are taking antifungal drugs, statins, or
certain anti-arrhythmia drugs should not take valerian. Valerian may
not be safe for people who have a liver disorder or are at risk for one.
After taking valerian, caution should be used in driving or using dan-
gerous machinery. Side effects of valerian can include drowsiness in
the morning, headache, stomach problems, excitability or anxiety, and
sleeplessness.
Four other botanicals: Three of the other botanicals marketed

with claims to benet arthritis pain include the following:
s 'INGER
s #URCUMINACOMPONENTOFTHESPICETURMERIC
s "OSWELLIAALSOCALLED)NDIANFRANKINCENSEMADEFROMTHERESIN
of a tree that grows in India)
These three botanicals have a history of use in Ayurveda to treat in-

mAMMATORYCONDITIONS"ASEDONSOMEEARLYlNDINGSTHATMAYINDICATE
promise, NCCAM is supporting studies at the University of Arizona
on these three botanicals, to increase scientic knowledge about them
and determine whether they are helpful for chronic inammatory
conditions such as arthritis and asthma.
A fourth botanical, feverfew, has been used in folk medicine with
an intent to treat arthritis, migraine, and other conditions. One small
published clinical trial was located for this report. It found no more
benet from feverfew than from the placebo. Overall, feverfew has not
been proven to help RA symptoms.
Gingers possible side effects include stomach upset, diarrhea, and
irritation to the mouth and throat. Ginger is not recommended for
people who have a bleeding disorder, a heart condition, or diabetes. Gin-
ger may further slow blood clotting when combined with other herbs
and drugs that slow blood clotting; add to the blood-pressure-lowering
495
effects of drugs for high blood pressure and heart disease; and add to
the blood-sugar-lowering effects of diabetes drugs.
Curcumin can have side effects of stomach problems, including nausea
and diarrhea. Curcumin could add to the effects of other herbs and drugs
that slow blood clotting. Curcumin can cause gallbladder contractions and
should not be used by people with gallbladder disease or gallstones.
"OSWELLIACANHAVESIDEEFFECTSOFSTOMACHPAINSTOMACHUPSET
NAUSEAANDDIARRHEA)TISNOTKNOWNWHETHER"OSWELLIAINTERACTS
with any drugs, supplements, or diseases and conditions.
Feverfew appears to be safe for short-term use, but the safety of long-
term use is not known. Feverfew can cause an allergic reaction, especially
in people who are allergic to the daisy family. Side effects can include
diarrhea and other stomach upsets. Chewing fresh leaves of feverfew may
cause mouth irritation and sores. Feverfew might interact with medica-
tions broken down by the liver and increase the actions of drugs that slow
blood clotting. Pregnant women should not take feverfew.
Glucosamine and chondroitin: Glucosamine sulfate (glu-

cosamine for short) and chondroitin sulfate (chondroitin) are popular
dietary supplements for arthritis. They are sold separately, in combi-
nation with each other, and in other combinations.
Glucosamine is a substance found in the uid around the joints. It can
also be obtained from the shells of shrimp, lobster, and crabs, or made in
the laboratory. The body uses glucosamine to make and repair cartilage,
a rm but exible tissue that covers the ends of bones, keeps them from
rubbing against each other, and absorbs the force of impact.
Chondroitin is a substance found in the cartilage around joints. As
a supplement, it is obtained from sources such as sharks and cattle.
"OTHGLUCOSAMINEANDCHONDROITINHAVESHOWNANTI INmAMMATORY
effects in animal studies. In humans, they have been studied only for
osteoarthritis so far, not for RA. Osteoarthritis is a different form of
arthritis than RA, with different causes, although the symptoms are
similar (such as joint pain and problems with function). One cannot as-
sume that if a treatment is helpful for one type of arthritis, it will also
be helpful for another type. The studies of glucosamine and chondroitin
for osteoarthritis mostly found a modest benet. However, some design
aws have been noted in those studies. In sum, there is no evidence
that glucosamine and chondroitin are helpful for RA.
Glucosamine appears to be safe for most people. However, it might
worsen asthma through an allergic reaction. Also, glucosamine might
cause higher blood sugar and insulin levels in people with diabetes,
and those who decide to use it need to carefully monitor their blood
496
Arthritis and CAM
sugar. Glucosamine could possibly decrease the effectiveness of certain

medicationsacetaminophen, some anticancer drugs, and antidiabetes
drugs. Generally, side effects of glucosamine can include mild stomach
problems and nausea; less commonly, there can be sleepiness, a skin
reaction, or a headache. Some people who are allergic to shellsh are
concerned about an allergic reaction to glucosamine. However, most
shellsh allergies are to proteins in the meat, not to the shell material
from which glucosamine supplements are made.
Chondroitin appears to be safe for most people. However, chondroi-
tin may possibly worsen asthma (through an allergic response), blood
clotting disorders, and prostate cancer. The side effects of chondroitin
can include stomach pain and nausea; less commonly, diarrhea, con-
stipation, swelling, and problems with heart rate.
"OTHSUPPLEMENTSCOULDAFFECTTHEACTIONOFTHEDRUGWARFARINBUT
this is not denite.
Special diets: Many people with RA are interested in whether

certain foods can affect their symptoms. Examples of foods that are
believed to possibly worsen the symptoms of arthritis (including RA)
are the nightshade family of plants (white potatoes, tomatoes, eggplant,
and peppers), dairy, citrus fruits, acidic foods, sweets, coffee, and animal
protein. There are various theories about how foods may affect RA,
including the following:
s 4HEFOODSONEEATSANDHOWTHEDIGESTIVESYSTEMHANDLESTHEM
AREKNOWNTOAFFECTTHEIMMUNESYSTEM"ECAUSE2!ISADISEASE
of the immune system, a connection between diet and the dis-
ease has been proposed.
s #ERTAINFATSMOSTLYFROMANIMALSOURCESBUTALSOFROMCORNAND
sunower oils) break down in the body into substances that can
cause inammation.
s 2!ANDORMEDICATIONSTOTREATITMAYAFFECTTHEWAYAPERSONS
digestive system handles foods.
s 2!CANAFFECTAPERSONSABILITYTOPREPAREANDEATFOODLEADING
to nutritional problems.
There is no strong, reproducible evidence that any foods or diets

have a specic role in causing or treating RA.
It is important for people who have RA to eat a healthy, balanced
diet. If one or more foods are eliminated from the diet, it is possible
to miss key nutrients and not get enough calories. It is important to
497
discuss any major dietary changes with your health care provider or
a registered dietitian.
A true food allergy may exist in a small percentage of patients with
RA. Many people think they have food allergies when they do not have
them or when they have a different condition called food intolerance.
Acupuncture: Acupuncture is a practice that developed as a part

of traditional Chinese medicine. Some people try acupuncture to treat
RA pain or to treat the RA itself.
Good research studies have shown that acupuncture can help re-
lieve pain associated with osteoarthritis. However, not much is known
about its effectiveness for symptoms of RA. A handful of small studies
have been conducted, and the ndings do not clearly answer this ques-
tion. Issues with the studies have included design problems, a small
number of participants, variations in where acupuncture was given
on the body, and how many treatments were given and for how long.
More and better research is needed.
Acupuncture tends to have minimal side effects, if any. Relatively
few complications from acupuncture have been reported to the FDA. If
a person decides to use acupuncture, it is important to nd a licensed
and certied practitioner, as any complications have usually occurred
from inadequate practitioner training and experience.
Magnets: Magnets are objects that produce a type of energy called

magnetic elds. The term magnets is also used to refer to consumer
products that contain magnets. Examples include shoe insoles, cloth-
ing, wraps for parts of the body, and mattress pads. These are of a type
called static magnets, because their magnetic elds are unchanging.
The research so far does not rmly support claims that static mag-
nets are effective for treating pain, including pain from RA. In those
cases where some benet was seen, it has not been proven why; many
scientists think it may be due to a placebo effect. If someone does ex-
perience a benet from a magnet, it will tend to occur quickly.
Static magnets should not be used by pregnant women; people who
have a conditionsuch as an acute sprain, inammation, infection,
or woundthat could be affected by dilation of the blood vessels; and
people who use a device such as a pacemaker, debrillator, or insulin
pump, or who use a medication patch.
The second type of magnets used for health purposes are called
electromagnets (EMs), because they produce magnetic elds only when
electric current ows through them. EMs are used in conventional
medicine to treat bone fractures that have not healed well, and they
498
Arthritis and CAM
are being studied in research settings for a number of other conditions

(including cancer, epilepsy, RA, and mental disorders). Some consumer
products using EMs are available.
EMs are being studied because there have been some encouraging
early ndings indicating the possibility of benets for pain, physical
function, and stiffness. However, it is too early to know for sure whether
EMs are of benet for patients with RA.
EMs should not be used by pregnant women; people who have a con-
ditionsuch as an acute sprain, inammation, infection, or wound
that could be affected by dilation of the blood vessels; and people who
use a device such as a pacemaker, debrillator, or insulin pump, or
who use a medication patch. It may be advisable for people who have
a history of cancer or seizure disorder to avoid using EMs until more
is known about their effects on these medical conditions.
Hydrotherapy: Hydrotherapy is the use of water for therapeutic

purposes. A few examples of hydrotherapy include bathing in heated
water, as from hot springs or the sea; mineral baths; and water-jet mas-
sages. Another term used for hydrotherapy baths is balneotherapy.
Hydrotherapy dates back to ancient Greece and Rome. In recent cen-
turies, it has been a popular treatment in Europe and Israel. Some forms
of hydrotherapy are used in conventional medicine in the United States,
such as whirlpool baths for athletic injuries and ice for sprains. As CAM,
hydrotherapy is often combined with other treatments, such as exercises,
massage, diets, herbs, and/or mud packs. It is used with the intent to ben-
et arthritis, circulation, and various other health issues, and to enhance
feelings of relaxation and well-being. Some also claim that hydrotherapy
detoxies the body. In this report, the term hydrotherapy refers to ex-
ternal water treatments and not to internal treatments using water, such
as colon irrigation or drinking specially treated water.
A small number of controlled studies have been done on hydro-
therapy for RA, most based on sea-bath treatments given in Israels
Dead Sea area. Most of these studies reported benet. However, there
have been quality issues noted with these studies, and it is not con-
sidered proven that the hydrotherapy itself provided the benets for
RA claimed in these studies. Larger and better studies are needed to
answer this question. Study authors have noted that there could be
other reasons for any benet, such as traveling to a spa, being removed
from ones daily routine, relaxation, socializing, etc.
The safety of hydrotherapy has not been well studied. Overall, it
appears to be a low-risk practice for most people if common-sense
precautions are taken, such as not exposing the body to too much
499
heat or cold or for too long a time, and being sure to drink enough
uid. However, hydrotherapy is riskier and could even be dangerous
for certain people:
s 4HOSEWHOHAVEACONDITIONTHATCOULDBEWORSENEDBYEXPOSURE
to extremes of heat or cold (for example, heart disease, lung dis-
ease, circulation disorder, Raynaud phenomenon, or chilblains)
or by strong motions from water jets
s 4HOSEWHOHAVEDIFlCULTYPERCEIVINGTEMPERATUREFOREXAMPLE
from neuropathy, or damage to the nerves)
s 7OMENWHOAREPREGNANT
s 0EOPLEWHOHAVEIMPLANTEDMEDICALDEVICESSUCHASPACEMAKERS
or pumps
Some people may get a skin irritation or infection from hydrothera-

py water, either as a reaction to something in the water or if the water
is not in sanitary condition.
Homeopathy: Homeopathy is a whole medical system that was

developed in Germany and brought to the United States in the 19th
century. Homeopathy involves giving very small doses of substances
called remedies that would produce the same or similar symptoms of
illness in healthy people when given in larger doses. This approach is
called like cures like. The remedies are diluted very highly, often to
a point where not one molecule of the original substance remains.
Little rigorous research has been done on homeopathy for RA. The
results have been mixed. It appears from some studies that home-
opathy might be more effective than a placebo for rheumatic diseases
and syndromes (including RA), but this evidence is not strong. Larger,
better-designed studies are needed to resolve this question.
Homeopathic remedies are considered safe and unlikely to cause
severe side effects. The FDA has learned of a few reports of illness
associated with the use of these remedies, but determined that the
remedies were not likely to be the cause. Homeopathic remedies are
not known to interfere with conventional drugs.
Acupuncture Relieves Pain and Improves Function in

Knee Osteoarthritis
Acupuncture provides pain relief and improves function for people
with osteoarthritis of the knee and serves as an effective complement
500
Arthritis and CAM
to standard care. This landmark study was funded by the National

Center for Complementary and Alternative Medicine (NCCAM) and the
National Institute of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS), both components of the National Institutes of Health. The
ndings of the studythe longest and largest randomized, controlled
phase III clinical trial of acupuncture ever conductedwere published
in the December 21, 2004, issue of the Annals of Internal Medicine.1
The multi-site study team, including rheumatologists and licensed
acupuncturists, enrolled 570 patients, aged 50 or older with osteoarthritis
of the knee. Participants had signicant pain in their knee the month
before joining the study, but had never experienced acupuncture, had not
had knee surgery in the previous 6 months, and had not used steroid or
similar injections. Participants were randomly assigned to receive one of
three treatments: acupuncture, sham acupuncture, or participation in a
control group that followed the Arthritis Foundations self-help course
for managing their condition. Patients continued to receive standard
medical care from their primary physicians, including anti-inammatory
medications, such as COX-2 [cyclooxygenase-2] selective inhibitors, non-
steroidal anti-inammatory drugs, and opioid pain relievers.
For the rst time, a clinical trial with sufcient rigor, size, and
duration has shown that acupuncture reduces the pain and functional
impairment of osteoarthritis of the knee, said Stephen E. Straus, MD,
NCCAM Director.
These results also indicate that acupuncture can serve as an effec-
tive addition to a standard regimen of care and improve quality of life
for knee osteoarthritis sufferers. NCCAM has been building a portfo-
lio of basic and clinical research that is now revealing the power and
promise of applying stringent research methods to ancient practices
like acupuncture.
More than 20 million Americans have osteoarthritis. This disease
is one of the most frequent causes of physical disability among adults,
said Stephen I. Katz, MD, PhD, NIAMS Director. Thus, seeking an
effective means of decreasing osteoarthritis pain and increasing func-
tion is of critical importance.
$URINGTHECOURSEOFTHESTUDYLEDBY"RIAN-"ERMAN-$$I-
rector of the Center for Integrative Medicine and Professor of Family
-EDICINEATTHE5NIVERSITYOF-ARYLAND3CHOOLOF-EDICINE"ALTIMORE
Maryland, 190 patients received true acupuncture and 191 patients
received sham acupuncture for 24 treatment sessions over 26 weeks.
Sham acupuncture is a procedure designed to prevent patients from
being able to detect if needles are actually inserted at treatment points.
In both the sham and true acupuncture procedures, a screen prevented
501
patients from seeing the knee treatment area and learning which treat-
ment they received. In the education control group, 189 participants
attended six, 2-hour group sessions over 12 weeks based on the Arthritis
Foundations Arthritis Self-Help Course, a proven, effective model.
On joining the study, patients pain and knee function were assessed
using standard arthritis research survey instruments and measure-
MENTTOOLSSUCHASTHE7ESTERN/NTARIO-C-ASTERS/STEOARTHRITIS
)NDEX7/-!# 0ATIENTSPROGRESSWASASSESSEDATAND
WEEKS"YWEEKPARTICIPANTSRECEIVINGACUPUNCTUREWERESHOWINGA
signicant increase in function and by week 14 a signicant decrease in
pain, compared with the sham and control groups. These results, shown
BYDECLININGSCORESONTHE7/-!#INDEXHELDTHROUGHWEEK
Overall, those who received acupuncture had a 40 percent decrease
in pain and a nearly 40 percent improvement in function compared to
baseline assessments.
This trial, which builds upon our previous NCCAM-funded re-
search, establishes that acupuncture is an effective complement to
conventional arthritis treatment and can be successfully employed
as part of a multidisciplinary approach to treating the symptoms of
OSTEOARTHRITISvSAID$R"ERMAN
Acupuncturethe practice of inserting thin needles into specic
body points to improve health and well-beingoriginated in China
more than 2,000 years ago. In 2002, acupuncture was used by an es-
timated 2.1 million U.S. adults, according to the Centers for Disease
Control and Preventions 2002 National Health Interview Survey.2
The acupuncture technique that has been most studied scientically
involves penetrating the skin with thin, solid, metallic needles that
are manipulated by the hands or by electrical stimulation. In recent
years, scientic inquiry has begun to shed more light on acupunctures
possible mechanisms and potential benets, especially in treating
painful conditions such as arthritis.
References
"ERMAN"-,AO,,ANGENBERG0,EE7,'ILPIN!-+(OCH-
berg MC. Effectiveness of Acupuncture as Adjunctive Therapy
in Osteoarthritis of the Knee: A Randomized, Controlled Trial.
Annals of Internal Medicine. 2004; 141(12):901910.
"ARNES00OWELL 'RINER%-C&ANN+.AHIN2CDC Advance
Data Report #343. Complementary and Alternative Medicine
Use Among Adults: United States, 2002. May 27, 2004.
502
Chapter 74
Asthma, Allergies, and CAM
What is alternative medicine?

Any unproven treatment for an illness or disease is considered
an alternative medical approach by most American medical doctors.
Unproven means there is not enough acceptable scientic evidence to
show that the treatment works. The term alternative medicine refers
to a wide variety of treatments considered outside mainstream or
usual medical approaches in the United States today.
Many people turn to alternative medicine to help alleviate their
asthma or allergy symptoms. These treatment approaches may include,
but are not limited to, one or more of the following:
s !CUPUNCTURE
s !YURVEDICMEDICINE
s "IOFEEDBACKMENTALIMAGINGSTRESSREDUCTIONRELAXATIONTECH-
niques
s #HIROPRACTICSPINALMANIPULATION
s $IETEXERCISEYOGALIFESTYLECHANGES
s (ERBALMEDICINEVITAMINSUPPLEMENTS
s &OLKMEDICINEFROMVARIOUSCULTURES
Alternative Therapies, reprinted with permission from the Asthma and Al-
lergy Foundation of America, 2005. All rights reserved. Reviewed by David A.
Cooke, MD, FACP, December 25, 2009.
503
s ,ASERTHERAPY
s -ASSAGE
s (YPNOSIS
s !RTORMUSICTHERAPY
Why do people use alternative medicine?

Recent statistics show that nearly 40 percent of Americans try some
form of alternative medicine. Medical and scientic experts do believe
that some remedies may be worth a try, providing they are not harm-
ful. In some cases, specic alternative medical treatment may improve
or relieve symptoms of a specic illness or disease. Risks should not
outweigh the potential benets.
If you believe a particular alternative medical approach might help
reduce your asthma or allergy symptoms, talk with your doctor about
it, and how you could integrate that treatment into your overall asthma/
allergy management plan.
No one should use alternative medicine without rst consulting a
board-certied physician. Any alternative medical approach should be
used in addition to your normal asthma or allergy management plan.
You should not substitute an alternative medical treatment for your
REGULARMEDICATIONSORTREATMENTS"EESPECIALLYCAREFULABOUTUSEOF
alternative medicine on children. Approaches that are harmless for
adults may not be harmless for children.
Does health insurance cover alternative medical treatment?

Health plans vary in what alternative medicine expenses they will
pay. Many plans provide coverage for some but not all alternative
therapies. If your doctor writes you a prescription for a specic treat-
ment such as acupuncture or massage, you may be more likely to get
partial or full reimbursement of the expense. Always check with your
insurance provider before assuming the coverage is available.
What are cautions or considerations for people who use al-

ternative medicine?
Beware the placebo effect. If you really want an alternative medi-
cal treatment to work, you may think it is working, even if it really isnt.
This placebo effect often occurs for people using alternative medicine.
Symptoms of asthma or allergy also may improve on their own as an
504
Asthma, Allergies, and CAM
illness (like a cold or u) runs its course. If you use prescribed medica-
tions for your allergy or asthma symptoms, it may take time for them to
kick in. So you may simply be feeling better because your medications
started workingnot because the alternative medicine is working.
Read between the label lines. The federal government requires

labels to state how an herb or vitamin may affect the body but labels
are not required to carry health warnings. Labels also cannot claim any
medical or health benet. Products often are not properly labeled, es-
pecially those imported from other countries. Many people experience
toxicand sometimes deadlyeffects from improperly using labeled
herbs. Some products contain unnamed medicines such as steroids,
anti-inammatories, or sedatives that act to reduce your symptoms.
Other hidden ingredients in various products can be dangerous or
even lethal. Use products tested for safety and effectiveness.
Follow directions. Never increase the amount or frequency of

a dose or use a treatment or device in a different way than recom-
mended. Do not use herbs in combinations. Do not take herbs if you
are pregnant or breast feeding.
Beware of developing allergy symptoms. Allergies to specic

plants and other substances (such as latex or nickel) can build up
over time. Products youve used for years may suddenly cause mild
to serious allergy symptoms, especially if you already are allergic to
something. Check to see if new herbs, foods, or other products you plan
to use are in the same family as your known allergens.
Use quality products and services. Lack of quality standards is

a serious problem for people who use various alternative medical treat-
ments. Look for products that list the amount of the active ingredient(s).
Make sure people giving you any kind of treatment are properly certied.
Ask your pharmacist or health product store manager for recommenda-
tions. Research the product or service before you use it.
Consult with your physician before starting any new treat-

ment. This point cannot be stressed enough. If you have symptoms of
asthma or allergy, but you have not been diagnosed, consult a board-
certied doctor for a proper diagnosis. Do not rely on health product
store personnel to help treat undiagnosed symptoms. If you know
you have asthma or allergies, again, talk with your doctor about the
alternative medicine you want to use before you try it.
505
Are there useful alternative therapies for people who have

asthma or allergies?
Keep in mind: Alternative therapy is medical treatment for which
there is no conclusive, supporting scientic evidence. This does not
necessarily mean the treatment is useless or ineffective. You simply
must be careful in what you choose and how you use it.
Acupuncture: A technique that involves inserting needles into key

points of the body. Evidence suggests that acupuncture may signal the
brain to release endorphins. These are hormones made by the body.
7HENRELEASEDENDORPHINSCANHELPREDUCEPAINANDCREATEASENSEOF
well-being. People with asthma or allergy may experience more relaxed
or calmer breathing. Users should be aware of the risk of contaminated
needles or punctured organs.
Biofeedback: A technique that helps people control involuntary

physical responses. Results are mixed, with children and teenagers
showing the greatest benet.
Chiropractic spinal manipulation: A technique that emphasizes

manipulation of the spine in order to help the body heal itself. There
is no evidence that this treatment impairs the underlying disease or
pulmonary function.
Hypnosis: An articially induced dream state that leaves the person

open to suggestion, hypnosis is a legitimate technique to help people
manage various conditions. Hypnosis might give people with asthma or
allergies more self-discipline to follow good health practices.
Laser treatment: A technique that uses high intensity light to

shrink swollen tissue or unblock sinuses. Laser therapy may provide
temporary relief, but it may also cause scarring or other long-term
physical problems.
Massage, relaxation techniques, art/music therapy, yoga:

Stress and anxiety may cause your airways to constrict more if you
have asthma or allergies. Various techniques can help you relax, reduce
anxiety, or control your breathing. The results may provide some benet
in helping you cope with asthma or allergy symptoms. However, evidence
is not conclusive that these techniques improve lung function.
506
Chapter 75
Cancer and CAM
Cancer and CAM

What is complementary and alternative medicine?
Complementary and alternative medicine is a group of diverse
medical and health care systems, practices, and products that are not
presently considered to be part of conventional medicine. Conventional
medicine is medicine as practiced by holders of MD (medical doctor)
or DO (doctor of osteopathy) degrees and by their allied health pro-
fessionals, such as physical therapists, psychologists, and registered
nurses. Some health care providers practice both CAM and conven-
tional medicine.
s #OMPLEMENTARYMEDICINEISUSEDTOGETHERWITHCONVENTIONAL
medicine.
s !LTERNATIVEMEDICINEISUSEDINPLACEOFCONVENTIONALMEDICINE
This chapter includes text from Cancer and CAM, by the National Center for
National Institutes of Health, June 2007. It also includes text from PC-SPES,
0$1#ANCER)NFORMATION3UMMARY.ATIONAL#ANCER)NSTITUTE"ETHESDA-$
PC-SPES (PDQ): CAMPatient. Updated 09/2007. Available at http://cancer.
gov. Accessed January 12, 2010; and from Selected Vegetables/Suns Soup, PDQ
#ANCER)NFORMATION3UMMARY.ATIONAL#ANCER)NSTITUTE"ETHESDA-$3ELECTED
Vegetables/Suns Soup (PDQ): CAMPatient. Updated 02/2007. Available at
http://cancer.gov. Accessed December 11, 2009.
507
s )NTEGRATIVEMEDICINECOMBINESTREATMENTSFROMCONVENTIONAL
medicine and CAM for which there is some high-quality evidence
of safety and effectiveness. It is also called integrated medicine.
Is CAM widely used?

According to a comprehensive survey on Americans use of CAM, 36
PERCENTOF53ADULTSAREUSINGSOMEFORMOF#!-7HENMEGAVITAMIN
therapy and prayer for health reasons are included in the denition of
CAM, that percentage rises to 62 percent. These results are based on the
2002 National Health Interview Survey, which was supported by NCCAM
and the National Center for Health Statistics (part of the Centers for Dis-
ease Control and Prevention). The survey found that rates of CAM use are
especially high among patients with serious illnesses such as cancer.
Several smaller studies of CAM use by cancer patients have been
conducted. A study of CAM use in patients with cancer in the July 2000
issue of the Journal of Clinical Oncology found that 69 percent of 453
cancer patients had used at least one CAM therapy as part of their
cancer treatment. A study published in the December 2004 issue of the
Journal of Clinical Oncology reported that 88 percent of 102 people
with cancer who were enrolled in phase I clinical trials (research stud-
ies in people) at the Mayo Comprehensive Cancer Center had used at
least one CAM therapy. Of those, 93 percent had used supplements
(such as vitamins or minerals), 53 percent had used nonsupplement
forms of CAM (such as prayer/spiritual practices or chiropractic care),
and almost 47 percent had used both.
A review article in the March 2005 issue of the Southern Medical
Journal reported that cancer patients take supplements to reduce side
effects and organ toxicity, to protect and stimulate their immune sys-
tems, or to prevent further cancers or recurrences. Patients frequently
see using supplements as a way to take control over their health and
increase their quality of life.
Additional information about CAM use among cancer patients can
be found in a review article published in Seminars in Oncology in
December 2002.
How are CAM approaches evaluated?

The same rigorous scientic evaluation used to assess conventional
cancer treatments should be used for CAM therapies. NCCAM is fund-
ing a number of clinical trials to evaluate CAM therapies for cancer.
Conventional cancer treatments are studied for safety and effec-
tiveness through a rigorous scientic process that includes laboratory
508
Cancer and CAM
research and clinical trials with large numbers of patients. Less is

known about the safety and effectiveness of complementary and al-
ternative methods to treat cancer, although some CAM therapies have
undergone rigorous evaluation.
A small number of CAM therapies, which were originally consid-
ered to be purely alternative approaches, are nding a place in cancer
treatmentnot as cures, but as complementary therapies that may
help patients feel better and recover faster. One example is acupunc-
ture. In 1997, a panel of experts at the National Institutes of Health
(NIH) Consensus Conference found acupuncture to be effective in
managing chemotherapy-associated nausea and vomiting and in con-
trolling pain associated with surgery. In contrast, some approaches,
such as the use of laetrile, have been studied and found ineffective or
potentially harmful.
Is NCCAM sponsoring clinical trials on CAM for cancer?

NCCAM is sponsoring a number of clinical trials to study comple-
mentary and alternative treatments for cancer. Some of these trials
study the effects of complementary approaches used in addition to
conventional treatments, while others compare alternative therapies
with conventional treatments. Recent trials include the following:
s !CUPUNCTURETORELIEVENECKANDSHOULDERPAINFOLLOWINGSURGERY
for head or neck cancer
s 'INGERASATREATMENTFORNAUSEAANDVOMITINGCAUSEDBY
chemotherapy
s -ASSAGEFORTHETREATMENTOFCANCERPAIN
s -ISTLETOEEXTRACTCOMBINEDWITHCHEMOTHERAPYFORTHETREATMENT
of solid tumors
Patients who are interested in taking part in these or any other

clinical trials should talk with their health care provider.
What should patients do when using or considering CAM

therapies?
Cancer patients who are using or considering CAM should discuss
this decision with their health care provider, as they would any therapy.
Some complementary and alternative therapies may interfere with
standard treatment or may be harmful when used along with standard
treatment.
509
As with any medicine or treatment, it is a good idea to learn about

the therapy, including whether the results of scientic studies support
the claims that are made for it.
When considering CAM, what questions should patients

ask their health care providers?
s 7HATBENElTSCANBEEXPECTEDFROMTHISTHERAPY
s 7HATARETHERISKSASSOCIATEDWITHTHISTHERAPY
s $OTHEKNOWNBENElTSOUTWEIGHTHERISKS
s 7HATARETHEPOTENTIALSIDEEFFECTS
s 7ILLTHETHERAPYINTERFEREWITHCONVENTIONALTREATMENT
s )STHISTHERAPYPARTOFACLINICALTRIAL)FSOWHOISSPONSORING
THETRIAL
s 7ILLTHETHERAPYBECOVEREDBYHEALTHINSURANCE
PC-SPES
What is PC-SPES?
PC-SPES is a mixture of herbs that was sold as a complementary
and alternative medicine (CAM) treatment for prostate cancer. The
mixture contains these eight herbs:
s "AIKALSKULLCAPScutellaria baicalensis)
s ,ICORICEGlycyrrhiza glabra or Glycyrrhiza uralensis)
s 2EISHIMUSHROOMGanoderma lucidum)
s )SATISIsatis indigotica)
s 'INSENGPanax ginseng or Panax pseudoginseng var. notoginseng)
s #HRYSANTHEMUMmOWERSDendranthema morifolium)
s 2ABDOSIARUBESCENSIsodon rubescens)
s 3AWPALMETTOSerenoa repens)
PC-SPES was taken off the market because some batches were
found to contain prescription medicines in addition to the herbs.
Clinical trials of PC-SPES that were underway were stopped. There
are products being sold now as substitutes for PC-SPES, but they are
not the same mixture.
510
Cancer and CAM
What is the history of the discovery and use of PC-SPES as

a complementary and alternative treatment for cancer?
Most of the herbs in PC-SPES have been used in traditional Chi-
nese medicine (TCM) for many health problems, including prostate
problems, for hundreds of years. A chemist in New York and a doctor/
herbalist in China worked together to create the mixture.
In 1997, a company was formed to make PC-SPES and sell it in
the United States without a prescription. Interest in PC-SPES grew,
and researchers began looking at it. Tests found that some batches of
PC-SPES contained one or more of the following drugs, which are not
found in nature:
s $%3;DIETHYLSTILBESTROL=ATYPEOFESTROGENMADEINALAB
s 7ARFARIN#OUMADIN ABLOODTHINNER
s )NDOMETHACINADRUGUSEDTODECREASEINmAMMATION
"ECAUSETHESEDRUGSARETOBEUSEDONLYBYPRESCRIPTIONANDCOULD
be harmful to some people, PC-SPES was taken off the market in 2002.
The company that made PC-SPES has closed.
What is the theory behind the claim that PC-SPES is useful

in treating cancer?
In lab tests, each herb used in PC-SPES has been reported to help
keep cancer cells from growing or to help prevent cell damage that can
lead to cancer and other diseases.
PC-SPES was reported to slow the growth of prostate cancer but did
not cure it. It is not known how PC-SPES works in the body. Some of
the herbs in the mixture contain phytoestrogens, which are estrogen-
like substances found in plants. Estrogen can cause the testicles to
stop making testosterone, which makes some prostate cancers grow.
Patients responses to PC-SPES were similar to responses to estrogen
therapy using DES. The DES found in some batches of PC-SPES, how-
ever, may not have been enough to cause all of the estrogen-like effects
that were seen in users of the mixture. There is some evidence that the
mixture works in a different way than DES does, and that PC-SPES
alone (without DES in it) may ght prostate cancer.
PC-SPES has also shown anticancer effects on prostate cancers
that do not depend on testosterone and on other types of cancer. This
suggests that PC-SPES may have anticancer qualities other than its
estrogen-like effects.
511
How is PC-SPES administered?

PC-SPES is taken by mouth in capsules.

conducted using PC-SPES?
Studies of PC-SPES in test tubes and using rats showed that it might
keep cancer cells from growing. These studies were done, however, before
it became known that some batches of the product contained unlisted
prescription medicines. Also, the product was not standardized (differ-
ent batches of PC-SPES were found to contain different strengths of the
herbal ingredients). For these reasons, the results of the lab tests and
animal studies are not considered to be good evidence.
The National Center for Complementary and Alternative Medicine
(NCCAM) is doing three laboratory studies using existing PC-SPES
supplies. The studies are being done to see how the herbs in PC-SPES
might act in the body.

PC-SPES been conducted?
Clinical trials of PC-SPES had begun before the product was taken
off the market. In these trials, PC-SPES was reported to improve qual-
ity of life, reduce pain, and lower PSA (prostate specic antigen) levels
in patients with prostate cancer. Rising PSA levels can be a sign that
prostate cancer is growing.
After it was learned that some batches of PC-SPES contained prescrip-
tion medicines, ongoing studies were stopped and previous study results
came into question. The responses reported in the studies may have been
caused by the prescription medicines that were in the PC-SPES, as well
as by the herbal ingredients. Also, since different batches of PC-SPES
contained different ingredients, the studies cannot easily be compared.
NCCAM plans to do clinical trials of PC-SPES once a standard
product is available.
Have any side effects or risks been reported from PC-SPES?

Common side effects were the same as those reported with estrogen
therapy:
s "REASTSWELLINGANDTENDERNESS
s ,OSSOFSEXDRIVE
s )MPOTENCEINABILITYTOHAVEANERECTION
512
Cancer and CAM
There were other, less common, side effects:

s "LOODCLOTSINTHELEGS
s $IARRHEA
PC-SPES may also change the way drugs, including anticancer

drugs, work in the body. It may cause drugs to be more or less effective,
or cause effects on the body that are not expected.
Is PC-SPES approved by the U.S. Food and Drug Adminis-

tration (FDA) for use as a cancer treatment in the United
States?
The U.S. Food and Drug Administration has not approved PC-
SPES for use in cancer treatment. It is not legally sold in the United
States.
Selected Vegetables/Suns Soup

What is Selected Vegetables/Suns Soup?
Selected Vegetables and Suns Soup are names given to several
different mixtures of vegetables and herbs that are being studied as treat-
ments for cancer and other medical conditions, including acquired immu-
nodeciency syndrome (AIDS). The following versions have been used:
s /RIGINAL-IXTURE3HIITAKEMUSHROOMMUNGBEANSHedyotis
diffusa; Scutellaria barbata (barbat skullcap). This mixture is
not sold in the United States.
s &REEZE DRIED3ELECTED6EGETABLES$36 !FREEZE DRIEDMIXTURE
of vegetables and herbs sold in the United States as a dietary
supplement. DSV is reported to contain the following ingredients:
s 3OYBEAN s ,EEK s ,ICORICE

s 3HIITAKE s ,ENTILS s $ANDELION
mushroom root
s (AWTHORN
s -UNGBEAN fruit s 3ENEGAROOT
s 2EDDATE s /NION s 'INGER
s 3CALLION s 'INSENG s /LIVE
s 'ARLIC s !NGELICA s 3ESAMESEED
root s 0ARSLEY
513
s &ROZEN3ELECTED6EGETABLES&36 !FROZENMIXTUREOFFRESH
vegetables and herbs, sold in the United States as a dietary
supplement. It contains the same vegetables and herbs as in
DSV.
What is the history of the discovery and use of Selected

Vegetables/Suns Soup as a complementary and alternative
treatment for cancer?
The vegetable and herb mixture now called Selected Vegetables/
Suns Soup was created by Dr. Alexander Sun to treat cancer.
s )NTHEMID S3UNCREATEDTHEMIXTURETOTREATARELATIVE
who was diagnosed with stage IV non-small cell lung cancer
and not helped by standard treatment. The mixture contained
shiitake mushroom, mung bean, and the herbs Hedyotis diffusa
and barbat skullcap. Sun believed these ingredients contain
substances that may block the growth of cancer cells and/or
help the bodys immune system attack cancer cells. The relative
was reported to be alive and free of cancer more than 13 years
later. Three more patients with advanced cancer were treated
with a combination of shiitake mushroom and mung bean.
These patients were also reported to benet from the treat-
ment.
s )N3UNAPPLIEDFORAPATENTFOR3ELECTED6EGETABLES3UNS
Soup as an herbal treatment of cancer. He reported on animal
studies done in mice. Sun then began doing clinical trials to test
Selected Vegetables/Suns Soup in cancer patients.
s )N3UNWASAWARDEDAPATENTFOR3ELECTED6EGETABLES3UNS
Soup.
s )N3UNREPORTEDATASCIENTIlCMEETINGTHATPATIENTSWITH
different types of cancer had been helped by treatment with Se-
lected Vegetables/Suns Soup.
Many of the vegetables and herbs in Selected Vegetables/Suns

Soup were chosen because previous research and traditional Chinese
medicine suggest they contain anticancer phytochemicals (substances
found in plants that may have effects on the body). These include
substances such as protease inhibitors, plant sterols, and isoavones.
These ingredients may block the growth of cancer cells and/or improve
the way the bodys immune system attacks cancer cells.
514
Cancer and CAM
What is the theory behind the claim that Selected Vegetables/

Suns Soup is useful in treating cancer?
The theory is that certain ingredients in Selected Vegetables/Suns
Soup may contain phytochemicals that have signicant anticancer
effects in humans. One of these ingredients is shiitake mushroom.
Lentinan, which is taken from shiitake mushroom, has been used in
Japan to treat stomach and colon cancer after surgery. Treatment with
lentinan is reported to help patients with stomach cancer live longer
and have a better quality of life. Lentinan may not be easily absorbed
by the body from food, so it is usually given by injection. Other sub-
stances in shiitake mushroom that are more easily used by the body
from food have shown anticancer activity in animal tests.
How is Selected Vegetables/Suns Soup administered?

Selected Vegetables/Suns Soup is eaten as part of the diet. Daily
doses of either 1 ounce of the DSV (mixed with water or other soup)
or 10 ounces of the FSV were used in clinical trials.

conducted using Selected Vegetables/Suns Soup?
Few preclinical studies have been done with Selected Vegetables/
Suns Soup. Research in a laboratory or using animals is done to nd out
if a drug, procedure, or treatment is likely to be useful in humans. Pre-
clinical studies are done before clinical trials (in humans) are begun.
A small number of mice were injected with tumor cells and fed
either standard food or food mixed with one or more ingredients from
Selected Vegetables/Suns Soup. The researchers reported that the
growth of tumors was slower in the mice that were fed the Selected
Vegetables/Suns Soup ingredients, compared to the mice that ate stan-
dard food. The tumor growth was slowest when the mice were fed both
mung bean and shiitake mushroom.

Selected Vegetables/Suns Soup been conducted?
Clinical trials using Selected Vegetables/Suns Soup to treat can-
cer have been done with small numbers of patients. These patients
received other types of treatment, either before or during treatment
with Selected Vegetables/Suns Soup, and different vegetable mixtures
were used in the different studies.
515
The results of these trials were compared with published informa-

tion on similar patients who did not receive Selected Vegetables/Suns
Soup. Most patients receiving the vegetable mixtures lived longer, were
better able to carry out their daily activities, and either gained weight
or did not lose weight. In some patients who ate Selected Vegetables/
Suns Soup, tumor growth slowed or the tumor completely went away.
"ECAUSEPATIENTSINTHESETRIALSRECEIVEDOTHERTREATMENTSITISNOT
known if their responses were caused by Selected Vegetables/Suns
Soup, the other treatments, or both. None of the trials were random-
ized or controlled. Randomized clinical trials give the highest level
of evidence. In randomized trials, volunteers are put randomly (by
chance) into one of two or more groups that compare different treat-
ments. In a controlled trial, one group (called the control group) does
not receive the new treatment being studied. The control group is then
compared to the groups that receive the new treatment, to see if the
new treatment works. Randomized controlled trials, enrolling larger
numbers of people, are needed to conrm the results of studies done
so far on Selected Vegetables/Suns Soup.
/NERANDOMIZEDCLINICALTRIALOFPATIENTSWITHSTAGE)))"ORSTAGE)6
non-small cell lung cancer is now being conducted. The trial is compar-
ing the survival of patients receiving Selected Vegetables/Suns Soup
WITHPATIENTSRECEIVINGAPLACEBOINACTIVESUBSTANCE "OTHGROUPSARE
receiving treatment with supportive care, such as radiation therapy,
surgery, or palliative care.
Have any side effects or risks been reported from Selected

Vegetables/Suns Soup?
No harmful side effects or risks have been reported in the use of
Selected Vegetables/Suns Soup. Some patients felt full or bloated after
eating the dry form, but patients who ate the frozen mixture did not
report this.
Is Selected Vegetables/Suns Soup approved by the U.S. Food

and Drug Administration (FDA) for use as a cancer treat-
ment in the United States?
The FDA has not approved any form of Selected Vegetables/Suns
3OUPFORTHETREATMENTOFCANCERORANYOTHERMEDICALCONDITION7ELL
designed clinical trials that test identical mixtures of vegetables and
herbs are needed to prove whether Selected Vegetables/Suns Soup is
useful in treating cancer.
516
Chapter 76
Cognitive Decline and CAM
Grape Seed Extract May Help Prevent and Treat

Alzheimer Disease
According to the National Institute on Aging (NIA), Alzheimer dis-
ease affects nearly 4.5 million Americans and is the most common form
of dementia in the elderly. Alzheimer disease is an incurable disease
with a slow progression beginning with mild memory loss and ending
with severe brain damage and death.
7HILENOTREATMENTISPROVENTOSTOP!LZHEIMERDISEASESOMECON-
ventional drugs may limit symptoms for a short period of time in
the early stages of the disease. Emerging research shows a correla-
tion between red wine consumption and reduced risk of Alzheimer
disease-type cognitive decline. Authors of a new NCCAM-funded study
in mice found that grape seed-derived polyphenolicssimilar to that
in red winesignicantly reduced Alzheimer disease-type cognitive
deterioration.
This chapter contains text from Grape Seed Extract May Help Prevent and
Treat Alzheimers, by the National Center for Complementary and Alternative
Medicine (NCCAM, nccam.nih.gov), part of the National Institutes of Health,
June 2008; Pilot Study Provides New Insight on Effect of Ginkgo Extract on
Dementia in the Elderly, by the NCCAM, 2008; and Study Suggests Coenzyme
Q10 Slows Functional Decline in Parkinson Disease, by the National Institute
of Neurological Disorders and Stroke (NINDS, www.ninds.nih.gov), part of the
National Institutes of Health, October 14, 2002. Reviewed and revised by David
A. Cooke, MD, FACP, January 23, 2010.
517
Researchers from Mount Sinai School of Medicine conducted experi-

ments in mice with Alzheimer disease to see if a highly puried 100
percent water-soluble polyphenolic extract from Vitis vinifera (cabernet
sauvignon) grape seeds, could affect Alzheimer disease-type cognitive
deterioration. The mice received 5 months of either water containing
grape seed extract or water alone as a placebo treatment. The mice
were then given behavioral maze tests to determine cognitive func-
tion and brain tissue samples were tested to determine evidence of
disease.
The researchers found that mice treated with grape seed extract
had signicantly reduced Alzheimer disease-type cognitive deteriora-
tion compared to the control mice. This is due to the prevention of a
molecule called amyloid forming in the brain that has been shown to
cause Alzheimer disease-type cognitive impairment.
Reference:7ANG*(O,:HAO7ETAL'RAPE $ERIVED0OLYPHE-

NOLICS0REVENT! "ETA/LIGOMERIZATIONAND!TTENUATE#OGNITIVE$E-
terioration in a Mouse Model of Alzheimers Disease. The Journal of
Neuroscience. June 18, 2008. 28(25);63886392.
Pilot Study Provides New Insight on Effect of Ginkgo

Extract on Dementia in the Elderly
Overall, in a pilot study of a ginkgo biloba extract for delaying the
onset of dementia in the elderly, researchers did not nd a reduction
in progression to dementia in those using ginkgo versus those using
placebo. However, when the researchers took into account participants
adherence to taking the compound, the group that took ginkgo did
appear to have a reduced risk of progression and a smaller decline in
memory.
This small study funded by the National Institute on Aging and
NCCAM and led by Hiroko Dodge, PhD, and colleagues at the Oregon
Health & Science University and the Oregon State University, fol-
lowed 118 volunteers age 85 or older over the course of 42 months. The
double-blind, randomized, and placebo-controlled study used 80 mg of
ginkgo extract taken three times per day. The participants were tested
on entering the trial for memory function and other measures of health
and were seen every 6 months to assess changes. Overall, both groups
had similar reports of adverse events; however, the ginkgo group had
more incidences of stroke, but there were no deaths due to stroke.
The study focused on those 85+ years, as more than half of indi-
viduals with dementia in developed countries are in their 80s or are
518
older, according to the authors. In addition, with an estimated 8 to 15

percent of those in the same age group progressing to dementia yearly,
it is important to nd safe treatments that can slow this process. The
authors conclude that there are limitations to the study and the sug-
gestive results of a possible benet from ginkgo need to be conrmed
by larger prevention clinical trials.
Reference:$ODGE((:ITZELBERGER4/KEN"3ETAL!2ANDOM-

IZED0LACEBO #ONTROLLED4RIALOF'INKGO"ILOBAFORTHE0REVENTIONOF
Cognitive Decline. Neurology. February 2008.
Study Suggests Coenzyme Q10 Slows Functional

Decline in Parkinson Disease
Results of the rst placebo-controlled, multicenter clinical trial of
the compound coenzyme Q10 suggest that it can slow disease progres-
SIONINPATIENTSWITHEARLY STAGE0ARKINSONDISEASE0$ 7HILETHE
results must be conrmed in a larger study, they provide hope that
this compound may ultimately provide a way of treating PD.
The phase II study, led by Clifford Shults, MD, of the University
of California, San Diego (UCSD) School of Medicine, looked at a total
of 80 PD patients at 10 centers across the country to determine if co-
enzyme Q10 is safe and if it can slow the rate of functional decline. The
study was funded by the National Institute of Neurological Disorders
and Stroke (NINDS) and appears in the October 15, 2002, issue of the
Archives of Neurology.
This trial suggested that coenzyme Q10 can slow the rate of dete-
rioration in Parkinson disease, says Dr. Shults. However, before the
compound is used widely, the results need to be conrmed in a larger
group of patients.
PD is a chronic, progressive neurological disease that affects about
500,000 people in the United States. It results from the loss of brain
cells that produce the neurotransmitter dopamine and causes tremor,
stiffness of the limbs and trunk, impaired balance and coordination,
and slowing of movements. Patients also sometimes develop other
symptoms, including difculty swallowing, disturbed sleep, and emo-
tional problems. PD usually affects people over the age of 50, but it can
AFFECTYOUNGERPEOPLEASWELL7HILELEVODOPAANDOTHERDRUGSCANEASE
the symptoms of PD, none of the current treatments has been shown
to slow the course of the disease.
The investigators believe coenzyme Q10 works by improving the
function of mitochondria, the powerhouses that produce energy in
519
cells. Coenzyme Q10 is an important link in the chain of chemical

reactions that produces this energy. It also is a potent antioxidant
a chemical that mops up potentially harmful chemicals generated
during normal metabolism. Previous studies carried out by Dr. Shults,
2ICHARD(AAS-$OF5#3$AND&LINT"EAL-$OF#ORNELL5NIVERSITY
have shown that coenzyme Q10 levels in mitochondria from PD pa-
tients are reduced and that mitochondrial function in these patients is
impaired. Animal studies have shown that coenzyme Q10 can protect
the area of the brain that is damaged in PD. Dr. Shults and colleagues
also conducted a pilot study with PD patients that showed that con-
sumption of up to 800 mg/day of coenzyme Q10 was well-tolerated and
signicantly increased the level of coenzyme Q10 in the blood.
All of the patients who took part in the new study had the three pri-
mary features of PDtremor, stiffness, and slowed movementsand
had been diagnosed with the disease within 5 years of the time they
were enrolled. After an initial screening and baseline blood tests, the
patients were randomly divided into four groups. Three of the groups
received coenzyme Q10 at three different doses (300 mg/day, 600 mg/
day, and 1,200 mg/day), along with vitamin E, while a fourth group
received a matching placebo that contained vitamin E alone. Each
participant received a clinical evaluation 1 month later and every 4
months for a total of 16 months or until the investigator determined
that the patient needed treatment with levodopa. None of the partici-
pants or the study investigators knew which treatment each patient
had received until the study ended.
The investigators found that most side effects of coenzyme Q10
were mild, and none of the patients required a reduction of their dose.
The percentage of people receiving coenzyme Q10 who reported side
effects was not signicantly different from that of the placebo group.
During the study period, the group that received the largest dose of
coenzyme Q10 (1,200 mg/day) had 44 percent less decline in mental
function, motor (movement) function, and ability to carry out activities
of daily living, such as feeding or dressing themselves. The greatest
effect was on activities of daily living. The groups that received 300 mg/
day and 600 mg/day developed slightly less disability than the placebo
group, but the effects were less than those in the group that received
the highest dosage of coenzyme Q10.
The groups that received coenzyme Q10 also had signicant in-
creases in the level of coenzyme Q10 in their blood and a signicant
increase in energy-producing reactions within their mitochondria.
The results of this study suggest that doses of coenzyme Q10 as high
as 1,200 mg/day are safe and may be more effective than lower doses,
520
says Dr. Shults. The ndings are consistent with those of a published
study of patients with early Huntington diseaseanother degenerative
neurological disorderthat showed slightly less functional decline in
groups that received 600 mg/day of coenzyme Q10.
The new study also used an efcient phase II clinical trial design
developed by biostatistician David Oakes, PhD, of the University of Roch-
ester, and other study investigatorswhich should be useful for testing
other drugs that might slow the progression of PD, says Dr. Shults. The
design allowed the researchers to study the effects of three doses plus
a placebo in less than 3 years, and to obtain useful data about the com-
pounds effectiveness. Dr. Shults and his colleagues strongly caution pa-
tients against taking coenzyme Q10 until a larger, denitive trial can be
CONDUCTED"ECAUSECOENZYME1ISCLASSIlEDASADIETARYSUPPLEMENT
it is not regulated by the U.S. Food and Drug Administration. The ver-
sions of the supplement sold in stores may differ, they may not contain
potentially benecial amounts of the compound, and taking coenzyme
Q10 over a number of years may be costly, says Dr. Shults. In addition,
the current study included only a small number of patients, and the nd-
ings may not extend to people in later stages of PD or to those who are at
risk but have not been diagnosed with the disorder, he notes. Finally, if
many people begin taking coenzyme Q10 because of these early results,
it might make it impossible for investigators to nd enough patients to
carry out denitive studies of the compounds effectiveness and the proper
dosages, since patients must not be taking any treatments in order to be
considered for enrollment in a denitive trial.
The investigators are now planning a larger clinical trial that will
examine the effects of 1,200 mg/day of coenzyme Q10 , and possibly a
higher dose as well, in a larger number of patients.
Source:3HULTS#7/AKES$+IEBURTZ+"EAL&(AAS20LUMB3

Juncos JL, Nutt J, Shoulson I, Carter J, Kompoliti K, Perlmutter JS,
2EICH33TERN-7ATTS2,+URLAN2-OLHO%(ARRISON-,EW-
and the Parkinson Study Group. Effects of coenzyme Q10 in early Par-
kinson disease: evidence of slowing of the functional decline. Archives
of Neurology, October 2002, Vol. 59, No. 10, pp. 15411550.
Editors Note: Additional studies of coenzyme Q10 therapy for Parkin-

son disease since the above study have shown positive results in some,
but not all, cases. Additional research is needed, particularly regarding
high-dose coenzyme Q10 therapy, as many of the studies performed to date
have used lower doses of the drug. The overall place, if any, of coenzyme
Q10 therapy in treatment of Parkinson disease remains uncertain.
521
Chapter 77
Diabetes and CAM
Diabetes is a chronic condition affecting millions of Americans.

Conventional medical treatments are available to control diabetes
and its complications. However, some people also try complementary
and alternative medicine (CAM) therapies, including dietary supple-
ments.
About Diabetes
Diabetes encompasses a group of diseases. Type 2 diabetes accounts
for 90 to 95 percent of all diagnosed cases and occurs more frequently
in older people. Type 1 diabetes, which accounts for 5 to 10 percent of
cases, usually strikes children and young adults. A third form, gesta-
tional diabetes, develops in some women during pregnancy.
In all forms of diabetes, the bodys ability to convert food into energy
is impaired. After a meal, the body breaks down most food into glucose
(a kind of sugar), the main source of fuel for cells. In people with dia-
betes, the body does not make enough insulina hormone that helps
glucose enter cellsor the cells do not respond to insulin properly. Of-
TENBOTHINSULINPRODUCTIONANDINSULINACTIONAREIMPAIRED7ITHOUT
treatment, glucose builds up in the blood instead of moving into the
cells, where it can be converted into energy. Over time, the high blood
glucose levels caused by diabetes can damage many parts of the body,
Excerpted from CAM and Diabetes: A Focus on Dietary Supplements, by the
National Center for Complementary and Alternative Medicine (NCCAM, nccam
.nih.gov), part of the National Institutes of Health, June 2009.
523
including the heart and blood vessels, eyes, kidneys, nerves, feet, and
skin. Such complications can be prevented or delayed by controlling
blood glucose, blood pressure, and cholesterol levels.
Type 2 diabetes, the focus of this text, most often is associated with
older age (although it is increasingly being diagnosed in children), obe-
sity (about 80 percent of people with type 2 diabetes are overweight),
a family history of diabetes, and physical inactivity. Certain minority
population groups are at greater risk, as are women who have had
gestational diabetes. Type 2 diabetes usually begins as insulin resis-
tance, a disorder in which cells do not use insulin properly. Symptoms
develop gradually and may include fatigue, frequent urination, exces-
sive thirst and hunger, weight loss, blurred vision, and slow-healing
wounds or sores. However, it is possible to have type 2 diabetes without
experiencing any symptoms.
People with diabetes should try to keep their blood glucose in a
healthy range. The basic tools for managing type 2 diabetes are healthy
eating, physical activity, and blood glucose monitoring. Many people
also need to take prescription pills, insulin, or both.
Dietary Supplements and Type 2 Diabetes

Some people with diabetes use CAM therapies for their health con-
dition. For example, they may try acupuncture or biofeedback to help
with painful symptoms. Some use dietary supplements in efforts to
improve their blood glucose control, manage symptoms, and lessen the
risk of developing serious complications such as heart problems.
This portion of text addresses what is known about a few of the
many supplements used for diabetes, with a focus on some that have
been studied in clinical trials, such as alpha-lipoic acid, chromium,
omega-3 fatty acids, and polyphenols.
Alpha-lipoic acid (ALA, also known as lipoic acid or thioctic acid)

is an antioxidanta substance that protects against cell damage. ALA
is found in certain foods, such as liver, spinach, broccoli, and potatoes.
Some people with type 2 diabetes take ALA supplements in the hope
of lowering blood glucose levels by improving the bodys ability to use
insulin; others use ALA to prevent or treat diabetic neuropathy (a
nerve disorder). Supplements are marketed as tablets or capsules.
s !,!HASBEENRESEARCHEDFORITSEFFECTONINSULINSENSITIVITY
glucose metabolism, and diabetic neuropathy. Some studies have
found benets, but more research is needed. (There are some stud-
ies, reported from outside the United States, of ALA delivered
524
Diabetes and CAM
intravenously; however, this research is outside the scope of this

text.)
s "ECAUSE!,!MIGHTLOWERBLOODSUGARTOOMUCHPEOPLEWITH
diabetes who take it must monitor their blood sugar levels very
carefully.
Chromium is an essential trace mineralthat is, the body re-

quires small amounts of it to function properly. Some people with
diabetes take chromium in an effort to improve their blood glucose
control. Chromium is found in many foods, but usually only in small
amounts; relatively good sources include meat, whole grain products,
and some fruits, vegetables, and spices. In supplement form (capsules
and tablets), it is sold as chromium picolinate, chromium chloride, and
chromium nicotinate.
s #HROMIUMSUPPLEMENTATIONHASBEENRESEARCHEDFORITSEFFECT
on glucose control in people with diabetes. Study results have
been mixed. Some researchers have found benets, but many
of the studies have not been well designed. Additional, high-
quality research is needed.
s !TLOWDOSESSHORT TERMUSEOFCHROMIUMAPPEARSTOBESAFEFOR
most adults. However, people with diabetes should be aware that
chromium might cause blood sugar levels to go too low. High dos-
es can cause serious side effects, including kidney problemsan
issue of special concern to people with diabetes.
Omega-3 fatty acids are polyunsaturated fatty acids that come

from foods such as sh, sh oil, vegetable oil (primarily canola and
soybean), walnuts, and wheat germ. Omega-3 supplements are avail-
able as capsules or oils (such as sh oil). Omega-3s are important in
a number of bodily functions, including the movement of calcium and
other substances in and out of cells, the relaxation and contraction of
muscles, blood clotting, digestion, fertility, cell division, and growth.
In addition, omega-3s are thought to protect against heart disease,
reduce inammation, and lower triglyceride levels.
s /MEGA FATTYACIDSHAVEBEENRESEARCHEDFORTHEIREFFECTONCON-
trolling glucose and reducing heart disease risk in people with
type 2 diabetes. Studies show that omega-3 fatty acids lower
triglycerides, but do not affect blood glucose control, total choles-
terol, or HDL (high-density lipoprotein, or good) cholesterol in
people with diabetes. In some studies, omega-3 fatty acids also
525
raised LDL (low-density lipoprotein, or bad) cholesterol. Addi-

tional research, particularly long-term studies that look speci-
cally at heart disease in people with diabetes, is needed.
s /MEGA SAPPEARTOBESAFEFORMOSTADULTSATLOW TO MODERATE
doses. Safety questions have been raised about sh oil supple-
ments, because some species of sh can be contaminated by
SUBSTANCESSUCHASMERCURYPESTICIDESOR0#"S;POLYCHLORINAT-
ed biphenyls]. In high doses, sh oil can interact with certain
medications, including blood thinners and drugs used for high
blood pressure.
Polyphenolsantioxidants found in tea and dark chocolate, among

other dietary sourcesare being studied for possible effects on vascu-
lar health (including blood pressure) and on the bodys ability to use
insulin.
s ,ABORATORYSTUDIESSUGGESTTHAT%'#'; EPIGALLOCATECHIN
gallate], a polyphenol found in green tea, may protect against
cardiovascular disease and have a benecial effect on insulin
activity and glucose control. However, a few small clinical trials
studying EGCG and green tea in people with diabetes have not
shown such effects.
s .OADVERSEEFFECTSOF%'#'ORGREENTEAWEREDISCUSSEDINTHESE
studies. Green tea is safe for most adults when used in moderate
amounts. However, green tea contains caffeine, which can cause,
in some people, insomnia, anxiety, or irritability, among other ef-
fects. Green tea also has small amounts of vitamin K, which can
make anticoagulant drugs, such as warfarin, less effective.
Other supplements are also being studied for diabetes-related ef-

fects.
s 0RELIMINARYRESEARCHHASEXPLOREDTHEUSEOFGARLICFORLOWERING
blood glucose levels, but ndings have not been consistent.
s 3TUDIESOFTHEEFFECTSOFMAGNESIUMSUPPLEMENTATIONONBLOOD
glucose control have had mixed results, although researchers
have found that eating a diet high in magnesium may lower the
risk of diabetes.
s 4HEREISNOTENOUGHEVIDENCETOEVALUATETHEEFFECTIVENESSOF
coenzyme Q10 supplementation as a CAM therapy for diabetes;
studies of its ability to affect glucose control have had conicting
ndings.
526
Diabetes and CAM
s 2ESEARCHERSARESTUDYINGWHETHERTHEHERBGINSENGANDTHE
trace mineral vanadium might help control glucose levels.
s 3OMEPEOPLEWITHDIABETESMAYALSOTRYBOTANICALSSUCHAS
prickly pear cactus, gurmar, Coccinia indica, aloe vera, fenu-
greek, and bitter melon to control their glucose levels. However,
there is limited research on the effectiveness of these botanicals
for diabetes.
If You Have Diabetes and Are Thinking about Using a

Dietary Supplement
Medicines for diabetes and other health conditions may need to be
adjusted if a person is also using a dietary supplement.
of using supplements to treat a child, should consult their health
care provider before using any dietary supplement.
s $ONOTREPLACESCIENTIlCALLYPROVENTREATMENTSFORDIABETESWITH
CAM treatments that are unproven. The consequences of not fol-
lowing ones prescribed medical regimen for diabetes can be very
serious.
s "EAWARETHATTHELABELONADIETARYSUPPLEMENTBOTTLEMAY
not accurately reect what is inside. For example, some tests of
dietary supplements have found that the contents did not match
the dose on the label, and some herbal supplements have been
found to be contaminated.
527
Chapter 78
Fibromyalgia and CAM
People with chronic health conditions such as bromyalgia often

turn to some form of complementary and alternative medicine (CAM)
a group of diverse medical and health care systems, practices, and prod-
ucts that are not generally considered part of conventional medicine. If
you are considering a CAM therapy for bromyalgia, this information
can help you talk to your health care provider about it.
About Fibromyalgia
Fibromyalgia is a disorder that causes muscle pain and fatigue.
People with bromyalgia have chronic widespread pain, as well as
tender points on the neck, shoulders, back, hips, arms, and legs, which
hurt when slight pressure (about 9 pounds) is applied.
People with bromyalgia may also have other symptoms, such as
the following:
s 4ROUBLESLEEPING
s -ORNINGSTIFFNESS
s (EADACHES
s 0ROBLEMSWITHTHINKINGANDMEMORYSOMETIMESCALLEDhlBROFOGv
s )RRITABLEBOWELSYNDROME
Excerpted from CAM and Fibromyalgia: At a Glance, by the National Cen-
ter for Complementary and Alternative Medicine (NCCAM, nccam.nih.gov),
part of the National Institutes of Health, July 2009.
529
7OMENWITHlBROMYALGIAMAYALSOHAVEPAINFULMENSTRUALPERIODS
Fibromyalgia may also be associated with depression.
The causes of bromyalgia are unknown, but problems with the
nervous system could be involved. It is estimated that bromyalgia
affects as many as one in 50 Americans. Most people with bromyalgia
are women, and most are diagnosed during middle age. However, men
and children also can have the disorder.
CAM Practices Used for Fibromyalgia

Conventional therapies for bromyalgia are limited, and research
shows that about 90 percent of people with bromyalgia use some form
of CAM. CAM practices used by people with bromyalgia include the
following:
s !CUPUNCTURE
s "IOFEEDBACK
s #HIROPRACTICCARE
s (YPNOSIS
s -AGNESIUMSUPPLEMENTS
s -AGNETTHERAPY
s -ASSAGETHERAPY
s 3!-E3 !DENOSYL , -ETHIONINE
s 4AICHI
What the Science Says about CAM and Fibromyalgia

According to reviewers who have assessed the research on CAM and
bromyalgia, much of the research is still preliminary, and evidence of
effectiveness for the various therapies used is limited.
s 2ESEARCHONACUPUNCTURESTIMULATIONOFANATOMICALPOINTS
with thin metallic needlesfor bromyalgia has produced mixed
results. One review article notes that three studies found some
evidence to support the use of electroacupuncture (in which the
needles are pulsed with electric current). However, the effects of
electroacupuncture in these studies were mostly short lived, and
two studies of traditional acupuncture had negative results.
s 3OMERESEARCHERSBELIEVETHATLOWLEVELSOFMAGNESIUMMAYCON-
tribute to bromyalgia. However, there is no conclusive scientic
530
Fibromyalgia and CAM
evidence that magnesium supplements relieve bromyalgia

symptoms. Two small studies had conicting results.
s !REVIEWOFTHERESEARCHONMASSAGETHERAPYFORlBROMYALGIA
notes only modest, preliminary support. Two studies had some
positive ndings, but two others found either no benets or only
short-term improvements.
s 3UPPLEMENTSCONTAININGTHEAMINOACIDDERIVATIVE3!-EARE
used for a variety of conditions. Although several small studies
of SAMe for bromyalgia have had mixed results, there is some
evidence of a benet. Reviewers conclude that more research is
needed.
s &INALLYACCORDINGTOREVIEWERSRESEARCHEVIDENCEISINSUFlCIENT
to draw conclusions about the effectiveness of other CAM treat-
mentsbiofeedback, chiropractic care, hypnosis, and magnet
therapyused for bromyalgia.
NCCAM Research on Fibromyalgia

(NCCAM) funds clinical trials that look at CAM for bromyalgia, in-
cluding the following:
s 4HEEFFECTSOFTAICHIONlBROMYALGIAPATIENTSMUSCULOSKELETAL
pain, fatigue, sleep quality, psychological distress, physical per-
formance, and health status
s "RAIN IMAGINGTECHNIQUESFORDETERMININGWHETHERACUPUNCTURE
relieves pain due to bromyalgia
s 4HEEFFECTIVENESSOFAFORMOFELECTROENCEPHALOGRAPH%%' BIO-
feedback in treating bromyalgia
If You Are Considering CAM for Fibromyalgia

Talk to your health care providers. Tell them about the therapy you
are considering and ask any questions you may have. They may know
about the therapy and be able to advise you on its safety, use, and likely
effectiveness in relieving your bromyalgia symptoms.
If you are considering a practitioner-provided CAM therapy such
as acupuncture, check with your insurer to see if the services will be
covered, and ask a trusted source (such as your bromyalgia doctor
or a nearby hospital or medical school) to recommend a practitioner.
531
Although acupuncture treatment is generally safe, complications can

result if needles are not adequately sterilized or if the treatment is
not properly delivered.
If you are considering dietary supplements, keep in mind that they
can act in the same way as drugs. They can cause medical problems if
not used correctly or if used in large amounts, and some may interact
with medications you may take. The health care providers you see
about your bromyalgia can advise you.
Tell all your health care providers about any complementary and
alternative practices you use. Give them a full picture of what you do
to manage your health. This will help ensure coordinated and safe
care.
532
Chapter 79
Headache and CAM
Acupuncture
This form of treatment originated in China some 3,000 years ago.
Although widely used in Europe since early in this century and univer-
sally acclaimed for its pain-relieving qualities, it has been of interest
in the United States for a much shorter time.
Physicians in the United States have not embraced acupuncture
mainly because it has lacked documented scientic validity and has
been taught as a practice based on Taoist philosophy passed down
through the centuries with relatively little change.
A small but increasing number of U.S. physicians have found acu-
puncture to be a useful part of their practice, despite the inability to
explain in terms acceptable to their colleagues how they obtained
favorable results by this method of treatment. Thus every day in the
United States and elsewhere, thousands of patients are being treated
with acupuncture for a variety of issues and reporting favorable re-
sults. Family physicians are with increasing frequency being asked
about acupuncture if established medical treatments have not relieved
the pain.
This chapter includes text from: Acupuncture, 2009 National Headache

&OUNDATIONWWWHEADACHESORG 2EPRINTEDWITHPERMISSIONh"IOFEEDBACKv
National Headache Foundation (www.headaches.org). Reprinted with permission;
Chiropractors, 2009 National Headache Foundation (www.headaches.org). Re-
printed with permission; and Feverfew (Tanacetum Parthenium), 2009 National
Headache Foundation (www.headaches.org). Reprinted with permission.
533
7HILETRADITIONALACUPUNCTURISTSSELECTFROMSOMEORMORE
points located on hypothetical meridians, the modern acupuncturist
USESASMALLERNUMBEROFPOINTS7ORKFROM!LBERT%INSTEIN-EDICAL
School has pointed out that many of the most effective acupuncture
points coincide with the motor points commonly used in electromyo-
graphy and, indeed, it has seemed that these may be the only points
that need stimulation. In the treatment of pain, motor points are se-
lected from within the same neural segment adjacent to the area of
pain. Other points are selected from the extremities where the largest
number of muscles is located. One of the most effective and widely
used acupuncture points, Ho Ku, is located at the base of the thumb.
The thumb, of all the digits and limb segments, has the largest corti-
cal representation.
Gaining scientic support is the theory that, in part, acupuncture
works through the release of brain neurotransmitters. Some evidence
indicates that acupuncture induces a release of endorphins in the hu-
man brain. Electrical stimulation has been found more effective than
needle twirling. Stimulation must be sufciently above the threshold
of medium-sized bers. Too strong a stimulus, however, serves to in-
tensify pain.
Treatment with acupuncture needles inserted deeply into muscle,
as with electroacupuncture, is the most commonly used technique.
7ITHTHISTHECHANGESPRODUCEDINTHECENTRALNERVOUSSYSTEMSEEM
to be sufcient to continue the benecial effect long after the stimula-
tion has ceased. However, traditional acupuncturists may utilize other
forms of treatment such as moxibustion (a form of heat therapy) and
a variety of massage and movement techniques.
Biofeedback
"IOFEEDBACKCANBEANEFFECTIVENON MEDICINALMODALITYUTILIZED
in managing headache (both migraine and tension-type). It is a way
that sufferers can learn to control body functions that were previously
thought to be involuntary. The patient becomes integrally involved in
his or her own headache treatment.
A person must be amenable to this type of therapy and willing to
practice and make a commitment. Relaxation techniques, through
warming of the hands and muscle relaxation, are practiced with the
aid of instruments such as a nger thermometer or computer for mea-
suring temperature or muscle tension. Some biofeedback techniques
monitor brain wave activity. After repeated exercise, the patient gradu-
ally learns physiological sensations or body cues that eventually allow
534
Headache and CAM
the elimination of the measuring instruments. Thus, biofeedback can

be utilized at any time or any place when needed.
Depending on the patient, biofeedback can be utilized alone or in
combination with medication to prevent attacks or reverse attacks
once started.
Chiropractors
Chiropractors are health care professionals that utilize manual
therapy as a component of their treatments.
Chiropractic manipulation can be of help in relaxing muscles in
cases where there is muscle spasm present. Sometimes a chiropractor
may refer to the vertebrae of the neck or back being out of alignment.
This does not represent a serious structural defect such as would occur
if a vertebra were dislocated. It is believed to be used in reference to the
visual changes seen on x-rays of the back associated with postural and
mechanical abnormalities of the back including muscle spasm. Other
manual techniques such as massage and heat also can be soothing.
The U.S. Headache Guidelines Consortium did not nd evidence to
recommend manual therapy including chiropractic manipulation as a
treatment for migraine headache. There is no consistent evidence for
manual therapy being effective in tension-type headache.
There are several different methods of applying manual treatments
to the back and neck. They vary in the amounts of rotation and force
used. Rarely manipulative treatment of the neck has been associated
with serious injury.
Chiropractors are not allowed to prescribe medications.
Feverfew (Tanacetum Parthenium)

Feverfew is Tanacetum parthenium, a member of the daisy family.
However, it is sometimes obtained under the name of Chrysanthemum
parthenium. It is easy to confuse the medicinal variety of feverfew
with chrysanthemum or even other varieties of feverfewthough none
of these are toxic, so a mistake would not be injurious.
Drs. Johnson, Hylands, and Hylands (1983) did several studies
on the use of feverfew for headache. One of these was a double-blind
study on 20 patients who had eaten fresh leaves of feverfew daily as
a migraine preventative for at least 3 months prior to the study. They
had a history of common or classical migraine for at least 2 years
duration with no more than eight attacks a month at the time of the
test. No subjects were used who had taken certain medications within
1 month before the test.
535
The average dosage for patients prior to the test was around 60 mg/
day. During the test, the xed dose was 25 mg per capsule of freeze-
dried feverfew leaf. The freeze-dried herb was chosen because it is most
like fresh leaves. Preparations like powdered extract or air-dried herb
may be too old or have been heated to 100 degrees Celsius, possibly
making it inactive.
The result of this test was that the patients now receiving the place-
bo had signicant increase in the frequency and severity of headache,
nausea, and vomiting while the feverfew group showed no change in
frequency or severity of symptoms of migraine. Johnson, et al. (1985)
concluded that feverfew does in fact prevent migraine attacks. Most
people need to take feverfew for many months before fully realizing
the benecial effects.
A low starting dose of 50 mg a day is recommended because the po-
tential for side effects is then reduced. One problem is that freeze-dried
feverfew capsules are not standardized in manufacture and different
preparations may vary in the active ingredients.
Feverfew is currently receiving a great deal of interest in the
United States although most headache experts still regard its use as
experimental. The recent reports of research indicate that continu-
ally taking feverfew extracts may decrease the symptoms of migraine
headaches.
Recently there has been a commercial product developed that uti-
lizes a standardized dose of feverfew based on the activity of the pur-
PORTEDACTIVEAGENTALONGWITHTHERAPEUTICAMOUNTSOFVITAMIN"
and Magnesium. This may be a more suitable formulation than others
of feverfew.
Used with permission of the National Headache Foundation. For more

information on headache causes and treatments visit www.headaches
.org.
536
Chapter 80
Heart Disease and

Chelation Therapy
What is coronary artery disease?

Coronary artery disease (CAD) is the most common form of heart
disease. In CAD the coronary arteries, the vessels that bring oxygen-
rich blood to the tissues of the heart, become blocked by deposits of a
fatty substance called plaque. As plaque builds, the arteries become
narrower and less oxygen and nutrients are transported to the heart.
This condition can lead to serious problems, such as angina (pain
caused by not enough oxygen-carrying blood reaching the heart) and
heart attack. In a heart attack, or myocardial infarction, there is such
poor oxygen supply to the heart that part of the heart muscle dies. If
a sufciently large portion of the heart is affected, it may no longer
be able to pump blood efciently to the rest of the body, resulting in
death or chronic heart failure.
Approximately 7 million Americans suffer from CAD. It is the
leading cause of death among American men and women; more than
500,000 Americans die of CAD-related heart attacks each year.
There are several factors that can each increase the risk of devel-
oping CAD:
Excerpted from Questions and Answers: The NIH Trial of EDTA Chelation
Therapy for Coronary Artery Disease, by the National Center for Complementary
tutes of Health, June 2004. Reviewed and revised by David A. Cooke, MD, FACP,
January 23, 2010.
537
s (IGHBLOODPRESSURE s $IABETES
s (IGHCHOLESTEROLLEVELS s &AMILYHISTORYOF#!$
s 3MOKING s 'ENDER
s /BESITY s !GE
s 0HYSICALINACTIVITY
A person with CAD may or may not have symptoms. Symptoms can
include chest pain from angina, shortness of breath, lightheadedness,
cold sweats, or nausea.
How is CAD diagnosed and treated?

"ECAUSETHESEVERITYOF#!$ANDITSSYMPTOMSCANVARYFROMPER-
son to person, the way the disease is diagnosed and treated can also
vary. CAD is often diagnosed through a series of tests that can include
blood tests to see if protein has been released into the bloodstream
from damaged heart tissues, electrocardiograms (EKG) to check the
hearts electrical activity, stress tests to record the heartbeat during
exercise, nuclear scanning to check for damaged areas of the heart,
and angiography to see how blood ows.
Treatment of CAD depends on many factors, such as the patients
age, heart function, and overall health. Often, treatment begins with
focusing on lifestylestopping smoking for patients who smoke, re-
ducing fat in the diet, and engaging in a prescribed exercise program.
Medications may also be prescribed, such as aspirin to prevent ad-
ditional heart attacks, medications that decrease the workload on
the heart, or medicines to reduce high blood cholesterol levels or high
blood pressure. If these efforts are not effective, a patient may need to
have the narrowed or blocked arteries reopened through a procedure
CALLEDBALLOONANGIOPLASTYORBYPASSEDTHROUGHSURGERY"ALLOONAN-
gioplasty involves threading a thin tube into the artery and expanding
a balloon-like apparatus as a way to increase the size of the artery so
MOREBLOODCANmOW"YPASSSURGERYISUSEDTOTREATSEVEREBLOCKAGES
by using veins or arteries from other areas of the body to divert blood
ow around the blocked coronary arteries.
What is EDTA (ethylene diamine tetra-acetic acid) chela-

tion therapy?
Chelation is a chemical process in which a substance is used to bind
molecules, such as metals or minerals, and hold them tightly so that
538
Heart Disease and Chelation Therapy
they can be removed from a system, such as the body. In medicine,

chelation has been scientically proven to rid the body of excess or
toxic metals. For example, a person who has lead poisoning may be
given chelation therapy in order to bind and remove excess lead from
the body before it can cause damage.
In the case of EDTA chelation therapy, the substance that binds
and removes metals and minerals are the salts of EDTA (ethylene
diamine tetra-acetic acid), a synthetic, or man-made, amino acid that
is delivered intravenously (through the veins). EDTA was rst used
in the 1940s for the treatment of heavy metal poisoning. Calcium
disodium EDTA chelation removes heavy metals and minerals from
the blood, such as lead, iron, copper, and calcium, and is approved by
the U.S. Food and Drug Administration (FDA) for use in treating lead
poisoning and toxicity from other heavy metals. In order to discover
the safety and efcacy of chelation therapy for people with coronary
artery disease, the National Institutes of Health have launched the
Trial to Assess Chelation Therapy (TACT). Rather than testing calcium
disodium EDTA, TACT uses another salt, disodium EDTA, under an
FDA license as an investigational new drug (IND). Although disodium
EDTA it is not approved by the FDA to treat CAD, some physicians
and alternative medicine practitioners have recommended disodium
EDTA chelation as a way to treat this disorder.
Does EDTA chelation therapy have side effects?

The most common side effect is a burning sensation at the site where
the EDTA is delivered into the vein. Rare side effects can include fever,
headache, nausea, and vomiting. Even more rare are serious and poten-
tially fatal side effects that can include heart failure, a sudden drop in
blood pressure, abnormally low calcium levels in the blood, permanent
kidney damage, and bone marrow depression (meaning that blood cell
counts fall). Reversible injury to the kidneys, although infrequent, has
been reported with EDTA chelation therapy. Other serious side effects can
occur if EDTA is not administered by a trained health professional.
How might EDTA chelation therapy work to clear blocked

arteries?
Several theories have been suggested by those who recommend this
form of treatment. One theory suggests that EDTA chelation might
work by directly removing calcium found in fatty plaques that block
the arteries, causing the plaques to break up. Another is that the pro-
cess of chelation may stimulate the release of a hormone that in turn
539
causes calcium to be removed from the plaques or causes a lowering of

cholesterol levels. A third theory is that EDTA chelation therapy may
work by reducing the damaging effects of oxygen ions (oxidative stress)
on the walls of the blood vessels. Reducing oxidative stress could reduce
inammation in the arteries and improve blood vessel function. None
of these theories has been well tested in scientic studies.
Is there evidence that EDTA chelation therapy works for CAD?

There is a lack of adequate prior research to verify EDTA chelation
therapys safety and effectiveness for CAD. The bulk of the evidence
supporting the use of EDTA chelation therapy is in the form of case
reports and case series. Some patients who have undergone chelation
therapy and the physicians who prescribed it claim improvement in
CAD. In addition, there are approximately 12 published descriptive
studies and ve randomized controlled clinical trials regarding the use
of EDTA chelation for CAD. Although each descriptive study did report
a reduction in angina, they were uncontrolled clinical observations or
retrospective data, typically with a small number of participants. Of the
ve clinical trials in which patients were randomly selected to receive
chelation therapy or a placebo (a dummy solution), the most rigorous
way of assessing a new treatment, three trials involved so few people
that only a dramatic improvement could have been detected. Studies
need a larger number of participants to detect more mild benets of a
treatment. The fourth study was never published in nal form, so its
conclusions are uncertain. Finally, the fth study reported that EDTA
chelation was associated with an improvement in ability to exercise,
but it had only 10 participants. [Editors Note: Additional studies and
analyses performed since this article was written have failed to prove
benet or safety of chelation therapy for CAD. Other studies have found
no benets of chelation therapy for peripheral arterial disease, a condi-
tion that has many relationships with coronary artery disease. The pos-
sibility of benet in CAD has not been fully excluded, but there is little
positive evidence to support its use at this time. The results of the NIH
study discussed in this article are expected to be published in 2010.]
How frequently is EDTA chelation therapy used?

It is estimated by the American College for Advancement in Med-
icine, a professional association that supports the use of chelation
therapy, that more than 800,000 visits for chelation therapy were made
in the United States in 1997 alone.
540
Chapter 81
Hepatitis C and CAM
Hepatitis C, a liver disease caused by a virus, is usually chronic

(long-lasting), with symptoms ranging from mild (or even none) to
severe. Conventional medical treatments are available for hepatitis C;
however, some people also try complementary and alternative medicine
(CAM) therapies, especially herbal supplements.
About Hepatitis C
Hepatitis C, a communicable (contagious) disease of the liver, is
caused by the hepatitis C virus (HCV). The term hepatitis means
inammation of the liver; HCV is one of several viruses in the hepatitis
family. If the liver becomes inamed, it cannot function properly and
remove harmful material from the blood or convert food into energy.
Hepatitis C is transmitted primarily through contact with infected
blood. It is not spread through sneezing, coughing, food or water, or
casual contact. There is no vaccine for hepatitis C; the only way to
prevent it is to avoid exposure.
People who are newly infected have what is called acute hepatitis
C. Most people with acute hepatitis C develop chronic hepatitis C,
which can injure the liver over time. Many people with hepatitis C
show no symptoms for many years; others experience mild or more
serious symptoms.
Excerpted from CAM and Hepatitis C: A Focus on Herbal Supplements, by the
National Center for Complementary and Alternative Medicine (NCCAM, nccam
.nih.gov), October 2008.
541
People with more serious hepatitis C may need medicationinter-

feron, alone or combined with ribavirin. However, not everyone with
hepatitis C responds to drug therapy, and the drugs have side effects
that can be difcult to tolerate.
Use of Herbal Supplements for Hepatitis C

A number of herbal products claim to be benecial for the liver, and
hepatitis C patients who do not respond to conventional drug therapy,
cannot tolerate its side effects, or simply want to support their bodys
ght against the disease may try these products. For example, a recent
survey of 1,145 participants in the HALT-C (Hepatitis C Antiviral
Long-Term Treatment Against Cirrhosis) trial, a study supported by
the National Institutes of Health (NIH), found that 23 percent were
using herbal products at the time of enrollment. Although participants
reported using many different herbal products, silymarin (milk thistle)
was by far the most common.

A review of the scientic evidence on CAM and hepatitis C found
the following:
s .O#!-TREATMENTHASBEENSCIENTIlCALLYPROVENTOSUCCESSFULLY
treat hepatitis C.
s !ANALYSISOFRESULTSFROMCLINICALTRIALSTESTINGTHEEF-
fects of various medicinal herbs on hepatitis C concluded that
there is not enough evidence to support using herbs to treat the
disease.
s 4WOOTHERREVIEWSTHATCOVEREDAVARIETYOF#!-MODALITIESFOR
hepatitis C concluded that conventional therapies are the only
scientically proven treatments for the disease.
s )NA.)(CONSENSUSSTATEMENTONTHEMANAGEMENTOFHEP-
atitis C, a panel of medical and scientic experts concluded that
alternative and nontraditional medicines should be studied.
Participants in a 2001 NIH research workshop on the benets
and risks of CAM therapies for chronic liver disease recommend-
ed research support for related laboratory and clinical studies.
The following text summarizes what is known about the safety and
effectiveness of milk thistle and some of the other CAM products that
people with hepatitis C use.
542
Hepatitis C and CAM
Milk thistle (scientic name Silybum marianum) is a plant from the

aster family. Silymarin, the active extract of milk thistle, is believed to
be responsible for the herbs medicinal qualities. Milk thistle has been
used in Europe as a treatment for liver disease and jaundice since the
16th century. In the United States, silymarin is the most popular CAM
product taken by people with liver disease.
Laboratory studies suggest that milk thistle may benet the liver
by protecting and promoting the growth of liver cells, ghting oxidation
(a chemical process that can damage cells), and inhibiting inamma-
tion. Study results from small clinical trials on milk thistle for liver
diseases have been mixed; however, most of these studies have not
been rigorously designed, or they have looked at various types of liver
diseasesnot just hepatitis C. High-quality, well-designed clinical
trials have not proven that milk thistle or silymarin is benecial for
treating hepatitis C. The HALT-C study mentioned above found that
silymarin use by hepatitis C patients was associated with fewer and
milder symptoms of liver disease and somewhat better quality of life,
but there was no change in virus activity or liver inammation. The
researchers emphasize that this was a retrospective study, not a con-
trolled clinical trial. More research on milk thistle for hepatitis C is
needed before a recommendation can be made.
Milk thistle is generally well tolerated and has shown few side ef-
fects in clinical trials involving patients with liver disease. It may cause
a laxative effect, nausea, diarrhea, abdominal bloating, fullness, and
pain, and it can produce allergic reactions (especially among people
who are allergic to plants in the same family, such as ragweed, chry-
santhemum, marigold, and daisy).
Other supplements are also being studied for hepatitis C.
s 'INSENGHASSHOWNSOMEBENElCIALEFFECTSONTHELIVERINLABORA-
tory studies but has not yet shown effects in people.
s 4HYMUSEXTRACTANDCOLLOIDALSILVERARESOMETIMESMARKETEDFOR
the treatment of hepatitis C, but there is currently no research
to support their use for this purpose. Colloidal silver products
can cause serious side effects.
s 0EOPLEWITHCHRONICLIVERDISEASESOMETIMESUSELICORICEROOTOR
its extract glycyrrhizin. Some studies, reported from outside the
United States, have looked at glycyrrhizin administered intrave-
nously for hepatitis C. Preliminary evidence from these studies
suggests that glycyrrhizin may have benecial effects against
hepatitis C. However, additional research is needed before reach-
ing any conclusions.
543
s 0RELIMINARYSTUDIESCONDUCTEDPRIMARILYOUTSIDETHE5NITED
States have examined the potential of the following herbal
products for treating chronic hepatitis C: lactoferrin, TJ-108 (a
mixture of herbs used in Japanese Kampo medicine), schisan-
dra, and oxymatrine (an extract from the Sophora root). More
research is needed before the safety and effectiveness of these
products can be fully evaluated.
If You Have Hepatitis C and Are Thinking about Using an

Herbal Supplement
s $ONOTREPLACEPROVENCONVENTIONALTREATMENTSFORHEPATITIS#
with CAM treatments that are unproven.
s "EAWARETHATSOMEHERBALPRODUCTSMAYDAMAGETHELIVER&OR
example, the herbs kava and comfrey have been linked to seri-
ous liver damage.
s !LSOBEAWARETHATTHELABELONASUPPLEMENTBOTTLEMAYNOTAC-
curately reect what is inside. For example, some tests of dietary
supplements have found that the contents did not match the
dosage on the label, and some herbal supplements have been
found to be contaminated.
s 4ELLYOURHEALTHCAREPROVIDERSABOUTANYCOMPLEMENTARYANDAL-
ternative practices you use. Give them a full picture of what you
safe care. If you are pregnant or nursing a child, or if you are
considering giving a child a dietary supplement, it is especially
important to consult your health care provider. Supplements
can act like drugs, and many have not been tested in pregnant
women, nursing mothers, or children.
Recent NCCAM-supported research includes projects studying the
effectiveness of the following:
s 3ILYMARINFORPREVENTINGANDREVERSINGCOMPLICATIONSOFCHRONIC
hepatitis C
s 3ILYMARINFORTHETREATMENTOFCHRONICHEPATITIS#INPEOPLE
who did not respond to conventional antiviral therapy, and in
people with nonalcoholic steatohepatitis (a type of fatty liver
disease)
544
Hepatitis C and CAM
s #OMMONLYUSEDHERBALREMEDIESFORTHETREATMENTOFHEPATITIS#
in methadone-maintained patients
s !RGININEANAMINOACID INREDUCINGLIVERINJURYININDIVIDUALS
with alcohol-related hepatitis
Also, NCCAM has supported studies that test the safety and toler-
ability of different dosages of silymarin in people with hepatitis C.
545
Chapter 82
Hormones, CAM, and Aging
People are living longer. In 1970, the average life expectancy at birth
was 70.8 years; in 2000, it was 76.9 years; and by 2030 it is estimated
that the oldest-old, age 85 and older, could grow to 10 million people.
Views on aging are also changing. It no longer necessarily means
physical decline and illnessin the last two decades, the rate of dis-
ability among older people has declined dramatically.
The National Institute on Aging (NIA), part of the federal gov-
ernments National Institutes of Health (NIH), investigates ways to
support healthy aging and prevent or delay the onset of diseases that
disproportionately affect us as we age. These studies not only may
increase what is known as active life expectancythe time of ad-
vancing years free of disabilitybut also may promote longevity. NIAs
research includes hormone and dietary approaches, including calorie
restriction.
Results from NIA-sponsored studies and others are likely to im-
prove our understanding of the benets and risks of hormone supple-
ments, calorie restriction, and other interventions to promote healthy
aging. This text provides an overview of what we know about hormone
supplements and calorie restriction and the research needed to learn
more. Until we have a better understanding, it is a good idea to be
skeptical of claims that hormone or other supplements can solve your
age-related problems. Instead, focus on what is known to help promote
healthy aging: healthy eating and physical activity.
&ROMh#AN7E0REVENT!GINGvBYTHE.ATIONAL)NSTITUTEON!GING.)!
nia.nih.gov), part of the National Institutes of Health, February 19, 2009.
547
What Is a Hormone?
The word hormone comes from the Greek word, hormo, mean-
ing to set in motion. Hormones are chemical messengers that set in
motion different processes to keep our bodies working properly. For
example, they are involved in our metabolism, immune function, sexual
reproduction, and growth. Hormones are made by specialized groups
of cells within the bodys glands. The glandssuch as the pituitary,
thyroid, adrenals, ovaries, and testesrelease hormones into the body
as needed to stimulate, regulate, and control the function of other vari-
ous tissues and organs involved in biological processes.
7ECANNOTSURVIVEWITHOUTHORMONES!SCHILDRENHORMONESHELP
us grow up. In teenagers, they drive puberty. As we get older, some
OFOURHORMONELEVELSNATURALLYDECLINE"UTWHATDOESTHATMEAN
Scientists do not know exactly. In order to know more, NIA investi-
gates how replenishing hormones in older people affects frailty and
function. Many of these studies focus on hormones that decline with
age, including:
s 'ROWTHHORMONE
s -ELATONIN
s $EHYDROEPIANDROSTERONE$(%!
s 4ESTOSTERONE
s %STROGENANDPROGESTERONEASPARTOFMENOPAUSALHORMONE
therapy)
How Hormones Work

Most hormones are typically found in very low concentrations in
THEBLOODSTREAM"UTAHORMONESCONCENTRATIONWILLmUCTUATEDEPEND-
ing on the bodys activity. Like a key that unlocks a door, a hormone
molecule is released by a gland and travels through the blood until it
nds a cell with the right t, a receptor. The hormone latches onto
a cells receptor and a signal is sent into the cell. These signals may
instruct the cell to multiply, make proteins or enzymes, or perform
other vital tasks. Some hormones can even cause a cell to release
other hormones.
One hormone may t with many types of cells but may not affect all
cells in the same way. For example, one hormone may stimulate one cell
to perform a task but it might also turn off a different cell. Additionally,
how a cell responds to a hormone may change throughout life.
548
Hormone Supplements
Levels of some hormones change naturally over the lifespan. Some
hormones increase with age, like parathyroid hormone that helps
regulate the amount of calcium in the blood and bone. Some tend
to decrease over time, such as testosterone in men and estrogen in
WOMEN7HENTHEBODYFAILSTOMAKEENOUGHOFAHORMONEBECAUSEOF
a disease or disorder, a doctor may prescribe hormone supplements.
As opposed to hormones produced naturally by the body, hormone
supplements come in many forms such as pills, shots, topical (rub-on)
gels, and medicated skin patches.
You may have read magazine articles or seen television segments
suggesting that hormone supplements can make people feel young
again or can slow or prevent aging. Thats because nding a fountain
of youth is an attractive story that captivates us all. The truth is no
research to date has shown that hormone supplements add years to
life or prevent age-related frailty. And, while some supplements have
real health benets for people with clinical hormone deciencies due
to a disease or disorder, they also can cause harmful side effects. Thats
why people who have a diagnosed hormone deciency should still only
take hormone supplements under a doctors supervision.
In some cases, the U.S. Food and Drug Administration (FDA) may
have approved a hormone supplement for one purpose, but it is pre-
scribed by physicians for another. This off-label use may occur when
physicians believe that research, such as clinical studies done on other
groups of people, demonstrates a supplements usefulness for another
CONDITION7HILETHISISTHENORMALPROCESSFOREVALUATINGDRUGSALREADY
approved by the FDA, consumers should be aware that a particular
off-label use of a drug may not have been tested and veried to the
same degree as the original use of the drug.
Dangers of Hormone Supplements

Higher concentrations of hormones in your body are not necessarily
better. The body maintains a delicate balance between how much hor-
mone it produces and how much it needs to function properly. Natural
hormone production uctuates throughout the day. That means that
the amount of hormone in your blood when you wake up may be dif-
ferent 2, 12, or 20 hours later.
If you take hormone supplements, especially without medical su-
pervision, you can adversely affect this tightly controlled, regulated
system. Hormone supplements cannot replicate your bodys natural
549
VARIATION"ECAUSEHORMONALBALANCEISSOINTRICATETOOMUCHOFAHOR-
mone in your system may actually cause the opposite of your intended
effect. For example, taking a hormone supplement can cause your own
hormone regulation to stop working. Or, your body may process the
supplements differently than the naturally produced hormone, caus-
ing an alternate, undesired effect. It is also possible that a supplement
could amplify negative side effects of the hormone naturally produced
by the body. Scientists may not know the consequences.
Some hormone-like products are sold over-the-counter without a
prescription. Self-medicating with them can be dangerous. Products
that are marketed as dietary supplements are not regulated by the
FDA. This means that companies making dietary supplements do not
need to get FDA approval or provide any proof that their products
are safe and effective before selling them. There is no guarantee that
the recommended dosage is safe, that there is the same amount
of active ingredients in every bottle, or that the substance is what
THECOMPANYCLAIMS"ECAUSETHEREARENOSTANDARDSTHEHORMONE
like dietary supplements sold over-the-counter may not have been
thoroughly studied and potential negative side effects may not be
understood or dened. In addition, these over-the-counter products
may interfere with your other medications. NIA does not recommend
taking any supplement touted as an anti-aging remedy because
there is no proof of effectiveness and the health risks of short- and
long-term use are unknown.
Human Growth Hormone

Human growth hormone (hGH) is important for normal growth
and development, as well as for maintaining tissues and organs. It is
made by the pituitary gland, a pea-sized structure located at the base
of the brain.
Research supports supplemental use of hGH injections in certain
circumstances. For instance, hGH injections can improve the growth of
children who do not produce enough hGH. Sometimes hGH injections
may be prescribed for young adults whose obesity is the result of having
had their pituitary gland surgically removed. These uses are different
from taking hGH as an anti-aging strategy. As with other hormones,
hGH levels often decline with age, but this decrease is not necessarily
bad. At least one epidemiological study suggests that people who have
high levels of hGH are more apt to die at younger ages than those with
lower levels of the hormone. Researchers have also studied animals
with genetic disorders that suppress growth hormone production and
550
secretion and found reduced growth hormone secretion may actually

promote longevity in those species that have been tested.
Although there is no conclusive evidence that hGH can prevent
aging or halt age-related physical decline, some clinics market hGH
for that purpose and some people spend a great deal of money on such
supplements. Shots can cost more than $15,000 a year. These shots are
only available by prescription and should be administered by a doctor.
"UTBECAUSEOFTHEUNKNOWNRISKSITISHARDTOlNDADOCTORWHOWILL
prescribe hGH shots. Over-the-counter dietary supplements, known
as human growth hormone releasers, are currently being marketed
ASLOW COSTALTERNATIVESTOH'(SHOTS"UTCLAIMSOFTHEIRANTI AGING
effects, like all those regarding hGH, are unsubstantiated.
Research is starting to paint a fuller picture of the effects of hGH
supplements, but there is still much to learn. For instance, study nd-
ings indicate that supplemental hGH can increase muscle mass; how-
ever, it seems to have little impact on muscle strength or function.
Questions about potential side effects, such as diabetes, joint pain, and
uid buildup leading to high blood pressure or heart failure remain
unanswered, too. A recent report that children who were treated with
pituitary growth hormone have an increased risk of cancer created a
HEIGHTENEDCONCERNABOUTTHEDANGERSOFH'(INJECTIONS7HETHEROLDER
people treated with hGH for extended periods have an increased risk of
cancer is unknown. To date, only small, short-term studies have looked
SPECIlCALLYATH'(ASANANTI AGINGTHERAPYFOROLDERPEOPLE"EFORE
supporting the use of hGH as an anti-aging therapy, the potential
benets and risks should be assessed through additional research.
Melatonin
Melatonin is a hormone involved with our daily sleep/wake cycle. It
is made by the pineal gland located in the brain. Despite some claims
to the contrary, melatonin production and release does not necessar-
ily decrease with age. Instead, a number of factors, including light
exposure and use of some common medications can affect melatonin
secretion in people of any age.
As with other hormones, melatonin is marketed as a dietary supple-
ment. Consumers should look with caution at claims about melatonin
supplements effects.
One claim for melatonin supplements is that they are an anti-aging
remedy, but research on the anti-aging effects has been very limited
and focused on animals, not humans. There are also claims that mela-
tonin helps with sleep. Research ndings have shown that melatonin
551
supplements, in amounts ranging from 0.1 to 0.5 milligrams, can im-

prove sleep in some cases; however, if taken at the wrong time, me-
latonin can actually disrupt the sleep/wake cycle. And, melatonins
benets as an antioxidant have been touted. Antioxidants protect the
body from the harmful effects of by-products, known as free radicals,
made when the body changes oxygen and food into energy. Early test-
tube studies suggested that, in large doses, melatonin might be an
effective antioxidant. More research is needed to know if using me-
latonin supplements as an antioxidant will decrease the amount of
antioxidants cells produce naturally.
Side effects of melatonin supplements may include confusion, drowsi-
ness, and headache. Animal studies suggest that melatonin may cause
some blood vessels to constrict, a condition that could be dangerous for
people with high blood pressure or other cardiovascular problems.
The usual dose of melatonin sold without a prescription in stores is
3 milligrams. This dose is much larger than the 0.1 to 0.5 milligrams of
melatonin researchers used to study its effects on sleep. People who take
these supplements may have a 10- to 40-times higher blood concentra-
tion of melatonin than normal. Long-term effects of such high concen-
trations of melatonin on the body are still unknown. Use caution when
considering taking these supplements until researchers learn more.
DHEA
Dehydroepiandrosterone, or DHEA, is made from cholesterol by the
adrenal glands, which sit on top of each kidney. It is converted by the
body into two other important hormones: testosterone and estrogen.
For most people, DHEA production peaks in the mid-20s and then
gradually declines with age. The effects of this decline including its role
in the aging process are unclear. Even so, some proponents claim that
over-the-counter DHEA supplements can improve energy and strength
and boost immunity. Claims are also made that supplements increase
muscle and decrease fat. To date, there is no conclusive scientic evi-
dence that DHEA supplements have any of these benets.
The conversion of naturally produced DHEA into a different amount
of estrogen and testosterone is highly individualized. There is no way
to predict whose body will make more and whose will make less of
these hormones. Having an excess of testosterone and estrogen in your
body can be risky.
Scientists do not yet know the effects of long-term use (over 1 year) of
DHEA supplements. Early indications are that these supplements, even
when taken briey, may have several detrimental effects on the body, in-
552
CLUDINGLIVERDAMAGE"UTTHEPICTUREISNOTCLEAR4WOSHORT TERMSTUDIES
showed that taking DHEA supplements has no harmful effects on blood,
prostate, or liver function. However, these studies were too small to lead
to conclusions about the safety or efcacy of DHEA supplementation.
Researchers are working to nd more denite answers about
DHEAs effects on aging, muscles, and the immune system. In the
meantime, if you are thinking about taking DHEA supplements, be
aware that the effects are not fully known and might turn out to cause
more harm than good.
Testosterone
Most people know testosterone as the hormone that transforms a
boy into a man and is somehow associated with sex drive. That may be
why some men are concerned about a possible decrease in testosterone
production as they age.
Testosterone is a vital sex hormone that plays an important role in
puberty. In men, testosterone not only regulates sex drive (libido), it also
helps regulate bone mass, fat distribution, muscle mass and strength,
ANDTHEPRODUCTIONOFREDBLOODCELLSANDSPERM"UTTESTOSTERONEISNT
exclusively a male hormonewomen produce small amounts, as well.
In men, testosterone is produced in the testes, the reproductive glands
that also produce sperm. The amount of testosterone produced in the
testes is regulated by the hypothalamus and the pituitary gland.
As men age, their testes often produce somewhat less testosterone,
especially when compared to years of peak testosterone production dur-
ing adolescence and early adulthood. Normal testosterone production
ranges widely, and it is unclear what amount of decline or how low a
level of testosterone will cause adverse effects.
In recent years, the popular press has reported frequently about
male menopause, a condition supposedly caused by diminishing tes-
tosterone levels in aging men. There is scant scientic evidence that
this condition, also known as andropause or viropause, exists. And
the likelihood that an aging man will experience a major shutdown
of testosterone production similar to a womans menopause is very
remote. In fact, many of the changes that take place in older men
often are incorrectly attributed to decreasing testosterone levels. For
instance, some men experiencing erectile difculty (impotence) may
be tempted to blame it on lowered testosterone, when in many cases
erectile problems are due to circulatory problems.
In certain cases, such as in men whose bodies make very little or no
testosterone, testosterone supplementation may offer benets. FDA-
553
approved testosterone supplements come in different forms, includ-

ing patches, injections, and topical gels. Men whose testes have been
damaged or whose pituitary glands have been harmed or destroyed by
trauma, infections, or tumors may be prescribed testosterone. Supple-
ments can also help men with exceptionally low testosterone levels
maintain strong muscles and bones and increase their sex drive. It
is unclear if men who are at the lower end of the normal range for
testosterone production would benet from supplementation.
More research is needed to learn what effects testosterone replace-
ment may have in healthy older men without these extreme decien-
cies. NIA is investigating the role of testosterone therapy in delaying
or preventing frailty and helping with other age-related health issues.
Results from preliminary studies involving small groups of men have
been inconclusive. Specically, it remains unclear to what degree tes-
tosterone supplements can help men maintain strong muscles and
sturdy bones, sustain robust sexual activity, or sharpen memory.
There are also concerns about the long-term harmful effects that
supplemental testosterone might have on the aging body. Some epi-
demiologic studies suggest that higher natural levels of testosterone
are not associated with a higher incidence of prostate cancerthe
second leading cause of cancer death among men. However, scientists
do not know if taking supplemental testosterone increases mens risk
for developing prostate cancer or promoting the growth of an existing
tumor. There is also concern about a potential increased risk for stroke
based on studies that suggest that testosterone supplementation might
trigger excessive red blood cell production, which thickens the blood.
The bottom line: Although some older men who use testosterone
therapy may report feeling more energetic or younger, there is no sci-
entic proof that testosterone therapy in healthy men will help them
age better. Until more scientically rigorous studies are conducted, it is
not known if the possible benets of testosterone therapy outweigh any
of its potential risks. NIA continues to conduct research to gather more
evidence about the effects of testosterone supplements in aging men.
Hormones in Women
Estrogen and progesterone are two hormones that play an impor-
tant part in womens menstrual cycle and pregnancy. Estrogen also
helps maintain bone strength and might prevent heart disease and
PROTECTMEMORYBEFOREMENOPAUSE"OTHESTROGENANDPROGESTERONE
are produced naturally by the ovaries. However, after menopause, the
ovaries stop making these hormones. For more than 60 years, millions
554
of women have used estrogen supplements to control for menopausal

SYMPTOMSESPECIALLYHOTmASHESANDVAGINALDRYNESS7OMENALSO
take it to prevent or treat osteoporosisloss of bone strengththat
often happens after menopause. The use of estrogen (by women whose
uterus has been removed) or estrogen with progesterone or a progestin,
a synthetic form of progesterone (by women with a uterus), to treat
the symptoms of menopause is called menopausal hormone therapy
(MHT), formerly known as hormone replacement therapy (HRT).
There is a rich research base investigating estrogen. Many large,
reliable long-term studies of estrogen and its effects on the body have
been conducted. Yet, much remains unknown. In fact, the history of
estrogen research demonstrates why it is important to examine both
the benets and risks of a hormone before it becomes widely used.
Heres what scientists know:
s Endometrial problems7HILEESTROGENHELPSSOMEWOMENWITH
symptom management during and after menopause, it can raise
the risk of certain problems. Estrogen may cause a thickening of
the lining of the uterus (endometrium) and a slightly increased risk
of endometrial cancer. To lessen these risks, doctors now prescribe
progestin to women with a uterus to protect the lining.
s Heart diseaseThe role of estrogen in heart disease is com-
plex. Early studies suggested MHT could lower postmenopausal
womens risk for heart diseasethe number one killer of women
INTHE5NITED3TATES"UTRESULTSFROMTHE7OMENS(EALTH
)NITIATIVE7() ASTUDYOF-(4BYTHE.)(SUGGESTTHATUS-
ing estrogen with or without a progestin after menopause does
not protect women from heart disease and may even increase
THEIRRISK)N7()SCIENTISTSREPORTEDTHATUSINGESTROGEN
plus progestin actually elevates some postmenopausal womens
chance of developing heart disease, stroke, blood clots, and
breast cancer, but women also experienced fewer hip fractures
ANDCASESOFCOLORECTALCANCER)N7()SCIENTISTSPUBLISHED
another report, this time on postmenopausal women who used
ESTROGENALONEWHICHHADSOMESIMILARlNDINGS7OMENHADAN
increased risk of stroke and blood clots, but fewer hip fractures.
4HENINACLOSERANALYSISOFTHE7()RESULTSINDICATEDTHAT
younger women, ages 50 to 59 at the start of the trial, who used
estrogen alone had signicantly less plaque in their coronary
arteries than women not using estrogen. Increased plaque in
coronary arteries is a risk factor for heart attacks. Scientists also
determined that the risk of heart attack might not be increased
555
in women who started MHT less than 10 years after menopause,

but that there is increasing risk in women who begin MHT more
than 10 years after menopause.
s DementiaSome studies suggest that estrogen may protect

against Alzheimer disease. However, this has not yet been prov-
EN)NRESEARCHERSINASUB STUDYOFTHE7()CALLEDTHE
7()-EMORY3TUDY7()-3 REPORTEDTHATWOMENAGEAND
older who take a combination of estrogen and progestin were at
twice the risk for developing dementia than women who do not
TAKEANYHORMONES)NTHESE7()-3SCIENTISTSREPORTED
that using estrogen alone could also increase the risk of develop-
ing dementia in women age 65 and older compared to women not
taking any hormones.
For all the research ndings, there are still many unknowns about
the risks of MHT. For instance, scientists have not yet determined
if risks differ between women who have menopausal symptoms and
those who dont. Also, because women in their early 50s were only a
SMALLPARTOFTHE7()SCIENTISTSDONOTYETKNOWIFCERTAINRISKSARE
applicable to younger women who use estrogen to control symptoms
during the menopausal transition.
You may also have heard about a relatively new approach to hor-
mone therapy for womenbioidentical hormones. These are man-
made hormones (from plants such as soy or yams) that have the same
chemical structure as hormones produced by the human body. The
term bioidentical hormones is now also being applied to the practice
of compounding or combining hormones such as estrogen and proges-
terone, theoretically based on a womans individual hormonal needs.
Large clinical trials of these compound hormones have not been done,
and many bioidentical hormones that are available without a prescrip-
tion are not regulated or approved for safety and efcacy by the FDA.
FDA-regulated bioidentical hormones, such as estradiol and proges-
terone, are available by prescription for women considering MHT.
For middle age and older women, the decision to take hormones
is far more complex and difcult than ever before. Questions about
MENOPAUSALHORMONETHERAPYREMAIN7OULDUSINGADIFFERENTESTROGEN
ANDORPROGESTINORDIFFERENTDOSECHANGETHERISKS7OULDTHERESULTS
be different if the hormones were given as a patch or cream, rather
THANAPILL7OULDTAKINGTHEPROGESTINLESSOFTENBEASEFFECTIVEAND
SAFE$OESSTARTINGMENOPAUSALHORMONETHERAPYAROUNDTHETIMEOF
MENOPAUSECOMPAREDTOYEARSLATERCHANGETHERISKS#ANWEPREDICT
556
which women will benet or be harmed by using menopausal hormone

THERAPY!STHESEANDOTHERQUESTIONSAREADDRESSEDBYRESEARCH
women should re-review the pros and cons of menopausal hormone
therapy with their doctors, assess the personal risks and benets, and
then make an informed decision about whether or not this therapy is
for them.
Calorie Restriction, Intermittent Fasting, and

Resveratrol
Scientists are discovering that what you eat, how frequently, and
how much may have an effect on quality and years of life. Of particu-
lar interest has been calorie restriction, a diet comprised by generally
25 to 40 percent fewer calories than normal but including all needed
nutrients. Research in animals has shown calorie restriction to have
an impressive effect on disease and markers of aging. It has been
found to extend the life of protozoa (very small, one-celled organisms),
yeast, fruit ies, mice, and rats. Recent calorie restriction studies with
humans and other primates, such as monkeys, are ongoing. However,
early ndings of the Comprehensive Assessment of Long-term Effects
of Reducing Intake of Energy (CALERIE) study, show that adults who
cut their calorie consumption by 25 percent lowered their fasting in-
sulin levels and core body temperature, both of which correlate with
increased longevity in animal models. In other studies with non-human
primates, researchers have found that calorie restriction reduced in-
cidence of heart disease and cancer.
Scientists do not know if long-term calorie restriction is safe for
humans. It is unclear whether or not a calorie-restricted diet will ever
be recommended for people. However, studying calorie restriction may
offer new insights into the aging process and biological mechanisms
that could inuence healthy aging. This research may also provide
clues about how to prevent or delay diseases that become more preva-
lent with age.
Other ongoing studies focus on identifying chemicals that mimic
calorie restrictions benets. Resveratrol, found naturally in very small
amounts in grapes and nuts, is one of the compounds being studied.
Scientists compared two groups of overweight mice on a high fat diet.
One group was given a high dose of resveratrol. The overweight mice
receiving resveratrol were healthier and lived longer than the other
overweight group. In a follow-up study, scientists found that, when
started at middle age, resveratrol slowed age-related health problems
in mice on a standard diet but did not increase longevity. More research
557
is needed before scientists know if resveratrol is safe for people or even

if it has the same effects as it has in mice.
Scientists are also studying the effect of intermittent fasting or
reduced meal frequency. In animal models, like mice, reduced meal
frequency appears to have a protective effect on the brain and may also
help with heart function and regulating sugar in the blood. However,
the inuence of intermittent fasting on human health and longevity
is currently unclear.
7HILERESEARCHINTOCALORIERESTRICTIONANDINTERMITTENTFASTING
continues, there is already plenty of research supporting the value of
a healthy, balanced diet and physical activity to help delay or prevent
age-related health problems.
Many Questions, Seeking Answers

NIA supports research that seeks to tell us more about aging and
the risks and benets of potential interventions such as hormone ther-
apies, supplements, and calorie restriction. One goal is to determine
whether DHEA, melatonin, and other hormonal supplements improve
the health of older people, have no effect, or are harmful. Researchers
are also trying to determine if calorie restriction is safe for humans
and if there are any compounds that could replicate in humans the
benets of calorie restriction seen in animals.
These studies will take some time. Research on supplements and
calorie restriction is ongoing and a great deal of basic animal and
clinical research is yet to be done. Dont be surprised if these studies
open the door to more questions as well as answers. Research is an
incremental process; results can move knowledge forward, but can also
take you back to basics.
Until more is known about DHEA, melatonin, hGH, and resveratrol,
consumers should view these types of supplements with a good deal
of caution and doubt. Despite what advertisements and media, like
television and magazines, may claim, there are no specic therapies
proven to prevent aging. Some harmful side effects already have been
discovered and additional research may uncover others.
People with genuine deciencies of hormones should consult with
their doctors about supplements. Talk to your doctor if you are interested
in any form of hormone supplementation or anti-aging approaches
beyond healthy diet and physical activity. Meanwhile, people who choose
to take any hormone supplement without a doctors supervision should
be aware that these supplements appear to have few clear-cut benets
for healthy individuals and no proven inuence on the aging process.
558
Chapter 83
Infertility and CAM
Chapter Contents
Section 83.1Herbal Remedies for Infertility .......................... 560
Section 83.2Infertility and CAM............................................. 561
559
Section 83.1
Herbal Remedies for Infertility

Treating Infertility with Herbal Medications, 2006 American Pregnancy
Association (www.americanpregnancy.org). Reprinted with permission.
Chinese herbs have been used for approximately 2,500 years to

treat a wide array of health problems. Herbal medicines may enhance
fertility by supporting the natural functions of the ovulation and fer-
tility process.
Herbs are not regulated by the FDA [U.S. Food and Drug
Administration], but are they safe?
In general, herbs are safe to use. However, there are herbs that
should not be taken during pregnancy, so it is always important to
discuss with your healthcare provider which herbs are safe to take.
7HENUSINGHERBSTOENHANCEFERTILITYITISRECOMMENDEDTHATYOU
consult a healthcare provider who is familiar with which herbs affect
different aspects of your fertility.
When should herbs not be taken?

One of the purposes of prescribing herbal medicines is to increase
ovarian function. Therefore, individuals who are taking birth control
pills, Antigon/Cetrotide, or Lupron should not take herbs. These medi-
cations are used to impede or lessen ovarian function; in other words
they have the opposite desired effect of herbs.
How long should I take herbs?

The effects of herbal medicines are generally cumulative, and the
clinical effect, at least from the perspective of treating the infertile
couple, is usually seen after 60120 days. Herbs are also cycle-depen-
dent, meaning they need the entire menstrual cycle and work best with
multiple cycles. In other words, if a woman is going to have an IVF [in
vitro fertilization] transfer in 1 week, herbs would not be prescribed.
560
Infertility and CAM
What types of infertility can herbal medicines treat?

In general, all types of infertility conditions are appropriate for
HERBALMEDICINES7HETHERITISADVANCEDMATERNALAGELUTEAL PHASE
defect, premature ovarian failure, male factor, or unexplained, herbs
have positive potential. Clinical observation has seen impressive re-
sults when mixing herbs with gonadotropins during IUI [intrauterine
insemination] and IVF cycles. The herbs seem to enhance the effects
of the gonadotropins, and they do not pose the risk of OHSS (ovarian
hyper stimulation syndrome).
Is herbal medicine a licensed profession?

(ERBALMEDICINEISNOTALICENSEDPROFESSIONHOWEVERTHEREIS"OARD
certication which some practitioners acquire. It is recommended that
you consult with a healthcare provider who is educated on the benets
and use of herbs for treatment of infertility. The recommendation is to
LOCATEAHEALTHCAREPROVIDERWHOIS"OARDCERTIlEDTOPRESCRIBEHERBAL
medicines.
Section 83.2
Infertility and CAM

Acupuncture Shows Promise in Improving Rates of Pregnancy Following
IVF, by the National Center for Complementary and Alternative Medi-
cine (NCCAM, nccam.nih.gov), part of the National Institutes of Health,
February 2008.
A review of seven clinical trials of acupuncture given with embryo

transfer in women undergoing in vitro fertilization (IVF) suggests that
acupuncture may improve rates of pregnancy. An estimated 10 to 15
percent of couples experience reproductive difculty and seek special-
ist fertility treatments, such as IVF. IVF, which involves retrieving
a womans egg, fertilizing it in the laboratory, and then transferring
the embryo back into the womans womb is an expensive, lengthy, and
stressful process. Identifying a complementary approach that can im-
prove success would be welcome to patients and providers.
561
According to Eric Manheimer of the University of Maryland School

of Medicines Center for Integrative Medicine and colleagues who con-
ducted the systematic review, acupuncture has been used in China
FORCENTURIESTOREGULATETHEFEMALEREPRODUCTIVESYSTEM7ITHTHIS
in mind, the reviewers analyzed results from seven clinical trials of
acupuncture in women who underwent IVF to see if rates of preg-
nancy were improved with acupuncture. The studies encompassed
data on over 1,366 women and compared acupuncture, given within
1 day of embryo transfer, with sham acupuncture, or no additional
treatment.
The reviewers found that acupuncture given as a complement to
IVF increased the odds of achieving pregnancy. According to the re-
searchers, the results indicate that 10 women undergoing IVF would
need to be treated with acupuncture to bring about one additional
pregnancy. The results, considered preliminary, point to a potential
complementary treatment that may improve the success of IVF and the
need to conduct additional clinical trials to conrm these ndings.
References
-ANHEIMER%:HANG'5DOFF,ETAL%FFECTOFACUPUNCTUREONRATES
of pregnancy and live birth among women undergoing in vitro fertiliza-
tion: systematic review and meta-analysis. British Medical Journal.
Published online, February 2008.
562
Chapter 84
Low Back Pain and CAM
Low-back pain is a common condition that can be difcult to treat.

Spinal manipulation is among the treatment options used by people
with low-back pain in attempts to relieve pain and improve function-
ing. It is performed by chiropractors and other health care profession-
als such as physical therapists, osteopaths, and some conventional
medical doctors.
About Low-Back Pain

Each year, up to one quarter of U.S. adults experience low-back pain.
Most people have signicant back pain at least once in their lives; of-
TENTHECAUSEISUNKNOWN"ACKPAINVARIESWIDELY&ORMANYPEOPLE
ITLASTSONLYAFEWWEEKSNOMATTERWHATTREATMENTISUSED"UTFOR
others, the pain can become chronic and even debilitating. Low-back
pain is a challenging condition to diagnose, treat, and study.
Spinal Manipulation and Low-Back Pain

Spinal manipulationsometimes called spinal manipulative
therapyis practiced by health care professionals such as chiroprac-
tors, physical therapists, osteopaths, and some conventional medi-
cal doctors. Practitioners perform spinal manipulation by using their
&ROMh3PINAL-ANIPULATIONFOR,OW "ACK0AINvFROMTHE.ATIONAL#ENTER

the National Institutes of Health, April 2009.
563
hands or a device to apply a controlled force to a joint of the spine, mov-

ing it beyond its passive range of motion. The amount of force applied
depends on the form of manipulation used. The goal of the treatment
is to relieve pain and improve physical functioning.
In the United States, spinal manipulation is often performed as
part of chiropractic care. Chiropractic is a health care approach that
focuses on the relationship between the bodys structuremainly the
spineand its functioning. In chiropractic, spinal manipulation is
SOMETIMESCALLEDhADJUSTMENTv"ACKPROBLEMSARETHEMOSTCOMMON
reason people seek chiropractic care.

Study Findings to Date
Overall, studies have shown that spinal manipulation can provide
mild-to-moderate relief from low-back pain and appears to be as ef-
fective as conventional medical treatments. In 2007 guidelines, the
American College of Physicians and the American Pain Society include
spinal manipulation as one of several treatment options for practitio-
ners to consider using when pain does not improve with self-care.
Research is under way to determine whether the effects of spinal
manipulation depend on the duration and frequency of treatment. Re-
cent studies have found that spinal manipulation provides relief from
low-back pain at least over the short term (i.e., up to 3 months), and
that pain-relieving effects may continue for up to 1 year. In one study
funded by the National Center for Complementary and Alternative
Medicine (NCCAM) that examines long-term effects in more than 600
people with low-back pain, results to date suggest that chiropractic
care involving spinal manipulation is at least as effective as conven-
tional medical care for up to 18 months. However, less than 20 percent
of participants in this study were pain free at 18 months, regardless
of the type of treatment used.
Challenges Facing Researchers

7HENCONSIDERINGTHEEVIDENCEONSPINALMANIPULATIONFORLOW BACK
pain, it is important to know about the research behind the evidence.
Although many clinical trials have been conducted, earlier trials tend-
ed to be small and poorly designed, making their ndings less reliable.
Moreover, studies have differed in focus (the specic type of back pain
treated and form of manipulation used) and design (comparisons with
other treatments vs. placebos). It can be difcult to clearly interpret
564
Low Back Pain and CAM
ndings when what is being measured varies widely from one study
to the next. Recent research has begun to address these issues.

Common Side Effects
Reviews have concluded that spinal manipulation is relatively safe
when performed by a trained and licensed practitioner. The most com-
mon side effects are generally minor and include temporary discomfort
in the treated area, headache, or tiredness. These effects usually go
away in 1 to 2 days.
Serious Complications
The rate of serious complications from spinal manipulation, al-
though not denitely known, appears to be very low overall. A potential
complication from low-back manipulation is cauda equina syndrome, a
condition in which nerves in the lower part of the spinal cord become
compressed, resulting in pain, weakness, and loss of feeling in one or
both legs. Other functionssuch as bowel or bladder controlmay
also be affected. Reports indicate that cauda equina syndrome is an
extremely rare complication. In people whose pain is caused by a her-
niated disc, manipulation of the low back also appears to have a very
low chance of either causing or worsening cauda equina syndrome.
NCCAM Research
Projects supported by NCCAM to study spinal manipulation for
low-back pain include studies of the following:
s 4HEOPTIMALNUMBERANDFREQUENCYOFTREATMENTSANDTHEDURA-
tion of care
s %STIMATEDUSECOSTSANDOUTCOMESOFCHIROPRACTICCAREFORRECUR-
rent back pain
s 7HATHAPPENSINTHEBODYDURINGMANIPULATIONOFTHELOWBACK
565
Chapter 85
Menopausal Symptoms
and CAM
Menopause is the permanent end of a womans menstrual periods.

Menopause can occur naturally or be caused by surgery, chemotherapy,
or radiation. Many women use complementary and alternative medi-
cine (CAM) for menopausal symptoms.
This text is based on ndings from a 2005 National Institutes of
Health (NIH) State-of-the-Science conference on the management of
menopause-related symptoms.
About Menopause
A woman is said to have completed natural menopause when she
has not had a period for 12 consecutive months. For American women,
this typically happens at around age 51 or 52. Menopause occurs im-
mediately if the uterus or both ovaries are surgically removed, or if
the ovaries are damaged in cancer treatment with radiation therapy
or certain drugs.
Common Symptoms during the Menopausal Transition

Some symptoms that women experience are related to menopause
and decreased activity of the ovaries. Others may be related to aging
in general.
From Menopausal Symptoms and CAM, by the National Center for Com-
plementary and Alternative Medicine (NCCAM, nccam.nih.gov), part of the Na-
tional Institutes of Health, January 2008.
567
Scientic evidence of a link to menopause is strongest for the fol-

lowing symptoms:
s (OTmASHESANDNIGHTSWEATSALSOCALLEDVASOMOTORSYMPTOMS
because they involve the expansion of the blood vessels)
s 3LEEPDIFlCULTIES
s 6AGINALDRYNESSWHICHCANLEADTOPAINFULINTERCOURSEANDOTHER
sexual problems
It is not certain whether the following symptoms are due to meno-

pause, other factors that can come with aging, or a combination of
menopause and these factors:
s 0ROBLEMSINTHINKINGORINREMEMBERINGTHINGS
s 5RINARYINCONTINENCE
s 0HYSICALCOMPLAINTSSUCHASTIREDNESSANDSTIFFORPAINFULJOINTS
s #HANGESINMOODSUCHASDEPRESSIONANXIETYANDORIRRITABILITY
The expert panel assembled for the NIH State-of-the-Science con-

ference noted that menopause is a normal part of womens aging and
advised that menopause should not be medicalized (or viewed as a
disease).
Hormone Replacement for Menopausal Symptoms

For decades, hormone replacement therapy (HRT)more recently
known as menopausal hormone therapy (MHT)was conventional
medicines main treatment for menopausal symptoms. In 2002, nd-
INGSFROMALARGESTUDYCALLEDTHE7OMENS(EALTH)NITIATIVERAISED
serious concerns about the long-term safety of MHT. These concerns
are one reason that many women are turning to CAM therapies.
What the Science Says about CAM Therapies for

Menopausal Symptoms
The NIH State-of-the-Science conference panel discussed the evi-
dence on several CAM therapies:
s 3IXBOTANICALSBLACKCOHOSHDONGQUAIROOTGINSENGKAVARED
clover, and soy
s $(%!DEHYDROEPIANDROSTERONE ADIETARYSUPPLEMENT
568
Menopausal Symptoms and CAM
Very little well-designed research has been done on CAM therapies

for menopausal symptoms. A small number of studies have been pub-
lished, but they have had limitations (such as the way the research
was done or treatment periods that may not have been long enough).
As a result, the ndings from these studies are not strong enough for
scientists to draw any conclusions. Also, many studies of botanicals have
not used a standardized product (i.e., one that is chemically consistent).
The National Center for Complementary and Alternative Medicine (NC-
CAM) is sponsoring a number of studies on botanicals using products
that are both well characterized (i.e., their ingredients have been care-
fully studied) and well standardized and on other CAM therapies that
have shown possible promise for reducing menopausal symptoms.
"ECAUSE#!-PRODUCTSUSEDFORMENOPAUSALSYMPTOMSCANHAVE
side effects and can interact with other botanicals or supplements
or with drugs, research in this area is addressing safety as well as
efcacy. Some ndings from this research are highlighted in the fol-
lowing text.
Botanicals
Black cohosh (Actaea racemosa, Cimicifuga racemosa): This
herb has received more scientic attention for its possible effects on
menopausal symptoms than have other botanicals. Studies of its ef-
fectiveness in reducing hot ashes have had mixed results. A study
funded by NCCAM and the National Institute on Aging found that
black cohosh, whether used alone or with other botanicals, failed to
relieve hot ashes and night sweats in postmenopausal women or those
approaching menopause. Other research suggests that black cohosh
does not act like estrogen, as once was thought.
United States Pharmacopeia experts suggest women should dis-
continue use of black cohosh and consult a health care practitioner if
they have a liver disorder or develop symptoms of liver trouble, such as
abdominal pain, dark urine, or jaundice. There have been several case
reports of hepatitis (inammation of the liver), as well as liver failure,
in women who were taking black cohosh. It is not known if black cohosh
was responsible for these problems. Although these cases are very rare
and the evidence is not denitive, scientists are concerned about the
possible effects of black cohosh on the liver.
Dong quai (Angelica sinensis): Only one randomized clinical

study of dong quai has been done. The researchers did not nd it to be
useful in reducing hot ashes. Dong quai is known to interact with,
569
and increase the activity in the body of, the blood-thinning medicine
warfarin. This can lead to bleeding complications in women who take
this medicine.
Ginseng (Panax ginseng or Panax quinquefolius): The panel

concluded that ginseng may help with some menopausal symptoms, such
as mood symptoms and sleep disturbances, and with ones overall sense
of well-being. However, it has not been found helpful for hot ashes.
Kava (Piper methysticum): Kava may decrease anxiety, but there

is no evidence that it decreases hot ashes. It is important to note that
kava has been associated with liver disease. The FDA [U.S. Food and
Drug Administration] has issued a warning to patients and providers
about kava because of its potential to damage the liver.
Red clover (Trifolium pratense): The panel reported that ve

controlled studies found no consistent or conclusive evidence that red
clover leaf extract reduces hot ashes. Clinical studies in women report
few side effects, and no serious health problems have been discussed
in the literature. However, there are some cautions. Some studies have
raised concerns that red clover, which contains phytoestrogens, might
have harmful effects on hormone-sensitive tissue (for example, in the
breast and uterus).
Soy: The scientic literature includes both positive and negative

RESULTSONSOYEXTRACTSFORHOTmASHES7HENTAKENFORSHORTPERIODSOF
time, soy extracts appear to have few if any serious side effects. How-
ever, long-term use of soy extracts has been associated with thickening
of the lining of the uterus.
About phytoestrogens: Some botanical products, such as soy and

red clover, contain estrogen-like compounds called phytoestrogens.
Plants rich in phytoestrogens may help relieve some symptoms of
menopause. However, it is uncertain whether this relief comes from
phytoestrogens or from other compounds in the plant. Much remains
to be learned about these plant products, including exactly how they
work in the human body. Doctors caution that certain women need to
be particularly careful about using phytoestrogens, especially:
s WOMENWHOHAVEHADORAREATINCREASEDRISKFORDISEASESORCON-
ditions that are affected by hormones, such as breast, uterine, or
ovarian cancer; endometriosis; or uterine broids; or
570
Menopausal Symptoms and CAM
s WOMENWHOARETAKINGDRUGSTHATINCREASEESTROGENLEVELSINTHE
body, such as birth control pills; MHT; or a type of cancer drug
called selective estrogen receptor modulators (SERMs), such as
tamoxifen.
DHEA [Dehydroepiandrosterone]
DHEA is a naturally occurring substance that is changed in the
body to the hormones estrogen and testosterone. It is also manufac-
tured and sold as a dietary supplement. A few small studies have sug-
gested that DHEA might possibly have some benet for hot ashes and
decreased sexual arousal, although small randomized controlled trials
HAVESHOWNNOBENElT"ECAUSELEVELSOFNATURAL$(%!INTHEBODY
decline with age, some people believe that taking a DHEA supplement
can help treat or prevent conditions related to aging; however, there
is no good scientic evidence to support this notion.
Concerns have been raised about whether DHEA is safe and effective.
Its long-term effects, risks, and benets have not been well studied, and
scientists are not certain whether it might increase the risk for breast
ORPROSTATECANCER"EFOREUSING$(%!FORANYPURPOSEPEOPLESHOULD
talk to their health care provider about potential benets and risks.
If You Are Considering CAM for Menopausal Symptoms

Although there is very little scientic evidence to support the ef-
fectiveness of CAM therapies for menopausal symptoms, it is possible
that some CAM therapies may provide some relief to women during
the menopausal transition. Here a few important points to keep in
mind if you are considering these therapies:
and safe care.
s +EEPINMINDTHATALTHOUGHMANYDIETARYSUPPLEMENTSAND
some prescription drugs) come from natural sources, natural
does not always mean safe. For example, the herbs comfrey and
kava can cause serious harm to the liver. Also, a manufacturers
use of the term standardized (or veried or certied) does
not necessarily guarantee product quality or consistency.
s "EAWARETHATANHERBALSUPPLEMENTMAYCONTAINDOZENSOF
compounds and that its active ingredients may not be known.
571
Researchers are studying many of these products in an effort

to identify active ingredients and understand their effects in the
body. Also consider the possibility that whats on the label may
not be whats in the bottle. Analyses of dietary supplements some-
times nd differences between labeled and actual ingredients.
7OMENWHOARELOOKINGFORALTERNATIVESTO-(4SHOULDBEAWARE
that CAM therapies are not their only option. Certain lifestyle changes
can contribute to healthy aging, including during the menopausal
transition. For example, quitting smoking, eating a healthy diet, and
exercising regularly have been shown to reduce the risks of heart
disease and osteoporosis.
NCCAM Research on CAM for Menopausal Symptoms

NCCAM supports a number of studies on CAM treatments (such
as botanicals and mind-body practices) for menopausal symptoms, as
do some of the other institutes and centers at NIH. Recent examples
of NCCAM-funded projects include the following:
s !NINITIATIVETOIMPROVEMEASURESOFHOTmASHESWHICHISEXPECT-
ed to add to the understanding of hot ashes and to aid future
clinical studies
s !STUDYOFWHETHERBLACKCOHOSHCANHELPWITHTHEANXIETYTHAT
may be experienced as a symptom of menopause
s !STUDYTOIDENTIFYBOTANICALSFROM#ENTRAL!MERICATHATHAVE
been used by the native population for menopausal symptoms
and to develop and test standardized extracts from these plants
s 3EVERALSTUDIESLOOKINGATTHEEFFECTOFACUPUNCTUREONTHERE-
currence and severity of hot ashes in postmenopausal women
and others who may suffer from hot ashes, such as men being
treated for prostate cancer
s !STUDYTODETERMINETHEEFFECTSOFMINDFULNESS BASEDSTRESSREDUC-
tion (a type of meditation) on hot ashes in menopausal women
s !STUDYTOUNDERSTANDHOWSOYSUPPLEMENTSMIGHTAFFECTHOT
ashes and night sweats
In addition, NCCAM and other NIH components are cofunding an

initiative to establish a network of research centers looking at potential
new treatments for menopausal symptoms.
572
Chapter 86
Mental Health Care and CAM
Chapter Contents
Section 86.1Overview of CAM Used in Mental
Health Care ......................................................... 574
Section 86.2Alcohol Addiction and
Electroacupuncture............................................. 579
Section 86.3Attention Decit Hyperactivity
Disorder (ADHD) and CAM................................ 580
Section 86.4Anxiety and Self-Hypnosis ................................. 582
Section 86.5Posttraumatic Stress Disorder
and Acupuncture ................................................. 583
573
Section 86.1
Overview of CAM Used in Mental Health Care

From Alternative Approaches to Mental Health Care, by the Sub-
stance Abuse and Mental Health Services Administration (SAMHSA,
mentalhealth.samhsa.gov), part of the U.S. Department of Health and
Human Services, April 2003. Reviewed and revised by David A. Cooke,
MD, FACP, January 23, 2010.
What Are Alternative Approaches to Mental Health Care?

An alternative approach to mental health care is one that emphasiz-
es the interrelationship between mind, body, and spirit. Although some
alternative approaches have a long history, many remain controversial.
The National Center for Complementary and Alternative Medicine at
the National Institutes of Health was created in 1992 to help evalu-
ate alternative methods of treatment and to integrate those that are
effective into mainstream health care practice. It is crucial, however,
to consult with your health care providers about the approaches you
are using to achieve mental wellness.
Self-Help
Many people with mental illnesses nd that self-help groups are
an invaluable resource for recovery and for empowerment. Self-help
generally refers to groups or meetings that have the following char-
acteristics:
s )NVOLVEPEOPLEWHOHAVESIMILARNEEDS
s !REFACILITATEDBYACONSUMERSURVIVOROROTHERLAYPERSON
s !SSISTPEOPLETODEALWITHAhLIFE DISRUPTINGvEVENTSUCHASA
death, abuse, serious accident, addiction, or diagnosis of a physi-
cal, emotional, or mental disability, for oneself or a relative
s !REOPERATEDONANINFORMALFREE OF CHARGEANDNONPROlTBASIS
s 0ROVIDESUPPORTANDEDUCATION
s !REVOLUNTARYANONYMOUSANDCONlDENTIAL
574
Diet and Nutrition

Adjusting both diet and nutrition may help some people with
mental illnesses manage their symptoms and promote recovery. For
example, research suggests that eliminating milk and wheat prod-
ucts can reduce the severity of symptoms for some people who have
schizophrenia and some children with autism. Similarly, some holistic/
NATURALPHYSICIANSUSEHERBALTREATMENTS" COMPLEXVITAMINSRIBO-
avin, magnesium, and thiamine to treat anxiety, autism, depression,
drug-induced psychoses, and hyperactivity. [Editors Note: Due to a
lack of good-quality research, it is unclear whether improvements in
the above listed disorders are due to these interventions, as opposed
to other factors. Many of these conditions have signicant natural
variation, and it is difcult to accurately measure change.]
Pastoral Counseling
Some people prefer to seek help for mental health problems from
their pastor, rabbi, or priest, rather than from therapists who are not
afliated with a religious community. Counselors working within tra-
ditional faith communities increasingly are recognizing the need to
incorporate psychotherapy and/or medication, along with prayer and
spirituality, to effectively help some people with mental disorders.
Animal-Assisted Therapies
7ORKINGWITHANANIMALORANIMALS UNDERTHEGUIDANCEOFAHEALTH
care professional may benet some people with mental illness by fa-
cilitating positive changes, such as increased empathy and enhanced
socialization skills. Animals can be used as part of group therapy pro-
grams to encourage communication and increase the ability to focus.
Developing self-esteem and reducing loneliness and anxiety are just
some potential benets of individual-animal therapy.
Expressive Therapies
Art therapy: Drawing, painting, and sculpting help many people
to reconcile inner conicts, release deeply repressed emotions, and
foster self-awareness, as well as personal growth. Some mental health
providers use art therapy as both a diagnostic tool and as a way to
help treat disorders such as depression, abuse-related trauma, and
schizophrenia. You may be able to nd a therapist in your area who
has received special training and certication in art therapy.
575
Dance/movement therapy: Some people nd that their spirits

soar when they let their feet y. Othersparticularly those who prefer
more structure or who feel they have two left feetgain the same
sense of release and inner peace from the Eastern martial arts, such
as Aikido and Tai Chi. Those who are recovering from physical, sexual,
or emotional abuse may nd these techniques especially helpful for
gaining a sense of ease with their own bodies. The underlying premise
to dance/movement therapy is that it can help a person integrate the
emotional, physical, and cognitive facets of self.
Music/sound therapy: It is no coincidence that many people turn

on soothing music to relax or fast tunes to help feel upbeat. Research
suggests that music stimulates the bodys natural feel good chemicals
(opiates and endorphins). This stimulation results in improved blood
ow, blood pressure, pulse rate, breathing, and posture changes. Music
or sound therapy has been used to treat disorders such as stress, grief,
depression, schizophrenia, and autism in children, and to diagnose
mental health needs.
Culturally Based Healing Arts

Traditional Oriental medicine (such as acupuncture, shiatsu, and
Reiki), Indian systems of health care (such as Ayurveda and yoga),
and Native American healing practices (such as the Sweat Lodge and
Talking Circles) all incorporate the following beliefs:
s 7ELLNESSISASTATEOFBALANCEBETWEENTHESPIRITUALPHYSICAL
and mental/emotional selves.
s !NIMBALANCEOFFORCESWITHINTHEBODYISTHECAUSEOFILLNESS
s (ERBALNATURALREMEDIESCOMBINEDWITHSOUNDNUTRITIONEXER-
cise, and meditation/prayer, will correct this imbalance.
Acupuncture: The Chinese practice of inserting needles into the

body at specic points manipulates the bodys ow of energy to balance
the endocrine system. This manipulation regulates functions such as
heart rate, body temperature, and respiration, as well as sleep pat-
terns and emotional changes. Acupuncture has been used in clinics to
assist people with substance abuse disorders through detoxication; to
relieve stress and anxiety; to treat attention decit and hyperactivity
disorder in children; to reduce symptoms of depression; and to help
people with physical ailments.
576
Ayurveda: Ayurvedic medicine is described as knowledge of how

to live. It incorporates an individualized regimensuch as diet, medi-
tation, herbal preparations, or other techniquesto treat a variety of
conditions, including depression, to facilitate lifestyle changes, and to
teach people how to release stress and tension through yoga or tran-
scendental meditation.
Yoga/meditation: Practitioners of this ancient Indian system of

health care use breathing exercises, posture, stretches, and medita-
tion to balance the bodys energy centers. Yoga is used in combina-
tion with other treatment for depression, anxiety, and stress-related
disorders.
Native American traditional practices: Ceremonial dances,

chants, and cleansing rituals are part of Indian Health Service pro-
grams to heal depression, stress, trauma (including those related to
physical and sexual abuse), and substance abuse.
Cuentos:"ASEDONFOLKTALESTHISFORMOFTHERAPYORIGINATEDIN
Puerto Rico. The stories used contain healing themes and models of
behavior such as self-transformation and endurance through adver-
sity. Cuentos is used primarily to help Hispanic children recover from
depression and other mental health problems related to leaving ones
homeland and living in a foreign culture.
Relaxation and Stress Reduction Techniques

Biofeedback: Learning to control muscle tension and involun-
tary body functioning, such as heart rate and skin temperature, can
be a path to mastering ones fears. It is used in combination with, or
as an alternative to, medication to treat disorders such as anxiety,
panic, and phobias. For example, a person can learn to retrain his
or her breathing habits in stressful situations to induce relaxation
and decrease hyperventilation. Some preliminary research indicates
it may offer an additional tool for treating schizophrenia and depres-
sion.
Guided imagery or visualization: This process involves going

into a state of deep relaxation and creating a mental image of recov-
ery and wellness. Physicians, nurses, and mental health providers
occasionally use this approach to treat alcohol and drug addictions,
depression, panic disorders, phobias, and stress.
577
Massage therapy: The underlying principle of this approach is

that rubbing, kneading, brushing, and tapping a persons muscles can
help release tension and pent-up emotions. It has been used to treat
trauma-related depression and stress. A highly unregulated industry,
certication for massage therapy varies widely from state to state.
Some states have strict guidelines, while others have none.
Technology-Based Applications
The boom in electronic tools at home and in the ofce makes access
to mental health information just a telephone call or a mouse click
away. Technology is also making treatment more widely available in
once-isolated areas.
Telemedicine: Plugging into video and computer technology is a

relatively new innovation in health care. It allows both consumers and
providers in remote or rural areas to gain access to mental health or
specialty expertise. Telemedicine can enable consulting providers to
speak to and observe patients directly. It also can be used in education
and training programs for generalist clinicians.
Telephone counseling: Active listening skills are a hallmark of

telephone counselors. These also provide information and referral to
interested callers. For many people telephone counseling often is a
rst step to receiving in-depth mental health care. Research shows
that such counseling from specially trained mental health providers
reaches many people who otherwise might not get the help they need.
"EFORECALLINGBESURETOCHECKTHETELEPHONENUMBERFORSERVICEFEES
a 900 area code means you will be billed for the call, an 800 or 888
area code means the call is toll-free.
Electronic communications: Technologies such as the inter-

net, bulletin boards, and electronic mail lists provide access directly
to consumers and the public on a wide range of information. Online
consumer groups can exchange information, experiences, and views
on mental health, treatment systems, alternative medicine, and other
related topics.
Radio psychiatry: Another relative newcomer to therapy, radio

psychiatry was rst introduced in the United States in 1976. Radio
psychiatrists and psychologists provide advice, information, and refer-
rals in response to a variety of mental health questions from callers.
578
The American Psychiatric Association and the American Psychological

Association have issued ethical guidelines for the role of psychiatrists
and psychologists on radio shows.
This text does not cover every alternative approach to mental health.
A range of other alternative approachespsychodrama, hypnotherapy,
RECREATIONALAND/UTWARD"OUND TYPENATUREPROGRAMSOFFEROPPOR-
TUNITIESTOEXPLOREMENTALWELLNESS"EFOREJUMPINGINTOANYALTERNA-
tive therapy, learn as much as you can about it. In addition to talking
with your health care practitioner, you may want to visit your local
library, book store, health food store, or holistic health care clinic for
more information. Also, before receiving services, check to be sure the
provider is properly certied by an appropriate accrediting agency.
Section 86.2
Alcohol Addiction and Electroacupuncture

From Electroacupuncture May Help Alcohol Addiction, by the National
Center for Complementary and Alternative Medicine (NCCAM, nccam.nih
.gov), part of the National Institutes of Health, October 2008.
Alcohol and drug addiction pose serious medical, social, and eco-
nomic problems in the United States. However, nding effective treat-
ments for addiction is challenging. Many people relapse due to intense
cravings and/or painful withdrawal symptoms. Electroacupuncture
(acupuncture combined with electrical stimulation) is currently be-
ing studied as a possible treatment option, and preliminary evidence
suggests that electroacupuncture can counteract addiction by affecting
related chemicals (opiates) in the brain.
In a study funded through a research center program jointly spon-
sored by NCCAM and the National Institute on Alcohol Abuse and
Alcoholism (NIAAA), researchers examined the effects of electroa-
cupuncture on alcohol intake by alcohol-preferring rats. After being
trained to drink alcohol voluntarily and then subjected to alcohol de-
privation, the rats received either electroacupuncture or sham elec-
troacupuncture, and their alcohol intake was monitored after the
intervention. Some rats were also pretreated with naltrexone (a drug
579
that blocks the effects of opiates), so researchers could look for evidence
that opiate mechanisms are involved in electroacupunctures effects.
The results showed that electroacupuncture reduced the rats al-
cohol intake. The researchers also found that injecting the rats with
naltrexone blocked the effect of electroacupuncture on alcohol intake
an indication that this effect may be through the brains opiate system.
On the basis of their ndings, the researchers recommend rigorous
clinical trials to study the effects of electroacupuncture in alcohol-
addicted people. They also recommend further investigation of how
electroacupuncture affects the brain.
Reference
Overstreet DH, Cui C-L, Ma Y-Y, et al. Electroacupuncture reduces vol-
untary alcohol intake in alcohol-preferring rats via an opiate-sensitive
mechanism. Neurochemical Research. 2008;33(10):21662170.
Section 86.3
Attention Decit Hyperactivity Disorder

(ADHD) and CAM
&ROMh3T*OHNS7ORT3HOWS.O)MPACTONTHE3YMPTOMSOF!$($vBYTHE
National Center for Complementary and Alternative Medicine (NCCAM,
nccam.nih.gov), part of the National Institutes of Health (NIH), 2008.
According to the National Institute of Mental Health (NIMH)at

NIH, attention decit hyperactivity disorder (ADHD) affects 3 to 5 per-
cent of children in the United States and it is one of the most common
mental disorders that develop in children. NIMH states that children
with ADHD have impaired functioning in multiple settings, including
home, school, and in relationships with peers. Children with chronic
conditions like ADHD are reported to have higher rates of complemen-
tary and alternative medicine use and may turn to dietary and herbal
supplements such as St. Johns wort. However, according to authors of
an NCCAM-funded study, St. Johns wort does not appear to have an
impact on the symptoms of ADHD in children and adolescents.
580
2ESEARCHERSAT"ASTYR5NIVERSITYCONDUCTEDAN WEEKRANDOMIZED
placebo-controlled, double-blind trial of St. Johns wort among a volun-
teer sample of 54 children aged 6 to 17 years with ADHD. Participants
were randomly assigned to receive 300 mg of Hypericum perforatum
(St. Johns wort) standardized to 0.3 percent hypericinan active in-
gredient in St. Johns wortor placebo three times daily for 8 weeks.
The participants were evaluated for changes in inattentiveness and
hyperactivity from baseline at weeks 1, 2, 4, 6, and 8.
7HILE SYMPTOM IMPROVEMENT WAS NOTED IN BOTH THE TREATMENT
and the placebo groups, the data suggest that St. Johns wort had no
additional benet beyond that of placebo for treating symptoms of
ADHD.
This study used a preparation of St. Johns wort with a standard-
ized hypericin content. However the researchers note that studies
involving St. Johns wort also standardized to hyperforinanother
active ingredient in St. Johns wortcould be benecial. Hyperforin
is believed to inhibit reuptake of key brain chemicalsserotonin, dop-
amine, and norepinephrine. The authors note that hyperforin is highly
unstable and can become inactive quickly. The researchers believe that
if a St. Johns wort product with a higher and more stable hyperforin
content became available, it would be worthy of further investigation
in ADHD.
Reference
7EBER76ANDER3TOEP!-C#ARTY2,ETAL(YPERICUMPERFORATUM
3T*OHNS7ORT FOR!TTENTION $ElCIT(YPERACTIVITY$ISORDERIN#HIL-
dren and Adolescents. JAMA. 2008;299(22):26332641.
581
Section 86.4
Anxiety and Self-Hypnosis

&ROMh3ELF (YPNOSIS"ENElCIALFOR7OMEN5NDERGOING"REAST"IOPSYvBY
the National Center for Complementary and Alternative Medicine (NC-
CAM, nccam.nih.gov), part of the National Institutes of Health, December
2006.
An NCCAM-funded trial found that women who used self-hypnosis

during a type of core needle breast biopsy experienced anxiety relief
and reduced pain when compared with standard care.
A large core needle breast biopsy is usually an outpatient procedure
THATLIMITSTHEUSEOFANESTHETIC7OMENHAVINGTHISPROCEDUREOFTEN
experience anxiety because of the possibility of a cancer diagnosis in
addition to the anxiety that patients typically experience during a
medical procedure. In this randomized, controlled trial researchers at
"ETH)SRAEL$EACONESS-EDICAL#ENTERIN"OSTONRECRUITEDWOMEN
who were randomly assigned to receive standard care, structured em-
pathic attention from a research assistant, or guided self-hypnotic
relaxation during the biopsy.
The study found that both self-hypnosis and empathic attention
reduced pain and anxiety during the procedure. Self-hypnosis provided
greater anxiety relief than empathic attention. Neither intervention
increased procedure time or signicantly increased cost. As a result,
the researchers suggest that self-hypnosis appears attractive for out-
patient pain management.
Reference
%LVIRA6,ANG+EVIN3"ERBAUM3ALOMAO&AINTUCHETAL!DJUNCTIVE
self-hypnotic relaxation for outpatient medical procedures: A prospec-
tive randomized trial with women undergoing large core breast biopsy.
Pain, December 2006.
582
Section 86.5
Posttraumatic Stress Disorder and

Acupuncture
From Acupuncture May Help Symptoms of Posttraumatic Stress Disorder,
by the National Center for Complementary and Alternative Medicine (NC-
CAM, nccam.nih.gov), part of the National Institutes of Health, June 2007.
A pilot study shows that acupuncture may help people with posttrau-
matic stress disorder. Posttraumatic stress disorder (PTSD) is an anxiety
disorder that can develop after exposure to a terrifying event or ordeal
in which grave physical harm occurred or was threatened. Traumatic
events that may trigger PTSD include violent personal assaults, natural
or human-caused disasters, accidents, or military combat.
Michael Hollield, MD, and colleagues conducted a clinical trial
examining the effect of acupuncture on the symptoms of PTSD. The
researchers analyzed depression, anxiety, and impairment in 73 people
with a diagnosis of PTSD. The participants were assigned to receive ei-
ther acupuncture or group cognitive-behavioral therapy over 12 weeks,
or were assigned to a wait-list as part of the control group. The people
in the control group were offered treatment or referral for treatment
at the end of their participation.
The researchers found that acupuncture provided treatment effects
similar to group cognitive-behavioral therapy; both interventions were
superior to the control group. Additionally, treatment effects of both
the acupuncture and the group therapy were maintained for 3 months
after the end of treatment.
The limitations of the study are consistent with preliminary re-
search. For example, this study had a small group of participants that
lacked diversity, and the results do not account for outside factors that
may have affected the treatments results.
Reference
-ICHAEL(OLLIlELD.ITYAMO3INCLAIR ,IAN4EDDY$7ARNERAND2ICH-
ard Hammerschlag. Acupuncture for Posttraumatic Stress Disorder: A
583
Randomized Controlled Pilot Trial. The Journal of Nervous and Mental

Disease, June 2007.
584
Chapter 87
Sleep Disorders and CAM
A good nights sleep is more than a luxury. Sleep is as important

to survival as food and water. On too little, we humans dont function
wellfor example, we run a higher risk of accidents, we sometimes
perform poorly at work or school, and our moods can turn sour.
A sleepless night or two isnt a medical emergency. However, if dif-
culties persist, a sleep disorder may be involved. People with sleep
disorders may have difculty falling or staying asleep or waking up
in the morning, fall asleep at inappropriate times, sleep too much, or
show unusual behaviors during sleep. Important new research, includ-
ing studies supported by the National Institutes of Health (NIH), has
linked lack of sleep with obesity, diabetes, and other related conditions.
(NCCAM) is supporting a number of research studies on potential
treatment options for sleep disorders using complementary and alter-
native medicine (CAM).
Sleep disorders are an important public health issue that is receiv-
ing serious attention from NCCAM and several other components of
NIH, said NCCAM Director Stephen E. Straus, MD.
As many as 70 million Americansabout one quarter of the popula-
tionexperience sleep disorders; half of this group have chronic sleep
problems. Conventional therapies are available for most sleep disorders,
but for some people they dont work well, cause unwanted side effects,
or cost too much. As a result, many people turn to CAM therapies.
&ROMh#ANT3LEEP3CIENCE)S3EEKING.EW!NSWERSvBYTHE.ATIONAL)NSTI-
tutes of Health (NIH, www.nih.gov), Summer 2005.
585
According to the 2002 National Health Interview Survey, 2.2 per-

cent of all adults in the survey who used CAM did so for sleep problems.
This represents approximately 1.6 million U.S. adults. CAM therapies
commonly used for sleep problems include dietary supplements (such
as melatonin and valerian); approaches that emphasize the interaction
between the mind and the body (such as meditation); and therapies
THATAREPARTOFNON 7ESTERNTRADITIONALMEDICALSYSTEMSSUCHAS
acupuncture and yoga).
h7HILESOME#!-PRODUCTSUSEDTOTREATSLEEPDISORDERSAREALREADY
available to consumers, in most cases they have not been proven to be
efcacious through rigorous research, explained Nancy J. Pearson,
PhD, NCCAM Program Ofcer and member of the Trans-NIH Sleep
Research Coordinating Committee. There is very little knowledge
about whether CAM therapies for sleep disorders work, and, if so,
how they work. NCCAM is supporting research to help answer these
questions.
Types and Causes of Sleep Disorders

Sleep problems can start with a sudden event. For example, a job
loss can lead to nighttime worries, which in turn can lead to trouble
SLEEPING7HENASLEEPPROBLEMOCCURSWITHOUTANOTHERIDENTIlEDDIS-
ease or condition, it is referred to as a primary sleep disorder. However,
in many cases, sleep disorders are associated with other causes. Some
circumstances and illnesses that can lead to sleep problems are as
follows:
s "ECAUSEOFLIFESTYLESORWORKSCHEDULESSLEEPJUSTISNTAPRIORITY
for some people. Stress from hectic schedules can make it dif-
cult to relax and fall asleep.
s 4HEBODYSINTERNALCLOCKPROGRAMSPEOPLETOFEELSLEEPYDURING
THENIGHTTIMEANDTOBEACTIVEDURINGDAYLIGHTHOURS7HENTHAT
clock goes off-kilter, sleep becomes difcult. For example, travel-
ers who y across multiple time zones quickly get jet lag be-
cause they cannot maintain a regular sleep-wake schedule.
s 0EOPLEWHOWORKATNIGHTANDTRYTOSLEEPDURINGTHEDAYARE
constantly ghting their internal clocks. This puts them at risk
FORDISTURBEDSLEEP7ITHOUTADEQUATERESTTHEYAREMORELIKELY
to make errors or have accidents at work.
s 3LEEPDISORDERSOFTENOCCURINPEOPLEWHOHAVEACHRONICDISEASE
that involves pain or infection, a neurological or psychiatric
586
disorder, or an alcohol or substance abuse disorder. (These are

sometimes called secondary sleep disorders.) For these individu-
als, sleep becomes difcult, potentially worsening the other med-
ical condition, and affecting the persons health and safety, mood
and behavior, and quality of life.
Sleep problems can arise during any period of life:

s )NCHILDRENINADEQUATESLEEPMAYLEADTODAYTIMESLEEPINESS
which can interfere with a childs ability to learn in school and
perform well in other activities. Sleep-deprived children may
also tend to fall or have other accidents that lead to injury. Many
children who are chronically deprived of sleep may not seem
sleepy and may even appear to be overactive. Chronic sleep loss
in these children may be overlooked or mistakenly attributed to
hyperactivity or other behavior disorders.
s 4EENAGERSARENOTORIOUSFORGETTINGTOOLITTLESLEEPASTHEYBURN
the midnight oil to study for exams or socialize late into the
NIGHT"ODYCLOCKSACTUALLYSHIFTDURINGTHESEYEARSSOTEENS
often stay up late and sleep beyond the morning hours. This
tendency, when combined with an increased need for sleep in
adolescence and an early rst bell at most high schools, can put
teenagers at risk for sleep disorders.
s 7OMENGOINGTHROUGHTHEMENOPAUSALTRANSITIONAREMORELIKELY
to experience sleep problems than are other women.
s /LDERADULTSSLEEPISOFTENEASILYDISTURBEDBYNOISEANDOTHER
environmental factors. Older people are also more likely to have
chronic health conditions or pain that make it more difcult for
them to get into the deep, restful stages of sleep.
s #ERTAINMEDICALCONDITIONSSUCHASRHEUMATOIDARTHRITIS0AR-
kinson disease, or chronic pain, may contribute to sleep prob-
lems.
NCCAM Research
NCCAM supports studies on whether certain CAM therapies might
be helpful for sleep disorders. Some examples include the following:
s 5NIVERSITYOF7ASHINGTONRESEARCHERSARETESTINGTHEHERBVALER-
ian in healthy older adults who experience sleep disturbances.
At Emory University, valerian is being studied in people with
587
Parkinson disease, and at the University of Virginia, it is being

studied in people with rheumatoid arthritis.
s 2ESEARCHERSAT"RIGHAMAND7OMENS(OSPITALIN"OSTONARE
studying a program of yoga and relaxation exercises as a treat-
ment for insomnia.
s 5NIVERSITYOF#HICAGORESEARCHERSARESTUDYINGTHEMECHANISM
of action of hops, an herb that has been used both alone and in
combination with valerian for sleep problems.
s !PRELIMINARYSTUDYAT"RIGHAMAND7OMENS(OSPITALWILLDE-
TERMINETHEMECHANISMOFACTIONOFVITAMIN"12 as a treatment
for a form of delayed sleep phase syndrome that affects more
than half of blind individuals and is also common in sighted in-
dividuals. In delayed sleep phase syndrome, a persons internal
body clock is out of sync, causing difculty falling asleep until
very late at night and difcult waking up in the morning.
s 2ESEARCHERSATTHE5NIVERSITYOF0ENNSYLVANIAARECOMPARING
the effects of a low-dose melatonin supplement, a high-dose me-
latonin supplement, and a placebo in elderly people who have
insomnia and a low level of natural melatonin in the body.
s !TTHE5NIVERSITYOF.ORTH#AROLINARESEARCHERSAREINVESTIGATING
whether high-intensity light, installed in common areas in a nurs-
ing home, could lessen the problems of sleep/wake disorders, de-
pressive symptoms, and agitationall frequent, difcult issues for
people with Alzheimer disease. At Harvard University, research-
ers are studying the effects of blue light therapy on sleep cycles.
s !TTHE5NIVERSITYOF!RIZONARESEARCHERSAREEXAMININGTHEIM-
pact of two different homeopathic remedies on sleep patterns in
adults.
Along with supporting studies, NCCAM also participates in other

activities to improve the state of scientic knowledge about treatments
for sleep disorders. First, NCCAM is part of the Trans-NIH Sleep Re-
search Coordinating Committee, which coordinates research efforts
across NIH and issues a report each year. NCCAM is supporting
along with 12 other NIH institutes, centers, and ofcesan initiative
to stimulate research on sleep and sleep disorders.
Second, NCCAM cosponsors conferences and workshops on areas
related to sleep disorders. In 2004, NCCAM cosponsored a conference
on the biology of the brains pineal gland, which produces melatonin.
588
In June 2005, NCCAM was one of several sponsors of the State-of-

the-Science Conference on insomnia at NIH. At that conference, the
invited panel of experts called for further research on commonly used
CAM treatments for insomnia, including supplements like melatonin
and valerian, and mind-body practices such as tai chi and yoga. Acu-
puncture and light therapy were also mentioned as treatments that
call for additional evaluation.
"ECAUSETHEUSEOFMELATONINSUPPLEMENTSBYTHEPUBLICFORSLEEP
problems is widespread, NCCAM requested and funded a report pub-
lished by the Agency for Healthcare Research and Quality that ana-
lyzed the existing scientic evidence on this topic. The authors found
that melatonin appears safe for short-term use, but that it may not be
effective for treating most primary sleep disorders, such as jet lag. It
may offer some benet for delayed sleep phase syndrome. How mela-
tonin works in humans is not well understood, and more research is
needed to answer many questions about this therapy.
Many people struggle with getting enough sleep or the right kind
OFSLEEPvSAID$R0EARSONh"ETTERSLEEPIMPROVESOURQUALITYOFLIFE
NCCAM, on its own and in collaboration with other institutes and cen-
ters at NIH, is committed to supporting research to uncover potential
new options from CAM for those with sleep problems.
Tips for Better Sleep
s &OLLOWAREGULARSLEEPSCHEDULE)TISHELPFULTOGOTOSLEEPAND
wake up at the same times as much as possible, even on week-
ends.
s %XERCISEATAREGULARTIMEEACHDAYATLEASTHOURSBEFOREBED-
time.
s 'ETSOMENATURALOUTDOORLIGHTEACHDAY
s !VOIDCAFFEINELATEINTHEDAY
s $ONTDRINKALCOHOLTOHELPYOUSLEEP
s !VOIDSMOKING
s #REATEASAFEANDCOMFORTABLEPLACETOSLEEPQUIETDARKAND
well ventilated).
s $EVELOPANIGHTTIMEROUTINETHATHELPSYOUSLOWDOWNANDRELAX
s )FYOUREHAVINGTROUBLEFALLINGASLEEPAFTERABOUTMINUTES
get up, do a quiet activity, and return to bed when you are sleepy.
589
s 4RYTHESETIPSANDRECORDYOURSLEEPANDSLEEP RELATEDACTIVITIES
in a sleep diary. If problems continue, discuss the sleep diary
with your doctor.
Source for tips: National Institute on Aging, with credit also to the
National Sleep Foundation.
590
Part Nine
Additional Help and

Information
Chapter 88
Glossary of Terms
Related to Alternative and
Complementary Medicine
acupuncture: A family of procedures that originated in traditional

Chinese medicine. Acupuncture is the stimulation of specic points
on the body by a variety of techniques, including the insertion of thin
metal needles through the skin. It is intended to remove blockages in
the ow of qi and restore and maintain health.1
aromatherapy: Aromatherapy is the use of essential oils from plants
to support and balance the mind, body, and spirit. Aromatherapy may
be combined with other complementary treatments like massage ther-
apy and acupuncture, as well as with standard treatments.2
Ayurvedic medicine: Ayurvedic medicine (also called Ayurveda) is
one of the worlds oldest medical systems. It originated in India and has
evolved there over thousands of years. In the United States, Ayurvedic
medicine is considered complementary and alternative medicine. The aim
of Ayurvedic medicine is to integrate and balance the body, mind, and
spirit. This is believed to help prevent illness and promote wellness.1
biofeedback: A method of learning to voluntarily control certain body
functions such as heartbeat, blood pressure, and muscle tension with
the help of a special machine. This method can help control pain.2
Denitions in this chapter were compiled from documents published by several
public domain sources. Terms marked 1 are from publications by the National Cen-
ter for Complementary and Alternative Medicine (nccam.nih.gov); terms marked
2 are from the National Cancer Institute (cancer.gov); terms marked 3 are from
the Ofce of Dietary Supplements (ods.od.nih.gov); and terms marked 4 are from
the Ofce on Womens Health (womenshealth.gov).
593
biologically based therapy: This area of CAM includes, but is not

limited to, botanicals, animal-derived extracts, vitamins, minerals,
fatty acids, amino acids, proteins, prebiotics and probiotics, whole diets,
and functional foods.1
botanical: A plant or plant part valued for its medicinal or therapeu-
tic properties, avor, and/or scent. Herbs are a subset of botanicals.
Products made from botanicals that are used to maintain or improve
health may be called herbal products, botanical products, or phyto-
medicines.3
chelation therapy: Chelation therapy is an investigational therapy
using a man-made amino acid, called EDTA (ethylene-diamine-tetra-
acetic acid). It is added to the blood through a vein. Disodium EDTA
has been in widespread use since the 1970s for disease of the heart
and arteries.1
chiropractic: A whole medical system that focuses on the relation-
ship between the bodys structuremainly the spineand function.
Practitioners perform adjustments (also called manipulation) with the
goal of correcting structural alignment problems to assist the body in
healing.1
clinical trial: A type of research study that uses volunteers to test
the safety and efcacy (the ability to produce a benecial effect) of new
methods of screening (checking for disease when there are no symp-
toms), prevention, diagnosis, or treatment of a disease. Also called a
clinical study.3
complementary and alternative medicine: A group of diverse
medical and health care systems, practices, and products that are not
presently considered to be part of conventional medicine. Comple-
mentary medicine is used together with conventional medicine, and
alternative medicine is used in place of conventional medicine.1
conventional medicine: Medicine as practiced by holders of MD
(medical doctor) or DO (doctor of osteopathy) degrees and by their
allied health professionals such as physical therapists, psychologists,
and registered nurses.1
Daily Value (DV): A term used on a food or dietary supplement prod-
uct label to describe the recommended levels of intake of a nutrient.
The percent Daily Value (% DV) represents how much of a nutrient
is provided in one serving of the food or dietary supplement. For ex-
ample, the DV for calcium is 1,000 mg (milligrams); a food that has
594
Glossary of Terms
200 mg of calcium per serving would state on the label that the % DV
for calcium is 20%.3
dietary supplement: A product that is intended to supplement the
diet; contains one or more dietary ingredients (including vitamins,
minerals, herbs or other botanicals, amino acids, and certain other
substances) or their constituents; and is intended to be taken by mouth,
in forms such as tablet, capsule, powder, softgel, gelcap, or liquid.1
energy medicine: Energy medicine is a domain in CAM that deals
with energy elds of two types: veritable, which can be measured,
and putative, which have yet to be measured. Practitioners of energy
medicine believe that illness results from disturbances of these subtle
energies (the bioeld).1
guided imagery: A type of CAM that encourages imagining a pleas-
ant scene to take your mind off your pain or anxiety.4
herbal supplements: One type of dietary supplement. An herb is a
plant or plant part (such as leaves, owers, or seeds) that is used for
its avor, scent, and/or therapeutic properties. Botanical is often used
as a synonym for herb. An herbal supplement may contain a single
herb or mixtures of herbs.1
homeopathy: A whole medical system that originated in Europe.
Homeopathy seeks to stimulate the bodys ability to heal itself by giv-
ing very small doses of highly diluted substances that in larger doses
would produce illness or symptoms (an approach called like cures
like).1
hypnosis: A trance-like state in which a person becomes more aware
and focused and is more open to suggestion.2
magnet therapy: A magnet produces a measurable force called a
magnetic eld. Magnets are used for many different types of pain,
including foot pain and back pain from conditions such as arthritis
and bromyalgia. Magnets in products such as magnetic patches and
disks, shoe insoles, bracelets, and mattress pads are used for pain in
the foot, wrist, back, and other parts of the body.1
manipulation: The application of controlled force to a joint, moving
it beyond the normal range of motion in an effort to aid in restoring
health. Manipulation may be performed as a part of other therapies
or whole medical systems, including chiropractic medicine, massage,
and naturopathy.1
595
manipulative and body-based practices: A group of CAM interven-

tions and therapies that include chiropractic and osteopathic manipu-
lation, massage therapy, Tui Na, reexology, Rolng, Bowen technique,
Trager bodywork, Alexander technique, Feldenkrais method, and a
host of others.1
massage: Pressing, rubbing, and moving muscles and other soft tis-
sues of the body, primarily by using the hands and ngers. The aim is
to increase the ow of blood and oxygen to the massaged area.1
meditation: Refers to a variety of techniques or practices intended to

focus or control attention. Most of them are rooted in Eastern religious
or spiritual traditions. These techniques have been used by many dif-
ferent cultures throughout the world for thousands of years.1
mind-body medicine: Medicine that focuses on the interactions

among the brain, mind, body, and behavior, and the powerful ways in
which emotional, mental, social, spiritual, and behavioral factors can
directly affect health. It regards as fundamental an approach that
respects and enhances each persons capacity for self-knowledge and
self-care, and it emphasizes techniques that are grounded in this ap-
proach.1
mineral: In nutrition, an inorganic substance found in the earth that

is required to maintain health.3
naturopathy: A whole medical system that originated in Europe.

Naturopathy aims to support the bodys ability to heal itself through
the use of dietary and lifestyle changes together with CAM therapies
such as herbs, massage, and joint manipulation.1
omega-3 fatty acids: Polyunsaturated fatty acids that come from

foods such as sh, sh oil, vegetable oil (primarily canola and soybean),
walnuts, and wheat germ. Omega-3s are important in a number of
bodily functions, including the movement of calcium and other sub-
stances in and out of cells, the relaxation and contraction of muscles,
blood clotting, digestion, fertility, cell division, and growth. In addition,
omega-3s are thought to protect against heart disease, reduce inam-
mation, and lower triglyceride levels.1
probiotics: Live microorganisms (in most cases, bacteria) that are

similar to benecial microorganisms found in the human gut. They are
also called friendly bacteria or good bacteria. Probiotics are available
to consumers mainly in the form of dietary supplements and foods.1
596
Glossary of Terms
qi: In traditional Chinese medicine, the vital energy or life force pro-
posed to regulate a persons spiritual, emotional, mental, and physical
health and to be inuenced by the opposing forces of yin and yang.1
reexology: A type of massage, which applies pressure to the feet
(or sometimes the hands or ears), to promote relaxation or healing in
other parts of the body.1
Reiki: A healing practice that originated in Japan. Reiki practitioners
place their hands lightly on or just above the person receiving treatment,
with the goal of facilitating the persons own healing response.1
spirituality: Spirituality may be dened as an individuals sense of
peace, purpose, and connection to others, and beliefs about the meaning
of life. Spirituality may be found and expressed through an organized
religion or in other ways.2
tai chi: Tai chi, which originated in China as a martial art, is a mind-
body practice in complementary and alternative medicine. Tai chi is
sometimes referred to as moving meditationpractitioners move their
bodies slowly, gently, and with awareness, while breathing deeply.1
traditional Chinese medicine: A whole medical system that origi-
nated in China. It is based on the concept that disease results from
disruption in the ow of qi and imbalance in the forces of yin and yang.
Practices such as herbs, meditation, massage, and acupuncture seek to
aid healing by restoring the yin-yang balance and the ow of qi.1
vegan: A person who does not eat any foods that come from animals,
including meat, eggs, and dairy products.2
vegetarian: A person who eats a diet free of meat. Lacto-vegetarians
consume milk and milk products along with plant-based foods. They
do not eat eggs. Lacto-ovo vegetarians eat eggs and milk and milk
products, in addition to plant-based foods.4
vitamin: A nutrient that the body needs in small amounts to function
and maintain health. Examples are vitamins A, C, and E.3
whole medical system: A complete system of theory and practice that
has evolved over time in different cultures and apart from conventional
medicine. Examples of whole medical systems include traditional Chi-
nese medicine, Ayurvedic medicine, homeopathy, and naturopathy.1
yin and yang: The concept of two opposing yet complementary forces
described in traditional Chinese medicine. Yin represents cold, slow,
597
or passive aspects of the person, while yang represents hot, excited,

or active aspects. A major theory is that health is achieved through
balancing yin and yang and disease is caused by an imbalance leading
to a blockage in the ow of qi.1
yoga: A mind-body practice in complementary and alternative medi-
cine with origins in ancient Indian philosophy. The various styles of
yoga that people use for health purposes typically combine physical
postures, breathing techniques, and meditation or relaxation.1
598
Chapter 89
Directory of Organizations
That Provide Information
about Alternative and
Government Agencies That Provide Information about
Alternative and Complementary Medicine
Agency for Healthcare Healthnder
Research and Quality National Health Information
Ofce of Communications and Center
Knowledge Transfer P.O. Box 1133
540 Gaither Road, Second Floor Washington, DC 20013-1133
Rockville, MD 20850 Toll-Free: 800-336-4797
Phone: 301-427-1364 Phone: 301-565-4167
Fax: 301-427-1873 Fax: 301-984-4256
Website: www.ahrq.gov Website: www.healthnder.gov
Centers for Disease Control
and Prevention National Cancer Institute
1600 Clifton Road 6116 Executive Blvd. Rm 3036A
Atlanta, GA 30333 Bethesda, MD 20892-8322
Toll-Free: 800-CDC-INFO Toll-Free: 800-4-CANCER
(232-4636) (422-6237)
Phone: 404-639-3311 TTY Toll-Free: 800-332-8615
Website: www.cdc.gov Website: www.cancer.gov
E-mail: [email protected] E-mail: [email protected]
.gov
Resources in this chapter were compiled from several sources deemed reli-
able; all contact information was veried and updated in January 2010.
599
National Center for National Institute of

Complementary and Neurological Disorders and
Alternative Medicine Stroke
National Institutes of Health NIH Neurological Institute
NCCAM Clearinghouse P.O. Box 5801
P.O. 7923 Bethesda, MD 20824
Gaithersburg, MD 20898-7923 Toll-Free: 800-352-9424
Toll-Free: 888-644-6226 Phone: 301-496-5751
TTY: 866-464-3615 TTY: 301-468-5981
Fax: 866-464-3616 Website: www.ninds.nih.gov
Website: nccam.nih.gov E-mail: [email protected]
National Institutes of
National Institute Health
of Arthritis and 9000 Rockville Pike
Musculoskeletal and Skin Bethesda, MD 20892
Diseases Phone: 301-496-4000
National Institutes of Health TTY: 301-402-9612
1 AMS Circle Website: www.nih.gov
Bethesda, MD 20892-3675 E-mail: [email protected]
Toll Free: 877-22-NIAMS
(226-4267) National Institute on Aging
TTY: 301-5652966 Building 31, Room 5C27
Phone: 301-495-4484 31 Center Drive, MSC 2292
Fax: 301-718-6366 Bethesda, MD 20892
Website: www.niams.nih.gov Phone: 301-496-1752
E-mail: [email protected] Fax: 301-496-1072
Website: www.nia.nih.gov
National Institute of
Diabetes, Digestive and Ofce of Dietary
Kidney Diseases Supplements
Building 31, Rm. 9A06 Suite 3B01
31 Center Drive, MSC 2560 6100 Executive Boulevard
Bethesda, MD 20892-2560 Bethesda, MD 20892-7517
Phone: 301-496-3583 Phone: 301-435-2920
Website: www.niddk.nih.gov Fax: 301-480-1845
Website: dietary-supplements
.info.nih.gov
600
Substance Abuse and Private Agencies That

Mental Health Services Provide Information
Administration about Alternative and
SAMHSAs Health Information
Network
P.O. Box 2345 Academy for Guided Imagery
Rockville, MD 20847-2345 10780 Santa Monica Boulevard,
Phone: 877-SAMHSA-7 Suite 290
(726-4727) Los Angeles, CA 90025
TTY: 800-487-4889 Toll-Free: 800-726-2070
Fax: 240-221-4292 Fax: 800-727-2070
Website: www.samhsa.gov Website: www.
E-mail: [email protected] academyforguidedimagery.com
U.S. Department of Health Acupressure Institute

and Human Services Website: www.acupressure.com
200 Independent Avenue, SW E-mail: [email protected]
Washington, DC 20201
Toll-Free: 877-696-6775 Alexander Technique
Website: www.hhs.gov International
1692 Massachusetts Ave., 3rd Fl.
U.S. Food and Drug Cambridge, MA 02138
Administration Toll-Free: 888-668-8996
10903 New Hampshire Avenue Phone: 617-497-5151
Silver Spring, MD 20903 Fax: 617-497-2615
Toll-Free: 888-463-6332 Website: www.ati-net.com
Website: www.fda.gov
Alternative Medicine
U.S. National Library of Foundation, Inc.
Medicine P.O. Box 60016
8600 Rockville Pike Potomac, MD 20859
Bethesda, MD 20894 Website: www.amfoundation.org
Toll-Free: 888-FIND-NLM
(346-3656) American Academy of Anti-
Phone: 301-594-5983 Aging Medicine
TDD: 800-735-2258 301 Yamato Road, Suite 2199
Fax: 301-402-1384 Boca Raton, FL 33431
Website: www.nlm.nih.gov Toll-Free: 888-997-0112
Website: www.worldhealth.net
601
American Academy of American Association of

Family Physicians Acupuncture and Oriental
11400 Tomahawk Creek Medicine
Parkway P.O. Box 162340
Leawood, KS 66211-2680 Sacramento, CA 95816
Toll-Free: 800-274-2237 Toll-Free: 866-455-7999
Fax: 913-906-6075 Phone: 916-443-4770
Website: www.aafp.org Fax: 916-443-4766
Website: www.aaaomonline.org
American Academy of
Medical Acupuncture American Association of
1970 E. Grand Ave, Suite 330 Colleges of Osteopathic
El Segundo, CA 90245 Medicine
Phone: 310-364-0193 5550 Friendship Boulevard
Website: Suite 310
www.medicalacupuncture.org Chevy Chase, MD 20815-7231
E-mail: administrator@ Phone: 301-968-4100
medicalacupuncture.org Fax: 301-968-4101
Website: www.aacom.org
American Apitherapy
Society American Association of
500 Arthur Street Integrative Medicine
Centerport, NY 11721 2750 East Sunshine
Phone: 631-470-9446 Springeld, MO 65804
Website: www.apitherapy.org Toll-Free: 877-718-3053
Phone: 417-881-9995
American Art Therapy Fax: 417-823-9959
Association Website: www.aaimedicine.com
225 North Fairfax Street
Alexandria, VA 22314 American Association of
Toll-Free: 888-290-0878 Naturopathic Physicians
Phone: 703-548-5860 4435 Wisconsin Avenue NW
Fax: 703-783-8468 Suite 403
Website: www.arttherapy.org Washington, DC 20016
E-mail: [email protected] Toll-Free: 866-538-2267
Phone: 202-237-8150
Fax: 202-237-8152
Website: www.naturopathic.org
E-mail: member.services@
naturopathic.org
602
American Botanical Council American Herbalists Guild

6200 Manor Road 141 Nob Hill Road
Austin, TX 78723 Cheshire, CT 06410
Phone: 512-926-4900 Phone: 203-272-6731
Fax: 512-926-2345 Fax: 203-272-8550
Website: abc.herbalgram.org Website:
E-mail: [email protected] www.americanherbalistsguild.com
American Chiropractic
Association American Holistic Health
1701 Clarendon Boulevard Association
Arlington, VA 22209 P.O. Box 17400
Phone: 703-276-8800 Anaheim, CA 92817-7400
Fax: 703-243-2593 Phone: 714-779-6152
Website: www.acatoday.org Website: www.ahha.org
American Dance Therapy
Association American Holistic Medical
10632 Little Patuxent Parkway Association
Suite 108 23366 Commerce Park
Columbia, MD 21044-3263 Suite 101B
Phone: 410-997-4040 Beachwood, OH 44122
Fax: 410-997-4048 Phone: 216-292-6644
Website: www.adta.org Fax: 216-292-6688
E-mail: [email protected] Website:
www.holisticmedicine.org
American Feng Shui E-mail:
Institute [email protected]
111 N. Atlantic Boulevard
Suite 352 American Massage Therapy
Monterey Park, CA 91754 Association
Website: www.amfengshui.com 500 Davis Street, Suite 900
E-mail: [email protected] Evanston, IL 60201
Toll-Free: 877-905-2700
American Heart Association Phone: 847-864-0123
National Center Fax: 847-864-5196
7272 Greenville Avenue Website: www.amtamassage.org
Dallas, TX 75231 E-mail: [email protected]
Toll-Free: 800-AHA-USA-1
(242-8721)
Website: www.americanheart.org
603
American Music Therapy American Polarity Therapy

Association Association
8455 Colesville Road 122 N. Elm Street
Suite 1000 Suite 512
Silver Spring, MD 20910 Greensboro, NC 27401
Phone: 301-589-3300 Phone: 336-574-1121
Fax: 301-589-5175 Fax: 336-574-1151
Website: www.musictherapy.org Website:
E-mail: [email protected] www.polaritytherapy.org
E-mail: APTAofces@
American Naturopathic polaritytherapy.org
Medical Association
P.O. Box 96273 American Psychological
Las Vegas, NV 89193 Association
Phone: 702-897-7053 750 First Street NE
Fax: 702-897-7140 Washington, DC 20002-4242
Website: www.anma.org Toll-Free: 800-374-2721
Phone: 202-336-5500
American Oriental Website: www.apa.org
Bodywork Therapy
Association American Reexology
1010 Haddoneld-Berlin Road Certication Board
Suite 408 P.O. Box 5147
Voorhees, NJ 08043-3514 Gulfport, FL 33737
Phone: 856-782-1616 Phone: 303-933-6921
Fax: 856-782-1653 Fax: 303-904-0460
Website: www.aobta.org Website: www.arcb.net
E-mail: [email protected] E-mail: [email protected]
American Osteopathic American Society for the

Association Alexander Technique
1090 Vermont Avenue NW P.O. Box 2307
Suite 510 Dayton, OH 45401
Washington, DC 20005 Toll-Free: 800-473-0620
Toll-Free: 800-962-9008 Phone: 937-586-3732
Phone: 202-414-0140 Fax: 937-586-3699
Fax: 202-544-3525 Website: www.alexandertech.org
Website: www.osteopathic.org
604
American Society of Association for Applied

Clinical Hypnosis Psychophysiology and
140 N. Bloomingdale Road Biofeedback
Bloomingdale, IL 60108 10200 West 44th Avenue
Phone: 630-980-4740 Suite 304
Fax: 630-351-8490 Wheat Ridge, CO 80033
Website: www.asch.net Toll-Free: 800-477-8892
E-mail: [email protected] Website: www.aapb.org
American Tai Chi and
Qigong Association Association of Reexologists
2465 J-17 Centreville Road, #150 5 Fore Street
Herndon, VA 20171 Taunton, Somerset TA1 1HX
Website: United Kingdom
www.americantaichi.org Phone: 011-44-1823-351010
Website: www.aor.org.uk
American Yoga Association E-mail: [email protected]
P.O. Box 19986
Sarasota, FL 34276 Atlantic Institute of
Website: Aromatherapy
www.americanyogaassociation.org 16018 Saddlestring Drive
E-mail: info@ Tampa, FL 33612
americanyogaassociation.org Phone: 813-265-2222
Website:
Arizona Center for www.atlanticinstitute.com
Integrative Medicine
P.O. Box 245153 Ayurvedic Institute
Tucson, AZ 85724-5153 P.O. Box 23445
Phone: 520-626-6417 Albuquerque, NM 87192-1445
Fax: 520-626-3518 Phone: 505-291-9698
Website: integrativemedicine Fax: 505-294-7572
.arizona.edu Website: www.ayurveda.com
Associated Bodywork and The Bach Centre

Massage Professionals Mount Vernon, Bakers Lane
25188 Genesee Trail Road Brightwell-cum-Sotwell, Oxon
Golden, CO 80401 OX10 0PZ
Toll-Free: 800-458-2267 United Kingdom
Fax: 800-667-8260 Phone: 011-44-1491-834678
Website: www.abmp.com Website: www.bachcentre.com
605
Bastyr Center for Natural Buteyko Breathing

Health Association
3670 Stone Way North 15 Stanley Place
Seattle, WA 98103 Chipping Ongar, Essex CM5
Phone: 206-834-4100 9SU
Website: www.bastyrcenter.org United Kingdom
Phone: 011-44-1277-366906
Benson-Henry Institute for Website:
Mind Body Medicine www.buteykobreathing.org
151 Merrimac Street E-mail:
Fourth Floor [email protected]
Boston, MA 02114
Phone: 617-643-6090 Center for Integrative
Fax: 617-643-6077 Health and Healing
Website: www.massgeneral.org/ 388 Kenwood Avenue
bhi Delmar, NY 12054
E-mail: [email protected] Phone: 518-689-2244
Fax: 518-689-2081
Biodynamic Craniosacral Website: www.cihh.net
Therapy Association of
North America Center for Integrative
150 Cross Creek Court Medicine
Chapel Hill, NC 27517 University of Maryland School
Phone: 734-904-0546 of Medicine
Website: Kernan Hospital Mansion
www.craniosacraltherapy.org 2200 Kernan Drive
E-mail: Baltimore, MD 21207-6697
[email protected] Phone: 410-448-6871
Fax: 410-448-6875
Biofeedback Certication Website:
Institute of America www.compmed.umm.edu
10200 W. 44th Avenue E-mail: [email protected]
Suite 310
Wheat Ridge, CO 80033-2840
Toll-Free: 866-908-8713
Phone: 303-420-2902
Fax: 303-422-8894
Website: www.bcia.org
606
Center for Mindfulness in Feldenkrais Resources

Medicine, Health Care, and 3680 6th Avenue
Society San Diego, CA 92103
University of Massachusetts Toll-Free: 800-765-1907
Medical School Phone: 619-220-8776
55 Lake Avenue North Fax: 619-330-4993
Worcester, MA 01655 Website: www.
Phone: 508-856-2656 feldenkraisresources.com
Fax: 508-856-1977 E-mail: ofce@
Website: www.umassmed.edu/ feldenkraisresources.com
Content.aspx?id=41252
E-mail: Flower Essence Society
[email protected] P.O. Box 459
Nevada City, CA 95959
Chi Energy Toll-Free: 800-736-9222
Website: chienergy.co.uk Phone: 530-265-9163
Fax: 530-265-0584
Complementary Healthcare Website: www.owersociety.org
Information Service E-mail: [email protected]
Website: www.chisuk.org.uk
E-mail: [email protected] Hellerwork International
P.O. Box 17373
DrWeil.com Anaheim, CA 92817
Website: www.drweil.com Phone: 714-873-6131
Website: www.hellerwork.com
Feldenkrais Educational E-mail: [email protected]
Foundation of North
America Holistic Network
5436 N. Albina Avenue Website:
Portland, OR 97217 www.holisticnetwork.org
Toll-Free: 800-775-2118
Phone: 503-221-6612 Homeopathic Educational
Fax: 503-221-6616 Services
Website: www.feldenkrais.com 2124B Kittredge Street
Berkeley, CA 94704
Phone: 510-649-0294
Fax: 510-649-1955
Website: www.homeopathic.com
607
Institute of Traditional International Feng Shui

Medicine Guild
2017 SE Hawthorne Boulevard 705 B SE Melody Lane
Portland, OR 97214 Suite 166
Phone: 503-233-4907 Lees Summit, MO 64063
Website: www.itmonline.org Toll-Free: 888-881-IFSG
(881-4374)
International Association Website: www.ifsguild.org
of Reiki Professionals E-mail: [email protected]
Website: www.iarpreiki.org
E-mail: [email protected] International Institute of
Reexology
International Association 5650 First Avenue North
of Yoga Therapists St. Petersburg, FL 33733-2642
P.O. Box 12890 Phone: 727-343-4811
Prescott, AZ 86304 Fax: 727-381-2807
Phone: 928-541-0004 Website:
Website: www.iayt.org www.reexology-usa.net
International Center for
Reiki Training International Medical
21421 Hilltop Street, Unit #28 and Dental Hypnotherapy
Southeld, MI 48033 Association
Toll-Free: 800-332-8112 P.O. Box 2468
Phone: 248-948-8112 Laceyville, PA 18623
Fax: 248-948-9534 Toll-Free: 800-553-6886
Website: www.reiki.org Phone: 570-869-1021
Website: www.imdha.com
International Chiropractors E-mail: [email protected]
Association
1110 N. Glebe Road, Suite 650 International Thai
Arlington, VA 22201 Therapists Association
Toll-Free: 800-423-4690 4715 Bruton Road
Phone: 703-528-5000 Plant City, FL 33565
Fax: 703-528-5023 Phone: 706-358-8646
Website: www.chiropractic.org Website: www.thaimassage.com
International College of
Applied Kinesiology Mayo Clinic
Website: www.icak.com Website: www.mayoclinic.org
608
Moores Cancer Center National Center for

University of CaliforniaSan Homeopathy
Diego Medical Center 101 S Whiting Street
3855 Health Sciences Drive Suite 16
La Jolla, CA 92093 Alexandria, VA 22304
Phone: 858-822-6146 Phone: 703-548-7790
Website: cancer.ucsd.edu Fax: 703-548-7792
Website:
National Association for www.homeopathic.org
Drama Therapy
44365 Premier Plaza, Suite 220 National Center on
Ashburn, VA 20147 Physical Activity and
Phone: 571-333-2991 Disability
Fax: 571-223-6440 1640 W. Roosevelt Road
Website: www.nadt.org Chicago, IL 60608-6904
E-mail: [email protected] Toll-Free: 800-900-8086
Website: www.ncpad.org
National Association for
Holistic Aromatherapy
P.O. Box 1868
National Certication
Banner Elk, NC 28604
Commission for
Phone: 828-898-6161
Acupuncture and
Fax: 828-898-1965
Website: www.naha.org Oriental Medicine
E-mail: [email protected] 76 South Laura Street
Suite 1290
National Association of Jacksonville, FL 32202
Cognitive-Behavioral Phone: 904-598-1005
Therapists Fax: 904-598-5001
P.O. Box 2195 Website: www.nccaom.org
Weirton, WV 26062
Toll-Free: 800-853-1135 National College of
Website: www.nacbt.org Naturopathic Medicine
E-mail: [email protected] 049 SW Porter Street
Portland, OR 97201
National Association of Phone: 503-552-1555
Nutrition Professionals Website: www.ncnm.edu
P.O. 2752 E-mail: [email protected]
Berkeley, CA 94702
Toll-Free: 800-342-8037
Fax: 510-580-9429
Website: www.nanp.org
609
National Headache Physicians Association of

Foundation Anthroposophic Medicine
820 N. Orleans, Suite 217 1923 Geddes Avenue
Chicago, IL 60610 Ann Arbor, MI 48104
Toll-Free: 888-NHF-5552 Website: www.paam.net
(643-5552) E-mail:
Phone: 312-274-2650 [email protected]
Website: www.headaches.org
E-mail: [email protected] Reexology Association
of America
National Institute of 375 North Stephanie Street
Ayurvedic Medicine Suite 1411
584 Milltown Road Henderson, NV 89014
Brewster, NY 10509 Phone: 980-234-0159
Phone: 845-278-8700 Fax: 401-568-6449
Fax: 845-278-8215 Website:
Website: www.niam.com www.reexology-usa.org
E-mail: [email protected] E-mail:
[email protected]
National Qigong
Association Rolf Institute of Structural
P.O. Box 270065 Integration
St. Paul, MN 55127 5055 Chaparral Court, Suite 103
Toll-Free: 888-815-1893 Boulder, CO 80301
Fax: 888-359-9526 Toll-Free: 800-530-8875
Website: www.nqa.org Phone: 303-449-5903
Fax: 303-449-5978
Natural Medicines Website: www.rolf.org
Comprehensive Database
Website: Scripps Center for
www.naturaldatabase.com Integrative Medicine
10820 North Torrey Pines Road
Nemours Foundation La Jolla, CA 92037
Center for Childrens Phone: 858-554-3300
Health Media Fax: 858-554-2965
1600 Rockland Road Website: www.scripps.org/
Wilmington, DE 19803 services/integrative-medicine
Phone: 302-651-4000
Website: www.kidshealth.org Society for Light Treatment
E-mail: [email protected] and Biological Rhythms
Website: www.sltbr.org
610
Society of Auricular University of Texas M.D.

Acupuncturists Anderson Cancer Center
29 Liverpool Lawn 1515 Holcombe Boulevard
Ramsgate, Kent CT11 9HJ Houston, TX 77030
United Kingdom Phone: 877-MDA-6789
Phone: 011-44-845-0949186 (632-6789)
Website: www. Website:
auricularacupuncturecollege.com www.mdanderson.org
Thai Yoga Center/SomaVeda Vegetarian Resource

Institute Group
4715 Bruton Road P.O. Box 1463
Plant City, FL 33565 Baltimore, MD 21203
Phone: 706-358-8646 Phone: 410-366-8343
Website: Website: www.vrg.org
www.thaiyogacenter.com E-mail: [email protected]
Therapeutic Touch WholeHealthMD
International 46040 Center Oak Plaza
Association, Inc. Suite 130
P.O. Box 419 Sterling, VA 20166
Craryville, NY 12521 Website:
Phone: 518-325-1185 www.wholehealthmd.com
Fax: 509-693-3537
Website: Zero Balancing Health
www.therapeutic-touch.org Association
Kings Contrivance Village
Trager International
Center
Website: www.trager.com
8640 Guilford Road
Suite 240
University of Minnesota Columbia, MD 21046
Center for Spirituality Phone: 410-381-8956
and Healing Fax: 410-381-9634
420 Delaware St. SE Website:
Mayo Memorial Building www.zerobalancing.com
5th oor, MMC #505, C592 E-mail:
Minneapolis, MN 55455 [email protected]
Phone: 612-624-9459
Fax: 612-626-5280
Website: www.csh.umn.edu
611
Index
Index
Page numbers followed by n indicate Acupuncture (National

a footnote. Page numbers in italics Headache Foundation) 533n
indicate a table or illustration. Acupuncture: An Introduction
(NCCAM) 81n
Acupuncture May Help
A
Symptoms of Posttraumatic
AAFA see Asthma and Allergy Stress Disorder (NCCAM) 583n
Foundation of America Acupuncture Relieves Pain and
AAFP see American Academy Improves Function in Knee
of Family Physicians Osteoarthritis (NCCAM) 491n
About Art Therapy (American Acupuncture Shows Promise in
Art Therapy Association) 299n Improving Rates of Pregnancy
About Zero Balancing (Zero Following IVF (NCCAM) 561n
Balancing Association) 487n A.D.A.M., Inc., touch therapy
Academy for Guided Imagery, publication 479n
contact information 601 Adequate Intakes (AI),
Accutane (isotretinoin), acne 134 vitamin A 130
Acupressure Institute, contact adjustments, described 23
information 601 adolescents
acupuncture detoxication diets 265
allergies 506 supplements 11719
arthritis 498, 500502 vegetarians 282
dened 593 adverse events, hyperbaric
described 25, 60, 75, 458 oxygen therapy 289
headache 53334 African Americans,
mental health care 576 osteoporosis 14950
overview 8184 Agency for Healthcare
posttraumatic stress Research and Quality (AHRQ)
disorder 58384 contact information 599
615
Agency for Healthcare Research Alzheimers Disease Cooperative
and Quality (AHRQ), continued Study 146
hyperbaric oxygen therapy American Academy of Anti-Aging
publication 285n Medicine, contact information 601
Age-Related Eye Disease American Academy of Family
Study 15758, 21011 Physicians (AAFP), contact
age-related macular information 602
degeneration (AMD) American Academy of Medical
vitamin E 15758 Acupuncture, contact information
zinc 21011 602
AHRQ see Agency for Healthcare American Apitherapy Association,
Research and Quality apitherapy publication 253n
AI see Adequate Intakes American Apitherapy Society,
ai chi, described 384, 39295 contact information 602
ai chi ne, described 385 American Art Therapy Association
alcohol addiction, art therapy publication 299n
electroacupuncture 57980 contact information 602
alcohol use American Association of Acupuncture
beta-carotene 134 and Oriental Medicine, contact
energy drinks 232 information 602
vitamin B6 139 American Association of Colleges
Alexander, F.M. 379, 38182 of Osteopathic Medicine, contact
Alexander Technique, overview information 602
37182 American Association of Integrative
Alexander Technique International, Medicine, contact information 602
contact information 601 American Association of Naturopathic
allergies Physicians, contact information 268,
bee sting 255 602
bee stings 255 American Board of Psychological
bioresonance therapy 48485 Hypnosis, contact information 326
CAM therapies 5036 American Botanical Council,
echinacea 207 contact information 603
sh oils 185 American Chiropractic Association,
alpha-carotene, vitamin A 130 contact information 603
alpha-linolenic acid 176 American Dance Therapy Association
alpha-lipoic acid, diabetes mellitus contact information 603
52425 dance therapy publication 359n
alpha-tocopherol, vitamin E 15354 American Feng Shui Institute,
Alpha-Tocopherol Beta-Carotene contact information 603
Cancer Prevention Study 131 American Heart Association,
Alternative Approaches to Mental contact information 603
Health Care (SAMHSA) 574n American Herbalists Guild,
alternative medicine, described 4, 21 contact information 603
Alternative Medicine Foundation, American Holistic Health Association,
contact information 601 contact information 603
Alternative Therapies (AAFA) 503n American Holistic Medical Association,
Alzheimer disease contact information 603
grape seed extract 51718 American Massage Therapy
research 2728 Association, contact information 603
616
Index
American Music Therapy Association antioxidants
contact information 604 age-related macular
music therapy publication 335n degeneration 21011
American Naturopathic Medical research 250
Association, contact information vitamin A 130
604 vitamin E 15354, 158
American Oriental Bodywork anxiety, self-hypnosis 582
Therapy Association, contact apitherapy, overview 25355
information 604 Applied Kinesiology (Natural
American Osteopathic Association, Medicines Comprehensive
contact information 604 Database) 448n
American Polarity Therapy applied kinesiology, overview 44849
Association apricot pits 54
contact information 604 Aquatic Therapy (NCPAD) 383n
polarity therapy publication 467n aquatic therapy, overview 38398
American Pregnancy Association, Are Detox Diets Safe? (Nemours
infertility treatment publication Foundation) 264n
560n Are You Considering CAM?
American Psychological Association (NCCAM) 7n
contact information 604 ARIC study see Atherosclerosis Risk
publications in Communities study
hypnosis 324n Arizona Center for Integrative
relaxation training 345n Medicine, contact information 605
American Reexology Certication Arnold, Joan 371n
Board aromatherapy
contact information 604 dened 593
reexology publication 431n overview 25761
American Society for the Alexander Aromatherapy and Essential
Technique, contact information 604 Oils (NCI) 257n
American Society of Clinical Hypnosis, Artemisia annua 61
contact information 326, 605 artemisinin 61
American Tai Chi and Qigong arthritis
Association, contact information 605 Alexander technique 374
American Yoga Association, contact apitherapy 25354
information 605 CAM therapies 491502
anaphylaxis, bee stings 255 health fraud 46
M.D. Anderson Cancer Center, selenium 195
contact information 611 art therapy
androstenedione, described 227 mental health care 575
anemia overview 299302
folic acid 161 Associated Bodywork and
vitamin B12 144 Massage Professionals,
angina pectoris, sh oils 178 contact information 605
angioplasty, sh oils 181 Association for Applied
animal-assisted therapies, Psychophysiology and Biofeedback
mental health care 575 biofeedback publication 303n
antibiotic medications, probiotics 220 contact information 605
anticonvulsant medications, folic acid Association of American Indian
163 Physicians, contact information 80
617
Association of Reexologists, barbiturates, folic acid 163
contact information 605 Bastyr Center for Natural Health,
asthma contact information 606
Alexander technique 37475 Beal, Flint 520
CAM therapies 5036 Beecher, Henry 294
sh oils 179 bee stings see apitherapy
Asthma and Allergy Foundation Bekhterev, Vladimir 431
of America (AAFA), alternative Benen 54
therapies publication 503n Benson, Herbert 34547
atherosclerosis, sh oils 176, 179 Benson-Henry Institute for
Atherosclerosis Risk in Communities Mind Body Medicine, contact
study (ARIC study) 172 information 606
athletes Berman, Brian M, 5012
Alexander technique 378 beta-carotene, vitamin A 130
sports supplements 22630 beta-cryptoxanthin, vitamin A 130
Atlantic Institute of Aromatherapy, Bidobacterium bidus 220
contact information 605 Biodynamic Craniosacral Therapy
attention decit hyperactivity disorder Association of North America,
(ADHD), CAM therapies 58081 contact information 606
autonomic nervous system, bioelectromagnetic-based
meditation 331 therapies, described 5
Awareness Through biofeedback
Movement 40910 allergies 506
Ayurveda dened 593
dened 593 headache 53435
described 25, 6162 mental health care 577
mental health care 577 overview 3039
overview 6571 Biofeedback (National
Ayurvedic Institute, contact Headache Foundation) 533n
information 605 Biofeedback Certication Institute of
Ayurvedic Medicine: An America, contact information 606
Introduction (NCCAM) 65n Biofeedback: Consumer Questions
Answered (Moss) 303n
bioeld, described 456
B
bioeld therapies, described 5
The Bach Centre, contact Biologically Based Practices: An
information 605 Overview (NCCAM) 243n
BackHab, described 385, 390 biologically based therapies
back pain, CAM therapies 56365 dened 594
bacteria, probiotics 21920 described 4, 22
Bad Ragaz, described 385 overview 24351
baiguo 214 bioresonance therapy, overview
bai guo ye 214 48485
balance bipolar disorder, sh oils 179
acupuncture 8182 Black Beauties (slang) 5354
Ayurvedic medicine 6769 black cohosh, menopause 569
Native American medicine 79 blood pressure levels,
naturopathy 91 magnesium 16970
traditional Chinese medicine 75 body-based practices, dened 596
618
Index
Bompey, Nanci 484n CAM and Diabetes: A Focus on
bone health Dietary Supplements (NCCAM)
calcium 198200 523n
vitamin D 147 CAM and Fibromyalgia: At a
borage, arthritis 493 Glance (NCCAM) 529n
Boswellia, arthritis 496 CAM and Hepatitis C: A Focus on
Botanical Dietary Supplements: Herbal Supplements (NCCAM)
Background Information (ODS) 541n
107n Camellia sinensis 236
botanicals Cam Use and Children (NCCAM) 17n
arthritis 49197 Cancer and CAM (NCCAM) 507n
Ayurvedic medicine 70 cancers
dened 594 aromatherapy 258
menopause 56971 CAM therapies 50716
overview 10710 deep breathing exercises 31115
Bowen Technique (Natural Medicines sh oils 179
Comprehensive Database) 449n folic acid 165
Bowen technique, overview 44950 Gerson therapy 26972
brain injury, hyperbaric oxygen health fraud 4546
therapy 287 macrobiotics 27374
breastfeeding research 2627
sh oils 18687 selenium 19394
probiotics 220 spiritual distress 34244
A Brief History of Foot Reexology vitamin A 131
(American Reexology Certication vitamin D 15051
Board) 431n vitamin E 15657
Briggs, Josephine 201 Cannon, Walter 294
Brunschwiler, Arjana 387 Cant Sleep? Science Is Seeking
Burdenko Method, described 385 New Answers (NIH) 585n
Buteyko Breathing Association, Can We Prevent Aging? (NIA) 547n
contact information 606 Caraka Samhita 66
carbohydrate metabolism,
magnesium 17071
C
carbohydrates, energy drinks 233
caffeine cardiac arrhythmias, sh oils 179
energy drinks 23132 cardiovascular disease
green tea 237 sh oils 17778, 181
sports supplements 228 folic acid 164
calcidiol, described 147 magnesium 17374
calcitriol, described 147 vitamin B12 14445
calcium Carotene and Retinol Efciency
bone health 147, 198200 Trial (CARET) 131
vegans 278 carotenoids, overview 12935
vegetarians 280 carpal tunnel syndrome
Calcium Supplements: What to Alexander technique 375, 377
Look for (NIAMS) 198n vitamin B6 139
calorie restriction, described 55758 cataracts, vitamin E 15758
CAM see complementary and CDC see Centers for Disease
alternative medicine Control and Prevention
619
Cellular Tea 54 children
Center for Integrative Health complementary and alternative
and Healing medicine 16, 1719
contact information 606 Rolng 446
publications vegetarians 28182
craniosacral therapy 403n Chinese herbal medicine, described 75
guided imagery 322n Chinese massage, overview 42122
lymphatic drainage Chinese Materia Medica, described 61
massage 419n Chinese tea 236
Shiatsu 475n chiropractic
Tui Na 421n allergies 506
Center for Integrative Medicine, dened 594
contact information 606 described 23
Center for Mindfulness in Medicine, headache 535
Health Care, and Society, contact overview 399402
information 607 Chiropractic: An Introduction
Centers for Disease Control and (NCCAM) 399n
Prevention (CDC), contact Chiropractors (National
information 599 Headache Foundation) 533n
cerebral palsy, hyperbaric cholecalciferol, described 148
oxygen therapy 28788 cholesterol levels
certication sh oils 177
art therapy 299300, 302 selenium 195
Ayurvedic medicine 70 vitamin E 15455
biofeedback 306 chondroitin
CAM practitioners 33 arthritis 49697
dance therapy 35960 overview 2014
homeopathy 8889 research 27
massage therapy 417 chromium, diabetes mellitus 525
naturopathy 94 Chromotherapy (Natural Medicines
Reiki 473 Comprehensive Database) 358n
traditional Chinese Clegg, Daniel O. 201, 203
medicine 77 Cleland, Rich 5152
Trager approach 451 clinical trials
yoga 355 aromatherapy 259
see also licensing requirements beta-carotene 134
chakras CAM practitioners 36
color therapy 358 complementary and alternative
polarity therapy 468 medicine 11
CHD see coronary heart dened 594
disease dietary supplements 246, 24951
chelation therapy Gerson therapy 27172
dened 594 ginkgo biloba 215
heart disease 53740 homeopathy 6364
research 26 magnesium 170, 172
chi see qi manipulative and body-based
Chi Energy practices 36467
feng shui publication 317n PC-SPES 510, 512
website address 607 selenium 194
620
Index
clinical trials, continued cupping, described 76
thunder god vine 492 curcumin, arthritis 496
vitamin D 15051 cyclosporine, sh oils 178, 182
vitamin E 15559 cystic brosis, sh oils 180
zinc 20911
cod liver oil 176
D
coenzyme Q10
Parkinson disease 51921 Daily Value (DV), dened 59495
research 250 dance therapy
cognitive function mental health care 576
vitamin B12 14546 overview 35960
vitamin E 15859 DASH diet see Dietary Approaches
coldwater sh 176 to Stop Hypertension
colonic irrigation, detoxication decoction, described 108
diets 26465 deep breathing exercises,
color therapy, overview 35859 overview 31115
complementary and alternative dehydroepiandrosterone (DHEA)
medicine (CAM) described 227, 55253
dened 594 menopause 571
overview 311 dementia
Complementary and Alternative CAM therapies 51719
Medicine (CAM) (NIA) 21n sh oils 180
Complementary Healthcare vitamin B12 14546
Information Service, contact Department of Health and Human
information 607 Services (DHHS) see US Department
complementary medicine, of Health and Human Services
described 34, 21 depression
constitution, Ayurvedic medicine 67 sh oils 180
conventional medicine, dened 594 St. Johns wort 216
Cooke, David A. 78n, 267n, 273n, detoxication diets, overview 26466
285n, 303n, 322n, 403n, 419n, 450n, DHA (docosahexaenoic acid)
486n, 491n, 503n, 517n, 537n, 574n described 55
Cornelius, Alfons 431 sh oils 176
coronary artery bypass grafting, DHEA see dehydroepiandrosterone
sh oils 181 DHHS see US Department of Health
coronary heart disease (CHD) and Human Services
chelation therapy 53740 diabetes mellitus
vitamin E 15456 CAM therapies 52327
cranberry juice, research 25051 sh oils 182
Craniosacral Therapy (Center for health fraud 47
Integrative Health and Healing) magnesium 17072
403n diarrhea, zinc 209
craniosacral therapy, overview 4035 diet and nutrition
creatine, described 22728 arthritis 49798
Crohn disease, sh oils 17980 CAM therapies 26483
Crystal and Gem Therapy folic acid 16162
(University of California) 486n Gerson therapy 26972
crystal therapy 48687 macrobiotics 27374
Cuentos, mental health care 577 mental health care 575
621
diet and nutrition, continued drug interactions
veganism 27579 sh oils 18788
vegetarianism 27983 St. Johns wort 217, 251
vitamin A 13031, 135 vitamin B6 139
vitamin B6 138, 14041 DrWeil.com, website address 607
Dietary Approaches to Stop Dull, Harold 387
Hypertension (DASH diet) 170 DV see Daily Value
Dietary Reference Intakes (DRI), dysmenorrhea, sh oils 180
folic acid 162
Dietary Supplement Health and
E
Education Act (DSHEA; 1994)
biologically based therapies 24344 echinacea
denitions 101, 1078, 111 naturopathy 62
regulations 53 overview 2067
dietary supplements research 251
adolescents 11719 Echinacea (NCCAM) 206n
arthritis 49197 eczema, sh oils 180
dened 595 EDTA chelation therapy, heart
described 12122 disease 53740
diabetes mellitus 52527 EGCG (epigallocatechin gallate) 236
health fraud 47 Electroacupuncture May Help
online safety 5256 Alcohol Addiction (NCCAM) 579n
overview 1015, 11115 electromagnetic energy
vitamin B12 144 arthritis 49899
vitamin D 148 described 46061
see also botanicals feng shui 31719
Dietary Supplements: Background electronic communications,
Information (ODS) 101n mental health care 578
Dietary Supplements Glucosamine elements, traditional Chinese
and/or Chondroitin Fare No Better medicine 75
than Placebo in Slowing Structural enemas, Gerson therapy 27072
Damage of Knee Osteoarthritis see also detoxication diets
(NIH) 201n energy drinks, overview 23133
dietary therapy, described 76 Energy Drinks: Power Boosts or
The Differences between Reexology Empty Boasts? (SAMHSA) 231n
and Massage (American Reexology energy medicine
Certication Board) 431n dened 595
digestive tract, probiotics 22021 described 5, 2223
digitalis 491 overview 45561
dilutions principle 86 Energy Medicine: An Overview
distant healing, described 460 (NCCAM) 455n
DNA (deoxyribonucleic acid) EPA (eicosapentaenoic acid)
folic acid 161 described 55
vitamin B12 143 sh oils 176
Dodge, Hiroko 518 ephedra
dong quai, menopause 56970 adolescents 118
doshas traditional Chinese medicine 77
Ayurvedic medicine 6768 ephedrine, dietary supplements 53
described 25 epigallocatechin gallate (EGCG) 236
622
Index
epinephrine, bee stings 255 nancial considerations
ergocalciferol, described 148 acupuncture 84
ergogenic aids, described 226 biofeedback 308
essential oils CAM therapies 3940, 44
apitherapy 253 dietary supplements 245
overview 25761 macrobiotics 274
estrogen, described 55457 manipulative and body-based
evening primrose oil, arthritis 493 practices 36869
exercises see also insurance coverage
relaxation 31315 sh body oil 176
water therapy 38995 sh extract 176
extract, described 108 sh liver oil 176
eye disorders, vitamin E 15758 sh oils
arthritis 49394
overview 17690
F
Fitzgerald, William 431
fasting axseed, overview 19091
hormone therapy 55758 Flaxseed and Flaxseed Oils
overview 26768 (NCCAM) 190n
Fasting (University of California) exible spending arrangements
267n (FSA), described 42
fat burners, sports supplements 228 Flower Essence Society, website
fats, vegans 277 address 607
FDA see US Food and Drug Folate (ODS) 161n
Administration folic acid (folate), overview 16167
FDA 101: Health Fraud Food, Drug, and Cosmetic Act (1938)
Awareness (FDA) 45n 86
Feldenkrais, Moshe 385, 407, 41112 Food and Drug Administration
Feldenkrais Educational Foundation (FDA) see US Food and Drug
of North America Administration
Feldenkrais method fossil tree 214
publication 407n fraud
website address 607 dietary supplements 124
Feldenkrais method overview 4549
described 385 frequency therapy 458
overview 40712 Frequently Asked Questions
Feldenkrais Resources, website (Arnold; Gillerman) 371n
address 607 Frequently Asked Questions
feng shui, overview 31719 (Feldenkrais Educational
Feng Shui Principles (ChiEnergy) Foundation) 407n
317n Frequently Asked Questions
feverfew (Rolf Institute of Structural
arthritis 496 Integration) 438n
headache 53536 Frequently Asked Questions
Feverfew (Tanacetum Parthenium) about Apitherapy (American
(National Headache Foundation) Apitherapy Association) 253n
533n Frequently Asked Questions About
bromyalgia, CAM therapies 52932 Music Therapy (American Music
ght or ight, described 294 Therapy Association) 335n
623
FSA (exible spending arrangements), Guided Imagery (Center for
described 42 Integrative Health and Healing)
Functional Integration 410 322n
G H
gamma-linolenic acid 493 Haas, Richard 520
garlic, research 26 Hahnemann, Samuel
gem therapy 48687 Christian 63, 85
Gerson, Max B. 26971 halibut oil 176
Gerson Therapy (NCI) 269n Halliwick, described 386
Gerson therapy, overview 26972 hatha yoga see yoga
Gillerman, Hope 371n Hayashi, Chujiro 471
ginger, arthritis 49596 Head, Henry 431
Ginkgo (NCCAM) 214n headache, CAM therapies 53336
ginkgo biloba healing touch therapy, described 22
dementia 51819 health care providers
overview 21415 CAM discussions 3738
ginseng dietary supplements 123
hepatitis C 542 see also practitioners
menopause 570 Healthnder, contact
glucosamine information 599
arthritis 49697 health fraud, overview 4549
overview 2014 health insurance see insurance
research 27 coverage
glycyrrhizin, hepatitis C 542 Health Professionals
GMP see good manufacturing Follow-up Study (HFS)
practices magnesium 171
goat weed 216 vitamin E 157
good manufacturing practices health risks
(GMP) acupuncture 82
biologically based therapies 243 carotenoids 13435
botanicals 110 chiropractic 401
dietary supplements 104, 112 dietary supplements 12223
sports supplements 226 folic acid 16667
grape seed extract, Alzheimer homeopathy 88
disease 51718 magnet therapy 466
Grape Seed Extract May Help manipulative and body-based
Prevent and Treat Alzheimers practices 368
(NCCAM) 517n naturopathy 9596
Green Hornet 54 online products 52
Green Tea (NCCAM) 236n probiotics 22223
green tea, overview 23637 spinal manipulation 565
guarine, energy drinks 232 tai chi 351
guided imagery vitamin A 13334
dened 595 vitamin B6 140
mental health care 577 yoga 355
overview 32224 health savings account (HSA),
see also imagery described 43
624
Index
heart disease HSA (health savings account),
selenium 195 described 43
vitamin B6 140 Huang Di Nei Jing 75
Heart Outcomes Prevention Hubbard, William 5152
Evaluation (HOPE) 155, 157 human growth hormone,
Heller, Joseph 436 described 55051
Hellerwork International human pathogenic trial,
Hellerwork publication 436n homeopathy 63
website address 607 hydrotherapy
Hellerwork structural integration, arthritis 499500
overview 43637 naturopathy 92
hemoglobin overview 38398
described 137 hyperbaric oxygen therapy,
vitamin B12 143 overview 28589
hemoglobin A1C levels, Hyperbaric Oxygen Therapy for
magnesium 172 Brain Injury, Cerebral Palsy, and
hepatitic C, CAM therapy 54145 Stroke (AHRQ) 285n
herbal supplements hypercholesterolemia, sh oils 182
adolescents 11719 hyperglycemia, magnesium 171
dened 595 Hypericum perforatum
hepatitis C 542 see St. Johns wort
see also botanicals hypertension (high blood
HFS see Health Professionals pressure), sh oils 177
Follow-up Study hypertriglyceridemia, sh oils 177
HHS see US Department of hypervitaminosis A, described 133
Health and Human Services hypnosis
high blood pressure see hypertension allergies 506
HIV (human immunodeciency virus) anxiety 582
health fraud 46 dened 595
selenium 19596 described 312
Holistic Network, website address 607 overview 32427
Homeopathic Educational Services, Hypnosis Today: Looking beyond
contact information 607 the media portrayal (American
homeopathy Psychological Association) 324n
arthritis 500 hypomagnesemia,
dened 595 magnesium 17073
described 25, 6364, 459
overview 8589
I
Homeopathy: An Introduction
(NCCAM) 85n IgA nephropathy, sh oils 180
homocysteine imagery, described 24, 296, 312
Alzheimer disease 28 see also guided imagery
vitamin B6 140 immune system
Hoodia (NCCAM) 238n craniosacral therapy 403
hoodia, overview 23839 echinacea 2067
hormones, sports supplements 22728 mind-body medicine 29596
hormone therapies probiotics 221
menopause 568 touch therapy 460
overview 54758 vitamin B6 137
625
immune system, continued International Society of Hypnosis,
vitamin D 147 contact information 327
vitamin E 15354 International Thai Therapists
zinc 20811 Association, contact information 608
infants An Introduction to Naturopathy
eye/brain development (NCCAM) 91n
and omega 3 fatty acids180 An Introduction to Probiotics
vegetarians 281 (NCCAM) 219n
infertility iron
CAM therapies 56162 vegans 278
herbal remedies 56061 vegetarians 281
inuenza, health fraud 48 isoniazid, vitamin B6 139
infusion, described 108 isotretinoin, acne 134
Ingham, Eunice D. 431
Inner Canon of the Yellow J
Emperor 75
Institute for Traditional Medicine, Japanese silver apricot 214
contact information 80 Japanese tea 236
Institute of Traditional Medicine, juice therapies, overview 26768
contact information 608
insurance coverage
K
alternative medicine 504
apitherapy 254 Kalahari cactus 238
CAM practitioners 33, 34 Kano, Jigaro 41112
CAM therapies 3944 kapha, Ayurvedic medicine 68
chiropractic 402 Katz, Stephen I. 203, 501
music therapy 33840 kava
integrative medicine, menopause 570
described 4, 21 research 251
interconnectedness, kew tree 214
Ayurvedic medicine 67 ki see qi
International Association kinesiology 44849
of Reiki Professionals, Kirlian photography 317
contact information 608 Klamath weed 216
International Association of Yoga Kneipp, Sebastian 92
Therapists, contact information 608 Konno, Jun 384
International Center for Reiki Krieger, Dolores 47980
Training, contact information 608 Kunz, Dora 47980
International Chiropractors
Association, contact information 608 L
International College of Applied
Kinesiology, website address 608 labels, dietary supplements 1024,
International Feng Shui Guild, 11415
contact information 608 Lactobacillus acidophilus 220
International Institute of Reexology, lactoferrin 544
contact information 608 lacto-ovo vegetarians, dened 279, 597
International Medical and Dental lacto-vegetarians, dened 280, 597
Hypnotherapy Association, contact Laetrile 54
information 608 Lane, Andrew J. 54
626
Index
laser therapy, allergies 506 ma huang (ephedra)
law of minimum dose 86 adolescents 118
licensing requirements described 228
biofeedback 306 traditional Chinese
CAM practitioners 18, 33 medicine 77
chiropractic 401 maidenhair tree 214
homeopathy 8889 Manheimer, Eric 562
massage therapy 417 manipulation
naturopathy 94 dened 595
Reiki 473 described 23
yoga 355 naturopathy 92
see also certication see also chiropractic; Rolng
licorice, hepatitis C 543 manipulative and body-based
life forces, Ayurvedic practices
medicine 6768 described 4, 23
light therapy, described 458 overview 36369
like cures like 85 Manipulative and Body-Based
list of medications Practices: An Overview
CAM practitioners 35 (NCCAM) 363n
health care providers 38 manipulative practices,
long chain polyunsaturated dened 596
fatty acids 176 marine oil 176
Lubar, Joel 306 massage, dened 596
lupus erythematosus, massage therapy
sh oils 180 described 23, 31317
Lust, Benedict 92 hydrotherapy 386
lutein, vitamin A 130 mental health care 578
lycopene, vitamin A 130 overview 41418
Lymphatic Drainage Massage Massage Therapy: An
(Center for Integrative Health Introduction (NCCAM) 414n
and Healing) 419n Mayo Clinic, website address 608
lymphatic drainage massage, medications
overview 41920 folic acid 163
Lyu Ki Dou, described 386 online cautions 5156
see also drug interactions
meditation
M
dened 596
mackerel oil 176 described 24, 296
Macrobiotics (University of guided imagery 32223
California) 273n mental health care 577
macrobiotics, overview 27374 overview 32933
Magnesium (ODS) 169n Meditation: An Introduction
magnesium, overview 16974 (NCCAM) 329n
Magnets for Pain (NCCAM) 463n melatonin
magnet therapy described 55152
arthritis 49899 sleep disorders 58889
dened 595 menhaden oil 176
described 22, 457 Menopausal Symptoms and
overview 46366 CAM (NCCAM) 567n
627
menopause, CAM therapies 56772 National Association of Cognitive-
mental health care, Behavioral Therapists, contact
CAM therapies 57479 information 609
Mentastics 451 National Association of Nutrition
meridians Professionals, contact information
acupuncture 82 609
described 60 National Cancer Institute (NCI)
traditional Chinese contact information 599
medicine 75 publications
metformin, folic acid 163 aromatherapy 257n
methionine, described 143 cancer, CAM 507n
methotrexate, folic acid 163, 165 deep breathing exercises 311n
MGN-3 54 Gerson therapy 269n
milk thistle spirituality 341n
hepatitis C 542 National Center for Complementary
research 250 and Alternative Medicine (NCCAM)
millimeter wave therapy, contact information 600
described 45758 publications
mind-body medicine acupuncture 81n
dened 596 alcohol addiction 579n
described 4, 2324 arthritis 491n
overview 29398 attention decit hyperactivity
Mind-Body Medicine: disorder 580n
An Overview (NCCAM) 293n Ayurvedic medicine 65n
mindfulness meditation, biologically based practices
described 331 243n
mineral, dened 596 CAM, children 17n
Moores Cancer Center, CAM, United States 13n
contact information 609 CAM overview 3n, 7n
Moss, Donald 303n CAM practitioners 32n, 37n
movement therapy, CAM treatment nancial
mental health care 576 considerations 39n
moxibustion, described 25, 60, 76 cancer 507n
multiple sclerosis (MS) chelation therapy, heart
apitherapy 25354 disease 537n
shiatsu 477 chiropractic 399n
music therapy diabetes mellitus 523n
described 315 dietary supplements 111n
mental health care 576 echinacea 206n
overview 33540 energy medicine 455n
sound energy therapy 458 bromyalgia 529n
axseed 190n
ginkgo biloba 214n
N ginkgo extract 517n
National Association for Drama grape seed extract 517n
Therapy, contact information 609 green tea 236n
National Association for Holistic hepatitis C 541n
Aromatherapy, contact homeopathy 85n
information 609 hoodia 238n
628
Index
National Center for Complementary National Institute of Ayurvedic
and Alternative Medicine (NCCAM), Medicine, contact information 610
continued National Institute of Diabetes and
publications, continued Digestive and Kidney Diseases
infertility treatment 561n (NIDDK), contact information 600
low back pain 563n National Institute of Neurological
magnet therapy 463n Disorders and Stroke (NINDS)
manipulative and body based coenzyme Q10 publication 517n
therapies 363n contact information 600
massage therapy 414n National Institute on Aging (NIA)
meditation 329n contact information 600
menopausal symptoms 567n publications
mind-body medicine 293n aging prevention 547n
naturopathy 91n CAM use 21n
posttraumatic stress National Institutes of Health (NIH)
disorder 583n contact information 600
probiotics 219n publications
Reiki 471n glucosamine/
St. Johns wort 216n chondroitin 201n
self-hypnosis 582n sleep disorders 585n
tai chi 349n National Library of Medicine
traditional Chinese (NLM), contact information 601
medicine 74n National Qigong Association
whole medical systems 59n contact information 610
yoga 353n qigong publication 427n
National Center for Homeopathy, Native American medicine
contact information 609 mental health care 577
National Center on Physical Activity overview 7880
and Disability (NCPAD) Native American Medicine
contact information 609 (University of California) 78n
hydrotherapy publication 383n Natural Medicines Comprehensive
National Certication Commission for Database, publications
Acupuncture and Oriental Medicine, applied kinesiology 448n
contact information 609 Bowen technique 449n
National College of Naturopathic color therapy 358n
Medicine, contact information 609 Natural Medicines Comprehensive
National Headache Foundation Database, website address 610
contact information 610 Natural Standard, sh oils
publications publication 176n
acupuncture 533n naturopathy
biofeedback 533n dened 596
chiropractic 533n described 26, 6263
feverfew 533n overview 9197
National Institute of Arthritis NCCAM see National Center for
and Musculoskeletal and Skin Complementary and Alternative
Diseases (NIAMS) Medicine
calcium supplements NCI see National Cancer Institute
publication 198n NCPAD see National Center on
contact information 600 Physical Activity and Disability
629
Nemours Foundation Ofce of Dietary Supplements
contact information 610 (ODS), continued
publications publications, continued
detoxication diets 264n vitamin A 129n
Pilates 423n vitamin B6 137n
sports supplements 226n vitamin B12 143n
vegetarianism 279n vitamin D 147n
Neoral (cyclosporine), sh oils 178, vitamin E 153n
182 zinc 208n
nephrotic syndrome, sh oils 181 Ogden, David 387
new dietary ingredient, older adults
described 101, 1023 CAM therapies 54758
NIA see National Institute on complementary and alternative
Aging medicine 2130
niacin, vitamin B6 137 dietary supplements 12127
NIAMS see National Institute of folic acid 166
Arthritis and Musculoskeletal omega-3 fatty acids
and Skin Diseases Alzheimer disease 28
NIDDK see National Institute dened 596
of Diabetes and Digestive and diabetes mellitus 52526
Kidney Diseases overview 17691
NIH see National Institutes regulations 55
of Health vegans 278
NINDS see National Institute of see also sh oils; axseed
Neurological Disorders and Stroke Omega-3 Fatty Acids, Fish Oil,
NLM see National Library of Alpha-Linoleic Acid (Natural
Medicine Standard) 176n
noise, feng shui 319 omega-6 fatty acids 493
Nurses Health Study omega fatty acids 176
magnesium 171 osteoarthritis
vitamin A 132 acupuncture 27, 500502
vitamin E 157 shiatsu 476
Nutrition Labeling and Education osteopathic manipulation,
Act (NLEA; 1990) 245 overview 399402
osteoporosis
magnesium 174
O vitamin A 13233
Oakes, David 521 vitamin D 14950
ODS see Ofce of Dietary Otikon Otic Solution 6263
Supplements otitis media, naturopathy 6263
Ofce of Dietary Supplements out of pocket expenses,
(ODS) CAM therapies 39
contact information 600 see also nancial considerations;
publications insurance coverage
botanicals 107n ovo-vegetarians, dened 279
dietary supplements 101n oxalic acid, calcium 278
folate 161n oxygen therapy, overview
magnesium 169n 28589
selenium 193n oxymatrine 544
630
Index
P potentization, described 86
The power of the relaxation
paclitaxel 491 response (American Psychological
Pain (NCI) 311n Association) 345n
pain management practitioners
Alexander technique 37374 acupuncture 8384
CAM therapies 56365 apitherapy 254
chiropractic 23 art therapy 3012
deep breathing exercises 31115 Ayurvedic medicine 70
magnet therapy 457 biofeedback 3068
mind-body medicine 29495 chiropractic 400401
therapeutic touch 480 complementary and
panchakarma, Ayurvedic medicine 69 alternative medicine 10
parasympathetic nervous system, Feldenkrais method 411
meditation 332 guided imagery 323
pastoral counseling, mental health manipulative and body-based
care 575 practices 36364
Pavlov, Ivan 431 music therapy 336
Paying for CAM Treatment naturopathy 9395
(NCCAM) 39n overview 3236
PC-SPES (NCI) 507n polarity therapy 46869
PC-SPES, described 51013 Reiki 473
Pearson, Nancy J. 586, 589 tai chi 351
pediatricians, complementary therapeutic touch 480, 482
and alternative medicine 1819 traditional Chinese
pernicious anemia, vitamin B12 144 medicine 7778
Physicians Association of yoga 355
Anthroposophic Medicine, contact prakriti, Ayurvedic medicine 67
information 610 prayer, overview 34144
phytoestrogens, menopause 57071 prebiotics, described 219
Pilates preeclampsia, sh oils 181
hydrotherapy 386 preformed vitamin A,
overview 42325 described 129
Pilates (Nemours Foundation) 423n pregnancy
Pilates, Joseph 386 Alexander technique 378
Pilates, Joseph H. 42324 sh oils 18687
Pilot Study Provides New Insight magnet therapy 499
on Effect of Ginkgo Extract on premenstrual syndrome,
Dementia in the Elderly (NCCAM) vitamin B6 139
517n principle of dilutions 86
pitta, Ayurvedic medicine 68 principle of similars 63, 85
placebo effect probiotics
alternative medicine 5045 dened 596
described 294, 29697 overview 21923
polarity therapy, overview 46769 professional organizations,
polyphenols, diabetes mellitus 52627 CAM practitioners 33
polyunsaturated fatty acids (PUFA) 176 progesterone, described 55457
posttraumatic stress disorder (PTSD), proprioceptive neuromuscular
acupuncture 58384 facilitation, described 386
631
proteins reexology
vegans 277 dened 597
vegetarians 280 described 23
provitamin A carotenoid, overview 43133
described 12930 Reexology Association of America,
psoriasis, sh oils 181 contact information 610
purication, detoxication regulations
diets 265 dietary supplements 53, 1023,
putative energy elds, 11213
described 455, 45861 omega-3 fatty acids 55
pyridoxal 137 Reiki
pyridoxamine 137 dened 597
pyridoxine 137 described 23
overview 47174
Reiki: An Introduction
Q
(NCCAM) 471n
qi (chi) relaxation therapy
acupuncture 82 allergies 506
dened 597 described 312
described 24, 69 overview 34547
feng shui 31718 sleep disorders 588
shiatsu 475 religious traditions
tai chi 349 counseling, described 313
traditional Chinese meditation 329
medicine 75 spirituality 34144
qi gong repetitive strain injury,
described 24, 76, 45859 Alexander technique 375, 377
overview 42729 resveratrol, described 55758
Questions and Answers: retinal, described 129
The NIH Trial of EDTA retinoic acid, described 129
Chelation Therapy for retinoids, described 134
Coronary Artery Disease retinol, described 12930
(NCCAM) 537n rheumatoid arthritis
CAM therapies 491502
sh oils 178
R
Rheumatoid Arthritis and
radio psychiatry, mental health Complementary and Alternative
care 57879 Medicine (NCCAM) 491n
RDA see Recommended Dietary rickets, vitamin D 148
Allowances Riley, Joe Shelby 431
reactive oxygen species (ROS), RNA (ribonucleic acid), folic acid 161
vitamin E 15354 Roaccutane (isotretinoin), acne 134
Recommended Dietary Rolf, Ida 436, 43840, 44546
Allowances (RDA) Rolng, overview 43846
folic acid 162 Rolf Institute of Structural
vitamin A 13031 Integration
vitamin B6 138 contact information 610
red clover, menopause 570 Rolng publication 438n
redirected thinking, described 312 ROS see reactive oxygen species
632
Index
S selenium
overview 19396
Saccharomyces boulardii 220 prostate cancer 15657
safety considerations research 27, 194
aromatherapy 260 Selenium (ODS) 193n
Ayurvedic medicine 7071 Selenium and Vitamin C Cancer
botanicals 10910 Prevention Trial (SELECT) 27, 194
CAM therapies 2830 self-hypnosis, anxiety 582
color therapy 359 Self-Hypnosis Benecial for
complementary and Women Undergoing Breast
alternative medicine 89, 18 Biopsy (NCCAM) 582n
dietary supplements 29, 11415, serotonin, vitamin B6 138
12223 sexual enhancement, health
sh oils 18485 fraud 47
massage therapy 41617 shark liver oil 176
online medical products 5156 Sherrington, Charles 431
Reiki 47273 Shiatsu (Center for Integrative
supplements 11819 Health and Healing) 475n
traditional Chinese shiatsu, overview 47578
medicine 7677 Shults, Clifford 51921
see also fraud side effects
St. Johns wort acupuncture 82
attention decit hyperactivity aromatherapy 260
disorder 58081 chiropractic 401
overview 21617 detoxication diets 265
research 251 echinacea 207
St. Johns Wort (NCCAM) 216n sh oils 18586
St. Johns Wort Shows No Impact axseed 191
on the Symptoms of ADHD Gerson therapy 272
(NCCAM) 580n ginkgo biloba 215
salmon oil 176 green tea 237
SAMe (S-adenosyl-L-methionine), homeopathy 88
research 250 isotretinoin 134
SAMHSA see Substance Abuse magnet therapy 466
and Mental Health Services meditation 332
Administration naturopathy 9596
Sawitzke, Allen D. 2012 probiotics 22223
schisandra 544 spinal manipulation 565
schizophrenia, sh oils 181 tai chi 351
Schroter, Aman 387 yoga 355
Scripps Center for Integrative similars principle 63, 85
Medicine, contact information 610 SkinAnswer 54
SeaSilver 54 sleep disorders, CAM
Selected Vegetables/Suns Soup therapies 58590
51316 Society for Clinical and Experimental
Selected Vegetables/Suns Soup Hypnosis, contact information 327
(NCI) 507n Society for Light Treatment and
Selecting a CAM Practitioner Biological Rhythms, website
(NCCAM) 32n address 610
633
Society of Auricular Acupuncturists, Study Suggests Coenzyme Q10 Slows
contact information 611 Functional Decline in Parkinson
sound energy therapy, described 458 Disease (NINDS) 517n
Sova, Ruth 395 Substance Abuse and Mental Health
soy, menopause 570 Services Administration (SAMHSA)
spinal manipulation contact information 601
described 23 publications
pain management 56365 energy drinks 231n
see also chiropractic mental health care 574n
Spinal Manipulation for supplements 117n
Low-Back Pain (NCCAM) 563n sulfasalazine, folic acid 163
spirituality Suns Soup 51316
dened 597 supplements see dietary
overview 34144 supplements; herbal supplements
Spirituality in Cancer Care Supplements: Added Risk, Doubtful
(NCI) 341n Benet (SAMHSA) 117n
sports supplements support groups, described 313
adolescents 11719 surgical preparation, mind-body
overview 22630 medicine 297
Sports Supplements Sushruta Samhita 66
(Nemours Foundation) 226n sympathetic nervous system,
statistics meditation 332
acupuncture 82 synbiotics, described 219
Ayurvedic medicine 66
CAM therapies 508
T
complementary and
alternative medicine 1316, 17 tai chi
dietary supplements 112, 24445 dened 597
homeopathy 86 described 24, 76
manipulative and body-based overview 34952
practices 363 qi gong 429
massage therapy 414 Tai Chi: An Introduction (NCCAM)
meditation 330 349n
naturopathy 9293 Takata, Hawayo 471
Reiki 472 TCM see traditional Chinese medicine
tai chi 350 telemedicine, mental health care 578
traditional Chinese medicine 74 telephone counseling, mental health
yoga 354 care 578
Stone, Randolph 468 testosterone, described 55354
Straus, Stephen E. 501, 585 Thai Yoga Center/Soma Veda
stress management Institute, contact information 611
Alexander technique 373 therapeutic touch see touch therapy
massage therapy 415516 Therapeutic Touch (A.D.A.M., Inc.)
mental health care 57778 479n
mind-body medicine 297 Therapeutic Touch International
relaxation therapy 347 Association, contact
stroke information 611
sh oils 182 thermogenics, described 228
hyperbaric oxygen therapy 288 Thomas, Jennifer 53
634
Index
thunder god vine United States Pharmacopeia (USP),
arthritis 49293 described 199
described 61 University of California,
tincture, described 108 publications
Tips for Older Dietary crystal therapy 486n
Supplement Users (FDA) 121n fasting 267n
Tips for Talking with Your Health macrobiotics 273n
Care Providers about CAM Native American medicine 78n
(NCCAM) 37n University of Minnesota Center for
TJ-108 544 Spirituality and Healing, contact
Tolerable Upper Intake Levels (UL), information 611
vitamin A 13031, 134 unpredictable command
touch therapy technique, described 387
described 313, 45960 urinary tract infections,
overview 47982 naturopathy 6263
toxins, described 264 US Department of Health and
traditional Chinese medicine (TCM) Human Services (DHHS; HHS),
dened 597 contact information 601
described 2425, 5960 Use Caution Buying Medical
mental health care 57677 Products Online (FDA) 51n
overview 7478 The Use of Complementary and
Traditional Chinese Medicine: An Alternative Medicine in the
Introduction (NCCAM) 74n United States (NCCAM) 13n
Trager approach, overview 45051 US Food and Drug Administration
Trager International (FDA)
contact information 611 contact information 601
Trager approach publication 450n publications
transcendental meditation, described dietary supplements 121n
331 health fraud awareness 45n
transplant rejections, sh oils 178, 182 online medical products 51n
Treating Infertility with Herbal Using Dietary Supplements Wisely
Medications (American Pregnancy (NCCAM) 111n
Association) 560n USP see United States
triamterene, folic acid 163 Pharmacopeia
triglyceride levels, sh oils 177 Usui, Mikao 471
Tripterygium wilfordii Hook F 61
tryptophan, vitamin B6 137
V
Tui Na, overview 42122
Tui Na: Chinese Massage (Center valerian
for Integrative Health and Healing) arthritis 49495
421n research 251
tuning fork therapy 458 vata, Ayurvedic medicine 68
Turn off Allergies (Bompey) 484n Vegan Diets in a Nutshell
(Vegetarian Resource Group) 275n
veganism, overview 27579
U
vegans, dened 280, 597
UL see Tolerable Upper Intake Levels Vegetarianism (Nemours
ulcerative colitis, sh oils 182 Foundation) 279n
ultra-high dilutions, described 87 vegetarianism, overview 27983
635
Vegetarian Resource Group What is CAM? (NCCAM) 3n
contact information 611 What Is Dance/Movement
veganism publication 275n Therapy? (American Dance
vegetarians, dened 597 Therapy Association) 359n
veritable energy elds, What is Polarity Therapy?
described 455, 45658 (American Polarity Therapy
vibrational therapy 458 Association) 467n
vis medicatrix naturae 91 What is Qigong? (National
vitamin A, overview 12935 Qigong Association) 427n
Vitamin A and Carotenoids What Is the Trager Approach?
(ODS) 129n (Trager International) 450n
Vitamin B6 (ODS) 137n WholeHealthMD, contact
vitamin B6, overview 13741 information 611
vitamin B12 whole medical systems
overview 14346 dened 597
vegans 27879 described 4, 2426
vegetarians 280 energy medicine 459
Vitamin B12 (ODS) 143n overview 5964
vitamin B17 54 Whole Medical Systems: An
vitamin C, research 250 Overview (NCCAM) 59n
vitamin D Wills, Lucy 161
overview 14751 wind chime therapy 458
vegans 277 Womens Angiographic
vegetarians 280 Vitamin and Estrogen
Vitamin D (ODS) 147n study 155
vitamin E Womens Antioxidant and
overview 15359 Folic Acid Cardiovascular
research 27, 250 Study 146
Vitamin E Fact Sheet (ODS) 153n Womens Health Study,
vitamins, dened 597 magnesium 171
wound healing
hydrotherapy 383
W millimeter wave therapy 457
Wassertanzen, described 387 mind-body medicine 297
water Pilates, described 386 zinc 2089
Watsu, described 387 Wykle, Mary 387
weight management
sh oils 182 X
green tea 23637
health fraud 47 Xhoba 238
hoodia 23839
resveratrol 55758
Y
What can I expect in a typical
Polarity Therapy session? yang see yin/yang
(American Polarity Therapy Yellow Jackets (slang) 5354
Association) 467n yinhsing 214
What Hellerwork Structural yin/yang
Integration Is (Hellerwork acupuncture 81
International) 436n dened 59798
636
Index
yin/yang, continued Z
described 24, 69
macrobiotics 273 zeaxanthin, vitamin A 130
polarity therapy 468 Zen macrobiotic diet 273
traditional Chinese medicine 75 zero balancing, overview 48788
yoga Zero Balancing Health Association
dened 598 contact information 611
described 24 zero balancing publication 487n
hydrotherapy 387 zinc
mental health care 577 overview 20811
overview 35356 research 251
Yoga for Health: An Introduction vegans 278
(NCCAM) 353n vegetarians 281
Yogalates, described 38788, 39192 Zinc (ODS) 208n
637

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What is the purpose of the Omnigraphics Health Reference Series?

What is the purpose of the Omnigraphics Health Reference Series?

What role do complementary and alternative medicine therapies play in health care?

What role do complementary and alternative medicine therapies play in health care?

Health Reference Series

Helping the Layperson Understand, Manage, Fourth Edition

Library of Congress Cataloging-in-Publication Data

Electronic or mechanical reproduction, including photography, recording, or any other infor-

Printed in the United States

Part I: An Overview of Complementary and Alternative

Part III: Dietary Supplements

Part IV: Biologically Based Therapies

Part V: Mind-Body Medicine

Part VI: Manipulative and Body-Based Therapies

Part VII: Energy-Based Therapies

Part VIII: Alternative Treatments for Specic Diseases

Part IX: Additional Help and Information

About This Book

About the Health Reference Series

A Note about Spelling and Style

Locating Information within the Health Reference Series

Our Advisory Board

Health Reference Series Update Policy

What Is Complementary and

There are many terms used to describe approaches to health care

Are complementary medicine and alternative medicine dif-

is using aromatherapy to help lessen a patients discomfort following

What is integrative medicine?

What are the major types of complementary and alterna-

Energy medicine: Energy therapies involve the use of energy

What is NCCAMs role in the eld of CAM?

Common Questions and

For thousands of Americans, health care includes some form of

How can I get reliable information about a CAM therapy?

Understanding a therapys potential benets, risks, and scientic

Are CAM therapies safe? How can I minimize risks in using

How can I determine whether statements made about the

Are CAM therapies tested to see if they work?

I am interested in a CAM therapy that involves treatment from

Can I receive treatment or a referral to a practitioner from

Can I participate in a CAM clinical trial?

The Use of CAM in the

In December 2008, the National Center for Complementary and

scientic studiesquestions such as whether these therapies are safe

Figure 3.1. CAM Use by U.S. Adults and Children

How Many People Use CAM

Who Uses CAM Most

CAM Therapies Used the Most

s "OTANICA s #URANDERO s %SPIRITISTA

Use of Natural Products

Health Conditions Prompting CAM Use

CAM Use among Children

CAM Use and Children

A wide range of complementary and alternative medicine (CAM)

Patterns of CAM Use in Children

Safety of Childhood CAM Use

Discussing CAM with Your Pediatrician

In addition to asking your childs physician what is known about

CAM Use in Older Adults

These four categories sometimes overlap.