Assessment for Adverse Food Reactivity. A Clinician's Guide.

Patients frequently note adverse food reactions and report significant food restrictions as a result. Physicians need to consider the nutritional consequences and necessity of such voluntary dietary limitations. They also should consider adverse food reactivity in their differential diagnosis for many frequently seen concerns. This article describes a three-step process for assessing a patient's potential for true adverse food reactivity. Readers will note the significant contributions nutritionists and dieticians can offer as team members.

Nutritional Assessment of the Symptomatic Patient on a Plant-Based Diet: Seven Key Questions.

Plant-based diets, both vegan and vegetarian, which emphasize grains, vegetables, fruits, legumes, nuts, and seeds are increasingly popular for health as well as financial, ethical, and religious reasons. The medical literature clearly demonstrates that whole food plant-based diets can be both nutritionally sufficient and medically beneficial. However, any person on an intentionally restrictive, but poorly-designed diet may predispose themselves to clinically-relevant nutritional deficiencies. For persons on a poorly-designed plant-based diet, deficiencies are possible in both macronutrients (protein, essential fatty acids) and micronutrients (vitamin B12, iron, calcium, zinc, and vitamin D). Practitioner evaluation of symptomatic patients on a plant-based diet requires special consideration of seven key nutrient concerns for plant-based diets. This article translates these concerns into seven practical questions that all practitioners can introduce into their patient assessments and clinical reasoning. Ideally, persons on plant-based diets should be able to answer these seven questions. Each serves as a heuristic prompt for both clinician and patient attentiveness to a complete diet. As such, these seven questions support increased patient nutrition knowledge and practitioner capacity to counsel, refer, and appropriately focus clinical resources.

Nutritional assessment in vegetarians and vegans: questions clinicians should ask.

Not all who adhere to vegetarian, vegan or other special diets have nutritionally sound eating habits. The clinical consequences of an insufficiently mindful vegetarian or vegan diet include many common symptoms such as anxiety, brain fog, depression, fatigue, insomnia, neuropathies and other neurologic dysfunction. Patients with such symptoms who report having a vegetarian or vegan diet, or a diet that severely restricts meat consumption, require a slightly expanded differential diagnosis. The challenge is to identify which patients require closer attention. This article lists questions to use to quickly assess for potential dietary drivers of clinical symptoms. In many cases, simple nutritional interventions, through diet and/or supplementation, can resolve or minimize problematic symptoms.

Introduction to traditional Asian therapeutic diets: two enduring perspectives.

In some ancient systems of medicine, health was understood as a state of balance, and diet was considered essential to achieving and maintaining that balance. Traditional Chinese medicine and Ayurveda are based on this premise. Here we present an overview of these two traditional systems' views on diet and eating. This article aims to explain the reasoning behind some of the recommendations that practitioners of these forms of medicine may be making.

Drug-nutrient interactions: a case and clinical guide.

Advances in pharmacokinetics and pharmacodynamics require new competencies related to pharmaceutical prescribing. First, both physicians and pharmacists need to recognize the potential negative impact of nutrients and dietary supplements on the absorption, metabolism, and utilization of prescription drugs. Second, physicians, even more than pharmacists, need to recognize the potential negative effects of pharmaceuticals on the absorption, metabolism, and utilization of nutrients. This article discusses common drug-nutrient interactions and presents a case that illustrates how unrecognized nutrient disruption may negatively affect a patient's health and potentially result in unnecessary prescribing of medications. In presenting the case, we also provide a conceptual framework for assessing and treating this patient and a summary of current knowledge regarding drug-nutrient interactions.

Interventional nutrition in cancer survivorship. A case study.

Interventional nutrition is an emerging field in medicine that utilizes advanced laboratory technologies to identify a patient's clinically relevant biochemical uniqueness in order to treat the metabolic contributors to multifactorial symptoms such as fatigue, insomnia, and pain. This article presents a complex case in which a breast cancer patient's severe symptoms fit no clear disease pattern and prevented her from undergoing chemotherapy and radiation treatment. Specialized testing for metabolic, gastrointestinal, and immunologic function uncovered important nutritional deficiencies that could not be identified through isolated tests or addressed by supplementation with a daily multivitamin. Nutritional intervention based on specific measurements, rather than a one-size-fits-all approach to supplementation, resolved this patient's debilitating symptoms and restored her capacity to benefit from chemotherapy and radiation.

Weather or not: the importance of vitamin D status monitoring and supplementation.

The Centers for Disease Control and Prevention's latest data show markedly high prevalence rates of severe vitamin D deficiency among Americans of all ages. Because of the numerous negative health consequences associated with vitamin D deficiency, we must consider all potential causes including insufficient exposure to the sun's ultraviolet B radiation. This article presents data from the National Weather Service that documents how few days in Minnesota offer the opportunity to make vitamin D. Thus, even Minnesotans who spend a significant amount of time outdoors and consider themselves to have sufficient sun exposure may still be at risk for vitamin D deficiency. This is especially true for the elderly, those with high melanin content in their skin, and those with a higher body mass index, all of whom require significantly more sun to achieve adequate levels of vitamin D. Given the lack of sufficient ultraviolet B radiation people in Minnesota get from the sun between October and April, measurement of vitamin D status is required for rational replenishment and maintenance dosing. The goal of replenishment should be at least 32 ng/mL and, ideally, more than 50 ng/mL.

Kampo in women's health: Japan's traditional approach to premenstrual symptoms.

Kampo is Japan's traditional herbal medicine and it is an integral part of the official Westernized medical system in Japan. We describe the Kampo approach to premenstrual symptoms. We present 3 clinical cases of women treated for premenstrual discomforts in a Kampo clinic in Japan. Each of these women reported improvement in their conditions. We argue that Kampo is well-suited for treatment of premenstrual symptoms in Japan and deserves the attention of Western clinicians for three reasons: (1) patient-centered Kampo diagnosis allows physicians to handle subjective and culture-bound symptoms that are often ignored by Western medicine; (2) Kampo herbal formulas are regulated by the Japanese government, and are pure and of high quality; and (3) the settings in which Kampo is practiced set a stage for therapeutic collaboration between the doctor and the patient.

A culturally appropriate, student-centered curriculum on medical professionalism. Successful innovations at Keio University in Tokyo.

Professionalism is a Western concept without a precise equivalent in Asian cultures. The term itself cannot be translated directly into any Asian language, nor does the spectrum of words based on the verb "to profess" exist in any Asian language. In addition, the foundational assumptions found in the West's celebrated Charter on Medical Professionalism do not match Asian ways of thinking regarding autonomy, service, and justice. Finally, there is no tradition in Asia of reciting an oath at medical school graduations. Despite the fact that professionalism is literally a foreign concept in Asia, Keio University School of Medicine in Tokyo has successfully introduced a professionalism curriculum that both supports Japan's cultural traditions and affirms the school's academic mission. This article describes a series of educational events for medical students in the university's 6-year undergraduate program. These include development of a course on medical professionalism for students in their third year, a year-long extracurricular oath-writing project for fourth-year students, introduction of a White Coat Ceremony at the start of the fifth year (when students begin their clinical rotations), and a reflective writing requirement for sixth-year students on professionalism and humanism as witnessed during clinical rotations.

Skin temperature rise induced by calcitonin gene-related peptide in gonadotropin-releasing hormone analogue-treated female rats and alleviation by Keishi-bukuryo-gan, a Japanese herbal medicine.

The effects of Keishi-bukuryo-gan on calcitonin gene-related peptide (CGRP)-induced elevation of skin temperature were investigated in gonadotropin-releasing hormone (GnRH) analogue-treated female rats. Leupline (1.0 mg/kg) as the GnRH analogue was subcutaneously (s.c.) injected into female rats. After Keishi-bukuryo-gan (100-1,000 mg/kg, p.o.) or 17beta-estradiol (0.010 mg/kg, s.c.) was administered to GnRH analogue-treated rats for 14 days, CGRP-induced skin temperature elevation, concentration of plasma 17beta-estradiol and pituitary gonadotropin (luteinizing hormone; LH, and follicle stimulating hormone; FSH) were measured. In addition, effects of 17beta-estradiol and Keishi-bukuryo-gan on the proliferation of estrogen-dependent human breast cancer (MCF-7) cells were investigated under in vitro conditions. GnRH analogue significantly lowered the concentrations of plasma 17beta-estradiol and pituitary gonadotropins. Tissue weights of the ovaries and uterus were also decreased by the analogue. Under the condition of estrogen deficiency, intravenous (i.v.) injection of exogenous CGRP (10 microg/kg) elevated the skin temperature of the hind paws more significantly than it did in sham-treated control rats. Estrogen supplementation inhibited this elevation of skin temperature with restoration of both the lowered plasma estrogen level and the decreased uterine weight in GnRH analogue-treated rats. On the other hand, Keishi-bukuryo-gan inhibited the elevation of skin temperature in a dose-dependent manner without restoring the plasma estrogen level and uterine weight. In addition, in an in vitro study, MCF-7 cells proliferated in a dose-dependent manner by the addition of 17beta-estradiol (10(-13)-10(-8) M) to the medium. However, Keishi-bukuryo-gan (10(-6)-10(-4) mg/ml) did not activate the MCF-7 cell proliferation. These results suggest that Keishi-bukuryo-gan, which does not exhibit estrogen activity, may be useful for the treatment of hot flashes in women who are undergoing medical ovariectomy with a GnRH analogue.

Top 10 vitamin D myths.

A growing body of evidence points to the tremendous importance of vitamin D in maintaining health. Yet misconceptions about the need for this vitamin and the clinical care of vitamin D-deficient patients remain. This article deconstructs 10 prevailing myths and addresses such issues as symptoms and clinical indicators of vitamin D deficiency; the various sources of vitamin D, including diet, sun exposure, and supplementation; current laboratory standards for assessing vitamin D levels, and the prevalence of deficiency.

Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain.

OBJECTIVE: To determine the prevalence of hypovitaminosis D in primary care outpatients with persistent, nonspecific musculoskeletal pain syndromes refractory to standard therapies. PATIENTS AND METHODS: In this cross-sectional study, 150 patients presented consecutively between February 2000 and June 2002 with persistent, nonspecific musculoskeletal pain to the Community University Health Care Center, a university-affiliated inner city primary care clinic in Minneapolis, Minn (45 degrees north). Immigrant (n = 83) and nonimmigrant (n = 67) persons of both sexes, aged 10 to 65 years, from 6 broad ethnic groups were screened for vitamin D status. Serum 25-hydroxyvitamin D levels were determined by radioimmunoassay. RESULTS: Of the African American, East African, Hispanic, and American Indian patients, 100% had deficient levels of vitamin D (< or = 20 ng/mL). Of all patients, 93% (140/ 150) had deficient levels of vitamin D (mean, 12.08 ng/mL; 95% confidence interval, 11.18-12.99 ng/mL). Nonimmigrants had vitamin D levels as deficient as immigrants (P = .48). Levels of vitamin D in men were as deficient as in women (P = .42). Of all patients, 28% (42/150) had severely deficient vitamin D levels (< or = 8 ng/mL), including 55% of whom were younger than 30 years. Five patients, 4 of whom were aged 35 years or younger, had vitamin D serum levels below the level of detection. The severity of deficiency was disproportionate by age for young women (P < .001), by sex for East African patients (P < .001), and by race for African American patients (P = .006). Season was not a significant factor in determining vitamin D serum levels (P = .06). CONCLUSION: All patients with persistent, nonspecific musculoskeletal pain are at high risk for the consequences of unrecognized and untreated severe hypovitaminosis D. This risk extends to those considered at low risk for vitamin D deficiency: nonelderly, nonhousebound, or nonimmigrant persons of either sex. Nonimmigrant women of childbearing age with such pain appear to be at greatest risk for misdiagnosis or delayed diagnosis. Because osteomalacia is a known cause of persistent, nonspecific musculoskeletal pain, screening all outpatients with such pain for hypovitaminosis D should be standard practice in clinical care.

Relation between climacteric symptoms and ovarian hypofunction in middle-aged and older Japanese women.

OBJECTIVE: To gain insight into the characteristics and current status of climacteric symptoms reported by middle-aged and older women in Japan, we surveyed women presenting at our menopause clinic. DESIGN: The participants included 1,069 women, ranging in age from 40 to less than 60 years (mean age, 50.2 y). Climacteric (indefinite) symptoms were objectively assessed with the use of the Keio questionnaire, which grades the severity of 40 types of symptoms classified into 20 subgroups. The total scores obtained for the 40 symptoms were used to calculate symptom prevalence and severity. To evaluate ovarian function, concentrations of estradiol and follicle-stimulating hormone (FSH) in sera were measured. RESULTS: The most frequent symptom was general fatigue, reported by 88.2% of the women. Shoulder stiffness was the symptom rated to be severe by the highest percentage of women (38.1%). The prevalence and severity of hot flushes (and sweats) were slightly higher in perimenopausal and early postmenopausal women than in premenopausal and late postmenopausal women. The prevalence and severity of hot flushes and sweats were higher in women with estradiol < 25 pg/mL and FSH > 40 mIU/mL than in those with estradiol > or = 25 pg/mL and FSH < or = 40 mIU/mL. CONCLUSION: General fatigue and shoulder stiffness, symptoms with low hormone dependence, are the two most frequent climacteric symptoms in our clinic. Hot flushes and sweats, symptoms with high hormone dependence, are also common symptoms.

Vitamin D--the steroid hormone prescription for every patient.

Physicians in the United States rarely screen for hypovitaminosis D and rarely prescribe vitamin D, even when medically indicated. This is of particular concern in Minnesota. The sun's intensity at Minnesota's latitudes limits vitamin D production, at best, to March through October. A variety of lifestyle situations, including long work hours, may preclude adequate sun exposure. Additionally, people of Northern European background may avoid sun exposure to reduce risk of skin cancer and premature aging. And people of Asian and African heritage may not have sufficient vitamin D production due to increased skin pigmentation. This brief article summarizes key points regarding the importance of vitamin D, including its action as a steroid hormone and its role in cancer, hypertension, and autoimmune disease as well as in perinatal and prenatal health. The potential benefit of hypovitaminosis D screening and vitamin D supplementation is discussed, as are the populations most likely to need screening and supplementation.

Food as medicine--cost-effective health care? The example of omega-3 fatty acids.

The United States accounts for more than 51% of the dollar 430.3 billion expended on pharmaceutical products worldwide each year. Yet, in comparison to other advanced industrial societies, the United States has relatively worse health outcomes across many measures. This disparity challenges the perceived efficacy and cost effectiveness of pharmaceutical agents in promoting the public health. Before access to prescription drugs, our society first needs access to low-cost, nontoxic, non-expert-dependent interventions to ensure basic health outcomes. Food may represent the most cost-effective means of promoting public health. This article introduces the topic of food as medicine by discussing briefly the evidence base for omega-3 fatty acid-rich foods as modulators of physiologic pathways. It provides background on the physiological role of omega-3 and omega-6 fatty acids, discusses their roles in disease and disease prevention, and looks at changes in food production in this country that have led to a decrease in omega-3 consumption. It also recommends dietary interventions to remedy omega-3 deficiency and asserts that now is the time for our state and our nation to more aggressively fund research into medicinal foods.

Hmong shamanism. Animist spiritual healing in Minnesota.

Hmong cultural attitudes, values, and behaviors influence when, where, why, and with whom a Hmong person will use Western medicine. Understanding the practices and importance of Hmong healing traditions will help majority-culture physicians provide respectful and effective health care to Hmong patients. The foremost Hmong traditional healer is the shaman (tu txiv neeb, pronounced "too tse neng"). There is no equivalent health professional in Western biomedicine, and the scope of the shaman as a healer extends beyond the capacities and expertise of physicians. Despite 25 years of Hmong acculturation in the United States and conversion to Christianity, Hmong shamanism maintains its traditional role in health and healing. Many Hmong who see physicians also rely on shamans for restoring health and balance to their body and soul. Thus, the Hmong shaman can be considered a powerful complement to Western health care professionals. This article presents the results of semistructured interviews with 11 Hmong shamans (5 males, 6 females, ranging in age from 35 to 85) and 32 nonrandomly selected Hmong patients (14 males, 18 females ranging in age from 21 to 85). The shamans described their spiritual perspectives, training and skills, and professional activities. Patients described their beliefs about spiritual healing and health care. These interviews suggest that Shamanism is considered effective care by many Hmong, irrespective of age, gender, or degree of acculturation. The article also includes summary charts of Hmong healing practices and concludes with a set of questions designed to help practicing physicians access the assumptions and beliefs of their Hmong patients so that they can provide efficient, effective, and satisfactory care.

Elevated Deoxycholic Acid and Idiopathic Recurrent Acute Pancreatitis: A Case Report With 48 Months of Follow-up.

Recurrent pancreatitis is a potentially life-threatening condition with a well-established differential diagnosis. In a significant number of cases, no explanation exists. This case report documents one patient with a clear pattern of recurrent acute pancreatitis and no identifiable cause despite great effort. After 7 years of recurrent symptoms, she was found to have marked elevation of fecal deoxycholic acid (DCA), a secondary bile acid used to precipitate pancreatitis in animal models. This report documents cessation of symptoms/hospitalizations with normalization of her fecal DCA levels. This secondary bile acid is easily measured in stool. Needed now is an observational study of fecal DCA levels in patients with recurrent acute pancreatitis.