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From the Townsend Letter
May 2008

Literature Review & Commentary
by Alan R. Gaby, MD

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Probiotics for seasonal allergies
Forty-four patients (mean age, 36 years) with Japanese cedar pollinosis were randomly assigned to receive, in double-blind fashion, Bifidobacterium longum strain BB536 or placebo for 13 weeks during the pollen season. The dose of the probiotic was 5 x 1010 colony-forming units in 100 ml of milk twice a day. The mean symptom severity was significantly less with active treatment than with placebo. The mean improvements compared with placebo were as follows: sneezing, 60% (p < 0.03); rhinorrhea, 53% (p < 0.01); nasal blockage, 53% (p < 0.02); eye symptoms, 37% (p < 0.09); throat symptoms, 53% (p < 0.03); and composite score, 40% (p < 0.02).

Comment: Probiotic agents have a number of different effects on immune function. Previous studies have suggested that administration of probiotics can prevent the development of allergy-related diseases in infants. To my knowledge, the present study is the first to show that treatment with a probiotic agent can relieve allergy-related symptoms in adults. Additional research is needed to determine which strains of probiotic organisms are effective and what the optimal dose is.

Xiao JZ, et al. Probiotics in the treatment of Japanese cedar pollinosis: a double-blind placebo-controlled trial. Clin Exp Allergy. 2006;36:1425-1435.

Case report: intravenous vitamins and minerals for seasonal allergic rhinitis
A 38-year-old man had a long history of seasonal allergic rhinitis, occurring each spring and lasting about a month. Symptoms were severe and included nasal congestion, itchy eyes, and fatigue. Conventional treatments provided only minimal benefit. During a symptomatic period, an intravenous infusion of 2.6 g of vitamin C, 600 mg of magnesium chloride hexahydrate, 1,000 mcg of vitamin B12 (hydroxocobalamin), 100 mg of pyridoxine, 250 mg of dexpanthenol, and 1 ml of B complex-100 provided rapid relief. This treatment was repeated once a week or less often, as needed, during the hay-fever season, and successfully controlled his symptoms. In subsequent years, he began receiving these injections shortly before, and repeated them periodically during, the hay fever season. This approach prevented the development of symptoms.

Comment: This treatment, which is a modified version of the Myers cocktail, was tried empirically based on potential anti-allergy effects of various individual components. For example, vitamin C has antihistamine activity, dexpanthenol may support adrenal function, niacinamide (a constituent of B complex-100) inhibits mast cell degranulation and experimentally induced anaphylaxis, and magnesium has been reported to be beneficial in the treatment of allergic rhinitis. Although there is little or no published research on using intravenous nutrients to treat hay fever, it worked for this patient, and he was gratified to be free of his annual month of misery.

Vitamin D for tuberculosis
Sixty-seven Indonesian patients with moderately advanced pulmonary tuberculosis who did not have AIDS were randomly assigned to receive, in double-blind fashion, 10,000 IU/day of vitamin D (not specified whether this was vitamin D2 or vitamin D3) or placebo during the initial six weeks of conventional treatment. After six weeks, the sputum conversion rate was 100% in the vitamin D group and 76.7% in the placebo group (p = 0.002). Among the 36 patients who had radiological evaluation after six weeks, 87.5% of those in the vitamin D group and 65% of those in the placebo group showed improvement (p value not stated). The mean serum calcium concentration after six weeks of treatment did not differ significantly between groups.

Comment: The results of this study indicate that the addition of vitamin D to conventional therapy accelerated recovery in patients with moderately advanced pulmonary tuberculosis. Patients with tuberculosis have been shown to have significantly lower serum concentrations of 25-hydroxyvitamin D when compared with healthy controls. This reduction in vitamin D levels could not be explained by differences in dietary intake or sunlight exposure. Vitamin D plays a role in immune function, and it also appears to enhance the immune system’s specific response to Mycobacterium tuberculosis. Based on these observations, vitamin D supplementation should be considered as a component of the overall treatment of tuberculosis. In addition, 25-hydroxyvitamin D levels should be monitored in patients with a history of tuberculosis. In those whose levels are low or suboptimal, vitamin D supplementation might help prevent a reactivation of the disease.

Nursyam EW, et al. The effect of vitamin D as supplementary treatment in patients with moderately advanced pulmonary tuberculous lesion. Acta Med Indones. 2006;38:3-5.

Soy lowers blood pressure
Sixty healthy postmenopausal women were randomly assigned in a crossover design to consume a low-fat diet or a diet of similar macronutrient content in which one-half cup per day of unsalted soy nuts (providing 25 g of soy protein and 101 mg of isoflavones daily) replaced 25 g of non-soy protein. The soy nuts were consumed in three or four portions spaced throughout the day. Each diet was followed for eight weeks. Compared with the low-fat diet alone, the addition of soy nuts lowered mean systolic and diastolic blood pressure by 9.9% (p = 0.003) and 6.8% (p = 0.001), respectively, in hypertensive women and by 5.2% (p < 0.001)and 2.9% (p = 0.02), respectively, in normotensive women.

Comment: A previous study showed that consumption of one liter per day of soy milk for three months significantly reduced blood pressure in patients with essential hypertension. However, other studies have found that soy products do not lower blood pressure. There is strong evidence that eating soy foods lowers serum cholesterol levels. When combined with its possible antihypertensive effect, soy appears to be a cardioprotective food. However, soy products inhibit the absorption of iron and possibly some other minerals, so excessive soy consumption might promote the development of nutritional deficiencies. Eating soy three times per week as part of an overall healthful diet seems reasonable.

Welty FK, et al. Effect of soy nuts on blood pressure and lipid levels in hypertensive, prehypertensive, and normotensive postmenopausal women. Arch Intern Med. 2007;167:1060-1067.

Pre-operative iron supplementation
Forty-five patients scheduled to undergo surgery for colorectal cancer were randomly assigned to receive 200 mg of ferrous sulfate three times per day or no iron supplementation (control group) for two weeks preoperatively. Operative blood loss did not differ significantly between groups. Immediately prior to surgery, the mean hemoglobin concentration was significantly higher in the iron-supplemented group than in the control group (13.1 g/dl vs. 11.8 g/dl; p = 0.04). The proportion of patients who required a blood transfusion (26% vs. 59%; p < 0.05) and the mean number units transfused per patient (0.65 vs. 3.62; p < 0.04) were significantly lower in the iron-supplemented group than in the placebo group.

Comment: Blood transfusions are expensive and are associated with a number of different potential adverse effects. According to the results of this study, preoperative iron supplementation can substantially decrease the need for blood transfusions in patients undergoing surgery for colorectal cancer. These findings would presumably also apply to other surgical patients with low or marginal iron stores. Iron status should therefore be measured in all patients who are scheduled for surgery, and iron supplementation should be recommended if appropriate.

Lidder PG, et al. Pre-operative oral iron supplementation reduces blood transfusion in colorectal surgery - a prospective, randomised, controlled trial. Ann R Coll Surg Engl. 2007;89:418-421.

Low DHEA levels associated with macular degeneration
In a case-control study in Wisconsin that included 67 patients with exudative (wet) age-related macular degeneration (AMD), 75 patients with non-exudative (dry) AMD, and age- and gender-matched controls, the mean serum DHEA concentration (measured as DHEA-S) was significantly lower in patients with either type of AMD than in controls (p = 0.001). There was a significant inverse correlation between AMD severity and serum DHEA-S levels.

Comment: This study showed that patients with AMD have significantly lower serum DHEA-S levels than matched controls. Although the study does not prove that DHEA deficiency is a cause of AMD, I have seen a reversal of various age-related conditions (including weight loss, weakness, poor appetite, and depression) in elderly people with low DHEA-S levels who were treated with DHEA. Several clinical trials have investigated whether DHEA supplementation has an "anti-aging" effect, and the results have been conflicting. It is my practice to measure serum DHEA-S levels in patients with age-related disorders and to recommend DHEA supplementation if their levels are below normal or in the bottom 20% of the normal range for young adults of the same gender. The usual doses I have used are 5-15 mg per day for women and 10-30 mg per day for men. Higher doses have been used in clinical trials, but these larger doses are supraphysiologic, and their long-term safety has not been demonstrated.

Tamer C, et al. Serum dehydroepiandrosterone sulphate level in age-related macular degeneration. Am J Ophthalmol. 2007;143:212-216.

Borage oil enhances weight loss
Forty-five formerly obese patients (mean age, 48 years) who had lost a mean of about 30 kg were randomly assigned to receive, in double-blind fashion, 5 g per day of borage oil (providing 890 mg per day of gamma-linolenic acid) or placebo (olive oil) for one year. After 12 patients in each group had completed one year of supplementation, the mean weight regain in was 2.17 kg in the borage oil group and 8.78 kg in the placebo group (p < 0.03). The initial study was then terminated, and all remaining patients were assessed over a six-week period. The mean weight regain was 1.8 kg in the borage oil group and 7.6 kg in the placebo group for the 13 and 17 subjects, respectively, who completed a minimum of 50 weeks.

Comment: The results of this study indicate that supplementation with borage oil reduced the amount of weight regained in previously overweight people who had lost a large amount of weight. The mechanism of action of borage oil is not known. In a previous study, supplementation with evening primrose oil (which contains gamma-linolenic acid, the presumed active ingredient in borage oil) did not enhance weight loss in overweight women. However, the amount of gamma-linolenic acid used in that study was only 216 mg per day, which is less than one-quarter the amount used in the present study.

Schirmer MA, Phinney SD. Gamma-linolenate reduces weight regain in formerly obese humans. J Nutr. 2007;137:1430-1435.

Lemonade prevents kidney stone recurrences
Eleven patients with recurrent kidney stones associated with hypocitraturia (low urinary citrate excretion) who had been on long-term lemonade therapy were evaluated after a mean treatment period of 3.7 years. Lemonade therapy consisted of 120 ml per day of concentrated lemon juice (containing 5.9 g of citric acid) mixed with two liters of water and consumed throughout the day. Ten of the 11 patients drinking lemonade had an increase in urinary citrate levels, and the mean level increased from 350 mg per day at baseline to 733 mg per day (p < 0.05). The mean stone formation rate decreased from 1.00 per person per year at baseline to 0.13 per person per year during lemonade therapy. This 87% decrease failed to achieve statistical significance, presumably because of the small sample size.

Comment: Many recurrent stone formers have hypocitraturia. Oral administration of potassium citrate increases the amount of citrate in the urine and has been shown to reduce the stone recurrence rate substantially. Potassium citrate is therefore considered first-line therapy by most urologists for patients with hypocitraturic recurrent nephrolithiasis. However, potassium citrate can cause gastrointestinal side effects, which preclude its use in some cases. Lemons have a high concentration of citrate, about five times as much as oranges. In a previous study, ingestion of two liters of lemonade per day more than doubled urinary citrate excretion in a group of recurrent stone formers and increased the level to normal in seven of 12 patients. The results of the new study suggest that lemonade is a reasonable alternative to potassium citrate in patients with hypocitraturic nephrolithiasis.

Kang DE, et al. Long-term lemonade based dietary manipulation in patients with hypocitraturic nephrolithiasis.
J Urol. 2007;177:1358-1362.

Alan R. Gaby, MD


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