UNIVERSITY OF CALIFORNIA
COOPERATIVE EXTENSION

NUTRITION PERSPECTIVES

Volume 26, No. 4
July/August 2001

TABLE OF CONTENTS

Varro E. Tyler, Herbal Medicine Expert, Dies at 74
Herbal Medicines and Perioperative Care
Mortality Risk Varies In Patients with Familial Hypercholesterolemia
Lipid Lowering is Beneficial In Elders with Coronary Disease
Predicting Heart Problems
Who Succeeds at Losing Weight?
Consequences of an Overweight Population
High Blood Pressure, Cholesterol, and Alzheimer's Disease
Diabetes, Hyperglycemia, and Neurological Function
Bone Density Predicts Breast Cancer
Center Supports Research to Identify Causes of Birth Defects
Federal Trade Commission Program Aims to Cut Consumer Fraud
Consumer Demand for Fruit and Vegetables
Adolescents Use the Internet for Health Information
Teen Eating Disorders: Health and Fitness Magazine Correlation Study
Newly Funded Healthy Tomorrows Partnership for Children Grants
Water Illness Alert: Don't Let Kids with Diarrhea Swim

Resources:

Lead Poisoning Prevention Hand book
The CDC Offers Guidance on Blood Lead Testing
Guide for Treating Obese Patients

Conference:
The Fourth International Congress on Vegetarian Nutrition

VARRO E. TYLER, HERBAL MEDICINE EXPERT, DIES AT 74

Varro E. Tyler, former dean and executive vice president for academic affairs at Purdue University and an internationally recognized authority on herbal medicine, died on Wednesday, August 22. He was 74 years of age.

Tyler was an internationally recognized expert on herbal medicine, known for his extensive studies and educational efforts in the field. He was the author of more than 270 publications, including three popular books, "Hoosier Home Remedies," "The Honest Herbal" and "Herbs of Choice," a book written for health care profession-als. He frequently appeared on TV and radio talk shows and was quoted extensively by the press. In recent years, he wrote a monthly column on herbal remedies for Prevention Magazine.

He joined the faculty in Purdue's School of Pharmacy and Pharmacal Sciences in 1966 and served as the school's dean from 1966 to 1979. He was promoted to dean of the School of Pharmacy, Nursing and Health Sciences in 1979, and served in that capacity until 1986.

After 20 years as dean, Tyler was named to the position of executive vice president for academic affairs of the Purdue system. He served in that capacity until 1991, when he rejoined the School of Pharmacy as the Lilly Distinguished Professor of Pharmacognosy. He retired from Purdue in December 1996.

Born in Auburn, Nebraska, Tyler studied pharmacy at the University of Nebraska, where he graduated with distinction. He received his master's and doctoral degrees from the University of Connecticut, and taught at the University of Nebraska and the University of Washington in Seattle before joining the Purdue faculty.
Tyler served as the first president of the American Society of Pharmacognosy, as well as president of the American Association of the Colleges of Pharmacy, the American Council on Pharmaceutical Education and the American Institute of the History of Pharmacy.

He was active in a number of professional organizations and was elected a fellow of the Academy of Pharmaceutical Research and Science, the American Association of Pharmaceutical Scientists and the American Association for the Advancement of Science. He was an honorary member of the American Society of Pharmacognosy and the Society for Medicinal Plant Research.

Adapted from: Purdue News; August 22, 2001; Purdue University website:

http://news.uns.purdue.edu/UNS/html3month/010822.Tyler.death.html

HERBAL MEDICINES AND PERIOPERATIVE CARE

There is enormous public enthusiasm for herbal medications. In a recent review, Ang-Lee and colleagues (1) discuss potential complications associated with the use of herbal medications prior to surgery. They address several aspects of patient care, including communication between physician and patient, regulation and safety of herbal medications, and physiologic and pharmacodynamic effects of common herbal preparations.

Recent studies found that 22 percent to 32 percent of preoperative patients use herbals (2,3). Of this group, as many as 70 percent do not disclose their herbal medicine use during preoperative assessment. Such communication failures may occur because patients believe that physicians are not knowledgeable about herbal medications or are prejudiced against their use. Additionally, patients may perceive use of herbals as unrelated to their medical care, or may not consider these substances to be medications. As a result, physicians must question pre-surgical patients directly about their use of herbal medicines.

Because herbal medications are classified as dietary supplements, manufacturers do not need to obtain FDA approval prior to marketing them (4). In other words, herbals are exempt from the preclinical animal studies, clinical trials, and post-marketing surveillance used to ensure conventional drug safety and efficacy. Instead, the FDA must determine which herbals are unsafe before they can be removed from the market. The potency of herbals often varies between manufacturers and from lot to lot within a manufacturer. Adverse reactions to herbal medications are underreported, making it difficult for physicians and consumers to assess the safety of herbal products.

Data for this review was collected from peer-reviewed medical literature on eight commonly used herbal medications: echinacea, ephedra, garlic, ginkgo, ginseng, kava, St. John's wort, and valerian.

Results are summarized below:

Educational literature of the American Society of Anesthesiologists suggests that patients discontinue use of herbal medications at least 2 to 3 weeks before surgery (5,6). This review suggests that a more targeted approach is desirable. Possible risks of discontinuation should also be considered, especially for herbals like valerian, which may produce acute withdrawal symptoms after long-term use. Clinicians should report adverse effects of herbal medications and other dietary supplements at the website of the Center for Food Safety and Applied Nutrition, Food and Drug Administration, http://vm.cfsan.fda.gov/~dms/supplmnt.html. This website also contains safety, industry, and regulatory information.

References:

Source: Erin Digitale, Doctoral Student, Graduate Group in Nutrition, University of California at Davis.

MORTALITY RISK VARIES IN PATIENTS WITH FAMILIAL HYPERCHOLESTEROLEMIA

Familial hypercholesterolemia is associated with premature coronary artery disease (CAD) and decreased life expectancy (1). However, risk estimates are based on data from patients who presented with CAD and, therefore, may overestimate mortality. To obtain a better estimate of mortality risk associated with this trait, Sijbrands and colleagues evaluated members of a large family with hypercholesterolemia.

Sijbrands and colleagues identified 3 distantly related carriers of the same LDL receptor gene mutation; these probands had mean fasting cholesterol concentrations from 356 to 495 mg/dL (9.2 to 12.8 mmol/L). Using official records, 412 descendants were traced from the original ancestral carriers. From 1830 through 1989, 70 deaths occurred among 250 descendents who did not emigrate and who survived until age 20 or older. Mortality in this family was compared with age-specific mortality in the general Dutch population.

The standardized mortality ratio was 1.32 for all family members and was 1.59 for the 118 family members who definitely were affected with hypercholesterolemia. However, carriers did not have increased mortality during the 19th and early 20th centuries; mortality rates rose after 1915, peaked between 1935 and 1964 (standardized morality ratio, 1.78), and fell thereafter. Two of 3 distinct branches of the family had increased risk for death; 1 branch did not. The variations in mortality ratios over time and among different family branches reported in this study demonstrate the importance of both genetic and environmental factors on health outcomes.

Reference:

1. Sijbrands EJ, Westendorp RG, Defesche JC, et al. Mortality over two centuries in large pedigree with familial hypercholesterolemia: Family tree mortality study. BMJ; April 28, 2001; 322:1019-23.

Adapted from: Journal Watch; 21(12); June 15, 2001; p. 101.

LIPID LOWERING IS BENEFICIAL IN ELDERS WITH CORONARY DISEASE

Relatively few elderly people have been included in randomized trials of statins for secondary prevention of cardiovascular disease. In this analysis from a previously published manufacturer-sponsored, randomized trial, Tonkin and Simes examined the effects of pravastatin (40 mg/day) in 9014 patients in Australia and New Zealand (1). All patients had suffered myocardial infarction or unstable angina in the previous 3 years and had median serum LDL cholesterol levels of approximately 150 mg/dL; 3514 patients were between 65 and 75, and the rest were younger.

Six-year mortality rates were significantly lower for pravastatin recipients than for placebo recipients, among both older patients (16.5 percent vs. 20.6 percent) and younger patients (7.6 percent vs. 9.8 percent). Although relative risk reductions were the same for elderly and younger pravastatin recipients (RR, 0.8), the number needed to treat to prevent 1 death was lower in elderly participants (22 vs. 46). Rates of MI, cardiovascular procedures, and cardiovascular procedures, and cardiovascular death also were reduced by treatment. Adverse events led to drug discontinuation in 13 percent of patients overall. Although adverse event rates did not differ significantly by treatment group, there was a trend toward greater risk for cancer in elderly pravastatin recipients compared with elderly placebo recipients (RR, 1.14; 95 percent CI, 0.98-1.32).

Although the reduction in mortality with pravastatin was small, the absolute reduction was greater in older than in younger patients (4 percent vs. 2 percent over 6 years). The trend toward greater cancer risk is troubling, but the mortality benefit suggests that age is no reason to withhold lipid-lowering therapy in patients with coronary artery disease (2).

References:

1. Tonkin A. and Simes RJ. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. N Engl J Med; 1998 Nov 5;339(19):1349-57.

2. Hunt D, et al. Benefits of pravastatin on cardiovascular events and mortality in older patients with coronary heart disease are equal to or exceed those seen in younger patients: Results from the LIPID trial. Ann Intern Med; May 15, 2001; 134; 931-940.

Source: Journal Watch; 21(12); June 15, 2001; p. 101.

PREDICTING HEART PROBLEMS

A routine test that measures levels of a protein in urine samples may reveal early, symptomless cardiovascular disease in postmenopausal women (1).
Roest and colleagues took urine samples and measured albumin levels from 118 healthy postmenopausal women who were followed up for as many as 18 years. Women in the highest quintile for urinary albumin levels had an age-adjusted cardiovascular death rate 4.4 times that of women without detectable urinary albumin. It is believed albumin appears in urine because blood vessels in the kidneys are leaking due to malfunctioning endothelial cells.

"Our finding supports the hypothesis that albumin in the urine is a reflection of vascular damage and a marker of early disease," said Jan Dirk Banga, MD, PhD, a co-author of the report and consultant in vascular medicine at the University Medical Center in Utrcht.

Women in the group with the highest urine albumin levels had a cardiovascular death rate of 13.2 for each 1000 years of the study's follow-up (for example, a woman followed for 15 years was counted as 15 follow-up years), compared with 2.6 deaths per 1000 follow-up years among women with no albumin detected in their urine.

Reference:

1. Roest M, Banga JD, Wilbert MT. Excessive urinary albumin levels are associated with future cardiovascular mortality in postmenopausal women. Circulation; 103: 3057-3061.

Source: JAMA; 286(4); July 25, 2001; p. 409.

WHO SUCCEEDS AT LOSING WEIGHT?

Dieters mistakenly tend to focus on losing weight instead of maintaining weight loss, according to James Hill, PhD, a professor of pediatrics and medicine and director of the Center for Human Nutrition at the University of Colorado Health Sciences Center in Denver. And once dieters achieve their desired weight, most tend to return to their former eating/exercise habits and regain their weight, Hill said at an American Medical Association briefing.

Now the good news, as co-director of the National Weight Control Registry, a long-term study of over 3000 "successful losers" of weight, Hill knows four common behaviors among those who have successfully maintained weight loss. The behaviors include the following:

· Eat a low-fat, high-carbohydrate diet
· Eat breakfast almost every day
· Self-monitor by weighing themselves daily and keeping a food journal
· Exercise for about an hour a day

Participants in the National Weight Control Registry have maintained an average weight loss of over 60 pounds for over five years.

The "successful losers" also ate an average of five times a day, which helped to spread out their calorie consumption throughout the day, avoided fast food, and ate out an average of 1.5 times a week. They also sought ways to increase their physical activity levels by doing the little things such as taking the stairs instead of the elevator and parking their car at the far end of the parking lot.

More important, almost 90 percent of the registry participants have failed at previous weight loss attempts. "This puts out the message that not everyone fails," said Hill.

Most experts consider success as losing 10 percent of body weight and maintaining that loss for at least one year. With this as a measuring stick, Hill estimates that one out of five people succeed in their weight loss maintenance efforts.

A 10 percent weight loss, however, offers significant health improvements such as lowering blood sugar levels, lessening the severity of sleep apnea, lessening joint problems, and improving gynecological problems. And more important, people have a better quality of life. "Not only are people healthier, but they are happier," Hill said.

Source: Nutrition Week; XXXI(28); July 23, 2001; p. 6.

CONSEQUENCES OF AN OVERWEIGHT POPULATION

The consequences of an overweight population are staggering. And it's only getting worse, obesity among adults has increased to over 60 percent within the past decade.

"The costs will dominate our health care in a way we have not seen before," William Dietz, MD, director of the division of nutrition and physical activity at the CDC's National Center for Chronic Disease Prevention and Health Promotion, said at an American Medical Association (AMA) briefing.

In 1995, the CDC estimated the direct cost of obesity at $50 billion. This cost equaled 5 percent of the national health care budget and does not include indirect costs such as lost time and workplace productivity.

The National Institutes of Health (NIH) defines overweight as a BMI of between 25 and 29.9 and obesity as a BMI of greater than 30. A BMI of 30 generally translates to a person being almost 30 pounds overweight. According to the NIH, more than half of US adults are either overweight or obese.

In preliminary 1999 survey results, the CDC reported that 13 percent of American children ages 6-11 are overweight, up from 11 percent from a survey conducted from 1988 to 1994. Overweight and physical inactivity account for more than 300,000 premature deaths each year in the US, second only to tobacco-related deaths, according to the CDC.

A call to action

The elevating weights of children are of particular concern to Dietz because the complications of childhood obesity are the risk factors that become diseases in adulthood, he said.

Preliminary CDC research has shown that more than half of obese children ages five to 10 years have at least one risk factor for cardiovascular disease including high blood pressure, elevated blood lipids, or elevated insulin levels. More than 25 percent have two or more of these complications.

Unfortunately, many parents do not believe excess weight is a problem unless they think it affects their child's self esteem, Dietz said. He, along with the AMA, called on physicians to take a central role in teaching patients about the dangers of being overweight. Dietz said physicians should initiate discussions with overweight and obese patients and then refer them to someone else for treatment, perhaps to a nutritionist. He recognized, however, that physicians need incentives to treat obesity.
The North American Association to the Study of Obesity (NAASO), a scientific society dedicated to obesity research, used the AMA briefing to call upon all health plans to begin reimbursement for the treatment of obesity. "This is a medical problem with consequences and it needs to be treated as such," NAASO president Charles Billington, MD, said at the briefing. Many health plans, according to Billington, refuse to pay for weight loss therapy.

Sweeping changes needed

Dietz said the environment and lifestyle changes have led to the population becoming more overweight. People are eating out more, watching more television, drinking more soda, skipping breakfast, eating separately, and taking advantage of the wide variety of foods offered in stores. They are also leading less active lifestyles.
As its primary strategy to combat obesity, the CDC is promoting breastfeeding, reducing television time, and encouraging more physical activity for the entire population (1). The CDC is also funding 12 states to target a group within their state for an obesity intervention.

Parents can also play a significant role, according to Robert Berkowitz, MD, associate professor of psychiatry and pediatrics at the Children's Hospital of Philadelphia and at the University of Pennsylvania School of Medicine, who is the medical director of the Weight and Eating Disorders Program at the University of Pennsylvania. They can shop better, keep junk food and soda out of the home, serve single portions of food and act as role models by watching what they eat, exercising more, and watching less television.

Obesity complications

Adult obesity is associated with a variety of complications including high blood pressure, coronary heart disease, diabetes, gallbladder disease, arthritis- and orthopedic-related problems, some cancers, and a number of other problems.

Type 2 diabetes can lead to complications such as heart disease, stroke, high blood pressure, blindness, kidney disease, amputations, and other complications. Type 2 diabetes related to overweight and obesity costs the nation an estimated $63 billion in direct and indirect costs, according to the NIH.

Reference:

1. Nutrition Week; "Making healthy choices the right choices." April 13, 2001.

Source: Nutrition Week; XXXI(28); July 23, 2001; pp. 6-7.

HIGH BLOOD PRESSURE, CHOLESTEROL, AND ALZHEIMER'S DISEASE

Cross-sectional studies of the relation between cardiovascular risk factors and Alzheimer's disease (AD) have yielded conflicting results. To investigate the association between risk factors in midlife (e.g., elevated blood pressure and serum cholesterol) and risk for AD later in life, Finnish researchers conducted a prospective, population-based study of individuals who originally had been examined between 1972 and 1987.

A total of 1449 participants (age range in 1997, 65 to 79) were re-examined in 1998 (mean follow-up, 21 years); 57 (4 percent) were diagnosed with dementia, 48 of whom fulfilled criteria for AD. Compared with participants without dementia, those with AD had higher body mass indices, systolic BP, and serum cholesterol in midlife; they also were older and had received less formal education. After adjustment for multiple risk factors (including age), elevated systolic BP (160 mm Hg or higher) and elevated cholesterol (251 mg/dL [6.5 mmol/L] or higher) in midlife emerged as the most potent predictors of AD later in life (odds ratios, 2.3-2.8 and 2.2-2.7, respectively; OR range depended on the number of factors included in the model). The risk for AD was greatest among people who had both high BP and high cholesterol in midlife (OR, 2.2-3.5). Although we don't know whether high BP and high cholesterol play a causal role in Alzheimer's disease, the association of these conditions with AD provides yet another reason to detect and treat them.

Source: Journal Watch; 21(15); August 1, 2001; p. 125.

DIABETES, HYPERGLYCEMIA, AND NEUROLOGICAL FUNCTION

For the first time, researchers have demonstrated that patients with type 1 diabetes experience slowing of brain function and other short-term symptoms from hyperglycemia (1).

University of Virginia researchers studied 105 adults with type 1 diabetes. The patients performed mental subtractions and were given verbal fluency and multiple-choice reaction-time tests. They also rated the prevalence of four symptoms, including being tired or sleepy and needing to urinate, and recorded their blood glucose levels on a hand-held computer 82 times during 4 weeks. The results of the study were presented in June at the annual meeting of the American Diabetes Association.

Cox and colleagues found that all four symptoms steadily increased as blood glucose levels increased. Verbal fluency and mental arithmetic ability slowed as blood glucose rose above 270 mg/dL (15.0 mmol/L).

Traditionally, experts didn't think hyperglycemia had acute effects, said Daniel J. Cox, PhD, head of the University of Virginia Center for Behavioral Medicine Research and principal investigator. "Now we're starting to recognize that both high and low blood sugar levels have both short-term and long-term effects."

Reference:

1. Cox DJ, et al. American Diabetes Association Annual meeting; June 2001.

Source: JAMA; 286(4); July 25, 2001; p. 409.

BONE DENSITY PREDICTS BREAST CANCER

Bone mineral density (BMD) is a powerful predictor of breast cancer risk in older women, reports a team from the University of Pittsburgh Medical Center (1). Women with high density at three skeletal sites are almost three times more likely to develop breast cancer as women with low density, and their tumors tend to be at an advanced stage at diagnosis.

At the start of the study, which followed up 8902 women aged 65 or older for almost 7 years, Zmuda and colleagues measured BMD at the wrist, forearm, and heel. A total of 315 developed cancer, and those with the highest BMD at the three sites had a relative risk of 2.7 compared with women with the lowest density.
Lead author and epidemiologist Joe Zmuda, PhD, said that while BMD may someday serve as a useful predictor of breast cancer risk, the evidence is just being flushed out. The prospective study does confirm a smaller, earlier report, but Zmuda said ongoing efforts seek to expand the findings into other groups, such as younger women.

The researchers stressed that high BMD does not itself cause breast cancer. "We're not sure, but we suspect a hormonal connection," said Zmuda. "Estrogen is a likely candidate, but there are other possibilities."

Reference:

1. Zmuda JM, Cauley JA, Ljung BM, Bauer DC, Cummings SR, Kuller LH. Bone mass and breast cancer risk in older women: differences by stage at diagnosis. J Natl Cancer Inst. 2001 Jun 20; 93(12):930-6.

Source: JAMA; 286(3); July 18, 2001; p. 295.

CENTER SUPPORTS RESEARCH TO IDENTIFY CAUSES OF BIRTH DEFECTS

Each year, birth defects afflict more than 150,000 infants, making them the leading cause of infant mortality in the United States, according to the US Centers for Disease Control and Prevention (CDC). In addition, 17 percent of US children under the age of 18 have some type of developmental disability such as autism, cerebral palsy or vision and hearing impairment.

Established April 12, 2001, by the CDC, the National Center on Birth Defects and Developmental Disabilities (NCBDDD) seeks to combat these numbers and "enhance the quality of life and prevent secondary conditions among children, adolescents, and adults who are living with a disability."

NCBDDD, created by the Children's Health Act of 2000, is currently under the direction of acting director Jose F. Cordero, MD, FAAP, who previously served seven years as deputy director of the CDC National Immunization Program. The newly formed NCBDDD incorporates many of the programs and activities of the National Center for Environmental Health's former Division of Birth Defects, Child Development, and Disability and Health. NCBDDD is divided into four branches, birth defects and pediatric genetics; developmental disabilities; disability and health; and fetal alcohol syndrome. Each branch supports research to identify causes and risk factors in the development of birth defects and disabilities in children, and promotes strategies to prevent them.

Since the causes of nearly 70 percent of birth defects are still unknown, the public is always anxious to hear about environmental factors or prenatal behaviors that may cause or contribute to the development of birth defects. The NCBDDD Web site, www.dcd.gov/ncbddd.htm, provides health care professionals with the latest findings from recent birth defects and pediatric genetics projects.

Organized by the CDC, the March of Dimes and the National Council on Folic Acid, one such project the NCBDDD serves as a clearinghouse for is the National Folic Acid Campaign. A recent CDC community-based intervention in China demonstrated that the use of folic acid can dramatically reduce the risk of having a baby with neural tube defects like spina bifida and anencephaly (1). The NCBDDD Folic Acid Web site offers a list of upcoming presentations about the vitamin, as well as recent articles of interest and recommendations from the US Public Health Service. The center also offers folic acid education materials targeted to different audiences and fact sheets on the campaign to prevent neural tube birth defects. Physicians also may find the site's "ABCs of Healthy Pregnancy," with tips on healthy eating and drinking extra fluids, a helpful handout for expectant mothers. For more information on NCBDDD, visit its Web site or call (770) 488-7150.

Reference:

1. Berry RJ, M.P.H.T.M., Li Z, et al. Prevention of Neural-Tube Defects with Folic Acid in China. N Engl J Med; November 11, 1999 341(20):1485-1490.

Source: AAP News; 19(1); July 2001; p. 14.

FEDERAL TRADE COMMISSION PROGRAM AIMS TO CUT CONSUMER FRAUD

Internet con schemes. Bogus prize promotions. Telemarketing scams. Fake advance-fee loans. Identity theft. Taken together, these crimes cost American consumers and businesses tens of billions of dollars yearly. But the Federal Trade Commission is fighting back with its "Consumer Sentinel" Web site, which brings together US, Canadian, and Australian law enforcers, along with organizations such as Better Business Bureaus, the US Postal Inspection Service, and the National Consumers League. The site, at www.consumer.gov/sentinel, allows consumers to register fraud complaints, which are then shared with law enforcement agents to determine, for example, if a reported scheme is local, regional, or national. In just the last two years, law enforcers using Consumer Sentinel have brought hundreds of cases to justice and have returned millions of dollars to consumers. Consumer Sentinel also links to various sites that have helpful information about avoiding consumer fraud when buying products online.

Source: FDA Consumer; 35(4); July-August 2001; p. 37.

CONSUMER DEMAND FOR FRUIT AND VEGETABLES

Fruit and vegetables consumption increases and the composition of products consumed changes as nations become wealthier. For example, fruit and vegetable consumption in the United States has increased over the past two decades along with the Nation's prosperity. Higher incomes provide consumers with freedom to make purchasing decisions based on factors other than meeting basic caloric needs.

Increased consumption in the United States has been influenced by several factors, including increased domestic production, product convenience, technological improvements that maintain the quality of fruit for greater periods of time and modify produce to meet consumers, preferences, and greater availability and diversity of products through trade. Americans have also increased their consumption of fruit and vegetables as they try to maintain healthier lifestyles.

Fruit and vegetables consumption has been shown to be an important part of any diet leading toward good health. In low-income countries, where meeting caloric requirements is the priority, vegetables, especially starches such as tubers, roots, and legumes make up the bulk of the diet. Food consumption patterns change, however, as income rise.

Trends in fruit and vegetable consumption

Fruit and vegetables (including melon) consumption in the United States averaged 741 pounds per person annually during 1997-99, 25 percent above 1977-79. Much of the increase is a result of higher vegetable and melon consumption, mostly fresh vegetables and processed potatoes in the form of french fries. Vegetable consumption increased more rapidly than fruit, rising 24 percent over this period, compared with 8 percent for fruit.

Since the mid-seventies, Americans have changed their consumption preferences. Consumers are eating more fresh and frozen vegetables and fruit and less canned produce. Since the seventies, fresh selections an quality in produce aisles of grocery stores have increased, improving consumers' choices. As a result, fresh vegetable and melon consumption increased 33 percent and fresh fruit consumption increased 26 percent.

Fresh potatoes accounted for the largest share of fresh vegetable consumption. While the consumption of fresh potatoes has remained stable between 1977-79 and 1997-99, their share of total fresh vegetable consumption has declined as other vegetables' share of the total rose. Consumers are varying their diet of fresh vegetables, increasing their demand for asparagus, broccoli, cauliflower, carrots, onions, and lettuces other than iceberg, among others.

Bananas were the number one fresh fruit consumed in 1997-99, with consumption increasing over the 20 years since 1977-79. The other leading fresh fruits, apples and oranges, are domestically produced. While fresh apple consumption has been on the rise, fresh orange consumption has declined. Americans are turning to other fresh fruit, such as grapes, pears, and strawberries, partially because they are now available in the market for longer periods of time than in the past. According to the 1994-96 Continuing Survey of Food Intake of individuals, conducted by USDA's Agricultural Research Service, only 23 percent of Americans consumed the recommended servings of fruit and 41 percent the recommended servings of vegetables.

Consumers increasingly demanding convenient fruit and vegetables

Convenience is an increasingly important factor for consumers when selecting fruit and vegetables. As a result, most Americans consume produce in processed forms. In 1997-99, 52 percent of vegetable consumption was canned, frozen, or dried products; 43 percent of fruit was consumed as juice. Processed forms of consumption often utilize a greater quantity of a commodity to get an equal serving size to fresh. Since more of a product is needed to produce a processed product, it results in higher per capita utilization of a good. This is not necessarily equivalent to higher servings of the commodity.

Some fruits are consumed more in processed form than as fresh. Oranges are the number one fruit consumed by Americans, and the most convenient way of consuming oranges is as juice, accounting for 86 percent of orange consumption in 1997-99. Other fruits are also increasingly being consumed in the juice form.
The most popular vegetables are also consumed in their most convenient forms, which often includes some processing. Potatoes are consumed mostly as french fries, and tomatoes are consumed in their canned form. The introduction of fresh-cut vegetables has increased consumption of several different products. The consumption of two major fresh-cut products, baby-cut carrots and bagged salads, has grown tremendously. These products were new to the markets in the late eighties and have since become a mainstay on the produce shelves in the grocery stores.

Technology makes fresh products more appealing

The demand for fresh products has increased as packing and shipping technology has improved. With improvements in shipping, handling, and plant breeding, fruit and vegetables can now be shipped long distances and over greater lengths of time and still maintain appearance and quality. Improved storage facilities provide for year-round availability of various commodities. For example, controlled atmosphere storage for apples has resulted in maintaining the fruit crisp until the next crop is harvested.

Concern for health increases consumption

Health issues have also become an increasingly important factor in consumer preferences for produce in recent years. Publicity surrounding scientific studies showing the beneficial values of various fruits and vegetables has been a boom to certain commodities. The growth in broccoli, grape, and berry consumption demonstrates the effect of such publicity on an industry.

Health issues alone, however, may not be sufficient to increase consumer demand, especially as the number of studies covering more produce increases. For example, while the grapefruit industry succeeded in receiving endorsements from the American Heart Association, the American Cancer Society, and the March of Dimes to include in their promotions, demand for grapefruit, both fresh and as juice, has declined since 1976-78. It appears that while health claims can initially increase demand for a product, they alone may not be sufficient to further expand consumer demand.

The aging of the baby boom population and the increase in the life expectancy of Americans has boosted demand for fresh produce. Studies have demonstrated that spending on fresh fruit and vegetables is higher for households with middle age and older members (1).
Imported produce expands consumers' selection

International trade has played a major role in changing consumer demand for fruit and vegetables. Traditionally, during the winter months, only citrus, bananas, and apples were available in the supermarkets. Since the mid-eighties, however, improved transportation and increased production in Southern Hemisphere countries has made certain fruit, previously unavailable in the United States, now common. Summer fruit, mostly from Chile, are being sold in US markets, providing alternatives for consumers.

Also through trade, new varieties of tropical produce not grown in the United States have become popular. With an increasingly diverse population in the United States, many people desire the fruit and vegetables they consumed in their native countries. As a result, tropical fruit imports, such as mangoes and papayas, have increased, especially in the nineties.

Conclusion

As incomes continue to grow in developing countries, demand for fruit and vegetables is expected to increase. With increased globalization and the associated changes in lifestyles, demand for produce in developed countries will likely be shaped by the same factors that have affected US demand for these products. As in the United States, availability, affordability, convenience, and health concerns will probably influence future consumption of fruit and vegetables across the world.

References:

1. Krebs-Smith SM, Cook A, Subar AF, Cleveland L, Friday J. US adults' fruit and vegetable intakes, 1989 to 1991: a revised baseline for the Healthy People 2000 objective. American Journal of Public Health; December 1995; 85(12): 1623-9.

Adapted from: Nutrition Week; XXXI(26); July 9, 2001; pp. 4-5.

ADOLESCENTS USE THE INTERNET FOR HEALTH INFORMATION

The Internet has become a common source of health information for adults. In this study, Borzekowski and Rickert found, perhaps surprisingly, that adolescents also frequently go online for health information (1).

Researchers studied a sample of 412 ethnically diverse 10th grade students form one community in New York State. Most (96 percent) of the students used the Internet, and 49 percent used it to obtain health information. (The Internet usually was not their first source of health information, however.) Common topics explored by adolescents on the Internet included sexually transmitted diseases, other diseases, diet, fitness and exercise, alcohol and drug use, sexual behavior, dating violence and rape, and medicines. Seeking health information online was not related significantly to gender, ethnicity, or maternal education. Adolescents valued online sources and found the information to be trustworthy, again with no significant differences by gender, ethnicity, or mother's education.

The Internet has become an important source of health information for adolescents. Teens with limited access to health care, and those reluctant to discuss sensitive topics with their health care providers, likely will turn increasingly to online resources.

Reference:

1. Borzekowski DLG and Rickert VI. Adolescent cyber surfing for health information: A new resource that crosses barriers. Arch Pediatr Adolesc Med; July 2001; 155:813-7.

Source: Journal Watch; 21(15); August 1, 2001; p. 124.

TEEN EATING DISORDERS: HEALTH AND FITNESS MAGAZINE CORRELATION STUDY

A study by researchers at Brigham Young University has found a positive statistical correlation between high school girls using certain unhealthy weight-control practices and the frequency of reading women's health and fitness magazines.

The study surveyed 498 sophomore, junior, and senior girls at two unidentified Salt Lake City high schools.

In the survey, about 11 percent reported that they used laxatives for weight loss or weight control, 15 percent took appetite control or weight-loss pills, 9 percent made themselves vomit after meals, and 52 percent restricted their calories to 1200 a day or fewer at some point. Of the girls with unhealthy practices, researchers found that 80 percent of those who vomit, 73 percent who use appetite suppressants or weight-control pills, 60 percent who took laxatives, and 60 percent who restricted their diets to 1200 daily calories were frequent (at least once a month) readers of health and fitness magazines.

The researchers recommended that teens be taught that magazine depictions of physical "ideals" often involve the use of images that are retouched or computer enhanced, and that similar body types often can't be obtained in real life without risking physical and emotional health.

Source: JAMA; 286(4); July 25, 2001; p. 409.

NEWLY FUNDED HEALTHY TOMORROWS PARTNERSHIP
FOR CHILDREN GRANTS

The Healthy Tomorrows Partnership for Children Program (HTPCP), a collaborative grant program of the American Academy of Pediatrics and the Federal Maternal and Child Health Bureau, has approved nine new community-based projects that began receiving funding on March 1, 2001. The programs will receive approximately $50,000 in funding per year for five years.

The HTPCP is part of the community-based component of the AAP Access to Care Initiative launched in 1989 to ensure access to quality health care for all children and pregnant women in the United States. Federal grants awarded through the program support family-centered, community-based health projects that improve the health status of mothers, infants, children, and adolescents by increasing their access to health services. Since 1989, a total of 136 grants have been awarded; 74 of the 136 projects have been completed.

To be eligible for funding, projects must represent a new initiative within the community or an innovative component that builds on existing community resources. For more information on HTPCP applications or requirements, contact Jane Bassewitz, AAP Division of Community-based Initiatives, at (800) 443-9016, est. 4750, or e-mail healthyt@aap.org.

The new programs approved for funding are:

· Continuity of Medical Care for Foster Children in Jefferson County, Alabama, in Birmingham, Alabama, provides children in foster care with a continuous source and site of comprehensive medical care, irrespective of any change in the child's placement.
· Creating Opportunities to Combat Obesity in Arkansas in Little Rock, Arkansas, provides clinical evaluations of children who are obese or overweight with co-morbidities, such as hypercholesterolemia, hypertension and type 2 diabetes. The program also provides community and physician targeted education about the complications of obesity and effective methods of reducing obesity.
· Kids Come First Program in Ontario, California, assists largely immigrant and Hispanic families access health care by providing comprehensive services and screening through a school-linked health center. Its goal is to improve student and family access to primary medical care that includes preventive health care screening and acute care treatment.
· Sonoma County People for Economic Opportunity in Santa Rosa, California, is an anemia-prevention program, combining better access to pediatric care at the neighborhood level for families and better access to pediatric expertise on a county level. The program replicates an outreach model used in a successful program to improve immunization rates.
· Parents and Children Together (PACT) in New Haven, Connecticut, addresses a need of parents to receive additional support beyond the prenatal period through group sessions, maternal postpartum depression screening, clinical phone follow-up during the child's first month, a home visit by a clinician at 3 months, and a 9-month well-child home visit by the primary care clinician.
· Healthy Smile for the Red River Valley in Moorhead, Minnesota, works to develop a community-based system of care designed to reduce the access barriers to dental care for low-income children and their families using a case management system, the integration of dental hygiene education/counseling into Maternal and Child Health programs, and the provision of dental screenings to children in high-risk areas.
· Finger Lakes Primary Care Outreach Program in Rochester, New York, addresses lower than expected immunization rates and preventive services in the Finger Lakes rural region of upstate New York. An interdisciplinary team addresses both health and phycho-social barriers preventing access to and receipt of preventive care by at-risk children.
· Rural Interdisciplinary Developmental Evaluation Clinic Initiative in Athens, Ohio, expands existing developmental and behavioral assessment clinics to three counties to provide interdisciplinary assessment services in partnership with local health and educational service providers for families with children ages 0 to 6 years old.
· Asthma Control Today (ACT) in Abingdon, Virginia, provides a home visitor and nurse to evaluate families' needs and provide education, monitoring, and referral for the families regarding their children's asthma or respiratory illness.

Source: AAP News; 18(6); June 2001; pp. 268-9.

WATER ILLNESS ALERT: DON'T LET KIDS WITH DIARRHEA SWIM

Every summer, public swimming pools, water parks, spas, rivers, lakes, and oceans are packed with families enjoying the weather and keeping cool, Yet two pool-related disease outbreaks form last summer have prompted the US Center for Disease Control and Prevention (CDC) to alert people to the dangers of swimming with any type of diarrhea infection.

Between 1989 and 1998, nearly 10,000 cases of diarrhea illness were associated with 32 recreational water-borne disease outbreaks in the United States, according to the CDC. Last year's outbreaks, which took place in Ohio and Nebraska, both involved private swim clubs and were caused by the parasite Cryptosporidium parvum. In both outbreaks, young children were often the victims.

The parasite is spread from the accidental swallowing of pool water that has been contaminated by fecal matter. Symptoms of infection include diarrhea, loss of appetite, abdominal cramps, and vomiting.

While most public pools use chlorine to kill germs, it takes time for the chemical to work and some germs like Cryptosporidium parvum are more resistant to chlorine and can stay active for days. Therefore, even the best maintained pools are capable of spreading the disease.

The CDC's Division of Parasitic Diseases has developed six healthy swimming tips for parents and their children in an effort to protect consumers from parasitic infection:

· Prohibit children from swimming when they have diarrhea, especially children in diapers. They can spread germs and make other people sick.
· Teach children never to swallow pool water, and even avoid getting it in their mouth at all.
· Take your children on bathroom breaks frequently to avoid accidents in the pool.
· Always wash your children's hands with soap and water after bathroom breaks or after changing diapers.
· Change your child's diaper in a bathroom, not at poolside or near the water. Germs can spread to surfaces in and around the water and spread disease.
· Wash your child thoroughly with soap and water before swimming.

In addition, the CDC urges consumers to notify a lifeguard if fecal matter is seen in a pool, and be supportive of management when a pool is closed to prevent the spread of parasitic infection. For more information on parasitic pathways, visit the CDC's Healthy Swimming 2001 spotlight at: www.cdc.gov/healthyswimming/.

Adapted from: AAP News; 19(1); July 2001; p. 31.

RESOURCES:

LEAD POSONING PREVENTION HANDBOOK

While lead poisoning is considered one of the most preventable pediatric health problems by many public health officials, nearly 1 million children in the United States still have lead levels in their blood that are high enough to cause irreversible damage to their health.

In response to this statistic, the University of North Carolina Environmental Resource Program recently published a handbook that presents community strategies for fighting this public health hazard. The book offers examples from successful lead poisoning education and outreach programs in North Carolina and across the United States.

To obtain a free copy of Working Together: Community-Based Approaches to Prevent Childhood Lead Poisoning, contact Claudia Rumfelt-Wright at (919) 715-8497 or Nicole Horstmann at (919) 715-5237; or write: Children's Environmental Health Branch of NCDENR, 1632 Mail Service Center, Raleigh, NC 27699-1632.

Source: AAP News; 19(1); July 2001; p. 34.

THE CDC OFFERS GUIDANCE ON BLOOD LEAD TESTING

Children receiving Medicaid accounted for 60 percent of children ages 1 to 5 years who had blood lead levels (BLLs) > 20 mg/dL, according to data from the National Health and Nutrition Examination Survey (NHAINES, 1991-1994) and a 1999 US General Accounting Office report. Despite this, less than 20 percent of young children enrolled in Medicaid had received a blood lead test.

Since 1989, the Health Care Financing Administration (HCFA) has required that all children enrolled in Medicaid be screened for lead poisoning. The Academy reminded its members in 1999 that lead screening is mandatory for all Medicaid-enrolled children (1).

The HCFA is now working with the US Centers for Disease Control and Prevention Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) to permit treated screening of Medicaid-enrolled children in states that can provide data to support selected screening.

The ACCLPP recently published recommendations for health care providers and state agencies on blood lead screening of young children enrolled in Medicaid (2). This document, which can be found at: www.cdc.gov/mmwr/preview/mmwrhtml/rr4914a1.htm, contains guidance for pediatricians on screening and interventions for Medicaid-enrolled children. Additionally, it urges state agencies to provide the necessary infrastructure to facilitate compliance with these recommendations (and HCFA rules) including:

· the requirement that state Medicaid managed care contracts specifically require lead screening and follow-up, and
· the recommendation that pediatricians and other health care providers receive adequate reimbursement and capitation rates for blood screening.

References:

1. AAP Division of Health Policy Research. Medicaid reimbursement disparity hits kids hard. AAP; 1999; 15(6) pp. 1-6.

2. Advisory Committee on Childhood Lead Poisoning Prevention. Recommendations for blood lead screening of young children enrolled in Medicaid: targeting a group at high risk. Morb Mortal Wkly Rep; Dec 8, 2000; 49 RR-14:1-13.

Source: AAP News; 18(6); June 2001; p. 259.

GUIDE FOR TREATING OBESE PATIENTS

A practical guide to help practitioners treat overweight and obese patients has been unveiled by the National Heart, Lung, and Blood Institute (NHLBI). The need for the tools couldn't be more pressing, as statistics from the National Health and Nutrition Examination Survey (NHANES) show that between 1994 and 1999 the number of US adults who are overweight or obese increased by 5 percent.

Claude Lenfant, MD, NHLBI director, said that now 61 percent of the US adult population, almost 108 million people, are at greater risk than slimmer people for major diseases including heart disease, stroke, diabetes, and cancer because of their weight. To help deliver better health care to this at-risk population, NHLBI prepared the guide based on 1998 clinical guidelines.

The guide includes a 10-step plan and a quick reference tool to help physicians assess, classify, and treat overweight and obesity; and detailed sections on dietary therapy, physical activity, and behavior therapy. In addition, the handbook discusses the appropriate use of weight loss drugs (with recommended doses of specific drugs) and indications for surgery as a treatment for obesity.

A patient section featuring practical information and tools for behavioral change rounds out the guide. It includes a weight management chart, sample walking and jogging programs, and tips for dining out, shopping, and cooking. An online version of the guide is available at http://www.nhlbi.nig.gov/gidelines/obesity/practgde.htm.

Source: JAMA; 285(15); April 18, 2001; p. 1952.

CONFERENCE:
THE FOURTH INTERNATIONAL CONGRESS ON VEGETARIAN NUTRITION

Loma Linda, California
April 8-11, 2002

In the past 30 years, scientific endeavors in the area of vegetarian nutrition have progressively shifted from investigating dietary philosophies held by nutritionists and other health professionals to creative solutions for various medical conditions and promoting preventive approaches to chronic diseases. Although professional interest in vegetarian nutrition has now reached unprecedented levels, scientific knowledge regarding vegetarian diets and their positive effects on human health is far from compete. This congress will not only provide a review of the accumulated findings, but will introduce theoretical concepts, practical applications, and implications of vegetarian dietary practices for both the prevention of disease and the promotion of health as well as for the furthering of research endeavors.

Major Conference Topics

· Vegetarian diets and longevity/morality
· Vegetarian diets: current issues
· Vegetarian diets and bone health
· High soy consumption: good, bad, or indifferent?

· Vegetarian diets for all: a solution to the environmental crisis?

Abstract Deadline

The program committee is soliciting abstracts for oral or poster presentation for the different scientific sessions of the congress as deemed appropriate by the program committee. The topic for abstracts will include the main themes of the program and also other related topics on vegetarian nutrition. Forms, specific guidelines, and deadline information is available on the conference's web site at: www.vegetariannutrition.org.

Conference Location

The Fourth International Congress on Vegetarian Nutrition will be held in the Drayson Center on the campus of Loma Linda University, Loma Linda, California, USA. This Health-sciences University is located near the San Bernardino Mountains, 60 miles east of Los Angeles and 50 miles east of Palm Springs.

Transportation

Congress participants will be responsible for their own travel arrangements. Ontario International Airport provides the most convenient service to Loma Linda. Most major domestic airlines and some smaller ones serve the airport. For the international traveler, Los Angeles International (LAX) offers additional and more complete options.

Lodging

Please check our web site for a comprehensive list of hotels in the Loma Linda area. There are a limited number of rooms at convention prices so make your arrangements as soon as possible.

Official Language

English is the official language of the Congress. There will be no arrangements for translation into other languages.

Contact Information and Registration

To register, please visit the conference web site at: www.vegetariannutrition.org

You can also send inquiries directly to:

Office of Extended Programs
Loma Linda University
School of Public Health
Loma Linda, CA 92350 USA
Telephone: (909) 558-7230
Fax: (909) 558-4087
E-mail: icvn@sph.llu.edu

Source: International Congress on Vegetarian Nutrition, Loma Linda University School of Public Health flier. July 2001.

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