Essentials of Complementary and Alternative Medicine (June 1999)

PRINCIPAL CONCEPTS OF NUTRITIONAL BIOTHERAPY
Several principles of nutritional biotherapy must be understood for its effective clinical implementation. These principles include:
1. A core dietary regimen.
2. Dietary fat as a separate food.
3. Variety and meaningful quantification.
4. Individual nutritional tailoring.
5. Safe and appropriate supplementation.
6. The complementary nature of nutrition with medical care.
Description of Principal Concepts
This chapter illustrates the application of nutritional biotherapy by describing the approach and rationale we take in our clinic. However, our approach is similar in its 
principal concepts and approach to many other programs around the world, as we describe later in the chapter.
C
ORE
 D
IETARY
 R
EGIMEN
The Block Integrative Nutritional Therapy (BINT) program, developed over a 20-year period at our Evanston clinics, uses a core diet upon which all individual 
adjustments are made. The core diet is plant-based, composed of 50 to 70% complex carbohydrates, 10 to 25% fat, and the remaining percent composed of protein. 
These criteria are individually tailored to meet the needs of those diagnosed with or recovering from illness. An initial goal is to reduce and eventually eliminate meat, 
dairy, and refined sugars, while obtaining more daily calories from complex carbohydrates (e.g., whole grains and grain products, vegetables, fruits). The primary 
sources of protein are vegetable proteins (from soy products and other legumes) and cold-water fish. White-flesh poultry without the skin is acceptable as a 
transitional item and is used to replace meat normally eaten for protein content.
Because of individual health and personal differences, the BINT program provides three levels of core diet:
The transitional level, which allows limited use of many of the food items generally found on the BINT “avoid list,” such as eggs, poultry, and wild game.
The maintenance level, which uses the diet structured around the standard exchange lists (see concept 3). The participant does not eat any of the “avoid list” foods 
and adheres to portions adjusted to meet individual needs.
The therapeutic level, which represents the maintenance level with special and individualized adjustments based on the patient's medical needs. For example, a 
patient suffering from bleeding colitis will be advised to consume minimal roughage. Some hypertensive individuals would restrict salt intake more aggressively. 
Diabetics may need to increase fiber intake beyond the usual level of intake for nondiabetics. With an improved or greatly stabilized physical condition, or with 
clinically confirmed reversal of the disease, the BINT program may then be shifted back to the maintenance level.
D
IETARY
 F
AT AS A
 S
EPARATE
 F
OOD
 G
ROUP
In the BINT program, we begin teaching patients ways to reduce their fat intake by identifying fat as one of five food groups:
1. Whole grains and grain products.
2. Vegetables.
3. Fruits.
4. Fats.
5. Protein.
Fats are obtained primarily from nuts, seeds, and oils. Protein is provided by both plant and lean animal sources, or legumes and fish, respectively. Cold-water fish or 
supplemental fish oils help ensure the proper balance of omega-3 to omega-6 fatty acids, which in turn helps lower the risk of chronic inflammatory disorders and 

immune dysfunction. The optimal range for dietary fat intake is likely to be between 10 and 20% of total calories, with the exception of infants and small children, who 
could benefit from a higher level of fat intake (25 to 35%), with increased emphasis on omega-3 fatty acids.
V
ARIETY AND
 M
EANINGFUL
 Q
UANTIFICATION
Variety is an important element in developing a health-promoting diet for long-range use. Rather than consume daily servings of the same food from each of the major 
food groups, one should choose a variety of foods within each group. To provide this dietary variety in a prescriptive yet meaningful way, the BINT program employs 
the concept of dietary exchange, referring to a food serving that can be exchanged, or traded, for other foods within the same grouping. The BINT exchange lists the 
five food groups mentioned previously. Each food, with its specified portion, grouped on the exchange list has approximately the same amount of carbohydrate, 
protein, fat, and calories as the other foods within the same group. Because they are approximate nutritional equivalents, any item on a particular exchange list can be 
exchanged for any other food item within the same exchange list.
The BINT exchange lists are used to develop a meal-based nutritional prescription that is both meaningful and attractive to the patient. An exchange system 
translates the scientific formula (total calories, percent of protein, percent of carbohydrates) into a tangible, easy-to-use format. With this system, daily meal planning 
can be carried out readily, and the desired amounts of protein, fat, carbohydrates, and calories can be monitored and can help a patient meet individual nutritional 
goals. Individuals are free to choose their favorite foods from a list that tells what one exchange is equal to. Usually the exchange formula is converted into a meal 
plan by dividing it into three meals or into the number of meals a person is consuming. In its usual application, this means 30% for breakfast, 30% for lunch, 30% for 
dinner, and 10% for snacks.
I
NDIVIDUALIZED
 N
UTRITIONAL
 R
EGIMENS
The BINT program considers individual tailoring of nutritional biotherapy protocols an essential part of designing the nutritional approach best suited for each patient's 
care. Biochemical individuality provides the primary rationale for individual tailoring. Optimal nutrient doses vary from individual to individual and from one disease 
state to the next. Therefore, the recommended daily allowances (RDAs) are average requirements that are generally inapplicable in nutritional biotherapy. Variations 
of 20-fold or more in individual requirements may occur, depending on the patient's genetics, biochemistry, and physiological state. Therefore, nutritional biotherapy is 
concerned with issues such as subclinical micronutrient deficiencies, conditional deficiencies, synergistic supplement combinations, and the need for supraphysiologic 
doses of one or more micronutrients. The existence of subtle, subclinical deficiency states have been frequently observed in our clinics and are widely reported. 
These biochemical alterations are targeted on an individual basis. The issue of nutritional requirements being both conditional and individualized becomes even more 
critical when treating complex, heterogeneous diseases such as cancer.
R
ATIONAL
 S
UPPLEMENTATION
Supplemental use of nutrients, botanicals, and phytochemicals to manage disease constitutes an important aspect of nutritional biotherapy. Most of the focus has 
been on prevention: supplemental antioxidants may reduce the risk of specific types of cancers and cardiovascular disease; vitamin B
6
 may prevent the onset of 
carpal tunnel syndrome; niacin can lower blood cholesterol levels; and folic acid for women of childbearing age reduces the risk of neural tube defects (
9
). However, 
supplemental nutrients may be particularly helpful in the context of psychological stress, metabolic stress (e.g., stress caused by surgery or cachexia), immunological 
dysfunction, and a polluted environment. Elderly individuals may benefit from supplementation to help malabsorption problems and difficulty in obtaining a balanced 
diet. Many commonly used medical treatments and certain disease states either cause or are associated with nutritional deficits that warrant careful supplementation 
(
10
, 
11
 and 
12
).
Safe dosages have been established for many nutritional agents and compounds; for those that have not been established in human trials, it is possible to extrapolate 
from animal data to suggest reasonably safe dosage ranges in humans. In general, temporary administration of very high doses of water-soluble vitamins is feasible 
without causing toxicity. Overdosing is more common with fat-soluble vitamins because they tend to accumulate in adipose tissues. It is important for physicians to 
understand these toxic thresholds and to advise their patients accordingly. Particularly, in therapeutic situations involving serious illness, patients may be inclined to 
think that “more is better.” Thus, patients should be advised to follow the recommended dosages to avoid adverse effects.
C
OMPLEMENTARY
 N
UTRITIONAL
 S
TRATEGIES
Complementary intervention with standard medical care is another important principle of nutritional biotherapy. In most cases, nutritional strategies are used in an 
adjuvant or adjunctive fashion–that is, as a complement to standard medical care. However, this requires careful attention to the potential for synergisms and 
antagonisms between food factors and medical treatments. The known interactions between drugs and nutrients are legion (
13
, 
14
). For example, many drugs can 
adversely affect nutrient absorption, transport, and metabolism (
15
). Thus, nutritional supplementation can be used to compensate for such drug-based interference. 
Micronutrients and phytochemicals also may act as enzymatic cofactors in the metabolism of various anticancer drugs as well as some antibiotics, barbiturates, oral 
contraceptives, calcitonin, and salicylates.
These interactions may not only modulate the activity of the drugs, but also may cause a decrease in micronutrient availability (
16
). Drugs such as hydralazine, 
d-penicillamine, and many antituberculosis drugs may adversely affect vitamin B
6
 status. Corticosteroids, thiazide diuretics, d-penicillamine, and several other drugs 
all adversely affect zinc status. Regular use of oral contraceptive pills may lead to excessive losses of vitamins B
1
, B
2
, B
6
, and folic acid (
17
, 
18
). Drug-nutrient 
interactions can affect every area of conventional medicine, especially pharmacology, and they represent the clearest example of a complementary medical 
application for nutritional biotherapy.
Therapeutically additive or synergistic interactions between drugs and nutrients are useful in determining the true therapeutic potential of those nutrients for 
modulating chronic disease progression. For example, vitamin C combined with antibiotic therapy has been shown to accelerate recovery among patients suffering 
from acute sinusitis (both purulent and catarrhal) (
19
). The nutrient-drug compound copper aspirinate (copper-bound aspirin) may have potent anti-inflammatory 
effects (
20
, 
21
); these beneficial effects may be augmented further by the use of fish oil supplements for the treatment of arthritis (
22
, 
23
). Copper aspirinate has also 
shown antiulcer, anticonvulsant, anticancer, antimutagenic, and radiation damage repair effects and may be used to prevent reperfusion injury (
24
). Supplemental 
N-acetylcysteine (NAC), for example, in combination with nitroglycerin and streptokinase in myocardial infarction is associated with significantly less oxidative stress, 
a trend toward more rapid reperfusion, and better preservation of left ventricular function (
25
). Similarly, a drug may be ineffective until a nutritional deficiency is 
corrected. Patients with chronic oral candidiasis may be clinically unresponsive to topical antifungal agents until iron deficiency is reversed (
26
).
A nutrient or nutrient combination may also be exploited for its ability to mitigate serious and often dose-limiting side effects of a drug. Peripheral neuropathy induced 
by the antituberculous drug isoniazid can be inhibited by the administration of vitamin B6 in doses of 50 to 100 mg/day (
27
). The use of appropriate supplements in a 
group of elderly people has been shown to improve antibody responsiveness to the influenza virus vaccine (
28
). The elderly also show greater tolerance toward 
antituberculous drugs, isoniazid, rifampicin, and pyrazinamide, when simultaneously treated with antioxidant supplements (
29
).
BASIC PRINCIPLES IN NUTRITIONAL ASSESSMENT
The physician should ensure that all patients, regardless of their particular diagnoses, are adequately nourished, either by the actual provision of nutrients or by 
counseling them in their dietary choices. Normal nutritional requirements vary greatly from one individual to the next, based on past diet, biochemical individuality 
(and/or individual physiology), age, gender, activity levels, current medications, and disease state. Nutritional needs for a particular nutrient or food factor may 
increase or decrease over time in response to disease processes and conventional treatments. Complementary medical practitioners should also assure appropriate 
aspects of the conventional medical approach (e.g., choice of specific medications) with nutritional concerns.
The first step in effective nutritional medicine is assessment of the patient's current nutritional status. Protein-calorie malnutrition is quite prevalent in hospital patients 
and has been shown to cause longer lengths of stay, higher costs, and increased rates of morbidity and mortality. In fact, when malnutrition is among the diagnoses 
as a complication or a comorbidity factor and treatment is provided, there is generally a corresponding increase in the reimbursement for the care of the patient. 
Conditions resulting from protein and calorie malnutrition include cachexia (lean-tissue wasting, which resembles marasmus) and a kwashiorkor-like syndrome, or a 
combination of these two syndromes. Detection of these conditions should lead to aggressive nutritional adjustments which, in turn, contribute to an improved 
prognosis and quality of life for the patient.

The nutritional assessment methods used by complementary medical practitioners are the same as, or may even be more comprehensive than, those used by 
conventional physicians. They involve the ABCDs of nutritional assessment, which stands for anthropometric, biochemical, clinical, and dietary assessment.
In anthropometric assessment, weight is considered in relation to height, and changes in weight are recorded with successive visits and compared with usual weight 
and reference weight to determine percent-change over time. Body Mass Index (BMI) can be calculated from this and used in risk factor assessment if needed. 
Biochemical studies include the standard laboratory measures of albumin, transferrin, and prealbumin, as well as vitamin and electrolyte levels, red cell counts and 
indices, and other aspects of the complete blood count. Clinical assessment includes consideration of nutrition-related problems and risk factors, such as anorexia 
and nausea, as well as potential treatment–nutrient interactions. A physical examination that looks at evidence of nutrient inadequacies is done (see 
Chapter 27
). 
Past and present dietary habits are evaluated based on standard questions issued by dietitians.
Within the BINT program, we also incorporate more sophisticated forms of laboratory testing to provide evidence of suboptimal or inadequate nutrition (
Fig. 29.1
). 
These tests include measures of antioxidant-micronutrient and antioxidant-phytochemical status, DNA oxidation, and essential fatty acids, immune detoxification, 
hormonal levels, and, when appropriate, other relevant analyses. In most cases, testing will reveal inadequate nutrition in an individual, even in the absence of clinical 
findings of classical deficiency syndromes. Because of the high cost of comprehensive nutritional testing, however, it is helpful to apply a disease-related, 
mechanism-based perspective to each case, focusing on those particular nutritional issues that are most likely to impact the particular disorder in question. A detailed 
description of the use of nutritionally focused biochemical testing is beyond the scope of this chapter. Interested readers are referred to the courses and literature by 
Jeffrey Bland, Jonathan Wright, Alan Gaby, and others (see 
Appendix A
).
F
IGURE
 29.1. BINT assessment chart.
A SURVEY OF DIETS USED IN COMPLEMENTARY MEDICINE
Within complementary medicine, many different diets and supplementation regimens are thought to affect disease processes. Some diets claim to help stop or reverse 
disease progression; others may help keep disease in remission. The following is a description of the major diets embraced by complementary practitioners.
These diets may be categorized into three basic groups:
1. High-fiber, high-carbohydrate, low-fat diets.
2. High-protein, low-carbohydrate diets.
3. Diets of variable nutrient composition.
A difficulty that many of these approaches face is the lack of a way to meaningfully translate percentages into food quantities and proportions.
High-Fiber, High-Carbohydrate, Low-Fat Diets
M
ACROBIOTIC
 D
IET
Macrobiotics is a philosophy of eating that originated in Japan with the teachings of Sagen Ishitsuka, MD, and his pupil George Ohsawa. Two of Ohsawa's students, 
Michio Kushi and Herman Aihara, introduced macrobiotics to the West as a dietary principle that accounts for differing climatic and geographical considerations, as 
well as a wide variety of individual factors. The so-called Standard Macrobiotic Diet consists of 50 to 60% whole grains, 20 to 25% vegetables, 5 to 10% beans and 
sea vegetables (typically combined), and 5% vegetable soups. Other foods, such as nuts and seeds, fruits, and fish are consumed on an occasional basis. Red meat, 
dairy, sugar, and raw fruits are generally avoided. Each person's dietary needs vary according to level of activity, gender, age, climate, season, and various individual 
factors.
P
RITIKIN
 D
IET
Founded by Nathan Pritikin, the Pritikin program is a low-fat, low-cholesterol, low-sodium, high-complex-carbohydrate diet (5 to 10% fat, 10 to 15% protein, and 80% 
carbohydrate) combined with regular aerobic exercise. The diet is similar to the macrobiotic diet, but with more rigid emphasis on restricting fat intake, as well as the 
inclusion of low-fat dairy products and greater variety in choices of animal products. Protein consumption is limited to 3.5 ounces of lean meat a day to reduce total fat 
and cholesterol intake, because most animal products have high levels of fat and cholesterol. Pritikin himself followed the diet throughout his adult life.
T
HE
 W
AIANAE
 D
IET
This program was designed by Hawaiian physician Terry Shintani, MD, MPH, in response to the disproportionately high rates of chronic disease among “westernized” 
native Hawaiians. The diet–which contains less than 10% fat; 12 to 15% protein; 75 to 78% carbohydrate–consists of traditional Hawaiian foods (e.g., fish, seaweed, 
bread, fruit, yams, sweet potatoes.) All foods are served either raw or steamed in a manner that approximates ancient styles of cooking. A “transition diet” provides 
palatable alternatives for those unaccustomed to Hawaiian cuisine. This culturally sensitive dietary program, which includes social support and community-based 
health education, has demonstrated impressive results in weight management. It is also likely to elicit high adherence among people of the same ethnic background.
G
ERSON
 D
IET
Developed by Austrian physician Max Gerson in the early 1900s, this vegetarian diet consists mainly of raw vegetables and fruit juices, raw calf liver juice (now largely 
discontinued because of the chemical residues now found in calves), and coffee enemas to stimulate bile elimination. The latter is said to expel toxins accumulated 
from manifestations of illness and dissolving tumor masses. The program initially includes a period of juice fasting and enemas, after which patients are placed on a 
low-sodium, high-potassium diet. A modified and more comprehensive Gerson program is used at CHIPSA (Centro Hospitalario Internacional del Pacifico, S.A.) by 
Gar and Chris Hildenbrand. This program, which is reported to reduce occurrence of malignant melanoma after conventional treatment (
30
), is easier to follow and is 
consistent with the standard low-fat, high-fiber dietary pattern.
T
HE
 R
EVERSAL
 D
IET
Developed by Dean Ornish, MD, to reverse the development of atherosclerosis and coronary heart disease, this diet is very similar to the Pritikin Diet. In terms of total 
calories, the diet is 10 to 12% fat, 70 to 75% carbohydrate, and 15 to 20% protein. Egg whites, nonfat yogurt, and skim milk are allowed as sources of complementary 
proteins. Additionally, like many other proponents of complementary medicine, Ornish emphasizes the importance of gentle exercises, such as yoga and walking, and 
of relaxation and visualization techniques to help relieve the body of stress and tension. A recent 5-year follow-up of cardiac patients who follow this program has 

shown continued regression of coronary lesions that had been reported previously (
3
).
N
EW
 F
OUR
 F
OOD
 G
ROUPS
 D
IET
In April 1991, the Physicians Committee for Responsible Medicine (PCRM) proposed the New Four Food Groups: grains, vegetables, fruits, and legumes (eliminating 
meat and dairy from the old Basic Four). This 100% plant-derived (vegan) diet may be among the most effective weight-loss diets on the market, as cogently argued 
by PCRM President Neal Barnard, MD, in his book,  Food for Life (Harmony, 1993). It is not only very low in fat (10% of total calories) and protein (20% of calories), 
but also very high in complex carbohydrates (70% of calories). Calcium balance is improved because high-protein diets tend to compromise the body's calcium 
supply.
M
C
D
OUGALL
 D
IET
The McDougall Program, proposed by John A. McDougall, MD, is virtually identical to the PCRM dietary plan (and similar to the Ornish, Pritikin, and Core BINT diets). 
With McDougall's system, however, a modicum of flexibility is granted for the infrequent (i.e., best to avoid) use of so-called feast foods, such as range-fed beef, 
organically grown poultry, and fresh fish. The tempered use of such foods may be considered part of a transition to the vegan diet proposed by PCRM. McDougall, 
who runs a 2-week residential training program for his approach, has documented clinical improvements and reductions in medication in hundreds of patients with 
chronic illnesses placed on this diet (
32
).