Natural Standard is now offering continuing education credits for all healthcare professionals, including medical doctors, naturopathic doctors, pharmacists, nurses and doctors of osteopathy. The continuing education programs are derived from Natural Standard’s evidence-based systematic reviews on popular herbs and supplements. In each training module, the available scientific evidence of effectiveness is evaluated using the Natural Standard Evidence-based Validated Grading Rationale™. The reviews also discuss expert opinion, folkloric precedent, history, mechanism of action, interactions, side effects, dosing and toxicology information. Review questions highlight the safety and effectiveness of each therapy. For more information, please visit www. naturalstandard.com.
CNME Accrediting Status Renewal Imminent
The Council on Naturopathic Medical Education (CNME) recently completed the second-to-last step in the renewal of CNME’s recognition as an accrediting agency by the U.S. Department of Education (USDE). The CNME’s USDE staff reviewer presented the Department’s recommendation for a five-year renewal (the maximum allowed) with no adverse findings. The National Advisory Committee for Institutional Quality and Integrity members voted unanimously to recommend that the Assistant Secretary for Post Secondary Education renew CNME’s recognition for five years. CNME’s mission is quality assurance: serving the public by accrediting naturopathic medical education programs that meet or exceed CNME’s standards. Students and graduates of programs accredited or preaccredited (candidacy) by CNME are eligible to apply for the naturopathic licensing examinations administered by the North American Board of Naturopathic Examiners (NABNE), and are generally eligible for state and provincial licensure in the U.S. and Canada. For more information, please visit: http://www.cnme. org.
Atrium Innovations Acquires Seroyal
In a statement released by Atrium Innovations Inc (TSX: ATB), Atrium announced the purchase of Seroyal International, which commercializes premium dietary supplement brands targeting healthcare practitioner channels in Canada and in the U.S. with annualized consolidated revenues of approximately $40 million USD. The transaction closed on December 31, 2010. Atrium is a globally recognized leader in the innovation, formulation, production and commercialization of science-based and professionally endorsed dietary supplements for the health & nutrition industry. Atrium markets a broad portfolio of finished products through its highly specialized sales and marketing network in more than 35 countries, primarily in North America and Europe. Seroyal was founded in 1984 and distributes three branded families of products (i.e. Genestra, Pharmax and CoreLab), and has distributed the Unda European homeopathic brand since 1990.
Vascular Compliance
Vascular Compliance
An important cardiovascular disease risk factor
The vascular endothelium is a dynamic living organ, performing a myriad of functions within the living body. It serves as a barrier between the vessel wall and lumen (Avogaro 2008), modulates vascular tone, directs coagulation/fibrinolysis balance, and regulates inflammation (Cines 1998). Furchgott, Murad, and Ignarro jointly received the Nobel Prize in medicine in 1998 for their discoveries of the role of the endothelium in regulating vascular tone, and specifically the role of nitric oxide as the principle signalling molecule responsible (Nobelprize.org 2010).
Nitric oxide (NO) is viewed as the principle regulator of endothelium- controlled vasodilation (Murad 2006). Vascular compliance, a measure of endothelial dysfunction, is characterized by the impairment of endothelium-dependent vasodilation due to reduced activity of NO (through reduced synthesis and/ or increased degradation), and/or an increase in contracting factors (Lian 2010). In addition to compromised NO functionality, endothelial dysfunction is associated with up-regulation of coagulation and inflammation cascades, leading to increased expression of endothelial adhesion molecules, as well as an increase in oxidative burden (Avogaro 2008).
Vascular compliance and disease risk A decrease in vascular compliance can be influenced by the presence of certain metabolites, plasma lipids, oxidative stress, or in more general terms, anything that can inhibit NO formation or increase its degradation. Hypercholesterolemia, diabetes mellitus, and hypertension are pathological conditions that share a common root of impairing NO production (Irace 2001). Multiple studies have demonstrated compromised vascular compliance among patients with traditional cardiovascular risk factors (Lian 2010), including application of a validated methodology by Framingham Heart Study investigators (Hamburg 2011, Hamburg 2008).
Multiple, large, well- controlled studies have found compromised vascular compliance to accurately predict risk of “hard” cardiovascular endpoints, notably cardiac death, acute myocardial infarction, unstable angina, and stroke (Halcox 2002, Matsuzawa 2010, Schachinger 2000, Suwaidi 2000). It is generally accepted that endothelial dysfunction and inflammation precedes atherosclerotic vascular disease and if not remedied, continues indefinitely resulting in the clinical manifestations of plaque formation and subsequent altered blood flow (Avogaro 2008, Deanfield 2007, Drexler 1999, Koh 2005, Price 1999, Ross 1999).
Most interestingly, measure of vascular compliance appears to more accurately predict risk of subsequent cardiovascular disease among patients with low baseline Framingham- predicted risk, relative to individuals with elevated Framingham- predicted baseline risk, as assessed in a meta analytic review of 211 trials (Witte 2005). Assessment of vascular compliance represents a strategy capable of identifying the earliest signs of underlying physiological abnormality leading to overt cardiovascular and cerebrovascular pathology (Lian 2010). It appears to identify the underlying cause of chronic vascular diseases long before such a risk profile emerges through the patient developing traditional cardiovascular risk factors.
While previously reserved for research laboratory settings due to methodological limitations, simple, in- office and validated systems of vascular compliance have since become available (Itamar Medical 2010, Kuvin 2003).
Strategies of Assessment
There are several clinical tests used to evaluate endothelial function and dysfunction, all of which involve pharmacological and or physiological stimulation of NO release from the endothelium (Deanfield 2007). By determining NO bio-availability, critical information regarding vascular tone, thromboregulation, cell adhesion and proliferation can be obtained (Deanfield 2007).
Flow- mediated dilatation (FMD) represents the gold standard among many methods of vascular compliance assessment (Deanfield 2007). FMD represented the least- invasive option, until the development of an in- office technique described below. In brief, FMD employs ultrasound to measure brachial artery reactivity in response to hyperaemic flow. A blood pressure cuff is placed distal to the brachial artery and inflated to create ischaemia in the distal vascular bed for approximately 5 minutes. This induced- ischemia triggers the release of NO from the endothelium. When the cuff is released, reactive hyperaemia forces the endothelium to accommodate by dilatation. Ultrasound of the bracial artery during the process allows for quantification of the magnitude by which the artery was able to dilate. After a rest period, the process is repeated with administration of a single dose of 0.4mg nitroglycerine (spray or sublingual tablet). The response achieved during the phase with nitroglycerine administration is considered a 100% vascular compliance score. The calculated vascular compliance score represents the percentage of the nitroglcyerine- induced response achieved in the absence of nitroglycerine administration (trial run before nitroglycerine administration, the brachial artery dilated to 40% of what was achieved when nitroglycerine was administered) (Corretti 2002, Deanfield 2007).
The ability of assessment of vascular compliance to become commonplace in outpatient clinical settings was made possible through the development of peripheral arterial tonometry (PAT). The technique quantifies pulse wave amplitude during reactive hyperaemia in the fingertip, and has reproducibly demonstrated tight correlation with measures of FMD (Kuvin 2003, Lian 2010). The investigation of vascular compliance previously mentioned by the investigators of the Framingham Heart Study (Hamburg 2011, Hamburg 2008), as well as many of the 211 trials included in the meta analytic review by Witte (2005) utilize the PAT methodology.
Postprandial physiology and vascular compliance
Investigating vascular compliance affords the clinician a rare glimpse into the realm of postprandial physiology. The concept is easily identified in the area of glucose control, with impaired postprandial management of glucose defining diabetes (oral glucose tolerance test). As with glucose, the postprandial response to several important factors differs considerably among individual patients. Abnormal postprandial management of a high fat meal (postprandial hypertriglyceridemia) as well as methionine (postprandial hyperhomocysteinemia) are rarely considered clinically. Below, assessment of their impact to measures of vascular compliance is reviewed.
Hypertriglyceridemia
Elevated levels of triglyceride have been established as an independent risk factor for cardiovascular disease. Fasting triglyceride levels are predictive of disease risk, but the strength with which risk is predicted is diminished when other factors (total cholesterol, HDL- cholesterol, markers of insulin sensitivity) are simultaneously considered (Bansal 2007, Bayturan 2010). Interestingly, non fasting triglyceride levels are likewise an independent predictor of cardiovascular disease risk, and the strength with which this variable predicts risk is not appreciably altered by simultaneous consideration of other conventional risk factors (Bansal 2007). It is the lipemic response to a meal (magnitude by which a mean induces a spike in triglyceride levels) as opposed to fasting triglyceride levels that impacts vascular compliance.
Studies have shown that in populations with no history of myocardial ischemia, diabetes, hypertension, tobacco use (Bae 2001), who are physically active (Blendea 2005), and normocholesterolemic (Plotnick 1997), feeding of a single high- fat meal reduces postprandial endothelial function for up to 4 hours. See Table 1.
Hypercholesterolemia has been suggested to negatively impair endothelial function by increasing the production of reactive oxygen species that deactivate NO (Nofer 2010, Ohara 1993, Shiode 1996). As such, it is postulated that repetitive induction of postprandial hypertriglyceridemia has the ability to promote the development of atherosclerosis (Bae 2001) via increasing reactive oxygen species (Ulker 2003), induction of adhesion molecules and the stimulation of pro-inflammatory mediators (Lundman 1997, Lundman 2003).
Hyperglycemia
Hyperglycemia has the ability to induce endothelial dysfunction by activating Protein Kinase C which mediates the over-expression of adhesion molecules (E-selectin, ICAM, VCAM) (Feener 2001). In healthy normoglycemic subjects, Zhu and colleagues (2007) have shown that after ingestion of 75g glucose, FMD declined to 7.3+/- 3.4% 1 hour after consumption from a baseline value of 11.4+/-3.8%, which then returned to baseline after 4 hours. Interestingly, when 45 minutes of treadmill exercise was introduced immediately after glucose consumption, no significant decrease in FMD occurred (Zhu 2007). Similarly, it was found that when healthy individuals participated in 60 minutes of endurance exercise (elliptical, stationary cycle or treadmill) 17 hours prior to consumption of a high sugar “snack” consisting of a 59g chocolate bar and 591ml soft drink (total glucose, fructose, sucrose: 28g, 38g, 27g respectively), postprandial endothelial function was improved; however, markers of oxidative stress were unchanged (Weiss 2008).
Studies have shown that a transient increase in blood sugar has the ability to impair endothelial function (Akbari 1998, Ceriello 2002, Kawano 1999, Title 2000,), furthering the hypothesis that endothelial dysfunction may precede overt diabetes mellitus. In addition, prolonged and repeated exposure to postprandial hyperglycemia may have a role in atherosclerosis development by impairing NO production and activity (Avogaro 2008). It has been shown that the fraction of L-arginine converted to NO is actually lower in patients with diabetes mellitus when compared to healthy individuals (Avogaro 2003), shedding further light on how hyperglycemia impairs endothelial function.
Hyperhomocysteinemia
Elevated fasting levels of homocysteine have been established as an independent predictor of cardiovascular and cerebrovascular disease risk. A meta analytic review of 30 prospective and retrospective studies concluded a 25% lower fasting homocysteine level was correlated with a 11% reduced risk of ischemic heart disease and a 19% reduced risk of stroke (Homocysteine Studies Collaboration 2002).
hyperhomocysteinemia on vascular compliance
A second meta analysis evaluated 72 case control studies and 20 prospective studies. Prospective studies demonstrated a 32% increased risk for ischemic heart disease and a 59% increased risk of stroke for each 5mmol/L increase in fasting homocysteine (Wald 2002).
Postprandial homocysteine responses appear to be more accurate predictors of vascular disease risk than fasting homocysteine levels. Eighteen patients (mean age 58+/- 8 years) with established vascular disease were recruited within three months of an acute vascular event. All patients received 5mg folic acid and 250mg vitamin B6 daily for three months. At baseline and following three months of supplementation, patients underwent assessment of fasting and postmethionine load homocysteine levels. While only two of eighteen patients presented with fasting hyperhomocysteinemia at baseline (>13.5micromol/L), all eighteen patients demonstrated postprandial hyperhomocysteinemia (defined as >40.6micromol/L six hours following administration of 100mg/kg body weight methionine). In a population of slightly younger age and sex matched controls (mean age 41 +/- 6 years), mean homocysteine levels reached 29.0micromol/L) following the methionine load test. Of interest is that following the three month supplementation period, postmethionine load responses decreased 34% (Constans 1999).
Several trials have demonstrated that a methionine load challenge detriments measures of vascular compliance. A selection of such trials is presented in Table 2.
It is postulated that hyperhomocysteinemia decreases vascular compliance by inhibition of NO synthesis, promotion of NO degradation through oxidative mechanisms, promotion of thrombogenesis, and stimulation of endothelin-1 (endogenous vasoconstrictor) release (Ross 1999, Tousoulis 2008).
Discussion
Assessment of vascular compliance allows for a novel, wholesystems view of cardiovascular health. The strategy appears most appropriate for application in settings of primary prevention, and can serve as a powerful tool to achieve/ maintain compliance with interventions best suited to improve the novel marker; diet and lifestyle modification. A very impressive body of literature has been able to establish assessment of vascular compliance as an independent cardiovascular risk factor of clinical significance. Of tremendous value, the test has reproducibly demonstrated the ability to predict perturbed aspects of postprandial physiology, an area not adequately addressed by current concepts in assessment of cardiovascular risk in otherwise healthy populations. Future reviews will further investigate clinical strategies capable of correcting abnormalities in vascular compliance scores.
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The Naturopathic Institute of Advanced Medicine
The Naturopathic Institute of Advanced Medicine
a focus on functional medicine
The Naturopathic Institute of Advanced Medicine was founded in 2005 in Oshawa, Ontario by Leigh Arseneau, ND, with a commitment to off er functional medicine to patients. Functional medicine closely parallels the principal tenants of naturopathic medicine, highlighting the importance of individualized treatments, which goes hand- in- hand with recognition of limitations of “standards of care”. A standard of care addresses a pathology, designed to help most people, most of the time; individualized treatment recognizes the pathology exists as the result of a longstanding and often subtle shift in normal physiological functioning. e underlying physiological imbalance responsible for the presenting pathology varies considerably between diff erent patients; individualized therapy attempts to delineate the underlying imbalance. Functional medicine is a science-based, personalized system’s biology approach that deals with primary prevention and underlying mechanisms for serious chronic disease. It understands the gene-environment interaction infl uence on a complex physiological web, which ultimately translates into health and disease.
Leigh describes the ability of the clinic to successfully partner with local conventional healthcare providers as a key aspect driving the success of the clinic. Leigh as had the privilege to lecture to local groups of family physicians, pharmacists, and nurses, and as a result has received referrals from many diff erent health care providers. is has provided him the opportunity to assess cases from a system’s biology approach and provide another viewpoint for complex, chronic, multisystem conditions. One area of focus of the clinic is cancer management, with the local Lakeridge Health hospital oncology ward providing many of the patients seen. Leigh also makes time to lecture to the general public, which has included schools, churches, public seminars hosted by the Orthomolecular society, and others.
e clinic is serviced by three offi ce staff , two naturopathic doctors, an herbalist, a nutritionist trained in off ering FLT services, and a lab technician. A wide array of integrative diagnostic services are employed, including IgG food allergy testing, salivary hormone testing, urinary organic acids, provocative heavy metal assessment, and a micronutrient assay that assesses adequacy of a broad array of essential nutrients.
Management of traditional cardiovascular risk factors represents a considerable focus of the facility, and as such a well-executed, therapeutic lifestyle programs called First Line erapy for weight management is an integral component. Intravenous therapies have become a mainstay for the facility, principally utilized in integrative oncology, autoimmune disease, chemical sensitivity, chronic fatigue syndrome and chronic pain management, most notably Fibromyalgia. A broad array of injection therapies are employed, including IV vitamin C, glutathione, sodium bicarbonate, Meyer’s (spelt Myer’s) cocktails, Helixor and other personalized formulations. e clinic has also found tremendous success with a European injection therapy called Biopuncture for the treatment of chronic pain.
Leigh has partnered with an integrative MD (Dr Gordon Ko) in the Markham, Ontario area, and practices part time in the facility managed by Dr Ko. Leigh describes a tremendous satisfaction from practicing alongside a respected MD, treated as a colleague and equal. While outpatient naturopathic centres have successfully improved patients lives for many decades, there is no debate that partnering with local physicians allows for the naturopathic model of care to reach many more people than naturopathic doctors are able to reach on their own.
We are greatful to the team of the Naturopathic Institute of Advanced Medicine for allowing us to showcase their facility. It is our hope that ND’s may be inspired to reach out to local physicians after learning of the success of this centre. For every physician that creates an obstacle to delivery of naturopathic care, there is a better- read one waiting to fi nd a competent ND to help deliver integrative medicine to their own patient base.
Dr Gordon Ko and the Canadian Centre for Integrative Medicine
Dr Gordon Ko and the Canadian Centre for Integrative Medicine
Integrative medical centre of excellence
Dr Gordon Ko, MD, has been practicing as a physiatrist (principally managing patients with chronic pain) since the late 1980’s. He is an accomplished author with several contributions to peer reviewed clinician journals, a practitioner and teacher at Sunnybrooke Hospital, and an active member of his community in terms of educating through public seminars, television appearances, and involvement in activities of his local church. He is a devoted father of four children, managing to juggle practice/media/teaching responsibilities with the demands of four full extracurricular schedules. From very early on in his training, Dr Ko developed a keen interest in the role of integrative medical strategies. He has since devoted much of himself to delivery of integrative medicine to his patients, as well as attempt to showcase the power of integrative techniques to his colleagues.
Upon entering the century home in Markham, Ontario which houses his private practice, it is obvious that Dr Ko embraces the true tenants of integrative medicine. Instead of the pharmaceutical ads which typically line the hallways and pamphlet racks of a physician’s office, waiting room literature included a poster on “10 steps to prevent a fall”, education on sleep apnea and its consequences, display of bioidentical hormone therapy and health concerns commonly addressed through the treatment, and brochures on physiotherapy, aquatherapy, and smoking cessation.
Dr Ko’s strategy of patient assessment and management was inspiring to observe… He keeps a figure in front of his desk similar to that seen below:
He then describes the process of patient assessment as physician playing the role of Sherlock Holmes. Neurological, Structural, Biochemical, and Psychological influences impact illness, in a manner that is different and unique for each patient. The physician’s role is to utilize patient history and diagnostic tools to delineate the underlying cause for the presenting concern in the specific patient. Platelet rich plasma therapy/ prolotherapy are employed to address structural causes of illness. EMG and MRI are utilized to assess neurological impairments, with acupuncture employed as a key strategy for addressing compromised function in this realm. Biochemical abnormalities are addressed through diet and nutraceutical supplementation. When a psychological basis is contributing to a chronic illness, or is identified as the underlying cause of a chronic illness, referral is made to a psychologist whom has been a long- time partner of Dr Ko’s treatment strategies.
During the discussion of individualized treatment and physician as Sherlock Holmes, Dr Ko quoted Sandy Wood, ND, a pioneer of the profession of naturopathic medicine. He also recited a story of bringing in a doctor of acupuncture for a guest lecture during his residency in the early 1980’s, and then having the director of cardiology of the hospital request a treatment of acupuncture for his painful knee, only to immediately profess “see, its placebo! My knee still hurts!”
Dr Ko has not only embraced integrative medicine himself, but has made a career of trying to showcase its amazing power to all medical practitioners. While we may be aware of obstacles to implementation of integrative medical techniques today, the obstacles overcome by Dr Ko and others 20+ years ago must have appeared insurmountable. But as Dr Ko stated, “patients let you know what is working and what is not!” There is a sense of accomplishment that elders of integrative medicine exude, and with good reason. Dr Ko tells the story of the cardiologist and others who were creators of obstacles to the introduction of integrative medical techniques. Now, Dr Ko describes how upcoming physicians he trains through Sunnybrooke hospital are eager to investigate and incorporate integrative therapies.
His commitment to educating others on integrative medicine is perhaps best exemplified by his efforts to create public awareness of the efficacy and safety of platelet rich plasma therapy (injection of the patients own platelets into damaged ligaments, joint spaces, etc…). He has made numerous national and local television appearances highlighting the therapy to the public, providing demonstrations of the technique as well as patient reports of phenomenal cases of restorative outcomes from the intervention. Physicians interested in learning more about platelet rich plasma therapy are encouraged to obtain a copy of a recent publication authored by Dr Ko, “Platelet-rich plasma therapy for low back pain caused by sacroiliac joint laxity” in the journal Practical Pain Management (September 2010 issue) www.ppmjournal.com. Dr Ko’s website links to appearances of himself on various national and local television programs discussing platelet rich plasma therapy; www.drprp.com.
Dr Ko requested announcement of an upcoming local event for educating the community, and we are pleased to help create awareness of the initiative. On Saturday April 9th the Christian Community Church will be hosting its 8th annual Look Well- Feel Well- Be Well wellness conference.
The keynote speaker is Christine Williams of the CTS television network. Workshops include discussions on financial wellness, bioidentical hormones, cosmetic surgical procedures, a medical psychotherapist discussing emotional boundries, and a lecture on spiritual wisdom.
Prior to incorporating platelet rich plasma therapy into his practice, Dr Ko had been a long- time advocate of prolotherapy. Prolotherapy has continued to be an integral strategy employed in his practice. He also utilizes an array of nutraceutical interventions, with the most frequently employed prescriptions including; fish oil, vitamin D, vitamin B12, magnesium, zinc, and vitamin C.
Recognizing the multifaceted nature of chronic pain, Dr Ko has surrounded himself with a team of integrative healthcare providers, called upon to provide a multifaceted treatment solution. He has maintained long- term referral networks with a local chiropractor, several local physiotherapists, and a local psychologist. Recently, Dr Ko partnered with Leigh Arseneau, ND, who practices out of Dr Ko’s facility two days per week. The Canadian Centre for Integrative Medicine also houses physicians who practice according to more conventional systems, including Dr Annie Hun, Dr Ko’s wife. It is exciting to see conventional and integrative models of medical practice successfully coexisting.
IHP is greatful to Dr Ko and the team of the Canadian Centre for Integrative Medicine for allowing us to showcase their amazing work. Regardless of training, all practitioners of integrative medicine meet with obstacles from conventionally- minded physicians. But as eloquently stated by Dr Ko, “patients tell you what works, and what doesn’t”. Identifying the underlying cause of illness is the most efficient and gentle way of restoring a patient to health. Delivery of such strategies achieves the most important outcome in medicine; patient wellness. The heightened awareness of integrative medicine over the past several decades is owed to individuals such as Dr Ko and other pioneers of the integrative medicine movement. Through persistence, tireless study and passion for learning, powerful tools of healing have been successfully delivered. Up and coming physicians cannot ignore the safety and efficacy of such techniques, and thereby become interested, then read, then curious, then practitioners themselves.
To the naturopathic readership of this article; there are many medical physicians employing integrative techniques, and many more with tremendous interest in the field not yet themselves utilizing the practices with patients. Their numbers are greater than our entire profession… Find them! They will be eager for the opportunity to partner with you.
