Plant-based diets, both vegan and vegetarian, which emphasize grains, vegetables, fruits, legumes, nuts, and seeds are increasingly popular for health as well as financial, ethical, and religious reasons. The medical literature clearly demonstrates that whole food plant-based diets can be both nutritionally sufficient and medically beneficial. However, any person on an intentionally restrictive, but poorly-designed diet may predispose themselves to clinically-relevant nutritional deficiencies. For persons on a poorly-designed plant-based diet, deficiencies are possible in both macronutrients (protein, essential fatty acids) and micronutrients (vitamin B12, iron, calcium, zinc, and vitamin D). Practitioner evaluation of symptomatic patients on a plant-based diet requires special consideration of seven key nutrient concerns for plant-based diets. This article translates these concerns into seven practical questions that all practitioners can introduce into their patient assessments and clinical reasoning. Ideally, persons on plant-based diets should be able to answer these seven questions. Each serves as a heuristic prompt for both clinician and patient attentiveness to a complete diet. As such, these seven questions support increased patient nutrition knowledge and practitioner capacity to counsel, refer, and appropriately focus clinical resources.

Patients frequently note adverse food reactions and report significant food restrictions as a result. Physicians need to consider the nutritional consequences and necessity of such voluntary dietary limitations. They also should consider adverse food reactivity in their differential diagnosis for many frequently seen concerns. This article describes a three-step process for assessing a patient’s potential for true adverse food reactivity. Readers will note the significant contributions nutritionists and dieticians can offer as team members.

INTRODUCTION Single-disorder or single-organ-system clinical practice guidelines are often of limited usefulness in guiding effective management of patients with chronic multidimensional signs and symptoms. The presence of multiple long-standing medical problems in a given patient despite intensive medical effort suggests that addressing systemic core imbalances could complement more narrowly focused approaches. CASE PRESENTATION A 72-year-old man experiencing longstanding depression, fatigue, irritable bowel syndrome, and chronic pain in the context of additional refractory illnesses was assessed and treated, guided by a system-oriented approach to underlying core imbalances termed functional medicine. This patient was referred from a team of clinicians representing primary care, cardiology, gastroenterology, hematology, and psychology. Prior treatment had been unsuccessful in managing multiple chronic comorbidities. Diagnostic assessment included comprehensive stool and nutritional/metabolic laboratory testing. RESULTS The blood-, urine-, or stool-based measurements of relevant markers for multiple systemic issues, including digestion/absorption, inflammation, oxidative stress, and methylation, identified previously unrecognized root causes of his constellation of symptoms. These functional measurements guided rational recommendations for dietary choices and supplementation. The patient experienced steady and significant improvement in his mental health, fatigue, chronic pain, and irritable bowel syndrome-as well as the unexpected resolution of his chronic idiopathic pancytopenia. CONCLUSION The success in this case suggests that other patients with chronic, complex, and treatment-refractory illness may benefit from a system-oriented assessment of core imbalances guided by specialized nutritional/metabolic and digestive laboratory testing.

Determining the Value of Vitamin D Supplementation To the Editor The Surgeon General’s 2004 report on bone health stated that osteoporosis “is a major threat to Americans” that is “largely preventable” and recommended: “Make sure you get enough vitamin D.”1 In contrast, the Viewpoint by Drs Manson and Bassuk2 suggested that vitamin D supplementation “threatens to jeopardize the ability of researchers to conduct randomized trials in ‘usual-risk’ populations.” Osteoporotic fractures cost $18 billion in direct costs each year.1 With an aging population, the costs are likely to increase. Given the substantial evidence for the bone health benefits of vitamin D at all ages,3,4 should patients at risk for osteoporosis be intentionally undertreated so that scientists can conduct clinical trials for other potential indications? The authors suggested that clinical enthusiasm results in overscreening for and oversupplementation with vitamin D. But such terms are value judgments that can only be assessed by measurement. Review of the evidence on bone health by the Institute of Medicine (IOM)3 and the Endocrine Society4 resulted in recommendations for a minimum 25-hydroxyvitamin D (25[OH]D) serum level of 20 ng/mL or 30 ng/mL, respectively (to convert to nmol/L, multiply by 2.496). Testing of 10 646 unique, low-risk employees in the Allina Health system demonstrated that 30% had serum levels less than 20 ng/mL and 60% had serum levels less than 30 ng/mL.5 The authors asserted that large-scale clinical trials currently under way will definitively determine the value of vitamin D supplementation for nonbone health. However, these trials are population-health one-size-fits-all studies. Their entrance criteria do not include vitamin D status. Vitamin D–sufficient participants can be oversupplemented, and deficient participants can be undersupplemented. In addition, these studies will not answer this clinically significant question: if a deficiency is measured, does replenishment and maintenance result in an improved clinical outcome? Only when vitamin D measurements are included in large health system or government databases will researchers be able to definitively refine understanding of optimal serum levels. Without vitamin D measurements in such databases, researchers will be unable to assess the effect of vitamin D status across innumerable diseases or conditions. Given the consequences of osteoporotic fractures, clinical caution means measurement of and rational supplementation with vitamin D.

Worldwide, health care systems are increasingly highlighting the importance of traditional medicines. The World Health Organization (WHO) plans to introduce traditional medicine into the international classification of diseases (ICD) for the first time since it started in 1900. Kampo medicine is a traditional Asian medical system that is unique in many ways. Kampo was transferred from the ancient Han Chinese dynasty and uniquely developed in Japan, especially during the Edo period (1603–1867). The theoretical understanding and the use of the abdominal examination “Fukushin” to assess the patient's constitutional state are particular to Kampo. After the Meiji restoration in 1867, Japan's new government accepted only Western medicine from Europe and founded one medical licensure system. The result was suppression of acquired wisdom and insights with marginalization of practitioners until 1976. At that time, the Japanese Medical Association promoted its coverage by Japan's National Health Insurance program by physicians who were trained in Western medicine. And now, all of Japan's 80 medical schools teach Kampo medicine. As a result, roughly 90% of physicians use Kampo medicine in their daily practice. This is a very unique model of integration of traditional medicine and modern biomedicine. To better understand the promise of this integration, this special issue features Kampo medicine in the context of modern biomedicine. Many provocative articles are included in this special issue. To begin, K. Katayama et al. address the current situation of Kampo use in the National Health Care program. The authors analyzed 67,113,579 health care claim records and found that only 1.34% represented Kampo prescriptions. This suggests that a very small portion of conventional practice includes Kampo treatment even though many physicians use Kampo. H. Okamoto et al. present us with a case series of patients with refractory glossodynia. Among 39 patients, 69.2% of patients reported a beneficial effect. This is one of the examples in which Kampo treatment is effective even for the difficult cases in the Western biomedicine. K. Ogawa et al. show the usefulness of daiobotanpito for the treatment of acute diverticulitis. Y. Tanaka and T. Sakiyama report the case series of the usefulness of the Kampo treatment for pediatric emotional and behavioral disorders which were also refractory to the modern biomedicine. M. A. Bahar et al. reported that goshajinkigan prevents paclitaxel induced peripheral neuropathy without interfering with the anticancer action of paclitaxel in the basic research. Kampo medicines are often used for the purpose of the reduction of the side effects of chemotherapy for malignancies. K. Watanabe et al. report the potentially preventive effect of diabetic complications. Goshajinkigan is often used for the neuropathy from diabetes mellitus. Additionally, this Kampo medicine may be beneficial for the blood glucose control. K. Katayama et al. report a computer-based diagnostic way of Kampo patient patterns termed “Sho.” This represents a promising blend of modern technology for a new world of traditional medicine in the future. Y.-C. P. Arai et al. reported about Fukushin, Kampo's unique diagnostic procedure. Certain Fukushin findings are related to the anxiety-depression levels. T. Namiki et al. report that cytosine-adenine (CA) repeat polymorphism of the estrogen receptor β gene can be the predictive biomarker of the effectiveness of Kampo medicine for the treatment of the climacteric syndrome. T. Yoshino et al. and H. Tokunaga et al. describe hie (cold sensation) and hiesho (cold disorder). Hie and hiesho are very important concepts in Kampo treatment. T. Yoshino et al. characterized hie and hiesho. H. Tokunaga et al. characterized the differences of male hie, female hie with menstruation, and female hie after menopause by data mining method. To conclude, S. Yakubo et al. summarize the history and pattern diagnosis of Kampo medicine. Together, these articles represent the promise and challenges present in the scientific understanding of Japan's herbal medicine tradition. We hope these articles help the readers to understand and appreciate the potential power of Kampo medicine outside of Japan. We invite you to explore Kampo. Kenji Watanabe Gregory A. Plotnikoff Takeshi Sakiyama Heidrun Reissenweber-Hewel

Recurrent pancreatitis is a potentially life-threatening condition with a well-established differential diagnosis. In a significant number of cases, no explanation exists. This case report documents one patient with a clear pattern of recurrent acute pancreatitis and no identifiable cause despite great effort. After 7 years of recurrent symptoms, she was found to have marked elevation of fecal deoxycholic acid (DCA), a secondary bile acid used to precipitate pancreatitis in animal models. This report documents cessation of symptoms/hospitalizations with normalization of her fecal DCA levels. This secondary bile acid is easily measured in stool. Needed now is an observational study of fecal DCA levels in patients with recurrent acute pancreatitis.

One of the great myths in modern medicine is the assertion that “one size fits all.” This myth is especially egregious in the realm of diet and nutrition. One dose of vitamin D? For young and old? Thin and overweight? Black and white? Tampa and Anchorage? It does not make scientific sense.

When a patient with symptoms presents to a physician or other healthcare professional, the skillful practitioner notices not only where the patient is compromised but also how the patient is healthy. From ancient times through the present, this way of seeing individual patients as whole beings, as having both strengths and challenges, has been the hallmark of professional practice. And now is the time to advance patient care through a focus on whole systems approaches.

Interdisciplinary scientific evaluation of the human microbiota has identified three enteric microbial biotransformations of particular relevance for human health and well-being, especially cancer. Two biotransformations are counterproductive; one is productive. First, selective bacteria can reverse beneficial hepatic hydroxylation to produce toxic secondary bile acids, especially deoxycholic acid. Second, numerous bacterial species can reverse hepatic detoxification-in a sense, retoxify hormones and xeonobiotics-by deglucuronidation. Third, numerous enteric bacteria can effect a very positive biotransformation through the production of butyrate, a small chain fatty acid with anti-cancer activity. Each biotransformation is addressed in sequence for its relevance in representative gastrointestinal and extra-intestinal cancers. This is not a complete review of their connection with every type of cancer. The intent is to introduce the reader to clinically relevant microbial biochemistry plus the emerging evidence that links these to both carcinogenesis and treatment. Included is the evidence base to guide counseling for potentially helpful dietary adjustments.

The Journal of Alternative and Complementary MedicineVol. 20, No. 5 Health Services ResearchVitamin D Recommended Daily Allowance (RDA) Insufficiency in Female Healthcare Employees of Childbearing AgeGregory Plotnikoff, Michael Finch, Steven Calvin, and Jeffery DusekGregory PlotnikoffSearch for more papers by this author, Michael FinchSearch for more papers by this author, Steven CalvinSearch for more papers by this author, and Jeffery DusekSearch for more papers by this authorPublished Online:7 May 2014https://doi.org/10.1089/acm.2014.5331.abstractAboutSectionsView articleView Full TextPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Vitamin D Recommended Daily Allowance (RDA) Insufficiency in Female Healthcare Employees of Childbearing Age." The Journal of Alternative and Complementary Medicine, 20(5), pp. A124–A125FiguresReferencesRelatedDetails Volume 20Issue 5May 2014 InformationCopyright 2014, Mary Ann Liebert, Inc.To cite this article:Gregory Plotnikoff, Michael Finch, Steven Calvin, and Jeffery Dusek.Vitamin D Recommended Daily Allowance (RDA) Insufficiency in Female Healthcare Employees of Childbearing Age.The Journal of Alternative and Complementary Medicine.May 2014.A124-A125.http://doi.org/10.1089/acm.2014.5331.abstractPublished in Volume: 20 Issue 5: May 7, 2014PDF download

Background— A large body of epidemiological and experimental evidence suggests that vitamin D deficiency may promote hypertension. This raises the possibility that vitamin D supplementation could be a simple intervention to reduce blood pressure, but data from prospective, randomized trials are limited. Methods and Results— A double-blind, randomized, controlled trial was conducted at 4 sites in the United States. We enrolled 534 individuals 18 to 50 years of age with low vitamin D status (25-hydroxyvitamin D levels ≤25 ng/mL) and systolic blood pressure of 120 to 159 mm Hg. Participants were randomized to high-dose (4000 IU/d) versus low-dose (400 IU/d) oral vitamin D 3 for 6 months. The primary end point was change in mean 24-hour systolic blood pressure. Secondary end points included change in ambulatory diastolic blood pressure and clinic systolic and diastolic blood pressures. The median age was 38 years, and 62% of participants were men. Forty-six percent of participants were white, and 48% were black. The median 25-hydroxyvitamin D level at baseline was 15.3 ng/mL. Four-hundred fifty-five participants (85%) had at least 1 follow-up blood pressure measurement; 383 participants (72%) completed the full 6-month study. At the end of the study, there was no significant difference in the primary end point (change in mean 24-hour systolic blood pressure, −0.8 versus −1.6 mm Hg in the high-dose and low-dose arms; P =0.71) or in any of the secondary end points. Furthermore, there was no evidence of association between change in 25-hydroxyvitamin D and change in 24-hour systolic blood pressure at 6 months (Spearman correlation coefficient, −0.05, P =0.34). Results were consistent across prespecified subgroups. Conclusions— Vitamin D supplementation did not reduce blood pressure in individuals with prehypertension or stage I hypertension and vitamin D deficiency. Our findings suggest that the association between vitamin D status and elevated blood pressure noted in observational studies is not causal. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01240512.

In 2011, at the Society for Integrative Oncology's international meeting in Cleveland, Ohio, Francis Collins, PhD, head of the National Institutes of Health, shocked the audience when he asserted that although his work in the human genome was exciting, he was more impressed by the potential represented by the National Institutes of Health's investment in the Human Microbiome Project. “This is the future,” he stated with great certainty. Surprisingly, this is also the past. More than 100 years earlier in 1908, Ilya Ilyich Metchnikov, co-winner of the 1908 Nobel Prize for Medicine, noted that “the dependence of the intestinal microbes on the food makes it possible to adapt measures to modify the flora in our bodies and to replace harmful microbes by useful microbes.”1 He coined the term dysbiosis to describe microbial ecological imbalance in the gut.

Food is perhaps the most common and most tangible expression of love, care, and concern. The shared sensual delight of cooking and of eating is a remarkably large dimension of the human experience. The prominence of food in life means that both patients and their families can undergo profound emotional and social shifts when illness is accompanied by neither the desire nor the capacity to eat. This can include significant disruption of established patterns, important relationships, and even one's self-image. Common human emotions experienced by patients and their loved ones can include helplessness, exclusion, rejection, anxiety, and other forms of distress.

Free accessAbstractFirst published online January - December 201315B. The Seven Questions for Symptomatic Vegans and VegetariansGregory PlotnikoffAll Articleshttps://doi.org/10.7453/gahmj.2013.097CP.S15B

Objective: To determine the prevalence of vitamin D deficiency (VDD) (25-hydroxyvitamin D level < 20 ng/mL) and severe VDD (25[OH] D level < 10 ng/mL) in a Minnesota immigrant and refugee population.Patients and Methods: This retrospective study evaluated a cohort of adult immigrants and refugees seen at Health Partners Center for International Health in St Paul, Minnesota. Study participants were all patients seen from August 1, 2008, through July 31, 2009, with a first vitamin D screen (N = 1378). Outcomes included overall prevalence of VDD and severe VDD. Covariates included country of origin, sex, age, month of test, and body mass index (BMI).Results: Vitamin D deficiency was significantly more prevalent in our Minnesota clinic immigrant and refugee population than among US-born patients (827 of 1378 [60.0%] vs 53 of 151 [35.1%]; P<.001). Severe VDD was also significantly more prevalent (208 of 1378 [15.1%] vs 12 of 151 [7.9%]; P=.02). Prevalence of VDD varied significantly according to country of origin (42 of 128 Russian patients [32.8%] vs 126 of 155 Ethiopian patients [81.3%]; P<.001). The BMI correlated negatively with VDD (488 of 781 [62.5%] when BMI was >= 25 vs 292 of 520 [56.2%] when BMI was < 25; P=.02). Vitamin D deficiency was present in 154 of 220 individuals (70.0%) 16 to 29 years old vs 123 of 290 (42.4%) in those older than 66 years (P<.001).Conclusion: Immigrants and refugees in a Minnesota clinic have a substantially higher rate and severity of VDD when compared with a US-born population. Country of origin, age, and BMI are specific risk factors for VDD and should influence individualized screening practices. (C) 2013 Mayo Foundation for Medical Education and Research square Mayo Clin Proc. 2013;88(1):31-37

In 1998, the British Medical Journal boldly stated in an editorial headline, "Vitamin D Deficiency: Time for Action."(1) The urgency was clear: vitamin D deficiency was going undiagnosed and untreated in large numbers of people. Patients were at risk and suffering needlessly. A simple, extremely low-cost, low-toxicity intervention was readily available. All that was required was vitamin D advocacy.

Not all who adhere to vegetarian, vegan or other special diets have nutritionally sound eating habits. The clinical consequences of an insufficiently mindful vegetarian or vegan diet include many common symptoms such as anxiety, brain fog, depression, fatigue, insomnia, neuropathies and other neurologic dysfunction. Patients with such symptoms who report having a vegetarian or vegan diet, or a diet that severely restricts meat consumption, require a slightly expanded differential diagnosis. The challenge is to identify which patients require closer attention. This article lists questions to use to quickly assess for potential dietary drivers of clinical symptoms. In many cases, simple nutritional interventions, through diet and/or supplementation, can resolve or minimize problematic symptoms.

Objective: To define the relationship between vitamin D status and employee presenteeism in a large sample of health care employees. Methods: Prospective observation study of 10,646 employees of a Midwestern-integrated health care system who completed an on-line health risk appraisal questionnaire and were measured for 25-hydroxyvitamin D. Results: Measured differences in productivity due to presenteeism were 0.66, 0.91, and 0.75 when comparing employees above and below vitamin D levels of 20 ng/mL, 30 ng/mL, and 40 ng/mL, respectively. These productivity differences translate into potential productivity savings of 0.191%, 0.553%, and 0.625%, respectively, of total payroll costs. Conclusions: Low vitamin D status is associated with reduced employee work productivity. Employee vitamin D assessment and replenishment may represent a low-cost, high-return program to mitigate risk factors and health conditions that drive total employer health care costs.

In some ancient systems of medicine, health was understood as a state of balance, and diet was considered essential to achieving and maintaining that balance. Traditional Chinese medicine and Ayurveda are based on this premise. Here we present an overview of these two traditional systems' views on diet and eating. This article aims to explain the reasoning behind some of the recommendations that practitioners of these forms of medicine may be making.