THE MIDDLE ROAD
by Robert W. Boxer, MD, Fellow of the American Academy of Environmental Medicine, the American Academy of Allergy, Asthma, and Immunology, and the American College of Allergy, Asthma, and Immunology
Over the years, there have been many outstanding programs presented at NOHA meetings, and NOHA NEWS has featured many very informative, outstanding articles, including the Doctor's Corner.
Occasionally divergent points of view have been presented, and sometimes presentations were either somewhat extreme, or perhaps unrealistically difficult for the average person to implement. Most of us have probably looked at all of the information and at times have been overwhelmed, perhaps thinking "I can't possibly do all of that, what makes some reasonable sense?"
The aim (or goal or purpose) of this Doctor's Corner is to make an attempt to put some of the vast amount of information presented over the last 25 years into (some reasonable) perspective. This Doctors Corner article is not meant to imply that the perspective that I present is necessarily the right one or the only one, but that it is an attempt on my part to present some reasonable balance that I professionally and personally feel might be appropriate. Obviously, I will address my area of specialty, which is allergy and environmental medicine, plus some other areas where I have either had extra training or unusual interest and experience.
As NOHA always states, it is important to work closely with the readers' own health care professionals and nothing presented by this article or by NOHA is meant to prescribe or medicate or take the place of any reader's or NOHA member's personal health care professional.
Thirty percent of our population has the atopic genetic trait, i.e. the capacity to develop more traditional allergies such as hay fever, asthma, hives, or eczema. In our experience, a certain number of patients will have symptoms that can involve any system in the body and might be somewhat difficult to suspect or diagnose with conventional approaches. We have seen allergy affect the musculo-skeletal system, the brain, the heart, and all of the other organs and organ systems as well.
We have also found that food allergy, often undetected and unsuspected, is responsible for a great many of these symptoms that can distress, and even sometimes disable patients. Chemical sensitivity, perhaps not being a true allergy in the classical definition, may also occur and cause puzzling symptoms in a smaller percentage of patients.
It is a mistake in our opinion to conclude that all illness is allergy and that that's where all searches for causes should begin. It is important to exclude non-allergic causes of conditions, either simultaneously with allergy investigation, or usually even before considering allergic causes. A physician with the middle of the road attitude might conclude that, after reasonable non-invasive methods have failed to disclose the cause of a somewhat elusive or mysterious ailment, an allergy investigation might then be warranted, or at least consultation with an allergist interested in that type of problem might be indicated.
A middle of the road approach might also empower a patient to evaluate the possibility of allergy themselves to the point where they could think about where symptoms occur, what relieves them, are they related to foods, vacations, work, etc.
A middle of the road approach would recognize that a five-day rotation is ideal but sometimes difficult and, for a patient who is not obviously having serious allergic problems, some modification, such as even a three- or four-day rotation would be useful and a reasonable compromise. In addition, contrary to what we were taught 35 years ago,
it isn't necessary to rotate by families. In other words, if someone is allergic to oranges, they are not necessarily allergic to lemons or limes or grapefruit. If someone is allergic to peanuts, they are not necessarily allergic to soybean or other legumes. This is based on our own experience of having tested many thousands of patients for food allergy, by skin test, by blood test, and by actual provocation neutralization, and by non-blinded oral challenge.
No, this is not what is meant by a Rotation Diet
Again the middle of the road approach recognizes that it's important not to become malnourished or weak in an effort to follow something that may not even be completely necessary in any given patient.
My very nice theme of "middle of the road" probably goes by the wayside (no pun intended) when I think of some of the individuals or more particularly industries that knowingly and blatantly and repeatedly violate pollution regulations. First of all,
society does need reasonably intelligent regulations and then the enforcement should be extremely strict. Penalizing a company financially is not nearly as effective as closing the company down when there have been blatant and repeated violations, in spite of warnings. Obviously it's always a sticky area, as is any situation when one has to regulate and judge. We do, however, as a society need to protect ourselves from the fortunately few greedy and unethical corporations and even individuals.
While electric heat is not common in this area and to a large extent it's prohibitively expensive, it may be preferable to gas, if available. A gas water heater can continue to be a potential source of health problems in a small minority of patients. Allergic patients should try to avoid uncemented and damp crawl spaces. Actually, ideally they would have homes will full, dry basements. Particle board cabinets or any source of formaldehyde such as plywood or some of the older insulations should be avoided or minimized. Carpeting is best avoided, particularly in the bedroom. One possible exception to this might be in the case of small children where safety considerations might outweigh allergic considerations.
Patients can choose less toxic chemicals to be used in cleaning, less toxic paints and finishes, etc. We feel that most homes with forced air heat should be equipped with a media-type HEPA-like air cleaner and we think that electronic air cleaners are best avoided because of the potential for producing ozone, which can, in excess amounts, have toxic effects in some patients. There are a variety of portable HEPA air cleaners available for apartments and residences with other than forced air heat.
There are a variety of vacuum cleaners designed for allergy purposes and even relatively inexpensive higher filtration capacity bags which, although not as effective as HEPA vacuum cleaners, nevertheless do offer an improvement.
Potpourri, scented candles, and room deodorizers, and other scented or chemical items are best avoided in the homes of allergic or potentially allergic patients. A number of non-toxic solutions are available for controlling pests. I think it's particularly important that pesticides, including insecticides, not be sprayed inside homes. Personally we also feel that it would be better if lawns were not sprayed either. Obviously you can't control your neighbor's actions in that regard.
When it comes to bedding, we think that pesticide-impregnated materials should be avoided if possible. In a non-smoking home, particularly where small children are not involved, fire retardant treatment may offer more disadvantages than advantages.
Choosing better tolerated breeds of dogs such as poodles or briards or bichon Frises can be helpful. With cats, weekly bathing, keeping the litter boxes far away from the patient, possibly using special litter box material, etc. can be useful.
Many of the patients that we see are somewhat " hung up" on the need to avoid antibiotics. Antibiotics are, of course, a two-edged sword. When prescribed for legitimate reasons by a qualified physician it's very important that the patient take them. While I think that most physicians would agree that the fewer the antibiotics, the better, there is a point in any particular illness where good judgment may very well dictate that antibiotics should in fact be used.
Remember, sometimes there's a greater risk in not taking a medication than there is in using it.
Some patients choose to use homeopathic remedies. Although these are, by-and-large relatively safe, and may be quite effective in some instances, there have been clear allergic and other adverse reactions to homeopathic remedies as well.
Allergic patients should remember that medications should never supplant environmental control, plus reasonable dietary measures.
It is important to remember that there's not only biologic individuality, but in addition each one of us exists in situations in life that are different both culturally and psychologically from those of every other human being.
Almost anything that has to do with electricity can produce electromagnetic fields and this includes not only high tension wires but television sets, computer monitors, copiers, electric timers and alarm clocks, electric blankets, microwave ovens, disposals, dishwashers, and again anything that is powered by electricity.
Prudent avoidance means that one can map out one's house and pretty much position beds and chairs and desks so that exposure is lessened.
Silver Mercury Amalgum Fillings
Our experience has been that some patients have benefited, some patients do not seem to have benefited, and a few patients seem to have suffered from removal of their amalgam fillings. This latter group, in most instances, had their fillings removed by dentists who were not experienced in the special precautions and techniques that need to be utilized for removal. It would also seem that the size of the latter group seems to be dwindling somewhat. There are still patients who react adversely to the alternatives, which might be a composite, such as Dicor, and occasionally patients may even be sensitive to gold, which does need to be alloyed with other metals to harden it. There is a blood test called the Clifford Panel, which can detect already present immune globulins directed against certain dental materials, suggesting that patients might already be reactive to those substances. While this test can't predict future sensitivities, it can occasionally guide dentists in their quest for more suitable substances in particular patients and is sometimes a useful tool.
In regard to amalgams, I see the middle of the road as being somewhat difficult to define. From my perspective, I would frankly rather see patients have fillings other than silver mercury amalgam, when feasible. On the other hand, whether or not to remove those that are already present is an individual choice that perhaps should be based on the severity of the symptoms, amount and perhaps even the age of fillings present, the general medical condition of the patient, and a host of other factors that need to be taken into consideration. We need to be on the lookout for additional evidence, including that acquired from other countries that are researching this question and taking some interesting, strong stands.
Water Quality and Safety
Even though, to a large extent, the water that is supplied to most of the communities in the Chicago area is relatively safe, many of us question whether it's really wise to ingest chlorinated water. The question of fluoridation, while undoubtedly effective in some areas of health, still remains controversial. Perhaps most importantly, local situations, such as lead from the solder and pipe junctions, whether inside the house or coming from the delivery system to the house, could ultimately contribute to the safety or lack of safety of the water as it presents at the tap. It is for this reason that finding a reliable source for evaluating the quality of the water periodically is probably a reasonable action.
Bottled water offers a potentially suitable alternative, but some bottled water is highly processed and basically not that different from tap water. Bottled water that is from an identified and isolated and stable natural source, particularly that which would be available in glass containers, might have some advantages, although even with the best situations, there have been episodes or periods of contamination.
While reverse osmosis filtration works very well, it may be relatively inefficient in terms of volume and cost, and may work in a sense too well, removing the beneficial minerals from the water, as well as the contaminants. On the other hand, for someone who is very interested in avoiding the possible contaminants, this may be the best way. Many of us use a good quality carbon block filter, which is helpful but certainly not a guarantee as to the purity of the water. This area does remain one in which the educated progressive consumer needs to continue to search for additional information and technology as it evolves.
Chronic Fatigue Syndrome
I suspect that the middle of the road approach in this area would ask that we all try to ensure that our food supply improve by purchasing, to the extent possible, those foods that are as natural as possible, organically grown if possible,
and packed or boxed or provided to us in a manner that will least contaminate them. In addition, obviously these foods need to be as reasonably priced as possible. Market pressures can drive this equation in a favorable direction. This means that we do not purchase that which is not healthy or reasonably priced.
It probably would be ideal if all of these substances could be inexpensively measured, not only in their actual concentration in the body, but in their functional capacity as well. This can be done in selected instances, but overall it is prohibitively expensive even when available. Most of us are left with a common sense "middle of the road" approach. A good, preferably hypoallergenic, multivitamin and mineral preparation with adequate vitamin C and calcium and magnesium is a start. Hypoallergenic usually means made without milk, wheat, yeast, soy, corn, or fish.
For patients who aren't allergic to fish, they are probably a good source of Omega-3 fatty acids, but for the many patients who can't tolerate fish, flaxseed oil is probably a practical approach. There are however, some patients who are allergic to flaxseed also. Many patients benefit from Omega-6 fatty acids, such as evening primrose oil.
A diversified healthy diet, composed at least partially, if not wholly, of organic foods is certainly recommended. It's probable that even patients who aren't allergic often have problems with both food and supplement absorption, for a variety of reasons, possibly at times including parasitic infection, a lack of adequate enzymes, or hydrochloric acid.
It's important to remember with supplements, that the old adage, "if a little is good, more is better," can be misleading and even dangerous. It has been known for decades that the fat soluble vitamins, such as D, E, and A, can, if taken in excess, be deleterious to one's health. There have been studies regarding the potential harmful effect of vitamin A in certain situations and also many studies extolling its benefits in even higher doses. It would seem that in pregnant or potentially pregnant women, one might need to be moderate in dosage, keeping it at 10,000 units per day or less.
We think that 400 units of vitamin D is probably adequate on a daily basis if the patient is not exposed to considerable sun, and this means without sun screen, and I'm aware that some endocrinologists and rheumatologists have prescribed huge doses of vitamin D in an effort to try to reverse osteoporosis. We must emphasize that, when large or megadoses are used, it is important for the user to be under knowledgeable medical supervision.
We personally would recommend 400 units of vitamin E daily, some have suggested higher doses, and we again emphasize the need for medical supervision when much higher doses are used.
When it comes to the B vitamins, by and large they are water soluble and in general excesses would ordinarily simply be excreted. However, there are exceptions and there have been some studies with very high doses of pyridoxine or vitamin B6 where neurologic syndromes occurred. The studies were in elderly VA hospital patients and it would seem that doses of 200 milligrams or less on a daily basis would likely be reasonably safe. This is the dose that has been recommended as a trial for carpal tunnel syndrome. Probably 50% of patients will respond but that's 50% more than zero. If larger doses are used, this should be with medical supervision. In general we recommend medium potency for most of the B vitamins as probably being most appropriate, i.e. 10-25 milligrams.
When it comes to minerals, excesses can cause problems. The total intake of calcium probably should vary from 1000 to 1500 milligrams, depending upon a number of factors including gender, age, protein intake, etc. Ordinarily magnesium would be half as much as calcium unless there is a clear magnesium deficiency.
While zinc is important, an excess of zinc over a period of time can depress the immune system. There probably is a considerable difference of opinion in this regard, but my preference is 50 milligrams or less on a daily basis, unless there is a marked zinc deficiency. If the zinc and copper levels need to be maintained, because there is a teeter- totter relationship between zinc and copper, then copper should be given in the ratio of zinc to copper, 15 to 1. In other words, if someone was low in both zinc and copper, and they took 30 milligrams of zinc, they would also take 2 milligrams of copper. On the other hand, if zinc was low and copper was extremely high, as we often see in hyperactive children, then giving 30 to 50 milligrams of unopposed zinc would be more helpful. Obviously, repeat values need to be done to check on the continuing appropriateness of the dose. Both zinc and copper are part of over one hundred essential metalloenzyme systems in the body.
I think that selenium should be kept at or below 200 micrograms per day. A middle of the road approach probably would apply to some of the other minerals such as chromium and manganese.
We haven't yet had much experience with the use of glucosamine and chondroitin sulfate in the prevention or treatment of arthritis and we are looking forward to obtaining more data on the subject.
DHEA and DHEA-Sulfate seem to be the current rage. We do think that these substances should be monitored by health professionals who can order laboratory assays to document deficiencies or excesses. Certainly there are patients who should not be taking DHEA and these would include male patients with a history of prostate cancer or female patients with concern about gynecological malignancies.
Many claim that melatonin is a completely safe hormone. There are however patients who experience unusual and unpleasant side effects from it. It would seem that a middle of the road approach or advice to one who is inclined to experiment with something that is unregulated and potentially harmful would dictate that one would ordinarily choose a dose that is fairly low to begin with. Perhaps its greatest current usage is in helping people cope with jet lag and also uncomplicated intermittent insomnia. I suspect that the coming years will see clarification of the possible useful role of some of these newer agents.
Considerable study is being done with antioxidants, including the so-called new generation of antioxidants, along with measurements of antioxidant status, and all of us who are interested in these aspects attend meetings periodically and are following this scene. We hope that it leads to enhanced patient care and health, and also to enhanced self care.
We haven't had a huge amount of experience with CoQ10, but many of our patients have used this, and perhaps other coenzymes and bioflavonoids. At this point, CoQ10 would seem to be relatively safe. It's always my impression that a person should start with lower doses and gradually increase, observing for any unusual adverse side effects. At the same time, it's important to notify health care professionals of that which you are taking, in detail. Many patients have been reluctant to do this in the past feeling that the health care professional will be upset or non-accepting, but this is perhaps one of the most important messages for this Doctors Corner. Whether or not the health care professional agrees, for your sake, he or she needs to know what you are taking. This is for your benefit, but ultimately it will also help to educate all of them or at least whet their interest.
that these should be taken for relatively short courses, perhaps three months at the longest, and there should then be a period when they are not used. There was one case in the literature where a patient took an herbal remedy for a lengthy period of many months and ended up having to have a liver transplant and there were no other apparent contributing factors. It would seem important to monitor patients on any potentially potent preparation with appropriate chem screens, blood counts, and urine analyses or other appropriate measurements. We have seen a number of acute allergic reactions to herbal preparations, and again like any other therapeutic modality, there is a certain risk and certain benefit and one has to intelligently weigh these opposite ends of the spectrum in order to stay in the middle road. Licorice preparations can cause hypertension and other side effects because of a cortisone-like effect. There have been a number of deaths from Ephedra when it has been used, usually in excess. I personally wish that there would be more herbal preparations that would be pure and fewer of the mixtures or concoctions because they simply increase the possibility of allergic reactions and may confound the situation.
Additives, Including MSG
Sulfites, bisulfites, and metabisulfites should be reasonably avoided particularly by patients who are known to be allergic. These can cause severe asthma at times. For patients who do not have asthma and are not known to be sulfite sensitive and have not suspected other type of reactions, then avoidance is not as critical, but in line with eating healthfully and naturally, again one would try to avoid preservatives where possible. Our goal is to help patients to eat and live intelligently, not compulsively or obsessively, unless absolutely necessary in some instances, but to have the knowledge to use intelligent and reasonable options when the situation presents itself. We think that in general, food products or items with long lists of ingredients are best avoided.
In summary, we've tried to present a common sense approach with some balance and which tends to avoid either extreme and, in particular instances, we have pointed out why this middle of the road approach is preferable. While I've tried to cover many aspects, I'm sure I've inadvertently left out a number of approaches, which might be useful. This Doctor's Corner, like my knowledge, like that of all professionals, is imperfect and incomplete.
Unfortunately, as is true with all knowledge, that which I have suggested as my perspective is just that. It may be shown to be incorrect even before it is printed, and certainly following printing of this issue of NOHA NEWS there may appear new studies that may shed additional light on some of the subjects. For this reason, and this is so traditional with NOHA members, we must continue to study and learn in these, as well as in all other areas of knowledge.
Article from NOHA NEWS, Vol. XXII, No. 3, Summer 1997, pages 2-9.