Food, Herbs & Supplements

Food, Herbs, and Supplements: St. John’s Wort

Common Name/Scientific Name:

Common Name: St. John’s Wort

Scientific Name: Hypericum perforatum

Use

St. John’s Wort is an invasive, flowering plant native to Europe and Asia and belongs to the Hypericaceae family and the species of the genus Hypericum. The name St. John’s wort refers to the priest, John the Baptist, since the plant blooms in late June, the time of the feast of St. John the Baptist. The plant’s flowers have a distinctive yellow color and are short-lived perennial shrubs that grow up to 1-2 feet. Its medicinal properties are derived from its stem, petals, and flowers. St John’s wort has been used for its antibacterial, antiviral, antidepressive, anti-inflammatory, and antioxidant properties dating back to ancient Greece, now available over the counter topically or as an oral herbal dietary supplement and is not FDA approved. It is indicated for those with mild to moderate depression, menopausal symptoms, ADHD, somatic symptom disorder, and obsessive-compulsive disorder. It can be used for nerve pain, anxiety, insomnia, and pain from sciatica, rheumatoid arthritis, and menstruation. Topically, it aids in wound healing from mild burns and sunburns, bruising, varicose veins, and muscle pain. It may take 4 to 6 weeks to see efficacy and is typically orally administered 300 to 400 mg three times a day with meals for the treatment of mild depression and mood disorders. Tinctures, teas, or liquid extracts are also available.

Mechanism of Action

St. John’s Worts therapeutic actions stem from its bioactive chemical makeup of flavonol derivatives, biflavones, proanthocyanidins, xanthones, phloroglucinols and naphthodianthrones. One of the principal mechanisms of action of this plant is that it acts as a serotonin reuptake inhibitor, which reduces the uptake of serotonin at neuronal synapses, thereby increasing levels of serotonin in the body. It also prevents the reuptake of dopamine and norepinephrine. Those suffering from depression may have a chemical imbalance of serotonin, hence, increasing serotonin through reuptake inhibition is used to treat this condition. Moreover, this supplement activates pregnane-X-receptor (PXR) cytochromes, thereby inducing the cytochrome P450 system, CYP3A4 enzyme and P-glycoprotein. P450s or monooxygenase enzymes metabolize the compound through hydroxylation, making it more polar, which increases its reactivity for conjugation into various polar groups. St John’s wort also inhibits monoamine oxidase A and B, which are enzymes responsible for the degradation of dopamine, serotonin, and norepinephrine. Through its monoamine oxidase inhibition, taking this supplement will increase norepinephrine levels. The bioactive constituent responsible for St. John’s wort’s antidepressant and anxiolytic effects is the phytochemical compound, hyperforin. Hyperforin acts as a serotonin and monoamine reuptake inhibitor, as well as GABA and glutamate, and activates the transient receptor potential ion channel, TRPC6. TRPC6 activation allows for the entry of sodium and calcium into the cell, which causes monoamine reuptake inhibition. Likewise, hyperforin induces CYP3A4 and CYP2C9 enzymes through binding and activation of pregnane X receptor (PXR).

Antidepressant activity is also seen due to the supplement’s activation of GABA receptors. Malfunctioning of GABA receptors can cause depression and anxiety; therefore, activating these receptors can help with mood regulation. St. John’s wort also plays in the downregulation (decrease the number of) of beta-adrenergic receptors and upregulation (increase the number of) of serotonin receptors. Beta-adrenergic receptors are activated upon the binding of epinephrine, which leads to increased heart rate and blood pressure. Due to downregulation, there is less opportunity for epinephrine to stimulate the beta-adrenergic receptors, which provide a calming effect. On the other hand, upregulation of serotonin receptors increases the chance for serotonin stimulation, thereby decreasing depressive and anxiolytic symptoms.

Side Effects, Drug Interactions, and Additional Considerations

Side effects of St. John’s Wort include insomnia, anxiety, dry mouth, dizziness, gastrointestinal symptoms, fatigue, headache, or sexual dysfunction.

There are numerous drug interactions in those taking St. John’s wort with other medications due to its induction of CYP3A4 and P-glycoprotein drug efflux transporter.

These include the following:

Decreased therapeutic efficacy of:

-Antidepressants -HIV protease inhibitors

-Birth control pills -Cancer medications, irinotecan and imatinib

-Cyclosporine -Warfarin

-Digoxin and Ivabradine -Statins

Given St. John’s wort’s mechanism of action, concomitant administration of this supplement with SSRIs may put the individual at risk for serotonin syndrome (mental confusion, agitation, sweating, tachycardia). There is an associated risk of those with bipolar depression taking St. John’s wort since it may induce manic episodes. It is advised to avoid St. John’s wort in these patients.

Additionally, St. John’s Wort may cause increased sensitivity to sunlight when taken in large doses. In regards to side effects of its topical form, it may cause severe skin reactions upon sun exposure. Therefore, it is advised in patients taking this supplement to wear sunscreen regularly and avoid sun exposure.

There is little evidence in regards to the supplement’s safety in a pregnant patient. In vitro animal studies do not show that it affects brain development or behavioral defects; however, low birth weight may occur. Further there is little evidence that the herb does not cross through breast milk or does not affect breast milk production. Additional studies need to be conducted to determine its safety in pregnant populations, and it must be used with caution.

Supporting Trials

A meta-analysis of 27 studies (total of 3,126 depressed patients) comparing efficacy and safety of St. John’s wort with SSRIs for the treatment of depression in adults from 1966 to April 2015 showed no difference in regards to clinical response, remission, and mean reduction in the Hamilton Rating Scale for Depression (HAMD) score. The primary outcome measure for treatment efficacy and safety was a change in total HAMD score between baseline and endpoint. The outcome of interest include: responder rate (reduction in HAMD score by 50%) remission rate (reduction in HAMD score by 75%), mean reduction in HAMD score, incidence of adverse events, total withdrawal rate, and withdrawals due to adverse events. St. John’s wort extract had a lower rate of adverse events compared to SSRIs evidenced by a summary relative risk: 0.77; 95% confidence interval: 0.70, 0.84, P=0.00. The safety profile of this supplement compared to SSRIs is superior. The findings of this meta analysis revealed that St. John’s Wort is comparable to SSRIs in efficacy but superior in safety evidenced by lower rates of adverse events and withdrawal due to adverse events.

References

Cui, Yong-Hua, and Yi Zheng. “A Meta-Analysis on the Efficacy and Safety of St John’s Wort Extract in Depression Therapy in Comparison with Selective Serotonin Reuptake Inhibitors in Adults.” Neuropsychiatric Disease and Treatment, 11 July 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4946846/.

G;, Dugoua JJ;Mills E;Perri D;Koren. “Safety and Efficacy of St. John’s Wort (Hypericum) during Pregnancy and Lactation.” The Canadian Journal of Clinical Pharmacology = Journal Canadien de Pharmacologie Clinique, 3 Nov. 2006, pubmed.ncbi.nlm.nih.gov/17085775/#:~:text=Conclusions%3A%20Caution%20is%20warranted%20with,but%20may%20cause%20side%20effects.

“Hyperforin.” Uses, Interactions, Mechanism of Action | DrugBank Online, go.drugbank.com/drugs/DB01892. Accessed 18 May 2023.

Peterson, Bahtya, and Hoang Nguyen. “National Center for Biotechnology Information.” St. John’s Wort, 19 May 2022, www.ncbi.nlm.nih.gov/books/NBK557465/.

Schwartz, Allan, and Mark Dombeck. “Major Depression and St. John’s Wort.” MentalHelp.Net, 26 Mar. 2019, www.mentalhelp.net/depression/st-john-s-wort/.

“St. John’s Wort.” National Center for Complementary and Integrative Health, Oct. 2020, www.nccih.nih.gov/health/st-johns-wort.

V;, Butterweck. “Mechanism of Action of St John’s Wort in Depression : What Is Known?” CNS Drugs, pubmed.ncbi.nlm.nih.gov/12775192/. Accessed 18 May 2023.

Nicotinamide for Non-Melanoma Skin Cancer Prevention

Nicotinamide (NAM) is an amide form of vitamin B3 which is a semi-essential vitamin. According to the FDA, the recommended daily intake of vitamin B3 for adults and children >4 years old is 16 mg. Certain foods like meat, fish, legumes, mushrooms, nuts, and grains contain NAM but if we do not consume enough in our diet, supplementation may be warranted. Those at the highest risk for deficiency would be those with conditions which impair absorption or limit consumption such as people with anorexia nervosa, malnutrition, alcohol use disorder, inflammatory bowel disease, and AIDS. Deficiency in NAM affects tissues that need high cellular energy such as the brain, gut, and skin. Supplementation with NAM is specifically recommended for patients with pellagra which is vitamin B3 deficiency presenting as dermatitis, diarrhea, and dementia.

Once ingested, NAM is converted into nicotinamide adenine dinucleotide, or NAD+. NAD+ is a necessary part of many different enzyme reactions in the body. It is especially an essential co-enzyme of redox reactions for adenosine triphosphate (ATP) production and lipid metabolism. Niacin which is converted to nicotinamide in the body is indicated for treatment of dyslipidemias due to its ability to reduce total cholesterol, apolipoprotein B, triglycerides, LDL, and VDL as well as increase HDL. In addition to supplementation with NAM for prevention of pellagra it has also been studied for the prevention of non-melanoma skin cancers in high risk patients.

Non-melanoma skin cancers are caused primarily by exposure to UV radiation. UV radiation increases the risk of skin cancer by damaging DNA, suppressing cutaneous antitumor immunity and inhibiting DNA repair by depleting cellular ATP. Since NAD+ is an essential cofactor for ATP production, it has been investigated for prevention of these cancers. It can prevent the ATP depletion and glycolic blockade induced by UV radiation which increases cellular energy and enhances DNA repair.

In a phase 3, double-blind, randomized, controlled trial the efficacy of oral nicotinamide for the chemoprevention of non-melanoma skin cancer in a high-risk population was studied. The 386 participants who had at least two non-melanoma skin cancers in the past 5 years were randomized to receive 500 mg of nicotinamide twice daily or placebo for 12 months. The primary endpoint was number of new non-melanoma skin cancer during the 12 months. At 12 months the rate of new non-melanoma skin cancer was lower by 23% in the nicotinamide group than in the placebo group (P = 0.02). Safety results showed no significant difference between the nicotinamide group and placebo group with limited side effects. These favorable results along with the low cost of oral nicotinamide supplements suggests that it may be a feasible option for the prevention of non-melanoma skin cancer along with other recognized prevention strategies such as limiting sun exposure and covering skin when exposure is unavoidable.

Resources:

Chen AC, Martin AJ, Choy B, et al. A phase 3 randomized trial of nicotinamide for skin-cancer chemoprevention. New England Journal of Medicine. 2015;373(17):1618-1626. doi:10.1056/nejmoa1506197

Fania L, Mazzanti C, Campione E, Candi E, Abeni D, Dellambra E. Role of Nicotinamide in Genomic Stability and Skin Cancer Chemoprevention. Int J Mol Sci. 2019;20(23):5946. Published 2019 Nov 26. doi:10.3390/ijms20235946

Green Tea

Common Name: green tea

Scientific Name: Camellia sinensis

What is it used for?

Tea has been used for medicinal purposes for thousands of years in China, Japan and India. Now, tea is the second most widely consumed beverage in the world. In traditional medicine, green tea is used as a stimulant, diuretic- to help rid excess fluids, and astringent- to control bleeding and help heal wounds. It is also used to treat gas, and regulate body temperature and blood sugar. Green tea improves mental alertness, relieves digestive symptoms and headaches, and promotes weight loss. It may also have protective effects against heart disease and cancer. There are studies indicating that the antioxidant properties of green tea may prevent atherosclerosis, particulary coronary artery disease. It may also lower total cholesterol and raise HDL (good cholesterol). Green tea may also help with inflammatory bowel disease by reduce inflammation in Crohn disease and ulcerative colitis. There is also a FDA approved topical ointment named Veregen, which contains sinecatechins or extracted components of green tea leaves, and is used for the treatment of genital warts.

How does it work?

The health benefits of green tea is thought to be due to polyphenols, which are chemicals with potent antioxidant potential. These antioxidants have antimutagenic, antidiabetic, antibacterial, antiinflammatory, and hypocholesterolemic properties. These polyphenols are classified as catechins- catechin, gallaogatechin, epicatechin, epigallocatechin, epicatechin gallate, and apigallocatechin gallate (also known as EGCG). EGCG is the most studied polyphenol component in green tea and the most active. Green tea also contains alkaloids- caffeine, theobromine and theophylline, which provides the stimulant effects. Lastly, it also contains L-theanine, which proves the calming effects.

What are some side effects?

Green tea is generally safe up to 8 cups per day. However, during pregnancy and breastfeeding, consuming green tea is safe up to 6 cups per day or no more than 300 mg of caffeine. Those who drink a large amount of caffeine may experience irritability, insomnia, heart palpitations and dizziness. Overdose of caffeine can cause nausea, vomiting, diarrhea, headaches and loss of appetite. Caffeine poisoning is when you start to vomit or have abdominal spasms after drinking a lot of tea.

With green tea extracts in pill form, there has been reports of liver problems such as abdominal pain, dark urine or jaundice. Therefore, people with liver disease should consult a health care provider before taking these products.

Are there any trials that support its use/non-use (efficacy)? Provide details.

· A 2006 meta-analysis of epidemiologic studies found that high intake of green tea was associated with a 20 percent reduction in the risk of breast cancer.

· A second meta-analysis found that high consumption of green tea was associated with an 18 percent reduction in the risk of colorectal cancer.

· 18,000 men were studied, and it was found that those who drank green tea were about one half as likely to develop stomach or esophageal cancer as men who drank little tea.

· 240 obese adults were studied for 12 weeks with a green tea extract beverage high in catechins and a lower catechin placebo; The results showed that the active treatment group had greater reductions in body weight, body mass index, body fat ratio, body fat mass, and waist and hip circumference.

· 40,000 Japanese adults were studied and it was found that green tea consumption was inversely associated with cardiovascular disease mortality.

· 1,000 Japanese adults in their 40s were studied and found no association between green tea intake and total cholesterol level.

· 240 Chinese adults with mild to moderate hypercholesterolemia who received a once-daily theaflavin-enriched green tea extract reduced their LDL by 16.4 percent ± 1.1 percent (P < .01) and their total cholesterol by 11.3 percent ± 0.9 percent compared with placebo.

Additional Considerations (Can include known drug interactions, special directions, etc.)

· Green, black and oolong tea comes from the leaves of the Camellia sinensis plant.

· To make green tea, the unfermented leaves from the plant are steamed, pan fried and dried.

· Among the teas, green tea contains the highest concentration of powerful antioxidants, polyphenols.

· The main component of green tea, EGCG, does not improve mental capabilities. It is the caffeine in the tea that prevents a decline in alertness.

· Amount of caffeine on green tea products indicates only the amount of added caffeine. It does not include the caffeine that are naturally in green tea.

· Green tea dietary supplements are capsules with dried leaf tea or liquid extracts made from the leaves and leaf buds.

· Average cup of green tea has 50 -150 mg of polyphenols. Decaffeinated green tea products contains concentrated polyphenols.

· 2 to 3 cups of green tea or 100 to 750 mg of standardized green tea extract per day is recommended

· Some drug interactions include adenosine, beta-lactam, benzodiazepines, beta blockers, blood thinning medications, clozapine, ephedrine, lithium, MAOIs, birth control pills, phenylpropanolamine, quinolone antibiotics, and others.

References

1. “Green Tea.” Mount Sinai Health System, https://www.mountsinai.org/health-library/herb/green-tea.

2. “Green Tea.” National Center for Complementary and Integrative Health, U.S. Department of Health and Human Services, https://www.nccih.nih.gov/health/green-tea.

3. Schneider C, Segre T. Green tea: potential health benefits. Am Fam Physician. 2009;79(7):591-594.

Asian Ginseng

Common Name: Chinese ginseng, Korean ginseng

Scientific Name: Panax ginseng

What is it used for?

It is an herb used in Chinese medicine for thousands of years, primarily to treat weakness and fatigue. Ginseng products are referred to as tonics or adaptogens, which means an agent that increases resistance to physical, chemical and biological stress and builds up general vitality. Asian ginseng is used to increase resistance to environmental stress and to improve well-being. It is also used as a dietary supplement to improve physical stamina, concentration, and memory; stimulate immune function; reduce the risk of certain cancers; slow the aging process and relieve various health problems such as respiratory and cardiovascular disorders, diabetes, depression, anxiety, menopausal hot flashes and erectile dysfunction.

How does it work?

It contains substances called ginsenosides or panaxosides, which are thought to be the active ingredient. It affects the hypothalamus-pituitary adrenal axis and the immune system. It also enhances phagocytosis, natural killer cell activity, and the production of interferon; causes vasodilation; increases resistance to exogenous stress factors and affects hypoglycemic activity.

What are some side effects?

Ginseng appears to be well-tolerated, but there are still side effects. If taken at high doses or with caffeine, it may cause nervousness or sleepiness. Some common side effects are insomnia, menstrual problems, breast pain, increased heart rate, high or low blood pressure, headache, loss of appetite and digestive problems. Some rare side effects are restlessness, anxiety, euphoria and nose bleed.

Are there any trials that support its use/non-use (efficacy)? Provide details.

· 227 healthy volunteers demonstrated that daily administration of 100 mg of ginseng for 12 weeks enhanced the efficacy of polyvalent influenza vaccine. Those who took ginseng had a lower incidence of influenza and colds, higher antibody titers and higher natural killer cell activity levels.

· 323 healthy volunteers were given 400mg of ginseng or placebo daily for 4 months. Those who had ginseng had fewer colds that were less severe and shorter than the colds of those who had placebo.

· 36 newly diagnosed non-insulin dependent diabetic patients were given 100 or 200mg per day for 8 weeks. The study showed improved fasting blood glucose levels, elevated mood, and improved psychophysical performance. Patients that took the 200mg dose also had improved hemoglobin A1C values.

Additional Considerations (Can include known drug interactions, special directions, etc.)

· Asian ginseng is a gnarled root with stringy shoots resembling a human body with 2 arms and 2 legs. The wrinkles around the neck of the root correspond to the age of the plant. Ginseng is not used as medicine until it has grown for about 6 years.

· There are white ginseng and red ginseng. White ginseng is dried and peeled, whereas red ginseng is unpeeled and steamed before drying.

· Asian ginseng supplements are made from the root and root hairs. They are available in water, water and alcohol, or alcohol liquid extracts, and in powders or capsules. They are also available as a decoction if the Asian ginseng root is boiled in water.

· The common daily dose of 200 mg of Asian ginseng extract or 0.5 to 2 g of dry ginseng root. Products with 4% ginsenoside content are standard.

· Asian ginseng should not be taken continuously, instead taken in cycles. For example, taking it every day for 3 weeks, then stopping for 3 weeks, and then restarting. It is a time-honored approach to strengthen the body and to treat the disease.

· Asian ginseng interacts with many medications such as ACE inhibitors, calcium channel blockers, anticoagulants and antiplatelets, caffeine, diabetes medications, including insulin, drugs that suppress the immune system, stimulants, MAOIs, morphine, furosemide, and others.

· Asian ginseng may also be unsafe to take during pregnancy.

· Asian ginseng should also not be given to infants and children.

· Check with a healthcare provider before taking Asian ginseng.

References

1. “Asian Ginseng.” Mount Sinai Health System, https://www.mountsinai.org/health-library/herb/asian-ginseng.

2. “Asian Ginseng.” National Center for Complementary and Integrative Health, U.S. Department of Health and Human Services, https://www.nccih.nih.gov/health/asian-ginseng.

3. Kiefer D, Pantuso T. Panax ginseng. Am Fam Physician. 2003;68(8):1539-1542.

Vitamin D Supplements

Common Name/Scientific Name:

Vitamin D3 / Cholecalciferol

What is it used for?

This supplement is given to adults who a vitamin D deficient, which can result in loss of bone mineral content, bone pain, and muscle weakness and soft bones.

How does it work?

Majority of the population receive less than optimal levels of vitamin D. The body naturally produces vitamin D through exposure to the sun. However, the sun is often not strong enough to meet the body’s needs. There are many reasons why the body isn’t able to produce the amount of vitamin D it needs. Some of these reasons are limited sun exposure during the winter months, older age, darker skin pigmentation, and use of sunscreen or clothes that shade the skin from the sun. Vitamin D is necessary for maintaining proper bone integrity, proper neuromuscular function, normal inflammatory response, muscle strength, proper calcium absorption, healthy immune response, and normal blood pressure. Having adequate vitamin D levels is also linked to decreased stress fractures, decreased injuries in athletes, and decreased rated of upper respiratory tract infections. Obtaining normal vitamin D levels can be through certain foods or supplements. Vitamin D supplements are fat soluble vitamins that can be taken orally and help the body absorb calcium and phosphorus. The absorption of calcium helps with building and keeping strong bones.

What are some side effects?

Vitamin D supplements are considered to be very safe and toxicity is very uncommon. The reason for this is because for vitamin d toxicity to occur, a healthy person would have to extremely large doses of vitamin D over a long period of time in order to reach dangerous or toxic levels of it. Some of the symptoms of vitamin D toxicity are chest pain, shortness of breath, growth problems for children taking cholecalciferol, weakness, metallic taste in the mouth, weight loss, muscle or bone pain, constipation, nausea, and vomiting. Although these side effects are uncommon, they can still occur if an individual were to overdose on vitamin D. However, vitamin D toxicity is more common in people with certain medical conditions. These conditions include granulomatous disorders, congenital disorders, some lymphomas, and dysregulated vitamin D metabolism.

Are there any trials that support its use/non-use (efficacy)? Provide details.

There have been many trials that have been conducted to evaluate the benefits of vitamin D supplements. I found a review article discussing the results of three different trials, VITAL, ViDA and D2d. These were all randomized trials and the combined number of participants of all three are over 30,000. One of the key takeaways from these trials are that Vitamin D and calcium supplementation can modestly decrease risk of major fractures in older adults. Also, there has been delays in age related bone loss and progression to type 2 diabetes and improved lung function. Another benefit is that they found vitamin d supplementation resulted in a modest decrease in cancer mortality, but has not affect on cancer risk. There hasn’t been any drastic or obvious benefits, with using vitamin d supplements, but correcting vitamin d deficiency remains essential.

References:

1. Bouillon, R., Manousaki, D., Rosen, C. et al. The health effects of vitamin D supplementation: evidence from human studies. Nat Rev Endocrinol 18, 96–110 (2022). https://doi.org/10.1038/s41574-021-00593-z

2. Spritzler, Franziska. “6 Side Effects of Too Much Vitamin D.” Healthline, Healthline Media, 15 Dec. 2021, https://www.healthline.com/nutrition/vitamin-d-side-effects#1.-Elevated-blood-levels.

Gastric Bypass and Nutritional Deficiencies

Gastric bypass is a type of bariatric surgery that is highly effective in treating obesity. It is a surgical procedure in which a portion of the stomach becomes bypassed, creating a smaller pouch, and connecting that smaller pouch to the small intestine. This means there is a large portion of the stomach that does not get involved during the digestion process. Once the procedure is completed, food eaten will go into the smaller pouch that was created, bypassing the other larger section of the stomach, and go right into the intestines. Because there is less room in the stomach, patients feel full faster and eat less causing weight loss over time. (Lupoli R, et al.)

Gastric bypass is used when diet and exercise have not helped to reach weight loss goals and the weight poses a large health risk to the patient. Drug treatment for obesity usually leads to a maximum of 15% of weight loss from baseline, but these effects do not last long. After about 1-5 years of weight loss from drug treatment, most patients gain the weight back and sometimes even greater than the baseline. Bariatric surgery has been proven to achieve greater weight loss and more importantly, have a lasting effect. Bariatric surgery is associated with a 42% reduction of CV disease and 30% decrease of all-cause mortality. All bariatric surgery, including gastric bypass, alters the anatomy and physiology of the GI tract causing deficiencies of nutrient absorption in some form. (Lupoli R, et al.)

There are a number of vitamin deficiencies that become evident during the first 4-6 weeks after bariatric surgery. This includes deficiencies in thiamine, riboflavin, folate, vitamin B12, and the fat soluble vitamins A,D,E, & K. Several studies have been conducted that confirm these nutrient deficiencies in patients who have undergone gastric bypass. The deficiencies can cause long term complications that could potentially offset the benefits of the surgery. It is important that patients are followed up after surgery to ensure that these deficiencies are not causing complications that can be avoided with vitamin supplementation. (Çalapkorur S, Küçükkatırcı H)

According to the American Society of Hematology, people who have gone through bariatric surgery show the highest risk of anemia. Anemia usually presents as fatigue, weakness, and cold extremities. 33%-49% of patients present with anemia 2 years after bariatric surgery. With gastric bypass specifically, it is 45-50% of patients. It’s important to note that many patients may have anemia prior to surgery, and it is recommended that patients be screened for this before undergoing surgery. Anemia post surgery is due to low iron as well as B12 deficiency as a secondary cause. There is decreased iron and B12 absorption because the duodenum and proximal jejunum are bypassed, which are the main sites of absorption. There is also a noted change in food preference, such as intolerance for meat and dairy products after the surgery. Folic acid deficiency can also contribute to anemia. Folate is absorbed primarily through the small intestine which is still intact after gastric bypass, so the deficiency is usually because of the shortage of dietary intake rather than non-absorption. (Lupoli R, et al)

Overall, there are a multitude of effects that can occur due to nutritional deficiencies after bariatric surgery which are significantly present in gastric bypass. They may present differently and health-care providers may confuse presentations with other disease states. In patients who have received gastric bypass, it is important to get a history and to be aware that symptomologies may be due to nutrient deficiencies.

References:

1. Lupoli R, Lembo E, Saltalamacchia G, Avola CK, Angrisani L, Capaldo B. Bariatric surgery and long-term nutritional issues. World J Diabetes. 2017;8(11):464-474. doi:10.4239/wjd.v8.i11.464

2. Çalapkorur S, Küçükkatirci H. Vitamin deficiencies and prevention methods after bariatric surgery. Mini-invasive Surgery. https://misjournal.net/article/view/3376#Cite_This_Article. Published March 11, 2020. Accessed December 9, 2021.

3. Gastric Bypass (roux-en-Y). Mayo Clinic. https://www.mayoclinic.org/tests-procedures/gastric-bypass-surgery/about/pac-20385189. Published October 17, 2020. Accessed December 9, 2021.

4. Seeras K, Acho RJ, Lopez PP. Roux-en-Y Gastric Bypass Chronic Complications. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519489/

5. Bariatric surgery procedures: ASMBS. American Society for Metabolic and Bariatric Surgery. https://asmbs.org/patients/bariatric-surgery-procedures. Accessed December 9, 2021.

Common Name/Scientific Name:

Turmeric, Haldo (North India), Manjal (South India),

Curcuma, Curcumin

What is it used for?

Turmeric, sometimes known as the “golden spice” is used for various things such as food spice, medicine, and even cosmetic use. It is what gives curry its yellow color and atypical flavor. It can be found in manufactured food products including canned beverages, dairy, baked goods, juices, cereals, and sauces. In traditional medicine, turmeric is believed to have medicinal properties such as giving the body energy, regulating menstrual periods, treating arthritic pain, and even helping to dissolve gallstones. Many countries in South Asia use turmeric as an antiseptic and as an anti-inflammatory agent. In India, turmeric paste is made and put on the skin of the bride and groom during traditional weddings. This practice is thought to keep harmful bacteria away from the bride and groom during their wedding day as well as make their skin glow.

How does it work?

Modern medicine has shown that turmeric is an antioxidant, anti-inflammatory, antimutagenic, antimicrobial, and anticancer agent. Some studies have shown that a certain level of turmeric ingestion is capable of providing antioxidant protection throughout the body. This antioxidant activity protects the body from free radicals, causes an increase in antioxidant enzyme levels, and inhibits the peroxidation of lipids.

What are some side effects?

There are few reported side effects of turmeric. It is generally safe in large amounts. Some reported side effects during trials using turmeric were diarrhea, headache, rash, and yellow stool. The patients reporting these side effects were receiving between 500 mg -12,000 mg of turmeric in a dose-response study.

Are there any trials that support its use/non-use (efficacy)? Provide details.

There are preventative and therapeutic studies of turmeric in animal models. In a study done to evaluate turmeric’s role in inhibiting chemical carcinogenesis in rats, it was found that turmeric extract helped to protect against genomic damage. In another study where a few fruits and vegetables were tested for their effectiveness in preventing dimethylbenz[a]anthracene (DMBA)-initiated and croton oil-promoted skin tumors, it was found that turmeric was the most potent nutraceutical used as the average number of tumors forms were significantly less than the others tested.

Additional Considerations (Can include known drug interactions, special directions, etc.)

The benefits of turmeric are mostly achieved through ingestion in food. A solid understanding of proper dosing, safety, and mechanism of action is not available for this supplement, as there have been no clinical trials to test it.

References:

1. Prasad S, Aggarwal BB. Turmeric, the Golden Spice: From Traditional Medicine to Modern Medicine. In: Benzie IFF, Wachtel-Galor S, editors. Herbal Medicine: Biomolecular and Clinical Aspects. 2nd edition. Boca Raton (FL): CRC Press/Taylor & Francis; 2011. Chapter 13. Available from: https://www.ncbi.nlm.nih.gov/books/NBK92752/#

2. Kotha RR, Luthria DL. Curcumin: Biological, Pharmaceutical, Nutraceutical, and Analytical Aspects. Molecules. 2019;24(16):2930. Published 2019 Aug 13. doi:10.3390/molecules24162930

Common Name/Scientific Name:

Elderberry/Sambucus Negra

What is it used for?

Elderberry has been traditionally used as alternative medicine to prevent and treat respiratory sicknesses such as the cold or flu. It has been sold over the counter for years and is given commonly to younger children who cannot take common cold medications such as ibuprofen or acetaminophen.

How does it work?

Elderberry contains a compound called anthocyanin, which is part of the overarching category of flavonoids that have possible anti-inflammatory effects. These anthocyanins attach to viral glycoproteins that allow the virus to enter host cells. By binding to the glycoproteins, the anthocyanins render the glycoprotein ineffective therefore not allowing the virus to enter the host cell. Elderberry may also influence the immune system via cytokines. It has been reported that elderberry may increase the production of inflammatory cytokines but also may reduce cytokine production.

What are some side effects?

Though elderberry is known to have beneficial effects the raw berries themselves can be poisonous and cause stomach problems. These stomach problems are caused by lectins that exist in small amounts of the bark, unripe berries, and seeds of elderberry. The actual berry must be cooked before it can be eaten. There is an estimated 3 mg of cyanide in about 100 grams of fresh elderberries, but this is not enough to be a fatal dose to a 60 kg person. Even so, elderberry that is sold or contained in any products commercialized do not contain this small amount of cyanide.

Are there any trials that support its use/non-use (efficacy)? Provide details.

There was a recent systematic review done to see if elderberry had any benefits or harms in treatment of viral respiratory infections, specifically analyzing the relationship of the inflammatory cytokines. 1187 records were screened that included 5 randomized trials on elderberry for the treatment or prevention of viral respiratory diseases. There were no studies that showed a clinical link to the use of elderberry, but there were 3 studies that looked at the production of cytokines after elderberry ingestion. The results from this study conclude that Elderberry may reduce the risk of developing a cold or lessen the severity. It may also reduce the severity of symptoms of influenza. There is no solid evidence for the use of elderberry and no evidence that it overstimulates the immune system in terms of cytokines.

References:

1. Wieland LS, Piechotta V, Feinberg T, et al. Elderberry for prevention and treatment of viral respiratory illnesses: a systematic review. BMC Complement Med Ther. 2021;21(1):112. Published 2021 Apr 7. doi:10.1186/s12906-021-03283-5

2. Mandl E. The pros and cons of elderberry. Healthline. https://www.healthline.com/nutrition/elderberry#risks-and-side-effects. Published March 12, 2021. Accessed January 28, 2022.

Green tea

Scientific Name: Camellia sinensis

Common Name: Green tea; Green Tea Extract; Tea

What is it used for?

Tea is arguably the most well-established and popular beverages with an extensively rich history dating back several millennia. What’s interesting is that the white, green, black, and oolong varieties all come from the same tea plant; the main difference between them is how they are harvested and stored and then ultimately processed. Green tea specifically is made by heating the green tea leaves directly after harvesting, usually through steaming, pan-frying, and drying, in order to halt the oxidation process and keep the tea leaves that bright green color. This gives green tea that fresh-picked flavor profile and is also the reason behind its many touted health benefits. Green tea has been purported to support mental alertness, relieve digestive symptoms, relieve headaches, and promote weight loss. It is also a potential candidate in the fight against cancer and heart disease as some state that its various components are able to delay and/or prevent these late-stage diseases. Moreover, “evidence from clinical trials suggests that green tea plays a role in metabolic syndrome because it may have an impact on body weight, glucose homeostasis, and other cardiovascular risk factors.” Additionally, there’s interest in its potential ability to prevent strokes, COPD, and UV damage. Lastly, there is an FDA-approved preparation called Veregen (sinecatechins) ointment that is indicated for the treatment of external genital and perianal warts in immunocompetent patients 18 years and older; it was first approved back in 2006.

How does it work?

To understand how green tea is potentially a remedy for all these diseases, we have to understand its complex chemical composition. The reason for its complexity lies within the fact that there are numerous components and factors that play a role in the formation of its chemical composition from maturation to harvest to processing. In essence, tea leaves contain a myriad of polyphenols in different quantities as well as caffeine, theanine, theobromine, theophylline, phenolic acids, minerals, and trace elements. Of the polyphenols, there exists also catechins, which play an essential role in preventing cell damage through various mechanisms. Not only that, but there also exists tannins, essential oils, riboflavin, niacin, folic, ascorbic, pantothenic, malic, and oxalic acids, all of which play a role in healthy body functions. There are, in total, more than 2,000 chemicals identified so far in green tea and the really important ones are the catechins, such as (-)-epigallocatechin-3-gallate (EGCG). These catechins are thought to be largely responsible for the aforementioned health benefits as they act as potent antioxidants. Their role as antioxidants are to essentially scavenge for free radicals in the body that cause DNA damage via reactive oxygen species. Moreover, these polyphenols are shown to inhibit tumor cell proliferation, induce apoptosis in laboratory and animal studies, inhibit angiogenesis, reduce tumor cell invasiveness, protect against UVB radiation, modulate immune system function, and provide detoxification enzymes, such as GST and quinone reductase. All of these characteristics are attributed to the potent antioxidant effects of tea, however, the precise mechanisms of action are still yet to be laid out.

What are some side effects?

· Excess intestinal gas

· Nausea

· Heartburn

· Stomach ache

· Abdominal pain

· Dizziness

· Headache

· Muscle pain

· Tachycardia

· Palpitations

· Insomnia

· Restlessness

· Nervousness

· Tremors

· Diarrhea

· Diuresis

· Dry mouth

· Nocturia

· Light-headedness

· Sore throat

· Increased appetite

Are there any trials that support its use/non-use (efficacy)? Provide details.

· A double-blind interventional trial involving 59 people with leukoplakia showed that 3 grams of mixed tea product given both orally and topically for 6 months elicited a partial regression in oral lesions in 38% of the participants, as compared to 10% in the placebo group

o There was also a lower percentage of patients with an increase in lesion size at the end of study

o Another study with 39 people showed no differences in response between green tea extract and placebo

· Two trials showed the effect of tea on a biomarker of oxidative DNA damage

o 8-hydroxydeoxyguanosine (8-OHdG) is a predictor of increased cancer risk and is especially concentrated in breast, lung, liver, kidney, brain, stomach, and ovarian tumor tissue

o One trial with 133 adult heavy smokers showed that green tea reduced urinary 8-OHdG levels by 31% while black tea had no change

o Another trial with 124 patients with hepatitis B and aflatoxin exposure showed that green tea reduced urinary 8-OHdG levels significantly after 3 months

o However, it’s inconclusive whether or not 8-OHdG levels are definitely linked to cancer risk

· A double-blind, placebo-controlled study with 60 men at increased prostate cancer risk showed that fewer prostate cancers were detected in the green tea extract group compared to placebo

o However, two other uncontrolled trials found no evidence of such a reduction

· Other trials with different other cancers also showed inconclusive or clinically ambiguous results

Green tea has been widely used in all regions of the world for thousands of years and many people correlate it to increased longevity. To some extent, there is definitely a potential for green tea to be helpful in all of these aspects; however, it is held back by improper study designs and the still explored and ambiguous realm of cancer risk identification. Though it’s relation to cancer is inconclusive presently, green tea is still very safe to consume as a beverage with most adverse effects only present in oral supplements and extracts. More than that, one could argue that there really is no harm in drinking green tea due to its non-existent toxicology and adverse reaction profile, with only the upside to consider in potential cancer risk prevention. Professionally speaking, I cannot either recommend or not recommend green tea for any medical purposes but it still is and will remain to