JANA Prevention of Neurological Disease

The Journal of the American Nutraceutical Association
Vol. 5, No. 1
Winter 2002
IN THIS EDITION
New Developments in the Prevention and Treatment of
Neurodegenerative Diseases Using Nutraceuticals and
Metabolic Stimulants
Biological and Chemical Terrorism: Natural Cures or
Bogus Claims
Why Funding for Nutraceutical Clinical Trial Research
Will Remain Minimal
Breast Cancer, Hormone Replacement Therapy, and Diet
Pilot Study:An Emulsified Fish Oil Supplement Improves
Conditions in Chronic Hemodialysis Volunteers
AND MORE
A Peer-Reviewed Journal on Nutraceuticals and Nutrition

ISSN-1521-4524
Contents Winter 2002, Vol. 5, No. 1

E
Journal of the
American
Nutraceutical
Association
EDITORIAL STAFF
EDITOR-IN-CHIEF
Mark Houston, MD
EDITORS
Medicine - Christopher M. Foley, MD
Pharmacy - Allen M. Kratz, PharmD
ASSOCIATE EDITORS
Bernd Wollschlaeger, MD
Lisa Colodny, PharmD
TECHNICAL EDITOR
Jane Lael
ART DIRECTOR
Gary Bostany
EDITORIAL BOARD
Russell Blaylock, MD
Jerome B. Block, MD
Lisa Colodny, PharmD, BCNSP
Derrick DeSilva, MD
Jeanette Dunn, EdD, RN, CNS
Brent Eagan, MD
Natalie D. Eddington, PhD
Clare M. Hasler, PhD
Ralph Hawkins, MD
Mark C. Houston, MD, FACP
David S. Hungerford, MD
Robert Krueger, PhD
Alexander Mauskop, MD
Mark J.S. Miller, PhD
Allen Montgomery, RPh
June Reidlinger, PharmD, RPh
Anthony J. Silvagni, DO, PharmD, MSc
John Strupp, MD
C.Wayne Weart, PharmD, BCPS, FASHP
Farred Wassef, RPh
_____________________________
American Nutraceutical Association

Executive Office
5120 Selkirk Drive, Suite 100
Birmingham, AL 35242
Phone: (205) 980-5710 Fax: (205) 991-9302
Website: www.Ana-Jana.org
CEO & PUBLISHER
ANA is an alliance of individuals with interest in

nutraceutical science, technology, marketing and
production. It was established to develop and provide educational materials and continuing education
programs for health care professionals on nutraceutical technology and science. ANA publishes a quarterly newsletter, The Grapevine, and the Journal of the
American Nutraceutical Association (JANA).
_____________________________
(ISSN-1521-4524) is published four times annually,
with frequent supplements, by the American
Nutraceutical Association (ANA). Send all inquiries,
letters, and submissions to the ANA Editorial
Department at 5120 Selkirk Drive, Suite 100,
Birmingham,AL 35242. Contents 2002 ANA, all
rights reserved. Printed in the United States of
America. Reproduction in whole or part is not
permitted without written permission. It is the
responsibility of every practitioner to evaluate the
appropriateness of a particular opinion in the context of actual clinical situations. Authors, editors,
and the publisher cannot be held responsible for
any typographical or other errors found in this
journal. Neither the editors nor the publisher
assume responsibility for the opinions expressed
by the authors.
Cover Photograph - Sierra Productions, Irvine, CA.
D I T O R I A L
Comments on Joint Remedies Article in Consumer Reports .......... 1

GUEST EDITORIAL
Breast Cancer, Hormone Replacement Therapy (HRT) and Diet:
Do We Have the Answers Yet?................................................................ 3
John Strupp, MD
Observations of an Emulsified Fish Oil Supplement
in a Dialysis Population .......................................................................... 4
Ralph Hawkins, MD
C
O N G R E S S I O N A L
P D A T E
Congress Acts on Dietary Supplement Issues .................................... 5

Kevin J. Kraushaar
C
O M M E N T A R Y
Biological and Chemical Terrorism:

Natural Cures or Bogus Claims? ............................................................ 7
I
N T E R V I E W
Mark Houston, MD, SCH, FACP, FAHA

Editor-in-Chief of JANA............................................................................ 9
Allen Montgomery, RPh, ANA CEO and Executive Director
O
P I N I O N
Why Funding for Nutraceutical Clinical Trial

Research Will Remain Minimal ..............................................................12
Steven Evans, MS, Jerome B. Block, MD
R E V I E W
R T I C L E
New Developments in the Prevention and Treatment of

Neurodegenerative Diseases Using Nutraceuticals and
Metabolic Stimulants ..............................................................................15
Russell L. Blaylock, MD
Breast Cancer, Hormone Replacement Therapy (HRT), and Diet...... 33
Gina L. Nick, PhD, ND
O
R I G I N A L
E S E A R C H
Pilot Study: An Emulsified Fish Oil Supplement Significantly

Improved C-Reactive Protein, Hemoglobin, Albumin and Urine
Output in Chronic Hemodialysis Volunteers ...................................... 45
Wendy Lou Jones, MS, Shaun P. Kaiser, RD, LD
To subscribe to JANA Phone 800-566-3622,

outside USA 205-833-1750.
_____________
To order reprints of articles, or additional copies of JANA,
write to or call:
Deana Hunter, Public Relations Director
5120 Selkirk Drive, Suite 100, Birmingham, AL 35242
Phone 205-980-5710 Fax 205-991-9302
Website: www.Ana-Jana.org
D I T O R I A L
Comments on Joint Remedies Article

in Consumer Reports
(JANA) is a peer-reviewed journal whose editorial board is
composed of physicians, pharmacists, academicians, and
researchers striving to educate healthcare professionals and
consumers about the latest research in the growing field of
nutraceutical science.
In the January 2002 issue of Consumer Reports, an article titled "Joint Remedies" provides guidance to consumers
on nutraceutical products that contain glucosamine and
chondroitin. While we applaud the efforts of Consumer
Reports to differentiate glucosamine and chondroitin supplements on the basis of their labeled claims and cost to consumers, we take exception to the concluding statement in this
article that advises consumers: "While no one knows which
formulation works best, it makes sense to try one of the least
expensive combination products." In essence, this recommendation by a highly respected publication guided the consumer in their purchasing decisions exclusively on the price
of products that matched label claim. While price and content
of the product as compared to label claim are important
issues, they are not enough, for it is equally important to evaluate bioavailability, which in turn can impact the efficacy of
these products, especially those containing chondroitin.
tant consideration, for the level of bioavailability can affect

the cost of the compound. This is especially true for chondroitin sulfate, as discussed in our journal in a study that
evaluated the potential intestinal transport of several marketed sources of chondroitin sulfate. In an original research
study published in the Journal of the American
Nutraceutical Association (Vol. 3, No. 1, 2000, 37-44),
Adebowale and colleagues at the University of Maryland
School of Pharmacy reported that the permeability coefficient for transport of chondroitin sulfate is affected by the
molecular weight of the raw materials used, demonstrating
that the bioavailability can be related to the size of the molecule. Several products examined in this study that passed
"label claim" failed in an absorption model. This means that
although a product meets its labeled claim, its molecular
weight, size, or configuration can impact its bioavailability,
with little or none of the ingredients actually absorbed, negatively impacting the product's intended clinical effect.
Well-researched parameters that can affect bioavailability
include molecular size, shape, and weight, excipients in the
formulation, and the manufacturing process.
Taber's Medical Dictionary defines bioavailability as

"the rate and extent to which an active drug or metabolite
enters the general circulation, permitting access to the site
of action." Bioavailability is determined either by measurement of the concentration of the ingredient in body fluids,
or by the magnitude of the pharmacologic response. Simply
put, when a product is not absorbed by the body, it will not
produce the desired effect.
We have all heard of tablets compressed so hard that

they do not dissolve in the GI tract, and therefore have no
bioavailability even when they meet label claims for quantity. The University of Maryland study concluded that the
bioavailability of chondroitin sulfate is increased by using
a product that has a smaller molecular weight. The important point that was not reflected in the Consumer Reports
article ("Joint Remedies") is that other factors can be just as
important as meeting the label claim of a dietary supplement, especially so in the case of chondroitin sulfate.
As members of the editorial board of JANA, we are

concerned that the approach to product selection suggested
in this Consumer Reports article does not adequately
address the complex issue of bioavailability. We agree that
a product must contain the amounts stated on the label.
However, the bioavailability and "efficacy" of a nutrient is
in many cases dependent on more than the quantity of the
ingredient found in the tablet or capsule. This is an impor-
The research team at the University of Maryland

School of Pharmacy also evaluated the % label claim of
chondroitin sulfate vs. price in retail dollars per daily dose.
They found that most products costing less than $1.00/dose
of 1200 mg of chondroitin sulfate were significantly below
label claim. They also found that products costing more
than $4.00/daily dose of 1200 mg were clearly below label
claims. This showed that there was no clear relationship
1 JANA Vol. 5, No. 1
Winter 2002
between product costs and content. A copy of the University

of Maryland study can be found on the ANA website at
http://www.americanutra.com/files/janaeddingtonstudy.pdf.
A problem unique to dietary supplements is that there is
no "bioavailability standard" or monograph that dietary supplement manufacturers are required to follow. Good examples of the "bioavailability standard" concept for prescription drugs are digoxin, coumadin, and thyroxine. These
generic pharmaceutical products all meet accepted bioavailability standards set by the United States Pharmacopeia
(USP). It is important for the consumer to know that quantitative equivalency is not synonymous with either bioequivalency or bioavailability, and no such standards for either currently exist for dietary supplements, or "nutraceuticals."
In our opinion, Consumer Reports inappropriately and
incorrectly related truth of label claim and price to bioavailability in its report. By doing this, Consumer Reports may
have accomplished exactly the opposite of its intent.
It is clear that when evaluating dietary supplements,
each brand should stand on its own original research, and
not be assessed by the research of other brands. To compare

bioavailability and make an accurate recommendation to
buy the least expensive product that is bioavailable when
consumed, Consumer Reports would have to test each
product for bioavailability. We hope that in future comparisons of dietary supplements containing glucosamine and
chondroitin, this fundamental error is not repeated.
We applaud Consumer Reports for attempting to guide
the consumer through the maze of dietary supplements now
used for joint health. However, when providing consumers
with advice on efficacy we refer to the Arthritis
Foundation's statement: "When a dietary supplement has
been studied with good results, find out which brand was
used in the study, and buy that."
In our opinion, until USP or another independent third
party develops a "bioavailability standard" or monograph
that dietary supplement manufacturers are required to follow for glucosamine/chondroitin products, this is the only
safe recommendation to make that incorporates the issues
of price, label claim and product content, bioavailability of
the product, and efficacy.
Mark Houston, MD, Editor-in-Chief

Journal of the American Nutraceutical Association (JANA)
Clinical Professor of Medicine
Vanderbilt University School of Medicine
Nashville, Tennessee
David S. Hungerford, MD
Professor, Orthopaedic Surgery
Johns Hopkins School of Medicine
Baltimore, Maryland
Robert Krueger, PhD
Cochair, ANA Pharmacy Advisory Council
Professor of Pharmacognosy, Ferris State University College of Pharmacy
Big Rapids, Michigan
Natalie D. Eddington, PhD
Associate Professor of Pharmaceutics,
University of Maryland - School of Pharmacy, Baltimore, Maryland
Chris Foley, MD
Coeditor (medicine), JANA
Medical Director, Integrative Care, St. Paul, Minnesota
Clinical Assistant Professor, University of Minnesota College of Pharmacy
Minneapolis, Minnesota
CEO and Executive Director
American Nutraceutical Association
Barry Fox, PhD
Chair, ANA Consumer Advisory Council
Coauthor, The Arthritis Cure
Calabasas, California
Winter 2002
Vol. 5, No. 1 JANA 2
U E S T
D I T O R I A L
Breast Cancer, Hormone Replacement Therapy

(HRT) and Diet: Do We Have the Answers Yet?
John Strupp, MD, Assistant Clinical Professor of Medicine
Vanderbilt University School of Medicine, Nashville, Tennessee
In this issue of JANA, Dr. Gina L. Nick has provided a

comprehensive review of a key area in cancer/nutrition
arena. The breast cancer/hormone replacement therapy controversy is a complex topic, and available data support a cautious approach when a physician discusses HRT with any
woman, particularly one with high risk for development of
breast cancer. The Nurses Health Study1,2 that surveyed
over 120,000 registered nurses between 1976 and 1992
clearly demonstrated an overall reduction in mortality
among the women receiving HRT (estrogens alone or combined estrogens and progestins). This benefit, due largely to
a reduction in death from cardiovascular disease, was diminished substantially by an increase in mortality due to breast
and endometrial cancers. Women receiving HRT for a minimum of 5 years had an adjusted relative risk of breast cancer of 1.45. This was particularly true among 60-64-yearold women (relative risk 1.71). Colditz and colleagues concluded that the tradeoffs between risks and benefits (of
HRT) should be carefully assessed.
Several small studies that Dr. Nick references in her article further demonstrate the correlation between HRT and
breast cancer risk. Collectively, these studies support changing a womans diet to better manage menopausal symptoms
(even in lieu of hormones) and/or to reduce risk of developing cancer. Additionally, a recent published report by
American Cancer Society epidemiologists suggests an
increased risk of ovarian cancer death with long-term estrogen replacement therapy.3
Breast cancer survivors and women without a breast
cancer diagnosis often seek nutritional guidance for many
reasons, including weight control, control of menopausal
* Correspondence:
John A. Strupp, MD
Chief of Oncology, St. Thomas Hospital
4230 Harding Road
Nashville, Tennessee 37205
Email: jstrupp@tnonc.com
symptoms, and to reduce cancer risk. While controversy

exists in many areas regarding the interface of nutrition and
cancer, the benefits of a diet rich in whole fruits and vegetables, low in saturated fats, and free of excessive alcohol consumption are well documented. The AICR-World Cancer
Research Fund Project summarized the existing scientific
evidence for nutritional factors in cancer prevention as either
convincing, probable, possible, or insufficient.3 They concluded that no one vitamin or mineral supplement (including
vitamins E and C, beta carotene, and selenium) has been convincingly shown to be chemoprotective or chemopreventive.
While single studies such as that by Favero, as discussed in
Dr. Nicks paper, show an inverse correlation between certain vitamin and mineral supplements and breast cancer risk,
these findings have been refuted by other authors.
Not to be forgotten are the importance of weight management and physical activity (as measured by body mass
index or BMI), and their benefits to breast cancer risk.
Perhaps more controversial, yet no less intriguing are the
phytoestrogens and soy components such as isoflavones and
their potential inhibitory effect on breast cancer cell growth.
These products clearly have estrogenic and antiestrogenic
effects. The estrogen receptor/progesterone status, especially
among breast cancer survivors, then may be very important
when deciding on the use of soy in such a womans diet.
Dr. Nick, in Figure 5 at the conclusion of her article, provides excellent suggestions for dietary modification to control
cancer risk and menopausal symptoms. This chart will be most
useful both to healthcare professionals and their patients.
REFERENCES
1. Colditz, GA, et al. The use of estrogens and progestins and the
risk of breast cancer in post-menopausal Women. NEJM.
1995;332(24).
2. Grodstein, F, et al. Post-menopausal hormone therapy and mortality. NEJM. 1997; 336925):1769-1775.
3. Brown J, et al. Nutrition during and after cancer treatment: A
guide for informed cancer survivors. Cancer Journal for
Clinicians. 2001;51(3):147-148,167-170.
Winter 2002
U E S T
D I T O R I A L
Observations of an Emulsified Fish Oil

Supplement in a Dialysis Population
Ralph Hawkins, MD,* Associate Professor
University of Tennessee School of Medicine, Memphis, Tennessee
In this issue of JANA, Jones and Kaiser report the results

of a pilot study conducted over eight weeks in a dialysisdependent renal failure population looking at the benefits of
supplementation with a novel emulsified fish oil product.
Fish oil supplementation has been studied in a wide
array of human diseases. Indeed, if one were to conduct a
computer-based MEDLINE search using only the words
fish oil, it would yield well over 7,000 articles in return.
Fish oil has been investigated in the field of nephrology primarily because of its ability to favorably influence lipid levels, to serve as an anticoagulant, an anti-inflammatory
agent, and for its anti-fibrotic and anti-sclerotic properties.
Anecdotally, investigations of the benefits of fish oil consumption on lipid levels were stimulated by the observation
that while inhabitants of the remote Arctic regions were typically overweight and had a high intake of fat in their diets,
the incidence of cardiovascular diseases was extremely low.
It was noted that the predominant fat in their diet was
derived from fish oil, omega-3 polyunsaturated fatty acids,
or eicosapentaenoic acid. The first reports on the beneficial
effects of the use of fish oils in laboratory animals are noted
from reports originating in the early 1980s.
Certainly numbered amongst the most famous of the
fish oil studies in nephrology is the report published in 1994
by Mayo Nephrology Collaborative Group demonstrating
* Correspondence:
Ralph Hawkins, MD
951 Court Avenue, Room 649D
Memphis, TN 38163
Phone: 901-448-5764 Fax: 901-448-5513
E-mail: rhawkins@utmem.edu
Winter 2002
significant reduction in urine protein losses and end-stage

renal failure in 106 randomized patients with an inflammatory disease called IgA nephropathy.1 IgA nephropathy, also
known as Bergers disease, is the commonest primary
inflammatory disease of the kidneys, resulting in microscopic hematuria, or blood in the urine. A long-term follow-up of 75 of the patients in the Mayo collaborative study
was published in 1999,2 again demonstrating that early and
prolonged use of fish oil supplements delays the progression of kidney disease in patients with IgA nephropathy,
and that the benefit of supplementation continued to be evident after many years of follow-up.
Reports of the use of fish oil in a hemodialysis population are far more limited. Fish oil supplements have previously been reported to reduce erythropoietin requirements,3
and to modify platelet aggregability and lipid levels in a
small group of hemodialysis patients.4 All investigators,
however, have not reproduced these findings, and some have
found no benefit of fish oil supplementation at all.5 For that
reason, further carefully constructed trials are warranted.
The eight-week pilot study by Jones and Kaiser reported in JANA examines the specific outcomes attributable to
fish oil supplementation of reduction in C-reactive protein,
albumin levels, hemoglobin levels, and erythropoietin use,
a recombinant hormone therapy injected to stimulate new
blood cell formation. The rationale for each of these observations is that hemodialysis dependency is known to be a
pro-inflammatory state. Measurement of C-reactive protein, which is a non-specific marker of inflammation, is
known to demonstrate high values in the majority of
hemodialysis patients. High C-reactive protein levels are
known to correlate with poorer outcomes in a dialysis pop-
ulation. Indeed, patients with active inflammatory states on

dialysis typically have lower hemoglobin levels, lower
albumin levels, and higher requirements for erythropoietin
at greater expense. Patients with high C-reactive protein
levels and low albumin levels are also at increased risk of
premature mortality.
The results of this trial are suggestive that C-reactive
protein levels might be reduced in a population of
hemodialysis patients, and that this reduction in the apparent inflammatory state might also confer the benefits of
improved albumin levels and maintenance of satisfactory
hemoglobin levels with smaller doses of erythropoietin
delivered. Furthermore, subjective observations suggest
that these patients might have somewhat increased urine
output, reductions in urine protein losses, and improvement
in generalized musculoskeletal pain.
The study of Jones and Kaiser is clearly a first step
towards designing a placebo-controlled, randomized trial to
determine whether fish oil supplementation will prove to be
both cost effective and beneficial to hemodialysis patients.
O N G R E S S I O N A L
The preliminary results of the pilot study are certainly

encouraging in that regard.
REFERENCES:
1. Donadio JV et al. A controlled trial of fish oil in IgA nephropathy. Mayo Nephrology Collaborative Group. N Engl J Med.
1994 Nov; 3:331(18):1194-1199.
2. Donadio JV et al. The long-term outcome of patients with IgA
nephropathy treated with fish oil in a controlled trial. J Am Soc
Nephrol. 1999;10:1772-1777.
3. Nordkild PK et al. Fish oil and antioxidant supplements reduce
erythropoietin requirements in haemodialysis patients.Letter.
Nephrol Dial Transplant.1993;8(6):569.
4. Rylance PB et al. Fish oil modifies lipids and reduces platelet
aggregability in haemodialysis patients. Nephron. 1986;43(3):196202.
5. de Fijter CW et al. Does additional treatment with fish oil mitigate the side effects of recombinant erythropoietin in dialysis
patients? Haematologica. 1995Jul-Aug;80(4):332-334.
P D A T E
Congress Acts on Dietary Supplement Issues

Kevin J. Kraushaar
Vice President & Director of Government Relations
Consumer Healthcare Products Association
Washington, D.C.
Since the passage of the Dietary Supplement Health

and Education Act (DSHEA) in 1994, the U.S. Food and
Drug Administration (FDA) and Congress have been reluctant or unable to designate financial resources necessary to
implement and enforce the law. This became even more
apparent after September 11 when FDA and Congress
turned their attention toward bioterrorism and food safety.
Despite a host of competing priorities during the last federal appropriations cycle, Congress was finally able to designate several million dollars specifically for dietary supplement programs.
In 2002, the Congress will also continue consideration
of legislation that will allow food stamps to be used to purchase vitamins, minerals, and other products to enhance
nutrition for qualified recipients. The Congress is also
expected to resolve differences between House and Senate

bills that would require registration of all facilities that
manufacture, handle, pack, or process food, including
dietary supplements. This article is a summary of recent
Congressional Action
FEDERAL FUNDING FOR DIETARY
SUPPLEMENT REGULATORY SYSTEM AND
SCIENTIFIC RESEARCH
Because of several competing priorities at FDA, dietary
supplements have traditionally not received adequate
agency attention when compared to other food products and
food ingredients. In an effort to address the situation,
President Bush has signed into law an appropriations bill for
Winter 2002
FDA that includes $2.5 million for the agency to update and
modernize the adverse event reporting system for dietary
supplements. A Congressional committee held hearings in
1999 that were quite critical of the agencys ability to collect, analyze, and maintain adequate information on the safety of particular dietary supplement products and there
appeared to be little or no follow up with manufacturers or
healthcare officials. The designation of $2.5 million will
allow FDA to develop specific procedures for dietary supplement adverse event reports and have those reports evaluated by scientific personnel that are adequately trained to
communicate their findings for appropriate follow-up.
massive reauthorization of federal farm, food, and nutrition

programs currently under debate on the Senate floor, the provision is intended to encourage more low-income families to
purchase vitamins and minerals, such as folic acid, iron, and
calcium. Proponents of the measure argue that allowing food
stamp recipients to purchase nutritional products will have
positive healthcare outcomes on a segment of the population
where improvements in nutrition are needed the most.
The Congress has also approved $500,000 for FDA to

enhance enforcement activities relating to unlawful labeling
of dietary supplements and an additional $500,000 to augment
the resources of the Office of General Counsel of the
Department of Health & Human Services (HHS) for legal
activities. The federal appropriations bills signed by President
Bush also contain language from House and Senate conferees
to strongly urge HHS Secretary Tommy Thompson to publish
proposed good manufacturing practices for dietary supplements. GMPs were authorized by DSHEA in 1994, but FDA
has failed to publish a GMP proposal.
The U.S. House and Senate have passed competing versions of legislation to improve the national preparedness for
a bioterrorist attack, including a requirement for food manufacturers and processors to register all facilities with FDA.
The two pieces of legislation authorize the spending of federal funds for bioterrorism preparedness to protect food supplies, improve the Centers for Disease Control and
Preventions medical response, and allow for HHS to expand
the national stockpile of antibiotics and vaccines. The facility registration provisions in both bills apply to manufacturers of dietary supplements as well as conventional foods.
Both bills also allow for the administrative detention of
imported foods that pose a potential threat of adverse health
consequences, maintenance and inspection of records for
foods, and prior notice of imported food shipments.
In addition to safety and enforcement, the Congress has

approved additional money for the National Institutes of
Health (NIH) and FDA to develop the science regarding
dietary supplements. The Office of Dietary Supplements at
NIH will receive $17 million in the next fiscal year that will
allow the office to speed up collaborative efforts to develop, validate, and disseminate analytical methods and reference materials for the most commonly used botanicals. The
National Center for Complimentary and Alternative
Medicine (NCCAM) will also receive $104.6 million, a
portion of which will be used in conjunction with other
institutes to appropriately study the science of certain
dietary supplement ingredients. An additional $1 million
has been designated to continue the work of FDA, in collaboration with the National Center for Nutritional Products
Research at the University of Mississippi, to identify and
analyze botanical ingredients.
BIOTERRORISM INCLUDES REGISTRATION FOR

FOOD MANUFACTURERS
A conference committee will be required to resolve the

differences between House and Senate versions of the
bioterrorism bills. President Bush is expected to sign the
conference report into law.
Correspondence:
Kevin Kraushaar
Consumer Healthcare Products Association
1150 Connecticut Avenue, NW
Washington, DC 20036
Phone: 202-429-9260 Fax: 202-223-6835
Email: KKraushaar@chpa-info.org
Unquestionably, Congress, FDA, and NIH made great

strides in the last federal budget cycle to more appropriately regulate and study dietary supplement products, including vitamins, minerals and other botanical ingredients. In
2002, the Federal Trade Commission (FTC) will also continue its mission by initiating enforcement actions against
false and deceptive advertising claims.
SENATE COMMITTEE APPROVES SUPPLEMENT
PURCHASES WITH FOOD STAMPS
The U.S. Senate Agriculture Committee has approved
legislation that will allow qualified families to use food
stamps to purchase nutritional supplements. As part of a
Winter 2002
O M M E N T A R Y
Biological and Chemical Terrorism:

Natural Cures or Bogus Claims?
Associate Editor, Journal of the American Nutraceutical Association
Chairman, Florida Medical Association Emergency and Disaster Preparedness Taskforce
Board Member, Center on Terrorism and Public Health, Florida State University College of Medicine
The events of September 11, 2001 have changed the

realities of life in the United States of America. We are
faced with a new sense of vulnerability that has not existed in the US since the attack on Pearl Harbor.
Among local, state and governmental agencies, the
Public Health system was challenged to provide an infrastructure to effectively respond to the challenges of disasters and emergencies that can threaten the integrity of our
national health. The potential for further attacks using
nuclear, biological or chemical agents has focused the
attention of the US public and healthcare community at
large on the issue of diagnosis and management of diseases
resulting from such agents.
Documented cases of anthrax infections (cutaneous
and inhalation) have occurred since October 4 throughout
five US states, claiming the lives of five citizens and exposing thousands to the disease. Many public health officials
openly discussed the possibility of the intentional use of
lethal agents such as smallpox and plague, and the protective measures to be taken in event of their occurrence.
Concerned citizens called their doctors offices and the
local public health departments demanding preventive prophylaxis with antibiotics and vaccinations. Since October
8, approximately 32,000 persons with potential exposure to
* Correspondence:
16899 B, NE 15th Avenue
North Miami Beach, Florida 33162
Phone: (786) 251-0655 Fax: 305-940-8717
Email: info@miamihealth.com
B. anthracis in four states and the District of Columbia

have initiated antimicrobial prophylaxis to prevent anthrax
infection, and for approximately 5,000 persons, a 60-day
course of antibiotics was recommended. Unfortunately,
few data exist regarding the use of these antimicrobials for
longer periods, and recent Centers for Disease Control
(CDC) recommendations suggest extending the post exposure prophylaxis to 90 days.
Between October 26 and November 6, 2001, an epidemiologic evaluation to detect adverse events associated
with antimicrobial prophylaxis was conducted among
8,424 postal employees who had been offered such prophylaxis for 60 days in New Jersey, New York City, and
one postal facility in the District of Columbia . During this
period of time 8,424 postal employees were offered
antimicrobial prophylaxis, 5,819 (69%) completed or were
administered a questionnaire to evaluate the occurrence of
adverse events.
A total of 3,863 (66%) had initiated antimicrobial prophylaxis; of these, 3,428 (89%) reported using ciprofloxacin
and 435 (11%) used other antimicrobials (when
ciprofloxacin was contraindicated), including doxycycline
(6%) and amoxicillin (1%). Of the 3,428 persons on
ciprofloxacin, 666 (19%) reported severe nausea, vomiting,
diarrhea, or abdominal pain; 484 (14%) reported fainting,
light-headedness, or dizziness; 250 (7%) reported heartburn
or acid reflux; and 216 (6%) reported rashes, hives, or itchy
skin. Of those persons taking ciprofloxacin, 287 (8%) discontinued the medication; 116 (3%) discontinued the medication because of adverse events, 27 (1%) discontinued
because of fear of possible adverse events, and 28 (1%)
stopped taking the drug because they "did not think it was
needed". The survey did not indicate if these patient
Winter 2002
received probiotic therapy to support their gastrointestinal

physiological function.
Probiotics are defined as the microbial food supplements that beneficially affect the host by improving its
intestinal microbial balance. Probiotics are the health
enhancing functional food ingredients used therapeutically
to prevent diarrhea, improve lactose tolerance and modulate
immunity. Lactobacillus, Bifidobacterium, and several
other microbial species are used as probiotic components to
exert such effects by restoring the composition of the gut
microbiota affected by antibiotic-therapy. The beneficial
role of such nonpathogenic bacteria in the management of
antibiotic induced intestinal dysbiosis should be the subject
of randomized-controlled trials to assess the clinical application of such modalities. The safety and specification of a
particular probiotic agent and methods of delivery to a particular population for a specific purpose should be carefully documented before making clinical recommendations.
Physicians who put patients on long-term antibiotic therapy
should consider a recommendation for probiotic supplementation while the patient is on such therapy.
Unfortunately, the fear of potential infection by bioterror agents and the concern of many Americans about
potential adverse effects of antibiotics therapy were abused
by opportunistic business people. Hundreds of websites
have mushroomed selling everything from mail sterilizers
to oregano oil to prevent and treat illnesses such as anthrax.
A BBC news report discovered more than 200 sites marketing bioterrorism-related products including gas masks,
protective suits, mail sterilizers, biohazard test kits, homeopathic remedies and dietary supplements. The sites are
claiming that dietary supplements such as colloidal silver,
zinc mineral water, thyme and oregano oil are effective
treatments for illnesses such as anthrax.
On other web sites herbal remedies such as echinacea,
garlic and Dr. Christophers "Anti-Plague" formula are
being featured as "treatment" options to cure Anthrax.
The mayor of a tiny central Florida town suggested
colloidal silver, an elixir of metallic silver particles in demineralized water as a "cure" for anthrax. He planned to
buy a colloidal silver generator for the town of 956 residents, located 30 miles northwest of Orlando and encouraged town residents to drink the potion as a "simple solution" to biological threats such as anthrax.
The mayor was forced to step down two months after
proclaiming that a silver-laced liquid could cure anthrax
and other ills, saying that he was the victim of a "Jihad"
against him.
prevent, or treat biological and chemical agents, including

anthrax. More than 200 sites marketing bioterrorism-related products were uncovered, and additional sites are being
evaluated for possible warning letters. Included in the
review were such items as gas masks and protective suits;
mail sterilizers; biohazard test kits, homeopathic remedies,
and dietary supplements such as colloidal silver, zinc mineral water, thyme, and oregano oil as treatments for contamination by biological agents.
Web sites may be subject to state or federal investigation or prosecution for making deceptive or misleading
marketing claims that their products can protect against,
detect, prevent, or treat biological or chemical contamination. "This marketing targets people worried about the
prospect of exposure to lethal biological or chemical
weapons. The FTC is aware of no scientific basis for any
of the self-treatment alternatives being marketed on the
Internet," said Howard Beales, FTC's Director of
Consumer Protection. "Essentially, these operators need to
shut down these areas of their sites or face prosecution".
On November 5, 2001, dietary supplement trade associations (American Herbal Products Association, Consumer
Healthcare Products Association, the Council for
Responsible Nutrition, the National Nutritional Foods
Association and the Utah Natural Products Alliance) issued
a press release emphasizing that dietary supplements have
not been proven to treat or prevent anthrax and that therapies for the treatment or prevention of anthrax should be
recommended only by qualified public health authorities.
The American Nutraceutical Association was established in 1997 to develop and provide educational materials and continuing education programs for health care professionals and consumers on nutraceutical technology and
science. We strongly support federal regulations that do
not allow dietary supplements to claim to treat or prevent
any disease, including anthrax.
We will continue to promote the rational application
of dietary and nutritional supplements such as probiotics
that may be used concurrently with ciprofloxacin for
antimicrobial prophylaxis, and support clinical studies to
assess the benefits of such modalities as an integral part of
current disease management protocols. However, we
encourage our members and readers to criticize and reject
the natural "bioterror cures" and to call those by their
name: sham and quackery.
The FTC, with the help of the Food and Drug

Administration (FDA), more than 30 state attorney generals, and the California Department of Health Services,
have cracked down on such quackery, focusing on web
sites offering products claiming to protect against, detect,
Winter 2002
N T E R V I E W
Mark Houston, MD, SCH, FACP, FAHA

Editor-in-Chief of JANA
In October 2001, Dr. Houston accepted the appointment of Editor-in-Chief of JANA.
The following interview was conducted by Allen Montgomery, RPh, ANA CEO and Executive Director.
Montgomery:
Dr. Houston, I am pleased to introduce you to our readers as the new editor-in-chief of JANA. Can you share with
JANA readers some details about your medical background,
both as a practitioner and an educator?
Houston:
I graduated from Vanderbilt University Medical
School, and completed my internship in internal medicine
at the University of California, San Francisco. For 12 years,
I was a full-time faculty member at Vanderbilt University
School of Medicine, serving as an Associate Professor of
Medicine, Co-Director of Medical ICU, Chief of Clinical
Section-General Internal Medicine, and as Medical Director
of the Executive Physical Program. I am still a Clinical
Professor of Medicine at Vanderbilt, but have left the fulltime faculty.
In 1990 I moved my practice to Saint Thomas Hospital.
There, I founded the Hypertension and Vascular Biology
Institute, along with the Life

Extension Institute, and
serve as medical director. I
have published over 110
medical articles in peerreviewed journals and
abstracts; written over 20
books, book chapters and
monographs; penned over
50 newspaper and magazine
articles; and serve as either a
member of the editorial
board or editorial consultant
Mark Houston, MD
for 20 medical journals
including the New England Journal of Medicine
(NEJM), and the Journal of the American Medical
Association (JAMA).
Montgomery:
What do you see as the future role of JANA?
Dr. Houston:
* Correspondence:
Mark C. Houston, MD, SCH, FACP
Hypertension and Vascular Biology Institute
Saint Thomas Medical Group
4230 Harding Road, Suite 400
Nashville, Tennessee 37205
Phone: 615-297-2700 Fax: 615-269-4584
E-Mail: MHouston@ana-jana.org
My goal is to make JANA the premiere clinical and

nutraceutical journal in the USA with an emphasis on
clinical practice. I want JANA to provide guidance to MDs,
pharmacists, osteopathic, chiropractic and naturopathic
physicians, nutritionists, and dieticians, as well as other
members of the healthcare delivery system, on the current
research in nutrition and nutraceuticals for the prevention
and treatment of disease. Editorially, we will cover specific
topics and new research pertinent to virtually all organ sys-
Winter 2002
tems of the body, with emphasis on neurological disease,

cardiovascular disease, immune function, gastrointestinal
disease, arthritis, diabetes, and cancer. This focus on the use
of nutraceuticals in clinical practice is vital, for it has been
proven that about 50% of all diseases affecting the U.S.
population are nutritionally related. Up to 70% of those diseases could either be prevented, or their severity reduced,
by incorporating proper nutrition and the appropriate
nutraceuticals into a daily healthcare regimen. Our mission
at JANA is to educate and guide healthcare professionals on
these topics.
The strength of any journal is dependent on the editorial board and the scientific quality of the articles submitted.
I have expanded the editorial board and have added leading
MDs, PharmDs, PhDs, NDs, and others that are affiliated
with institutions such as the University of Maryland School
of Medicine, Vanderbilt University School of Medicine, the
University of Tennessee School of Medicine, the Medical
University of South Carolina, the Department of Optometry
at the VA Medical Center in Chicago, and the Department
of Health and Exercise Science at Colorado State
University. These professionals will serve as consulting editors and members of the editorial board. We will continue to
seek qualified members who share our goals and wish to
become affiliated with JANA. Anyone interested in serving
on our editorial board should submit their curriculum vitae
and formal request to me at mhouston@ana-jana.org.
From an editorial point of view, we will continue to
seek submissions that are based in good science, and that
provide useful data applicable to the clinical practice. I
encourage researchers, companies and others involved in
clinical studies to submit manuscripts for consideration to:
Mark Houston, MD
Editor-in-Chief, JANA
5120 Selkirk Drive, Suite 100
Birmingham, AL 35242
mhouston@ana-jana.org
Instructions for authors can be found on our website at
www.ana-jana.org. Click on JANA, then scroll to the bottom
of the screen for instructions for authors. Authors with
additional questions can direct them to our editorial office
at 205-980-5710.
Montgomery:
You are recognized nationally as an expert in the diagnosis and treatment of hypertension. What experiences have
you had in the use of nutrition and nutraceuticals in its prevention and treatment, and how have your patients reacted
to these approaches?
Winter 2002
Dr. Houston:
Hypertension affects about 40% of the adult U.S. population. It is a genetic disease with strong environmental
influences. One factor is nutrition. About half of the mild
or stage I hypertensive patients could have their blood pressures controlled to normal levels utilizing a scientifically
based nutrition and nutraceutical program. I have seen this
happen in my practice in the last 10 years.
Ive spent the last twelve months reviewing the worlds
scientific, English-language medical literature on the role
of nutrition and nutraceuticals in the prevention and treatment of hypertension. From this literature search, I have
completed a 75-page manuscript with over 700 references
on the topic The Role of Vascular Biology, Nutrition, and
Nutraceuticals in the Prevention and Treatment of
Hypertension. The manuscript documents the efficacy of
such a program. This manuscript is undergoing peer-review
and will be published soon in JANA. I am also exploring
with major publishers the potential of developing a book on
this on this topic for both consumers and healthcare professionals.
As for patient response, the vast majority of my
patients prefer and seek non-pharmacologic management
of their hypertension. This includes nutrition, nutraceuticals, vitamins, antioxidants, exercise, weight reduction, and
other modalities. Ive been delighted to see blood pressure
return to normal levels in about 80% of patients who follow
the treatment regimen I have directed. Side effects with this
nutritional and nutraceutical approach are basically nonexistent. Instead of side effects, patients sense an increase in
their well being, energy, and mental focus. I find that in
most cases their overall quality of life improves.
Montgomery:
Have your colleagues adopted or become more accepting of the use of nutraceuticals in a traditional medical
practice?
Dr. Houston:
There is an increasing interest among traditional physicians in learning and applying non-traditional complementary and integrative approaches. The point I want to make
is that physicians must be provided with scientific validation of any tool they may use in their practice. This is why
its so important for nutraceutical companies to develop
strong research programs. As physicians, we cannot recommend products or services that are not supported by good
science and clinical studies. As more and more nutraceutical products are validated by clinical studies, more traditional physicians will use them in their practices. I personally use a clinically validated nutraceutical product, (glucosamine/chondroitin) for the management of osteoarthri-
tis. I only use this and other nutraceutical products that are
supported by well-controlled clinical studies.
It is important for physicians to become better educated
in nutrition and the use of nutraceuticals. The majority of consumers that I meet at various speaking engagements throughout the United States are seeking physicians who are open to
and knowledgeable about integrative medicine. Data shows
that the per capita expenditure on complimentary medicine is
increasing over traditional medicine. Over time, more and
more consumers will seek out physicians who are knowledgeable in these topics and can provide guidance on them.
Montgomery:
Your medical training and practice would be considered traditional. What led you into complementary and integrative medicine, and how have your patients responded to
these approaches?
Dr. Houston:
It began as a personal issue related to my own health,
and that of my father who had prostate cancer. I learned as
much as I could about preventing and treating prostate cancer with nutrition and nutraceuticals. I used this in conjunction with traditional medical treatments.
As I learned more about the role of nutrition and can-
SUBSCRIBE
cer, it became more apparent how they are connected.

Nutrition also has a tremendous impact on cardiovascular
disease, neurodegenerative diseases, aging, diabetes, and
virtually all other diseases.
Unfortunately, traditional MD training pays very little
attention to the use of nutrition and nutraceuticals. Thus,
like many other physicians, I continue to educate myself
independently of my formal medical training. In fact, I am
currently working on a two-year MS degree in nutrition.
In my opinion, successful physicians of the future will
be those who can guide their patients in traditional medical
treatments as well as complementary, or integrative medicine, with an emphasis on nutrition and the proper use of
clinically validated nutraceuticals, vitamins, minerals and
other dietary supplements.
To point out how quickly times change, when the
American Nutraceutical Association was founded in 1997,
the word nutraceutical was not even in the dictionary.
Today, it is defined by Websters as nutraceutical n. A
food or naturally occurring food supplement thought to
have a beneficial effect on human health. It is important
that physicians, pharmacists, nurses, nutritionists, dieticians,
chiropractic, osteopathic and naturopathic physicians learn
what is happening in the field of nutraceuticals and complementary medicine. I want to make JANA one of the primary
sources to help guide and educate these healthcare professionals on these topics.
TODAY TO THE LEADING JOURNAL ON NUTRACEUTICAL SCIENCE
The Journal of the American Nutraceutical Association (JANA)

To subscribe to JANA - Phone 800-566-3622
(outside the USA, 205-833-1750),
or visit the ANA website at www.ana-jana.org
Winter 2002
P I N I O N
Why Funding for Nutraceutical Clinical

Trial Research Will Remain Minimal
Steven Evans, MS,1* Jerome B. Block, MD2
1. Genetic Services Management, Inc., Omaha, Nebraska
2. Division of Medical Oncology and Hematology, Department of Medicine
Harbor-UCLA Medical Center, Torrance, California
INTRODUCTION
Question: If selected dietary supplements, such as vitamins, minerals, herbals, food substances or their combinations,
are beneficial for specific chronic conditions or illnesses, or to
maintain wellness, should we expect major pharmaceutical
drug companies and/or government agencies to fund nutraceutical human clinical trial research in order to more precisely
assess and validate such benefits? That is, if there were anything worthwhile to pursue, surely the major pharmaceutical
drug companies and/or the government would be among the
first to seize the opportunity for improvements in health care.
Given governmental medical panels recommendations of
many key vitamins and minerals, there is already orthodox
acceptance of some of these products beneficial health value.
Moreover, financial disclosures from pharmaceutical companies note that many are losing some of their high-profit-profile patents and are anxiously seeking new avenues for drug
successes. If some elements of the over-the-counter dietary
supplement market have usefulness, particularly for preventative care and for maintenance of wellness, as well as for specific chronic diseases and chronic conditions, should we not
expect pharmaceutical companies as proven, efficient developers of drug remedies to seize the opportunity to demonstrate
their value through clinical trial research? Moreover, when a
scientific case can be made for potential benefits of some
* Correspondence:
Steven Evans, MS
Genetic Services Management, Inc.
418 North 38th Street
Omaha, Nebraska 68131
Phone: 402-551-1020 Fax: 402-556-5743
E-mail: sevans@gsm-usa.com
Winter 2002
nutraceuticals, do not appropriate government researchdirected agencies have responsibility to serve the public
through funding of human clinical trials, furthering the
prospects of low-cost, effective interventions and/or preventative measures? In this commentary, we focus on why major
pharmaceutical companies have not pursued dietary supplement clinical trials research in primary or secondary prevention and why we should also expect government funding to
continue to be modest in such areas.
PHARMACEUTICAL COMPANY DISINCENTIVES
The lack of incentives for conducting clinical trials on
nutraceuticals on the part of pharmaceutical companies
(commonly called Big Pharma in the industry) can be
clearly delineated. The first is that it is quite unlikely that
Big Pharma could make significant profit, or possibly any
profit at all, from such a venture. In conducting the trial,
sponsors must compensate collaborating principal investigators for their administrative roles. Additional costs include
trial participant solicitation, participant monitoring charges
such as lab and radiologic studies, data recording and analysis, and administrative overhead. Separately added in is the
cost of products to be tested. These expenses recur over several years. To measure therapeutic impact, trials are typically targeted for at least five years, with recruitment projected to take several years.
Dr. Joseph DiMasi and his research team at Tufts
University have been issuing research cost estimates for
years based upon proprietary surveys of top drug companies.1 In December, 2001, new cost estimates were released;
preclinical out-of-pocket expenses averaged $121 million,
while clinical costs averaged $282 million.2 Presumably
these clinical costs include actually bringing the drug to mar-
ket when results warrant. When the estimated cost of tiedup capital is added, clinical costs alone total $466 million.
Although some argue that the cost of capital should not be
included, the pharmaceuticals do so in their planning, and
thus their perception is that $466 million could potentially be
consumed. Whether it is the $282 million out-of-pocket
average inclusive clinical trial costs, or the over-$400 million
total costs as perceived by Big Pharma, there can be no question that clinical trials are costly.
The challenge to recoup the R&D principal invested,
and garner a return-on-capital as well, is undermined by the
reality that a successful trial will not likely give any company an exclusive patented product when the evaluated
product is comprised of recognized nutraceuticals. A product recognized by the FDA as beneficial for a diseases
treatment or prevention is the basis for potential widespread
use as a standard of care and possibly enormous profit
potential. However, a specific vitamin, mineral, food substance, etc. cannot as such be patented. A unique production version could claim patent protection, as could a
unique combination of dietary supplements. But again, a
modest variation of the combination opens the marketplace
to competitors who can tout the original investigators clinical trial success without having spent the millions it took to
get it to market in the first place.
Given that the nutraceutical product would not likely be
a successfully patent-protected entity tied into an FDAapproved response to a specific disease state, the charges to
patients that Big Pharma could expect for the product are
extremely constrained. Big Pharma report in their year-end
corporate reports that they are looking to replace drugs going
off-patent, ones that have generated billions per year in revenue. A typically under-ten-dollar supplement would need
tens of millions of customers buying monthly to generate a
billions-per-year revenue. This is quite a challenging barrier,
particularly in light of the fact that the marketplace could be
highly fractionalized among numerous selling contenders.
Further, given that most preventative remedies, over-thecounter remedies, and non-physician-prescribed remedies are
not reimbursed under virtually all health care insurance, the
typical user would have to expect no reimbursement for this
nutraceutical usage. This makes sales expectations even
more tenuous.
In addition, many such remedies are preventative in
nature, and there is hardly a milieu in the USA for serious,
consistent commitments to preventative measures. For
example, nutraceuticals for immunologic enhancement,
anti-aging compounds, and chronic condition suppressants
are typically taken by those in a state of health deemed normal by most standard medical assessments. These supplements address issues which are not typically of interest nor
sources of insurance reimbursement for our health care system targeted to disease diagnosis and treatment. In this
milieu, nutraceutical recommendations would be very
unlikely to become a standard of care, diminishing expectations of the large and consistent sales Big Pharma need to
enter the marketplace.
In summary, Big Pharma would be correct to summarize that there is little, if any, money to be made in this area,
that any advantage of nutraceutical research trials would be
short-lived, and that the prospects of losing substantial
investment are great. Thus one should hardly fault Big
Pharma for avoiding this area. If some top-level managers
of a Big Pharma firm were to decide to embrace such a mission, we could readily expect its shareholders to elect toplevel managers who understood what their mission really is.
GOVERNMENTAL/ACADEMIC DISINCENTIVES
Governmental disincentives differ substantially from
those affecting Big Pharma. Governmental agencies funding
research and clinical trials emanate primarily from various
divisions of NIH, so we will refer to NIH as an eponym for
its individual institutes and programs. Some analysts are
encouraged by the observation that NIH is funding, for
example, a 3000-patient study on Ginkgo for just $15 million, but unfortunately the 3000 patients may yield data
which would most likely support a call for a much larger
definitive trial, rather than being able to yield unequivocally
definitive patient recommendations. It is informative to look
at the National Cancer Institutes (NCI) SELECT trial which
explicitly attempts to determine policy recommendations
concerning whether selenium and/or vitamin E have a protective role in cancer prevention. We could assume that its
extremely highly visible stature and surrounding publicity
compelled NCI to carefully craft its patient accrual size and
scrutinize the trials cost. The trials projected cost is $180
million, with a 7 year accrual period to recruit approximately 32,000 people for its various treatment arms for at least a
five year testing period. Although merely one example,
NCIs goal of reconciling public policy in this area suggests
that these costs and patient numbers support the case for the
non-trivial price for such undertakings. Even with governmental support, the profit potential for commercial firms supplying nutraceuticals is extremely modest. For example, if
the vitamin E arm of the SELECT trial proved efficacious,
one can obtain an entire years supply of vitamin E for
$15.32 from a common, popular mail order catalogue.3 If the
seller even nets 25% of the price before taxes, the less than
$4 net per year per patient speaks for itself in terms of
investment attractiveness.
In defense of the NIH, one can point to the establishment of the National Center for Complementary and
Alternative Medicine (NCCAM) as an indication of
expanded government interest in areas including nutraceuticals. This demonstrates that the government is not without
some worthwhile initiatives, but useful perspective is
gained by noting the NCCAMs allocated fiscal year (FY)
Winter 2002
2001 budget is $89 million against the backdrop of an

approximately $20 billion NIH budget, or less than half a
percent in support of cancer research studies. NCCAM
reports that there was a three-fold increase spent in FY 2000
over FY 1999. As favorable as this may first appear, the
actual dollar value spent in FY 2000 was $4 million versus
less than $1.5 million the preceding year specifically for
cancer research. In contrast, in FY 1999, the National
Cancer Institute estimates it spent $3.2 billion on cancer
research. Given that NCCAM came into existence in FY
1999, one can point to exponentially increasing budgets
over recent history. With prior research funding at much
lower levels, the situation has certainly improved.
Nonetheless, in absolute dollars, given the fiscal challenge
of this area of research, the funding prospects remain sobering. Thus it is reasonable to inquire as to the underpinnings
of such relative reservations regarding nutraceutical
research, for indeed, the problems are challenging.
First, the area of nutraceutical marketing historically
has been rampant with ill-conceived claims and false
promises and has been tainted with quackery and hyperbole. Perceived legitimate medical science after World War
II has focused on disease per se and its treatment; prevention as a whole has been quite the step-child, if not the
orphan. Funding sources can respond only to those seeking
funding, and new researchers could hardly be faulted for
avoiding a field that in its past was rife with charlatans and
quackery. Peer-review boards allocating funds could hardly be faulted for funding treatment research over more historically dubious endeavors in disease prevention or health
enhancement.
Another factor contributing to the disinterest in
nutraceutical research has been the myth that the American
diet was either adequate or could be; from this viewpoint,
research on the impact of nutraceuticals needlessly wastes
precious dollars. Even as the integrity of the American diet
declines precipitously,4,5 this myth prevails, even while
more and more data evolve questioning its premises. A significant portion of the scientific community appear to
embrace a traditionalist American ethic that says we can
address the issue of nutrients if we would just eat from the
food pyramid which the government has insured is displayed in every elementary school classroom around the
country. With this cultural perspective, funding research in
the area of disease prevention or health maintenance
through the peer-review process could hardly be expected
to yield a great deal of enthusiasm. This cycle of indifference has historically fed upon itself, with the lack of previously funded research supporting the proposition that there
was little support for further research.
been as much research to date as has been published for

nutraceuticals. Much of what transpires is often short-term,
highly specific-agent focused, and more often than not,
mouse-model-directed with regard to acute disease states.
This permits researchers to keep expenditures low, adhere to
models of single-agent focus, for a specific disease, and still
have publishable results. The counter-point of course is that
such research has less salience for humans over long intervals or with chronic conditions. Consequently, skeptics may
demand far more conclusive evidence before any public policy recommendations may be derived. As a consequence,
the research fails to lead to definitive conclusions, only reinforcing the recognition that funding should be directed to
more productive arenas.
One response to this funding conundrum is an alternative funding model proposed by some investigators, involving fee-for-service research.6 In this model, healthy individuals or suitably non-acutely-sick patients who can give
informed consent are asked to pay a modest fixed fee toward
the cost of such clinical trial research. This model incorporates the interested public into the funding equation as an
informed and consenting funding participator. Another
recently evolved model has been successful business people
(e.g., dot-com multimillionaires) who fund selected projects that interest them personally. These alternative models
are relatively embryonic. For the foreseeable future, we
should expect virtually no funding by Big Pharma and relatively modest levels of funding from the government in the
nutraceutical clinical trial research area, which nonetheless
offers potentially significant, beneficial outcomes, typically
at low product cost and often with few side effects.
REFERENCES
1. Cost of Developing Drugs Found to Rise. Wall Street Journal,
December 3, 2001:B14.
2. Ibid.
3. Swanson Health Products Catalogue, Edition DBX, 2001:9.
4. Veggie Nutrients Dip in Tests. New House News Service,
Washington, Omaha-World-Herald. January 29, 2000:6.
5. Subar A, et al. Fruit and vegetable intake in the United States:
the baseline survey of the Five a Day for Better Health
Program. Am J Health Promotion. 1992;9:352-360.
6. Evans S, Block, JB. Ethical issues regarding fee-for-servicefunded research within a complementary medicine context.
Journal of Alternative and Complementary Medicine.
2001;6:697-702.
FUTURE FUNDING EXPECTATIONS

In light of these barriers, it is remarkable that there has
Winter 2002
E V I E W
A R T I C L E
New Developments in the Prevention and

Treatment of Neurodegenerative Diseases Using
Nutraceuticals and Metabolic Stimulants
Russell L. Blaylock, MD*
Board Certified Neurosurgeon, Clinical Assistant Professor
University of Mississippi Medical Center, Jackson, Mississippi
INTRODUCTION
Neurodegeneration was once considered to be a simple
acceleration of the normal aging process. Aging of the
brain, however, generally produces little deterioration of
neurological function. Neurodegeneration on the other
hand, results in an appreciable loss of cognitive and motor
function. Hence, a significant loss of cognitive ability is
always pathological. In this review I will discuss several
changes that occur with neurodegeneration and offer potential ways to reduce ones risk of developing a neurodegenerative disorder.
THE CENTRAL MECHANISM OF
NEURODEGENERATION
When one reviews the extensive literature on neurodegeneration, one finds many seemingly unrelated pathological events, such as excitotoxicity, viral inflammation,
autoimmune reactions, trauma, cerebrovascular impairment, and metal toxicity. Surprisingly, a single central
mechanism explains all.1 This mechanism is a combination
of excitotoxic injury coupled with free radical damage to
neural tissue. Excitotoxins are neurotransmitters, such as
* Correspondence:
Russell L. Blaylock, MD
315 Rolling Meadows
Ridgeland, Mississippi 39157
Phone: 601-982-1175
E-mail: dodd@netdoor.com
glutamate or aspartate, that can cause cell death when their

actions are prolonged. These chemicals are thought to play
and important role in ischemic brain damage.
A free radical molecule has an unpaired electron in its
outer orbital, one that robs surrounding molecules of their
electrons, generating a process referred to as oxidation or
oxidative stress. The particles responsible for this oxidative
injury are referred to as reactive oxygen species (ROS). A
related particle, discussed less often in the lay literature, is
the reactive nitrogen species (RNS). Its nitrogen atom interacts chiefly with amino acids, such as tyrosine, interfering
with numerous biochemical processes in the central nervous
system. When these particles react with tyrosine they form
nitrotyrosine, a measurable marker for RNS damage. As we
shall see, these oxygen and nitrogen products are commonly found in the tissues of those with neurodegenerative disorders, such as Alzheimers dementia, Parkinsons disease,
Huntingtons disease and Lou Gehrigs disease (ALS).
The excitotoxic process entails a complicated series of
reactions involving the release of the amino acid neurotransmitter glutamate. Glutamate reacts at a series of receptors on the neurons surface that in turn, either directly or
indirectly, control the calcium pore or channel.2 This channel tightly regulates the entry of calcium into the neuron.
Calcium homeostasis is critical because its loss is the trigger for numerous abnormal signaling systems in the neuron, which when over-stimulated can precipitate the
destructive generation of free radicals and inflammatory
reactions that can ultimately lead to the death of the cell.
For this reason, glutamate levels outside the neuron are
Winter 2002
carefully regulated. Even small elevations in glutamate can

precipitate the destructive reactions we refer to as excitotoxicity. Glutamate content outside the neuron is controlled
by a re-uptake system that involves a series of glutamate
transport proteins.3 Should too much calcium enter the neuron, other cellular mechanisms act to remove it, either by
moving it into the mitochondria, pumping it outside the
neuron, or sequestering it in the endoplasmic reticulum.4
All of these processes require cellular energy. When cellular energy supplies fall, these protective systems fail.
Calcium acts as a biochemical trigger for numerous
reactions, all of which play a vital role in neuron function,
such as nitric oxide signaling information, activation of
special eicosanoids and regulation of the neurons gene
messages.5 When too much calcium enters the cell, it triggers an excessive production of nitric oxide, a cell-signaling molecule.6 As the nitric oxide begins to build up, it
interacts with the superoxide radical to produce the highly
reactive and destructive peroxynitrite radical. This radical
wreaks havoc on the mitochondria, producing injury to its
enzymes (electron transport chain) and in addition, damages mitochondrial DNA.7 A significant loss of cellular
energy production results.
Excess calcium also stimulates the activation of the
enzyme protein kinase C, which activates the membranebound enzyme, phospholipase A2 ( PLA2).8 This enzyme in
turn releases arachidonic acid from the membrane lipid stores,
where it is then acted upon by two enzymes, cyclooxygenase
(COX) and lipoxygenase (LOX), which convert it into numerous reactive molecules called prostaglandins and leukotrienes.
Both metabolic products, when present in excess, can drastically increase free radical production.9
As the level of free radicals begin to rise, they interact
with the lipids in the cells various membranes, setting up
a chain reaction called lipid peroxidation. The peroxyl radical plays a major role in membrane injury as well as injury
to mitochondria.10 As the destructive process spreads
through the membrane, secondary metabolic products are
produced, such as 4-hydroxynonenal, which can be even
more destructive.11
Cellular proteins are building blocks for the hundreds of
enzymes used by each cell to function. Free radicals interact
with both proteins and carbohydrates in the cell, causing
conformational changes in their structure. While free-radical-altered proteins, called carbonyl products, increase with
aging, they dont increase to the extent we see in the tissues
of those with neurodegenerative diseases.12,13
Another cell component damaged by free radicals is
DNA. The cell contains two sets of DNA: one type in the
nucleus, and another in each of the cells numerous mitochondrion. Mitochondrial DNA is especially vulnerable to
oxidation reactions, being about 10X more sensitive to free
radical damage.14 This is important because with aging,
Winter 2002
oxidized DNA begins to accumulate, resulting in dwindling

cell energy supplies.15 Cellular low energy causes reduced
function of the neurons and increased sensitivity to excitotoxicity. The susceptibility of mitochondrial DNA to free radical oxidation increases with age, being 15X more active
after age 70. As this process accelerates, a special autodestructive gene, called the p53 gene, is activated.16 Its purpose
is to kill the neuron when the cell is so badly damaged that it
cannot be restored to health by the cells reparative enzymes.
Much of the destructive change seen in neurodegenerative disorders, at least in the earlier stages, does not entail
neuron death. Several studies have shown that in the case of
Alzheimers disease, most of the damage is directed at the
neuron processes, such as the dendrites and synapses.17
While we do not completely understand the role played by
-amyloid peptides, we do know that much of their destructive potential comes from the free-radical-generating molecule hydrogen peroxide.18 Amyloid has also been shown to
enhance excitotoxicity.19
Another pathological characteristic of Alzheimers disease is the presence of microscopic neurofibrillary tangles
composed of over-phosphorylated tau protein. Recent evidence has demonstrated that the lipid peroxidation product
4-hydroxynonenal interacts with the tau protein to accelerate this process, and prevents the tau proteins from dephosphorylating.20 Several of the transition metals such as aluminum and mercury, and exposure to MSG can precipitate
the same event experimentally.21
Finally, the entire process involves an overreacting
immune system apparently triggered by excitotoxicity and
free radical injury.22 The microglial cell, the cellular basis
of central nervous system immunity, is activated by any
event that increases the free radical-excitotoxicity cascade.23 As we shall see, CNS immune activation plays a
major role in neurodegeneration.
This entire process appears to be the same for numerous conditions including autoimmune diseases, viral
encephalitis, Lyme disease, AIDS dementia syndrome,
brain injury, strokes, heavy metal toxicity, spongioform
encephalitis (Mad Cow disease), and most of the degenerative brain disorders, such as Alzheimers dementia,
Parkinsons disease, Huntingtons disease, and ALS.
IRON AND NEURODEGENERATION
It is known that as we age our brain accumulates more
free iron.24 In the past it was assumed that only free iron
was harmful; recent evidence indicates that even iron combined to ferritin can damage neurons.25 Excessive iron
accumulation is seen in many neurodegenerative disorders,
including Alzheimers dementia, Parkinsons disease, and
ALS. In biological systems, iron is known as one of the
most powerful free radical generators.
Recent evidence indicates that those at risk of developing Parkinsons disease have a defect in iron metabolism.26
In this study, Parkinson patients total iron binding capacity
and transferritin saturation were significantly lower than
that of controls, with no difference in their dietary intake of
iron. Other researchers have found increased iron and aluminum in the neuromelanin pigment in the substantia nigra
of Parkinsons patients.27 Aluminum appears to displace
iron from the ferritin molecule, thereby increasing the interaction of iron during the hydrogen peroxide interaction with
superoxide. This reaction forms the powerful hydroxyl radical.28
In the brains of Alzheimers disease patients, aluminum, iron, and mercury are consistently found in elevated concentrations in affected neurons,29 transferritin levels
are decreased, and iron, ferritin, and transferritin are concentrated around the senile plaques.
ALUMINUM AND NEURODEGENERATION
The connection between aluminum exposure and brain
dysfunction was strengthened when several dialysis units
reported patients with an unusual dementing syndrome related to elevated aluminum levels in the dialyslate.30 Once the
dialysis water was cleared of aluminum, the dementing syndrome disappeared. Based on this finding, others began to suspect aluminum toxicity as an etiology of Alzheimers disease.
One early study, in which individuals were examined in
88 counties in England and Wales, areas with elevated aluminum levels in the drinking water had higher incidences of
Alzheimers dementia.31 A later, more well-controlled
study found that elderly people who drank water high in
aluminum had a 4.4X higher incidence of Alzheimers disease than those who drank water with lower levels.32
After this suggestive research, more accurate studies
were conducted for measuring brain levels of aluminum in
several neurodegenerative disorders. Despite early conflicting results, the latest studies performed with microtechnique high-tech laser and x-ray probes clearly indicate elevated levels of aluminum in the area of neurofibrillary tangles in Alzheimers disease.33 Similar results have been
found in cases of Parkinsons disease.34 The results of one
ALS study indicated that while spinal cord levels of aluminum were not elevated above controls, they did find a
1.5- to 2-fold elevation in iron and calcium.35 Using more
sophisticated methods, another study confirmed the earlier
finding of elevated aluminum levels in the motor neurons of
ALS patients.36
Besides increasing free radical generation, aluminum
has several other negative effects on cell function. One
study found that primates exposed to excess aluminum had
a significant decrease in total lipid, glycolipid, and phospholipid content in their brains.37 Aluminum also damages
membrane-bound enzymes such as Na+-K+ATPase, acetyl-
cholinesterase, and 2, 3-cyclic nucleotide phosphohydrolase, all enzymes necessary for normal neuron function.
A recent study found that aluminum in the presence of
melanin significantly enhanced lipid peroxidation.38 This is
important in the case of Parkinsons disease, since the neuromelanin-containing cells of the substantia nigra are the
cells most affected by the disease. Of enormous importance
is the finding that high aluminum levels can inhibit the
activity of many antioxidant enzymes, such as catalase,
superoxide dismutase, and glutathione peroxidase.39
Several studies have linked aluminum to formation of
the paired helical filaments found in Alzheimers disease.40
Aluminum appears to interfere with dephosphorylation of
the hyperphosphorylated tau protein. Experimentally, using
the aluminum-chelating agent desferrioxamine, researchers
could reverse this resistance to aluminum-induced dephosphorylation.41
The entry of aluminum into the brain, past the bloodbrain barrier, is significantly enhanced when aluminum is
bound to glutamate.42 Once in the brain, aluminum has
been shown to potentate excitotoxicity by enhancing glutamate-triggered calcium accumulation within the neuron,43
and to increase the formation of iron-induced free radicals.
Is aluminum the only cause of these neurodegenerative
diseases? I dont think so. However, I do think that it is a significant contributing factor. Numerous environmental agents,
viruses, autoimmune disorders, and injuries can all trigger the
same central destructive mechanismexcitotoxicity. Often
we see several of these factors coexisting in the same person.
At high risk is the person having mineral deficiencies, poor
nutritional supply of antioxidants, and antioxidant enzyme
deficiencies.
It is interesting to note that gastrointestinal absorption
of aluminum was found to be enhanced in Downs syndrome, a condition with pathological features similar to
Alzheimers disease.44 In this study, aluminum absorption
in Downs syndrome was 4X greater when absorbed as an
antacid, and 6X higher in the presence of citrate than that
seen in controls. Another study found that adding citrate to
aluminum hydroxide antacid increased absorption as much
as 11X in normal adults.45 This may be a good reason to not
add lemon juice to your tea, since tea is high in aluminum
and lemons are high in citrate.
A monocarboxylic acid transporter controls entry of
aluminum into the brain. Pyruvate competes with aluminum citrate for entry, thereby providing a way to inhibit
brain accumulation of aluminum.46 Pyruvate, as well as
malate, have also been shown to inhibit glutamate toxicity.47
INFLAMMATION, CYTOKINES AND
AUTOIMMUNITY
For many years scientists suspected that the immune
Winter 2002
system played an important role in neurodegeneration. It is

known that with aging we begin to develop immune complexes to brain components.48 Some have proposed that this
is the function of immune suppression commonly seen with
aging, to reduce the immune attack. Studies of Alzheimers
patients have shown elevated cytokines IL-1, IL-2, IL-6,
S-100 protein, tumor necrosis factor alpha (TNF-alpha),
and significant isolated autoantibodies to GM1.49,50 One
also sees elevated levels of PGD2 and thromboxane B2,
both inflammatory cytokines, in Alzheimers disease.51
Autoantibodies have also been described in amyotrophic
lateral sclerosis as well.52
This immune attack on neurons produces a state of
chronic inflammation that generates a constant high level of
free radicals.53 As the damage continues, the p53 gene is
activated, leading to apoptosis.54 Short of actual destruction
of the neurons, a reduction in mitochondrial energy generation leads to increased free radical production. In addition,
low energy levels make the neurons infinitely more sensitive to the excitotoxic effects of glutamate and aspartate.55,56 In fact, in the face of low energy production, even
normal levels of glutamate can kill neurons. Glutamate, in
turn, stimulates the microglia, the CNS immune cell, to
produce even more cytokines, and to release the two excitotoxins glutamate and quinolinic acid.57 This viscous cycle
leads to eventual neuronal cell death.
As we see, glutamate itself can act as the trigger for
microglial activation leading to the release of numerous
inflammatory cytokines, or some other event may trigger
the process, such as a viral infection, Lyme disease organism invasion, or even heavy metal exposure. One factor that
may lead to autoimmunity is the prolonged assault of the
brains cellular components to oxidative stress. Oxidation
of the proteins, which alters their structure, can lead to
autoimmunity.
Recent studies have shown that activation of the transcription factor NF kappa B plays a major role in neurodegeneration. This transcription factor stimulates the production of various cytokines including IL-1, IL-2, IL-6 and
TNF-alpha, all of which are increased in neurodegenerative
diseases.58,59,60 Oxidative stress is a common trigger for NF
kappa B activation.
Beta-amyloid has been shown to activate microglia by
way of protein kinase C.61 Studies indicate that beta-amyloid production is increased in the face of activated
microglia and that the presence of beta-amyloid is sufficient
to maintain chronic brain inflammation. Microglia themselves contain enough glutamate to elicit excitotoxicity.
They can also precipitate excitotoxicity by stimulating the
release of arachidonic acid.62 Microglia also contain considerable amounts of the excitotoxin quinolinic acid, which
can be released during activation.63 Quinolenic acid is a
metabolic product of serotonin metabolism.
Winter 2002
Animal studies have shown that mice with autoimmune disorders have a more rapid decline in aged-related
learning than normal animals.64
ADVANCED GLYCATION END PRODUCTS
One of the consequences of a high dietary intake of
glucose, and especially fructose, is the glycation of numerous proteins in the cell.65 When proteins are glycated, that
is, combined with sugar molecules, they become significantly more vulnerable to free radical damage and produce
advance glycation end products (AGEs) which can interfere
with tyrosine and dopa utilization. Elevated levels of AGEs
have been found in Alzheimers, Parkinsons disease, and
ALS.66,67 This is especially so in Parkinsons disease
because of the early fall in cellular glutathione levels.
The problem of large amounts of AGEs is that they signal glia cells to produce superoxide and nitric oxide,68 a
combination that leads to the production of the powerful peroxynitrite radical. Cytokines are also potent stimulators of
inducible nitric oxide, and hence peroxynitrite production.
PEROXYNITRITE
As stated, when nitric oxide combines with superoxide it
produces peroxynitrite. This free radical is unusual in that it is
resistant to most of the common antioxidants, such as vitamin
C, vitamin E and the carotenoids.69 The most powerful scavenger of peroxynitrite is glutathione. When glutathione levels are low, as is seen in Parkinsons disease as well as
Alzheimers dementia and ALS, neurons become significantly more vulnerable. Peroxynitrite tends to concentrate in the
mitochondria, where it damages enzymes as well as DNA.70
These events dramatically interfere with the cells ability to produce energy. Neurons and glia are very energy
dependent. Virtually every cellular process requires enormous amounts of energy. The brain consumes 20% of the
bloods oxygen and 25% of its glucose, even though it constitutes only 2% of body weight. Even under deep anesthesia, the brains metabolism is reduced only 50%.71
Several studies have demonstrated elevated peroxynitrite levels in Alzheimers disease, ALS and Parkinsons
disease.72 Damage by peroxynitrite is indicated by the accumulation of nitrotyrosine.
4-HYDROXYNONENAL (4-HNE)
4-hydroxynonenal (4-HNE) is an aldehydic product of
lipid peroxidation. While malondialdhyde (MDA) is the most
abundant product of lipid peroxidation, 4-hydroxynonenal is
the most reactive with proteins. Interestingly, the distribution
of damage by peroxynitrite parallels that of 4-HNE.73
There is growing evidence that 4-HNE plays a major
role in several neurodegenerative disorders, including
Alzheimers dementia, Parkinsons disease and ALS. In one

study of seven Alzheimers disease patients, 4-HNE was
found to be associated with all amyloid deposits and most
perivascular areas (89%).74
Another study found increased 4-HNE in several areas
of the brain in Alzheimers disease, reaching significant levels in the amygdala, hippocampus and parahippocampus,
areas of primary damage in the disorder.75 Elevations of 4HNE have also been found in the ventricular fluid of
Alzheimers patients but not in age-matched controls.76
The distribution of 4-HNE appears to be dependent on
the presence of the APOE genotype. APOE4-possessing
subjects demonstrated primary accumulation of 4-HNE in
the cytoplasm of pyramidal neurons, while APOE3 genotypes had both astrocytic and pyramidal cell distribution.77
APOE4 is strongly associated with Alzheimers disease as
well as a high risk of dementia pugilistica in boxers.78 It is
also known that individuals with APOE4 genotype have
impaired antioxidant enzymes, which may be the basis of
their increased incidence of neurodegenerative diseases.79
Injecting 4-HNE into the brain of rats causes a widespread loss of neurons in the basal forebrain ipsilateral to
the injection and a 60 to 80% reduction in choline acetyltransferase seven days post-injection.80 When FeCl2 is
given, it increases the levels of 4-HNE in the brain.
Similar elevation of 4-HNE has been demonstrated in
Parkinsons disease.81 A study of seven brains of
Parkinsons disease patients, demonstrated immunostaining
for 4-HNE in the striatum, but demonstrated the same findings in only 9% of aged-matched controls.
Direct injection of 4-HNE into the substantia nigra of
mice caused a dose-dependent depletion of glutathione in
the brainstem.82 Glutathione levels fall early in Parkinsons
disease. 4-HNE has also been shown to rapidly inactivate
glutathione reductase, needed to convert oxidized glutathione to its reduced form.83
LDL and HDL can become oxidized, especially in the presence of increased catalytic iron.87
It has been shown that oxidized LDL in the striatum
enters the neuron and can induce cell death. The mechanism
of neuronal injury is closely connected to excitotoxicity
since glutamate-blocking drugs, such as MK-801, protect
the neuron from oxidized LDL-mediated cell death.88
Highly oxidized HDL in the brain has also been shown to
increase oxidative stress in astrocytes, microglia, and neurons, causing death in the latter.89 When oxidized lipoproteins exist in the presence of glutamate and/or amyloid, neuronal killing is enhanced.90 Oxidized LDL is toxic to motor
neuron cells, possibly linking it to amyotrophic lateral sclerosis.91 Antioxidants, just as in the case of plasma lipoproteins, reduce oxidized LDL and HDL neurotoxicity.92
Homocysteine has been strongly associated with cardiovascular disease, even though the mechanism has not
been fully elucidated. Less well appreciated is the connection between elevated levels of homocysteine and neurodegeneration. Several recent studies have shown a strong correlation between homocysteine levels and incidence of
Alzheimers disease.93,94 Rarely discussed is the fact that
homocysteine is an excitotoxin, as are homocysteic and
homocysteine sulphinic acid,95 two of its metabolic breakdown products.
These excitotoxins act at the N-methyl-D-aspartate
(NMDA) receptor, triggering the entry of excessive
amounts of calcium into the neuron, leading to numerous
destructive reactions including the generation of peroxynitrite, 4-HNE, hydroxyl and peroxyl radicals, and activation
of the eicosanoid cascade. Whether lowering homocysteine
levels will reduce Alzheimers disease is as yet unknown.
We do know that folate, pyridoxine, and antioxidant vitamin deficiencies are common in Alzheimers disease
patients.96,97 Several studies have shown low levels of vitamin B12 as well.97
HOMOCYSTEINE AND OXIDIZED

CHOLESTEROL
It is important to appreciate that the classical hematological signs of B12 deficiency, macrocytosis and hypersegmented neutrophils, are usually absent in these patients.98
While homocysteine levels were found to be consistently
elevated in Alzheimers patients, nutritional deficiency was
not confirmed using retinol binding protein (RBP). This
indicates an impaired cobalamin delivery to the tissues,
which explains the observed discrepancy between normal
serum levels of cobalamin and folate and low tissue metabolic products found frequently in the elderly.
While the cardiovascular system has gotten most of the

attention as regards homocysteine and cholesterol, the nervous system is also vulnerable to its effects. Both LDL and
HDL exist in the brain, with LDL acting as a transporter of
cholesterol and phospholipids in the CNS. Receptors for
LDL have been located on microvessels, astrocytes,
microglia, and neurons.86 Like LDL in the plasma, brain
One recent study throws the homocysteine theory into

question.99 Centenarians living in two northern Italian
provinces were examined for blood levels of homocysteine,
folate and B12. They examined centenarians who were cognitively normal, cognitively impaired, and those with a
diagnosis of Alzheimers disease. Elevated homocysteine
levels were found in 77% of normal, 100% of cognitively
One of the best correlations with cognitive function in

Alzheimers disease is the synaptic concentration in the
brain.84 4-HNE has been shown to conjugate to synaptic
proteins and to impair transport of both glucose and glutamate. Both result in a significant decrease in cellular production of ATP.85
Winter 2002
impaired, and 82% of Alzheimers patients. Demented centenarians had the lowest folate levels. Low B12 and B6 levels were found in 33% and 66% respectively of all centenarians regardless of cognitive status.
There are several explanations for these negative findings. First, the study was based on blood levels of the vitamins, and as we have seen, there is little correlation
between blood levels and tissue levels of these three vitamins. As for the lower level of homocysteine seen in the
centenarian Alzheimer patients, perhaps it was secondary to
metabolic burnout, something we see in the case of glutamate as well.
Homocysteine is known to elicit apoptosis quite rapidly when hippocampal neurons are exposed to this amino
acid.100 The mechanism includes DNA strand breaks with
activation of poly-ADP-ribose polymerase (PARP) which
depletes nicotinamide adenine dinucleotide) (NAD). This
in turn leads to mitochondrial dysfunction, oxidative stress
and caspase activation. In essence it markedly enhances the
vulnerability of hippocampal neurons to excitotoxic and
oxidative injury.
ENERGY PRODUCTION, EXCITOTOXICITY. AND
FREE RADICALS
There is an intimate connection between energy production, excitotoxicity, and free radicals. It has been known
for some time that impaired mitochondrial energy production can lead to dramatic increases in free radical production, and that reduced neuronal energy production significantly increases the neurons sensitivity to excitotoxicity.101
In fact, under such conditions even normal concentrations
of extracellular glutamate can trigger excitotoxic reactions.
Further, an increase in free radical production, either as
reactive oxygen or reactive nitrogen species, increases the
release of glutamate from the astrocyte. Glutamate in turn
increases free radical production, which further reduces
energy production. This vicious cycle continues until the
p53 gene is activated and apoptosis ensues. The neurons are
destroyed by necrosis as well. When elevated iron levels are
present, as it does in all neurodegenerative disorders, free
radical generation reactions are accelerated.
Another result of increased free radical generation is its
effect on the blood-brain barrier system. This gatekeeper
normally prevents or slows the passage of harmful molecules into the brains environment. Unfortunately, the system is not perfect. Recent studies have shown that free radicals can open the barrier, allowing harmful compounds
inside, including the excitotoxins glutamate and aspartate.102 Evidence also indicates that the barrier contains
glutamate receptors and that glutamate itself can open the
barrier.103 This means that elevated levels of blood glutamate can open the barrier, further elevating the level of this
powerful excitotoxin in the extracellular space.
Winter 2002
Related to energy deficits in neurodegeneration is the

finding that the glucose transporter is impaired in
Alzheimers disease secondary to alteration in the brains
vasculature.104 In addition, glutamate itself can impair glucose entry into the brain.
So we see that there is an intimate connection between
glutamate, free radicals, energy production, and the widespread destruction of neurons. Because neurons differ in the
types of neurotransmitter receptors present on their membranes, some will be more sensitive than others.. This
accounts for the difference in pathological presentation.
Reduced energy production has been demonstrated in
all four major neurodegenerative disorders: Alzheimers
disease, Parkinsons disease, Huntingtons disease and
amyotrophic lateral sclerosis. In each instance, specific
enzyme deficiencies are present. In Parkinsons disease,
complex I is deficient.105 In Alzheimers disease complex I,
IV and pyruvate dehydrogenase complex are all deficient.106,107
MAGNESIUM
Magnesium plays a special role in excitotoxicity and
free radical generation. The magnesium receptor is located
near the calcium channel on neurons possessing the NMDA
receptor, which regulates calcium entry into the neuron. As
we have seen, excessive intracellular calcium can trigger
destructive reactions involving nitric oxide synthase induction, arachidonic acid release from the membrane with
eicosanoid activation, and changes in mitochondrial function. Magnesium can block calcium entry as long as the neuron is not firing. It has been demonstrated that low magnesium levels greatly enhance the neurons sensitivity to glutamate, again, where even normal levels can be excitotoxic.108
Other studies indicate that magnesium plays a major
role in preventing free radical accumulation.109 Cells isolated in a low magnesium environment not only generate more
free radicals but are twice as sensitive to free-radicalinduced cell death as cells with normal magnesium levels.110
In addition, hypomagnesmia lowers the cells glutathione
level and increases its cytokine level, which, as we have
seen, can inhibit glutamate uptake, thereby increasing free
radical generation that leads to excitotoxic neuron death.
Both experimental and clinical studies have demonstrated significant neuroprotective effects of elevated magnesium levels.111,112 An additional benefit is that magnesium also inhibits the entry of oxidized lipids into the
endothelial cells of blood vessels.
INHIBITORS OF GLUTAMATE UPTAKE: THE
GLUTAMATE TRANSPORT PROTEINS
Because even small concentrations of extracellular
glutamate can trigger neuron destruction, it is carefully reg-
ulated by a special re-uptake system. This system consist of

approximately five different transport proteins, EAAT 1-5,
whose job it is to bind to glutamate, transport it to the astrocyte and transfer it into the intercellular compartment. Once
this is done, the glutamate is converted into glutamine and
stored until needed. The distribution of the different types
of transport proteins is brain specific.113 EAAT 1-5 are
found in the retina.
iron can play a role in producing the neurodegenerative diseases. They all increase oxidative stress, inhibit glutamate
transport, activate microglia, and trigger excitotoxicity.
There is growing evidence that abnormalities in these

transport proteins play a major role in many neurodegenerative diseases. This is best demonstrated in amyotrophic lateral sclerosis (Lou Gehrig disease).114 There is some evidence that a similar process operates in Alzheimers dementia and Parkinsons disease.115,116
A principal cause of neurodegeneration, oxidative

stress, can be substantially reduced by the consumption of
various nutraceuticals.128 Flavonoids are powerful, versatile antioxidants whose potency is enhanced when combined with vitamins and minerals.
We now know that several events and compounds (such

as viral infections,117 hereditary SOD1 mutants in ALS,118
oxidative stress119 and exposure to mercury) can trigger
excitotoxicity by inhibiting the glutamate transporters.
ANTIOXIDANT EFFECTS
Mercury is a very potent inhibitor of glutamate transporters. In one study a mercury dose as low as 10(-5)M was
found to be inhibitory.120 Mercury is unique, since no other
metal tested, including aluminum, lead, cobalt, strontium,
cadmium and zinc, had any effect on glutamate transport.121
What makes this important is the ubiquitous nature of
mercury exposure. The number one source for humans is
dental amalgam.122 Other sources include industrial fumes,
coal burning, contaminated fish and contaminated lakes and
streams. Dental amalgam is composed of 50% mercury,
which has been shown to vaporize in the mouth, especially
in the presence of heat. Drinking hot liquids and chewing
has been shown to increase the release of mercury vapor
from amalgams at levels 3X higher than normal for 90 minutes.123,124 Over 80% to 90% of this vapor is absorbed into
the circulation. Because of its fat solubility, mercury accumulates in high levels in the nervous system and is very difficult to remove.125 Mercury is also a potent stimulus for the
production of free radicals and it inhibits numerous
enzymes, including the antioxidant enzymes.126
As I demonstrated earlier, a key player in excitotoxicity and neurodegenerative diseases is 4-hydroxynonenal (4HNE), a product of lipid peroxidation, and a potent
inhibitor of glutamate transport proteins.127 This once again
forges a strong connection between excitotoxicity and
oxidative stress. Inflammatory cytokines, such as IL-1, IL2, IL-6 and TNF-alpha, can also inhibit the glutamate transporters, likely via increased lipid peroxidation and production of excessive amounts of 4-hydroxynonenal.
So we see that anything that increases oxidative stress
in the nervous system over a long period of time will
increase the risk of neurodegeneration. This explains why
so many seemingly unrelated factors such as viral infections, trauma, pesticide exposure, hereditary enzyme
defects, and exposure to mercury, aluminum, fluoride and
THE USE OF NUTRACEUTICALS AND PLANT

EXTRACTS IN PREVENTING AND TREATING
NEURODEGENERATION
Most are familiar with the antioxidant effects of vitamins such as the tocopherols and tocotrienols, ascorbate,
vitamins D and K, and the minerals zinc, magnesium and
selenium. As efficient as these antioxidants are, especially
in combination, they are ineffective against some of the
major free radicals and reactive nitrogen species. A study of
Alzheimers and multi-infarct dementia patients found that
both were more often deficient in vitamin E and beta
carotene than matched controls.129 Only the Alzheimers
patients were deficient in vitamin A.
A number of antioxidants have been shown to inhibit
glutamate-induced cytotoxicity (excitotoxicity) including
vitamin E, Ginkgo biloba extract, pycnogenol, N-acetyl Lcysteine, alpha lipoic acid, DHLA, and individual
flavonoids.130 Of even greater interest is the finding that not
only can flavonoids protect DNA from oxidative injury,
they initiate fast chemical repair of DNA as well.131
As we have seen, peroxynitrite plays a central role in
neurodegeneration because of its toxic effects on mitochondrial enzymes and mitochondrial DNA. While the
antioxidant vitamins are generally ineffective in inhibiting
these radicals, flavonoids are quite efficient. In fact, a study
of the scavenging capacity of flavonoids as compared to a
standard peroxynitrite scavenger, ebselen, found that the
flavonoids were 10X more potent.132
Researchers recently found that teas, both black and
green, have peroxynitrite scavenging ability equal to that of
red wine polyphenols.133 In their study, lipopolysaccharideinduced nitric oxide synthease (iNOS) activity was dramatically reduced, most likely by epigallocatechin gallate, but
the mixed theoflavins from black tea were also potent
inhibitors. Peroxynitrite is formed when nitric oxide is produced in excess. The black tea component, theaflavin digallate, was also found to decrease superoxide production in
macrophages and to chelate iron to a significant degree,
moreso than green tea components.134
Curcumin, from the spice turmeric, is also a potent
inhibitor of peroxynitrite and lipid peroxidation.135 By
Winter 2002
enhancing the production of glutathione, curcumin further

protects neurons from peroxynitrite, as well as numerous
other free radical oxygen and nitrogen species. Alpha lipoic
acid and its reduced form, dehydrolipoic acid (DHLA) also
enhances cellular glutathione production. Studies have
shown alpha lipoic acid to increase glutathione levels from
30 to 70% higher than normal.136 Hydroxytyrosol, found in
extra virgin olive oil, is highly protective against the peroxynitrite radical as well.137
Ubiquinone (coenzyme Q10) may act as a significant
antioxidant in biological systems. It may do this by regenerating vitamin E.138 In turn, alpha-lipoic acid can increase
the level of ubiquenol in the face of oxidative stress.139 So
we see a complex interplay of the antioxidants that allows
them to be regenerated for further use.
The reduced form of alpha-lipoic acid, DHLA, has the
greatest versatility in neutralizing free radicals. DHLA can
neutralize the hydroxyl radical, singlet oxygen, hypochlorite, NO radicals, superoxide, peroxyl radicals and H202,
whereas alpha-lipoic acid cannot neutralize superoxide or
peroxyl.140 In mammalian cells alpha-lipoic acid is rapidly
converted to DHLA.141 Both alpha-lipoic acid and DHLA
have been shown to be protective against NMDA and malonic acid-induced striatal lesions in the brain, reducing the
size of the lesion by 50%.142 This would be important in
preventing the oxidative stress lesion responsible for
Parkinsons disease.
Melatonin is also gaining interest as a powerful neuroprotectant. It has been shown to react with the hydroxyl radical, hydrogen peroxide, singlet oxygen, peroxynitrite,
nitric oxide, and hypochlorus acid.143 In addition, it stimulates the production of the antioxidant enzymes: superoxide
dismutase, glutathione peroxidase and glutathione reductase. In a test using dopamine, neuronal cell cultures grown
in vitro in a medium without supporting growth factors, all
of the cells were dying within a short period of time.144
When melatonin was added to the suspension, nearly all of
the dying cells were rescued, including tyrosine hydroxylase positive DA neurons.
Dietary supplementation with alpha-tocopherol has

been shown to reduce the oxidative modification of LDL, a
reduction even greater in diabetics.145 Ascorbate has also
been shown to be an effective inhibitor of LDL oxidation,
and combined with alpha-tocopherol, has reduced the susceptibility of LDL to oxidation at all concentrations of copper tested.146
Coenzyme Q10 has been shown to significantly reduce
the oxidizability of LDL in the face of aqueous free radical
generation at a dose of 300 mg a day in humans.147
Numerous flavonoids have been shown to reduce LDL-oxidizability including red wine polyphenols (catechins),
myricetin, quercetin, epigallocatechin gallate, epicatechin
and rutin.148
I would caution that drinking red wine for health benefits may be more hazardous because of the high concentration of fluoride in California wines and the use of sulfites
in most wines.149 The sulfite connection is especially strong
because of the observed enhancement of neuronal toxicity
when sulfite exists in the presence of peroxynitrite, especially when combined with glutathione depletion, as is seen
in Parkinsons disease.150 Finally, the alcohol itself is particularly toxic to neurons. A recent study found a graded
deleterious effect of alcohol on antioxidant levels within
synaptosomes and neuronal mitochondria.151 There was
also a dose-dependent increase in lipid peroxidation.
A recent study found that the most effective protection
against oxidized LDL-induced cytotoxicity was from cyanidin, epicatechin and kaempferol, with 80% protection.152
One of the most effective flavonoids, epicatechin, was 10X
more efficient in protecting neurons under these conditions
than ascorbate. Pretreatment with taxifolin, apigenin and
naringenin enhanced the toxic effect of oxidized LDH in
vitro, even though they were not neurotoxic alone. This study
demonstrates the usefulness of selected flavonoids as powerful neuroprotectants under conditions of oxidative stress.
The double advantage to lowering LDL and HDL oxidation is a reduction in both direct neurotoxicity of oxidized LDL and HDL, and the prevention of atherosclerotic
cerebrovascular disease.
PREVENTION OF LDL OXIDATION

As we have seen, LDL and HDL exist in the brain and
when oxidized can induce neuron cytotoxicity. It is interesting to note that oxidized LDL cytotoxicity acts through the
NMDA receptor by way of the excitotoxic mechanism. One
major system preventing lipoprotein oxidation is the
arrangement of tocopherol molecules within the LDL and
HDL units. The LDL structure contains six tocopherol molecules. As with all tocopherols, those in lipoproteins can
become oxidized when exposed to excessive oxidative
stress. Regeneration of embedded tocopherol depends on
other antioxidants, such as the carotenoids, ascorbate, alphalipoic acid, DHLA, coenzyme Q10, and the flavonoids.
Winter 2002
INFLAMMATION, CYTOKINES AND

NUTRACEUTICALS
All of the major neurodegenerative disorders are associated with microglial activation and excessive production
of cytokines IL-1beta, IL-6, and TNF-alpha.153 This inflammatory process involves overactivation of the eicosanoid
system through activation of phospholipase A2 and the
release of arachidonic acid from the membrane. This in turn
is acted on by lipoxygenase and cyclooxygenase with the
production of numerous pro-inflammatory leukotrienes and
prostaglandins. Excitotoxins also induce interleukin-1beta
both in microglia and astrocytes.154
Attempts to reduce neurodegeneration have recently

focused on ways to inhibit this series of pro-inflammatory
reactions. In one transgenic Alzheimers mouse model
study, it was found that ibuprofen significantly reduced IL1beta and glial fibrillary protein levels and reduced the total
number of amyloid deposits.155
Another cytokine of importance in neurodegeneration is
tumor necrosis factor-alpha (TNF-alpha), which is elevated in
Alzheimers disease, Parkinsons disease, and ALS. It is
known that (-) epigallocatechin gallate inhibits the production
of TNF-alpha by modulating the pro-inflammatory transcription factor NF kappa B. Other flavonoids, such as curcumin
and quercetin,156,157 can also modulate NF kappa B. In one
study, all flavonones tested protected cells against TNF cytotoxicity, with eriodictyol being most potent.158 Apigenin
markedly enhanced the cytotoxicity of TNF. Zinc has been
shown to markedly inhibit apoptosis induced by TNF.159
Critical to the neurodegenerative process is the inflammatory cascade, which involves numerous cytokines,
eicosanoids, and other immune factors. We know there is an
intimate connection between excitotoxicity and the inflammatory cascade in cells. The inflammatory cascade can be
blocked or reduced at any one of these levels.
IMPROVING ENERGY PRODUCTION

As we have seen, cellular energy production plays a
pivotal role in protection against excitotoxicity. At present,
there are numerous ways to improve mitochondrial energy
generation. Of great importance in neurodegenerative disorders is the ability to bypass blocks in the electron transport chain, as is seen in both Parkinsons and Alzheimers
disease. For example, coenzyme Q10, succinate, and hydroxybutyrate have all been shown to bypass complex I
defects.167 Pyruvate and malate have been shown to protect
cortical neuron cultures from excitotoxic cell death following exposure to glutamate, mostly by increasing cell energy generation.168 Supplementation with creatine also protects against excitotoxic injury.169
Many other vitamins and minerals play a role in cellular energy production, including magnesium, thiamine,
riboflavin, niacinamide, menadione, tocopherols, folate,
ascorbic acid, succinate, acetyl-L-carnitine, and alphalipoic acid.170 Acetyl-L-carnitine has been shown to partially restore mitochondrial function in elderly rats,171 while
treatment of old rats with alpha-lipoic acid has been shown
to improve mitochondrial energy production and increase
their metabolic rate.172
Since NF-kappa B transcription factor plays a major role

in CNS inflammation, blocking its activity can reduce
inflammation, making quercetin, apigenin, and curcumin
especially useful in this regard.160 Some flavonoids inhibit
the release of arachidonic acid from the membrane.161 These
include amentoflavone (Ginkgo leaf), quercetagetin-7-0-glucoside, apigenin, fisetin, kaempferol, luteolin, and quercetin.
Protecting the cell, and its mitochondria, from the

effects of free radicals plays a key part in preserving cellular
energy production. Remember, mitochondrial DNA is 10X
more sensitive to free radical injury than is nuclear DNA.
Apigenin, genistein, and kaempferol have been found to

be potent inhibitors of the COX-II enzyme, which is responsible for inflammatory reactions.162 Curcumin is also a
potent inhibitor of the COX enzymes and is equal in potency to NSAIDs.164 They also inhibit inducible nitric oxide
synthease (iNOS), which triggers the production of the powerful and destructive peroxynitrite radical. Quercetin, which
significantly inhibits COX enzymes, is a more potent
inhibitor of lipoxygenase (LOX).163 Interleukin-12 also
plays a vital role in inflammation; it is potently inhibited by
the flavonoid curcumin. In addition, curcumin has been
shown to potently inhibit prostaglandin activation in cases of
toxic damage to the brain by alcohol.165
Several nutrients can directly block the excitotoxic

process itself. For example, methylcobalamin has been
shown to block the NMDA glutamate receptor on the neuron.173 Pycnogenol has been shown to inhibit the cytotoxic
effects of amyloid -protein and to protect hippocampal
neurons from high concentrations of glutamate.174
So we see that flavonoids act at multiple sites to inhibit the destructive reactions precipitated during neurodegeneration, including excitotoxicity, microglia activation, glutamate transporter inhibition, transitional metal activation
of free radicals, and direct inhibition of the inflammatory
processes. Finally, there is some evidence that one herb,
Ashwagandha, can act as an immune modulator.166 That is,
it can suppress an overactive immune response.
Another way flavonoids may help prevent excitotoxic

lesions in the nervous system is by reducing histamine
release and activity. A recent study found that activated
mast cells in the CNS increased excitotoxic injury 60% by
potentiating receptor-mediated events at the NMDA receptor.177 Vitamin C inhibits the release of histamine from mast
cells, and quercetin blocks the histamine receptor. While
neuroprotection by quercetins action on brain histamine
has not been demonstrated, it deserves a closer look.
DIRECT BLOCKING OF EXCITOTOXICITY
The natural product vinpocetine not only increases

cerebral blood flow but also inhibits glutamate receptors and
regulates Na+-channels, offering potential benefits against
neurodegenerative disorders.175 Low doses of vitamin D
have been shown to protect neurons by down-regulating Ltype voltage-sensitive calcium channels, thereby protecting
hippocampal neurons in culture from excitotoxcicity.176
Combining nutrients appears to offer more neuropro-
Winter 2002
tection than using single agents. In one study, combining

coenzyme Q10 and nicotinamide significantly protected
striatal neurons in vivo, against excitotoxic destruction,
while CoQ10 alone was not protective.178 Likewise, vitamin C and alpha-tocopherol used in combination inhibited
lipid peroxidation in mice brains significantly better than
either agent used alone.179
OTHER NEUROPROTECTIVE NUTRACEUTICALS
Docosahexaenoic acid (DHA) is essential for the normal development and function of the infant brain and for
the maintenance of the adult brain. It should be remembered
that the adult brain is constantly remolding itself, a process
called plasticity. This remodeling process primarily
involves synaptic reorganization. Considerable scientific
literature confirms the importance of docosohexanoic acid
(DHA) in this process.180 Because of the widespread consumption of processed foods, deficiencies of DHA are common. The ratio of N-6 fats to N-3 fats is now 25:1 when it
should be 5:1.181 DHA reduces the risk of neurodegeneration not only by improving cerebral plasticity, but also by
reducing inflammation.182 Without antioxidant supplementation, DHA alone can increase free radical production and
lipid peroxidation.
A fairly recent study found significant abnormalities in
amino acid metabolism in Alzheimers disease patients.183
Significantly reduced plasma amino acids included tryptophan and methionine. Excessive supplementation with serotonin precursors could potentially lead to increased excitotoxic injury due to a buildup of the serotonin metabolic
product quinolinic acid, a known excitotoxin. Taurine has
been shown to have neuromodulatory effects in the CNS
and to regulate cell volume.184
Another study found low levels of s-adenosylmethionine in Alzheimers patients.185 A postmortem study of 11
patients with Alzheimers disease found low levels of sadenosylmethionine in all areas of the brain as compared
with matched controls. In this same study, normal levels
were found in cases of Parkinsons disease, demonstrating
that a low level of s-adenosylmethionine was not merely an
epiphenomenon of neurodegeneration. No studies have
been done to supplement Alzheimers patients with sadenosylmethionine. It may be that these low levels merely
reflect a deficiency in folate, pyrodoxine, and cobalamin,
which is known to occur in Alzheimers disease.186 Chronic
folate deficiency has been associated with cancer and may
also have a significantly deleterious effect on brain function
as well, especially when combined with prolonged injury
by reactive oxygen and nitrogen species.
Growing evidence indicates that several hormones can
protect neurons from numerous types of injury including
neurodegeneration. The earliest attention was given to
estrogen hormones and their ability to attenuate the symp-
Winter 2002
toms of Parkinsons disease.187 More recent studies have

shown that estrogens are essential for maintaining the
nigrostriatal dopamine neurons and that the number of
dopamine neurons in females is higher because of the estrogen stimulation.188
Alzheimers disease is significantly reduced in postmenopausal women taking estrogen supplementation as
compared with unsupplemented controls.189 Estrogen acts
at several levels to protect neurons. Estrogens are trophic
factors for cholinergic neurons that modulate the expression of Apo-E, act as an antioxidant, and inhibit the formation of amyloid beta-peptide. Estrogenic phytonutrients
such as genistein, exhibit neuroprotective effects against
excitotoxicity.190 Several flavonoids, such as quercetin,
have significant estrogenic activity. In addition to its neuroprotective estrogenic activity, quercetin is a powerful and
versatile antioxidant. While estrogen may play a role in preventing Alzheimers disease, one recent study found no evidence that it slows the progression of mild to moderate
Alzheimers disease in women.191 The problem with this
trial is that the estrogen used was premarin, which has been
shown to break down into neurotoxic products itself.
Natural hormones have not been tried in clinical trials.
Experimentally, the phytoestrogen from quercetin and apigenin did significantly inhibit amyloid -protein-induced
cytotoxicity. Soy-based phytoestrogens have also been
shown to protect neurons in vivo.192
Dehydroepiandrosterone sulphate (DHEA-S) also has
been shown to be generally neuroprotective.193 In addition,
it protects hippocampal neurons against glutamate-induced
excitotoxicity.194 While DHEA-S levels tend to fall with
age, the levels are significantly lower in Alzheimers disease. Pregnenolone sulfate, a precursor to steroid hormones
acting higher up the ladder than DHEA, has been shown to
protect animals against spinal cord injury.195 The serum levels of pregnenolone, in one study, fell as much as 60% by
the mean age of 75 years as compared to levels at age 35.196
There is new evidence that testosterone may protect
men from Alzheimers disease, apparently by decreasing
the secretion of amyloid -peptide from neurons. Several
plant extracts have shown an ability to increase testosterone
secretion in both males and females.
Several water-soluble vitamins have shown promise in
preventing excitotoxic-neurodegenerative injury to the nervous system. For example, nicotinamide has been shown to
reduce the size of a middle cerebral infarction in a dosedependent manner for up to two hours after vessel occlusion in a stroke model.198 It has also been demonstrated to
enhance brain choline levels 199 and reduce apoptosis-associated DNA fragmentation, commonly seen in the
Alzheimer brain.200 Despite the fact that at least one study
found low levels of vitamin C in Alzheimers patients, no
trials have been done supplementing these patients with
ascorbate.201 In this study, plasma vitamin C levels fell in

proportion to the severity of the disease.
Two herbs, Ginkgo biloba and Panax ginseng, have
shown both clinical and experimental promise in preventing
and treating neurodegenerative disorders,. In a doubleblind, randomized, placebo-controlled clinical study
involving 309 patients with mild to moderate Alzheimers
dementia, researchers found that moderately low doses of
Ginkgo extract (EGb 761) could slow the course of the disease and improve mental functioning in a substantial number of patients.202 Another study using 240 mg of Ginkgo
biloba extract also found substantial benefit in Alzheimers
patients with a wide margin of safety.203
In another trial, 256 healthy, middle-aged volunteers
were given either 160 mg or 320 mg of a mixture of standardized Ginkgo biloba and Panax ginseng for 14 weeks.204
At the end of the trial, substantial improvements in both
working and long-term memory were seen, an effect that
lasted beyond the two-week washout at the end of the trial.
Studies have shown that Ginkgo biloba extract can protect neuron membranes against hypoxia-related breakdown,
something that probably plays a vital role in Alzheimers
disease.205 By its powerful antioxidant effects, Ginkgo biloba demonstrates an ability to preserve mitochondrial function in aged animals, which, as we have seen, is vital to preventing accumulative excitotoxic-free radical injury.206
Ginsenosides Rb1 and Rg3 have been found to significantly protect cultured rat cortical neurons from neurodegeneration precipitated by excess glutamate.207 Important in
preventing Alzheimers-type neurodegeneration, Rb1
increases choline acetytransferase in the basal forebrain and
nerve growth factor in the hippocampus.208 This also
explains the finding of improved memory function in
scopolamine-treated young and old rats treated with ginsenosides Rb1 and Re.209
Finally, one naturally found substance with much
promise is GM-1 ganglioside. In experiments using monkeys treated with 1-methyl-1,4-phenyl-1,2,3,6-tetrahydropryidine (MPTP) to induce Parkinsons disease, GM-1
ganglioside was found to exert a neurotrophic effect on the
surviving neurons in the substantia nigra.210 In another
study, GM-1 ganglioside was found to protect against motor
neuron death in rats,211 and to reduce by half the number of
degenerating fibers in their spinal cords following injury.
REDUCING MERCURY TOXICITY
Mercury is one of the most neurotoxic elements found
in nature. Unfortunately, millions of people are being put at
unnecessary risk by having dental amalgam placed in their
teeth as a restorative. Amalgam contains approximately
50% mercury. Another common source is thimerosal, a
preservative in some vaccines. With tens of millions of
babies and children being vaccinated each year with up to

33 vaccinations before age two, a frightening health disaster
is in the making. There is no known safe level of mercury.
The ability of our cells to resist toxins depends on their
overall health and especially their antioxidant capacity. It
has been demonstrated that ones sensitivity to mercury is
directly related to tissue levels of alpha-tocopherol and
selenium,212 especially in the nervous system. Zinc may
protect the nervous system from mercury toxicity via its
role in the production of metallothionein.
While no one has tested the ability of plant flavonoids
to chelate mercury, several, including curcumin, hesperidin,
quercetin, tea catechins, and rutin, have been shown to have
powerful chelating ability for iron and copper.
Mercury has been shown to powerfully bind with citrate and malate to form a harmless compound.213 In addition, both easily penetrate the blood-brain barrier. Removal
of mercury from the brain is a difficult and slow process,
but by utilizing these organic compounds one can significantly reduce its toxicity. Combining magnesium to malate
and citrate would further reduce mercury toxicity by their
combined ability to reduce NMDA activity, increase cellular glutathione levels and reduce free radical injury.
Garlic extract has also been shown to efficiently
remove mercury from the brain.214 In fact, it is almost as
efficient as 2,3-dimercaptosuccinic acid (DMSA). In addition, garlic binds and removes mercury within the GI tract,
the major reservoir for mercury. The active principle may
be selenium.215
High doses of alpha-lipoic acid, a powerful and versatile antioxidant, are also an efficient chelator of mercury.216
It easily penetrates the blood-brain barrier and has been
shown to reverse the age-related changes in long-termed
potentiation (LTP) responsible for laying down memory.217
Since mercury in brain tissue is associated with dramatic increases in free radical formation, all preceding
comments concerning antioxidant supplements and
flavonoids apply.218 In addition, recent studies have directly linked neuron exposure to mercury with the formation of
-amyloid as well as hyperphosphorylation of the tau protein. This is most likely related to both free radical generation and direct effects of mercury on amyloid protein and
tau phosphorylation.
Finally, exposure to mercury induces autoantibodies to
neurotypic and gliotypic proteins, common to all three of
the major neurodegenerative diseases.220 Mercury exposure
has been shown to increase the number of microglia cells
in the brain, wherein the mercury accumulates.221 Again, all
nutritional factors affecting the immune response would
apply here.
Winter 2002
SUMMARY
We have seen that neurodegeneration is a complex
process involving several cellular systems including free
radical generation, the antioxidant network, eicosanoid
activation, lipid peroxidation products that inhibit glutamate re-uptake, a loss of cellular energy production, and the
buildup of advanced glycation end products. All of these
processes are connected to the excitotoxic reaction.
That chronic inflammation may be the central cause of
neurodegenerative diseases is only one part of the puzzle.
Overactivation of the glutamate receptors will trigger activation of the microglia, leading to the immunecytokine
activation process, and will trigger a tremendous generation
of reactive oxygen and nitrogen species. This in turn leads
to impairment of the energy-generating system, primarily
by the action of free radicals (peroxynitrite and hydroxyl
ions) on the mitochondrial DNA and electron transport system enzymes.
While different triggering events can initiate these
destructive processes at any level, all result in glutamate
receptor overactivity and initiaton of the excitotoxic
process. We have seen that several nutraceuticals can act at
one of multiple levels in this destructive process. The
flavonoids, in fact, operate simultaneously at many arms of
the excitotoxic reaction.
One key to preventing neurodegeneration is to maintain the cells energy supply. Events that interfere with cellular energy production, no matter the cause, will result in
neurodegeneration. Nutraceutical research remains an area
of much promise in conquering this dreaded process.
REFERENCES
1. Lipton SA, Rosenberg PA. Excitatory amino acids as a final
common pathway in neurologic disorders. N Eng J Med.
1994;330:613-622.
2. Blaylock RL. Neurodegeneration and aging of the central nervous system: prevention and treatment by phytochemicals and
metabolic nutrients. Integrative Med. 1998;1:117-133.
9. Prasad KN, Hovland AR, et al. Prostaglandins as punative neurotoxins in Alzheimers disease. Proc Soc Exp Biol Med.
1998;219:120-125.
10. Kristal BS, Chen J, Yu BP. Sensitivity of mitochondrial transcription to different free radical species. Free Radic Biol
Med. 1994;16:323-329.
11. Keller JN, Mark RJ, et al. 4-hydroxynonenal, an aldehydic
product of membrane lipid peroxidation, impairs glutamate
transport and mitochondrial function in synaptosomes.
Neuroscience. 1997;80:685-696.
12. Blakeman DP, Ryan RA, et al. Protein oxidation: examination
of potential lipid-independent mechanisms for protein carbonyl formation. J Biochem Molecular Toxicol. 1998;12:185190.
13. Stadtman ER. Protein oxidation and aging. Science.
1992;257:1220-1224.
14. Ames BN, et al. Oxidants, antioxidants, and degenerative diseases of aging. Proc Nat Acad Sci USA. 1993;90: 7915-7922.
15. Burcham PC. Genotoxic lipid peroxidation products: their
DNA damaging properties and role in formation of endogenous DNA adducts. Mutagenesis. 1998;13:287-305.
16. Lane DP, Midgley CA, et al. On the regulation of the p53
tumor suppressor, and its role in the cellular response to DNA
damage. Philos Trans R. Soc Biol Sci. 1995;347: 83-87.
17. Hamos JE, DeGennaro LJ, Drachman DA. Synaptic loss in
Alzheimers disease and other dementias. Neurology.
1989;39:355-361.
18. Behl C, Davis JB, et al. Hydrogen peroxide mediates amyloid
beta protein toxicity. Cell. 1994;77:817-827.
19. Mattson MP, Cheng B, Davis D, et al. -amyloid peptides destabilizes calcium homeostasis and renders human cortical neurons vulnerable to excitotoxicity. J Neurosci. 1992;12:376-389.
20. Mattson MP, Fu W, Eaeg G, Uchida K. 4-hydroxynonenal, a
product of lipid peroxidation, inhibits dephosphorylation of
the microtubule-associated protein tau. Neuroreport.
1997;8:2275-2281.
21. Mattson MP. Antigenic changes to those seen in neurofibrillary tangles are elicited by glutamate and Ca+2 influx in cultured hippocampal neurons. Neuron. 1990;2: 105-117.
3. Seal RP, Amara SG. Excitatory amino acid transporters: a family in flux. Ann Rev Pharmacol Toxico. 1999;39:431-456.
22. Stoll G, Jander S. The role of microglia and macrophages in

the pathophysiology of the CNS. Prog Neurobiol. 1999;58:
233-247.
4. Seeburg PH. The molecular biology of mammalian glutamate

receptor channels. Trends Neurosci. 1993;16:359-364.
23. Banati RB, Gehrmann J, et al. Cytotoxicity of microglia. Glia.

1993;7:111-118.
5. Churn SB, Sombati S, et al. Excitotoxicity affects membrane

potential and calmodulin kinase II activity in cultured rat cortical neurons. Stroke. 1993;24:271-278.
24. Markesbery WR, Ehmann WD, et al. Brain trace element concentration in aging. Neurobiol Aging. 1984;5:19-28.
6. Lipton SA. Prospects for clinically tolerated NMDA antagonist:

open-channel blockers and alternative redox states of nitric
oxide. Trends Neurosci. 1993;16:527-532.
7. Torreilles F, Salman-Tabcheh S, et al. Neurodegenerative disorders: the role of peroxynitrite. Brain Res Rev. 1999;30:153-163.
8. Worley PF, Baraban JM, Snyder SH. Beyond receptors: multiple second-messenger systems in brain. Ann Neurol.
1987;21:217-229.
Winter 2002
25. Johnson S. Iron catalyzed oxidative damage, in spite of normal ferritin, and transferritin saturation levels and its possible
role in Werners syndrome, Parkinsons disease, cancer, gout,
rheumatoid arthritis, etc. Med Hypotheses. 2000;5:242-244.
26. Leveugle B, Faucheux BA, et al. Cellular distribution of the
iron-binding protein lactotransferrin in the mesencephalon of
Parkinsons disease cases. Acta Neuropathol (Berl).
1996;91:566-572.
27.Good PF, Olanow CW, Perl DP. Neuromelanin-containing neurons of the substantia nigra accumulate iron and aluminum in
Parkinsons disease: a LAMMA study. Brain Res.
1992;593:343-346.
43. Mundy WR, Freudenrich TM, Kodavanti PR. Aluminum

potentiated glutamate-induced calcium accumulation and
iron-induced oxygen free radical formation in primary neuronal cultures. Mol Chem Neuropathol. 1997;32:41-57.
28. Yoshida T, Tanaka M, Sotomatsu A, Hirai S, Okamoto K.

Activated microglia cause iron-dependent lipid peroxidation
in the presence of ferritin. Neuroreport. 1998;9:1929-33.
44. Moore PB, Edwardson JA, et al. Gastrointestinal absorption of

aluminum is increased in Downs syndrome. Biol Psychiatry.
1997;41:488-492.
29. Markesbery WR, Ehmann WD. Brain trace elements in

Alzheimers disease. In: Terry RD, Katzman R, Bick KL, eds.
Alzheimers Disease. New York, Raven Press, LTD;1994:353367.
45. Coburn JW, Mischel MG, et al. Calcium citrate markedly

enhances aluminum absorption from aluminum hydroxide.
Am J Kidney Dis.1991;17:708-711.
30. Crapper DR, Quittkat S, Krishnan SS, et al. Intranuclear aluminum content in Alzheimers disease, dialysis encephalopathy and experimental aluminum encephalopathy. Acta
Neuropath (Berlin), 1980;50:19-24.
31. Martyn CN, Barker DJP, Osmond C, et al. Geographical relation between Alzheimers disease and aluminum in drinking
water. Lancet 1. 1989:59-62.
32. Michel PH, Commenges D, Dartigues JF, Gagnon M. Study of
the relationship between Alzheimers disease and aluminum in
drinking water. Neurobiol Aging. 1990;11:264.
33. Bouras C, Giannakopoulos P, Good PF, et al. A laser microprobe mass analysis of the brain aluminum and iron in dementia pugilistica: a comparison with Alzheimers disease. Eur
Neurol. 1997;38:53-58.
34. Hirsch EC, Brandel JP, et al. Iron and aluminum increase in the
substantia nigra of patients with Parkinsons disease: an X-ray
microanalysis. J Neurochem. 1991;56:446-451.
35. Kasarskis EJ, Tandon L, et al. Aluminum, calcium, and iron in
the spinal cord of patients with sporadic amyotrophic lateral
sclerosis using laser microprobe mass spectroscopy: a preliminary study. J Neurol Sci. 1995;130:203-208.
46. Ackley DC, Yokel RA. Aluminum citrate is transported from

the brain via the monocarboxylic acid transporter located at
the blood-brain barrier. Toxicology. 1997;120:89-97.
47. Ruiz F, Alverez G, et al. Protection by pyruvate and malate
against glutamate-mediated neurotoxicity. Neuroreport.
1998;9:1277-1282.
48. Dickson DW, Sunhee CL, et al. Neuroimmunology of aging
and Alzheimers disease with emphasis on cytokines, In:
Ransohoff RM, Beneviste EN, eds. Cytokines and the CNS.
Boca Raton, Fla: CRC Press;1996:239-267.
49. Aisen PS, Davis KL. Inflammatory mechanisms in
Alzheimers disease: implications for therapy. Am J.
Psychiatry. 1994;151:1105-1113.
50. Murray CA, Lynch MA. Evidence that increased hippocampal
expression of the cytokine interleukin-1 is a common trigger
for age-related and stress-induced impairments in long-term
potentiation. J Neurosci.1998;18:2974-2981.
51. Prasad KN, Hovland AR, et al. Prostaglandins as putative neurotoxins in Alzheimers disease. Proc Soc Exp Biol Med.
1998;219:120-125.
52. Smith RG, Hamilton S, et al. Serum antibodies to L-type calcium channels in patients with amyotrophic lateral sclerosis. N
Engl J Med. 1992;327:1721-1728.
36.Yoshida S, Mitani K, et al. Bunina body formation in amyotrophic lateral sclerosis: a morphologic-statistical and trace
element study featuring aluminum. J Neurol Sci. 1995;30:8894.
53. Rogrove AD, Tsirka SE. Neurotoxic responses by microglia

elicited by excitotoxic injury in the mouse hippocampus. Curr
Biol. 1998;8:19-25.
37. Sarin S, Gupta KD. Alterations in lipid composition and neuronal injury in primates following chronic aluminum exposure. Biol Trace Elem Res. 1997; 58:133-143.
54. Sakhis S, Bruce A, et al. Induction of tumor suppressor p53

and DNA fragmentation in organotypic hippocampal cultures
following excitotoxin treatment. Ex Neurol. 1997;145:81-88.
38. Meglio L, Oteiza PI. Aluminum enhances melanin-induced

lipid peroxidation. Neurochem Res. 1999;24:1001-1008.
55. Nicholls DG, Budd SL. Mitochondria and neuronal glutamate

excitotoxicity. Biochem Biophys Acta. 1998;1366:97-112.
39. Julka D, Gill. Effect of aluminum on regional brain antioxidant

defense status in Wistar rats. Res Exp Med (Berl).
1996;196:187-194.
56. Sanchez-Carbente MR, Massieu L. Transient inhibition of glutamate uptake in vivo induces neurodegeneration when energy
metabolism is impaired. J Neurochem. 1999;72:129-138.
40. Shin RW. Interaction of aluminum with paired helical filament

tau is involved in neurofibrillary pathology of Alzheimers disease. Gerontology. 1997:43:16-23.
57. Heyes MP, Achim CL, et al. Human microglia convert L-tryptophan into the neurotoxin quinolinic acid. Biochem J. 320:595597,1996; Piani D, Frei K, et al. Murine brain macrophages
induce NMDA receptor mediated neurotoxicity in vitro by
secreting glutamate, Neurosci Lett. 1991;133:159-162.
41. Savory J, Huang Y, et al. Reversal by desferrioxamine of tau

protein aggregates following two days of treatment in aluminum-induced neurofibrillary degeneration in rabbit: implications for clinical trials in Alzheimers disease.
Neurotoxocology. 1998;19:209-214.
42. Deloncle R, Guillard O, et al. Modification of the blood-brain
barrier through chronic intoxication by aluminum glutamate.
Possible role in the etiology of Alzheimers disease. Biol Trace
Elem Res. 1995:47:227-233.
58. Lio Y, Hattori A, et al. Intrastriatal dopamine injection

induces apoptosis through oxidation-involved activation of
transcription factors AP-1 and NF-kappa B in rats. Mol
Pharmacol. 1999;56:254-264.
59. Downen M, Amaral TD, et al. Neuronal death in cytokineactivated primary human brain cell culture: role of tumor
necrosis factor-alpha. Glia. 1999;28:114-127.
Winter 2002
60. Popovic M, Caballero-Bleda M, et al. Importance of immunological and inflammatory processes in the pathogenesis and
therapy of Alzheimers disease. Intern J Neuroscience.
1998;95:203-236.
61. Eikelenboom P, Stam FC. Immunoglobulins and complement
factors in senile plaques: an immunochemical study. Acta
Neuropathol ( Berl). 1982;57:239-252.
62. Murphy T, Parikh A, et al. Arachidonic acid metabolism in
glutamate neurotoxicity. Ann NY Acad Sci. 1989;559:474-477.
ease is associated with genotype. J Neuropath Exp Neurol.

1998;57:415-425.
78. Jordan BD, Relkin NR, et al. Apolipoprotein E 4 associated
with chronic traumatic brain injury in boxing. JAMA.
1997;278:136-140.
79. Tamaoka A, Miyatake F, et al. Apolipoprotein E allele-dependent antioxidant activity in brains with Alzheimers disease.
Neurology. 2000;54:2319-2321.
63. Klergis A, McGeer PL. -amyloid protein enhances

macrophage production of oxygen free radicals and glutamate.
J Neurosci Res. 1997;49:229-235.
80. Bruce-Keller AJ, Li YJ, et al. 4-hydroxynonenal, a product of

lipid peroxidation, damages cholinergic neurons and impairs
visiospacial memory in rats. J Neuropath Exp Neurol.
1998;57:257-267.
64. Lal H, Forster MJ. Autoimmune mice as models for discovery

of drugs against age-related dementia. Drug Dev Res.
1991;24:1-27.
81. Yoritaka A, Hattori N, et al. Immunohistochemical detection

of 4-hydroxynonenal protein adducts in Parkinsons disease.
Proc Natl Acad Sci USA. 1996;93:2696-2701.
65. Levi B, Werman MJ. Long-term fructose consumption accelerates glycation and several age-related variables in male rats.
J Nutr. 1998;128:1442-1449.
82. Selly ML. (E)-4-hydroxy-2-nonenal may be involved in the

pathogenesis of Parkinsons disease. Free Radic Biol Med.
1998;25:169-174.
66. Castellani R, Smith MA, et al. Glycooxidation and oxidative

stress in Parkinsons disease and diffuse Lewy body disease.
Brain Res. 1996;737:195-200.
83.Vander Jagt DL, Hunsaker LA, et al. Inactivation of glutathione reductase by 4-hydroxynonenal and other endogenous aldehydes. Biochem Pharmacol. 1997;53:1133-1140.
67. Kato S, Horiuchi S, et al. Astrocytic hyaline inclusions contain

advanced glycation endproducts in familial amyotrophic lateral sclerosis with superoxide dismutase 1 gene mutation:
immunohistochemical and immunoelectron microscopical
analysis. Acta Neuropathol (Berl). 1999;97:260-266.
84.Terry RD, Mashiah E, et al. Physical basis of cognitive alteration in Alzheimers disease: synapse loss is the major correlate of cognitive impairment. Ann Neurol. 1991;30:572-580.
68. Much G, Gerlach M, et al. Advanced glycation end products

in neurodegeneration: more than early markers of oxidative
stress? Ann Neurol. 1998;44:(3 supp1):S85-S88.
85. Keller JN, Pang Z, et al. Impairment of glucose and glutamate

transport and induction of mitochondrial oxidative stress and
dysfunction in synaptosomes by amyloid beta-peptide: role of
lipid peroxidation product 4-hydroxynonenal. J Neurochem.
1997;69:273-284.
69. Balanos JP, Almeida A, et al. Nitric oxide-mediated mitochondrial damage in the brain: mechanisms and implications for
neurodegenerative diseases. J Neurochem. 1997;68:22272240.
86. Bu G, Maksymovitch EA, et al. Expression and function of the

low-density lipoprotein receptor-related protein (LPR) in
mammalian central neurons. J Biol Chem. 1994;269:1852118528.
70. Cassina R, Radi LC. Differential inhibitory action of nitric

oxide and peroxynitrite on mitochondrial electron transport.
Arch Biochem Biophysic. 1996;328:309-316.
87. Poirier J, Baccichet A, et al. Cholesterol synthesis and lipoprotein reuptake during synaptic remodeling in hippocampus in
adult rats. Neuroscience. 1993;55 81-90.
71. Siesjo BK. Brain Energy Metabolism. New York:: John Wiley
& Sons;1978:233-265.
88. Schroeter H, Williams RJ, et al. Phenolic antioxidants attenuate neuronal cell death following uptake of oxidized low-density lipoprotein. Free Radic Biol Med. 2000;29:1222-1233.
72. Smith MA, Richey Harris PL, et al. Widespread peroxynitritemediated damage in Alzheimers disease. J Neurosci. 1997;17:
2653-2657.
73. Smith MA, Harris PLR, et al. Widespread peroxynitrite-mediated damage in Alzheimers disease. J Neurosci.
1997;17:2653-2657.
74. Ando Y, Brannstrom T, et al. Histochemical detection of 4hydroxynonenal protein in Alzheimers amyloid. J Neurol Sci.
1998;156:172-176.
75. Markesbery WR, Lovell MA. Four-hydroxynonenal, a product
of lipid peroxidation, is increased in the brain in Alzheimers
disease. Neurobiol Aging. 1998;19:33-36.
76. Lovell MA, Ehman WD, et al. Elevated 4-hydroxynonenal in
ventricular fluid in Alzheimers disease. Neurobiol Aging.
1997;18:457-461.
77. Montine KS, Reich E, et al. Distribution of reducible 4hydroxynonenal adduct immunoreactivity in Alzheimers dis-
89. Keller JN, Hanni KB, Kindy MS. Oxidized high-density

lipoprotein induces neuron death. Exp Neurology.
2000;161:621-630.
90. Keller JN, Hanni KB, Markesbery WR. Oxidized low-density
lipoprotein induces neuronal death: implications for calcium,
reactive oxygen species, and caspases. J Neuochem.
1999;72:2601-2609 .
91. Keller JN, Hanni KB, et al. Opposing actions of native and
oxidized lipoprotein on motor neuron-like cells. Exp Neurol.
1999;157:201-210.
92. Dracynska-Lusiak B, Doung A, Sun AY. Oxidized lipoproteins
may play a role in neuronal cell death in Alzheimers disease.
Mol Chem Neuropathol. 1998;33:139-148.
93. Clarke R, Smith AD, et al. Folate, vitamin B12, and serum
total homocysteine levels in confirmed Alzheimers disease.
Arch Neurol. 55:1449-1455.
94. Lehmann M, Gottfries CG, Regland B. Identification of cog-
Winter 2002
nitive impairment in the elderly: homocysteine is an early

marker. Dement Geriatr Cogn Disord. 1999;10: 12-20.
protective efficacy of magnesium chloride. J Neurochem.

1999;73:271-280.
95. Flott-Rahmel B, Schurmann M, et al. Homocysteic and homocysteine sulphinic acid exhibit excitotoxicity in organotypic cultures from rat brain. Eur J Pediatr. 1998;157:(suppl):S112-S117.
112. Heath DL, Vink R. Neuroprotective effects of MgSO4 and

MgCl2 in closed head injury: a comparative phosphorus
NMR study. J Neurotrauma. 1998;15:183-189.
96. Joosten E, Lesafre E, et al. Is metabolic evidence for vitamin

B-12 and folate deficiency more frequent in elderly patients
with Alzheimers disease? J Gerontol A Biol Sci Med Sci.
1997;52:M76-M79.
113. Bar-Peled O, Ben-Hur H, et al. Distribution of glutamate

transporter subtypes during human brain development. J
Neurochem. 1997;69:2571-2580.
97. Carmel R, Gott PS, et al. The frequently low cobalamin levels
in dementia usually signify treatable metabolic, neurologic
and electrophysiologic abnormalities. Eur J Haematol.
1995;54: 245-253.
98. McCaddon A, Daves G, et al. Total homocysteine in senile
dementia of Alzheimer type. In J Geriatr Psychiatry.
1998;13:235-239.
99. Ravaglia G, Forti P, et al. Elevated plasma homocysteine levels in centenarians are not associated with cognitive impairment. Mech Aging Dev. 2001;121:251-261.
100. Kruman II, Culmsee C, et al. Homocysteine elicits a DNA
damage response in neurons that promotes apoptosis and
hypersensitivity to excitotoxicity. J Neurosci. 2000;20: 69206926.
101. Van Westerlaak MG, Joosten EA, et al. Chronic mitochondrial inhibition induces glutamate-mediated corticomotoneuron
death in an organotypic culture model. Exp Neurol.
2001;167:393-400.
102. Lagrange P, Romero IA, et al. Transendothelial permeability
changes induced by free radicals in an in vitro model of the
blood-brain barrier. Free Rad Biol Med. 1999;27:667-672.
103. Koenig H, Trout JJ, et al. Capillary NMDA receptors regulate
blood-brain barrier function and breakdown. Brain Res.
1992;588:297-303.
114. Rothstein JD, Martin LJ, Kuncl RW. Decreased glutamate

transport by the brain and spinal cord in amyotrophic lateral
sclerosis. N Engl J Med. 1992;326:1464-1468.
115. Li S, Mallory M, et al. Glutamate transporter alterations in
Alzheimers disease are possibly associated with abnormal
APP expression. J Neuropath Exp Neurol. 1997;56:901-911.
116. Berman SB, Hastings TG. Inhibition of glutamate transport
in synaptosomes by dopamine oxidation and reactive oxygen
species. J Neurochem. 1997;69:1185-1195.
117. Kort JJ. Impairment of excitatory amino acid transport in
astroglial cells infected with human immunodeficiency virus
type I AIDs. Res Human Retroviruses. 1998;14:1329-1339.
118. Trotti D, Rolfs A, et al. SOD1 mutants linked to amyotrophic lateral sclerosis selectively inactivate a glial glutamate
transporter. Nat Neurosci. 1999 2:427-433.
119. Tritti D, Danbolt NC, Volterra A. Glutamate transporters are
oxidant-vulnerable: a molecular link between oxidative and
excitotoxic neurodegeneration. TIPS. 1998;19:328-334.
120. Aschner M, Du YL, et al. Methylmercury-induced alterations
in excitatory amino acid transport in rat primary astrocyte
cultures. Brain Res. 1993;602:181-186.
121. Brooks N. Specificity and reversibility of the inhibition by
HgCl2 of glutamate transport in astrocyte cultures. J.
Neurochem. 1988;50:1117-1122.
104. Kalaria RN, Harik SI. Reduced glucose transporter at the

blood-brain barrier and in cerebral cortex in Alzheimer disease. J Neurochem. 1989;53:1083-1088.
122. Aposhian HV, Bruce DC, et al. Urinary mercury after administration of 2,3-dimercaptopropane 1-sulfonic acid: correlation with dental amalgam score. FASEB J. 1992;6: 24722476.
105. Schapira AHV, Cooper JM, et al. Mitochondrial Complex I deficiency in Parkinsons disease. J Neuorchem 1990;54:823-827.
123. Vimy MJ, Lorscheider FL. Intra-oral air mercury released

from dental amalgam. J Dental Res. 1985;64:1069-1071.
106. Parker WD, Filley CM, Parks JK. Cytochrome oxidase deficiency in Alzheimers disease. Neurology. 1990;40:1302-1303.
124. Bjorkman L, Lind B. Factors influencing mercury evaporation rates from dental amalgam fillings. Scand J Dental Res.
1992;100:354-360.
107. Beal MF, Hyman T, Koroshetz W. Do defects in mitochondrial energy metabolism underlie the pathology of neurodegenerative diseases. Trends Neurosci. 1993;16:125-131.
108. Glick JL. Dementias: the role of magnesium deficiency and
an hypothesis concerning the pathogenesis of Alzheimers
disease. Med Hypothesis. 1990;31:211-225.
109. Gunther T, Vormann J, Hollreigl V. Effects of magnesium and
iron on lipid peroxidation in cultured hepatocytes. Mol Cell
Biochem.1995;144:141-145.
110. Weglicki WB, Phillips TM, et al. Magnesium deficiency elevates circulating levels of inflammatory cytokines and
endothelin. Mol Cell Biochem. 1992;110: 169-173.
111. Bareyre FM, Saatman KE, et al. Alterations in ionized and
total blood magnesium after experimental traumatic brain
injury: relationship to neurobehavioral outcome and neuro-
125. Letz R, Gerr F, et al. Residual neurologic deficits 30 years

after occupational exposure to elemental mercury.
Neurotoxicology. 2000;21:459-474.
126. Bulat P, Dujic I, et al. Activity of glutathione peroxidase and
superoxide dismutase from workers occupationally exposed to
mercury: in Arch Occup Environ Health. 1998;71(suppl)S37S39.
127. Blanc EM, Keller JN, et al. 4-hydroxynonenal, a lipid peroxidation product, impairs glutamate transport in cortical astrocytes. Glia. 1998;22:149-160.
128. Blaylock R. Phytonutrients and metabolic stimulants as protection against neurodegeneration and excitotoxicity. JANA.
2000;2:30-39.
129. Zaman Z, Roche S, et al. Plasma concentration of vitamin A
Winter 2002
and E and carotenoids in Alzheimers disease. Age Aging.

1992;21:91-94.
130. Kobayashi MS, Han D, Packer L. Antioxidant and herbal
extracts protect HT-4 neuronal cells against glutamateinduced cytotoxicity. Free Radic Res. 2000;32:115-124.
131. Anderson RF, Amarasinghe G, et al. Reduction in free radical-induced DNA strand breaks and base damage through
fast chemical repair by flavonoids. Free Radic Res.
2000;33:91-103.
132. Haenen GR, Paguay JB, et al. Peroxynitrite scavenging by
flavonoids. Biochem Biophysic Res Comm. 1997; 236:591-593.
133. Paguay JB, Haenen CR, et al. Protection against nitric oxide
toxicity by tea. J Agri Food Chem. 2000;48:5768-5772.
134. Yoshida H, Ishikawa T, et al. Inhibitory effect of tea
flavonoids on the ability of cells to oxidize low density
lipoproteins. Biochem Pharmacol. 1999;58:1695-1703.
135. Rajakrishnan V, Viswanathan P, et al. Neuroprotective role of
curcumin from Curcuma longa on ethanol-induced brain
damage. Phytother Res. 1999;13:571-574.
136. Busse E, Zimmer G, et al. Influence of alpha lipoic acid on
intracellular glutathione in vitro and in vivo. ArzneimittelForschung. 1992;42:829-831.
137. Deiana M, Aruoma OI, et al. Inhibition of peroxynitrite
dependent DNA base modification and tyrosine nitration by
the extra virgin olive oil-derived antioxidant hydroxytyrosol.
Free radic Biol Med. 1999;26:726-769.
Am Coll Nutr. 1993;12:631-637.

147. Mohr D, Bowry VW, Sticker R. Dietary supplementation
with coenzyme Q10 results in increased levels of circulating
lipoproteins and increased resistance of human low-density
lipoproteins to the initiation of lipid peroxidation. Biochem
Biophys ACTA. 1992;1126:247- 253.
148. Leake DS. Effects of flavonoids on the oxidation of low-density lipoproteins. In: Rice-Evans CA, Packer L, eds.
Flavonoids in Health and Disease. NY: Marcel Dekker,
Inc;1998: 253-276.
149. Mullenix P, Denbesten PK, et al. Neurotoxicity of sodium
fluoride in rats. Neurotoxicology Teratology. 1995;17:169177.
150. Marshall K-A, Reist M, et al. The neuronal toxicity of sulfite
plus peroxynitrite is enhanced by glutathione depletion:
implications for Parkinsons disease. Free Radic Biol Med.
1999;27:515-520.
151. Reddy SK, Husain K, et al. Dose response of ethanol ingestion on antioxidant defense system in rat brain subcellular
fractions. Neurotoxicology. 1999;20:977-988.
152. Schoeter H, William RT, et al. Phenolic antioxidants attenuate
neuronal cell death following uptake of oxidized low-density
lipoproteins. Free Radic Biol Med. 2000;29:1222-1233.
153. Merrill JE, Benveniste EN. Cytokines in inflammatory brain
lesions: helpful and harmful. Trends Neurosci. 1996;19:331338.
138. Packer L. Prevention of free radical damage in the brain: protection by alpha-lipoic acid. In: Packer L, Hiramatsu M,
Yoshikawa T, eds. Free Radicals in Brain Physiology and
Disorders. NY: Academic Press;1996:19-34.
154. Pearson VL, Rothwell NJ, Toulmond S. Excitotoxic brain

damage in the rat induces interleukin-1beta protein in
microglia and astrocytes: correlation with the progression of
cell death. Glia. 1999;25:311-323.
139. Gotz ME, Dirr A, et al. Effect of lipoic acid on redox state of
coenzyme Q in mice treated with 1-methyl-4-phenyl-1,2,3,6tetrahydropyridine and diethyl dithiocarbamate. Eu J
Pharmacol. 1994;266:291-300.
155. Lim GP, Yang F, et al. Ibuprofen suppresses plaque pathology and inflammation in a mouse model for Alzheimers disease. J Neurosci. 2000;20:5709-5714.
140. Packer L. Prevention of Free radical damage in the brain:

Protection by alpha-lipoic acid. In: Packer L, Hiramatsu M,
Yoshikawa T, eds. free Radicals in Brain Physiology and
Disorders; NY: Academic Press;1996:19-34.
141. Handelman GJ, Han D, et al. Alpha-lipoic acid reduction by
mammalian cells to the dithol form, and release into the culture medium. Biochem Pharmacol. 1994;47:1725-1730.
142. Greenamyre JT, Garcia-Osuna M, et al. The endogenous
cofactors, thiotic acid and dihydrolipoic acid, are neuroprotective against NMDA and malonic acid lesions of striatum.
Neurosci Lett. 1994;171:17-20.
143. Reiter RJ, Tan D, et al. Actions of melatonin in the reduction
of oxidative stress: a review. J Biomed. 2000;7:444-458.
144. Iacobitti L, Stull ND, Johnston K. Melatonin rescues
dopamine neurons from cell death in tissue culture models of
oxidative stress. Brain Res. 1997;768:317-326.
145. Jialal I, Grundy SM. Effect of dietary supplementation with
alpha-tocopherol on the oxidative modification of low density lipoproteins. J Lipid Res. 1992;33:899-905.
146. Rifici VA, Khachadurian AK. Dietary supplementation with
vitamins C and E inhibits in vitro oxidation of lipoproteins. J
Winter 2002
156. Jobin C, Bradham CA, et al. Curcumin blocks cytokinemediated NF-kappa-B activation and proinflammatory gene
expression by inhibiting inhibitory factor I-kappa B kinase
activity. J Immunol. 1999;163:3474-3483.
157. Sato M, Miyazaki T, et al. Quercetin, a bioflavonoid, inhibits
the induction of interleukin 8 monocyte chemoattractant protein-1 expression by tumor necrosis factor alpha in cultured
human synovial cells. J Rheumatol. 1997;24: 1680-1684.
158. Habtenariam S. Flavonoids as inhibitors or enhancers of the
cytotoxicity of tumor necrosis factor-alpha in L-929 cells. J
Nat Prod. 1997;60:775-778.
159. Meerarani P, Ramadass P, et al. Zinc protects against apoptosis of endothelial cells induced by linoleic acid and tumor
necrosis factor alpha. Am J Clin Nutr. 2000;71:81-87.
160. Grill M, Memo M. Nuclear factor-kappaB/Rel proteins: a
point of convergence of signaling pathways relevant in neuronal function and dysfunction. Biochem Pharmacol.
1999;57:1-7.
161. Tordera M, Ferrandiz ML, Alcaraz MJ. Influence of antiinflammatory flavonoids on degranulation and arachidonic acid
release in rat neutrophils. Z Natuforsch. 1994;49:235-240.
162. Liang YC, Huang YT, et al. Suppression of inducible
cyclooxygenase and inducible nitric oxide synthease by api-
genin and related flavonoids in mouse macrophages.

Carcinogenesis. 1999;20:1945-1952.
1994;(suppl 2): A177.

179. Bano S and Parihar MS. Reduction of lipid peroxidation in
different brain regions by a combination of alpha-tocopherol
and ascorbic acid. J Neural Trans. 1997;104: 1277-1286.
163. Liang YC, Huang YT, et al. Suppression of inducible

cyclooxygenase and inducible nitric oxide synthease by apigenin and related flavonoids in mouse macrophages.
Carcinogenesis. 1999;20:1945-1952.
180. Horrocks LA, Yeo YK. Health benefits of docosahexaenoic

acid (DHA). Pharmacol Res. 1999;40: 211-225.
164. Kang BY, Chung SW, et al. Inhibition of interleukin-12 production in lipopolysacchride-activated macrophages by curcumin. Eur J Pharmacol. 1999;19:191-195.
181. Simopoulos AP. Omega-3 fatty acids in health and disease

and in growth and development. Am J Clin Nutr.
1991;54:438-463.
165. Jayadeep VR, Arun OS, et al. Changes in prostaglandin levels in alcohol toxicity: effect of curcumin and N-acetylcysteine. J Nutr Biochem. 2000;11:509-514.
182. James MJ, Gibson RA, Cleland LG. Dietary polyunsaturated

fatty acids and inflammatory mediator production. Am J Clin
Nutr. 2000;71(suppl):343S-348S.
166. Agarwal R, Diwanay S, et al. Studies on immunomodulatory activity of Withania somifera (Ashwagandha) extracts in
experimental immune inflammation. J Ethnopharmacol.
1999;67:27-35.
183. Fekkes D, van der Cammen TJ, et al. Abnormal amino acid
metabolism in patients with early stage Alzheimers disease.
J Neural Transm. 1998;105: 287-294.
167. Beal MF, Hyman BT, et al. Do energy deficits in mitochondrial energy metabolism underlie the pathology of neurodegenerative diseases? Trends Neurosci. 1993;16:125-131.
168. Ruiz F, Alverez G, et al. Protection by pyruvate and malate
against glutamate mediated neurotoxicity. Neuroreport.
1998;9:1277-1282.
184. Holopainen I, Kontro P, Oja SS. Release of taurine from cultured cerebellar granule cells and astrocytes: co-release with
glutamate. Neuroscience. 1989;29:425-432.
185. Morrison LD, Smith DD, Kish SJ. Brain S-adenosylmethionine levels are severely decreased in Alzheimers disease. J
Neurochem. 1996;67:1328-1331.
169. Brustovetsky N, Brustovetsky T, Dubinsky JM. On the

mechanism of neuroprotection by creatine and phosphocreatine. J Neurochem. 2001;76:425-434.
186. Joosten E, Lesaffre E, et al. Is metabolic evidence for vitamin B-12 and folate deficiency more frequent in elderly
patients with Alzheimers disease. J Gerontol A Biol Sci Med
Sci. 1997;52:M76-M79.
170. Calvani M, Koverech A, Caruso G. Treatment of

Mitochondrial Diseases. In: DiMauro S, Wallace DC, eds.
Mitochondrial DNA in Human Pathology. NY: Raven Press;
1993;173-198.
187. Mayeaux R, Denaro J, et al. A population-based investigation

of Parkinsons disease with and without dementia.
Relationship to age and gender. Arch Neurol. 1992;49:492497.
171. Hagen TM, Ingersoll RT, et al. Acetyl-L-cartinine fed to old

rats partially restores mitochondrial function and ambulatory activity. Proc Natl Acad Sci USA. 1998;95:9562-9566.
188. Leranth C, Roth RH, et al. Estrogen is essential for maintaining nigrostriatal dopamine neurons in primates: implications for Parkinsons disease and memory. J Neurosci.
2000;8604-8609.
172. Ingersoll RT, Hagen TM, et al. (R) alpha-lipoic acid-supplemented old rats have improved mitochondrial function,
decreased oxidative damage and increased metabolic rate.
FASEB J. 1999;13:411-418.
173. Kiluchi K, et al. Protective effects of methylcobalamin, a vitamin B12 analog, against glutamate-induced neurotoxicity
in retinal cell culture. Invest Opthalmol Vis Sci.
1997;38:848-851.
189. Inestrosa NC, Marzolo MP, Bonnefont AB. Cellular and molecular basis of estrogens neuroprotection. Potential relevance for Alzheimers disease. Mol Neurobiol.1998;17:7386.
190. Trieu VN, Uckun FM. Genistein is neuroprotective in murine
models of familial amyotrophic lateral sclerosis and stroke.
Biochem Biophys Res Commun. 1999;258:685-688.
174. Rohdewald P. Pycnogenol. In: Rice-Evans CA, Packer L.

eds,. Flavonoids in Health and Disease. NY: Marcel Dekker
Inc;1998;405-436.
191. Mulnard RA, Cotman CW, et al. Estrogen replacement therapy for treatment of mild to moderate Alzheimers disease: a
randomized controlled trial. JAMA. 2000;283:1007-1215.
175. Bonoczk P, Gulyas B, et al. Role of sodium channel inhibition in neuroprotection: effect of vinpocetine. Brain Res
Bull. 2000;53:245-254.
192. Pan Y, Anthony M, Clarikson TB. Evidence for up-regulation

of brain-derived neurotrophic factor mRNA by soy phytoestrogens in the frontal cortex of retired breeder female rats.
Neurosci Lett. 1999;262:17-20.
176. Brewer LD, Thiabault V, et al. Vitamin D hormone confers

neuroprotection in parallel with downregulation of L-type
calcium channel expression in hippocampal neurons. J
Neurosci. 2001;21:98-108.
177. Skaper SD, Facci L, et al. Potentiation by histamine of
synaptically mediated excitotoxicity in cultured hippocampal neurons: a possible role for mast cells. J Neurochem.
2001;76:47-55.
178. Beal MF. Coenzyme Q10 and niacinamide are neuroprotective against mitochondrial toxins in vivo. Neurology.
193. Kaasik A, Kalda A, et al. Dehydroepiandrosterone sulphate

prevents oxygen-glucose deprivation-induced injury in cerebellar granule cell culture. Neurosci. 2001;102:427-432.
194. Mao X, Barger SW. Neuroprotection by dehydroepiandrosterone-sulphate: role of an NF KappaB-like factor.
Neuroreport. 1998;9:759-763.
195. Guth L, Zhang Z, Roberts E. Key role for pregnenolone in
combination therapy that promotes recovery after spinal cord
Winter 2002
injury. Proc Nat Acad Sci USA. 1994;91:12308-12312.

196. Roberts E. Pregnenolone-from Seyle to Alzheimer and a
model of the pregnenolone sulfate binding site on GABA
receptor. Biochem Pharmacol. 1995;49:1-16.
197. Gouras GK, Xu H, et al. Testosterone reduces neuronal secretion of Alzheimers -amyloid peptides. PNAS.
2000;97:1202-1205.
198. Ayoub IA, Lee EJ, et al. Nicotinamide reduces infarction up
to two hours after the onset of permanent focal cerebral
ischemia in Wistar rats. Neurosci Lett. 1999;259:21-24.
199. Reb C, Klein J. Enhancement of brain choline levels by
nicotinamide: mechanism of action. Neurosci Lett.
1998;249:111-114.
200. Mukherjee SK, Adams JD Jr. The effects of aging and neurodegeneration on apoptosis-associated DNA fragmentation
and the benefits of nicotinamide. Mol Chem Neuropathol.
1997;32:59-74.
212. Adachi T, Ischido M, Kunimoto M. Studies in protective factors for cell death of cerebellar neurons induced by
methylmercury. Neurotoxicol. 2000;21:615-640.
213. Hibberd AR, Howard MA, Hunnisett AG. Mercury from
dental amalgam fillings: studies on oral chelating agents for
assessing and reducing burdens in humans. J Nutr Environ
Med. 1998;8:219-231.
214. Lee JH, Kang HS, Roh J. Protective effects of garlic juice
against embryotoxicity of methylmercuric chloride administered to pregnant Fischer 344 rats. Yonsei Med J.
1999;40:483-489.
215. Seppanen K, Kantola M, et al. Effect of supplementation
with organic selenium on mercury status as measured by
mercury in pubic hair. J Trace Elem Med Biol. 2000;14:8487.
216. Packer L, Witt EH, Tritschler HJ. Alpha-lipoic acid as a biological antioxidant. Free Radic Biol Med. 1995;19:227-250.
201. Riviere S, Birlouez-Aragon I, et al. Low plasma vitamin C in

Alzheimer patients despite an adequate diet. Int J Geriatr
Psychiatry. 1998;13:749-754.
217. B M, McGahon, Martin DSD, et al. Age-related changes in

LTP and antioxidant defenses are reversed by an alpha-lipoic
acid-enriched diet. Neurobiol Aging. 1999;20: 655-664.
202. Le Bars PL, Latz MM, et al. A placebo-controlled, doubleblind, randomized trial of an extract of Ginkgo biloba for
dementia. JAMA. 1997;278:1327-1332.
218. Olivieri G, Brack CH, et al. Mercury induces cell cytotoxicity and oxidative stress and increases -amyloid secretion
and tau phosphorylation in SHSY5Y neuroblastoma cells. J
Neurochem. 2000;74:231-236.
203. Kanowski S, Herrmann WM, et al. Proof of efficacy of the

Ginkgo biloba special extract EGb 761 in outpatients suffering from mild to moderate primary degenerative dementia of
the Alzheimers type or multi-infarct dementia.
Pharmacopsychiat. 1996;29:47-56.
204. Wesnes KA, Ward T, et al. The memory enhancing effect of
a Ginkgo biloba/Panax ginseng combination in healthy middle-aged volunteers. Psychopharmacology (Berl).
2000;152:353-361.
205. Klein J, Chatterjee SS, Loffelholz K. Phospholipid breakdown and choline release under hypoxic conditions: inhibition by bilobalide, a constituent of Ginkgo biloba. Brain Res.
1997;755:347-350.
219. Sorg O, Schilter B, et al. Increased vulnerability of neurones

and glial cells to low concentrations of methylmercury in a
prooxidant situation. Acta Neuropathol (Berl). 1998;96:621627.
220. el-Fawal HA, Gong Z, et al. Exposure to methylmercury
results in serum autoantibodies to neurotypic and gliotypic
proteins. Neurotoxicology. 1996;17:531-539.
221. Charleston JS, Body RL, et al. Changes in the number of astrocytes and microglia in the thalamus of the monkey Macaca
fascicularis following long-term subclinical methylmercury
exposure. Neurotoxicology. 1996;17:127-138.
206. Brailowsky S, Montiel T. Motor function in young and aged

hemiplegic rats: effects of Ginkgo biloba extract. Neurobiol
Aging. 1997;18:219-227.
207. Kim YC, Kim SR, et al. Ginsenosides Rb1 and Rg3 protect
cultured rat cortical cells from glutamate-induced neurodegeneration. J Neurosci Res. 1998;53:426-432.
208. Salim KN, McEwen BS, Chao HM. Ginsenoside Rb1 regulates ChAT, NGF and trKA mRNA expression in the rat
brain. Brain Res Mol Brain Res. 1997;47:177-182.
209. Yamaguchi Y, Higashi M, Kobauashi H. Effects of ginsengosides on maze performance and brain choline acetyltransferase activity in scopalamine-treated young rats. Eur J
Pharmacol. 1997;18:37-41.
210. Herrero MT, Perez-Otano I, et al. GM-1 ganglioside promotes
the recovery of surviving midbrain dopaminergic neurons in
MPTP-treated monkeys. Neuroscience. 1993;56:965-972.
211. Oliveira AL, Langone F. GM-1 ganglioside treatment reduces
motorneuron death after ventral root avulsion in adult arts.
Neurosci Lett. 2000;293:131-134.
Winter 2002
E V I E W
R T I C L E
Breast Cancer, Hormone Replacement

Therapy (HRT), and Diet
Gina L. Nick, PhD, ND, Longevity Through Prevention, Inc., Brookfield, Wisconsin
Breast cancer is second only to lung cancer as the most

common cause of cancer mortality in women in the United
States. Further, in 2000 alone, there were a predicted
182,000 new cases of breast cancer diagnosed and 40,800
associated female deaths in the U.S. as a result of this disease.1 A womans chance of developing breast cancer significantly increases with age (Table 1). As a woman ages,
she will naturally approach menopause and the cessation of
ovarian function, increasing her chances of taking hormone
replacement therapy (HRT) to reduce symptoms commonly
associated with menopause and to prevent the onset of heart
disease. Disturbingly, HRT also increases a womans risk of
breast cancer, sometimes by more than 50%.2-6
Two small studies, not adequately controlled for confounding variables, showed some promise that combined
Table 1. A womans chance of developing breast cancer significantly increases with age.7
Age
By 30
By 40
By 50
By 60
By 70
By 80
By 90
Chance of developing breast cancer

1 out of 2,212
1 out of 235
1 out of 54
1 out of 23
1 out of 14
1 out of 10
1 out of 8
* Correspondence:
Gina L. Nick, PhD, ND
Longevity Through Prevention, Inc.
PO Box 627
Brookfield, WI 53008
Phone: (866) 587- 4622 Fax: (262) 569-9571
E-mail: drgina@ltponline.com
HRT was protective against breast cancer risk.8,9 The much

larger Nurses Health Study10 was one of the first studies to
provide reliable data that showed that combined therapy
actually increases a womans risk of breast cancer! Persson
et al. studied the risk of breast and endometrial cancer in a
cohort of 11,231 Swedish women prescribed different
replacement hormone regimens and concluded that longterm recent use of estrogen-progestin combined replacement therapy may increase the risk of breast cancer.11
Further, they concluded that exposure to estrogen alone
substantially elevates the risk of endometrial cancer, an
increase that can be reduced or perhaps avoided by adding
progestins. Remarkably, this study found that for 6 or more
years of current or recent use of combined HRT, a womans
risk of breast cancer is increased by 70% as compared to
the risk associated with estrogen alone, RR = 4.2 (95% CI
2.5-8.4). Considering the fact that in December of 2001 a
study of more than 200,000 women was published in the
Journal of the American Medical Association12 that found
that those women who used estrogen replacement therapy
(ERT) for a decade or longer also had at least a 51 percent
greater chance of dying from ovarian cancer, and that the
risk persisted for 29 years after cessation of use, these findings may leave a woman concerned about the impact of
HRT on long-term health. While ERT is a regimen that was
for the most part discontinued in the late 1970s, one wonders if, 30 years from now, other risks associated with HRT
may surface from the research. The results of an HRT and
breast cancer study published in the Journal of the
American Medical Association13 in 2000 provide further
confirmation of the breast cancer risk associated with
menopausal estrogen and estrogen-progestin replacement
therapy. While HRT appears to increase breast cancer risk,
there is evidence suggesting that diet, particularly the use of
unprocessed whole foods and herbs, meaning those natural
raw materials that have not been fractionated to isolate
and/or potentate one or several compounds, and the use of
Winter 2002
a calorie restricted diet, may play a role in diminishing

breast cancer risk. This paper represents a review of evidence supporting this notion.
DIET AND BREAST CANCER
Migration studies have shown that people who move
from geographical areas with low breast cancer risk to areas
with high risk acquire the breast cancer rate of the host country within two generations, and the breast cancer rates are
steadily rising in countries with previously low rates.14 These
results suggest that environmental factors, most likely dietary
patterns, play a major role in breast cancer etiology.
Analysis of an Italian case-control study conducted

from 1991-1994 by Favero et al. on a large sample of
women (2,569 women with breast cancer and 2,588 controls) on dietary factors affecting breast cancer risk
revealed direct associations between risk and consumption
of such foods as bread and cereals, sugar and candy, and
pork and processed meats, but inverse associations with the
intake of raw vegetables and fish (Table 2).15 However,
cooked vegetables, fruit, and red meat were among the
foods that did not seem to have an effect on risk.
Starch, saturated fat, and alcohol were significantly
and positively associated with cancer risk while unsaturated fat was inversely associated. Interestingly, olive oil
Table 2. Odds ratios (OR) of breast cancer among 2,569 cases and 2,588 controls by intake quintile of selected food groups.
Italian (Favero) study, 1991-1994.15
Reference category
Winter 2002
Chi-square test
Safflower, maize, peanut, or soya.

showed a protective effect but did not show statistical significance. Beta-carotene, vitamin E, and calcium-rich foods
are inversely correlated with risk of breast cancer when
controlled for overall energy intake and confounding
intakes of other micronutrients (Table 3).
In Italy, pasta and bread comprise a large percentage of
the dietary starch and energy, and it is often in the form of
very refined grain products.15 Processed meats are quite
common in the Italian diet as prosciutto, salami, and
sausage, and these were found to be particularly detrimental with regard to breast cancer risk.
Seed oils and fish in the diet correspond to significantly decreased cancer risk. These foods are especially high in
omega-3 fatty acids, supporting growing evidence that this
type of fat bestows protection from breast cancer.
Raw vegetables are an important source of dietary fiber
and may decrease cancer risk by helping to curb caloric
(energy) intake.
The Favero study took into account strong intercorrelations between various macronutrients in the diet, sometimes
neglected in other studies. It emphasized a whole food
approach by examining not just isolated macronutrients, but
macronutrients within a dietary framework. For example,
they found in their sample that starch intake correlated negatively with saturated fat intake. This is an interaction that
may influence risk. Polyunsaturated fat intake was strongly
positively correlated with raw vegetable intake and both of
these factors together lower breast cancer risk. Interestingly,
the inverse relationship of breast cancer risk to calcium
intake was very strong and is supported by several case control studies.16,17 There was also a high correlation between
starch and energy intake (Pearson r=0.80). In general, the
researchers concluded that energy intake may be related to

cancer risk by increasing oxidative metabolism and free
radical generation in the body. In keeping in line with a free
radical metabolic hypothesis of cancer initiation, dietary
restriction may offer a means of reducing cancer risk.
DIETARY RESTRICTION AND CANCER
Caloric restriction without malnutrition (cutting daily
caloric intake by 30-50% while maintaining a nutritionally
balanced diet) is the only proven method to date that slows
the human aging process and extends lifespan, while
improving health and well-being.18 Researchers have been
stating this once theoretical notion as fact for well over 60
years.19-21 While human trials are lacking to support the
connection between breast cancer risk and the use of a calorie restricted diet, particularly those that address confounding variables such as ethnicity, BMI, exercise habits, and
specific BRCA mutations, the available relevant data does
offer some groundwork upon which future researchers may
build a greater understanding of this method.
POSSIBLE MECHANISMS OF ACTION
Dietary restriction reduces the number of reactive oxidant molecules in the body.19,22 While numerous mechanisms have been proposed for the observed long-term
health benefits of caloric restriction,21-24 the free radical
theory is the most widely accepted. Dietary restriction
modulates many key aspects of free radical metabolism,
including free radical generation, lipid peroxidation, DNA
damage, and cytosolic cellular defense systems.22 This theory offers a solid explanation for the following biochemical
and physiologic phenomena:25
Table 3. Odds ratios (OR) of breast cancer among 2,569 cases and 2,588 controls by intake quintile of selected micronutrients. Italian (Favero) study, 1991-1994.15
Reference category
Chi-square test
Winter 2002
The inverse relationship between basal metabolic rate and

average lifespan in mammals
The connection between increased incidences of degenerative diseases in the latter part of life, and the cumulative
effects of oxidative damage over time
The demonstrated health benefits of dietary restriction
Greater longevity of females
The increase in autoimmune dysfunctions with age
DIETARY RESTRICTION AND FREE RADICALS
In diet restricted rats, free radical damage as measured
by thiobarbituric acid-reactive material and lipofuscin accumulation in the liver was much lower than in rats fed ad
libitum.26 In liver tissue, the expression of superoxide dismutase and catalase typically decrease with age in ad libitum fed rats. However, in diet restricted rats these antioxidant enzymes were significantly elevated even at 21 and 28
months of age. Glutathione peroxidase was also elevated at
28 months of age. This result has been supported by additional research27,28 in which glutathione reductase, glutathione S-transferase, and catalase enzyme activities were
essentially unchanged in diet restricted rats at 24 months,
while the levels in ad libitum fed rats steadily declined from
12 to 24 months of age. These studies suggest that the beneficial effects of dietary restriction result from the preservation of antioxidant enzyme activity in animals.
Some researchers argue that dietary restriction inhibits
the generation of oxidative molecules and does not directly
affect antioxidant enzyme levels. Gong et al.,29 reported an
apparent reduction in antioxidant enzyme activity in rat lens
and kidney in response to dietary restriction, presumably
due to a decrease in substrate molecules. Dietary restriction
at various ages in the rat decreases the formation of superoxide and hydroxyl radicals, and hydrogen peroxide in liver
microsomes.30 Additionally, mitochondrial resting respiratory rates in brain, heart, and kidney tissues remain constant
with age in diet restricted rats while they progressively rise
in controls, with a corresponding increase in superoxide
radical and hydrogen peroxide generation in the latter.31
This result supports the mitochondrial hypothesis in that
dietary restriction successfully maintained the resting respiratory rate, showing that this method keeps the mitochondria functioning more efficiently over time.
Unmistakably, dietary restriction offers substantial
health benefits due to its effect on modulating the production and metabolism of reactive oxygen species, or free radicals. Supplementing the restricted diet with powdered vacuum or freeze-dried vegetables and fruits that are naturally
rich in antioxidants may provide additional health benefits.
Epidemiological and clinical studies have revealed roles for
antioxidants in the reduction of risk from cancer.32
of experimental mammary cancer in rats. The researchers

found that caloric restriction correlated linearly with prolongation of latency to palpable carcinomas and a reduction
in final incidence of mammary cancer. This experimental
case may validate the potential use of caloric restriction to
inhibit the conversion of precancerous cells to malignant
cells. Caloric restriction also correlated with an increase in
cortical steroid levels that explained 95% of the linear relationship between cancer and dietary restriction. Thus,
dietary restriction may offer some chemoprotection by normalizing adrenal function.
DIETARY RESTRICTION AND HUMANS
A clinical study on the effects of dietary restriction
was performed on four men and four women housed in
Biosphere 2, a closed ecological space of 7 million cubic
feet near Tucson, Arizona.34 As a result of poor food
yields, the inhabitants of the biosphere consumed a lowcalorie but nutrient dense diet for their two-year stay in the
habitat. The men and women showed 18% and 10% weight
loss, respectively. Further, the researchers measured blood
lipids, glucose, insulin, glycosylated hemoglobin and renin
in blood samples collected at several points during and
after the two year period.
The nature of the largely vegetarian diet, with a high
essential nutrient content per calorie, resembled that which
retards aging, extends lifespan, and reduces age-related disease incidence in animals.35 Thus, Biosphere 2 offers an
opportunity to study caloric restriction in humans under carefully monitored conditions and warrants deeper investigation.
The inhabitants of Biosphere 2 were all nonsmokers in
good health. During the study each received three meals per
day, and even though available food was less than expected, each received equal portions regardless of body size or
gender. All of the inhabitants remained in excellent health
throughout the two years, with the exception of minor ailments. The weight lost while in the biosphere was fully
regained by six months after the end of the experiment and
return to ad libitum diet.
Glucose, insulin, and glycated hemoglobin levels in the
inhabitants all significantly decreased inside Biosphere 2.
It is important to note that Biosphere 2 crew members
were calorie restricted but well supplied with all essential
nutrients, so they were truly experiencing caloric restriction
without malnutrition. Additionally, the crew members performed extensive physical and mental labor throughout the
two years, which may have contributed to their good health.
This is the first study of caloric restriction in humans
that can be compared in any meaningful way with corresponding observations in rodents and primates.35,36
Introducing the possible connection between breast

cancer and caloric restriction, Zhu et al.33 conducted a study
Winter 2002
UNFRACTIONATED FRUITS AND VEGETABLES

(WHOLE FOODS) VS. SUPPLEMENTAL ISOLATES
In premenopausal women, a diet high in fruits and vegetables appears to be protective against breast cancer, especially if rich in specific carotenoids and vitamins.37 The protection is not bestowed by any single anticarcinogenic compound but appears to be a combined effect of numerous
beneficial antioxidants and nutrients. Dietary antioxidants
have been shown to protect against breast and several other
cancer types. These antioxidants probably act by scavenging free radicals and quenching lipid peroxidation reactions,
thus protecting cells from oxidative stress and damage.
However, a large-scale study of 83,234 women examining
the diet/cancer relationship found no association between
cancer risk and dietary intake of vitamins C and E, a result
supported by other studies.38-40 A recent study has suggested that vitamin C may be potentially carcinogenic by precipitating formation of lipid hydroperoxides that generate
genotoxins,21 thus negating any radical scavenging activity.
On the other hand, an inverse correlation between diet and
risk of breast cancer has been found for carotenoids, vitamin A, lutein/zeaxanthin, and combined fruit and vegetable
intake, with the strongest relationships in premenopausal
women. These dietary factors had no apparent effect on risk
in postmenopausal women.14
While a high intake of fruits and vegetables correlates
with decreased breast cancer risk, supplements of vitamins
A, C, and E, and multivitamins were not associated with
overall risk, supporting a whole food philosophy.14 Fruits
and vegetables contain numerous tertiary, non-nutritive
compounds including isoflavones, dithiolthiones, indoles,
flavonoids, and phenols, all of which have proposed mechanisms of action and relative sites along the normal to
abnormal cell transformation pathways that inhibit carcinogenesis and provide chemoprotection (Figure 1).
In addition, a diet high in fruits and vegetables reflects
an overall healthier lifestyle and dietary pattern correlating
with lower intake of saturated fat, less smoking, and more

physical exercise.
XENOESTROGENS AND BREAST CANCER
Xenoestrogens are environmental compounds with estrogen-like activity that may cause hormone-related cancer in
some individuals. Chlorinated pesticides, such as DDT and
its metabolite DDE are examples of such compounds which
have been linked to increased incidence of breast cancer,4345 although other studies have found no link between
breast cancer and serum levels of pesticides.46-51 For example, Wolff et al.45 found that elevated levels of DDE and
polychlorinated biphenyls (PCB) in the serum can result in
a four-fold increased risk of breast cancer, while Krieger et
al.46 found no difference in serum levels of DDE and PCB
in their prospective cohort study of 300 women.
Interestingly, Kreigers group did find that when the subjects were divided into racial subgroups, a risk was noticeable between black women and DDE levels. This association was further verified by Schildkraut et al.52 who investigated the effect of body mass index (BMIdiscussed
briefly in the latter part of this paper) on plasma levels of
DDE in black and white women. Results of multiple
regression analyses indicated that black women did indeed
have significantly higher plasma levels of DDE than white
women. BMI was also found to be an independent predictor of DDE plasma levels in white and African-American
women. Because the prevalence of obesity is higher among
black women than white women, it may be possible that
greater degrees of adiposity increase the bodys capacity to
accumulate lipophilic contaminants such as DDT. Ethnic
differences should certainly be considered in future studies
examining the relationship between DDT, BMI and breast
cancer risk. Until this occurs, and despite conflicting evidence regarding the links between xenoestrogens and breast
cancer, it may be a good idea for women consuming large
amounts of fruits and vegetables for breast cancer preven-
Figure 1. The potential mechanisms and sites for the inhibition of carcinogenesis by protective tertiary compounds found
within a whole food matrix.42
Winter 2002
tion, to consider eating pesticide-free, certified organic produce whenever possible.
Table 4. Odds ratios (OR) of breast cancer among 2,569

cases and 2,588 controls according to body mass index by
menopausal status. Italian study, 1991-1994.15
BEEF AND PORK CONSUMPTION, OXIDATIVE

DNA DAMAGE, AND BREAST CANCER
BMI
(kg/m2)
NASA recognizes 5-hydroxymethyluracil as a biochemical marker of oxidative DNA damage that is positively associated with breast cancer risk (personal communication with NASA scientists at the Johnson Space Center
Nutritional Biochemistry Laboratory). Djuric et al.53 measured serum levels of 5-hydroxymethyluracil in 21 healthy
outpatient women with a first-degree relative with breast
cancer. The women were assigned randomly to a low fat
(N=9) or non-intervention (N=12) diet for 3-24 months. Diet
data were obtained from 3-day food diaries. The researchers
examined meat consumption by type (pork, beef, fish, or
poultry) and by cooking temperature. They also examined
intakes of either cooked or raw vegetables, respectively.
< 21.7
21.7-23.7
23.8-25.7
25.8-28.8
28.9
P
Intake of cooked vegetables and the sum of beef and pork

intake explained the greatest variation (85%) in DNA damage
marker levels induced by diet. The preliminary results of this
study suggest a positive association between levels of serum
5-hydroxymethyluracil and beef and pork intake, and a negative association with cooked vegetable intake.
Any model of breast cancer risk must take into account
the complex interaction of covariables, including BMI, hormone levels, composition of fatty tissue, hormone receptor
status, menopausal status, diet, and physical activity.
COMPOSITION OF FATTY TISSUE
In menopause, female steroid hormones are generated
in fatty tissue by aromatase. The increased risk of breast cancer in overweight, menopausal women may have to do with
elevated conversion of androgens to estrogens in fatty tissue.
Estrogens then may stimulate mitotic activity in breast tissue
leading to abnormal cell growth. Obesity also increases
insulin levels and insulin resistance and decreases sex hormone binding globulin (SHBG) levels, all factors that influence risk.54 Insulin can increase proliferative activity of the
breast epithelium. Thus, the mechanism may involve the
interaction of diet with endogenous and exogenous estrogens, androgens, and glucose metabolic substances. If overweight is a major factor in postmenopausal breast cancer
risk, weight reduction through caloric restriction, exercise,
and nutritional supplementation may prove therapeutic.
SHBG levels increase with weight loss, sometimes to levels
higher than in healthy, non-obese, menopausal controls,
offering significant protection from unopposed estrogen.54
GENETIC CONSIDERATIONS
Genetic factors are an immutable risk factor and a history of familial breast cancer may modify associations
Winter 2002
Premenopausal OR
11
0.93 (0.7-1.2)
0.85 (0.6-1.1)
0.89 (0.6-1.2)
0.67 (0.5-0.9)
<0.05
Postmenopausal OR
11
1.00 (0.8-1.3)
1.07 (0.8-1.4)
1.21 (1.0-1.5)
1.39 (1.1-1.8)
<0.01
Reference category
between diet and breast cancer in premenopausal

women.15 Nonetheless, lifestyle is not immutable and can
be beneficially modified.54 Diets high in fruits and vegetables rely on an interaction of many variables for their
chemoprotective effects and are probably beneficial
regardless of genetic factors.
BODY MASS INDEX (BMI) AND BREAST CANCER
Body mass index (BMI) has been inversely correlated
with premenopausal breast cancer risk but positively correlated with postmenopausal risk, a finding supported elsewhere (Table 4).54,15
Maintaining a healthy body weight reduces the risk of
many cancers in women, particularly breast and uterine.55
So-called apple-shaped women (those with adipose tissue
around the waist and stomach) are 34% more likely to develop breast cancer than pear-shaped women (those with adipose tissue around the hips and thighs) after menopause,
especially if they have never taken hormone replacement
therapy. Body shape does not appear to affect risk in premenopausal women, however.54 Women who gain significant
weight in adulthood (after age 30) are more likely to develop uterine (endometrial) cancer and postmenopausal weight
loss is suggested to decrease the risk.54,55
Height, weight, BMI, and shape all seem to play a role
in breast cancer development. For all age groups, height is
found to correlate positively with breast cancer risk.
Population studies in Europe have shown that height and
age at the first term pregnancy describe almost 80% of the
total variation in breast cancer incidence. Conversely, BMI
is negatively associated with risk in premenopausal women
but positively associated in postmenopausal women. A possible confound to these results is that height is positively
associated with osteoporosis in weight-bearing bones for
which estrogen supplementation often is recommended in
postmenopause. Thus, as height increases, so does the tendency for estrogen supplementation, which increases the
risk for estrogen-sensitive breast cancer.54
Nutrition during periods of rapid growth (childhood

and puberty) seems to be an important factor for final
height. As a result, height may only be a proxy variable of
nutritional status during the years of growth with the latter
being the true risk factor for breast cancer.54 Indeed, energy
intake in childhood has been associated with the development of cancers later in life.56 This would also support
caloric restriction research suggesting that reduced caloric
intake lengthens the time to onset of some disease states.57
Figure 2 Effects of isoflavones (10 mM) on T-47D breast

cancer cell growth after 72 hr incubation.59
The age at menarche is related to childhood nutritional

status and an earlier age corresponds to increased nutrition
and increased cancer risk.54,58 Further, a growth spurt in the
mammary glands during adolescence is thought to be
responsible for the final number of mammary cells that are
vulnerable to carcinogenic transformation. An increase in
weight during this period is associated with anovulatory
cycles that limit this growth spurt. Thus, weight gain during
adolescence may reduce premenopausal breast cancer risk
by reducing the number of cancer-vulnerable cells.
Contrary to much public opinion, dietary fat does not
appear to be a significant risk factor linking weight and
cancer risk.55 In fact, monounsaturated fats may be cancer
protective.
Regular exercise is very important also. It may reduce
a womans risk of cancer by as much as 30%. In fact, BMI
may be a proxy variable for physical activity because exercise correlates with a lower BMI and with lower risk.54
The specific impact that a change in diet may have on
a womans risk of breast cancer, depending upon the presence of a gene mutation, her BMI, her ethnic background,
serum levels of SHBG and other metabolic-endocrine factors is not clear at this time. Further research needs to be
done prior to proposing an explanatory model of the interconnections between such confounding variables.
PHYTOESTROGENS
In vitro, the soy phytoestrogens genistein, daidzein,
biochanin A, and coumestrol, as well as the extracts of several herbs, were tested for their effects on the growth of
breast cancer cell lines T-47D and MCF-7.59 The
isoflavones significantly inhibited the growth of both cell
types in the range of 10-100 mM, but no effect was
observed below 1 mM. Over three days coumestrol was the
most inhibitory, followed by genistein, daidzein, and
biochanin A (Figure 2). The result roughly equates to the
putative estrogenic activity of the isoflavones. Biochanin A,
the weakest, is methoxylated, which abolishes its estrogenicity.60 Hops, black cohosh root, dong quai root, and
vitex berry all inhibited growth significantly at full strength,
while ginseng was ineffective.
Zava et al.61 reported on the content and bioactivity of
plant phytoestrogens and progestins in various foods,
plants, and spices before and after human consumption.

150 plants were extracted and tested for their ability to compete for estradiol and progesterone binding to intracellular
estradiol (ER) and progesterone (PR) receptors in intact
human breast cancer cells. The seven highest ER-binding
plants, foods and spices were: soy, licorice, red clover,
thyme, turmeric, hops, and verbena. The six highest PRbinding plants, foods and spices were: oregano, verbena,
turmeric, thyme, red clover, and damiana (Table 5). The
foods, plants, and spices that showed high levels of phytoestrogens and phytoprogestins were further tested for
bioactivity in regulating the growth of ER positive and ER
negative breast cancer cell lines and in inducing or inhibiting the synthesis of alkaline phosphatase, an end product of
progesterone action, in PR positive cells. ER-binding plant
extracts demonstrated agonist activity, acting in a way similar to estradiol. Conversely, PR-binding extracts were neutral or acted as antagonists of progesterone, in general.
In ER positive T47D cells, licorice, red clover, yucca,
hops, and motherwort stimulated significantly higher
growth than control, with yucca and red clover found to be
nearly equipotent with estradiol at the concentrations tested. Most ER-binding extracts were neutral on growth of ER
negative MDA468 cells, but interestingly, mandrake,
bloodroot, mistletoe, and juniper actually markedly inhibited cell growth in ER negative MDA468 cells (Figures 3
and 4), suggesting these foods and plants are chemoprotective via an estrogen receptor-independent mechanism.
Dilute extracts of high PR-binding plants were incubated with T47D cells and monitored for alkaline phosphatase activity. Controls were progesterone and progesterone+RU486, a potent antiprogestin. None of the extracts
significantly elevated alkaline phosphatase, categorizing
them as either neutral or antagonists of progesterone.
Winter 2002
Table 5. Herbs and spices containing ER-and PR-binding

components.61
ER-binding*
PR-binding**
Soy milk
8/200cc
Licorice
4/2g
3/2g
Red clover
Mandrake
Bloodroot
100
Thyme
Yucca
0.5
Turmeric
0.5
Hops
0.5
Verbena
0.5
Yellow
0.5
Sheep sorrel
0.5
Ocotillo
Oregano
Damiana
Pennyroyal
Nutmeg
Calamus root
Goldenseal
Mistletoe
Cumin
Fennel
Chamomile
Cloves
Figure 3. In vitro growth of ER positive breast cancer cells

in the absence (control) or presence of ER-binding herbal
extracts (1:500 dilution), estradiol, estradiol+hydroxytamoxifen, or coumestrol as assessed by protein content.61
Figure 4. In vitro growth of ER negative breast cancer cells

in the absence (control) or presence of ER-binding plant
extracts (1:500 dilution), estradiol, estradiol+hydroxytamoxifen, or coumestrol as assessed by protein content.61
* (mcg estradiol equivalents/200cc or 2g dry herb)

** (mcg progesterone equivalents/2g dry herb)
Damiana, dong quai, yucca, and mistletoe failed to competitively inhibit the induction of alkaline phosphatase by
exogenous progesterone, categorizing them as neutral.
Conversely, red clover, licorice, goldenseal, pennyroyal,
and nutmeg either completely or partially blocked alkaline
phosphatase induction by progesterone, categorizing them
as putative antiprogestins.
THE 2-HYDROXYESTRONE: 16A-HYDROXYESTRONE (2:16) RATIO AND BRASSICA
VEGETABLES
16--hydroxyestrone (16HE) is known to increase and
to promote breast cell proliferation in vitro by binding covalently to estrogen receptors on breast cells, and to promote
mammary tumors in mice.62,63 Another metabolite of estro-
Winter 2002
Figure 5 Menopause, HRT Contraindications, and Associated Dietary Considerations
Winter 2002
gen, 2-hydroxyestrone (2HE) is not known to be carcinogenic. It appears to have anti-estrogenic properties in breast
tissue and may inhibit angiogenesis.62,64,65 In humans, these
two metabolites are products of alternate and irreversible
metabolic pathways such that the ratio of E2:E16 may be a
putative endocrine biomarker for estrogen-related breast
cancer risk in humans.66 Any mechanism that shifts estrogen metabolism toward 2HE hypothetically would lower
breast cancer risk from 16HE.
ranted to further evaluate the relationship between these

variables, particularly in varying ethnic groups, as they may
be potentially important modifying factors for breast cancer
risk. Addressing biochemical individuality as much as is
possible in future diet and herb-related breast cancer studies will undoubtedly provide us with a clearer assessment
of the role that foods, diets and herbs play in the prevention
and/or treatment of breast cancer.
Interestingly, brassica vegetable consumption has been

shown to significantly increase the 2HE:16HE ratio in
healthy postmenopausal women consuming brassicas
approaching levels equivalent to 70 mg/day of glucosinolates.67 The health-promoting indole and isothiocyanate
breakdown products of glucosinolates are known to stimulate Phase I and Phase II detoxification enzymes.68-70 Phase
I cytochrome P-450 enzymes hydroxylate estrogen to 2HE,
depleting the pool available for conversion to 16HE,71 consistent with reducing breast cancer risk.
REFERENCES
N-ACETYLTRANSFERASES (NAT)
N-acetyltransferases (NAT) are major enzymes of
breast tissue that activate aromatic and heterocyclic amines,
such as those found in cigarette smoke and well-cooked red
meat.72,73 In addition to explaining the generally increased
cancer risk from smoking, these researchers also found that
certain polymorphisms, or genetic variations, of NAT alleles found in humans are significantly more highly correlated with breast cancer risk due to smoking and red meat consumption than others. These alleles code for the
rapid/intermediate acetylator phenotype in which heterocyclic amines are more quickly activated, increasing the
risk of toxic DNA damage leading to cancer.72 Women with
the rapid/intermediate acetylator phenotype may be at significantly higher risk for breast cancer when they smoke
and consume meat cooked at high temperatures.
OVERVIEW
The research studies cited in this review article reveal
that hormone replacement therapy (HRT) increases a
womans risk of breast cancer. Figure 5 offers summary of
the dietary factors that may reduce breast cancer risk in
women and aid in menopausal hormonal balance. While
HRT increases breast cancer risk, caloric restriction and the
use of phytoestrogenic and phytoprogesterenic foods may
reduce the risk. Interestingly, in most cases, a diet high in
unfractionated fruits and vegetables is also protective
against breast cancer although the protection is not
bestowed by any single anti-carcinogenic compounds found
within fruits and vegetables. While BMI, insulin levels,
incidence of insulin resistance, sex hormone binding globulin (SHBG) levels and exposure to xenoestrogens all seem
to be connected to breast cancer risk, more research is war-
Winter 2002
1. Greenlee R T et al. Cancer statistics, 2000. CA Cancer J Clin.

2000;50:7-33.
2. Schairer C et al. Menopausal estrogen and estrogen-progestin
replacement therapy and breast cancer risk. JAMA. 2000;283:
485-491.
3. Persson I et al. Risks of breast and endometrial cancer after
estrogen and progestin replacement. Cancer Causes Control.
1999;10:253-260.
4. Colditz G A et al. Use of estrogen plus progestin is associated
with greater increase in breast cancer risk than estrogen alone.
Am J Epidemiol. 1998;147(suppl):64S.
5. Colditz G A et al. The use of estrogens and progestins and the
risk of breast cancer in postmenopausal women. N Engl J Med.
1995;332:1589-1593.
6. Pike M C et al.. Estrogens, progestogens, normal breast cell
proliferation, and breast cancer risk. Epidemiol Rev.
1993;15(1):17-35.
7. Nogueira S M, Appling S E. Breast cancer: genetics, risks, and
strategies. Nurs Clin North Am. 2000;35(3):663-669.
8. Nachtigall L E et al. Estrogen replacement therapy, II: a prospective study in the relationship to carcinoma and cardiovascular and
metabolic problems. Obstet Gynecol. 1979;54:74-79.
9. Gambrell R D et al. Decreased incidence of breast cancer in
postmenopausal estrogen-progestogen users. Obstet Gynecol.
1983; 62:435-443.
10. Colditz G A et al. 1998. Use of estrogen plus progestin is associated with greater increase in breast cancer risk than estrogen
alone. Am J Epidemiol. 147(suppl):64S.
11. Persson I et al. Risks of breast and endometrial cancer after
estrogen and progestin replacement. Cancer Causes Control.
1999;10:253-260.
12. Rodriguez C et al. Estrogen replacement therapy and ovarian
cancer mortality in a large prospective study of US women.
JAMA. 2001;285(11):1460-5.
13. Schairer C et al.. Menopausal estrogen and estrogen-progestin
replacement therapy and breast cancer risk. JAMA.
2000;283:485-491.
14. McKeown N Antioxidants and breast cancer. Nutr Rev.
1999;57(10):321-324.
15. Favero A et al. Diet and risk of breast cancer:major findings
from an Italian case-control study. Biomed Pharmacother.
1998;52(3):109-115.
16. Katsouyanni K et al. Risk of breast cancer among Greek women
in relation to nutrient intake. Cancer. 1988;61:181-185.
17. Landa M C et al. Diet and the risk of breast cancer in Spain.
Eur J Cancer Prev. 1994;3:313-320.
36. Lane M A et al. Beyond the rodent model: calorie restriction

in rhesus monkeys. AGE. 1997; 20:45-56.
18. Roth G S et al. Effects of reduced energy intake on the biology of aging: The primate model. Eur J Clin Nutr. 2000;54
(suppl)3:S15-S20.
37. McKeown N. Antioxidants and breast cancer. Nutr Rev.

1999;57(10):321-324.
19. Harman D The aging process. Proc Natl Acad Sci USA.
1981;78(11):7124-7128.
38. Zhang S. et al. Dietary carotenoids and vitamins A, C, and E

and risk of breast cancer. J Natl Cancer Inst. 1999;91:547556.
20. Aspnes L E et al. Dietary restriction , aging and disease prevention: a discussion of human application. Topics in Clinical
Nutrition. 1997;12 (3):76-83.
39. Rohan T E et al. Dietary fiber, vitamins A, C, and E, and risk

of breast cancer: cohort study. Cancer Causes Control.
1993;4:29-37.
21. Weindruch R Caloric restriction and aging. Scientific

American. 1996;274(1):32-38.
40. Kushi L H et al. Intake of vitamins A, C, and E and postmenopausal breast cancer. The Iowa Womens Health Study.
Am J Epidemiol. 1996;144:165-174.
22. Yu B P Antioxidant action of dietary restriction in the aging

process. J Nutr Sci Vitaminol (Tokyo). 1993;39 (suppl):S75S83.
23. Yu B P Aging and oxidative stress: modulation by dietary
restriction. Free Radic Biol Med. 1996;21(5):651-668.
41. Lee S H et al. Vitamin C-induced decomposition of lipid

hydroperoxides to endogenous genotoxins. Science.
2001;292(5524):2083-2086.
24. Hart R W, Turturro A. Dietary restrictions and cancer. Environ

Health Perspect. 1997;105 (suppl 4):989-992.
42. Lindsay D G et al. Maximising the functional benefits of plant

foods. In:Functional foods: concept to product. Boca Raton,
FL: CRC Press; 2000:186.
25. Yu B P Approaches to anti-aging intervention: the promises

and the uncertainties. Mech Ageing Dev. 1999;111(2-3):7387.
43. Dewailly E et al. High organochlorine body burden in women

with estrogen receptor-positive breast cancer. J Natl Cancer
Inst. 1994;86:232-234.
26. Rao G et al. Effect of dietary restriction on the age-dependent

changes in the expression of antioxidant enzymes in rat liver.
J Nutr. 1990;120(6):602-609.
44. Falck F.et al. Pesticide and polychlorinated biphenyl residues

in human breast lipids and their relation to breast cancer. Arch
Environ Health. 1992;47:143-146.
27. Laganiere S, Yu B P. Effect of chronic food restriction in aging

rats. II. Liver cytosolic antioxidants and related enzymes.
Mech Ageing Dev. 1989;48(3):221-230.
45. Wolff M S et al. Blood levels of organochlorine residue and

risk of breast cancer. J Natl Cancer Inst. 1993;85:648-652.
28. Pieri C et al. Antioxidant enzymes in erythrocytes from old

and diet restricted old rats. Boll Soc Ital Biol Sper.
1990;66(10):909-914.
29. Gong X et al. Antioxidant enzyme activities in lens, liver, and
kidney of caloric restricted Emory mice. Mech Ageing Dev.
1997;99(3):181-192.
30. Lee D W, Yu B P. Modulation of free radicals and superoxide
dismutases by age and dietary restriction. Aging (Milano).
1990;2(4):357-362.
31.Sohal R S. et al. Oxidative damage, mitochondrial oxidant generation, and antioxidant defenses during aging and in
response to food restriction in the mouse. Mech Ageing Dev.
1994;74(1-2):121-133.
32. Meydani M et al. The effect of long-term dietary supplementation with antioxidants. Ann NY Acad Sci. 1998;854:352360.
33. Zhu Z et al. Effect of caloric restriction on pre-malignant and
malignant
stages
of
mammary
carcinogenesis.
Carcinogenesis. 1997;18(5):1007-1012.
34. Walford R L et al. Physiologic changes in humans subjected
to severe, selective calorie restriction for two years in
Biosphere 2: Health, aging, and toxicological perspectives.
Toxicological Sciences. 1999;52(2 suppl.):61-65.
35. Weindruch RH, Walford RL. The retardation of aging and disease by dietary restriction. Springfield: Charles C.
Thomas;1998;28-53.
46. Krieger N et al. Breast cancer and serum organochlorines: a

prospective study among white, black and Asian women. J
Natl Cancer Inst. 1994;86:598-599.
47. Hunter D J et al. Pesticide residues and breast cancer: the harvest of a silent spring? J Natl Cancer Inst. 1993;85:598-599.
48. Moysich K B et al. Environmental organochlorine exposure
and postmenopausal breast cancer risk. Cancer Epidemiol
Biomark.Prev. 1998;7:181-199.
49. Lopez-Carrillo L et al. Dichlorodiphenyltrichloroethane
serum levels and breast cancer risk: a case-control study from
Mexico. Cancer Res. 1997;57:3728-3732.
50. Vant Veer P et al. DDT (dicophane), and postmenopausal
breast cancer in Europe: case-control study. Br Med J.
1997;315: 81-85.
51. Hunter D J et al. Plasma organochlorine levels and the risk of
breast cancer. N Engl J Med. 1997;337:1253-1258.
52. Schildkraut J M et al. Environmental contaminants and body
fat distribution. Can Epid Biom & Preven. 1999;8:179-183.
53. Djuric Z et al. Oxidative DNA damage levels in blood from
women at high risk for breast cancer are associated with
dietary intakes of meats, vegetables, and fruits. J Am Diet
Assoc. 1998;8(5):524-528.
54. Cold S et al. A womans build and the risk of breast cancer.
Euro J Cancer. 1998; 34(8):1163-1174.
55. Golub C Protect yourself against cancer: a diet guide especially for women. Env Nutr. 2000; 23(5):1-4.
Winter 2002
56. Frankel S et al. Childhood energy intake and adult mortality

from cancer: The Boyd Orr Cohort Study. BMJ.
1998;316(7130):499-504.
73. Zheng W et al. N-acetyltransferase 1 genetic polymorphism,

cigarette smoking, well-done meat intake, and breast cancer
risk. Cancer Epidemiol Biomarkers Prev. 1999;8(3):233-239.
57. Weindruch R Caloric restriction and aging. Scientific

American. 1996;274(1):32-38.
74. Gandini S et al. Meta-analysis of studies on breast cancer risk

and diet: the role of fruit and vegetable consumption and the
intake of associated micronutrients. Eur J Cancer.
2000;36(5):636-646.
58. Moisan J et al. A nested case-control study of the correlates

of early menarche. Am J Epidemiol. 1990;132(5):953-961.
59. Dixon-Shanies D, Shaikh N. Growth inhibition of human
breast cancer cells by herbs and phytoestrogens. Oncol Rep.
1999;6(6):1383-1387.
60. So F V et al. Inhibition of proliferation of estrogen receptorpositive MCF-7 human breast cancer cells by flavonoids in
the presence and absence of excess estrogen. Cancer Lett.
1997; 112(2):127-133.
61. Zava D T et al. Estrogen and progestin bioactivity of foods,
herbs, and spices. Proc Soc Exp Biol Med. 1998;217(3):369378.
62. Bradlow H L et al. 2-hydroxyestrone: the good estrogen.
J Endocrinol. 1996;150:S256-S265.
75. Jacob R A, Burri B. J. . Oxidative damage and defense. Am

J Clin Nutr. 1996;63(6):985S-990S.
76. Graham S et al. Nutritional epidemiology of postmenopausal
breast cancer in western New York. Am J Epidemiol.
1991;134(6):552-566.
77. Freudenheim J L et al. Premenopausal breast cancer risk and
intake of vegetables, fruits, and related nutrients. J Natl
Cancer Inst. 1996;88(6):340-348.
78. Hunter D J et al. A prospective study of the intake of vitamins C, E, and A and the risk of breast cancer. N Engl J Med.
1993;329(4):234-240.
63. Nebert DW. Elevated estrogen 16-a-hydroxylase activity: Is

this a genotoxic or nongenotoxic biomarker in human breast
cancer risk? J Natl Cancer Inst. 1993; 85:1888-1891.
79. Shibata A et al. Intake of vegetables, fruits, beta-carotene,

vitamin C and vitamin supplements and cancer incidence
among the elderly: a prospective study. Br J Cancer.
1992;66(4):673-679.
64. Schneider J et al. Antiestrogen action of 2-hydroxyestrone on

MCF-7 human breast cancer cells. J Biol Chem. 1984;259:
4840-4845.
80. Lieberman S. A review of the effectiveness of Cimicifuga

racemosa for the symptoms of menopause. J Womens
Health. 1998;7(5):525-529.
65. Fotsis T et al. The endogenous oestrogen metabolite 2methoxyoestradiol inhibits angiogenesis and suppresses
tumour growth. Nature. 1994;368(6468):237-239.
81. Liske E. Therapeutic efficacy and safety of Cimicifuga racemosa for gynecologic disorders. Adv Nat Ther.
1998;15(1):45-53
66. Kabat G C et al. Urinary estrogen metabolites and breast cancer: a case-control study. Cancer Epidemiol Biomarkers Prev.
1997;6(7):505-509.
67. Fowke J H et al. Brassica vegetable consumption shifts
estrogen metabolism in healthy postmenopausal women.
Cancer Epidemiol Biomarkers Prev. 2000;9(8):773-779.
68. Staack R et al. A comparison of the individual and collective
effects of four glucosinolate breakdown products from brussels sprouts on induction of detoxification enzymes. Toxicol
Appl Pharmacol. 1998;149(1):17-23.
69. Vang O et al. Combined effects of complex mixtures of
potentially anti-carcinogenic compounds on antioxidant
enzymes and carcinogen metabolizing enzymes in the rat.
Cancer Lett. 1997;114(1-2):283-286.
70. McDanell R et al. Differential induction of mixed-function
oxidase (MFO) activity in rat liver and intestine by diets containing processed cabbage: correlation with cabbage levels of
glucosinolates and glucosinolate hydrolysis products. Food
Chem Toxicol. 1987;25(5): 363-368.
71. Jellinck P H et al. Ah receptor binding properties of indole
carbinols and induction of hepatic estradiol hydroxylation.
Biochem Pharmacol. 1993;45(5):1129-1136.
72. Deitz A C et al. N-acetyltransferase-2 genetic polymorphism,
well-done meat intake, and breast cancer risk among postmenopausal women. Cancer Epidemiol Biomarkers Prev.
2000; 9(9):905-910.
Winter 2002
R I G I N A L
E S E A R C H
Pilot Study: An Emulsified Fish Oil Supplement

Significantly Improved C-Reactive Protein,
Hemoglobin, Albumin and Urine Output in
Chronic Hemodialysis Volunteers
Wendy Lou Jones, MS,* CEO, Royal Knight, Inc., Rochester, Minnesota
Member, National Kidney Foundation Council on Renal Nutrition
Shaun P. Kaiser, RD, LD, DaVita Med-Center Dialysis, Houston, Texas
ABSTRACT
Objective: Elevated C-reactive protein (CRP) levels,
in conjunction with diminished albumin and hemoglobin
(Hgb) values, are associated with increased morbidity and
mortality in patients with end stage renal disease (ESRD).
Evidence suggests that a number of factors, including dialysis, alone or in combination with erythropoietin administration, can cause CRP values to rise. Omega-3 fatty acids
have been shown to exhibit significant anti-inflammatory/antioxidant activity affecting a wide variety of disorders.
A highly bioavailable omega-3 dietary fatty acids supplement was tested for its ability to suppress CRP, and positively impact serum albumin and hemoglobin values, as
well as urine output and pain.
Methods: ESRD volunteers took 3 packets of
Coromega, each containing 650 mg of emulsified fish oil
(350 mg of EPA, and 230 mg of DHA) for a total of 1,950 mg
of emulsified omega-3 fatty acids per day for a period of 8
consecutive weeks. Serum albumin, CRP, hemoglobin and
erythropoietin usage was measured at specific intervals during the test period. Volunteers were asked to measure urine
output and rate pain on specific days.
This pilot study was performed with ESRD volunteers
* Correspondence:
Wendy Lou Jones
2015 41st Street NW, Ste G33,
Rochester, MN 55901
Phone: 507-289-8192 Fax: 501-421-7869
E-mail: WLJ_1998@Yahoo.com
who were undergoing treatment with chronic intermittent

maintenance hemodialysis at a Minnesota clinic, and at various Fresenius clinics in Houston,Texas.
Results: Serum albumin, hemoglobin, and urine volume
increased, while CRP measurably decreased. Concomitantly,
the amount of erythropoietin needed per treatment to maintain
adequate non-anemic Hgb levels fell (mean Hgb
[Erythropoietin]: initial Hgb 12.05+0.83 [Epo. 6346+2556.65]
vs final: Hgb 12.25+0.64 [Epo. 5336+2399.27] ) (P < .05).
Conclusion: A highly bioavailable emulsified omega-3
fatty acid dietary supplement positively impacted hemoglobin, serum albumin, urine output, and CRP values.
Volunteers, completing additional subjective tests (urine
foaming and joint pain), indicated a substantial decrease in
both. Considering the impact this highly bioavailable dietary
supplement had on improving hematological values and in
reducing the total required dose of erythropoietin needed per
treatment to maintain adequate hemoglobin levels, a major
study is warranted.
Key Words: Emulsified fish oil, hemoglobin, erythropoietin, C-reactive protein, nutritional supplement, Coromega.
INTRODUCTION
Both acute and subclinical inflammatory states can be
characterized by an excessive release of a variety of inflammatory factors. This antagonistic molecular cascade can, in
turn, exert a negative influence on every physiological system, and has been implicated as a forerunner of atherosclerotic plaques in both the normal and ESRD populations.
Elevated C-reactive protein (CRP), an easily identifiable
Winter 2002
non-specific inflammatory marker, is an acute phase protein, produced in response to an inflammatory event
(cytokine activation) regardless of its cause.1
Many hemodialysis patients have high levels of CRP.
Repeated exposure to artificial membranes (dialysis membrane, synthetic tubing, and containers),2-3 erythropoietin
administration, as well as idiopathic causes native to ESRD
conditions, have all been implicated as having the potential
to evoke an inflammatory response. In addition to atherosclerotic plaques,4 an elevation in CRP has been associated
with an increase in cardiovascular disease,5 decrease in
serum albumin synthesis,6,7 and an increase in erythropoietin resistance with ensuing anemia in ESRD. Elevated
CRP levels, in conjunction with diminished albumin and
hemoglobin values, are associated with increased morbidity in the ESRD patient maintained on chronic hemodialysis,
and can be viewed as a strong predictor of poor survival.
Significant anti-inflammatory properties have been
associated with fish oil (omega-3 fatty acids) supplements.
Immune-activated T cells and cytokines are found throughout the circulatory system as well as at sites of injury.
Cytokines such as interlukin-1 (IL-1) and tumor necrosis
factor (TNF) will generate reactive oxygen intermediaries,
which may contribute to free radical cell and tissue damage.
These reactive intermediaries can, in turn, attack cell membrane polyunsaturated fatty acids, resulting in derivatives
that subsequently attract inflammatory cells. In their un-oxidized form, omega-3 fatty acids may inhibit circulatory
inflammation by decreasing the precursors, which, in themselves, may lead to free radical mediated events.8,9,10,11,12
Omega-3 fatty acids have been shown to inhibit the
production of eicosanoids (proinflammatory compounds).
Arachidonic acid (an omega-6 fatty acid) is metabolized
into one such proinflammatory eicosanoid. Conversely,
omega-3 fatty acids can displace arachidonic acid from the
cell membrane reducing membrane bound proinflammatory
compounds. Omega-3 also competes with arachidonic acid
for cyclooxygenase and lipoxygenase enzymes, shifting
ecosanoid production to the non-inflammatory series-3
prostaglandins and series-5 leukotrienes. This specific competitive activity has been hypothesized to directly suppress
immunological and/or inflammatory mediators.
A number of other statistically significant, physiologically positive events have been associated with omega-3
fatty acid supplementation when given at doses between 1.8
-18 grams per day. Those specifically noted include: mild
antithrombotic effects,13 a mild glomerular protective effect
(by limiting production of cytokines and eicosanoids
evoked by immunologic renal injurious events),14 a mild
antihypertensive effect in persons with confirmed hypertension,15,16 anti-inflammatory benefits associated with emphysema,17 asthma,18 rheumatoid arthritis,19,20 and increased
hemoglobin in ESRD volunteers.21
Winter 2002
In the case of hemoglobin production, two explanations have been postulated: (1) hemoglobin production
increases because inflammatory factors (as well as free
oxygen radicals) are reduced, lessening the negative impact
on the system (body) as a whole, and (2) a protective effect
is being exerted by omega-3 fatty acids on the red cells,
preventing early cell death (the average lifespan of a red
blood cell is 120 days in the normal individual vs 40 for the
dialysis patient). While the mechanism for these numerous
positive observations, seen across an entire spectrum of disorders, is not fully understood, a hypothesis, focusing on
cell and tissue oxidative and inflammatory processes as a
basis for the initiation of all organ (and aging related) deleterious events, would seem a logical place to begin.
The effective dose of fish oil, necessary to attain the
results observed in each study, has varied greatly from
study to study, for both the same, and dissimilar, disease
conditions. Possible explanations for this variation may
have to do with the preoxidized state, and/or biovailability
of the fish oil preparation being used. Fish oil can oxidize
when exposed to air, both during processing and storage.
The degree to which it oxidizes varies with the length of
time exposed and the prevailing temperature. Significant
antioxidative activity has been associated with fish oil. If its
affinity for oxidative free radicals is, at least in part, the
mechanism by which it exerts its biological affect, the
effectiveness of emulsified fish oil could be significantly
reduced after oxidation. The bioavailability of any one specific preparation would also be a key factor in the amount
needed to achieve a desired affect.
The fish oil preparation Coromega (manufactured by
the European Reference Botanical Laboratories) was selected
for use in this pilot study because of its reported high bioavailability and hermetically sealed packaging. The bioavailability
of 4 grams of this emulsified and flavored fish oil product was
compared to a standard, commercially available, encapsulated fish oil in a feeding trial using non-dialyzing men.
Findings indicated that the percent of eicosapentaenoic (EPA)
and docosahexaenoic (DHA) acids assimilated into the bloodstream from the emulsified product reached approximately
30% at 8 hours, compared to approximately 10% for the traditional encapsulated fish oil group for the same time period.
Incorporation percentage remained uniformly higher at 48
hours for the emulsified fish oil, compared to the encapsulated version (>20% vs >10%).22
The objectives of this pilot study were to determine if
this highly bioavailable fish oil preparation was capable of
causing a statistically significant reduction in the amount of
erythropoietin needed to maintain a non-anemic state, a
reduction in CRP values, while concomitantly stimulating
increased production of serum hemoglobin, and albumin.
Because this was a pilot study with strictly limited funded
resources, the authors sought to maximize the observations
possible in this study by enlisting the volunteers aid in
observing and recording data for the following subjective

aspects of this study: (I) urine foaming, (II) increase (or
decrease) in urine production, and (III) reduction (or
increase) in joint pain. Subjective parameters involved athome recording of urine protein spillage by observing urine
foam forming capacity, urine volume, and rating joint pain
(on a scale of 0 to 10) for 60 consecutive days.
SUBJECTS AND METHODS
Subjects: Subjects were fully informed of the nature of
the pilot study in which they were being asked to participate,
and each volunteer provided written consent.The pilot study
protocol conformed to the policies for research on human
subjects, and the Medical Directors approval was obtained.
Additionally, Medical Director oversight continued throughout the duration of the study. Twenty adult hemodialysis
ESRD volunteers (mean 55.9 years) of either gender, having
both of their original kidneys, and who had been maintained
on chronic hemodialysis for at least 4 months (labs drawn at
regular intervals and data collected), were recruited into this
pilot study where the volunteers acted as their own controls.
Approximately 30% of all volunteers had ESRD secondary
to unspecified hypertensive renal disease, ESRD diabeticrelated 30%, Lupus-related 12%, ischemic 6%, other 22%.
An effort was made to recruit individuals with high initial
CRP (>10 mg/L) values and/or relatively large erythropoietin unit needs (>10,000 units). Qualitative analysis was
used to measure CRP; therefore values less than 6.9 were
undetected. For statistical analysis, those patients with a
CRP < 6.9, were recorded as 6.8. This method allowed for
the most conservative treatment of the data set. With the
exception of one volunteer, who was admitted to the pilot
study because of an exceptionally large erythropoietin unit
need, none of the other volunteers were taking a prophylactic oral anticoagulant (warfarin sodium).
Intervention: Each participant took 3 packets of
Coromega, each containing 650 mg of emulsified fish oil
(350 mg of EPA and 230 mg of DHA) or 1,950 mg of emulsified omega-3 fatty acids per day, for a period of 8 consecutive weeks. Serum albumin, CRP, hemoglobin and erythropoietin usage was measured prior to and at specific intervals
during the test period. In addition to omega-3 fatty acids, each
packet of the product also contained: 8 mg of cholesterol
(from 1:80 of a pasteurized egg yolk), 25 mg of vitamin C, 3
IU of vitamin E, 50 micrograms of folic acid, and 5 mg of stevia leaf extract.
Interested volunteers were asked to measure urine output on specific days, and count free floating foam (greater
than 3 inches in diameter), after urinating in a toilet, as +
or less than 3 as -. Individuals so inclined kept a pain
diary scoring their pain on a scale of 0 to 10 each day (where
0 = no pain, and 10 = severe and intolerable pain).
Erythropoietin Administration: The amount of erythropoietin administered per treatment is listed in table 3
(under EPO). The number of erythropoietin units administered to each volunteer during the pilot study was closely
monitored and was gradually decreased to keep pace with
any rises observed in the volunteers hemoglobin level. The
target hemoglobin level was at or above 12.1 mg/dL.
Erythropoietin was held only when the volunteers hemoglobin level rose above 13 mg/dL (in accordance with the
dialyzing centers policy for erythropoietin administration).
Data: Predialysis data were obtained for all parameters: CRP and albumin (initial and at week 8), hemoglobin
and erythropoietin units administered (initial and at two
week intervals), urine foaming and volume (initial and at
weekly intervals), and pain (scored daily).
Analysis: Only data from participants who completed all
8 weeks, taking 3 packets per day, were used. Percentage of
decrease and increase for all values was calculated at the conclusion of the pilot study, and the results expressed as an average reduction or increase for each test parameter. All data were
further analyzed using t-test: paired two sample for means.
Due to the data sets small size and large variance,
change in C-reactive protein values (Table 1) was not statistically significant even though reductions in CRP for
many of the volunteers were observed. An overall change
of 12.6 % was noted among the means of CRP (CRPmean
initial of 19.09 mg/L vs CRPmean final of 16.67 mg/L).
However, with large variances of 234.9 and 218.9 respectively, no statistical significance could be shown. This does
not discount that 7 of 14 patients showed a marked decrease
in CRP after treatment.
Albumins (Table 2), approached statistical significance
in change of the means (Albmean initial of 3.86 g/dl vs
Albmean final of 3.99 g/dl) (P = 0.056). Change of the means
for hemoglobin (Hgb) and erythropoietin (Epo) were compared from week 0 to week 8. As designed, there was no
significant change in Hgb from the initial lab draw to the
final lab draw (Hgbmean initial of 12.05 g/dl compared to
Hgbmean final of 12.25 g/dl). However, Epo use was significantly reduced (16%) from a mean dose of 6346 units to
5336 units three times per week (P < .05).
RESULTS
Of the 20 initial recruits, data was obtained for 14
(70%) volunteers for CRP, 18 (90%) for albumin, and 11
(55%) for hemoglobin and erythropoietin. Missed samplings accounted for the discrepancy in the number of participants sampled for each parameter. Volunteers compliance in subjective testing was substantially less than that of
Winter 2002
the objective. Five volunteers (25%) elected to participate

in the foaming study, three (15%) in the urine volume
study, and two (10%) in the pain study.
As shown in Table 1, CRP was reduced 5-89%. The
mean initial CRP was 19.09+8.85 mg/L (SD 15.33) vs mean
final CRP of 16.67+8.54 mg/L (SD 14.80).
As shown in Table 2, albumin values increased 2-19%.
The mean initial albumin was 3.86+0.20 g/dl (SD 0.40) vs a
mean final albumin of 3.99+0.14 g/dl (SD 0.29).
As shown in Table 3, by the end of the study hemoglobin increased 2-25%. The initial mean Hgb was 12.05+0.83
g/dl (SD 1.24) vs the final mean Hgb of 12.25+0.64 g/dl
(SD 0.96). The amount of erythropoietin needed to combat
anemia decreased. Initial mean erythropoietin use was
6346+2557 units (SD 3805.62) vs final mean erythropoietin
use of 5336+2399 units (SD 3571.35).
At the beginning of the pilot study, urine foaming was uniformly noted by each participant. Four of the five participants
reported a cessation in foaming beginning with the first week
and continuing through the eighth. During the study, none of
the participants reported that they had consumed an excess of
fluid during any particular week. Each of the three participants
measuring their urine volume reported increases in urine output. While these increases occurred almost every week, no
conclusions from the numbers generated could be drawn
because they never reached a statistically significant level.
Both volunteers scoring daily pain indicated substantial
reductions in pain intensity. While pain reduction was noted
during the first week of the study, it was reported to be
very pronounced after day 20.
DISCUSSION
Volunteers responded positively to the emulsified fish
oil preparation used in this pilot study. Comments concerning fishy burps, fishy after taste, or fishy indigestion
were absent with this preparation.
As observed, most of the participants test parameters
were positively influenced. There appeared to be no consistent pattern with respect to the few individuals for whom
one or more negative values were generated. For example, volunteer #109 returned the highest CRP value and the
largest decrease in hemoglobin, yet experienced a rise in
albumin, or increase in urine volume, and a significant
decrease in pain scores. Volunteer #114 attained the second
highest hemoglobin increase of the group, but scored the
second largest increase in CRP value. Volunteer #111
scored the highest increase in urine output and second
largest decrease in pain scores, yet experienced a slight
decrease in hemoglobin value. No bleeding episodes or
periods of illness were noted for any volunteer, and we are
unable to give a plausible explanation for the sharp increase
in CRP, or decrease in hemoglobin (for volunteer 109 and
Winter 2002
111, respectively) noted on the final test.

Of special interest was the highly significant impact (P
< 0.05) the emulsified fish oil preparation had on the number of units of erythropoietin (6346+2557 reduced to
5336+2399) needed to maintain hemoglobin at, or above,
12.1 mg/dL (a recognized non-anemic state). There was no
significant change in mean hemoglobin between the first and
eighth week of the pilot study (12.05+0.83 vs 12.25+0.64).
The reduced need for erythropoietin to maintain adequate
hemoglobin levels during emulsified fish oil supplementation was a paramount finding in this pilot study.
The reduced erythropoietin usage observed in this
study represents an estimated dollar saving to the patients
(and the healthcare system) of between $200,000-$300,000
per 100 patients/year (based on $100-$150/10,000 units
cost). While the small sample size of this pilot study limits
the absolute conclusiveness of these findings, the impact of
their potential cannot be ignored. If the same results can be
realized in a larger trial, one could easily extrapolate the
expected increase in patient quality of life health benefits
and substantial decrease in cost of erythropoietin used.
Given the significance of the findings, in the absence of any
adverse events, a larger trial is warranted.
ACKNOWLEDGEMENTS
The authors are grateful to the physicians, dietitians,
technicians, and especially the volunteers who participated in
this pilot study. Special thanks is given to the renal specialists of Houston: Bilal Moukaddem, MD; Whitson Etheridge,
MD; Eric Faust, MD; and Sarah Shearer, MD. Additional
thanks for their dedication and hard work is extended to Gail
McLaughlin, BSN, RN; Rachelle Bussey, RD, LD; Suzanne
Lopez, MPh, RD, LD; and Jeanne McCowan, RD, LD, RN
of Fresenius Medical Care, and to Chris Kaiser, LSW, for her
original inspiration in this project.
A special thanks to Frank Morley and Barbara Apps of
the European Reference Botanical Laboratories, Inc. for their
support and encouragement throughout the study.
Table 1. C-Reactive Protein Values (mg/L)

Volunteer
Initial
Final (8 Weeks)
% Reduction
#101
#102
#103
#104
#105
#106
#107
#108
#109
#110
#111
#112
#113
#114
12
15
32
11
22
24
19
65
<6.9
<6.9
18
<6.9
<6.9
22
<6.9
<6.9
29
<6.9
26
14
18
<6.9
39
<6.9
<6.9
<6.9
<6.9
53
43%
54%
9%
37%
Mean
19.09+8.85
16.67+8.54
Increase
+15%
42%
5%
89%
+82%
0%
6%
0%
0%
+58%
NS (-)
NS (-) = Not statistically significant
Table 2. Albumin (g/dL) Values

Volunteer
Initial
Final (8 Weeks)
#101
#102
#103
#104
#105
#106
#107
#108
#109
#110
#111
#112
#113
#114
#115
#116
#117
#118
3.9
3.5
3.7
3.5
3.7
3.5
3.5
3.4
4.2
4.9
3.9
4.5
4.1
4.1
3.9
4.0
3.6
3.5
3.9
3.8
3.6
4.3
4.0
3.7
3.6
3.9
4.3
4.4
3.9
4.4
4.4
4.1
3.7
4.3
3.8
3.8
Mean
3.86+0.20
3.99+0.14
% Reduction
Increase
0%
8%
-3%
19%
8%
5%
3%
13%
2%
-10%
0%
-2%
7%
0%
-5%
7%
5%
8%
Change: (3.6%, p = 0.056)
Winter 2002
Table 3. Hemoglobin (Hgb g/dL) vs. Erythropoietin (EPO) Administered (U/dialysis session)
Initial
Week 2
Week 4
% Increase/(Decrease) Week 6
Hgb (EPO)
Hgb (EPO)
Hgb (EPO)
in Hgb
Week 8
Hgb (EPO) Hgb (EPO)
% Increase/[decrease]
from initial value
Hgb (EPO/session)
#101
11.9 (1,800)
12.3 (1,800)
12.5 (1,500)
#109
14.5 (2,000)
13.1 (1,500)
12.7 (1,500)
#110
12.5 (4.500)
11.8 (4,500)
12.8 (4,500)
#111
12.3 (5,500)
11.5 (5,500)
11.4 (5,000)
#112
12.2 (7,500)
12.0 (7,500)
13.6 (5,500)
10%
#113
12.1 (500)
12.2 (500)
12.4 (500)
#114
11.4 (10,000)
12.6 (9,500)
13.9 (hold)
#115
12.7 (6,500)
12.5 (6,000)
12.2 (6,000)
#116
9.2 (11,000)
9.9 (11,000)
10.7 (11,000)
#117
11.8 (10,000)
11.5 (10,000)
11.6 (10,000)
#118
11.9 (10,500)
11.7 (10,500)
12.2 (9,000)
Mean Hgb (EPO)
5%
12.7 (1,500) 12.4 (1,500)
4%
[- 300 U]
13.2 (1,000) 11.9 (1,000)
[-18%]
[- 1,000 U]
12.4 (4,000) 12.8 (4,000)
2%
[- 500 U]
11.2 (5,000) 12.1 (5,500)
[-8%]
13.0 (5,500) 13.4 (5,500)
10%
[-2,000 U]
2%
12.0 (200)
12.5 (200)
3%
[- 300 U]
18%
14.7 (hold)
13.3 (5,000)
14%
[-5,000 U]
12.6 (6,000) 12.7 (6,000)
0%
[- 500 U]
11.3 (11,000) 12.3 (10,000)
25%
[- 1,000 U]
11.3 (10,000) 11.3 (10,000)
[ -4%]
0 U
12.0 (9,000) 10.0 (10,000)
[-16%]
[- 500 U]
(-12%)
2%
(-7%)
(-4%)
14%
(-2%)
3%
Initial: 12.05+0.83 (6346+2556.65)
Final: 12.25+0.64 (5336+2399.27)
REFERENCES
1. McQuiston B. C-reactive protein: its role in ESRD patients.
Contemp Dial Nephrol. August:1999;31-32.
2. Cavaillon JM, Poigner JL, Fitting C, Deloris S Serum interlukin6 in long term hemodialysis patients. Nephron. 1992;60:307313.
3. Libetta C, De Nicola L, Rampino T, De Simone W, Memoli B.
Inflammatory effects of peritoneal dialysis: evidence of systemic monocyte activation. Kidney Int. 1996;49:506-511.
4. Anonymous. C-reactive Protein and atherosclerosis in dialysis
patients (letters). Nephrol Dial Transplant. 1998;13:2710-2711.
5. Zimmerman J, Herrlinger S, Prav A, Metxger T, Wanner C.
Inflammation enhances cardiovascular risk and mortality in
hemodialysis patients. Kidney Int. 1999;55:648-658.
6. Yeun JY, Kaysen GA. Factors influencing serum albumin in
dialysis patients. Am J Kidney Dis. 1998;32:S118-S125.
7. Qureshi AR, Alvestrand A, Danielson A, Divino-Filho JC,
Gutierrez A, Lindholm B, Bergstrom J. Factors predicting
malnutrition in hemodialysis patients: a cross sectional study.
Kidney Int. 1998;53:773-782.
8. Brown AC. Lupus erythematosus and nutrition: A review of the
liturature. J Renal Nutr. 2000;10(4):170-183.
9. Hardardottir I, Kinsella JE. Tumor necrosis factor production
by murine resident peritoneal macrophages is enhanced by
dietary n-3 polyunsaturated fatty acids. Biochem Biophys
Acta.1991;1095:187-195.
10. Henderson CD, Black HS, Wolf JE. Influence of omega-3 and
omega-6 fatty acid sources on prostaglandin levels in mice.
Lipids. 1989;24:502-505.
11. Kinsella JE, Lokesh B. Dietary lipids, eicosanoids, and the
immune system. Crit Care Med.1990;18:S94-S113 (suppl 2).
12. Scharschmidt L, Miller M, Holthofer H, Sinha A, Schlondorff
D, Gibbons N, Santiago A. A fish oil diet preserves renal
Winter 2002
0U
Change: NS (-16%, p<0.05)
function in nephrotoxic serum nephritis. J Lab Clin

Med.1990;115:405-414.
13. Furst P, and Kuhn KS. Fish oil emulsions: what benefits can
they bring? Clin Nutr.1999;19(1):7-14.
14. Donadio JV Jr, Bergstralh EJ, Offord KP, Spencer DC, Holley
KE. A controlled trial of fish oil in IgA nephropathy. N Engl
J Med.1994;331(18):1194-1199.
15. Morris MC, Sacks F, Rosener B. Does fish oil lower blood
pressure? A meta-analysis of controlled trials. Circulation.
1993;88(2):523-533.
16. Radack K, Deck C, Huster G. The effects of low doses of n3 fatty acid supplementation on blood pressure in hypertensive subjects. Arch Intern Med.1991;151:1173-1180.
17. Shahar E, Folsom AR, Melnick SL, Tockman MS, Comstock
GW, Gennaro GW, Higgins MW, Sorlie PD, Ko WJ, Szklo
M. Dietary n-3 polyunsaturated fatty acids and smokingrelated chronic obstructive pulmonary disease. N Engl J
Med.1994;331(4):228-233.
18. Broughton SK, Johnson CS, Pace BK, Liebman M,
Kleppinger KM. Reduced asthma symptoms with n-3 fatty
acid ingestion are related to 5-series leukotriene production.
Am J Clin Nutr.1997;65:1011-1017.
19. Kremer JM, Jubiz W, Michalek A, Rynes RI, Bartholomew
LE, Bigaouette J, Timchalk M, Beeler D, Lininger L. Fish-oil
fatty acid supplementation in active rheumatoid arthritis: a
double-blinded, controlled crossover study. Ann Intern
Med.1987;106(4):497-503.
20. Kremer, JM. n-3 fatty acid supplements in rheumatoid arthritis. Am J Clin Nutr. 2000;17(suppl):S349-S351.
21. Nordkild PK, Graff J, Jorgensen HE, Fugleberg S. Fish oil
and antioxidant supplementats reduce erythropoietin requirements in haemodialysis patients. Nephrology, Dialysis,
Transplantation. 1993;8(6):569,Letters.
22. Bibus DM, Schumacher K, Holman RT. Bioavailability studies of emulsified flavored fish oil. American Oil Chemists
Society Press. 2000;11(suppl5):94.

JANA Prevention of Neurological Disease

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

JANA Prevention of Neurological Disease

Uploaded by

Copyright:

Available Formats

The Journal of the American Nutraceutical Association

A Peer-Reviewed Journal on Nutraceuticals and Nutrition

Contents Winter 2002, Vol. 5, No. 1

American Nutraceutical Association

ANA is an alliance of individuals with interest in

Comments on Joint Remedies Article in Consumer Reports .......... 1

Congress Acts on Dietary Supplement Issues .................................... 5

Biological and Chemical Terrorism:

Mark Houston, MD, SCH, FACP, FAHA

Why Funding for Nutraceutical Clinical Trial

New Developments in the Prevention and Treatment of

Pilot Study: An Emulsified Fish Oil Supplement Significantly

To subscribe to JANA Phone 800-566-3622,

Comments on Joint Remedies Article

tant consideration, for the level of bioavailability can affect

Taber's Medical Dictionary defines bioavailability as

We have all heard of tablets compressed so hard that

As members of the editorial board of JANA, we are

The research team at the University of Maryland

1 JANA Vol. 5, No. 1

between product costs and content. A copy of the University

not be assessed by the research of other brands. To compare

Mark Houston, MD, Editor-in-Chief

Vol. 5, No. 1 JANA 2

Breast Cancer, Hormone Replacement Therapy

In this issue of JANA, Dr. Gina L. Nick has provided a

3 JANA Vol. 5, No. 1

symptoms, and to reduce cancer risk. While controversy

Observations of an Emulsified Fish Oil

In this issue of JANA, Jones and Kaiser report the results

significant reduction in urine protein losses and end-stage

Vol. 5, No. 1 JANA 4

ulation. Indeed, patients with active inflammatory states on

The preliminary results of the pilot study are certainly

Congress Acts on Dietary Supplement Issues

Since the passage of the Dietary Supplement Health

5 JANA Vol. 5, No. 1

expected to resolve differences between House and Senate

massive reauthorization of federal farm, food, and nutrition

The Congress has also approved $500,000 for FDA to

In addition to safety and enforcement, the Congress has

BIOTERRORISM INCLUDES REGISTRATION FOR

A conference committee will be required to resolve the

Unquestionably, Congress, FDA, and NIH made great

Vol. 5, No. 1 JANA 6

Biological and Chemical Terrorism:

The events of September 11, 2001 have changed the

7 JANA Vol. 5, No. 1

B. anthracis in four states and the District of Columbia

received probiotic therapy to support their gastrointestinal

prevent, or treat biological and chemical agents, including

The FTC, with the help of the Food and Drug

Vol. 5, No. 1 JANA 8

Mark Houston, MD, SCH, FACP, FAHA

Institute, along with the Life

9 JANA Vol. 5, No. 1

My goal is to make JANA the premiere clinical and

tems of the body, with emphasis on neurological disease,

Vol. 5, No. 1 JANA 10

cer, it became more apparent how they are connected.

TODAY TO THE LEADING JOURNAL ON NUTRACEUTICAL SCIENCE

The Journal of the American Nutraceutical Association (JANA)

11 JANA Vol. 5, No. 1

Why Funding for Nutraceutical Clinical