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East Meets West: Integrative Veterinary Medicine Robert J. Silver DVM, MS Boulder's Natural Animal: An Integrative Wellness Center Boulder, CO INTRODUCTION Veterinary Medicine is a dynamically growing and changing field. Modern advances in technology have contributed substantially to the improvement of both diagnosis and therapy in conventional veterinary medicine. These advances have taken place not just in academic veterinary medicine, but also in private practice. Specialists abound in every geographical location and 24/7 Animal ERs have reduced the need to be on call all the time. These advancements have contributed substantially to our ability as a profession to provide the highest standards and quality of medical care to our patients and our clients. At the same time as conventional veterinary medicine has been advancing technologically, there has been a resurgence of interest both by the general public and by veterinarians in medical therapies that are more natural. Harsh side-effects from conventional medical therapies have driven many people to seek out more natural approaches to manage their own medical problems, especially persons with chronic diseases that have not been adequately addressed by conventional medicine. As a result, many people are finding benefits to the use of natural therapies which they did not receive from conventional medical approaches. From their own personal successes, people are then also looking to help their family members and friends, including their four-legged family members, by providing them with natural approaches to their health care. Thus, many clients have been requesting from their vets that they provide some non-conventional medical therapies. The internet has become a resource for many in their pursuit of information about natural medicines for pets. Although accurate and reliable information is available on the internet, if one knows where to look, a lot of the information on the internet is tainted by market pressures. The information is actually an "Infomercial" designed to sell product. In the absence of strong veterinary advice and guidance, pet owners are turning to animal communicators and veterinary para-professionals first before consulting their veterinarians. It is this author's thesis that the family veterinarian is the first animal health professional that a pet owner or guardian should consult for anything relating to their animal's health. The purpose of this seminar is to provide basic information and scientific perspectives that form the basis of the principles and practices that underlie Integrative Veterinary Medicine. Clinical protocols derived from this author's 20 years practice of Integrative Veterinary Medicine are provided to help illustrate the practical application of these principles and practices. The goal for today's seminar is to provide a practical knowledge base so that practitioners can better field those questions from those clients who are interested in Integrative Veterinary Medicine. Also for those practitioners interested in getting started gaining skills in Integrative Veterinary Medicine, this seminar should provide a sound introduction, and some clinical perspectives and cases. Complementary and alternative veterinary medicine, (CAVM) refers to the use of alternative medical therapies a) instead of conventional medical therapies; or b) the use of alternative medical therapies as a complement to conventional therapies. In human medicine this type of medical practice is called: "Integrative Medicine". This term implies that both types of therapies are "integrated" into a single medical practice. Another term used commonly for this type of medical practice is: "Holistic" or "Wholistic" medicine, which is a synonym for "Integrative" medicine. The National Center for Complementary and Alternative Medicine, the branch of the NIH responsible for establishing an evidence-basis for alternative therapies defines Integrative Medicine as the: "combining of mainstream therapies and Complementary and Alternative Medicine (CAM) therapies for which there is some high-quality scientific evidence of safety and effectiveness."Andrew Weil, MD a physician who has helped to popularize Integrative Medicine through his media efforts defines Integrative Medicine as: "…not synonymous with CAM…it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship."Thus, Integrative Veterinary Medicine blends the best of conventional medicine with the patient-specific appropriate selection of alternative therapies that have an evidence-basis for their effectiveness and safety. These therapies are then used in a manner in which the veterinarian emphases the bond-centered relationship between their client and their pet. Typical integrative therapies that a veterinarian might employ include: Wholesome diets, Botanical and Nutraceutical therapeutics, Acupuncture, Manual Therapies (Massage and manipulative therapies), and Flower Essences and Homeopathy. Other more esoteric integrative therapies include: Ozone therapy, Homotoxicology, Qi Gong, Reiki, Crystal healing, Sound and light therapies. One common misconception of people not familiar with holistic or integrative medicine is the use of the term "homeopathic". Not uncommonly, a practitioner of integrative or holistic medicine will be referred to as a "homeopathic" vet. If the veterinarian practices homeopathy, which is a subset of holistic medicine, then that terminology is correct. Many veterinarians, this author included, do not use homeopathic medicine in their holistic practice, thus it is erroneous to refer to them as such. The appropriate terminology would be a "holistic" vet or an "integrative" vet. In this author's small animal veterinary practice, patients are initially assessed based on physical exam, history and diagnostic tests. Many patients arrive from specialists with very detailed diagnoses already in hand. During the initial intake exam and consultation, a diagnostic and treatment plan is developed that takes into account: a) The clients' goals with respect to the clinical outcomes that are desired and b) How interested they are in the use of integrative therapies. Clients are educated to the fact that not all clinical outcomes are achievable with natural therapies alone, and that in some cases natural therapies may be countraindicated in the initial stages of diagnostic and therapeutic workups when the medical condition of the patient may be terminal or life-threatening. Triage has as much of a place in an integrative practice, as it does in the ER. Most clients, when the facts and details are explained to them, are more than willing to allow our veterinary hospital to use whatever it takes to get their pets well. Many times we will explain to the client that we will start with conventional therapies to get the situation under control, and then use natural therapies and integrative approaches to maintain and manage the condition as well as to help mitigate potential side-effects from the stronger conventional therapies. Many clients who are interested in integrative medicine are also interested in wholesome homemade or commercial diets. These diets are primarily raw or cooked meat, cooked carbohydrate sources, cooked and raw fruit and vegetables. Anecdotal stories abound on the internet in discussion groups about dogs or cats who had chronic diseases that were miraculously "cured" when their owners put them on these diets. In this author's integrative veterinary medical practice clients are given the recommendation that wholesome, well prepared and balanced homemade diets are the best food they can provide both themselves and their four-legged family members. Clients who are interested in homemade diets are counseled in their safe and nutritious preparation. Home made diets are not for everyone, so for those clients who want to provide their pets with improved nutrition but who aren't ready willing or able to provide home-prepared meals, recommendations are made for reputable commercial raw meat diets, or "natural" kibble, canned and/or freeze-dried diets. Observations made by this author over the past 20 years of recommending these diets, have shown substantial benefits to many of these patients. In a few patients, these homemade diets (either raw or cooked) have not been a good "fit". No matter how much we try to get these patients to make the conversion to more wholesome foods, their systems just never adapt. These patients will develop (or may have already had): Soft stools, diarrhea, vomiting, eructation, flatulence, borborygmus or exacerbation of some other systemic weakness. In addition to dietary improvements for these patients, this author's medical practice also offers acupuncture, botanical and nutraceutical therapies, as well as the use of homeopathic remedies for acute medical conditions. Many patients seen in this practice have been referred from Colorado State University's Veterinary Teaching Hospital or from private specialists in the Denver metro region. They come with diagnoses and therapeutic programs recommended by these specialists. Generally, the referring doctor's prescriptions are not countermanded, but are used as a foundation upon which nutritional, botanical, nutraceutical and Traditional Chinese medical therapies are integrated. It is important to note that the concurrent use of conventional and integrative therapies frequently works better than either system of therapeutics alone. There are many ways of using Integrative medical practices in veterinary medicine. For some practices, Integrative Medicine simply means the use of integrative therapies alongside conventional therapies. One example of this would be the dog who has arthritis who doesn't tolerate NSAIDs. Liver and kidney enzymes aren't elevated from the use of the NSAIDs, but the dog vomits with each NSAID it is given. In this case, the use of acupuncture could substantially improve this arthritic patient's mobility. When nutraceuticals and botanicals are added to this patient's program, as well as life style and weight management, improvements in mobility can become substantial. Another application of alternative therapies for this patient would be to strengthen and stabilize its digestive system using sucralfate, pepcid and/or ginger root, glutamine, licorice root, and white rice. For some practitioners of Integrative Medicine, the use of specific alternative therapeutic modalities are not as important as the principles and philosophies that underlie integrative medicine. The integrative, holistic perspective has the practitioner looking at the patient in the context of its genetics, environment, diet, lifestyle, and emotional and behavioral considerations. It may seem that this is the way that you are already approaching your patients. Integrative medicine is nothing new, it is really, just "good" medical practice. In fact, many conventional practitioners use this approach to some extent. Taking this "Wholistic" approach is especially useful for patients with chronic, multiple, degenerative disease conditions. Modern veterinary medicine is following human medicine in becoming increasingly more specialised, compartmentalized and subjected to rigid corporate guidelines (managed care) that may serve the bottom line better than the patient. Patients are being reduced to case numbers or diagnoses. Doctor-Client "face time" is being reduced to accommodate the need to "post more transactions daily" in order to increase gross receipts to cope with increased economic pressures. As will be described in the following pages, many of these Integrative therapies use different ways to "frame" the patient other than by the conventional approaches that we as veterinarians have been trained. Being able to look at a case differently can help the practitioner to "break through" the stalemate that often occurs during therapy of difficult, complex disease patterns. Many times this different approach can effect positive change in a patients' clinical picture when conventional therapies were unable to help much. Integrative medicine is not an "all or nothing" form of medicine. As you learn more about integrative medicine you will see that there are many ways that it can fit into your own practice style without forcing you to completely "retool" your practice or spend inordinate amounts of time learning esoteric therapies that may have little general value to your clinical practice. This author invites you to approach the information in this seminar with an open mind and the perspective that this "inclusive" medical approach can revitalize your own spirit when it comes to medical practice as well as rejuvenate your relationship with your clients and your patients. DEFINITIONS Alternative Medicine Alternative medicine describes practices used in place of conventional medical treatments. It refers to those practices explicitly used for the purpose of medical intervention, health promotion or disease prevention which are not currently taught at U.S. medical schools. Alternative medicine includes practices that incorporate spiritual, metaphysical, or religious underpinnings; non-European medical traditions, or newly developed approaches to healing. There are almost 500 such systems. Applied Kinesiology Applied kinesiology (AK) is related to diagnostic kinesiology. It is a method that purportedly gives feedback on the functional status of the body. Proponents say that when properly applied, the outcome of an AK test, such as a muscle strength test, will provide for a low risk diagnostic method to help determine the efficacy of therapy for patients. Applied Kinesiology is classified with alternative medicine, and is therefore distinct from academic kinesiology, which is the scientific study of human movement and its application. Ayurvedic Medicine Ayurveda is an ancient East Indian system of healing that seeks to promote health through a "balanced" lifestyle and various natural healing methods. Ayurvedic practitioners tailor treatments to each patient's unique condition. Bach Flower Essence therapy Bach flower remedies are dilutions of flower "essences" developed by Dr. Edward Bach. They are similar to homeopathy in many respects and form a part of alternative medicine. Some researchers believe that they exert their claimed effects via the placebo effect, however practitioners feel the "energetic signature" of the flower can be transmitted to the user and affect a person's psychological state. One difference between homeopathy and Bach flower remedies are the "potentization" methods used to produce the remedies, Flower remedies are produced using the sun method or, for the hardier plants, the boiling method. Both these methods were invented by Bach. Another key difference is that Bach remedies are only used to treat the mental symptoms believed by practitioners to be the root cause of the many diseases. Bach flower remedies are not dependent on the theory of successive dilutions, and are not based on the Law of Similars. The Bach Remedies are all derived from non-toxic substances, with the idea that a "positive energy" can redirect or neutralize "negative energy". There are thirty-eight original Bach remedies plus "Rescue Remedy TM" (see below), each prescribed for certain mental and emotional problems. They form a complete system with which practitioners treat every variety of human emotional imbalance. Other systems of remedies have been developed by practitioners who have access to flowers that are indigenous to other regions, and that were therefore unknown to Bach. Botanical Medicine or Herbal Medicine "Veterinary botanical medicine is the use of plants and plant derivatives as therapeutic agents. Since some of these botanicals may be toxic when used at inappropriate doses, it is imperative that veterinary botanical medicine be practiced only by licensed veterinarians who have been educated in veterinary botanical medicine. Communication on the use of these compounds within the context of a valid veterinarian/client/patient relationship is important." (AVMA Guidelines 1996) Chiropractic Medicine: A system of healing based on the premise that poor spinal health ("dynamic" subluxations) leads to improper nerve flow and disease. Through specific adjustments of the spine and extremities one can restore spinal health and normal bodily function. "Veterinary chiropractic is the examination, diagnosis, and treatment of non-human animals through manipulation and adjustments of specific joints and cranial sutures. The term "veterinary chiropractic" should not be interpreted to include dispensing medication, performing surgery, injecting medications, recommending supplements, or replacing traditional veterinary care. While sufficient research exists documenting efficacy of chiropractic in humans, research in veterinary chiropractic is limited. Sufficient clinical and anecdotal evidence exists to indicate that veterinary chiropractic can be beneficial. It is recommended that further research be conducted in veterinary chiropractic to evaluate efficacy, indications, and limitations. The assurance of education in veterinary chiropractic is central to the ability of the veterinary profession to provide this service. Veterinary chiropractic should be performed by licensed veterinarians; however, at this time, some areas of the country do not have an adequate supply of veterinarians educated in veterinary chiropractic. Therefore, it is recommended that, where the state's practice acts permit, licensed chiropractors educated in veterinary chiropractic be allowed to practice this modality under the supervision of, or referral by, a licensed veterinarian who is providing concurrent care." (AVMA Guidelines 1996) Complementary medicine or Complementary and Alternative Veterinary Medicine (CAVM) Complementary medicine describes alternative medicine used in conjunction with conventional medicine. The term complementary and alternative medicine (CAM) is an umbrella term for both branches. The National Center for Complementary and Alternative Medicine defines complementary and alternative medicine as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine". Conventional Medicine: The medical theory and practice that is taught in established educational institutions according to current scientific, historical and cultural standards Crystal Healing The theory that underlies this modality is that every living organism has a "vibrational energy system," which includes chakras, subtle bodies and meridians. By using the appropriate crystals one can allegedly "tune" an energy system or rebalance energies, thus improving well-being. The earliest records of crystal healing come from ancient Egypt. The Ebers papyrus states the medicinal uses of many different gems. Healing with crystals is also recorded in India's Ayurvedic records and in traditional Chinese medicine from around five thousand years ago. Eclectic medicine Eclectic medicine refers to a branch of alternative medicine which makes use of herbal remedies. The term was coined by Constantine Rafinesque (1784-1841), a doctor living among the Native Americans, and observing their use of medicinal plants. He coined the word "eclectic" to refer to those physicians who adopted in practice whatever was found to be beneficial to their patients. The Eclectic Medical Institute was formed in the 1830s as an alternative to the conventional medicine of the time. By the 1850s, several American doctors, especially from the New York Academy of Medicine, had begun using herbal salves. Eclectic medicine is still practiced today, but mainly by medical herbalists rather than physicians. Functional Medicine Functional medicine is anchored by an examination of the core clinical imbalances that underlie various disease conditions. Those imbalances arise as environmental inputs such as diet, nutrients (including air and water), exercise, and trauma are processed by one's body, mind, and spirit through a unique set of genetic predispositions, attitudes, and beliefs. The fundamental physiological processes include communication, both outside and inside the cell; bioenergetics, or the transformation of food into energy; replication, repair, and maintenance of structural integrity, from the cellular to the whole body level; elimination of waste; protection and defense; and transport and circulation. The core clinical imbalances that arise from malfunctions within this complex system include:
"Holistic veterinary medicine is a comprehensive approach to healthcare employing alternative and conventional diagnostic and therapeutic modalities. In practice, holistic veterinary medicine incorporates, but is not limited to the principles of acupuncture and acutherapy, botanical medicine, chiropractic, homeopathy, massage therapy, nutraceuticals, and physical therapy as well as conventional medicine, surgery and dentistry. It is recommended that holistic veterinary medicine be practiced only by licensed veterinarians educated in the modalities employed. The modalities comprising holistic veterinary medicine should be practiced according to the licensure and referral requirements concerning each modality." (AVMA Guidelines1996) Homeopathic Medicine Homeopathy is a system of natural healing based on the premise that "like cures like". Homeopathic remedies are highly diluted medicines that stimulate the healing response of the body. Homotoxicology The use of specialized homeopathic solutions that are administered by injection into specific acupuncture points to initiate a process of detoxification of the body in order to address chronic disease complaints. Homotoxicology theory posits that there are 6 levels of disease starting superficially in the body and culminating in deep-seated deposition of toxins at the intracellular level that contribute to disease such as cancer and autoimmune disease. Integrative Medicine The National Center for Complementary and Alternative Medicine defines integrative medicine as "[combining] mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness". Ralph Snyderman and Andrew Weil state "integrative medicine is not synonymous with complementary and alternative medicine (CAM). It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship" Proponents of evidence-based medicine regard the distinction between conventional and alternative medicine as moot, preferring "good medicine" (with provable efficacy) and "bad medicine" (without it). "Bad medicine" is any treatment where the efficacy and safety of which has not been verified through peer-reviewed, double blind placebo controlled studies, regarded as the "gold standard" for determining the efficacy of a compound. It is thus possible for a method to change categories in either direction, based on increased knowledge of its effectiveness or lack thereof. NAET NAET (Nambudripad Allergy Elimination Technique) is an alternative medicine treatment for allergies using a combination of chiropractic, applied kinesiology and acupressure. It was founded in 1976 by Devi S. Nambudripad while treating her own allergy symptoms. Devi S. Nambudripad is a licensed chiropractor and acupuncturist practicing in California, US. Nutritional Medicine The use of whole food materials or isolated or concentrated components of food or food materials that have a beneficial influence on the health of an individual or which can positively influence the healing process. Nutraceutical medicine "Veterinary nutraceutical medicine is the use of micronutrients, macronutrients, and other nutritional supplements as therapeutic agents. Communication on the potential risks and benefits from the use of these compounds within the context of a valid veterinarian/client/patient relationship is important. Continued research and education on the use of nutraceuticals in veterinary medicine is advised." (AVMA Guidelines 1996) Orthomolecular therapy The term "orthomolecular" was first used by Linus Pauling in 1968, to express the "idea of the right molecules in the right amounts within the context of physiology" and subsequently defined "orthomolecular medicine" as "the treatment of disease by the provision of the optimum molecular environment, especially the optimum concentrations of substances normally present in the human body." or as "the preservation of good health and the treatment of disease by varying the concentrations in the human body of substances that are normally present in the body and are required for health." Since 1968 the orthomolecular field has developed further through the works of researchers. Despite this it is still often closely associated by the public with Pauling's advocacy of multi-gram doses of vitamin C for optimal health. Orthomolecular medicine posits that many typical diets are insufficient for long term health; thus, orthomolecular medical diagnoses and treatment often focus on use of natural substances found in a normal diet such as vitamins, dietary minerals, enzymes, antioxidants, amino acids, essential fatty acids, dietary fiber and intestinal short chain fatty acids. Orthomolecular medicine argues that some diseases reflect biochemical anomalies and that it is advantageous to recognize and to correct these anomalies at an early stage, before they result in recognizable diseases. The orthomolecular practitioner relies heavily on laboratory testing. In addition to standard clinical chemistries, orthomolecular practitioners now employ a wide range of laboratory analysis, including those for amino acids, organic acids, vitamins and minerals, functional vitamin status, hormones, immunology, microbiology, and gastrointestinal function. Many of these tests have not been accepted by mainstream medicine. Orthomolecular therapy consists in attempting to provide optimal amounts of substances normal to the body, most commonly by oral administration. In the early days of orthomolecular medicine, this usually meant high-dose, single-agent nutrient therapy. Thus, "optimal" is a matter of the "clinical judgment" of the orthomolecular practitioner. Most often, the orthomolecular practitioner uses many substances: amino acids, enzymes, non-essential nutrients, hormones, vitamins, minerals etc. in a therapeutic effort to restore those (or derivative substances) to optimum levels for healthy young persons. Often supplementation with relatively large doses of vitamins is given and the name megavitamin therapy has become popularly associated with the field. Megavitamin therapy is the administration of large amounts of vitamins, often many times greater than the recommended dietary allowance (RDA). Short chained fatty acids are produced by fermentation of dietary fiber in the colon, then absorbed and utilized, often aided with a combination of probiotics, prebiotics and "glyconutrients" added to the diet. The substances may be administered by changing the diet to emphasize certain elements high in nutrients, dietary supplementation with tablets, or intravenous injection of nutrient solutions. Ozone therapy Ozone therapy is a the medical use of ozone in the treatment of infectious diseases and cancer. Ozone can be introduced to the body in many ways, including through water absorption, injection, transdermal application and insufflation. The gas is used at very carefully controlled levels. The super-oxygenated oxygen that is ozone gives up its singlet oxygen very easily. This free radical is microbicial and preferentially more toxic to cancer cells than to healthy tissue. O3 = O2 + O-. Medical ozone therapy is recognized in Bulgaria, Cuba, Czech Republic, France, Germany, Israel, Italy, Mexico, Romania and Russia. It is currently used legally in 16 Nations. At least 12 states in the USA (AK, AZ, CO, GA, MN, NY, NC, OH, OK, OR, SC and WA) have passed legislation to ensure that alternative therapies are available to consumers. Physicians in those states can legally use ozone as an alternative treatment in their practice. Paradigm Shift This term was first used by Thomas Kuhn in his 1962 book The Structure of Scientific Revolutions to describe a change in basic assumptions within the ruling theory of science. It has since become widely applied to many other realms of human experience as well. A scientific revolution occurs, according to Kuhn, when scientists encounter anomalies which cannot be explained by the universally accepted paradigm within which scientific progress has thereto been made. The paradigm, in Kuhn's view, is not simply the current theory, but the entire worldview in which it exists, and all of the implications which come with it. There are anomalies for all paradigms, Kuhn maintained, that are brushed away as acceptable levels of error, or simply ignored. Phototherapy Light therapy or phototherapy consists of exposure to specific wavelengths of light using lasers, LEDs, fluorescent lamps, dichroic lamps or very bright, full-spectrum light, for a prescribed amount of time. It has proven effective in treating Acne vulgaris, seasonal affective disorder (SAD), and for some people it has ameliorated delayed sleep phase syndrome. Phototherapy has recently been shown effective in non-seasonal depression. Proponents claim demonstrable benefits for skin conditions such as psoriasis. Phototherapy has also been shown to be effective for pain management, and can be used to stimulate acupuncture points. Reiki Reiki, (English pronunciation: Ray-kee) is a form of spiritual healing and spiritual practice. proposed for the treatment of physical, emotional, mental and spiritual diseases. Mikao Usui developed Reiki in early 20th century Japan, where he claimed to receive the ability of 'healing without energy depletion' after three weeks of fasting and meditating on Mount Kurama. Practitioners use a technique similar to the laying on of hands, in which they claim to be channels for energy ("Ki") guided by a universal spirit or spiritual nature ("Rei") - flowing through their palms to heal a person wherever they may need healing. A study in Alternative Therapies (Jan/Feb 2005 issue) said that in 2002 there were over one million U.S. adults who had experienced Reiki treatments. Reiki is controversial because there is no scientific evidence it works by any means other than suggestion or the placebo effect. Shamanism Shamanism refers to a range of traditional beliefs and practices similar to Animism that claim the ability to diagnose and cure human suffering. Some anthropologists and religion scholars define a shaman as an intermediary between the natural and spiritual world, who travels between worlds in a trance state. Once in the spirit world, the shaman would commune with the spirits for assistance in healing, hunting or weather management. Shamanistic practices are sometimes claimed to predate all organized religions, and certainly date back to the Neolithic period. Aspects of shamanism are encountered in later, organized religions, generally in their mystic and symbolic practices. Greek paganism was influenced by shamanism, Some of the shamanic practices of the Greek religion later merged into the Roman religion. The shamanic practices of many cultures were marginalized with the spread of monotheism in Europe and the Middle East. In Europe, starting around 400, the Catholic Church was instrumental in the collapse of the Greek and Roman religions. Temples were systematically destroyed and key ceremonies were outlawed or appropriated. The Early Modern witch trials may have further eliminated lingering remnants of European shamanism. The repression of shamanism continued as Catholic influence spread with Spanish colonization. The shaman plays the role of healer in shamanic societies; shamans gain knowledge and power by traversing the axis mundi (the "world tree" which is the connection between heaven and earth) and bringing back knowledge from the heavens. Even in western society, this ancient practice of healing is referenced by the use of the caduceus as the symbol of medicine, also known as the Rod of Asclepius. The staff of the caduceus is the axis mundi itself, and the serpent (or serpents) are the guardians or guides to the other realm. Oftentimes the shaman has, or acquires, one or more familiar helping entities in the spirit world; these are often spirits in animal form, spirits of healing plants, or (sometimes) those of departed shamans Traditional medicine That medical practice which is based in historical, empirical, cultural and folk practices Traditional Chinese Medicine (TCM) Traditional Chinese medicine (also known as TCM or T.C.M.) is a range of traditional medical practices used in China that developed during several thousand years. These practices include herbal medicine, acupuncture, and massage. TCM is a form of Oriental medicine, which includes other traditional East Asian medical systems such as Japanese and Korean medicine. TCM says processes of the human body are interrelated and constantly interact with the environment. Therefore the theory looks for the signs of disharmony in the external and internal environment of a person in order to understand, treat and prevent illness and disease. TCM theory is based on a number of philosophical frameworks including the Theory of Yin-yang, the Five Elements, the human body Meridian system, Zang Fu theory, and others. Diagnosis and treatment are conducted with reference to these concepts. TCM does not usually operate within a scientific paradigm but some practitioners make efforts to bring practices into an evidence-based medicine framework. Unani medicine Though the threads which comprise Unani healing can be traced all the way back to the Greek physician Galen, who is credited as the father of modern Western medicine, who lived in the second century AD. The basic knowledge of Unani medicine as a healing system was collected by Hakim Ibn Sina (known as Avicenna). The time of origin is dated at circa 980 AD in Persia. It is a comprehensive system encompassing virtually all of the known healing systems of the world. As an alternative medicine, Unani has found favor in Asia especially India. In India, Unani practitioners can practice as qualified doctors, as the Indian government approves their practice. Unani medicine is very close to Ayurveda. Both are based on theory of the presence of the elements (in Unani, they are considered to be fire, water, earth and air) in the human body. (The elements, attributed to the philosopher Empedocles, determined the way of thinking in medieval Europe.) According to followers of Unani medicine, these elements are present in different fluids and their balance leads to health and their imbalance leads to illness. Most medicines and remedies (often common herbs and foods) used in Unani are also used in Ayurveda. While Unani was influenced by Islam, Ayurveda is associated with Vedic culture. The basic nutritional tool used in Unani medicine is honey. Honey is considered by some to have healing properties and hence is used in food and medicines practiced in the Islamic world. Real pearls and metal are also used in the making of Unani medicine based on the kind of ailment it is aimed to heal. ETHNOMEDICINE: THE ROOTS OF INTEGRATIVE MEDICINE In recent years, there has been an increase of interest on the part of the pharmaceutical industry in discovering medicines derived from other cultures. These derivatives of traditional folk medicines often times have yielded potent and effective pharmaceuticals that become a part of our conventional pharmaceutical armamentarium. These unique medical remedies may address disease conditions that do not respond well enough with conventional medicines. Lay people as well as professions share this interest in non-conventional traditional systems of healing. This upsurge of interest in medicines from other cultures, known as "Ethnomedicine" has been a strong stimulus to increase in the number of practitioners that are now offering specific ethnomedical therapies, such as acupuncture and Chinese Herbal therapies with TCM (Traditional Chinese medicine), or massage diet and herbal therapies as are found used with Ayurvedic traditional medicine. The following sections will briefly cover the most widely used of these ethnomedical systems. TRADITIONAL CHINESE VETERINARY MEDICINE ACUPUNCTURE: A VERY POWERFUL TOOL Acupuncture is the insertion of thin needles into specific anatomic locations, known as "acupuncture points" that stimulate a response that involves as complex cascade of physiological responses, including the release of numerous neurochemicals and hormones in the CSF, tissues and bloodstream, as well as increasing regional blood flow. Acupuncture is used to treat specific "patterns of dysfunction" by bringing the body systems back into balance or homeostasis. Acupuncture was developed in China thousands of years ago, based on their philosophy of the Universe regarding concepts of Yin and Yang. This reflects the Taoist point of view, and as an Ethnomedical system, acupuncture diagnosis and treatment is based upon this idea that everything in the world possesses a unique combination of Yin and Yang. Yin and Yang are the two complementary energies that are expressed in this table:
This Ethnomedical system is called Traditional Chinese Medicine (TCM). TCM encompasses more than just acupuncture. It also includes herbal medicine, which is organized in a parallel fashion to acupuncture, massage and manipulative therapies (called Tuina), dietary therapy, and lifestyle modification. TCM is truly a holistic medical discipline when practiced according to Taoist philosophy. Veterinary medicine in ancient China incorporated the use of acupuncture and herbal therapies and was used as a means of maintaining a robust food supply, as well as medical maintenance of the "beasts of burden" that were used to till the fields, and for transportation and running wells. TCVM or Traditional Chinese Veterinary Medicine is still practiced in China, and is taught to veterinarians in China. In the last 20 years, TCVM has found roots in Europe, Australia and North America, and is currently taught through the following organizations: The International Veterinary Acupuncture Society (IVAS) and the Chi Institute in the United States. "Medical Acupuncture" is a form of acupuncture that does not use the Asian philosophy in its diagnostic and therapeutic strategies. Instead it looks at the neurophysiologic basis of acupuncture, and uses point selection based on the biomedically-defined actions of the acupuncture points. Currently this approach to acupuncture is being taught to medical doctors (MDs, Dos and DCs) and to veterinarians. The Veterinary Medical Acupuncture courses are part of the curriculum of several Veterinary Teaching Hospitals in the United States. For this paper, the neurophysiologic basis of medical acupuncture will be discussed. Resources and references at the end of this paper will point the reader in the direction of the TCVM courses and reference texts. ACUPUNCTURE POINTS Acupuncture points are located anatomically near plexi of nerves, arteries and veins. The stimulation of these points produces the complex beneficial response associated with acupuncture therapy. When electrical conductance of the skin is measured at acupuncture points versus non-acupuncture points, it is found that these locale has a lower electrical conductance. This allows the use of electrical meters to accurately locate acupuncture points. These points that can be located by instrumentation correspond exactly to the anatomical locations determined 4000 years ago by the Chinese. On a microscopic basis, these points can be identified by their very specific structure. There have been four types of acupuncture points defined.
When acupuncture points have been stimulated they send their stimuli along acupuncture pathways or "meridians" or "channels" or "vessels". The acupuncture meridians carry stimuli and information from the acupuncture point to the brain and target organs. These signals travel along afferent peripheral nerves, from the acupuncture point to the spinal cord. Once the signal reaches the spinal cord, afferent neurons synapse on inhibitory, excitatory and projection neurons. The projection neurons travel cranially through the spinal cord to the brain via the lateral spinothalamic tract. After synapsing in the caudal thalamus, the projection neurons are distributed to the cortex. Projection neurons, exception in primates, have a diffuse and multisynaptic pathway. This pathway is interrupted by axons that leave their pathway and then rejoin the pathway contralaterally or ipsilaterally. This is one reason why animal patients with spinal cord lesions can respond to acupuncture as compared to primate and human patients. MECHANISMS of ACTION There have been 6 mechanisms of action defined based on neurochemicals relationships. These are:
Canine Nares Feline Nares How Does This Point Work? From Narda Robinson DVM, DO: VeterinaryPracticeNews.com 2005 (http://www.animalnetwork.com/vpn/detail.aspx?aid=24836&cid=3880&category=) Anatomy of GV 26 The indications of acupuncture points often become apparent after analyzing their key anatomical features. Tissues associated with GV 26 receive sympathetic fibers from the cervical sympathetic ganglia. Trigeminal nerve branches provide sensation to the skin and underlying structures. A recent study in the Journal of Comparative Neurology showed that sensory-sympathetic and sensory-parasympathetic fiber combinations occur in blood vessels of the face. Intimate interconnections between sensory and autonomic fibers serve to regulate microcirculation. These communications may also mediate autonomic responses to afferent stimulation provided by acupuncture. Physiology of GV-26 Acupuncture at GV 26 activates the sympathetic nervous system. This elevates catecholamine levels, increases cardiac output and stroke volume. Furthermore, stimulation of extracranial trigeminal nerve fibers can increase cortical cerebral blood flow. Electrical stimulation at 2 hertz delivered to sympathetic fibers of the nose can cause vigorous sympathetic activation, exhibited as strong vasoconstriction of nasal mucosal blood vessels.3 Two cycles of stimulation per second (i.e., 2 hertz) approximates the frequency of pecking GV 26 during resuscitation maneuvers. Combined, these neurophysiologic responses help explain GV 26's role in reversing cardiorespiratory collapse and loss of consciousness. Sometimes, stimulation of the same acupuncture point under different clinical conditions can produce opposite responses. The reason for this is that acupuncture works by neuromodulation, which may raise or flatten physiologic reactions based on the direction needed for homeostasis. The latest functional brain imaging studies on acupuncture illustrate such modulatory neural and autonomic responses in various parts of the brain, including the limbic, paralimbic and subcortical gray areas, as well as the cerebellum. Evidence of Effectiveness Research literature attesting to the effectiveness of GV 26 in treating cardiovascular depression began appearing in the English language veterinary literature in the 1970s. Over the following two decades, numerous papers documented the sympathomimetic effects of GV 26 in various species. Further studies showed that pretreatment with either alpha or beta blockers inhibited the sympathomimetic effect. Needling adjacent regions as "sham acupuncture" points failed to result in significant changes in cardiovascular function. More recently, a report on using GV 26 for resuscitation of neonatal kittens delivered by Caesarean section demonstrated success following unproductive cardiopulmonary resuscitation attempts. RESOURCES for TRAINING in VETERINARY ACUPUNCTURE MEDICAL ACUPUNCTURE COURSES
(Easy to find these at Chinese herbal suppliers such as the ones listed under resources)
"You are what you eat" may be more than just a catchy phrase. Our daily nutrient intake provides the building blocks for maintenance of health, tissue repair and energy. It is well documented in the literature that the processing of foods, both human and pet, creates by-products that have a proinflammatory and insulin dysregulating effect. These two side-effects from eating processed foods are at the root of many degenerative health conditions. In human integrative medicine inflammation and insulin dysregulation are known collectively as "Metabolic Syndrome" or "Syndrome X". The feeding of homemade diets and unprocessed foods can help to reverse the chronic effects of longterm ingestion of these by-products of food processing. Kibble and canned foods both contain these potentially toxic by-products. When carbohydrates and protein are heated at high temperatures, and when they are also exposed concurrently to high pressures, a chemical reaction occurs called the: "Maillard Reaction". Bread crust forms as the result of this Maillard reaction, also known as the "Bronzing Effect". The chemical name for these new compounds that are created by food processing is: Advanced Glycosolation End products, which is given the acronym: "AGE's". Studies have shown that these AGEs contribute to pro-inflammatory processes in the body, and to the aging process as well. (3) There are other problems associated with processed commercial foods. Food storage mites can create a substantial impact on atopic dogs. (4) Reactive oxidative species (ROS) are also created by food processing (5), and many degenerative conditions are the result of tissue damage secondary to these free radicals' impact on delicate living tissue (6). Chemical preservatives may have an adverse effect due to their long term usage, even if the amounts ingested at each meal have been measured to be not toxic. (7) Aflatoxins and other mycotoxins are commonly found on grains (especially corn and wheat) that have been stored for a while, which is usually the case in the manufacture of commercial kibble (8, 9) Appropriate levels of essential or necessary nutrients may not be present in commercial diets. One example of this is the recent report of cardiomyopathy in Newfoundland dogs secondary to taurine deficiency when fed a commercial dog kibble. (10) Home prepared diets for companion animals can also provide other benefits to companion animals other than improved nutritional intake. There is so much talk these days in Veterinary medicine about the "bond-centered" practice. Preparing food at home for one's pet is one of the most bonding experiences you can imagine. For patients with terminal diseases, this is an opportunity for the pet's guardian to minister to their beloved critter in their last days, weeks, or months on earth. Many pets with chronic or terminal diseases will become fussier about their diets. Many times its not the brand or the meat type that is in the commercially processed kibble, but it is the kibble itself that these animals will not eat. Switching them to a homemade diet can have very positive effects. In recommending a homemade diet, especially one that contains raw meat, it takes consultation time for the veterinarian to educate the client to ensure that the food preparation will be nutritionally adequate and safe. In the marketplace there are now fresh frozen raw diets, including one that has passed AAFCO feeding trials. Veterinarians can sell these diets in their clinics, thus providing an additional income stream, similar to income generated by the sale of kibble and canned diets. Research conducted at Colorado State University' Veterinary Teaching Hospital supports that high protein and lower carbohydrate diets, associated with higher levels of healthy fatty acids, including fish oil fatty acids in high dosages, and supplemental arginine, has shown statistically significant improvement in survival times in canine lymphoma patients. (11). Home made diets or commercial raw food diets can supply these same nutritional components and proportions, and have comparable effect when supplemental fish oil and the free form amino acid l arginine are included in the diet. Some animals lose interest in the Hills prescription diet, N/D™. Homemade diets can be more palatable and keep a cancer patient eating, which is very important to their therapy. Information on home made diet recipes can be found in a number of published books. (add citations including Strombeck, etc.) There are several websites designed to help with diet formulation (12). This author has developed a methodical process for understanding the principles and practices that underlie homemade diet preparation. (13, 14). HOME MADE DIET: PRINCIPLES AND PRACTICES Instructing clients in the preparation of safe and nutritious home made food takes time. This author spends a significant amount of time in an exam room setting or in a group class to explain the details involved in diet preparation. Home made diets are not for every client. Many clients are unable to prepare wholesome meals for themselves. It is unreasonable to expect that these clients can follow through consistently and accurately with home diet preparation for their pets. During the food preparation discussion, attempts are made to have an interactive dialog during which clients can express their concerns regarding the use of raw meat, bones, specific types of foods, and amounts of macronutrients such as protein, and the use of grains as a carbohydrate source. Clients are becoming increasingly more knowledgeable and informed about these food preparation considerations, although in many cases their source of information may be based on half-truths and emotional bias. The internet has been a source for information that many clients are accessing. Unfortunately it is not always a reliable source of information. The information is often tainted by mercenary motivations or adherence to a position. Many individuals interested in improving their animals help go to these sources of information, or receive anecdotal information from an acquaintance about something that they may have heard about, or which may have worked in one case for their pets, and they generalize this case to be true for all animals. Many people have a cult-like adherence to these ideas, some of which could be harmful to their animals. Some examples of the misinformation that clients may be coming into a veterinarian's office with include the notion that all animals, regardless of their age, weight or health status need to eat high protein diets, consisting solely of raw meat. Another commonly held misbelieve or "Urban Legend" is that carbohydrates, and particularly grains are the cause of many diseases, including cancer, Cushings disease and thyroid disease. This author spends a lot of time trying to debunk these myths. These clients are potentially terrific clients to for a veterinarian to have. They want to improve their pets health, they are willing to go to a great deal of effort and expense to do so. They are simply "misinformed," and thus, "misguided." By taking extra time with them, and kindly and gently explaining to them why these ideas they hold are not true for all critters, and might even be harmful to some, including their own, these people usually come around. People inherently respect the authority position of a veterinarian or physician as a resource of truthful information, and it is not hard to reclaim their adherence to a more moderate approach to natural pet health with a little bit of education and communication. This author has tried to make the meal preparation as simple as possible, in order to facilitate compliance. Following the giving of this advice, the author asks clients to return to the office in 30-60 days for a recheck visit to discuss the clients trials and tribulations and success with the diet preparation. At that time the patient is reweighed and re-examined. If deemed appropriate, blood tests such as creatinine, BUN, hematocrit and serum albumen are performed, and fecal examinations may also be conducted to check for nutritional sufficiency, parasites and food-borne pathogens, respectively. STANDARDS OF MEASUREMENT As part of the effort to simplify the food preparation process, this author recommends that clients use volumetric cup measurement which is easiest for day to day food preparation. The food portion measurements are more accurate if the vegetables are chopped up fine, the meat is ground or chopped into small cubes, and the starches are well cooked to a porridge-like consistency. This way there will be no air in the cup measurements, and since the food density is fairly uniform (a little light for the veggies and a little heavy for the meat), volume is approximately equal to weight. Weight measurement of the food is more accurate for precise nutritional calculations, but can be more of a "chore" for the clients. FEEDING GUIDELINES: The "Circle of Nutrition" How much to feed and what proportions of macronutrients to recommend need to be individualized for a specific patient. Does the patient need more protein to address protein loss through the bowel or kidneys, obesity or diabetes, growth, wound healing or performance? Does the patient need less protein due to azotemia or other concerns? How about the amount of calcium that needs to be supplemented? It certainly would be different for a giant breed versus a toy breed. More when we are dealing with fracture repair and nutritional Hyperphosphatemia, and less when we are dealing with hypercalcemia due to a paraneoplastic syndrome or hyperparathyroidism (primary or secondary). How about the amount of carbohydrate to feed? And what type of carbohydrate? If the patient is diabetic, then the glycemic index of the carbohydrate may have a bearing on insulin demand. If the patient has gluten intolerance or food allergies or intolerance to grain, then avoiding grain sources of carbohydrates would be recommended. The American College of Veterinary Nutrition recommends using the "Circle of Nutrition" approach when formulating a diet for a patient. The Circle of Nutrition describes an iterative process, whereby the patient's health status and nutritional needs are first assessed, and from that assessment a nutritional "prescription" is written. A diet is then formulated or a ready-made diet is chosen to match that initial prescription, and is fed according to that patient's energy needs and lifestyle considerations. The diet is fed for a given amount of time, which could vary based on the critical nature of that patient's condition, and at the end of that initial feeding period, the patient is then reassessed. The reassessment could be a simple as a cursory physical exam and weigh-in, or involve diagnostic tests such as creatinine and BUN to assess the safety to an azotemic or potentially azotemic patient of the amount of protein in that first diet prescription. If this initial assessment indicates that the first diet prescription is working well in this patient, then the initial diet is continued. If, however that assessment indicates that the diet is not working for that patient, then based on this second assessment, the diet is changed accordingly. The iterative process continues until the nutritionist is comfortable with the patient's response to the diet formulation or packaged diet prescription. CANINE CUISINE Feeding dogs ~1.5-2.0 cups of this diet for every 25 pounds (approx 10 kg) of ideal body weight per day supplies ~700 kcal and ~35 g protein/day as recommended daily for a 10 kg (22.2 lb) neutered adult dog.(6) As a rule of thumb, this is approximately 1.5 -2 times the volume of dry food to get the same caloric density. Variables that need to be accounted for include the caloric content of the individual foods in the recipe, the protein density per 100 kcal food, and the metabolism and activity level of the animal. Puppies will have increased caloric needs of up to 4-6 cups/25 pounds of weight, during their rapid growth phase. Remember that empirical adjustments need to be made for any patient on any diet, commercial or home made, based on individual metabolism the presence of disease, and moment-to-moment energy expenditures. In general adult dogs require about 1 gram of protein per pound of body weight per day. Resting energy requirements (RER) are defined by the equation: RER (kcal/day) = 70 (BWkg)0.75 or 30 (BWkg) + 70 if the BW > 2 kg (4.4 pounds) or >45 kg (100 pounds) (6) FELINE FARE For cats, feed about 6-8 oz of the home prepared diet for each 8-10 pounds of ideal body weight per day to provide ~260 kcal and 23 g protein/day for a neutered adult cat.(6) In general a healthy adult cat needs about 2 grams of protein for each pound of body weight. Feline energy requirements are computed in using the same formula quoted above for canine energy requirements. Cats can be more unpredictable as far as amounts to feed, based on whether they are indoor, or outdoor cats, and their age. Indoor cats do not receive enough exercise, generally, and thus need to be fed 25-50% less to start. Increased amounts of food can be fed later, if the initial amounts are not sufficient to supply a feline patient's needs. It's a lot easier to put weight on a cat then to take it off! CARBOHYDRATES Complex carbohydrate rich foods: DOGS---25% -33%- 50% CATS-0%-10%-33-50% Cooked grains (cook rice or barley wetter than usual, using 2.5-3 cups of water for each cup of grain); Oatmeal is easiest, owners can pour boiling hot water on top of the rolled oats and allow it to soak in, thus not needing to use a lot of heat, time in preparation, or necessitate cleaning up cookware later on. With oats the meals can be made "on the fly" each day. Baked potatoes, yams, sweet potatoes and squash are all good complex carbohydrate sources. Simply have your clients use cup measurements of the cooked complex carbohydrates to put the meal together. Dry oat flakes are used in the diet measurements versus the cooked cereal to provide more caloric density to the meals. Less allergenic cooked grains such as buckwheat, quinoa or millet can be used as alternate starches for some gluten or grain sensitive patients. PROTEIN Protein-rich foods: DOGS---25%-33%-67% CATS---67%-75 %-100% Ground turkey or beef is recommended as the meat source, unless there are specific allergies identified. If clients want to go vegetarian (which is not recommended) then cooked beans, tofu, eggs and cottage cheese are recommended as substitutes for this fraction. Clients can mix meat with the above "vegetarian" protein sources to fill the requisite amount of cups required for the pet's meal. RAW MEAT? This author recommends raw meat for its unadulterated content of nutrients, including food enzymes, but doesn't push the issue with clients who are reluctant. Cooked meat has a higher caloric and protein density than raw meat so it is necessary to account for that when recommending portions to feed. Ground meat is easier to estimate its fraction by volume in this recipe. A problem with feeding "raw meaty bones" (a la BARF) is the variability in protein, fat and carbohydrate content from bone to bone, which makes it more difficult to estimate portions to feed. Clients get easily confused with the meaty bone approach, and this author has seen many cases of inadequate or over-abundant caloric and protein feeding with that approach. VEGETABLES - "GREEN" FOODS Vegetables: DOGS---10%-33%-50% CATS---0%-12.5%-40% Vegetables are a great source of soluble and insoluble fiber, and are also a wonderful source of vitamins and minerals, anti-oxidants and other valuable phytonutrients. Vegetables can be served raw and or cooked, but in every case it is recommended that they be chopped up finely in a food processor and mixed in with the ground meat and cooked complex carbohydrates. Cats may need the vegetables to be pureed, or for convenience can be fed a vegetable baby food without onions or garlic. Seaweed (kelp, dulse, etc.), alfalfa, nettles, lecithin, spirulina, chlorella, wheat grass and/or barley grass juice powder can be added to each meal to improve its nutrient profile. (1/8-1 tsp per meal) FATS and OILS Healthy fats are provided to dogs using flax seed oil, and to cats with fish oils such as cod liver oil or salmon oil. Oil contains ~40 calories/tsp. Dogs are given about 1 tsp of oil/15 pounds/day to provide about 5-15% of their total consumed energy from fats. Cats are given about ½ tsp of oil/10 pounds/day. Flax seed oil provides both linoleic acid (essential) and alpha linolenic acid (possibly essential), an omega 3 fatty acid in approximately equal proportions. Feeding flax seed is another way to provide fresh vegetable oil, and also provides soluble fiber, vitamins, minerals and phytolignans. Flax seed needs to be ground freshly just before serving or needs to be soaked for 20' before adding to the diet. It can be added to the vegetables just before they are ground up in the food processor. Flax seed contains 30% oil, so it is recommended that 1 Tbsp per 15 pounds per day be added to the dog or cat's diet. For cats this is usually about 1.5 teaspoon of freshly milled seed per meal. The fiber portion of the milled flax seed will help manage hairballs. Flax seed oil contains the extremely heat-labile omega three fatty acid alpha linolenic acid (ALA). Following pressing, rancidity of the ALA can begin as early as 12 weeks, even when the oil is stored in a cool dark place. Freezing the oil will substantially increase its shelf life before rancidity develops, but each time the oil needs to be served it needs to be defrosted in order to enable it to pour. CALCIUM: PHOSPHORUS Dogs and cats have a much higher calcium requirement than do humans, estimated to be 5 times the average requirement for humans. For that reason it is important that any homemade diet have adequate calcium supplementation appropriate to the needs of the patient. The Calcium RDA for dogs and cats is about 1000 mg calcium per 25 pounds. The calcium RDA for humans = 400-1200 mg/day depending on size and metabolic age.. Assuming the average human weight to be 70 kg or 150 pounds, its approximate calcium need could be 1200 mg per day. A dog of the same 150 pound weight would need 6000 mg daily of calcium. Due to the high phosphorus content of muscle and organ meats and of grains, it is important to add a source of calcium to provide adequate calcium as well as a balanced ratio of calcium to phosphorus in the animal's diet. Total daily need for calcium as a crude estimate, would be 0.5g-1.0g of calcium per 25 pound dog. is enough for this balance, based on the calcium content of the specific foods fed and the renal function of the individual.(6) In the wild, predators eat the bones of their prey. It would be uncommon in the wild for animals to consume the quantities that are recommended in some diet plans such as the raw meaty bone BARF diets. Sources of calcium other than raw bones include: Dried bone meal, dried egg shells, oyster shell, mineral-rich plants such as seaweed, coral calcium, alfalfa, nettles, or green leafy vegetables. FEEDING THE LARGE BREED DOG-PUPPY Energy The energy requirements for any individual puppy will depend on breed, age, neuter status, environment and activity level. However, in general, growing puppies require twice the energy that a mature adult requires for maintenance. The need is greatest right after birth and decreases as the dog grows. The rate of growth of the dog is directly influenced by the dietary energy intake. Puppies should be fed based on their energy needs. However developing a calculation to estimate these needs is difficult, and often impractical. A puppy's energy needs will be continuously changing as the dog grows. A body condition scoring (BCS) system provides an easy and practical way to evaluate the effectiveness of the amount of food being fed in terms of affecting the body mass of the growing cat or dog, and therefore how well the diet and amount fed are meeting the young animal's appropriate energy needs. Current thinking recommends maintaining a BCS of (3) during growth will reduce excess body fat, help control excess growth, and reduce the development of skeletal abnormalities. Body condition scoring needs to be taught to owners/guardians and should be done every two weeks during puppy growth. Maintenance of an optimal BCS can be managed by altering the amount of food fed. Calcium The absolute level of calcium in the diet has been shown to be more important than the calcium/phosphorus ratio with respect to skeletal development. Excess dietary calcium has been shown to significantly increase the incidence of developmental bone diseases in growing puppies. Chronically high dietary calcium intake increases the frequency and severity of OCD. Its easier for dogs to adjust to slightly lower serum calcium levels, by mobilizing bodily calcium stores, than it is for the body to deal with eliminating excess calcium. A calcium of 1.1% (dry matter basis) is recommended for high risk growing puppies. This translates into approximately 1100 mg of calcium daily for a 50 pound puppy. 110 mg of calcium daily for a 5 pound puppy. Protein Protein requirements of growing puppies are higher than protein requirements for adult dogs. Both quality and quantity of protein in the diet are important to supply the proper balance of amino acids. Amino acids are vital for growth and development. Protein excesses in growing large breed dogs has not been shown to adversely affect skeletal development. Excess dietary protein only contributes to the energy content of the food, it does not accelerate the growth of bone or muscle. It is recommended that a growth formula for large breed dogs contain a high quality protein, with 28% or greater protein content (dry matter basis). SOURCES of CALCIUM Raw bones, bone meal, calcium supplements, seaweed, green leafy vegetables, milk, mezotrace, oyster shell, alfalfa, nettles, horsetail, commercial diets, coral calcium. Depending on calcium needs, supplementing with about 100 mg calcium per 5 pounds per day, total daily calcium consumption, assuming a 30-40% absorption from dietary sources. This may translate into ¼ to 1 teaspoon of a calcium rich substance each meal, or a raw bone or two per meal can also provide adequate daily calcium. BONES as CALCIUM SOURCE A small amount of raw bone can be fed as a means of providing healthy exercise for the gums and jaw muscles, and as an additional source of dietary calcium. Raw chicken wings, backs and necks (small cancellous bones) have been recommended in this author's practice without a single incident or problem to date (5 years). Clients are advised to exercise caution, that it is not appropriate to feed raw bones to some dogs (the gulpers or competitive feeders or those with small mouths or poor dentition), and clients are informed that this is a practice that they must assume at their own risk. INTRODUCTION OF THE NEW FOOD TO THE OLD PET Cats may need added palatability enhancers to assist in their transition to a home made diet. Introduce new foods slowly and gradually to all animals, especially cats. The use of bribe foods or familiar foods can assist greatly in convincing cats to make the transition. I often quote Mary Poppins: "A spoonful of tuna helps the new food go down." Using strongly smelling highly tasteful foods in small amounts to flavor the new food may assist in the transition, or may be necessary throughout the feeding process. Cats that are dry food junkies may never make the transition. They imprinted to dry food at weaning so strongly when they were kittens that they don't recognize anything else as legitimate food. A cat that won't eat canned food or tuna fish or "people" food, probably won't eat a homemade diet readily. For those cats that eat canned food you can gradually add increasing amounts of home made diet to the canned food ration as a means of introduction of the new unfamiliar tasting food. THE "TABLE-SCRAPS" DIET It is appropriate for veterinarians to NOT recommend the feeding of table scraps because they may unbalance a complete commercial diet, or add unnecessary or unhealthy amounts of calories and/or protein to an animal's balanced nutritional regimen. Also some table scraps may be excessively fatty and promote pancreatitis or diarrhea and vomiting in some patients. However, for clients who pay attention to providing themselves and their families with wholesome nutritious and balanced meals, it is not unreasonable to suggest that they simply divert some of the food intended for their family to their animal in the proportions and amounts that their veterinary nutritionist recommends. After all, before the inception of commercial foods, this is how companion animals were fed. RECIPE DRIFT One factor that is important to take into account is that human nature being what it is, it is not uncommon for clients who are preparing food for their animals to substitute other food materials or use differing proportions and amounts than have been recommended by their veterinary nutritionist. The professional recommendations have been given in order to provide for that animal a complete and balanced diet. Changing the diet this way is called: "Recipe Drift", and potentially could be a source of inadequate nourishment of the animal. For this reason, it is important that during annual examinations and other medical appointments that the client be queried as to the exact food materials amounts and proportions that are actually being fed. It takes a little more time to do this, but clients are appreciative of your interest in their animal's diet, and it helps to ensure nutritional adequacy. COMPROMISE DIETS If this were the "best of all possible worlds", then we would all have enough time and resources to prepare every meal for ourselves and for our pets from scratch from totally organic and range-fed sources. Since for most individuals, this is not the case, I recommend for flexibility an approach to feeding called the "Compromise Diet." A compromise diet is inclusive of the best possible meals that can be served, under whatever the moment to moment circumstances may be regarding kitchen facilities, preparation time, storage capacity, and food material availability. Many clients will express the desire to prepare meals for their pets on a regular basis, but actually cannot make the time to do that in their busy lives. I would rather clients prepare one good meal a week. At least their pet will get some wholesome nutrition. Combining meals of the best commercial food with healthy leftovers from family meals or healthy restaurants is a simple way to do this. I have the client offer the same proportions of carbohydrate, protein and vegetables as they would if they were preparing a meal from scratch. Many people eat well, so providing their starch de jour, protein de jour and veggies de jour can offer a superior plane of nutrition to their pets without much effort. This is the table scrap diet. If people are traveling with their pets, they can go to a restaurant and order a beef patty, baked potato or rice pilaf and steamed broccoli, and they are "good to go". Using the feeding guidelines suggested above, for each cup of fresh food offered, be sure to have the pet guardian remove a half cup of kibble, to approximately account for the additional carbs and protein. This way the pet won't be given an excessive amount of calories or grams of protein that are not needed. I have found that by being too rigid and demanding too much perfection from my clients turns many of them off from home made diet preparation. If they know that when their lives get busy its OK to bail on homemade diet preparation, at least in part, and its OK to go back to commercial foods, if only briefly, and its OK to mix commercial diets with home made diets or with left-overs as long as consideration is given to not feed an excessive amount of carbs and protein. TABLE SUMMARIZING INGREDIENT PROPORTIONS for CONDITION-SPECIFIC DIETS
NOTES: *protein sources should be branched chain amino acid rich, such as egg and dairy and poultry; carbohydrates need to be complex with low glycemic index **avoid carbohydrates with carbohydrate-based allergies; reduce amount of protein with protein-based allergies ***degree of protein restriction based on degree of azotemia measured against amount of protein loss from kidney and serum albumen determinations ****use low glycemic index carbohydrates INTEGRATIVE MEDICINE CLINICAL EXAMPLES OF BLENDING OF CONVENTIONAL WITH ALTERNATIVE THERAPIES
THE PRINCIPLES OF INTEGRATIVE MEDICINE: "GRUB GUTS & GALT" Integrative medicine recognizes several principles that underly the pathophysiology of chronic disease patterns. The over-riding principle, though, is that all of the systems of the body are interrelated. One corollary of this principle is the mind-body-spirit connection. Dr. Candace Pert described this in her landmark book: "The Molecules of Emotion", which established the interdisciplinary field of psychoneuroimmunology. What we think and feel can "somatacize" (manifest physically in the body) and convert into physical dysfunction or disease. One commonly found example of this are stress-induced ulcers. Another example is the case of acute cardiomyopathy and heart failure secondary to the extreme grief associated with the loss of a loved one or an important relationship. This is what can happen when you have a "broken heart". According to integrative medicine principles, the digestive tract is more than simply a means of deriving nourishment. In addition to the very important functions of digestion and absorption, the gastrointestinal tract is also the largest organ of the immune system in the body. Estimates range between 60-80% for the percentage of lymphocytes that reside in the GI tract. When we eat food, we want the GI tract to absorb all the good stuff, but we also want it to keep out all of the potentially toxic, antigenic and pathogenic materials that food also contains. How can the bowel have the innate intelligence to exclude noxious materials, but allow for the entry of nutrients? The answer to this question lies in several mechanisms that constitute 4 levels of protection by the barrier system of the GI mucosal wall.. The GIT (gastrointestinal tract) has the greatest amount of surface area exposed to the environment. In humans, the skin has less than 10 square meters of surface area, whereas the lungs have about 140 square meters of exposed surface area! The gastrointestinal tract in humans, though, has 200 square meters of surface area exposed to the environment. These surface area relationships are comparable in our animal species as well. This is why the GIT has such a specialized defensive system that combines both immune defenses as well as barrier and secretory and digestive defenses. The GALT (Gut Associated Lymphoid Tissue), in humans produces 10 grams of immunoglobulins daily, of which 60% is secretory IgA. There are estimated 1010 lymphocytes per linear meter of bowel in humans. These relationships are comparable in our animal species. Intestinal permeability is a double-edged sword. The GIT has the paradoxical double role of both needing to optimally absorb necessary nutrients, while at the same time excluding toxins, pathogens and antigens. The GI mucosal barrier is maintained by several mechanisms which can be disturbed by a variety of factors associated with GIT injury or infection. These barrier maintenance mechanisms will be discussed in the next section. Bacterial infections can cause injury to the tight junctions that hold intestinal mucosal cells together and that in part form the mucosal barrier of the GIT. Without the protection that the tight junctions provide, bacterial cytotoxins enter the host, paving the way for bacterial invasion. Bacterial overgrowth secondary to the use of H2 blockers and antacids can lead to proximal gut colonization by pathogenic bacteria who are "attracted" to the imbalance in the pH. Immunosuppressed or protein-deficient patients can have decreased sIgA (secretory IgA) production which impairs the immunoprotective value of this secretory immunoglobulin. 60-70% of the lymphocytes in Peyers patches are B-cells which are the precursors to the sIgA -secreting plasma cells. sIgA is found in the mucous layer (or glycocalyx) that overlies mucosal epithelia where it functions to decrease the adherence of viruses, macroglobulins and specific bacteria. The liver provides defensive activity both in terms of its phagocytic Kupffer cells, and in terms of its detoxification enzyme systems. The liver has a dual-phase system of detoxification. Hepatic enzymes decontaminate toxins and metabolic toxic by-products as well as help to degrade antigens and antigen/antibody complexes. Kupffer cells are the sessile hepatic macrophages that are found in hepatic sinusoids and play an important role in the GI immune system by removing bacteria, particulate matter and toxins. Digestive functions themselves can also serve protective functions within the GI immune system. For instance, HCL, which serves a vital function in protein digestion, also denatures many bacteria due to the acidic environment it engenders, especially when lowered pH is combined with prolonged gastric emptying time. Many of our patients are on antacids and H2 blockers such as famotidine or cimetadine. These can help many clinical conditions, but may also exacerbate conditions where normal stomach HCL secretion is essential. The denaturing of pathogens in the stomach, the cleaving of pro-proteolytic enzymes are two examples of the potential problems that long-term use of antacids can cause to your patients. Intestinal mucosal cells also produce defensive protein molecules, known as Defensins which function as part of the non-specific immune system (intrinsic immune system) to reduce intestinal pathogens. Peristalsis, or bowel transit time, helps to move pathogenic bacteria through the bowel before they have an opportunity to adhere and enter the host. Commonly used pharmaceutical agents such as vasopressors, corticosteroids and NSAIDs can also result in decreased GI mucosal cell mucus production and cause the subsequent loss of the bowel's protective mechanical barrier function. Contrary to the recommendations of folk medicine, prolonged fasting may do more harm than good in patients with challenged immune systems. (15). "Bowel rest" for more than 3 days has been shown to cause deterioration of the enterocytes population, which can lead to atrophy of the mucosal surface, alterations in bowel permeability and an overall diminution of gastrointestinal immune function. Studies have shown that early enteral feeding can improve splanchnic blood flow, and can improve immune system function. (16) THE FOUR-PART INTESTINAL MUCOSAL BARRIER The first layer of this barrier is the glycocalyx that consists of mucus secreted by goblet cells in the intestinal mucosal villus. The formation of this mucus is dependent upon sulfation in the liver. If the liver is being challenged by toxins, drugs, etc, it may not be able to provide adequate sulfation to produce a protective mucus layer. This allows for the introduction of more toxins, which will further tax the liver and impede its nutritive and protective roles. The second layer of this barrier is made up of the beneficial intestinal bacteria species such as Lactobacillus acidophilus in the upper GI tract and Lactobacillus bifidus in the lower GI tract which are embedded in this mucus-gel layer and adhere to the intestinal villus cell membrane, thus mechanically preventing the invasion of pathogenic bacteria. These gram-positive lactose-fermenting facultative-anerobic organisms also secrete enzymes and other molecules possessing antibiotic properties. It has been recently determined that the cell wall fraction of these bacterial organisms has an stimulating effect on the innate immune system by means of the generation of immune-enhancing cytokines. This positive effect on immune function occurs when cell wall fractions are brought into contact with the immune system. Bacterial cell wall fractions are created when the dead and dying bacterial flora auto digest themselves or are digested by the hosts' digestive system. The third protective layer of the bowel barrier system is provided by the tight junctions between the intestinal mucosal cells, providing a mechanical barrier to the introduction of unwanted compounds. With inflammation, infection and certain drugs these tight junctions can weaken, thus allowing the ingress of inappropriate compounds. The fourth and last protective mechanism for the barrier function of the bowel is provided by the immune system. Through a complex process, antigens and pathogens and toxic substances can be recognized by the Gut Associated Lymphoid Tissue (GALT), which then elaborates the immunoglobulin sIgA, which is the first line of defense of the immune system for the mucous membranes of the bowel and the respiratory systems. When the barrier function is disrupted, antigens and pathogens are allowed to gain entrance into the systemic immune system, first in the Peyer's patches that are found contiguous to the epithelial mucosal cells that line the bowel, and then in the mesenteric lymph nodes, and finally these noxious substances can disseminate throughout the lymph nodes into distal regions of the body. When food allergens and pathogens are eliminated by barrier mechanisms and secretory IgA, there is no systemic reaction, mediated via the reactive production of IgE which leads to the histaminic response that is associated with hypersensitivity reactions. But, once this barrier is disturbed, these noxious compounds can enter the circulation and cause the symptoms we commonly associate with food allergies and food intolerances or sensitivities. "LEAKY GUT" = INCREASED INTESTINAL PERMEABILITY This condition where the barrier function of the bowel is disrupted is called "Leaky Gut", and has been well-documented in both the human and veterinary literature (17, 18). It has been demonstrated that not only do symptoms of food allergies align with leaky gut, but a pathologic mechanism called "Bacterial Translocation" occurs in which commensal or pathogenic bacteria from the gut can migrate to other organs where they are not commonly found. Once in these distal target organs these "foreign" bacteria stimulate an inflammatory response, which is first localized to the organ system and then becomes systemic. Appropriately enough this systemic post-bacterial translocation phase is called: "SIRS" or systemic inflammatory response syndrome. One example of this is the polyarthritis associated in some patients with enteric salmonellosis infections (19). In the conventional model, SIRS is initiated by infection or tissue injury and then further exacerbated by bacterial translocation, which provides for the release of endotoxin, which stimulates pro-inflammatory cytokine and leukotriene release (TNF-?, IL-1, IL-6) which, with activation of PMNs and the production of ROS further amplify the inflammatory response. Have you ever wondered why we see so commonly in clinical practice, patients that present with diarrhea who will then develop (either concurrently or following the first infection) a urinary tract infection? Anatomically, the urinary bladder is contiguous to the rectum. They share some venous drainage and lymphatic vessels. When the bowel's barrier system is functioning within normal limits, an acute infection stays within the bowel lumen or within the bladder. But either due to the pathogenesis of the infectious diarrhea or when the bowel barrier has already been breached, the bacteria will translocate to the bladder, or visa versa. Of course transmission of pathogens can also occur externally from rectum to vulva from licking or contamination with feces of the vulva. Following SIRS, if the condition does not find correction, it then progresses to the final and most serious stage, known as MODS or multiple organ dysfunction syndrome. This is where you have multiple organ involvement and a patient with refractory multiple symptoms. This is the underlying mechanism involved with many chronic and degenerative conditions, including both inflammatory and autoimmune disorders. The first step in the correction of BT, SIRS and/or MODS is to correct Leaky Gut. Clients may understand how food allergies could relate to dysfunctional digestive barrier processes, but it is often difficult for a client to understand how digestive function can play a role in the pathogenesis of asthma, arthritis, chronic sinusitis, rhinitis or even epilepsy. For patients with chronic GI disease, such as chronic diarrhea, IBD or hepatitis, the connection between these disorders and Leaky Gut is easier to grasp. I think it is important to take the time necessary to explain to clients how Leaky Gut and the bowel barrier mechanism failure promotes these chronic diseases. An informed and educated client is a better partner for the complicated process involved in addressing these chronic diseases. Often the "homework" for clients who want to pursue Integrative Medicine for their pets is quite extensive. These patients will be receiving home-made custom-designed diets, multiple nutraceutical and botanical supplements, and probably some degree of conventional pharmaceutical therapy as well. When a client understands why these tasks are necessary to re-establish healthy patterns, it makes it a lot easier for them to be compliant. The following 4 step approach to correct this condition has been developed by the Functional Medicine group out of Gig Harbor, Washington. (20) It is called the "4-R Program". I initiate this program in many of my patients, and often will use as at least a part of this program for all of my patients. I have clinically seen it benefit these patients, repeatedly. Some patients with long-standing chronic disease issues may need longer exposure to these tools to effect any clinical change at all. Some patients are so "stuck" in their pathology that it is possible that none of these tools will do any good. The only way to identify these difficult to address patients is by offering them these tools and maintaining them on them for at least 6 months before deciding that they are not working and at that point could be discontinued. THE 4-R PROGRAM FOR LEAKY GUT AND CHRONIC DISEASE 1: REMOVE pathogens allergens and toxins. By lowering the "total load" (the body's burden) of these troublesome substances, the immune system and liver do not need to work as much in processing them. This makes more energy available to these systems to direct toward re-establishing healthy patterns. Removal can be by elimination from the diet or environment, or by the use of agents such as antimicrobial agents to reduce the population of pathogenic organisms. Summary of Appropriate Dietary Supplements and Medications:
Inadequate pancreatic or intestinal enzyme production leaves digesta only partially broken down, thus altering the environment in the bowel, providing opportunity for pathology to develop. The beneficial bacteria that produce short chain fatty acids (SCFA) from soluble fiber in the bowel need a narrrow range of temperatures and pH, as well as adequate substrate for their activity. When food is only partially digested, the intermediate breakdown products of the ingested food that result is not conducive to the normal function of these probiotic species. Some patients will have genetically inadequate pancreatic function, others will have acquired pancreatic function defects due to bouts of clinical or subclinical pancreatitis. Supplementing with either pancreatic enzymes or fungal source digestive enzymes can help these patients to better digest their food. I have found that pancreatic enzymes work best in those patients with abnormally low or low normal cTLI test results. For all the other patients I use fungal source digestive enzymes that have been derived from Aspergillus niger. Fungal source digestive enzymes function over a wider range of temperatures and pH conditions than both pancreatic and plant based enzymes. For non-EPI patients I suggest fungal-source digestive enzymes for their 4R Program. Hypochlohydria is the insufficiency of hydrochloric acid in the stomach. It can be due to genetic factors, disease factors such as pathogens attacking the parietal cells in the gastric mucosal lining, or an iatrogenic cause such as the rampant use of antacids such as cimetadine, famotidine and ranitidine. In the absence of HCL you get inadequate cleaving and activation of the proteolytic pro-enzymes present in the stomach. With inadequate protein digestion an number of problems can occur. Nutritional science is discovering the importance of adequate protein for a variety of necessary bodily functions involved in cell signaling and cellular repair and activity. If you are ingesting adequate protein dietarily, but your digestive system cannot break it down or absorb it, then you have a non-dietary protein deficiency. Patients with hypochlorhydria commonly present with foul and putrid breath or eructation, and in some cases may even have very foul and putrid flatulance. Hypochlorhydria is considered to be a risk factor for helicobacter infections, and thus may underlie some cases of chronic vomiting in your patients. Unfortunately it is not easy to measure stomach acid content, and thus there is no easy test to determine hypochlorhydria, other than by clinical signs. Naturopathic physicians have been recommending the use of a supplement that is derived from beet root called betaine hydrochloride as a means of augmenting weak gastric hydrochloric acid levels. The supplement contains not just the betaine hydrochloride, but also pepsin which will directly help in the breakdown of protein molecules. The medicine comes in one strength and is dosed to effect. I usually recommend a single capsule be given 20 minutes before meals. If one capsule does not produce desired effects within a week, I then will double the dose, irrespective of patient size or species. I dose patients with betaine hydrochloride when they are showing signs or symptoms of hypochlorhydria. Usually, if I am uncertain if hypochlorhydria is present, I will challenge these patients with 30 days on betaine hydrochloride and observe for improvement. If no improvement is seen with respect to the burping odors or vomiting, I will then discontinue the use of this supplement. Summary of Appropriate Dietary Supplements
Appropriate Dietary Supplements The use of the free form amino acid l glutamine has been found to reduce bacterial translocation (21), and to increase the protein synthesis of the enterocytes which enables them to increase their rate of self-repair. The phospholipid-rich compound lecithin, and the omega three fatty acids commonly found in fish oil, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are also integral to the repair of intestinal mucosa damaged from disease, stress or diet. (22) Antioxidants reduce ROS damage to intestinal mucosa. Zinc and Vitamin B5 (pantothenic acid) are involved in the mucosal repair process. Soluble fiber promotes SCFA production which provides nourishment for repair of damaged lower bowel mucosal cells.
Normal indigenous GI bacterial flora are an extremely important factor in maintaining the healthy GI mucosal barrier. Anaerobes are the most numerous bacteria in the bowel. These commensal beneficial microorganisms compete with potential pathogens for nutrients and for attachment sites to the mucosa, and thereby inhibit bacterial overgrowth by the pathogenic gram negative bacteria. Antibiotics can upset this balance between the good bugs and the bad bugs. H2 blockers, as well as hyperosmolar enteral diets can result in bacterial overgrowth and colonization of the stomach. Appropriate Dietary Supplements
Developed and promoted by Jeffery Bland, PhD and founder of the institute for functional medicine (IFM) in Gig Harbor, WA. Dr. Bland developed and tested the 4R program clinically before introducing it to clinicians. "Functional medicine is a science-based field of health care that is grounded in the following principles:
Herbs are becoming used more commonly by clients for their pets. As a result, veterinarians need to know about these herbs in order to evaluate their impact on their patients. Additionally, veterinarians need to be able to advise their clients in the safe and judicious use of herbs for their animals. The following information will help you as a veterinarian understand better these botanicals and nutraceuticals and their potential benefit or detriment to your patients. Later in this section this author will discuss 10 specific botanical compounds that can be important adjuncts to a conventional veterinarians practice of medicine. The complex constituents of herbal remedies allows them to have a broad range of therapeutic actions. Thus, effective herbal dosage regimens usually are not as precise as those for pharmaceutical medicines. Patient response time to many natural remedies may take days or weeks to become evident, making it much more difficult on the part of the practitioner to judge the effectiveness of the therapeutic protocol chosen for that patient. Natural remedies also may be more difficult to administer. Most veterinarians do not know how to evaluate an herbal product for potency, quality and safety, much less therapeutic effectiveness. Clinical success with a patient involves more than just knowing the nature of the disease. Practical considerations concerning the therapeutics for a patient are as important as any other portion of that patient's medical workup. One could have the most effective therapeutic regimen for a patient, but if one is unable to administer it adequately, the patient will not benefit. A practitioner may know what herb to use for a given condition, but when they go ahead and purchase this herb from a supplier, it doesn't work. Was the therapeutic choice of that specific herb wrong, or is there another reason for the failure of the herbal therapy such as lack of patient compliance or inadequate potency of the herbal formula? Not all herbs or herbal formulas are created the same. The same herb, supplied by different suppliers can have entirely different potencies or biological effects. How can a practitioner effectively predict clinical outcomes without standardization of content and potency of natural medicines? To successfully treat your patient with any type of medical therapeutic, whether it be "natural" or pharmaceutical in nature, there is a six step process that every clinician must go through:
Although no direct evidence exists explaining how humans and animals initially learned which plants were safe to use as foods or for healing, there is anthropological evidence that supports the premise that plants have been used by humans for themselves and for their animals since the dawn of humanity 60,000 years ago (23). The Roman herbalist Pliny wrote in the first century AD of the discovery of the medical uses of plants by animals such as swallows, dogs and deer as having been influential in teaching humans which plants to select. (24) Research in the field of zoopharmacognosy (the study of animals' recognition and utilization of wild plants) demonstrated that elephants, monkeys, bison, pigs, civets, jackals, tigers, bears, wild dogs, rhinoceros, mole rats and desert gerbils use plants as medicines. (25) Physicians in the US studied and relied on plant "drugs" as primary medicines through the 1930's. Up until the 1930's, medical schools in the US taught basic plant taxonomy, pharmacognosy and medicinal plant therapeutics. Physicians routinely used plant drugs as their primary medicines. In fact, the word "drug" is derived from a word for the root of a plant. In 1870 the US Pharmacopoeia listed 638 herbs in its publication. By 1990 there were only 58 listed. (26). Some of these plants fell out of use due to their weakness or toxicity, however the majority of clinically useful plants were replaced by pharmaceuticals which could be patented, thereby capable of generating larger profits, as well as supporting the increased industrialization and materialism of contemporary conventional medicine. (27) Herbal medicine is a vibrantly alive discipline that is being used actively in many cultures throughout the world today. There is no question that botanical preparations can have a beneficial or therapeutic effect. The World Health Organization estimates that 80% of the world's population relies on herbs for their primary health care needs. In France and Germany it has been estimated that 30-40% of all medical doctors rely on herbal preparations as their primary medicines. (28) THE "DOCTRINE OF SIGNATURES" AND THE "DOCTRINE OF SIMILARS" These are ancient concepts stating that the appearance of a plant, or plant part, or the environment that the plant grows in, or the season that the plant grows, are reflections of that plant's uses. Each herb has a sign or "signature pointing to its medicinal virtue. The origins of the Doctrine of Signatures is shared with the Doctrine of Similars, which is expressed in the saying: "Like Treats Like". This doctrine states that the herb which holds the cure is similar to the organ, tissue, or constitution that it acts upon. The herb may even be similar to the disease state being expressed. There is also a correspondence between our emotions and the environment. We often express our emotions in terms of the natural world. We say we feel "bright" or "hot". Thus there can be a correspondence between our emotions and plants. The plant which has learned to deal with a certain expression of cold in nature will also be able to cure a similar emotional "cold." In this way, plants can "teach" our emotions as well as our bodies. Our emotions correspond to our bodily organs. Each emotion has a physical organ which vibrates so to speak, when that emotion is active. When an emotion is blocked, the analogous organ becomes lifeless, and at last, diseased. The plant which corresponds to the affected organ also corresponds to the emotion which animates it. We cannot have our physical health without the emotional health which lies behind it. Plants are embodiments of processes which correspond to both physical and emotional expressions of life. They present complex personalities, thoughts and feeling, as articulate as our own, sometimes, more. They can be our "teachers", both physically and mentally, and are an ideal means for both education and healing." (21) The Doctrine of Signatures can be found in all Ethnobotanical herbal systems, including TCM. There are several legends in TCM regarding how certain herbs found their usages. For instance, Cheryl Schwartz (14) writes of the sour mountain date, (Cornus fruit; Shanzhuyu), begins to flower in Spring and lasts through summer and fall, and the fruit finally becomes ripe in November. The ancients saw that this herb withstands a wide range of temperatures and is productive for so long, that early herbalists felt it could be a longevity herb. It is still used for that purpose today. Morinda root, Bajitian, another longevity herb, is known as "never withering and falling" because it is a persistent hanging vine. HOW HERBS WORK Botanical compounds (herbs) have a variety of ways they can effect biological systems. Herbs are complex compounds consisting of amino acids, proteins and peptides, vitamins, minerals, carbohydrates, polysaccharides, fats and oils, as well as a number of biologically active compounds like alkaloids, saponins, sterols, volatile oils and other "phytochemicals". There are nine classes of these biologically active phytochemicals that will be detailed in the next section. Herbs create their effects in biological systems from providing nutrients that can influence health, or from providing phytochemicals that have a direct or indirect biological effect on the animal at the cellular level. Often the effects of the herbs on biological systems is the result of the concerted effect of multiple phytochemicals in the herb combined with the nutritive effect of the herb. When a multiple herb formulation is being used, the result response is very complex based on the multiple effects of the multiple constituents of the multiple ingredients in the formulation. Before modern chemistry was able to define the actual chemicals found in plants, herbal actions were described by qualities of the herb based on its physical properties, taste and its general effect on a biological system. Herbs are described as having taste, temperature, and direction. Thus an herb that tastes bitter, and has a downward direction, could be useful for nausea or vomiting. It is known from practical experience that the bitter taste of an herb stimulates normal gastric emptying, and the downward direction keeps the stomach from "UP" chucking its contents via vomition, and instead moves its contents "downward" which is its normal direction to move digesta. Some herbs are diaphoretic, which means they induce sweating, whereas other herbs are cholegogue, which means they stimulate the contraction of the gall bladder and the release of bile into the duodenum. There are many descriptive names such as these listed in texts of herbal medicine which were used (and still are used) by traditional herbologists. In modern times, herbal medicine has incorporated the science of pharmacology and pharmacognosy into isolating and describing the active ingredients that make up an herbal medicine, and uses more of an indication-based system of prescribing, versus the Ethnobotanical systems that match the properties of the herbs and herbal formula with the characteristics of the disease pathology and the symptoms of the patient. PHARMACOGNOSY and PHARMACOLOGY of HERBAL COMPOUNDS With the establishment of the science of Chemistry, active constituents in herbs were purified, extracted, and ultimately, copied or synthesized, thus giving birth to the science of "pharmacognosy": "The science dealing with 1) all information concerning medicines from natural sources: Plants, animals and micro-organisms, and, 2) the science of synthesizing complex organic compounds with biological activity". Modern pharmacognosy recognizes 9 categories of plant-based chemical constituents (Phytochemicals) that mediate the biological effect of plants. (29) NINE CATEGORIES OF BIOLOGICALLY ACTIVE ORGANIC CHEMICALS COMMONLY OCCURRING IN NATURAL COMPOUNDS
Natural does not necessarily mean safe. For many herbs the difference between effective and toxic is a matter of dosage. Fortunately, except for a few extremely potent plants, the volume of material that needs to be ingested to achieve patient toxicity is usually greater than that which an animal would voluntarily accept. In fact, in most cases, the toxicity is so low that even when administered against the animal's will, toxicity will not occur. There always are exceptions and exceptional |