A Controlled Trial To Increase Detection and Treatment of Osteoporosis in Older Patients with a Wrist Fracture

Background: Despite the high risk for future fractures and the availability of effective treatments, fewer than 10% to 20% of patients who sustain a fragility fracture are tested or treated for osteoporosis.

Objectives: To improve rates of testing and treatment for osteoporosis in patients with wrist fractures who are seen in the emergency department.

Design: Nonrandomized, controlled trial with blinded ascertainment of outcomes.

Setting: Emergency departments in Edmonton, Alberta, Canada.

Patients: Persons 50 years of age or older who were treated for a wrist fracture and their physicians. Patients admitted to the hospital or treated for osteoporosis were excluded. Overall, 572 consecutive patients with fractures were screened, and 102 patients (55 intervention, 47 control) and 101 physicians were studied.

Measurements: The primary end point was the prescription of osteoporosis treatment 6 months after fracture. Secondary end points included rates of testing for bone mineral density and patients' knowledge, satisfaction, and quality of life.

Intervention: Faxed physician reminders that contained osteoporosis treatment guidelines endorsed by local opinion leaders and patient education. Control patients received usual care and information about falls and home safety.

Results: The median patient age was 66 years. Most patients were female (78%) and white (79%); 70% of patients reported a previous fracture, and 22% had a fall with injury in the previous year. The intervention increased the rates of testing for bone mineral density to 62% (vs. 17% for controls; adjusted relative increase, 3.6 [P <> treatment to 40% (vs. 10% for controls; adjusted relative increase, 3.8 [P = 0.002]) within 6 months of fracture. Intervention patients were more likely to report a diagnosis of osteoporosis, but other patient-reported outcomes did not differ significantly between groups.

Limitations: This was a small, nonrandomized, controlled study with process-based outcomes.

<> Conclusions: In a multifaceted intervention directed at patients and their physicians, the rates of testing and treatment for osteoporosis after emergency department care for a fragility fracture were more than 3 times those of controls.

Author and Article Information

From University of Alberta, Edmonton, Alberta, and University of Calgary, Calgary, Alberta, Canada.

Deceased.

Acknowledgment: The authors dedicate this work to the memory of Deb Folk, RN, our project coordinator, who was not able to see the final study results published. Without her dedication, enthusiasm, and tireless efforts on our behalf, this study would not have been possible. The authors also thank the Orthopedic Plaster Room Technicians at the University of Alberta Hospital and the Royal Alexandra Hospital for their time and effort in carrying out the study; the Epidemiology Coordinating and Research (EPICORE) Centre of the University of Alberta for providing services related to trial coordination and data management; and the expertise and efforts of our independent data monitoring and safety committee (Dr. Ross Tsuyuki, chairman).

Grant Support: By the Medical Services Budget Innovation Fund (Alberta Medical Association and Alberta Health and Wellness) and the Alberta Heritage Foundation for Medical Research. Drs. Majumdar and Johnson are Population Health Investigators and Dr. Maksymowych is a Senior Scholar of the Alberta Heritage Foundation for Medical Research; Dr. Majumdar is a New Investigator of the Canadian Institutes of Health Research; and Drs. Rowe and Johnson hold Canada Research Chairs.

Potential Financial Conflicts of Interest: Consultancies, Honoraria, Grants Received, Member of Speakers' Bureau: D.A. Hanley (Merck Frosst Canada, NPS Pharmaceuticals, Eli Lilly Canada, Procter and Gamble Canada, Aventis, Novartis, Roche, Pfizer, Wyeth, Dairy Farmers of Canada).

Requests for Single Reprints: Sumit R. Majumdar, MD, MPH, Department of Medicine, University of Alberta, 2E3.07 Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112th Street, Edmonton, Alberta T6G 2B7, Canada; e-mail, me2.majumdar@ualberta.ca.

Current Author Addresses: Drs. Majumdar, Maksymowych, Morrish, Harley, Wirzba, and Russell: Department of Medicine, University of Alberta, 2E3.07 Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112th Street, Edmonton, Alberta T6G 2B7, Canada.

Drs. Rowe, Holroyd, and Steiner and Ms. Blitz: Division of Emergency Medicine, University of Alberta, 1G1.43 Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440-112th Street, Edmonton, Alberta T6G 2B7, Canada.

Dr. Johnson: Institute of Health Economics, #1200, 10405 Jasper Avenue, Edmonton, Alberta T5J 3N4, Canada.

Dr. Hanley: Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada.

Advising Patients Who Seek Complementary and Alternative Medical Therapies for Cancer

Many patients with cancer use complementary and alternative medical (CAM) therapies. Physicians need authoritative information on CAM therapies to responsibly advise patients who seek these interventions. This article summarizes current evidence on the efficacy and safety of selected CAM therapies that are commonly used by patients with cancer. The following major categories of interventions are covered: dietary modification and supplementation, herbal products and other biological agents, acupuncture, massage, exercise, and psychological and mind–body therapies. Two categories of evidence on efficacy are considered: possible effects on disease progression and survival and possible palliative effects. In evaluating evidence on safety, two types of risk are considered: the risk for direct adverse effects and the risk for interactions with conventional treatments. For each therapy, the current balance of evidence on efficacy and safety points to whether the therapy may be reasonably recommended, accepted (for example, dietary fat reduction in well-nourished patients with breast or prostate cancer), or discouraged (for example, high-dose vitamin A supplementation). This strategy allows the development of an approach for providing responsible, evidence-based, patient-centered advice to persons with cancer who seek CAM therapies.

Author and Article Information

From Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts; Canadian College of Naturopathic Medicine and University of Toronto, Toronto, Ontario, Canada; and National Center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, Maryland.

Grant Support: In part by grant U24 AR 43441 from the National Institutes of Health, Bethesda, Maryland; the John E. Fetzer Institute, Kalamazoo, Michigan; American Specialty Health Plans, San Diego, California; the Bernard Osher Foundation, San Francisco, California; and the Kevin Kelly Fund, Boston, Massachusetts.

Potential Financial Conflicts of Interest: Consultancies: H. Boon; Honararia: M. Smith, D.M. Eisenberg; Stock ownership or options (other than mutual funds): H. Boon, M. Smith, D.M. Eisenberg.

Requests for Single Reprints: Wendy A. Weiger, MD, PhD, Osher Institute, Division for Research and Education in Complementary and Integrative Medical Therapies, Harvard Medical School, The Landmark Center, 2nd Floor West, Suite 22A, 401 Park Drive, Boston, MA 02215; e-mail, wendy_weiger@hms.harvard.edu.

Current Author Addresses: Drs. Weiger, Kaptchuk, and Eisenberg: Osher Institute, Division for Research and Education in Complementary and Integrative Medical Therapies, Harvard Medical School, The Landmark Center, 2nd Floor West, Suite 22A, 401 Park Drive, Boston, MA 02215.

Dr. Smith: Canadian College of Naturopathic Medicine, 1255 Sheppard Avenue, East, North York, Ontario M2K 1E2, Canada.

Dr. Boon: Faculty of Pharmacy, University of Toronto, 19 Russell Street, Toronto, Ontario M5S 2S2, Canada.

Dr. Richardson: National Center for Complementary and Alternative Medicine, National Institutes of Health, 6707 Democracy Boulevard #406, Bethesda, MD 20892.

How Vitamin C Is Administered Affects How Much Reaches the Bloodstream and May Affect the Results of Studies of Its Potential Effect on Cancer

Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.

Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians.

The summary below is from the full report titled "Vitamin C Pharmacokinetics: Implications for Oral and Intravenous Use." It is in the 6 April 2004 issue of Annals of Internal Medicine (volume 140, pages 533-537). The authors are S.J. Padayatty, H. Sun, Y. Wang, H.D. Riordan, S.M. Hewitt, A. Katz, R.A. Wesley, and M. Levine.

What is the problem and what is known about it so far?

Some scientists and medical practitioners have suggested that vitamin C may have a role in the treatment of advanced cancer. Scientists know that high concentrations of vitamin C can kill cancer cells, at least in laboratory test tubes. However, studies of its effectiveness in people have been inconclusive. To help interpret future studies, researchers must determine whether the way vitamin C is administered affects the results. Previous studies have used vitamin C given by mouth (oral administration) or by injection into a vein (intravenous administration). The potential effect of vitamin C on cancer is probably greater if more of the vitamin reaches the bloodstream and produces a higher concentration, or "blood level," of the drug.

Why did the researchers do this particular study?

To determine whether giving vitamin C orally produced different blood levels than if it was given intravenously.

Who was studied?

17 healthy volunteers who agreed to be hospitalized for 3 to 6 months.

How did the researchers do the study?

The researchers first controlled the starting blood level of vitamin C by using a diet containing very little of the vitamin. They then gave gradually increasing daily doses and measured the blood level of vitamin C at each dose. The same doses that had been given orally were then given intravenously, and blood levels were again measured.

What did the researchers find?

Intravenous doses of vitamin C consistently produced a higher blood level than did oral doses. Increasing the oral dose (particularly at high doses) did not always produce a higher blood level because the body may control how much is absorbed from the intestine. By using the measurements at each dose level, the researchers predicted what the blood levels of vitamin C would have been if the volunteers had been given very high oral doses. They found that intravenous doses of vitamin C could produce blood levels about 70 times higher than those that could be achieved by the highest oral dose tolerated by humans.

What are the limitations of this study?

This study was done in healthy young persons. The results may not be the same in older patients or those with other serious illnesses.

What are the implications of the study?

This study evaluated only the blood levels that could be achieved by oral versus intravenous doses of vitamin C. It was not designed to determine whether vitamin C has any effect on cancer. Future research on the effects of vitamin C on cancer needs to recognize that much higher blood levels can be achieved when the drug is given intravenously rather than orally.

Overview of Nutrition in Cancer Care

Cancer and cancer treatments may cause nutrition-related side effects.

The diet is an important part of cancer treatment. Eating the right kinds of foods before, during, and after treatment can help the patient feel better and stay stronger. To ensure proper nutrition, a person has to eat and drink enough of the foods that contain key nutrients (vitamins, minerals, protein, carbohydrates, fat, and water). For many patients, however, some side effects of cancer and cancer treatments make it difficult to eat well. Appetite, taste, and the ability to eat enough food or absorb the nutrients from food may be affected. Malnutrition (lack of key nutrients) can result, causing the patient to be weak, tired, and unable to resist infections or withstand cancer therapies. Eating too little protein and calories is the most common nutrition problem facing many cancer patients. Protein and calories are important for healing, fighting infection, and providing energy.

Anorexia and cachexia are common causes of malnutrition in cancer patients.

Anorexia (the loss of appetite or desire to eat) is a common symptom in people with cancer. Anorexia may occur early in the disease or later, when the tumor grows and spreads. Some patients may have anorexia when they are diagnosed with cancer. Almost all patients who have widespread cancer will develop anorexia. Anorexia is the most common cause of malnutrition in cancer patients.

Cachexia is a wasting syndrome that causes weakness and a loss of weight, fat, and muscle. Anorexia and cachexia often occur together. Cachexia can occur in people who are eating enough, but who cannot absorb the nutrients. Cachexia is not related to the tumor size, type, or extent. Cancer cachexia is not the same as starvation. A healthy person's body can adjust to starvation by slowing down its use of nutrients, but in cancer patients, the body does not make this adjustment.

Good eating habits during cancer care help the patient cope with the effects of the cancer and its treatment.

Nutrition therapy can help cancer patients get the nutrients needed to maintain body weight and strength, prevent body tissue from breaking down, rebuild tissue, and fight infection. Eating guidelines for cancer patients can be very different from the usual suggestions for healthful eating. Nutrition recommendations for cancer patients are designed to help the patient cope with the effects of the cancer and its treatment. Some cancer treatments are more effective if the patient is well nourished and getting enough calories and protein in the diet. People who eat well during cancer treatment may even be able to handle higher doses of certain treatments.

Reference citations in some PDQ Supportive Care information summaries may include links to external Web sites that are operated by individuals or organizations for the purpose of marketing or advocating the use of specific treatments or products. These reference citations are included for informational purposes only. Their inclusion should not be viewed as an endorsement of the content of the Web sites or of any treatment or product by the PDQ Supportive Care Editorial Board or the National Cancer Institute (NCI).

A Healthy Mouth for Your Baby

1. Protect Your Baby's Teeth with Fluoride

Fluoride(said like floor-eyed) protects teeth from tooth decay and helps heal early decay.

Fluoride is in the drinking water of some towns and cities.

Ask your dentist or doctor if your water has fluoride in it. If it doesn't, talk to your dentist or doctor about giving you a prescription for fluoride drops for your baby.

2. Check and Clean Your Baby's Teeth

Check your baby's teeth

Healthy teeth should be all one color. If you see spots or stains on the teeth, take your baby to your dentist.

Clean your baby's teeth

as soon as they come in with a clean, soft cloth or a baby's toothbrush. Clean the teeth at least once a day. It's best to clean them right before bedtime.

At about age 2, most of your child's teeth will be in. Now you can start brushing them with a small drop of fluoride toothpaste. Use a drop of toothpaste about as big as this --

As your child gets older let him use his own toothbrush -- but you put the toothpaste on the toothbrush until about age 6.

Young children cannot get their teeth clean by themselves. Until they are 7 or 8 years old, you will need to help them brush. Try brushing their teeth first and then letting them finish. And be sure that you put the toothpaste on the brush-use only a pea-sized amount of toothpaste.

3. Feed Your Baby Healthy Food

Choose foods that do not have a lot of sugar in them. Give your child fruits and vegetables instead of candy and cookies.

4. Prevent Baby Bottle Tooth Decay

Do not put your baby to bed with a bottle at night or at nap time. (If you put your baby to bed with a bottle, fill it only with water. )

Milk, formula, juices, and other sweet drinks such as soda all have sugar in them. Sucking on a bottle filled with liquids that have sugar in them can cause tooth decay. Decayed teeth can cause pain and can cost a lot to fill.

During the day, do not give your baby a bottle filled with sweet drinks to use like a pacifier.

If your baby uses a pacifier, do not dip it in anything sweet like sugar or honey.

Near his first birthday, you should teach your child to drink from a cup instead of a bottle.

5. Take Your Child to the Dentist

Ask your dentist when to bring your child in for his first visit. Usually, the dentist will want to see a child by his first birthday. At this first visit, your dentist can quickly check your child's teeth.

What Is Asthma?

Asthma (AZ-muh) is a chronic disease that affects your airways, which are the tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways are inflamed (swollen). The inflammation (IN-fla-MAY-shun) makes the airways very sensitive, and they tend to react strongly to things to which you are allergic or find irritating. When the airways react, they get narrower and less air flows through to your lung tissues. This causes symptoms like wheezing (a whistling sound when you breathe), coughing, chest tightness, and trouble breathing.

Asthma cannot be cured, but for most patients it can be controlled so that you have only minimal and infrequent symptoms and you can live an active life. So, if you have asthma, taking care of it is an important part of your life. Controlling your asthma means staying away from things that bother your airways and taking medicines as directed by your doctor. By controlling your asthma every day, you can prevent serious symptoms and take part in all activities. If your asthma is not well controlled, you are likely to have symptoms that can make you miss school or work and keep you from doing things you enjoy. Asthma is one of the leading causes of children missing school.

When you experience a worsening of your asthma symptoms, it is called an asthma episode or attack. In an asthma attack, muscles around the airways tighten up, making the airway openings narrower so less air can flow through. Inflammation increases and the airways become more swollen and narrow. Cells in the airways also make more mucus than usual. This extra mucus also narrows the airways. These changes cause the symptoms of asthma and make it harder to breathe. Asthma attacks are not all the same-some are worse than others. In a severe asthma attack, the airways can close so much that not enough oxygen gets to vital organs. This condition is a medical emergency. People can die from severe asthma attacks.

If you have asthma, you should see your doctor regularly. You will need to learn what things cause your asthma symptoms to worsen and how to avoid them. Your doctor will also prescribe medicines to keep your asthma under control.

The 7 Principles for Controlling Your Diabetes for Life

Principle 1: Find Out What Type of Diabetes You Have ^ top

Type 1 diabetes. People who have this type of diabetes need to take insulin every day. This type of diabetes used to be called juvenile diabetes.

Type 2 diabetes. This type of diabetes can often be controlled by the food you eat and regular physical activity. Some people may also need to take diabetes pills or insulin. This type of diabetes used to be called adult onset diabetes.


Risk Factors for Diabetes. Are you at risk for diabetes?

• Being older than 45
  
  
• Being overweight
  
  
• Having a close family member, like a parent, brother, or sister, who has, or had, diabetes
  
  
• Having had diabetes when you were pregnant
  
  
• Being African American, Hispanic/Latino, Asian American or Pacific Islander, or Native American.

Action Items:

> Find out from your doctor what type of diabetes you have.

> If you know someone who has any of the risk factors, tell them to ask their doctor about getting tested for diabetes.

---

Principle 2: Get Regular Care for Your Diabetes ^ top

People with diabetes should:

• Always receive high-quality care.
  
  
• Work with health care providers to make changes to their treatment plan when needed.
  
  
• See a doctor, diabetes educator, or a nutritionist on a regular basis.
  
  
• Be able to get their health care needs taken care of regardless of their race, age, disability, or ability to pay.
  
  
• Get support from family, friends, and coworkers.
  
  
• Be able to get car insurance and a driver's license.
  
  
• Be treated fairly at work.
  
  
• Be able to get Medicare to help pay for diabetes supplies if they are on Medicare.

You have the right to get the best health care to help you control your diabetes.


Action Items:

> Ask your doctor or nurse how often you need to see them for a checkup.

> Write down the date and time for your next visit.

> Ask your doctor or clinic staff to help you find resources if you have problems paying for food, medicines, and medical supplies.

> Make a list of things you want to talk about at your next visit to the doctor or clinic.

---

Principle 3: Learn How To Control Your Diabetes ^ top

You and your family have the right to get correct information from your doctor and other health care providers to help you learn how to control your diabetes.


How Active Are You in Controlling Your Diabetes?

• I ask my doctor for accurate information about my diabetes.
  
  
• I have talked with my doctor about referrals to other people, like nutritionists and diabetes educators.
  
  
• I ask the diabetes educator and nutritionist about diet and other ways to control my diabetes.
  
  
• I talk to my doctor regularly about my special needs and controlling my diabetes.

If you have done everything on the list above, you are taking an active role in learning how to control your diabetes.


Action Items:

> If you have not done everything on the list, ask your doctor about things that you should do to learn more about how to control your diabetes.

> Ask your doctor about where to go to learn more about diabetes and how to control it.

---

Principle 4: Treat High Blood Sugar ^ top

The number 1 goal of diabetes treatment is to control high blood sugar levels.

Some of the ways that this can be done are:

• Eating a healthy diet
  
• Getting regular physical activity
  
• Taking medicine for your diabetes if your doctor tells you to
  
• Testing your blood sugar.

Action Items:

> Talk to your doctor about the best ways to control your high blood sugar.

> Get involved in making a treatment plan and other decisions about your diabetes care.

---

Principle 5: Monitor Your Blood Sugar Level ^ top

Testing Your Own Blood Sugar
You may need to test your own blood sugar on a regular basis to help you control your diabetes.


Action Items:

Talk with your health care provider about:

> What type of test to use

> How to do the test the right way

> How often to test

> How often to report the test results

> Getting the supplies you need to do the tests.


Hemoglobin A-1-c Testing
A hemoglobin A-1-c test is done by your doctor. It measures how well your blood sugar has been controlled over the last 2 to 3 months. This test is very important because it tells you how well you are taking care of your diabetes.


Action Items:

Ask your doctor or nurse educator:

> What your last hemoglobin A-1-c test result was.

> What your target hemoglobin A-1-c test result should be.

---

Principle 6: Prevent and Diagnose Long-Term Diabetes Problems ^ top

People with diabetes must control their blood sugar levels to prevent problems.

Long-term complications of diabetes are:

• Eye disease
  
• Kidney disease
  
• Nerve damage
  
• Heart disease and stroke

Action Items:

Some of the tests that you should get on a regular basis include:

> Blood pressure checks

> Cholesterol tests

> Other blood fat tests (ask your doctor what tests you should have).


Remember:

To help control and manage your diabetes, you should also:

• Eat a healthy diet
  
• Take medicine if your doctor tells you to
  
• Get regular physical activity
  
• Get regular foot and eye exams
  
• Work with your health care providers to do these things.

---

Principle 7: Get Checked for Long-Term Problems and Treat Them ^ top

To check for problems that diabetes can cause, you should see your doctor or other health care providers on a regular basis. Doing this can prevent problems or find them early, when they can be treated and managed well.


Action Items:

Ask your doctor or other health care providers about how often you should have your:

> Feet checked

> Eyes tested

> Kidneys tested.

Ask your doctor or other health care providers about other tests you may also need to have.

How Do the Lungs Work?

To understand ARDS (Acute Respiratory Distress Syndrome) , it is helpful to understand how your lungs work.

Normal lung function. A slice of normal lung looks like a pink sponge—filled with tiny bubbles or holes. Around each bubble is a fine network of tiny blood vessels. These bubbles surrounded by blood vessels give the lungs a large surface to exchange oxygen (into the blood where it is carried throughout the body) and carbon dioxide (out of the blood). This process is called gas exchange. Healthy lungs do this very well.

Here's how normal breathing works:

• You breathe in air through your nose and mouth. The air travels down through your windpipe (trachea) through large and small tubes in your lungs called bronchial (BRON-kee-ul) tubes. The larger ones are bronchi (BRONK-eye), and the smaller tubes are bronchioles (BRON-kee-oles). Sometimes we use the word "airways" to refer to the various tubes or passages that air must travel from the nose and mouth into the lungs. The airways in your lungs look something like an upside-down tree with many branches.
  
  
• At the ends of the small bronchial tubes, there are groups of tiny bubbles called air sacs or alveoli (al-VEE-uhl-eye). The bubbles have very thin walls, and small blood vessels called capillaries are next to them. Oxygen passes from the air sacs into the blood in these small blood vessels. At the same time, carbon dioxide passes from the blood into the air sacs.

Effects of ARDS. In ARDS, the tiny blood vessels leak too much fluid into the lung. This results from toxins (poisons) that the body produces in response to the underlying illness or injury. The lungs become like a wet sponge, heavy and stiffer than normal. They no longer provide the effective surface for gas exchange, and the level of oxygen in the blood falls. If ARDS is severe and goes on for some time, scar tissue called fibrosis may form in the lungs. The scarring also makes it harder for gas exchange to occur.

People who develop ARDS need extra oxygen and may need a breathing machine to breathe for them while their lungs try to heal. If they survive, ARDS patients may have a full recovery. Recovery can take weeks or months. Some ARDS survivors take a year or longer to recover, and some never completely recover from having ARDS.

Counseling parents and children on sun protection

Balk SJ, O'Connor KG, Saraiya M.

Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA. sbalk@montefiore.org

OBJECTIVE: To describe pediatricians' attitudes toward skin cancer (SC), sun protection (SP) counseling, and the quantity and content of such counseling and to identify barriers to counseling. METHODS: An American Academy of Pediatrics Periodic Survey was mailed to 1616 randomly selected US members between October 2001 and February 2002. The response rate was 54.6%. RESULTS: More than 90% of pediatricians agreed that SC is a significant public health problem and that preventing episodic high exposures to the sun during childhood will reduce the risk of adult melanoma. However, only 22.3% of respondents reported counseling most patients in all age groups. Female pediatricians were more likely to counsel most patients; pediatricians located in the South and West and those who practice in hospital/clinic settings were least likely to counsel compared with those in other regions. Approximately half (53%) of pediatricians reported selectively counseling on the basis of patient characteristics The most important SP recommendation named was using a sunscreen with a sun protection factor > or =15. Only 38% of pediatricians rated SP as very important to their patients' health compared with other topics such as use of car seats (86%), nutrition (79%), immunization issues (76%), and smoking/avoidance of environmental tobacco smoke (74%). The most frequently named barrier to SP counseling was lack of time (58% reporting). CONCLUSIONS: Although the majority of pediatricians believe that SC prevention is a worthy issue, only a minority reported providing routine SP counseling to most patients in every age group, and most ranked SP lower in importance than other issues. Interventions might include programs and materials to educate patients and pediatricians alike. To have an effect on increasing rates of SC and SC mortality, a broader public health approach is needed as a complement to pediatricians' counseling efforts.

Proximity of supermarkets is positively associated with diet quality index for pregnancy.

Laraia BA, Siega-Riz AM, Kaufman JS, Jones SJ.

Research Assistant Professor, Department of Nutrition, University of North Carolina, Carolina Population Center, Chapel Hill, NC 27599, USA.

Objectives. To investigate the association between distance to the closest supermarket and a composite measure of diet, the diet quality index for pregnancy (DQI-P) was constructed. Methods. Data from the Pregnancy, Infection and Nutrition (PIN) cohort, a prospective study of determinants of preterm birth, were analyzed. Food frequency questionnaires were used to construct DQI-P which includes: servings of grains, vegetables, fruits, folate, iron and calcium intake, percentage of calories from fat, and meal pattern score. Street address of residence, supermarkets, grocery and convenience stores were geocoded. Participants with complete food frequency and address data were included (n = 918). Multinomial logistic regression was used to estimate the conditional association of food outlets on diet quality, controlling for confounders and using a robust variance estimator to account for clustering of neighborhood characteristics. Results. Women living greater than 4 miles from a supermarket were more than twice the odds (adjusted odds ratio = 2.16; 95% confidence interval = 1.2, 4.0) of falling into the lowest compared to highest DQI-P tertile compared to women living within 2 miles of a supermarket, after controlling for individual characteristics, other food retail outlets. Conclusion. These findings suggest that proximity of food retail outlets influences the diet quality of pregnant women.

Proposal for a dietary "phytochemical index".

Pantox Laboratories, 4622 Santa Fe St., San Diego, CA 92109, USA.

There is ample reason to believe that diets rich in phytochemicals provide protection from vascular diseases and many cancers; direct antioxidant activity as well as modulation of enzyme expression or hormone activity contribute to this effect. Phytochemicals derived from diverse foods presumably can interact additively and (possibly) synergistically; thus, the total dietary load of phytochemicals may have important implications for health. As a means of very roughly quantifying this load, a "phytochemical index" (PI) is proposed, defined as the percent of dietary calories derived from foods rich in phytochemicals. Calories derived from fruits, vegetables (excluding potatoes), legumes, whole grains, nuts, seeds, fruit/vegetable juices, soy products, wine, beer, and cider - and foods compounded therefrom - would be counted in this index. Partial credit could be given for antioxidant-rich extra virgin olive oil. Other added oils, refined sugars, refined grains, potato products, hard liquors, and animal products - regrettably, the chief sources of calories in typical Western diets - would be excluded. Although the PI would provide only a very rough approximation of the quantity or quality of phytochemical nutrition, it nonetheless could aid epidemiologists in exploring the health consequences of diets high in phytochemical-rich plant foods, and could also help clinical nutritionists in their efforts to improve the phytochemical nutrition of their clients.

What We Know about the Flu

Virus Structure


A flu virus is roughly round, but it can also be elongated or irregularly shaped. Inside are eight segments of single-strand RNA containing the genetic instructions for making new copies of the virus. Flu's most striking feature is a layer of spikes projecting from its surface. There are two different types of spikes: one is the protein hemagglutinin (HA), which allows the virus to "stick" to a cell and initiate infection, the other is a protein called neuraminidase (NA), which enables newly formed viruses to exit the host cell.

Credit: CDC


Virus A, B, C

Influenza viruses are classified as type A, B, or C based upon their protein composition. Type A viruses are found in many kinds of animals, including ducks, chickens, pigs, whales, and also in humans. The type B virus widely circulates in humans. Type C has been found in humans, pigs, and dogs and causes mild respiratory infections, but does not spark epidemics.

Type A influenza is the most frightening of the three. It is believed responsible for the global outbreaks of 1918, 1957 and 1968. Type A viruses are subdivided into groups based on two surface proteins, HA and NA. Scientists have characterized 15 HA subtypes and 9 NA subtypes.
Naming Viral Strains

Type A subtypes are classified by a naming system that includes the place the strain was first found, a lab identification number, the year of discovery, and, in parentheses, the type of HA and NA it possesses, for example, A/Hong Kong/156/97 (H5N1). If the virus infects non-humans, the host species is included before the geographical site, as in A/Chicken/Hong Kong/G9/97 (H9N2). There are no type B or C subtypes.
Where Influenza Comes From

In nature, the flu virus is found in wild aquatic birds such as ducks and shore birds. It has persisted in these birds for millions of years and does not typically harm them. But the frequently mutating flu viruses can readily jump the species barrier from wild birds to domesticated ducks and then to chickens. From there, the next stop in the infectious chain is often pigs.

Pigs can be infected by both bird (avian) influenza and the form of influenza that infects humans. In a setting such as a farm where chickens, humans and pigs live in close proximity, pigs act as an influenza virus mixing bowl. If a pig is infected with avian and human flu simultaneously, the two types of virus may exchange genes. Such a "reassorted" flu virus can sometimes spread from pigs to people.

Depending on the precise assortment of bird-type flu proteins that make it into the human population, the flu may be more or less severe.

In 1997, for the first time, scientists found that bird influenza skipped the pig step and infected humans directly. Alarmed health officials feared a worldwide epidemic (a pandemic). But, fortunately, the virus could not pass between people and thus did not spark an epidemic. Scientists speculate that chickens may now also have the receptor used by human-type viruses.
Drifting and Shifting

Influenza virus is one of the most changeable of viruses. These genetic changes may be small and continuous or large and abrupt.

Small, continuous changes happen in type A and type B influenza as the virus makes copies of itself. The process is called antigenic drift. The drifting is frequent enough to make the new strain of virus often unrecognizable to the human immune system. For this reason, a new flu vaccine must be produced each year to combat that year's prevalent strains.

Type A influenza also undergoes infrequent and sudden changes, called antigenic shift. Antigenic shift occurs when two different flu strains infect the same cell and exchange genetic material. The novel assortment of HA or NA proteins in a shifted virus creates a new influenza A subtype. Because people have little or no immunity to such a new subtype, their appearance tends to coincide with very severe flu epidemics or pandemics.

Heterocyclic Amines in Cooked Meats

Research has shown that cooking certain meats at high temperatures creates chemicals that are not present in uncooked meats. A few of these chemicals may increase cancer risk. For example, heterocyclic amines (HCAs) are the carcinogenic chemicals formed from the cooking of muscle meats such as beef, pork, fowl, and fish. HCAs form when amino acids (the building blocks of proteins) and creatine (a chemical found in muscles) react at high cooking temperatures. Researchers have identified 17 different HCAs resulting from the cooking of muscle meats that may pose human cancer risk.

Research conducted by the National Cancer Institute (NCI) as well as by Japanese and European scientists indicates that heterocyclic amines are created within muscle meats during most types of high temperature cooking.

Recent studies have further evaluated the relationship associated with methods of cooking meat and the development of specific types of cancer. One study conducted by researchers from NCI’s Division of Cancer Epidemiology and Genetics found a link between individuals with stomach cancer and the consumption of cooked meats. The researchers assessed the diets and cooking habits of 176 people diagnosed with stomach cancer and 503 people without cancer. The researchers found that those who ate their beef medium-well or well-done had more than three times the risk of stomach cancer than those who ate their beef rare or medium-rare. They also found that people who ate beef four or more times a week had more than twice the risk of stomach cancer than those consuming beef less frequently. Additional studies have shown that an increased risk of developing colorectal, pancreatic, and breast cancer is associated with high intakes of well-done, fried, or barbequed meats.

Four factors influence HCA formation: type of food, cooking method, temperature, and time. HCAs are found in cooked muscle meats; other sources of protein (milk, eggs, tofu, and organ meats such as liver) have very little or no HCA content naturally or when cooked. Temperature is the most important factor in the formation of HCAs. Frying, broiling, and barbecuing produce the largest amounts of HCAs because the meats are cooked at very high temperatures. One study conducted by researchers showed a threefold increase in the content of HCAs when the cooking temperature was increased from 200° to 250°C (392° to 482°F). Oven roasting and baking are done at lower temperatures, so lower levels of HCAs are likely to form, however, gravy made from meat drippings does contain substantial amounts of HCAs. Stewing, boiling, or poaching are done at or below 100°C (212°F); cooking at this low temperature creates negligible amounts of the chemicals. Foods cooked a long time (“well-done” instead of “medium”) by other methods will also form slightly more of the chemicals.

Meats that are partially cooked in the microwave oven before cooking by other methods also have lower levels of HCAs. Studies have shown that microwaving meat prior to cooking helps to decrease mutagens by removing the precursors. Meats that were microwaved for 2 minutes prior to cooking had a 90-percent decrease in HCA content. In addition, if the liquid that forms during microwaving is poured off before further cooking, the final quantity of HCAs is reduced.

One study has evaluated the content of HCAs in fast food restaurants. After evaluating five kinds of meat products from various fast food restaurant chains, the study concluded that there were low levels of HCAs found in fast food meat products due to factors such as cooking temperature and time. The study suggested that greater exposure to HCAs stems from home cooking and cooking in non-fast-food restaurants where food may be cooked to order and where a larger amount of meat is consumed.

Studies are being conducted to assess the amount of HCAs in the average American diet, but at present the maximum daily intake of HCAs in food has not been established. At the moment, no Federal agency monitors the HCA content of cooked meats (how much a person could be eating), there is no good measure of how much HCAs would have to be eaten to increase cancer risk, and there are no guidelines concerning consumption of foods with HCAs. Further research is needed before such recommendations can be made.

However, concerned individuals can reduce their exposure to HCAs by varying methods of cooking meats; microwaving meats more often, especially before frying, broiling, or barbecuing; and refraining from making gravy from meat drippings.

References

1. Adamson RH, Thorgeirsson UP. Carcinogens in foods: Heterocyclic amines and cancer and heart disease. Advances in Experimental Medicine and Biology 1995; 369:211–220.

2. Adamson RH, Thorgeirsson UP, Snyderwine EG, et al. Carcinogenicity of 2-amino-3-methylimidazo[4,5-f] quinoline in nonhuman primates: Induction of tumors in three macaques. Japanese Journal of Cancer Research 1990; 81(1):10–14.

3. Bjeldanes LF, Morris MM, Felton JS, et al. Mutagens from the cooking of food. II. Survey by Ames/Salmonella test of mutagen formation in the major protein-rich foods of the American diet. Food and Chemical Toxicology 1982; 20(4):357–363.

4. Bjeldanes LF, Morris MM, Timourian H, Hatch FT. Effects of meat composition and cooking conditions on mutagen formation in fried ground beef. Journal of Agricultural and Food Chemistry 1983; 31(1):18–21.

5. Bogen KT. Cancer potencies of heterocyclic amines found in cooked foods. Food and Chemical Toxicology 1994; 32(6):505–515.

6. Dolara P, Commoner B, Vithayathil A, et al. The effect of temperature on the formation of mutagens in heated beef stock and cooked ground beef. Mutation Research 1979; 60(3):231–237.

7. Esumi H, Ohgaki H, Kohzen E, Takayama S, Sugimura T. Induction of lymphoma in CDF1 mice by the food mutagen, 2-amino-1-methyl-6-phenylimidazo[4,5-b] pyridine. Japanese Journal of Cancer Research 1989; 80(12):1176–1178.

8. Felton JS, Fultz E, Dolbeare FA, Knize MG. Effect of microwave pretreatment on heterocyclic aromatic amine mutagens/carcinogens in fried beef patties. Food Chemical Toxicology 1994; 32(10):897–903.

9. Felton JS, Knize MG, Shen NH, et al. Identification of the mutagens in cooked beef. Environmental Health Perspectives 1986; 67:17–24.

10. Felton JS, Knize MG, Wood C, et al. Isolation and characterization of new mutagens from fried ground beef. Carcinogenesis 1984; 5(1):95–102.

11. Hayatsu, H. Mutagens in food: detection and prevention. Florida, CRC Press, 1991.

12. Knize MG, Sinha R, Rothman N, et al. Heterocyclic amine content in fast-food meat products. Food and Chemical Toxicology 1995; 33(7):545–551.

13. Layton DW, Bogen KT, Knize MG, et al. Cancer risk of heterocyclic amines in cooked foods: An analysis and implications for research. Carcinogenesis 1995; 16(1):39–52.

14. Murray S, Gooderham NJ, Boobis AR, Davies DS. Detection and measurement of MelQx in human urine after ingestion of a cooked meat meal. Carcinogenesis 1989; 10(4):763–765.

15. Muscat JE, Wynder EL. The consumption of well-done meat and the risk of colorectal cancer. American Journal of Public Health 1994; 84(5):856–858.

16. Nader CJ, Spencer LK, Weller RA. Mutagen production during pan-broiling compared with microwave irradiation of beef. Cancer Letter 1981; 13(2):147–152.

17. Pariza MW, Ashoor SH, Chu FS, Lund DB. Effects of temperature and time on mutagen formation in pan-fried hamburger. Cancer Letter 1979; 7(2–3):63–69.

18. Sinha R, Rothman N, Brown ED, et al. High concentrations of the carcinogen 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) occur in chicken but are dependent on cooking method. Cancer Research 1995; 55(20):4516–4519.

19. Snyderwine EG. Some perspectives on the nutritional aspects of breast cancer research. Food-derived heterocyclic amines as etiologic agents in human mammary cancer. Cancer 1994; 74(3 Supplement):1070–1077.

20. Stavric B. Biological significance of trace levels of mutagenic heterocycylic aromatic amines in human diet: A critical review. Food and Chemical Toxicology 1994; 32(10):977–994.

21. Wakabayashi K, Ushiyama H, Takahashi M, et al. Exposure to heterocyclic amines. Environmental Health Perspectives 1993; 99:129–134.

Vitamins, Anti-Bacterials May Prevent Stomach Cancer

Vitamin C, beta-carotene, and an anti-bacterial treatment may -- singly or in combination -- help prevent stomach (gastric) cancer, according to a long-term clinical trial involving more than 600 people at high risk of developing the disease. The results of the trial appeared in the Dec. 6, 2000, issue of the Journal of the National Cancer Institute.

Gastric cancer is the second leading cause of cancer death in the world and five-year survival rates are low. An effective means of preventing the disease could have a dramatic impact on public health worldwide.

Pelayo Correa, M.D., and colleagues at Louisiana State University, New Orleans, together with researchers from Colombia, conducted the trial in an area of Colombia known for its high rate of gastric cancer. Participants were randomly assigned to receive either:

* a standard treatment for H. pylori infection, a bacteria that has been associated with the development of gastric cancer;
* one gram of ascorbic acid (vitamin C) twice a day;
* 30 milligrams of beta-carotene once a day;
* various combinations of these treatments; or
* a placebo.

To compare the treatments, the researchers looked at the status of precancerous abnormalities in the stomachs of each of the participants over the course of the six-year study. They analyzed biopsy specimens at the beginning of the study, after three years, and again after six years. The biopsies showed that precancerous abnormalities were more likely to shrink or disappear among people who received treatment than among those who took placebos.

The three different treatments all had about the same effect, and combining treatments did not appear to add any advantage.

For example, among people with a precancerous abnormality known as nonmetaplastic atrophy, those who received the anti-H. pylori treatment (an antibiotic plus other agents) were 4.8 times more likely than the placebo group to undergo a regression in their abnormalities. People with this condition receiving vitamin C were 5.0 times more likely to have abnormalities that regressed, and those receiving beta-carotene, 5.1 times more likely.

In an accompanying editorial, William Blot, Ph.D., of the International Epidemiology Institute in Rockville, Md., notes that the findings agree with those of other studies showing that people who eat many fruits and vegetables, which are rich sources of ascorbic acid and beta-carotene, have lower rates of gastric cancer. He cautions, however, that the findings must be confirmed by other studies.

A number of gastric cancer prevention trials are under way around the world. The largest, Correa said, is taking place in the Shandong province of China, where gastric cancer rates are very high. Sponsored by the National Cancer Institute, this trial is comparing the effects of vitamin and mineral supplements, a garlic extract, and anti-H. pylori treatment. Other trials are under way in Italy, England, Mexico, and elsewhere.

Diet Rich in Foods with Vitamin E May Reduce Alzheimer's Disease Risk

A new population-based study of antioxidants, appearing in the June 26, 2002, Journal of the American Medical Association (JAMA), suggests that a diet rich in foods containing vitamin E may help protect some people against Alzheimer's disease (AD). The study is also noteworthy for its finding that vitamin E in the form of supplements was not associated with a reduction in the risk of AD. The latest in a series of reports on vitamin E and dementia, the study findings heighten interest in the outcome of clinical trials now underway to test the effectiveness of vitamin E and other antioxidants in preventing or postponing cognitive decline and AD.

The JAMA study was conducted by Martha Clare Morris, Sc.D., of the Rush Institute for Healthy Aging at Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL, Denis A. Evans, M.D., and colleagues. A related study by Morris and colleagues, in press in the July 2002 Archives of Neurology, a JAMA publication, also associates vitamin E with protection against more general cognitive decline. (Reporting of additional detail on this study is embargoed for July 14, 2002, 4 p.m. ET.) Both studies were supported by the National Institute on Aging (NIA) at the National Institutes of Health.

The June 26 issue of JAMA includes similar findings from scientists in The Netherlands, who also reported a link between high dietary intake of vitamins C and E and protection against AD in certain people. In addition, the journal contains an editorial on the epidemiological study of dietary intake of antioxidants and the risk of AD by Daniel J. Foley, M.S., of the NIA's Laboratory of Epidemiology, Demography, and Biometry, and Lon White, M.D., Pacific Health Research Institute, Honolulu.

"This and a number of important population studies have pointed to vitamin E as possibly protective against oxidative damage or other mechanisms associated with cognitive decline and dementia,” says Neil Buckholtz, Ph.D., head of the Dementias of Aging Branch at the NIA. "The only way this association can really be tested is through clinical studies and trials now underway. These will help us determine whether vitamin E in food or in supplements – or taken together – can prevent or slow down the development of mild cognitive impairment or AD.”

It is not recommended, based on current evidence, that people take high-dose vitamin E supplements or other antioxidant pills in an effort to prevent mental decline, Buckholtz says. While population-based studies and animal research have suggested that antioxidants may be neuroprotective, clinical trials to test that notion are currently in progress. Little is known about safety, effectiveness, and dosages of various antioxidant supplements that are proposed for neuroprotective purposes, Buckholtz emphasizes.

In excessively high doses (above 2,000 International Units daily, or IU/d), for example, vitamin E may be associated with increased risk of bleeding, and patients taking anti-coagulant medications may be especially at risk. Interactions with other medications commonly taken by older people are also of potential concern. People are advised to consult with their physicians before taking high doses of supplemental vitamin E or other antioxidants.

The 815 people participating in the Morris study were part of the Chicago Health and Aging Project (CHAP), a study of a large, diverse community of people age 65 and older. Participants were free of dementia at the start of the study and followed for an average of 3.9 years. At an average of 1.7 years from their baseline assessment, participants completed a questionnaire, asking them in detail about the kinds and quantities of foods consumed in the previous year.

Some 131 participants had been diagnosed with AD by the end of the study period, when researchers examined the relationship between intake of antioxidants, including dietary and supplemental vitamins E and C, beta carotene, and a multivitamin, and development of AD. The most significant protective effect was found among people in the top fifth of dietary vitamin E intake (averaging 11.4 IU/d), whose risk of AD was 67 percent lower when compared to people in the group with the lowest vitamin E consumption from food (averaging 6.2 IU/d). (The recommended dietary allowance of vitamin E is 22 IU/d.)

No significant change in risk of AD was found when the scientists looked at vitamin E supplements, the other antioxidants and their supplements, or a general multivitamin. There was some evidence, though not statistically significant, that increased intake of dietary vitamin C and beta carotene was moving in a "protective direction,” the researchers said.

The data were also analyzed to see if age, gender, race, education, or possible genetic risk for AD would influence the findings. Only the presence or lack of apoE-4, one form of a protein associated with increased risk of late-onset AD, seemed to matter: the protective effect of vitamin E from food was strongest among people who did not have the apoE-4 risk factor allele. "Dietary vitamin E may protect against Alzheimer's disease,” says Morris, "but the protection may only occur among people without the apoE-4 allele.”

Morris suggests that further study in key areas is needed to confirm and explain some of the study's findings, including the link with apoE status and the study's striking distinction between dietary intake of vitamin E and use of supplements. For example, the lack of a protective effect for the supplements could be explained by several factors.

Some participants in the study started taking supplements only recently and there may not have been sufficient time for the supplement to be found effective. Also, people who believe they have memory problems could be more likely to take the supplements in the first place. Another possible explanation might be variations in the forms of vitamin E, scientists note. Most vitamin E supplements consist of alpha tocopherol while foods are generally more rich in gamma tocopherol.

These forms of vitamin E scavenge different types of free radicals, with one possibly more important than another in potentially reducing risk of cognitive decline. To help determine whether vitamin E might play a role in preventing AD, or at least in delaying its onset, a number of clinical trials are now being supported by the NIA. These include:

Memory Impairment Study – This study targets people with mild cognitive impairment, or MCI, testing the usefulness of vitamin E and donepezil to slow or stop the conversion from MCI to AD. (Study has completed recruitment.) Principal investigator: Dr. Ronald Petersen, Mayo Clinic, Rochester, MN.

Prevention of AD by Vitamin E and Selenium (PREADVISE) – An add-on to the National Cancer Institute's Selenium and Vitamin E Prostate Cancer Prevention Trial (SELECT), this investigation is testing vitamin E and selenium in healthy men age 60 and older for preventing cognitive decline and AD. (Some study sites have begun recruitment and others will begin enrolling participants over the next few months. See below on obtaining more information from NIA's ADEAR Center.) Principal investigator: Dr. William Markesberry, University of Kentucky.

Women's Antioxidant Cardiovascular Study (WACS) – Testing vitamin E, vitamin C, beta carotene, and folate for slowing cognitive decline in women age 65 and older at high risk of cardiovascular disease, the WACS is funded by the National Heart, Lung, and Blood Institute (NHLBI). An add-on for cognitive testing is supported by the NIA. (Recruitment and some cognitive testing of participants have been completed.) Principal investigator: Dr. Francine Grodstein, Harvard University.

Women's Health Study (WHS) – Testing aspirin and vitamin E in healthy women age 65 and older for slowing cognitive decline, the WHS is supported by the NHLBI and the National Cancer Institute. An add-on for the cognitive studies is supported by the NIA. (Recruitment and some cognitive testing of participants have been completed.) Principal investigator: Dr. Francine Grodstein, Harvard University.

Physician's Health Study II (PHS II) – Testing beta carotene, vitamin E, vitamin C and multivitamin with folate in healthy men age 65 and older for slowing cognitive decline. NIA supports the cognitive supplement to this privately funded study. (Recruitment and baseline cognitive testing of participants have been completed.) Principal investigator: Dr. Francine Grodstein, Harvard University.

More information on these studies, as it becomes available, will appear on the NIA-supported Alzheimer's Disease Education and Referral (ADEAR) Center Web site at www.alzheimers.org. The ADEAR Center also provides general information on AD research for health professionals, the media, and the general public. ADEAR can be contacted weekdays, toll free, at 1-800-438-4380.

The NIA leads the Federal effort supporting and conducting biomedical, clinical, social, and behavioral research on aging and on Alzheimer's disease specifically. Press releases, fact sheets, and other materials about aging and aging research can be viewed at the NIA's general information Web site, www.nia.nih.gov.

###

Eating Hints for Cancer Patients: Before, During, and After Treatment

After Treatment Ends

Ways to Get Back Into Eating

Most eating-related side effects associated with radiation, chemotherapy, or other treatments go away after cancer treatment ends. If you have had side effects, you should gradually begin to feel better, and your interest in food and mealtimes will come back. Sometimes, though, side effects persist, especially weight loss. If this happens to you, talk to your doctor and work out a plan together for how to address the problem.

After cancer treatment ends and you're feeling better, you may want to think again about the traditional guidelines for healthy eating. Just as you wanted to go into treatment with all the reserves that such a diet could give you, you'll want to do the best for yourself at this important time. There's no current research that suggests that the foods you eat will prevent your cancer from recurring. But, we do know that eating right will help you regain your strength, rebuild tissue, and help you feel well. Here are the fundamentals:

* Focus on eating a variety of foods every day. No one food contains all the nutrients you need.
* Emphasize fruits and vegetables. Raw or cooked vegetables, fruits, and fruit juices provide the vitamins, minerals, and fiber you need.
* Emphasize breads and cereals, especially the whole grain varieties, such as whole wheat bread, oats, and brown rice. These foods are good sources of complex carbohydrates, vitamins and minerals, and fiber.
* Go easy on fat, salt, sugar, alcohol, and smoked or pickled foods. Choose low-fat milk products, and small portions (no more than 6-7 oz. a day) of lean meat and poultry without skin. Try lower-fat cooking methods, such as broiling, steaming, and poaching.

The U.S. Department of Agriculture and U.S. Department of Health and Human Services have published materials to help Americans learn how to choose a healthy diet. The Resources section at the end of this booklet gives you information on how to get these materials. If you have any questions about guidelines for healthy eating, or whether such guidelines are right for you at this time, talk to a registered dietitian.

Some patients need to have treatments that last a long time. Others may have surgery to remove part of their stomach or intestines. These patients may have ongoing eating-related concerns. If this is your situation, talk to your doctor and a registered dietitian. He or she can give you more information about the long-term issues that you will deal with and can help you develop an individual diet plan.

Ways to Get Back Into Eating

Even if your treatment is over and you're feeling much better, you still may not feel completely back to your old self. Here are some ways to help you ease back to regular meals and mealtimes, without overdoing it:

* Make simple meals using familiar, easy-to-prepare recipes.
* Cook enough for two or three meals, then freeze the remainder for a later meal.
* Take advantage of the supermarket's salad bar and prepared foods to make cooking easier.
* Think about ways you used to make mealtime special and try them again.
* Don't be afraid to ask a friend or family member for help with cooking or shopping.

High Homocysteine Levels May Double Risk of Dementia, Alzheimer's Disease, New Report Sugges

People with elevated levels of homocysteine in the blood had nearly double the risk of developing Alzheimer’s disease (AD), according to a new report from scientists at Boston University.The findings, in a group of people participating in the long-running Framingham Study, are the first to tie homocysteine levels measured several years before with later diagnosis of AD and other dementias.The report, which appears in the February 14, 2002, issue of The New England Journal of Medicine, provides some of the most powerful evidence yet of an association between high plasma homocysteine and later, significant memory loss.

The relationship between AD and the amino acid homocysteine is of particular interest because blood levels of homocysteine can be reduced, for example, by increasing intake of folic acid (or folate) and vitamins B6 and B12.The therapeutic use of these compounds is being explored as scientists try to understand better homocysteine's role in AD or other types of dementia as well as its possible link to various forms of heart disease.

The dementia/AD study is being conducted by Philip A. Wolf, M.D., Boston University (BU), and colleagues at BU and Tufts University, who authored the new findings.The study was supported by the National Institute on Aging (NIA), part of the National Institutes of Health (NIH). The researchers were also funded by NIH’s National Institute of Neurological Disorders and Stroke (NINDS). The Framingham Heart Study is supported by the NIH’s National Heart, Lung, and Blood Institute (NHLBI).

"The Framingham population gave us the perfect opportunity to look at homocysteine levels in a group of people without memory problems over a period of several years, well before any evidence of dementia," Wolf pointed out."This is the clearest demonstration yet of the relationship between elevated homocysteine levels and dementia," he noted.

"The evidence is beginning to mount regarding homocysteine’s role in dementia," according to Neil Buckholtz, Ph.D., chief of the Dementias of Aging program at the NIA. "The good news is that we may have found a potential risk factor for AD that is modifiable. We don’t know yet whether reducing homocysteine levels will reduce dementia risk, but this is something that can and will be tested in clinical trials."

Buckholtz noted that the NIA-sponsored Alzheimer’s Disease Cooperative Study, a nationwide consortium of research centers, is already planning a clinical trial of folate and vitamins B6 and B12 to test whether reducing homocysteine levels with high doses of these vitamin supplements can slow the rate of cognitive decline in people diagnosed with AD.

Wolf and colleagues followed 1,092 people in a "dementia-free" group of the Framingham cohort.Participants in this group, whose average age was 76, were enrolled in the study between 1976 and 1978. Plasma homocysteine levels were measured between 1979 and 1982 and between 1986 and 1990.
Researchers also considered age, sex, vascular risk factors other than homocysteine, and plasma levels of folate and vitamins B6 and B12 of the participants. Information from the participants was also available on the late-onset AD genetic risk factor APOE-e4.

From the 1986-1990 examinations through December 2000, some 111 people developed dementia, including 83 diagnosed specifically with AD. Elevated homocysteine levels (defined as greater than 14 mmol/liter) doubled the chance that a participant would develop AD and each 5 mmol/liter elevation increased the risk of AD by 40 percent.The analysis showed further that people with consistently high levels of homocysteine throughout the period of the study were at highest risk for dementia and AD.

The researchers also examined whether the earlier levels of homocysteine, measured between 1979 and 1982, had any relationship to the development of dementia or AD later on; this analysis, too, linked elevated levels at least 8 years prior to a later diagnosis of dementia and AD.The association between homocysteine and AD was found to be strong and independent of other factors, such as age, gender, APOE genotype, and other known or suspected risk factors for dementia and AD.

There was no direct association in this study between the serum levels of folate and vitamins B6 and B12 and the development of dementia among the participants. As the relationship between these B vitamin levels, homocysteine, AD, and cardiovascular disease continues to be studied, scientists speculate that consuming adequate amounts of B vitamins by diet or supplementation might help reduce levels of homocysteine in some individuals.

Findings from the NHLBI-supported DASH (Dietary Approaches to Stop Hypertension) study suggest that a diet rich in green leafy vegetables, low-fat dairy products, citrus fruits and juices, whole wheat bread, and dry beans can significantly lower levels of homocysteine.

The Food and Drug Administration (FDA) now requires the addition of folic acid to enriched breads, cereals, flours, corn meals, pastas, rice, and other grain products. "Although there is no evidence that actually reducing homocysteine levels will prevent AD or cardiovascular disease, a healthy diet low in fat and rich in nutrients is always a good idea," says BU’s Wolf.

The NIA leads the Federal effort to support and conduct basic, clinical, and social and behavioral studies on aging and AD.It supports the Alzheimer’s Disease Education and Referral (ADEAR) Center, which provides information on AD research, including clinical trials, to the public, health professionals, and the media.ADEAR can be contacted toll free at 1-800-438-4380 weekdays or by visiting the website www.alzheimers.org.

Press releases, fact sheets, and other materials about aging and aging research can be viewed at the NIA’s general information website, www.nia.nih.gov.

The NHLBI is the nation’s leading supporter of biomedical research on diseases of the heart, blood vessels, and lung; sleep disorders; and on the management of blood resources.The Institute’s Framingham Heart Study began in 1948 as the first long-term population-wide epidemiological study and has led to such medical breakthroughs as identifying the risk factors for heart disease, including high blood cholesterol and high blood pressure.Information about Framingham is available online at www.nhlbi.nih.gov/about/framingham. NHLBI press releases, fact sheets, and other materials are available on the NHLBI website at www.nhlbi.nih.gov.

Antioxidant Vitamins and Zinc Reduce Risk of Vision Loss from Age-Related Macular Degeneration

National Eye Institute (NEI)


High levels of antioxidants and zinc significantly reduce the risk of advanced age-related macular degeneration (AMD) and its associated vision loss. These same nutrients had no significant effect on the development or progression of cataract. These findings from a nationwide clinical trial are reported in the October 2001 issue of Archives of Ophthalmology.

Scientists found that people at high risk of developing advanced stages of AMD, a leading cause of vision loss, lowered their risk by about 25 percent when treated with a high-dose combination of vitamin C, vitamin E, beta-carotene, and zinc. In the same high risk group — which includes people with intermediate AMD, or advanced AMD in one eye but not the other eye — the nutrients reduced the risk of vision loss caused by advanced AMD by about 19 percent. For those study participants who had either no AMD or early AMD, the nutrients did not provide an apparent benefit. The clinical trial — called the Age-Related Eye Disease Study (AREDS) — was sponsored by the National Eye Institute (NEI), one of the Federal government's National Institutes of Health.

"This is an exciting discovery because, for people at high risk for developing advanced AMD, these nutrients are the first effective treatment to slow the progression of the disease," said Paul A. Sieving, M.D., Ph.D., director of the NEI. "AMD is a leading cause of visual impairment and blindness in Americans 65 years of age and older. Currently, treatment for advanced AMD is quite limited. These nutrients will delay the progression to advanced AMD in people who are at high risk — those with intermediate AMD in one or both eyes, or those with advanced AMD in one eye already.

"The nutrients are not a cure for AMD, nor will they restore vision already lost from the disease," Dr. Sieving said. "But they will play a key role in helping people at high risk for developing advanced AMD keep their vision."

A common feature of AMD is the presence of drusen, which are yellow deposits under the retina. Often found in people over age 60, drusen can be seen by an eye care professional during an eye exam in which the pupils are dilated. Drusen by themselves do not usually cause vision loss, but an increase in their size and/or number increases a person's risk of developing advanced AMD, which can cause serious vision loss.

The three stages of AMD analyzed in this study are:

1. Early AMD. People with early AMD have, in one or both eyes, either several small drusen or a few medium-sized drusen; these people do not have vision loss from AMD.
2. Intermediate AMD. People with intermediate AMD have, in one or both eyes, either many medium-sized drusen or one or more large drusen; in these people, there is usually little or no vision loss.
3. Advanced AMD. In addition to drusen, people with advanced AMD have, in one or both eyes, either:
* A breakdown of light-sensitive cells and supporting tissue in the central retinal area (advanced dry form); or
* Abnormal and fragile blood vessels under the retina that can leak fluid or bleed (wet form).

These two forms of advanced AMD can cause serious vision loss. Scientists are unsure about how or why an increase in the size and/or number of drusen can sometimes lead to advanced AMD, which affects the sharp, central vision required for the 'straight ahead' activities in our daily routine, such as reading, driving, and recognizing faces of friends. One observation is that the larger and more numerous the drusen, the higher the risk of developing either form of advanced AMD. People who have advanced AMD in one eye are at especially high risk of developing advanced AMD in the other eye. The formulation used in the study contained several antioxidant vitamins, which are nutrients that can help maintain healthy cells and tissues. They also contained zinc, which is an important mineral incorporated into many body tissues.

The nutrients evaluated by the AREDS researchers contained 500 milligrams of vitamin C; 400 international units of vitamin E; 15 milligrams of beta-carotene; 80 milligrams of zinc as zinc oxide; and two milligrams of copper as cupric oxide (Copper was added to the AREDS formulations containing zinc to prevent copper deficiency, which may be associated with high levels of zinc supplementation). In this trial, the NEI collaborated with Bausch & Lomb, an eye care company that provided the formulation evaluated by the AREDS researchers and financially supported the laboratory testing and distribution of study medications.

"Previous studies have suggested that people who have diets rich in green, leafy vegetables have a lower risk of developing AMD," said Frederick Ferris, MD, director of clinical research at the NEI and chairman of the AREDS. "However, the high levels of nutrients that were evaluated in the AREDS are very difficult to achieve from diet alone.

"Almost two-thirds of AREDS participants chose to take a daily multivitamin in addition to their assigned study treatment," Dr. Ferris said. "The AREDS also showed that, even with a daily multivitamin, people at high risk for developing advanced AMD can lower the risk of vision loss by adding a formulation with the same high levels of antioxidants and zinc used in the study."

The Age-Related Eye Disease Study involved 4,757 participants, 55-80 years of age, in 11 clinical centers nationwide. Participants in the study were given one of four treatments: 1) zinc alone; 2) antioxidants alone; 3) a combination of antioxidants and zinc; or 4) a placebo, a harmless substance that has no medical effect. The benefits of the nutrients were seen only in people who began the study at high risk for developing advanced AMD — those with intermediate AMD, and those with advanced AMD in one eye only. In this group, those taking "antioxidants plus zinc" had the lowest risk of developing advanced stages of AMD and its accompanying visual loss. Those in the "zinc alone" or "antioxidant alone" groups also reduced their risk of developing advanced AMD, but at more moderate rates compared to the "antioxidants plus zinc" group. Those in the placebo group had the highest risk of developing advanced AMD.

Dr. Ferris said some people with intermediate AMD may not wish to take large doses of antioxidant vitamins or zinc because of medical reasons. "For example, beta-carotene has been shown to increase the risk of lung cancer among smokers," he said. "These people may want to discuss with their primary care doctor the best combination of nutrients for them. With the use of the high levels of zinc, it is important to add appropriate amounts of copper to the diet to prevent copper deficiency."

In the cataract portion of the study, researchers discovered that the same nutrients had no significant effect on the development or progression of age-related cataract. A cataract is a clouding of the eye's lens that blocks some light from reaching the retina and interferes with vision. "Participants taking the 'zinc alone' treatment, the 'antioxidants alone' treatment, or the combination of zinc and antioxidants were all about as likely to develop a cataract as those taking a placebo," Dr. Ferris said.

"At the time the study was planned, laboratory and animal research had suggested that antioxidants might be of benefit in treating or preventing cataract," he said. "Also at that time, limited epidemiologic and clinical trial data suggested that antioxidants might affect the development of cataract. However, our analyses did not find any connection between the antioxidant vitamins used in the AREDS and cataract development."

Despite the evidence that these nutrients did not lower the risk of cataract development over the seven-year period of the study, Dr. Ferris noted that an effect over a longer period of time, or with different doses of these or other antioxidants, cannot be ruled out.

The AREDS participants reported minor side effects from the treatments. About 7.5 percent of participants assigned to the zinc treatments — compared with five percent who did not have zinc in their assigned treatment — had urinary tract problems that required hospitalization. Participants in the two groups that took zinc also reported anemia at a slightly higher rate; however, testing of all patients for this disorder showed no difference among treatment groups. Yellowing of the skin, a well-known side effect of large doses of beta-carotene, was reported slightly more often by participants taking antioxidants.

"The AREDS formula is the first demonstrated treatment for people at high risk for developing advanced AMD," he said. "Slowing the progression of AMD to its advanced stage will save the vision of many who would otherwise have had serious vision impairment."

A list of study centers is attached.

The National Eye Institute (NEI) is part of the National Institutes of Health (NIH) and is the Federal government's lead agency for vision research. NEI-supported research leads to sight-saving treatments and plays a key role in reducing visual impairment and blindness. The NIH is an agency of the US Department of Health and Human Services.

Vitamins, Anti-Bacterials May Prevent Stomach Cancer

Vitamin C, beta-carotene, and an anti-bacterial treatment may -- singly or in combination -- help prevent stomach (gastric) cancer, according to a long-term clinical trial involving more than 600 people at high risk of developing the disease. The results of the trial appear in the Dec. 6, 2000, issue of the Journal of the National Cancer Institute.

Gastric cancer is the second leading cause of cancer death in the world and five-year survival rates are low. An effective means of preventing the disease could have a dramatic impact on public health worldwide.

Pelayo Correa, M.D., and colleagues at Louisiana State University, New Orleans, together with researchers from Colombia, conducted the trial in an area of Colombia known for its high rate of gastric cancer. Participants were randomly assigned to receive either:

* a standard treatment for H. pylori infection, a bacteria that has been associated with the development of gastric cancer;
* one gram of ascorbic acid (vitamin C) twice a day;
* 30 milligrams of beta-carotene once a day;
* various combinations of these treatments; or
* a placebo.

To compare the treatments, the researchers looked at the status of precancerous abnormalities in the stomachs of each of the participants over the course of the six-year study. They analyzed biopsy specimens at the beginning of the study, after three years, and again after six years. The biopsies showed that precancerous abnormalities were more likely to shrink or disappear among people who received treatment than among those who took placebos.

The three different treatments all had about the same effect, and combining treatments did not appear to add any advantage.

For example, among people with a precancerous abnormality known as nonmetaplastic atrophy, those who received the anti-H. pylori treatment (an antibiotic plus other agents) were 4.8 times more likely than the placebo group to undergo a regression in their abnormalities. People with this condition receiving vitamin C were 5.0 times more likely to have abnormalities that regressed, and those receiving beta-carotene, 5.1 times more likely.

In an accompanying editorial, William Blot, Ph.D., of the International Epidemiology Institute in Rockville, Md., notes that the findings agree with those of other studies showing that people who eat many fruits and vegetables, which are rich sources of ascorbic acid and beta-carotene, have lower rates of gastric cancer. He cautions, however, that the findings must be confirmed by other studies.

A number of gastric cancer prevention trials are under way around the world. The largest, Correa said, is taking place in the Shandong province of China, where gastric cancer rates are very high. Sponsored by the National Cancer Institute, this trial is comparing the effects of vitamin and mineral supplements, a garlic extract, and anti-H. pylori treatment. Other trials are under way in Italy, England, Mexico, and elsewhere.