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Critiquing CAM remedies for Candida and BV

Of the numerous complementary and alternative treatments now being used to treat vaginal candidiasis and bacterial vaginosis (BV), four are worth a closer look: lactobacillus, boric acid, tea tree oil, and douching.

Although many of the clinical trials on lactobacillus are poorly designed, they suggest that it may have value in preventing and treating BV and candidiasis. In one of the best studies, a multicenter, randomized, placebo-controlled trial, patients were given hydrogen peroxide-producing Lactobacillus acidophilus vaginal tablets that also contained a small amount of estrogen (0.03 mg of estriol) to enhance acid production for 6 days (Gynoflor vaginal tablets, Medinova Ltd, Zurich, Switzerland). After 4 weeks, 88% of women were cured of BV in the lactobacillus group, compared to 22% in the controls. It's likely the cure rate would have been even better if the patients had received tablets containing L crispatus and L jensenii, the species that most commonly inhabit the vagina. Possible adverse effects of lactobacillus include GI upset if patients who are lactose-intolerant use an oral, yogurt-based formula, and lactobacillemia in immunosuppressed patients.

Several studies support the use of boric acid for the treatment of chronic yeast infections that don't respond to standard topical and systemic antifungals. In one double-blind trial of yeast vaginitis, boric acid, given vaginally once a day for 2 weeks, cured 92% of patients by 7 to 10 days posttreatment; 72% remained disease free after a month. Nystatin cured only 64% at 7 to 10 days and 50% at 30 days. Possible adverse effects to contend with are vulvovaginal burning and male dyspareunia.

Tea tree oil contains several terpenes, which have antimicrobial effects. Several in vitro studies and a few case reports suggest it may relieve Candida and BV but there are no clinical trials available yet. And the research on douching makes it pretty clear that its dangers outweigh any potential benefits. Several trials have shown it increases the risk of pelvic inflammatory disease, endometritis, and ectopic pregnancy.

Van Kessel K, Assefi N, Marrazzo J et al. Common complementary and alternative therapies for yeast vaginitis and bacterial vaginosis: a systematic review. Obstet Gynecol Surv. 2003;58:351-358.

A once-a-day vitamin thwarts infections

A daily multivitamin/mineral really can reduce the threat of infectious disease, according to this randomized double-blind trial. To arrive at that conclusion, investigators put 130 middle-aged and older adults on supplements or placebo for 1 year and asked them to report infectious symptoms and absenteeism from work. Seventy-three percent of those on placebo reported infectious disease—including upper and lower respiratory tract infection, influenza-like syndromes, urinary tract infections, and gastrointestinal infections—versus 43% of those on the multivitamin/mineral. Similarly, absenteeism was 57% versus 21% in the two groups. The supplement's beneficial effects occurred primarily among subjects who had type 2 diabetes. And in this group the difference between those on supplements and placebos was dramatic (93% vs. 17%). It's likely diabetics responded so well because so many were suffering from subclinical micronutrient deficiencies.

Barringer TA, Kirk JK, Santaniello AC, et al. Effect of a multivitamin and mineral supplement on infection and quality of life. Ann Intern Med. 2003;138:365-371.

Avoiding gluten may be in your patient's best interest

Although conventional wisdom says that gluten intolerance (celiac disease) is quite rare in the United States, the first large-scale epidemiologic study done in the states indicates that it's more common than once believed. According to lead researcher Alessio Fasano, MD, it affects up to 1.5 million Americans or about 1 in 133, versus the 1/10,000 previously estimated.

As most clinicians already know, gluten intolerance can produce a variety of GI symptoms, and can indirectly contribute to several nutritional deficiencies by causing malabsorptrion. A simple screening test that detects the presence of anti-endomysial antibody is at least 90% accurate in pinpointing the disease and warrants an intestinal biopsy to confirm the diagnosis.

Celiac disease: Not so rare, after all. Tufts University Health and Nutrition Letter, April 2003, p. 8.

Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States. Arch Intern Med. 2003;163:286-292.

Omega-3 fats and the neonatal nervous system

The more omega-3 fatty acids a pregnant woman consumes, the more mature her newborn's central nervous system will likely be. At least that's the conclusion hinted at by this recent University of Connecticut study.

The research literature leaves little doubt about the value of omega-3 fatty acids like docosahexaenoic acid (DHA) in the maturation of the embryonic brain. The new investigation has found that infants of mothers who had higher serum DHA levels had sleep patterns that suggested greater CNS maturity, when compared to infants born to mothers with lower DHA levels. More specifically, higher DHA levels were associated with less active sleep and a lower ratio of active to quiet sleep. Likewise, infants in the high DHA group had less sleep-wake transitions.

Cheruku SR, Montgomery-Downs HE, Farkas SL, et al. HIgher maternal plasma docosahexaenoic acid during pregnancy is associated with more mature neonatal sleep-state patterning. Am J Clin Nutr. 2002;76:608-613.

Does the Atkins diet work? Is it safe?

Yes and yes, at least over the short term. When University of Cincinnati researchers randomized 53 healthy obese women to either a low-fat, calorie-restricted diet or a very low-carbohydrate, high-protein, high-fat regimen that was not calorie restricted (an Atkins-type diet), they discovered that the latter group actually lost more than twice the weight over a 6-month period (8.5 kg vs. 3.9 kg). And while those on the low-carbohydrate diet significantly increased their intake of saturated fat and cholesterol, the regimen had no deleterious effects on blood lipids, blood pressure, fasting glucose, or insulin levels.

Although experts can't fully explain these unusual findings, it's worth mentioning that subjects on the low-carbohydrate, high-fat diet also significantly increased their intake of mono- and polyunsaturated fats, both of which are believed to improve serum lipids.

The other lingering question raised by this study was: Why would a diet that doesn't restrict calories help a person lose more weight than one that does? Surprisingly, the investigators found that both groups had reduced their caloric intake by about 450 kilocalories a day! One possibility is that the increased protein and fat in the low-carbohydrate diet has a profound satiating effect. It's also possible that because a person's food choices are greatly limited by cutting carbohydrates to less than 10% of calories, they simply eat less. Others have theorized that the ketosis generated by this regimen blunts the appetite.

This clinical trial was very recently supported by two other controlled studies. When investigators put severely obese patients, many of whom had diabetes or the metabolic syndrome, on either a low-carbohydrate or a low-fat diet, 79 completed the trial over a 6-month period. Those on the low-carbohydrate regimen lost on average 5.8 kg, compared to only 1.9 kg in the low-fat group. They also had better serum triglyceride readings.

But once again, researchers cautioned that these results may not apply over the long term. And in fact, the third trial, while reporting greater weight loss in the low-carbohydrate group at 3 and 6 months, noticed that the difference between groups was no longer statistically significant by the end of a year.

Brehm BJ, Seeley RJ, Daniels SR, et al. A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women. J Clin Endocrinol Metab. 2003;88:1617-1623.

Samaha FF, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med. 2003;348:2074-2081.

Foster GD, Wyatt HR, Hill JO. A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med. 2003;348:2082-2090.

A word of caution for women on high-protein diets

Anyone with even mild kidney dysfunction should probably avoid high-protein weight loss regimens—and perhaps one in four American women has mild, asymptomatic renal impairment. When Harvard investigators analyzed data from the ongoing Nurses' Health Study, they found that, over an 11-year period, protein intake was significantly associated with a decline in glomerular filtration rate among women with mild renal impairment—defined as a GFR >55 mL/min per 1.73 m2 but <80 mL/min. Every 10-g increase in protein intake was linked to an estimated 7.72 mL/min decline in GFR, with meat protein apparently having a more detrimental effect than non-meat protein. Women with normal renal function saw no such deterioration on a high-protein regimen.

Knight EL, Stampfer MJ, Hankinson SE, et al. The impact of protein intake on renal function decline in women with normal renal function or mild renal insufficiency. Ann Intern Med. 2003;138:460-467.

Department editor Paul L. Cerrato, MA, Managing Editor of Contemporary OB/GYN, is a guest lecturer at the Institute of Human Nutrition, Columbia University College of Physicians and Surgeons, New York, N.Y.


Paul Cerrato. Altmed Watch. Contemporary Ob/Gyn Jul. 1, 2003;48:84-86.

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