Nutritional Update for Physicians: Plant-Based Diets

Nutritional Update for Physicians: Plant-Based Diets

Philip J Tuso, MD

Regional Co-Lead for the Complete Care Program of the Southern California Permanente Medical Group and the National Physician Lead for the Care Management Institute’s Total Health Program. E-mail: gro.pk@osut.j.pillihp.

Mohamed H Ismail, MD

Physician at the Riverside Medical Center in CA. E-mail: gro.pk@liamsi.h.demahom.

Benjamin P Ha, MD

Associate Area Medical Director for Family Medicine at the Bakersfield Medical Center in CA. E-mail: gro.pk@ah.p.nimajneb.

Carole Bartolotto, MA, RD

Author information ► Copyright and License information ►

See "What Does Professionalism Mean to the Physician?" on page 88.

See "Plant-Based Diets Are Not Nutritionally Deficient" on page 93.

This article has been cited by other articles in PMC.

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Abstract

The objective of this article is to present to physicians an update on plant-based diets. Concerns about the rising cost of health care are being voiced nationwide, even as unhealthy lifestyles are contributing to the spread of obesity, diabetes, and cardiovascular disease. For these reasons, physicians looking for cost-effective interventions to improve health outcomes are becoming more involved in helping their patients adopt healthier lifestyles. Healthy eating may be best achieved with a plant-based diet, which we define as a regimen that encourages whole, plant-based foods and discourages meats, dairy products, and eggs as well as all refined and processed foods. We present a case study as an example of the potential health benefits of such a diet. Research shows that plant-based diets are cost-effective, low-risk interventions that may lower body mass index, blood pressure, HbA1C, and cholesterol levels. They may also reduce the number of medications needed to treat chronic diseases and lower ischemic heart disease mortality rates. Physicians should consider recommending a plant-based diet to all their patients, especially those with high blood pressure, diabetes, cardiovascular disease, or obesity.

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Introduction

In the HBO documentary The Weight of the Nation, it was noted that if you “go with the flow” in the US, you will eventually become obese.1 In 2011, Witters reported that in some areas of the country, the rate of obesity is 39% and is increasing at a rate of 5% per year.2 Risks of obesity, diabetes, hypertension, and cardiovascular disease, along with their ensuing complications (eg, behavioral health and quality-of-life problems) often go hand-in-hand and are strongly linked to lifestyle, especially dietary choices.3 Of all the diets recommended over the last few decades to turn the tide of these chronic illnesses, the best but perhaps least common may be those that are plant based.

Despite the strong body of evidence favoring plant-based diets, including studies showing a willingness of the general public to embrace them,4 many physicians are not stressing the importance of plant-based diets as a first-line treatment for chronic illnesses. This could be because of a lack of awareness of these diets or a lack of patient education resources.

National dietary guidelines for active living and healthful eating are available at www.ChooseMyPlate.gov.5 A typical healthful plate of food is 1/2 plant foods (nonstarchy vegetables and fruits), 1/4 whole grains or unprocessed starchy food, and 1/4 lean protein.

The goal of this article is to review the evidence supporting plant-based diets and to provide a guideline for presenting them to patients. We start with a case study and conclude with a review of the literature.

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Case Study

A 63-year-old man with a history of hypertension presented to his primary care physician with complaints of fatigue, nausea, and muscle cramps. The result of a random blood glucose test was 524 mg/dL, and HbA1C was 11.1%. Type 2 diabetes was diagnosed. His total cholesterol was 283 mg/dL, blood pressure was 132/66 mmHg, and body mass index (BMI) was 25 kg/m2. He was taking lisinopril, 40 mg daily; hydrochlorothiazide, 50 mg daily; amlodipine, 5 mg daily; and atorvastatin, 20 mg daily. He was prescribed metformin, 1000 mg twice daily; glipizide, 5 mg daily; and 10 units of neutral protamine Hagedom insulin at bedtime. His physician also prescribed a low-sodium, plant-based diet that excluded all animal products and refined sugars and limited bread, rice, potatoes, and tortillas to a single daily serving. He was advised to consume unlimited non-starchy vegetables, legumes, and beans, in addition to up to 2 ounces of nuts and seeds daily. He was also asked to begin exercising 15 minutes twice a day.

The patient was seen monthly in his primary care clinic. Over a 16-week period, significant improvement in biometric outcome measures was observed. He was completely weaned off of amlodipine, hydrochlorothiazide, glipizide, and neutral protamine Hagedorn insulin. Follow-up blood pressure remained below 125/60 mmHg, HbA1C improved to 6.3%, and total cholesterol improved to 138 mg/dL. Lisinopril was gradually decreased to 5 mg daily and his diabetes is controlled with metformin alone, 1000 mg twice daily.

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Definitions of Plant-Based Diets

The presented case is a dramatic example of the effect a plant-based diet can have on biometric outcomes like blood pressure, diabetes, and lipid profile. The reduction in HbA1C from 11.1% to 6.3% in 3 months is much better than would be expected with monotherapy with metformin6 or daily exercise.7 The improvement in blood pressure observed over a 4-month period with few medications is also rarely encountered in clinical practice and is likely related to a low-sodium diet and the avoidance of red meat. Because the patient was not obese and did not have significant weight loss with the diet, the dramatic improvements appear to be related to the quality of his new diet.

A healthy, plant-based diet aims to maximize consumption of nutrient-dense plant foods while minimizing processed foods, oils, and animal foods (including dairy products and eggs). It encourages lots of vegetables (cooked or raw), fruits, beans, peas, lentils, soybeans, seeds, and nuts (in smaller amounts) and is generally low fat.8,9 Leading proponents in the field have varying opinions as to what comprises the optimal plant-based diet. Ornish et al recommends allowing animal products such as egg whites and skim milk in small amounts for reversal of disease.10,11

Esselstyn, who directs the cardiovascular prevention and reversal program at the Cleveland Clinic Wellness Institute, recommends completely avoiding all animal-based products as well as soybeans and nuts, particularly if severe coronary artery disease is present.12

Despite these smaller differences, there is evidence that a broadly defined plant-based diet has significant health benefits. It should be noted that the term plant-based is sometimes used interchangeably with vegetarian orvegan. Vegetarian or vegan diets adopted for ethical or religious reasons may or may not be healthy. It is thus important to know the specific definitions of related diets and to ascertain the details of a patient’s diet rather than making assumptions about how healthy it is. The following is a brief summary of typical diets that restrict animal products. A key distinction is that although most of these diets are defined by what they exclude, the plant-based diet is defined by what it includes.

• Vegan (or total vegetarian): Excludes all animal products, especially meat, seafood, poultry, eggs, and dairy products. Does not require consumption of whole foods or restrict fat or refined sugar.
• Raw food, vegan: Same exclusions as veganism as well as the exclusion of all foods cooked at temperatures greater than 118°F.
• Lacto-vegetarian: Excludes eggs, meat, seafood, and poultry and includes milk products.
• Ovo-vegetarian: Excludes meat, seafood, poultry, and dairy products and includes eggs.
• Lacto-ovo vegetarian: Excludes meat, seafood, and poultry and includes eggs and dairy products.
• Mediterranean: Similar to whole-foods, plant-based diet but allows small amounts of chicken, dairy products, eggs, and red meat once or twice per month. Fish and olive oil are encouraged. Fat is not restricted.
• Whole-foods, plant-based, low-fat: Encourages plant foods in their whole form, especially vegetables, fruits, legumes, and seeds and nuts (in smaller amounts). For maximal health benefits this diet limits animal products. Total fat is generally restricted.

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Benefits of Plant-Based Diets

The goal of our diet should be to improve our health. In this section, we will review the literature for key articles that demonstrate the benefits of plant-based diets. Our review consists of existing studies that include vegan, vegetarian, and Mediterranean diets.

Obesity

In 2006, after reviewing data from 87 published studies, authors Berkow and Barnard13 reported in Nutrition Reviews that a vegan or vegetarian diet is highly effective for weight loss. They also found that vegetarian populations have lower rates of heart disease, high blood pressure, diabetes, and obesity. In addition, their review suggests that weight loss in vegetarians is not dependent on exercise and occurs at a rate of approximately 1 pound per week. The authors further stated that a vegan diet caused more calories to be burned after meals, in contrast to nonvegan diets which may cause fewer calories to be burned because food is being stored as fat.13

Farmer et al14 suggest that vegetarian diets may be better for weight management and may be more nutritious than diets that include meat. In their study, they showed that vegetarians were slimmer than their meat-eating counterparts. Vegetarians were also found to consume more magnesium, potassium, iron, thiamin, riboflavin, folate, and vitamins and less total fat. The authors conclude that vegetarian diets are nutrient dense and can be recommended for weight management without compromising diet quality.14

In 2009, Wang and Beysoun15 analyzed the nationally representative data collected in the 1999–2004 National Health and Nutrition Examination Survey. The aim of their study was to analyze the associations between meat consumption and obesity. Using linear and logistic regression analyses, they showed that there was a positive association between meat consumption and obesity.15

The Oxford component of the European Prospective Investigation into Cancer and Nutrition assessed changes in weight and BMI over a five-year period in meat-eating, fish-eating, vegetarian, and vegan men and women in the United Kingdom. During the five years of the study, mean annual weight gain was lowest among individuals who had changed to a diet containing fewer animal foods. The study also reported a significant difference in age-adjusted BMI, with the meat eaters having the highest BMI and vegans the lowest.16 Similar results were reported by the Adventist Health Study.17

According to Sabaté and Wien,18 “Epidemiologic studies indicate that vegetarian diets are associated with a lower BMI and a lower prevalence of obesity in adults and children. A meta-analysis of adult vegetarian diet studies estimated a reduced weight difference of 7.6 kg for men and 3.3 kg for women, which resulted in a 2-point lower BMI. Similarly, compared with nonvegetarians, vegetarian children are leaner, and their BMI difference becomes greater during adolescence. Studies exploring the risk of overweight and food groups and dietary patterns indicate that a plant-based diet seems to be a sensible approach for the prevention of obesity in children. Plant-based diets are low in energy density and high in complex carbohydrate, fiber, and water, which may increase satiety and resting energy expenditure.”18 The authors conclude that plant-based dietary patterns should be encouraged for optimal health.

Diabetes

Plant-based diets may offer an advantage over those that are not plant based with respect to prevention and management of diabetes. The Adventist Health Studies found that vegetarians have approximately half the risk of developing diabetes as nonvegetarians.19 In 2008, Vang et al20 reported that nonvegetarians were 74% more likely to develop diabetes over a 17-year period than vegetarians. In 2009, a study involving more than 60,000 men and women found that the prevalence of diabetes in individuals on a vegan diet was 2.9%, compared with 7.6% in the nonvegetarians.17 A low-fat, plant-based diet with no or little meat may help prevent and treat diabetes, possibly by improving insulin sensitivity and decreasing insulin resistance.

Barnard et al21 reported in 2006 the results of a randomized clinical trial comparing a low-fat vegan diet with a diet based on the American Diabetes Association guidelines. People on the low-fat vegan diet reduced their HbA1C levels by 1.23 points, compared with 0.38 points for the people on the American Diabetes Association diet. In addition, 43% of people on the low-fat vegan diet were able to reduce their medication, compared with 26% of those on the American Diabetes Association diet.18

Heart Disease

In the Lifestyle Heart Trial, Ornish10 found that 82% of patients with diagnosed heart disease who followed his program had some level of regression of atherosclerosis. Comprehensive lifestyle changes appear to be the catalyst that brought about this regression of even severe coronary atherosclerosis after only 1 year. In his plant-based regimen, 10% of calories came from fat, 15% to 20% from protein, and 70% to 75% from carbohydrate, and cholesterol was restricted to 5 mg per day.

Interestingly, 53% of the control group had progression of atherosclerosis. After 5 years, stenosis in the experimental group decreased from 37.8% to 34.7% (a 7.9% relative improvement). The control group experienced a progression of stenosis from 46.1% to 57.9% (a 27.7% relative worsening). Low-density lipoprotein had decreased 40% at 1 year and was maintained at 20% less than baseline after 5 years. These reductions are similar to results achieved with lipid-lowering medications.10,11

In the Lyon Diet Heart Study, a prospective, randomized, secondary prevention trial, de Lorgeril found that the intervention group (at 27 months) experienced a 73% decrease in coronary events and a 70% decrease in all-cause mortality. The intervention group’s Mediterranean-style diet included more plant foods, vegetables, fruits, and fish than meat. Butter and cream were replaced with canola oil margarine. Canola oil and olive oil were the only fats recommended.22

In 1998, a collaborative analysis using original data from 5 prospective studies was reviewed and reported in the journal Public Health Nutrition. It compared ischemic heart disease-specific death rate ratios of vegetarians and nonvegetarians. The vegetarians had a 24% reduction in ischemic heart disease death rates compared with nonvegetarians.23 The lower risk of ischemic heart disease may be related to lower cholesterol levels in individuals who consume less meat.24

Although vegetarian diets are associated with lower risk of several chronic diseases, different types of vegetarians may not experience the same effects on health. The key is to focus on eating a healthy diet, not simply a vegan or vegetarian diet.25

High Blood Pressure

In 2010, the Dietary Guidelines Advisory Committee performed a literature review to identify articles examining the effect of dietary patterns on blood pressure in adults. Vegetarian diets were associated with lower systolic blood pressure and lower diastolic blood pressure.26 One randomized crossover trial found that a Japanese diet (low sodium and plant based) significantly reduced systolic blood pressure.27

Mortality

The Dietary Guidelines Advisory Committee also performed a 2010 literature review to determine the effect of plant-based diets on stroke, cardiovascular disease, and total mortality in adults. They found that plant-based diets were associated with a reduced risk of cardiovascular disease and mortality compared with non-plant-based diets.26

The benefit of plant-based diets on mortality may be primarily caused by decreased consumption of red meat.28Several studies have documented the benefits of avoiding excessive consumption of red meat, which is associated with an increased risk of all-cause mortality and an increased risk of cardiovascular mortality.29 Low meat intake has been associated with longevity.30

In 2012, Huang et al31 performed a meta-analysis to investigate cardiovascular disease mortality among vegetarians and nonvegetarians. They only included studies that reported relative risks and corresponding 95% confidence intervals. Seven studies with a combined total of 124,706 participants were analyzed. Vegetarians had 29% lower ischemic heart disease mortality than nonvegetarians.31

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Health Concerns About Plant-Based Diets

Protein

Generally, patients on a plant-based diet are not at risk for protein deficiency. Proteins are made up of amino acids, some of which, called essential amino acids, cannot be synthesized by the body and must be obtained from food. Essential amino acids are found in meat, dairy products, and eggs, as well as many plant-based foods, such as quinoa.32 Essential amino acids can also be obtained by eating certain combinations of plant-based foods. Examples include brown rice with beans, and hummus with whole wheat pita. Therefore, a well-balanced, plant-based diet will provide adequate amounts of essential amino acids and prevent protein deficiency.33

Soybeans and foods made from soybeans are good sources of protein and may help lower levels of low-density lipoprotein in the blood34 and reduce the risk of hip fractures35 and some cancers.

Vegetarian diets were associated with lower systolic and diastolic blood pressure …

A study in the Journal of the American Medical Association36 reported that women with breast cancer who regularly consumed soy products had a 32% lower risk of breast cancer recurrence and a 29% decreased risk of death, compared with women who consumed little or no soy.36 An analysis of 14 studies, published in theAmerican Journal of Clinical Nutrition, showed that increased intake of soy resulted in a 26% reduction in prostate cancer risk.37

Because of concerns over the estrogenic nature of soy products, women with a history of breast cancer should discuss soy foods with their oncologists. Also, overly processed, soy-based meat substitutes are often high in isolated soy proteins and other ingredients that may not be as healthy as less processed soy products (ie, tofu, tempeh, and soy milk).

Iron

Plant-based diets contain iron, but the iron in plants has a lower bioavailability than the iron in meat. Plant-based foods that are rich in iron include kidney beans, black beans, soybeans, spinach, raisins, cashews, oatmeal, cabbage, and tomato juice.38 Iron stores may be lower in individuals who follow a plant-based diet and consume little or no animal products. However, the American Dietetic Association states that iron-deficiency anemia is rare even in individuals who follow a plant-based diet.39

Vitamin B12

Vitamin B12 is needed for blood formation and cell division. Vitamin B12 deficiency is a very serious problem and can lead to macrocytic anemia and irreversible nerve damage. Vitamin B12 is produced by bacteria, not plants or animals. Individuals who follow a plant-based diet that includes no animal products may be vulnerable to B12deficiency40 and need to supplement their diet with vitamin B12 or foods fortified with vitamin B12.41

Calcium and Vitamin D

Calcium intake can be adequate in a well-balanced, carefully planned, plant-based diet. People who do not eat plants that contain high amounts of calcium may be at risk for impaired bone mineralization and fractures. However, studies have shown that fracture risk was similar for vegetarians and nonvegetarians. The key to bone health is adequate calcium intake, which appears to be irrespective of dietary preferences.42 Some significant sources of calcium include tofu, mustard and turnip greens, bok choy, and kale. Spinach and some other plants contain calcium that, although abundant, is bound to oxalate and therefore is poorly absorbed.43

Vitamin D deficiency is common in the general population. Plant-based products such as soy milk and cereal grains may be fortified to provide an adequate source of Vitamin D.44 Supplements are recommended for those who are at risk for low bone mineral density and for those found to be deficient in vitamin D.

Fatty Acids

Essential fatty acids are fatty acids that humans must ingest for good health because our bodies do not synthesize them. Only two such essential fatty acids are known: linoleic acid (an omega-6 fatty acid) and alpha-linolenic acid (an omega-3 fatty acid). Three other fatty acids are only conditionally essential: palmitoleic acid (a monounsaturated fatty acid), lauric acid (a saturated fatty acid), and gamma-linolenic acid (an omega-6 fatty acid). Deficiency in essential fatty acids may manifest as skin, hair, and nail abnormalities.45

The fatty acids that vegans are most likely to be deficient in are the omega-3 fats (n-3 fats). Consumptions of the plant version of omega-3 fats, alpha-linolenic acid, are also low in vegans. Adequate intake of n-3 fats is associated with a reduced incidence of heart disease and stroke. Foods that are good sources of n-3 fats should be emphasized. They include ground flax seeds, flax oil, walnuts, and canola oil.46

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Conclusion

A healthy, plant-based diet requires planning, reading labels, and discipline. The recommendations for patients who want to follow a plant-based diet may include eating a variety of fruits and vegetables that may include beans, legumes, seeds, nuts, and whole grains and avoiding or limiting animal products, added fats, oils, and refined, processed carbohydrates. The major benefits for patients who decide to start a plant-based diet are the possibility of reducing the number of medications they take to treat a variety of chronic conditions, lower body weight, decreased risk of cancer, and a reduction in their risk of death from ischemic heart disease.

A plant-based diet is not an all-or-nothing program, but a way of life that is tailored to each individual. It may be especially beneficial for those with obesity, Type 2 diabetes, high blood pressure, lipid disorders, or cardiovascular disease. The benefits realized will be relative to the level of adherence and the amount of animal products consumed. Strict forms of plant-based diets with little or no animal products may be needed for individuals with inoperable or severe coronary artery disease. Low-sodium, plant-based diets may be prescribed for individuals with high blood pressure or a family history of coronary artery disease or stroke. A patient with obesity and diabetes will benefit from a plant-based diet that includes a moderate amount of fruits and vegetables and minimal low-fat animal products. Severe obesity may require counseling and initial management with a low-calorie diet or very-low-calorie diet and the supervision of a physician’s team. Patients with kidney disease may need a plant-based diet with special restrictions, for example fruits and vegetables that are high in potassium and phosphorus. Finally, patients with thyroid disease will need to be careful when consuming plants that are mild goitrogens, like soy, raw cruciferous vegetables, sweet potatoes, and corn. These patients should be informed that cooking these vegetables inactivates the goitrogens.

Physicians should advocate that it is time to get away from terms like vegan and vegetarian and start talking about eating healthy, whole, plant-based foods (primarily fruits and vegetables) and minimizing consumption of meat, eggs, and dairy products. Physicians should be informed about these concepts so they can teach them to staff and patients.

A registered dietitian should be part of the health care team that designs a plant-based diet for patients with chronic disease, especially if multiple medications are involved. Depending on the underlying conditions, patients with chronic disease who take multiple medications need close monitoring of low blood sugar levels, low blood pressure, or rapid weight loss. If these occur, the physician may need to adjust medications. In some cases, such as the one presented here, the need for certain medications can be eliminated altogether. Although the risk of deficiencies may be low, health care teams need to be aware that a motivated patient on a strict plant-based diet may need monitoring for deficiencies of certain nutrients, as outlined above.

The purpose of this article is to help physicians understand the potential benefits of a plant-based diet, to the end of working together to create a societal shift toward plant-based nutrition. There is at least moderate-quality evidence from the literature that plant-based diets are associated with significant weight loss and a reduced risk of cardiovascular disease and mortality compared with diets that are not plant based. These data suggest that plant-based diets may be a practical solution to prevent and treat chronic diseases.

Further research is needed to find ways to make plant-based diets the new normal for our patients and employees. We cannot cure chronic diseases, but we may be able to prevent and control them by changing how we eat. With education and monitoring for adherence, we can improve health outcomes. Patterns of families and other colleagues who may be reluctant to support the efforts of individuals who are trying to change are a challenge to be overcome.

We should invite our colleagues, patients, and their families to a shared decision-making process with the goal of adopting a plant-based diet and a regular exercise program. We should invite health care teams to complete a course on healthy eating and active living. We should encourage staff to be knowledgeable about plant-based nutrition. Finally, we should encourage performance-driven measurable outcomes, which may include:

1. the percentage of physicians who have completed a course on nutrition that includes a discussion of the benefits of a plant-based diet and exercise;
2. the percentage of our hospitals, cafeterias, and physicians’ meeting facilities that serve meals that are consistent with a plant-based diet;
3. the percentage of patients on a physician panel who are obese and who have completed a course on weight management and nutrition that emphasizes a plant-based diet; and
4. the percentage of patients in a physician panel with high blood pressure, diabetes, high cholesterol, or cardiovascular disease who completed a course on nutrition that emphasizes a plant-based diet.

Too often, physicians ignore the potential benefits of good nutrition and quickly prescribe medications instead of giving patients a chance to correct their disease through healthy eating and active living. If we are to slow down the obesity epidemic and reduce the complications of chronic disease, we must consider changing our culture’s mind-set from “live to eat” to “eat to live.” The future of health care will involve an evolution toward a paradigm where the prevention and treatment of disease is centered, not on a pill or surgical procedure, but on another serving of fruits and vegetables.

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Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

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Footnotes

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Onclolgy -in- Ayurveda

Anti Cancer Treatment in Ayurveda

Onclolgy -in- Ayurveda

January 16, 2015 at 10:21pm

PublicFriendsOnly MeCustomKerala Ayurveda Hospital TrichyDOCTORSee all lists...doctorThrissur (Trichur), India AreaVaidyaratnam Ayurveda CollegeTiruchirappalli, India AreaFamilyThrissur AreaVaidyaratnam Ayurveda CollegeKerala Ayurveda HospitalKunnamkulam AreaGo Back

CANCER IN AYURVEDA.

One of the major reasons for redefining ayurvedic practices is the emergence of new diseases, whichare less amenable to conventional standard treatments. We may openly admit that, cancer, as we knowtoday, is not described in classic ayurvedic works such as Brhatrayi. In ancient times cancer had thestatus of an orphan illness. Orphan illness refers to a disease entity which was not taken up for elaboratestudies in terms of its etio-pathology, therapeutics and prognosis. It may be presumed that the neglectwas for want of large patient population. In the case of cancer the situation has thoroughly changed andit is now the major cause of fatality, second only to cardiac ailments. It is no more considered as anorphan illness as in the past. Naturally ayurveda too has to develop an oncology – both theoretical andapplied.No one can honestly claim to know the cure for cancer. Many of the questions related to etiopathologyof cancer remain unanswered.The therapeutic choices offered to a cancer patient are rather grim. The treatment strategies of cancerare mainly three. - Cut it out (surgery), Burn it out (radiation) and Destroy it (chemotherapy).There is a strong anti-surgery feeling among patients. Cancer patients want to move away from radiationand chemotherapy fearing of physical disfigurations that may result from the therapies. To many, traumaof the treatment is worse than that of the disease. They are therefore, put in a climate of opinion ruled byfear and uncertainty. As a safer option they turn to other systems of medicine. Unfortunately, we havenot so far succeeded in developing an effective ayurvedic methodology to deal with cancer cases.Because of this reason the patients often face agonizing dilemma. In this situation we are bound to takestock of the situation and improve ourselves to come up to the expectations of the ailing fraternity. We just can’t afford to wait to treat cancer patients until we evolve a definite system in oncology.Case StudiesKeeping this in view, our institution has started an exclusive clinic for cancer patients, where primarilywe act as service providers. Meanwhile, we are trying to document the case histories of cancer patientsin a systematic manner so that the data generated thereof can be retrieved for further studies. Our 6years old cancer clinic now has documented clinical case histories of about 2000 cancer patientsbelonging to different categories. The primary analysis of the clinical patient population reveals that fourgroups of patients are seeking ayurvedic treatment.There are patients who want to try ayurvedic treatment along with conventional anti-cancer treatments.They hope that combined therapy will be helpful to nullify the side effects of radiation and chemotherapy.They also hope that ayurvedic therapy would help prevent recurrence in a safer way. Terminally cancerpatients take recourse to ayurvedic treatment for supportive and palliative care. A third group of patientsare those who decide to try ayurvedic treatment on a regular basis for total and permanent cure thoughthey are temporarily released from the clutches of cancer with the help of surgery, radiation orchemotherapy. There is yet another group of patients on whom we are concentrating just because theyare fully dependent on ayurvedic treatment. Admittedly, this category of patients constitute only a minorpercentage of the patient population. Their decision to opt exclusively for ayurvedic treatment is essentially based on their understanding of limitations and risk of other treatment options. Our commitment towardsthis group of patients is relatively more because of the faith they have deposited in ayurveda.As of now we do not have statistically significant number of cancer cases, to establish the efficacy of ayurvedic treatment. But there are medical case histories of cancer patients suggestive of the scope andrelevance of ayurvedic treatment for management of malignant disorders. The guidelines for researchmethodologies designed by WHO include a specific clause which is very pertinent in this context. Itsays single case studies for evaluation of efficacy of herbal medicine should not be ignored because of its potential contribution to traditional medicine.I vividly remember the case of a patient who had adenocarcinoma of stomach. His brother who wasundergoing treatment in our hospital had a discussion with us about the possibilities of ayurvedic treatmentfor stomach cancer in which the western system had nothing much to offer in terms of a medicaltreatment. Based on the reports made available to us we suggested a course of treatment to be tried athis residence. In fact we did not get an occasion to see the patient personally even once before chalkingout the treatment profile. The medicines included Nimbamrithadi Panchathiktham Kashayam, SahadevyadiLeham and a few adjuvants. We too were not very hopeful in the initial stages of treatment. To oursurprise we were getting reports from the patient indicating the progress that he was making towardsrecovery. He made his own arrangement to continue the treatment at Gulf collecting medicines fromKottakkal. He continued the medication without any interruption for a period of more than five years.To him at least ayurveda has a cure for Cancer. Similarly I would now like to refer to another example.In this case the patient is a fifty year-old Keralite lady who was diagnosed as Ca. Lung. She approachedus for medical advice forwarding her full medical case history. In addition to NimbamrithadiPanchathiktham Kashayam, Sahadevyadi Leham, we prescribed Parthadyarishtam andAgasthyarsayanam in view of the specific site of cancerous lesion. One cannot expect a tangibleimprovement in lung cancer cases. But this lady improved rapidly and she attained a near normalcondition. The improvement was not merely symptomatic. Radiological examination revealed theremarkable changes suggestive of the regression of the disease. (I have with me the X-ray films of thispatient).I may now refer to the treatment of one more case. It is about a sixteen year-old patient, diagnosed asAcute Myloid Leukemia M-1. The diagnosis was done at Nizam’s Institute of Medical Sciences,Hyderabad. The presenting symptoms were abdomen pain, low grade fever, dry cough, and generalizedbody ache. On examination there was detectable splenomegaly. Patient was advised to try NimbamrithadiPanchathiktham Kashayam, Chandraprabha vatika, Ayolipta thippali, Rasasindooram and combinationof Nityakalyani extract, Thippali choornam, Rajathabhasmam and Thalakabhasmam. Patient continuedthe treatment on a regular basis and intimated the progress at regular intervals. She was registeringimprovement gradually. Case was personally reviewed after three months. Patient was totally free fromall symptoms recorded initially and there was no splenomegaly. Her blood picture showed tremendousimprovement in every aspect. The patient has now resumed her studies as if she has totally recoveredfrom the ailment. She has been advised to continue the medication and send us the reports without failat regular intervals.These instances cannot be set aside as odd events or miracles. Any way the time is not ripe to make tallclaims about the curative effects of Ayurvedic treatment in cancer cases. I am sure many of you mighthave come across similar incidences. My request is that all of you should as far as possible try topreserve your findings for the future because ‘miracles are also extensions of normal capabilities’.

3Collaborative research activities also bring forth valuable data. I may now refer to a few of such activitiesundertaken by our institution joining hands with Calicut Medical College. Here the attempt was directedto provide terminally ill cancer patients with supportive palliative care. Primarily it was decided to splitthe goals and aim at achievable bits. To cite an example, Opioid induced constipation is a big menaceto the cancer patients who are receiving morphine therapy for pain relief. They cannot do away withopioid preparation because no therapeutically equivalent drug is available to replace it. The standardtreatment adopted to relieve constipation has many inadequacies. It was why doctors were willing totry some herbal preparation. A team of doctors studied the efficacy of well known ayurvedic preparationMisrakasneham to relieve constipation. The study brought out highly encouraging results including betteracceptance by patients. I am happy to say here that an international journal on pain managementpublished an article about this study. Similarly Viswamritham was tried for anorexia, Sathadhouta grithamfor oral mucositis. For various reasons the study could not yield statistically significant data but wecould prove that it is well worth considering ayurvedic medicaments in the treatment profile of cancer.Theoretical OncologyI would now like to touch upon a few hints that could be considered while developing an Ayurvedictheoretical oncology. What should be the starting point? We should have a clear-cut understandingabout contemporary knowledge on cancer. We may look at this information from an ayurvedic perspectiveto form an ayurvedic oncology with theoretical soundness. I have tried to pick up a few points fromclassical ayurvedic works which have relevance in forming an ayurvedic oncology. The booklet amongyou contains a brief account of this information. Kindly subject it for a critical analysisSystematic function of any biological entity requires three fundamental regulatory processes - input/ output (transport), transformation and storage. In other words, we may say -

Tridoshaconcept of ayurveda also has a sound basis of thissystemstheory.To obtain a fair idea about the basic structural and functional concepts of human body we may look intothe derivations of a few words commonly used to denote the human body in Ayurvedic classics.1):As far as our knowledge goes, cell is the basic structural unit of the human body. It may be rationallypresumed that there was some knowledge of the cell boundary and molecular traffic between the extracellular and intracellular fluids even before the advent of electron microscope. Human body is composedof between 50-100 trillion cells. Charaka says It essentially means that the basic body components are structurally atomic, innumerable and microscopicAn individual cell is on one of the two largely exclusive paths: division or differentiation. Cells capableof dividing are undifferentiated (stem cells) whereas terminally differentiated cells are unable to divide.Stem cells produce daughter cells that can either become new stem cells or undergo terminal differentiationdepending on tissue specific programming interacting with environmental signals. Both types of cellshave different patterns of gene expression.Each cell has unique characteristics (either inherited or acquired) to perform certain subset of functions.Integrity of human system is maintained by the synchronization of functions of sub-systems, which areorganically interconnected and biologically regulated by thetridoshas, biophysico chemical energies of the body. Of the three forms of energies,vayuacts as the master force.We may now have a brief overview of how cellular metabolism is governed by the threedoshas.

Vatagoverning input/output is responsible for regulating transport across all membranes including entry of food and other molecules into the cell and elimination of waste materials. Governing motion (kinetics) itwould also be responsible for cell division and differentiation (samyogavibhage karanam vayu).Pittabeing responsible for metabolism (biochemical energy production and regulation) governs thekrebs cycle wherein assimilated food is used to create high energy molecules required for cell growthand sustenance.Pittais also responsible for all processess involving enzyme synthesis needed to bringabout transformation.Kapha,being responsible for storage can be identified with the cell membrane and cell wall, basicreserves for the cell to call upon in hard times. On a molecular levelkahpacan be identified with lipidsand polysaccharides the molecular basis for membrane and cell walls respectively. Mucus ispolysaccharide while other lubrication may use lipids.It may be of interest to note that the strategies, which maintain process of control in single cells possessan underlying continuity throughout their biologic development, starting from the microscopic level of regulation of biochemical processes in single cells, and proceeding to the macroscopic level of controlprocesses regulating whole body and its subsystems. It can be seen that the processes of biologicdevelopment have maintained similar strategies of control to those used in the original cells, adding toand building on them as appropriate, but without fundamental alteration.Cancer is a disorder of cellular behaviour, in which the structural/functional integrity is distorted.What is cancer?We come across descriptions of disease entities in ancient ayurvedic texts that have remarkable similaritieswith modern interpretations of cancer. However, one can hardly find a single comprehensive word inayurveda denoting a disease entity, which is fully comparable with concept of cancer.Etymologically the word ‘Arbuda’ represents an enormously growing mass encroaching and destroyingthe normal structural and functional status of an organ and on a larger scale the entire human body.On conducting a literature survey, we get a fairly good amount of information with regard to theunderstanding and interpretations of our predecessors about cancer. In this context, appropriate referencehas to be made to a variety of diseases which have this particular feature in onset, growth spread or

5manifestation. It includesgranthi,apachi,gulma,udara,vidhradianddustavrana. Benign forms of these diseases are likely to become malignant over a period of time where the standard treatmentsprove ineffective. We may say thatsannipathikastage of doshavitiation of diseases is comparablewith malignant conditions.One of the criteria adopted by the exponents of ayurveda in naming and grouping of diseases was theircommonalities in ethiopathogenesis, disease processes, clinical manifestations and terminal stages of the diseases. 5manifestation. It includesgranthi,apachi,gulma,udara,vidhradianddustavrana. Benign forms of these diseases are likely to become malignant over a period of time where the standard treatmentsprove ineffective. We may say thatsannipathikastage of doshavitiation of diseases is comparablewith malignant conditions.One of the criteria adopted by the exponents of ayurveda in naming and grouping of diseases was theircommonalities in ethiopathogenesis, disease processes, clinical manifestations and terminal stages of the diseases. The following descriptions with its appropriate interpretations provide a sound basis fordevelopment of ayurvedic oncologyBasic ApproachAyurvedic treatment for cancer should be basically holistic in approach and so modulated as to havethe following results.1) eradication of morbid tissues2) protection of healthy cells from toxicity and other unfavourable conditions.3) promotion of regeneration of healthy tissues.Anti cancer treatment has five major categories depending upon the level of medical care required –preventive, prophylactic, curative, palliative and supportive.Based on the current understanding of the biology of carcinogens preventive and prophylactic measurescan be adopted. It includes early identification of disease, avoidance of carcinogens and specificinterference to lower cancer risk. Ayurveda definitely has some important role to play in preventiveoncology because carcinogenesis is not an event but a process evolved over a considerable period of time. Manipulation of genetic, biologic and environmental factors in the causal pathway should beattempted. It could be made easy by adopting and updating the principles and practices laid down insvasthavrtta. It may perhaps be possible to influence the mutations leading to carcinogenesis at embryoniclevel by resorting to well designed prenatal care systems. The methods and materials recommended inayurveda in this regard could be subjected for indepth study. Life style modification in terms of diet,relaxation, exercise, attitude, and motivation can be effectively practiced. Patient education and publicawareness programmes enlightening the need of upkeeping positive health could be contributory.Chemoprevention is a relatively new concept. It involves the use of natural agents (chemical agents arealso considered in western medicine) to reverse, suppress or prevent carcinogenesis before thedevelopment of invasive malignancy. The purificatory treatment regimen of ayurveda followed by theregular use of rasayanas may prove an effective mode of chemoprevention.The inbuilt health potentials of human body could be appropriately channeled to inactivate the carcinogenicproliferation. It may perhaps be possible to influence the mutation leading to carcinogenesis at cellularTable IIThe various stages of development of arbudaDwirarbudam(Distant metastasis)Vidhradhi(abscess)Vrana(Malignant ulcers)Sopha(Oedema)Granthi/Gulma(Glandular swellings)Arbudam(Tumour)Adhyarbudam(Metastasis - Primary site)Dwirarbudam(Distant metastasis)


7level. This appears to be one of the basic axioms of the biologic therapy which is aimed at manipulatingthe host-tumour interaction in favour of the host. The very existence of a cancer in a person is testimonyto the failure of the immune system to deal effectively with the cancer. Tumour cells have inherentcapabilities to escape the attention of the defensive mechanism of the host. This could be comparedwith underground terrorism. In the initial phase tumour cells do not exhibit notable difference fromnormal cells so that they are not identified as possible culprits. Tumour activity at this level is too downregulated to be recognized by the cells so that normal antigen-antibody complex does not develop.Tumour cells can cloak themselves in a protective shell of fibrin to minimize contact with surveillancemechanisms. In short the entire purpose of immune mechanism is thus defeated by the tumour cellsmoving in a hidden path. It is unfortunate that most of the universally accepted anti-caner treatmentsalso suppress the immune mechanism adding to the misery of the individual affected. This may perhapsbe one of the demerits of the cancer therapy.There are guidelines in ayurvedic classics to deal with neoplasia of various types. But therapeuticefficacy of such measures to counteract the process of carcinogenesis remains to be established. Thecentres of advanced studies in ayurveda and allied sciences are equipped with the infrastructure capableof isolating drugs having anti-mutagenic, anti-proliferative activity. There is every reason to believe thatin the near future ayurvea would have an Arbudaharaganam to be incorporated into the chapter of Sodhanadigana sangrahaneeyam..Ayurvedic practitioners have already started using classical formulation such as GulguluthikthamKwatham, Kanchanaragulgulu, Rasasindooram, Gandhira rasayanam etc. of treatment of malignantdisorders. Guided by my experience, I may make an incidental mention about auto-urine therapy too.My personal observation is that urine contains some anti-cancerous ingredients. As scholar of bothwestern medicine and ayurveda, Dr. K. Rajagopalan holds the view that medicaments recommended inArshochikitsa have specific role in the treatment of colon cancer. In a way we are finding clinicallymeaningful anti-tumour and anti-cancerous effect of ancient classical preparations. The observationaland empirical data so obtained would be helpful to form a medical oncology of ayurveda.Palliative care refers to the medical or comfort care that reduces the severity of a disease, slows itsprogress rather than providing a cure. In the case of cancer, palliative care becomes the focus of thetreatment in certain conditions. This helps management of pain and other distressing symptoms 

Massive breakthrough: Scientists create first new antibiotic in nearly 30 years

LONDON: In a massive breakthrough, scientists have created the first new antibiotic in more than three decades, Teixobactin, that can treat many common bacterial infections such as tuberculosis, septicemia and C Diff or clostridium difficile colitis. 

The discovery comes at a time when World Health Organization has sent out warnings that humanity is staring at a post-antibiotic era when common infections will no longer have a cure. The first antibiotic, Penicillin, was discovered by Alexander Fleming in 1928, and more than 100 compounds have been found since then, but no new class has been found since 1987. 

Antibiotics have been magic bullets for human health for decades but irrational use has made most bugs resistant to these. Northeastern University's professor Kim Lewis announced Thursday the discovery of the antibiotic that eliminates pathogens without encountering any detectable resistance. 

Lewis and Northeastern biology professor Slava Epstein co​authored the finding with colleagues from the University of Bonn in Germany, Novo Biotic Pharmaceuticals in Cambridge, Massachusetts, and Selcia Ltd in the United Kingdom. 

Most antibiotics target bacterial proteins, but bugs can become resistant by evolving new kinds of proteins. What's unique about Teixobactin is that it launches a double attack on the building blocks of bacterial cell walls. Experts say this will pave the way for a new generation of antibiotics because of the way it was discovered. 

Teixobactin could be available in the next five years. Its testing on mice has shown it clears infections without side-effects. The NU team led by Prof Lewis is now concentrating on upscaling production of Teixobactin to test it on humans. 

Northeastern researchers' pioneering work to develop a novel method for growing uncultured bacteria led to the discovery of the antibiotic, and Lewis's lab played a key role in analyzing and testing the compound for resistance from pathogens. 

Lewis said this marks the first discovery of an antibiotic to which resistance by mutations of pathogens have not been identified. 

"So far, the strategy has been based on developing new antibiotics faster than the pathogens acquire resistance. Teixobactin presents a new opportunity to develop compounds that are essentially free of resistance," Lewis said. 

The screening of soil micro-organisms has produced most antibiotics, but only one per cent of these will grow in the lab, Lewis explained. He and Epstein spent years seeking to address this problem by tapping into a new source of antibiotics beyond those created by synthetic means: uncultured bacteria, which make up 99% of all species in external environments. 

They developed a novel method for growing uncultured bacteria in their natural environment. Their approach involves the iChip, a miniature device Epstein's team created that can isolate and help grow single cells in their natural environment and provide researchers with much improved access to uncultured bacteria. 

"Novo Biotic has assembled about 50,000 strains of uncultured bacteria and discovered 25 new antibiotics, of which Teixobactin is the latest and most interesting," Lewis said. 

"Our impression is that nature produced a compound that evolved to be free of resistance," Lewis said. "This challenges the dogma that we've operated under that bacteria will always develop resistance. Well, maybe not in this case." 

Britain's chief medical officer, Dame Sally Davies, recently said antibiotic resistant was "as big a risk as terrorism", and warned that Britain faced returning to 19th century scourges when the smallest infection or operations could kill. 

WHO said a comprehensive study of antibiotic development, covering innovative, small firms, as well as pharmaceutical giants found that only 15 out of 167 antibiotics under development had a new mechanism of action with the potential to meet the challenge of multidrug resistance.