jana prevention of neurological disease

The Journal of the American Nutraceutical Association

Vol. 5, No. 1 Winter 2002

IN THIS EDITION

• New Developments in the Prevention and Treatment ofNeurodegenerative Diseases Using Nutraceuticals andMetabolic Stimulants

• Biological and Chemical Terrorism: Natural Cures or Bogus Claims

• Why Funding for Nutraceutical Clinical Trial Research Will Remain Minimal

• Breast Cancer, Hormone Replacement Therapy, and Diet

• Pilot Study:An Emulsified Fish Oil Supplement ImprovesConditions in Chronic Hemodialysis Volunteers

AND MORE

A Peer-Reviewed Journal on Nutraceuticals and Nutrition ISSN-1521-4524

Contents – Winter 2002, Vol. 5, No. 1

Comments on “Joint Remedies” Article in Consumer Reports .......... 1

Breast Cancer, Hormone Replacement Therapy (HRT) and Diet:Do We Have the Answers Yet?................................................................ 3John Strupp, MD

Observations of an Emulsified Fish Oil Supplement in a Dialysis Population .......................................................................... 4Ralph Hawkins, MD

Congress Acts on Dietary Supplement Issues .................................... 5Kevin J. Kraushaar

Biological and Chemical Terrorism:Natural Cures or Bogus Claims? ............................................................ 7Bernd Wollschlaeger, MD

Mark Houston, MD, SCH, FACP, FAHAEditor-in-Chief of JANA............................................................................ 9Allen Montgomery, RPh, ANA CEO and Executive Director

Why Funding for Nutraceutical Clinical TrialResearch Will Remain Minimal ..............................................................12Steven Evans, MS, Jerome B. Block, MD

New Developments in the Prevention and Treatment ofNeurodegenerative Diseases Using Nutraceuticals andMetabolic Stimulants ..............................................................................15Russell L. Blaylock, MD

Breast Cancer, Hormone Replacement Therapy (HRT), and Diet...... 33Gina L. Nick, PhD, ND

Pilot Study: An Emulsified Fish Oil Supplement SignificantlyImproved C-Reactive Protein, Hemoglobin, Albumin and UrineOutput in Chronic Hemodialysis Volunteers ...................................... 45Wendy Lou Jones, MS, Shaun P. Kaiser, RD, LD

E D I T O R I A L

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O R I G I N A L R E S E A R C H

C O M M E N T A R Y

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Website: www.Ana-Jana.orgCover Photograph - Sierra Productions, Irvine, CA.

Journal of the American Nutraceutical Association

EDITORIAL STAFF

EDITOR-IN-CHIEFMark Houston, MD

EDITORSMedicine - Christopher M. Foley, MD Pharmacy - Allen M. Kratz, PharmD

ASSOCIATE EDITORSBernd Wollschlaeger, MDLisa Colodny, PharmD

TECHNICAL EDITORJane Lael

ART DIRECTOR Gary Bostany

EDITORIAL BOARDRussell Blaylock, MDJerome B. Block, MDLisa Colodny, PharmD, BCNSPDerrick DeSilva, MDJeanette Dunn, EdD, RN, CNSBrent Eagan, MDNatalie D. Eddington, PhDClare M. Hasler, PhDRalph Hawkins, MDMark C. Houston, MD, FACPDavid S. Hungerford, MD Robert Krueger, PhDAlexander Mauskop, MDMark J.S. Miller, PhDAllen Montgomery, RPhJune Reidlinger, PharmD, RPhAnthony J. Silvagni, DO, PharmD, MScJohn Strupp, MD C.Wayne Weart, PharmD, BCPS, FASHPFarred Wassef, RPhBernd Wollschlaeger, MD

_____________________________

American Nutraceutical AssociationExecutive Office 5120 Selkirk Drive, Suite 100Birmingham,AL 35242Phone: (205) 980-5710 Fax: (205) 991-9302Website: www.Ana-Jana.org

CEO & PUBLISHERAllen Montgomery, RPh

ANA is an alliance of individuals with interest innutraceutical science, technology, marketing andproduction. It was established to develop and pro-vide educational materials and continuing educationprograms for health care professionals on nutraceu-tical technology and science. ANA publishes a quar-terly newsletter,The Grapevine, and the Journal of theAmerican Nutraceutical Association (JANA).

_____________________________

The Journal of the American Nutraceutical Association(ISSN-1521-4524) is published four times annually,with frequent supplements, by the AmericanNutraceutical Association (ANA). Send all inquiries,letters, and submissions to the ANA EditorialDepartment at 5120 Selkirk Drive, Suite 100,Birmingham,AL 35242. Contents © 2002 ANA, allrights reserved. Printed in the United States ofAmerica. Reproduction in whole or part is notpermitted without written permission. It is theresponsibility of every practitioner to evaluate theappropriateness of a particular opinion in the con-text of actual clinical situations. Authors, editors,and the publisher cannot be held responsible forany typographical or other errors found in thisjournal. Neither the editors nor the publisherassume responsibility for the opinions expressedby the authors.

E D I T O R I A L

Comments on “Joint Remedies” Article in Consumer Reports

The Journal of the American Nutraceutical Association(JANA) is a peer-reviewed journal whose editorial board iscomposed of physicians, pharmacists, academicians, andresearchers striving to educate healthcare professionals andconsumers about the latest research in the growing field ofnutraceutical science.

In the January 2002 issue of Consumer Reports, an arti-cle titled "Joint Remedies" provides guidance to consumerson nutraceutical products that contain glucosamine andchondroitin. While we applaud the efforts of ConsumerReports to differentiate glucosamine and chondroitin supple-ments on the basis of their labeled claims and cost to con-sumers, we take exception to the concluding statement in thisarticle that advises consumers: "While no one knows whichformulation works best, it makes sense to try one of the leastexpensive combination products." In essence, this recom-mendation by a highly respected publication guided the con-sumer in their purchasing decisions exclusively on the priceof products that matched label claim. While price and contentof the product as compared to label claim are importantissues, they are not enough, for it is equally important to eval-uate bioavailability, which in turn can impact the efficacy ofthese products, especially those containing chondroitin.

Taber's Medical Dictionary defines bioavailability as"the rate and extent to which an active drug or metaboliteenters the general circulation, permitting access to the siteof action." Bioavailability is determined either by measure-ment of the concentration of the ingredient in body fluids,or by the magnitude of the pharmacologic response. Simplyput, when a product is not absorbed by the body, it will notproduce the desired effect.

As members of the editorial board of JANA, we areconcerned that the approach to product selection suggestedin this Consumer Reports article does not adequatelyaddress the complex issue of bioavailability. We agree thata product must contain the amounts stated on the label.However, the bioavailability and "efficacy" of a nutrient isin many cases dependent on more than the quantity of theingredient found in the tablet or capsule. This is an impor-

tant consideration, for the level of bioavailability can affectthe cost of the compound. This is especially true for chon-droitin sulfate, as discussed in our journal in a study thatevaluated the potential intestinal transport of several mar-keted sources of chondroitin sulfate. In an original researchstudy published in the Journal of the AmericanNutraceutical Association (Vol. 3, No. 1, 2000, 37-44),Adebowale and colleagues at the University of MarylandSchool of Pharmacy reported that the permeability coeffi-cient for transport of chondroitin sulfate is affected by themolecular weight of the raw materials used, demonstratingthat the bioavailability can be related to the size of the mol-ecule. Several products examined in this study that passed"label claim" failed in an absorption model. This means thatalthough a product meets its labeled claim, its molecularweight, size, or configuration can impact its bioavailability,with little or none of the ingredients actually absorbed, neg-atively impacting the product's intended clinical effect.Well-researched parameters that can affect bioavailabilityinclude molecular size, shape, and weight, excipients in theformulation, and the manufacturing process.

We have all heard of tablets compressed so hard thatthey do not dissolve in the GI tract, and therefore have nobioavailability even when they meet label claims for quan-tity. The University of Maryland study concluded that thebioavailability of chondroitin sulfate is increased by usinga product that has a smaller molecular weight. The impor-tant point that was not reflected in the Consumer Reportsarticle ("Joint Remedies") is that other factors can be just asimportant as meeting the label claim of a dietary supple-ment, especially so in the case of chondroitin sulfate.

The research team at the University of MarylandSchool of Pharmacy also evaluated the % label claim ofchondroitin sulfate vs. price in retail dollars per daily dose.They found that most products costing less than $1.00/doseof 1200 mg of chondroitin sulfate were significantly belowlabel claim. They also found that products costing morethan $4.00/daily dose of 1200 mg were clearly below labelclaims. This showed that there was no clear relationship

1 JANA Vol. 5, No. 1 Winter 2002

between product costs and content. A copy of the Universityof Maryland study can be found on the ANA website athttp://www.americanutra.com/files/janaeddingtonstudy.pdf.

A problem unique to dietary supplements is that there isno "bioavailability standard" or monograph that dietary sup-plement manufacturers are required to follow. Good exam-ples of the "bioavailability standard" concept for prescrip-tion drugs are digoxin, coumadin, and thyroxine. Thesegeneric pharmaceutical products all meet accepted bioavail-ability standards set by the United States Pharmacopeia(USP). It is important for the consumer to know that quanti-tative equivalency is not synonymous with either bioequiva-lency or bioavailability, and no such standards for either cur-rently exist for dietary supplements, or "nutraceuticals."

In our opinion, Consumer Reports inappropriately andincorrectly related truth of label claim and price to bioavail-ability in its report. By doing this, Consumer Reports mayhave accomplished exactly the opposite of its intent.

It is clear that when evaluating dietary supplements,each brand should stand on its own original research, and

not be assessed by the research of other brands. To comparebioavailability and make an accurate recommendation tobuy the least expensive product that is bioavailable whenconsumed, Consumer Reports would have to test eachproduct for bioavailability. We hope that in future compar-isons of dietary supplements containing glucosamine andchondroitin, this fundamental error is not repeated.

We applaud Consumer Reports for attempting to guidethe consumer through the maze of dietary supplements nowused for joint health. However, when providing consumerswith advice on efficacy we refer to the ArthritisFoundation's statement: "When a dietary supplement hasbeen studied with good results, find out which brand wasused in the study, and buy that."

In our opinion, until USP or another independent thirdparty develops a "bioavailability standard" or monographthat dietary supplement manufacturers are required to fol-low for glucosamine/chondroitin products, this is the onlysafe recommendation to make that incorporates the issuesof price, label claim and product content, bioavailability ofthe product, and efficacy.

Mark Houston, MD, Editor-in-Chief Journal of the American Nutraceutical Association (JANA)

Clinical Professor of MedicineVanderbilt University School of Medicine

Nashville, Tennessee

David S. Hungerford, MD Professor, Orthopaedic Surgery

Johns Hopkins School of Medicine Baltimore, Maryland

Robert Krueger, PhDCochair, ANA Pharmacy Advisory Council

Professor of Pharmacognosy, Ferris State University College of Pharmacy Big Rapids, Michigan

Natalie D. Eddington, PhDAssociate Professor of Pharmaceutics,

University of Maryland - School of Pharmacy, Baltimore, Maryland

Chris Foley, MDCoeditor (medicine), JANA

Medical Director, Integrative Care, St. Paul, Minnesota Clinical Assistant Professor, University of Minnesota College of Pharmacy

Minneapolis, Minnesota

Allen Montgomery, RPhCEO and Executive Director

American Nutraceutical Association

Barry Fox, PhDChair, ANA Consumer Advisory Council

Coauthor, The Arthritis CureCalabasas, California

Vol. 5, No. 1 JANA 2Winter 2002



Breast Cancer, Hormone Replacement Therapy(HRT) and Diet: Do We Have the Answers Yet?

John Strupp, MD, Assistant Clinical Professor of MedicineVanderbilt University School of Medicine, Nashville, Tennessee

* Correspondence:John A. Strupp, MDChief of Oncology, St. Thomas Hospital4230 Harding RoadNashville, Tennessee 37205Email: [email protected]

In this issue of JANA, Dr. Gina L. Nick has provided acomprehensive review of a key area in cancer/nutritionarena. The breast cancer/hormone replacement therapy con-troversy is a complex topic, and available data support a cau-tious approach when a physician discusses HRT with anywoman, particularly one with high risk for development ofbreast cancer. The Nurses Health Study1,2 that surveyedover 120,000 registered nurses between 1976 and 1992clearly demonstrated an overall reduction in mortalityamong the women receiving HRT (estrogens alone or com-bined estrogens and progestins). This benefit, due largely toa reduction in death from cardiovascular disease, was dimin-ished substantially by an increase in mortality due to breastand endometrial cancers. Women receiving HRT for a min-imum of 5 years had an adjusted relative risk of breast can-cer of 1.45. This was particularly true among 60-64-year-old women (relative risk 1.71). Colditz and colleagues con-cluded that the “tradeoffs between risks and benefits (ofHRT) should be carefully assessed.”

Several small studies that Dr. Nick references in her arti-cle further demonstrate the correlation between HRT andbreast cancer risk. Collectively, these studies support chang-ing a woman’s diet to better manage menopausal symptoms(even in lieu of hormones) and/or to reduce risk of develop-ing cancer. Additionally, a recent published report byAmerican Cancer Society epidemiologists suggests anincreased risk of ovarian cancer death with long-term estro-gen replacement therapy.3

Breast cancer survivors and women without a breastcancer diagnosis often seek nutritional guidance for manyreasons, including weight control, control of menopausal

symptoms, and to reduce cancer risk. While controversyexists in many areas regarding the interface of nutrition andcancer, the benefits of a diet rich in whole fruits and vegeta-bles, low in saturated fats, and free of excessive alcohol con-sumption are well documented. The AICR-World CancerResearch Fund Project summarized the existing scientificevidence for nutritional factors in cancer prevention as eitherconvincing, probable, possible, or insufficient.3 They con-cluded that no one vitamin or mineral supplement (includingvitamins E and C, beta carotene, and selenium) has been con-vincingly shown to be chemoprotective or chemopreventive.While single studies such as that by Favero, as discussed inDr. Nick’s paper, show an inverse correlation between cer-tain vitamin and mineral supplements and breast cancer risk,these findings have been refuted by other authors.

Not to be forgotten are the importance of weight man-agement and physical activity (as measured by body massindex or BMI), and their benefits to breast cancer risk.Perhaps more controversial, yet no less intriguing are thephytoestrogens and soy components such as isoflavones andtheir potential inhibitory effect on breast cancer cell growth.These products clearly have estrogenic and antiestrogeniceffects. The estrogen receptor/progesterone status, especiallyamong breast cancer survivors, then may be very importantwhen deciding on the use of soy in such a woman’s diet.

Dr. Nick, in Figure 5 at the conclusion of her article, pro-vides excellent suggestions for dietary modification to controlcancer risk and menopausal symptoms. This chart will be mostuseful both to healthcare professionals and their patients.

REFERENCES

1. Colditz, GA, et al. The use of estrogens and progestins and therisk of breast cancer in post-menopausal Women. NEJM.1995;332(24).

2. Grodstein, F, et al. Post-menopausal hormone therapy and mor-tality. NEJM. 1997; 336925):1769-1775.

3. Brown J, et al. Nutrition during and after cancer treatment: Aguide for informed cancer survivors. Cancer Journal forClinicians. 2001;51(3):147-148,167-170.


Observations of an Emulsified Fish OilSupplement in a Dialysis Population

Ralph Hawkins, MD,* Associate Professor University of Tennessee School of Medicine, Memphis, Tennessee

In this issue of JANA, Jones and Kaiser report the resultsof a pilot study conducted over eight weeks in a dialysis-dependent renal failure population looking at the benefits ofsupplementation with a novel emulsified fish oil product.

Fish oil supplementation has been studied in a widearray of human diseases. Indeed, if one were to conduct acomputer-based MEDLINE search using only the words“fish oil,” it would yield well over 7,000 articles in return.Fish oil has been investigated in the field of nephrology pri-marily because of its ability to favorably influence lipid lev-els, to serve as an anticoagulant, an anti-inflammatoryagent, and for its anti-fibrotic and anti-sclerotic properties.Anecdotally, investigations of the benefits of fish oil con-sumption on lipid levels were stimulated by the observationthat while inhabitants of the remote Arctic regions were typ-ically overweight and had a high intake of fat in their diets,the incidence of cardiovascular diseases was extremely low.It was noted that the predominant fat in their diet wasderived from fish oil, omega-3 polyunsaturated fatty acids,or eicosapentaenoic acid. The first reports on the beneficialeffects of the use of fish oils in laboratory animals are notedfrom reports originating in the early 1980s.

Certainly numbered amongst the most famous of thefish oil studies in nephrology is the report published in 1994by Mayo Nephrology Collaborative Group demonstrating

significant reduction in urine protein losses and end-stagerenal failure in 106 randomized patients with an inflamma-tory disease called IgA nephropathy.1 IgA nephropathy, alsoknown as Berger’s disease, is the commonest primaryinflammatory disease of the kidneys, resulting in micro-scopic hematuria, or blood in the urine. A long-term fol-low-up of 75 of the patients in the Mayo collaborative studywas published in 1999,2 again demonstrating that early andprolonged use of fish oil supplements delays the progres-sion of kidney disease in patients with IgA nephropathy,and that the benefit of supplementation continued to be evi-dent after many years of follow-up.

Reports of the use of fish oil in a hemodialysis popula-tion are far more limited. Fish oil supplements have previ-ously been reported to reduce erythropoietin requirements,3

and to modify platelet aggregability and lipid levels in asmall group of hemodialysis patients.4 All investigators,however, have not reproduced these findings, and some havefound no benefit of fish oil supplementation at all.5 For thatreason, further carefully constructed trials are warranted.

The eight-week pilot study by Jones and Kaiser report-ed in JANA examines the specific outcomes attributable tofish oil supplementation of reduction in C-reactive protein,albumin levels, hemoglobin levels, and erythropoietin use,a recombinant hormone therapy injected to stimulate newblood cell formation. The rationale for each of these obser-vations is that hemodialysis dependency is known to be a“pro-inflammatory” state. Measurement of C-reactive pro-tein, which is a non-specific marker of inflammation, isknown to demonstrate high values in the majority ofhemodialysis patients. High C-reactive protein levels areknown to correlate with poorer outcomes in a dialysis pop-

* Correspondence:Ralph Hawkins, MD951 Court Avenue, Room 649DMemphis, TN 38163Phone: 901-448-5764 Fax: 901-448-5513 E-mail: [email protected]


ulation. Indeed, patients with active inflammatory states ondialysis typically have lower hemoglobin levels, loweralbumin levels, and higher requirements for erythropoietinat greater expense. Patients with high C-reactive proteinlevels and low albumin levels are also at increased risk ofpremature mortality.

The results of this trial are suggestive that C-reactiveprotein levels might be reduced in a population ofhemodialysis patients, and that this reduction in the appar-ent inflammatory state might also confer the benefits ofimproved albumin levels and maintenance of satisfactoryhemoglobin levels with smaller doses of erythropoietindelivered. Furthermore, subjective observations suggestthat these patients might have somewhat increased urineoutput, reductions in urine protein losses, and improvementin generalized musculoskeletal pain.

The study of Jones and Kaiser is clearly a first steptowards designing a placebo-controlled, randomized trial todetermine whether fish oil supplementation will prove to beboth cost effective and beneficial to hemodialysis patients.

The preliminary results of the pilot study are certainlyencouraging in that regard.

REFERENCES:

1. Donadio JV et al. A controlled trial of fish oil in IgA nephropa-thy. Mayo Nephrology Collaborative Group. N Engl J Med.1994 Nov; 3:331(18):1194-1199.

2. Donadio JV et al. The long-term outcome of patients with IgAnephropathy treated with fish oil in a controlled trial. J Am SocNephrol. 1999;10:1772-1777.

3. Nordkild PK et al. Fish oil and antioxidant supplements reduceerythropoietin requirements in haemodialysis patients.Letter.Nephrol Dial Transplant.1993;8(6):569.

4. Rylance PB et al. Fish oil modifies lipids and reduces plateletaggregability in haemodialysis patients. Nephron. 1986;43(3):196-202.

5. de Fijter CW et al. Does additional treatment with fish oil mit-igate the side effects of recombinant erythropoietin in dialysispatients? Haematologica. 1995Jul-Aug;80(4):332-334.

C O N G R E S S I O N A L U P D A T E

Congress Acts on Dietary Supplement IssuesKevin J. Kraushaar

Vice President & Director of Government RelationsConsumer Healthcare Products Association

Washington, D.C.

Since the passage of the Dietary Supplement Healthand Education Act (DSHEA) in 1994, the U.S. Food andDrug Administration (FDA) and Congress have been reluc-tant or unable to designate financial resources necessary toimplement and enforce the law. This became even moreapparent after September 11 when FDA and Congressturned their attention toward bioterrorism and food safety.Despite a host of competing priorities during the last feder-al appropriations cycle, Congress was finally able to desig-nate several million dollars specifically for dietary supple-ment programs.

In 2002, the Congress will also continue considerationof legislation that will allow food stamps to be used to pur-chase vitamins, minerals, and other products to enhancenutrition for qualified recipients. The Congress is also

expected to resolve differences between House and Senatebills that would require registration of all facilities thatmanufacture, handle, pack, or process food, includingdietary supplements. This article is a summary of recentCongressional Action

FEDERAL FUNDING FOR DIETARYSUPPLEMENT REGULATORY SYSTEM ANDSCIENTIFIC RESEARCH

Because of several competing priorities at FDA, dietarysupplements have traditionally not received adequateagency attention when compared to other food products andfood ingredients. In an effort to address the situation,President Bush has signed into law an appropriations bill for


FDA that includes $2.5 million for the agency to update andmodernize the adverse event reporting system for dietarysupplements. A Congressional committee held hearings in1999 that were quite critical of the agency’s ability to col-lect, analyze, and maintain adequate information on the safe-ty of particular dietary supplement products and thereappeared to be little or no follow up with manufacturers orhealthcare officials. The designation of $2.5 million willallow FDA to develop specific procedures for dietary sup-plement adverse event reports and have those reports evalu-ated by scientific personnel that are adequately trained tocommunicate their findings for appropriate follow-up.

The Congress has also approved $500,000 for FDA toenhance enforcement activities relating to unlawful labelingof dietary supplements and an additional $500,000 to augmentthe resources of the Office of General Counsel of theDepartment of Health & Human Services (HHS) for legalactivities. The federal appropriations bills signed by PresidentBush also contain language from House and Senate confereesto strongly urge HHS Secretary Tommy Thompson to publishproposed good manufacturing practices for dietary supple-ments. GMPs were authorized by DSHEA in 1994, but FDAhas failed to publish a GMP proposal.

In addition to safety and enforcement, the Congress hasapproved additional money for the National Institutes ofHealth (NIH) and FDA to develop the science regardingdietary supplements. The Office of Dietary Supplements atNIH will receive $17 million in the next fiscal year that willallow the office to speed up collaborative efforts to devel-op, validate, and disseminate analytical methods and refer-ence materials for the most commonly used botanicals. TheNational Center for Complimentary and AlternativeMedicine (NCCAM) will also receive $104.6 million, aportion of which will be used in conjunction with otherinstitutes to appropriately study the science of certaindietary supplement ingredients. An additional $1 millionhas been designated to continue the work of FDA, in col-laboration with the National Center for Nutritional ProductsResearch at the University of Mississippi, to identify andanalyze botanical ingredients.

Unquestionably, Congress, FDA, and NIH made greatstrides in the last federal budget cycle to more appropriate-ly regulate and study dietary supplement products, includ-ing vitamins, minerals and other botanical ingredients. In2002, the Federal Trade Commission (FTC) will also con-tinue its mission by initiating enforcement actions againstfalse and deceptive advertising claims.

SENATE COMMITTEE APPROVES SUPPLEMENTPURCHASES WITH FOOD STAMPS

The U.S. Senate Agriculture Committee has approvedlegislation that will allow qualified families to use foodstamps to purchase nutritional supplements. As part of a

massive reauthorization of federal farm, food, and nutritionprograms currently under debate on the Senate floor, the pro-vision is intended to encourage more low-income families topurchase vitamins and minerals, such as folic acid, iron, andcalcium. Proponents of the measure argue that allowing foodstamp recipients to purchase nutritional products will havepositive healthcare outcomes on a segment of the populationwhere improvements in nutrition are needed the most.

BIOTERRORISM INCLUDES REGISTRATION FORFOOD MANUFACTURERS

The U.S. House and Senate have passed competing ver-sions of legislation to improve the national preparedness fora bioterrorist attack, including a requirement for food manu-facturers and processors to register all facilities with FDA.The two pieces of legislation authorize the spending of fed-eral funds for bioterrorism preparedness to protect food sup-plies, improve the Centers for Disease Control andPrevention’s medical response, and allow for HHS to expandthe national stockpile of antibiotics and vaccines. The facil-ity registration provisions in both bills apply to manufactur-ers of dietary supplements as well as conventional foods.Both bills also allow for the administrative detention ofimported foods that pose a potential threat of adverse healthconsequences, maintenance and inspection of records forfoods, and prior notice of imported food shipments.

A conference committee will be required to resolve thedifferences between House and Senate versions of thebioterrorism bills. President Bush is expected to sign theconference report into law.

Correspondence:Kevin Kraushaar

Consumer Healthcare Products Association1150 Connecticut Avenue, NW

Washington, DC 20036Phone: 202-429-9260 Fax: 202-223-6835

Email: [email protected]


C O M M E N T A R Y

Biological and Chemical Terrorism: Natural Cures or Bogus Claims?

Bernd Wollschlaeger, MD Associate Editor, Journal of the American Nutraceutical Association

Chairman, Florida Medical Association Emergency and Disaster Preparedness TaskforceBoard Member, Center on Terrorism and Public Health, Florida State University College of Medicine

The events of September 11, 2001 have changed therealities of life in the United States of America. We arefaced with a new sense of vulnerability that has not exist-ed in the US since the attack on Pearl Harbor.

Among local, state and governmental agencies, thePublic Health system was challenged to provide an infra-structure to effectively respond to the challenges of disas-ters and emergencies that can threaten the integrity of ournational health. The potential for further attacks usingnuclear, biological or chemical agents has focused theattention of the US public and healthcare community atlarge on the issue of diagnosis and management of diseasesresulting from such agents.

Documented cases of anthrax infections (cutaneousand inhalation) have occurred since October 4 throughoutfive US states, claiming the lives of five citizens and expos-ing thousands to the disease. Many public health officialsopenly discussed the possibility of the intentional use oflethal agents such as smallpox and plague, and the protec-tive measures to be taken in event of their occurrence.

Concerned citizens called their doctors’ offices and thelocal public health departments demanding preventive pro-phylaxis with antibiotics and vaccinations. Since October8, approximately 32,000 persons with potential exposure to

B. anthracis in four states and the District of Columbiahave initiated antimicrobial prophylaxis to prevent anthraxinfection, and for approximately 5,000 persons, a 60-daycourse of antibiotics was recommended. Unfortunately,few data exist regarding the use of these antimicrobials forlonger periods, and recent Centers for Disease Control(CDC) recommendations suggest extending the post expo-sure prophylaxis to 90 days.

Between October 26 and November 6, 2001, an epi-demiologic evaluation to detect adverse events associatedwith antimicrobial prophylaxis was conducted among8,424 postal employees who had been offered such pro-phylaxis for 60 days in New Jersey, New York City, andone postal facility in the District of Columbia . During thisperiod of time 8,424 postal employees were offeredantimicrobial prophylaxis, 5,819 (69%) completed or wereadministered a questionnaire to evaluate the occurrence ofadverse events.

A total of 3,863 (66%) had initiated antimicrobial pro-phylaxis; of these, 3,428 (89%) reported using ciprofloxacinand 435 (11%) used other antimicrobials (whenciprofloxacin was contraindicated), including doxycycline(6%) and amoxicillin (1%). Of the 3,428 persons onciprofloxacin, 666 (19%) reported severe nausea, vomiting,diarrhea, or abdominal pain; 484 (14%) reported fainting,light-headedness, or dizziness; 250 (7%) reported heartburnor acid reflux; and 216 (6%) reported rashes, hives, or itchyskin. Of those persons taking ciprofloxacin, 287 (8%) dis-continued the medication; 116 (3%) discontinued the med-ication because of adverse events, 27 (1%) discontinuedbecause of fear of possible adverse events, and 28 (1%)stopped taking the drug because they "did not think it wasneeded". The survey did not indicate if these patient

* Correspondence:Bernd Wollschlaeger, MD16899 B, NE 15th AvenueNorth Miami Beach, Florida 33162Phone: (786) 251-0655 Fax: 305-940-8717Email: [email protected]


received probiotic therapy to support their gastrointestinalphysiological function.

Probiotics are defined as the microbial food supple-ments that beneficially affect the host by improving itsintestinal microbial balance. Probiotics are the healthenhancing functional food ingredients used therapeuticallyto prevent diarrhea, improve lactose tolerance and modulateimmunity. Lactobacillus, Bifidobacterium, and severalother microbial species are used as probiotic components toexert such effects by restoring the composition of the gutmicrobiota affected by antibiotic-therapy. The beneficialrole of such nonpathogenic bacteria in the management ofantibiotic induced intestinal dysbiosis should be the subjectof randomized-controlled trials to assess the clinical appli-cation of such modalities. The safety and specification of aparticular probiotic agent and methods of delivery to a par-ticular population for a specific purpose should be careful-ly documented before making clinical recommendations.Physicians who put patients on long-term antibiotic therapyshould consider a recommendation for probiotic supple-mentation while the patient is on such therapy.

Unfortunately, the fear of potential infection by bioter-ror agents and the concern of many Americans aboutpotential adverse effects of antibiotics therapy were abusedby opportunistic business people. Hundreds of websiteshave mushroomed selling everything from mail sterilizersto oregano oil to prevent and treat illnesses such as anthrax.A BBC news report discovered more than 200 sites mar-keting bioterrorism-related products including gas masks,protective suits, mail sterilizers, biohazard test kits, home-opathic remedies and dietary supplements. The sites areclaiming that dietary supplements such as colloidal silver,zinc mineral water, thyme and oregano oil are effectivetreatments for illnesses such as anthrax.

On other web sites herbal remedies such as echinacea,garlic and Dr. Christopher’s "Anti-Plague" formula arebeing featured as "treatment" options to cure Anthrax.

The mayor of a tiny central Florida town suggestedcolloidal silver, an elixir of metallic silver particles in dem-ineralized water as a "cure" for anthrax. He planned tobuy a colloidal silver generator for the town of 956 resi-dents, located 30 miles northwest of Orlando and encour-aged town residents to drink the potion as a "simple solu-tion" to biological threats such as anthrax.

The mayor was forced to step down two months afterproclaiming that a silver-laced liquid could cure anthraxand other ills, saying that he was the victim of a "Jihad"against him.

The FTC, with the help of the Food and DrugAdministration (FDA), more than 30 state attorney gener-als, and the California Department of Health Services,have cracked down on such quackery, focusing on websites offering products claiming to protect against, detect,

prevent, or treat biological and chemical agents, includinganthrax. More than 200 sites marketing bioterrorism-relat-ed products were uncovered, and additional sites are beingevaluated for possible warning letters. Included in thereview were such items as gas masks and protective suits;mail sterilizers; biohazard test kits, homeopathic remedies,and dietary supplements such as colloidal silver, zinc min-eral water, thyme, and oregano oil as treatments for conta-mination by biological agents.

Web sites may be subject to state or federal investiga-tion or prosecution for making deceptive or misleadingmarketing claims that their products can protect against,detect, prevent, or treat biological or chemical contamina-tion. "This marketing targets people worried about theprospect of exposure to lethal biological or chemicalweapons. The FTC is aware of no scientific basis for anyof the self-treatment alternatives being marketed on theInternet," said Howard Beales, FTC's Director ofConsumer Protection. "Essentially, these operators need toshut down these areas of their sites or face prosecution".

On November 5, 2001, dietary supplement trade asso-ciations (American Herbal Products Association, ConsumerHealthcare Products Association, the Council forResponsible Nutrition, the National Nutritional FoodsAssociation and the Utah Natural Products Alliance) issueda press release emphasizing that dietary supplements havenot been proven to treat or prevent anthrax and that thera-pies for the treatment or prevention of anthrax should berecommended only by qualified public health authorities.

The American Nutraceutical Association was estab-lished in 1997 to develop and provide educational materi-als and continuing education programs for health care pro-fessionals and consumers on nutraceutical technology andscience. We strongly support federal regulations that donot allow dietary supplements to claim to treat or preventany disease, including anthrax.

We will continue to promote the rational applicationof dietary and nutritional supplements such as probioticsthat may be used concurrently with ciprofloxacin forantimicrobial prophylaxis, and support clinical studies toassess the benefits of such modalities as an integral part ofcurrent disease management protocols. However, weencourage our members and readers to criticize and rejectthe natural "bioterror cures" and to call those by theirname: sham and quackery.



I N T E R V I E W

Mark Houston, MD, SCH, FACP, FAHAEditor-in-Chief of JANA

In October 2001, Dr. Houston accepted the appointment of Editor-in-Chief of JANA. The following interview was conducted by Allen Montgomery, RPh, ANA CEO and Executive Director.

Montgomery:

Dr. Houston, I am pleased to introduce you to our read-ers as the new editor-in-chief of JANA. Can you share withJANA readers some details about your medical background,both as a practitioner and an educator?

Houston:

I graduated from Vanderbilt University MedicalSchool, and completed my internship in internal medicineat the University of California, San Francisco. For 12 years,I was a full-time faculty member at Vanderbilt UniversitySchool of Medicine, serving as an Associate Professor ofMedicine, Co-Director of Medical ICU, Chief of ClinicalSection-General Internal Medicine, and as Medical Directorof the Executive Physical Program. I am still a ClinicalProfessor of Medicine at Vanderbilt, but have left the full-time faculty.

In 1990 I moved my practice to Saint Thomas Hospital.There, I founded the Hypertension and Vascular Biology

Institute, along with the LifeExtension Insti tute, andserve as medical director. Ihave published over 110medical articles in peer-reviewed journals andabstracts; written over 20books, book chapters andmonographs; penned over50 newspaper and magazinearticles; and serve as either amember of the editorialboard or editorial consultantfor 20 medical journalsincluding the New England Journal of Medicine(NEJM), and the Journal of the American MedicalAssociation (JAMA).

Montgomery:

What do you see as the future role of JANA?

Dr. Houston:

My goal is to make JANA the premiere clinical andnutraceutical journal in the USA – with an emphasis onclinical practice. I want JANA to provide guidance to MDs,pharmacists, osteopathic, chiropractic and naturopathicphysicians, nutritionists, and dieticians, as well as othermembers of the healthcare delivery system, on the currentresearch in nutrition and nutraceuticals for the preventionand treatment of disease. Editorially, we will cover specifictopics and new research pertinent to virtually all organ sys-

* Correspondence:Mark C. Houston, MD, SCH, FACPHypertension and Vascular Biology Institute Saint Thomas Medical Group4230 Harding Road, Suite 400Nashville, Tennessee 37205Phone: 615-297-2700 Fax: 615-269-4584E-Mail: [email protected]

Mark Houston, MD


tems of the body, with emphasis on neurological disease,cardiovascular disease, immune function, gastrointestinaldisease, arthritis, diabetes, and cancer. This focus on the useof nutraceuticals in clinical practice is vital, for it has beenproven that about 50% of all diseases affecting the U.S.population are nutritionally related. Up to 70% of those dis-eases could either be prevented, or their severity reduced,by incorporating proper nutrition and the appropriatenutraceuticals into a daily healthcare regimen. Our missionat JANA is to educate and guide healthcare professionals onthese topics.

The strength of any journal is dependent on the editor-ial board and the scientific quality of the articles submitted.I have expanded the editorial board and have added leadingMDs, PharmDs, PhDs, NDs, and others that are affiliatedwith institutions such as the University of Maryland Schoolof Medicine, Vanderbilt University School of Medicine, theUniversity of Tennessee School of Medicine, the MedicalUniversity of South Carolina, the Department of Optometryat the VA Medical Center in Chicago, and the Departmentof Health and Exercise Science at Colorado StateUniversity. These professionals will serve as consulting edi-tors and members of the editorial board. We will continue toseek qualified members who share our goals and wish tobecome affiliated with JANA. Anyone interested in servingon our editorial board should submit their curriculum vitaeand formal request to me at [email protected].

From an editorial point of view, we will continue toseek submissions that are based in good science, and thatprovide useful data applicable to the clinical practice. Iencourage researchers, companies and others involved inclinical studies to submit manuscripts for consideration to:

Mark Houston, MDEditor-in-Chief, JANA

5120 Selkirk Drive, Suite 100Birmingham, AL [email protected]

Instructions for authors can be found on our website atwww.ana-jana.org. Click on JANA, then scroll to the bottomof the screen for “instructions for authors.” Authors withadditional questions can direct them to our editorial officeat 205-980-5710.

Montgomery:

You are recognized nationally as an expert in the diag-nosis and treatment of hypertension. What experiences haveyou had in the use of nutrition and nutraceuticals in its pre-vention and treatment, and how have your patients reactedto these approaches?

Dr. Houston:

Hypertension affects about 40% of the adult U.S. pop-ulation. It is a genetic disease with strong environmentalinfluences. One factor is nutrition. About half of the mildor stage I hypertensive patients could have their blood pres-sures controlled to normal levels utilizing a scientificallybased nutrition and nutraceutical program. I have seen thishappen in my practice in the last 10 years.

I’ve spent the last twelve months reviewing the world’sscientific, English-language medical literature on the roleof nutrition and nutraceuticals in the prevention and treat-ment of hypertension. From this literature search, I havecompleted a 75-page manuscript with over 700 referenceson the topic “The Role of Vascular Biology, Nutrition, andNutraceuticals in the Prevention and Treatment ofHypertension.” The manuscript documents the efficacy ofsuch a program. This manuscript is undergoing peer-reviewand will be published soon in JANA. I am also exploringwith major publishers the potential of developing a book onthis on this topic for both consumers and healthcare profes-sionals.

As for patient response, the vast majority of mypatients prefer and seek non-pharmacologic managementof their hypertension. This includes nutrition, nutraceuti-cals, vitamins, antioxidants, exercise, weight reduction, andother modalities. I’ve been delighted to see blood pressurereturn to normal levels in about 80% of patients who followthe treatment regimen I have directed. Side effects with thisnutritional and nutraceutical approach are basically nonex-istent. Instead of side effects, patients sense an increase intheir well being, energy, and mental focus. I find that inmost cases their overall quality of life improves.

Montgomery:

Have your colleagues adopted or become more accept-ing of the use of nutraceuticals in a traditional medicalpractice?

Dr. Houston:

There is an increasing interest among traditional physi-cians in learning and applying non-traditional complemen-tary and integrative approaches. The point I want to makeis that physicians must be provided with scientific valida-tion of any tool they may use in their practice. This is whyit’s so important for nutraceutical companies to developstrong research programs. As physicians, we cannot recom-mend products or services that are not supported by goodscience and clinical studies. As more and more nutraceuti-cal products are validated by clinical studies, more tradi-tional physicians will use them in their practices. I person-ally use a clinically validated nutraceutical product, (glu-cosamine/chondroitin) for the management of osteoarthri-

The Journal of the American Nutraceutical Association (JANA)To subscribe to JANA - Phone 800-566-3622

(outside the USA, 205-833-1750),or visit the ANA website at www.ana-jana.org

SUBSCRIBE TODAY TO THE LEADING JOURNAL ON NUTRACEUTICAL SCIENCE

Winter 200211 JANA Vol. 5, No. 1

tis. I only use this and other nutraceutical products that aresupported by well-controlled clinical studies.

It is important for physicians to become better educatedin nutrition and the use of nutraceuticals. The majority of con-sumers that I meet at various speaking engagements through-out the United States are seeking physicians who are open toand knowledgeable about integrative medicine. Data showsthat the per capita expenditure on complimentary medicine isincreasing over traditional medicine. Over time, more andmore consumers will seek out physicians who are knowl-edgeable in these topics and can provide guidance on them.

Montgomery:

Your medical training and practice would be consid-ered traditional. What led you into complementary and inte-grative medicine, and how have your patients responded tothese approaches?

Dr. Houston:

It began as a personal issue related to my own health,and that of my father who had prostate cancer. I learned asmuch as I could about preventing and treating prostate can-cer with nutrition and nutraceuticals. I used this in conjunc-tion with traditional medical treatments.

As I learned more about the role of nutrition and can-

cer, it became more apparent how they are connected.Nutrition also has a tremendous impact on cardiovasculardisease, neurodegenerative diseases, aging, diabetes, andvirtually all other diseases.

Unfortunately, traditional MD training pays very littleattention to the use of nutrition and nutraceuticals. Thus,like many other physicians, I continue to educate myselfindependently of my formal medical training. In fact, I amcurrently working on a two-year MS degree in nutrition.

In my opinion, successful physicians of the future willbe those who can guide their patients in traditional medicaltreatments as well as complementary, or integrative medi-cine, with an emphasis on nutrition and the proper use ofclinically validated nutraceuticals, vitamins, minerals andother dietary supplements.

To point out how quickly times change, when theAmerican Nutraceutical Association was founded in 1997,the word nutraceutical was not even in the dictionary.Today, it is defined by Webster’s as nu·tra·ceu·ti·cal n. Afood or naturally occurring food supplement thought tohave a beneficial effect on human health. It is importantthat physicians, pharmacists, nurses, nutritionists, dieticians,chiropractic, osteopathic and naturopathic physicians learnwhat is happening in the field of nutraceuticals and comple-mentary medicine. I want to make JANA one of the primarysources to help guide and educate these healthcare profes-sionals on these topics.


O P I N I O N

Why Funding for Nutraceutical Clinical Trial Research Will Remain Minimal

Steven Evans, MS,1* Jerome B. Block, MD2

1. Genetic Services Management, Inc., Omaha, Nebraska2. Division of Medical Oncology and Hematology, Department of Medicine

Harbor-UCLA Medical Center, Torrance, California

INTRODUCTION

Question: If selected dietary supplements, such as vita-mins, minerals, herbals, food substances or their combinations,are beneficial for specific chronic conditions or illnesses, or tomaintain wellness, should we expect major pharmaceuticaldrug companies and/or government agencies to fund nutraceu-tical human clinical trial research in order to more preciselyassess and validate such benefits? That is, if there were any-thing worthwhile to pursue, surely the major pharmaceuticaldrug companies and/or the government would be among thefirst to seize the opportunity for improvements in health care.Given governmental medical panels’ recommendations ofmany key vitamins and minerals, there is already orthodoxacceptance of some of these products’ beneficial health value.Moreover, financial disclosures from pharmaceutical compa-nies note that many are losing some of their high-profit-pro-file patents and are anxiously seeking new avenues for drugsuccesses. If some elements of the over-the-counter dietarysupplement market have usefulness, particularly for preventa-tive care and for maintenance of wellness, as well as for spe-cific chronic diseases and chronic conditions, should we notexpect pharmaceutical companies as proven, efficient devel-opers of drug remedies to seize the opportunity to demonstratetheir value through clinical trial research? Moreover, when ascientific case can be made for potential benefits of some

nutraceuticals, do not appropriate government research-directed agencies have responsibility to serve the publicthrough funding of human clinical trials, furthering theprospects of low-cost, effective interventions and/or preven-tative measures? In this commentary, we focus on why majorpharmaceutical companies have not pursued dietary supple-ment clinical trials research in primary or secondary preven-tion and why we should also expect government funding tocontinue to be modest in such areas.

PHARMACEUTICAL COMPANY DISINCENTIVES

The lack of incentives for conducting clinical trials onnutraceuticals on the part of pharmaceutical companies(commonly called “Big Pharma” in the industry) can beclearly delineated. The first is that it is quite unlikely thatBig Pharma could make significant profit, or possibly anyprofit at all, from such a venture. In conducting the trial,sponsors must compensate collaborating principal investi-gators for their administrative roles. Additional costs includetrial participant solicitation, participant monitoring chargessuch as lab and radiologic studies, data recording and analy-sis, and administrative overhead. Separately added in is thecost of products to be tested. These expenses recur over sev-eral years. To measure therapeutic impact, trials are typical-ly targeted for at least five years, with recruitment project-ed to take several years.

Dr. Joseph DiMasi and his research team at TuftsUniversity have been issuing research cost estimates foryears based upon proprietary surveys of top drug compa-nies.1 In December, 2001, new cost estimates were released;preclinical out-of-pocket expenses averaged $121 million,while clinical costs averaged $282 million.2 Presumablythese clinical costs include actually bringing the drug to mar-

* Correspondence:Steven Evans, MSGenetic Services Management, Inc. 418 North 38th StreetOmaha, Nebraska 68131Phone: 402-551-1020 Fax: 402-556-5743E-mail: [email protected]


ket when results warrant. When the estimated cost of tied-up capital is added, clinical costs alone total $466 million.Although some argue that the cost of capital should not beincluded, the pharmaceuticals do so in their planning, andthus their perception is that $466 million could potentially beconsumed. Whether it is the $282 million out-of-pocketaverage inclusive clinical trial costs, or the over-$400 milliontotal costs as perceived by Big Pharma, there can be no ques-tion that clinical trials are costly.

The challenge to recoup the R&D principal invested,and garner a return-on-capital as well, is undermined by thereality that a successful trial will not likely give any com-pany an exclusive patented product when the evaluatedproduct is comprised of recognized nutraceuticals. A prod-uct recognized by the FDA as beneficial for a disease’streatment or prevention is the basis for potential widespreaduse as a standard of care– and possibly enormous profitpotential. However, a specific vitamin, mineral, food sub-stance, etc. cannot as such be patented. A unique produc-tion version could claim patent protection, as could aunique combination of dietary supplements. But again, amodest variation of the combination opens the marketplaceto competitors who can tout the original investigator’s clin-ical trial success without having spent the millions it took toget it to market in the first place.

Given that the nutraceutical product would not likely bea successfully patent-protected entity tied into an FDA-approved response to a specific disease state, the charges topatients that Big Pharma could expect for the product areextremely constrained. Big Pharma report in their year-endcorporate reports that they are looking to replace drugs goingoff-patent, ones that have generated billions per year in rev-enue. A typically under-ten-dollar supplement would needtens of millions of customers buying monthly to generate abillions-per-year revenue. This is quite a challenging barrier,particularly in light of the fact that the marketplace could behighly fractionalized among numerous selling contenders.Further, given that most preventative remedies, over-the-counter remedies, and non-physician-prescribed remedies arenot reimbursed under virtually all health care insurance, thetypical user would have to expect no reimbursement for thisnutraceutical usage. This makes sales expectations evenmore tenuous.

In addition, many such remedies are preventative innature, and there is hardly a milieu in the USA for serious,consistent commitments to preventative measures. Forexample, nutraceuticals for immunologic enhancement,anti-aging compounds, and chronic condition suppressantsare typically taken by those in a state of health deemed nor-mal by most standard medical assessments. These supple-ments address issues which are not typically of interest norsources of insurance reimbursement for our health care sys-tem targeted to disease diagnosis and treatment. In thismilieu, nutraceutical recommendations would be very

unlikely to become a standard of care, diminishing expec-tations of the large and consistent sales Big Pharma need toenter the marketplace.

In summary, Big Pharma would be correct to summa-rize that there is little, if any, money to be made in this area,that any advantage of nutraceutical research trials would beshort-lived, and that the prospects of losing substantialinvestment are great. Thus one should hardly fault BigPharma for avoiding this area. If some top-level managersof a Big Pharma firm were to decide to embrace such a mis-sion, we could readily expect its shareholders to elect top-level managers who understood what their mission really is.

GOVERNMENTAL/ACADEMIC DISINCENTIVES

Governmental disincentives differ substantially fromthose affecting Big Pharma. Governmental agencies fundingresearch and clinical trials emanate primarily from variousdivisions of NIH, so we will refer to NIH as an eponym forits individual institutes and programs. Some analysts areencouraged by the observation that NIH is funding, forexample, a 3000-patient study on Ginkgo for just $15 mil-lion, but unfortunately the 3000 patients may yield datawhich would most likely support a call for a much largerdefinitive trial, rather than being able to yield unequivocallydefinitive patient recommendations. It is informative to lookat the National Cancer Institute’s (NCI) SELECT trial whichexplicitly attempts to determine policy recommendationsconcerning whether selenium and/or vitamin E have a pro-tective role in cancer prevention. We could assume that itsextremely highly visible stature and surrounding publicitycompelled NCI to carefully craft its patient accrual size andscrutinize the trial’s cost. The trial’s projected cost is $180million, with a 7 year accrual period to recruit approximate-ly 32,000 people for its various treatment arms for at least afive year testing period. Although merely one example,NCI’s goal of reconciling public policy in this area suggeststhat these costs and patient numbers support the case for thenon-trivial price for such undertakings. Even with govern-mental support, the profit potential for commercial firms sup-plying nutraceuticals is extremely modest. For example, ifthe vitamin E arm of the SELECT trial proved efficacious,one can obtain an entire year’s supply of vitamin E for$15.32 from a common, popular mail order catalogue.3 If theseller even nets 25% of the price before taxes, the less than$4 net per year per patient speaks for itself in terms ofinvestment attractiveness.

In defense of the NIH, one can point to the establish-ment of the National Center for Complementary andAlternative Medicine (NCCAM) as an indication ofexpanded government interest in areas including nutraceu-ticals. This demonstrates that the government is not withoutsome worthwhile initiatives, but useful perspective isgained by noting the NCCAM’s allocated fiscal year (FY)


2001 budget is $89 million against the backdrop of anapproximately $20 billion NIH budget, or less than half apercent in support of cancer research studies. NCCAMreports that there was a three-fold increase spent in FY 2000over FY 1999. As favorable as this may first appear, theactual dollar value spent in FY 2000 was $4 million versusless than $1.5 million the preceding year specifically forcancer research. In contrast, in FY 1999, the NationalCancer Institute estimates it spent $3.2 billion on cancerresearch. Given that NCCAM came into existence in FY1999, one can point to exponentially increasing budgetsover recent history. With prior research funding at muchlower levels, the situation has certainly improved.Nonetheless, in absolute dollars, given the fiscal challengeof this area of research, the funding prospects remain sober-ing. Thus it is reasonable to inquire as to the underpinningsof such relative reservations regarding nutraceuticalresearch, for indeed, the problems are challenging.

First, the area of nutraceutical marketing historicallyhas been rampant with ill-conceived claims and falsepromises and has been tainted with quackery and hyper-bole. Perceived legitimate medical science after World WarII has focused on disease per se and its treatment; preven-tion as a whole has been quite the step-child, if not theorphan. Funding sources can respond only to those seekingfunding, and new researchers could hardly be faulted foravoiding a field that in its past was rife with charlatans andquackery. Peer-review boards allocating funds could hard-ly be faulted for funding treatment research over more his-torically dubious endeavors in disease prevention or healthenhancement.

Another factor contributing to the disinterest innutraceutical research has been the myth that the Americandiet was either adequate or could be; from this viewpoint,research on the impact of nutraceuticals’ needlessly wastesprecious dollars. Even as the integrity of the American dietdeclines precipitously,4,5 this myth prevails, even whilemore and more data evolve questioning its premises. A sig-nificant portion of the scientific community appear toembrace a traditionalist American ethic that says we canaddress the issue of nutrients if we would just eat from thefood pyramid which the government has insured is dis-played in every elementary school classroom around thecountry. With this cultural perspective, funding research inthe area of disease prevention or health maintenancethrough the peer-review process could hardly be expectedto yield a great deal of enthusiasm. This cycle of indiffer-ence has historically fed upon itself, with the lack of previ-ously funded research supporting the proposition that therewas little support for further research.

FUTURE FUNDING EXPECTATIONS

In light of these barriers, it is remarkable that there has

been as much research to date as has been published fornutraceuticals. Much of what transpires is often short-term,highly specific-agent focused, and more often than not,mouse-model-directed with regard to acute disease states.This permits researchers to keep expenditures low, adhere tomodels of single-agent focus, for a specific disease, and stillhave publishable results. The counter-point of course is thatsuch research has less salience for humans over long inter-vals or with chronic conditions. Consequently, skeptics maydemand far more conclusive evidence before any public pol-icy recommendations may be derived. As a consequence,the research fails to lead to definitive conclusions, only rein-forcing the recognition that funding should be directed tomore productive arenas.

One response to this funding conundrum is an alterna-tive funding model proposed by some investigators, involv-ing fee-for-service research.6 In this model, healthy individ-uals or suitably non-acutely-sick patients who can giveinformed consent are asked to pay a modest fixed fee towardthe cost of such clinical trial research. This model incorpo-rates the interested public into the funding equation as aninformed and consenting funding participator. Anotherrecently evolved model has been successful business people(e.g., “dot-com” multimillionaires) who fund selected pro-jects that interest them personally. These alternative modelsare relatively embryonic. For the foreseeable future, weshould expect virtually no funding by Big Pharma and rela-tively modest levels of funding from the government in thenutraceutical clinical trial research area, which nonethelessoffers potentially significant, beneficial outcomes, typicallyat low product cost and often with few side effects.

REFERENCES

1. Cost of Developing Drugs Found to Rise. Wall Street Journal,December 3, 2001:B14.

2. Ibid.

3. Swanson Health Products Catalogue, Edition DBX, 2001:9.

4. Veggie Nutrients Dip in Tests. New House News Service,Washington, Omaha-World-Herald. January 29, 2000:6.

5. Subar A, et al. Fruit and vegetable intake in the United States:the baseline survey of the Five a Day for Better HealthProgram. Am J Health Promotion. 1992;9:352-360.

6. Evans S, Block, JB. Ethical issues regarding fee-for-service-funded research within a complementary medicine context.Journal of Alternative and Complementary Medicine.2001;6:697-702.

15 JANA Vol. 5, No. 1


New Developments in the Prevention andTreatment of Neurodegenerative Diseases Using

Nutraceuticals and Metabolic Stimulants

Russell L. Blaylock, MD*Board Certified Neurosurgeon, Clinical Assistant Professor

University of Mississippi Medical Center, Jackson, Mississippi

Winter 2002

INTRODUCTION

Neurodegeneration was once considered to be a simpleacceleration of the normal aging process. Aging of thebrain, however, generally produces little deterioration ofneurological function. Neurodegeneration on the otherhand, results in an appreciable loss of cognitive and motorfunction. Hence, a significant loss of cognitive ability isalways pathological. In this review I will discuss severalchanges that occur with neurodegeneration and offer poten-tial ways to reduce one’s risk of developing a neurodegen-erative disorder.

THE CENTRAL MECHANISM OFNEURODEGENERATION

When one reviews the extensive literature on neurode-generation, one finds many seemingly unrelated patholog-ical events, such as excitotoxicity, viral inflammation,autoimmune reactions, trauma, cerebrovascular impair-ment, and metal toxicity. Surprisingly, a single centralmechanism explains all.1 This mechanism is a combinationof excitotoxic injury coupled with free radical damage toneural tissue. Excitotoxins are neurotransmitters, such as

glutamate or aspartate, that can cause cell death when theiractions are prolonged. These chemicals are thought to playand important role in ischemic brain damage.

A free radical molecule has an unpaired electron in itsouter orbital, one that robs surrounding molecules of theirelectrons, generating a process referred to as oxidation oroxidative stress. The particles responsible for this oxidativeinjury are referred to as reactive oxygen species (ROS). Arelated particle, discussed less often in the lay literature, isthe reactive nitrogen species (RNS). Its nitrogen atom inter-acts chiefly with amino acids, such as tyrosine, interferingwith numerous biochemical processes in the central nervoussystem. When these particles react with tyrosine they formnitrotyrosine, a measurable marker for RNS damage. As weshall see, these oxygen and nitrogen products are common-ly found in the tissues of those with neurodegenerative dis-orders, such as Alzheimer’s dementia, Parkinson’s disease,Huntington’s disease and Lou Gehrig’s disease (ALS).

The excitotoxic process entails a complicated series ofreactions involving the release of the amino acid neuro-transmitter glutamate. Glutamate reacts at a series of recep-tors on the neuron’s surface that in turn, either directly orindirectly, control the calcium pore or channel.2 This chan-nel tightly regulates the entry of calcium into the neuron.Calcium homeostasis is critical because its loss is the trig-ger for numerous abnormal signaling systems in the neu-ron, which when over-stimulated can precipitate thedestructive generation of free radicals and inflammatoryreactions that can ultimately lead to the death of the cell.

For this reason, glutamate levels outside the neuron are

* Correspondence:Russell L. Blaylock, MD315 Rolling MeadowsRidgeland, Mississippi 39157Phone: 601-982-1175 E-mail: [email protected]


carefully regulated. Even small elevations in glutamate canprecipitate the destructive reactions we refer to as excito-toxicity. Glutamate content outside the neuron is controlledby a re-uptake system that involves a series of glutamatetransport proteins.3 Should too much calcium enter the neu-ron, other cellular mechanisms act to remove it, either bymoving it into the mitochondria, pumping it outside theneuron, or sequestering it in the endoplasmic reticulum.4

All of these processes require cellular energy. When cellu-lar energy supplies fall, these protective systems fail.

Calcium acts as a biochemical trigger for numerousreactions, all of which play a vital role in neuron function,such as nitric oxide signaling information, activation ofspecial eicosanoids and regulation of the neuron’s genemessages.5 When too much calcium enters the cell, it trig-gers an excessive production of nitric oxide, a cell-signal-ing molecule.6 As the nitric oxide begins to build up, itinteracts with the superoxide radical to produce the highlyreactive and destructive peroxynitrite radical. This radicalwreaks havoc on the mitochondria, producing injury to itsenzymes (electron transport chain) and in addition, dam-ages mitochondrial DNA.7 A significant loss of cellularenergy production results.

Excess calcium also stimulates the activation of theenzyme protein kinase C, which activates the membrane-bound enzyme, phospholipase A2 ( PLA2).8 This enzyme inturn releases arachidonic acid from the membrane lipid stores,where it is then acted upon by two enzymes, cyclooxygenase(COX) and lipoxygenase (LOX), which convert it into numer-ous reactive molecules called prostaglandins and leukotrienes.Both metabolic products, when present in excess, can drasti-cally increase free radical production.9

As the level of free radicals begin to rise, they interactwith the lipids in the cell’s various membranes, setting upa chain reaction called lipid peroxidation. The peroxyl rad-ical plays a major role in membrane injury as well as injuryto mitochondria.10 As the destructive process spreadsthrough the membrane, secondary metabolic products areproduced, such as 4-hydroxynonenal, which can be evenmore destructive.11

Cellular proteins are building blocks for the hundreds ofenzymes used by each cell to function. Free radicals interactwith both proteins and carbohydrates in the cell, causingconformational changes in their structure. While free-radi-cal-altered proteins, called carbonyl products, increase withaging, they don’t increase to the extent we see in the tissuesof those with neurodegenerative diseases.12,13

Another cell component damaged by free radicals isDNA. The cell contains two sets of DNA: one type in thenucleus, and another in each of the cell’s numerous mito-chondrion. Mitochondrial DNA is especially vulnerable tooxidation reactions, being about 10X more sensitive to freeradical damage.14 This is important because with aging,

oxidized DNA begins to accumulate, resulting in dwindlingcell energy supplies.15 Cellular low energy causes reducedfunction of the neurons and increased sensitivity to excito-toxicity. The susceptibility of mitochondrial DNA to free rad-ical oxidation increases with age, being 15X more activeafter age 70. As this process accelerates, a special autode-structive gene, called the p53 gene, is activated.16 Its purposeis to kill the neuron when the cell is so badly damaged that itcannot be restored to health by the cell’s reparative enzymes.

Much of the destructive change seen in neurodegener-ative disorders, at least in the earlier stages, does not entailneuron death. Several studies have shown that in the case ofAlzheimer’s disease, most of the damage is directed at theneuron processes, such as the dendrites and synapses.17

While we do not completely understand the role played byß-amyloid peptides, we do know that much of their destruc-tive potential comes from the free-radical-generating mole-cule hydrogen peroxide.18 Amyloid has also been shown toenhance excitotoxicity.19

Another pathological characteristic of Alzheimer’s dis-ease is the presence of microscopic neurofibrillary tanglescomposed of over-phosphorylated tau protein. Recent evi-dence has demonstrated that the lipid peroxidation product4-hydroxynonenal interacts with the tau protein to acceler-ate this process, and prevents the tau proteins from dephos-phorylating.20 Several of the transition metals such as alu-minum and mercury, and exposure to MSG can precipitatethe same event experimentally.21

Finally, the entire process involves an overreactingimmune system apparently triggered by excitotoxicity andfree radical injury.22 The microglial cell, the cellular basisof central nervous system immunity, is activated by anyevent that increases the free radical-excitotoxicity cas-cade.23 As we shall see, CNS immune activation plays amajor role in neurodegeneration.

This entire process appears to be the same for numer-ous conditions including autoimmune diseases, viralencephalitis, Lyme disease, AIDS dementia syndrome,brain injury, strokes, heavy metal toxicity, spongioformencephalitis (Mad Cow disease), and most of the degenera-tive brain disorders, such as Alzheimer’s dementia,Parkinson’s disease, Huntington’s disease, and ALS.

IRON AND NEURODEGENERATION

It is known that as we age our brain accumulates morefree iron.24 In the past it was assumed that only free ironwas harmful; recent evidence indicates that even iron com-bined to ferritin can damage neurons.25 Excessive ironaccumulation is seen in many neurodegenerative disorders,including Alzheimer’s dementia, Parkinson’s disease, andALS. In biological systems, iron is known as one of themost powerful free radical generators.


Recent evidence indicates that those at risk of develop-ing Parkinson’s disease have a defect in iron metabolism.26

In this study, Parkinson patients’ total iron binding capacityand transferritin saturation were significantly lower thanthat of controls, with no difference in their dietary intake ofiron. Other researchers have found increased iron and alu-minum in the neuromelanin pigment in the substantia nigraof Parkinson’s patients.27 Aluminum appears to displaceiron from the ferritin molecule, thereby increasing the inter-action of iron during the hydrogen peroxide interaction withsuperoxide. This reaction forms the powerful hydroxyl rad-ical.28

In the brains of Alzheimer’s disease patients, alu-minum, iron, and mercury are consistently found in elevat-ed concentrations in affected neurons,29 transferritin levelsare decreased, and iron, ferritin, and transferritin are con-centrated around the senile plaques.

ALUMINUM AND NEURODEGENERATION

The connection between aluminum exposure and braindysfunction was strengthened when several dialysis unitsreported patients with an unusual dementing syndrome relat-ed to elevated aluminum levels in the dialyslate.30 Once thedialysis water was cleared of aluminum, the dementing syn-drome disappeared. Based on this finding, others began to sus-pect aluminum toxicity as an etiology of Alzheimer’s disease.

One early study, in which individuals were examined in88 counties in England and Wales, areas with elevated alu-minum levels in the drinking water had higher incidences ofAlzheimer’s dementia.31 A later, more well-controlledstudy found that elderly people who drank water high inaluminum had a 4.4X higher incidence of Alzheimer’s dis-ease than those who drank water with lower levels.32

After this suggestive research, more accurate studieswere conducted for measuring brain levels of aluminum inseveral neurodegenerative disorders. Despite early conflict-ing results, the latest studies performed with microtech-nique high-tech laser and x-ray probes clearly indicate ele-vated levels of aluminum in the area of neurofibrillary tan-gles in Alzheimer’s disease.33 Similar results have beenfound in cases of Parkinson’s disease.34 The results of oneALS study indicated that while spinal cord levels of alu-minum were not elevated above controls, they did find a1.5- to 2-fold elevation in iron and calcium.35 Using moresophisticated methods, another study confirmed the earlierfinding of elevated aluminum levels in the motor neurons ofALS patients.36

Besides increasing free radical generation, aluminumhas several other negative effects on cell function. Onestudy found that primates exposed to excess aluminum hada significant decrease in total lipid, glycolipid, and phos-pholipid content in their brains.37 Aluminum also damagesmembrane-bound enzymes such as Na+-K+ATPase, acetyl-

cholinesterase, and 2’,3’-cyclic nucleotide phosphohydro-lase, all enzymes necessary for normal neuron function.

A recent study found that aluminum in the presence ofmelanin significantly enhanced lipid peroxidation.38 This isimportant in the case of Parkinson’s disease, since the neu-romelanin-containing cells of the substantia nigra are thecells most affected by the disease. Of enormous importanceis the finding that high aluminum levels can inhibit theactivity of many antioxidant enzymes, such as catalase,superoxide dismutase, and glutathione peroxidase.39

Several studies have linked aluminum to formation ofthe paired helical filaments found in Alzheimer’s disease.40

Aluminum appears to interfere with dephosphorylation ofthe hyperphosphorylated tau protein. Experimentally, usingthe aluminum-chelating agent desferrioxamine, researcherscould reverse this resistance to aluminum-induced dephos-phorylation.41

The entry of aluminum into the brain, past the blood-brain barrier, is significantly enhanced when aluminum isbound to glutamate.42 Once in the brain, aluminum hasbeen shown to potentate excitotoxicity by enhancing gluta-mate-triggered calcium accumulation within the neuron,43

and to increase the formation of iron-induced free radicals.

Is aluminum the only cause of these neurodegenerativediseases? I don’t think so. However, I do think that it is a sig-nificant contributing factor. Numerous environmental agents,viruses, autoimmune disorders, and injuries can all trigger thesame central destructive mechanism—excitotoxicity. Oftenwe see several of these factors coexisting in the same person.At high risk is the person having mineral deficiencies, poornutritional supply of antioxidants, and antioxidant enzymedeficiencies.

It is interesting to note that gastrointestinal absorptionof aluminum was found to be enhanced in Down’s syn-drome, a condition with pathological features similar toAlzheimer’s disease.44 In this study, aluminum absorptionin Down’s syndrome was 4X greater when absorbed as anantacid, and 6X higher in the presence of citrate than thatseen in controls. Another study found that adding citrate toaluminum hydroxide antacid increased absorption as muchas 11X in normal adults.45 This may be a good reason to notadd lemon juice to your tea, since tea is high in aluminumand lemons are high in citrate.

A monocarboxylic acid transporter controls entry ofaluminum into the brain. Pyruvate competes with alu-minum citrate for entry, thereby providing a way to inhibitbrain accumulation of aluminum.46 Pyruvate, as well asmalate, have also been shown to inhibit glutamate toxicity.47

INFLAMMATION, CYTOKINES ANDAUTOIMMUNITY

For many years scientists suspected that the immune

Winter 2002 Vol. 5, No. 1 JANA 18

system played an important role in neurodegeneration. It isknown that with aging we begin to develop immune com-plexes to brain components.48 Some have proposed that thisis the function of immune suppression commonly seen withaging, to reduce the immune attack. Studies of Alzheimer’spatients have shown elevated cytokines IL-1ß, IL-2, IL-6,S-100 protein, tumor necrosis factor alpha (TNF-alpha),and significant isolated autoantibodies to GM1.49,50 Onealso sees elevated levels of PGD2 and thromboxane B2,both inflammatory cytokines, in Alzheimer’s disease.51

Autoantibodies have also been described in amyotrophiclateral sclerosis as well.52

This immune attack on neurons produces a state ofchronic inflammation that generates a constant high level offree radicals.53 As the damage continues, the p53 gene isactivated, leading to apoptosis.54 Short of actual destructionof the neurons, a reduction in mitochondrial energy gener-ation leads to increased free radical production. In addition,low energy levels make the neurons infinitely more sensi-tive to the excitotoxic effects of glutamate and aspar-tate.55,56 In fact, in the face of low energy production, evennormal levels of glutamate can kill neurons. Glutamate, inturn, stimulates the microglia, the CNS immune cell, toproduce even more cytokines, and to release the two exci-totoxins glutamate and quinolinic acid.57 This viscous cycleleads to eventual neuronal cell death.

As we see, glutamate itself can act as the trigger formicroglial activation leading to the release of numerousinflammatory cytokines, or some other event may triggerthe process, such as a viral infection, Lyme disease organ-ism invasion, or even heavy metal exposure. One factor thatmay lead to autoimmunity is the prolonged assault of thebrain’s cellular components to oxidative stress. Oxidationof the proteins, which alters their structure, can lead toautoimmunity.

Recent studies have shown that activation of the tran-scription factor NF kappa B plays a major role in neurode-generation. This transcription factor stimulates the produc-tion of various cytokines including IL-1ß, IL-2, IL-6 andTNF-alpha, all of which are increased in neurodegenerativediseases.58,59,60 Oxidative stress is a common trigger for NFkappa B activation.

Beta-amyloid has been shown to activate microglia byway of protein kinase C.61 Studies indicate that beta-amy-loid production is increased in the face of activatedmicroglia and that the presence of beta-amyloid is sufficientto maintain chronic brain inflammation. Microglia them-selves contain enough glutamate to elicit excitotoxicity.They can also precipitate excitotoxicity by stimulating therelease of arachidonic acid.62 Microglia also contain con-siderable amounts of the excitotoxin quinolinic acid, whichcan be released during activation.63 Quinolenic acid is ametabolic product of serotonin metabolism.

Animal studies have shown that mice with autoim-mune disorders have a more rapid decline in aged-relatedlearning than normal animals.64

ADVANCED GLYCATION END PRODUCTS

One of the consequences of a high dietary intake ofglucose, and especially fructose, is the glycation of numer-ous proteins in the cell.65 When proteins are glycated, thatis, combined with sugar molecules, they become signifi-cantly more vulnerable to free radical damage and produceadvance glycation end products (AGEs) which can interferewith tyrosine and dopa utilization. Elevated levels of AGEshave been found in Alzheimer’s, Parkinson’s disease, andALS.66,67 This is especially so in Parkinson’s diseasebecause of the early fall in cellular glutathione levels.

The problem of large amounts of AGEs is that they sig-nal glia cells to produce superoxide and nitric oxide,68 acombination that leads to the production of the powerful per-oxynitrite radical. Cytokines are also potent stimulators ofinducible nitric oxide, and hence peroxynitrite production.

PEROXYNITRITE

As stated, when nitric oxide combines with superoxide itproduces peroxynitrite. This free radical is unusual in that it isresistant to most of the common antioxidants, such as vitaminC, vitamin E and the carotenoids.69 The most powerful scav-enger of peroxynitrite is glutathione. When glutathione lev-els are low, as is seen in Parkinson’s disease as well asAlzheimer’s dementia and ALS, neurons become significant-ly more vulnerable. Peroxynitrite tends to concentrate in themitochondria, where it damages enzymes as well as DNA.70

These events dramatically interfere with the cell’s abil-ity to produce energy. Neurons and glia are very energydependent. Virtually every cellular process requires enor-mous amounts of energy. The brain consumes 20% of theblood’s oxygen and 25% of its glucose, even though it con-stitutes only 2% of body weight. Even under deep anesthe-sia, the brain’s metabolism is reduced only 50%.71

Several studies have demonstrated elevated peroxyni-trite levels in Alzheimer’s disease, ALS and Parkinson’sdisease.72 Damage by peroxynitrite is indicated by the accu-mulation of nitrotyrosine.

4-HYDROXYNONENAL (4-HNE)

4-hydroxynonenal (4-HNE) is an aldehydic product oflipid peroxidation. While malondialdhyde (MDA) is the mostabundant product of lipid peroxidation, 4-hydroxynonenal isthe most reactive with proteins. Interestingly, the distributionof damage by peroxynitrite parallels that of 4-HNE.73

There is growing evidence that 4-HNE plays a majorrole in several neurodegenerative disorders, including


Alzheimer’s dementia, Parkinson’s disease and ALS. In onestudy of seven Alzheimer’s disease patients, 4-HNE wasfound to be associated with all amyloid deposits and mostperivascular areas (89%).74

Another study found increased 4-HNE in several areasof the brain in Alzheimer’s disease, reaching significant lev-els in the amygdala, hippocampus and parahippocampus,areas of primary damage in the disorder.75 Elevations of 4-HNE have also been found in the ventricular fluid ofAlzheimer’s patients but not in age-matched controls.76

The distribution of 4-HNE appears to be dependent onthe presence of the APOE genotype. APOE4-possessingsubjects demonstrated primary accumulation of 4-HNE inthe cytoplasm of pyramidal neurons, while APOE3 geno-types had both astrocytic and pyramidal cell distribution.77

APOE4 is strongly associated with Alzheimer’s disease aswell as a high risk of dementia pugilistica in boxers.78 It isalso known that individuals with APOE4 genotype haveimpaired antioxidant enzymes, which may be the basis oftheir increased incidence of neurodegenerative diseases.79

Injecting 4-HNE into the brain of rats causes a wide-spread loss of neurons in the basal forebrain ipsilateral tothe injection and a 60 to 80% reduction in choline acetyl-transferase seven days post-injection.80 When FeCl2 isgiven, it increases the levels of 4-HNE in the brain.

Similar elevation of 4-HNE has been demonstrated inParkinson’s disease.81 A study of seven brains ofParkinson’s disease patients, demonstrated immunostainingfor 4-HNE in the striatum, but demonstrated the same find-ings in only 9% of aged-matched controls.

Direct injection of 4-HNE into the substantia nigra ofmice caused a dose-dependent depletion of glutathione inthe brainstem.82 Glutathione levels fall early in Parkinson’sdisease. 4-HNE has also been shown to rapidly inactivateglutathione reductase, needed to convert oxidized glu-tathione to its reduced form.83

One of the best correlations with cognitive function inAlzheimer’s disease is the synaptic concentration in thebrain.84 4-HNE has been shown to conjugate to synapticproteins and to impair transport of both glucose and gluta-mate. Both result in a significant decrease in cellular pro-duction of ATP.85

HOMOCYSTEINE AND OXIDIZEDCHOLESTEROL

While the cardiovascular system has gotten most of theattention as regards homocysteine and cholesterol, the ner-vous system is also vulnerable to its effects. Both LDL andHDL exist in the brain, with LDL acting as a transporter ofcholesterol and phospholipids in the CNS. Receptors forLDL have been located on microvessels, astrocytes,microglia, and neurons.86 Like LDL in the plasma, brain

LDL and HDL can become oxidized, especially in the pres-ence of increased catalytic iron.87

It has been shown that oxidized LDL in the striatumenters the neuron and can induce cell death. The mechanismof neuronal injury is closely connected to excitotoxicitysince glutamate-blocking drugs, such as MK-801, protectthe neuron from oxidized LDL-mediated cell death.88

Highly oxidized HDL in the brain has also been shown toincrease oxidative stress in astrocytes, microglia, and neu-rons, causing death in the latter.89 When oxidized lipopro-teins exist in the presence of glutamate and/or amyloid, neu-ronal killing is enhanced.90 Oxidized LDL is toxic to motorneuron cells, possibly linking it to amyotrophic lateral scle-rosis.91 Antioxidants, just as in the case of plasma lipopro-teins, reduce oxidized LDL and HDL neurotoxicity.92

Homocysteine has been strongly associated with car-diovascular disease, even though the mechanism has notbeen fully elucidated. Less well appreciated is the connec-tion between elevated levels of homocysteine and neurode-generation. Several recent studies have shown a strong cor-relation between homocysteine levels and incidence ofAlzheimer’s disease.93,94 Rarely discussed is the fact thathomocysteine is an excitotoxin, as are homocysteic andhomocysteine sulphinic acid,95 two of its metabolic break-down products.

These excitotoxins act at the N-methyl-D-aspartate(NMDA) receptor, triggering the entry of excessiveamounts of calcium into the neuron, leading to numerousdestructive reactions including the generation of peroxyni-trite, 4-HNE, hydroxyl and peroxyl radicals, and activationof the eicosanoid cascade. Whether lowering homocysteinelevels will reduce Alzheimer’s disease is as yet unknown.We do know that folate, pyridoxine, and antioxidant vita-min deficiencies are common in Alzheimer’s diseasepatients.96,97 Several studies have shown low levels of vita-min B12 as well.97

It is important to appreciate that the classical hemato-logical signs of B12 deficiency, macrocytosis and hyperseg-mented neutrophils, are usually absent in these patients.98

While homocysteine levels were found to be consistentlyelevated in Alzheimer’s patients, nutritional deficiency wasnot confirmed using retinol binding protein (RBP). Thisindicates an impaired cobalamin delivery to the tissues,which explains the observed discrepancy between normalserum levels of cobalamin and folate and low tissue meta-bolic products found frequently in the elderly.

One recent study throws the homocysteine theory intoquestion.99 Centenarians living in two northern Italianprovinces were examined for blood levels of homocysteine,folate and B12. They examined centenarians who were cog-nitively normal, cognitively impaired, and those with adiagnosis of Alzheimer’s disease. Elevated homocysteinelevels were found in 77% of normal, 100% of cognitively


impaired, and 82% of Alzheimer’s patients. Demented cen-tenarians had the lowest folate levels. Low B12 and B6 lev-els were found in 33% and 66% respectively of all cente-narians regardless of cognitive status.

There are several explanations for these negative find-ings. First, the study was based on blood levels of the vita-mins, and as we have seen, there is little correlationbetween blood levels and tissue levels of these three vita-mins. As for the lower level of homocysteine seen in thecentenarian Alzheimer patients, perhaps it was secondary tometabolic burnout, something we see in the case of gluta-mate as well.

Homocysteine is known to elicit apoptosis quite rapid-ly when hippocampal neurons are exposed to this aminoacid.100 The mechanism includes DNA strand breaks withactivation of poly-ADP-ribose polymerase (PARP) whichdepletes nicotinamide adenine dinucleotide) (NAD). Thisin turn leads to mitochondrial dysfunction, oxidative stressand caspase activation. In essence it markedly enhances thevulnerability of hippocampal neurons to excitotoxic andoxidative injury.

ENERGY PRODUCTION, EXCITOTOXICITY. ANDFREE RADICALS

There is an intimate connection between energy pro-duction, excitotoxicity, and free radicals. It has been knownfor some time that impaired mitochondrial energy produc-tion can lead to dramatic increases in free radical produc-tion, and that reduced neuronal energy production signifi-cantly increases the neuron’s sensitivity to excitotoxicity.101

In fact, under such conditions even normal concentrationsof extracellular glutamate can trigger excitotoxic reactions.Further, an increase in free radical production, either asreactive oxygen or reactive nitrogen species, increases therelease of glutamate from the astrocyte. Glutamate in turnincreases free radical production, which further reducesenergy production. This vicious cycle continues until thep53 gene is activated and apoptosis ensues. The neurons aredestroyed by necrosis as well. When elevated iron levels arepresent, as it does in all neurodegenerative disorders, freeradical generation reactions are accelerated.

Another result of increased free radical generation is itseffect on the blood-brain barrier system. This gatekeepernormally prevents or slows the passage of harmful mole-cules into the brain’s environment. Unfortunately, the sys-tem is not perfect. Recent studies have shown that free rad-icals can open the barrier, allowing harmful compoundsinside, including the excitotoxins glutamate and aspar-tate.102 Evidence also indicates that the barrier containsglutamate receptors and that glutamate itself can open thebarrier.103 This means that elevated levels of blood gluta-mate can open the barrier, further elevating the level of thispowerful excitotoxin in the extracellular space.

Related to energy deficits in neurodegeneration is thefinding that the glucose transporter is impaired inAlzheimer’s disease secondary to alteration in the brain’svasculature.104 In addition, glutamate itself can impair glu-cose entry into the brain.

So we see that there is an intimate connection betweenglutamate, free radicals, energy production, and the wide-spread destruction of neurons. Because neurons differ in thetypes of neurotransmitter receptors present on their mem-branes, some will be more sensitive than others.. Thisaccounts for the difference in pathological presentation.

Reduced energy production has been demonstrated inall four major neurodegenerative disorders: Alzheimer’sdisease, Parkinson’s disease, Huntington’s disease andamyotrophic lateral sclerosis. In each instance, specificenzyme deficiencies are present. In Parkinson’s disease,complex I is deficient.105 In Alzheimer’s disease complex I,IV and pyruvate dehydrogenase complex are all defi-cient.106,107

MAGNESIUM

Magnesium plays a special role in excitotoxicity andfree radical generation. The magnesium receptor is locatednear the calcium channel on neurons possessing the NMDAreceptor, which regulates calcium entry into the neuron. Aswe have seen, excessive intracellular calcium can triggerdestructive reactions involving nitric oxide synthase induc-tion, arachidonic acid release from the membrane witheicosanoid activation, and changes in mitochondrial func-tion. Magnesium can block calcium entry as long as the neu-ron is not firing. It has been demonstrated that low magne-sium levels greatly enhance the neuron’s sensitivity to gluta-mate, again, where even normal levels can be excitotoxic.108

Other studies indicate that magnesium plays a majorrole in preventing free radical accumulation.109 Cells isolat-ed in a low magnesium environment not only generate morefree radicals but are twice as sensitive to free-radical-induced cell death as cells with normal magnesium levels.110

In addition, hypomagnesmia lowers the cell’s glutathionelevel and increases its cytokine level, which, as we haveseen, can inhibit glutamate uptake, thereby increasing freeradical generation that leads to excitotoxic neuron death.

Both experimental and clinical studies have demon-strated significant neuroprotective effects of elevated mag-nesium levels.111,112 An additional benefit is that magne-sium also inhibits the entry of oxidized lipids into theendothelial cells of blood vessels.

INHIBITORS OF GLUTAMATE UPTAKE: THEGLUTAMATE TRANSPORT PROTEINS

Because even small concentrations of extracellularglutamate can trigger neuron destruction, it is carefully reg-


ulated by a special re-uptake system. This system consist ofapproximately five different transport proteins, EAAT 1-5,whose job it is to bind to glutamate, transport it to the astro-cyte and transfer it into the intercellular compartment. Oncethis is done, the glutamate is converted into glutamine andstored until needed. The distribution of the different typesof transport proteins is brain specific.113 EAAT 1-5 arefound in the retina.

There is growing evidence that abnormalities in thesetransport proteins play a major role in many neurodegener-ative diseases. This is best demonstrated in amyotrophic lat-eral sclerosis (Lou Gehrig disease).114 There is some evi-dence that a similar process operates in Alzheimer’s demen-tia and Parkinson’s disease.115,116

We now know that several events and compounds (suchas viral infections,117 hereditary SOD1 mutants in ALS,118

oxidative stress119 and exposure to mercury) can triggerexcitotoxicity by inhibiting the glutamate transporters.

Mercury is a very potent inhibitor of glutamate trans-porters. In one study a mercury dose as low as 10(-5)M wasfound to be inhibitory.120 Mercury is unique, since no othermetal tested, including aluminum, lead, cobalt, strontium,cadmium and zinc, had any effect on glutamate transport.121

What makes this important is the ubiquitous nature ofmercury exposure. The number one source for humans isdental amalgam.122 Other sources include industrial fumes,coal burning, contaminated fish and contaminated lakes andstreams. Dental amalgam is composed of 50% mercury,which has been shown to vaporize in the mouth, especiallyin the presence of heat. Drinking hot liquids and chewinghas been shown to increase the release of mercury vaporfrom amalgams at levels 3X higher than normal for 90 min-utes.123,124 Over 80% to 90% of this vapor is absorbed intothe circulation. Because of its fat solubility, mercury accu-mulates in high levels in the nervous system and is very dif-ficult to remove.125 Mercury is also a potent stimulus for theproduction of free radicals and it inhibits numerousenzymes, including the antioxidant enzymes.126

As I demonstrated earlier, a key player in excitotoxici-ty and neurodegenerative diseases is 4-hydroxynonenal (4-HNE), a product of lipid peroxidation, and a potentinhibitor of glutamate transport proteins.127 This once againforges a strong connection between excitotoxicity andoxidative stress. Inflammatory cytokines, such as IL-1ß, IL-2, IL-6 and TNF-alpha, can also inhibit the glutamate trans-porters, likely via increased lipid peroxidation and produc-tion of excessive amounts of 4-hydroxynonenal.

So we see that anything that increases oxidative stressin the nervous system over a long period of time willincrease the risk of neurodegeneration. This explains whyso many seemingly unrelated factors – such as viral infec-tions, trauma, pesticide exposure, hereditary enzymedefects, and exposure to mercury, aluminum, fluoride and

iron can play a role in producing the neurodegenerative dis-eases. They all increase oxidative stress, inhibit glutamatetransport, activate microglia, and trigger excitotoxicity.

THE USE OF NUTRACEUTICALS AND PLANTEXTRACTS IN PREVENTING AND TREATINGNEURODEGENERATION

A principal cause of neurodegeneration, oxidativestress, can be substantially reduced by the consumption ofvarious nutraceuticals.128 Flavonoids are powerful, versa-tile antioxidants whose potency is enhanced when com-bined with vitamins and minerals.

ANTIOXIDANT EFFECTS

Most are familiar with the antioxidant effects of vita-mins such as the tocopherols and tocotrienols, ascorbate,vitamins D and K, and the minerals zinc, magnesium andselenium. As efficient as these antioxidants are, especiallyin combination, they are ineffective against some of themajor free radicals and reactive nitrogen species. A study ofAlzheimer’s and multi-infarct dementia patients found thatboth were more often deficient in vitamin E and betacarotene than matched controls.129 Only the Alzheimer’spatients were deficient in vitamin A.

A number of antioxidants have been shown to inhibitglutamate-induced cytotoxicity (excitotoxicity) includingvitamin E, Ginkgo biloba extract, pycnogenol, N-acetyl L-cysteine, alpha lipoic acid, DHLA, and individualflavonoids.130 Of even greater interest is the finding that notonly can flavonoids protect DNA from oxidative injury,they initiate fast chemical repair of DNA as well.131

As we have seen, peroxynitrite plays a central role inneurodegeneration because of its toxic effects on mito-chondrial enzymes and mitochondrial DNA. While theantioxidant vitamins are generally ineffective in inhibitingthese radicals, flavonoids are quite efficient. In fact, a studyof the scavenging capacity of flavonoids as compared to astandard peroxynitrite scavenger, ebselen, found that theflavonoids were 10X more potent.132

Researchers recently found that teas, both black andgreen, have peroxynitrite scavenging ability equal to that ofred wine polyphenols.133 In their study, lipopolysaccharide-induced nitric oxide synthease (iNOS) activity was dramat-ically reduced, most likely by epigallocatechin gallate, butthe mixed theoflavins from black tea were also potentinhibitors. Peroxynitrite is formed when nitric oxide is pro-duced in excess. The black tea component, theaflavin digal-late, was also found to decrease superoxide production inmacrophages and to chelate iron to a significant degree,moreso than green tea components.134

Curcumin, from the spice turmeric, is also a potentinhibitor of peroxynitrite and lipid peroxidation.135 By


enhancing the production of glutathione, curcumin furtherprotects neurons from peroxynitrite, as well as numerousother free radical oxygen and nitrogen species. Alpha lipoicacid and its reduced form, dehydrolipoic acid (DHLA) alsoenhances cellular glutathione production. Studies haveshown alpha lipoic acid to increase glutathione levels from30 to 70% higher than normal.136 Hydroxytyrosol, found inextra virgin olive oil, is highly protective against the perox-ynitrite radical as well.137

Ubiquinone (coenzyme Q10) may act as a significantantioxidant in biological systems. It may do this by regen-erating vitamin E.138 In turn, alpha-lipoic acid can increasethe level of ubiquenol in the face of oxidative stress.139 Sowe see a complex interplay of the antioxidants that allowsthem to be regenerated for further use.

The reduced form of alpha-lipoic acid, DHLA, has thegreatest versatility in neutralizing free radicals. DHLA canneutralize the hydroxyl radical, singlet oxygen, hypochlo-rite, NO radicals, superoxide, peroxyl radicals and H202,whereas alpha-lipoic acid cannot neutralize superoxide orperoxyl.140 In mammalian cells alpha-lipoic acid is rapidlyconverted to DHLA.141 Both alpha-lipoic acid and DHLAhave been shown to be protective against NMDA and mal-onic acid-induced striatal lesions in the brain, reducing thesize of the lesion by 50%.142 This would be important inpreventing the oxidative stress lesion responsible forParkinson’s disease.

Melatonin is also gaining interest as a powerful neuro-protectant. It has been shown to react with the hydroxyl rad-ical, hydrogen peroxide, singlet oxygen, peroxynitrite,nitric oxide, and hypochlorus acid.143 In addition, it stimu-lates the production of the antioxidant enzymes: superoxidedismutase, glutathione peroxidase and glutathione reduc-tase. In a test using dopamine, neuronal cell cultures grownin vitro in a medium without supporting growth factors, allof the cells were dying within a short period of time.144

When melatonin was added to the suspension, nearly all ofthe dying cells were rescued, including tyrosine hydroxy-lase positive DA neurons.

PREVENTION OF LDL OXIDATION

As we have seen, LDL and HDL exist in the brain andwhen oxidized can induce neuron cytotoxicity. It is interest-ing to note that oxidized LDL cytotoxicity acts through theNMDA receptor by way of the excitotoxic mechanism. Onemajor system preventing lipoprotein oxidation is thearrangement of tocopherol molecules within the LDL andHDL units. The LDL structure contains six tocopherol mol-ecules. As with all tocopherols, those in lipoproteins canbecome oxidized when exposed to excessive oxidativestress. Regeneration of embedded tocopherol depends onother antioxidants, such as the carotenoids, ascorbate, alpha-lipoic acid, DHLA, coenzyme Q10, and the flavonoids.

Dietary supplementation with alpha-tocopherol hasbeen shown to reduce the oxidative modification of LDL, areduction even greater in diabetics.145 Ascorbate has alsobeen shown to be an effective inhibitor of LDL oxidation,and combined with alpha-tocopherol, has reduced the sus-ceptibility of LDL to oxidation at all concentrations of cop-per tested.146

Coenzyme Q10 has been shown to significantly reducethe oxidizability of LDL in the face of aqueous free radicalgeneration at a dose of 300 mg a day in humans.147

Numerous flavonoids have been shown to reduce LDL-oxi-dizability including red wine polyphenols (catechins),myricetin, quercetin, epigallocatechin gallate, epicatechinand rutin.148

I would caution that drinking red wine for health ben-efits may be more hazardous because of the high concen-tration of fluoride in California wines and the use of sulfitesin most wines.149 The sulfite connection is especially strongbecause of the observed enhancement of neuronal toxicitywhen sulfite exists in the presence of peroxynitrite, espe-cially when combined with glutathione depletion, as is seenin Parkinson’s disease.150 Finally, the alcohol itself is par-ticularly toxic to neurons. A recent study found a gradeddeleterious effect of alcohol on antioxidant levels withinsynaptosomes and neuronal mitochondria.151 There wasalso a dose-dependent increase in lipid peroxidation.

A recent study found that the most effective protectionagainst oxidized LDL-induced cytotoxicity was from cyani-din, epicatechin and kaempferol, with 80% protection.152

One of the most effective flavonoids, epicatechin, was 10Xmore efficient in protecting neurons under these conditionsthan ascorbate. Pretreatment with taxifolin, apigenin andnaringenin enhanced the toxic effect of oxidized LDH invitro, even though they were not neurotoxic alone. This studydemonstrates the usefulness of selected flavonoids as power-ful neuroprotectants under conditions of oxidative stress.

The double advantage to lowering LDL and HDL oxi-dation is a reduction in both direct neurotoxicity of oxi-dized LDL and HDL, and the prevention of atheroscleroticcerebrovascular disease.

INFLAMMATION, CYTOKINES ANDNUTRACEUTICALS

All of the major neurodegenerative disorders are asso-ciated with microglial activation and excessive productionof cytokines IL-1beta, IL-6, and TNF-alpha.153 This inflam-matory process involves overactivation of the eicosanoidsystem through activation of phospholipase A2 and therelease of arachidonic acid from the membrane. This in turnis acted on by lipoxygenase and cyclooxygenase with theproduction of numerous pro-inflammatory leukotrienes andprostaglandins. Excitotoxins also induce interleukin-1betaboth in microglia and astrocytes.154


Attempts to reduce neurodegeneration have recentlyfocused on ways to inhibit this series of pro-inflammatoryreactions. In one transgenic Alzheimer’s mouse modelstudy, it was found that ibuprofen significantly reduced IL-1beta and glial fibrillary protein levels and reduced the totalnumber of amyloid deposits.155

Another cytokine of importance in neurodegeneration istumor necrosis factor-alpha (TNF-alpha), which is elevated inAlzheimer’s disease, Parkinson’s disease, and ALS. It isknown that (-) epigallocatechin gallate inhibits the productionof TNF-alpha by modulating the pro-inflammatory transcrip-tion factor NF kappa B. Other flavonoids, such as curcuminand quercetin,156,157 can also modulate NF kappa B. In onestudy, all flavonones tested protected cells against TNF cyto-toxicity, with eriodictyol being most potent.158 Apigeninmarkedly enhanced the cytotoxicity of TNF. Zinc has beenshown to markedly inhibit apoptosis induced by TNF.159

Critical to the neurodegenerative process is the inflam-matory cascade, which involves numerous cytokines,eicosanoids, and other immune factors. We know there is anintimate connection between excitotoxicity and the inflam-matory cascade in cells. The inflammatory cascade can beblocked or reduced at any one of these levels.

Since NF-kappa B transcription factor plays a major rolein CNS inflammation, blocking its activity can reduceinflammation, making quercetin, apigenin, and curcuminespecially useful in this regard.160 Some flavonoids inhibitthe release of arachidonic acid from the membrane.161 Theseinclude amentoflavone (Ginkgo leaf), quercetagetin-7-0-glu-coside, apigenin, fisetin, kaempferol, luteolin, and quercetin.

Apigenin, genistein, and kaempferol have been found tobe potent inhibitors of the COX-II enzyme, which is respon-sible for inflammatory reactions.162 Curcumin is also apotent inhibitor of the COX enzymes and is equal in poten-cy to NSAIDs.164 They also inhibit inducible nitric oxidesynthease (iNOS), which triggers the production of the pow-erful and destructive peroxynitrite radical. Quercetin, whichsignificantly inhibits COX enzymes, is a more potentinhibitor of lipoxygenase (LOX).163 Interleukin-12 alsoplays a vital role in inflammation; it is potently inhibited bythe flavonoid curcumin. In addition, curcumin has beenshown to potently inhibit prostaglandin activation in cases oftoxic damage to the brain by alcohol.165

So we see that flavonoids act at multiple sites to inhib-it the destructive reactions precipitated during neurodegen-eration, including excitotoxicity, microglia activation, glu-tamate transporter inhibition, transitional metal activationof free radicals, and direct inhibition of the inflammatoryprocesses. Finally, there is some evidence that one herb,Ashwagandha, can act as an immune modulator.166 That is,it can suppress an overactive immune response.

IMPROVING ENERGY PRODUCTION

As we have seen, cellular energy production plays apivotal role in protection against excitotoxicity. At present,there are numerous ways to improve mitochondrial energygeneration. Of great importance in neurodegenerative dis-orders is the ability to bypass blocks in the electron trans-port chain, as is seen in both Parkinson’s and Alzheimer’sdisease. For example, coenzyme Q10, succinate, and ß-hydroxybutyrate have all been shown to bypass complex Idefects.167 Pyruvate and malate have been shown to protectcortical neuron cultures from excitotoxic cell death follow-ing exposure to glutamate, mostly by increasing cell ener-gy generation.168 Supplementation with creatine also pro-tects against excitotoxic injury.169

Many other vitamins and minerals play a role in cellu-lar energy production, including magnesium, thiamine,riboflavin, niacinamide, menadione, tocopherols, folate,ascorbic acid, succinate, acetyl-L-carnitine, and alpha-lipoic acid.170 Acetyl-L-carnitine has been shown to partial-ly restore mitochondrial function in elderly rats,171 whiletreatment of old rats with alpha-lipoic acid has been shownto improve mitochondrial energy production and increasetheir metabolic rate.172

Protecting the cell, and its mitochondria, from theeffects of free radicals plays a key part in preserving cellularenergy production. Remember, mitochondrial DNA is 10Xmore sensitive to free radical injury than is nuclear DNA.

DIRECT BLOCKING OF EXCITOTOXICITY

Several nutrients can directly block the excitotoxicprocess itself. For example, methylcobalamin has beenshown to block the NMDA glutamate receptor on the neu-ron.173 Pycnogenol has been shown to inhibit the cytotoxiceffects of amyloid ß-protein and to protect hippocampalneurons from high concentrations of glutamate.174

The natural product vinpocetine not only increasescerebral blood flow but also inhibits glutamate receptors andregulates Na+-channels, offering potential benefits againstneurodegenerative disorders.175 Low doses of vitamin Dhave been shown to protect neurons by down-regulating L-type voltage-sensitive calcium channels, thereby protectinghippocampal neurons in culture from excitotoxcicity.176

Another way flavonoids may help prevent excitotoxiclesions in the nervous system is by reducing histaminerelease and activity. A recent study found that activatedmast cells in the CNS increased excitotoxic injury 60% bypotentiating receptor-mediated events at the NMDA recep-tor.177 Vitamin C inhibits the release of histamine from mastcells, and quercetin blocks the histamine receptor. Whileneuroprotection by quercetin’s action on brain histaminehas not been demonstrated, it deserves a closer look.

Combining nutrients appears to offer more neuropro-


tection than using single agents. In one study, combiningcoenzyme Q10 and nicotinamide significantly protectedstriatal neurons in vivo, against excitotoxic destruction,while CoQ10 alone was not protective.178 Likewise, vita-min C and alpha-tocopherol used in combination inhibitedlipid peroxidation in mice brains significantly better thaneither agent used alone.179

OTHER NEUROPROTECTIVE NUTRACEUTICALS

Docosahexaenoic acid (DHA) is essential for the nor-mal development and function of the infant brain and forthe maintenance of the adult brain. It should be rememberedthat the adult brain is constantly remolding itself, a processcalled plasticity. This remodeling process primarilyinvolves synaptic reorganization. Considerable scientificliterature confirms the importance of docosohexanoic acid(DHA) in this process.180 Because of the widespread con-sumption of processed foods, deficiencies of DHA are com-mon. The ratio of N-6 fats to N-3 fats is now 25:1 when itshould be 5:1.181 DHA reduces the risk of neurodegenera-tion not only by improving cerebral plasticity, but also byreducing inflammation.182 Without antioxidant supplemen-tation, DHA alone can increase free radical production andlipid peroxidation.

A fairly recent study found significant abnormalities inamino acid metabolism in Alzheimer’s disease patients.183

Significantly reduced plasma amino acids included trypto-phan and methionine. Excessive supplementation with sero-tonin precursors could potentially lead to increased excito-toxic injury due to a buildup of the serotonin metabolicproduct quinolinic acid, a known excitotoxin. Taurine hasbeen shown to have neuromodulatory effects in the CNSand to regulate cell volume.184

Another study found low levels of s-adenosylmethion-ine in Alzheimer’s patients.185 A postmortem study of 11patients with Alzheimer’s disease found low levels of s-adenosylmethionine in all areas of the brain as comparedwith matched controls. In this same study, normal levelswere found in cases of Parkinson’s disease, demonstratingthat a low level of s-adenosylmethionine was not merely anepiphenomenon of neurodegeneration. No studies havebeen done to supplement Alzheimer’s patients with s-adenosylmethionine. It may be that these low levels merelyreflect a deficiency in folate, pyrodoxine, and cobalamin,which is known to occur in Alzheimer’s disease.186 Chronicfolate deficiency has been associated with cancer and mayalso have a significantly deleterious effect on brain functionas well, especially when combined with prolonged injuryby reactive oxygen and nitrogen species.

Growing evidence indicates that several hormones canprotect neurons from numerous types of injury includingneurodegeneration. The earliest attention was given toestrogen hormones and their ability to attenuate the symp-

toms of Parkinson’s disease.187 More recent studies haveshown that estrogens are essential for maintaining thenigrostriatal dopamine neurons and that the number ofdopamine neurons in females is higher because of the estro-gen stimulation.188

Alzheimer’s disease is significantly reduced in post-menopausal women taking estrogen supplementation ascompared with unsupplemented controls.189 Estrogen actsat several levels to protect neurons. Estrogens are trophicfactors for cholinergic neurons that modulate the expres-sion of Apo-E, act as an antioxidant, and inhibit the forma-tion of amyloid beta-peptide. Estrogenic phytonutrientssuch as genistein, exhibit neuroprotective effects againstexcitotoxicity.190 Several flavonoids, such as quercetin,have significant estrogenic activity. In addition to its neuro-protective estrogenic activity, quercetin is a powerful andversatile antioxidant. While estrogen may play a role in pre-venting Alzheimer’s disease, one recent study found no evi-dence that it slows the progression of mild to moderateAlzheimer’s disease in women.191 The problem with thistrial is that the estrogen used was premarin, which has beenshown to break down into neurotoxic products itself.Natural hormones have not been tried in clinical trials.Experimentally, the phytoestrogen from quercetin and api-genin did significantly inhibit amyloid ß-protein-inducedcytotoxicity. Soy-based phytoestrogens have also beenshown to protect neurons in vivo.192

Dehydroepiandrosterone sulphate (DHEA-S) also hasbeen shown to be generally neuroprotective.193 In addition,it protects hippocampal neurons against glutamate-inducedexcitotoxicity.194 While DHEA-S levels tend to fall withage, the levels are significantly lower in Alzheimer’s dis-ease. Pregnenolone sulfate, a precursor to steroid hormonesacting higher up the ladder than DHEA, has been shown toprotect animals against spinal cord injury.195 The serum lev-els of pregnenolone, in one study, fell as much as 60% bythe mean age of 75 years as compared to levels at age 35.196

There is new evidence that testosterone may protectmen from Alzheimer’s disease, apparently by decreasingthe secretion of amyloid ß-peptide from neurons. Severalplant extracts have shown an ability to increase testosteronesecretion in both males and females.

Several water-soluble vitamins have shown promise inpreventing excitotoxic-neurodegenerative injury to the ner-vous system. For example, nicotinamide has been shown toreduce the size of a middle cerebral infarction in a dose-dependent manner for up to two hours after vessel occlu-sion in a stroke model.198 It has also been demonstrated toenhance brain choline levels 199 and reduce apoptosis-asso-ciated DNA fragmentation, commonly seen in theAlzheimer brain.200 Despite the fact that at least one studyfound low levels of vitamin C in Alzheimer’s patients, notrials have been done supplementing these patients with


ascorbate.201 In this study, plasma vitamin C levels fell inproportion to the severity of the disease.

Two herbs, Ginkgo biloba and Panax ginseng, haveshown both clinical and experimental promise in preventingand treating neurodegenerative disorders,. In a double-blind, randomized, placebo-controlled clinical studyinvolving 309 patients with mild to moderate Alzheimer’sdementia, researchers found that moderately low doses ofGinkgo extract (EGb 761) could slow the course of the dis-ease and improve mental functioning in a substantial num-ber of patients.202 Another study using 240 mg of Ginkgobiloba extract also found substantial benefit in Alzheimer’spatients with a wide margin of safety.203

In another trial, 256 healthy, middle-aged volunteerswere given either 160 mg or 320 mg of a mixture of stan-dardized Ginkgo biloba and Panax ginseng for 14 weeks.204

At the end of the trial, substantial improvements in bothworking and long-term memory were seen, an effect thatlasted beyond the two-week washout at the end of the trial.

Studies have shown that Ginkgo biloba extract can pro-tect neuron membranes against hypoxia-related breakdown,something that probably plays a vital role in Alzheimer’sdisease.205 By its powerful antioxidant effects, Ginkgo bilo-ba demonstrates an ability to preserve mitochondrial func-tion in aged animals, which, as we have seen, is vital to pre-venting accumulative excitotoxic-free radical injury.206

Ginsenosides Rb1 and Rg3 have been found to signifi-cantly protect cultured rat cortical neurons from neurode-generation precipitated by excess glutamate.207 Important inpreventing Alzheimer’s-type neurodegeneration, Rb1increases choline acetytransferase in the basal forebrain andnerve growth factor in the hippocampus.208 This alsoexplains the finding of improved memory function inscopolamine-treated young and old rats treated with gin-senosides Rb1 and Re.209

Finally, one naturally found substance with muchpromise is GM-1 ganglioside. In experiments using mon-keys treated with 1-methyl-1,4-phenyl-1,2,3,6-tetrahy-dropryidine (MPTP) to induce Parkinson’s disease, GM-1ganglioside was found to exert a neurotrophic effect on thesurviving neurons in the substantia nigra.210 In anotherstudy, GM-1 ganglioside was found to protect against motorneuron death in rats,211 and to reduce by half the number ofdegenerating fibers in their spinal cords following injury.

REDUCING MERCURY TOXICITY

Mercury is one of the most neurotoxic elements foundin nature. Unfortunately, millions of people are being put atunnecessary risk by having dental amalgam placed in theirteeth as a restorative. Amalgam contains approximately50% mercury. Another common source is thimerosal, apreservative in some vaccines. With tens of millions of

babies and children being vaccinated each year with up to33 vaccinations before age two, a frightening health disasteris in the making. There is no known safe level of mercury.

The ability of our cells to resist toxins depends on theiroverall health and especially their antioxidant capacity. Ithas been demonstrated that one’s sensitivity to mercury isdirectly related to tissue levels of alpha-tocopherol andselenium,212 especially in the nervous system. Zinc mayprotect the nervous system from mercury toxicity via itsrole in the production of metallothionein.

While no one has tested the ability of plant flavonoidsto chelate mercury, several, including curcumin, hesperidin,quercetin, tea catechins, and rutin, have been shown to havepowerful chelating ability for iron and copper.

Mercury has been shown to powerfully bind with cit-rate and malate to form a harmless compound.213 In addi-tion, both easily penetrate the blood-brain barrier. Removalof mercury from the brain is a difficult and slow process,but by utilizing these organic compounds one can signifi-cantly reduce its toxicity. Combining magnesium to malateand citrate would further reduce mercury toxicity by theircombined ability to reduce NMDA activity, increase cellu-lar glutathione levels and reduce free radical injury.

Garlic extract has also been shown to efficientlyremove mercury from the brain.214 In fact, it is almost asefficient as 2,3-dimercaptosuccinic acid (DMSA). In addi-tion, garlic binds and removes mercury within the GI tract,the major reservoir for mercury. The active principle maybe selenium.215

High doses of alpha-lipoic acid, a powerful and versa-tile antioxidant, are also an efficient chelator of mercury.216

It easily penetrates the blood-brain barrier and has beenshown to reverse the age-related changes in long-termedpotentiation (LTP) responsible for laying down memory.217

Since mercury in brain tissue is associated with dra-matic increases in free radical formation, all precedingcomments concerning antioxidant supplements andflavonoids apply.218 In addition, recent studies have direct-ly linked neuron exposure to mercury with the formation ofß-amyloid as well as hyperphosphorylation of the tau pro-tein. This is most likely related to both free radical genera-tion and direct effects of mercury on amyloid ß protein andtau phosphorylation.

Finally, exposure to mercury induces autoantibodies toneurotypic and gliotypic proteins, common to all three ofthe major neurodegenerative diseases.220 Mercury exposurehas been shown to increase the number of microglia cellsin the brain, wherein the mercury accumulates.221 Again, allnutritional factors affecting the immune response wouldapply here.


SUMMARY

We have seen that neurodegeneration is a complexprocess involving several cellular systems including freeradical generation, the antioxidant network, eicosanoidactivation, lipid peroxidation products that inhibit gluta-mate re-uptake, a loss of cellular energy production, and thebuildup of advanced glycation end products. All of theseprocesses are connected to the excitotoxic reaction.

That chronic inflammation may be the central cause ofneurodegenerative diseases is only one part of the puzzle.Overactivation of the glutamate receptors will trigger acti-vation of the microglia, leading to the immune–cytokineactivation process, and will trigger a tremendous generationof reactive oxygen and nitrogen species. This in turn leadsto impairment of the energy-generating system, primarilyby the action of free radicals (peroxynitrite and hydroxylions) on the mitochondrial DNA and electron transport sys-tem enzymes.

While different triggering events can initiate thesedestructive processes at any level, all result in glutamatereceptor overactivity and initiaton of the excitotoxicprocess. We have seen that several nutraceuticals can act atone of multiple levels in this destructive process. Theflavonoids, in fact, operate simultaneously at many arms ofthe excitotoxic reaction.

One key to preventing neurodegeneration is to main-tain the cell’s energy supply. Events that interfere with cel-lular energy production, no matter the cause, will result inneurodegeneration. Nutraceutical research remains an areaof much promise in conquering this dreaded process.

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Breast Cancer, Hormone Replacement Therapy (HRT), and Diet

Gina L. Nick, PhD, ND, Longevity Through Prevention, Inc., Brookfield, Wisconsin

Breast cancer is second only to lung cancer as the mostcommon cause of cancer mortality in women in the UnitedStates. Further, in 2000 alone, there were a predicted182,000 new cases of breast cancer diagnosed and 40,800associated female deaths in the U.S. as a result of this dis-ease.1 A woman’s chance of developing breast cancer sig-nificantly increases with age (Table 1). As a woman ages,she will naturally approach menopause and the cessation ofovarian function, increasing her chances of taking hormonereplacement therapy (HRT) to reduce symptoms commonlyassociated with menopause and to prevent the onset of heartdisease. Disturbingly, HRT also increases a woman’s risk ofbreast cancer, sometimes by more than 50%.2-6

Two small studies, not adequately controlled for con-founding variables, showed some promise that combined

HRT was protective against breast cancer risk.8,9 The muchlarger Nurses’ Health Study10 was one of the first studies toprovide reliable data that showed that combined therapyactually increases a woman’s risk of breast cancer! Perssonet al. studied the risk of breast and endometrial cancer in acohort of 11,231 Swedish women prescribed differentreplacement hormone regimens and concluded that long-term recent use of estrogen-progestin combined replace-ment therapy may increase the risk of breast cancer.11

Further, they concluded that exposure to estrogen alonesubstantially elevates the risk of endometrial cancer, anincrease that can be reduced or perhaps avoided by addingprogestins. Remarkably, this study found that for 6 or moreyears of current or recent use of combined HRT, a woman’srisk of breast cancer is increased by 70% as compared tothe risk associated with estrogen alone, RR = 4.2 (95% CI2.5-8.4). Considering the fact that in December of 2001 astudy of more than 200,000 women was published in theJournal of the American Medical Association12 that foundthat those women who used estrogen replacement therapy(ERT) for a decade or longer also had at least a 51 percentgreater chance of dying from ovarian cancer, and that therisk persisted for 29 years after cessation of use, these find-ings may leave a woman concerned about the impact ofHRT on long-term health. While ERT is a regimen that wasfor the most part discontinued in the late 1970s, one won-ders if, 30 years from now, other risks associated with HRTmay surface from the research. The results of an HRT andbreast cancer study published in the Journal of theAmerican Medical Association13 in 2000 provide furtherconfirmation of the breast cancer risk associated withmenopausal estrogen and estrogen-progestin replacementtherapy. While HRT appears to increase breast cancer risk,there is evidence suggesting that diet, particularly the use ofunprocessed whole foods and herbs, meaning those naturalraw materials that have not been fractionated to isolateand/or potentate one or several compounds, and the use of

* Correspondence:Gina L. Nick, PhD, NDLongevity Through Prevention, Inc. PO Box 627 Brookfield, WI 53008 Phone: (866) 587- 4622 Fax: (262) 569-9571 E-mail: [email protected]

Age Chance of developing breast cancer

By 30 1 out of 2,212

By 40 1 out of 235

By 50 1 out of 54

By 60 1 out of 23

By 70 1 out of 14

By 80 1 out of 10

By 90 1 out of 8

Table 1. A woman’s chance of developing breast cancer sig-nificantly increases with age.7


a calorie restricted diet, may play a role in diminishingbreast cancer risk. This paper represents a review of evi-dence supporting this notion.

DIET AND BREAST CANCER

Migration studies have shown that people who movefrom geographical areas with low breast cancer risk to areaswith high risk acquire the breast cancer rate of the host coun-try within two generations, and the breast cancer rates aresteadily rising in countries with previously low rates.14 Theseresults suggest that environmental factors, most likely dietarypatterns, play a major role in breast cancer etiology.

Analysis of an Italian case-control study conductedfrom 1991-1994 by Favero et al. on a large sample ofwomen (2,569 women with breast cancer and 2,588 con-trols) on dietary factors affecting breast cancer riskrevealed direct associations between risk and consumptionof such foods as bread and cereals, sugar and candy, andpork and processed meats, but inverse associations with theintake of raw vegetables and fish (Table 2).15 However,cooked vegetables, fruit, and red meat were among thefoods that did not seem to have an effect on risk.

Starch, saturated fat, and alcohol were significantlyand positively associated with cancer risk while unsaturat-ed fat was inversely associated. Interestingly, olive oil

Table 2. Odds ratios (OR) of breast cancer among 2,569 cases and 2,588 controls by intake quintile of selected food groups.Italian (Favero) study, 1991-1994.15

1 Reference category 2 Chi-square test 3 Safflower, maize, peanut, or soya.


showed a protective effect but did not show statistical sig-nificance. Beta-carotene, vitamin E, and calcium-rich foodsare inversely correlated with risk of breast cancer whencontrolled for overall energy intake and confoundingintakes of other micronutrients (Table 3).

In Italy, pasta and bread comprise a large percentage ofthe dietary starch and energy, and it is often in the form ofvery refined grain products.15 Processed meats are quitecommon in the Italian diet as prosciutto, salami, andsausage, and these were found to be particularly detrimen-tal with regard to breast cancer risk.

Seed oils and fish in the diet correspond to significant-ly decreased cancer risk. These foods are especially high inomega-3 fatty acids, supporting growing evidence that thistype of fat bestows protection from breast cancer.

Raw vegetables are an important source of dietary fiberand may decrease cancer risk by helping to curb caloric(energy) intake.

The Favero study took into account strong intercorrela-tions between various macronutrients in the diet, sometimesneglected in other studies. It emphasized a whole foodapproach by examining not just isolated macronutrients, butmacronutrients within a dietary framework. For example,they found in their sample that starch intake correlated neg-atively with saturated fat intake. This is an interaction thatmay influence risk. Polyunsaturated fat intake was stronglypositively correlated with raw vegetable intake and both ofthese factors together lower breast cancer risk. Interestingly,the inverse relationship of breast cancer risk to calciumintake was very strong and is supported by several case con-trol studies.16,17 There was also a high correlation betweenstarch and energy intake (Pearson r=0.80). In general, the

researchers concluded that energy intake may be related tocancer risk by increasing oxidative metabolism and freeradical generation in the body. In keeping in line with a freeradical metabolic hypothesis of cancer initiation, dietaryrestriction may offer a means of reducing cancer risk.

DIETARY RESTRICTION AND CANCER

Caloric restriction without malnutrition (cutting dailycaloric intake by 30-50% while maintaining a nutritionallybalanced diet) is the only proven method to date that slowsthe human aging process and extends lifespan, whileimproving health and well-being.18 Researchers have beenstating this once theoretical notion as fact for well over 60years.19-21 While human trials are lacking to support theconnection between breast cancer risk and the use of a calo-rie restricted diet, particularly those that address confound-ing variables such as ethnicity, BMI, exercise habits, andspecific BRCA mutations, the available relevant data doesoffer some groundwork upon which future researchers maybuild a greater understanding of this method.

POSSIBLE MECHANISMS OF ACTION

Dietary restriction reduces the number of reactive oxi-dant molecules in the body.19,22 While numerous mecha-nisms have been proposed for the observed long-termhealth benefits of caloric restriction,21-24 the free radicaltheory is the most widely accepted. Dietary restrictionmodulates many key aspects of free radical metabolism,including free radical generation, lipid peroxidation, DNAdamage, and cytosolic cellular defense systems.22 This the-ory offers a solid explanation for the following biochemicaland physiologic phenomena:25

Table 3. Odds ratios (OR) of breast cancer among 2,569 cases and 2,588 controls by intake quintile of selected micronu-trients. Italian (Favero) study, 1991-1994.15

1 Reference category 2 Chi-square test


• The inverse relationship between basal metabolic rate andaverage lifespan in mammals

• The connection between increased incidences of degener-ative diseases in the latter part of life, and the cumulativeeffects of oxidative damage over time

• The demonstrated health benefits of dietary restriction • Greater longevity of females• The increase in autoimmune dysfunctions with age

DIETARY RESTRICTION AND FREE RADICALS

In diet restricted rats, free radical damage as measuredby thiobarbituric acid-reactive material and lipofuscin accu-mulation in the liver was much lower than in rats fed adlibitum.26 In liver tissue, the expression of superoxide dis-mutase and catalase typically decrease with age in ad libi-tum fed rats. However, in diet restricted rats these antioxi-dant enzymes were significantly elevated even at 21 and 28months of age. Glutathione peroxidase was also elevated at28 months of age. This result has been supported by addi-tional research27,28 in which glutathione reductase, glu-tathione S-transferase, and catalase enzyme activities wereessentially unchanged in diet restricted rats at 24 months,while the levels in ad libitum fed rats steadily declined from12 to 24 months of age. These studies suggest that the ben-eficial effects of dietary restriction result from the preserva-tion of antioxidant enzyme activity in animals.

Some researchers argue that dietary restriction inhibitsthe generation of oxidative molecules and does not directlyaffect antioxidant enzyme levels. Gong et al.,29 reported anapparent reduction in antioxidant enzyme activity in rat lensand kidney in response to dietary restriction, presumablydue to a decrease in substrate molecules. Dietary restrictionat various ages in the rat decreases the formation of super-oxide and hydroxyl radicals, and hydrogen peroxide in livermicrosomes.30 Additionally, mitochondrial resting respira-tory rates in brain, heart, and kidney tissues remain constantwith age in diet restricted rats while they progressively risein controls, with a corresponding increase in superoxideradical and hydrogen peroxide generation in the latter.31

This result supports the mitochondrial hypothesis in thatdietary restriction successfully maintained the resting respi-ratory rate, showing that this method keeps the mitochon-dria functioning more efficiently over time.

Unmistakably, dietary restriction offers substantialhealth benefits due to its effect on modulating the produc-tion and metabolism of reactive oxygen species, or free rad-icals. Supplementing the restricted diet with powdered vac-uum or freeze-dried vegetables and fruits that are naturallyrich in antioxidants may provide additional health benefits.Epidemiological and clinical studies have revealed roles forantioxidants in the reduction of risk from cancer.32

Introducing the possible connection between breastcancer and caloric restriction, Zhu et al.33 conducted a study

of experimental mammary cancer in rats. The researchersfound that caloric restriction correlated linearly with pro-longation of latency to palpable carcinomas and a reductionin final incidence of mammary cancer. This experimentalcase may validate the potential use of caloric restriction toinhibit the conversion of precancerous cells to malignantcells. Caloric restriction also correlated with an increase incortical steroid levels that explained 95% of the linear rela-tionship between cancer and dietary restriction. Thus,dietary restriction may offer some chemoprotection by nor-malizing adrenal function.

DIETARY RESTRICTION AND HUMANS

A clinical study on the effects of dietary restrictionwas performed on four men and four women housed inBiosphere 2, a closed ecological space of 7 million cubicfeet near Tucson, Arizona.34 As a result of poor foodyields, the inhabitants of the biosphere consumed a low-calorie but nutrient dense diet for their two-year stay in thehabitat. The men and women showed 18% and 10% weightloss, respectively. Further, the researchers measured bloodlipids, glucose, insulin, glycosylated hemoglobin and reninin blood samples collected at several points during andafter the two year period.

The nature of the largely vegetarian diet, with a highessential nutrient content per calorie, resembled that whichretards aging, extends lifespan, and reduces age-related dis-ease incidence in animals.35 Thus, Biosphere 2 offers anopportunity to study caloric restriction in humans under care-fully monitored conditions and warrants deeper investigation.

The inhabitants of Biosphere 2 were all nonsmokers ingood health. During the study each received three meals perday, and even though available food was less than expect-ed, each received equal portions regardless of body size orgender. All of the inhabitants remained in excellent healththroughout the two years, with the exception of minor ail-ments. The weight lost while in the biosphere was fullyregained by six months after the end of the experiment andreturn to ad libitum diet.

Glucose, insulin, and glycated hemoglobin levels in theinhabitants all significantly decreased inside Biosphere 2.

It is important to note that Biosphere 2 crew memberswere calorie restricted but well supplied with all essentialnutrients, so they were truly experiencing caloric restrictionwithout malnutrition. Additionally, the crew members per-formed extensive physical and mental labor throughout thetwo years, which may have contributed to their good health.

This is the first study of caloric restriction in humansthat can be compared in any meaningful way with corre-sponding observations in rodents and primates.35,36


UNFRACTIONATED FRUITS AND VEGETABLES(WHOLE” FOODS) VS. SUPPLEMENTAL ISOLATES

In premenopausal women, a diet high in fruits and veg-etables appears to be protective against breast cancer, espe-cially if rich in specific carotenoids and vitamins.37 The pro-tection is not bestowed by any single anticarcinogenic com-pound but appears to be a combined effect of numerousbeneficial antioxidants and nutrients. Dietary antioxidantshave been shown to protect against breast and several othercancer types. These antioxidants probably act by scaveng-ing free radicals and quenching lipid peroxidation reactions,thus protecting cells from oxidative stress and damage.However, a large-scale study of 83,234 women examiningthe diet/cancer relationship found no association betweencancer risk and dietary intake of vitamins C and E, a resultsupported by other studies.38-40 A recent study has suggest-ed that vitamin C may be potentially carcinogenic by pre-cipitating formation of lipid hydroperoxides that generategenotoxins,21 thus negating any radical scavenging activity.On the other hand, an inverse correlation between diet andrisk of breast cancer has been found for carotenoids, vita-min A, lutein/zeaxanthin, and combined fruit and vegetableintake, with the strongest relationships in premenopausalwomen. These dietary factors had no apparent effect on riskin postmenopausal women.14

While a high intake of fruits and vegetables correlateswith decreased breast cancer risk, supplements of vitaminsA, C, and E, and multivitamins were not associated withoverall risk, supporting a whole food philosophy.14 Fruitsand vegetables contain numerous tertiary, non-nutritivecompounds including isoflavones, dithiolthiones, indoles,flavonoids, and phenols, all of which have proposed mech-anisms of action and relative sites along the normal toabnormal cell transformation pathways that inhibit carcino-genesis and provide chemoprotection (Figure 1).

In addition, a diet high in fruits and vegetables reflectsan overall healthier lifestyle and dietary pattern correlating

with lower intake of saturated fat, less smoking, and morephysical exercise.

XENOESTROGENS AND BREAST CANCER

Xenoestrogens are environmental compounds with estro-gen-like activity that may cause hormone-related cancer insome individuals. Chlorinated pesticides, such as DDT andits metabolite DDE are examples of such compounds whichhave been linked to increased incidence of breast can-cer,4345 although other studies have found no link betweenbreast cancer and serum levels of pesticides.46-51 For exam-ple, Wolff et al.45 found that elevated levels of DDE andpolychlorinated biphenyls (PCB) in the serum can result ina four-fold increased risk of breast cancer, while Krieger etal.46 found no difference in serum levels of DDE and PCBin their prospective cohort study of 300 women.Interestingly, Kreiger’s group did find that when the sub-jects were divided into racial subgroups, a risk was notice-able between black women and DDE levels. This associa-tion was further verified by Schildkraut et al.52 who inves-tigated the effect of body mass index (BMI—discussedbriefly in the latter part of this paper) on plasma levels ofDDE in black and white women. Results of multipleregression analyses indicated that black women did indeedhave significantly higher plasma levels of DDE than whitewomen. BMI was also found to be an independent predic-tor of DDE plasma levels in white and African-Americanwomen. Because the prevalence of obesity is higher amongblack women than white women, it may be possible thatgreater degrees of adiposity increase the body’s capacity toaccumulate lipophilic contaminants such as DDT. Ethnicdifferences should certainly be considered in future studiesexamining the relationship between DDT, BMI and breastcancer risk. Until this occurs, and despite conflicting evi-dence regarding the links between xenoestrogens and breastcancer, it may be a good idea for women consuming largeamounts of fruits and vegetables for breast cancer preven-

Figure 1. The potential mechanisms and sites for the inhibition of carcinogenesis by protective tertiary compounds foundwithin a whole food matrix.42


tion, to consider eating pesticide-free, certified organic pro-duce whenever possible.

BEEF AND PORK CONSUMPTION, OXIDATIVEDNA DAMAGE, AND BREAST CANCER

NASA recognizes 5-hydroxymethyluracil as a bio-chemical marker of oxidative DNA damage that is positive-ly associated with breast cancer risk (personal communica-tion with NASA scientists at the Johnson Space CenterNutritional Biochemistry Laboratory). Djuric et al.53 mea-sured serum levels of 5-hydroxymethyluracil in 21 healthyoutpatient women with a first-degree relative with breastcancer. The women were assigned randomly to a low fat(N=9) or non-intervention (N=12) diet for 3-24 months. Dietdata were obtained from 3-day food diaries. The researchersexamined meat consumption by type (pork, beef, fish, orpoultry) and by cooking temperature. They also examinedintakes of either cooked or raw vegetables, respectively.

Intake of cooked vegetables and the sum of beef and porkintake explained the greatest variation (85%) in DNA damagemarker levels induced by diet. The preliminary results of thisstudy suggest a positive association between levels of serum5-hydroxymethyluracil and beef and pork intake, and a nega-tive association with cooked vegetable intake.

Any model of breast cancer risk must take into accountthe complex interaction of covariables, including BMI, hor-mone levels, composition of fatty tissue, hormone receptorstatus, menopausal status, diet, and physical activity.

COMPOSITION OF FATTY TISSUE

In menopause, female steroid hormones are generatedin fatty tissue by aromatase. The increased risk of breast can-cer in overweight, menopausal women may have to do withelevated conversion of androgens to estrogens in fatty tissue.Estrogens then may stimulate mitotic activity in breast tissueleading to abnormal cell growth. Obesity also increasesinsulin levels and insulin resistance and decreases sex hor-mone binding globulin (SHBG) levels, all factors that influ-ence risk.54 Insulin can increase proliferative activity of thebreast epithelium. Thus, the mechanism may involve theinteraction of diet with endogenous and exogenous estro-gens, androgens, and glucose metabolic substances. If over-weight is a major factor in postmenopausal breast cancerrisk, weight reduction through caloric restriction, exercise,and nutritional supplementation may prove therapeutic.SHBG levels increase with weight loss, sometimes to levelshigher than in healthy, non-obese, menopausal controls,offering significant protection from unopposed estrogen.54

GENETIC CONSIDERATIONS

Genetic factors are an immutable risk factor and a his-tory of familial breast cancer may modify associations

between diet and breast cancer in premenopausalwomen.15 Nonetheless, lifestyle is not immutable and canbe beneficially modified.54 Diets high in fruits and vegeta-bles rely on an interaction of many variables for theirchemoprotective effects and are probably beneficialregardless of genetic factors.

BODY MASS INDEX (BMI) AND BREAST CANCER

Body mass index (BMI) has been inversely correlatedwith premenopausal breast cancer risk but positively corre-lated with postmenopausal risk, a finding supported else-where (Table 4).54,15

Maintaining a healthy body weight reduces the risk ofmany cancers in women, particularly breast and uterine.55

So-called “apple-shaped” women (those with adipose tissuearound the waist and stomach) are 34% more likely to devel-op breast cancer than “pear-shaped” women (those with adi-pose tissue around the hips and thighs) after menopause,especially if they have never taken hormone replacementtherapy. Body shape does not appear to affect risk in pre-menopausal women, however.54 Women who gain significantweight in adulthood (after age 30) are more likely to devel-op uterine (endometrial) cancer and postmenopausal weightloss is suggested to decrease the risk.54,55

Height, weight, BMI, and shape all seem to play a rolein breast cancer development. For all age groups, height isfound to correlate positively with breast cancer risk.Population studies in Europe have shown that height andage at the first term pregnancy describe almost 80% of thetotal variation in breast cancer incidence. Conversely, BMIis negatively associated with risk in premenopausal womenbut positively associated in postmenopausal women. A pos-sible confound to these results is that height is positivelyassociated with osteoporosis in weight-bearing bones forwhich estrogen supplementation often is recommended inpostmenopause. Thus, as height increases, so does the ten-dency for estrogen supplementation, which increases therisk for estrogen-sensitive breast cancer.54

Table 4. Odds ratios (OR) of breast cancer among 2,569cases and 2,588 controls according to body mass index bymenopausal status. Italian study, 1991-1994.15

BMI Premenopausal OR Postmenopausal OR (kg/m2)

< 21.7 11 11

21.7-23.7 0.93 (0.7-1.2) 1.00 (0.8-1.3)

23.8-25.7 0.85 (0.6-1.1) 1.07 (0.8-1.4)

25.8-28.8 0.89 (0.6-1.2) 1.21 (1.0-1.5)

≥ 28.9 0.67 (0.5-0.9) 1.39 (1.1-1.8)

P <0.05 <0.01 1 Reference category


Nutrition during periods of rapid growth (childhoodand puberty) seems to be an important factor for finalheight. As a result, height may only be a proxy variable ofnutritional status during the years of growth with the latterbeing the true risk factor for breast cancer.54 Indeed, energyintake in childhood has been associated with the develop-ment of cancers later in life.56 This would also supportcaloric restriction research suggesting that reduced caloricintake lengthens the time to onset of some disease states.57

The age at menarche is related to childhood nutritionalstatus and an earlier age corresponds to increased nutritionand increased cancer risk.54,58 Further, a growth spurt in themammary glands during adolescence is thought to beresponsible for the final number of mammary cells that arevulnerable to carcinogenic transformation. An increase inweight during this period is associated with anovulatorycycles that limit this growth spurt. Thus, weight gain duringadolescence may reduce premenopausal breast cancer riskby reducing the number of cancer-vulnerable cells.

Contrary to much public opinion, dietary fat does notappear to be a significant risk factor linking weight andcancer risk.55 In fact, monounsaturated fats may be cancerprotective.

Regular exercise is very important also. It may reducea woman’s risk of cancer by as much as 30%. In fact, BMImay be a proxy variable for physical activity because exer-cise correlates with a lower BMI and with lower risk.54

The specific impact that a change in diet may have ona woman’s risk of breast cancer, depending upon the pres-ence of a gene mutation, her BMI, her ethnic background,serum levels of SHBG and other metabolic-endocrine fac-tors is not clear at this time. Further research needs to bedone prior to proposing an explanatory model of the inter-connections between such confounding variables.

PHYTOESTROGENS

In vitro, the soy phytoestrogens genistein, daidzein,biochanin A, and coumestrol, as well as the extracts of sev-eral herbs, were tested for their effects on the growth ofbreast cancer cell lines T-47D and MCF-7.59 Theisoflavones significantly inhibited the growth of both celltypes in the range of 10-100 mM, but no effect wasobserved below 1 mM. Over three days coumestrol was themost inhibitory, followed by genistein, daidzein, andbiochanin A (Figure 2). The result roughly equates to theputative estrogenic activity of the isoflavones. Biochanin A,the weakest, is methoxylated, which abolishes its estro-genicity.60 Hops, black cohosh root, dong quai root, andvitex berry all inhibited growth significantly at full strength,while ginseng was ineffective.

Zava et al.61 reported on the content and bioactivity ofplant phytoestrogens and progestins in various foods,

plants, and spices before and after human consumption.

• 150 plants were extracted and tested for their ability to com-pete for estradiol and progesterone binding to intracellularestradiol (ER) and progesterone (PR) receptors in intacthuman breast cancer cells. The seven highest ER-bindingplants, foods and spices were: soy, licorice, red clover,thyme, turmeric, hops, and verbena. The six highest PR-binding plants, foods and spices were: oregano, verbena,turmeric, thyme, red clover, and damiana (Table 5). Thefoods, plants, and spices that showed high levels of phy-toestrogens and phytoprogestins were further tested forbioactivity in regulating the growth of ER positive and ERnegative breast cancer cell lines and in inducing or inhibit-ing the synthesis of alkaline phosphatase, an end product ofprogesterone action, in PR positive cells. ER-binding plantextracts demonstrated agonist activity, acting in a way sim-ilar to estradiol. Conversely, PR-binding extracts were neu-tral or acted as antagonists of progesterone, in general.

In ER positive T47D cells, licorice, red clover, yucca,hops, and motherwort stimulated significantly highergrowth than control, with yucca and red clover found to benearly equipotent with estradiol at the concentrations test-ed. Most ER-binding extracts were neutral on growth of ERnegative MDA468 cells, but interestingly, mandrake,bloodroot, mistletoe, and juniper actually markedly inhibit-ed cell growth in ER negative MDA468 cells (Figures 3and 4), suggesting these foods and plants are chemoprotec-tive via an estrogen receptor-independent mechanism.

Dilute extracts of high PR-binding plants were incu-bated with T47D cells and monitored for alkaline phos-phatase activity. Controls were progesterone and proges-terone+RU486, a potent antiprogestin. None of the extractssignificantly elevated alkaline phosphatase, categorizingthem as either neutral or antagonists of progesterone.

Figure 2 Effects of isoflavones (10 mM) on T-47D breastcancer cell growth after 72 hr incubation.59


Damiana, dong quai, yucca, and mistletoe failed to compet-itively inhibit the induction of alkaline phosphatase byexogenous progesterone, categorizing them as neutral.Conversely, red clover, licorice, goldenseal, pennyroyal,and nutmeg either completely or partially blocked alkalinephosphatase induction by progesterone, categorizing themas putative antiprogestins.

THE 2-HYDROXYESTRONE: 16A-HYDROXYE-STRONE (2:16) RATIO AND BRASSICAVEGETABLES

16-α-hydroxyestrone (16HE) is known to increase andto promote breast cell proliferation in vitro by binding cova-lently to estrogen receptors on breast cells, and to promotemammary tumors in mice.62,63 Another metabolite of estro-

Table 5. Herbs and spices containing ER-and PR-bindingcomponents.61

ER-binding* PR-binding**

Soy milk 8/200cc -

Licorice 4/2g 3/2g

Red clover 3 3

Mandrake 3 8

Bloodroot 2 100

Thyme 2 4

Yucca 0.5 4

Turmeric 0.5 4

Hops 0.5 -

Verbena 0.5 5

Yellow 0.5 -

Sheep sorrel 0.5 -

Ocotillo - 8

Oregano - 8

Damiana - 6

Pennyroyal - 5

Nutmeg - 4

Calamus root - 3

Goldenseal - 3

Mistletoe - 3

Cumin - 2

Fennel - 2

Chamomile - 2

Cloves - 2

* (mcg estradiol equivalents/200cc or 2g dry herb)** (mcg progesterone equivalents/2g dry herb)

Figure 3. In vitro growth of ER positive breast cancer cellsin the absence (control) or presence of ER-binding herbalextracts (1:500 dilution), estradiol, estradiol+hydroxyta-moxifen, or coumestrol as assessed by protein content.61

Figure 4. In vitro growth of ER negative breast cancer cellsin the absence (control) or presence of ER-binding plantextracts (1:500 dilution), estradiol, estradiol+hydroxyta-moxifen, or coumestrol as assessed by protein content.61


Figure 5 Menopause, HRT Contraindications, and Associated Dietary Considerations


gen, 2-hydroxyestrone (2HE) is not known to be carcino-genic. It appears to have anti-estrogenic properties in breasttissue and may inhibit angiogenesis.62,64,65 In humans, thesetwo metabolites are products of alternate and irreversiblemetabolic pathways such that the ratio of E2:E16 may be aputative endocrine biomarker for estrogen-related breastcancer risk in humans.66 Any mechanism that shifts estro-gen metabolism toward 2HE hypothetically would lowerbreast cancer risk from 16HE.

Interestingly, brassica vegetable consumption has beenshown to significantly increase the 2HE:16HE ratio inhealthy postmenopausal women consuming brassicasapproaching levels equivalent to 70 mg/day of glucosino-lates.67 The health-promoting indole and isothiocyanatebreakdown products of glucosinolates are known to stimu-late Phase I and Phase II detoxification enzymes.68-70 PhaseI cytochrome P-450 enzymes hydroxylate estrogen to 2HE,depleting the pool available for conversion to 16HE,71 con-sistent with reducing breast cancer risk.

N-ACETYLTRANSFERASES (NAT)

N-acetyltransferases (NAT) are major enzymes ofbreast tissue that activate aromatic and heterocyclic amines,such as those found in cigarette smoke and well-cooked redmeat.72,73 In addition to explaining the generally increasedcancer risk from smoking, these researchers also found thatcertain polymorphisms, or genetic variations, of NAT alle-les found in humans are significantly more highly correlat-ed with breast cancer risk due to smoking and red meat con-sumption than others. These alleles code for the“rapid/intermediate acetylator phenotype” in which hetero-cyclic amines are more quickly activated, increasing therisk of toxic DNA damage leading to cancer.72 Women withthe rapid/intermediate acetylator phenotype may be at sig-nificantly higher risk for breast cancer when they smokeand consume meat cooked at high temperatures.

OVERVIEW

The research studies cited in this review article revealthat hormone replacement therapy (HRT) increases awoman’s risk of breast cancer. Figure 5 offers summary ofthe dietary factors that may reduce breast cancer risk inwomen and aid in menopausal hormonal balance. WhileHRT increases breast cancer risk, caloric restriction and theuse of phytoestrogenic and phytoprogesterenic foods mayreduce the risk. Interestingly, in most cases, a diet high inunfractionated fruits and vegetables is also protectiveagainst breast cancer although the protection is notbestowed by any single anti-carcinogenic compounds foundwithin fruits and vegetables. While BMI, insulin levels,incidence of insulin resistance, sex hormone binding glob-ulin (SHBG) levels and exposure to xenoestrogens all seemto be connected to breast cancer risk, more research is war-

ranted to further evaluate the relationship between thesevariables, particularly in varying ethnic groups, as they maybe potentially important modifying factors for breast cancerrisk. Addressing biochemical individuality as much as ispossible in future diet and herb-related breast cancer stud-ies will undoubtedly provide us with a clearer assessmentof the role that foods, diets and herbs play in the preventionand/or treatment of breast cancer.

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O R I G I N A L R E S E A R C H

Pilot Study: An Emulsified Fish Oil Supplement Significantly Improved C-Reactive Protein,Hemoglobin, Albumin and Urine Output in

Chronic Hemodialysis VolunteersWendy Lou Jones, MS,* CEO, Royal Knight, Inc., Rochester, Minnesota

Member, National Kidney Foundation Council on Renal Nutrition

Shaun P. Kaiser, RD, LD, DaVita Med-Center Dialysis, Houston, Texas

who were undergoing treatment with chronic intermittentmaintenance hemodialysis at a Minnesota clinic, and at var-ious Fresenius clinics in Houston,Texas.

Results: Serum albumin, hemoglobin, and urine volumeincreased, while CRP measurably decreased. Concomitantly,the amount of erythropoietin needed per treatment to maintainadequate non-anemic Hgb levels fell (mean Hgb[Erythropoietin]: initial Hgb 12.05+0.83 [Epo. 6346+2556.65]vs final: Hgb 12.25+0.64 [Epo. 5336+2399.27] ) (P < .05).

Conclusion: A highly bioavailable emulsified omega-3fatty acid dietary supplement positively impacted hemoglo-bin, serum albumin, urine output, and CRP values.Volunteers, completing additional subjective tests (urinefoaming and joint pain), indicated a substantial decrease inboth. Considering the impact this highly bioavailable dietarysupplement had on improving hematological values and inreducing the total required dose of erythropoietin needed pertreatment to maintain adequate hemoglobin levels, a majorstudy is warranted.

Key Words: Emulsified fish oil, hemoglobin, erythropoi-etin, C-reactive protein, nutritional supplement, Coromega.™

INTRODUCTION

Both acute and subclinical inflammatory states can becharacterized by an excessive release of a variety of inflam-matory factors. This antagonistic molecular cascade can, inturn, exert a negative influence on every physiological sys-tem, and has been implicated as a forerunner of atheroscle-rotic plaques in both the normal and ESRD populations.Elevated C-reactive protein (CRP), an easily identifiable

* Correspondence:Wendy Lou Jones2015 41st Street NW, Ste G33, Rochester, MN 55901Phone: 507-289-8192 Fax: 501-421-7869 E-mail: [email protected]

ABSTRACT

Objective: Elevated C-reactive protein (CRP) levels,in conjunction with diminished albumin and hemoglobin(Hgb) values, are associated with increased morbidity andmortality in patients with end stage renal disease (ESRD).Evidence suggests that a number of factors, including dial-ysis, alone or in combination with erythropoietin adminis-tration, can cause CRP values to rise. Omega-3 fatty acidshave been shown to exhibit significant anti-inflammato-ry/antioxidant activity affecting a wide variety of disorders.A highly bioavailable omega-3 dietary fatty acids supple-ment was tested for its ability to suppress CRP, and posi-tively impact serum albumin and hemoglobin values, aswell as urine output and pain.

Methods: ESRD volunteers took 3 packets ofCoromega,™ each containing 650 mg of emulsified fish oil(350 mg of EPA, and 230 mg of DHA) for a total of 1,950 mgof emulsified omega-3 fatty acids per day for a period of 8consecutive weeks. Serum albumin, CRP, hemoglobin anderythropoietin usage was measured at specific intervals dur-ing the test period. Volunteers were asked to measure urineoutput and rate pain on specific days.

This pilot study was performed with ESRD volunteers


non-specific inflammatory marker, is an acute phase pro-tein, produced in response to an inflammatory event(cytokine activation) regardless of its cause.1

Many hemodialysis patients have high levels of CRP.Repeated exposure to artificial membranes (dialysis mem-brane, synthetic tubing, and containers),2-3 erythropoietinadministration, as well as idiopathic causes native to ESRDconditions, have all been implicated as having the potentialto evoke an inflammatory response. In addition to athero-sclerotic plaques,4 an elevation in CRP has been associatedwith an increase in cardiovascular disease,5 decrease inserum albumin synthesis,6,7 and an increase in erythropoi-etin resistance with ensuing anemia in ESRD. ElevatedCRP levels, in conjunction with diminished albumin andhemoglobin values, are associated with increased morbidi-ty in the ESRD patient maintained on chronic hemodialysis,and can be viewed as a strong predictor of poor survival.

Significant anti-inflammatory properties have beenassociated with fish oil (omega-3 fatty acids) supplements.Immune-activated T cells and cytokines are found through-out the circulatory system as well as at sites of injury.Cytokines such as interlukin-1 (IL-1) and tumor necrosisfactor (TNF) will generate reactive oxygen intermediaries,which may contribute to free radical cell and tissue damage.These reactive intermediaries can, in turn, attack cell mem-brane polyunsaturated fatty acids, resulting in derivativesthat subsequently attract inflammatory cells. In their un-oxi-dized form, omega-3 fatty acids may inhibit circulatoryinflammation by decreasing the precursors, which, in them-selves, may lead to free radical mediated events.8,9,10,11,12

Omega-3 fatty acids have been shown to inhibit theproduction of eicosanoids (proinflammatory compounds).Arachidonic acid (an omega-6 fatty acid) is metabolizedinto one such proinflammatory eicosanoid. Conversely,omega-3 fatty acids can displace arachidonic acid from thecell membrane reducing membrane bound proinflammatorycompounds. Omega-3 also competes with arachidonic acidfor cyclooxygenase and lipoxygenase enzymes, shiftingecosanoid production to the non-inflammatory series-3prostaglandins and series-5 leukotrienes. This specific com-petitive activity has been hypothesized to directly suppressimmunological and/or inflammatory mediators.

A number of other statistically significant, physiologi-cally positive events have been associated with omega-3fatty acid supplementation when given at doses between 1.8-18 grams per day. Those specifically noted include: mildantithrombotic effects,13 a mild glomerular protective effect(by limiting production of cytokines and eicosanoidsevoked by immunologic renal injurious events),14 a mildantihypertensive effect in persons with confirmed hyperten-sion,15,16 anti-inflammatory benefits associated with emphy-sema,17 asthma,18 rheumatoid arthritis,19,20 and increasedhemoglobin in ESRD volunteers.21

In the case of hemoglobin production, two explana-tions have been postulated: (1) hemoglobin productionincreases because inflammatory factors (as well as freeoxygen radicals) are reduced, lessening the negative impacton the system (body) as a whole, and (2) a protective effectis being exerted by omega-3 fatty acids on the red cells,preventing early cell death (the average lifespan of a redblood cell is 120 days in the normal individual vs 40 for thedialysis patient). While the mechanism for these numerouspositive observations, seen across an entire spectrum of dis-orders, is not fully understood, a hypothesis, focusing oncell and tissue oxidative and inflammatory processes as abasis for the initiation of all organ (and aging related) dele-terious events, would seem a logical place to begin.

The “effective dose” of fish oil, necessary to attain theresults observed in each study, has varied greatly fromstudy to study, for both the same, and dissimilar, diseaseconditions. Possible explanations for this variation mayhave to do with the preoxidized state, and/or biovailabilityof the fish oil preparation being used. Fish oil can oxidizewhen exposed to air, both during processing and storage.The degree to which it oxidizes varies with the length oftime exposed and the prevailing temperature. Significantantioxidative activity has been associated with fish oil. If itsaffinity for oxidative free radicals is, at least in part, themechanism by which it exerts its biological affect, theeffectiveness of emulsified fish oil could be significantlyreduced after oxidation. The bioavailability of any one spe-cific preparation would also be a key factor in the amountneeded to achieve a desired affect.

The fish oil preparation Coromega™ (manufactured bythe European Reference Botanical Laboratories) was selectedfor use in this pilot study because of its reported high bioavail-ability and hermetically sealed packaging. The bioavailabilityof 4 grams of this emulsified and flavored fish oil product wascompared to a standard, commercially available, encapsulat-ed fish oil in a feeding trial using non-dialyzing men.Findings indicated that the percent of eicosapentaenoic (EPA)and docosahexaenoic (DHA) acids assimilated into the blood-stream from the emulsified product reached approximately30% at 8 hours, compared to approximately 10% for the tra-ditional encapsulated fish oil group for the same time period.Incorporation percentage remained uniformly higher at 48hours for the emulsified fish oil, compared to the encapsulat-ed version (>20% vs >10%).22

The objectives of this pilot study were to determine ifthis highly bioavailable fish oil preparation was capable ofcausing a statistically significant reduction in the amount oferythropoietin needed to maintain a non-anemic state, areduction in CRP values, while concomitantly stimulatingincreased production of serum hemoglobin, and albumin.Because this was a pilot study with strictly limited fundedresources, the authors sought to maximize the observationspossible in this study by enlisting the volunteers aid in


observing and recording data for the following subjectiveaspects of this study: (I) urine foaming, (II) increase (ordecrease) in urine production, and (III) reduction (orincrease) in joint pain. Subjective parameters involved at-home recording of urine protein spillage by observing urine“foam forming” capacity, urine volume, and rating joint pain(on a scale of 0 to 10) for 60 consecutive days.

SUBJECTS AND METHODS

Subjects: Subjects were fully informed of the nature ofthe pilot study in which they were being asked to participate,and each volunteer provided written consent.The pilot studyprotocol conformed to the policies for research on humansubjects, and the Medical Director’s approval was obtained.Additionally, Medical Director oversight continued through-out the duration of the study. Twenty adult hemodialysisESRD volunteers (mean 55.9 years) of either gender, havingboth of their original kidneys, and who had been maintainedon chronic hemodialysis for at least 4 months (labs drawn atregular intervals and data collected), were recruited into thispilot study where the volunteers acted as their own controls.Approximately 30% of all volunteers had ESRD secondaryto unspecified hypertensive renal disease, ESRD diabetic-related 30%, Lupus-related 12%, ischemic 6%, other 22%.An effort was made to recruit individuals with high initialCRP (>10 mg/L) values and/or relatively large erythropoi-etin unit needs (>10,000 units). Qualitative analysis wasused to measure CRP; therefore values less than 6.9 wereundetected. For statistical analysis, those patients with aCRP < 6.9, were recorded as 6.8. This method allowed forthe most conservative treatment of the data set. With theexception of one volunteer, who was admitted to the pilotstudy because of an exceptionally large erythropoietin unitneed, none of the other volunteers were taking a prophylac-tic oral anticoagulant (warfarin sodium).

Intervention: Each participant took 3 packets ofCoromega™, each containing 650 mg of emulsified fish oil(350 mg of EPA and 230 mg of DHA) or 1,950 mg of emul-sified omega-3 fatty acids per day, for a period of 8 consecu-tive weeks. Serum albumin, CRP, hemoglobin and erythro-poietin usage was measured prior to and at specific intervalsduring the test period. In addition to omega-3 fatty acids, eachpacket of the product also contained: 8 mg of cholesterol(from 1:80 of a pasteurized egg yolk), 25 mg of vitamin C, 3IU of vitamin E, 50 micrograms of folic acid, and 5 mg of ste-via leaf extract.

Interested volunteers were asked to measure urine out-put on specific days, and count free floating foam (greaterthan 3 inches in diameter), after urinating in a toilet, as “+”or less than 3” as “-“. Individuals so inclined kept a “pain”diary scoring their pain on a scale of 0 to 10 each day (where0 = no pain, and 10 = severe and intolerable pain).

Erythropoietin Administration: The amount of ery-thropoietin administered per treatment is listed in table 3(under “EPO”). The number of erythropoietin units admin-istered to each volunteer during the pilot study was closelymonitored and was gradually decreased to keep pace withany rises observed in the volunteer’s hemoglobin level. Thetarget hemoglobin level was at or above 12.1 mg/dL.Erythropoietin was “held” only when the volunteer’s hemo-globin level rose above 13 mg/dL (in accordance with thedialyzing center’s policy for erythropoietin administration).

Data: Predialysis data were obtained for all parame-ters: CRP and albumin (initial and at week 8), hemoglobinand erythropoietin units administered (initial and at twoweek intervals), urine foaming and volume (initial and atweekly intervals), and pain (scored daily).

Analysis: Only data from participants who completed all8 weeks, taking 3 packets per day, were used. Percentage ofdecrease and increase for all values was calculated at the con-clusion of the pilot study, and the results expressed as an aver-age reduction or increase for each test parameter. All data werefurther analyzed using t-test: paired two sample for means.

Due to the data set’s small size and large variance,change in C-reactive protein values (Table 1) was not sta-tistically significant even though reductions in CRP formany of the volunteers were observed. An overall changeof 12.6 % was noted among the means of CRP (CRPmean

initial of 19.09 mg/L vs CRPmean final of 16.67 mg/L).However, with large variances of 234.9 and 218.9 respec-tively, no statistical significance could be shown. This doesnot discount that 7 of 14 patients showed a marked decreasein CRP after treatment.

Albumins (Table 2), approached statistical significancein change of the means (Albmean initial of 3.86 g/dl vsAlbmean final of 3.99 g/dl) (P = 0.056). Change of the meansfor hemoglobin (Hgb) and erythropoietin (Epo) were com-pared from week 0 to week 8. As designed, there was nosignificant change in Hgb from the initial lab draw to thefinal lab draw (Hgbmean initial of 12.05 g/dl compared toHgbmean final of 12.25 g/dl). However, Epo use was signif-icantly reduced (16%) from a mean dose of 6346 units to5336 units three times per week (P < .05).

RESULTS

Of the 20 initial recruits, data was obtained for 14(70%) volunteers for CRP, 18 (90%) for albumin, and 11(55%) for hemoglobin and erythropoietin. Missed sam-plings accounted for the discrepancy in the number of par-ticipants sampled for each parameter. Volunteers compli-ance in subjective testing was substantially less than that of


the objective. Five volunteers (25%) elected to participatein the “foaming” study, three (15%) in the urine volumestudy, and two (10%) in the pain study.

As shown in Table 1, CRP was reduced 5-89%. Themean initial CRP was 19.09+8.85 mg/L (SD 15.33) vs meanfinal CRP of 16.67+8.54 mg/L (SD 14.80).

As shown in Table 2, albumin values increased 2-19%.The mean initial albumin was 3.86+0.20 g/dl (SD 0.40) vs amean final albumin of 3.99+0.14 g/dl (SD 0.29).

As shown in Table 3, by the end of the study hemoglo-bin increased 2-25%. The initial mean Hgb was 12.05+0.83g/dl (SD 1.24) vs the final mean Hgb of 12.25+0.64 g/dl(SD 0.96). The amount of erythropoietin needed to combatanemia decreased. Initial mean erythropoietin use was6346+2557 units (SD 3805.62) vs final mean erythropoietinuse of 5336+2399 units (SD 3571.35).

At the beginning of the pilot study, urine foaming was uni-formly noted by each participant. Four of the five participantsreported a cessation in foaming beginning with the first weekand continuing through the eighth. During the study, none ofthe participants reported that they had consumed an excess offluid during any particular week. Each of the three participantsmeasuring their urine volume reported increases in urine out-put. While these increases occurred almost every week, noconclusions from the numbers generated could be drawnbecause they never reached a statistically significant level.

Both volunteers scoring daily pain indicated substantialreductions in pain intensity. While pain reduction was notedduring the first week of the study, it was reported to be“very pronounced” after day 20.

DISCUSSION

Volunteers responded positively to the emulsified fishoil preparation used in this pilot study. Comments concern-ing “fishy burps”, “fishy after taste”, or “fishy indigestion“were absent with this preparation.

As observed, most of the participant’s test parameterswere positively influenced. There appeared to be no consis-tent pattern with respect to the few individuals for whomone or more “negative” values were generated. For exam-ple, volunteer #109 returned the highest CRP value and thelargest decrease in hemoglobin, yet experienced a rise inalbumin, or increase in urine volume, and a significantdecrease in pain scores. Volunteer #114 attained the secondhighest hemoglobin increase of the group, but scored thesecond largest increase in CRP value. Volunteer #111scored the highest increase in urine output and secondlargest decrease in pain scores, yet experienced a slightdecrease in hemoglobin value. No bleeding episodes orperiods of illness were noted for any volunteer, and we areunable to give a plausible explanation for the sharp increasein CRP, or decrease in hemoglobin (for volunteer 109 and

111, respectively) noted on the final test.

Of special interest was the highly significant impact (P< 0.05) the emulsified fish oil preparation had on the num-ber of units of erythropoietin (6346+2557 reduced to5336+2399) needed to maintain hemoglobin at, or above,12.1 mg/dL (a recognized non-anemic state). There was nosignificant change in mean hemoglobin between the first andeighth week of the pilot study (12.05+0.83 vs 12.25+0.64).The reduced need for erythropoietin to maintain adequatehemoglobin levels during emulsified fish oil supplementa-tion was a paramount finding in this pilot study.

The reduced erythropoietin usage observed in thisstudy represents an estimated dollar saving to the patients(and the healthcare system) of between $200,000-$300,000per 100 patients/year (based on $100-$150/10,000 unitscost). While the small sample size of this pilot study limitsthe absolute conclusiveness of these findings, the impact oftheir potential cannot be ignored. If the same results can berealized in a larger trial, one could easily extrapolate theexpected increase in patient quality of life health benefitsand substantial decrease in cost of erythropoietin used.Given the significance of the findings, in the absence of anyadverse events, a larger trial is warranted.

ACKNOWLEDGEMENTS

The authors are grateful to the physicians, dietitians,technicians, and especially the volunteers who participated inthis pilot study. Special thanks is given to the renal special-ists of Houston: Bilal Moukaddem, MD; Whitson Etheridge,MD; Eric Faust, MD; and Sarah Shearer, MD. Additionalthanks for their dedication and hard work is extended to GailMcLaughlin, BSN, RN; Rachelle Bussey, RD, LD; SuzanneLopez, MPh, RD, LD; and Jeanne McCowan, RD, LD, RNof Fresenius Medical Care, and to Chris Kaiser, LSW, for heroriginal inspiration in this project.

A special thanks to Frank Morley and Barbara Apps ofthe European Reference Botanical Laboratories, Inc. for theirsupport and encouragement throughout the study.


Volunteer Initial Final (8 Weeks) % Reduction Increase

#101 12 <6.9 43%#102 15 <6.9 54%#103 32 29 9%#104 11 <6.9 37%#105 22 26 +15%#106 24 14 42%#107 19 18 5%#108 65 <6.9 89%#109 <6.9 39 +82%#110 <6.9 <6.9 0%#111 18 <6.9 6%#112 <6.9 <6.9 0%#113 <6.9 <6.9 0%#114 22 53 +58%

Mean 19.09+8.85 16.67+8.54 NS (-)

Table 1. C-Reactive Protein Values (mg/L)

NS (-) = Not statistically significant

Volunteer Initial Final (8 Weeks) % Reduction Increase

#101 3.9 3.9 0%#102 3.5 3.8 8%#103 3.7 3.6 -3%#104 3.5 4.3 19%#105 3.7 4.0 8%#106 3.5 3.7 5%#107 3.5 3.6 3%#108 3.4 3.9 13%#109 4.2 4.3 2%#110 4.9 4.4 -10%#111 3.9 3.9 0%#112 4.5 4.4 -2%#113 4.1 4.4 7%#114 4.1 4.1 0%#115 3.9 3.7 -5%#116 4.0 4.3 7%#117 3.6 3.8 5%#118 3.5 3.8 8%

Mean 3.86+0.20 3.99+0.14 Change: (3.6%, p = 0.056)

Table 2. Albumin (g/dL) Values


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Initial Week 2 Week 4 % Increase/(Decrease) Week 6 Week 8 % Increase/[decrease]

Hgb (EPO) Hgb (EPO) Hgb (EPO) in Hgb Hgb (EPO) Hgb (EPO) from initial value

Hgb (EPO/session)

#101 11.9 (1,800) 12.3 (1,800) 12.5 (1,500) 5% 12.7 (1,500) 12.4 (1,500) 4% [- 300 U]

#109 14.5 (2,000) 13.1 (1,500) 12.7 (1,500) (-12%) 13.2 (1,000) 11.9 (1,000) [-18%] [- 1,000 U]

#110 12.5 (4.500) 11.8 (4,500) 12.8 (4,500) 2% 12.4 (4,000) 12.8 (4,000) 2% [- 500 U]

#111 12.3 (5,500) 11.5 (5,500) 11.4 (5,000) (-7%) 11.2 (5,000) 12.1 (5,500) [-8%] 0 U

#112 12.2 (7,500) 12.0 (7,500) 13.6 (5,500) 10% 13.0 (5,500) 13.4 (5,500) 10% [-2,000 U]

#113 12.1 (500) 12.2 (500) 12.4 (500) 2% 12.0 (200) 12.5 (200) 3% [- 300 U]

#114 11.4 (10,000) 12.6 (9,500) 13.9 (hold) 18% 14.7 (hold) 13.3 (5,000) 14% [-5,000 U]

#115 12.7 (6,500) 12.5 (6,000) 12.2 (6,000) (-4%) 12.6 (6,000) 12.7 (6,000) 0% [- 500 U]

#116 9.2 (11,000) 9.9 (11,000) 10.7 (11,000) 14% 11.3 (11,000) 12.3 (10,000) 25% [- 1,000 U]

#117 11.8 (10,000) 11.5 (10,000) 11.6 (10,000) (-2%) 11.3 (10,000) 11.3 (10,000) [ -4%] 0 U

#118 11.9 (10,500) 11.7 (10,500) 12.2 (9,000) 3% 12.0 (9,000) 10.0 (10,000) [-16%] [- 500 U]

Mean Hgb (EPO) Initial: 12.05+0.83 (6346+2556.65) Final: 12.25+0.64 (5336+2399.27) Change: NS (-16%, p<0.05)

Table 3. Hemoglobin (Hgb g/dL) vs. Erythropoietin (EPO) Administered (U/dialysis session)


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