Common Herbs and Supplements Patients Use

1. Common Herbs and Supplements Patients Use Laura Dankof, MSN, ARNP

2. Objectives • 1. Identify common herbs and supplements being used by the general population. • 2. Discuss the potential benefits and risks of herbs and supplements beings used today. • 3. Evaluate the research behind the herbs and supplements patients use.

3. Why are patients using herbs and supplements? • People are taking a more active role in their healthcare. • Desire for a more holistic approach to care. • Seeking relief from chronic or terminal illness or side effects of conventional treatments. • Distrust in conventional healthcare (Barnes & Bloom, 2007). Less than 40% of patients discuss their use of herbal therapies with their healthcare provider (Wetzel, Kaptchuk, Haramati, & Eisenberg, 2003). • Inability to afford conventional care (Marchione & Stobbe, 2009).

4. Regulation and Marketing of Herbs and Supplements • In 2007 $33.9 billion was spent on Complimentary and Alternative Medicine (CAM), of which $14.8 billion was spent on herbs and supplments (NCCAM, 2009). • Dietary Supplement and Health Education Act (DSHEA) of 1994. • National Center for Complementary and Alternative Medicine. • Institute of Medicine.

5. Regulation and Marketing of Herbs and Supplements • Good Manufacturing Practices (GMP) • U.S. Pharmacopeia (USP) • Consumer Lab Program • Dietary Supplement Verification Program (DSVP) • NSF International Dietary Supplement Certification Program • National Product Association • Natural Standards (American Pharmacists Association, 2007).

6. Benefits: Active vs passive patient participation Less side effects Greater patient satisfaction Noninvasive Emphasis on nutrition Focus on healing (Life Extension Foundation, 2009; Pick, 2009; Shumway, Maskarinec, Kakai, & Gotay, 2001). Risks: Drug to Supplement interactions and contraindications. Adverse reactions Lack of regulation and monitoring. Out of pocket cost. Self diagnosing and delay in seeking medical care (NCCAM, 2009). Potential Benefits and Risks associated with supplement use

7. Arthritis Diabetes Hypertension Hyperlipidemia Depression Anxiety GERD Menopausal symptoms Common cold Insomnia Osteoporosis BPH Most common conditions where herbs and supplements are being used

8. Uses: Osteoarthritis (A) Venous insufficiency (C) Inflammatory Bowel Disease (C) Rheumatoid arthritis (C) Leg pain (C) Dosing: 500mg t.i.d. or 1500mg qd Safety: Likely safe: When used orally in studied doses of standardized products (500mg taken three times daily or 1,500mg once daily) for short durations by otherwise healthy adults. Possibly unsafe: Due to lack of sufficient data, may be unsafe in pregnancy and in children under the age of two years. Patients with shellfish allergies should avoid. ArthritisGlucosamine Sulfate

9. Adverse Effects: Tachycardia, photosensitivity, rash, GI upset, insomnia, drowsiness, headache, proteinuria, asthma exacerbation Precautions/Warnings/CI: May cause drowsiness, somnolence or insomnia. Possible link to asthma exacerbation Bleeding disorders or in those taking drugs that increase the risk of bleeding May increase insulin resistance with diabetes mellitus Use cautiously shellfish allergies Use cautiously in patients with renal impairments due to renal excretion of glucosamine hydrochloride Use cautiously in patients with active peptic ulcer disease as may cause GI upset Glucosamine Sulfate

10. Glucosamine Sulfate • Drug Interactions: • Acetaminophen • Anti-neoplastics • Anti-coagulants • Diabetic agents • Diuretics • Herbal Interactions: • Bromelain • Chondroitin • Fish oil • Vitamin C • Maganese

11. Uses: Osteoarthritis (A) Urinary Incontinence (B) Interstitial cystitis (C) Psoriasis (C) Muscle soreness (D) Dosing: 200-400mg 2-3 times daily, or 800-1200mg qd Safety: Likely Safe: When used for OA for up to three years. Use beyond three years has not been studied. Possibly Unsafe: When used with anticoagulants, NSAIDS, asthmatics, and with prostate cancer, or those individuals at increased risk for prostate cancer, due to theoretical risk of increased spread or recurrence of prostate cancer. Chondroitin Sulfate

12. Adverse Effects: Rash, photosensitivity, dyspepsia, diarrhea, constipation, pancytopenia, asthma exac., hair loss Precautions/Warnings/CI: Blood thinners, asthmatics, prostate ca, pregnancy, and breastfeeding Drug Interactions: Anticoagulants NSAIDS Photosensitizing agents Herbal Interactions: Vitamin E Omega 3 Fish Oil Melatonin Calcium Iron Peppermint oil Shark cartilage Chondroitin Sulfate

13. Uses: Diabetes (A) Neuropathy (A) Alcoholic Liver Disease (C) HIV (C) Kidney Disease (C) Pancreatic Ca (C) Wound healing (C) Dosing: 600-1800mg may be taken qd or in divided dose Safety: Likely Safe: No adverse or unsafe reports reported. Likely Unsafe: When allergic reaction is reported. DiabetesAlpha Lipoic Acid

14. Adverse Effects: Nausea, vomiting, dizziness Precautions: Diabetics, Thiamin deficiency, hypothyroidism, pregnancy, and breastfeeding Drug Interactions: Diabetic meds. Thyroid meds. Doxorubicin Adriamycin NSAIDS Herbal Interactions: Any herbals that may have similar effects as drug interactions (i.e. iodine, chromium, MSM, etc). Alpha Lipoic Acid

15. Uses: Diabetes (C) Hypoglycemia (B) PCOS (glucose Intolerance (B) Hyperlipidemia (C) Bipolar d.o. (C) Depression (C) Parkinson’s Ds (C) Obesity/weight loss (F) Dosing: 200-1,000 mcg qd Safety: Likely Safe: When used in otherwise healthy adults. May also be safe with pregnancy or breastfeeding. Likely Unsafe: When taking larger than recommended amts., or for extended periods of time When used with renal or hepatic insufficiency, iron deficiency, CNS agents, TPN, and diabetics Chromium

16. Adverse Effects: Glucose and insulin metabolism, nausea, vomiting, anemia, rhabdomyolysis, headache, insomnia, mood changes, renal failure Precautions/warnings/CI: Renal and hepatic insufficiency, iron deficiency, neurologic or behavioral d.o., diabetics Drug Interactions: Antacids NSAIDS SSRIs and MAOIs Antidiabetic agents Antihypertensive agents Antilipdemics Steroids, immunomodulators Cytochrome P450 agents Herbal Interactions: Calcium Biotin, Grapeseed Zinc Vitamin C Chromium

17. Uses: Type 1 and type 2 Diabetes (B) Hyperlipidemia (C) Weight loss (C) Dosing: 200 mg GS4 extract bid Possibly unsafe: When used with hypoglycemic agents Adverse Effects: Hypoglycemia Precautions/CI: Pregnancy and breastfeeding Drug Interactions: Antidiabetic agents Antilipedemic agents Antiobesity agents Herbal Interactions: Chromium Fat soluable vitamins Garcinia Gymnema

18. Uses: CHF (A) Anxiety (C) Hypertension (C) CAD/angina (C) Dosing: 160-900 mg per day in divided doses Safety: Likely safe: When taken in recommended dosage. Possibly unsafe: When used with other cardiovascular meds., herbs, or supplements (i.e. antihypertensives, vasodilators, and cardiac glycosides). When pregnant or breastfeeding. HypertensionHawthorn

19. Adverse Effects: Nausea, agitation, headache, dizziness, fatigue, dyspnea, rash, insomnia, diaphoresis, tachycardia Precautions/warnings/CI: Individuals at risk for hypotension, hypersensitivity/allergic reaction, cardiovascular drugs, and the elderly Drug Interactions: Antihypertensives (i.e. beta blockers, CCB, dig., nitrates) Metronidazole Antabuse Ephedrine Anticoagulants Herbal Interactions: Any herbal that would act similar to any of the above drug interactions. Hawthorn

20. Uses: CoQ10 deficiency (A) Hypertension (B) Cancer (C) Chronic Fatigue Syndrome (C) CHF (C) Adjunct to statin (C) Migraine Headache (C) Diabetes (D) Tinnitus (C) Exercise performance (C) Dosing: 100-300 mg qd Safety: Likely Safe: When taken in doses up to 300mg daily. Possibly Unsafe: Doses greater than 300mg may elevate SGOT and LDH. When taken with anticoagulants and liver disease. CoQ10 (Ubiquinol)

21. Adverse Effects: Nausea, rash, flu-like sxs.,diarrhea, elevated liver enzymes, headache, photosensitivity Precautions/warnings/CI: Biliary obstruction, hepatic insufficiency, pregnancy, and breastfeeding Drug Interactions: Antihypertensives Antilipidemics TCAs Coumadin Antineoplastics Immunosuppressants Herbal Interactions: Gingko biloba Saw Palmetto Garlic L-Carnitine Red Yeast Rice Fat soluable vitamins CoQ10 (Ubiquinol)

22. Uses: Hyperlipidemia (A) CAD (C) Diabetes (C) Dosing: 600-2400mg qd or in divided dose (bid) Safety: Use cautiously with muscular, hepatic, or renal dysfunction. Adverse Effects: Headache, heartburn, bloating, Increase liver fx., myopathy, rhabdomyolysis, dizziness Precautions/warnings/CI: Pregnancy, breastfeeding, allergy to yeast or molds; muscular, hepatic or renal dysfunction Drug Interactions: Alcohol, NSAIDs, anticoagulants, antifungals, antilipidemics, antihypertensives, antidiabetics, CYP450 agents, digoxin, thyroid hormones, antibiotics Herbal Interactions: Milk thistle, CoQ10, Niacin, St. John’s Wort, Vit. A, zinc, grapefruit HyperlipidemiaRed Yeast Rice

23. Uses: Hypertriglyceridemia (A) Hypertension (A) Cardiovascular disease prevention (A) Rheumatoid arthritis (B) Stroke prevention (C) Depression/mental illness (C) Dosing: 1000-3000mg qd (ratio 180mg of EPA to 120mg of DHA per 1000mg) Safety: Likely safe when used in recommended daily dose. Possibly unsafe: When used in high doses (3 grams of DHA plus EPA or 10 grams of fish oil). Increase risk of bleeding may occur. Adverse Effects: Nausea, reflux, bloating, low LDL, bleeding, Vit. E deficiency, rash, mercury contamination. Precautions/warnings/CI: Fish allergies, those using anticoagulants, and during preoperative period. Omega 3 Fish Oil

24. Drug Interactions: Anticoagulants, antihypertensives, antilipidemics Herbal Interactions: Gingko biloba, garlic, ginseng, black cohosh, grapeseed, arnica, vitamin E, tumeric, celery seed, bilberry, flaxseed, guggul, devil’s claw, bladderwrack, fenugreek, licorice root, evening primrose oil, passionflower, white willow, Vit. A., Vit. D., niacin, sweet almond, soy, horse chestnut, gymnema, aloe vera, bitter melon, burdock, milk thistle, maitake mushroom, rosemary, shark cartilage, calendula, hawthorn, wild cherry, coleus, and several other herbs…. Omega 3 Fish Oil

25. Uses: Depression (A) Anxiety (C) ADHD (C) OCD (C) Pain relief after surgery (C) PMS (C) Severe Depression (D) Dosing: 900-1500 mg qd in divided doses Safety: Likely safe when not taking other drugs. Likely unsafe in transplant patients on immunosuppressive therapy, drugs that use CYP450 pathway, when going through surgery requiring anesthesia, and when suicidal ideation. Depression/AnxietySt. John’s Wort

26. Adverse Effects: Fatigue, restlessness, anxiety, photosensitivity, sexual dysfunction, dizziness, headache, dry mouth, HTN, tachycardia, rash, nausea, vomiting, diarrhea, constipation, Precautions/warnings/CI: Avoid with suicidal ideation, with chemotherapeutic agents, prior to surgery, when using drugs using CYP450, and renal transplant patients. Drug Interactions: Anxiolytics, anesthetics, alcohol, anticoagulants, MAOIs, SSRIs, TCAs, fexofenadine, antifungals, statins, antineoplastics, antiretrovirals, carbamazepine, digoxin, parafon forte, BCP, immodium, immunosuppressants, omeprazole, opiates, theophylline Herbal Interactions: Gingko, 5-HTP, valerian, and herbals with similar action as above drug interactions St. John’s Wort

27. Uses: Cerebellar ataxia (B) Depression (B) Fibromyalgia (B) Headache (B) Sleep d.o. (C) Anxiety (C) Dosing: 100-300mg qd or in divided doses Safety: Likely Safe: When used in recommended dose for up to 4 months. Possibly unsafe: Use cautiously in patients with HIV, GI disorders, epilepsy, patients taking antidepressants, renal insufficiency, pregnant, or breastfeeding. 5-HTP

28. Adverse Effects: Heart palpitations, sclerodermatous changes, allergic reactions, rash, nausea, vomiting, heartburn, abdominal pain, diarrhea, flatulence, eosinophilia, mitochondrial encephalopathy, hypomania, irritability, Precautions/warnings/CI: Avoid in infants with Down’s Syndrome, eosinophilia, mitochondrial encephalopathy; use cautiously with TCAs, MAOIs, SSRIs, seizure meds., tramadol, zolpidem, renal insufficiency, HIV, epilepsy, mental do, pregnancy, and breast feeding. Drug Interactions: ARBs, antidepressants, antiepileptics, antipsychotics, CNS depressants, Ultram, CYP450 agents, lithium carbonate, pindolol, Herbal Interactions: Chromium, CYP450 herbals, L-tyrosine, SAMe, Magnesium, Melatonin, St. John’s Wort, thyroid agents, tryptophan, B6 5-HTP

29. Uses: Anxiety (A) Insomnia (C) Parkinson’s Ds (C) Stress (C) Dosing: 50-400mg qd 100mg tid is the most common dose. Safety: Likely Safe: When taken for short periods (<1-2 months). Possibly unsafe: In history of liver disease or when taking MAOIs. When taken >1-2 months there may be an increase risk of hepatotoxicity. Adverse Effects: GI distress, rash, tachycardia, headache, sedation, Precautions/warnings/CI: Liver ds, renal ds, pulmonary HTN, pregnancy, breastfeeding, Parkinson’s ds, or when operating heavy machinery. Kava

30. Drug Interactions: ACE inhibitors, alcohol, opiods, anxiolytics, anesthetics, antineoplastics, MAOIs, SSRIs, anticoagulants, benzodiazepines, beta blockers, CNS depressants, diuretics, CYP450 agents, BCPs, hepatotoxic agents (acetominophen, methotrexate, antigungals, steriods, amiodarone) Herbal Interactions: Guarana, gingko, chromium, ephedra, St. John’s Wort, tyrosine, valerian, yohimbe, 5-HTP, DHEA, DLPA, SAMe, Vit. B6, homeopathies, sepia, melatonin, calamus, calendula, catnip, capsicum, celery, ginseng, gotu kola, chamomile, hops, lemon balm, sage, skull cap, sassafras, shepherd’s purse, stinging nettle, yerba mansa, wild carrot, wild lettuce, and tyramine/tryptophan containing berverages. Kava

31. Uses: Reduced AEs of ATB (A) Atopic dermatitis (A) H. Pylori (A) Cirrhosis (B) Colon CA (B) Diarrhea (B) Dental caries (B) Immune enhancement (B) IBS (B) Pancreatitis (B) Ulcerative colitis (B) Asthma (C) BV (C) Sinusitis (C) DosingVaries with form of probiotic (Lactobacillus, Bifidobacterium, Streptococcus, Saccharomyces) and product (1-450 billion CFUs) Safety: Probiotics have been found to be safe in the general population. Probiotics have not been shown to have significant adverse effects, precautions/warnings/CI, or drug/herbal interactions. GERDProbiotics

32. Uses: Arthritis pain (C) Breast CA (C) Infertility (C) Menopausal sxs (C) Migraines (C) Dosing: 40-200mg qd in divided doses Safety: Likely safe: When taken for up to 6 months, and in individuals with a h/o breast or uterine CA. Possibly unsafe: During pregnancy or labor Adverse Effects: Potential effects with breast or uterine CA not known; fatigue, arrhythmia, rash, nausea, vomiting Precautions/warnings/CI: Use cautiously in h/o breast or uterine CA, thromboembolic ds, seizure do, liver ds, HRT, pregnancy, or breastfeeding. Menopausal Sxs.Black Cohosh

33. Drug Interactions: Anticoagulants, SSRIs, NSAIDS, CYP 450 agents, antineoplastics, Antabuse, hormonal agents, antifungals, alcohol, tamoxifen, raloxifene Herbal Interactions: Pennyroyal, chasteberry, Evening primrose oil, Phytoestrogens, CYP450 agents, willow bark, St. John’s Wort, Other menopausal herbals: Pomegranate extract (C) Evening Primrose oil (D) Flaxseed (C) Chasteberry (C) Sage (B) Soy (C) Black Cohosh

34. Uses: Cold prevention/tx (D) Scurvy (A) Iron absorption (B) Cancer prevention (C) Dosing: 60-2,000mg qd Safety: Avoid with sensitivity reactions Adverse Effects: Nausa, vomiting, heartburn, HA abdominal pain, flushing, dizziness, Drug Interactions: Acetaminophen, aluminum antacids, aspirin, barbiturates, fluphenazine, indinavir, levodopa, nicotine, tetracycline antibiotics, oral estrogens, warfarin Herbal Interactions: Lutein vitamins Common ColdVitamin C

35. Uses: Colds/URIs (B) Cancer (C) Immune stimulation (C) Radiation-assoc. leukopenia (C) Genital Herpes (D) Dosing: 300mg tid Safety: Likely safe: When taken for 8 weeks, pregnancy and children. Possibly unsafe: In cancer, AIDs, MS, autoimmune ds Adverse Effects: Urticaria, rash, nausea, vomiting, leukopenia, TTP Precautions/warnings/CI: Autoimmune ds, hemochromatosis, liver ds, Echinacea

36. Drug Interactions: Amoxicillan, anesthetics, antineoplastics, steroids, CYP450 agents, antifungals, immunosuppresants Herbal Interactions: Caffeine, vitamin B, goldenseal, Other cold/flu herbals: Astragalus (C) Vitamin D Andrographis (A) Sage (B) Zinc (C) Echinacea

37. Uses: Jet Lag (A) Insomnia (B) Anti-inflammatory (C) Age-related Macular Degeneration (C) Anxiety (C) Chronic Fatigue Syndrome (C) HTN (C) Menopause (C) RLS (C) Seasonal Affective do (C) Tinnitus (C) Dosage: 1-5mg @HS Safety: Likely Safe: Safe at 5mg for up to 2yrs. Possibly Unsafe: With hypotension, hormonal imbalances, psychotic do, pregnancy InsomniaMelatonin

38. Adverse Effects: Disorientation, hypotension, increase other hormone levels, hyperglycemia, nausea, vomiting, diarrhea, fatigue, dizziness, headache, irritability, drowsiness, seizure, mood changes Precautions/warnings/CI: Seizure do, diabetes, hormonal imbalances, psychiatric do, ADHD, pregnancy, and breastfeeding Drug Interactions: Anesthesia, anxiolytics, warfarin, anticonvulsants, antidiabetics, SSRIs, antihypertensives, antineoplastics, CYP450 agents, CNS depressants, haldol, HRT, INH, propofol, valproic acid, zolpidem, venlafaxine Herbal Interactions: Caffeine, chasteberry, DHEA, echinacea, folate, Melatonin

39. Uses: Hyperparthyroid d/t low Vit D (A) Hypocalcemia d/t hypoparathyroidism (A) Osteomalacia (A) Psoriasis (A) Rickets (A) Muscle pain/weakness (B) Osteoporosis (B) Cancer prevention (C) Diabetes (C) HTN (C) Dosing: 400 iu qd (RDA likely to be revised). Safety: Generally considered safe. Adverse Effects: Hypercalcemia Drug Interactions: Antacids, cholestyramine, steroids, Orlistat, mineral oil, laxatives, thiazide diuretics, OsteoporosisVitamin D

40. Uses: BPH (A) Alopecia (C) Hypotonic neurogenic bladder (C) Prostatitis (C) Prostate CA (C) Dosing: 320mg qd Safety: Likely safe at recommended dose. May be unsafe with bleeding disorders or pregnancy. Adverse Effects: Abdominal pain, diarrhea, fatigue, nausea, headache, decreased libido, rhinitis, HTN, tachycardia, increase risk of bleeding in hypercoagulable states Precautions/warnings/CI: Bleeding do, hormone sensitive conditions, HTN, pregnancy BPHSaw Palmetto

41. Drug Interactions: Testosterone, Proscar, Lupron, Casodex, warfarin, NSAIDs, Antabuse, immunomodulators, Herb Interactions: Echinacea, soy, red clover, iron Saw Palmetto

42. HCG Diet • Human Chorionic Gonadotropin is hormone produced only during pregnancy. • HCG first used in 1930 by Dr. A.T.W. Simeons to treat obesity. • Claims: decrease appetite, mobilize fat burning cells through action in the hypothalamas, while sparing muscle cells. • Research: No quality studies have shown that HCG itself helps weight loss. Rather, the following of a very low calorie diet is likely the reason for weight loss regardless of the use of HCG (Mayo Clinic, Rowan, Dale).

43. HCG Diet • 500 calorie diet along with daily injections of HCG (expensive at ~$600/month). • Homeopathic HCG drops are cheaper and safer. • HCG side effects: headaches, mood swings, depression, blood clots, confusion, dizziness, ovarian hyperstimulation, pelvic pain, SOB, diarrhea, nausea, vomiting, immune suppression.

44. Homeopathy • Homeopathy is from 2 Greek words, homoios: meaning similar and pathos: meaning suffering. Homeopathy therefore means similar cures similar or like cures like. • The word Homeopathy was first coined by Samuel Hahnemann, the founder of modern homeopathy. • Homeopathic medicines are micro-dosed natural substances derived from botanical, animal or mineral sources. The medicine is diluted or de-concentrated and then vigorously shaken, traditionally referred to as succussion. This process transforms the original substance into a therapeutically active medicine. • Homeopathy is a safe and natural method to balance the body and allow the body to heal. Incredibly small amounts of homeopathic substances are needed to aid in healing. (Dale, 2011).

45. Homeopathy • SIMILLIMUM - the remedy that most closely matches to a person's set of unique symptoms. • Potency - the strength of a homeopathic remedy. You will see the potencies referred to as, 12X, 6C, 30C, 10M or 6LM. • X stay in the body a short period of time and can be used safely for repeat dosing. X potencies are used for 1st Aid, trauma,recovery from injury, preventative dosing, sudden illness, seasonal problems, general family use. • C are used for first aid, seasonal ailments and chronic health concerns. 200C is in the high range of the C potencies. . • M potency is used for health problems or constitutional treatment. Very high potencies may stay working in the body for months. High LM potencies are very popular and safe for dealing with children’s ailments, sensitive people and emotional issues.

46. Homeopathy • Homeopathy has survived years of scathing criticism; yet is prospering. In the U.S., consumer sales of homeopathic treatments reached $870 million in 2009, growing 10 percent over the previous year, according to Nutrition Business Journal estimates. • For example, Oscillococcinum, is sold in 60 countries. Estimated annual retail sales in the U.S. are more than $20 million, according to the manufacturer, Boiron. It ranks 49th out of 318 cold and flu brand products that do more than $1 million in sales. Other popular homeopathic products include arnica gel for bruises and strains and diluted zinc remedies for colds (Dierdorff, 2011).

47. Homeopathy • Research: • Homeopathic research has been published in peer reviewed journals and has shown positive clinical results. Several studies have confirmed the biological activity of homeopathic medicines (Montagnier, 2010). • The North American Society of Homeopaths has published numerous current and ongoing studies in the field of homeopathy (Homeopathy, 2011). • An in vitro study showed cytotoxic effects on breast cancer cells with homeopathic dilutions (Frenkel et al., 2009).

48. References • American Pharmacists Association (2007). Popular herbal and dietary supplements. • Barnes, P., & Bloom, B. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. U.S. Department of Health and Human Services: National Center for Health Statistics (No. 12, pp. 1-24). • Dale, T. (2011). Homeopathy. Retrieved March 15, 2011, from www.wellnesscenter.net. • Deardorff, J. (2011). Homeopathy prospers even as controversy rages. Retreived March 3, 2011, from www.PhysOrg.com. • Frenkel, M., Mishra, B., Sen, S., Yang, P., et. Al., (2009). Cytotoxic effects of ultra-diluted remedies on breast cancer cells. International Journal of Oncology 36, 395-403. • Life Extension Foundation. (2009). The need for complimentary alternative cancer therapies. www.lef.org.

49. References • Marchione, M., & Stobbe, M. (2009). Americans spend $34B for alternative medicine. AP Medical Writers. Retrrieved July 31, 2009, from http://news.yahoo.com. • Mayo Clinic (2011). HCG diet: Is it safe and effective? Retreived February 26, 2011 from www.mayoclinic.com. • Medicine & Health (2011). Homeopathy prospers even as controversy rages. Retrieved March 13, 2011 from www.physorg.com. National Center for Complimentary and Alternative Medicine. (2009). Are you considering CAM? www.nccam.nih.gov. • Montagnier, L. (2010). French Nobelist escaptes “intellectual terror” to pursue radical ideas in China. Science 330, 1732. • Natural Standards (2010). www.naturalstandard.com.

50. References • North American Society of Homeopathys (2011). www.homeopathy.org. • Rowen, R. (2011). Some alternative doctors recommend this diet-but here’s why you should stay away. Second Opinion, 21, 5-7. • Shumway, D., Maskarinec, G., Kakai, H., & Gotay, C. (2001). Why some cancer patients choose complimentary and alternative medicine instead of conventional treatment. The Journal of Family Practice. 50 (12). • Wetzel, M., Kaptchuk, T., Haramati, A., & Eisenberg, D. (2003). Complimentary and alternative therapies: Implications for medical education. Annuals of Internal Medicine 138, 191-196.