Complementary Medicine: Exploring the Issues U3A Short Course (3 of 3 sessions), Nov 2014 Dr Ken Harvey Page 1 Complementary Medicine: Exploring the Issues Dr Ken Harvey and Grace Jackel and Aaron Kovacs (SPH&PM Summer Research Program students) Short Course (3 of 3 sessions), Nov 2014, Multicultural Hub Issues that could be explored 2 • What is complementary &/or alternative medicine? • Who uses it, why and what for? • Regulation of products and practitioners; • The current review of the private health insurance rebate for natural therapies; • How do we know if it works: what is evidence? • Evidence for and against specific products &/ or therapies for certain conditions; • Sources of good information about complementary medicine, and • Using complementary medicine wisely.
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Complementary Medicine: Exploring the · • Clinical trials have shown that 1500 mg glucosamine sulfate as sodium chloride complex significantly improves pain and functionality in
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Complementary Medicine: Exploring the Issues U3A Short Course (3 of 3 sessions), Nov 2014
Dr Ken Harvey Page 1
Complementary Medicine: Exploring the Issues
Dr Ken Harveyand
Grace Jackel and Aaron Kovacs (SPH&PM Summer Research Program students)
Short Course (3 of 3 sessions), Nov 2014, Multicultural Hub
Issues that could be explored
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• What is complementary &/or alternative medicine?
• Who uses it, why and what for?
• Regulation of products and practitioners;
• The current review of the private health insurance rebate for natural therapies;
• How do we know if it works: what is evidence?
• Evidence for and against specific products &/or therapies for certain conditions;
• Sources of good information about complementary medicine, and
• Using complementary medicine wisely.
Complementary Medicine: Exploring the Issues U3A Short Course (3 of 3 sessions), Nov 2014
Dr Ken Harvey Page 2
• Of the 25 products on the list most are unremarkable: Iron, Calcium, Vitamin D, Psyllium fibre and Ispaghula husk for constipation, Clove oil for toothache.
• More innovative products are:– IBEROGAST (Flordis). A specific nine herb mixture, “for the
treatment of functional dyspepsia and irritable bowel syndrome”.
– KALOBA (Schwabe) containing a specific extract of Pelargonium sidoides (EPs 7630) for “for the treatment of acute bronchitis and sinusitis” (an alternative to prescribing an antibiotic).
– FLEXAGIL (Blackmores). A specific extract of Symphytum officinale(Comfrey) for topical application for the “relief of lower back pain, painful joints and strains”.
• Nature’s Way Glucosamine 1500 mg contains the clinically recommended daily dose of glucosamine in just one convenient tablet.
• Glucosamine is considered the most important nutrient for the protection, renewal and building of joint tissue and in forming the ‘cushioning’ effect of the joints and surrounding tissues.
• Glucosamine promotes the protection, repair and rebuilding of damaged joints and cartilage in the fingers, hands, wrists, knees, back, neck, hips, ankles and feet.
• Clinical trials and research show that glucosamine helps:– Provide temporary relief of the pain of osteoarthritis,
– Reduce joint inflammation and swelling,
– Increase joint mobility,
– Keep all the joints in the body lubricated and supple.
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$30.99 (180 tabs)SAVE $9.00RRP $39.99
Dose: 1 tab per day(17 cents per day) http://tinyurl.com/lppbv6f
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Glucosaminefor osteoarthritis
• Cenovis® Glucosamine 750 helps to maintain the structure and function of cartilage in joints, while also helping to repair and rebuild damaged cartilage.
– May assist in the management of osteoarthritis.
– Temporarily relieves pain and enhances joint mobility.
– May help reduce the joint inflammation, swelling and tenderness associated with arthritis.
– May assist in the maintenance of proper joint function.
– May provide temporary relief of joint pain.
– May enhance joint mobility.
– Maintains structure and function of joint cartilage.
– May help reduce joint inflammation, swelling and tenderness associated with arthritis.
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$30.19 (200 tabs)Dose: 2 caps daily30 cents per day
http://www.cenovis.com.au/glucosamine-750/
Glucosaminefor osteoarthritis
• Blackmores Glucosamine 1500 offers a convenient, one a day dose to help reduce joint inflammation and swelling, and help relieve the pain caused by osteoarthritis.
• Supplementary glucosamine sulfate helps reduce cartilage wear, increase joint mobility and decrease joint stiffness in osteoarthritis.
– Effective for osteoarthritic pain relief
– Helps reduce cartilage wear
– Contains the most scientifically validated form of glucosamine; glucosamine sulfate sodium chloride complex
– Results expected after 2‐4 weeks
• Clinical trials have shown that 1500 mg glucosamine sulfate as sodium chloride complex significantly improves pain and functionality in osteoarthritis. In addition, glucosamine sulfatemay have a long‐term protective effect, acting to reduce cartilage wear.
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$59.49 (180 tabs)Dose 1 tab per day33 cents per day
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Glucosaminefor osteoarthritis
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• DONA® Glucosamine is a patented formulation of glucosamine sulfateclinically proven to reduce the pain and assist in the management of osteoarthritis.
• DONA Glucosamine may also help to maintain joint health and rebuild cartilage that has been worn away by progressive age or injury.
• It is manufactured using a patented process by one of the leading natural medicine companies in the world, Madaus/Rottapharm.
• DONA Glucosamine was developed following many years of research and has been the subject of 25 clinical trials.
Glucosamine is sold by itself in the form of glucosamine hydrochloride or sulphate or in combination with other supplements (such as chondroitin).
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Glucosamine for osteoarthritis
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• Major studies of glucosamine for osteoarthritis of the knee have had conflicting results.
– A large National Institutes of Health (NIH) study, compared glucosamine hydrochloride, chondroitin, both supplements together, celecoxib (a prescription drug used to manage osteoarthritis pain), or a placebo (an inactive substance) in patients with knee osteoarthritis. Most participants in the study had mild knee pain. Those who received the prescription drug had better short‐term pain relief (at 6 months) than those who received a placebo.
– Overall, those who received the supplements had no significant improvement in knee pain or function, although the investigators saw evidence of improvement in a small subgroup of patients with moderate‐to‐severe pain who took glucosamine and chondroitin together.
– In several European studies, participants reported that their knees felt and functioned better after taking glucosamine. The study participants took a large, once‐a‐day dose of a preparation of glucosamine sulfate (Rottapharm) sold as a prescription drug in Europe.
– In general, research on chondroitin has not shown it to be helpful for pain from knee or hip osteoarthritis. http://nccam.nih.gov/health/glucosaminechondroitin
Glucosamine for osteoarthritis
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• A few studies have looked at whether glucosamine or chondroitin can have beneficial effects on joint structure. Some but not all studies found evidence that chondroitin might help, but the improvements may be too small to make a difference to patients. There is little evidence that glucosamine has beneficial effects on joint structure.
• No serious side effects have been reported in large, well‐conducted studies of people taking glucosamine, chondroitin, or both for up to 3 years.
• However, glucosamine or chondroitin may interact with the anticoagulant (blood‐thinning) drug warfarin (Coumadin) and also the way your body handles sugar, especially if you have diabetes or other blood sugar problems, such as insulin resistance or impaired glucose tolerance.
• If you take warfarin or have blood sugar problems, make sure you talk to your doctor about potential side effects if you are considering or taking glucosamine or chondroitin supplements.
• [Many, but not all products, are derived from seafood and thus are not suitable for those with an allergy to shellfish]
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• This update includes 25 studies with 4963 patients.
• Pain: High quality studies showed that pain improved about the same whether people took glucosamine or fake pills.
– However, if all of the studies are examined (including low quality and old studies), then glucosamine improved pain more than fake pills.
– Studies testing only the Rotta brand of glucosamine (including low quality and older studies) showed that glucosamine improved pain more than fake pills.
• Function: The high quality studies show that glucosamine improved function more than fake pills when measured by one type of scale, but improved the same amount as fake pills when measured by another scale.
– Studies testing only the Rotta brand of glucosamine (including low quality and older studies) showed that glucosamine improved function more than fake pills.
• Side effects: There was no difference in the number of people taking glucosamine or placebo who reported side effects; these mainly included stomach upset and other joint pain.
• All four groups demonstrated reduced knee pain over the first year, but no significant differences between groups (p=0.93) were detected.
• 303 (50% ) of knee X‐rays were available for the 2‐year follow‐up.– The combination (glucosamine–chondroitin) resulted in a statistically significant
(p=0.046) reduction of 2‐year joint narrowing compared to placebo: mean difference 0.10 mm (95% CI 0.00 mm to 0.20 mm). Regardless, is this of clinical significance?
– no significant structural effect for the single treatment allocations was detected.
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The problem with p values:
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• The current consensus is that if p is less than .05, a study has reached the holy grail of being statistically significant, and therefore likely to be published.
• Over .05 and it’s usually back to the drawing board.
• However, it’s been contended that using .05 is a key reason why false claims are published and many published results fail to replicate. Some advocate requiring .005 or even .001 as the criterion for statistical significance.
• But this would require larger and more expensive studies.
• A confidence interval gives us the best estimate of the true effect, and also indicates the extent of uncertainty in our results. Confidence intervals also us to integrate results from a number of experiments into a meta‐analysis.
• Conclusion:– The divergent results of randomised
controlled trials can be attributable to the use of different glucosamine preparations, different trial methodologies, study populations, durations and possibly the influence of product sponsors.
– The evidence for efficacy is inconclusive.
– The U.K. National Institute for Health and Care Excellence (NICE) 2014 osteoarthritis guidelines state:
• The use of glucosamine or chondroitin products is not recommended.
• Activity, exercise and weight loss are important non‐drug measures.
• Paracetamol is the first choice for pain relief.
– If you wish to trial glucosamine use the sulphate form (1500 mg daily) and objectively evaluate your pain using a daily diary for three months before and after.
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Turmeric (curcumin) for osteoarthritis
• Our special formulation of curcumin has been shown in clinical trials to:
– Improve mobility in osteoarthritis,
– Decrease osteoarthritis pain, swelling and inflammation.
– Help reduce the impact of osteoarthritis on social and leisure activities.
– Be absorbed up to 29 times more effectively than standard curcumin extracts.
– Get into your bloodstream twice as fast as standard curcuminsto get to work faster!
• In fact, in recent clinical trials, people with osteoarthritis who took the special Meriva® curcumin in Curcumin Anti‐Inflammatory Pain Reliever could walk over twice as far on a treadmill test as those who did not.
• Medline Plus:– Some research shows that taking some turmeric extracts can reduce the
pain caused by osteoarthritis of the knee.
• Cochrane:– No results.
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Turmeric (curcumin) for osteoarthritis
• Efficacy and safety of Meriva®, a curcumin‐phosphatidylcholine complex, during extended administration in osteoarthritis patients (Altern Med Rev. 2010 Dec;15(4):337‐44).
– The long‐term efficacy and safety of Meriva were investigated in an eight month study involving 100 OA patients.
– The clinical end points (Western Ontario and McMaster Universities [WOMAC] score, Karnofsky Performance Scale Index, and treadmill walking performance) were complemented by the evaluation of a series of inflammatory markers.
– The treatment consisted of two 500‐mg tablets daily, one after breakfast and one after dinner (1,000 mg/day, corresponding to 200 mg curcumin/day).
– Significant improvements of both the clinical and biochemical end points were observed for Meriva compared to the control group. This, coupled with an excellent tolerability, suggests that Meriva is worth considering for the long‐term complementary management of osteoarthritis.
• Comment:– The same authors had previously conducted a smaller preliminary trial with similar results
but these 2010 results are yet to be replicated. 24
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Turmeric (curcumin) for osteoarthritis
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• No clinical trials found on the use of Theracurmin® in osteoarthritis.
• Only studies on absorption and blood levels.
Evening Primrose oil for osteoarthritis
• Famously associated with relief of the symptoms of PMT, premenstrual breast pain and the hot flushes and sweatsof menopause.
• Evening Primrose Oil also helps relieve the pain of swollen joints, arthritis and rheumatism.
• The health benefits of Blooms Evening Primrose Oil 1000 mg extends to improving digestion, relief of constipation and the maintenance of healthy blood pressure, blood circulation and cholesterol levels in healthy people.
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Evening Primrose oil for osteoarthritis
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• Medline Plus:– There is not enough evidence to support the use of
evening primrose oil for any health condition.
– The best‐designed clinical trials of evening primrose oil for premenstrual symptoms (PMS) found no effect.
– Evening primrose oil does not appear to affect menopausal symptoms.
– Evening primrose oil is well tolerated by most people, when taken for short periods of time. Mild side effects include gastrointestinal upset and headache. However, the safety of long‐term use of evening primrose oil has not been established.
– Evening primrose oil may increase bleeding in people who are taking the anticoagulant (blood thinning) medication warfarin.
• Medline:– No clinical trials found on the use of Evening Primrose Oil in
osteoarthritis.
Omega‐3 fatty acids (fish oil): Heart disease
• 5 Things To Know About Omega‐3s for Heart Disease– Experts agree that fish rich in omega‐3 fatty acids should be
included in a heart‐healthy diet (a least 2‐3 times a week).
– Omega‐3s in supplement form have not been shown to protect against heart disease.
– Omega‐3 supplements may interact with drugs that affect blood clotting.
– Fish liver oils (which are not the same as fish oils) contain vitamins A and D as well as omega‐3 fatty acids; these vitamins can be toxic in high doses. The amounts of vitamins in fish liver oil supplements vary from one product to another.
– Talk to your health care provider before using omega‐3 supplements.28http://nccam.nih.gov/health/tips/omega3
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Omega‐3 fatty acids: Krill oil
• What’s the difference between fish oil and krill oil?
• In a word, absorbability. While fish oil and krill oil both contain omega‐3 fatty acids, they exist in different forms.
• The omega‐3 in krill oil is mainly in the form of phospholipids, while the omega‐3 found in fish oil is mainly in the form of triglycerides. The omega‐3 in phospholipid form is more easily absorbed by the body.
• As a result, you may not need to take as much krill oil in order to get the same health benefits.
A re‐examination of krill oil bioavailability studies• It has proven difficult to compare the bioavailability of krill oil vs. fish oil
due to several of the characteristics of krill oil.
• However, several claims have been made suggesting greater bioavailability of krill oil vs. fish oil. These have largely been based on a statistical argument where a somewhat lower dose of krill oil has been used to result in a similar bloodstream level of EPA and/or DHA or their total.
• However, the magnitude of the dosage differential is shown to be too small to be expected to result in differing blood levels of the long chain n‐3 PUFAs.
• It is concluded that there is at present no evidence for greater bioavailability of krill oil vs. fish oil and that more carefully controlled human trials must be performed to establish their relative efficacies after chronic administration.
Lipids Health Dis. 2014; 13(1): 137.Published online Aug 26, 2014.doi: 10.1186/1476-511X-13-137
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Omega‐3 fatty acids: Chia seeds
• Chia is an edible seed that comes from the desert plant Salvia hispanica, grown in Mexico dating back to Mayan and Aztec cultures.
• Chia seeds are an unprocessed, whole‐grain food that can be absorbed by the body. Chia seed contains a high concentration of the omega‐3 fatty acid, alpha‐linolenic acid. They also contains a significant concentration of dietary fibre, protein, calcium, magnesium, iron, and antioxidants
• The mild, nutty flavour of chia seeds makes them easy to add to foods and beverages. They are most often sprinkled on cereal, sauces, vegetables, rice dishes, or yogurt or mixed into drinks and baked goods.
• There is no evidence of any special health benefits apart from the nutrients they contain.
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Calcium & Vitamin D: Preventing osteoporosis
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The groups at greatest risk of vitamin D deficiency in Australia are dark-skinned and veiled women (particularly in pregnancy),
their infants, and older persons living in residential care
Recommended sun exposure Melbourne (face, hands & arm)
Dec‐Jan (10:00 or 14:00) 6‐8 minJul‐Aug (12:00) 25 min
Vitamin C / Garlic / Echinacea for colds
• Helps to reduce the severity and duration of colds.
• Helps to protect against free radical damage.
• Promotes wound healing via its role in collagen production.
• Stress of all kinds, including ill health and emotional stress, increases the excretion of vitamin C from the body and may increase the need for this vitamin.
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Vitamin C / Garlic / Echinacea for colds
• Vitamin C (ascorbic acid) for preventing and treating the common cold has been a subject of controversy for 70 years.
• This review is restricted to placebo‐controlled trials testing 0.2 g/day or more of vitamin C.
• Regular ingestion of vitamin C had no effect on preventing common colds in the ordinary population, based on 29 trials involving 11,306 participants.
• Thirty‐one trials examined the effect of regular vitamin C on common cold duration (9745 episodes). In adults the duration of colds was modestly reduced by 8% (3% to 12%).
• Seven comparisons examined the effect of therapeutic vitamin C (3249 episodes). No consistent effect of vitamin C was seen on the duration or severity of colds in the therapeutic trials.
• Echinacea plant preparations are widely used for common colds.
• Most consumers and physicians are not aware that products available under the term Echinacea differ appreciably in their composition, mainly due to the use of variable plant material, extraction methods and the addition of other components.
• Twenty‐four double‐blind trials with 4631 participants including a total of 33 comparisons of Echinacea preparations and placebo met the inclusion criteria.
• Echinacea products have not here been shown to provide benefits for treating colds.
• It is possible there is a weak benefit from some Echinacea products however the effects are of questionable clinical relevance.
• Magnesium intake with our food has greatly declined due to the use of inorganic fertilisers
• Also because the medical profession overemphasises our need for a high calcium intake and excessive calcium supplementation at the expense of magnesium.
• If the magnesium levels are low, then the calcium levels rise to restore balance.
• What does the body do with the excess calcium in the blood? It dumps it into tissue wherever there is some chronic inflammation.
Magnesium chloride for health and rejuvenationhttp://www.nexusmagazine.com/ Feb - Mar 2008, pg 21-26
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Magnesium (Nigari flakes, etc)
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• This leads to the calcification of joints, as in arthritis, and to the calcification of ovaries and other glands, resulting in declining hormone production. Calcifying kidneys eventually require dialysis, and calcifications in breast tissue, especially the milk ducts, are often managed with unnecessary mastectomies and other invasive treatments.
• A solution to this problem is to lower calcium levels in the blood by keeping up a high intake of magnesium.
• Magnesium chloride can be added to food or drink, like juice, mostly to disguise the salty‐bitter taste. I mix it with juice myself, a quarter of a teaspoon at a time, and it is fine.
• When dealing with factors such as stress, advancing age, cardiovascular problems and signs of calcification, up to 1,000 mg is the daily dosage recommended by many health practitioners.
Magnesium chloride for health and rejuvenationhttp://www.nexusmagazine.com/ Feb - Mar 2008, pg 21-26
Miracle Mineral Supplement
• About the author: – Jim Humble has written a book, Breakthrough:
The Miracle Mineral Supplement of the 21st Century –Parts I and II, available from his website http://www.miraclemineral.org .
– Part I can be downloaded for free.
• We recommend that readers visit his web site to learn more about chlorine dioxide, the use of his Miracle Mineral Supplement and his treatment protocols.
A Miracle Treatment for Malaria and Other Diseaseshttp://www.nexusmagazine.com/ Feb - Mar 2008, pg 19-24
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Miracle Mineral Solution slammed by AMA & TGA
• Ten Victorians have reported being poisoned by MMS in the past five years –which is believed to be a “vast under‐reporting” of cases – critics say the bleach is potentially deadly.
• It is recommended to treat diseases including cancer, HIV/AIDS, asthma and autism and it’s suggested it is a “promising” treatment for Ebola.
• The product contains 28% sodium chlorite solution (bleach) which, mixed with acid which produces chlorine dioxide.
• Victorian Poisons Information Centre specialist Dr Dawson MacLeod said people had reported symptoms including vomiting and diarrhoea after using MMS. Of the 10 people who had reported being poisoned by MMS, four had to be hospitalised.
• Dr MacLeod said, “There’s no basis in science for it being effective.”
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MMS solution available for sale online from an
Australian website. http://tinyurl.com/pfxencd; http://www.tga.gov.au/alert/miracle-mineral-solution-mms
Magnesium
• Swisse Ultiboost Magnesium is a premium quality formula containing a bioavailable form of magnesium (citrate) to help reduce muscle cramps and spasms, support a healthy nervous system and help relieve premenstrual syndrome (PMS) symptoms.
• Lifestyle factors such as prolonged stress and lack of sleep may deplete magnesium levels.
• Swisse Ultiboost Magnesium has been formulated based on scientific evidence to support a physically active lifestyle
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Complementary Medicine: Exploring the Issues U3A Short Course (3 of 3 sessions), Nov 2014
• Magnesium is found naturally in many foods. You can get recommended amounts of magnesium by eating a variety of foods, including the following:
– Legumes, nuts, seeds, whole grains, and green leafy vegetables (such as spinach)
– Milk, yogurt, and fortified breakfast cereals .
• Magnesium is also available in multivitamin‐mineral supplements and other dietary supplements.
– Forms of magnesium in dietary supplements that are more easily absorbed by the body are magnesium aspartate, magnesium citrate, magnesium lactate, and magnesium chloride.
• Pathological effects of primary nutritional deficiency of magnesium occur only rarely unless low intakes are accompanied by prolonged diarrhoea or excessive urinary loss.
• Symptoms of magnesium deficiency include loss of appetite, nausea, vomiting, fatigue, and weakness. Extreme magnesium deficiency can cause numbness, tingling, muscle cramps, seizures and an abnormal heart rhythm..
• In healthy people, the kidneys can get rid of any excess in the urine. But magnesium in dietary supplements and medications should not be consumed in amounts above the upper limit, unless recommended by a health care provider.
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Magnesium
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• Magnesium supplements can interact or interfere with some medicines. For example:
– Bisphosphonates, used to treat osteoporosis, are not well absorbed when taken too soon before or after taking dietary supplements or medications with high amounts of magnesium.
– Antibiotics might not be absorbed if taken too soon before or after taking a dietary supplement that contains magnesium.
– Diuretics can either increase or decrease the loss of magnesium through urine, depending on the type of diuretic.
– Prescription drugs used to ease symptoms of acid reflux or treat peptic ulcers can cause low blood levels of magnesium when taken over a long period of time.
– Very high doses of zinc supplements can interfere with the body’s ability to absorb and regulate magnesium.
• Acupuncture is known to treat a wide range of disorders including:– Musculoskeletal disorders such as osteoarthritis,
sciatica, lumbago, weak back, low back pain, rheumatoid arthritis, gout, tenosynovitis, shoulder and neck pain, cervicobrachial syndrome, 'frozen shoulder', and 'tennis elbow'.
– The disorders above which appear in bold have been recognised by the World Health Organisation (December 1979) as having been successfully treated by acupuncture. The disorders which do not appear in bold above are other common disorders which have been found to respond well to acupuncture.
Acupuncture
• How much do we know about acupuncture?– There have been extensive studies conducted on acupuncture,
especially for back and neck pain, osteoarthritis/knee pain, and headache. However, researchers are only beginning to understand whether acupuncture can be helpful for various health conditions.
• What do we know about the effectiveness of acupuncture?– Research suggests that acupuncture can help manage certain pain conditions,
but evidence about its value for other health issues is uncertain.
• What do we know about the safety of acupuncture?– Acupuncture is generally considered safe when performed by an experienced,
well‐trained practitioner using sterile needles. Improperly performed acupuncture can cause serious side effects.
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Acupuncture
• It’s difficult to compare acupuncture research results from study to study and to draw conclusions from the cumulative body of evidence.
• This is because studies may use different acupuncture techniques (e.g., electrical vs. manual), controls (“placebo” or “sham” ) and varied outcome measures.
• An emerging theme in acupuncture research is the role of the placebo.
• For example, a 2009 systematic review of research on the pain‐relieving effects of acupuncture compared with placebo (simulated) or no acupuncture was inconclusive.
• The reviewers found a small difference between acupuncture and placebo and a moderate difference between placebo and no acupuncture but the effect of placebo acupuncture varied considerably.
• To use CM wisely:– ALWAYS tell your health practitioners about ALL the medicines you take.
– Ask your practitioner for advice, especially:• Evidence of efficacy from well conducted clinical trials concerning the specific product recommended,
• Possible side‐effects and potential interactions with your existing therapy.
– Search for independent information from trusted sources used in this course:
• Also good consumer sites e.g.– https://www.chf.org.au/useful‐links.php
– http://www.chronicillness.org.au/
– http://www.arthritisaustralia.com.au/
– Be very skeptical about promotional claims. 62
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Remember: CM are no substitute for a good diet and exercise
63http://www.shapeup.gov.au/start-shaping-up
Health care interventions: Choosing wisely
2015 Short course (8 sessions)
• Medical advances have helped many of us live longer and have a better quality of life.
• Yet a number of studies have shown that around one third of what we spend on health care is probably unnecessary, wasteful and sometimes harmful. This is especially true for medical interventions near the end‐of‐life.
• Ironically, many doctors die differently from their patients. They don’t want fancy treatment, expensive chemotherapy offering little benefit or cardiopulmonary resuscitation (CPR). They know the downsides and they just say no.
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Health care interventions: Choosing wisely
• This 2015 short course will encourage people to ask questions of their healthcare professionals about the risks, benefits and costs of certain medical investigations and procedures.
• Topics to be covered will include cardiopulmonary resuscitation (CPR), cancer chemotherapy, screening for breast, colorectal cancer and prostate cancer, testosterone therapy in ageing men, polypharmacy (multiple medications), antipsychotics in dementia and the use of antibiotics for upper respiratory tract infection.
• We will also discus (with Dr Rodney Syme) dying with dignity, advance healthcare directives, refusal of treatment and enduring medical power of attorney certificates. 65