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Natural Medicine Journal Podcast

Natural Medicine Journal's interviews with thought-leaders in the field of natural and integrative medicine dig deep into the most important topics in the field. Whether it's a one-on-one with top researchers in integrative medicine or a conversation with a practitioner about treating hard-to-tackle conditions, each episode promises to provide trusted, cutting-edge, evidence-based knowledge about natural medicine that you won't find anywhere else.
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Now displaying: 2017
Dec 4, 2017

In this interview, Natural Medicine Journal Publisher Karolyn Gazella discusses the challenges and solutions associated with enhanced integrative care for cancer survivors with integrative oncologist Dr. Matt Mumber. More than 15.5 million cancer survivors are currently living in the United States, with more than two-thirds alive five years after their diagnosis. And yet, most survivors report side effects long after treatment and many experience significant distress and fear of recurrence. Mumber describes how an integrative approach can help all practitioners serve the special needs of cancer survivors in their practice.

About the Expert

Matt Mumber, MD, is a board certified radiation oncologist with the Harbin Clinic in Rome, Georgia. He received his medical doctorate from the University of Virginia and he also did a fellowship in integrative medicine with the University of Arizona. He is the coauthor of the book Sustainable Wellnessand the editor of the textbook Integrative Oncology: Principles and Practice. Mumber is the director of medical affairs of the iTHRIVE Plan.

About the Sponsor

iThrive Plan Integrative Cancer Care

iTHRIVE is an online web application that creates personalized wellness plans for cancer survivors that focuses on five key areas: diet, movement, environment, rejuvenation, and spirit. Cancer centers, hospitals, and clinics can license the iTHRIVE Plan to help meet the special needs of their cancer survivors. iTHRIVE also helps cancer centers meet the Commission on Cancer Mandate. For more information, visit iTHRIVEplan.com.

Transcript

Karolyn Gazella: Hello, I'm Karolyn Gazella, the publisher of the Natural Medicine Journal. Today our topic is cancer survivorship. My guest is radiation oncologist, Dr. Matt Mumber, who's also the editor of the textbook, Integrative Oncology. Before we begin, I'd like to thank the sponsor of this podcast, who is iTHRIVE Plan. That's ithriveplan.com. Dr. Mumber, thank you so much joining me.

Matt Mumber: Oh, thanks for having me. It's always good talking with you.

Gazella: Yeah, well, you know I've been reading research clearly showing that cancer survivors say they have unmet needs and they have special needs. Take us through what some of those needs are, specific to cancer survivors.

Mumber: The diagnosis of cancer is really a whole-person diagnosis. People wonder about, first thing they wonder, "Gosh, am I to somehow blame for this diagnosis?" I think people think about that. Of course, various levels of lifestyle and choices they've made throughout their life. Whether they're smokers, how they've generally eaten, what environment they live in. What their family history is, so they think about all of that, obviously. Then stress weighs in on it. When people get the diagnosis, they have a lot of stress. Then people maybe even think about compounding the fact their lives are stressful, well maybe my stress caused the cancer. That type of thing. That all impacts them and then the physical aspect of it. Of course, we're all, as whole people, we have a physical body that we inhabit.

We have our minds and our spirits, our heart, our emotions, and pretty much all of those are impacted by cancer diagnosis. The physical aspects, people can feel different, they can have symptoms related to the cancer or actual problems. Bleeding, pain and other issues that are outside of normal function. Then, for example, just the fatigue that comes along with having a cancer diagnosis, because fatigue is multifactorial, too, and tends to weigh on people emotionally. Then that has a physical ramification.

The stress and so forth can cause problems with how we eat, drink, move. How we sleep at night. How we relate to others. Different things like sexuality and other aspects that we take for granted as just people walking around being healthy. One of my teachers says that he really enjoys, every now and then, takes time to enjoy the fact that he doesn't have a toothache, because when he has a toothache, it's kind of all-encompassing, so we can be happy our non-toothacheness. I think people with cancer often feel that way. "Gosh, if I could just get a break from having cancer," because once you have cancer you're kind of a cancer patient and you're a cancer survivor, so it really does define who you are.

It's a very much of whole person oriented type of thing. Of course there's all the practical matters, financial, social, and so forth. It really does affect people in a multifactorial way. Perhaps because of the general stigma that's associated with a diagnosis of cancer, for then has been for decades, perhaps more than most of other types of chronic illnesses.

Gazella: I think you may be right, and then there's this issue of fear of reoccurrence. I read in one study saying that upwards of 90% of cancer patients, even if it's not valid, they're afraid. They're so afraid of a reoccurrence of getting cancer again.

Mumber: That's right. No doubt.

Gazella: You've just mentioned a lot of factors. Is this the reason why the American College of Surgeon created the Commission on Cancer Mandate, and you can talk to us a little bout about that Commission on Cancer Mandate?

Mumber: The Commission on Cancer is a wonderful organization, their real mission is to make all of the hospitals that participate in their system as good as they can be. First things they start with were very conventional, let's make sure we have accurate data. Let's make sure people are being treated in facilities that have up-to-date conventional types of processes and that they're recorded and they're followed over time so we can then get feedback and learn and grow with regards to how we're doing in the conventional care of cancer patients.

Then about the time that the Institute of Medicine started to branch out and look at things like cancer survivorship and psycho-social screening, and integrative approaches ... what I would call integrative approaches. They started saying, "Gosh, this is just as important as the conventional. We've got that under control. We've got that to the point where we have standards, we really need to create some standards that affect more of this whole person, outside of the what we do to people," type of scenario. That's really when they started to build these criteria, starting with patient navigation, trying to identify access to caring disparities that people face. Then moving on to actual distress screening, so that we can find a way to identify the stress, almost like another vital sign. Recognize distress and then intervene early before it becomes a problem.

Then moving past when we've gone through active treatment and people that have been treated definitely and curatively and they've done active treatment. Like I said, they're always cancer patients. Cancer survivors now. How do we address that survivorship such that we can make sure they're getting appropriate screenings, that they understand what's been done to them and ultimately what they need to do in order to stay connected, to try to decrease recurrence rates and to function in a way that gives them the best chance of surviving long term.

Gazella: Speaking of these special needs, it certainly seems that because of the sheer number of cancer survivors, pretty soon there's going to be 20 million cancer survivors alive in the United States alone. It certainly seems like their care is spilling out into other medical disciplines, well beyond oncology. I'm wondering what role can general practitioners or integrative practitioners play when it comes to meeting the special needs. Physical, mental, emotional, special needs of cancer survivors.

Mumber: Medicine, I think is evolving. Medicine has evolved from being purely focused on the downhill, what we do to somebody, and has really become more of a partnership where we are able to focus on the commonalities that make us all human and to do so in a way that is therapeutic. For the physician, the physician can bring the power of themselves as they are, what they do to help stay healthy. They can bring in a compassionate way to the doctor patient interaction. Primary care has led the way in this, with the primary care patient center medical home concept. That's now actually something that's billable and is paid for through Medicare, where you can get a group of people together and you can give them ideas and ways to help prevent certain illnesses, for example diabetes, heart disease. Haven't done it so much with cancer yet, because that hasn't filtered into the primary care mechanism, but it's happening and it's a good way for that to happen, because there's only so many oncologists available and there's a much larger pool of primary care doctors.

Prevention has really been in the purview of primary care physicians. There's really 3 types of prevention. Primary prevention in order to try to prevent diseases before they come up. Secondary prevention to prevent disease when people are high risk group, for example prevent heart disease or lung disease from people that are already smokers. Then finally tertiary prevention, which means when people already have an illness or have a diagnosis, for example, cancer, we try to decrease the chance of that recurring or having it again. The primary care center medical home is mainly focused on the primary prevention, somewhat in the secondary prevention and then it also filters over into the tertiary prevention.

In each of those groups, one of the foundational principles that I found to be true in my life is that there's tremendous power in getting groups of people together with similar experience. It's kind of like if I went, no matter how compassionate I am, if I went and tried to sit down with a group of pregnant women and talk with them about what it's like to be pregnant and to be able to have a baby and so forth, I would just be ... There's no way I would add anything that would mean anything to anybody, but if you get a group of pregnant women together, they're going to be able to speak a language that women who have gone through that experience will have. I think that's a very powerful thing and that's filtering into medicine more and more, it's getting reimbursed by Medicare through the primary care patient center medical home.

It's filtering into oncology care. Certainly there are specialty oncology medical homes, as well. However they tend to focus more on what to do during therapy, how to support patients during therapy and it really hasn't filtered over into the tertiary prevention model. I think as a field, medicine in general is evolving a very positive way, mainly it costs so much to have illness, right?

If we can prevent it, the ounce of prevention, right? I think that's a good thing. I do think that's the wave of the future. How it's going to filter into oncology versus primary care, with regards to that tertiary prevention piece, I think that's still to be worked out.

Gazella: Yeah, I would agree. We're making progress though. It is all about serving these special needs of cancer survivors. Now you are the lead investigator on a study that combined patient navigators with an online tool. Can you tell us a little bit about that research and what the outcomes were?

Mumber: Yeah, yeah, so my research is mainly focused on the application and implementation of integrative approaches, especially those that focus on people being able to make and embrace long-term change, kind of what I think of as the difference between translation, which is just giving people information and hoping that they'll understand it. Maybe apply it, versus transformation, which is being able to actually apply information in one's life and make a major change in life. Initially, we started looking at, can we approach this with physicians, for example with integrative medicine approach. We did a study about a dozen or so years ago that was a computer-based educational program, did it in conjunction with the University of Arizona and the Georgia Center of Oncology Research and Education and GSSACO, Georgia's State Society of the American Society for Clinical Oncology.

Basically, we did a prostate cancer where they did integrative medicine, educational module, to educate physicians and provides, nurses, other providers associated with prostate cancer about different complementary alternative methods associated with prostate cancer. We found that that web based educational intervention was very successful. Kind of fast forward to this most recent study, the next logical step would be is there anything we can do to improve upon the ability of this translational information delivery to move more towards a transformational approach. Or what people think of is generally a transformational approach.

The study that we did was, basically, a randomized trial, a small pilot trial. We had 24 people, 24 patient navigators in the state of Georgia that were randomized in this trial to give 1 of either 2 arms. One was an educational, web-based modality that looked at educating about integrative oncology for a patient navigators. We had a bunch of didactic presentation. We had a weekly video presentation that people could watch with regards to how they eat, drink, move, manage their stress, based upon our sustainable wellness book that we had ... Heather Reed and I had written.

Then there were a variety of materials that were present. There was the ability to chat online. That was one arm of the study. The other arm of the study was to do all that, but to also to have the opportunity to do a residential retreat, which I've been facilitating those types of educational types of retreats for years. Focusing more on a variety of contemplative practices and a personal experience and providing those contemplative practices with people that have similar experience. In this case, patient navigators.

The word contemplative is often kind of confusing. It sounds kind of mysterious and mystical. Contemplative is a good way of thinking about, contemplative practice when we can be in a position in which our body and our mind and our heart are in the same place at the same time. That's likely a contemplative practice. One of the features of it are that the result of that is that it brings about a certain level of awareness. It brings about a sense of communion and it brings about a sense of connection.

We would sit with people. We had a three day residential retreat that Heather and I facilitated and basically just experienced a variety of things, like yoga, meditation, massages. Everybody loves massage. We did some creative art therapy, like picture drawing and interpretation of those things. We randomized the trial and the outcome measure was do people learn better when they have this in person interaction, then they do when they have more of an online interaction.

It was a very small study. The numbers hint that there's a slight increase in educational benefit with the in person interaction, in addition to the online interaction. However both interactions resulted in, just like our previous study, significant learning and ability to actually apply these integrative modalities. It was the next step in research with a more focused group. I do think that's it a pretty exciting trial, because it does show the value of somehow having that link to that group of similars. Now whether or not that needs to be based in person or whether it could be based online, with like an online chat that's real active, that's kind of another question, research question, but it was an interesting study.

Gazella: Yeah, sounds very interesting. You know the point with some of the emerging research is to reduce the burden of care. It reminds me of research that was presented at this year's ASCO [American Society of Clinical Oncology] with Dr. Hess from Switzerland, who used the web-based modification tool for cancer survivors and she demonstrated that distress was significantly reduced and quality of life significantly enhanced without a face to face visit. I'm just curious, is this in part the way of the future?

Mumber: I think it could be. I think, of course, that intervention what they did was really more of a psychologist or psychiatrist doing counseling with the individual. They did a good bit of that. They tried to, instead of having to take the patient's time because there's some access to care and disparity issues, in that study, 70% of the patients had an online presence. They were open to using that modality. The counselors would basically do counseling with the patient, instead of them being in a room, basically do it online.

I think as time goes on and as people have more penetrance and more of an online life, I do think that that's going to become more applicable. The current ... It depends on where you are, I guess. It depends on the age of your population and penetrance of internet use and so forth, but I do think that's a positive study. I do think it addresses some of the barriers that can occur, relative to actual time for both the therapist and for the patient, to actually sit down and do it, it's a heck of a lot easier than if you have to travel. Let's say you had to travel 45 minutes. There's also a stigma, I think, to especially the psychological counseling piece where people say, "Gosh, I've got to go to a counselor." It's almost like they're admitting some kind of a weakness.

That gets over that barrier as well. I do think it's going to have applicability in multiple methods. Just in the research that we did, relative to the many uses of the internet and how they pertain to educating people and bringing along. There's absolutely no doubt that the internet has revolutionized the ability to educate people, there's no doubt about it. It makes perfect sense that it would have the ability to be applied in this specific situation, to reduce the stress, to do things with cancer patients that require, in the past, that required face to face interactions, but to do so in a way that's much more practical and less costly, ultimately, than actually having to take the time to do that. Yeah, I think it has significant potential benefit.

Gazella: Yeah, I would agree. I'd like to talk briefly about the iTHRIVE Plan, which is an online tool. Now you in your clinic, the Harbin Clinic in Georgia, you're using the iTHRIVE plan in conjunction with a nonprofit called Cancer Navigators. I'm wondering what your experience has been with the patients who are using the iTHRIVE plan, in particular.

Mumber: Yeah, I think the folks that are using it really enjoy it. Basically, it's a plan that when we set them up, we just basically say, "Look, this is a plan that's written by cancer survivors for cancer survivors." What it does is it evaluates you in 5 different domains of your health, how you eat, how you drink, how you move your body, your spirituality and then how your environment affects you and what things in your environment may be lurking that you're not even aware of that could potentially influence you.

Basically, it's written in a way that there's a nice melding of really good, hard science that each one of the little action steps that are given, are discrete action steps. It's really hard for a patient, when they sit in a room for 15 minutes at a follow up visit where we're talking about, "Well, gosh, you got to do your screening here. You've got to come back for this appointment. Got any questions? Okay, hey, by the way, make sure to eat better, drink pretty of fluids. Exercise. Manage your …" It's such a big elephant, it's hard to bite off. What you do is you start off with one discrete action step. Each of those steps, to the extent people happen to have like a little scientific citation with them. It's very, very valuable.

The people that have been involved in it, they may not like every one of the steps, because everybody's different. Everybody has their own way of doing things. People have different expertise and so forth, but what I tell them is, "Gosh, if you have a set of action steps and one or two really hit home, that's a big deal," because just think about the difference between saying, "Oh, go ahead, eat better, drink better, move better, etc. Handle your stress," and then giving people an option of let's say 30 different steps that pertain to one of those topics. They can go around, in their own time, on their phone and look at each one of those steps and say, "I'm going to try that." It might really hit home and it might stick with them for the rest of their life.

It's a really beneficial thing. The feedback we've gotten has been very good. It has helped us, as well, in identifying people that are in distress that we wouldn't have known otherwise. As a part of that, they'll take a 15-minute survey that evaluates them in those 5 domains. Then one of the domains ... Then it has different symptom complexes like fatigue and pain and so forth. If they reach a certain threshold, then our nurse is identified. Our nurse calls them up and what that's done is it's allowed us to get them to specific services they would not have gotten to otherwise. It's a very beneficial thing on multiple levels. On the patient navigation level, to go back to the COC, well, what a great tool for being able to intervene and educate and identify access to care and disparities issue.

Some of those could be a person can't travel to do various things, so this is a great way of addressing that. The second piece, distress screening, we can identify distress, and appropriately manage it. The third thing, of course, this is a survivorship piece. Really the weakest part of survivorship, in the COC platform, has been that tertiary prevention piece. How you take care of yourself in order to decrease the chances of them coming back.

Gazella: Right, and I'd like to talk a little bit about that, because you and I and Dr. Lise Alschuler wrote a paper that was published in the Natural Medicine Journal that shined a light on emerging research that's showing that survivorship care plans that only focus on the treatment summary and the follow up care are actually causing more distress, because they're not focusing on proactive prevention strategies that can empower the patient. What do you think is the solution to that, because that's kind of troubling, that even after the mandate, these SCPs are causing more distress?

Mumber: I think what's happened is that they've followed the general history of the medical model, ultimately. That is that we figure out what needs to be done and in our infinite wisdom, we then deliver it. We deliver it in the best way that we can, unfortunately the initial way we deliver almost everything in medicine is from the top down. From somebody who knows something better to somebody that doesn't know anything.

Somebody who needs help to somebody's who's going to be stronger and has the ability to get the help. Somebody who's broken to somebody who's going to get fixed. It's not unusual, it's a normal part of the evolutionary process of the way medicine is delivered over time. In the initial part of this, it's very important for us to get the conventional part right. It is very important that people get to their screenings, to make sure that people understand how important it is to eat well, to drink well, to manage your stress, to understand what radiation and chemo they got. How that might place them at greater risk, etc. those are all very important pieces of the puzzle.

However, if all we do is try to deliver information downhill and to a person that literally, all they know is what we're telling them, for the most part, it's going to create distress. It's going to create more distress than if we didn't tell them anything. It's almost like ignorance is bliss to a certain extent. When we overload people with information, without any real applicability of how it means something in their life, it tends to cause more distress. I think it's very important and over time, I think what we'll see is a progression for engaging the patient, engaging the patient in their own care. Engaging the whole person in their own care. That's where I think that it's going to evolve over time, naturally.

Gazella: I would agree with that. What would you like to see happen in the future, when it comes to getting these special needs met? Physical, mental, emotional needs met for cancer survivors in the future?

Mumber: Well, I think from a standpoint of Medicine. Medicine with a big 'M'. Not just medicine that we use to fix people, but medicine that serves the needs of all the participants that are involved. Not just the patient, doctor, community member, all aspects of the community in general. All people involved in it at all levels of their being. Physically, mentally, emotionally, spiritually, and all levels at which they experience life. As an individual person, as a family member, as a community member, etc. That's an integrative approach, a whole approach that addresses everyone at all levels of their being and experience.

That, again, that's a huge elephant. What we're starting with is the ground foundational stuff of what's the science of all these things. What do we need to make sure people have done in order to have just a basement, foundational understanding of what's required for basic science survivorship. Basic science 101. That's the level we're at right now. Going from not doing that at all to doing that is a big step. That's a big step. We don't want to minimize that. It's going to take time. However, ultimately, what's going to happen is that it's going to evolve over time and it's going to progress to the point where we look at the person not just as a patient and as a body, but we look at the patient as somebody who's a responsible participant in their care.

We take therapeutic advantage of their physical presence. Their emotional presence. Their mental and spiritual presence. We optimize their environmental existence such that it impacts everybody in the system. That is where medicine, that's what I'd like to see. I guess to say I'd like to see that is maybe a little self-centered. I think everybody would like to see that, right? It's just a matter of patiently, one step at a time, applying tools that we have that are capable of making incremental change at each of those areas.

For me, I have a lot of people, a lot of colleagues say, "Gosh, I'd look to do some kind of integrative approach." I think starting small and then growing organically with it makes sense and using tools that apply to yourself as an individual, as well as the patient, is a good place to start. Using systems that are in place that can increase communication, break down some of those access to care disparity barriers and move things forward in a way of increasing patient responsibility and participation in their health.

Gazella: I think that's great advice to practitioners who are looking to have a more integrative approach. Well, once again, I would like to thank the sponsor of this interview, which is iTHRIVE Plan. That's ithriveplan.com. Dr. Mumber, I'd like to thank you for joining me today.

Mumber: Happy to be here. Thanks a lot.

Gazella: Have a great day.

Mumber: Alright, you too.

Nov 7, 2017

In this interview, Christopher Shade, PhD, discusses the many factors that can block effective detoxification and how clinicians can address these issues. Cholestasis, endotoxins, estrogen, oxidation, and other detoxification disruptions are explained, as well as key nutrients and botanicals that can be used to help push toxins out and prevent re-absorption. Shade goes into detail about the detoxification protocol he has created.

 

About the Expert

Christopher Shade, PhD

Christopher W. Shade, PhD, founder and CEO of Quicksilver Scientific, specializes in the biological, environmental, and analytical chemistry of mercury in all its forms and their interactions with sulfur compounds, particularly glutathione and its enzyme system. He has patented analytical systems for mercury speciation (separation of different forms of mercury), founded the only clinical lab in the world offering mercury speciation in human samples, and has designed cutting edge systems of nutraceuticals for detoxification and antioxidant protection, including advanced phospholipid delivery systems for both water- and fat-soluble compounds. Quicksilver Scientific is recognized globally for innovating on behalf of the pharmaceutical and nutraceutical industries. Dr. Shade is regularly sought out to speak as an educator on the topics of mercury, environmental toxicities, neuroinflammation, immune dysregulation, and the human detoxification system for practitioners and patients in the United States and internationally.

About the Sponsor

Quicksilver Scientific

Quicksilver Scientific is a leading manufacturer of advanced nutritional systems with a focus on detoxification. We specialize in superior liposomal delivery systems and heavy metal testing to support optimal health. Our advanced liposomal supplements are highly absorbable, and support the body in the elimination of ubiquitous toxins, enabling you to achieve your genetic potential. At Quicksilver Scientific, we are passionate about health and well-being, and are committed to improving the lives of everyone we touch.

Oct 24, 2017

About the Interview

Tina Kaczor, ND, FABNO, recently sat down with Dugald Seely, ND, MSc, FABNO, director of the Ottawa Integrative Cancer Centre, to discuss several ongoing studies in integrative oncology. Studying integrative oncology has unique study design challenges. They talked about how these challenges are met and how current study designs are attempting to accurately reflect complex in-office care. Seely covered a broad range of topics, from details of specific studies to an overview of the current landscape of collaborating with peers in integrative oncology. He also offered some tips on how private practice clinicians can begin to participate in research.

The Thoracic POISE Trial

One of Seely’s current research endeavors is the Thoracic Peri-Operative Integrative Surgical Care Evaluation (POISE) Trial. Seely says it’s probably the most interesting and complex study his team is currently working on. The goal of this trial is to explore the impact of naturopathic medicine in addition to conventional usual care at the hospital for patients who have thoracic cancers and are eligible for surgery.

The researchers are randomizing a group of these patients into receiving standard usual care at the hospital only, or getting usual care plus an integrated approach delivered by a naturopathic doctor before surgery and for a year after surgery. They’ll be looking at a whole battery of different outcomes, including adverse events related to surgery, quality-of life-measures, immune function, inflammatory changes, cost-effectiveness, and, ultimately, long-term survival and recurrence rate over 5 years.

Seely sees this study as an opportunity to investigate the effectiveness of truly holistic, whole-person care. To do that, they’ll be employing interventions in 4 domains:

  • Targeted natural health products
  • Nutritional approaches
  • Fitness improvements (particularly pulmonary fitness)
  • Mind and body medicine and psychological well-being

At the end of the study, Seely expects to be able to say whether, as a whole, naturopathic medicine in this setting can make a difference in outcomes related to survival or adverse events related to surgery. 

Canadian/US Integrative Oncology Study

Another study Seely is working on is called the Canadian/US Integrative Oncology Study. This is being done in partnership with Bastyr University. The other principal investigator is Leanna Standish, ND, PhD, LAc, FABNO.

This study, which will be conducted over a 6- to 7-year period, will recruit and observe the interventions given to patients with 4 types of late-stage cancer. The researchers will look at the naturopathic care interventions given to these patients at 11 different clinics across North America.

Seely and the research team are looking at clinics with the most innovative and useful therapies in naturopathic oncology. They’ll document the interventions and follow the patients to observe effects on survival rates. In addition, they’ll be looking at cost and quality of life.

In the end, Seely hopes the CUSIOS trial will shed light on the outcomes we see with patients who go through these advanced integrative oncology clinics.

How Can Clinicians Get Involved in Research?

For clinicians interested in getting involved in research, Seely offered this guidance: Build relationships. For him, doing graduate work was key because it automatically caused him to engage and collaborate with others. If you’re interested in research, start by connecting with people at academic institutions and begin the dialog.

If you’d like to learn more about the sites currently involved in integrative medicine research, visit Clinicaltrials.gov.

About the Expert

Dugald Seely

Dugald Seely, ND, MSc, FABNO, leads the clinical practice and cancer research program for the Ottawa Integrative Cancer Centre. In addition to his clinical role as a naturopathic doctor, he also serves as the executive director of research & clinical epidemiology at the Canadian College of Naturopathic Medicine, affiliate investigator for the Ottawa Hospital Research Institute, and vice president for the Oncology Association of Naturopathic Physicians. Seely completed his master of science in cancer research at the University of Toronto and is a fellow of the American Board of Naturopathic Oncology. As a clinician scientist, Seely has been awarded competitive grant and trainee funding from the Canadian Institutes of Health Research, the Canadian Breast Cancer Research Alliance, the SickKids Foundation, the Lotte and John Hecht Memorial Foundation, the Ottawa Regional Cancer Foundation, and the Gateway for Cancer Research Foundation.

Transcript

Tina Kaczor, ND, FABNO: Hello. I'm Tina Kaczor with the Natural Medicine Journal. I'm speaking today with naturopathic physician and researcher, Dugald Seely. Dr. Seely is the founder and executive director of the Ottawa Integrative Cancer Center in Ontario, Canada. He has led numerous research projects including the largest integrative naturopathic cancer care clinical trial ever conducted in North America. He has more than 50 MEDLINE indexed peer-reviewed publications. Last but not least, among his many accolades over the years, he has most recently been awarded the Dr. Rogers Prize, which is a prize awarded in Canada for excellence in complementary medicine. Dr. Seely, thanks so much for joining me today.

Dugald Seely, ND, FABNO: Thanks so much for having me on to talk, Tina.

Kaczor: There are so many things that we could talk about in the realm of research. You're also a practicing clinician, so there's lots we could discuss. I want to start off with a couple projects that are currently ongoing for you, maybe that you're knee-deep in. If you could just start us off with a couple research projects that you have going on these days.

Seely: Yeah. Sure. One of the ones that you mentioned, the integrative oncology study, is a big study that we're doing. That's probably the most interesting and complex study that we're running right now. I say running a little bit loosely because we actually haven't started it yet. We're waiting on final ethics approval. We're nearing the runway anyways. This is the Thoracic POISE Trial, which is the Thoracic Peri-Operative Integrative Surgical Care Evaluation Trial. The goal for this trial is to explore the impact of naturopathic medicine in addition to conventional usual care at the hospital for patients who have thoracic cancers and are eligible for surgery.

What we're doing in this study is we're going to be randomizing a group of these patients into receiving standard usual care at the hospital only, or getting usual care plus an integrated approach delivered by a naturopathic doctor prior to their surgery and for a year after the surgery as well. We have a whole battery of different outcomes that we're exploring, including adverse events related to surgery. We're looking at quality of life measures. We're looking at some biological surrogates, including immune function, inflammatory changes in the body, and we're looking at some cost-effective outcomes and, ultimately, long-term survival and recurrence rate over 5 years. This study is a long study. It's going to take us probably, by the end of the whole thing, maybe 12 years. We're starting off with a feasibility component to explore the interventions and how effective they can be applied before we move into the randomized component with a much larger population.

Kaczor: That brings up a question in my mind. That is, when you talk about the feasibility aspect, are you designing it such that the intervention will be standardized across the patients, or will this be more naturopathic in it being more personalized per patient in a systems-based approach?

Seely: Yeah. That's a great question. We've struggled a lot with how to develop the intervention in a way that could be representative of naturopathic medicine in the field. Then, also scalable and standardizable in a way that it could be replicated in another trial. I think we balanced it as much as we can from both ends. It depends on who you speak to I suppose around that. The goal is truly holistic or a whole-person care. We have components that relate to the use of targeted natural health products that we've standardized for this population. We've got a nutritional approach that we've standardized to some degree. We have interventions related to improving fitness and pulmonary fitness in particular. Then we have interventions related to mind and body medicine and psychological well-being. Those four domains comprise the types of interventions that we have.

Within each of those, we developed specific interventions that we detailed how this would be applied, and under what conditions, to these patients so that this can be clearly documented. There is a standardized approach that we're using. There is some flexibility in terms of the patients and how they represent in terms of making changes to the intervention. For example, if someone presents with diarrhea, they will be provided with probiotics as well as their core interventions. If they have weight loss, they would get whey protein as well. If they're experiencing mucositis or neuropathy, we'll apply glutamine. There are some things that we can tweak based on symptoms that the patient has.

Initially, at least, everyone in the study is going to get a course of intervention that everyone will receive similar. We don't know what is going to be providing what effect. That's the nature of a pragmatic study like this. We'll be able to say, at the end of the day, that this whole-person approach, what effect does it have on the outcomes that we're looking at. These are important outcomes for these patients regardless. It's a bit of a black box at the end of the day. We won't be able to identify what specific intervention has what effect, but we can say, as a whole, naturopathic medicine in this setting can make a difference in outcomes related to survival or adverse events related to surgery. Things like duration of hospitalization after surgery, so we'll have information on that.

Kaczor: This particular trial is being done in conjunction with area cancer centers and your center specifically. This is site-specific. Is that right?

Seely: It is initially. The feasibility study, which won't be randomized, is going to happen with the Ottawa Hospital as the hospital site. Then, the Ottawa Integrative Cancer Center (OICC) will be the site where the naturopathic care will be delivered. Once we have run in a few of them, when we do the randomization, we do plan on having at least 2 additional sites across the country. We have a couple places identified that will be good sources for recruitment. It will take place in other sites as well.

Kaczor: Great. I like the idea of it being a whole-systems approach because that's one of the things that we run into in naturopathic medicine is that the reductionist view of a single agent being studied is never reflective of what we're actually doing. That's great. My understanding is you have another study that has multiple locations. Is that correct?

Seely: Yeah. We're doing another study, which is quite different. It's an observational study called CUSIOS. It's the Canadian/US Integrative Oncology Study. This is being done in partnership with Bastyr University and the other co-PI is Dr. Leanna Standish. Really, we're looking at in this study over a 6- to 7-year period to recruit and observe the interventions that are given to patients with late-stage cancer, 4 types of late-stage cancer. We're looking at what the naturopathic care interventions are being given to these patients at 11 different clinics across North America—5 in Canada and 6 in the United States. Each of these clinics are being led by what one would consider to be a naturopathic oncologist or someone steeped in naturopathic oncology.

We're tying to look at clinics that have some of the best therapies, the most innovative and useful therapies, in the naturopathic oncology realm being given to these patients. We want to look at what those interventions are and we're documenting that using REDCap. Then, we're going to be also following these patients to see what the survival rate is amongst these patients. Then, we're also doing a substudy within that looking at cost and quality of life. Their experience through the care as well in a more of a qualitative kind of a way. Again, a lot of outcomes that we're trying to track, it is observational so it won't have the same sort of subjective biases for sure. It'll give us, I think, a lot of really good information about what the practice of naturopathic oncology is ostensively at its best, and what are some of the outcomes that we're seeing patients go through these advanced integrative oncology clinics.

Kaczor: Yeah. Let me ask you this as far as time horizons. These are both pretty lengthy studies. I have a 2-part question. One, when can we look forward to preliminary results or the first publications coming out of either of these trials? Two, are they registered such that, regardless of how the data shakes out, positive or negative, that it will be published? I understand that once trials are registered in a certain way, the data has to be published at some point.

Seely: Yes. For sure, we will publish regardless of what the outcomes are. The CUSIOS study is ongoing. It is registered under clinicaltrials.gov. Thoracic POISE is not yet registered because we haven't got it through ethics yet. We will be establishing that soon. We will be publishing those, no question. We actually have submitted one publication so far and it's been peer reviewed. This is looking at the intervention development process that we used for thoracic POISE, which is really a collaborative effort with physicians at the hospitals, at the hospital pharmacists, the naturopathic doctors as well. That's being submitted for publication.

We also have information related to the survey. When you survey the whole profession through the Oncology Association of Naturopathic Physicians (OncANP), we wanted to know what were the best interventions, what were people using. That really helped influence the interventions that are being chosen for this study. That's also being submitted for publication. Hopefully, we'll see those out in the literature in the next few months.

Kaczor: Great. I'm going to switch gears just a little bit. You mentioned pharmacists and other doctors at these cancer centers. I guess one question to us out there, whether we're clinicians or we're in the research realm, is collaboration and creating those bridges that are required to really study integrative oncology. My question to you is, how to go about that? Maybe just let me know if, over the years, has it changed? It seems like it would be easier now than say 10 years ago, or even 15 years ago. Can you speak on that a little bit?

Seely: Yeah. I think it has gotten easier. There's more of an openness to doing the evaluations and the studies. We're seeing more interest in research, I would say overall, into naturopathic and complementary approaches to care. There's still certainly resistance that exists. Academics and researchers are much more open to looking at these questions typically than clinicians may be. The interest is really in trying to figure out what works from a research perspective. I do believe it's getting more easy to collaborate in that way. Funding opportunities are not easy for sure. I think that, within the naturopathic community, we know that we have a lot of low-lying fruit from our own intervention palate that it should be researched. There's good reason for it, and there's a lot of [inaudible], and there's some early evidence of benefit. [inaudible] have not been researched adequately in many cases.

In terms of building relationships and trying to engage with others, I found doing graduate work was really helpful. There's an automatic process that you engage with others. There's an expectation to be collaborative, and reaching out to people who are doing research at institutions to say, "You've got a good idea about an intervention that might have some effect." I think people are surprised when there's really a good openness for those questions. I think finding people in academic institutions that have a focus on research is a good place to start and to try to start a dialogue and a relationship really.

Kaczor: Yeah. Let me ask you one last question. That is, if people are interested either in your area geographically or they want to look up the centers that are involved in the US/Canadian collaboration trial, where should they look for more information?

Seely: Clinicaltrials.gov will list all the different sites that are involved in the trial. I think there's more information related to that probably on our website, OICC.ca. Yeah, clinicaltrials.gov will have the information related to that.

Kaczor: Okay. Great. As far as getting funding, this is usually in collaboration. I mean, you have a research background and a masters degree and such, so your advice to clinicians who just have their clinical degree is to collaborate basically and find others who are of the same passion for whatever question is being asked and maybe try for grants in that direction? Is that correct?

Seely: Yeah. I think trying to become part of a team, reaching out to different groups that are involved in research techniques through the colleges. They often have research departments and may have some information related to that. Talking to universities and people there. A really great place to start, I think, in terms of doing research too is publishing case reports. There's more of a drive for case reports in [inaudible]. That's something that is ... I know that the AANP is trying to support more case reports. I think that diving into that and writing up a case report that really clinically just gets someone steep into what the evidence is in the literature around the topic and leads to more investment. It's a more accessible entry point into research I would say.

Kaczor: That's a great bit of advice. We, as clinicians, are always ... Everybody has a few cases that are extraordinary over the years, so that's a good bit of advice, especially within integrative oncology when extraordinary cases do happen. It would be great to document that and see if there's commonalities and create studies like yours around those treatments. That would be incredible. I really appreciate your work, your time with me today. I hope we get to talk again in the near future. Thanks, Dugald.

Seely: Thanks so much, Dr. Kaczor. I totally appreciate the journal and what you're doing with it. Thanks for having me.

Kaczor: Take care.

Oct 4, 2017

Sponsored by Quest Diagnostics

In this interview, gastroenterologist and leading irritable bowel syndrome (IBS) expert Christine Frissora, MD, describes how to effectively diagnose and treat this common disorder. Frissora also discusses the conditions that need to be ruled out when IBS is suspected.

About the Expert

Dr. Frissora

Christine L. Frissora, MD, is a leading physician in gastroenterology and hepatology. She has extensive experience in IBS and other gastrointestinal disorders including gastroesophageal reflux disease, celiac disease, colon cancer and polyps. Frissora has been board certified as a diplomat of the American Board of Gastroenterology since 1998 and has been in practice for more than 20 years.

Frissora has acted in the role of principal investigator, collaborator, and consultant for various research studies including the areas of symptom management for IBS with constipation, minimally invasive interventions for IBS with diarrhea, and clinical trials for various pharmacologic IBS treatments.

She has developed and directed several courses in the field of gastroenterology and has delivered over 50 noteworthy presentations.

Frissora has authored nearly 20 articles in peer reviewed medical journals since 1992 spanning the fields of gastroenterology and hepatology. She currently practices at a nationally recognized hospital in the greater New York City area, and she continues her involvement in research within the field.

About the Sponsor

Quest Diagnostics

Quest Diagnostics is the world’s leading provider of diagnostic testing services with a medical and scientific staff of more than 650 MDs and PhDs, an extensive network of convenient patient locations and laboratories and a range of complementary diagnostic products. Our advanced health information technology solutions enable better healthcare decisions today, and our support of clinical trials is helping to find the cures of tomorrow. Quest Diagnostics is driven to discover and deliver diagnostic insights and innovations that help to improve human health

IBS affects as much as 20 percent of the population, however, many cases remain undiagnosed–often because patients believe their symptoms are trivial or due to secondary factors like diet, stress, or anxiety.

For those who ultimately do seek medical help, diagnosing IBS has always been an arduous and expensive diagnosis of exclusion. IBSDetex™ blood test can help confirm post-infectious IBS-D (diarrhea-predominant IBS) or IBS-M (IBS with diarrhea and constipation) in as little as 72 hours from the time the specimen is received in our laboratory. This simple non-invasive test can provide answers to millions of IBS patients much quicker thus ending their years of suffering and frustration. Learn more about IBSDetex.

Sep 7, 2017

If you work with patients with small intestinal bacterial overgrowth (SIBO), Crohn's disease, colitis, or food intolerances, you've probably heard about the elemental diet. But there's a lot of confusion about what the diet is, when it's appropriate, and how it can be used most effectively. In this interview, digestive health expert Lela Altman, ND, LAc, explains how the elemental diet allows the gut to rest and repair. She offers practical information for patients and practitioners about how to choose an elemental diet or how to make your own. In addition, she outlines the steps she takes to reduce the risk of relapse after coming off the diet. And she reveals the one question every practitioner needs to ask to identify a major red flag that would contraindicate the elemental diet.

About the Expert

Dr. Lela Altman

Lela Altman, ND, LAc, began working in the medical field in 1998, first as a nursing assistant, then as a medical assistant. This experience inspired her to pursue an education in the natural health sciences. Altman earned her bachelor of science degree from The Evergreen State College where she focused on ethnobotany, biology, and chemistry. She then earned her doctorate in naturopathic medicine and masters of science in acupuncture at Bastyr University in 2011. She went on to complete a 3-year residency at the Bastyr Center for Natural Health. While working as a chief resident, she completed additional training in evidence-based medicine and carried out diabetes research. She recently created the Digestive Wellness clinic at the Bastyr Center for Natural Health, which she currently supervises. Additionally, she teaches full time at Bastyr University and has a private practice.

About the Sponsor

Integrative Therapeutics

 

 

 

Integrative Therapeutics is focused on helping integrative medicine professionals cultivate healthy practices—from the development of science-based nutritional supplements to innovative, actionable resources and professional insights that have the power to inspire and enrich you, your patients, and your practice.

We take pride in our evidence-based approach and meticulous process, and we focus on investing time and resources into developing formulations that have the support of today's scientific community—not the latest 'nutritional craze.' This process includes months of research, rigorous ingredient testing, and quality assurance testing before a product is ready to be released.

Other resources include ElementalDiets.com.

Transcript

Tina Kaczor: Hello, I'm Tina Kaczor with the Natural Medicine Journal. Before we begin, I'd like to thank the sponsor of this podcast, Integrative Therapeutics. Today we're talking about the elemental diet, which is a specialized diet sometimes used in patients with inflammatory bowel disease or small intestinal bacterial overgrowth, better known as SIBO. My guest today is naturopathic doctor Lela Altman, from Bastyr University. She's a specialist in gastrointestinal medicine and has used the elemental diet to improve her own health. Dr Altman, thank you so much for joining me.

Lela Altman: Thank you so much for having me.

Kaczor: So, let's jump right in. I'd like you to start us out with a definition. In doing a little research for this interview, I noticed that the elemental diet or, the words "elemental diet" have been around for decades. So maybe you can just start us out with just a simple definition of what is an elemental diet and what does that term exactly mean?

Altman: Sure, so a true elemental diet is a formula, it can be used in place of meals, and it proves all the nutrition that you need in its most basic, easily absorbed form. And that allows the gut to rest and repair. So, for example, instead of having proteins you would have individual amino acids, which are the building blocks of proteins. Instead of having fibers or starches it would contain simple sugars, which can be easily absorbed. And it also the essential vitamins, minerals, nutrients you need to survive. Fiber isn't typically included in an elemental formula because it can feed gut bacteria so that's something that we wanna look at and make sure it doesn't contain. There are a lot of formulas on the market that kind of market themselves as elemental diets that do have full proteins in them. And so it's not that those are bad formulas, but they're not necessarily totally an elemental formula. So it is important to know what you're looking for when you're evaluating formulas to determine whether or not they're elemental.

Kaczor: Okay, so we'll get into the diet specifics but it sounds fairly regimented in that, when I looked online I saw that there were a lot of various forms. There were homemade recipes and then there were products for sale, like you mentioned. And I guess ... the patient experience, can you tell me a little bit about the patient experience? I mean, is there a breadth of options for the patient where if they wanted to use their own kitchen they could do this diet themselves at home all the way to here's the pre-packaged thing? So what should a patient expect when they're put on this?

Altman: Yeah, absolutely. So you can make your own. Dr. Allison Siebecker has a great website, siboinfo.com, that has a recipe for a homemade version and there are also various other forms. So there are supplement companies that make them, there's, I mean, pharmaceutical-type versions of them. So there's a lot of range of what you can purchase and there's a lot variation in price based on that range. So it really depends on whether the patient wants to make their own and save a little bit of money or finds the convenience more important and maybe the taste more important and is willing to buy prepackaged option. Not all of the prepackaged options taste good but there are some that taste better than others.

Kaczor: So in, I guess ... Well it may depend on condition but is this something that people typically do for days, weeks, months, how long are we talking for patients?

Altman: It does really depend on the condition. So for SIBO it's typically done for 2 to 3 weeks. And an elemental diet, again, it's used in place of food. So you're not typically eating food with the elemental diet, you're only doing the formula. So for SIBO, that would be the formula only for 2 to 3 weeks. It can be used really anywhere from a few days for a few months depending on what you're not using it for. Or, sorry, not a few months, a month. So, if you wanna do a little bit of bowel rest you maybe would be on a elemental for 3 to 5 days. If you have maybe Crohn's disease and are using the elemental diet for treatment of an acute, really severe flare of Crohn's disease then you might be on that for up to 4 weeks. Also, sometimes I'll use the elemental formula for people who have a lot of food intolerance or allergies and are unable to maintain their weight, as a way to provide antiallergenic calories. And in that case they are eating food in additional to the elemental formula and so they may be on the formula for months while they're recovering their weight.

Kaczor: And in that, just to clarify, in that scenario they're doing it as an add-on to an otherwise tailored diet for them.

Altman: Right. Typically, if the elemental diet is being given completely alone without any other food it doesn't exceed more than 4 weeks.

Kaczor: Okay, and so what conditions exactly ... I know you mentioned food intolerances so just so are we are complete, what other conditions do you use the elemental diet for?

Altman: The big three that I use the elemental diet for is for treatment of SIBO, also for, again, as I mentioned, addition of calories in people who are underweight and have a lot of food intolerances. And then also just for a short term bowel rest, which might be needed in a Crohn's or colitis flare. There is some research on multiple other conditions though that elemental diets or sub-semi elemental diets have been used to treat. So eosinophilic esophagitis is one, cystic fibrosis, AIDS-related diseases, acute pancreatitis, sometimes rheumatological diseases. So there's a number of different conditions that we are looking at elemental diets to treat. My focus is mostly on the gastrointestinal diseases.

Kaczor: Okay, and so because it's void of fiber completely I'm guessing that the microbiota of the gut changes dramatically without those fibers. So how do people come off of this diet? In other words, how do they step off it without having a massive reaction to fiber from foods?

Altman: Yeah, so, I mean, the first part of that question really is kind of addressing the lack of fiber issue. These diets are not health long term. The elemental diet wouldn't be health long term, nor would necessarily the low-FODMAP diet or something like that. So when I take people off of the elemental diet, I usually have them start with homemade low-FODMAP broth. And if they are tolerating those well on the first day then I'll have them add some well-cooked, low-FODMAP veggies and they can even puree that into a soup to help break it down a little bit more. And if all is going well, the next day I will have them eat lightly cooked low-FODMAP veggies like steamed or lightly sauteed. And they can add some grains if they tolerate grains, though not everybody does. Meat, eggs, those things need to be well tolerated and fairly easy to digest after the elemental diet. And then on phase 3, I kind of transition back to a low-FODMAP diet, that's the diet I'm typically using. Some people are on a SCD [specific-carbohydrate diet] or SIBO-specific diet. I kind of transition them back to whatever diet they were on before that was working for them.

And then when their gut stabilizes, then we start to challenge food. So, for example, we would start challenging low-FODMAP foods to see what they can tolerate and what they can't. The idea is once the SIBO is cleared they shouldn't have to stay strictly adherent to one of those diets.

Kaczor: Okay, so that brings up a question because it seems like there's a lot of relapse in SIBO that a lot of ... there's a lot of talk in the chat groups about what does one do after they feel like they've exhausted many protocols. Do you find in your practice that there is a lot of relapse and a lot of people end up with a recurrence of it?

Altman: Yeah, definitely, so there's one study that shows the recurring aftertreatment with Rifaximin that's about 50% at 6 months. We don't have specific studies looking at different types of treatment and whether the recurrence rate changes, say, for somebody treated with Rifaximin versus somebody treated with an elemental diet. This is why, in my practice, I implement a lot of other things to help prevent recurrence like maybe long-term antimicrobial herbs, prokinetics, maybe a modified diet or a low-FODMAP diet. So, unfortunately, we don't have studies showing what if we do all of these other things too then what is the recurrence rate? But in my practice I think it's lower when we add in those things. And unfortunately, for years SIBO's just been treated with Rifaximin and follow-up testing wasn't even necessarily done and then that's it. And so the studies that we have are based on that type of treatment.

Kaczor: Okay, so, yeah, that answered one of my questions. I didn't know if this was a diet people had to go on intermittently but it sounds like if one can get to the root cause of what's going on and kind of get the gut into a healthier place and perhaps do a few things like longer-term antimicrobial herbs or prokinetics ... And just out of curiosity, prokinetics, when you say that in the naturopathic realm, what are you talking about exactly?

Altman: So, prokinetics can be in various forms. They can be pharmaceutical and they can be herbal and I use both, sort of depends on the person and what they respond to and sort of what level of prokinetics they need. So a prokinetic is essentially something that makes the gut move, it increases motility of the small intestine, which can be a really big problem, particularly in the autoimmune type of SIBO. And so naturopathically I'm generally starting with herbal options, which may include things like ginger and 5-HTP, bitter herbs, things like that.

Kaczor: Yeah and that brings up another question I have and that is with that idea of the lack of peristalsis within the small intestine that seems to be implicated in SIBO and those prokinetics working for those people, it seems to me, and correct me if I'm wrong, that stress has a lot to do with this. That people who maybe have more anxiety or anxiousness and we say they hold it in their gut kind of thing. Is that true in your experience? Do you notice stress having any effect on SIBO or on their GI symptoms?

Altman: I would definitely say so. I have a few patients whose only known risk factor for getting SIBO has been going through a very stressful event. And actually it's those people are the ones that tend to have fewer recurrences or not have recurrence at all because there's not an anatomical or motility issue that you have to deal with. Essentially once you clear the SIBO it's more stress management that helps keep it away. So yeah, that is definitely true. Also, if we think about the sympathetic versus parasympathetic nervous systems, so in the sympathetic nervous system is the fight or flight. And in the fight or flight nervous system, we shunt blood away from our digestive system to our limbs so that we can run. In a parasympathetic nervous system, that's the rest and digest, and so we're shunting blood to the digestive system to help break down food. And so if you're stressed you're kind of constantly in this sympathetic, fight or flight state and you are not shunting blood toward your digestive system to function properly. So that's a really concrete example of why stress would make this worse.

Kaczor: Yeah, yeah, that makes perfect sense. And then, I guess, kinda sticking to the mind-body idea and how the physiology is functioning, I guess, one question I had for you as a practitioner. Do you find that sometimes doing dietary restrictions like an elemental diet, especially when there is a lot of concentration, a lot of time and effort on eating the right things and making sure that the wrong things don't go down, and all of that, have you ever found that there's some trigger for relapse in those who have a prior eating disorder? Especially people, young women, and they might be in high school or college, they had bulimia or anorexia and here they are in their 50s and maybe they have to go through either an elemental diet or more likely the other diets you were talking like the FODMAP diets or the specific carbohydrate diets, very restrictive diets. And they get into kind of a neuroses about food is basically what I'm asking. Have you found that to be true at all?

Altman: Yep, unfortunately I have found that people having eating disorders by trigger them through giving them an elemental diet. So no, it wasn't in the history I was aware of and then they went on the elemental diet and then suddenly this history of an eating disorder became an issue because the elemental diet did trigger that. And that's also true for, I think, any restrictive diet. So a history of or current eating disorder for me is a relatively strong contraindication to an elemental diet or any other type of restrictive diet. I think, I agree with you, I think it's a fine line between treating SIBO and having disordered eating. So when you feel poorly every time you eat and every time you eat you get more bloated, it created a negative feedback pattern associated with food and over time that can cause bigger problems like fear of eating almost anything. You know that anything you eat is gonna make you feel poorly and I think that's something to be really careful of if you have SIBO or if you are treating a lot of SIBO.

Kaczor: Yeah, and thanks for saying it because I think that's a big heads up for everyone who is looking at using this diet. Especially practitioners, that's a very simple thing to have on an intake form so it doesn't have to be too deep of a probe with the patient. It can be very simply asked. So on that note, are there any other contraindications, any other patient populations that we should be aware of that we should be especially careful with this diet?

Altman: Well, you need to think about it, I think, really on a case by case basis. Anybody could have something that could be a contraindication. One of the biggest concerns people have is about weight loss or low BMI. I find that's a relative contraindication. A lot of people think of the elemental diet as a fast, which it's really not. You have all of the calories and nutrition you need and you can increase the amount of formula somebody's taking as needed to meet their caloric requirements. So I've actually had several patients who are really malnourished, had a lot of difficulty maintaining weight, actually gain weight on the elemental formula because it was providing nutrition for them in a way that they could actually absorb and utilize in their bodies. So, I mean, that's something to think about. Diabetes for me is some concern, especially with the insulin needs and blood sugar dysregulation. The elemental diet, as I mentioned in the beginning, the carbohydrates come in the form of sugar and so it does have some potential for blood sugar dysregulation if you're drinking it really quickly. You can really mitigate not a lot by drinking it slowly over time but that would be another concern.

Fungal overgrowth can definitely be exacerbated by an elemental diet, again, because of the sugar content. I initially, when I started using it, thought that maybe kidney disease would be a concern. But I looked it, wasn't really able to find anything that verified that there was any issue with giving an elemental diet in somebody with kidney disease. And actually there was one study I found that showed improvement in kidney function in people with chronic kidney disease on an elemental diet. You might wanna be a little bit more careful in somebody with compromised liver function because amino acid metabolism can lead to ammonia production and build up in their liver and so that might raise liver enzymes. But again, if you're only doing this for 2 weeks or so that really shouldn't make a big difference. And then, as I already mentioned, really that history of the eating disorder is a big red flag for me and then contraindication.

Kaczor: Well that's ... I know this has been incredibly helpful from a practical perspective. I think that in less than 20 minutes we've touched on a few things that are definitely what I would consider clinical pearls for our listeners. So I really appreciate you taking the time of your schedule and offering up your expertise for our listeners. So thanks for being here with me.

Altman: Oh, it's been a pleasure. Thank you.

Kaczor: And once again, this is Tina Kaczor with the Natural Medicine Journal. And I'd like to thank the sponsor of this podcast, Integrative Therapeutics.

Sep 7, 2017

In over half of all cases of hospitalization for a cardiovascular event, the first symptom is the event itself. So anything we can do to get any early indicator that something is going wrong in the cardiovascular system can have a huge impact. Erectile dysfunction is one such early signal. According to cardiovascular health expert Daniel Chong, ND, identifying sexual dysfunction is essential for improving cardiovascular outcomes. 

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Approximate listening time: 30 minutes

About the Interview

It may seem counterintuitive to interview a cardiologist, and not a urologist, on the topic of erectile dysfunction (ED). But we now know that ED is a result of endothelial cell dysfunction and ED can be an early warning sign of systemic atherosclerosis. Looking at ED from a cardiovascular perspective is essential.

That’s why we invited cardiovascular expert Daniel Chong, ND, to talk to us about ED’s connection to heart health. In this interview, Natural Medicine Journal’s editor-in-chief, Tina Kaczor, ND, FABNO, asks Chong about the complex interplay between vascular function and sexual function.

According to Chong, cardiovascular disease always has some degree of contribution—potentially a major one—in ED. That’s in part because blood flow is the key facet to obtaining a full erection. Cardiovascular dysfunction, including plaque in the arteries that regulate that blood flow, can therefore have an impact on ED. Even before plaque development becomes a problem, endothelial dysfunction in the inside walls of the arteries can play a role in erectile function.

In this enlightening interview, Chong explains the different issues that can contribute to ED, including anatomical, physiological, and psychological problems. It’s an important listen for any practitioner who sees men, since beyond being a problem in and of itself ED can be an early signal of other serious health concerns.

About the Expert

Daniel Chong, ND

Daniel Chong, ND, has been a licensed naturopathic physician, practicing in Portland, Oregon, since 2000 and focusing on risk assessment, prevention, and drug-free treatment strategies for cardiovascular disease and diabetes, as well as general healthy aging, and acute and chronic musculoskeletal injuries. Chong has also completed certificate training in cardio-metabolic medicine from the American Academy of Anti-Aging Medicine and is an active member of the Society for Heart Attack Prevention and Eradication (SHAPE). In addition to his clinical work, Chong serves as a clinical consultant for Boston Heart Diagnostics Lab.

Transcript

Tina Kaczor, ND, FABNO: Hello. I’m Tina Kaczor for the Natural Medicine Journal. Today, we’re going to be talking about erectile dysfunction and cardiovascular disease with Dr Daniel Chong. Dr Chong is a naturopathic physician with a private practice in Portland, Oregon for the past 17 years. He specializes in what he likes to call "vascular wellness optimization." He’s also the founder of the web-based consulting company, the Healthy Heart Project which offers a number of educational and direct consulting options for both the general public as well as healthcare practitioners on how best to assess and reduce risk for cardiovascular disease. Dr Chong also lectures and serves as a clinical consultant for Boston Heart Diagnostics Lab.

Thanks so much for joining me today, Dr Chong.

Daniel Chong, ND: You're welcome, Tina. Good to be here.

Kaczor: As I mentioned, our topic today is erectile dysfunction. At first, it may seem odd to our listeners that I’m talking to a cardiology expert and not a urologist or men’s health expert but we now know that erectile dysfunction is a result of dysfunction of endothelial cells and in fact, this can be an early warning sign of systemic atherosclerosis. Dr Chong, can you start us out with a brief overview of how erectile dysfunction and cardiovascular disease are related?

Chong: Sure. I can do my best there. There’s definitely going to be different circumstances that can contribute to erectile dysfunction. Some of which may not be actually anatomical, so to speak, or physiological from the cardiovascular perspective but I would say the majority is at least indirectly affected because even if we’re talking, for example, about a psychological contributor which we may touch on later, if somebody has dysfunctional arteries down there in the penis, they’re going to be more vulnerable to effects from psychological aspects than they would be otherwise. In other words, a young teenager may get stressed out in an early sexual experience but that’s not going to affect function as much as it could a 50-year-old man.

Anyways, in general, we could just say that cardiovascular disease is going to have some degree of contribution and potentially major. Obviously, blood flow is the key facet to obtaining a full erection and certain arteries are going to be more vulnerable to impacts from the development of cardiovascular disease but even so, the arteries in the penis may or may not actually have plaque in them but they can still dysfunction. Typically, we know, and we’re going to talk about this later, in cardiovascular disease, the preceding step prior to actual anatomical change or plaque development is endothelial dysfunction or dysfunction in the inside wall of the arteries and even that going on without any actual plaque having developed yet can affect erectile function and not to be noticeable by the person.

All in all, I guess you could say they’re intimately intertwined because you have to have good blood flow. It may or may not have plaque. Plaque may or may not be actually playing a role yet but it will in some cases and cause really significant dysfunction, but even minor dysfunction is going to be at least the partial result of the arteries starting to misbehave for various reasons that hopefully we’ll touch on.

Kaczor: Yeah. I actually came across some mention of erectile dysfunction in that whole idea of plaque formation. One author said that it could signify in some patients, or at least it should be followed up to see if it signifies subclinical atherosclerosis.

Chong: Correct.

Kaczor: Yeah. Atherosclerosis being pretty much asymptomatic in people until there’s larger consequences. On that note-

Chong: Right. Yeah. Sorry to cut you off. Sadly, it’s been shown that in over 50% of cases of hospitalization for a cardiovascular event, the first symptom is the event and that’s over half of all of them, so anything we can do to get any early indicator of something in this, so to speak, before, for example, erectile dysfunction, is hugely important for us because we are not doing a very good job at least conventionally in identifying early on what’s going on with people.

Kaczor: Yeah. I look forward later in this discussion to talk to you about how to assess it, to find early markers besides just the symptom of erectile dysfunction but let’s start with the larger picture in conventionally recognized erectile dysfunction and cardiovascular disease risk factors. Can you talk a little bit about like when we’re, as clinicians, who walk into our office, who we should suspect it in or at least engage in the conversation because many patients won’t bring it up themselves unless they're directly asked?

Dr Chong: Yeah, absolutely, so, certainly age. The older a man gets, the more potential there's going to be for all kinds of different changes going on physiologically. Some people are well aware of testosterone production, how crucial that is and that certainly begins to change as a man ages. But certainly, very standard, interestingly enough, it’s the same standard risk factors you might consider for cardiovascular disease in general in terms of high blood pressure, diabetes, certainly, smoking.

Conventionally, you're going to see high cholesterol as a stated contributor but we can certainly talk in more detail about that because I know that some people out there in the functional medicine world, naturopathic world, et cetera, consider high cholesterol as a past tense risk factor for cardiovascular disease which it really is and it’s just more complicated than that. Obesity, lifestyle factors in terms of exercise and then certainly, psychological factors, depression and anxiety, et cetera are all going to be key things.

I also want to make a just brief mention even though this is kind of a topic in and of itself, when we talk about erectile dysfunction, obviously, we’re talking about men but it should be very clearly stated that the same potential processes are going on in women as they age. Women with difficulty with sexual activity or orgasm, et cetera, may in fact be having their own version of “erectile dysfunction” with the clitoris as essentially an analogous structure in a woman and all of these blood flow issues can occur in women as well. It’s important to really kind of make mention to that. I say men, I keep saying men, as men age, blah, blah, blah, but it really should be looked at as both sides of the coin, so to speak.

Kaczor: That’s actually an important point. Thank you for mentioning that.

Chong: Sure.

Kaczor: I want to do a follow-up on that cholesterol thing that you just mentioned because I think that that’s kind of top of mind. I think it’s important to give voice to any new data on looking at cholesterol because I'm with you on it being much more complex and it’s more complex than I understand. I'm happy for you to kind of flesh it out for us.

Chong: Yeah. I mean, I guess anybody that says that cholesterol has nothing to do with cardiovascular disease is not really thinking about the fine details of the situation. You can't have a plaque form without cholesterol and lipoprotein particles being involved because they are what are the sort of primary components to the development of the plaque.

What I don’t agree with conventionally is the idea that high cholesterol, in and of itself, is just going to definitively contribute to cardiovascular disease because obviously, there are many people out there who have relatively “high cholesterol” who don’t get cardiovascular disease. There's certainly something else going on that’s playing a role as to whether or not high cholesterol is going to lead to that issue in some people versus others.

Long story short, I consider cholesterol and related markers to be secondary factors. They are absolutely involved but they are not … There's going to be other things that help sort of determine the likelihood or lack thereof of the high cholesterol sort of turning into cardiovascular disease. That’s a really fun discussion in and of itself. It could be another hour or so by itself but hopefully, that kind of answers your question, at least preliminarily.

Kaczor: Well, it brings up another question which is-

Chong: Certainly, keep going with that. Yeah.

Kaczor: Yeah. If cholesterol is considered a secondary factor, and I see what you're saying, cholesterol is not … needs to be present but can't be causative because there's not a cause and effect 100% of the time.

Chong: Correct.

Kaczor: If it’s secondary, what are you looking at as primary?

Chong: Well, to me, the absolute most important thing that’s going to contribute to the potential or lack thereof of eventual cardiovascular disease development or i.e. plaque, development is the health and vitality of the walls of the artery and how well they're functioning. In other words, the healthier, more nutritionally replete the walls of the arteries are themselves and the better they're being sort of manufactured in the first place by the body, are going to be the primary factor that leads to vulnerability or not.

If you imagine like … I would like to use analogies. On a coastline, you may have, let’s say, in Hawaii versus somewhere else on the mainland. Hawaii is made up of volcanic rock which is, tends to be a little bit more brittle and it can sort of erode more easily. If you have waves crashing into the wall, into a wall of rock in Hawaii, it may erode more quickly. Then, an analogous wall somewhere else in the world that’s made up of a different, harder, more resilient material, the waves are still crashing into them with the same potential force but one’s going to erode more quickly than another.

If we then relate that to the vascular system, somebody who has poor nutrition and tons of inflammation, oxidative stress, et cetera, and especially long-term poor nutrition, they're not going to be able … especially if we’re talking about collagen production, they're not going to be able to manufacture the sort of strong, resilient vascular walls that they should which will inevitably be, if they are stronger, will inevitably be more resistant and resilient to the impact of the turbulence of the flow of blood.

There are certainly other things that are going to impact that as well especially the turbulence itself and the viscosity of the blood. That’s going to make for essentially like stronger waves crashing in which obviously, the stronger the waves is crashing into the area, the more potential there is for erosion as well. To me, long story short, the primary situation that’s going to lead to the potential development of plaque is a combination of two primary factors. That’s the vulnerability of the wall of the artery and the stress that is being placed on the wall of artery.

Kaczor: By-

Chong: If you look at every single risk factor we know of, they are impacting one or both of those factors.

Kaczor: Okay. When you say stress, you mean mechanical forces, as well as chemical?

Chong: Chemical. Absolutely.

Kaczor: As in oxidative stress?

Chong: Correct. That would be one of them. I mean, even environmental toxins, different types of infectious organisms and certainly mechanical stress as well or what we call blood viscosity which is impacted by a variety of factors. Primarily, probably the main ones for blood viscosity would be hydration and like even iron levels or high sort of … basically, concentrated solid substances in the blood and then also, cloudiness of the blood, how high is fibrinogen levels and things like that are going to impact the viscosity of the blood. Then, the classic risk factor of high blood pressure is going to be too, more or less, stress on the wall of artery.

Kaczor: Let’s-

Chong: Sorry. One other thing. I mean, one of the ways that high cholesterol may be contributing to things is it’s known that the higher the cholesterol is, the stronger the impact on the vascular wall is. It actually causes … High cholesterol itself can contribute to endothelial dysfunction or stress on the function of the wall of the artery.

Kaczor: Doing mechanical forces, you're saying, to the viscosity of the blood.

Chong: Right, and more technical reasons, like it literally messes with certain aspects of how the wall, the endothelium is supposed to be functioning. It’s not just that it gets into and becomes part of the plaque. The higher your cholesterol goes, the potentially worse the endothelial function initially.

Kaczor: Okay. Let’s switch gears a little bit. If we’re talking about endothelial dysfunction as the commonality between erectile dysfunction, atherosclerosis, cardiovascular disease, it’s all about a healthy endothelium.

Chong: Right.

Kaczor: It’s interesting, in that same paper I mentioned before, I came across a term that I had not seen before. It was the endothelium as a single organ which I thought was a really interesting concept like, “Oh,” thinking, “I'm sure it’s different, in different tissues,” but just the idea of overall health of it being a singular thing was interesting to me.

Chong: Right. People look at the blood vessel as like these tubes that are just allowing for the passage of blood flow. There's so much going on at the wall of the artery physiologically. It is absolutely an entire organ.

Kaczor: Let me ask you this. As far, for us as clinicians, what are either biomarkers or assessment tools, how do we gauge endothelial function in a patient?

Chong: Well, technically, when we’re specifically talking about endothelial function, there's only a few ways to directly assess that. Clinically, they're going to involve some way, shape, or form of actually testing, in-office, the function of the arteries themselves. There's a general … There's a few … There's basically two main machines that I'm aware of. One is called an EndoPAT and one is called the EndoTherm that are designed to directly assess endothelial function.

The way they basically work is they … You have your fingers in some type of device that’s monitoring either blood flow or temperature at the fingertips. Then, you basically occlude the artery and the arm like you would with the blood pressure cuff. You have to do that for about 5 minutes which is not enjoyable for the patient because, as you can imagine, it isn’t feel very good to have your blood occluded for 5 minutes. Then, prior to doing that though, you're doing a general assessment on blood flow and temperature of the fingers. Then, you occlude the blood flow and then you let it out all at once.

When the blood comes, as you might imagine, rushing back into the extremities in the fingers, you should get some degree of expansion of the arteries. Normal function would lead to the arteries, as the blood really rushes in there, would lead to the arteries expanding to a certain extent. People that have endothelial dysfunction, their blood vessels will not expand appropriately. The machines are designed to sort of read that, sort of the tip, where your tips of your fingers are sitting, the machines is detecting, is there a significant enough change in temperature and or blood flow.

There's also something called arterial pulse velocity which basically, there's a smaller device called an iHeart like an iPod but it’s iHeart. I'm not connected to any of these companies or anything like that but that is a newer device that’s being developed that checks sort of indirectly the same thing. It looks kind of like a pulse oximeter but it’s actually detecting arterial pulse wave velocity and literally how quickly a pulse rate is moving down the arterial tree.

If you might imagine, the sort of left compliant and arterial, an artery is, the quicker the pulse rate is going to move down it. That’s generated by heart, a heartbeat. Those are the only ways that I'm aware that are … Those are the only things that I'm aware that are being used in-office to directly assess endothelial function. There is a lab test that can be measured with people called ADMA. It stands for asymmetric dimethylarginine. That is considered a surrogate or indirect assessment of endothelial function. The higher the ADMA is, the higher the potential for endothelial dysfunction because it’s a direct sort of inhibitor of nitric oxide production.

Kaczor: All right. Well, that leads us into our next little piece, doesn’t it? Nitric oxide production being integral to the whole relaxation of the smooth muscle and the endothelium to allow for blood flow whether we’re talking about the fingertips or the penis. Can you talk a little bit about nitric oxide? Maybe briefly mention how an assessment can be made, the ADMA being one of the means of assessing that as far as the blood test and anything else that might be accessible to a general physician or clinician that might be seeing these patients.

Chong: Well, I mean, endothelial function is, to me, the ideal way to get an assessment of that because I'm a big proponent of the idea that we want to check end of point factors as often as we can. Classic example of this is looking at the different impacts of certain dietary changes on cholesterol markers and making conclusions about whether or not that is good for the vascular system or not, certain changes like HDL going up, for example, after the implementation of a certain diet did not guarantee by any stretch of the imagination that you're having a positive effect on the vascular system so I like to use endpoint markers or end, sort of, functional markers as much as possible so far and away still, the best way to me to assess nitric oxide levels is via those endothelial function tests that we mentioned already.

Other ways to sort of try to get an assessment of it, the only other way that I’m really aware of is if you've seen … You've been to enough conferences, I know. You’ve probably seen this company that has this little saliva test that you can use to check basically nitrate levels in the saliva. That’s going to be … Nitrate is a crucial factor, nitric oxide production as well, so some people are using these little saliva tests to check what a person’s typical nitrate intake is and then recommending dietary or supplement interventions based on that. Those are really the only ways that I’m aware of to sort of really truly get an assessment on that other than, obviously, history and talking to a person, seeing how well things are working, so to speak.

Kaczor: Can I ask you a question? I don’t mean to put you on the spot and I do not know the company that’s offering nitrate levels in saliva but is this something that’s been validated or is it with any rigor or is this one of those early adoption things that happen?

Chong: Right. You're asking me if something has been validated with scientific tests or research? Can you restate?

Kaczor: Or at least … Yeah.

Chong: You do that with everything which is great. That’s why I like you so much but I don't know for sure. This is … In all honesty, I haven’t really looked too deeply into that method of assessment with people, so I wouldn’t be able to say with any certainty at all. I know that they’re quite widely used and it’s not a very complicated, technically complicated test so I think it’s pretty straightforward. I do recall seeing literature being made available by these companies but I have not looked that in-depth at that at this point.

Kaczor: Well, I appreciate your honesty. When you're on the cutting edge, early adoption of new technologies is part of our … We get to do that. We get to be right there doing, instituting things but it’s important, I think, for us all to go at a pace that has some, at least reproducibility, if not rigor.

Chong: Absolutely. The other thing that I would say to add to that is like using different angles of assessment is also crucial, not just relying on one piece of information whether it be cholesterol. That’s why the classic conventional mistake is like, “Okay, we’re going to check and see if you have a high risk for cardiovascular disease. Let’s check your lipid panel. There’s so much more beyond that that can be done to assess and evaluate people and get a much clearer picture. That’s a classic idea, just sort of not settling on one thing, not just using the newest thing, whatever it is. Use as many tools as you can within reason to get the clearest picture.

Kaczor: Yeah. I want to continue on the molecular biology of this and specifically, we have just a few minutes left, really talk about-

Chong: Time flies when you're talking about erectile dysfunction.

Kaczor: What’s that?

Chong: I said time flies when you're talking about erectile dysfunction.

Kaczor: Well, oxidative stress, being something that you mentioned and it’s just something that we’re … That inflammation is kind of always at the forefront of anyone who’s doing integrative medicine or optimal wellness or however you want to term it. I guess my thought is this. In a concise way, can you tell me if you use any actual blood markers that are widely available and what are some of your favorite ways of, kind of across the board, addressing oxidative stress issues, which even beyond erectile dysfunction, it becomes part and parcel with that but it’s also just part of life and part of being alive, is creating oxidation?

Chong: Right. In the realm of assessment, especially if we were going to so far as to separate out inflammation in oxidative stress because obviously, they aren’t exactly the same thing, when we’re talking inflammation, the primary markers that I’m measuring with people certainly are high sensitivity CRP as our sort of general global marker of inflammation or lack thereof. When we’re talking about the vascular system, I’m also typically going to be checking something called Lp-PLA2 or what’s also known as the PLAC test. That is more specifically an inflammation marker for the vascular system so it’s going to actually reveal immunoactivity and inflammation going on in the wall of the artery whereas a high CRP is not going to be able to definitively determine that or not. MPO or myeloperoxidase is a later stage, nonspecific but frequently correlated marker for late stage vascular inflammation for a vulnerable vascular system.

In the realm of oxidative stress, the 2 primary markers that I might look at is actually … number 1 is actually oxidized LDL so it’s pretty hard to have moderately elevated LDL levels and a high amount of oxidative stress and not see a relatively increased level of oxidized LDL in the bloodstream. That is sort of a good, what you'd call extracellular oxidative stress marker, but we can also get intracellular oxidative stress for different reasons.

For that, you can also check something called 8-oxoguanine which is an actual, actually a urinary test. Not too many labs run that. I’m not sure if we’re supposed to name names here but that is an … If you just Google 8-oxoguanine test or something like that, you can probably find the labs that run that but that’s going to give you more of an assessment of intracellular oxidative stress. Then, beyond that, you can, in all honesty, get a pretty good idea whether or not somebody is going to be a candidate for high oxidative stress just by talking to them and looking at them and that type of thing as well.

Kaczor: Yeah. A lot of those other markers for cardiovascular disease like obesity, even the aging process, certainly smoking, all-

Chong: Right. Absolutely.

Kaczor: Obviously, we would take into account for oxidation. Can you let me know or let the listeners know your top three? Someone looks at you and they’re like, “Listen. I do everything right. I exercise. I eat well. My BMI is normal. I don’t drink. I don’t smoke. What are the three supplements you …” You only get to see them once. They’re going to leave your office.

Chong: These people are eating well, you said, in my opinion?

Kaczor: Okay. That brings up the point. What would that look like in your opinion?

Chong: No, no. I’m sorry. I’m just-

Kaczor: We only have 2 minutes left but what would be an ideal guy in your opinion and then-

Chong: No, no, no, no, no. I’m sorry. I was just clarifying the question. If these people are already eating well like they’re eating lots of fruits and vegetables, et cetera and I’m just talking about supplements, the 3 main ones I’m going to recommend are going to be vitamin C, magnesium, and then probably some type of concentrated plant-based antioxidant. As a naturopath, herbal medicine trained, I have an affinity to hawthorn but also, I frequently recommend hibiscus tea to people.

Kaczor: Nice. Hibiscus being, you're also from Hawaii so that’s-

Chong: Good point. You could certainly go beyond that and complement it with things like arginine, citrulline, and then there are a number of nitric oxide precursor type of products that are high in dietary nitrates.

Kaczor: Well, Dan, I really appreciate this. I feel like we could have a whole part 2 where we go into the therapeutics and more details into all of this but I think the listeners have gotten good overview today and I really do appreciate the time you've taken and your expertise, and best of luck with your Healthy Heart Project.

Chong: Thank you, Tina. It was good to talk to you and happy to help as I can.

Kaczor: All right. Take care.

Chong: All right.

Sep 7, 2017

One in four men over the age of 65 has urinary incontinence, according to the Centers for Disease Control and Prevention. In this interview, men's health expert Ronald Morton, MD, FACS, describes how urinary incontinence is diagnosed and treated. He also provides detailed information about the key medical devices that are available to treat this condition.

Approximate listening time: 14 minutes

About the Interview

Although urinary incontinence is not as common in men as it is in women, it is more prevalent than many people think. According to the Centers for Disease Control and Prevention, one in four men over the age of 65 suffers from it.

The underlying causes are often similar in both genders: aging and weakening of the pelvic floor muscles. However, pelvic trauma or prostate disease or surgery can also contribute to the problem in men.

Urinary incontinence creates significant quality-of-life issues, so finding effective treatments is very important.

In this interview with urologist Ronald A. Morton, Jr., MD, FACS, Natural Medicine Journal’s publisher Karolyn A. Gazella discusses the prevailing treatment options for male urinary incontinence. For some men, pelvic floor exercises alone can provide relief. For others, diet and weight modification are necessary. Others may opt for more advanced interventions, including surgery.

Surgical options range minimally invasive to extensive. On the simpler end of the spectrum is the basic urinary sling. In this quick procedure, a sling is inserted to replicate the support lost in previous interventions or trauma. On the other end of the spectrum is an artificial urinary sphincter, which regulates urine flow through a pump.

Of course, surgical interventions are not without risks and side effects. Morton addresses those and discusses how to determine whether a patient is a good candidate for surgery.

Listen to this interview to learn more about the current treatment options for male urinary incontinence, as well as Morton’s predictions for the future of incontinence treatment.

Scroll down for the full transcript.

About the Expert

Ronald A. Morton, JR, MD, FACS, is the vice president of clinical sciences for the Urology and Pelvic Health division of Boston Scientific, a position that he has held since August 2015. Before joining Boston Scientific, via acquisition, Morton worked for Endo International plc as chief surgical officer, American Medical Systems. Previously, he worked for GTx, a biotech company in Memphis, TN, as chief medical officer. Prior to joining GTx, Morton was chief of urology at Robert Wood Johnson Medical School and director of urologic oncology for the Cancer Institute of New Jersey. He also held an endowed chair position as director of the General Clinical Research Center. Morton holds a BA in natural sciences from The Johns Hopkins University and received his medical doctorate from The Johns Hopkins University School of Medicine. He has board certification as a diplomat, American Board of Urology.

Transcript

Karolyn: Hello, I'm Karolyn Gazella, the publisher of the Natural Medicine Journal. Today our topic is male urinary incontinence and my expert guest is Dr. Ronald Morton. Dr. Morton, thank you for joining me.

Dr. Morton: Hi, Karolyn, and thank you for having me today.

Karolyn: Well great. Well, let's just start with the basics. How is urinary incontinence diagnosed in men?

Dr. Morton: Karolyn, urinary incontinence is not as common in men as it is in women, although it does happen more commonly than people think. The main causes are as it is with women, aging and weakening of the pelvic floor muscles. But more importantly, and the reason for many of the interventions that we have for urinary incontinence in men is it can be due to trauma to the male pelvis and/or surgery for diseases of the prostate. When I say disease of the prostate I mean both benign conditions like BPH, which many men suffer from and are aware of, and then also prostate cancer, which is a very common cause for surgery on the male pelvis.

Karolyn: And then what's considered the gold standard of treatment for this particular men's health condition?

Dr. Morton: There are many ways to treat male incontinence, as there are many ways to treat female incontinence. The usual approach that will be taken by a urologist is to go from the least invasive to more invasive solutions until the patient is happy. I think that one thing that always has to be kept in mind is that this is really a quality of life issue for most men, especially since urinary incontinence in males is generally a disease of men who are older. The median age of diagnosis of prostate cancer is about 63 years of age or so. Since operations on the prostate are the common cause for this, they're generally older men and it's a quality of life issue.

What one male will find satisfactory control of the urinary incontinence might be totally unsatisfactory to another. So the general approach would be to start with exercises, commonly called Kegel exercises. The same exercises that we suggest that women do who have a mild degree of urinary incontinence and see if that won't help. If Kegel exercises won't help and it's not something that can be helped with diet and weight modification, then we go into more invasive treatments for male urinary incontinence.

The first level of invasion is a procedure that only takes a few minutes, really, less than a half an hour called a male urinary sling. It's much like the slings that are used in women. It  supports the male urethra and holds it up, providing support that has been lost due to the previous surgical intervention or pelvic trauma in hopes that that will correct the incontinence.

Fore more severe degrees of incontinence we often times need to move towards what is really considered, as you say in your question, the gold standard for severe incontinence, which is the artificial urinary sphincter [AUS]. In that procedure, a cuff is placed around the urethra and this cuff is connected to a pressure-regulating balloon, which controls pressure in the cuff, keeping the urethra closed and preventing leakage of urine and also a pump, which is placed in the scrotum. When it's time to urinate, the male can just activate the device. The fluid leaves the cuff and goes into the pressure-regulating balloon, opening the urethra. The male can then urinate and then after a period of lock-out time, the cuff will refill, returning him to a state of continence.

Karolyn: So let's talk about these two, the sling and the sphincter. What determines whether or not a patient is severe enough for the sphincter versus the sling? What's the difference between those two patients, the one that gets the sling and the one that gets the sphincter?

Dr. Morton: Good question because again, it has a lot to do with personal preference. But there are some general guidelines that one can go by. When we measure incontinence and it can be a difficult thing to put a number on, but most men who have incontinence will use urinary pads in their shorts in order to trap urine leaking. A good gauge of to what degree a male leaks is how many times they have to change that pad. Now, some men will as soon as there's a small amount of urine because of the discomfort it will cause will change that pad right away. Some men tend to allow the pad to get very, very soaked before they'll change it. Everyone behaves a little bit differently.

A way to get a handle on exactly how much leakage a man has it to do what we call the pad weight test. So we'll give them all the pads that they might need for a day and a bag that can prevent evaporation and they just collect the pads that they use for the day, put it in this bag, and everything is pre weighed, and then we weigh it to see what the volume of urine leakage is.

A rule of thumb, if they're leaking around five pads or 300cc of urine a day, that's severe and is more likely to be treated with the artificial urinary sphincter. Degrees of urinary leakage that are less than that can be and generally might be recommended that they be treated with the sling procedure.

Karolyn: Now are there are any contraindications associated with each of these options, the sling or the sphincter? So in other words, are there men who would not be a good candidate for either of these options?

Dr. Morton: Well, they have to be able to undergo a surgical procedure, and while the sling procedure is relatively short, it does require at least a regional anesthetic. The artificial urinary sphincter procedure is a little bit longer and requires a general anesthetic so they have to be fit for the surgery. The sling is generally not recommended for men if they have been treated for prostate cancer with radiation. The outcomes there haven't been as good as they have been with the artificial urinary sphincter so in that setting we generally would recommend a sphincter as opposed to a sling, even if they were otherwise a good candidate for a sling.

Karolyn: What about side effects? Are there any side effects associated with either of these devices?

Dr. Morton: I'll take that question separately for each of the two devices. The side effects associated with the sling are that if you don't choose the patient in the best way, two things can happen. One, the patient can not have their incontinence adequately treated. A second issue is if you put a sling in a patient whose major problem is not one of the urethra but is a bladder issue, and that can be sorted out ahead of time with uro dynamics, but if you did you may render that patient obstructed or in urinary retention. The problem doesn't have to do with external sphincter deficiency for that patient.

For the artificial urinary sphincter what we're doing is we're placing this cuff around the urethra. It does over time potentially compromise some of the blood supply to the urethra in that area and you can get what's known as atrophy of the urethra in the area of the cuff. When you get atrophy in the area of the cuff there can be a return to urinary incontinence. Of course for both of these procedures, since you're putting a foreign body in, there's a risk of infection, although infectious problems with these devices have been relatively low.

Karolyn: Okay, that makes a lot of sense. Now, I'm just curious because you have a certain expertise in this area as chief surgical officer of American Medical Systems. What general advice do you give to physicians who are treating men with urinary incontinence?

Dr. Morton: One, most of the advice that I have is for physicians who have men with incontinence but aren't necessarily the experts in treating them. There's a couple of things. One of the things that our research has shown us is that many men who are subjected to surgery for prostate cancer, for example, and who then suffer from incontinence don't recognize, or aren't made aware that there are treatments for it and they suffer in silence we like to say. So, if we can get anything out to the many physicians listening to this podcast it would be don't let this happen to any of your patients. Make sure they understand that if they do get incontinence after, for example, radical prostatectomy, there are options and there are potential solutions for this.

The second message is I spend a lot of time working with the engineers and we're constantly looking at ways to come up with a better mouse trap if you will. What can we do to avoid the complications we spoke of earlier? What can we do to help physicians identify the proper patients so we don't use a sling in a patient who should've had an AUS, or an AUS in a patient who should've had a sling? And what can we do to make the functioning of the AUS a little bit easier so that in this elderly population of men they are always candidates for the device?

Karolyn: Yeah, that makes a lot of sense and I'm glad that you brought that up about suffering in silence and information. Obviously, a well-informed patient is the best patient to have. So letting that patient know his options is absolutely critical.

So one final question for you Dr. Morton. What is on the horizon when it comes to devices for this particular issue with men? Do you see existing devices just being improved? Do you see new devices? Are we kind of where we should be? Look into your crystal ball and tell me what the future holds for this.

Dr. Morton: I don't know if I'm the best person to predict the future, but I think that our efforts are to make sure that A, these are the right solutions. We are constantly looking at, are there other options? Are there other ways to manage urinary incontinence? Could we come up with a less invasive way to place the sling or a less invasive device would replicate the great performance of a sling?

On the urinary sphincter side of things it's a mechanical device, so can we simplify that mechanism so that it's easier for the patient to implement? Remember there's a patient interface with the AUS. Most devices that we implant, like when a cardiologist implants a pacemaker, there's no patient interface. The patient doesn't have to decide whether or not their pacemakers work. It's in and it just works. For our device, at least for the artificial urinary sphincter, there's that patient interface. So if we can improve that patient interface with the device and make it as reliable as possible, that's what we're looking to do in order to improve the overall performance of the device and have men have a greater satisfaction with their quality of life.

Karolyn: Yeah, that makes a lot of sense. Well, this has been very informative. Once again, thank you, Dr. Morton, for joining me today.

Dr. Morton: Karolyn, thank you for having me.

Karolyn: Have a great day.

Jul 19, 2017

By Natural Medicine Journal 

The FDA recently held a meeting (July 10-11, 2017) to discuss ways to decrease the frequency and patterns associated with opioid misuse and abuse. In this interview, pain management expert, Beth Darnall, PhD, talks about the crisis of opioid addiction and how to create safe, effective non-opioid pain management strategies.

About the Expert

Beth Darnall, PhD

Beth Darnall, PhD, is clinical associate professor in the department of anesthesiology, perioperative and pain medicine at Stanford University. Past roles include president of the Pain Society of Oregon and cochair of the Pain Psychology Task Force at the American Academy of Pain Medicine. Her NIH-funded research investigates mechanisms of pain catastrophizing, cognitive behavioral therapy for pain, and a targeted intervention she developed. She is also investigating the impact of an online psychological intervention she developed on postsurgical pain and opioid use in various surgical populations, including cancer and orthopedic trauma. Finally, she is investigating effective opioid tapering strategies in community-based outpatients with chronic pain.

Darnall is author of The Opioid-Free Pain Relief Kit and Less Pain, Fewer Pills: Avoid the dangers of prescription opioids and gain control over chronic pain, and the forthcoming book from the American Psychological Association titled Psychological Treatment for Chronic Pain. She is owner of Optimized Psychology Consulting. Her work and viewpoint has been featured by multiple media outlets, including the San Francisco ChronicleNew York MagazineMORE magazine, Forbes, and Scientific American. For more information visit her website at bethdarnall.com.

Jul 5, 2017

By Natural Medicine Journal

 

While vitamin C may seem like a straightforward topic, it's actually rather complicated. In this interview, leading integrative medical expert Russell M. Jaffe, MD, PhD, describes some of the clinical complexities associated with this popular nutrient. Jaffe describes the different forms, dosages, and synergy with other nutrients. He ends with a description on how ascorbate helps with toxic mineral removal. 

Approximate listening time: 18 minutes

About the Expert

Russell Jaffe

Russell M. Jaffe, MD, PhD, is CEO and Chairman of PERQUE Integrative Health (PIH). He is considered one of the pioneers of integrative and regenerative medicine. Since inventing the world’s first single step amplified (ELISA) procedure in 1984, a process for measuring and monitoring all delayed allergies, Jaffe has continually sought new ways to help speed the transition from our current healthcare system’s symptom reactive model to a more functionally integrated, effective, and compassionate system. PIH is the outcome of years of Dr. Jaffe’s scientific research. It brings to market 3 decades of rethinking safer, more effective, novel, and proprietary dietary supplements, supplement delivery systems, diagnostic testing, and validation studies.

About the Sponsor

Perque Integrative Health

PERQUE Integrative Health (PIH) is dedicated to speeding the transition from sickness care to healthful caring. Delivering novel, personalized health solutions, PIH gives physicians and their patients the tools needed to achieve sustained optimal wellness. Combining the best in functional, evidence-based testing with premium professional supplements and healthful lifestyle guides, PIH solutions deliver successful outcomes in even the toughest cases.

Jun 5, 2017

Leading integrative medicine pioneer, Russell Jaffe, MD, PhD, CCN, describes his philosophy regarding hard-to-treat thyroid conditions. Jaffe starts with proper diagnosis and then takes listeners through to the environmental impact, alkalinizing the body, and using targeted nutrients to provide an individualized approach.

Approximate listening time: 21 minutes

About the Expert

Russell Jaffee

Russell M. Jaffe, MD, PhD, is CEO and Chairman of PERQUE Integrative Health (PIH). He is considered one of the pioneers of integrative and regenerative medicine. Since inventing the world’s first single step amplified (ELISA) procedure in 1984, a process for measuring and monitoring all delayed allergies, Jaffe has continually sought new ways to help speed the transition from our current healthcare system’s symptom reactive model to a more functionally integrated, effective, and compassionate system. PIH is the outcome of years of Dr. Jaffe’s scientific research. It brings to market 3 decades of rethinking safer, more effective, novel, and proprietary dietary supplements, supplement delivery systems, diagnostic testing, and validation studies.

About the Sponsor

Perque Integrative Health

PERQUE Integrative Health (PIH) is dedicated to speeding the transition from sickness care to healthful caring. Delivering novel, personalized health solutions, PIH gives physicians and their patients the tools needed to achieve sustained optimal wellness. Combining the best in functional, evidence-based testing with premium professional supplements and healthful lifestyle guides, PIH solutions deliver successful outcomes in even the toughest cases.

 

May 1, 2017

Lyme disease can be a challenging condition to treat. In this interview, integrative medicine expert, Russell Jaffe, MD, PhD, CCN, describes his treatment approach and also explains the important connection between Lyme disease and small intestinal bacterial overgrowth (SIBO).

Approximate listening time: 20 minutes

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About the Author

Russell M. Jaffe, MD, PhD, CCN, is CEO and Chairman of PERQUE Integrative Health (PIH). He is considered one of the pioneers of integrative and regenerative medicine. Since inventing the world’s first single step amplified (ELISA) procedure in 1984, a process for measuring and monitoring all delayed allergies, Jaffe has continually sought new ways to help speed the transition from our current healthcare system’s symptom reactive model to a more functionally integrated, effective, and compassionate system. PIH is the outcome of years of Dr. Jaffe’s scientific research. It brings to market 3 decades of rethinking safer, more effective, novel, and proprietary dietary supplements, supplement delivery systems, diagnostic testing, and validation studies.

About the Sponsor

Perque Integrative Health

PERQUE Integrative Health (PIH) is dedicated to speeding the transition from sickness care to healthful caring. Delivering novel, personalized health solutions, PIH gives physicians and their patients the tools needed to achieve sustained optimal wellness. Combining the best in functional, evidence-based testing with premium professional supplements and healthful lifestyle guides, PIH solutions deliver successful outcomes in even the toughest cases.

Apr 17, 2017

People who currently and have historically struggled with eating disorders often have many eating disorder-related symptoms that respond positively to an integrative approach to treatment. Just like many other chronic health conditions, with appropriately selected interventions, recovery from an eating disorder can be further facilitated with holistic support. Nutritional support, and natural support for mental health and digestive issues are just a few of the topics that we discussed during this interview with naturopathic expert Carrie Decker, ND. 

Listening time: 33 minutes

About the Author

Carrie Decker, ND, is a certified naturopathic doctor who graduated with honors from the National College of Natural Medicine (now the National University of Natural Medicine) in Portland, Oregon. Decker also holds graduate degrees in biomedical and mechanical engineering from the University of Wisconsin-Madison and University of Illinois at Urbana-Champaign respectively. Decker sees patients at her office in Portland as well as remotely. Her practice focuses on gastrointestinal disease, eating disorders, allergies, mood imbalances, autoimmune disease, chronic fatigue, thyroid disorders, and skin conditions. The primary modalities Decker employs are clinical nutrition, botanical medicine, homeopathy, biotherapeutic drainage, and counselling. Decker also supports integrative medicine education as a clinical education thought leader with Allergy Research Group and by writing for various other educational resources. More about her practice may be found at www.carriedecker.com or www.blessedthistle.info.

About the Sponsor

Allergy Research Group

Founded in 1979 by molecular geneticist Stephen Levine, PhD, Allergy Research Group® is one of the very first truly hypoallergenic nutritional supplement companies. For over 30 years Allergy Research Group® has been a leading innovator and educator in the natural products industry. Our dedication to the latest research about cutting-edge nutritional supplements continues to this day.

Our purpose is to provide customers with products they can use to improve their patients’ quality of life, through scientific based innovation, purity of ingredients, education and outstanding service.

ARG is proud to be a sponsor of the Clinical Education LinkedIn Forum. A closed peer-to-peer group on LinkedIn where healthcare professionals can ask clinical questions and receive evidence-based and clinical-based responses by experts in their field.

Visit www.clinicaleducation.org/linkedin for more information & to sign up for free!

Visit www.allergyresearchgroup.com for more information on ARG and our products.

Apr 17, 2017

In this interview Tieraona Low Dog, M.D., discusses the state of micronutrient deficiencies in America. Vitamin D, vitamin B6, magnesium, omega-3 fatty acids, and even vitamin C are deficient in tens of millions of Americans. Tieraona Low Dog, M.D. also discusses what can be done to identify and treat what she calls a “hidden epidemic of micronutrient deficiencies.” 

Tieraona Low Dog, M.D. will be speaking at the AANP Annual Conference, which will be held July 12-15, 2017, at the Arizona Biltmore in Phoenix.

Approximate listening time: 23 minutes

About the Author

Tieraona Low Dog, M.D., began her exploration of natural medicine and its role in modern health care more than 35 years ago while studying midwifery, herbal medicine, massage therapy and martial arts before earning her medical degree from the University of New Mexico School of Medicine. She served as the Fellowship Director at the University of Arizona Center for Integrative Medicine, where she oversaw the training of more than 500 physicians and nurse practitioners in integrative medicine and is currently the Fellowship Director for the Academy of Integrative Health and Medicine. An internationally recognized expert in integrative medicine, dietary supplements and women’s health, Tieraona Low Dog, M.D. was appointed by President Bill Clinton to the White House Commission on Complementary and Alternative Medicine Policy, and has served as Chair of the US Pharmacopeia Dietary Supplements and Botanicals Expert Information Panel. Learn more about Tieraona Low Dog, M.D.

Apr 4, 2017

In this interview, Ronald Hoffman, MD, discusses how he uses the specific carbohydrate diet (SCD) to treat inflammatory bowel conditions. Hoffman recently wrote an Abstract & Commentary on the efficacy of the SCD in children with Crohn's and ulcerative colitis. In this interview, he describes techniques to enhance compliance and outcomes with the SCD. He also compares and contrasts the SCD with the Paleo and low-FODMAP diets. Hoffman draws on his clinical experience in this area to give practitioners advice on how to manage difficult-to-treat cases of inflammatory bowel conditions.

Approximate listening time is 15 minutes.

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About the Author

Ronald Hoffman, MD, is a physician in private practice of integrative medicine in New York City. He is a graduate of Columbia College and Albert Einstein College of Medicine. Since 1984, he has served as Medical Director of the Hoffman Center in Manhattan. Hoffman is past president of the American College for the Advancement of Medicine (ACAM).

Hoffman is the host of Intelligent Medicine, a nationally syndicated radio program, and he produces the daily Intelligent Medicine podcast. He is a certified nutrition specialist (CNS) and the author of several books, including How to Talk with Your Doctor (About Complementary and Alternative Medicine).

Mar 7, 2017

Christopher Shade, PhD, is a globally recognized expert on the topic of human detoxification. In this interview he describes his testing and treatment protocol that effectively cleanses the system of mercury and other toxins. Shade also discusses dietary supplement liposomal delivery technology.

About the Expert

Christopher Shade, PhD, obtained bachelor of science and masters of science degrees from Lehigh University in environmental and aqueous chemistry, and a PhD from the University of Illinois where he studied metal-ligand interactions in the environment and specialized in the and analytical chemistries of mercury. During his PhD work, Shade patented analytical technology for mercury speciation analysis and later founded Quicksilver Scientific, LLC, to commercialize this technology. Shortly after starting Quicksilver Scientific, Shade turned his focus to the human aspects of mercury toxicity and the functioning of the human detoxification system. He has since researched and developed superior liposomal delivery systems for the nutraceutical and wellness markets and also specific clinical analytical techniques for measuring human mercury exposure. He used his understanding of mercury and glutathione chemistry to design a unique system of products for detoxification that repairs and then maximizes the natural detoxification system.

About the Sponsor

Quicksilver Scientific is a CLIA-certified laboratory and health supplement wholesaler located in Lafayette, CO, specializing in superior liposomal delivery systems and blood metals testing for human health and detoxification. We use state-of-the-art technology, including patented mercury speciation, for the most accurate and reliable testing available today. Our liposomal supplements incorporate our Quicksilver Delivery System which brings the power of intravenous therapy to oral delivery and dramatically increases absorption and effectiveness, to restore the body’s natural detoxification system and re-establish natural health and optimum functioning. Our tiny particles encapsulate health-supporting compounds that absorb directly through the mouth into the bloodstream, bypassing the harsh digestive process that destroys or excretes most pill-form supplements. Smaller and faster, Quicksilver Scientific's Etheric Delivery™ systems are clearly superior to other products on the market.

Jan 4, 2017

In this podcast, Danielle Citrolo, PharmD, describes how a unique combination of L-glutamine and L-alanine can enhance electrolyte and water absorption in the intestines, stimulate glycogen synthesis, inhibit muscle protein breakdown and promote the synthesis of muscle protein. This dipeptide compound has also been shown to help protect the integrity of the gastrointestinal tract, contributing to better nutrient absorption.

About the Expert

Danielle Citrolo, PharmD, is manager of technical services at Kyowa Hakko, where she provides technical, scientific, and regulatory support. She also acts as liaison with regulatory authorities in the United States, Canada, and Latin America. Before joining Kyowa, Citrolo was the clinical coordinator at The Hospital for Special Surgery in New York City. She has experience in developing clinical research protocols and managing clinical trials. She earned her bachelor of science in biochemistry and bachelor of arts in chemistry from North Carolina State University and her doctorate in pharmacy from Albany College of Pharmacy in New York. She is licensed by the New York State Board of Pharmacy.

About the Sponsor

Sustamine®  L-Alanyl-L-Glutamine is an excellent choice for use in clinical nutrition because it does not have the problems of poor stability and low solubility that are associated with free-glutamine. Glutamine begins to degrade when mixed with liquids, but Sustamine®  is a unique dipeptide form of glutamine that’s been designed for maximum stability. This means patients get the amount listed on the label when they add it to water or their favorite beverage. Sustamine®  is tasteless, colorless, odorless and dissolves completely in hot or cold liquids – so there is no gritty texture. Manufactured exclusively by KYOWA HAKKO BIO CO., Sustamine® L-Alanyl-L-Glutamine is also ultra-pure, vegetarian and allergen-free.

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