Michael Carlston, M.D. - Family Practice & Complementary Medicine

Carlston, M.D.
Family Practice and Complementary Medicine

www.carlstonmd.com

December 22, 2007

Dear Patients

Happy Holidays!

I have been looking forward to this time for quite a while because of the family gatherings. It is an extremely stressful time for many people because they have so much to do and their family gatherings are emotionally challenging for a variety of reasons. Barring unexpected difficulties, I am among those blessed by the prospect of a peaceful and loving holiday this year. Those of us who are so fortunate should remember that it is a hard time for others and share our emotional good fortune in kindness towards each other. That is not a bad way to approach the New Year, either.

Happy Holidays
Michael Carlston, MD

Are Those Presents Lead-Free?
Vitamin D and Cold/Flu Prevention
Herb Quality

Are Those Presents Lead-Free?
Scares about toxin-laden toys are unfortunately warranted. As a young physician I worked a great deal with a refugee community whose infant children often suffered from lead poisoning. Older physicians often asked me about managing patients with lead poisoning because they had seen so few patients with this problem compared to my experience. As we became increasingly aware of environmental toxicity, removing lead from the environment was a high priority, and for many years, relatively controlled.

These days lead exposure is not coming so much from gasoline, lead paint or contaminated folk remedies, as in the past. Now we have toys to blame as the major source.

Although testing is imperfect, there are test kits available which can give you a certain level of confidence that objects in your home do not contain high levels of lead. These test kits (Lead Inspector and Lead Check) are available on the Internet and inexpensive. They are only able to test the surface of an object however, so seeing your infant child or grandchild chewing on a painted toy from China should make you nervous, even if it tested fine.

Vitamin D and Cold/Flu Prevention
It has long been clear that people get colds and flus during the winter months. A recent theory postulated that this could be because dry winter air allows viruses to float in the air longer, jumping from person to person. A very big problem with that theory is that people in wet northern climates (like here, for example) still get sick. While this “dry air” theory might be true, the seasonal drop of vitamin D as the sunlight wanes seems much more important.

The best way to be really certain that something works is to try it out. Recently, investigators tested vitamin D as a preventive for colds and influenza. As people with darker skin need more sun to make vitamin D, this study enrolled African-American women to make it easier to find a difference. For three years investigators tracked the number of colds and flus suffered by these women. When the study started the women in the active treatment group received 800 iu of vitamin D a day. In the final year of the study, recognizing that 800 iu/day was too low a dose, investigators raised the vitamin D dose for women in the active treatment group to 2,000 iu/day. When the data were analyzed, it turned out that women in the placebo group were 300% more likely to get sick.

Herb Quality

An Herb is an Herb, Right?
Estimates are that 80% of the world’s population use herbs medicinally. Ralph Waldo Emerson wrote that weed is simply a plant we do not know how to use. Humans have been using plants as medicines as far back as we know. In fact, there is evidence that monkeys, and other animals will seek out certain medicinal plants when they are ill. Not only is there consistency in the plants selected, scientific testing has found that these plants often have biologic effects (e.g. antibacterial) that should be helpful to that sick animal. (Search zoopharmacognosy if you want to learn more)

Just like these animals know where to go to find what they need, we have convenient access to herbs at health food stores, pharmacies and online. However, lacking connection to the original source of the herb, we have to rely on herb suppliers to provide the herbs we want and label them properly. Unfortunately, this is not quite so easy.

Herb Substitution
In 1993 a number of patients at a weight-loss clinic in Belgium died of kidney failure after they took an herbal mixture containing aristolochia, instead of a similar herb stephania. Because of the potential confusion between these herbs, at least one high profile herbal manufacturer decided not to sell stephania. Although they were confident about their own ability to identify the herb, they feared that by selling stephania they would be encouraging its use, and consequently increasing the likelihood of someone accidentally purchasing the misidentified toxic aristolochia from other manufacturers.

Herbs Gone Missing
When St John’s Wort first surged into the American consciousness, the LA Times purchased seven bottles of St. John’s Wort from various stores and then had the herbs chemically analyzed. Three of the seven bottles did not contain any measurable quantity of St John’s Wort.

In 2003 the ARCHIVES OF INTERNAL MEDICINE published a study of the herb Echinacea. There are different forms of Echinacea– most common are Echinacea purpurea, Echinacea angustafolia and Echinacea pallida. Each of these herbs have somewhat differing biological effects. In this study, none of the 59 samples purchased from local stores contained what the labels said they contained. Half of the time the wrong species of Echinacea was identified. Six had no Echinacea. The quantities contained were also often substantially above or below what was listed on the labels.

Contamination
Another more recent survey found a sample of Echinacea containing significant lead contamination. A colleague who runs an herbal supplier told me once that they had to reject over 1/3 of the herbs his company purchased from China and India because they were either misidentified or contaminated. Heavy metals are the most common contaminant, especially lead. Studies of Chinese herbs distributed in Asia, Europe and the United States have found 3-10% of them contaminated with lead. Many other heavy metals (arsenic, mercury, cadmium, thalium, copper) have been discovered in herbs sometimes at very dangerous levels. Contamination with herbicides or pesticides is, unfortunately, commonplace as well.

Adulteration
A study of over 2600 samples of traditional Chinese herbal medicines in Taiwan found that 24% had at least one conventional prescription medication in the mixture. A similar study in California found that 7% of the 251 samples analyzed contained prescription medication that was not listed among the ingredients. Among the pharmaceuticals commonly found in these herbs are steroids, diuretics, pain medications and drugs used to control seizures.

One of the most notorious episodes of adulterated herbs occurred with the product, PC-SPES, which was used to treat prostate cancer. Initial scientific studies and clinical reports looked very promising, and the last medical school I worked for (University of California, San Francisco) was conducting a clinical trial. It generated a great deal of excitement for a couple of reasons: it was the first serious investigation using herbs for cancer treatment at a major medical institution and second, this combination of herbs appeared to have effects that none of the individual herbs had alone. The consequences of demonstrating synergistic effects could be very important.

The study compared anti-hormonal treatment of prostate cancer using DES (diethylstibesterol) with the PC-SPES herbal combination. As the study was underway, early results showed that men in the PC-SPES were doing better, with twice as many patients showing a 50% drop in their PSA levels. However, following up on a recent report of adulterated lots of PC-SPES, the investigators analyzed the PC-SPES and found it contained DES. They immediately stopped the study and the manufacturers of PC-SPES went out of business.

Sadly, there is still uncertainty about whether PC-SPES might actually have been helpful alone or in conjunction with DES. Various batches of PC-SPES seemed to have been more or less effective in previous studies; and some studies showed DES contamination, while others did not. The men in the UCSF study who received the DES contaminated PC-SPES were receiving only a few percent of the dosage of DES received by the men in the DES group. Given the suspicions and bad feelings engendered in this incident, it is impossible to see any study clarifying potential benefits of PC-SPES in the foreseeable future.

Part of the Plant
The proper part of the medicinal plant must be used. Sometimes it must be collected at a specific season or time of day. Then it must be processed in the correct way. For example, the hairs of Ginseng are traditionally discarded, as they are believed to be ineffective or even detrimental. However, there are ginseng products out there made exclusively from these hairs (clue- they are surprisingly inexpensive).

Processing
We usually have little if any idea which one of the hundreds of chemicals in any one herb creates the herb’s beneficial effects. The optimal effect may depend on some combination of those chemicals. Traditional herbal wisdom is the best place to begin.

Dried herbs usually have the best balance of chemical components, and so are usually the best source material for the processed herbs you buy at the store.

Companies have been working to identify what are called "marker compounds", which we can test for, and then semi-confidently determine which herbs are reliable. For many herbs there is more than one marker compound. As examples, we look for anthocyanosides in bilberry, echinacoside in Echinacea, escin for Horsechestnut, kava lactones in Kava, ginsenosides in Panax Ginseng, eleutherosides in Siberian Ginseng, hypericin and hyperforin in St John’s Wort. The presence of established levels of marker compounds in the final product can also reassure us that the processing did not remove the chemicals most likely to be helpful.

Extracts?
The question mark represents uncertainty. When we process herbs and use their extracts we are medicalizing them. We hope to extract their powerful essence, and so, maximize the benefit. The problem is that we often don’t know what is important, which can lead to miscues. Also, this extraction process can create an imbalance, making us more vulnerable to toxic effects. Using the entire herb might make this problem less likely.

I am comfortable with most extracts, as they are still very much like the whole herb. These extracts are in essence simply “condensed” for easier usage. The extracts which are heavily processed to dramatically raise levels of certain chemicals thought to be therapeutic, concern me. I use them rarely, and only with great care.

Remember that the numbers by “extract” tell you a lot about the strength of the product in your hand. A 100:1 extract means that the product has been concentrated to a strength 100 times that of the source material, so 1 mg of the product came from 100 mg of herb. Conversely, when the ratio is the other way around, for example 1:4, it means that the 200 mg tablets contain 50 mg of the herb.

Avoid proprietary blends. In the interest of maximizing profits, herbal manufacturers in the United States are allowed to sell blends of herbs without telling the consumer how much of each herb is included. This is like me telling a patient to go to the drug store and get some antibiotics for his pneumonia. The patient then goes to the drugstore and buys SUPER BOB’S ANTIBIOTIC BLEND because it has an attractive label, not because it has the right amount of the right antibiotic to treat his pneumonia. Fortunately for them, citizens of other countries are better protected.

Certification
Independent confirmation of the safety and quality of herbal products, as with dietary supplements, is a good idea. Manufacturers have been developing voluntary Good Manufacturing Process (GMP) guidelines, and the FDA is proposing mandatory GMPs. While this will create major financial problems from small herbal suppliers, overall it could be a good step forward. The US Pharmacopeia certifying process (USP) could be an option, but may only be realistic for chemically simple products like vitamins. There might be a “middle ground” option whereby USP could certify levels of established marker compounds in herbs as well as absence of contaminants. You can also learn about contents of some products through an organization like ConsumerLab.com, which independently analyzes herbs and supplements.

Summary
These issues of quality control severely impact upon your health.   If you take an herb contaminated with pollutants or prescription medication, it is likely to hurt you. If you take the wrong herb it won’t work. If you take the correct herb, but it is relatively inactive because it was processed incorrectly or the wrong part of the plant was used, it won’t work. If poor quality herbs were used, or good quality herbs used incorrectly, studies conducted to learn how well an herb works will reach the wrong conclusion.

Remember that herbs are powerful and thus deserving of respect
            Don’t take them without a specific need
            Take care to use them properly
            Choose high quality herbal products
Read the labels –
            Is the herb identified fully (name and plant part used)
            Is the production process specified?
                        (extract are most common but ratio 1:5, 1:2 should be specified as well)
            Is it made from dried herb (usually better due to chemical balance) or fresh?
            How much is in a dose? ("Proprietary blend" means they won’t tell us)
            Was the extract cold?
            Was the extract made using ethanol, glycerol or aqueous solution?
            Are marker compounds identified?
Buy from the best possible sources

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December 22, 2007

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