Over the last decade, there’s been an explosion of “alternative” diagnostic methods purporting to identify nutrient deficiencies, detect environmental toxins, predict serious diseases before they emerge, and help guide health conscious individuals in their diet and supplementation choices.
Look through any consumer-oriented health magazine and you’ll see a plethora of ads and articles referencing iridology, bio-impedance testing, hair analysis, applied kinesiology, meridian analysis, oxidative stress measurement and a host of other things.
The popularity of these alternative self-diagnosis methods is part of the broader movement toward patient self-empowerment, self-care and personal responsibility. Many people know they’re not eating balanced diets rich in vitamins, minerals, and antioxidants. Their concerns for their health are warranted, and in many cases nutritional supplementation is reasonable.
But are these testing methods valid? Can they really provide the sort of guidance our patients seek?
In this and future articles, I will explore some of the most common over-the-counter alternative diagnostic methods with an eye toward separating the legitimate helps from the overwrought hypes. We’ll begin with hair analysis and antioxidant testing.
Hair Analysis
Techniques for measuring minerals, metals and other substances in hair have been around for decades. Advocates say they can indicate chronic mineral and nutrient deficiencies thus identifying which nutrients should be supplemented. Others use hair analysis to detect toxic heavy metals like mercury or lead, to guide detoxification protocols.
The American Medical Association and other mainstream medical societies have been categorically dismissive of hair analysis. In 1994, AMA issued a statement indicating that it “opposes chemical analysis of the hair as a determinant of the need for medical therapy and supports informing the American public and appropriate governmental agencies of this unproven practice.”
But outright dismissal may be as misguided as wanton embrace, and we shouldn’t throw the baby out with the bathwater! While it is not likely that hair analysis can accurately detect vitamin/mineral deficiencies or imbalances, as our patients hope it will, it can screen for exposure to heavy metals like mercury, lead, and aluminum.
The truth is that over time, heavy metals like mercury, found in the earth’s crust and ubiquitously in our environment, do find their way into our blood, our tissues and our hair. The problem with hair analysis is that normal hair levels for minerals or heavy metals have not been well established.
Hair analysis may serve as an initial “tip-off” for mercury exposure. Then, based on the type of mercury suspected (e.g., organic or inorganic), you can test blood and/or urine levels that may more accurately represent potentially toxic levels. If you really want to get fancy, research tools like cold vapor atomic absorption spectrophotometry can confirm these levels.
Surprisingly, it’s rare to find a person with no mercury in his/her body. Many people, even without amalgam dental fillings, have a blood mercury level of 5 mcg/L based on exposure from the environment.
Mineral and vitamin imbalances in the body (i.e., calcium, zinc, iron, copper, manganese) may be due to multiple factors such as improper diet, medication usage, stress, and genetics. Common medications like birth control pills may deplete zinc and some B vitamins; corticosteroids deplete calcium, selenium, and zinc. Histamine-2 receptor antagonists for ulcers may deplete iron, zinc, and vitamin B12. If the results of a hair analysis indicate a low level of minerals, it is prudent to screen for and try to address these possible root causes before recommending dietary supplements. Again, the next step would be blood tests.
Since hair has no blood supply and grows slowly, mineral levels in hair do not correlate with the amount of minerals in other body tissues. Contrary to what patients may believe, a hair analysis will not reflect a person’s recent dietary or current health status. Further, many people color their hair, expose it to sun, chemicals in pool water, and hair dryer heat, all of which can affect the function of the hair follicle as well as alter the analysis of a given hair sample. Traces of substances we eat, drink or breathe may end up in our hair, but so will many other things, making it difficult to glean meaningful information about nutritional needs from hair studies alone (Seidel S. JAMA. 2001; 285; 67–72).
There is also the big question of reference standards. Regardless of the specific analytic technique, it must be validated against a standard reference. Not all clinical labs use a reference. Examples of reliable analytical methods used to measure and verify substances in the hair include the following: cold vapor atomic absorption (used for methyl mercury); inductively coupled argon plasma mass spectrometry (methyl mercury); inductively coupled argon plasma optical emission spectrometry (trace elements); neutron activation analysis (trace elements); X-ray fluorescence (mercury); and proton induced X-ray emission spectrometry (good for discerning external hair contamination from internal hair follicle contamination). Only a trained scientist can understand the differences among these tests and it’s important to note which one is used when interpreting hair analysis.
Physicians should discourage patients from depending on hair analysis for detect-ing mineral deficiencies in place of a clinical diagnosis during an office visit. A better approach involves measuring blood levels of iron, calcium, zinc, plasma copper, and manganese to assist you in nutritional re-commendations. Multi-elemental hair anal-ysis may hold a clue or two regarding a patient’s heavy metal exposure or nutritional status, but it should not take the place of a thorough health history, medication & dietary supplement history, and physical exam.
Oxidative Stress and Antioxidant Testing
The concept of oxidative stress has gotten a lot of media attention, as researchers learn more about how free radicals contribute to the aging process and chronic diseases. Likewise, the public has shown tremendous interest in antioxidants and their role in preventing free radical oxidative damage. These concerns have spawned wide consumer interest in tests to assess their oxidative stress levels and their antioxidant capacities.
In principle, there’s nothing unreasonable about this. The body does produce several measurable markers of oxidative stress, including 8-isoprostane, a prostaglandin-like compound; Oxysterols (i.e., 7-ketocholesterol, 7_-hydroxycholesterol); Allantoin, the product of uric acid oxidation by purine catabolism; Total hydroxy-octadecadienoic acid (tHODE), a measure of hydrogen donor capacity; and Thiobarbituric acid reactive substances (TBARS), measured with an assay utilizing malondialdehyde (MDA).
Natural antioxidants found in our bodies and thought to counteract reactive oxygen species include erythrocyte superoxide dismutase, glutathione peroxidase, lipid hy-droperoxide, and selected protein carbonyl groups. Common dietary antioxidants found in foods as well as supplements include vitamin C, vitamin E, vitamin A, beta carotene, and many others, all of which can be measured to some degree of accuracy.
But what can measuring these things tell us, and can these measurements really be used to guide supplementation regimens?
Blood Antioxidant Measurements: Many patients are asking about their ‘antioxidant health’ in an effort to stave off free radical cellular damage from high levels of oxidative stress. Clinical testing labs offer a wide range of tests for the various natural antioxidants listed above, as well as exogenous antioxidants from dietary supplements like Co-Enzyme Q 10, vitamin A, vitamin E, Selenium, and Beta Carotene. These are legitimate testing methods and may be used to guide nutritional or dietary supplement recommendations.
The only caveat is that they can be costly. Measuring each of the antioxidants listed above could cost your patient over $100 per test. Patients should check with their insurance carriers to find out if such tests are covered, or be prepared to foot the bill themselves, before jumping into extensive antioxidant blood testing.
FRAP Test: The total antioxidant “power” of blood plasma can be defined by way of an assay called the FRAP test, measuring ferric reducing/anti-oxidant power in μmol/L. There are several published clinical studies of FRAP testing. One small study indicates the need to differentiate test results by gender (Chung W. Atherosclerosis. 1998; 78(1): 136). Another demonstrates how the FRAP test may be used to evaluate the antioxidant effectiveness of wine (Katalini V. Food Chemistry. 2004; 86: 593–600). Results of the FRAP test may have more application to food analysis than clinical practice, and may not correlate well with antioxidant deficiencies in the body.
TBARS Assay: This test is used for screening and monitoring lipid peroxidation, one indicator of oxidative stress. Blood contains a mixture of thiobarbituric acid reactive substances (TBARS) including lipid hydroperoxides and aldehydes, which may increase from metabolic processes, environmental exposures, and life choices. All may cause the formation of reactive oxygen species in the body. For perspective, normal plasma or serum TBARS levels are <1.5 and <2 malondialdehyde (MDA) units, respectively. Elevated TBARS levels have been shown in patients with Alzheimer’s Disease (Lovell M. Neurology. 1995; 45: 1594–1601). If a blood sample contains elevated TBARS, it should be further tested by high-performance liquid chromatography (HPLC), which is more specific for lipid peroxidation.
The TBARS assay can be used to measure anti-oxidant activity of compounds, but it has not been proven to correlate with free radical activity (or lack there of) in human disease states. There are several reasons for this. First, non-lipid TBARS may be present in the blood sample, confounding results. Second, TBARS cannot be performed in patients with certain conditions; samples from patients with icteric or lipemic plasma are not suitable for use in the TBARS assay. TBARS is a clinically useful test to screen a patient with ‘normal blood’ for clinically significant oxidative stress but may not correlate with inflammatory markers such as C-Reactive Protein or Erythrocyte Sedimentation Rate.
Skin Carotenoid Test: This test has been widely popularized in recent years by Pharmanex, a multi-level, network-marketing supplement company that has made it a cornerstone of its sales strategy.
The test, called Biophotonic Scanning or “Bioscan” makes use of the fact that carotenoids in human skin resonate with a certain wavelength of blue laser light, releasing a light signal of altered wavelength that can be easily measured.
Pharmanex representatives use the Bioscan as a way of detecting antioxidant deficiencies in their prospective clients. The client receives a piece of paper called a Bioscan certificate with her “skin carotenoid score.” The score is mapped on a color bar ranging from low to high, then given a numerical value. Generally, if the value is low, the individual’s intake of carotenoid-containing food and/or sup-plements is low, and the representative encourages the prospective client to increase his/her intake, preferably with Pharmanex products. The Bioscan is a legitimate test for skin carotenoid levels but cannot predict total body stores or nutritional deficiencies.
Leaving aside the ethical question of using a test like this to sell supplements, there is the clinical question of whether the level of skin carotenoids—a single class of antioxidant compounds in our diets—accurately represents an individual’s overall dietary intake of foods containing potentially thousands of different flavonoid-like constituents found in nature. Further, can carotenoid levels alone be used to guide nutrition-based strategies? The carotenoid test is a snapshot of one nutritional day not a trend over months or years and may have little clinical bearing beyond an initial screening tool regarding the nutritional status of your patient.
A well balanced diet including vitamins and minerals, while imperative for optimal health seems to be difficult for most Americans to maintain. Supplements do offer an alternative, and research tells us that antioxidant-rich dietary supplements or foods have promise in the area of cancer prevention, cardiovascular health, and memory health. However, we do not know the optimal dose for each nutrient/ingredient for prevention of these conditions, according to a recent National Institutes of Health-funded study (Huang H. Ann Intern Med. 2006; 145: 372–385).
More long-term research is needed to confirm endogenous as well as exogenous baseline antioxidant status, as well as confirm the magic combination of antioxidants, doses, and duration of therapy necessary to help prevent certain diseases. A lot of the tests patients are seeking are probably not able to provide them the guidance they need.
There are legitimate reasons to question some of the testing methods that have captured patients’ interest. But it is equally important to recognize that in getting these tests, patients are revealing their health concerns and demonstrating a wish to make changes. If a patient is proactively seeking over-the-counter lab tests, he or she is showing an impulse toward empowerment, and this represents an opportunity to begin a dialogue regarding health regimens including a back to basics approach to nutrition.
While you may need to explain why you think that the tests they’re using are not appropriate, make sure you do not squash their enthusiasm for making positive changes. A patient’s wish to take greater control of his/her health is certainly something to be encouraged, not derided. If you are not well-versed in nutrition, you may wish to seek out trained clinical nutritionists or naturopathic physicians, as well as good clinical laboratories with high integrity and solid analytical testing methodologies that can help you better serve your patients.
For more information on clinical laboratory testing, please visit the Clinical Laboratory Science Internet Resources website at http://members.tripod.com/~LouCaru/index-5.html, and look under “doctor’s guide” and “consumer laboratory testing information” pages.
