Chevy Chase Trust BLOG

STEVE HULL: Thank you all so much for coming. Our format today would be a moderated discussion followed by a Q&A. Our Georgetown panelists are, from the far left: Dr. Ladan Eshkevari, Assistant Professor and Assistant Program Director of the Nurse Anesthesia Program at Georgetown; Dr. Leena Hilakivi-Clarke, a Professor of Oncology, who studies the effects of soy foods on breast cancer, in addition to her work with vitamin E and breast endometrial cancer; Dr. Tom Sherman, Associate Professor of Pharmacology and Physiology and an expert on endocrine hormones as well as nutritional medicine. Our host-moderator, and my friend, will be Stacy Murchison, who is Managing Director of Chevy Chase Trust.

STACY MURCHISON: Thank you, Steve, and welcome everyone. Your interest in today’s program really serves as evidence of the increasing curiosity about ancient remedies and therapies currently being used by more than one out of every three adult Americans –pretty impressive number.
Georgetown University Medical Center is one of only 40 academic medical centers that teach medical and other graduate students about evidence-based eastern medical treatments. The official term is Complementary and Alternative Medicine or CAM, and that’s the term we’re going to be using throughout the discussion today. So let’s get started.
Tom, you’re first here. Until we started speaking in June, I was unaware that Georgetown University was the first university in the country to create a Master’s Degree in Complementary and Alternative Medicine. Certainly we’re all seeing an increase in the prevalence and availability of eastern medical treatments, such as Tai Chi, massage therapy, acupuncture, circling and the like. Can you give us some of the history associated with Georgetown’s decision to offer this course of study and why was it important for the university to take this step?

THOMAS G. SHERMAN: Well, the first and the only degree-granting program in Complementary and Alternative Medicine. It’s actually a very interesting history and speaks to the interest of a lot of different faculty that share the different aspects of our normal research and almost a hobby, if you will, into stress reduction, nutrition, herbs, acupuncture, and with the huge increased use among the public, it was felt like there was a need to start training our physicians to be at least familiar with their patients’ use of complementary and alternative medicine.
So, about a dozen years ago or so, one of the faculty in physiology, Adi Haramati, wrote a large grant to the National Center for Complementary and Alternative Medicine to get funds to try to incorporate some CAM teaching into the medical curriculum.
And as part of this large grant, they wanted us to form a graduate program, and so another of my colleagues, Dr. Myers took that on and, I have to admit, just shaped a very interesting program because there is no academic field for CAM. Depending on who you talk to, it’s pseudoscience, it’s all charlatanism. And he created a program that not only allowed us to look at what evidence supports some of the modalities of complementary and alternative medicine but in fact supports conventional medicine. And probably the real surprise for us at the time was not that there was mixed support for different CAM modalities but really how little evidence there was for many treatments in conventional medicine.
We’ve just investigated this whole thing, and the idea really and why it was important to us in Georgetown even though it exposed us to critics, I think what was important to us is that we wanted these students in the medical and going on to medical school to be open to some of the treatments that their patients were using and be able to have the conversation with these patients.
And that something that will come up from all three of us today is that what is really different and powerful about complementary and alternative medicine practitioners is that they talk and listen to their patients and make them partners in healthcare. So we wanted doctors who understood that and didn’t say, “Oh no, you’re taking herbs,” which I’m sure you do.

STACY MURCHISON: More and more primary care physicians are referring their patients to various forms of eastern remedies, and for our purposes, remember we’re using this name complementary and alternative medicine or CAM in today’s discussion. There’s naturopathic, chiropractic, osteopathic medicines, acupuncture, Chinese herbal medicine, among others. Many of us are a little bit confused about what these different terminologies mean, what these practices are, so I’m hoping to get some help from our panelists here today, and I’ll ask Tom to begin by helping us understand what is meant by the term “complementary medicine” and how do we determine each today.

THOMAS G. SHERMAN: So, complementary medicine is probably the most common form of complementary and alternative medicine, and it’s really blending both conventional and CAM practices to try and reach some health goal. So, people will continue to go to their physicians, they may continue to take prescription medication or other medication but will combine that with even nutritional remedies or herbs or acupuncture or chiropractic care or any number of things. So, they’re doing a mix and a match to come up with something that they are comfortable with, they have more control over their own healthcare and ideally will find a physician who will support that, and so “complementary” – complementary to conventional medicine.

STACY MURCHISON: What exactly is alternative medicine? How are eastern principles fused in western medicine, and how is it involved with what you are doing?

LADAN ESHKEVARI: So, whereas complementary medicine is more adjunct, so you would be doing your everyday … let’s say you suffer from high blood pressure and you’re taking your blood pressure medicine and you start to go to yoga because you understand that that might help, that’s complementary. Alternative would be if you were to stop taking your blood pressure medicine altogether and just go towards eastern medicine, for example, to control your blood pressure. So you would maybe do yoga and tai chi, maybe use acupuncture for stress reduction and try to exercise a lot more. So that’s more kind of the difference where, in one place, you were using it more as an adjunct, whereas in another place you’re using it as the sole treatment. So, that’s the biggest difference.

STACY MURCHISON: OK. Leena, could you help us out with the definition of conventional medicine?

LEENA HILAKIVI-CLARKE: So that is the—can you hear me?—western evidence-based medicine. And, as Tom mentioned, the best way perhaps nowadays is to try to combine that with different forms of medicine, and I can give you an example from my own research how it works. And so I’m in the business of trying to prevent breast cancer, and that is a very broad goal, because you know that one in eight women get breast cancer during their lifetime but 80% of these women have no known risk factors, so we don’t really know what is causing breast cancer.
Tamoxifen—you are probably familiar with—it is used to treat breast cancer and it seems to be also very effective in preventing breast cancer in high-risk women. But if a woman is at high risk, she doesn’t necessarily want to take tamoxifen, because tamoxifen causes also different side effects. It puts a woman to menopause, and so she starts to have hot flashes. It increases the risk of endometrial cancer and can have some other very severe side effects.
So the best way to try to prevent breast cancer is to find a natural way to do it, and the natural way might be some dietary factors that we should consume every day, and so there might be lots of promise in actually preventing breast cancer in perfectly healthy women without causing side effects.

STACY MURCHISON: Let’s talk a little bit about the effectiveness of the practice and modalities that fall under complementary and alternative medicines. Are these ancient medicines based on scientific evidence at all, or is their reputation really anecdotal in nature, passed down through the generations?

LADAN ESHKEVARI: So I think probably a little bit of both, probably mostly anecdotal. So I am more familiar with Chinese medicine. That’s part of my training, Chinese medicine and acupuncture. So, a lot of Chinese medicine is anecdotal. It’s passed from one generation to the next to the next, and that’s all the evidence that they need. You know, my great grandfather was a practitioner, I pass it down, you’re learning the trade, and then you will pass it down, and so on and so forth. So, a lot of it is anecdotal, and that’s why as someone who may be using it, you have to be very cognizant of what there is evidence on and what there isn’t.
But there’s also some very good evidence recently for things like acupuncture. There have been some really great studies done. At the University of Maryland, for example, there’s a group that does a lot of acupuncture research, and they found, for example, that for knee osteoarthritis, acupuncture is really a nice adjunct and it really does improve quality of life. So that’s spring in 2000.
And then, there’s physiologic evidence as well. So my work is on acupuncture and stress, for example, and my research was on animals because a lot of the idea is, well, what if it’s just placebo? What if the fact that you’re talking to a practitioner and they are touching you with needles and what if there’s a placebo effect? So I did my study on rats and I chose some placebo whites and I chose traditional Chinese medicine so as not to stress the rats, and I had some very good results that have been accepted for publication and something.
So there is some evidence but there is also a lot where there is no evidence. So an example of where there is no evidence, I’m sure you guys are all familiar with the Washingtonian magazine, and probably three or four years ago there was an article in the Washingtonian about beautifying yourself as a woman. And, you know, it was all about spas and all of those things, but a part of that was also acupuncture for wrinkles.
So, for a few months when I was doing my research and doing pain management with acupuncture, my female patients in particular would ask about acupuncture for wrinkles, and I was getting a little frustrated because acupuncture doesn’t work for wrinkles. There is no such thing. It might make you relaxed and so you might relax your wrinkles for a day, you know. I also practice anesthesia and so I could tell them, “Well, I do work with a lot of very good plastic surgeons, and if you don’t want to have wrinkles, that’s the one you should go to.”
So, you know, there are lots of things that people use it for or … and, you know, the Washingtonian is very reputable. It’s is a good place to go to see what’s the best restaurant to go to next. It’s not necessarily the best place to go to see what to do about wrinkles. So I think there is something to be said about it. If you are going to use alternative medicine or complementary medicine, you really have to do some homework. So there is some that has evidence and some that doesn’t.

LEENA HILAKIVI-CLARKE: So in terms of the nutritional health, there is lots of evidence that nutrients have what I want to call unique biological changes that can be linked to the disease a person would like to treat. For example, in cancer treatment, fish oil can be used in addition to the conventional cancer treatments, and the fish oil then will help with the conventional therapy to kill the cancer cells. And there are several other nutritional factors where we know that they have biological functions that they might be working the way we want them to work. I think more of a problem in nutrition is that they have so many different biological functions that we want to focus on one, and then if that doesn’t work and then we think, “OK, that nutrient is not necessarily involved in preventing or treating what we want to.”

THOMAS G. SHERMAN: Well, I think evidence, certainly in nutrition and then in all fields, just comes in lots of flavors, and certainly I think there are many aspects of what constitutes evidence that has to take into account biases by the researcher, alternative or conflicts of interests by sponsoring organizations. There’s all of these other things that just because somebody does an experiment and comes up with a result doesn’t mean that that is real evidence. And that certainly can be true in nutrition and that’s certainly true in a lot of other fields. And as more and more of our research gets handed to corporations that have their growing interests and interests to their shareholders, then people just need to be aware of that.
And the other aspect, of course, is arrogance of the researchers, and certainly that’s been very true in nutrition, and most of you have lived through the low-fat era. You’re living through the low-carbohydrate era. You’ve lived through countless bran muffins. You’ve lived through margarine. You’ve lived through trans-fat. Most of these were recommendations that were made with perfectly good intention but no evidence.
And so, moving towards evidence-based nutrition, for example, is a real challenge, and giving you good data from humans is a real challenge, and getting unbiased, un-conflicted results is a real challenge. But it’s good because if you put together good experiments and you put together good study groups and responsible cohorts and nice epidemiological statisticians or whatever, you can come up with good data, and I think we’re moving towards that era and this idea of low-fat diets is just not making real sense, and this idea of … we saw trans fat go away as a result of good data showing its correlation with coronary heart disease.
So I think coming from nutrition as a biochemist and being interested with metabolism sort of gives me a grounding in evidence that really helps in nutritional recommendation. But at the same time, you can’t just pretend like you know the answers, and sometimes it seems like a good idea and you just have to qualify it, because you don’t really know it, in view of the population.
And, you know, some it is the scientific method, and really it can be fair. Sometimes you get a result and then the lab gets a different result, and people continue to replicate these studies until they come up perhaps with a consensus. So what we view as just things switching day and night and things going back and forth or sensationalism by journalism, you know, it’s just not the science that’s involved. They are just working out the method and trying to come up with data.

STACY MURCHISON: OK. Ladan, will you clarify for us what you were talking about? I mean the first, the mind-body connection?
LADAN ESHKEVARI: Sure. Everything in your body obviously is controlled by your brain. I mean, we all know that. If you didn’t have a brain, most of your systems wouldn’t operate. So, the mind-body connection is there and it is real, that your mind can help your body. And so it’s basically that idea that, for example some people like yoga or tai chi or deep breathing or guided imagery can really help you in terms of relaxing your body and getting your autonomic system, which is your fight-or-flight versus your relaxation system to kind of work together to bring you down to a certain point.
So there would be definitely more evidence that some of these methods work, but I have to tell you one of the things that we practice in anesthesia a lot is if you’re having pain and I give you some medication, I’ll be giving it by IV. It’s going to take a good few minutes for it to peak. So while it’s peaking, I always tell my patients, “OK. Come to the beach with me. I’m at the beach. We’re hanging out. We’re having a cocktail. We’re just starting to relax,” and I just go through that guided imagery.
And to me, you know, I don’t have any evidence that it’s working, because I haven’t collected data or any of that, but you can certainly see people start to relax a little bit more. And I always tell them, “Let the medicine work,” because if your mind is so caught up in just the pain, even the medications that we know, and we have written evidence that they do work, don’t work as well, so there is definitely a mind-body connection in there.
And, you know, for those of us who do stress research, it is very evident that if you are under stress, which is basically a brain setting off a whole slew of physiologic effects, it’s going to have an effect. It is. It’s going to cause depression. It’s going to cause anxiety. It’s going to cause lots of physiologic distortions, and the stress pathways are classic, and they have been studying it for years and years, and that’s, again, that mind-body connection from a physiologic perspective.

STACY MURCHISON: My follow-up question is going to be about stress and, you know, everybody is complaining about stress…

LADAN ESHKEVARI: Yes.

STACY MURCHISON: And avoiding stress. Do you have one area over another that you would recommend for stress reduction?

LADAN ESHKEVARI: Well, in anesthesia it’s easy, because we have drugs. So if you’re stressed, I can give you drugs and it will go away. [Laughter] So the benzodiazepines are our friends in anesthesia, but obviously not all of us can be doing that on a regular basis.
And I think there’s lots of good evidence for exercise as a stress reducer, certainly mind-body techniques, tai chi—and I think Leena teaches some of that in Georgetown, so she can probably speak to that quite a bit—things like tai chi and certainly acupuncture. Acupuncture is very useful in stress reduction. There is more and more evidence for that coming about, but certainly that’s another very good practice in terms of.
And you can try talking. You know, they are doing some research now and, you know, calling up a friend and saying, “I’m stressed, and this is why I’m stressed,” and even just taking it out of yourself and out there and putting it on a friend or something like that is helpful.
So, there are lots of different things that you can do. Because stress is real; it is very real and it does affect us. It affects you physiologically, and there is lots of evidence for that. So the better you can control your stress … and we all have it. I mean, we are all moms, dads, grandparents. We all have, you know, life is stressful and we really have to try to bring it really down under control because it can affect you.

STACY MURCHISON: Leena, do you mind touching on tai chi or …?

LEENA HILAKIVI-CLARKE: Not tai chi – meditation.

LADAN ESHKEVARI: Meditation. I’m sorry.

LEENA HILAKIVI-CLARKE: Add to the list of adverse effects of stress … we are studying in my lab. I have a student who studies the impact of stress on breast cancer, and the way she stresses the animals is to isolate them, so solitude is also stress. And the reasons he gives them … they can be high-fat diet or normal diet, and if they are stressed by not being able to play with the other girls and they get the high-fat diet, they are very, very prone to breast cancer.
So in terms of ways to reduce the stress, I am a runner and exercise certainly helps. But when I first, perhaps five years ago, was asked whether I was interested in deep thinking meditation class at Georgetown for the graduate students and medical students, I was like “all this time I have never meditated. I’m very, very, very stressed out, I have no time!” But first of all, she asked me to see Sam. The one who brought this to Georgetown was Nancy?

THOMAS G. SHERMAN: That’s right.

LEENA HILAKIVI-CLARKE: And she said, “A couple of your colleagues and the two of you would be very good in doing this.” I said, “OK. If it helps me release my stress, I will take the training and let’s see what happens.” And it was so … it totally changed me. So now I’m sitting behind the wheel and earlier I have to get someone. Now I’m just OK, relaxed state, a couple of deep breaths.
And I highly recommend that if you are being stressed out and have never tried this meditation, it works very well. It can be, just try this, you can take a couple of deep breaths and just letting your mind to be totally free of any thoughts, and in a minute you will feel much better. But you have to go through that training to really get the essence of it. But it’s really, really powerful for releasing stress.

STACY MURCHISON: Tom, what about nutrition? Let’s talk about the role that good nutrition plays. I mean, we can start by just defining good nutrition. Does it mean consuming specially grown or specially prepared foods? What does it mean?

THOMAS G. SHERMAN: You know, a good diet constitutes a lot of different factors but if … so if there’s anything that has been proven in nutritional research, it would be what our parents told us: that a diet rich in fruits and vegetables, diets that are rich in polyunsaturated fats and mono-unsaturated fats, diets that incorporate lots of leafy green vegetables are good for us. And I think that what constitutes a good diet are going to be diets that address many of the chronic diseases of today. For example, if you look at obesity, if you look at diabetes, if you look at hypertension, if you look at cardiovascular disease and hypercholesterolemia or any of this sort of so-called chronic disease that plague modern civilization, they’re all nutritional-based, and that our diets for the most part have been warped by just the modern days and the fact that we are lucky enough to live in a country that has a wealth of foods, and these foods need to be marketed to somebody.
But some of that nutritional advice is a little bit skewed, and I think when you come to real evidence-based nutrition, it really is avoiding excessive carbohydrates, avoiding processed foods, and eating a nice balance that probably would be best characterized by some version of the Mediterranean-style diet. Don’t avoid animal products unless you’re doing so on a personal or religious or whatever reason, but eat a diet rich in fruits and vegetables and oils.
I would encourage people to … you know, we are trained to think of things as low-fat as being good for us, and that’s just not the case, and that what we really should focus on are plant oils, olive oils, fish oils, complex oils, and instead avoid excess carbohydrates in our diet. And then, I think we would make tremendous strides towards relieving many of these chronic diseases.
You know, our lives … our children are, for the very first time, they have life expectancies that are shorter than ours and that’s because many of us have these chronic diseases.

STACY MURCHISON: OK. So as a follow-up question, should we all be headed to Whole Foods after this is over to buy our fruits and vegetables? Is that, you know … do we need to be focused on going to the Farmer’s Market, Whole Foods?

THOMAS G. SHERMAN: You know, I think there is a lot to be said for locally grown produce. I think there is a lot to be said for minimizing carbon footprints. I think there’s a lot to be said to understanding where our food comes from, and I really do find that I think reasons for buying organic foods and locally produced foods and minimally processed foods and humanely grown foods are not because those foods are inherently better for us. The evidence for that is essentially nonexistent. The reason for eating foods like that is because they have fewer pesticides and they have fewer herbicides, and that if we choose to eat more of those products, I think it’s part of our responsibility to eat animal products that are humanely grown and are humanely fed, you know, humane processes and things like that. So I think it’s a personal choice obviously.
But if you go to a farmer’s market here and your farmer’s circle or anywhere else in the best and then you’re talking to say, “There’s no organic produce here,” and the farmer might say, “Oh, we’re not certified organic or small farm. We haven’t gotten our certification yet, but I can tell you I don’t use herbicides, I don’t use pesticides. My goats roam free, my cows roam free,” and so you’re talking to the food producer, and they’ve told you where their food came from, and you can trust that for the most part. And I think there’s an advantage to that.
So I think thinking about food and understanding where it comes from and what part and place they grew right is just as important about the food itself because, as Leena and Ladan say, you know, coping with stress is an important thing and coming up with constructive ways to cope with stress is important, and that doesn’t involve coping with stress by overeating and coping with stress by other maladaptive or counterproductive measures.

STACY MURCHISON: But how about herbal medicine? I mean, should we drink it? Should we take it in pill form? Is it safe? Can you overdo it?

LADAN ESHKEVARI: Yes, you can overdo it. That is for sure. So herbs are interesting. Herbs are very useful. Actually, a lot of our drugs come from herbs. So, for example—I don’t know if any of you have ever had heart disease or know someone who has—but digoxin is a very popular heart disease medication and it comes from foxglove. And, you know, our classic opioid pills, for example, come from opium, so morphine, all of those, the parent drugs were the opium, and they’re derivatives. So obviously herbs are very useful.
But you have to be very careful in this country because the herbs are not regulated. In the United States, the FDA regulates our drugs but they don’t regulate the herbs or actually any of the nutritional supplements, so you have to be very careful and I’ll you what I mean by that.
So if you, let’s say for example, ginseng is very useful for your stomach. Ginseng root is actually a very nice remedy for stomachaches or stomach problems, and it’s used a lot in eastern medicine and in Europe. But let’s say that you decided to try ginseng and so you go to Whole Foods, which is very reputable, so you go and get a bottle of ginseng and you read it and it tells you, claiming it has ginseng root 20%.
And what scientists have done, actually locally, I think in the University of Maryland, there’s a group of scientists who do this on a regular basis. They go to GNC, Whole Foods, Trader Joe’s and other various places, and they get the drugs off the shelf, and they’ve done research to see what exactly is in those formulations. And what they found is that unfortunately a lot of the time there’s nothing in them.
So, you’re paying … if it says 20% ginseng, it might even not have what it’s saying it has, so you have to be very careful. If you are going to be taking herbs or herb formulations, it’s probably to get a European brand because the Europeans, in particular the Germans, regulate their herbal remedies just like they do their drugs, so that if you get 20% ginseng, you are sure that there is 20% ginseng and that it is the ginseng root.
So because they regulate it, they have tighter regulation. If you are thinking about getting herbs, I would highly recommend that you look at the bottle. And they do sell them; they sell them at Whole Foods. You can get it at an apothecary. In fact, there’s a good apothecary near Bethesda, Village Green Apothecary, and they sell a lot of the European brands, so you will see it says “distributed in the U.S.” but “made in France” or “made in Germany.” So, if you’re going to take herbs, I would recommend those types of herbs.
There’s lots of Chinese loose herbs as well that come in the formulations of teas, so to your point of drinking. Obviously, it’s a plant and it’s visible. You can see the specific plant and you’re making a tea of it; it should be a lot more reliable and harmless. But unfortunately, a lot of those herbs, because they are not controlled as well, may have trace elements in them, and that’s not because … it’s not intentional. It’s just because China and some of the countries where they are grown is very industrialized. And so because of that, you might have trace elements in the herbs that you might be inadvertently taking.
So, I don’t know how many of you watched the show called “Entourage.” Well, there is this show on HBO, “Entourage,” and the lead character in that, Ari Gold is this big Hollywood agent, and the actor actually was due to go on Hollywood, on Broadway, and do a live version of Entourage. He became very ill and he went to the hospital, and what they found was that he had mercury poisoning, and the reason being that he was taking a lot of Chinese herbs that were laced with mercury and he had no idea. And mercury is extremely dangerous. So, for a long time he couldn’t get a job other than to be a [thermometer]. So, you have to be very conscientious of where you’re getting your herbs and herbal products.

STACY MURCHISON: Do you want to elaborate on this, Tom, on the supplements? Nutritional supplements?

THOMAS G. SHERMAN: That’s a very good … yes, I get a lot of questions about nutritional supplements, and in certain … there’s in mediology called “nutritionism,” and it was coined by a food writer in Australia. It was made very popular here Michael Pollan who writes about it. It’s a craft in mediology that essentially argues that what is important about food is what we know is in it, and so we don’t eat carrots because they are crunchy and fresh and sweet, but we eat carrots because they have beta-carotene. We don’t eat avocados because they’re creamy and rich; we eat them because they are a good source of monounsaturated fats.
And we can go on and on about all different kinds of foods, and the truth is for most vitamins and phytochemicals and all of these range of chemicals that exist within foods, whenever we do trials (and this is particularly true for antioxidants) that when we do trials with individual antioxidants, that the trials are largely negative. And not because we assume that because beta-carotene is a powerful antioxidant that exists in carrots that it must be the important ingredient that makes fruits and vegetables so effective. It is not true.
It’s just one of hundreds of carotenoids in foods, and all foods that are rich in these trace amounts of phytochemicals and there’s no doubt that it’s this combination that’s critically important and not just one thing that we have isolated from garlic or one thing that we have isolated from cranberry juice or whatever, and so, it’s the mixture that’s important. And so, taking supplements and things with a few exceptions, certainly fish oils and some things are useful supplements, for the most part, you know, I will encourage you to eat good food.
And that’s also remembering, and I meant to mention this earlier, that you eating a diet rich in fruits and vegetables will lower your blood pressure into the same extent that for a normal first-line antihypertensive would. Taking fish oils will lower your blood pressure to the same extent as a normal first-line antihypertensive. In using food as medicine to avoid a cholesterol-lowering drug for the rest of your life or taking an antihypertensive for the rest of your life, I think it’s a smart choice to begin with and just see.
Can I control certain illnesses? Can we control cholesterol? Can I control my blood pressure? Can I control my blood sugar, my weight loss by eating fruits and vegetables and avoiding simple carbs without having to go to some of these other medications that I will be on for the rest of my life? So it seems like a reasonable place to start.

STACY MURCHISON: OK. We gave our audience members an opportunity to write in questions prior to this day’s event, and we do have a question from one individual who wanted to ask about really chronic autoimmune diseases, and in particular this person was asking about Meniere’s disease. Do any of you all know any remedies that can be used to help with Meniere’s disease?

THOMAS G. SHERMAN: I looked into it last time, and I don’t have any exciting news. I will tell you that. So whenever you have a condition that we don’t really understand, and this would be characterized as very debilitating, it can be extremely debilitating, and people become desperate. And so you’re willing to try just about anything, and that’s just perfectly understandable, and we all have many examples of similar cases. And Meniere’s disease is definitely in this category where there isn’t a particularly effective treatment certainly in the can-do range.
I will tell you that I went to several really good, unbiased sources of information. Surgery seems not to be an option; it really is not effective. Some infusions with steroid hormones seem to be effective. Gingko biloba comes up quite a bit; it’s a vasodilating agent. There’s a sense that by opening up blood flow to the inner ear you may regain some balance, and so … it certainly had mixed results. I read some studies that look perfectly reasonable where they had significant results and other studies also seem perfectly reasonable where they have negative result.
So this is definitely in the category of where there isn’t a great solution. There isn’t a good solution to the problem, and I’m going to encourage anybody who is sort of in that situation to try and balance responsible self-care with your obvious desire to come up with a remedy. Sometimes there just isn’t any good remedy.

LADAN ESHKEVARI: So the only time I have ever seen Meniere’s patients has been in the operating room for anesthesia and surgery, and I know that the surgical outcome isn’t always useful, and so then the question becomes, “Well, how about just improving quality of life and symptom management?” And for that I think, given that the brain is very plastic, we increase your neuroplasticity by doing certain exercises perhaps or making something to that effect, and then the steroids. These are the things that I can recommend.

STACY MURCHINSON: Can you just explain what the disease is all about?

LADAN ESHKEVARI: What’s that?

THOMAS G. SHERMAN: It’s an autoimmune disease of the inner ear that leads to tinnitus or ringing in the ear, unbalance, dizziness, vertigo, and so typically in mild cases, you know, it seems manageable, but it can be very debilitating where you just feel like you’re going to fall down and you have a constant ringing in your ears. And so, different aspects of that seem to be amenable to either steroid treatment or perhaps vasodilation, but certainly, as a syndrome, there wasn’t an obvious first form of treatment.

STACY MURCHISON: OK. We’d like to open the question-and-answer session to the audience members. Carlton, are you here with the mic, please?

THOMAS G. SHERMAN: There’s a woman here who’s had her hands up the entire session.

STACY MURCHISON: Yes.

AUDIENCE MEMBER: This is a practical question. Is it true that there are some CAM procedures that are covered by Medicare?

LADAN ESHKEVARI: I don’t know about Medicare. I do know that some insurance companies, for example, will cover chiropractic medicine as well as acupuncture. I don’t know about Medicare. I’m not familiar with that.

AUDIENCE MEMBER: I believe that Medicare covered a portion of my mother’s acupuncture, but they have a certain point they will discontinue that and I don’t know if she met the level or if she should go beyond that or after that.

LADAN ESHKEVARI: So in terms of acupuncture, there’s definitely a prescription.

AUDIENCE MEMBER: Yes.

LADAN ESHKEVARI: So for example, if you are going in for pain management, which is why a lot of people go to acupuncture, the treatment regimen is basically two to four weeks of twice-a-week, depending on how bad the pain is, and then another month of once-a-week, and then maybe another couple of weeks, and that should usually … so there’s a treatment regimen by which your issue should be resolved.

AUDIENCE MEMBER: Yes, that’s about how it went.

LADAN ESHKEVARI: Yes.

AUDIENCE MEMBER: And then we did about six months, and then didn’t go any more while we waited until it was time to go back again.

LADAN ESHKEVARI: That’s exactly right. And so a lot of insurance companies that do cover acupuncture, and perhaps Medicare as well, will cover it for that traditional Chinese medicine regimen, and then they will stop. But then if your issue comes back or worsens, I think they do have to restart it, but then they’ll have to stop at the end of the treatment regimen.

AUDIENCE MEMBER: Thank you very much.

LADAN ESHKEVARI: Of course.

AUDIENCE MEMBER: You were speaking about Meniere’s, I believe an autoimmune disease. What does the alternative or CAM community do about the genetic links- if you ever see that in the family? And what is the … has any investigation drawn into …? Obviously, people have genetic issues and have had that for millennia. Is there any kind of recognition of that or anything that you know of or speak of?

LEENA HILAKIVI-CLARKE: I will say that some of the things that you mentioned I think are genetic. I’m pleased to say genetic in the sense that they are caused by alterations in the DNA, so by mutations—if you’re comfortable with that term—that something is wrong with your DNA strand and you inherited it from your parents and therefore you also have the disease.
There is, for example, now evidence that breast cancer, inherited breast cancers are not caused by inherited mutations, but they are caused by inherited epigenetic changes, and these epigenetic changes … I’m not going into details but they are reversible. They don’t alter the DNA. They alter the genes programmed to be finished first or not.
And there’s more and more research on that area and there it’s possible to actually reverse the, let’s say increasing breast cancer risk by using drugs that reverse these epigenetic changes, and there’s also nutrients that reverse these epigenetic changes, so more research is needed on the actual, what are the bases of these inherited diseases. Are they caused by mutation or are they caused by epigenetic changes that are inherited? If they are caused by epigenetic changes, then they might be treatable.

THOMAS G. SHERMAN: To answer your specific question, there are a group of very chronic, again, very painful diseases that exist at the interface between our gastrointestinal system and the bacterial flora that occupy our intestines. And this is a field that is shockingly complicated and underappreciated, and certainly we have a group of bacteria that greatly outnumber the number of human cells that we have in our body that play a very critical role in our immune response and that play a critical role in metabolism of foods.
And the interplay between our bodies and these bacteria is very important, and there are many things that we do, both by the foods we eat and toxins we are exposed to, the kinds of medicines, the antibiotics that we take that really play this interface. And if you disturb the … you know, so we recognize these bacteria as beneficial, but once you start disturbing this immune recognition, then you get inflammation and pain and disease that manifest itself in many of these different chronic gastrointestinal disorders.
And it’s just very unclear how they’re best treated, and there are many physicians now who look at replacing the bacteria with beneficial flora and doing cleanse, like that, with very interesting results. But it’s just hard to extrapolate and move beyond anecdotal evidence until you get big, double-blinded, placebo-controlled trials that we move by and remove investigator expectation. But we just have backups here and they’re just very difficult to do on humans.
So I don’t want to think we’re beginning to understand this interface. We don’t understand it enough to treat Crohn’s disease and celiac disease and many of these other diseases that have autoimmune components and perhaps genetic predispositions and dietary constraints and all of that, so it is very complicated.
AUDIENCE MEMBER: Are any of you familiar with the current out there, “The Emperor of All Maladies”?

THOMAS G. SHERMAN: “The Emperor of All Maladies,” I think I’ve heard –

AUDIENCE MEMBER: I’m wondering if it’s a reliable depiction of the history of cancer and cancer research?

LEENA HILAKIVI-CLARKE: What is this called?

THOMAS G. SHERMAN: “The Emperor of All Malady”?

AUDIENCE MEMBER: “Emperor of All Maladies.”

AUDIENCE MEMBER: It’s a war on cancer. It’s “The Emperor of All Maladies.”

THOMAS G. SHERMAN: Yes it is

THOMAS G. SHERMAN: Well, I will definitely allow Leena to answer the one on the soy protein, but a low-carbohydrate diet is not new. If we think of Atkins, if we go back to 1856 monograph by Dr. Banting who had been doing the same thing and so many earlier than that. And every other generation or so, somebody recognizes the advantage of eating pure carbohydrates and their ability to lose weight, they write a book and they make lots of money because of that. And then, it’s goes away and then we get a little fat and then we go to something else.
But the evidence that the amount of calories that we eat influences our weight is very weak. The evidence that you can lose weight by going on a calorie-restricted diet is very weak, and instead the evidence suggests that by constantly eating carbohydrates and maintaining a state where insulin, our main carbohydrate response hormone, is constantly making and storing fats instead of mobilizing them so that we can use it, it’s just keeping weight in our bodies.
And so by eating foods that are low in carbohydrates and not avoiding your fruits and vegetables, by just avoiding the excess amount of high-fructose corn syrup and potatoes and pastas and rice and breads that we love to eat but we just eat too much off, and it’s not so much that we’re eating pure calories, we’re just avoiding carbohydrates to allow us to mobilize our fat so that we can use it for energy and get back to a normal balance between stores and use.
So I’ve never been one to advocate a strict low-carbohydrate diet the way that Dr. Atkins did, but that I will recognize that most of the obesity and the data would suggest that that exists, because we just eat too much carbohydrates, and we keep attempts to just lower the sugars in our life that would give us tremendous evidence.

LEENA HILAKIVI-CLARKE: And it’s not only the obesity. It’s the type-II diabetes…

THOMAS G. SHERMAN: Absolutely.

LEENA HILAKIVI-CLARKE: –which is increasing dramatically in the population and that the high-carbohydrate diet most likely contributes to it. OK. So, I’ll give you a little bit of a history. So because women in Asian countries have very low breast cancer risk, compared to breast cancer here, and then the men have much lower prostate cancer risk than men here, and they eat soya in Asian countries whilst soya consumption is very low in the west, it caused us to believe that soya is the answer to reducing breast and prostate cancers.
In terms of the prostate cancer, it’s probably true, and so men should include soy to the diet, and that’s probably helpful in trying to prevent prostate cancer. I would also eat tomatoes, the all-tomato pasta, if I was a man wanting to have no prostate cancer.
OK. So, in women, soya and breast cancer, it was initially thought that soya contains this compound, genistein, that is very similar to the natural estrogen that it could work as an anti-estrogen, and that is how to prevent breast cancer, but there is no evidence to support that. Genistein is an estrogenic compound, so can women eat estrogenic food and expect to have reduced breast cancer risk? So, the evidence at the moment suggests that if soya foods are consumed during childhood that primes the breast, so that later on the woman has a much lower risk of getting breast cancer.
And there is now also studies that women, who, after their breast cancer diagnosis, consumed soya had a much lower risk of getting reoccurrence, but that is mainly Asian women. So a woman who has consumed soy throughout her life, if she gets breast cancer, she can safely continue consuming soy and that probably helps her not to get any reoccurrence, so the chances she would be cured, in a sense, is increased if she continues consuming soy.
There are also studies done in women here in the west who do not consume very much soy, and there is no evidence in those studies that women who consume soy in the Caucasian countries would be at increased risk of getting breast cancer or can or would be at increased risk of getting breast cancer the first time, but there’s no evidence that it would be protective either.
So, I know that there are some studies now being prepared for publication, which can show more and more evidence that soya is very beneficial after breast cancer diagnosis; it reduces the risk. Just be aware that if you have never consumed soy before, do not stop because we don’t know. These are observational studies done in humans, whether who has no feel or any manipulations per se. These women have most likely been Asian who have been consuming throughout their life, and that women here who consume soy, have never consumed it before they get the breast cancer.
I don’t think that there are too many women at the present time who stopped consuming soy, but when … after the diagnosis. But when they hear about these studies, they might think, “Hmm, I really don’t want my breast cancer to reoccur. Perhaps I should start consuming because the studies show that it’s good for me.”
I would recommend do not stop consuming high levels of soya products. You can use soya foods as a part of a balanced diet, and that is perfectly safe. Particularly the supplements, women should avoid using them, whether they have breast cancer or not. Soya supplements, isoflavone supplements are, in my mind, no-no. Even for men who have the symptoms, there is no evidence that soya can be helpful in trying to reduce prostatitis.
In fact, I have just read a study that was published this year where they gave women 200 mg of soya isoflavone supplements in the pill form. So two years when they were taking these, there was no beneficial benefit for bone, and the women who were taking these pills—they didn’t know whether it was soya or a placebo pill—they actually had no prostatitis.

STACY MURCHISON: We are out of time. I think we have time for just one more question.

AUDIENCE MEMBER: I was wondering — OK. You were saying that the risk of breast cancer related to genetics, and I’m assuming you’re talking about the BRCA1 and BRCA2 gene is really more related to epigenetic factors, if I understood you well.

LEENA HILAKIVI-CLARKE: So, in terms of the family of breast cancers, the BRCA1 and 2 mutations are the ones that we know of are related to inherited breast cancers, but of the inherited breast cancers, they explained perhaps 30% always, so there’s 70% of women who have a very high incidence of breast cancer in their family but no specific mutations have been found. So in those cases, it is very likely that there’s actually epigenetic changes that happened.

AUDIENCE MEMBER: You mentioned that there are drugs for these epigenetic mutations- what were they?

LEENA HILAKIVI-CLARKE: So there are, these drugs are called DNA methyltransferase inhibitors, and HDAC inhibitors. They are used to treat lots of different common cancers. But there are lots of dietary compounds that have the same properties. For example, cruciferous vegetables and green tea can have the same properties as these drugs. So in terms of prevention, it doesn’t hurt to drink a cup of green tea a day or include some broccoli in your diet.

THOMAS G. SHERMAN: So broccoli –

LEENA HILAKIVI-CLARKE: It’s cruciferous vegetables.

THOMAS G. SHERMAN: The cruciferous vegetables.

STACY MURCHISON: This concludes the question-and-answer part of the program. I’m going to invite Blake Robison, who is the artistic director of Round House Theatre. [Applause]

BLAKE ROBISON: We just want to thank Stacy and the Chevy Chase Trust for bringing this informative and wonderful event to our building. You know, I found that part about the “Entourage” actor to be very interesting, because we know friends who have to pull out his Broadway production because he had mercury poisoning from eating too much sushi. Everybody in the theater industry knows it was because he couldn’t learn his lines. That’s what I know from my part of the story.
I see some familiar faces out here. Round House family members, welcome. If you’re new to Round House, if you’re just in this building for the first time, I just want to say this: Another way to reduce stress is to enjoy a thought-provoking and entertaining evening of theater with your friends and neighbors. So we hope that you’ll come back and see us. Thank you.