Nutrition Perspectives March

UNIVERSITY OF CALIFORNIA
COOPERATIVE EXTENSION

NUTRITION PERSPECTIVES

Volume 25, No. 2
March/April 2000

TABLE OF CONTENTS

Resources:
Getting Active, Staying Active
Tips for Children’s Serving Sizes from the Food Guide Pyramid
Nutritionists Use New Training Kit to Educate Health Care Workers on Research Findings and Prevention Strategies for Pediatric Obesity
Food Safety for Kids and Educators
Full Text of AMA Journals On-line
Risky "Weight Loss" Product Prompts Warning from FDA
Subscription for NUTRITION PERSPECTIVES

Sheri Zidenberg-Cherr, PhD, Editor
University of California
Department of Nutrition
One Shields Ave.
Davis, CA 95616

NUTRITION PERSPECTIVES is prepared by Sheri Zidenberg-Cherr, PhD, Nutrition Specialist, Cristy Hathaway, and staff. It is designed to provide research-based information on ongoing nutrition and food-related programs. It is published bimonthly (six times annually) as a service of the University of California Cooperative Extension and the United States Department of Agriculture. Subscription to NUTRITION PERSPECTIVES is available from UC Cooperative Extension, Department of Nutrition, University of California, Davis, California. Cost is ten dollars ($10.00) for a one-year subscription. Subscriptions and questions or comments on articles may be addressed to: NUTRITION PERSPECTIVES, University of California, Department of Nutrition, One Shields Ave., Davis, CA 95616-5270. Phone (530) 752-3387; Fax (530) 752-8905.

The Food and Nutrition Board of the National Academy of Sciences is currently reviewing recommendations for vitamin C (ascorbic acid) intake. The 1989 RDA of 60 mg/d was primarily based on the amount required for the prevention of deficiency, or scurvy. Vitamin C deficiency has been shown to result in a weakening of collagenous structures, causing tooth loss, joint pains, bone and connective tissue disorders, and poor wound healing, fatigue, and lethargy. However, the new RDA (now termed Dietary Reference Intakes, or DRI, as defined later in this article) is in the process of being released and are targeted primarily toward prevention of disease rather than correction of deficiency.

Two recent articles, which took different empirical approaches, suggest increasing the recommendation for vitamin C intake. Experts at the National Institutes of Health (NIH) conclude that the level should be 100 to 200 mg daily (1). Researchers form the Linus Pauling Institute at Oregon State University conclude that the RDA should be doubled, to 120 mg (2).

The NIH experts base their conclusions on a review of the role of vitamin C in metabolic processes and the criteria used for recommended intake of vitamin C. Their extensive calculations include dietary availability, steady-state concentrations, urine excretion, adverse effects, biochemical and molecular function, direct beneficial effects and epidemiologic observations, and prevention of deficiency. Their recommendations follow an application of the Food and Nutrition Board’s new classifications for providing estimates of nutrients needs.

DRIs

The new DRI now include four reference values:

The estimated average requirement (EAR);
The RDA;
The adequate intake (AI) when an EAR cannot be determined; and
The tolerable upper intake level (UL).

Based on an EAR of 100 mg/d, the proposed RDA of vitamin C is 120 mg/d. The NIH group also estimated the AI to be either 200 mg/d from five servings of fruits and vegetables or 100 mg/d of vitamin C as a supplement. For the UL (the highest level of nutrient intake that does not pose risk or adverse health effects to almost all individuals), they propose 1g (1000 mg) of vitamin C daily.

The Linus Pauling researchers looked more closely at recent scientific evidence on the level of vitamin C associated with a reduced risk of chronic diseases, primarily cancer and cardiovascular disease. From their review of the biochemical, clinical, and epidemiologic evidence, they estimate that an intake of 90 to 100 mg/d of vitamin C is beneficial and suggested that the RDA be increased to 120 mg/d. However, they caution that most of the risk reduction they found was from epidemiologic studies and not from clinical trials. They therefore propose that double-blind, placebo-controlled, randomized clinical trials of vitamin C supplementation in populations with low to very low vitamin C status are needed to provide "proof of concept" that vitamin C can lower morbidity or mortality from cardiovascular disease, cancer, and cataracts.

The NIH article is accompanied by a patient advice page, "How much vitamin C do you need?" It provides practical patient advice, including a list of foods that contain vitamin C, and emphasizes that whenever possible, that the vitamin C should be obtained from consumption of five servings of fruits and vegetables daily rather than from supplements.

Source: Nutrition and the MD 26(1), January 2000.

Reference:

1. Levine M, Rumsey SC, Daruwala R, Park JB, Wang Y. Criteria and recommendations for vitamin C intake. JAMA, Apr 21, 281(15):1415-23, 1999.

2. Carr AC, Frei B. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health effects in humans. Am J Clin Nutr, Jun, 69(6):1086-107, 1999.

VITAMIN C FOR REFLEX SYMPATHETIC DYSTROPHY AFTER WRIST FRACTURES

Reflex sympathetic dystrophy (RSD) is a form of pseudo-inflammation that occurs after wrist fractures. Initially, in the hot phase, there are sympathetic microcirculatory disturbances; a cold phase follows, during which the tissues undergo secondary trophic changes. The condition is persistent and leads to loss of work time and increased health care costs; the cause in unknown, and there is no definitive treatment.

Several studies have investigated the role of toxic oxygen radicals in RSD. Therapeutic use of vitamin C (ascorbic acid), an antioxidant that scavenges hydroxyl and superoxide radicals and thus stops free-radical

reactions, was investigated in a double-blind trial from the Netherlands (1). A total of 115 adults with 119 conserv-atively treated (plaster-cast immobilization after reduction under local anesthesia) wrist fractures were randomized to either 500 mg per day of vitamin C or placebo for 50 days. Patients were assessed for RSD after 1 week, 4 to 5 weeks (at removal of the plaster cast), 6 to 7 weeks, 12 weeks, 26 weeks, and 1 year. Significantly fewer RSD cases occurred in the vitamin C group than in the placebo group (7 percent vs. 22 percent of fractures).The authors conclude that prophylactic vitamin C is helpful in preventing reflex sympathetic dystrophy after uncomplicated wrist fractures and suggest that this treatment also may help for other fractures.

Source: Jarman B. Journal Watch 20 (2); January 15, 2000.

Reference:

1. Zollinger PE et al. Effect of vitamin C on frequency of reflex sympathetic dystrophy in wrist fractures: A randomized trial. Lancet 354: 2025-8, December 11, 1999.

DEPARTMENT OF HEALTH AND HUMAN SERVICES UNVEILS HEALTHY PEOPLE 2010

As we head into a new decade, US health officials are hoping to improve the quality of health for all Americans and eliminate racial and ethic disparities that exist in the nation’s health status. Major challenges facing health officials include increasing rates of physical activity among Americans, reducing the number of people who are overweight or obese, and decreasing incidences of diabetes and asthma.

The US Department of Health and Human Services (HHS) introduced the nation’s health goals for this decade during a conference in Washington, DC. "Healthy People 2010" outlines health objectives and intervention strategies designed to improve the quality of life for all Americans. "The new century brings new challenges and opportunities to improve the health of everyone in the United States," said HHS Secretary Donna Shalala. "People not only want to live a long life, but they also want to enjoy a healthy life," Shalala continued. "With Healthy People 2010, we want to add years to your life and health to your years."

In addition to improving the quality of health and longevity of life, another major goal is to eliminate racial disparities in national health. Minorities suffer from higher levels of diseases such as hypertension and diabetes which makes for poor overall public health, officials said. "Our greatest opportunities for reducing health disparities are in empowering individuals to make informed health care decisions and in providing the skills, education, and care necessary to improve health," said Surgeon General David Satcher. "The underlying premise of Healthy People 2010 is that the health of the individual is inseparable from the health of the larger community."

Healthy People 2010 is composed of 467 health objectives that are broken down into 28 "focus areas," including access to quality health services, food safety, nutrition and overweight, family planning, cancer, diabetes, and physical activity and fitness.

HHS also unveiled its "Leading Health Indicators" to allow Americans to assess the overall health of the nation and of their own communities (see following chart).

The health objectives for the last decade were met for the most part. Successes included decreases in deaths from cancer, stroke, and heart disease. In the 1990s, however, the nation saw an increase in obesity, diabetes, and asthma, and a decrease in overall physical activity.

The goals for this decade include getting everyone "up and moving," and increasing rates of physical activity, and consuming a healthy diet high in fruits, vegetables, and fiber, health officials said.

To help combat the high rates of childhood obesity, communities need to heighten an awareness of physical activity in the nation’s schools, Satcher said. "It is important for parents to invest in their children’s physical activity and nutrition ... and we realize that is a challenge today."

The American Obesity Association (AOA) applauded Healthy People 2010 for recognizing weight as a leading health indicator, but said it did not provide practical ways to help curb the rising incidence of obesity.

Healthy People 2010 represents the third time that HHS has developed a national 10-year health assessment plan. The health objectives for 2010 took four years to create, with consultation coming from the public, health experts, and the Healthy People Consortium, a public/private alliance of over 350 national organizations and 270 state agencies.

For more information about Healthy People 2010, or to access Healthy People 2010 documents on-line, visit www.health.gov/healthypeople/ or call (800) 367-4725.

Healthy People 2010 Leading Health Indicators

Physical activity: Increase the proportion of teens who exercise for 20 minutes a day/3 times a week from 64 percent to 85 percent by 2010. Increase the number of adults who engage in 30 minutes of moderate physical activity every day from 15 percent of the population to 30 percent.

Overweight and obesity: Lower the proportion of children and teenagers aged 6 to 19 who are overweight or obese from 11 percent to 5 percent by 2010, and reduce the number of adults who are obese from 23 percent of the population to 15 percent.

Tobacco use: Reduce adolescent cigarette smoking, currently at 36 percent, to 16 percent. Also, reduce adult smoking from 24 percent to 12 percent by 2010.

Substance abuse: Increase the proportion of adolescents not using alcohol or illicit drugs during the past 30 days from 77 percent to 89 percent by 2010. Reduce binge drinking during the past month among adults from 16 percent to 6 percent of the population.

Responsible sexual behavior: Increase the proportion of teens who abstain from sexual intercourse or use condoms from 85 percent to 95 percent by 2010. Increase the number of sexually active adults who use condoms from 23 percent of the population to 50 percent.

Mental health: Increase the proportion of adults with recognized depression who receive treatment from 23 percent to 50 percent by 2010.

Injury and death: Reduce the homicide rate from 7.2 per 100,000 to 3.2 per 100,000 by 2010, and reduce deaths caused by motor vehicle crashes from 15.8 per 100,000 to 9 per 100,000.

Environmental quality: Reduce the proportion of persons who are exposed to air that does not meet the Environmental Protection Agency’s health-based standards for ozone from 43 percent to 0 percent.

Immunization: Increase the proportion of young children who receive all vaccines that have been recommended for universal administration for at least five years from 73 percent to 86 percent by 2010.

Access to health care: Increase the number of people with health insurance from 86 percent to 100 percent of the population by 2010, and increase the proportion of pregnant women who begin prenatal care in the first trimester of pregnancy from 83 percent to 90 percent.

Source: Nutrition Week; Vol. XXX No. 4; January 28, 2000; pp. 1-2.

CHITOSAN DEBUNKED

A controlled trial has found that the supplement chitosan does not affect weight or serum cholesterol levels (1). The study involved 30 overweight volunteers who received four capsules of either chitosan or a placebo for 28 consecutive days and were told to eat their normal diet. The chitosan and placebo groups showed no differences in weight or serum cholesterol levels. Chitosan is derived from chitin, a polysaccharide found in the exoskeleton of shellfish such as shrimp, lobster, and crabs. Many sellers falsely claim that chitosan causes weight loss by binding fats in the stomach and preventing them form being digested and absorbed. Some refer to it as a "fat magnet."

Source: Nutrition Forum 16(5); September/October 1999; p. 38.

Reference:

1. Pittler MH, Abbot NC, Harkness EF, Ernst E. Randomized, double-blind trial of chitosan for body weight reduction. Eur J Clin Nutr, 1999 May, 53(5):379-81.

CALCIUM MAY HELP REDUCE RISK OF COLON TUMORS

A recent study provided further evidence that calcium may play a key role in reducing the risk of colon cancer, the third leading cause of cancer death and new cancer cases in both men and women in the United States (1). The randomized, double-blinded clinical trial found that people who previously had a colorectal adenoma (a non-cancerous tumor, which is a precursor to colon cancer) removed and who consumed additional calcium were less likely to develop new tumors. The addition of 1,200 mg of calcium (which equals the amount of calcium found in about four servings of milk, cheese, or yogurt) to the diets of these high-risk patients reduced the return of single tumors by 19 percent and reduced the total number of tumors by 24 percent.

Source: National Dairy Council Update on Research in the News; Nutrition and Health News Alert; 12/99.

Reference:

1. Baron JA, Beach M, Mandel JS, et al. Calcium supplements for the prevention of colorectal adenomas. Calcium Polyp Prevention Study Group. New Eng J Med, 1999, Jan 14, 340(2):101-7.

CONTAMINANTS IN MILK

Anti-milk advocates allege that milk should be avoided since it may contain harmful levels of contaminants including pesticides and residues of drugs used to treat dairy cows.

For example, in the book, Milk—The Deadly Poison, author Robert Cohen claims that genetically-engineered bovine somatotropin (bST), a hormone sometimes given to cows to increase milk production, is hazardous to human health. However, there is ample information supporting the safety of bST. The FDA, the National Institutes of Health, the World Health Organization, and the Office of the Inspector General of the Department of Health and Human Services have all performed independent reviews of the studies and agree that milk from bST-supplemented cows is safe. According to C. Everett Koop, MD, former Surgeon General of the United States, "Milk from cows given supplemental bovine somatotropin is the same as any other milk."

Pesticide residues in milk are not a significant health threat. As is the case with other food commodities, the minute quantities of pesticides occasionally found in milk are well below the tolerances set by the government and do not pose a health hazard.

Both the cow’s digestive system and the milk secretion process provide a measure of screening which protects the consumer of milk from many potentially harmful substances. For example, milk contains far lower concentrations of arsenic, cadmium, and mercury than are found in the cows’ feed or in most other foods consumed by humans.

As with pesticides, drug residues are not a major problem. It is true that there have been instances in the past in which dairy farmers have violated regulations and allowed milk containing antibiotics to be sold. (The milk is supposed to be discarded until drug treatment ends and the cow stops secreting the drug in her milk.) Such incidents have always been rare, however, and they are now being prevented by better enforcement efforts. A nation-wide milk quality program is in place that prevents milk containing illegal antibiotic residues from entering the marketplace. All loads of milk are tested for these residues, and any load that contains them is rejected and cannot be sold.

Source: The American Council On Science and Health Presents Much Ado About Milk; Second Edition; October 1999; pp.19-20.

MORE EVIDENCE ABOUT CALCIUM-RICH DAIRY AND HIGH BLOOD PRESSURE

Adults who get 1,000 mg of calcium per day not only meet current calcium recommendations, but may also lower their blood pressure. Researchers conducted a meta-analysis of 42 randomized control trials that examined the effect of calcium on blood pressure (1). The results showed that calcium may help reduce both systolic and diastolic blood pressure. The research also suggested calcium-rich foods such as dairy products may have a greater effect on lowering blood pressure than calcium supplements. The DASH eating plan (Dietary Approaches to Stop Hypertension), which recommends a diet low in fat and rich in lowfat dairy products, fruits, and vegetables to help lower blood pressure, was one of the studies examined.

Source: National Dairy Council Update on Research in the News; Nutrition and Health News Alert; 12/99.

Reference:

1. Griffith LE, Guyatt GH, Cook RJ, Bucher HC, Cook DJ. The influence of dietary and non-dietary calcium supplementation on blood pressure: An updated meta-analysis of randomized controlled trials. American Journal of Hypertension, 1999 Jan, 12(1 Pt 1):84-92.

VITAMIN D MAY HELP REDUCE BREAST CANCER RISK

Getting vitamin D from dietary sources such as milk, along with sunlight exposure, may help reduce the risk of breast cancer. A recent study looked at the sunlight exposure and dietary vitamin D intakes of more than 5,000 women. The results showed that those women with high sunlight exposure and dietary vitamin D intakes of at least 200 IU per day, had a lower risk for developing breast cancer. The risk reductions were greatest for women who lived in US regions receiving more intense sunlight. The authors noted that "if confirmed, these results would be particularly promising for the primary prevention of breast cancer because dietary vitamin D and casual sunlight exposure are modifiable lifestyle factors" (1).

Source: National Dairy Council Update on Research in the News; Nutrition and Health News Alert; 12/99.

Reference:

1. John EM, Schwartz GG, Dreon DM, Koo J. Vitamin D and breast cancer risk: The NHANES I Epidemiologic follow-up study, 1971-1975 to 1992. National Health and Nutrition Examination Survey. Cancer Epidemiology, Biomarkers and Prevention, 1999 May, 8(5):399-406.

A NEW SCREENING TOOL FOR EATING DISORDERS

Eating disorders are among the most common psychiatric disorders in young women. Early detection and treatment are believed to improve prognosis, but there is no simple approach to screening. British investigators developed and tested a 5-question tool called the SCOFF questionnaire (1). As in the CAGE questionnaire, used to screen for alcohol abuse, each letter stands for a reminder term in one of the questions (Make yourself Sick because you feel full? Lost Control over how much you eat? Lost more than One stone [about 6 kg] recently? Believe yourself to be Fat when others say you’re thin? Does Food dominate your life?).

The SCOFF questionnaire was tested in 116 women with confirmed eating disorders and 96 controls, recruited through advertising, who were known not to have eating disorders. All respondents found the question-naire acceptable. Using a positive response to 2 or more questions as cutoff, yielded a sensitivity of 100 percent for anorexia and bulimia, and an overall specificity of 87.5 percent. This questionnaire performed well in a care-fully selected population. It now needs to be tested in a broader population to see how will it will perform as a screening tool.

Source: Marton KI. Journal Watch 20 (2); January 15, 2000.

Reference:

1. Morgan JF et al. The SCOFF questionnaire: Assessment of a new screening tool for eating disorders. BMJ 319:1467-8; December 4, 1999.

‘NUTRACEUTICAL’ BILL INTRODUCED

The Nutraceutical Research and Education Act (HR 30001), introduced by Rep. Frank Pallone (D–NJ), would reward those who do clinical research demonstrating that "natural" substances provide specific health or medical benefit. The bill defines "nutraceutical" as a "dietary supplement, food, or medical food...that (1) possesses health benefits; and (2) is safe for human consumption in such quantity, and with such frequency, as required to realize such properties." The bill provides that if the FDA approves a petition for approval of a new health claim, the person or company that developed the supporting evidence would be entitled to exclusive use of that claim for ten years. The bill would also establish the Nutraceutical Advisory Council and periodic publication of a Nutraceutical Index listing the claims that have been approved or are still under consideration.

Source: Nutrition Forum 17(1); January/February 2000; p. 7.

FIBER INTAKE AND CORONARY HEART DISEASE IN WOMEN

A 10-year epidemiologic study supports the hypotheses that higher fiber intake from cereal sources reduces the risk of coronary heart disease (CHD) in women (1). The study compared the incidence of heart attacks of death due to CHD to the amount of dietary fiber consumed by 68,682 women aged 37 to 64 years who had no previously diagnosed angina, heart attack, stroke, diabetes, or high blood cholesterol when the study began. Women in the highest 20 percent of cereal fiber intake had a 34 percent lower risk of CHD than those in the lowest 20 percent.

Source: Nutrition Forum 16(5); September/October 1999; p. 38.

Reference:

1. Wolk A, Manson JE, Stampfer MJ, Colditz GA, et al. Long-term intake of dietary fiber and decreased risk of coronary heart disease among women. JAMA, 1999 June 2, 281(21):1998-2004.

THYROID DEFICIENCY DURING PREGNANCY

Identifying and treating women for thyroid deficiency early in pregnancy may lead to improved performance on intelligence tests by their children, according to researchers who studied 186 women (1).

Investigators measured serum thyrotropin in stored blood samples from 25,216 pregnant women who participated in a Maine prenatal serum screening program. Forty-seven of the 75 women with hypothyroidism, as determined by high serum thyotropin concentration, agreed to participate in the study. An additional 15 women with milder cases also took part.

Researchers then identified two control subjects for each of the 62 women with hypothyroidism. Case and control subjects were matched according to age at delivery, education, gestational age at time of serum sampling, length of time serum sample was stored, and child’s sex.

Each woman’s child, who was between 7 and 9 years old, was given a battery of neuropsychological tests to assess intelligence, attention, language, reading ability, school performance, and visual-motor performance. None had hypothyroidism as newborns.

Results showed children whose mothers had hypothyroidism during pregnancy scored significantly lower than control children on 2 of the 15 tests.

Researchers then grouped children according to whether their mother’s hypothyroidism was treated during pregnancy. The data showed children whose mothers were not treated scored significantly lower than control children on 9 of the 15 tests. Their IQ scores were an average of 7 points lower, and 19 percent had an IQ score of 85 or lower compared with 5 percent of control children. Meanwhile, children whose mothers were treated for thyroid deficiency during pregnancy scored similarly to control children in most test categories.

The authors concluded that treating maternal hypothyroidism during pregnancy appears to benefit the child, even when treatment is inadequate as determined by thyrotropin measurements. Therefore, routine screening may be warranted.

Source: AAP News 15(11), November 1999, p. 3.

Reference:

1. Haddow JE, et al. Maternal thyroid deficiency during pregnancy and subsequent neuro-psychological development of the child. New Eng J Med, 1999 Aug 19, 341(8):549-55.

ALTERNATIVE MEDICINE

Complementary and alternative medicine (CAM) has a large and growing following in this country and throughout the world. The estimated number of US visits to CAM practitioners increased from 427 million in 1990 to 629 million in 1997, and the estimated out-of-pocket expenditures reached $27 billion, with an additional $3 to 4 billion spent by the public on herbal supplements. In France and Germany, both herbal and homeopathic medicines are routinely prescribed by physicians along with conventional pharmaceuticals. In the UK, there has long been a tradition of homeopathy, and, following recent changes, unorthodox treatments are available under National Health Service guidelines.

In short, the increasing use of CAM represents a significant shift in the health care received by the populations of industrialized countries. Accordingly, it is important that it is being evaluated in the biomedical literature, both within existing journals and in a series of more specialized publications, such as The Journal of Alternative and Complementary Medicine, Alternative Therapies in Health and Medicine, and Alternative Medicine Review, as well as The Scientific Review of Alternative Medicine (1).

The Scientific Review of Alternative Medicine is the latest in a series of peer-reviewed journals launched to examine CAM. It is sponsored by the Council for Scientific Medicine, a group that includes several Nobel Prize winners, biomedical scientists, clinicians, and consumer advocates. The "Guidelines fro Authors" state that articles must relate to topics in "alternative medicine" or aberrant medical practices. The articles consist of reports of original studies, including bench research and clinical trials; analysis and reviews of claims, treatments, practices, and methods in alternative medicine; critiques of reports or data published elsewhere; commentary from other fields or from personal experiences; and letters to the editor discussing recent articles. This journal differs from others in the field because it begins from an unashamedly critical position, dedicating itself to "scientific, rational evaluations of unconventional health claims." An attitude of scientific rigor clearly needs to be maintained in the debate over the value, if any, of CAM. And there is no doubt that it has sometimes been absent, as witness the burgeoning numbers of popular books on the subject and the necessity for the formation in the United Kingdom of the Research Council for Complementary Medicine in 1983 and in the United States of the Office for Alternative Medicine in 1992. Thus, this journal is important because it provides a forum for detractors. In fact, in the three issues reviewed, there is only one article (about homeopathy) with a positive point of view.

The problem with this journal may be that it could find itself without a readership. Those in mainstream medicine may believe that its focus does not require attention, while supporters of CAM may react with avoidance. Neither response would be appropriate. Alternative medicine is a field of endeavor that is not going to disappear, but it is also one that needs critical, scientific evaluation, not only to see if specific components work, but also, if they do, how. And if indeed there are alternative practices that work, then how can research contribute to improving them and making them available to those in need? Though The Scientific Review of Alternative Medicine may arouse antipathy among the supporters of CAM, it will hopefully further stimulate rigorous research into the field. It is definitely recommended for health sciences libraries.

Source: Petty RG, Katz LMG. JAMA; Vol. 282 No. 17; November 3,1999; pp. 1682-83.

Reference:

1. Eisenberg DM, Davis RB, Ettner SI, et al. Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA. 1998; 280:1569-75.

RISK OF DRUG INTERACTIONS WITH ST. JOHN'S WORT AND INDINAVIR AND OTHER DRUGS

The Food and Drug Administration has released the results from a study conducted by The National Institutes of Health (NIH) that showed a significant drug interaction between St. John's wort (hypericum perforatum), an herbal product sold as a dietary supplement, and indinavir, a protease inhibitor used to treat HIV infection. In this study, concomitant administration of St. John's wort and indinavir substantially decreased indinavir plasma concentrations, potentially due to induction of the cytochrome P450 metabolic pathway(1).

Recommendations:

At this time, pharmacokinetic data are available only for concomitant administration of indinavir with St. John's wort. However, based on these results, it is expected that St. John's wort may significantly decrease blood concentrations of all of the currently marketed HIV protease inhibitors (PIs) and possibly other drugs (to varying degrees) that are similarly metabolized, including the non-nucleoside reverse transcriptase inhibitors (NNRTIs). Consequently, concomitant use of St. John's wort with PIs or NNRTIs is not recommended because this may result in sub-optimal antiretroviral drug concentrations, leading to loss of virologic response and development of resistance or class cross-resistance.

Because herbal products are widely used in the United States and are available in various forms such as combination products and teas, it is important that health care professionals ask patients about concomitant use of products that could contain St. John's wort (hypericum perforatum). In addition, the FDA is working closely with drug manufacturers to ensure that product labeling of antiretrovirals is revised to highlight the potential for drug interactions with St. John's wort.

Other Drugs:

Based on this study and reports in the medical literature, St. John's wort appears to be an inducer of an important metabolic pathway, cytochrome P450. As many prescription drugs used to treat conditions such as heart disease, depression, seizures, and certain cancers, or to prevent conditions such as transplant rejection or pregnancy (oral contraceptives) are metabolized via this pathway, health care providers should alert patients about these potential drug interactions to prevent loss of therapeutic effect of any drug metabolized via the cytochrome P450 pathway.

All health care professionals are encouraged to report any serious adverse event associated with the concomitant use of prescription drugs and St. John's wort products to the FDA's MedWatch program at 1-800-FDA-1088 (fax 1-800-FDA-0178).

Source: FDA Press Release: February 10, 2000.

Reference:

1. Yue QY, Bergquist C, Gerdén B. Safety of St. John's wort (Hypericum perforatum) Lancet, 355(9203):576-7; Feb 12, 2000.

SUPPORT FOR NEW DIETARY GUIDELINES WHICH IMPLEMENT NUTRITION RECOMMENDATIONS

The American Society for Nutritional Science (ASNS) and the American Society for Clinical Nutrition (ASCN) announced their support of the proposed Dietary Guidelines for Americans 2000 on February 23, 2000.

The proposed changes to the guidelines are substantiated by research conducted by nutrition scientists, many of whom are members of the two premier nutrition societies in North America, ASNS and ASCN. Indeed, much of the evidence was published in the two societies’ peer-reviewed publications, the Journal of Nutrition and the American Journal of Clinical Nutrition.

"As nutrition scientists, it gives us tremendous satisfaction to see our work, and that of our peers, implemented in this manner," says Laura S. Sims, spokesperson for the Public Information Committee of the ASNS/ASCN. "The proposed recommendations have the potential to improve the health of the American people, and that is our ultimate goal."

The guidelines, first published in 1980 and updated every 5 years, were written by an 11-member committee of scientific experts. The new recommendations are based on scientific evidence, but are carefully crafted to eliminate confusion for the public, spelling out, in A-B-C style, what Americans need in order to achieve and maintain good health: (A) aim for fitness, (B) build a healthy base by using the Pyramid to guide food choices, and (C) choose sensibly to minimize intake of saturated fat, cholesterol, sugar salt, and alcoholic beverages.

Within the A-B-C categories are ten specific guidelines that go beyond dietary advice, emphasizing that a healthy diet alone is not enough, and that you have to be physically active.

One notable change is the approach to fat intake. For years, Americans have been urged to restrict intake of saturated fat and cholesterol found in some meats, poultry, and whole milk dairy products, but the new guidelines encourage consumption of moderate amounts of fats that scientists have deemed "healthful," such as those found in olive oil, fresh fish, lean meat and poultry, and low-fat dairy products.

The dietary guidelines are for healthy adults and children over the age of 2. Some minority populations and people with medical problems may need to modify their diet and exercise regimens to meet their individual needs.

Adapted from: Press release ASNS/ASCN, February 23, 2000.

BRIGHT FUTURES NUTRITION GUIDELINES RELEASED

Emphasizing health promotion and disease prevention, Bright Futures in Practice: Nutrition provides guidelines for healthy eating from infancy through adolescence. The guide, sponsored by the Maternal and Child Health Bureau, Department of Health and Human Services (DHHS), includes strategies and tools to help health professionals incorporate nutrition information and counseling into health services and build partnerships in nutrition with families and communities. In addition to age-specific developmental chapters (infancy, early child-hood, middle childhood, and adolescence), special issue chapters present the guidelines on topics such as obesity, hypertension, iron-deficiency anemia, eating disorders, vegetarian eating practices, and nutrition and sports.

Bright Futures in Practice: Nutrition includes the following information:

An overview of the role nutrition and physical activity play in a healthy lifestyle, a discussion of cultural influences on food choices, and guidelines for community outreach;

Nutrition supervision guidelines for infancy, early childhood (ages 1 to 4), middle childhood (ages 5 to 10), and adolescence (ages 11 to 21);

Overviews of common nutrition issues and concerns for these same age groups; and

Screening tools and other resources for health professionals, families, and communities.

The chapter on nutrition counseling for infants covers (1) introducing solid foods, (2) typical behaviors demonstrated by infants who are learning to eat, and (3) preliminary oral health practices such as using fluori-dated water and cleaning infants' gums.

According to the guidelines, "the most important nutrition message for parents during early childhood is to ensure that their children consume enough calories and nutrients to support adequate growth and development."

During the middle childhood years, children may become concerned about their appearance, which can affect their nutritional intake and physical activity levels. Parents are advised to model healthy behaviors, involve their children in food preparation and physical activity, and avoid criticism of the child's weight or size.

Adolescence is a period of significant growth. Between the ages of 11 and 21, adolescents (1) achieve full adult height, (2) gain 50 percent of adult body weight, and (3) gain as much as 40 percent of bone mass. Poor nutrition can interfere with these outcomes as well as with daily energy levels. Parents and health professionals are advised to counter media images with information about physical changes and body weight and size norms.

Availability information at http://www.brightfutures.org/op/opppnu.htm . Or contact: National Maternal and Child Health Clearinghouse, 2070 Chain Bridge Road, Suite 450, Vienna, VA 22182-2536. Phone: (703) 356-1964; Fax: (703) 821-2098; Email: nmchc@circsol.com; Web site: http://www.nmchc.org.

Source: Story M, Holt K, Sofka D, eds. Bright Futures in Practice: Nutrition. Arlington, VA: National Center for Education in Maternal and Child Health (270 pages); 2000.

GENETICALLY ENGINEERED FOOD LABELING

On November 16, 1999, Rep. Dennis Kucinich, D–OH, and 20 cosponsors introduced the Genetically Engineered Food Right to Know Act. The bill would require labels on food that contains or is produced with genetically engineered material, which it defines as material derived from any part of a genetically engineered organism, without regard to whether the altered molecular or cellular characteristics of the organism are detectable in the material. The Institute of Food Technologists has concluded that genetic modification is safe, will increase world food production, and can improve plant characteristics that will benefit farmers, consumers, and the environment. The FDA has stated that special labeling would be inappropriate unless a technique significantly changes the composition of a food. Proponents of labeling claim that legislation is needed to enable consumers to exercise their "right to choose." Some who advocate labeling perceive it as an efficient way to undermine public confidence in genetically modified foods. Forty-eight congressional representatives have asked the FDA to require labels.

Source: Nutrition Forum; 17(2); March/April 2000.

LABELING OF TRANS FATTY ACIDS PROPOSED

The FDA has published a proposed rule that would require the amount of trans fatty acids in foods, including dietary supplements, to be included in the amount and percentage Daily Values declared in the nutritional labeling of saturated fats. When trans fatty acids are present, the declaration of saturated fatty acids would be required to contain a symbol that refers to a footnote stating the number of grams of trans fatty acids per serving. Trans fatty acids would be subject to the same limits as saturated fats for the purposes of nutrient content claims, health claims, or disclosure and disqualifying levels. The FDA also proposed to define the nutrient content claim for "trans fat free."

The proposal is at: http://vm.cfsan.fda.gov/~lrd/fr991117.html

Resource: Federal Register 64: 62745-62825, 1999.

Source: Nutrition Forum; 17(2); March/April 2000.

MOTIVATIONAL TIPS TO KEEP YOU MOVING

Even the most enthusiastic start to exercise can fizzle out after a few weeks. Motivation is the one thing that will keep you going through busy days, bad weather, and tired spells. That’s why it’s important to form a positive attitude toward physical activity: it’s not something you really ought to get around to, it’s something you deserve that will enrich your life for years to come.

Try exercising with a friend or family member. You will have someone to share your experiences with and you are less likely to skip a session if it means letting someone else down.
If you get bored easily, change activities frequently to keep your mind alert and your body challenged.
Realize improvements don’t happen overnight. Keep a fitness diary to chart your progress and see how far you have come.
From time to time, push yourself by trying to go a bit further or a bit faster. Personal challenges keep you entertained as well as continually improving fitness.
Enter an event. A goal, such as walk or run for charity, a swim-a-thon or a cycling event, provides marvelous incentive to keep moving. Start with a comfortable, attainable distance and give yourself adequate time to prepare.
If you are exercising to lose weight, have patience and enjoy the other benefits that come first. It won’t be long before you feel more energy, more strength, and less stress. A change in weight will take more time, but it will happen.
Keep in mind that exercise gets easier as your body adapts. Before long, you’ll find that physical activity becomes a way of life, something you are eager to get back to if you have to take a break, something that is one of the most enjoyable and comfortable parts of your day!

Adapted from: American Institute for Cancer Research; Getting Active, Staying Active; December 1999 pp. 20-21.

NUTRITION SAVVY: MOMS NUTRITION KNOWLEDGE IMPACTS NUTRITION QUALITY OF PRESCHOOLERS

A new study confirms that the more a mother knows about health and nutrition, the better the overall quality of her preschool child’s diet. However, among children aged 6 to 12, a mom’s influence wears off as older children begin to make more dietary decisions on their own and eat away from home.

"Our results suggest that if we want long-term diet improvements in the US, nutrition education programs would do well to address the nutrition knowledge and lifestyle choices of our mothers," said Betsey Kuhn, director of the Economic Research Service’s Food and Rural Economics Division, which carried out the study.

A high level of maternal knowledge about nutrition translated into significantly lower intakes of total fat, saturated fat, cholesterol, and sodium, and higher intakes of fiber in 2– 5-year old children, the study found. Maternal knowledge did not result in higher intakes of calcium and iron in children, however. The Economic Research Service (ERS) attributed this lack of influence on children’s calcium and iron intakes to the perception by some mothers that under consumption of these minerals is not a serious problem, and the lower attention these nutrients receive in the media compared to fat and cholesterol.

Maternal smoking had a substantial negative effect on the children’s diet quality, even though mothers who smoke are as informed about diet and health as nonsmokers, the study found. Given that smokers’ diets are worse than those of nonsmokers, the ERS notes that nutrition education programs need to target smokers who are the main meal planners in a household in order to alert them to the possible negative influence of their health habits on children’s diets.

Contrary to other findings, the ERS found that the race and ethnicity of a mother had little impact on the quality of children’s diets, with the exception of a few nutrients such as sodium, fat, and fiber. Black preschoolers and school-age children had lower levels of calcium than white preschoolers and school-age children, while Hispanic children consumed less fat than non-Hispanic children aged 6 to 17.

The health habits of individual family members can greatly influence children, the study concluded. It found that having a vegetarian member in the household had a positive effect on children’s’ diets. Fiber intake increased, calories from fat and saturated fat decreased, and cholesterol levels declined in those children who had vegetarian family members.

The ERS recommends that health and nutrition educators target their programs at mothers with preschool children. Then, once maternal influence begins to decline, nutrition education should be directly targeted at school-age children.

Source: Nutrition Week; Vol. XXIX No. 46; December 10, 1999; p. 3.

Reference:

1. Maternal Nutrition Knowledge and Children's Diet Quality and Nutrient Intakes. Research report. USDA Economic Research Service; 40 pp. November 1999.

CREATINE SIDE EFFECTS

A survey of athletes who took creatine (28 male baseball players and 24 male football players, ages 18 to 23) found that 16 (31 percent) experienced diarrhea, 13 (25 percent) experienced muscle cramps, 7 (13 percent) reported unwanted weight gain, 7 (13 percent) reported dehydration, and 12 (23 percent) reported various other adverse effects (1).

Source: Nutrition Forum 16(5); September/October 1999; p. 38.

Reference:

1. Juhn MS, O'Kane JW, Vinci DM. Oral creatine supplementation in male collegiate athletes: A survey of dosing habits and side effects. J Am Diet Assoc 1999 May, 99(5):593-5.

RESOURCES:

GETTING ACTIVE, STAYING ACTIVE

Young or old, nimble or not, this brochure will help your patients and clients look at exercise in a whole new way. Many Americans know they should be more physically active to improve their health. Yet a 1997 Surgeon General’s report revealed that 60 percent of adults don’t get enough exercise to achieve health benefits and 25 percent are not active at all. This brochure will give those you help the inspiration they need to get moving and enjoy a more physically active lifestyle.

Topics included in the brochure help:

Emphasize a gradual, customized approach to becoming more active.
Offer ideas to overcome barriers (too busy, too old, too tired).
Present options for both formal and informal exercise.
Give tips for positive thinking and staying motivated.

This brochure has been reviewed and recommended by physicians and dietitians. To order, call the American Institute for Cancer Research at 1-800-843-8114 or 203-328-7744. The web site is at: www.aicr.org.

Source: Getting Active, Staying Active brochure; American Institute for Cancer Research; December 1999.

TIPS FOR CHILDREN’S SERVING SIZES FROM THE FOOD GUIDE PYRAMID

Young children’s appetites can vary widely from day to day, depending on how they are growing and how active they are. As long as they have plenty of energy, are healthy, are growing well, and are eating a variety of foods, they are probably getting enough of the nutrients they need from the foods they eat. If you are concerned about your child eating too much or too little, check with your doctor or other healthcare provider.

The following is a list of the estimated serving sizes recommended by the USDA when using the Food Guide Pyramid for young children:

Children 2- to 3-years of age need the same variety of foods as 4- to 6-year-olds but may need fewer calories. Offer them smaller amounts.

A good estimate of a serving for a 2- to 3-year-old child is about 2/3 of what counts as a regular Food Guide Pyramid serving.
Two- to 6-year-old children need a total of 2 servings from the milk group each day.
Younger children often eat small portions. Offering smaller servings and allowing them to ask for more, satisfies their hunger and does not waste food.
By the time children are 4 years old, they can eat amounts that count as regular Food Guide Pyramid servings eaten by older family members, that is, 1/2 cup fruit or vegetable, 3/4 cup of juice, 1 slice of bread, 2 to 3 ounces of cooked lean meat, poultry, or fish.
Offer new foods in small "try me" portions, perhaps 1 or 2 tablespoons, let your children ask for more.
Remember, variety is key for the whole family. Offer a variety of foods from the five major food groups, and let your children decide how much to eat.

Source: USDA Tips for Using the Food Guide Pyramid for Young Children 2 to 6 years old; March 1999.

NUTRITIONISTS USE NEW TRAINING KIT TO EDUCATE HEALTH CARE WORKERS ON RESEARCH FINDINGS AND PREVENTION STRATEGIES FOR PEDIATRIC OBESITY

The rate of pediatric obesity in California has been rising rapidly in the past two decades, and University of California nutrition experts are at the forefront in working to turn the tide. Thanks to a new training kit from the University of California Division of Agriculture and Natural Resources (ANR), their job just got easier.

"Children and Weight: What Health Professionals Can Do" (ANR Publication #3416) is a multimedia tool for nutritionists to use in training clinicians, nurses, dietitians, social workers, and other health care professionals who work with children. The kit was developed by nutritionists in UC Cooperative Extension (UCCE) and the State Department of Health’s Child Health and Disability Prevention Program (CHDP).

Each kit includes:

A notebook with five-unit lesson plans on the prevalence, risk, and measurement of pediatric obesity; a review of current research; clinical assessment and care planning; body image perception in children; and how to involve parents, schools, and communities in prevention efforts.

A videotape with segments on body image perception, with a discussion among teenage girls on pressures to achieve an idealized body image; on evaluation and screening for medical risks in overweight children; and on modeling assessment techniques and treatment.

A teaching "flip chart" on children and weight for use with low-literacy families.

Sample pamphlets for parents, including 1998’s "If My Child Is Overweight, What Should I Do About It?" The pamphlet is also available separately (ANR Publication #21455).

A review of recent scientific research on pediatric obesity.

An evaluation instrument.

An extensive resource list for health practitioners working in this area.

In the spring of 1998, the authors pilot-tested the kits in training sessions with more than 500 health professionals around the state. In attendees’ evaluations of the sessions, 93 percent of 155 nurses reported better understanding of the causes of pediatric obesity and increased confidence in their ability to assess cases and recommend treatment plans. More than 80 percent of 24 doctors said they planned to use the kit’s new body-mass index (BMI) charts to plot the heights and weights of children they see and for treatment planning for overweight youths.

The "Children and Weight" training kit is available for $100 plus tax and shipping from UC ANR Communication Services at (510) 642-2431.

Source: ANR News; February 7, 2000.

FOOD SAFETY FOR KIDS AND EDUCATORS

Kids who bring their lunches to school may enjoy a meal more tailored to their preferences than cafeteria fare, but storing the food so that it’s safe to eat by lunch time may be a challenge. However, with a few precautions, it’s possible to minimize risks and help ensure that lunch doesn’t cause any sickness. How? "Quick Tips to Packing a Safe Lunch" tells you. It’s one of more than two dozen pages on topics ranging from safe cooking to the proper way to wash hands featured on www.foodsagety.gov/~fsg/fsgkids.html. Along the way you’ll find a coloring book, crossword puzzle, word scramble, and family vacation game, Also on the site are food safety tips for baby-sitters and suggestions for packing a summer camp lunch. The site is a collaboration between the FDA and several federal, state, and local agencies.

Source: FDA Consumer; March/April 2000.

FULL TEXT OF AMA JOURNALS ON-LINE

All recent editorial material, including original research, review articles, editorials, letters, and book reviews, from JAMA and the Archives Journals is now available on-line. Users can view complete text versions of the articles and search the single or multiple journals using text words, author names, or related articles. Links to references and abstracts are also included. This collection is available free of charge for a limited time. Users also can receive a free e-mail alert of the journals’ tables of contents. To access the on-line JAMA and Archives Journals articles, visit the AMA’s publications Web site at http://pubs.ama-asn.org .

Source: Nutrition Forum 17(1); January/February 2000; p. 1.

RISKY "WEIGHT LOSS" PRODUCT PROMPTS WARNING FROM THE FDA

The FDA is warning consumers not to buy or use a product sold for weight loss because it could cause serious health problems.

The product, Triax Metabolic Accelerator, contains a potent thyroid hormone that could cause heart attacks, strokes, and other serious health effects. It has been marketed in retail stores and on the Internet as a dietary supplement, but the FDA considers it an unapproved drug.

Through its MedWatch reporting system, the FDA learned of several people who had abnormal thyroid function test results while using Triax. These individuals sought medical attention because of symptoms such as severe diarrhea, fatigue, drowsiness, and extreme loss of weight after using the product.

The active ingredient in Triax Metabolic Accelerator is triiodothyroacetic acid (TRIAC). The FDA urges consumers to stop using any product containing that ingredient and to seek medical attention if they experience insomnia, nervousness, sweating, or diarrhea.

Syntrax Innovations Inc., Cape Girardeau, MO., marketed Triax Metabolic Accelerator. Missouri officials embargoed the product, preventing sale of the company’s on-hand supply. The product’s manufacturer, Pharmatech, Linden, UT, agreed to stop distributing any product containing TRIAC.

Source: FDA Consumer; March/April 2000

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