Fatty Liver All Slides Together Powerpoint

Fatty Liver:
An Integrated Chinese Medicine Approach to a Growing Global Epidemic
Misha Ruth Cohen, OMD, L.Ac.
Lecture presented at the ICCM Congress

Integrating Eastern and Western Medicine for in
Western Diagnosed Liver Disease

Clinic Director, Chicken Soup Chinese Medicine
Research Specialist in Integrative Medicine, Former, UCSF
Executive Director, Misha Ruth Cohen Education Foundation
Contact: TCMPaths@docmisha.com

Liver Support for Patients Using
Integrated Chinese Medicine
NAFLD/Fatty
Liver
Autoimm
PBC/PSC une
Hepatitis
Chinese Medicine HCV

Provides Support
for ... Viral
Cirrhosis Hepatitis
HBV
Liver
HCC Transplant
Liver Pre-
Post-
Cancer transplant
transplan
t © Misha Cohen
2016
Part One: Self-Care in Liver Disease
Step One Step Two Step Three

Adopt the Expand The Daily Implement a Liver
Comprehensive Journal Self-Care Plan
Program for •Dietary Guidelines
Strengthening Organ •Exercise Plan
Qi and Protective Qi •Meditation
•Self-Massage
•Nutritional
Supplements
•Support Group
© Misha
For a fuller discussion, see Misha Ruth Cohen, The New Chinese Medicine Handbook, Fairwinds Press, 2015 Cohen 2016
Part Two: Assembling the Liver Team

Obtain a Western Obtain Chinese •Bring in Other
Baseline, Diagnosis Medicine Diagnosis Modalities
and Treatment Plan and Treatment •Nutritional
•Lab Tests •Acupuncture Supplements
•Imaging •Moxibustion •Dietary
•Pathology •Herbs Recommendations
•Western •Diet •Exercise
Recommendations for •Exercise •Massage/Bodywok
Care •Meditation
•Acupressure
© Misha
For a fuller discussion, see Misha Ruth Cohen, The New Chinese Medicine Handbook, Fairwinds Press, 2015 Cohen 2016
Chinese Medicine & Liver Disease
Diagnostic Process
We can help a client develop and

manage a comprehensive treatment
plan integrated with Western medicine
practitioners, Western treatments and
other care.
The client is at the center of care.
6
© Misha Cohen 2016
Chinese Herbal Medicine
Chinese herbal medicine

can be used in liver
disease. The herbs
selected reflect the type
of imbalance that has
been diagnosed. Herbal
medicine may be used
alone or in conjunction
with other therapies.
7
©Misha Cohen 2008
Chinese Herbs
8
Western Herbal Treatment Concepts

●Decrease liver inflammation
●Normalize liver function
●Improve blood microcirculation
●Repair liver damage
●Anti-inflammatory
●Support normal weight
9
Contraindications/Interactions
Qualified herbal practitioners should always

be consulted. Specific herbal medicines are
for specific diagnoses. There are herbs
contraindicated in both Chinese and Western
diagnoses as well as negative interactions
between drugs and herbs as well as between
herbs and herbs. In our clinic we use
sophisticated interactions programs to
monitor current studies and
recommendations on herb/drug interactions.
10
Integrated Chinese Medicine & Liver
Disease
Integrating East and West
■ Client is in the center and in charge
■ Communication among practitioners is key
■ Develop practical treatment plans/care
management
■ Discuss drug side effects and how to manage
side effects and how to choose which medicine
to use
■ Labs, cancer screening and biopsies regularly
done by Western provider whether or not
Western treatment is currently pursued 11
Liver Support for Patients Using
NAFLD/Fatty
Liver
Autoimm
PBC/PSC une
Hepatitis
Chinese Medicine HCV

Provides Support
for ... Viral
Cirrhosis Hepatitis
HBV
Liver
HCC Transplant
Liver Pre-
Post-
Cancer transplant
transplan
t © Misha Cohen
2016
Misha Ruth Cohen
Education Foundation
(415) 864-7234
www.TCMeducation.org
(writing, externships,
subsidized programs)
*****************
Chicken Soup
Chinese Medicine
(415) 861-1101 (clinic)
www.DocMisha.com
13
14
Evaluation of Abnormal Liver Tests

Overview
• Background
• Transaminases
• Alkaline phosphatase
• Bilirubin
• Other liver labs
• Summary
Background
Background
• Liver enzyme and function tests ordered routinely

• 1 - 4% of asymptomatic patients have abnormal
values
• Components
– Transaminases
– Alkaline phosphatase
– Bilirubin
– Others: albumin, protein
Transaminases
Transaminases
• Located in hepatocytes
– Released after hepatocellular injury
• 2 Forms
– AST
• Non-specific to liver: heart, skeletal muscle,
blood
– ALT
• More specific: elevated in myopathies
Transaminases
• May not be elevated in chronic liver disease

– HCV - apoptosis
– Cirrhosis
• Minimal ALT elevations (<1.5 X normal)
– Race/Gender
– Obesity
– Muscle injury
Transaminases
• Mild elevations – more to come

• Marked elevations
– Acute toxic injury- ie tylenol, herbs, ischemia
– Acute viral disease
– Alcoholic hepatitis
Transaminases
• AST:ALT ratio
– Elevated in alcoholic disease
• 2:1
• If AST > 500 consider other cause
– No alcohol use suggests cirrhosis
Mild Transaminitis
Mild Transaminitis
• AST/ALT < 5 times upper limit of normal

• Etiologies
– Hepatic: ALT-predominant
• Chronic Hep C ▪Hemochromatosis
• Chronic Hep B ▪Medications/Toxins
• Acute viral hep ▪Autoimmune Hep
• Steatosis ▪Alpha1 Antitrypsin Def
• Wilson’s Disease ▪Celiac Disease
Mild Transaminitis
– Hepatic: AST predominant

• Alcohol
• Steatosis
• Cirrhosis
– Non-hepatic
• Hemolysis
• Myopathy
• Thyroid disease
• Strenuous exercise
Elevated AST & ALT,
<5X normal
Hx & physical; stop

hepatotoxic meds
Serologies:
HAV IgM
HBsAg
HBcIgM
Enzymes, PT, albumin, HCV Ab or
CBC, Hep A/B/C, Fe, RNA
TIBC, Ferritin
Negative serology,
Negative serology Positive serology
asymptomatic
Hepatotoxic Medications
• Analgesics - acetaminophen, NSAIDS

• Antimicrobials
– Amox-clav, nitrofurantoin, sulfonamides
– INH
– Azoles
– Protease Inhibitors
• Anticonvulsants - carbamazepine, valproic acid,
phenyton
• Cardiovascular - alpha-methyldopa, amiodarone,

labetalol
• Hyperglycemics - glyburide, troglidazone
• Psychiatric - trazadone, disulfiram
• Heparin
• Propylthiouracil
• Statins
• Zafirlukast
Hepatotoxic Herbs (Alleged)
• Chaparral leaf • Reported in

• Germander http://livertox.nih.gov
/Herbals_and_Dietary
• Senna
_Supplements.htm
• Kava kava
• Skullcap
• Vitamin A
Literature is not always accurate!!
☺
Serology
Negative Serology
Positive Serologies
Serologic Tests
Negative Serology - Asymptomatic
Stop EtOH & meds;
wt loss; glucose
control
6 months
Repeat Enzymes
Abnormal Normal
Ultrasound, ANA, smooth Observation

muscle Ab, ceruloplasmin,
antitrypsin, gliadin &
endomysial Ab
Liver biopsy ☺
Negative Serology - Clinical
Signs/Symptoms of Liver Disease
Consider ultrasound,
ANA, smooth muscle
Ab, ceruloplasmin,
antitrypsin
Abnormal
Liver biopsy
☺
Positive Serologies
+ Hep C/B
⁭ Hep A IgM
infection
Follow clinically,
Observation
serial LFTs
Clinical
Persistent
improvement,
elevated LFTs >
LFTs normalize in
6 mo’s
<6 mo’s
Observation Liver biopsy

Serologic Tests for Viral Hepatitis
• HAV
– Hep A IgM- ↑ in acute infxn
– Hep A IgG- ↑ in previous infxn or vaccination
• HCV
– HCV Ab- ↑ during or after infection
– HCV-RNA- ↑ during infection
• Detectable prior to HCV Ab turning positive
Serologic Tests for Viral Hepatitis
• HBV
– Hep B Surface Ag- ↑ in active infxn
– Hep B Surface Ab- ↑ in prior infxn or vaccinated
– Hep B Core Ab IgM- ↑ in active infxn
– Hep B Core Ab IgG- ↑ in current or prior infxn
– HBV-DNA- ↑ in active infxn
– Hep B e Ag & Ab- markers of viral presence and
potential infectivity
Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course
Sympto
ms
HBeA anti-
g HBe
Total anti-
Titre HBc
HBsA IgM anti- anti-

g HBc HBs
0 4 8 1 1 2 2 2 3 3 5 10
2 6 0 4 8 2 6 2 0
Weeks after Exposure
Alkaline Phospatase
Alkaline Phosphatase
• Produced by biliary epithelial cells

– Non-specific to liver: bone, intestine, placenta
• Elevations
– Biliary duct obstruction
– Primary biliary cirrhosis
– Primary sclerosing cholangitis
– Infiltrative liver disease- ie sarcoid, lymphoma
– Hepatitis/cirrhosis
– Medications
Medications
• Hormones- anabolic steroids, estrogen,

methyltestosterone
• Antimicrobials- augmentin, erythromycin,
flucloxacillin, TMP-SMX, HIV meds
• Cardiovascular- captopril, diltiazem, quinidine
• Hyperglycemics- chlorpropamide, tolbutamide
• Psychiatric- fluphenazine, imipramine, iprindole
• Others- allopurinol, carbamazepine
Elevated Alk Phos
Normal Enzymes,
Abnormal Enzymes
bili
RUQ u/s for ductal

GGT or 5’-NNT dilatation
- + Yes No
Other source RUQ us, med ERCP AMA

review, AMA
Neg
No dilatation
⁭ ALT eval, liver
Observation bx, ERCP or
Liver bx ⁭ AP > MRCP
6 mo
Bilirubin
Bilirubin
• Product of hemoglobin breakdown

• 2 Forms
– Unconjugated (indirect)- insoluble
•↑ in hemolysis, Gilbert syndrome, meds
– Conjugated (direct)- soluble
•↑ in obstruction, cholestasis, cirrhosis,
hepatitis, primary biliary cirrhosis, etc.
• No elevation until loss of > 50% capacity
Elevated Bilirubin
Unconjugated bili; Conjugated bili;

Normal alk phos, Abnormal alk
ALT, AST phos, ALT, AST
RUQ u/s to assess

ductal dilatation
Hemolysis studies, + -
review meds
ERCP or ⁭ ALT eval,
MRCP review meds,
AMA, ERCP or
MRCP, liver bx
Other Liver Labs
• Albumin
– Poor marker of liver function by itself - decreased by trauma,
inflammatory conditions, malnutrition
• Prothrombin time (PT)

– Insensitive: no change until liver loses 80% capacity
• Ammonia
– No correlation between brain & serum values
– Only one contributor to encephalopathy
Summary
• Algorithms based on poor quality or absence of

evidence
• Most asymptomatic patients can safely be
followed for a period of time to see if
abnormalities resolve
• If lab abnormalities persist be thoughtful with
ordering
References
• AGA Clinical Practice Committee. AGA medical position

statement: evaluation of liver chemistry tests.
Gastroenterology 2002;123:1364-66.
• AGA technical review on the evaluation of liver chemistry
tests. Gastroenterology 2002;123:1367-84.
• Bayard M, et al. Nonalcoholic fatty liver disease
2006;73:1961-8.
• Giboney PT. Mildly elevated liver transaminase levels in the
asymptomatic patient. Am Fam Physician 2005;71:1105-
10.
• Johnston DE. Special considerations in interpreting liver
function tests. Am Fam Physician 1999;59:
Misha Ruth Cohen
Chicken Soup
Chinese Medicine
www.DocMisha.com
49
50
Liver Health

DEFINE TREATMENT
Western Medications
Substance Use Referral
Client
52
Integrative Medicine
Liver Health Treatment Choices
❖ Western (allopathic) medicine

❖ Chinese medicine
❖ Naturopathic medicine
❖ Integrative medicine
❖ Other client chosen options
▪Ayurveda, homeopathy, mind-body therapies, etc.
© Misha Cohen 2016
Complementary and Alternative
Medicine (CAM)
CAM in liver disease and hepatitis may include:

• Asian Medicine
• Western herbal therapies
• Relaxation & visualization
• Nutritional Supplements
• Exercise
• Other CAM Therapies
© Misha Cohen 2015

Chinese Medicine and Liver Support
Overview
Chinese traditional
medicine uses traditional www.docmisha.com
diagnosis and traditional

modalities such as
acupuncture,
moxibustion, food and
nutrition therapy, herbal
remedies, Chinese
exercise and meditation.
© Misha Cohen 2011
Chinese Medicine
CAM in Liver Disease
Chinese Medicine may be used as complementary

or alternative therapies in liver disease.
Complementary medicine is used in conjunction
with or as an adjunct to primary Western medicine
or standard treatments
Alternative medicine is defined as a medicine that
may be used instead of standard therapies
©Misha Cohen 2008

Diagnostic Concepts
When the flow of Qi is
unimpeded there is harmony,
balance, and good health.
When there are Qi blockages,
too much or too little Qi, there
is an imbalance which can lead
to disharmony and disease.
From The New Chinese Medicine Handbook

by MIsha Ruth Cohen
Chinese Medicine and Liver Disease
Role of the Liver in CM

▪ Liver stores Xue
▪ Liver Xue nourishes sinews and joints
▪ Moistens the eyes, skin, hair, tendons, nails
▪ Ensures smooth flow of Qi and Xue:
▪ emotional state
▪ digestion
▪ bile secretion ©
Mish
a
Diagnostic Process
Traditionally, Chinese medicine does not define
viruses or bacteria as triggers of disease or
disorders, so we use Chinese medicine patterns to
make our primary diagnoses and treat according
to these diagnoses. For example typical Chinese
medicine diagnoses in viral hepatitis might
include “Spleen Qi Deficiency with Dampness” or
“Liver Qi Stagnation”, Liver Damp-Heat or “Toxic
Heat”.
© Misha Cohen 2016
Chinese Medicine
and Liver Support
Diagnostic Process
We will use traditional
diagnostic procedures to
treat people with liver
disease: palpation of the
pulse, channels and
abdomen, observation
of the tongue and face,
etc. With herbal
medicine we always
include tongue
observation.
©Misha Cohen 2008
Diagnostic Process
A diagnosis may include diagnosing imbalances of
the Eight Principles (Yin/Yang, Hot/Cold,
Deficient/Excess, Internal/External), Five Phases
(Wood, Fire, Earth, Metal, Water), Organ Systems,
Essential Substances (Qi, Xue/Blood, Jing/Essence,
Jin/Fluids), and Channel Theory. Different systems
vary in diagnostic procedures used to develop a
diagnosis and may vary in the final diagnoses.
© Misha Cohen 2016

Differential Diagnosis (TCM)

For example all HCV is associated with the li qi
(pestilence/Epidemic Factor), Toxic Heat:
Symptoms: Itching, sensations of heat, agitation
Tongue: Red spots and red body
Pulse: Rapid
© Misha Cohen 2016

Differential Diagnosis (TCM)

▪ There are also several traditional Chinese
medical patterns specifically associated with
various liver diseases.
▪ Patterns are diagnosed depending upon the
physical examination and an individual’s
symptomatology
▪ For example, the most common initial
diagnostic patterns found in chronic hepatitis C
are Liver Qi Stagnation, mild Xue Stasis and
Toxic Heat. © Misha Cohen 2016
HCV Example: Hepatitis C Symptoms &
CM Differential Diagnosis
Acute Infection Chronic Infection Stage 4/Cirrhosis End-Stage Liver Disease
Jaundice, fatigue, Maybe nothing… Maybe nothing… Symptoms of liver,

nausea/vomiting, Maybe URQ aches, body Maybe same as early kidney failure, often
diarrhea aches, fatigue often stage disease more cold signs
better with exercise, Maybe chronic fatigue,
digestive ssx, memory blood sugar imbalances,
problems, nutritional deficiencies,
Maybe spider
angiomata, palmar
erythema, increased or
stabbing pain, etc.
•Damp-Heat • Liver Qi Stagnation • Liver Qi Stagnation •Qi Deficiency
•Damp-Cold • Possible mild Blood • Much more Blood •Xue Deficiency
(Xue) Stasis (Xue) Stasis •Yin Deficiency
• Toxic Heat • Toxic Heat •Yang Deficiency
• Kid-Liv Xue or Yin •Lingering Stagnation
Deficiency
• Perhaps beginning
of Qi/Xue/Yin Def
For a fuller discussion, see Cohen, Misha Ruth., Robert G. Gish, and Kalia Doner. The Hepatitis C Help Book: a Groundbreaking Treatment Program
Combining Western and Eastern Medicine for Maximum Wellness and Healing. New York: St. Martin's Griffin, 2007.
Modern Approaches (General)

▪ Interprets traditional medicine concepts with input
and terms from Western medicine
▪ New concepts, therapies, and remedies
▪ Treats intractable diseases not defined in Chinese
traditional medicine, such as auto-immune hepatitis
or viral hepatitis
▪ New herbal formulas for Western defined diseases
rather than traditional pattern-defined
© Misha Cohen
2016
Chinese Medicine and Hepatitis C
Modern Approaches (Virus)

▪ Fu Zheng Qu Xie
▪ “Support righteous qi and dispel evil”
▪ Regulate immunity and enhance health to fight
off the infectious agent
▪ Restoring balance is the primary objective, not
ridding the body of the infectious agent
©
Mish
a
Diagnostic Process
In the best of all worlds,
we as Chinese traditional
medicine practitioners
using Integrated Chinese
Medicine take into
account both Western
diagnoses and Eastern
diagnoses when creating
a treatment plan.
©Misha Cohen 2008
Diagnostic Process
By doing this, we can help a client develop
and manage a comprehensive treatment
plan integrated with Western medicine
practitioners, Western treatments and other
care; the client is at the center of care and
is in charge of the overall treatment plan.
©Misha Cohen 2008

Diagnostic Process
When a person is treated in Chinese
medicine, there is ongoing assessment.
Treatments may be changed according to
the current health status evaluation by the
practitioner.
This should include ongoing Chinese
traditional diagnostic assessment along with
changes in Western diagnosis and therapies.
©Misha Cohen 2008
Treatment Objectives
Treatment objectives using Chinese medicine
may be based on traditional Chinese
medicine or modern Western concepts.
The Integrated Chinese Medicine approach is
to use treatment objectives that are
practical, using the best of both worlds,
while remaining true to the underlying
Chinese medicine diagnostic and treatment
principles
©Misha Cohen 2008
Treatment Objectives: Chinese

1. Clear Heat Clean Toxin
2. Regulate Qi and Xue
3. Tonify Qi, Xue, Jing and Jin
4. Harmonize Liver and Spleen/Stomach
5. Remove Dampness
6. Clear Damp Heat
7. Harmonize Mind/Body/Spirit
©Misha Cohen 2008

Treatment Objectives: Western

1. Control inflammation and restore liver function
2. Regulate immunity
3. Improve microcirculation and decrease fibrosis
4. Facilitate bile secretion and excretion
5. Lower portal vein pressure
6. Treat liver related symptoms and complications
7. Viral clearance is not a goal for Chinese treatment
although it can be for integrated treatment
©Misha Cohen 2008

Chinese Medicine
and Liver Disease
Chinese Herbal
Medicine
Chinese herbal medicine
can be used in liver
disease. The herbs
selected reflect the type of
pattern imbalance that has
been diagnosed. Herbal
medicine may be used
alone or in conjunction
with other therapies.
©Misha Cohen 2008
Chinese herbal medicine has been used to treat

hepatitis and liver disease for many centuries. The
Chinese people have developed herbal therapies
according to Chinese medicine’s theories of
physiological and pathological mechanisms.
Recently, there has been extensive basic science
research on herbal medicine in China and Japan.
© Misha Cohen 2016

In my clinic we use many forms of herbal

treatment. We have a bulk Chinese herb pharmacy
for individualized formulas and sometimes prescribe
individualized granule herb formulas sent to clients
from an outside pharmacy.
We use prepared tablets, capsules, tinctures,
extracts, and liniments based on traditional
formulas as well as those developed specifically for
Western constitutions and conditions.
© Misha Cohen 2016
The prepared pill formulas we used are often those

designed for liver issues as well as symptoms. They
are designed to be taken for long time periods.
The specific formulas given are based on a complex
consultation process and are evaluated regularly for
efficacy using both Eastern and Western diagnostic
procedures.
© Misha Cohen 2016

Chinese Herbs
77
Western Herbal Treatment Concepts

● Immune regulation
● Decrease liver inflammation Cordyceps
● Normalize liver function
● Improve blood microcirculation
● Enhance bone marrow function
● Repair liver damage
● Anti-inflammatory and anti-viral
Ling Zhi
© Misha Cohen 2016

It is important to have additional education as there
are specific herbal medicines for specific diagnoses.
There are herbs contraindicated in both Chinese
diagnoses and Western diagnoses as well as
negative interactions between pharmaceutical
medications and herbal medications as well as
between herbs and herbs. You can use
sophisticated interactions programs to monitor
current studies and recommendations on herb/drug
interactions. © Misha Cohen 2016
▪ People taking protease inhibitors (used in HCV)
should not take St. Johns Wort as there is
inhibition of the cytochrome P450 in the liver
which metabolizes both substances.
▪ Other substances, such as garlic supplements
and grapefruit juice (often never), should be
cautiously taken as they may interfere with
metabolism of drugs.
▪ Practitioners should determine any known
interactions
© Misha Cohen 2016
Herb Evidence
There are many basic research studies as well as

clinical data from China and Japan we use to
develop herbal treatments and other
complementary and alternative treatment options
for people with viral hepatitis.
Formulas developed by knowledgeable Chinese
medicine practitioners are often designed with this
basic research in mind in conjunction with
traditional Chinese principles of differential
diagnosis.
© Misha Cohen 2016

Acupuncture
Acupuncture is a great way

to support people with liver
disease. There are many
studies of acupuncture in
liver disease as well as in
related issues such as
inflammation.
Shen J. J Altern Complement Med. 2001;7 Suppl 1:S121-7; Research on the

neurophysiological mechanisms of acupuncture: review of selected studies and
methodological issues.
Acupuncture
The most well known--

discovered in the 1970’s-
- is pain relief through
stimulation of
endorphins.
Sugai GC, Freire Ade O, Tabosa A, Yamamura Y, Tufik S, Mello LE.Division of Chinese Medicine and
Acupuncture, Department of Orthopedics and Traumatology, Universidade Federal de Sao Paulo (UNIFESP),
Brazil
Han JS, Neurosci Lett. 2004 May 6;361(1-3):258-61;
Acupuncture and endorphins.
©Misha Cohen 2008
Acupuncture
Another mechanism is
through stimulation of
serotonin levels within the
brain, which leads to a
sense of well-being as well
as pain relief.
Sugai GC, Freire Ade O, Tabosa A, Yamamura Y, Tufik S, Mello LE.Division of Chinese Medicine and
Acupuncture, Department of Orthopedics and Traumatology, Universidade Federal de Sao Paulo (UNIFESP),
Brazil
©Misha Cohen 2008
Acupuncture
Acupuncture also has

anti-inflammatory
effects, which may
help relieve symptoms
and possibly decrease
inflammation.
Zijlstra FJ, van den Berg-de Lange I, Huygen FJ, Klein J Anti-inflammatory actions of acupuncture; Department of
Anesthesiology, Erasmus Medical Centre, Centre location, Rotterdam, The Netherlands.
©Misha Cohen 2008
Acupuncture
86
Acupuncture
Contraindication
▪ Acupuncture may be contraindicated in
bleeding disorders. Careful evaluation of labs
and patient response is necessary for safe
treatment.
▪ People with allergies to metal should not use
acupuncture. People with liver disease often
have increased autoimmune reactions.
▪ Rarely, some people develop “needle sickness”
and cannot tolerate acupuncture. There is no
evidence this is more prevalent in people with
liver disease. 87
Moxibustion
We regularly use
moxibustion to
stimulate specific
acupuncture
points or areas
that need
treatment. We
teach clients to
moxa
themselves. Smokeless Moxa
88
Moxibustion
Contraindications:
Moxibustion is generally
contraindicated with
Heat or Damp Heat
syndromes. Exceptions
include abdominal
cramping related to
Damp Heat type chronic
diarrhea as there is
always an underlying
Spleen Deficiency.
89
Qi Gong Exercise & Meditation
Sifu
Larry
Wong
90
Qi Gong Exercise & Meditation
Caring Ambassadors Videos - Sifu Larry Wong

● https://vimeo.com/19310331
91
Massage - Tui Na and More
We ask clients to seek

medical advice before
having therapeutic
bodywork if they suffer
from phlebitis,
thrombosis, varicose
veins, severe acute back
pain, or fever. This is
especially important in
immunocompromised or
very sick individuals. 92
Massage - Tui Na and More
Contraindications:
● Swellings, fractures, skin infections, or severe
hematomas should not be massaged. Lumps and
swellings should be checked by an allopathic
physician. This is also true for acupuncture.
● People with cancer are best treated by specially
trained practitioners who know which areas to
avoid and which kind of bodywork is appropriate.
93
Diet and Nutrition
● Dietary recommendations
are based on traditional
Chinese diagnoses as well
as current evidence-based
nutritional research and
knowledge.
● Support for digestion is
critical to liver function as
well as improving
symptoms such as fatigue.
94
Treatment Objectives -- Chinese
▪ Clear Heat Clean Toxin

▪ Regulate Qi and Xue
▪ Tonify Qi, Xue, Jing and Jin
▪ Harmonize Liver and Spleen/Stomach
▪ Remove Dampness
▪ Clear Damp Heat
▪ Harmonize Mind/Body/Spirit
© Misha Cohen
2011
Treatment Objectives -- Western
▪ Support immune function

▪ Control inflammation
▪ Support liver and other organ functions
▪ Treat liver-related symptoms and
complications
▪ Treat side effects of medications
▪ Viral suppression or eradication is not
the goal for Chinese medicine treatment
© Misha Cohen
2011
Integrating East and West
1. Client is in the center and in charge

2. Communication among practitioners is key
3. Develop practical treatment plans/care management
4. Discuss medication side effects and how to manage
side effects and how to choose which medicine to use
5. Discuss what to do if Western treatment is not
warranted, not chosen, must be discontinued or does
not clear virus (HCV) or suppress virus (HBV)
6. Labs, cancer screening and biopsies regularly done
by Western provider whether or not Western
treatment is used
97
Informed Self Care
● Daily Journal
● Dietary Guidelines
● Exercise Plan
● Meditation Plan
● Self-Massage
● Moxibustion
● Soaks and Saunas
● Nutritional Supplements
98
Comprehensive Healing Programs
Eastern Medicine
Natural Therapies
Western Medicine
Scientific Evidence
99
QUESTIONS?
© Misha Cohen
2016
Misha Ruth Cohen
(415) 864-7234
*****************
Chicken Soup
Chinese Medicine
(415) 861-1101 (clinic)
www.DocMisha.com
101
102
Fatty Liver, NAFLD and NASH

Fatty Liver Disease
▪ Fatty liver, also known as steatosis, has become the

most prevalent liver disease in the Western world
▪ Fatty liver is the buildup of fat in liver cells
▪ Alcohol consumption is the main reason for the
development of fatty liver disease
▪ Fatty liver disease we are addressing today may be
found in people who drink little or no alcohol, called
Nonalcoholic Fatty Liver Disease or NAFLD
© Misha Cohen
2016
Fatty Liver Disease
▪ Fatty liver affects up to one out of four adults

▪ It is the leading cause of chronic liver disease
▪ It is the third most common reason for liver transplants in
the United States after hepatitis C and chronic
alcoholism
© Misha Cohen
2016
Fatty Liver Disease and Inflammation
▪ If no inflammation is present, fat stored in the liver cells is

called steatosis
▪ In people who drink little or no alcohol, this steatosis is
called Nonalcoholic Fatty Liver Disease or NAFLD
▪ Presence of fat in liver cells along with inflammation is
called steatohepatitis
▪ In people who drink little or no alcohol, this hepatitis is
called is called Nonalcoholic steatohepatitis or NASH
© Misha Cohen
2016
FDefining NAFLD - Ruling out Acohol
NASH Clinical Research Network has defined the exclusion

criteria as patients who consume:
▪ Greater than 7-10 drinks per week (70 -100 g of total
alcohol) for women and greater than 14 drinks per week
(140 g of total alcohol) for men.
▪ Elevated ALT not suspected to be secondary to
hepatotoxic drugs, inflammatory bowel disease,
myopathy, prior surgery that could cause fatty liver (e.g.,
bilio-pancreatic diversion) or celiac disease.
© Misha Cohen
2016
Defining NAFLD – Alcohol Parameters
Standard drink is equal to 13.7 grams of pure alcohol

▪ 12 ounces of beer.
▪ 8 ounces of malt liquor.
▪ 5 ounces of wine.
▪ 1.5 ounces or a “shot” of
▪ 80-proof distilled spirits liquor
▪ (gin, rum, vodka, whiskey, etc).
© Misha Cohen
2016
NAFLD Signs and Symptoms
■ NAFLD is commonly asymptomatic or occasionally

associated with nonspecific right upper quadrant
discomfort.
■ 53%-80% of NAFLD patients are overweight (body mass
index [BMI] >25 kg/m2)
■ > 1/3 cases have metabolic syndrome.
■ 75% of lean patients (BMI <25 kg/m2) have at least one
feature of metabolic syndrome.
■ Hepatomegaly may be present on physical examination,
although stigmata of chronic liver disease suggestive of
cirrhosis are uncommon.
© Misha Cohen
2016
NAFLD
▪ 20% to 30% of adult populations in developed countries

have NAFLD
▪ In studies carefully screened for alcohol abuse, 20–30%
prevalence rates for NAFLD persisted in Northern Italy
and Israel.
▪ 15% in Shanghai, China.
▪ 18-28% in Japan
Liver International 2006: 26: 856–863.

J Clin Gastro 2006;40(1):S11-S16 © Misha Cohen
2016
NAFLD
● NAFLD is also increasing in children

● Approximately 2% to 3% percent of people with NAFLD
will progress to NASH
● NAFLD is associated with insulin resistance and an
increased risk of developing Type 2
111
Prevalence of NAFLD
© Misha Cohen
2016
NAFLD Prevalence Living Liver Donors
● Among living liver donors, the prevalence of

NAFLD based on liver biopsies varies from
33% to 88%
● Prevalence of moderate to severe steatosis
(>30%) ranged from 5% to 41%.
Liver Transpl. 2002;8:1114-1122. World J Surg. 1998;22:837-844.Transplantation. 2003;76:344-348.

Transplantation. 2000;69:2410-2415 113
NAFLD Prevalence in Children
● 9.6% of those age 2-19 have fatty liver-

● 6.5 million children in the U.S.
● The overweight and obese children
accounted for 81% of the fatty liver cases.
● 23% have steatohepatitis (NASH) with risk for
cirrhosis
Pediatrics Oct 2, 2006
114
NAFLD
● PRIMARY NAFLD:
○ Fatty liver associated with metabolic syndrome-
obesity, DM II, dyslipidemia and insulin resistance, or
in the absence of other identifiable causes
● SECONDARY NAFLD:
○ Other causes- jejuno-ileal bypass surgery, certain
drugs (glucocorticoids, anti-estrogens), metabolic
diseases (lipodystrophy, Weber-Christian disease), or
other miscellaneous causes (HIV infection, certain
hepatotoxins, rapid weight loss)
115
NAFLD Diagnosis
● Fatty infiltration of the liver as detected by

ultrasonography, is present in 14% to 16% of the general
population and is also likely to be due to NAFLD in the
majority of cases. Sonograms can only detect NAFLD
when there is more than 30% fat infiltration in the liver.
● Just the above ARE NOT SUFFICIENT TO RULE OUT
fatty liver.
116
NAFLD Diagnosis Using ALT
● Elevated serum ALT levels above 39 U/L as the

diagnostic tool for NAFLD yielded a prevalence of 3.7%
● Adjusting to normal ALT < 19.5, sensitivity and specificity
were increased to 72% and 60%.
● Liver sonography used as a diagnostic tool found 30% of
the same population to have NAFLD.
BMC Gastroenterology 2006, 6:33
117
NAFLD Diagnosis Using Biopsy
● In hepatology clinics, which see a high

proportion of chronic liver disease, a clinical
diagnosis of NAFLD based on serologic and
imaging studies without liver biopsy is correct
in only 53% to 83% of cases.
● Biopsy is the gold standard for diagnosing
NAFLD
Am J Gastroenterol. 2000;95:3206-3210. 118
The Role of Biopsy in NASH
● Absence of any reliable surrogate markers (serum,

radiologic or genetic) of disease presence or severity
● Attempt to treat associated risk factors
● Consider biopsy in those with persistently elevated
AST/ALT (> 6 mo) , esp. if risk factors for more
progressive disease
● Confirm diagnosis: most sensitive and specific
● Assess the grade and stage of disease, providing
prognostic data
● Identify those who may benefit most from therapeutic
(and investigational) interventions, and assess
subsequent response 119
Who Benefits from Biopsy in NASH?
Risk Factor Odds Ratio (95% CI)

___________________________________________________________________________
➢ Age > 45 yr 5.6 (1.5-21.7)

➢ Obesity (BMI > 30) 4.3 (1.4-13.8)
➢ AST:ALT >1 4.3 (1.5-12)
➢ Type 2 DM 3.5 (1.2-9.8)
_______________________________________________________________________________________
Angulo 2002 120

NASH and Insulin Resistance
● Visceral obesity is the most common cause of IR

● IR promotes energy accumulation for leaner times
● IR is initially ‘peripheral’, later ‘hepatic’
● Metabolic effects of IR:
○ Decreased mitochondrial β-oxidation of fatty
acids
○ Increased hepatic FFA uptake
○ Decreased hepatic FFA oxidation
○ Increased peripheral lipolysis
○ Increased CYP2E1 expression, pro-oxidants
121
NAFLD Pathogenesis
The ‘Two-hit’ Theory
Inflammation
Normal Steatosis & Fibrosis
■ Hit # 1: ■ Hit # 2:
Insulin Resistance ↑ Oxidant Stress

(CYP2E1, Iron, ↓ ATP)
Hyperinsulinemia
Leptin Resistance ↑ TNFα , ↑ TGFβ
↑ FFA Influx ↑ Leptin
↓ FFA Oxidation
↑ FFA flux
↓ Triglyceride Export
122
Ferritin NAFLD Predictors
123
GGT NAFLD Predictors
124
W J Gastroenterol 2009;15:2132
NAFLD Standard Screening Tools
● Fasting insulin > 10

● Fasting glucose > 110
● ALT > 30
● GGT > 35
● BMI >30
● Waist circumference: >102 male > 88 female
● HDL: <40 male < 50 female
● TG: > 150
● BP: > 130/85
Hepatology 2005;42:44-52. 125

NAFLD Caused By Environmental Toxins
● Petrochemicals
● organic solvents: benzene, toluene, styrene,
hexane, carbon tetrachloride, chloroform,
methanol, TCE, and vinyl chloride. (CYP2E-up-
regulated in NASH)
● These solvents are commonly found in cigarette
smoke, paints, automobile exhaust, pesticides, air
fresheners, and solvents used for cleaning and
dry cleaning.
Hepatology 2005;42:44-52. 126

NAFLD & Persistent Organic Pollutants (POP)
● Study looked at ALT levels in 2211 participants in

2003 - 2004 National Health and Nutrition
Examination Survey (NHANES) to see if there
were associations with low-level chemical
exposures and NAFLD.
● Elevated ALT were considered >30 in men and
>19 in women
Thanks to Lyn Patrick, ND
127
Gastroenterol 2009;136(5):S1:289
NAFLD, NHANES & NAFLD

128
Pollutants most likely to be associated

with ⇧ ALT

Gastroenterol 2009;136(5):S1:289 129
Organochlorine pesticides

130
Toxic Metals

131

Polychlorinated Biphenyls, Lead, and Mercury Are Associated with Liver Disease In American Adults: 132
NHANES 2003-2004 doi:10.1289/ehp.1002720
NASH
▪ NASH is the most prevalent form of progressive liver

disease in the U.S.
▪ NASH is a common and often “silent” and affects up to
5% of people in the U.S.
▪ Most people with NASH feel well and do not know they
have liver disease
▪ NASH can progress to cirrhosis and poor liver function,
liver cancer, and/or liver failure
▪ NASH is likely an important cause of cryptogenic
cirrhosis ©
Mish
a
NASH
● “NASH is the liver manifestation of obesity and the

metabolic syndrome.”
Dr. Matt Cave, hepatologist, University of Louisville
● Over 30 million adults have NAFLD
● 8.6 million may have NASH
● progressed stage of NAFLD, present in up to 30% of
NAFLD
● approximately 50% with NASH develop liver fibrosis
● 12 to 25% will develop cirrhosis and die in 7-10 years.
Hepatology 2006;43:S99, NEJM 2002;346:1221 ©
Mish
a
NASH Diagnosis
● Elevated liver enzyme levels found in routine blood

tests, such as increased levels ALT and AST
● Additional testing needed to rule out other causes of
liver disease (see previous slideshow)
● If no other reason, imaging and biopsies can reveal
liver fat, steatohepatitis and the stage of liver
disease as well as level of inflammation
Hepatology 2006;43:S99, NEJM 2002;346:1221 ©

Mish
a
Progression of Fatty Liver Disease
© Misha Cohen 2016

Progression of Fatty Liver Disease
Patients on Waiting List for Liver Transplants
Gish, R. 2002 Hepatitis C Professional Certification Program Slide Presentation

*Washington Regional Transplant Consortium 2003
Predisposing Factors NAFLD Progression
■ Obesity – Pt undergoing Bariatric surgery (90% steatosis, 30% NASH,

10% advanced fibrosis/cirrhosis)
■ Metabolic conditions
❑ Type 2 DM – 66% will have US evidence of NAFLD
❑ Polycystic ovarian syndrome – 50%
■ Age (may reflect longer standing undiagnosed NAFLD)
■ Gender
❑ M>F (? protective effect of estrogen)
■ Ethnicity
❑ Hispanics > Other white > African Americans
■ Genetics
❑ PNPLA3 gene (Others include NCAN, GCKR, LYPLAL1)
■ Other (HCV/HIV)
Vernon G, Baranova A, Younossi ZM (2011). Systematic review: the epidemiology and natural history of NAFLD and NASH in
adults. Alimentary Pharmacology and Therapeutics 34:274-285
Medications That Increase NAFLD Risk
■ Synthetic estrogens
■ Aspirin
■ Glucocorticoids
■ Calcium-channel blockers: Diltiazem
■ Tamoxifen
■ Methotrexate
■ Tetracycline
■ Valproic acid
■ Cocaine
■ HIV meds
■ Amiodarone
NAFLD, NASH and Obesity
● The fatter a person is the more likely to

have NAFLD
● From 2004 to 2014, the rate of obesity in
the U.S. doubled in adults and tripled in
children according to NIH
● Half of obese people have steatosis
● Likely that more than 25% of U.S.
population has steatosis
Obesity
● Body mass index (BMI) is a measure of

body fat based on dividing height by
weight and applies to adult men and
women
● Normal BMI runs between 20 and 25
● Obesity is defined medically as having a
BMI of greater than 30 and affects up to
50% of the U.S. population
● Free BMI calculator at
http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.ht
m
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1999, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
1990 1999
2009
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

NASH and Obesity
● By 2025 up to 45% of adult

population could be obese
● Up to 25 million Americans
with NAS
● Possibly 3.75 million
additional cases of
cirrhosis.
NASH and Morbid Obesity (BMI > 40)
● 84% to 96% who have undergone bariatric

surgery have NAFLD
● 25% to 55% of those with BMI>40 with
NAFLD have NASH
● 34% to 47% have fibrosis, and 2% to 12%
have bridging fibrosis or cirrhosis.
Metabolic Syndrome
● Fatty liver can be part of a complex of

symptoms called “metabolic syndrome”
● This may be found in addition to liver
disease
● People with advanced liver disease,
including hepatitis C, have a greater risk of
having metabolic syndrome
© Misha Cohen 2016

Metabolic Syndrome
● International Diabetes Foundation and the American

Heart Association/National Heart, Lung, and Blood
Institute defines metabolic syndrome as the presence
of at least three of the following symptoms:
● Increased waist circumference (≥102 centimeters/40
inches in men and ≥88 centimeters/34 inches in
women)
● Elevated blood pressure (≥130/85 mmHg)
● Elevated blood sugar (fasting glucose ≥100 mg/dL)
● High triglycerides (≥150 mg/dL)
● Low high-density lipoprotein (40 mg/dL in men and 50
mg/dL in women) © Misha Cohen 2016
NAFLD and Metabolic Syndrome
● Over 90% of patients with NAFLD have at least one

feature of the metabolic syndrome
● About 30% have the complete syndrome with three of
the following:
-central obesity
-impaired fasting glucose
-hypertriglyceridemia
-low HDL cholesterol
-hypertension
-elevated uric acid
© Misha Cohen 2016
Diagnosis of Metabolic Syndrome
Hepatology 2005;42:987-1000. © Misha Cohen 2016

Diagnosis of Metabolic Syndrome
■ NAFLD Is Found In
▪ 43% in those with impaired fasting glucose
▪ 62% in patients with newly diagnosed
▪ diabetes.
▪ BMI, triglyceride, total cholesterol and fasting plasma
glucose were independently associated with NAFLD
in non-diabetic individuals.
▪ 27% in subjects with normal fasting glucose
Diabet Med 2005; 22 : 1141–1145. © Misha Cohen 2016

Referral to Liver Specialist
● If you suspect a patient has NAFLD or NASH, make a

referral to a liver specialist for a liver biopsy which can
determine if if there is steatosis as well as the level of
liver damage.
● Liver biopsy is still the gold standard for determining the
amount of liver damage
● Fibroscan and Fibrosure are non-invasive tests that are
often used instead of biopsy, although they are not as
accurate
© Misha Cohen 2016

Metabolic Syndrome Is Very
Common In NASH
• n = 304 with NAFLD, without overt DM

• n = 120 NASH: 105 (88%) with Metabolic
Syndrome
• Metabolic Syndrome was associated with high
risk of severe fibrosis (OR 3.5, 95% CI 1.1-11.2,
p=0.032) Marchesini 2003
Age Specific Prevalence Of Metabolic
Syndrome - NHANES III
Ford 2002
• Estimated prevalence of Metabolic Syndrome - 24%

Calculate NAFLD fibrosis score or fatty liver

index!
(Age, BMI, hyperglycaemia, plts, albumin,
AST/ALT ratio). –
AUROC 0.85 for advanced fibrosis.
www.nafldscore.com
Dowman JK, Tomlinson JW, Newsome PN (2011). Systematic review: the diagnosis and staging of NAFLD and
NASH. Alimentary Pharmacology and Therapeutics 33: 525-540
High Fructose Corn Syrup Connection
▪ Increase in both total caloric consumption and certain

substances in the typical American diet
▪ HFCS is sweetener in many foods and drinks
▪ HFCS is corn starch converted into high fructose mix
▪ Twice as sweet as sucrose and has replaced sucrose in
sodas, fruit juices, dairy products, most baked goods and
numerous processed products.
▪ Accounts for more than 40% of caloric sweeteners added
to foods and drinks
Merriman, Raphael, “High Fructose Corn Syrup (HFCS) and its Potential Role in Fatty Liver Disease” , ALF,
July 2006
▪ Not just increase in portion size and increased sugars

▪ HFCS is metabolized differently than glucose
▪ Fructose does not stimulate insulin release or leptin
release, hormone important in regulating appetite
▪ Then the brain does not sense the need to limit food
intake, leading to further caloric intake, weight gain and
obesity.
Meriiman, Raphael, “High Fructose Corn Syrup (HFCS) and its Potential Role in Fatty Liver Disease” ,
ALF, July 2006
● When large quantities of fructose are consumed, it

bypasses the usual control mechanisms and is
preferentially converted to fat, leading to liver fat
accumulation and high cholesterol
● Long term consumption of high HFCS diets implicated in
development of insulin resistance
● HFCS use point to its potential role in the development of
NASH
Merriman, Raphael, “High Fructose Corn Syrup (HFCS) and its Potential Role in Fatty Liver Disease” ,
ALF, July 2006
● 15% and 25% of calories as fructose (>50 g fructose daily)

leads to insulin resistance
● 17-20% of calories as fructose (60-70 g fructose daily)
leads to triglycerides
● High fructose diets: increase arterial BP, tissue lipid
peroxidation, dyslipidemia, advanced glycation end-
products (AGE)
Endocrine Reviews 2009;30:96-116.

Soft Drink Consumption and NAFLD
High Fructose Corn Syrup & Agave?
● HFCS- 55% fructose

● Agave nectar- 60-90% fructose
● 1 cup blueberries = 7 grams fructose
● An apple = 9.5 grams fructose
● 1 cup dried figs = 23 grams fructose
● 1 tablespoon agave nectar = approx 14 grams fructose
doi:10.3748/wjg.v16.i21.2579
High Fructose Corn Syrup & Agave?
1 cup Coconut Bliss ice cream = 20-24 grams fructose

High Fructose and NAFLD
High Fructose and NAFLD
■ High fructose (glucose as well) :

■ Free fatty acid synthesis and transport to liver: VLDL and
triglycerides leading to increased hepatic oxidative stress
and necroinflammation
■ Over 25 grams fructose leads to malabsorption creating
fructose fermentation by gut bacteria and increased gut
permeability leading to increased levels of
lipopolysaccharides to liver
Misha Ruth Cohen
(415) 864-7234
*****************
Chicken Soup
Chinese Medicine
(415) 861-1101 (clinic)
www.DocMisha.com
168
169
Management of NAFLD

Pharmaceutical Management of NAFLD
■ Metformin
■ Reduces insulin resistance
■ Lipid-lowering agents (statins)
■ commonest cause of death is cardiovascular.
■ Reduced rate of HCC and improvement in LFTs
■ Statins are safe in liver disease!! (RCTs)
■ Vitamin E
■ PIVENS trial 2010 – Improvement in NASH: 43% vs 19%,
p=0.001
■ Considered 1st line for pharmacotherapy of NASH (not in
diabetic patients!)
Sanyal AJ et al (2010). Pioglitazone, Vitamin E or placebo for NASH. New England Journal of
Medicine 362: 1675-85
Pharmaceutical Management of NAFLD
■ Thiazolidinediones (pioglitazone)
■ Improvement in liver histology whilst on drug
but may relapse on stopping. Causes weight
gain
■ ?role for Glucagon-like peptide 1 (GLP-1), DPP-4
inhibitors.
■ Small proof of concept studies in
Sanyal AJ et al (2010). Pioglitazone, Vitamin E or placebo for NASH. New England Journal of
Medicine 362: 1675-85
Western Weight Loss Interventions
Examples
Orlistat
▪ Zelber-Sagi et al 2006: Orlistat vs no orlistat
▪ 6/12 treatment resulted in improved
transaminases, steatosis on USS, and weight
loss
▪ Hussein et al 2007: Orlistat in NASH
▪ 6/12 treatment improves histological steatosis,
fibrosis and inflammation
Western Weight Loss Interventions
Examples
Orlistat
Gastric Band/Bypass
▪ Mathurin et al.Gastroenterology 2009;137:532-540
– Prospective study – clinical, metabolic and liver
histology at baseline, Yr 1 and Yr 5 after bariatric
surgery. (56% Gastric Band, 21% Gastric bypass,
Bilio-intestinal bypass 23%)
▪ Significant Improvement in steatosis and
hepatocyte ballooning, but equivocal as to whether
fibrosis improves.
▪ Cost neutral at 18 months
Naturopathic NAFLD Treatment – Dr. Lyn
Patrick
■ Weight Loss
■ Diet
■ Magnesium
■ Vitamin E
■ Betaine (TMG)
■ Alpha lipoic acid/NAC
■ Curcumin/ECGC/Resveratrol/Cordyceps
■ Omega-3 fatty acids
■ Probiotics
Patrick
■ Improving Liver Biopsy

○ Diet: 55% carbohydrate, 15% protein, 30% fat
○ Exercise was added to promote 1 pound loss/wk
○ BMI - at onset: 26 - 35
○ Mean weight loss of 13 pounds over 3 months
improved fasting insulin and significantly
reduced steatosis on liver biopsy (regardless of
genotype) in untreated HCV.
Gut 2002;51:89-94.
Patrick
● Rapid weight loss increases steatosis and

necroinflammation.
● The rate of weight loss is important in minimizing the
influx of free fatty acids to the liver.
● Safe weight loss is no more than:
○ 1.1 pounds per week for children
○ 3.5 pounds per week for adults
NAFLD and Therapeutic Diets – Dr. Lyn
Patrick
Am J Clin Nutr 2007;86:285.

NAFLD and Antioxidant Research– Dr.
Lyn Patrick
NAFLD and Omega 3 Fatty Acids –
Dr. Lyn Patrick
▪ Animal/Human studies:
▪ improved insulin sensitivity
▪ lowered markers of liver inflammation in
animal models of NAFLD
▪ lowered markers of liver inflammation in
clinical trials of NAFLD
NAFLD and Magnesium – Dr. Lyn
Patrick
● Lowest levels of magnesium in:

● most insulin-resistant
● NASH with fibrosis (1.5 mg/dL)
● Independently related to high HOMA-IR
● Independently related to NASH
NAFLD and Vitamin D – Dr. Lyn
Patrick
● Low Vitamin D levels in 60 NAFLD patients

were closely associated with
○ Severity of steatosis
○ Severity of inflammation and fibrosis
○ Independent of age, sex, BMI,
creatinine, HOMA (steady state beta
function and insulin sensitivity)
NAFLD and Vitamin E – Dr. Lyn Patrick
■ Vitamin E Decreases Fibrosis

❖ TGF-β1 is a peptide found in many cell types that
regulates wound progression and apoptosis.
❖ The isoform found in hepatic cells, TGF- β1, has
been found in many models of hepatic fibrosis
❖ Levels increase in chronic active hepatitis and
fibrotic alcoholic liver disease. Kupffer cells and
stellate cells, two cell types involved in the
inflammatory sequence in NASH, secrete TGF- β1
as part of the process of fibrosis.
Aliment Pharmacol Ther 2001;15:1667.

● Vitamin E Improves Biopsy in Overweight

NAFLD
● Repeat liver biopsy in nine of 12 NASH patients after

12 months of 300 IU α-tocopherol treatment
revealed that inflammation
● Fibrosis were significantly improved in five, and the
remaining four had significant improvement in
steatosis.
● Vitamin E Decreases Fibrosis

● Plasma TGF- β1 was measured in the 10 NAFLD and
12 NASH patients at baseline, after completion of
dietary intervention, and after one year on α-
tocopherol.
● Baseline levels, which had been significantly higher
than NAFLD patients or healthy controls (p<0.01),
were unchanged after dietary intervention, but
significantly decreased after α- tocopherol (p<0.01).
J Hepatol 1992;14:259.
NAFLD & Betaine (Trimethylglycine) –
Dr. Lyn Patrick
● 7 patients with biopsy-proven NASH were given 10

grams of anhydrous betaine solution twice daily for
12 months:
● ALT and AST; normalization in 3 patients, 1
remaining unchanged.
● Repeat liver biopsy at 12 months: Significant
improvements occurred in both steatosis and
fibrosis.
Am J Gastroenterol 2001;96:2711.
NAFLD and Melatonin – Dr. Lyn Patrick
■ In animal models of NASH, 10 mg/kg of melatonin:

❖ reduced steatosis
❖ Increased hepatic antioxidant enzyme levels
❖ normalized ALT, AST, and decreased levels of
oxidative stress in high-fat diet induced liver
fibrosis
J Pineal Res 2006;41(1):79.

NAFLD and Botanicals – Dr. Lyn Patrick
■ IAnimal Studies of Botanicals
❖ Reservatrol- 10 mg qd 4 wks: decreased steatosis,

inflammatory markers decreased, anti-oxidant
markers increased.
❖ ECGC ( extract from green tea)- 3.2 g/kg diet for 16
wks: decreased steatosis
❖ Curcumin- ip injections inhibited steatosis and
fibrosis in animal model of NAFLD
J Pineal Res 2006;41(1):79.
NAFLD and Probiotics – Dr. Lyn Patrick
❖ Bacterial overgrowth (dysbiosis) has been

documented in NAFLD
❖ Dysbiosis: the production of ethanol and
lipopolysaccharides in the intestine leads to the
production of inflammatory cytokines in the
intestinal epithelium and liver macrophages
World J Gastroenterol 2010;16:403.

● VSL#3 given to mice with NAFLD improved fibrosis,

steatosis, decreased ALT and reduced inflammatory
markers
● “intestinal bacteria induce endogenous signals that
play a pathogenic role in hepatic insulin resistance
and NAFLD and suggest novel therapies for these
common conditions”
Hepatology. 2003 Feb;37(2):343-50.

● Improvement in liver enzymes in human trial of

alcoholic liver disease
● ↓ bacterial translocation, improved colonic barrier
function
● ↓ TNF-alpha production in cirrhotics
● Protects against NASH by ↑ IL-10 and hepatic NKT
cells
Alcohol 2008;42:675.
Comprehensive Program for Liver
Support - Self-Care
Adopt the Expand The Daily Implement a Liver

Comprehensive Journal Self-Care Plan
Program for •Dietary Guidelines
Strengthening Organ •Exercise Plan
Qi and Protective Qi •Meditation
•Self-Massage
•Nutritional
Supplements
•Support Group
Support - Self-Care
● Have patient adopt the General Comprehensive

Program for Strengthening Organ Qi and Protective
Qi
○ Balanced diet
○ Regular exercise and meditation
○ Self massage
○ Stress-reduction techniques
Cohen, Misha, The New Chinese Medicine Handbook, Chapter 13 and Chapter 17,
Fairwinds Press, October 2015
Support - Self-Care
● Expand the daily journal entries from the General

Comprehensive Program to include the following
○ Food cravings or times when you lose your appetite for
specific foods or food in general
○ Alcohol and caffeine consumption
○ Energy levels and ability to exercise
○ Times when fatigue, abdominal pain, digestive
problems, depression or weakness make it difficult to
exercise or to work
Support - Self-Care
● Expand the daily journal entries from the General

Comprehensive Program to include the following
○ Physical symptoms you suspect are associated with your
liver, such as fatigue, headaches, blood sugar problems,
changes in sleep patterns, swollen legs, swollen abdomen,
and pain over the liver area
○ Cognitive problems, whether you have “brain fog”, feel
sleepy during the day and wakeful at night, excessive
forgetfulness, changes in moods, irritability or easily
angered
Support - Self-Care
● Adjust the diet guidelines from the General

Comprehensive Program to include foods that Remove
Damp, promote the proper flow of Qi and Xue, improve
insulin sensitivity and help to lose weight
○ Eat a diet of warm, cooked foods. Reduce cold and raw
foods to a minimum unless you have Excess Heat.
○ Eliminate or drastically reduce dairy products, to decrease
Dampness and Strengthen Spleen. Helps increase weight
and fat loss.
Support - Self-Care
Comprehensive Program
○ Eliminate alcohol completely. Reduce caffeine if it increases
symptoms.
○ Eat less fatty foods, especially no transfats. A fatty diet can
also increase Qi Stagnation and Dampness, and increase
weight.
○ Eat a diet high in protein, especially fish, vegetable protein.
People with liver disease should eat 90 to 100 grams of high-
quality protein every day.
Cohen, Misha, The New Chinese Medicine Handbook, Chapter 17, Fairwinds Press,
October 2015
Support - Self-Care
Comprehensive Program
○ Adopt a diet focused on balancing high glycemic foods with
lower glycemic foods and proteins www.glycemicindex.com
is a good resource
○ Try to eliminate any foods that contain high fructose corn
syrup
○ Eliminate excess salt from diet to reduce fluid retention
October 2015
Support – Self Care
● Implement exercise plan
○ Exercise according to constitution, energy, and disease

level
○ To lose weight, walk 10,000 steps per day
○ Weight lifting should be moderate to support Spleen
○ Tai Chi, Qi Gong or moderate forms of Yoga exercises
every day
October 2015
● Implement meditation plan
○ Breathing exercises such as Breath Circulation

○ Zen Walking
○ Self-chosen forms of meditation or prayer
October 2015
● Implement self massage
● Qi Gong abdominal massage

● Self acupressure – for example Liver 3, Stomach 36,
Spleen 6, Spleen 9, Ren 9, Kidney 3
● Ear massage – ten minutes per day
October 2015
● Nutritional Supplements
● Omega 3 fatty acids

● Vitamin D
● Ear massage – ten minutes per day
● Vitamin E (see guidelines from AASLD)
● No iron supplements or Vitamin A unless prescribed by MD
for deficiency
● Lactobacillus acidophilus
October 2015

Obtain a Western Obtain Chinese Bring in Other Modalities
Baseline, Diagnosis and Medicine Diagnosis and •Nutritional
Treatment Plan Treatment Supplements
•Lab Tests •Acupuncture •Dietary
•Imaging •Moxibustion Herbs Recommendations
•Pathology •Diet •Exercise
•Western •Exercise •Massage/Bodywork
Recommendations for •Meditation
Care •Acupressure
© Misha Cohen 2016
For a fuller discussion, see Misha Ruth Cohen, The New Chinese Medicine Handbook,
Fairwinds Press, 2015
Assembling the Liver Team
● Western Medicine
● Test for liver enzymes regularly

● Blood Pressure
● Cholesterol
● Triglycerides
● Glucose
● BMI
October 2015
● Eastern Medicine
● Maintain metabolic balance

● Reduce symptoms of fatigue, weakness, brain fog,
swelling
● Reduce side effects of medications
● Improve overall balance of Qi, Xue, Jing and Jin
October 2015
Western Medicine
▪ Liver enzymes
▪ Rule out cause of elevations
▪ Imaging
▪ Ultrasound, MRI
▪ Refer to hepatologist
▪ Liver biopsy
▪ Regular follow-up and scans
▪ Weight loss or weight management program
October 2015
Eastern Medicine
▪ Chinese diagnostic examinations

▪ Pulse diagnosis
▪ Tongue diagnosis
▪ Palpate abdomen and Channels
▪ Facial diagnosis
▪ Read labs, biopsy reports and imaging tests
▪ See Western exams slide
▪ Ultrasound, MRI
▪ Provide Integrated Chinese Medicine treatment
▪ Refer to Western physician when necessary
Chinese Medicine Diagnostics
▪ Fatty Liver Common Patterns
▪ “Ji Ju” (accumulation in Chinese)

▪Liver Qi Stagnation
▪Phlegm and Dampness
Chinese Medicine Diagnostics
▪ Fatty Liver Pathology
▪Accumulation of Dampness, Heat, Phlegm and

sometimes Cold
▪Blood Stasis
▪Liver and Gallbladder Fail to Move Qi and therefore Fail
to Vitalize Xue
Chinese Medicine Treatment Principles
▪ Fatty Liver Treatment Principles
▪Transform Phlegm
▪Drain Damp
▪Strengthen Spleen
▪Harmonize Spleen/Stomach
▪Remove Blood Stasis
▪Clear Heat
▪Regulate Liver and Gallbladder Qi
*Can be used for other liver diseases with similar pattern differentiations
Chinese Medicine Herbal Formulas
▪ Formulas to Drain Dampness - Examples
▪Drain Dampness (based on Wu Ling San)*

■ Removes Damp Stagnation
■ Strengthen Spleen
■ Chronic hepatitis, ascites with cirrhosis
■ Tongue pale
■ Pulse thin, weak, floating
*Health Concerns – Ze xie, Fu ling, Zhu ling, Gui zhi, Bai zhu
▪ Formulas to Drain Dampness - Examples
▪Wu Ling San/Wan*

■ Promotes Urination
■ Drains Damp
■ Strengthens Spleen
■ Warms Yang
■ Tongue pale
■ Pulse thin, weak, floating
*Plum Flower – Ze xie, Fu ling, Bai zhu, Zhu ling, gui zhi
▪ Formulas to Transform Phlegm - Examples
▪Er Chen San/Wan*

■ Dries Dampness
■ Transforms Phlegm
■ Regulates Qi
■ Harmonizes Spleen and Stomach
■ Tongue swollen, thick wuite greasy fur
■ Pulse slippery, wiry, soft
*Plum Flower – Ze xie, Fu ling, Bai zhu, Zhu ling, gui zhi

▪Six Gentlemen (Xiang Sha Liu Jun Zi Formula)*
■ Tonify Qi
■ Harmonize Spleen and Stomach
■ Transform Phlegm
■ Tongue pale, toothmarks, thick greasy white fur
■ Pulse thin, deficient , slippery, soft, weak, wiry
*Health Concerns – Dang shen, Bai zhu, Fu ling, Zhi gan cao, Chen pi,
Ban xia, Mu xiang, Sha ren

▪Wen Dan San/Wan*
■ Regulates Qi
■ Clears and Transforms Phlegm
■ Harmonizes Gallbladder and Stomach
■ Calms the Shen
■ Tongue greasy white or yellow fur
■ Pulse rapid, slippery, wiry
■ Can be used in chronic hepatitis, chronic cholecystitis,
chronic gastritis
*Plum Flower – Zhu ru, Zhi shi, Ban xia, Chen pi, Fu ling, Gan cao,
Sheng jiang, Da zao
▪ Formulas to Strengthen Spleen- Examples

▪Six Gentlemen Plus (Xiang Sha Liu Jun Zi San)*
■ Tonifies Spleen Qi
■ Transforms Dampness
■ Expels Phlegm
■ Regulates Qi in the Middle Jiao
■ Chronic hepatitis, malabsorption syndrome, general debility,
chronic gastritis
*Plum Flower – Zhu ru, Zhi shi, Ban xia, Chen pi, Fu ling, Gan cao,
Sheng jiang, Da zao
▪ Formulas to Strengthen Spleen - Examples

▪Bu Zhong Yi Qi San/Wan (Central Chi Teapills)*
■ Tonifies Qi
■ Strengthens Spleen and Stomach
■ Raises Sunken Yang
chronic gastritis, debility, prolapse
■ Tongue pale, toothmarks, thin white fur
■ Pulse deficient, flooding or deficient and rootless at middle
Guan
*Plum Flower – Huang qi, Gan cao, Dang shen, Bai zhu, Dang gui,
Sheng ma, Chai hu, Chen pi, Da zao, Sheng jiang
▪ Formulas to Harmonize Spleen/Stomach - Examples

▪Shen Ling Ba Zhu Pian*
■ Harmonizes Stomach
■ Transforms dampness
■ Benefits the Lungs
■ Stops diarrhea
■ Loose stools with undigested food, chronic hepatitis, mild
abdominal pain, edema, weak muscles, fatigue
■ Tongue pale, swollen, thin white greasy fur
■ Pulse thin, weak, soft
*Plum Flower – Dang shen, Fu ling, Bai zhu, Shan yao, Lian zi, Yi yi ren, Bai bian dou, Jie geng, Sha
ren,Gan cao

▪Shen Ling (Shen Ling Ba Zhu San)*
■ Tonifies Spleen
■ Drains Dampness
■ Warms Center
■ Face pale
*Health Concerns– Dang shen, Bai zhu, Fu ling, Zhi gan cao, Shan yao, Bai bian dou Lian zi, Yi yi ren,
Sha ren, Jie geng, Chen pi

■ Tonify Qi
*Health Concerns – Dang shen, Bai zhu, Fu ling, Zhi gan cao, Chen pi, Ban xia, Mu xiang, Sha ren
▪ Formulas to Remove Blood Stasis - Examples

▪Hepatoplex Two*
■ Invigorate the Blood
■ Clear Damp Heat
■ Chronic hepatitis with cirrhosis or fibrosis
■ Decreased microcirculation in blood vessels and capillaries
■ Pulse choppy, quick
■ Tongue dusky, sublingual thick blue/purple veins and reddish
sides, purple spots on sides of tongue
*Health Concerns – Yin Chen hao, Hong hua, Dang gui, Chi shao, Dan shen, Zhi shi, Fo shou, Tao ren,
Chuan xiong, Gan cao (disclaimer - Misha Cohen designed formula)

▪Shao Fu Zhu Yu San (Stasis in the Lower Palace)*
■ Invigorates the Blood
■ Dispels Blood Stasis
■ Warms the Channels
■ Dispels Cold
■ Alleviates Pain
■ Cirrhosis, abdominal masses
■ Tongue pale or purple, possibly purple or dark spots or
distended and dark sublingual veins
■ Pulse deep, wiry, choppy, thready
*Plum Flower – Tao ren, Hong hua, Dang gui, Chuan niu xi, Chuan xiong, Mo yao, Ru xiang, Di long,
Gan cao, Qin jiao, Qiang huo, Xiang fu
▪ Formulas to Strengthen Spleen- Examples

▪Six Gentlemen Plus (Xiang Sha Liu Jun Zi San)*
■ Transforms Dampness
■ Expels Phlegm
■ Regulates Qi in the Middle Jiao
chronic gastritis
* Plum Flower –Bai zhu, Fu ling, Dang shen, Ban xia, Chen pi, Sha ren, Mu
xiang, Gan cao, Da zao, Sheng jiang
▪ Formulas to Strengthen Spleen - Examples

▪Bu Zhong Yi Qi San/Wan (Central Chi Teapills)*
■ Tonifies Qi
■ Strengthens Spleen and Stomach
■ Raises Sunken Yang
chronic gastritis, debility, prolapse
■ Tongue pale, toothmarks, thin white fur
■ Pulse deficient, flooding or deficient and rootless at middle
Guan
* Plum Flower – Huang qi, Gan cao, Dang shen, Bai zhu, Dang gui, Sheng ma,
Chai hu, Chen pi, Da zao, Sheng jiang

▪Shen Ling Ba Zhu Pian*
■ Harmonizes Stomach
■ Transforms dampness
■ Benefits the Lungs
■ Stops diarrhea
* Plum Flower – Dang shen, Fu ling, Bai zhu, Shan yao, Lian zi, Yi yi ren, Bai
bian dou, Jie geng, Sha ren,Gan cao

▪Shen Ling (Shen Ling Ba Zhu San)*
■ Tonifies Spleen
■ Drains Dampness
■ Warms Center
■ Face pale
* Health Concerns– Dang shen, Bai zhu, Fu ling, Zhi gan cao, Shan yao, Bai bian
dou Lian zi, Yi yi ren, Sha ren, Jie geng, Chen pi

■ Tonify Qi
* Health Concerns – Dang shen, Bai zhu, Fu ling, Zhi gan cao, Chen pi, Ban xia,
Mu xiang, Sha ren

▪Hepatoplex Two*
■ Invigorate the Blood
■ Clear Damp Heat
■ Chronic hepatitis with cirrhosis or fibrosis
■ Decreased microcirculation in blood vessels and capillaries
■ Pulse choppy, quick
■ Tongue dusky, sublingual thick blue/purple veins and reddish
sides, purple spots on sides of tongue
* Health Concerns – Yin Chen hao, Hong hua, Dang gui, Chi shao, Dan shen, Zhi
shi, Fo shou, Tao ren, Chuan xiong, Gan cao (disclaimer - Misha Cohen
designed formula)

▪Shao Fu Zhu Yu San (Stasis in the Lower Palace)*
■ Invigorates the Blood
■ Dispels Blood Stasis
■ Warms the Channels
■ Dispels Cold
■ Alleviates Pain
■ Cirrhosis, abdominal masses
■ Tongue pale or purple, possibly purple or dark spots or distended
and dark sublingual veins
■ Pulse deep, wiry, choppy, thready
* Plum Flower– Tao ren, Hong hua, Dang gui, Chuan niu xi, Chuan xiong, Mo
yao, Ru xiang, Di long, Gan cao, Qin jiao, Qiang huo, Xiang fu

▪Dan Shen Yin Wan (Salvia Teapills)*
■ Invigorates Qi and Blood
■ Removes Blood Stasis
■ Alleviates Pain
■ Hepatitis, early cirrhosis, hemangioma, coronary artery
disease, gastritis
■ Tongue purple, possibly purple or dark spots or distended
and dark sublingual veins
■ Pulse wiry, choppy
* Plum Flower– Dan shen, Tan xiang, Sha ren, Gan cao
▪ Formulas to Clear Heat - Examples

▪Long Dan Xie Gan San/Wan*
■ Clears Damp Heat from Liver and Gallbladder Channels
■ Clears Damp Heat from Lower Jiao
■ Cools Liver Fire
■ Acute and chronic hepatitis, chronic viral infections, costal
pain, headaches, itching, irritability, bitter taste in mouth
■ Tongue red, possible reddish sides or red dots along sides
and tip with greasy yellow coat
■ Pulse forceful, wiry, rapid
* Plum Flower – Long dan cao, Chai hu, Ze xie, Sheng di huang, Dang gui,
Huang qin, Zhi zi, Mu tong, Che qian zi, Gan cao
▪ Formulas to Clear Heat - Examples

▪Clear Heat*
■ Clears Heat and Cleans Toxin
■ Dissolves Phlegm Nodules
■ Tonify Kidney Jing
■ Tonify Lung Yin
■ Chronic viral infections, pain with Heat signs
■ Red spots throughout tongue, whether tongue body is
reddish or pale,
■ Quick
* Health Concerns– Da qing ye/Ban lan gen Extract, Baihu she she cao, Jin yin
hua, Xia ku cao, Chuan xin lian, Kun bu, Zi hua di ding, Dong chong xia cao, Gan
cao
▪ Formulas to Regulate Liver and Gallbladder Qi- Examples

▪Ecliptex*
■ Vitalize Qi and Blood circulation
■ Tonify Kidney and Liver Yin
■ Tonify Blood
■ Liver damage and inflammation, hepatitis, protects liver from
environmental chemical, drugs, alcohol and other agents
■ Tongue pale or pale reddish, sublingual thick blue veins,
■ Pulse wiry, possibly slightly rapid, possibly choppy
* Health Concerns – Han lian cao, Milk thistle, Yu jin, Dan shen, Gou qi zi, Nu
zhen zi, Chai hu, Wu wei zi, San qi, Dang gui, Che qian zi, Gan cao,
Misha Ruth Cohen
(415) 864-7234
*****************
Chicken Soup
Chinese Medicine
(415) 861-1101 (clinic)
www.DocMisha.com
235
236
Herbal Quality and Safety
Chinese Herbal Medicine in Liver Disease

Misha Visits China
© Misha Cohen
2016
239 Are Chinese Herbs Safe?
● This Depends on The Circumstances!

● Know The Herb Company From Where You
Are Buying Herbs
● The Herb Company Should Be Able to Supply a
Paper Trail and Documentation of All Steps in
the Herb Supply Chain
© Misha Cohen 2016

Mayway Hebei Herb Factory
Are Chinese Herbs Safe?
■ Determine Origin of Herbs

■ Test Individual Herbs
❑ Correct Species
❑ Freshness
❑ Pesticides, Heavy Metals, Toxins
■ Manufacture Formulas
■ Test Manufactured Formulas
■ Certificates of Analysis (COA) © Misha Cohen 2016
Example
One Company’s Quality Assurance
Program
Laboratory Testing
Trained herbalists evaluate the herbs for quality
on the basis of smell, taste and appearance, as
has been done for thousands of years.
The amount of active components, strength, and
efficacy are then verified by analysis.
© Misha Cohen 2016

Example
Program
Laboratory Testing
To screen for pesticides, heavy metals, sulfites,
and bacterial contamination, samples are sent to
independent labs, which use the latest
technology.
Capillary electrophoresis, high-pressure liquid
chromatography, gas chromatography, and thin-
layer chromatography provide detailed
compositional analysis of the molecular level.
© Misha Cohen 2016
Example
Program
Processing and Potency

Once the herbs have passed inspection, they are
processed according to tradition to maximize
potency and eliminate undesired effects. Raw
herbs may be steamed, baked, alcohol-soaked or
ginger processed.
© Misha Cohen 2016

Example
Program
Processing and Potency

The selection of each herb is double-checked and
quantities are weighed twice so that formulas are
uniform from batch to batch. Herbs are
granulated and cooked as a decoction to improve
bioavailability.
© Misha Cohen 2016

Example
Program
Combining Components
Devoted meticulous attention is given to each
individual component of a formula and then, of
course, to how components work together. Roots
are cooked over low temperature overnight.
Flowers are prepared by infusion.
© Misha Cohen 2016

Example
Program
Combining Components
Alkaloid-containing herbs are soaked in alcohol,
and aromatic extracts are added last to preserve
their volatile components. A small amount of
acacia gum and cellulose are used to bind the
ingredients together, while magnesium aids the
tableting process.
© Misha Cohen 2016

Example
Program
Tableting and Packaging

Once the herbs are compressed into tablets, they
are coated to ease swallowing and preserve
freshness. To make sure they can be absorbed,
their disintegration is timed.
© Misha Cohen 2016

Example
Program
Tableting and Packaging

During the final stage of manufacturing, they are
packaged into bottles, inner and outer safety
seals are applied, and each bottle is stamped with
a lot number and manufacture date. A sample of
each batch is sent to an outside lab to ensure the
accuracy, purity and potency.
© Misha Cohen 2016
Example
Program
Fully Tested & Guaranteed

Scientific and traditional assessment
combined with time-honored methods of
processing result in the most effective and reliable
herbs available anywhere.
© Misha Cohen 2016

Example
Program

The testing criteria, known as SIDI
(Standardized Information on Dietary Ingredients),
is endorsed by American Herbal Products
Association (AHPA), the Consumer Healthcare
Products Association (CHPA), the Council for
Responsible Nutrition (CRN), and the Natural
Products Association.
© Misha Cohen 2016
Example
Program

The herbalists brings decades of training,
experience, and care to the task of evaluation.
The company guarantees its products without
reservation.
© Misha Cohen 2016

Sample COAs
©
Mish
a
Pesticide Testing - Zero Tolerance
254
What About Drug - Herb
Interactions?
■ As Chinese medicine practitioners we should
be extremely concerned about client safety as
well as efficacy of treatment
■ Therefore, we should ask all clients to give us
a list of all drugs, supplements and herbs they
are currently taking
■ Then we can develop a treatment plan that
includes herb – drug interactions © Misha Cohen
2016
What About Drug - Herb
Interactions?
We use qualified professional databases to
develop interactions recommendations
■ The IBIS Guide to Drug-Herb and Drug-Nutrient Interactions
(MedicineWorks.com)
■ Natural Medicines Comprehensive Database Natural
Product/Drug Interaction Checker
http://naturaldatabase.therapeuticresearch.com/home.aspx
?cs=&s=ND
■ Other Databases and Articles as Needed –PubMed,©USDA,
Misha Cohen
etc. 2016
Sample Interactions Review
© Misha Cohen 2016

Sample Interactions Review
© Misha Cohen 2016

Misha Ruth Cohen
(415) 864-7234
*****************
Chicken Soup
Chinese Medicine
(415) 861-1101 (clinic)
www.DocMisha.com
259
260
Treatment Planning
Case Management

TREATMENT PLANNING
• Goals
(both Patient and Practitioner)
○ Consultation
○ Treatment
○ Future Plans
© Misha Cohen March 2018

TREATMENT PLANNING
● Integrative Medicine
○ Definition
○ Absence of AOM definition
○ How defined by NDs and
MDs?

Integrated Medicine
What do we mean by “integrated

medicine?”
Whom do we work with?
○ A large portion of our clientele are living with
complex health conditions that often require
careful monitoring, if not ongoing treatment,
from a western perspective as well as
Chinese medical diagnosis and treatment.

Integrated Medicine
○ We are profoundly aware of the

power of Chinese traditional
medicine and what it can offer to
our clients
○ We are likewise aware of what
western diagnostics and treatment
can offer and are happy for our
clients to benefit from both.

Integrated Medicine
At Chicken Soup, we believe in an

integrated East/West medical
approach: not only do we want to
know how the western treatments are
going, we want to make sure that our
treatment plans support and facilitate
the healthcare decisions a client is
making with other providers.

Integrated Medicine
● Depending upon our relationship with

western medical providers, we may
be in frequent contact with them to
ensure that we are working together
optimally for the client’s best health
outcomes.
● We also want to be sure to make
appropriate referrals where needed.

Integrated Medicine
What does this mean to our clients?
● Mostly, it means they don’t have to

constantly juggle approaches,
educating themselves in two (or more)
medical systems so that they can get
what you need out of each kind of
practitioner.

Integrated Medicine
● We help a client understand how our

care will work in conjunction with their
western care, so they can put these
different puzzle pieces together for
themselves to best effect.

Integrated Medicine
● We are also well versed in such issues

as drug-herb interaction, so that our
clients can feel secure in their
healthcare when they combine
western and eastern remedies.

The level of co-management of different illnesses will vary for clients
with different needs. This table shows examples how we integrate with
western care in hepatitis C.

TREATMENT PLANNING
Diagnostics
● Western/Naturopathic Medicine
○ Interview
○ Labs
○ Imaging
○ Palpation
○ Observation
○ Other

TREATMENT PLANNING
Diagnostics
● Chinese/Asian Medicine Systems
○ Tongue
○ Pulse
○ Palpation – Channels, Abdomen,
Other
○ Palpation – Abdomen
○ Face Observation
○ Gait and More
TREATMENT PLANNING
Diagnostics
● Other
○ Ayurvedic
○ Chiropractic
○ Physical Therapy
○ Other

TREATMENT PLANNING
Treatment Principles:
● Chinese/Asian Medicine
○ Examples?????
● Naturopathic Medicine
○ Examples?

TREATMENT PLANNING
Practitioner Care Plan
● Acupuncture
● Herbs
● Supplements
● Massage/Bodywork
● Qi Gong/Exercise
● Other

TREATMENT PLANNING
Self-Care Plan:
● Diet
● Self-Massage
● Self-Moxa
● Exercise
● Meditation
● Hydrotherapy/Baths
● Other
TREATMENT PLANNING
Communication with Other

Practitioners
● Western Physicians
● Western Treatment Team
● Chiropractor, Massage Therapist,
Bodyworker
● Mental Health Professionals
● Exercise Specialists: Eastern and Western
● Other Chinese Medicine Providers
TREATMENT PLANNING
Referrals
• Western Medicine
• Bodywork, Chiropractic, Osteopathy
• Mental Health
• Support Group
• Exercise
• Chinese Medicine/Acupuncture
• Naturopathic Medicine
TREATMENT PLANNING
Patient Issues
• Non-adherence with treatment plan

• Financial issues
• Interactions issues
• Conflicts with other practitioners
regarding treatment plan

TREATMENT PLANNING
Physician Issues
● Non-communicative PCP/other
providers
● Lack of belief or antagonism toward IM,
CAM or Chinese/Asian medicine
● No knowledge of herbs, discourages use
● No knowledge of supplements,
discourages us
● Bad doctor, vulnerable patient

TREATMENT PLANNING
Cultural competency
● Cross cultural
● Patients from other countries, culture
● Women
● LGBT
● MD (culture of privilege)

TREATMENT PLANNING
Challenges
● Successes
● Limited Successes
● Admitted Failures

TREATMENT PLANNING
End of Life Issues
● What treatment to do?

● When to stop treatment?
● What happens when someone you are
treating dies?

TREATMENT PLANNING
LAST WORDS
What do I ALWAYS do in complex cases?

Contact
Information
Misha Ruth Cohen, OMD,
L.Ac.
Chicken Soup Chinese
Medicine
TCMPaths@docmisha.com
www.docmisha.com
Thank you 286

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Fatty Liver:

An Integrated Chinese Medicine Approach to a Growing Global Epidemic

Misha Ruth Cohen, OMD, L.Ac.

Lecture presented at the ICCM Congress

Misha Ruth Cohen, OMD, L.Ac.

Lecture presented at the ICCM Congress

Chinese Medicine HCV

Step One Step Two Step Three

Step One Step Two Step Three

We can help a client develop and

Chinese herbal medicine

Western Herbal Treatment Concepts

Qualified herbal practitioners should always

Chinese Medicine HCV

Misha Ruth Cohen, OMD, L.Ac.

Lecture presented at the ICCM Congress

• Liver enzyme and function tests ordered routinely

• May not be elevated in chronic liver disease

• Mild elevations – more to come

• AST/ALT < 5 times upper limit of normal

– Hepatic: AST predominant

Hx & physical; stop

• Analgesics - acetaminophen, NSAIDS

• Cardiovascular - alpha-methyldopa, amiodarone,

• Chaparral leaf • Reported in

Literature is not always accurate!!

Ultrasound, ANA, smooth Observation

Observation Liver biopsy

HBsA IgM anti- anti-

• Produced by biliary epithelial cells

• Hormones- anabolic steroids, estrogen,

RUQ u/s for ductal

Other source RUQ us, med ERCP AMA

• Product of hemoglobin breakdown

Unconjugated bili; Conjugated bili;

RUQ u/s to assess

• Prothrombin time (PT)

• Algorithms based on poor quality or absence of

• AGA Clinical Practice Committee. AGA medical position

Misha Ruth Cohen, OMD, L.Ac.

Lecture presented at the ICCM Congress

Substance Use Referral

❖ Western (allopathic) medicine

CAM in liver disease and hepatitis may include:

© Misha Cohen 2015

diagnosis and traditional

Chinese Medicine may be used as complementary

©Misha Cohen 2008

From The New Chinese Medicine Handbook

Role of the Liver in CM

© Misha Cohen 2016

Differential Diagnosis (TCM)

© Misha Cohen 2016

Differential Diagnosis (TCM)

Acute Infection Chronic Infection Stage 4/Cirrhosis End-Stage Liver Disease

Jaundice, fatigue, Maybe nothing… Maybe nothing… Symptoms of liver,

Modern Approaches (General)

Modern Approaches (Virus)