A Landmark Work on Clinical Nutrition

An interview with Alan Gaby, MD by Daniel Redwood, DC. Dr. Gaby s past-president of the American Holistic Medical Association. He has been contributing medical editor for the Townsend Letter for Doctors since 1985, and contributing editor for Alternative Medicine Review since 1996. His new nutrition textbook, Nutritional Medicine is the culmination of a 30-year project.

How would you describe the quality and quantity of clinical nutrition education at the medical school you attended at the time you were there? And could you also speak about nutrition education at medical schools today.

There was virtually no nutrition education when I went to medical school. They taught you what the vitamins were in biochemistry class, and the implication was that no one needs to take them because the average diet contains adequate amounts. There was no discussion about food allergy except the obvious anaphylactic reaction that would cause asthma, for example, if someone would eat peanuts. So the answer is “essentially zero.” Today, I haven’t closely monitored what’s being taught, but my understanding is that some of the medical schools offer integrative medicine electives, where they cover some of this material. But as far as I know, it’s not part of the core curriculum at any conventional medical school.

It has always struck me that using nutritional supplements to treat disease is conceptually very similar to using pharmaceuticals to treat disease. But the medical profession seems to have largely ceded this area to CAM practitioners – chiropractors and naturopaths in particular – which seems quite odd. Is there something in the history of nutrition in the medical profession that would explain this?

I’ve attempted to figure out why that is. There is no question that there is a bias against micronutrient supplements in conventional medicine. There was actually an article in 1998 in the Archives of Internal Medicine on attitudes about micronutrients in conventional medicine. This was not written by an apologist for nutritional therapy; it was an academician who was bemused by the fact that he repeatedly observed negative attitudes regarding nutritional supplements. When there was news of toxicity, it was welcomed uncritically. When there was news of effectiveness, it was essentially ignored. And there were disparaging remarks made about this kind of approach which were not made about any other controversial field, using terms like “deplorable.”

So where does this come from?

I think it’s multi-factorial. One is that professions, in general, are not so keen on alternatives that can be administered by the people themselves. For example, I would guess that accountants are not that pleased about Turbo Tax. Medical doctors are not pleased that someone can go to the health food store and take care of themselves. That’s one aspect. Another aspect, which is probably more important, is that nutrients are in direct conflict economically with pharmaceuticals, and the pharmaceutical industry has a long history of funding research that appears to be designed to produce negative results with nutrients, and putting press releases and other information out there that cast this in a disparaging light. Part of it is inertia — since nutritional therapy is not taught in medical school, people assume that it has no value, and then the assumption that it has no value keeps it from being taught in medical school.

There’s no good reason for it. There are reasons but none of them are acceptable reasons and I think that if the medical profession were to embrace this, there would be a reduction in the cost of health care and an improvement in overall health. And certainly a great reduction in toxic reactions to drugs, because we would use far fewer drugs.

What’s right and wrong with today’s typical American diet?

There’s not a lot that’s right. There are four or five major factors that are contributing to a wide range of conditions. Refined sugar and high-fructose corn syrup, to begin with. There’s some evidence that high-fructose corn syrup causes even more adverse effects than sucrose, which it has replaced to some extent in the diet. Trans fatty acids, which still comprise 5-7 percent of calories in some diets, are another problem. They don’t occur in nature except in small amounts in dairy products, and the kind that occurs in dairy is actually different than the kind you get in margarine. There’s evidence that trans fatty acids contribute to heart disease, possibly cancer, and possibly nonalcoholic fatty liver disease, which is becoming an epidemic.

There are refined flours, which account for 30 percent of our calories. Refined flours are depleted of fiber and depleted of between 30 and 90 percent of various micronutrients. Then we have overheated foods, heavily cooked food, particularly meats, which form a number of different toxic compounds when heated to high temperatures. One of these is advanced glycation end products, which may promote diabetes complications, cardiovascular disease, and renal disease.

There’s also the fact that we tend to eat the same foods all the time. For many people, 90 percent of calories are derived from sugar, wheat, dairy products, and a couple of other foods. For people who have an allergic constitution, repeatedly eating the same foods can lead to the development of food allergies. And food allergies appear to be a major contributing factor to a number of different chronic illnesses.

So those are the major points. Of course, some people consume too much alcohol, too much salt, or too much caffeine.

You’ve given us a list of what’s bad in our diets. What’s good?

What’s good is that people can make choices. People can choose to eat a very healthful diet. It’s just that not enough of us do. We tend to have food addictions. There’s evidence now that refined sugar is addictive, and not just in the sense that it causes blood sugar swings and that when the blood sugar drops we have to eat more. There’s also evidence that it creates an addiction through the opioid system in the body. There was a very interesting animal experiment where they fed rats sucrose or glucose in their drinking water and then gave them an injection of nalaxone, which is an opioid antagonist. After receiving naloxone, the rats went through typical manifestations of narcotic withdrawal. On the other hand, when they fed them the usual diet without the sugar in the water, and then gave them naloxone, nothing happened.

Are you assuming that this will apply to humans as well?

I am assuming that it might, based on my clinical observation that so many people are addicted to sugar.

If a patient comes to you and says that he doesn’t want to change anything about his typical American diet (with the sugar, the fat, and so on) but he wants you to prescribe the right regimen of vitamin and mineral pills, what do you say to him?

Well, that happens frequently. [Laughter] What I say is that I will be happy to do that, as long as you are aware, and accept, that your results will be far below optimal. If they’re okay with that, I will work with them, because I think it’s better to have fair health than miserable health. Depending on the person’s condition and what their current diet is, I will sometimes say that for you, 15 percent of your health benefit will come from supplements and 85 percent will come from diet and lifestyle changes. And that if you’re willing to be satisfied with the 15 percent, let’s do it. But I try to push them to make the changes and sometimes it works, because people want to be healthy.

So supplements should be supplementary, not the main course.

Right. Of course, there are certain medical conditions where diet may not be the most important thing. Let’s say somebody comes in with heart failure. They need coenzyme Q10 and magnesium and a few other things, and diet is secondary for them, other than the fact they shouldn’t have too much salt. If you can improve cardiac function with nutrients, then you do it. So there are certain situations where nutrients are paramount and other situations where they are less important. Lifestyle modification is encouraged for everybody, but more strongly pushed for some than for others.

As I’ve been reading your new book, Nutritional Medicine, again and again I’ve noticed that alongside references from relatively recent research, there are references from research from 50 or more years ago that seems to have been almost completely forgotten by later generations of doctors. Why do we have to keep reinventing the wheel?

Some of this research was forgotten and some was ignored from the beginning, and never even known.

Can you give an example or two?

One good example is riboflavin, vitamin B2. Back in the 1940s and 1950s, there were two different studies that showed that moderate doses of riboflavin (such as 15-30 milligrams a day) can reduce the recurrence rate of migraine headaches. This apparently never got any traction back then, but after 40 years passed, in 1998 and again in 2004, there were studies showing the same thing. Here’s an interesting sidelight. Roger Williams, who wrote Nutrition Against Disease, was my mentor. His son, who is now in his 80s, contacted me about four years ago. He had learned about riboflavin for migraines and some of his friends were essentially cured of their migraines by taking it. He was so surprised that when he tried to talk to doctors about this, none of them would listen to him. He tried to tell them, he showed them the research, and they said, “Well, if it worked, everyone would be doing it.”

There’s that circular reasoning again. It’s tough to break the pattern.

There is a bias against this type of therapy. You keep demonstrating it and people keep ignoring it. One of the reasons I cited older studies in my book is to demonstrate the historical fact that this has been out there for a long time and has been ignored. But also, in some cases these early studies are the only ones that were ever done. Nobody ever followed up on the original findings.

There was some work from the 1920s on using a bone marrow and spleen extract to treat anemia. Certain types of anemia respond to that. I’ve had occasion, two or three times over the years, to use this treatment. And it worked, just like they said in that research in the 1920s. So I think we have a tendency to be what I call “modern chauvinists.” We make an assumption that the most recent is always the best. But it’s been argued that about a third of medical “advances” are in the wrong direction.

Because these nutrients are not patentable, so there’s no economic motivation for a corporation to push the research, or push the therapy, because they can’t make money on it.

Exactly. With a few caveats, they aren’t patentable, although some companies have been trying their darnedest to patent some of these things. For example, pyridoxal phosphate, which is the biologically active form of vitamin B6, has been studied by a small company and they’re working hard to prohibit other people from selling it. Thus far, they haven’t been successful. Melatonin is another example. Someone tried to get a use-patent on melatonin and one of the manufacturers selling it at the time was interviewed by the Wall Street Journal, and he said, “I thought God owned the patent on melatonin.”

I teach clinical nutrition to senior level chiropractic students, and one of the things we discuss as a challenge is that it’s not unusual to have a major news story and for a period of years this explanation is accepted and becomes common knowledge. But then, new research comes out that seems to contradict the earlier conclusion. I think that many members of the general public tune out at a certain point. Could you talk about this?

Are you referring to drugs and nutrients?

I was talking about nutrients but it would apply to medications, too. Also, the initial story could be about something (a component of food or a drug) being really harmful, but then years later we find out that the issue is much more complex.

We’re seeing that a lot, particularly in the past few years. Or we’re seeing stories about potentially beneficial treatments that [according to new research studies] don’t work. For example, supplementing with vitamin E, or lowering homocysteine levels with B vitamins, didn’t prevent heart attacks. Things like that.

There are two factors involved. Number one is that somebody out there is paying somebody to get these reports covered by the press. This all hearsay, but I have a colleague who is involved in the political side of alternative medicine, and she told me that she was at a cocktail party one time, and nobody knew who she was. She was standing next to some pharmaceutical people and they were bragging about how easy it is to issue press releases regarding the negative effects of nutrients.

For example, when there was one study showing that St. John’s wort didn’t work for depression — even though it was a very poorly designed study and it contradicted about 20 other studies that say it works – it made the front cover of Newsweek. So there is a press machinery in place to cast a negative light on nutrients. The other thing is that the researchers themselves don’t always understand the complexities of nutrition, and as a result they will sometimes design studies that won’t really answer the questions they are looking at.

Let’s take vitamin E, for example. Vitamin E was actually shown to increase the risk of developing heart failure in people who already have high cardiovascular risk. The problem is that researchers are all using pure alpha-tocopherol, which is only one of the four forms of vitamin E in nature — alpha, beta, gamma and delta. There is now evidence that alpha-tocopherol in high doses depletes gamma-tocopherol, and gamma-tocopherol has numerous health benefits for the heart and elsewhere. So to conclude that vitamin E doesn’t work, based on a study where only alpha-tocopherol was used, is not appropriate. What we really need is well-designed studies, expert analysis of the research, and appropriate conclusions. But the media tends to be shallow. They just want a story.

The more dramatic the better.

Exactly. We have to look at the whole body of evidence in an unbiased way, know our biochemistry, know our clinical nutrition, and come up with reasonable conclusions based on the available evidence. Unfortunately, those reasonable conclusions are not always the same ones you see in the press.

From your point of view, what would be a good ongoing structure or mechanism through which to do this? The Institute of Medicine? The NIH?

I’m not sure what their motivations are. But I can tell you that when they (NIH) tested glucosamine for osteoarthritis, they used glucosamine hydrochloride rather than glucosamine sulfate. And everybody who has studied this knows that the hydrochloride is an inferior product, that the sulfate is an important component. So I think it’s important to have research studies designed by people who are knowledgeable about how to optimize the results of a particular therapy. I would certainly be available to consult with researchers who want to find out the best ways to make these treatments work. I’ve spent half my life working on this book and now I’m sitting here wondering what I am going to do next. We need to have proper research designs.

Another example is lowering homocysteine. The results are all over the map. Some studies show that it prevented strokes. One study showed that it prevented coronary artery restenosis [narrowing] in people who had had angioplasty. But the majority of the studies showed no benefit when they gave B6, B12 and folic acid. The problem is that that’s not the way we do nutrition in the real world. We don’t give three nutrients and not touch the patient’s diet and not give them backup nutrients.

So there are two potential problems there. One is that some of the B-vitamins might deplete some other nutrients. For example, B6 might deplete magnesium, and many heart patients already have low magnesium status. So a beneficial effect of lowering homocysteine might have been counterbalanced by an adverse effect of depleting magnesium. Second, they used only the nutrients that have been shown to lower fasting homocysteine levels, not the ones that are the most powerful for lowering post-prandial [after a meal] homocysteine levels, those being betaine and choline. A case can be made, with some supportive evidence, that the peak homocysteine levels (which would be post-prandial) are more important for disease risk than the fasting levels are.

Research studies should be designed to optimize the results of a particular treatment. Instead, many studies do little more than prove that a suboptimal treatment produces suboptimal results.

You mentioned the relationship between B6 and magnesium. These are often used in combination for premenstrual syndrome. Any thoughts on that?

Yes, the evidence that B6 depletes magnesium is actually relatively weak. It was based on an observation by Adele Davis that when kids take B6, they sometimes wet their bed and become irritable, and have some other side effects. These side effects can be prevented by giving magnesium along with the B6. I have observed some people feeling wired or having insomnia when they take B6, and if they also take magnesium that doesn’t happen. But to your point, there are probably four or five different conditions where the combination of B6 and magnesium may work better than either one of them alone. Examples are kidney stone prevention, autism, hyperactivity, and PMS, as you said. They probably work together in the body.

Since this will be read by many chiropractors and chiropractic students, I want to ask about some bone and musculo-skeletal issues. From your knowledge and experience, what can you share with us about osteoarthritis, and nutritional approaches that may either prevent or ease it?

Aside from diet and lifestyle changes, the first thing I would do in many cases is niacinamide. That’s based on the old clinical work from William Kaufman back in the 1940s and 1950s. Wayne Jonas, who was an early director of the Office of Alternative Medicine at NIH, did a double-blind study back in the 1990s and confirmed the benefit. The mechanism is not known but it improves joint range of motion, relieves pain, and improves overall well-being. And we know that it’s not a pain reliever because it takes weeks to start working. It also takes weeks to wear off once people stop. It has some effect on the disease process. Niacinamide is potentially hepatotoxic when given in large doses, so you have to know the proper dosing regimen.

So niacinamide is the first thing I’d use and glucosamine sulfate, with or without chondroitin sulfate, would be second. There is also a possible benefit from vitamin C and vitamin D. For some people food allergies are an issue, but it’s not a common cause.

How about musculoskeletal pain – back pain, neck pain, disc problems?

As far as back pain is concerned, there is no nutritional magic bullet. I look for food allergies. I try to keep the muscles loose, perhaps with a magnesium and calcium supplement. Maybe also increase potassium intake to relax the muscles. Avoiding caffeine is also beneficial in some cases.

Is there anything else you’d like to share with our readers?

One of the main problems in our failing health care system is that so many people are so sick, and one of the reasons is that conventional medicine ignores much of the research showing that diet and nutritional supplements can improve health. People often say there’s not enough research. One of the reasons I wrote Nutritional Medicine is to put all of the research in one place so that people will realize how much there is.

It’s not a problem of inadequate research, it the fact of underutilization of the available research. We need to incorporate dietary changes, nutritional supplements, and other natural substances as a primary modality for both prevention and treatment of illness. Part of that requires participation by the patient. There are many people who would love to make lifestyle changes that might improve their health, but they don’t have anybody who can guide them. So if both doctors and the public would incorporate this into their health care management, I would guess that the cost of health care would drop by at least 50 percent. We’d have a much healthier nation. That’s where we need to go. We need to start taking this work seriously because our health care system is not going to survive the way it is. Regardless of whether it’s Obamacare, Republican-care, or whatever care, it’s not going to make it otherwise.

About the Interviewer: Dr. Daniel Redwood is a Professor at Cleveland Chiropractic College–Kansas City. He is the Editor-in-Chief of Health Insights Today and The Daily HIT, and serves on the editorial boards of the Journal of the American Chiropractic Association, Journalof Alternative and Complementary Medicine, and Topics in Integrative Healthcare. This interview was adapted and is used with permission.