Clinical Briefs
With Comments from John La Puma, MD, FACP
Zinc for Taste Abnormalities in Cancer Patients
April 1999; Volume 2: 47
Source: Ripamonti C, et al. A randomized controlled clinical trial to evaluate the effects of zinc sulfate on cancer patients with taste alterations caused by head and neck irradiation. Cancer 1998;82:1938-1945.
In uncontrolled clinical trials, the administration of oral zinc sulfate has been reported both to prevent and correct taste abnormalities in cancer patients receiving external radiotherapy (ERT) to the head and neck region.
Eighteen patients (14 male, mean age 57) were randomized to receive either elemental zinc sulfate tablets (a dose of 45 mg) or placebo tablets three times a day at the onset of subjective perception of taste alterations during the course of ERT and up to one month after ERT termination. Taste acuity was determined by measuring detection and recognition thresholds for four taste qualities. Intolerance of zinc sulfate or placebo administration was investigated, and the oral cavity was examined. All the evaluations were studied prior to, at weekly intervals during, and one month after ERT administration.
Taste acuity for one or more taste qualities was already impaired before ERT. During ERT, taste alterations were experienced at least once for a minimum of three of the eight measured thresholds by all nine of the patients, and three of the nine patients became aware of some alteration within the first week. The patients treated with placebo experienced a greater worsening of taste acuity during ERT compared with those treated with zinc sulfate. One month after ERT, the patients receiving zinc sulfate had a quicker recovery of taste acuity than those receiving placebo.
After ERT termination, statistically significant differences between the two groups emerged for urea (bitter) detection, and sodium chloride (salt), saccharose (sweet), and hydrogen chloride (sour) recognition thresholds.
This pharmacologic therapy is effective and well tolerated; it could become a routine in clinical practice to improve the supportive care of patients with taste alterations resulting from head and neck cancer.
COMMENT
Taste is a funny thing. For one, it’s incredibly individual. Taste buds tell us salty, sweet, sour, and bitter, and maybe savory. Some of us have 11 taste buds per centimeter squared of tongue, and some of us have 1,100. And the number of buds doesn’t even correlate with how good something tastes!
Most taste disorders—hypogeusia (less), ageusia (none) and dysgeusia (distorted)—are not at the top of the medical record problem list. Many physicians think of them as an early, usually reversible complication of cancer and of chemo and radiotherapy. If only there were something that could give flavor back to people denied this basic sensual pleasure.
Maybe zinc. These Italian investigators, at the National Cancer Institute of Milan, found zinc blood levels and subjects’ taste acuity to be low prior to ERT. The investigators started zinc and placebo when subjects reported "the moment of subjective worsening of taste acuity."
No side effects or dropouts were reported. There were significant differences, as above, in the nine zinc patients.
No one knows why zinc may work. Zinc is an essential element which has a role in a number of metalloenzymes, including alkaline phosphatase, which is the "most abundant enzyme isolated from the taste bud membrane."
If zinc does work, it may have a steep price. Too much zinc in HIV-positive patients probably reduces immunity. Barrette writes "...cohort studies [of HIV-positive patients] suggest that increasing dietary intake of zinc or use of any zinc supplement increases the risk of disease progression." Barrette discourages the use of zinc supplements in these patients, other than in a multivitamin, until further studies prove their safety. (See Alternative Medicine Alert, February 1998; pp. 18-20).
Recommendation
To all of your immuno- and taste-compromised patients, recommend other types of flavor not dependent on taste buds—the heat of chilies and the bubbles of seltzer, for example, both taste good because they jangle the VIIth cranial nerve. With HIV-negative patients who desperately want to try to recover the flavor of their food, discuss a single, time-limited, two- to four-week trial of zinc sulfate. HIV-positive patients should not take supplemental zinc.
Vegan Diet and Rheumatoid Arthritis
April 1999; Volume 2: 47-48
Source: Nenonen MT, et al. Uncooked, lactobacilli-rich, vegan food and rheumatoid arthritis. Br J Rheumatol 1998;37:274-281.
We tested the effects of an uncooked vegan diet, rich in lactobacilli, in rheumatoid arthritis (RA) patients randomized into diet and (omnivorous) control groups. The intervention group experienced subjective relief of RA symptoms during intervention. Return to an omnivorous diet aggravated symptoms. Half of the diet patients experienced adverse effects (nausea or diarrhea) during the three-month diet and withdrew from the experiment prematurely.
Indicators of RA activity did not differ statistically between groups. The positive subjective effect experienced by patients was not discernible in objective measures of disease activity (Health Assessment Questionnaire, duration of morning stiffness, pain at rest, and pain on movement). However, a composite index showed a higher number of patients with between three and five improved disease activity measures in the intervention group. Stepwise regression analysis showed a decrease in disease activity with three factors: intake of lactobacilli-rich and chlorophyll-rich drinks; an increase in fiber intake (mean 42 g daily); and no need for gold, methotrexate or steroid medication (r2 = -0.48, P = 0.02). Subjects also lost 9% of their body weight on average, and increased their daily protein intake from 58 g to 80 g daily.
COMMENT
These investigators, from the Helsinki National Research and Development Center for Welfare and Health, tested a "living food" or uncooked vegan diet. Seeds, grains, and fermented products, together with their processing, characterize a "living food" diet, as does the absence of animal products, added salt or raffinated (conventionally sweetened) substances.
Both diet and control groups were prohibited from having caffeine, chocolate, and alcohol, and no one was taken off medication. Patients with the best adherence had the least objective disease activity, but adherence was a problem. Only five or six of the 19 (mean age 49; 18 women) who completed the diet intervention drank their 0.5-1 liter of fermented wheat and wheatgrass drink daily. Eight dropped out because of nausea; three dropped out because of diarrhea. The fermented wheat bacteria supplied the lactobacilli; the wheatgrass drink was not analyzed.
Specific foods are often linked with RA symptoms. Though the authors note that RA patients’ intestinal flora appear to differ from that of healthy subjects, it is unclear from this analysis why fermented and uncooked products may be useful in RA.
Creative chefs might help these investigators and their subjects. Good cooks can make almost anything taste good, even without cream, butter and salt, though those are like stethoscope, reflex hammer, and tongue depressor to doctors. But there’s no cooking here. Just fermenting.
It’s impossible to tell whether the fiber, the relatively high protein level, the lactobacilli, the weight loss, the wheatgrass, or something else completely were responsible for the modest subjective effect.
Recommendation
For RA patients who are truly committed to changing their symptoms, and can stick to an extreme diet, a living food diet may be worth a short, time-limited trial. These results warrant better quality future research, and more work in the kitchen.
Spirituality in the Medical Office
April 1999; Volume 2: 48
Source: Daaleman TP, Frey B. Spiritual and religious beliefs and practices of family physicians: A national survey. J Fam Pract 1999;48:98-104.
The current movement in ameri-can medicine toward patient-centered or relationship-centered care highlights the importance of assessing physician core beliefs and personal philosophies. Religious and spiritual beliefs are often entwined in this domain.
An anonymous survey was mailed to a random national sample of active members of the American Academy of Family Physicians who had the self-designated professional activity of direct patient care. Of 756 physicians, 438 (58%) responded; responders’ primary practice sites were significantly (P < 0.001) less often urban than AAFP member physicians as a whole.
Seventy-four percent of the surveyed physicians reported at least weekly or monthly service attendance. Seventy-nine percent reported a strong religious or spiritual orientation. Thirty-five percent reported daily time in private religious or spiritual practices. Fifty-seven percent classified themselves as Protestant; 24% Catholic; 6% Jewish; 0.5% Muslim; 4.5% atheist (vs. 1.4% of the general population).
COMMENT
Family physicians as a group are as spiritually oriented and worshipful as most of their patients, according to this brief study. Regional variations in reported religiosity, however, were not assessed; a previous, referenced study of Vermont physicians showed only 43% reporting feeling "somewhat close" or more to God, vs. 78% in the present study. The difference between spirituality (conceptual and personal) and religion (doctrine, ritual and practice) is reiterated in an editorial.
Though this study has a bit less than 90% power and is biased toward nonurban family physicians (already more religious than their brethren in the city), the data may be useful. Other recent data (N Engl J Med 1998;339:861-867) indicating progress in smoking, cholesterol, and blood pressure reduction nationwide while rates of myocardial infarction rise suggest that another factor—perhaps a need for spirituality, improved socioeconomic status, or a more inclusive sense of community—may be closer to the heart of some therapeutic encounters.
Recommendation
Because family physicians appear to believe and practice as their patients do, especially in nonurban settings, there is common, unexpected ground for spirituality in the office. There is also an opportunity for outcomes research: Can a shared moment in prayer make a difference in care?
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