Complementary & Alternative Medicine - Florida Academy of Family ...

Florida Family Physician
Official Publication of the Florida Academy of Family Physicians Winter 2008
Complementary
& Alternative
Medicine

Florida Academy of Family Physicians
OFFICERS
President
Timothy Davlantes, MD, Jacksonville
President-Elect
Dennis Mayeaux, MD, Milton
Vice President
George A.W. Smith, MD, Pensacola
Secretary-Treasurer
Bruce Flareau, MD, Clearwater
Board Chair
Cyneetha Strong, MD, Tallahassee
Directors
TERMS EXPIRE 2009
David Feller, MD, Gainesville
John Gross, MD, St. Petersburg
Robert Raspa, MD, Jacksonville
Coy Irvin, MD, Gulf Breeze
Caroline Van Sant-Crowle, MD, Palm Harbor
TERMS EXPIRE 2010
Marvin Dewar, MD, Gainesville
Jennifer Keehbauch, MD, Orlando
Martha Price, MD, Tampa
Greg Sloan, MD, Chipley
Anne Waldron, MD, Jacksonville
TERMS EXPIRE 2011
Gregg Gutowski, MD, Plant City
Amber Isley, MD, Orange Park
Ira Pearlstine, MD, Port St. Lucie
Marc Rivo, MD, Miami Beach
Bernd Wollschlaeger, MD, Miramar
EX-OFFICIO DIRECTORS
(Family Medicine Department Chairs)
H. James Brownlee, MD, Tampa
R. Whit Curry, MD, Gainesville
E. Robert Schwartz, MD, Miami
Daniel J. Van Durme, MD, Tallahassee
RESIDENT DIRECTORS
Carrie Vey, MD, President (Daytona Beach)
Brooke Orr, MD, Vice President (Clearwater)
Terreze Gamble, MD, Secretary-Treasurer
(Tallahassee)
STUDENT DIRECTORS
Catherine Crawford (University of Miami)
Raj Mehta (University of Florida)
Coren Menendez (University of South Florida)
Kim Plumitallo (Florida State University)
DELEGATES/ALTERNATE DELEGATES
Delegates
Alma Littles, MD, Tallahassee
Dennis Saver, MD, Vero Beach
Alternate Delegates
Amber Isley, MD, Orange Beach
Donald Twiggs, MD, Callahan
Florida Family Physician
Volume 57 • Issue 2
Florida Academy of Family Physicians
6720 Atlantic Boulevard • Jacksonville, Florida 32211-8730
(904) 726-0944 • (800) 223-3237 • Fax (904) 726-0923 • www.fafp.org
FAFP Staff:
Tad P. Fisher, Executive Vice President (tad@fafp.org)
Camille Adams, Director of CME Programs and Exhibits (camille@fafp.org)
Mary Jo Griseuk, Director of Membership Development (maryjo@fafp.org)
Joyce Lowe, Comptroller & Executive Assistant to the EVP (joyce@fafp.org)
Annelle McClean, Director of Meeting Planning
& Director of Resident & Student Relations (amcclean@fafp.org)
Kathy Short, Administrative Assistant (kathy@fafp.org)
FAFP Consultants:
Ed Shahady, MD, Director of Centers of Office Practice Excellence (eshahady@att.net)
Jim Daughton, Metz, Husband & Daughton, Legislative Consultant (jim.daughton@metzlaw.com)
Christine P. Fisher, Director of Public Affairs (cpf1219@aol.com)
Amanda Fliger, Moore Consulting Group, Communications Consultants (amandaf@moore-pr.com)
Ray Lowe, EHR Now! Project Director (ray_lowe@comcast.net)
Guest Editor:
Jan Larson, MD
Florida Family Physician is printed on recycled paper with soy-based inks.
The opinions expressed in this publication are not necessarily those of the Florida Academy of Family Physicians.
Florida Family Physician Writing Guide
The Florida Academy of Family Physicians is seeking contributors for its official quarterly journal on such
topics as practice management and physician community involvement, as well as clinical subjects.
Articles can contain up to 900 words. Photos of authors are requested but are not required. Photos should
be emailed as a JPG file scanned at 400 dpi. If you are unsure, e-mail us what you have and we will have
our publisher evaluate it. We are also seeking cover photos that may accompany a feature article or simply
an interesting photo with a two- or three-sentence description.
The editor reserves the right to edit in a reasonable manner for grammar, spelling and punctuation. If there
are any questions regarding content or if any major changes are necessary, the editor will contact the author.
If you have questions, please contact Christine Fisher, Managing Editor, cpf1219@aol.com.
2009 Editorial Calendar
Spring issue (March) copy due to FAFP by January 31, 2009
Summer issue (June) copy due to FAFP by April 30, 2009
Fall issue (September) copy due to FAFP by July 31, 2009
The theme of the winter issue of Florida Family Physician is “Emerging Crisis — Primary Care
Physician Shortage.” Please contact the Managing Editor, Christine P. Fisher, at cpf1219@aol.com,
if you would like to submit an article. Letters to the editor are accepted.
Published December 2008
FAFP FOUNDATION OFFICERS
President
Daniel B. Lestage, MD, Orange Park
Vice President
Dennis Saver, MD, Vero Beach
Treasurer
Bruce Flareau, MD, Clearwater
Secretary
Tad Fisher, Jacksonville
Amber Isley, MD
Communications Chair & Editor, Orange Park
Carolyn Mayeaux
Editorial Assistant
Editorial Board
Tad P. Fisher
Executive Editor, Jacksonville
Christine P. Fisher
Managing Editor, Jacksonville

Contents
Features
Medical Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
To Herb or Not to Herb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Menopause and Botanicals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
CAM Primer for Family Physicians. . . . . . . . . . . . . . . . . . . . . . . . . 18
Treatment of Hypertension with Nutraceuticals, Vitamins,
Antioxidants and Minerals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
The Root Doctor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Extras
FAFP New England and CME Cruise on the Jewel of the Seas . . . . . 7
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Departments
Family Medicine in the News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Your FAFP Foundation at Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Calendar of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Residents’ & Students’ Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Florida Family Physician is published by Innovative Publishing Ink.
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Innovative Publishing Ink specializes in creating custom magazines for associations. Please direct all inquiries to Aran Jackson, ajackson@ipipublishing.com.
5

F A M I L Y M E D I C I N E I N T H E
N E W S
AAFP Congress of Delegates in San Diego
John M. Montgomery, MD, of Jacksonville
was awarded the 2008 Robert Graham
Physician Executive Award by the American
Academy of Family Physicians at the AAFP
annual meeting in San Diego in September.
This award recognizes an outstanding family
physician whose executive skills in
health care organizations have contributed
to excellence in the provision of high-quality
health care. Dr. Montgomery is vice
president for professional relations at Blue
Cross Blue Shield of Florida. He is the
immediate past president of the Duval
County Medical Society, secretary and
board member of the Florida Patient Safety
Attending the AAFP Congress of Delegates in San Diego: Tim Davlantes, MD, FAFP president; John
Montgomery, MD; Tanya Anim (FSU College of Medicine), AAFP FMIG national coordinator; Donald
Twiggs, MD, alternate delegate; Amber Isley, MD, alternate delegate; Dennis Saver, MD, delegate; Alma
Littles, MD, delegate; and Cyneetha Strong, MD, FAFP Board chair
John M. Montgomery, MD, MPH, FAAFP; and Jim
King, MD, AAFP president
Corporation and member of the board and
executive committee of the Florida Division
of the American Cancer Society. Dr.
Montgomery is also a member of the
Mayor’s Council of Wellness and Physical
Fitness and serves as one of the commissioners
of the AMA-NMA Commission to
End Health Care Disparities. He is boardcertified
in family practice, a fellow of the
American Academy of Family Physicians
and a member of the FAFP.
Congratulations to You!
At the 2008 AAFP Annual Leadership
Forum, Florida received a second-place
award for the Highest Percentage of Increase
in the Active Category in 2007 for chapters
with more than 1,000 active members.
Y O U R F A F P F O U N D A T I O N A T W O R K
Dr. Shahady Honored with National Award
The American Academy of Family Physicians and the
Society of Teachers of Family Medicine selected
Fernandina Beach physician Edward Shahady, MD, honoring
him as the national winner of the 2008 Medical
Economics Award for Innovation in Practice
Improvement. The award was given for his work in
developing the Diabetes Master Clinician Program.
Developed as a project of the FAFP Foundation, the goal
of the DMCP is to help primary care physicians and
their patients manage diabetes by implementing an
Internet-based diabetes registry and improving the quality
of care through group visits. Currently, 80 Florida
practices participate in the program, with 13,000
patients in the registry. Dr. Shahady is the medical director
of the DMCP and has more than 40 years of experience
with advising on prevention and treatment of the
disease. He is a member of the AAFP and the FAFP and
is also a past president of both the Society of Teachers of
Family Medicine and its Foundation. He continues to be
an active leader and innovator for family medicine. Dr.
Shahady received his award at the AAFP Conference on
Practice Improvement on December 6 in Savannah.

FAFP New England and CME
Cruise on the Jewel of the Seas
FAFP Future Meetings
March 27-29, 2009
102nd Family Medicine Weekend
Bay Point Marriott Golf Resort & Spa
Panama City
July 16-19, 2009
2009 Summer Break Away
Boca Raton Resort & Club
C A L E N D A R O F E V E N T S
November 13-15, 2009
103rd Family Medicine Weekend
Buena Vista Palace
Lake Buena Vista
Florida Family Physician 7

MEDICAL ACUPUNCTURE
A COMPLEMENT TO YOUR PRACTICE
by Kirksak Jay Poonkasem, MD, LMT, Administrative Fellow, University of South Florida/Morton Plant Mease Family Medicine
Residency, Integrative Medicine Fellow, University of Arizona College of Medicine – Center for Integrative Medicine
“Mrs. J, could you please tell me what food you have the most affinity for,
given no restrictions at all What about your favorite color What time of
the year do you look forward to the most” These are not the standard
types of questions that we ask patients in our primary care practices. I was
not trained to ask such questions while I was in medical school, and most
likely, you were not either. However, you will hear these questions being
asked by practitioners trained in the Eastern philosophies of medicine.
Several months ago, I embarked on a journey to explore other worlds and
discover fresh ideas for treating my patients. To expand my mind and to
look at medicine from a totally new perspective, I took part in a medical
acupuncture course for physicians. Interestingly, I found physicians from
all specialties of medicine participating in this course (family medicine,
internal medicine, surgery, physical medicine and rehabilitation, sports
medicine, anesthesiology, pain management, OB/GYN, etc.).
Most physicians have heard about acupuncture but do not understand it.
It can be difficult for us to understand the Eastern medical philosophies
and accept them because they are so different from the philosophies our
minds draw from when we see patients. To most of us, the concepts of
“energy,” and yin and yang are foreign and, at best, theoretical. With a little
background information, you can begin to realize the intricacies and
the foundations of this type of medicine. A full discussion of the theory of
acupuncture is beyond the scope of this article, but a simplified explanation
will suffice.
According to acupuncture theory, an energetic entity called Qi (pronounced
“chee”) flows throughout the body. There are different types of
Qi, and each type has its own properties and functions. Qi flows throughout
the body through a multitude of energy channels called meridians. In
a balanced and disease-free state, the energy flow is smooth and uninterrupted.
When minor symptoms occur or diagnosable diseases are present,
it is said that the energetic system of the body is out of balance and/or that
the Qi flow is impeded or blocked. With careful placement of acupuncture
needles at points along the meridians, we strive to unblock and rebalance
the energetic system of the body.
My current medical acupuncture course has continued to open my eyes to
ways we can use this to help our patients every day, either in a hospital or
office setting. Can you imagine decreasing the length of a patient’s stay
with post-operative ileus using acupuncture Or making a patient more
comfortable post-operatively by managing pain with only a few acupuncture
needles Helping a patient to quit smoking non-pharmacologically, to
tolerate chemotherapy better or to finally be rid of that bothersome tennis
elbow These are just some of the possibilities. Practitioners are using
acupuncture to treat these and many other conditions all over the country
and the world!
Many people inquire about the safety of acupuncture. The needles that I,
and most physicians, use in practice are sterile, disposable needles that are
meant for one-time use. The standard acupuncture needles that I use for
the body are 0.25 mm in diameter and 40 mm in length. These needles are
Dr. Poonkasem treating a patient with lateral epicondylitis
different from the hypodermic needles we are accustomed to using.
They are solid, non-cored and non-beveled. Acupuncture needles
separate tissue as they are inserted rather than cutting the tissue.
There is also no need to be concerned with introducing the skin plug
down to the deeper tissue levels.
Complications from acupuncture are very few. Some patients may experience
“needle shock,” which is a vaso-vagal reaction to being needled.
Most contraindications are relative. Patients should be evaluated on a
case-by-case basis to determine if acupuncture is right for them.
There is abundant literature available describing many randomized,
controlled trials on acupuncture. Due to the nature of the modality, it is
challenging to design acupuncture studies. Every patient is evaluated separately,
and treatments are highly individualized.
From my experience thus far, belief (or disbelief) in acupuncture is not
necessary for it to work. Acupuncture has even been performed on animals
with positive results. Family, friends and patients whom I have
treated with acupuncture embrace it because they see results. As I near
the completion of my medical acupuncture program, I can see that it
has transformed how I evaluate and treat patients while never neglecting
the standard of care. Acupuncture has been a great adjunct to my
current practices.
The American Academy of Medical Acupuncture is an outstanding
resource for more information about medical acupuncture. If
you are interested in incorporating this into your practice, a list
of training programs is available on their Web site, at
http://www.medicalacupuncture.org. You may also contact me
for more information at kirksak.poonkasem@baycare.org.
8

The FAFP Partners with
Atlantic Health Partners
The Florida Academy of Family Physicians is pleased to announce a partnership with Atlantic
Health Partners, a leading physician vaccine-purchasing program. With the increased burden
you face providing a growing number of vaccines to your patients in a fiscally responsible
manner, Atlantic may be able to help lower your costs and improve your purchasing terms.
Advantages of Atlantic’s program include:
• Favorable pricing for sanofi pasteur and Merck vaccines
• Improved purchasing terms, as you do not need to make large,
multi-product orders
• No fee to participate and enrollment is voluntary
• Online or phone orders placed directly with sanofi pasteur and Merck
• Full spectrum of pediatric, adolescent, adult and travel vaccines
• Reimbursement support provided by Atlantic
We encourage you to contact Jeff Winokur at Atlantic Health Partners at (800) 741-2044 or jwinokur@atlantichealthpartners.com
for more information and to determine how Atlantic can benefit your practice.

MULTIPLE
SCLEROSIS
by Megan W. Barrett,
MSN, ARNP-c, Multiple
Sclerosis Certified Nurse;
Research Advocate, North
Florida Chapter, National
MS Society
Important Information
for the Family Physician
Multiple sclerosis (MS) is a chronic, unpredictable,
usually relapsing-remitting, demyelinating
disease of the central nervous system.
A specific cause has not been identified;
however, the etiological associations include
genetic predisposition, environmental triggers
and autoimmunity. 1 MS is the most common
neurological disease in people under the age of 40, and it
afflicts more than 400,000 Americans. 2 Its diagnosis is one of
exclusion, and its symptomatology mimics that of many other conditions
with which people present to their family physicians (FPs).
The Institute for Healthcare Improvement, the Robert Wood Johnson
Foundation, the U.S. Department of Health and Human Services and
the World Health Organization recognize appropriate management
of chronic illness as a problem in care delivery. The chronicity of
MS, coupled with the fact that the lifespan of people with the disease
is similar to that of people without it, mandate the need for FPs
to be familiar with the neurological aspects of the disease, as well as
the primary care needs of people with it. 3, 4
The most common comorbid conditions in people with MS are
hypertension, hypercholesterolemia, arthritis, irritable bowel syndrome
and chronic lung disaease. 5 Unfortunately, people with MS
tend to lack knowledge about other chronic diseases, and may also
dismiss the possibility of acquiring a second chronic illness. 6 The
Approximately 85 percent of people with MS start out with a
relapsing-remitting course, and about half of these people will
experience secondary progressive disease after 10 years. Less
common types of MS include primary progressive (10 percent)
and progressive relapsing (5 percent). There are six available disease-modifying
agents for MS: Avonex (interferon beta 1a),
Betaseron (interferon beta 1b), Copaxone (glatiramir acetate);
Rebif (interferon beta 1a, Novantrone (mitoxantrone) and Tysabri
(natalizumab). 1 These medications require monitoring for adherence,
site reactions and/or systemic side effects. The most common
primary care needs of people with MS relate to bladder and bowel
symptoms, fatigue, sexual dysfunction, depression, acute bacterial
or viral illness and pseudoexacerbation related to the latter. A
patient’s neurologist may be managing disease-modifying and
symptomatic treatment; however, the FP should be well-versed in
the drugs used to treat the common symptoms, as well as the monitoring
required for the disease-modifying agents in order to ensure
that essential elements of chronic illness care are provided.
Collaboration between the neurologist and FP is vital in the care of
these patients in order to maintain their health and prevent the
development of secondary conditions.
10

influence of the FP is extremely important in these cases. Barriers
to primary care, including physical barriers to access, patient frustration
with lack of primary care provider familiarity or experience
with MS and erroneous assumptions, have been identified in the literature
as significant roadblocks to the receipt of recommended
preventive screening in this population. 3, 7-10 The literature also suggests
that recommended screening and counseling needs are not
being met in the MS population. So what can a busy FP do to
provide appropriate preventive care to this vulnerable population
Primarily, consider the disability-friendliness of your office environment.
Secondly, make sure that patients with MS are scheduled for
preventive health screening visits. If a patient presents to the office
for an acute illness, be sure to review screening history at the visit,
and schedule testing and follow-up appointments if needed. Thirdly,
be aware of your closest comprehensive MS center, local neurologists,
rehabilitation and counseling services, and social and community
services. Such information can be readily found on the National
MS Society’s Web site, http://www.nationalmssociety.org.
While a cure for MS has yet to be discovered, recent progress has
been made in all of the proposed etiological areas contributing to the
disease. Susceptibility genes have been reported, environmental risk
factors identified, new therapies targeting autoimmunity and nerve
protection are being studied, advanced rehabilitation techniques are
being used, and advocacy for people with MS is on the rise.
Encouraging healthy lifestyles and being the stimulus for preventive
care in this population will increase the likelihood of a healthy life
for people with MS.
Disclosure: The author serves on speakers’ bureaus for Bayer, Biogen-Idec,
Serono-Pfizer and Teva Neuroscience.
References
1. http://www.nationalmssociety.org
2. Holland, N. Clinical bulletin: Information for health professionals –
Overview of multiple sclerosis. Retrieved September 7, 2008, from National
MS Society Web site: http://www.nationalmssociety.org/for-professionals/
publications/clinicalbulletins/download.aspxid=161, 2006.
3. Cheng, E., Myers, L., Wolf, S., Shatin, D., Cui, X., Ellison, G., et al.
Mobility impairments and use of preventive services in women with multiple
sclerosis: observational study. British Medical Journal, 2001; 323: 968-969.
4. The National Coalition on Health Care, The Institute for Healthcare
Improvement. Curing the system: Stories of change in chronic illness care.
From http://www.ihi.org/IHI/Topics/ChronicConditions/
AllConditions/Literature/ CuringthesystemStories ofchangeinchronicillness.htm
5. Marie, R., Cutter, G., Tyry, T., Vollmer, T., & Campagnolo, D. Comorbid conditions
are common in multiple sclerosis. Paper presented at the Consortium of
Multiple Sclerosis Centers, 2007.
6. O’Connell, D. When the diagnosis is MS...& something else. InsideMS,
2005; June-July: 50-53.
7. Beatty, P., Hagglund, K., Neri, M., Dhont, K., Clark, M., & Hilton, S. Access
to health care services among people with chronic or disabling conditions: patterns
and predictors. Archives of Physical Medicine and Rehabilitation, 2003;
84: 1417-1425.
8. DeJong, G. An overview of the problem. American Journal of Physical
Medicine & Rehabilitation, 1997; 76(3): 2-8.
9. Tezzoni, L., McCarthy, E., Davis, R., Harris-Davis, L., & O’Day, B. Use of
screening and preventive services among women with disabilities. American
Journal of Medical Quality, 2001; 16(4): 135-144.
10. Nosek, M. H., B., Rintala, D., Young, M., & Chanpong, G. National study
of women with physical disabilities: Final report. Sexuality and Disability,
2001; 19(1): 5-39.
Florida Family Physician 11

y Diego T. Torres II, MD,
Ormond Beach
To Herb
or Not to Herb
Herbal medicine use has increased approximately 380 percent since
1990. Market sales have reached an estimated $3.4 billion annually. 1,2
Eisenberg et al. recently reported that the use of complementary
therapies was more common among women, middle-aged, collegeeducated
and higher-income individuals. Almost one in five people in
the survey taking herbs and/or high-dose vitamins were also taking
prescribed medicines. 1 Another large national survey revealed that only
one-third of the adults who reported using herbal supplements did so
“in accordance with evidence-based indications.” 3 Surprisingly, a study
by the Stanford University Center for Research in Disease Prevention
showed that dissatisfaction with traditional allopathic medicine was
NOT a predictor of herbal use. The most important variable was that
alternative medicine parallels their own values and health philosophy.
Poor health status, back pain, allergies and digestive and lung problems
were also measures for the use of complementary treatments. 4 The purpose
of this article is to emphasize this dynamic and review the riskbenefit
profiles of a few of the top herbs based on reported use. I hope
this will encourage dialogue between primary care physicians and their
patients and raise awareness of not only potential benefits of herbal
medicines in select populations, but also the potential drug-herb interactions
that put an estimated 15 million adults at risk. 1
Echinacea
Echinacea is among the most popular herbal medicines used in North
America, reaching annual sales of more than $300 million. 2,5 It is a member
of the daisy family, and its potentially active compounds have
immunostimulatory as well as anti-inflammatory, anesthetic, antiviral,
antineoplastic and antioxidant activity. 6-9 It is used for the treatment and
prophylaxis of upper respiratory infections. 5,6,8 Standard dosing is 250 to
500 mg of the capsule form t.i.d. at the onset of symptoms. 8 In vitro,
E. purpurea has been shown to increase TNF-α and interleukins, thus
activating macrophages and increasing neutrophil phagocytosis. 5,7,9
Experts, therefore, warn of its use in patients who may need immunosuppression,
such as those awaiting organ transplantation and patients diagnosed
with systemic illnesses such as TB, HIV/AIDS, multiple sclerosis
and autoimmune disease. 6,8 However, it has been reported that long-term
use (more than eight weeks) has been associated with immunosuppression
and can, therefore, increase the risk of infection and cause poor
wound healing. 6
Due to the immunostimulatory effects of Echinacea, allergic reactions
are the most commonly reported side effects. 6,7 Thus, caution should be
taken in patients with a history of asthma and atopy. 6 An Australian
Advisory Committee has reported cases of hepatitis, asthma, rash and
anaphylaxis in conjunction with Echinacea use. 7 A small Canadian
study published in 2000 was the first to prospectively study fetal safety
after gestational use of Echinacea. Findings showed that “the rate of
major malformations between the study and control groups were not
statistically significant.” 2
Furthermore, a University of Washington study showed that
Echinacea was not effective in 2- through 11-year olds treated for
URI symptoms and it increased the risk of rash. 5 The PDR for
Herbal Medicines, Third Edition, reports reduced sperm motility
and velocity after contact with donor sperm. Echinacea has also
been shown to inhibit CYP 450 3A4, and caution is advised with coadministration
of medications that act as substrates. 9
Ginko Biloba
Ginko Biloba is a fossil tree that has not changed in more than 200
million years and has a high tolerance to pollution, insects and microorganisms.
10 It has been marketed as a memory enhancer and is used in
clinical practice for dementia, tinnitus and claudication. 7,11 It has also
been used experimentally for macular degeneration (age-related), vertigo,
erectile dysfunction and altitude sickness. 6,7 The most common
dosage used clinically is 40 mg t.i.d. Sales reached approximately $151
million in 1998. 7
Active components, especially the ginkolides, antagonize platelet-activating
factor (PAF). PAF causes platelet aggregation, promotes inflammation
and contracts smooth muscle (including bronchial). 10 Studies show in
vitro and in vivo actions against edema, hypoxia, free-radicals and platelet
aggregation. 7 In addition to improving cerebral capillary blood flow, it has
been observed that Ginko is an inhibitor of monoamine oxidase A and
B. 10,11 Thus, its actions with respect to dementia are due to vasoregulation
and neurotransmitter modulation. 6 High-quality studies suggest Ginko is
12

more effective than placebo in slowing cognitive decline in dementia. The
evidence for enhancing normal cognitive function is not as compelling. A
review of clinical trials for its use in tinnitus showed a statistically significant
effect on the perceived loudness of ringing after 12 weeks of
treatment. Furthermore, European studies have shown similarities in
effectiveness between Ginko and pentoxifylline for claudication. 7
The adverse effects of Ginko are usually mild and reversible, but serious
bleeding events have been reported. Due to its antiplatelet effect, it may
increase the action of warfarin. It is recommended to discontinue Ginko
use at least 36 hours prior to surgery. Intracranial bleeding, seizures and
post-operative bleeding have been reported. 6,7
St. John’s Wort
St. John’s Wort (Hypericum perferatum) grows as a common weed in the
United States. 12 It is used almost exclusively now as an antidepressant,
with clinical trials supporting its use in mild-to-moderate depression but
not in major depression. 6,7,13 The dosage is 300 mg of extract t.i.d. 8,9 It is
one of the most prescribed antidepressants in Europe, and U.S. sales
reached $86 million in 2000. 12,14
Many of the active compounds of Hypericum have been shown to inhibit
the reuptake of serotonin, dopamine and norepinephrine. 6,7,12 It has been
shown to be more effective than placebo and equivalent to imipramine,
amitriptyline and fluoxetine in improving depression scores. 7,9 Anxiolytic
effects have also been described most likely through Hypericum’s effects
on L-glutamate and GABA. Reversal of this effect has been shown after
administration of the benzodiazepine antagonist flumazenil. 9 Hypericin, a
component of St. John’s Wort, inhibits colon cancer cells in vitro. Other
reported effects include antioxidant, antiviral and antibacterial activity.
Another fraction has shown activity against S. aureus (including MRSA)
and H. pylori.
References
1. Eisenberg, D. et al. Trends in alternative medicine use in the United States, 1990-
1997. JAMA. 1998: 280: 1569-1575.
2. Gallo, M. et al. Pregnancy outcome following gestational exposure to Echinacea.
Arch Intern Med. 2000: 160: 3141-3143.
3. Bardia, A. et al. Use of herbs among adults based on evidence-based indications:
Findings from the National Health Interview Survey. Mayo Clin Proc. 2007 May:
82(5): 561-566.
4. Astin, J. Why patients use alternative medicine. JAMA. 1998: 279: 1548-1553.
5. Taylor, J. et al. Efficacy and safety of Echinacea in treating upper respiratory infections
in children. JAMA. 2003: 290: 2824-2830.
6. Ang-Lee, M. et al. Herbal medicines and perioperative care. JAMA.
2001: 286: 208-216.
7. Ernst, E. The risk-benefit profile of commonly used herbal therapies:
ginko, St. John’s Wort, Ginseng, Echinacea, Saw Palmetto, and Kava. Ann
Intern Med. 2002: 136: 42-53.
8. Debusk, R. and Treadwell, P. Herbs as Medicine. What You Should Know. 2000.
Debusk Communications, Tallahassee, Florida, USA.
9. PDR for Herbal Medicines, Third Edition. 2004. Thomson PDR, Montvale, NJ.
10Oken, B. et al. The efficacy of Ginko biloba on cognitive function in Alzheimer
disease. Arch Neurol. 1998: 55: 1409-1415.
11. Palacioz, K. Ginko for memory. Prescriber’s Letter detail-document #180926.
Sept. 2002; Vol 18: #180926.
12. Gaster, B. and Holroyd, J. St. John’s Wort for depression. Arch Intern Med.
2000: 160: 152-156.
13. Markowitz, J. et al. Effect of St. John’s Wort on drug metabolism by induction
of cytochrome P450 3A4 enzyme. JAMA. 2003: 290: 1500-1504.
14. Lecrubier, Y. et al. Efficacy of St. John’s Wort extract WS 5570 in major
depression: A double-blind, placebo-controlled trial. Am J Psychiatry. 2002:
159: 1361-1366.
The most common side effects are nausea, rash and photosensitivity. 7-9,12
The suggested mechanism for herb-drug interactions is by induction of
CYP 450 3A4 and the P-glycoprotein drug efflux transporter. Therefore,
St. John’s Wort can significantly increase the metabolism of many drugs,
causing reduced levels of such medicines as amiodarone, digoxin,
cyclosporine, anti-retrovirals, anticoagulants, ß-blockers and calcium
channel blockers. 6,7,9,13 Blood levels of oral contraceptives may also be
reduced, resulting in unwanted pregnancy. 9,13 Expert opinion also concurs
with a theoretical possibility of serotonin syndrome in conjunction with
SSRIs and MAOIs. 6-9 Mania and hypomania have also been reported. St.
John’s Wort is contraindicated in pregnancy, and in vitro studies showed
mutagenicity in sperm cells.
In conclusion, the Dietary Supplement Health and Educations Act of 1994
exempts herbal supplements from safety and efficacy requirements, such
as those regulating prescription drugs. 3,6 The herbal industry claims it cannot
sustain the costs of long-term studies, but retail sales prove otherwise. 7
Healthy patients who lack polypharmacy may indeed find benefit from
herbal supplements. Unfortunately, the public perceives herbal medicines
as safe when there are not many high-quality studies supporting their indications.
Furthermore, potency and pesticide, herbicide and heavy-metal
content of herbal products is controversial. 7 I fear that the use of herbal supplements
is severely underreported, as most sample populations do not
include non-English-speaking minorities. 4 It is our duty to promote safety
and encourage discussions with our patients. The clinical importance of
this dialogue is magnified not only by the potential for drug-herb interactions,
but also by large population surveys that suggest that only one-third
of patients may be using herbs for their evidence-based indications. 3

y Kathy D. Sella, MD,
PGY-2, Mayo Family
Medicine Residency,
Jacksonville
Menopause and
The term menopause is derived
from two Greek words:
“meno,” which translates into
“month,” and “pausis,” which
means “cessation.” Together,
they literally mean “last menstruation.”
A modern definition
of the term has defined it as the
absence of menses for a full
year and does not differentiate
the underlying mechanism. It is
during this average four-year 1
period leading up to menopause
that women may experience a
variety of symptoms related to
fluctuating hormonal levels,
notably decreasing levels of
estrogen and progesterone. 2
Perimenopausal symptoms include vasomotor
symptoms, urinary incontinence, vaginal
atrophy, disrupted sleep, sexual dysfunction
and mood disorders. The most dominant of
these symptoms include vasomotor symptoms,
including hot flashes and night
sweats. Hot flashes occur in as many as 75
percent of Western females over the age of
50 years old, but rates vary with age and
ethnicity. 3 The SWAN study showed that
presentation of symptoms varies between
racial groups, with white American women
experiencing higher rates of psychomotor
symptoms than other ethic/racial groups,
and African-Americans experiencing more
vasomotor symptoms. 4
Women often seek treatment for perimenopausal
symptoms. Traditionally, hormone
replacement therapy (HRT) was used
for symptomatic relief. However, the
Women’s Heath Initiative questioned the
safety of this therapy, and many women
began to seek out alternatives, leading to
increased research in botanical and dietary
supplements. Studies have shown that 44 to
66 percent of menopausal women use botanical
dietary supplements, often in addition
to hormone replacement therapy. 5,6 Often,
women do not receive advice from their
health care providers, nor do they make
records of their use of botanicals. Vashisht,
Domoney, Cronje and Studd 6 concluded that
physicians were the primary source of
information regarding botanicals for
menopausal women less than 20 percent of
the time. Fortunately, a University of
Chicago study found that health care
providers were willing to increase their
knowledge and usage regarding these
alternative treatments. 7 The most commonly
used botanicals for menopausal symptoms
include black cohosh, evening
primrose oil, red clover, dong quai and soy
isoflavones. Numerous studies have evaluated
the effectiveness, safety and side
effects of these botanicals.
Black cohosh is a native North American
plant that has been studied for many years.
A common preparation of this herb is
Remifemin, with daily dosing recommendations
between 40 to 80mg/day. It has
been the target of clinical trials that generally
show supportive evidence for the
treatment of menopausal symptoms such
as hot flashes, profuse sweating, insomnia
and anxiety. However, many studies have
been limited by methodology, and further
evaluation is needed. 8
The herb is noted to have minor transient
side effects, including nausea, vomiting,
headaches, dizziness, mastalgia and weight
gain. There have been case reports of hepatotoxicity
associated with black cohosh, but
direct correlation has not been demonstrated,
and previous safety trials on the herb
have shown it to be safe for daily usage.
However, the U.S. Pharmacopecia Council
of Experts recently reviewed reports of
liver damage possibly connected to black
cohosh and concluded that, while all
reports of “liver damage were assigned
possible causality, none were probable
or cer tain causality.” 9 The Dietar y
Supplemental Expert committee did conclude
that black cohosh products should
bear a warning label.
The mechanism of action of black cohosh is
poorly understood, but a small 2007 study
from Columbia University on postmenopausal
women showed the herb to
have central nervous system effects,
specifically on the mu receptors with up
regulation and down regulation in different
parts of the brain. However, this effect had
also been seen in placebos in prior studies. 10
The study was able to conclude that black
cohosh did not have an estrogen-like effect
on the opiod activity restoration. 10 The
HALT study also concluded that black
cohosh, when taken for vasomotor symptoms,
after one year of use had no effect on
vaginal cytology or reproductive hormones,
notably follicle stimulating hormone
(FSH), luteinizing hormone or estradiol. 11
Perimenopausal women with a history of
breast cancer may have another benefit.
Some evidence shows that black cohosh
is safe for this subset of the population
and may even have some tumor-growthinhibiting
properties. 12
14

Botanicals
Evening primrose oil is another North
American plant with high levels of linoleic
and gamma linolenic acid. Daily dosing recommendations
vary from 3 to 6 grams/day
with some preparations containing Vitamin
E as a natural stabilizer. Mild side effects
noted included bloating, nausea, flatulence
and diarrhea. 8 A small, randomized trial of
56 females in menopause (with only 35
completing the study) were given either 2
grams of evening primrose oil per day or a
placebo. The only significant difference was
a reduced number of nighttime flushes over
baseline (P

with Shanghai Endometrial Cancer Study
found that postmenopausal women did not
have an increased risk of endometrial cancer
with consumption of soy isoflavones
whether or not at least one A allele
of the rs605059 polymorphism of the
17Éß-hydroxysteroid dehydrogenase type I
(17Éß-HSD1) gene was present. 19 17Éß-
HSD1 is the final step of the estrogen pathway,
converting estrone (E1) to the more
biologically active estradiol (E2). 19
Soy isoflavones do appear to have an effect
on breast tissue in a biphasic manner,
dependent on estrogen levels. In a recent
in-vitro study by Imhof, Imhof and Molzer,
in MCF-7 (ER +) breast cancer cells
showing unphysiologically low levels of
estrogen (

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Florida Family Physician 17

y David B. Feller, MD,
Clinical Associate
Professor, University of
Florida College of
Medicine, Gainesville
CAM
Primer for Family
Physicians
Complementary and alternative medicine (CAM) represents a broad range of healing philosophies, approaches and
therapies. In general, CAM has been defined as treatments and health care practices not taught widely in medical
schools, nor used in hospitals or usually reimbursed by medical insurance companies. What is considered CAM
versus a standard therapy may change depending upon the historical period, the particular culture or the politically
dominant health system. Common examples include homeopathy, herbal medicine, TCM (traditional Chinese
medicine, which includes acupuncture, herbals and energy therapies), chiropractic manipulation, Ayurvedic medicine,
chelation therapy, mind-body medicine and therapeutic touch.
Despite the fact that most physicians have minimal formal training
with these modalities, our patients commonly use them. Eisenberg’s
(JAMA, 1998. 280(18):1569-75) highly publicized survey demonstrated
that more than 42 percent of patients used some type of alternative
therapy. More recent studies have suggested that nearly 50
percent of patients (including physicians themselves) used CAM at
some point. Even with CAM’s increasing popularity, patients are
often hesitant to tell their physicians they are using it. Surveys
demonstrate patients only volunteer the information about CAM use
about one-third of the time, so direct questioning is essential.
So why do our patients use CAM Well, modern Western medicine
just doesn’t hold all the answers to many of our common medical
problems. In addition, many of our patients perceive significant risk
with our usual allopathic therapies (recall the hype associated with
the recall of Baycol and Vioxx and the recent estrogen “scare”). It’s
not surprising, then, that our patients look for other modalities that
are perceived as either safer or more effective. Unfortunately, this
perception that CAM is either safer or better than traditional therapies
can be faulty. It, therefore, becomes important that physicians
become familiar with CAM modalities enough to provide
reasonable guidance to our patients. Any therapy (traditional or not)
prescribed to our patients involves a personalized risk/benefit
analysis. CAM therapies should be no different and foster the same
scrutiny as any other therapy. In doing this analysis, safety (which
includes interactions with concomitant therapies) should be of
highest concern, followed by efficacy (objective or perceived) and
cost. Data quantity and quality vary greatly between the CAM
therapies, so one should judge the specific therapy, not all CAM as
a single entity.
One of the best sources of non-biased CAM information is from the
National Center for Complementary and Alternative Medicine
(NCCAM), http://nccam.nih.gov/. This section of the National
Institute of Health (NIH) functions as both a clearinghouse for CAM
information and as a funding source for CAM research. Although
research in many areas of CAM is still lacking, much more information
is available than in previous years.
The following is a quick summary of some common CAM therapies:
Acupuncture
Typically, acupuncture is performed by stimulating specific points along
the body either with needling (most commonly), laser, manual pressure or
moxibustion. It is thought that stimulating specific points helps return the
internal balance of energy that is blocked in the diseased state. To date,
these energy fields have not been validated, but regional effects on neurotransmitter
expression have been demonstrated. From a safety standpoint,
acupuncture is actually quite safe, and very few complications have been
reported to the FDA. However, if not practiced appropriately, acupuncture
has been associated (rarely) with cellulitis, Hepatitis B transmission,
pneumothorax and even cardiac trauma. Osteoarthritis of the knee,
headache, post-operative nausea and vomiting, chemotherapy-induced
nausea and vomiting and post-operative dental pain all have reasonable
data demonstrating a positive clinical effect from acupuncture.
Homeopathy
Homeopathic medicine is based on the principle of similars, and remedies
are often prescribed in high dilutions of materials thought to induce the
signs or symptoms one is treating. In most cases, the dilutions are so high
that they may not contain any molecules of the original agents at all. As a
consequence, homoeopathic remedies cannot act by typical pharmacological
means. Theories for a mechanism of action invoke the homeopathic
solution and postulate that information is actually stored in the dilution
process by some physical means. In general, homeopathic solutions have
been found to be safe but, despite much anecdotal success, are not felt to
demonstrate any clinical efficacy in randomized trials over placebo.
Ayurvedic Medicine
With a similar philosophy to traditional Chinese medicine, Ayruveda aims
to balance the mind, body and spirit. This is done through a variety of
practices and products, including herbal mixtures, meditation, diet and
lifestyle. Unfortunately, there have been safety concerns with the mixtures.
For example, a random survey of OTC-purchased remedies

evealed clinically significant heavy-metal contamination (lead, mercury
and arsenic) in more than 20 percent. Few good trials have been done to
assess the safety and efficacy of Ayurveda, so one should use caution in
recommending this therapy, given its unknown efficacy and documented
problems with herbal contamination. At the same time, some Ayurvedic
herbals have been shown to exhibit pharmacologic activity and deserve
further evaluation (e.g., guggul has lipid-lowering properties).
Chiropractic Manipulation
Central to chiropractic care is physical manipulation of the spine. It is theorized
that misalignments of the spine interfere with the energy flow that
normally supports good health. The goal then is to realign the spine to
regain appropriate energy flow. Chiropractic care is unique in that most
insurance companies reimburse for it, and it is generally considered the
least “alternative” of the CAM therapies. In general, spinal manipulation
is considered safe, with serious complications quite rare. Controlled trials
indicate that spinal manipulation is an equally effective alternative to conventional
therapies for mild to moderate low-back pain.
Chelation Therapy
This therapy involves using chelating agents, usually intravenous EDTA
(ethylene diamine tetra-acetic acid), to treat CAD. EDTA is thought to
work by removing calcium from coronary plaque, which then results in
dissolution of the plaque. Others postulate that EDTA exhibits
anti-inflammatory and anti-oxidant effects on the endothelium, which
result in improved endothelial function. Both safety and efficacy are indeterminate,
since most data is anecdotal. Randomized trials that have been
published have so few patients that it is unwise to conclude anything. The
NCCAM is currently enrolling patients into a large multicenter trial to try
to answer safety and efficacy issues more scientifically.
Herbal Therapy
Plants/herbals provide the backbone for the modern pharmaceutical
industry, so herbals typically represent the most commonly used form
of CAM. The safety, efficacy and utility depend upon the specific herb
in question and the source from which it is acquired. Examples include:
• Saw Palmetto appears very safe, has few interactions with other medications
or herbals and appears at least modestly effective for mild to
moderate BPH.
• St. Johns Wort is relatively safe but has numerous drug-herb interactions.
Studies also suggest it may be as effective as SSRIs for mild to
moderate depression with potentially fewer side effects.
• Ephedra was removed from the market because of concerns of severe
toxicity, including death. Although this was usually associated with
excessive doses, significant toxicity was reported even at typical
doses. Most clinical trials found minimal clinical efficacy for congestion
or weight loss.
In summary, it’s important to be familiar with CAM, since many of our
patients are using these therapies, and some do appear to provide safe and
effective alternatives to standard therapies. As further studies are done,
evidence, rather than anecdote, can fuel our recommendations.
Regardless of popularity, CAM should be evaluated to the same degree as
any traditional therapy.
Florida Family Physician 19

TREATMENT OF
HYPERTENSION
by Mark C. Houston, MS,
MS, FACP, FAHA
Abstract
Hypertension is the most common reason for visits to
physicians’ offices and the number-one reason for prescription
drug use. The target organ damage associated
with hypertension, such as stroke, myocardial infarction,
congestive heart failure, renal disease and large artery
disease, can be mitigated by aggressive non-drug and drug therapies.
Hypertension is a syndrome of various metabolic, functional and structure abnormalities
that must be viewed in a more global setting of cardiovascular risk.
Aggressive detection, evaluation and treatment of the “blood vessel health” are
mandatory to modern hypertensive care. Lifestyle modifications in conjunction
with vitamins, minerals, antioxidants, nutraceutical supplements, optimal nutrition
and drug therapy will prevent and treat hypertension and its sequelae while
addressing global cardiovascular risk, vascular biology, endothelial dysfunction
and overall vascular health.
Introduction
New and future treatment guidelines for lower target blood pressure (BP) levels in
the general hypertensive population, as well as in specific populations of hypertensive
patients with diseases such as diabetes mellitus, renal disease or coronary heart
disease, will demand a combination of nonpharmacologic (lifestyle modifications)
and pharmacologic therapy. 1, 2, 3, 4, 5 Lower recommended target BP goals of 130/80
mm Hg or perhaps 110/70 mm Hg cannot be attained without aggressive use of balanced
drug and non-drug treatments. Nutrition, dietary supplements, nutraceuticals,
vitamins, antioxidants, minerals, achieving ideal body weight, exercise (aerobic and
resistance training), restriction of caffeine and alcohol and cessation of all tobacco
products are crucial ingredients of this combination approach, if BP and subsequent
target organ damage (TOD) are to be reduced.
Hypertension (HTN) is a consequence of the interaction of our environment and
genetics. Macronutrients and micronutrients are crucial in the regulation of BP, subsequent
TOD and atherosclerosis (AS). Nutrient-gene interactions, oxidative stress
and subsequent gene expression have either positive or negative influences on vascular
biology (VB) in humans. Endothelial dysfunction (ED) and vascular smooth
muscle (VSM) dysfunction are the initiating and perpetuating factors in essential
Florida Family Physician 21

HTN. The correct combination of macronutrients
and micronutrients will significantly influence
the prevention and treatment of HTN and
subsequent vascular complications.
Nutrition Trials and
Hypertension
Reductions in BP, as well as reductions in CV
morbidity and mortality, have been demonstrated
in numerous short- and long-term clinical
HTN nutritional trials. 6, 7, 8, 9, 10, 11, 12, 13, 14 Even mild
increases in BP may increase TOD, such that
more aggressive and earlier treatment may be
needed to decrease CV risk. Combined
nutrients present in food, especially fruits and
vegetables, as well as single and combined
nutraceutical, nutrient or dietary supplementation,
have been demonstrated to reduce BP. 15
The combined low-sodium DASH II diet 10
reduced blood pressure 11.5/6.8 mm Hg
within two weeks, maintained this BP for
the duration of the two-month study and
improved quality of life. This level of BP
reduction is equivalent to that achieved with
pharmacologic monotherapy.
Nutraceuticals, Vitamins,
Antioxidants and Minerals
Sodium
A reduction in sodium intake to 2,400 mg per
day may reduce the incidence of hypertension
and lowers BP an average of 4 to 6 mm Hg systolic
and 2 to 3 mm Hg diastolic BP, especially
in salt-sensitive hypertensive patients. 16
Reduced sodium intake also reduces renal
dysfunction, proteinuria, CHF, CVA, vascular
hypertrophy, diastolic dysfunction and left ventricular
hypertrophy (LVH). 15 Further reductions
of BP can be achieved with progressive
restriction from 150 mmol to 100 mmol to 50
mmol of dietary sodium per day in the DASH
II diet. 10 A low-sodium diet combined with
increased potassium and magnesium is even
more effective. 16
Potassium
The magnitude of BP reduction with dietary
supplementation of 60 to 120 mEq per day of
potassium is 4.4 mm Hg systolic and 2.5 mm
16, 17
Hg diastolic BP in hypertensive patients.
In addition, potassium may reduce CV events
and CVA independent of BP and reduce the
risk of cardiac arrhythmias. 15 The recommended
dietary intake is a K+/Na+ ratio of
5:1. 4,15 Potassium reduces vascular smooth
muscle hypertrophy and vasoconstriction,
induces natriuresis and blunts the effects of
15, 16, 17
A-II and catecholamines.
Magnesium
Magnesium supplementation in the range of
500 to 1,000 mg per day reduces systolic BP 2.7
mm Hg and diastolic BP 3.4 mm Hg. 18
Magnesium lowers systemic vascular resistance
(SVR) and reduces arrhythmias. The mechanism
is blockade of calcium influx into VSM
cells (calcium channel blocker-like effect) and
increased levels of the vasodilating
prostaglandin E1(PGE1). 15
Calcium
A recent meta-analysis of the effect of calcium
supplementation in hypertensive patients
demonstrated a reduction in systolic BP of 4.3
mm Hg and diastolic BP of 1.5 mm Hg. 19
Calcium is particularly effective in patients
with a high sodium intake and when given in a
natural form with potassium and magnesium.
20, 21, 22 Blacks, elderly, diabetic, salt-sensitive,
pregnant and postmenopausal women
and low-renin hypertensives have the best
response. 15 Vitamin D may be intimately
involved in the role of calcium in hypertension
15, 20, 21, 22
through effects on rennin.
22

Table 1
Natural Antihypertensive Compounds
Categorized by Antihypertensive Class
Intervention
Diuretics
1. Hawthorne berry
2. Vitamin B-6 (Pyridoxine)
3. Taurine
4. Celery
5. GLA
6. Vitamin C (Ascorbic Acid)
7. K +
8. Mg ++
9. Ca ++
10. Protein
11. Fiber
12. Co-Enzyme Q-10
13. L-Carnitine
15. Celery
16. ALA (Alpha Lipoic Acid)
Calcium Channel Blockers (CCB)
1. Alpha Lipoic Acid (ALA
2. Vitamin C (Ascorbic Acid)
3. Vitamin B-6 (Pyridoxine)
4. Magnesium (Mg ++ )
5. N-Acetyl Cysteine (NAC)
6. Vitamin E
7. Hawthorne berry
8. Celery
9. Omega-3 fatty acids (EPA and DHA)
10. Calcium
11. Garlic
Beta-Blockers (BB)
1. Hawthorne berry
Central Alpha Agonists (CAA)
1. Taurine
2. K +
3. Zinc
4. Na + Restriction
5. Protein
6. Fiber
7. Vitamin C
8. Vitamin B-6
9. Co Enzyme Q-10
10. Celery
11. GLA/DGLA
12. Garlic
Direct Vasodilators
1. Omega-3 FA
2. MUFA (Omega-9 FA)
3. K +
4. Mg ++
5. Ca ++
6. Soy
7. Fiber
8. Garlic
9. Flavonoids
10. Vitamin C
11. Vitamin E
12. Co-Enzyme Q-10
13. L-Arginine
14. Taurine
Angiotensin Converting Enzyme Inhibitors (ACEI)
1. Garlic
2. Seaweed – various (wakame, etc.)
3. Tuna protein/muscle
4. Sardine protein/muscle
5. Hawthorne berry
6. Bonito fish (dried)
7. Pycnogenol
8. Casein
9. Hydrolyzed whey protein
10. Sour milk
11. Gelatin
12. Sake
13. Essential fatty acids (Omega-3 FA)
14. Chicken egg yolks
15. Zein
16. Dried salted fish
17. Fish sauce
18. Zinc
19. Hydrolyzed wheat germ isolate
Angiotensin Receptor Blockers (ARBs)
1. Potassium (K + )
2. Fiber
3. Garlic
4. Vitamin C
5. Vitamin B-6 (pyridoxine)
6. Co-Enzyme Q-10
7. Celery
8. Gamma Linolenic Acid (GLA) and DGLA

Protein
High intake of non-animal protein (1
g/kg/day) (Intersalt Study, Intermap Study) is
associated with a lower BP. 15, 16, 23 Hydrolyzed
whey protein 24 and sardine muscle extract 25
significantly lower BP in humans through an
angiotensin-converting enzyme inhibitor
(ACEI) mechanism. Animal protein with
reduced fat content may offer the same antihypertensive
15, 16, 23, 24
benefit.
Fats
Consumption of omega-3 fatty acids (polyunsaturated
fatty acids — PUFA), such as EPA
(eicosapentaenoic acid) and DHA (docosahexanoic
acid), significantly reduce mean BP in
humans by 5.8 to 8.1 mm Hg. 26, 27, 28, 29 This,
combined with omega-9 fatty acids (olive oil)
(monounsaturated, oleic acid), low saturated fat,
elimination of trans-fatty acids and increased
GLA (gamma linolenic acid), may have dramatic
effects on BP, VB and AS. The omega-3
to omega-6 fatty acid ratio should be 1:1 to 4:1
with consumption of cold-water fish (cod, tuna,
mackerel, salmon) or EPA/DHA supplements
(3 to 4 grams per day).
The omega-3 fatty acids increase nitric oxide,
decrease leukotrienes and throboxane A2,
improve insulin sensitivity and membrane fluidity,
have PPAR gamma activity, reduce calcium
influx, decrease plasma norepinephrine and
26, 27, 28, 29
improve endothelial dysfunction.
The omega-9 fatty acids lower BP about 8/5
mm Hg, reduce LDL oxidation, improve nitric
oxide bioavailability, reduce oxidative stress
and improve endothelial dysfunction. 30
There are concerns about mercury and other
toxic metals in fish. For this reason, high-potency-certified
fish oil capsules may be substituted
or used with fish consumption. The olive oil
dose is 40 grams of extra-virgin olive oil per
day (4 tablespoons). 30
Garlic
The prospective placebo-controlled studies utilizing
the correct form (wild garlic is best) and
dose of garlic demonstrate only minimal
decreases in systolic BP of 5 to 8 mm Hg or a
mean BP of 2 to 3 mm Hg. 31,32,33 However, garlic
may have numerous other beneficial vascular
effects, as it is a natural ACEI and calcium
15, 31, 32, 33, 34
channel blocker (CCB).
Seaweed
Wakame seaweed in doses of 3.3 grams per day
significantly lowered BP in hypertensive
humans within four weeks, due to its ACEI
activity and high mineral content. 35 The average
reduction in BP was 14/5 mm Hg. Long-term
15, 35
use in Japan appears to be safe.
Fiber
Clinical trials with various types of fiber to
reduce BP have been inconsistent. 16, 36 The average
BP reduction in prospective studies using
60 grams per day of oatmeal fiber (3 grams of
betaglucan per day, glucomannan or 7 grams of
psyllium per day) is 7.5 mm Hg/5.5 mm Hg, 15,
16, 36
but retrospective, epidemiologic studies and
meta-analysis suggest lower reductions in BP.
Vitamin C
Vitamin C at doses of 250 to 500 mg BID lowers
BP, especially in hypertensive patients with
37, 38, 39
initially low plasma ascorbate levels.
Vitamin C improves ED, improves aortic compliance,
increases nitric oxide levels, is a potent
antioxidant, decreases SVR and BP falls an
average of 7/4 mm Hg. The greater the initial
BP and the lower the plasma ascorbate level, the
greater the response. Combinations with other
antioxidants and vitamins may have synergistic
antihypertensive effects.
Vitamin B-6
Supplemental vitamin B-6 at 5 mg/kg/day
reduced BP 14/10 mm Hg over four weeks. 40
Vitamin B-6 reduces central sympathetic nervous
system activity and acts as a central alpha
agonist (i.e., Clonidine), a CCB and a diuretic.
Pyridoxine also improves insulin sensitivity and
carbohydrate metabolism, which improves BP.
Daily doses should probably not exceed 200 mg
to avoid peripheral neuropathy. 15
Lycopene
Paran et al 41 evaluated 30 subjects with
grade I hypertension given tomato lycopene
extract for eight weeks. The BP fell 9/7 mm
Hg within eight weeks. Lycopene is found
in high concentrations in tomatoes, tomato
products, guava, pink grapefruit, watermelon,
papaya and apricots. 15
Co-Enzyme Q-10 (Ubiquinone)
Enzymatic assays show a deficiency of Co-
Enzyme Q-10 (Co-Q-10) in 39 percent of
essential hypertensive patients versus only a 6
percent deficiency in controls. 15, 42 Human studies
demonstrate significant and consistent
reductions in BP averaging 15/10 mm Hg in all
43, 44, 45, 46, 47, 48
reported prospective clinical trials.
Doses of 100 to 225 mg per day (1 to 2
mg/kg/day) to achieve a therapeutic plasma
level of more than 3 micrograms/ml are effective
within four to eight weeks in reducing BP.
The BP remains steady at this level and returns
to baseline at two weeks following discontinuation
of Co-Q-10. Co-Q-10 reduces SVR, catecholamine
and aldosterone levels, improves
insulin sensitivity and endothelial function and
increases nitric oxide levels. 43, 44, 47 No adverse
effects have been noted at these doses with
chronic use. Patients have been able to stop or
reduce the number of antihypertensive drugs by
one to three with chronic ingestion of Co-
Enzyme Q-10. A reputable, certified
absorbable form, with excellent bioavailability
and measurement plasma levels, is an important
clinical consideration.
L-Arginine
L-arginine is the natural predominant precursor
for vascular nitric oxide. Administration of 10
grams orally per day in food and/or as a supple-
24

Table 2
Recommendations
Nutrition........................................................................Daily Intake
1. DASH I and DASH II-Na + diets
2. Sodium restriction ................................................50 to 100 mmol
3. Potassium ................................................................60 to 100 mEq
4. Potassium/Sodium ratio > 5:1 ........................................................
5. Magnesium ......................................................................1,000 mg
6. Calcium ............................................................................1,000 mg
7. Zinc ........................................................................................25 mg
8. Protein: total intake
(30 percent total calories) ................................1.0 to 1.5 grams/kg
A. Non-animal sources preferred, but lean or wild animal protein
in moderation is acceptable
B. Hydrolyzed whey protein ............................................30 grams
C. Soy protein (fermented is best)....................................30 grams
D. Hydrolyzed wheat germ isolate..............................2 to 4 grams
E. Sardine muscle concentrate extract ....................................3 mg
F. Cold water fish, fowl, poultry ....................3 servings per week
9. Fats: ..........................................................30 percent total calories
A. Omega-3 fatty acids (30 percent) PUFA ..............3 to 4 grams
(DHA, EPA, cold water fish)
B. Omega-6 fatty acids (10 percent) PUFA ........................1 gram
(GLA, canola oil nuts)
C. Omega-9 fatty acids (30%) MUFA......................4 tablespoons
(olive oil – extra virgin)
D. Saturated FA
(lean, wild animal meat) (30%)
E. P/S ratio
(polyunsaturated/saturated) fats > 2.0
F. Omega-3/Omega-6 PUFA, ratio 2:1 – 4:1
G. No trans-fatty acids
H. (hydrogenated margarines, vegetable oils)
I. Nuts: almonds, walnuts, hazelnuts, etc.
10. Carbohydrates (40 percent total calories)
A. Reduce or eliminate refined sugars and simple carbohydrates
B. Increase complex carbohydrates and whole grain fiber
(oat, barley, wheat), vegetables, beans, legumes
Oatmeal ..............................................................................60 grams
Oatbran (dry)......................................................................40 grams
Beta-glucan ..........................................................................3 grams
Psyllium ................................................................................7 grams
11. Garlic..................................................................4 cloves/4 grams
12. Wakame seaweed (dried) ..................................3.0 to 3.5 grams
13. Celery
Celery sticks ........................................................................4 sticks
Celery juice ..........................................................8 teaspoons TID
Celery seed extract ..................................................1,000 mg BID
Celery oil (tincture)............................................to 1 teaspoon TID
14. Lycopene
Tomatoes and tomato products, guava, watermelon, apricots,
pink grapefruit, papaya
Exercise....................................................................seven days/week
• Aerobically at 60 to 80 percent MHR
60 minutes daily
4,200 KJ/week
• Resistance training ..........................................three days per week
Weight Loss
• To LBW (lean body weight)
• Lose 1 to 2 pounds/week
• BMI < 25
• Waist circumference
< 35 inches in female
< 40 inches in male
• Total body fat
< 16 percent in males
< 22 percent in females
• Increased lean muscle mass
• Reduce WHR to below 0.9
Alcohol Restriction..................................................< 20 grams/day
Wine < 10 ounces
Beer < 24 ounces
Liquor < 2 ounces (100-proof whiskey)
Caffeine Restriction ..................................................< 100 mg/day
Tobacco and Smoking ............................................................STOP
Avoid drugs and interactions that increase BP
Vitamins, Antioxidants and Nutraceutical Supplements
1. Vitamin C........................................................250 to 500 mg BID
2. Vitamin B-6 ................................................................100 mg BID
3. Co-Enzyme Q-10 ..........................................100 mg QD to BID
4. L-Arginine (supplement) plus lentils,
hazelnuts, walnuts, peanuts ......................................5 grams BID
5. Taurine ................................................................2 to 3 grams BID
6. Pycnogenol ..................................................................200 mg QD

ment significantly reduces BP in human subjects
by 6.2/6.8 mm Hg and improves ED and
49, 50
blood flow.
Taurine
Taurine, a sulfonic beta-amino acid, is significantly
reduced in the urine of essential hypertensive
patients. 51 Administration of six grams
of taurine per day lowers BP 9/4 mm Hg. 52
Taurine induces a sodium-water diuresis and
vasodilation, increases atrial natriuretic factor
(ANF), reduces sympathetic nervous system
activity and aldosterone levels, improves insulin
sensitivity and reduces homocysteine levels.
Celery
Celery has antihypertensive properties due
to 3-N-butyl phthalide, apigenin and other
substances that act like ACEI or CCB blockers.
Four large celery sticks per day or the
equivalent in celery juice, celery oil or
celery-seed extract reduces BP in animals
53, 54, 55, 56, 57
and humans.
Pycnogenol
Pycnogenol, a bark extract from the French
maritime pine, is a mixture of bioflavonoids
with antioxidant and antihypertensive properties.
58 A dose of 200 mg per day significantly (p
< 0.05) reduced systolic BP in a small study of
eleven hypertensive patients during an eightweek
period. 58
Combinations
Combinations of various nutraceutical or
dietary supplements, vitamins and antioxidants
may further enhance BP reduction, reduce
oxidative stress and improve vascular function
and structure. 59 Optimal doses and combinations
are yet to be determined, but future
research will provide important data.
Natural Antihypertensive
Compounds Categorized by
Antihypertensive Class
As has been discussed previously, many of the
natural compounds such as food, nutraceutical
and dietary supplements, vitamins, antioxidants
or minerals function in a similar fashion to a
specific class of antihypertensive drugs (Table
1). 15 Although the potency of these natural compounds
may be less than or equal to the antihypertensive
drug and the onset of action slower
when used in combination, the antihypertensive
effect is magnified. In addition, many of these
natural compounds have varied, additive or synergistic
antihypertensive mechanisms.
Conclusion
Individuals with pre-hypertension and Stage I
hypertension can incorporate numerous
lifestyle changes, including the selective use
of nutraceuticals, vitamins, antioxidants and
minerals to achieve a normal blood pressure
and improve vascular structure, function and
health. This will achieve improved reductions
in TOD. Specific recommendations are shown
in Table 2. The combinations of natural remedies
and lifestyle changes are most likely
additive to the antihypertensive effects of
pharmacologic agents. Utilization of different
“classes” of natural antihypertensive compounds
are likely to have similar, but smaller,
effects on BP, based on the known or previous
response to pharmacologic drugs(s).
Mark C. Houston, MS, MS, FACP, FAHA
Associate Clinical Professor of Medicine
Vanderbilt University School of Medicine
Director, Hypertension Institute and
Vascular Biology
Medical Director, Division of Nutrition
Saint Thomas Medical Group,
Saint Thomas Hospital
4230 Harding Road, Suite 400
Nashville, Tennessee 37205
Phone: 615.297.5551
Fax: 615.467.0365
E-mail: mhoustonhisth@yahoo.com
26

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blood pressure in cortisol-treated humans. J.
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50. Siani A, Pagano E, Iacone R, et al. Blood pressure and
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51. Ando K, Fujita T. Etiological and physiopathological
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52. Fujita T, Ando K, Noda H, et al. Effects of
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58. Hosseini S, Lee J, Sepulveda RT, et al. A randomized,
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Florida Family Physician 27

y Russ Hostetler, MD
Plant City
The Root Doctor
And other Musings on Being a Family Doctor
As soon as I walked into the exam room, she started crying. She did not look away for
even a second. She just stared at me, following my every movement with apprehension
on her tearful face. Her mother, leaning on the exam table just behind her, started
to rub her back gently and told her everything was going to be all right.
I would have expected such behavior from a 2-year-old. At that age,
having had the experience of immunization shots, kids just assume
you are going to try to kill them, and they cling to their mothers and
fathers like pups to the belly of a possum. But even though she was
tiny for her age, this girl was nearly 7 years old, and we had met
before, years earlier. I thought she’d remember me, but her memory
was clouded by the experiences of the intervening two years, and it
was clear that she was afraid. I tried to console her.
“It’s OK, LaTeesha. Don’t you remember me” I reached out and
gently touched her knee. She withdrew, scrunching up closer to her
mother. I looked to the mother for help.
“LaTeesha, you be ahrye. Dis doctah ain’t gonna hurcha,” she consoled.
“Let him zamen you so wees can figger out whatta do.” She
gently pushed her daughter back to the end of the exam table. The
tears continued but with a more quiet sob.
“Of what is she so afraid” I asked softly.
“Teesha, tell da doctah whuh you so ’fraid uh.” The mother was gentle
and encouraging, not demanding or forceful.
The little girl whimpered a bit more, sniffed, drew a finger under her
nose and wiped it on her jeans, then looked up from a bowed head
and asked, “You gonna pee on the ground an make mud”
“What” came out of my mouth before I could think, and my tone
implying incredulousness was not mistaken by the mother. She
looked at my white face with a look that said she understood my lack
of understanding, my cultural ignorance.
“Huh daddy tuhk huh tuh ah root doctah. Fuh a treatmen, dey tuhk
huh intuh duh woods at nye by duh full moon ’til he foun duh rye
kindduh red clay duht. Den he pissed awn duh duht tuh make mud.
Den he strip huh naked an make huh lay down innit an pack duh mud
aroun’ huh neck an huh knees an huh elbahs.”
LaTeesha’s crying intensified. The memory of the trips to the woods,
the malodorous mud and the nakedness overwhelmed her. She
crawled up into her mother’s lap. Her mother did not refuse her.
I was dumbfounded. Three minutes is a long time during which to
say nothing and do nothing, except allow this youngster to experience
the warmth of her mother’s protective embrace, but that’s what
we did. I had to pull my handkerchief from my pocket to dab my
eyes. Finally, I spoke.
“LaTeesha, that other doctor’s treatment isn’t anything like what
modern medical treatment has to offer. Let me examine you so we
can figure out what might help you feel better. I promise I’ll try not
to hurt you. If any part of my exam hurts, just let me know, and I’ll
stop right away, OK”
She peered out from her mother’s chest. Her mother gently pushed
her back onto the exam table. I got out my stethoscope and started
listening to LaTeesha’s mother’s upper arm. “See, it doesn’t hurt,
does it, Mom” I asked rhetorically.
Mom cooperated nicely, “Ih doan huht, Teesha.”
I examined LaTeesha carefully. I found a grade 2 systolic heart murmur,
but no rub. It didn’t appear to be hemodynamically significant
at that point, but I wondered if she had some dilatation of her aortic
root left over from the pericarditis she had when I first met her. I
28

couldn’t see any eye problems with the hand-held ophthalmoscope,
especially no anterior chamber changes with the scope dialed into
the higher black numbers, but one knee and the contralateral ankle
and elbow were tender and a bit red and swollen. I had LaTeesha
walk around the room. Her gait was antalgic.
Two years earlier, she had presented with fever, swollen joints, a soft
pericardial rub and photophobia. X-rays, labs (ANA+ but RF-) and
a visit to the ophthalmologist confirmed what used to be eponymously
called Still’s onset juvenile rheumatoid arthritis and now is
called pauciarticular JRA, one of the three ways JRA presents — the
others being polyarticular (five or more joints) and systemic. The
ophthalmologist started her on some steroid drops for a mild uveitis,
a finding that goes along with the positive ANA in young females
with JRA. I sent her to a pediatric cardiologist, too, and had heard
that he had overridden my ibuprofen prescription and started IV and
then oral steroid treatment; however, as so often happened, she did
not come back to me. To my shame, I did not follow up with
inquiries about how she was doing, either. Looking back, a busy
practice was not a good excuse for a primary care physician not to
follow up on a patient’s significant and chronic disease.
“Ih come down tuh thuh sheriff’s depuhtee pullin’ awn one ahm an
huh daddy pullin’ awn thuh uhthuh. When LaTeesha scream, day bo’
stop pullin’ an look at each uhthuh. Finuhly, huh daddy leh go an
stomp back intuh he house. Dat wuh two week ago, an ah ain’t huhd
from him since. I wen tuh duh county an got huh awn Med-caid an
heeuh we awh.”
We did get her on ibuprofen, and she did well. Still’s does abate
(permanent remission) in some patients, and if there wasn’t too much
damage done before such a blessed development, they can lead fairly
normal lives. Seeing LaTeesha run up to my office from her mother’s
parked car led me to hope for such an outcome for LaTeesha.
The mother ultimately moved to Detroit, where she was promised a
job with relatives. I imagined that LaTeesha had a good chance of
being cared for by a black doctor in the Detroit area, and I wondered
if he or she would take LaTeesha’s history in stride or if he or she
would have to pick his or her jaw up off the floor after hearing the
story of this child’s potentially dangerous encounter with alternative
medicine in the form of a root doctor.
I asked her mother what had happened after we sent her to the cardiologist.
She reported that they went there a couple of times, but the
copays imposed by their insurance for doctor visits and medications
was a burden. Her ex-husband, LaTeesha’s father, had complained,
but when she told him there was no alternative and that he’d have to
change his lifestyle to accommodate their child’s medical needs, he
came up with an alternative.
To my shame, I did not follow up with
inquiries about how she was doing, either.
Looking back, a busy practice was not a
good excuse for a primary care physician
not to follow up on a patient’s significant
and chronic disease.
At first, she didn’t object, because she thought he had as much right to
make decisions about LaTeesha’s health care as she did, and a trusted
aunt advised her to let the root doctor have a chance to help the child.
Additionally, she didn’t have any money for a lawyer, so when he
assumed custody of LaTeesha, she felt powerless to fight him. But after
a few months, she could tell that LaTeesha was much worse, that she
had stopped growing and that her joint pains were crippling her. It took
more than eight months to finally get LaTeesha back from her father’s
house and bring her to me to restart medical treatments.
Florida Family Physician 29

R E S I D E N T S ’ & S T U D E N T S ’
by Terreze Gamble, MD, PGY-3, Tallahassee
Memorial Family Medicine Residency
C O R N E R
Mind-Body Medicine
Many residency programs have implemented
various aspects of complementary
and alternative medicine, including an
acupuncture specialist at Morton Plant and
the initiation of a mind-body medicine
grant in Tallahassee. Mind-body medicine
enhances the mind’s capacity to affect bodily
function and symptoms. It includes but
is not limited to meditation, prayer, music,
art and dance therapy.
One key theory of mind-body medicine is biofeedback research.
This concept has shown that individuals can learn to control
brainwave activity, cardiovascular and respiratory functioning. By
focusing in on one’s “core” or wherever the individual finds that
calm place, he or she can obtain a more variable brainwave activity
similar to what we see on a fetal monitoring strip, which, as you will
recall, is reassuring. This in turn invokes a sustainable lower heart
rate. Deep breathing is one of the methods used to create that sense
of calmness. The idea is that persons experiencing anxiety can, at
any time, come back to their core.
Mind-body medicine focuses on the interactions among the brain,
mind, body and behavior. The emotional, mental, social, spiritual
and behavioral factors intertwine in a dynamic way, which directly
affects health. This field uses a variety of techniques: relaxation,
hypnosis, meditation, yoga and concepts essential to conventional
medicine, such as cognitive-behavioral therapies and group support.
Mind-body medicine has provided considerable evidence that psychological
factors can play a significant role in the development and
progression of certain disease states. These techniques have even
been employed in the treatment of various types of pain.
Mind-body medicine approaches have potential benefits and advantages.
The physical and emotional risks of using these interventions
are minimal. 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.
30

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