Primary Prevention and Medical Treatment with Nutritional Supplements in Primary Care

1
Primary Prevention and Medical Treatment with
Nutritional Supplements in Primary Care

• A Brief Overview by William R. Rogers D.O., CCN

2
Flow of the Lecture

• Introduce the topic of Nutrigenomics
• Discuss landmark study on the need for one year
  preconceptional vitamins with folic acid to
  reduce preterm labor by 70
• Discuss Co Enzyme Q 10 and its importance for
  supplementation
• Discuss Omega 3 oils, digestive enzymes,
  probiotics, and vitamin D
• Discuss cGMP
• Case histories

3
University of California Davis
4
Nutrigenomics

• The goal of nutritional genomics is to identify
  those positive and negative interactions between
  the common constituents of diet and the genetic
  determinants they interact with
• the use of genetic/genomic/ epigenomic
  information and nutritional inventions to promote
  health and prevent disease.

5
Nutrigenetics

• Nutrigenomics is a rapidly growing field making
  use of molecular biology methodologies, such as
  microarray technology, to study how specific
  nutrients or diets affect gene expression
• Recently the word "nutrigenetics" is being used
  to refer to study of the effects of genetic
  variation and gene-nutrient interactions in the
  management of chronic diseases

6
Labor-Associated Gene Expression in the Human
Uterine Fundus, Lower Segment, and Cervix

• The elucidation of the mechanisms of gene
  expression likely to be fundamental for
  controlling labor is an important prerequisite to
  the development of effective treatments for major
  obstetric problemsincluding prematurity, with
  its long-term consequences to the health of
  mother and offspring.
• Radek Bukowski, 2006
• http//dx.doi.org/10.13712Fjournal.pmed.0030169

7
Fetal growth in early pregnancy and risk of
delivering low birth weight infant

• Adverse outcome of pregnancy in a considerable
  proportion of women is likely to be determined
  before their first prenatal visit. These findings
  underline the importance of detailed study of the
  periconceptional period and first trimester of
  pregnancy when assessing factors that influence
  the risk of adverse outcome and in the
  development of predictive tests.
• Radek Bukowski
• BMJ. 2007 April 21 334(7598) 836.

8
Preterm Delivery an Enigma

• The severity of health problems depends on the
  degree of prematurity preterm babies born
  between 34 and 36 weeks of pregnancy rarely
  develop severe disabilities, but a quarter of
  babies born before 28 weeks of pregnancy develop
  serious lasting disabilities and half have
  learning and behavioral problems
• it is impossible to predict who will have an
  early birth and there is no effective way to
  prevent preterm births.

9
Infant Mortality rates Effected

• Every year, half a million babies in the United
  States (12.5 of all babies) are born prematurely
  (before 37 completed weeks of pregnancy). Sadly,
  premature babies are more likely to die than
  full-term babies and many have short- and/or
  long-term health problems.

10
Preconceptional Folate May 2009

• In a cohort of 38,033 low-risk singleton
  pregnancies enrolled in a study of aneuploidy
  risk, preconceptional folate supplementation was
  prospectively recorded in the first trimester of
  pregnancy
• Duration of pregnancy was estimated based on
  first trimester ultrasound examination

11
Preconceptional Folate

• Natural length of pregnancy was defined as
  gestational age at delivery in pregnancies with
  no medical or obstetrical complications that may
  have constituted an indication for delivery.
  Spontaneous preterm birth was defined as duration
  of pregnancy between 20 and 37 wk without those
  complications

12
UTMB Cohort Retrospective study published Feb
2009

• Multiple Vitamins with folic acid taken by
  pregnant women 1 year continuously prior to
  getting pregnant reduced risk of preterm labor by
  70
• Review of NIH data on 38 thousand women surveyed.
  
• Although the study did not ask the amount taken,
  the assumption is that the women took the
  currently recommended 400-µg daily dose.

13
Preconceptional Folate

• The association between preconceptional folate
  supplementation and the risk of spontaneous
  preterm birth was evaluated using survival
  analysis.
• Comparing to no supplementation, preconceptional
  folate supplementation for 1 y or longer was
  associated with a 70 decrease in the risk of
  spontaneous preterm delivery between 20 and 28 wk
  (41 0.27 versus 4 0.04 spontaneous preterm
  births, respectively HR 0.22, 95 confidence
  interval CI 0.080.61, p 0.004) and a 50
  decrease in the risk of spontaneous preterm
  delivery between 28 and 32 wk (58 0.38 versus
  12 0.18 preterm birth, respectively HR 0.45,
  95 CI 0.240.83, p 0.010).

14
Preconceptional Folate Supplementation and the
Risk of Spontaneous Preterm Birth A Cohort Study

• Low plasma folate concentrations in pregnancy are
  associated with preterm birth.
• Radek Bukowski ET. AL. shows an association
  between preconceptional folate supplementation
  and the risk of spontaneous preterm birth.
• every woman of childbearing age should consume
  400 micrograms of folic acid daily."

15
Limitations of the study on Preconceptional folate

• Nicholas Fisk and colleagues also point out
  limitations to the study -
• information on folic acid dose, formulation (with
  or without other supplements), and daily
  compliance is incomplete. The study design was
  observational, so the presence of other factors,
  such as healthier behaviors on the part of women
  who take folate supplements, may explain the
  findings. Further evidence as to whether folic
  acid prevents spontaneous preterm birth will
  require a randomized controlled trial.
• http//www.medicalnewstoday.com/articles/150078.p
  hp

16
Poor Periconceptional Nutrition and Idiopathic
Preterm Labor

• Leonie Callaway,1,2 Paul B. Colditz,2,3 and
  Nicholas M. Fisk2,3
• Poor periconceptional nutrition is implicated in
  idiopathic preterm labor in both animal models
  and human studies.
• Women taking supplements for at least one year
  before conception had a 70 reduction in
  spontaneous preterm birth between 2028 weeks,
  and a 50 reduction between 2832 weeks, when
  compared to those with no additional
  supplementation. Long-term compared to no
  supplementation was associated with a reduction
  in the risk of spontaneous preterm birth before
  32 weeks from one in 154 to one in 423.
• http//www.pubmedcentral.nih.gov/articlerender.fcg
  i?artid2671593

17
Preconceptional Folate

• However, the risk of spontaneous preterm birth
  decreased with the duration of preconceptional
  folate supplementation contained in a multiple
  vitamin (test for trend of survivor functions, p
  0.01) and was the lowest in women who used
  folate supplementation for 1 y or longer.

18
Folic Acid From Leafy Green Vegetables, Fruits,
and dried Beans
19
Preconceptional Folate

• Folate (folic acid), a vitamin found in leafy
  green vegetables, fruits, and dried beans, helps
  to prevent neural tube birth defects.
• In this study, the researchers test this idea by
  analyzing data collected from nearly 38,000
  pregnant women enrolled in a study that was
  originally designed to investigate screening for
  Down's syndrome.
• one of the very few opportunities to prevent
  first preterm births.

20
Oral Contraceptives and Nutritional Depletion

• Back in the mid-1970's studies reporting that
  oral contraceptives depleted a variety of
  nutrients began appearing in the scientific
  literature. Numerous studies now document the
  fact that oral contraceptives deplete the
  following nutrients folic acid, vitamin B6,
  vitamin B12, vitamin B2, vitamin C, magnesium and
  zinc. http//www.healingwithnutrition.com/newsclip
  s/archive/drugdepletion.html

21
Reversing Congestive Heart Failure with Co Q 10
22
Coenzyme Q10

• Coenzyme Q10 (Co Q 10) or ubiquinone is
  essentially a vitamin or vitamin-like substance.
• The biosynthesis of CoQ10 from the amino acid
  tyrosine is a multistage process requiring at
  least eight vitamins and several trace elements.

23
Co Q 10

• Coenzyme Q10 is the coenzyme for at least three
  mitochondrial enzymes (complexes I, II and III)
  as well as enzymes in other parts of the cell.
  Mitochondrial enzymes of the oxidative
  phosphorylation pathway are essential for the
  production of the high-energy phosphate,
  adenosine triphosphate (ATP), upon which all
  cellular functions depend. The electron and
  proton transfer functions of the quinone ring are
  of fundamental importance to all life forms

24
Nutritional Deficiencies Lead to TO COENZYME Q10
Deficiencies

• In 1958, Professor Karl Folkers and coworkers at
  Merck, Inc determined the precise chemical
  structure of CoQ10
• Biosynthesis of this complex, 17 step process,
  requiring at least seven vitamins (vitamin B2 -
  riboflavin, vitamin B3 - niacinamide, vitamin B6,
  folic acid, vitamin B12, vitamin C, and
  pantothenic acid) and several trace elements, is,
  by its nature, highly vulnerable. Karl Folkers
  argues that suboptimal nutrient intake in man is
  almost universal and that there is subsequent
  secondary impairment in CoQ10 biosynthesis. PETER
  H. LANGSJOEN, M.D., F.A.C.C., http//faculty.washi
  ngton.edu/ely/coenzq10.html

25
Statins deplete Co Q 10

• Statin drugs decreases cholesterol synthesis by
  inhibiting the conversion of acetyl CoA to
  mevalonate. Mevalonate is also necessary in the
  production of ubiquinone, or coenzyme Q10
  (CoQ10).
• CoQ10 is necessary for mitochondrial energy
  production as well as exhibits potent antioxidant
  activity.
• Crane FL Biochemical functions of coenzyme Q10. J
  Am Coll Nutr. 2001 Dec20(6)591-8.

26
Use Supplement CoQ10 for Heart Failure

• HMG-CoA reductase inhibitors used to treat
  elevated blood cholesterol levels by blocking
  cholesterol biosynthesis also block CoQ10
  biosynthesis
• In patients with heart failure this is more than
  a laboratory observation. It has a significant
  harmful effect which can be negated by oral CoQ10
  supplementation.
• Folkers K., Langsjoen Per H., Willis R.,
  Richardson P., Xia L., Ye C., Tamagawa H. (1990)
  Lovastatin decreases coenzyme Q levels in humans.
  Proc. Natl. Acad Sci. Vol. 87, pp.8931-8934.

27
Co Enzyme Q 10

• CoQ10 is known to be highly concentrated in heart
  muscle cells due to the high energy requirements
  of this cell type
• Specifically, congestive heart failure (from a
  wide variety of causes) has been strongly
  correlated with significantly low blood and
  tissue levels of CoQ10
• The severity of heart failure correlates with the
  severity of CoQ10 deficiency
• Dosage is 100 to 300 mg/day

28
Supplement Co Q 10 in Heart Failure

• nine studies on heart failure have confirmed the
  effectiveness of CoQ10 as well as its remarkable
  safety
• There have now been eight international symposia
  on the biomedical and clinical aspects of CoQ10
  (from 1976 through 1993 ). These eight symposia
  comprised over 300 papers presented by
  approximately 200 different physicians and
  scientists from 18 different countries.
• consistent in their conclusions that treatment
  with CoQ10 significantly improved heart muscle
  function while producing no adverse effects or
  drug interactions.
• It has no known toxicity or side effects.
• http//faculty.washington.edu/ely/coenzq10.html

29
Controversy on Co Q 10 Political and Economic

• The controversy surrounding CoQ10 likewise is
  political and economic as the previous 30 years
  of research on CoQ10 have been remarkably
  consistent and free of major controversy.
  Although it is not the first time that a
  fundamental and clinically important discovery
  has come about without the backing of a
  pharmaceutical company.
• PETER H. LANGSJOEN, M.D., F.A.C.C,
  http//faculty.washington.edu/ely/coenzq10.html

30
Omega-3 Fish Oils
31
Omega-3 supplementation

• Survival curves for n-3 PUFA treatment diverged
  early after randomization, and total mortality
  was significantly lowered after 3 months of
  treatment (relative risk RR 0.59 95 CI 0.36
  to 0.97 P0.037). The reduction in risk of
  sudden death was specifically relevant and
  statistically significant already at 4 months (RR
  0.47 95 CI 0.219 to 0.995 P0.048). A
  similarly significant, although delayed, pattern
  after 6 to 8 months of treatment was observed for
  cardiovascular, cardiac, and coronary deaths.
• Circulation. 20021051897-1903

32
Statistically Significant Decrease Sudden Death
in Just 4 Months

• Conclusions The early effect of low-dose (1 g/d)
  n-3 PUFAs on total mortality and sudden death
  supports the hypothesis of an antiarrhythmic
  effect of this drug. Such a result is consistent
  with the wealth of evidence coming from
  laboratory experiments on isolated myocytes,
  animal models, and epidemiological and clinical
  studies.
• Circulation. 20021051897-1903

33
N-3 polyunsaturated fatty acids help reduce
coronary death

• randomized controlled trials, published in all
  languages from 1966 to 1999.
• 7,951 patients in the intervention groups (range
  31 to 5,666) and 7,855 patients in the control
  groups (range 28 to 5,658). The mean age was 49
  to 66 years between 33 and 100 had a previous
  myocardial infarction and the average follow-up
  lasted 20 months (range 6 to 46 months).

34
N-3 polyunsaturated fatty acids help reduce
coronary death

• In patients with coronary heart disease, diets
  enriched with n-3 polyunsaturated fatty acids
• had no effect on nonfatal myocardial infarction
  (risk ratio 0.8, 95 confidence interval 0.5 to
  1.2)
• reduced the risk of fatal myocardial infarction
  (risk ratio 0.7, 95 confidence interval 0.6 to
  0.8)
• reduced the risk of sudden death (risk ratio
  0.7, 95 confidence interval 0.6 to 0.9 5
  trials)
• reduced the risk of overall mortality (risk
  ratio 0.8, 95 confidence interval 0.7 to 0.9 9
  trials).

35
Cost-Effectiveness Analysis of n-3
Polyunsaturated Fatty Acids (PUFA) after
Myocardial Infarction

• The cost effectiveness of long term treatment
  with n-3 PUFA is comparable with other drugs
  recently introduced in the routine care of
  secondary prevention after MI. Since the clinical
  benefit provided by n-3 PUFA is additive, this
  therapy should be added to the established
  routine practice, with additive costs.
  http//ideas.repec.org/a/wkh/phecon/v19y2001i4p411
  -420.html Franzosi , Maria Grazia , 2001

36
Understanding Benefits Of Omega-3 Fatty Acids

• n-6 arachidonic acid was converted by the body
  into pro-inflammatory agents called
  prostaglandinE2 series while Eicosapentaenoic
  (EPA) acid produces prostaglandin E 3 series. The
  Arachnodonic acid metabolites and the EPA
  metabolites have opposing actions.
• Eicosanoids made from n-3 fats often have
  opposing functions to those made from n-6 fats,
  anti-inflammatory rather than inflammatory

37
Standard American Diet

• Typical Western diets provide ratios of between
  101 and 301 - i.e., dramatically skewed toward
  n-6. Here are the ratios of n-6 to n-3 fatty
  acids in some common oils canola 21, soybean
  71, olive 3131, sunflower (no n-3), flax 13,
  cottonseed (almost no n-3), peanut (no n-3),
  grape seed oil (almost no n-3) and corn oil 46 to
  1 ratio of n-6 to n-3.
• Hibbeln et al., 2006
• http//efaeducation.nih.gov/sig/esstable.html

38
Prenatal Exposure to n-3 Polyunsaturated Fatty
Acids Protects Against Asthma CME

• Participants were randomized 211 to receive
  four 1-g gelatin capsules per day containing fish
  oil providing 2.7 g n-3 PUFAs (n 266) four
  1-g, similar-appearing capsules per day
  containing olive oil (n 136) or no oil
  capsules (n 131).
• 16-year follow-up, an asthma-related diagnosis
  was reported in 19 children from the fish oil and
  olive oil groups, including 10 diagnosed with
  allergic asthma. For the fish oil vs. the olive
  oil group, the hazard rate of asthma was reduced
  by 63 (95 confidence interval CI, 8 - 85 P
  .03), and the hazard rate of allergic asthma
  was reduced by 87 (95 CI, 40 - 97 P .01).
  July 2008,American Journal of Clinical Nutrition

39
Effect of n-3 Polyunsaturated Fatty Acids in
Asthma after Low-Dose Allergen Challenge

• dietary supplementation with an n-3 PUFA-enriched
  fat blend (0.69 g/day) for 5 weeks
• Conclusion Our results provide evidence that
  dietary supplementation with n-3 PUFA is able to
  reduce bronchial inflammation even after low-dose
  allergen challenge.
• Int Arch Allergy Immunol 2009148321-329

40
Digestive Enzymes

• Most food today is processed and enzymes have
  been deactivated.
• Irradiation of whole foods destroys some enzyme
  activity.
• Cooking destroys enzyme activity.
• Use of proton pump inhibitors blocks stomach
  acids.
• Removal of the gallbladder removes bile acids.
• Humans use to consume fresh whole foods.

41
Computer Controlled Gastrointestinal Model

• The T NO gastro- I ntestinal tract M odel (TIM)
  is a dynamic computer-controlled in vitro system
  that mimics the human physiological conditions in
  the stomach and small intestine. In the current
  TIM physiological parameters such as pH,
  temperature, peristaltic movements, secretion of
  digestion enzymes, bile and pancreatic juices,
  and absorption of digested products
  http//www.sciencedirect.com/science

42
Computer Controlled Gastrointestinal Model

• A Study was done comparing healthy digestion and
  healthy digestion with plant based digestive
  enzymes
• A Study was done with 70 impaired digestion
  without and with adding digestive enzymes
• http//www.infinity2.net/office/docs/1920.pd

43
Digestive Enzymes

• In the perfect digestive function, digestive
  enzymes improved absorption of carbohydrates 4
  fold and protein 2 fold.
• In the 70 impaired digestive function, plant
  based digestive enzymes showed increased
  absorption of proteins 1.75fold,and carbohydrates
  7 fold in the jejunum and ileum.
• http//www.infinity2.net/office/docs/1920.pdf

44
Probiotics

• One of the primary defenses of the GI tract is
  friendly bacteria.
• Lactobicillus DDF-1 and bifidobacterium bifidum
  are two of the commonly supplemented normal
  flora. FOS is a sugar often included in the
  formula.
• I take probiotics daily.

45
Probiotic Usage

• Use to replace flora during and after antibiotic
  usage
• Prevention of c dif colitis.
• In irritable bowel syndrome.
• For treatment of viral or bacterial
  gastroenteritis.
• May add Saccharmyces boulardii.
• http//www.mayoclinic.com/health/probiotics/AN0038
  9

46
Sunshine in a Bottle
47
The Sun Through a DermatologistEye
48
Making Vitamin D
49
Vitamin D Found To Stimulate A Protein That
Inhibits The Growth Of Breast Cancer Cells

• Calcitrol, the active form of vitamin D, has been
  found to induce a tumor suppressing protein that
  can inhibit the growth of breast cancer cells,
  according to a study by researcher Sylvia
  Chistakos, Ph.D., of the UMDNJ-New Jersey Medical
  School.
• Vitamin D3 is synthesized by humans in the skin
  when it is exposed to ultraviolet-B (UVB) rays
  from sunlight.

50
New Model Of Cancer Development Low Vitamin D
Levels May Have Role

• "Vitamin D may halt the first stage of the cancer
  process by re-establishing intercellular
  junctions in malignancies having an intact
  vitamin D receptor,"
• Garland said that diet and supplements can
  restore appropriate vitamin D levels, and perhaps
  help in preventing cancer development. "Vitamin D
  levels can be increased by modest supplementation
  with vitamin D3 in the range of 2000 IU/day," he
  noted.
• http//www.sciencedaily.com/releases/2009/05/09052
  2081212.htm

51
Consider Taking 2,000 Units Vitamin D3 a Day

• The major biologic function of vitamin D is to
  maintain normal blood levels of calcium and
  phosphorus. Vitamin D aids in the absorption of
  calcium, helping to form and maintain strong
  bones. Recently, research also suggests vitamin D
  may provide protection from osteoporosis,
  hypertension (high blood pressure), cancer, and
  several autoimmune diseases.
• http//www.mayoclinic.com/health/vitamin-d/NS_pati
  ent-vitamind

52
cGMP TGA certification
53
Good Manufacturing Practices (GMPs)

• meets required specifications for quality and
  purity
• is evaluated and monitored for potential
  contaminants such as filth, heavy metals,
  pesticides, and microbiological organisms
  (Designs for Health packaging is also monitored
  to ensure against contamination)
• is analyzed to confirm the quantity of all
  dietary ingredients, thereby ensuring the
  consistency and accuracy of label claims

54
NSF

• NSF International is The Public Health and Safety
  Company, providing public health and safety risk
  management solutions to companies, governments
  and consumers around the world.
• http//www.nsf.org/regulatory/

55
Dietary Supplements

• A dietary supplement is defined under the Dietary
  Supplement Health and Education Act of 1994
  (DSHEA) as a product that is intended to
  supplement the diet and contains any of the
  following dietary ingredients
• a vitamin, mineral, herb or other botanical, or
  amino acid
• a dietary substance for use by people to
  supplement the diet by increasing the total
  dietary intake
• a concentrate, metabolite, constituent, extract,
  or combination of any of the above
• Furthermore, it must also conform to the
  following criteria
• intended for ingestion in pill, capsule, tablet,
  powder or liquid form
• not represented for use as a conventional food or
  as the sole item of a meal or diet
• labeled as a "dietary supplement"
• The hormones DHEA , pregnenolone (also a steroid)
  and the pineal hormone melatonin are marketed as
  dietary supplements in the US.

56
Dietary Supplement Health and Education Act of
1994

• all dietary supplement manufacturers to ensure by
  June 2010 that production of dietary supplements
  complies with current good manufacturing
  practices, and be manufactured with "controls
  that result in a consistent product free of
  contamination, with accurate labeling.
• exception on quality assurance for raw material
  suppliers (with the burden placed on
  manufacturers) will lead to continued quality
  problems.

57
The Need for Daily Supplements

• Every day our bodies need certain raw materials
  to support the vast biological mechanisms that
  fuel our physical and mental activity, support
  our immune defenses, and regenerate skin, muscle,
  blood, tissue, and bone. This fuel comes in the
  form of macronutrients protein, carbohydrates,
  and fat and micronutrients vitamins and
  minerals (which fall into four more categories
  water-soluble vitamins, fat-soluble vitamins,
  major minerals, and trace minerals).

58
The Best Multivitamin

• Complete. Based on the latest nutritional
  science, women need at least 30 vitamins and
  minerals, plus a rich essential fatty acid
  formula (i.e., EPA and DHA).
• Bioavailable. The nutrient forms must be the most
  bioavailable. There are six patented chelated
  formulas we recommend be included. And of course
  it must meet USP standards for solubility.
• Natural. No artificial preservatives, dyes,
  allergens or other contaminants. The fatty acid
  formula (derived from marine lipids) must be
  certified to be free of mercury and lead.
• Reliable. NSF and GMP labeled.
• Laboratory tested. As is true for pharmaceutical
  drugs, every production batch of a nutritional
  supplement must be tested in a laboratory (i.e.,
  standardized) to ensure that it contains
  exactly what is on its label.
• Makes a difference. You are the final test. If
  the nutritional supplement doesnt make you feel
  better within the first 30 days, try another
  formula. It may not resolve all your symptoms in
  that time, but you should feel a real
  improvement.

59
Case History Wayne 60
60
Wayne the Tennis Partner/Banker

• Birthday11/4/48
• Medications none
• 6 foot 190 pounds BMI 28
• Days absent from work for illness past 14 years
  none
• Supplements CLO, B complex, occuvite, mega
  minerals, Co Q 10, red yeast rice, saw palmetto,
  glucosamine ,chon, MSM
• Exercise daily life as hunter, president bank

61
Wayne

• CT calcium scoring zero calcium this year
• Past surgical history-adrenal pheochomocytoma age
  3.5 years
• Meniscus surgery 2000, missed one day work
• Total cholesterol 2009 190 ldl 100 hdl 55
• Income up 300
• Diet wild game, many vegetables, little fruit or
  grain
• Mild occasional aching in knee

62
Case History John 56
63
John The Golf Partner

• 56 year old male
• Medications none
• Supplements Omega pure 600, vitamin D3 2000
  units, angi nox one packet, panothenic acid, it C
  500, multi vitamin
• Exercise daily stretching, sit ups push ups
• Golf 2x a week
• Weight 170 height 68 inches BMI 26

64
John

• Days absent from work past two years while
  religiously taking supplements0
• Diet Cave man diet lost 30 pounds past two years
  on the program
• CT calcium scoring heart 0
• Cholesterol was over 200 now 140
• Pain free

65
Case History Cindy 56
66
Cindy

• 56 year old female
• Medications estradiol and progesterone
• 14 years essentials for life, Nordic natural cod
  liver oil, eye vitamins, bone guard, vit D 2000,
  Co q 10 50 mg, resviratrol,
• Daily exercise 1 hour
• P-2 g-2
• Past surgical history- oopherectomy

67
Cindy

• Days absent from work for illness 2 in 14 years
• Prior to supplements 6 sinus infections a year
  and gastroenteritis twice a year requiring IVs
• Height 62 inches, weight 100 pounds
• Pain free
• Modified low carb diet, few grains

68
Case History Will 60
69
Will Golfer, Tennis Player

• Birthday 9/19/1048
• Medications none
• Supplements past 15 years essentials for life, Co
  Q 10 50 mg, Nordic natural cod liver oil and
  omega pure 600, resviratrol, Vit D3 2000, angi
  nox
• Surgery ACL knee 2008 5 days back to work
• Pain free

70
Will

• Prior to supplements severe nasal allergies, hair
  loss, irritability, depression
• Since supplements no allergies, missed one half
  day work for illness, mood stable
• CT calcium scoring 0
• HDL cholesterol went from 42 to 56 in 14 years
• Height 67 inches weight 163
• Diet modified low carb

71
Case History Judy 58
72
Judy

• 58 year post menopausal
• Past medical history fibromyalgia, chronic
  fatigue, depression
• Meds estradiol, progesterone, testosterone
• Supplements m foundation Pac with multiple
  vitamins, minerals, omega 3DHA/EPA, and
  antioxidants x 3 years
• After one month, patient started to feel really
  good. If she missed two days, she feels the ill
  effect.
• Pain free, no depression, and no fatigue

73
National Nutritional Survey

• Nutrient Below RDA
• Vitamin B-6 80
• Magnesium 75
• Calcium 68
• Vitamin A 50
• Vitamin B-1 45
• Vitamin C 41
• Vitamin B-2, B-3, B-12 34
• Pao EM, Mickle SJ. Problem Nutrients in the
  United States.
• Food Technology 3558-62, 1981.

74
Offer Your Patients Quality Supplements and Take
Them Yourself

• Try to make sure every patient in your practice
  is on a sound foundation of a pharmaceutical-grade
  multivitamin, multi-mineral, and essential fatty
  acids (EFAs).
• you have to rely on the quality of the research
  and the manufacturing methods that are behind
  your vitamin supplements when choosing a
  multivitamin