UNIVERSITY OF CALIFORNIA
COOPERATIVE EXTENSION

NUTRITION PERSPECTIVES

Volume 28, No. 3
May/June 2003

TABLE OF CONTENTS PAGE

Get the Lead Out
Iron Deficiency In Lead Poisoning: Correlation or Coincidence
Lead: Devastating Effects, Even at Low Levels of Exposure
Editorial: What Is Nutrition
Guidelines Address Screening, Treatment of Type 2 Diabetes
Public Health Officials Caution Against Ephedra Use
Use of Botanical Dietary Supplements Is Common Among Middle-Aged Women
Ephedrine for Weight Loss and Athletic Performance, Possibly Dangerous
The FDA Proposes Standards for Supplements
First New Vitamin In 55 Years
Food Safety Begins at Home
Calculating the Cost of Salmonella
Mercury and Fish Consumption: Weighing the Risks
Reducing Chronic Diseases Among Minority Populations
The FDA Issues Guidance on Race and Ethnicity Data
Breakfast: Kids’ Most Important Meal of the Day

Resources:
The ADA Offers Diabetes Booklets
Mealtime Memo for Child Care
Children’s Oral Health Care Tips In Spanish

Subscription for NUTRITION PERSPECTIVES

Sheri Zidenberg-Cherr, PhD, Editor
Department of Nutrition
University of California
Davis, CA 95616

NUTRITION PERSPECTIVES is prepared by Sheri Zidenberg-Cherr, PhD, Nutrition Specialist, Cristy Hathaway, Nutrition Assistant, 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, Department of Nutrition, University of California, Davis, CA 95616-5270. Phone (530) 752-3387; FAX, (530) 752-8905.

Get the Lead Out

Recent legislation is helping to win the fight to end childhood lead poisoning here in California. As you may know, lead remains one of the most serious environmental health threats to children in the United States and in California. Toddlers in low-income families are at greatest risk because they are most likely to live in old housing with exposure to deteriorating lead-based paint, and they are at an age when they put their hands in their mouths frequently. Lead poisoning can cause intellectual and developmental delay in young children.

You can help prevent lead poisoning by ensuring that every child participating in a publicly sponsored health plan such as Medi-Cal, the Child Health and Disability Prevention (CHDP) Program, Healthy Families, or the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) gets a blood lead test, if lead poisoned services are available to the child and family.

Low-income children are not only at risk for lead poisoning, but also for poor nutrition. A child whose blood lead level is above ten micrograms per deciliter needs Medical Nutrition Therapy to prevent or minimize developmental delay. A Registered Dietitian may provide that Medical Nutrition Assessment and Therapy. Optimal nutrition for children includes adequate food sources of iron and calcium that may reduce the child's absorption of lead.

Screening for childhood lead poisoning:

Every health care provider is required by California regulation to test each child who receives services from a publicly funded program for low-income children such as Medi-Cal, CHDP, Healthy Families, or WIC for lead. Blood lead testing should be done when the child is 12 and 24 months of age, or anytime up to 72 months if the child has not previously received a blood lead test.

Children not in low-income programs should be screened by asking if they have spent a lot of time in a place built before 1978 that has peeling or chipped paint or that has recently been renovated. If the family's answer is “yes” or “don't know”, a blood lead test should be done.

A law passed and signed by the Governor, effective January 1, 2003, has two important features:
· Universal Reporting of Blood lead test results requires laboratories to notify the Department of Health Services (DHS) of all blood lead analyses performed on California residents. Prior to January 1, 2003, only very elevated blood lead values were required to be reported. The change allows the DHS Childhood Lead Poisoning Prevention Branch (CLPPB) to track the incidence and prevalence of lead poisoning and follow results on individual children.
· Enforcement of lead abatement laws authorizes DHS and local enforcement agencies to order corrective actions when lead hazards are present. “Lead hazards” include deteriorated lead-based paint, lead-contaminated dust, lead-contaminated soil, or disturbing lead-based paint (or presumed lead-based paint) without containment. Only persons who have a certificate from DHS are authorized to perform permanent lead abatement. Violations to accreditation, certification, and work practice standards regulations are subject to fines and penalties.

For details see Health & Safety Code Sections 17920.10, et seq., 105251 et seq., 124130 et seq., or contact Kendra Frazier, CLPPB at 510-622-4933.
Source: Jan Schilling, MPH, MS, RD.

IRON DEFICIENCY IN LEAD POISONING: CORRELATION OR COINCIDENCE

Both lead poisoning and iron deficiency (ID) are disproportionately common in children from lower socioeconomic groups and children living in the inner city. Are these health problems merely common but otherwise unrelated consequences of living in poverty? Or is there more to this relationship than meets the eye?

One could reasonable argue that the connection is largely social and nothing more; children with iron-deficient diets are simply more likely to live in older housing that contain lead paint. But this is not the only possible explanation. Some maintain that the link between ID and lead poisoning is not merely social, but biological as well. According to this line of thinking, ID and lead poising commonly are found together because ID exacerbates the impact of environmental lead exposure, thereby increasing the risk of lead poisoning.

There is some evidence to support this claim. Laboratory studies have demonstrated that iron-deficient animals absorb more ingested lead than iron-replete animals. But the data are less conclusive in clinical research, where at least one controlled study supports a positive ID/lead poisoning association between the two (1).

The question is of more than theoretical importance: if ID does in fact aggravate the effects of lead exposure, then iron supplementation might be warranted as an effective lead poisoning prevention strategy.

New Study Suggests “Causality”

A new longitudinal study from Harvard University affirms a correlation between ID and lead exposure in children. It also reports that ID appears to precede the development of lead poisoning, a finding that supports a cause/effect relationship between the two. Taken together, conclude the authors, “the results suggest that increasing iron body stores can mitigate the risk of subsequent lead poisoning” (2).

The investigators reviewed data from 1275 children aged 9 to 42 months who were screened for lead poisoning and anemia over a three-year period in a Boston primary care clinic. Only children who were given simultaneous blood lead tests and complete blood cell counts at two consecutive visits were included in the analysis. An average of 10 months passed between the first and second clinic visits.

The authors defined ID according to American Academy of Pediatrics criteria (mean corpuscular volume <70 femtoliters (fl) for children younger than two years and <73 fl for children aged 2 years or older; red cell distribution width >14.5) and defined lead poisoning according to current CDC standards (blood lead greater than or equal to 10 mg/dL). The analysis included both a crude comparison of iron status and blood lead levels and a logistic regression analysis that controlled for certain covariates (including age, insurance status, and hemoglobin level).

The unadjusted data showed that children who were iron-deficient at baseline were nearly three times as likely to have lead poisoning at the second visit compared to children who were iron-replete at baseline (odds ratio = 2.77). This association was even stronger after the logistic regression analysis (odds ratio = 4.12).

Moreover, the results showed that improving iron status over time was associated with decreased likelihood of lead poisoning at the second visit. The adjusted risk of lead poisoning was highest in those children who were iron-deficient at both clinic visits (odds ratio = 5.54); by contrast, children who were iron-deficient at baseline but iron-replete at the second visit saw their risk of lead poisoning reduced by more than half (odds ratio = 2.73).

According to the authors, the significance of this study is that it is the first to show a longitudinal relationship between ID and subsequent elevation in blood lead levels. “The argument that ID is ‘causally’ associated with lead poisoning is strengthened by our ability to demonstrate this temporal relation between ID and lead poisoning,” note Wright et al. They add, “All studies of which we are aware have been cross-sectional and cannot determine whether ID preceded lead poisoning or vice versa.
It is not yet clear whether iron supplementation would help mitigate the toxic effects of lead exposure in children. In light of these results, however, the hypothesis deserves to be tested in a randomized controlled trial.

References:
1. McGeehim MA. Getting the lead out: Can iron help? Journal of Pediatrics; 142(1); January 2003; pp. 3-4.
2. Wright RO, Tsaih S-W, Schwartz J, et al., Association between iron deficiency and blood lead level in a longitudinal analysis of children followed in an urban primary care clinic. Journal of Pediatrics, 142(1); January 2003; pp. 9-14.
Nutrition & the M.D.; 29(3); March 2003; pp. 6-7.

LEAD: DEVASTATING EFFECTS, EVEN AT LOW LEVELS OF EXPOSURE

The relation between high blood lead blood levels and intelligence is well defined, IQ declines 2 to 5 points as lead concentration increases from 10 mg/dL to 30 mg/dL. However, the effects of lower lead exposure are uncertain. Investigators enrolled 172 children at age 6 months and followed them for 5 years; blood lead concentrations were measured 6 times, and IQ was measured twice.

After accounting for possible confounders, including maternal IQ and home environment, each 10 mg/dL increase in lifetime average blood lead concentration was associated significantly with a 4.6-point decrease in IQ. When analysis was restricted to 101 children whose maximum lead levels never exceeded 10 mg/dL, as lifetime average blood lead concentrations increased from 1 mg/dL to 10 mg/dL, IQ decreased by 7.4 points.

“As an editorialist notes, the CDC has repeatedly lowered its definition of elevated lead levels, it now stands at 10 mg/dL. It is gratifying that children’s median blood lead concentrations have fallen (from 15 mg/dl to 2 mg/dL) since gasoline was deleaded. However, almost 500,000 children still have lead levels higher than 10 mg/dL and many more have levels higher than 2 mg/dL. Lead levels should be measured in children at high risk (such as those who live in older houses with lead paint”).

References:
1. Canfield RL et al. Intellectual impairment in children with blood lead concentrations below 10 mg per deciliter. N Eng J Med; 2003 Apr 17; 348:1517-26.
2. Rogan WJ and Ware JH. Exposure to lead in children – How low is low enough? N Eng J Med; 2003 Apr 17; 348:1515-6.
Source: Howard Bauchner, MD. Journal Watch; 23(10); May 15, 2003; p. 81.

EDITORIAL: WHAT IS NUTRITION?

In an attempt to define the limits of the field which the American Journal of Clinical Nutrition should cover, members of the Editorial Board were asked, in effect: “What is nutrition?”

To the surprise of practically no one, there emerged no boundary line, which could be unanimously accepted. The cause lied not in our humble ignorance of so vast a science, but is inherent in the role of nutrition in all life processes. From the cataclysmic union of sperm and ovum, through intrauterine development, through birth, growth, maturity and simultaneous decline and senescence, through disease and injury, until at last vital forces are overcome and all metabolic activity ceases, the processes of nutrition are absolutely essential.

The very functions of life are completely dependent on energy, which in turn is derived from the combustion of foodstuffs. Growth and the unceasing process of repair depend on the utilization of protein and allied nutrients. The life of the individual cell is dependent on oxygen and water; but it is the iron-porphyrin-protein, hemoglobin, which carries the oxygen to the cell, and it is the ultimate breakdown of carbohydrate and interrelated nutrients, which, with the fluids we drink, supplies the water. Enzymes and vitamins are two sides of a coin; ubiquitous minerals come from the earth and from flesh to reach every cell.

As the branch of biology dealing with nutrients, substances ingested and necessary for the proper functioning of the body, nutrition is a large and vital part of all the medical sciences. At once cause and effect, it has no beginning and no end. Without adequate nutrition, there is disease, starvation, and death. With improper amounts or unbalanced combinations of nutrients, there are violent disturbances in every part of he body. The ramifications of nutrition are universal.

Think of the obstetrician, he is concerned with the nutrition of the fetus through the mother, the anemias of pregnancy, the management of toxemias; the pediatrician, his greatest role is that of the normal growth and development of the child; the internist, he is preoccupied with nutrition as an essential in the management of the diabetic, hypertensive, the pellagrin, ad infinitum; the surgeon, he pioneered in recognizing the essentiality of fluid balance and nitrogen replacement; yes, and the geriatrician, for he holds out to the elderly the hope of happier years through sane eating. Why, all physicians are involved with nutrition, for it is not the disease that is important, but the person who has the disease, and each person is the product of his nutrition.

No one can foretell what future advances in this old, yet young, science will bring forth. How much closer to realization will be the happier, fuller life when the food supply of all peoples is adequate, when scientific progress, industrial efficiency and common knowledge have built for everyone the very basis of good health, good nutrition. What is nutrition? It is the cornerstone of preventive medicine, the handmaiden of curative medicine, and the responsibility of every physician.
Source: Editorial reproduced from the January-February 1953 issue of the Journal. Am J Clin Nutr; 77(5); May 2003; p.1093.

GUIDELINES ADDRESS SCREENING, TREATMENT OF TYPE 2 DIABETES

With the rise in childhood obesity and the “epidemic” of type 2 diabetes in children and youth, much is being written about the association between obesity and insulin resistance and the progression of this to pre-diabetes and diabetes.

A consensus statement of the American Diabetes Association (ADA) and the American Academy of Pediatrics (AAP) titled Type 2 Diabetes in Children and Adolescents give recommendations on how to approach the pediatric subject at risk for type 2 diabetes (1).

Following are some answers to some common questions based on the consensus statements:

Who should be screened?

The consensus statement recommends that asymptomatic children and youth older than 10 years with two or more risk factors be evaluated for diabetes every two years.

What are the risk factors for type 2 diabetes?

The risk factors include body mass index greater than the 85th percentile for gender and age; family history of type 2 diabetes; being a member of a racial/ethnic group at risk for type 2 diabetes (i.e., African American, Hispanic American, Native American, and Asian American); and signs of insulin resistance such as dyslipidemia, hypertension, polycystic ovarian syndrome, and acanthosis nigricans.

What tests should be done?

If two or more risk factors are present, testing should be considered. Fasting plasma glucose is the preferred test to diagnose diabetes, although this diagnosis can also be made with an oral glucose tolerance test (OGTT). The diagnosis of diabetes in youth is made per the following criteria established by the American Diabetes Association: 1) symptoms of diabetes plus a plasma glucose greater than or equal to 200 mg/dL; 2) fasting plasma glucose > 126 mg/dL; 3) two-hour plasma glucose > 200 mg/dL during an OGTT. If the diagnosis of diabetes is made in someone who is asymptomatic, the diagnosis must be confirmed by repeat tests on another day.

How should type 2 diabetes be treated?

Lifestyle intervention is the first line of therapy in those who are asymptomatic with mild elevation of the glucose level. In those with moderate elevation of blood glucose level and without ketosis, oral hypoglycemic agents can be used. Metformin is the first line agent preferred by pediatric endocrinologists. If there is moderate to severe elevation of the blood glucose level and ketosis, insulin therapy should be initiated.

What about insulin resistance in pediatric patients?

Much has been written about insulin resistance in pediatric patients. To date, however, there are no established criteria to make this diagnosis, particularly because there is innate insulin resistance as children progress through puberty. There are no set levels for fasting insulin or the two-hour insulin level during an OGTT that absolutely equate with insulin resistance.

How should insulin resistance be treated?

The implication that children and youth should be treated for insulin resistance beyond lifestyle intervention is premature. At this time, we lack not only sufficient evidence on how to diagnose this syndrome but also how to treat it. In fact, during a recent meeting of the American Association of Clinical Endocrinologists on insulin resistance, it was decided to not make recommendations concerning children and youth at this time since there is no evidence that pharmacologic intervention is effective, safe or protective against cardiovascular risk later in life. In addition, no group has specifically correlated fasting and the two-hour post-OGTT insulin levels, lipids or blood pressure with cardiovascular risk as has been done in adults.
It would be a grave mistake at this point to apply adult recommendations to children and youth without adequate evidence. It would be unjustified on the clinical care basis to perform OGTTs on patients simply to make the diagnosis of insulin resistance until compelling evidence exists as to the benefit of pharmacologic therapy. Pediatricians should focus on identifying patients at risk and on the early intervention with counseling on the benefits of appropriate nutrition and physical activity. At this time, it would be inappropriate to exceed the recommendations of the ADA and the AAP, particularly regarding pharmacologic intervention unless as a part of a study protocol. Instead, pediatricians should be advocating for change from a public health perspective, looking to improve schools and communities as the safest and most effective long-term strategy to stem the epidemic of type 2 diabetes.

Reference:
1. Rosenbloom A., Arslanian S., Brink S., et al. Type 2 Diabetes in Children and Adolescents. Pediatrics; 2000; 105:671-680.
Source: Francine R. Kaufman, M.D., FAAP; AAP News; February 2003; p. 66.

PUBLIC HEALTH OFFICIALS CAUTION AGAINST EPHEDRA USE

The death of Baltimore Orioles pitcher Steve Bechler in February 2003 brought renewed attention to the dangers of using the herb ephedra. Bechler died from multiple organ failure due to heat stroke, and a dietary supplement containing ephedra was a contributing factor, according to Joshua Perper, M.D., chief medical examiner in Broward County, Florida.

Soon after Bechler's death at age 23, minor league baseball banned ephedra, joining other sports organizations that had already banned its use, the National Football League, the National Collegiate Athletic Association, and the International Olympic Committee.

Health officials recently cautioned American consumers against using ephedra-containing products, especially if strenuous exercise is involved, or in combination with other stimulants such as caffeine. Because ephedra is an adrenaline-like stimulant, it can have potentially dangerous effects on the nervous system and heart.

A naturally occurring substance derived from ma huang, a Chinese herbal medicine, and ephedra, has been promoted to help people lose weight, enhance athletic performance, and increase energy. Its principal active ingredient is a chemical called ephedrine.

Because ephedra is an herb, it is considered a dietary supplement regulated under the Dietary Supplement Health and Education Act of 1994. Under that law, the Food and Drug Administration (FDA) does not review dietary supplements for safety and effectiveness before they are marketed. Rather, the law allows the FDA to prohibit sale of a dietary supplement only if it “presents a significant or unreasonable risk of injury.”

Synthetic ephedrine, however, is regulated as a drug. Ephedrine-containing products taken orally can be sold over-the-counter (OTC) without pre-market approval as long as they conform to the final monograph for OTC drug products used for temporary relief of asthma symptoms. Final monographs cover the formulation, use, and labeling of OTC drug products. Prescription medicines with ephedrine for uses other than those covered by the monograph require pre-market review for safety and effectiveness.

Synthetic ephedrine can be found in OTC and prescription drugs taken orally for temporary relief of shortness of breath, chest tightness, and wheezing due to bronchial asthma. Synthetic ephedrine can also be used as a topical nasal decongestant (nose drops, sprays, or jelly) for temporary relief of nasal congestion due to colds, hay fever, sinusitis, or other upper respiratory allergies. As a regulated drug product, synthetic ephedrine has mandatory warnings and labeling for short-term use. Ephedra is also not allowed to be used in combination with caffeine or other stimulants that could interact with it. The controlled availability of synthetic ephedrine drug products under FDA regulation has not been reported to be associated with the same level of severe adverse events that have been reported with dietary supplements containing ephedra.

Still, Barbara Michal, a paralegal in San Bernardino, California, says she's extremely concerned about the OTC availability of ma huang, ephedra, and ephedrine, whether in herbal form in dietary supplements or as synthetic ephedrine in drugs. She founded a nonprofit group called Halt Ephedrine Abuse Today (HEAT) after her son Kristopher died in 1997, at age 24, of sudden cardiac arrest due to an accidental ephedrine overdose.

“I got a frantic call from Kristopher's wife, Nicole, saying that he collapsed,” says Michal. “All the paramedics could tell me was that he was down for 10 minutes and that they were working on him,” she says. “I drove for three hours to get there, knowing without really knowing that my son was dead.”

Michal says Kristopher was using one of two over-the-counter products containing synthetic ephedrine at different times: maximum strength Efedrin and Mini Two Way Action, formerly called Mini Thins. “The products are labeled as asthma aids, but I've known people who bought them from gas stations, truck stops, convenience stores and liquor stores, and used them as stimulants,” Michal says. “Kristopher took them for a pick-me-up and, like many people, had no idea of the risks. For one thing, if he wasn't drinking Mountain Dew, he was drinking coffee. I have since learned that caffeine makes ephedrine even more dangerous.” Both beverages contain caffeine.

The Department of Health and Human Services (HHS) Announces New Actions

In February 2003, researchers at the RAND Corporation released results of a federally sponsored study that examined available information on products containing the herb ephedra and the drug ephedrine. The study included a review of more than 1,500 adverse event reports related to ephedra that were voluntarily reported to the FDA, and 125 such reports related to products containing synthetic ephedrine.

The researchers concluded that ephedra is associated with risks of side effects such as heart palpitations, psychiatric and upper gastrointestinal effects, and symptoms of hyperactivity such as tremor and insomnia, especially when taken with other stimulants.
The RAND Corporation's review of some 15,000 additional reports submitted by Metabolife International in the summer of 2002 revealed two deaths, four heart attacks, nine strokes, one seizure, and five psychiatric cases involving ephedra, in which no other contributing factors were identified. RAND called such cases “sentinel events” because they may indicate a safety problem, but don't prove that ephedra caused the adverse event. The review also found some evidence of ephedra’s modest effect on short-term weight loss and scant evidence of its effect on performance enhancement in certain physical activities.

In February 2003, the HHS and the FDA announced a series of actions designed to protect Americans from potentially serious risks of dietary supplements containing ephedra.

These include:
· Seeking rapid public comment on the new information on health risks associated with dietary supplements containing ephedrine alkaloids. This will establish an up-to-date public record to support new restrictions on products containing ephedrine alkaloids.
· Seeking rapid public comment on whether currently available information and medical literature present a “significant or unreasonable risk of illness or injury” from dietary supplements containing ephedra. In seeking comment, the FDA reopened a 1997 proposed rule titled “Dietary Supplements Containing Ephedrine Alkaloids.” That rule would have required a warning statement for these products, as well as restrictions on dosage. The FDA withdrew parts of this 1997 proposed rule because of concerns expressed by the General Accounting Office about the information used to establish dose limits.
· Seeking public comment on a mandatory warning label on any ephedra products that continue to be marketed. The proposed warning label warns about the risks of serious adverse events, including heart attack, seizure, stroke, and death, and further cautions that the risk can increase with dose, with strenuous exercise, and when used with other stimulants, such as caffeine. The proposed label specifies those who should never use these products, such as women who are pregnant or breast-feeding. It also lists other conditions, such as diabetes and the use of certain medications, that rule out the use of products containing ephedra.
· Taking actions against ephedra products making unsubstantiated claims about sports performance enhancement. The FDA has sent more than two dozen warning letters to firms marketing dietary supplements that contain ephedrine alkaloids. The letters explain that any claims products make on the structure and function of the human body must be truthful and not misleading. The agency letters also warn companies that they must not make claims about their products' ability to treat or cure a disease or condition, such as obesity. Under the Federal Food, Drug, and Cosmetic Act, dietary supplements with disease claims are considered unapproved new drugs and therefore subject to prompt regulatory actions, including injunctions against firms and seizures of their products.

The FDA continues to work closely with the Federal Trade Commission to ensure that makers of dietary supplements containing ma huang or ephedra don't make false and misleading claims. Commissioner of Food and Drugs Mark B. McClellan, M.D., Ph.D., says the steps announced show the FDA's commitment to taking the most effective actions possible under current law. “The standard for regulating the safety of dietary supplements is largely untested,” McClellan says, “but we are committed to finding the right public health solution.”
Source: FDA Consumer; 37(3); May-June 2003; pp.8-9.

USE OF BOTANICAL DIETARY SUPPLEMENTS IS COMMON AMONG MIDDLE-AGED WOMEN

Sales of herbal preparation have increased dramatically in the US during the past few decades, but estimates of their use among specific groups are rare. To examine use of botanical dietary supplements (BDS) among perimenopausal women (age range 40-60), researchers in Chicago used standardized questionnaires to interview 500 female outpatients at university hospital clinics.
Almost half of the respondents were black, 40 percent were white, and 11 percent were Hispanic. Use of BDS was reported by 79 percent of the respondents; the number of different preparations used per respondent ranged from 1 to 11 (mean 2.9). About 37 percent of respondents claimed to use BDS daily, 14 percent used them weekly, and 18 percent used them as needed or seasonally. Only 24 percent said they used botanicals to prevent disease, and 68 percent said they used botanicals to treat symptoms or diseases. Among users, 42 percent used soy products, and 35 percent used green tea. Most women believed that BDS were effective, and about 68 percent said that they had never experienced adverse reactions. Only 4 percent of respondents obtained BDS information from healthcare professionals, and about 70 percent did not inform their physicians of BDS use.

Although these results might not be representative of BDS use in the entire population, this study documents widespread use of herbal preparations in middle-aged women and emphasizes the importance of asking specifically about such use.
Source: Robert W. Rebar, M.D. Journal Watch; April 1, 2003; p. 55.

EPHEDRINE FOR WEIGHT LOSS AND ATHLETIC PERFORMANCE, POSSIBLY DANGEROUS

Ephedrine and its herbal cousin ephedra frequently are used to promote weight loss or to enhance athletic performance. Several highly publicized deaths in athletes who took ephedrine or ephedra have led to calls for tighter federal regulation. A meta-analysis (1) was commissioned by the US Department of Health and Human Services to assess both efficacy and safety. A literature search resulted in discovery of 19 controlled trials of weight loss, 8 of athletic performance, and 50 of safety and adverse events, plus more than 18,000 case reports (284 were reviewed).

Ephedrine, with or without caffeine, resulted in incremental weight loss compared with placebo, of 0.6 kg monthly; no trials followed subjects for longer than 6 months. Trials of ephedrine for enhanced athletic performance were too heterogeneous to pool, but 6 trials (conducted by the same research team) showed some significant benefits for the combination of ephedrine and caffeine, including increases in time to exhaustion, running speed, muscular endurance, and anaerobic power. Ephedrine use was associated significantly with gastrointestinal symptoms, palpitations, anxiety, and hypertension (pooled odds ratios, 2.2-3.). Case reports revealed several deaths, myocardial infarctions, cerebrovascular accidents, and seizures, but these events were too infrequent to justify conclusion about causation.

“The benefits of ephedrine for weight loss or for enhanced athletic performance are modest at best. Minor adverse events are common, and serious ones are rare but catastrophic. The regulatory implications of this analysis are unclear, despite the current public furor.”

Reference:
1. Shekelle PG et al. Efficacy and safety of ephedra and ephedrine for weight loss and athletic performance: A meta- analysis. JAMA; 289(12) March 26, 2003; pp.1537-45.
Source: Thomas L. Schwenk, MD. Journal Watch; 23(9); May 1, 2003; p. 74.

THE FDA PROPOSES STANDARDS FOR SUPPLEMENTS

A new regulation proposed by the FDA in March 2003 would, for the first time, establish standards to ensure that dietary supplements are not adulterated with contaminants or impurities. The regulation also would require current good manufacturing practices (CGMPs) for dietary supplements and ensure that manufacturers accurately label them to reflect the active ingredients and other ingredients in the products.

In recent years, analysis of dietary supplements by a private lab suggests that a substantial number of supplements may not contain the amounts of ingredients indicated on their product labels. In addition, the FDA has discovered products being marketed that are not accurately labeled or that contain harmful contaminants. For example, one firm recalled dietary supplements contaminated with excessive amounts of lead, which may have posed a health risk to many consumers, especially children and women of childbearing age. Another firm recalled its product after it was found that a dietary supplement containing folic acid, often taken by women to reduce the risk of having a baby with neural tub defects, contained only 35 percent of the amount of folic acid claimed on the label.

To view the proposed regulation, go to www.fda.gov/OHRMS/DOCKETS/98fr/03-5401.html.
Source: FDA Consumer; 37(3); May-June 2003; p. 3.

FIRST NEW VITAMIN IN 55 YEARS

Japanese scientists have discovered a new vitamin, pyrroloquinoline quinone (1), believed to belong to the B group. While scientists have known of the substance since 1979, researchers determined in April that it can be classified as a vitamin, defined as an organic substance needed in small quantities for heath and growth. Researchers at the Tokyo-based Institute of Physical and Chemical Research said in a news release that PQQ assisted in fertility in mice, and those deprived of the substance also had roughened fur. Vitamins that have an important effect on mice usually act in the same way in humans, said lead researcher Takafumi Kato.

Reference:
1. Blake JA, Richardson JE, Bult CJ, Kadin JA, Eppig JT, and the members of the Mouse Genome Database Group. 2003. MGD: The Mouse Genome Database. Nucleic Acids Res 31: 193-195.
Source: Nutrition Week; XXXIII (9); May 5, 2003; p. 6.

FOOD SAFETY BEGINS AT HOME

Most consumers associate food poisoning with tainted meals served at restaurants or other commercial establishments. Contrary to this popular perception, however, research suggests that meals cooked in private homes deserve just as much, if not more, scrutiny for food-safety issues. A recent review of consumer food-safety studies found that a substantial number of reported food-borne illness outbreaks, anywhere from 10 percent to 50 percent of cases in industrialized Western countries, are associated with food that is prepared or eaten in private homes. And, as one would imagine in light of these statistics, research shows that consumers often are not aware of or do not adhere to safe food-handling guide-lines that would reduce the risk of contamination.

Food-Safety Review

Elizabeth C. Redmond and Christopher J. Griffith of the University of Wales Institute, Cardiff identified 88 studies dealing with consumer food safety (1). These studies presented data obtained via surveys, focus groups, and direct observation of consumer food-handling practices. The analysis included a wide range of results on many aspects of food safety.

Among the most important findings for patient education and clinical practice are the following:

· Awareness of Risk
It is reasonable to suggest that consumers would be more motivated to implement safe food-handling practices at home if they perceived a high threat of illness from home-prepared foods. However, results show that only 9 percent to 23 percent of consumers in the United States, United Kingdom, and Canada feel that their homes are a likely source of food poisoning. Research conducted in the 1970’s suggested that most consumers believed the government was responsible for preventing bacterial contamination of raw meat and poultry; data collected in the late 1990’s indicate that this view may still be prevalent.

· Knowledge of Safety Practices
Implementation of appropriate hygienic practices could vastly reduce the incidence of foodborne illness in consumer homes. However, studies show varying, and, in some cases, inadequate levels of knowledge about the basic tenets of safe food handling. For example, studies in the United States have shown that 80 percent to 93 percent of consumers do not know the correct refrigerator temperatures. By estimation, millions of consumers lack the information they need to prevent foodborne illness in their homes.

· Knowledge of High-Risk Foods
Survey respondents demonstrated high awareness of the contamination risk posed by certain foods, but in other cases nearly half of the respondents appeared to be misinformed. For example, in US surveys, 88 percent of participants correctly recognized that rare hamburgers and raw eggs pose a high risk off contamination, but only 56 percent considered poultry a high-risk food. This is significant because studies have determined that 7 percent to 48 percent of poultry contains Salmonella organisms. In fact, Campylobacter sp. is now thought to cause the majority of foodborne illness in the United States and some Western nations. Still, consumer awareness of this pathogen remains low: only 5 percent to 21 percent of study respondents had even heard of Campylobacter.

· Observed Practices
Regardless of what consumers report in surveys and focus groups, observation of their food-handling practices at home is arguably the best measure of thier compliance with safety guidelines. And here the results are perhaps most disconcerting. Studies of US home kitchens have found that 46 percent and 82 percent of participants, respectively, undercooked meatloaf and chicken; 95 percent did not use a meat thermometer; 29 percent to 57 percent did not wash their hands appropriately during food preparation; and 25 percent to 71 percent used inappropriate methods to prevent cross-contamination.

· Information for Clinicians
Because Redmond and Griffith did not analyze the methodology of studies reviewed, it is difficult to assess the validity of these results. Still, the volume and consistency of the findings suggest that safe food-handling practices are unknown or under-appreciated by a significant number of consumers.

Nutrition professional can help ease the burden of foodborne illness by educating their patients and clients about the four basic elements of food safety, as presented in the Fight BAC! Consumer Education Campaign. (Guidelines and additional consumer education materials are available at the Partnership for Food Safety Education’s website, www.fightbac.org). Special consideration should be given to individuals who are at high risk of acquiring foodborne illness.

Individuals at High-Risk for Foodborne Illness and Foods They Should Avoid:
High-Risk Patient Categories Food To Avoid
Young Children Raw fish or shellfish
Pregnant women Raw or un-pasteurized milk or cheeses
Elderly individuals Soft, French-style cheeses and patés
Immuno-compromised individuals Raw or undercooked eggs or foods containing raw or lightly cooked eggs (e.g. certain salad dressings, cookie and cake batters, sauces and beverages such as un-pasteurized eggnog)
Raw or undercooked meat or poultry
Precooked processed meats that have been reheated (e.g. deli meats, hotdogs)
Raw sprouts (alfalfa, clover, and radish)
Un-pasteurized fruit of vegetable juices

Reference:
1. Redmond, E.C. and Griffith, C.J. Review: Consumer Food Handling in the Home: A Review of Food Safety Studies. Journal of Food Protection; 66(1); January 2003; pp. 130–161.
Source: Nutrition & the M.D.; 29(3); March 2003; pp. 7-8.

CALCULATING THE COST OF SALMONELLA

Ever wonder about the direct cost of health care and premature death related to Salmonella, Camphylobacter, Escherichia coli variants, and Listeria? The US Department of Agriculture (USDA) can figure that out for you now that the Economic Research Service (ERS) put its foodborne illness cost calculator on the Web. The ERS estimates of the costs of illness and premature death for a number of foodborne illnesses have been used in the regulatory cost-benefit and impact analyses. Like all cost estimates, the ERS estimates include assumptions about disease incidence, outcome severity, and the level of medical, productivity, and disutility costs.

Changing any of these assumptions changes the cost estimates. The UDSA hopes policymakers and other people who might use this tool get a better understanding of how the numbers change according to how well Salmonella is controlled, and then help them prioritize spending and formulate food safety policies. The Foodborne illness cost calculator provides information on the assumptions behind foodborne illness cost estimates, and gives you a chance to make your own assumptions and calculate your own cost estimates. Right now, only the Salmonella section is operational, but the other sections will come online soon.
Go to: www.ers.usda.gov/data/foodborneillness/ to play with this online tool.
Source: Nutrition Week; XXXIII (9); May 5, 2003; p. 6.

MERCURY AND FISH CONSUMPTION: WEIGHING THE RISKS

An increasing number of studies suggest that consumption of long-chain fatty acids helps reduce the risk of cardiovascular disease. However, fish, a primary food source of these beneficial compounds, often contains environmental toxins such as methyl mercury. Are the potential health heart benefits of fish consumptions more compelling than the dangers posed by exposure to these toxins? The answer depends both on the fish being eaten and the person eating it.

Caution for Women and Children

Like other toxins, such as polychlorinated biphenyls (PCDs) and dioxins, methyl mercury is present at low levels in many waterways but tends to accumulate in older predatory fish. Methyl mercury is an especially worrisome contaminant because it has a long half-life in the body and can accumulate in individuals who eat fish frequently. It produces a variety of neurotoxic effects and can impair fetal neurological development.

The vast majority of people can safely consume two servings of fish per week (particularly fatty fish), as recommended for healthy individuals by the American Heart Association (1). But the maximum safe intake may be lower for certain fish and certain individuals identified in advisories by the Environmental Protection Agency (EPA), the Food and Drug Administration (FDA), and individual states and identified areas.

The federal agencies have developed population-wide guidelines for fish consumption based on a report from the National Academy of Science, National Research Council, as well as recent prospective studies linking methyl mercury exposure in fish to toxic neurological effects (2). The EPA regulates fish that are caught by individuals for personal consumption (sport-caught fish); the FDA regulates all commercially sold fish in the United States, including farm-raised and imported fish.

The EPA recommends that women who are pregnant, may become pregnant, or are nursing limit consumption of sport-caught fish to 6oz per week of cooked fish (3).

The FDA recommends that pregnant women and women of childbearing age completely limit certain species of fish that typically contain high levels of mercury from their diets. These species are shark, swordfish, king mackerel, tilefish (also known as golden bass or golden snapper). As a matter of “prudent public health advice,” the FDA says that nursing mothers and young children should avoid these species as well.

Women covered by this advisory can safely consume up to 12 oz per week of all other cooked fish, the FDA says. These women should strive to consume a wide variety of fish species, including shellfish, canned fish, smaller ocean fish, or farm-raised fish (4).

All other individuals not covered under this advisory can safely consume up to 7 oz per week of the high-mercury species and 14 oz per week of many of many other species (e.g. fresh tuna, orange roughly, marlin, and red snapper). It remains unclear how much canned tuna is safe to eat, although ongoing research should soon shed light on this question.

Additional advisories regarding mercury and other toxins are issued by individual states and may apply to the entire state or only to specific water. A comprehensive list of advisories is available on the EPA website referenced earlier.

Mercury and Heart Disease

Although most advisories focus on children and women of childbearing age-groups with low risk of cardiovascular disease, a recent report suggests that methyl mercury exposure is linked to increased heart disease risk in adult men. It is therefore possible, say the authors, that the high mercury content of fish may limit the cardiovascular benefits of fish intake in these individuals.

Eliseo Guallar MD, DrPH, and colleagues analyzed toenail mercury concentrations, as well as adipose tissue levels of docosahexanoic acid (DHA, a long-chain n-3 fatty acid), in a case-control study involving 684 men with one previous myocardial infarction (MI) and 724 male controls. They found that mercury levels, after adjustment for fat tissue DHA levels and coronary risk factors, were 15 percent higher in the MI group compared to the control group. They also reported that individuals with the highest mercury levels had more than twice the risk of MI compared to those with the lowest levels. However, the DHA from fish sill provided a small net protective effect (5).

These findings are still preliminary. Another recent analysis of toenail mercury levels in 33,737 male health professionals showed no significant relationship between mercury exposure and the risk of coronary heart disease (6). Interestingly, many participants in this study were dentists, who had occupation exposure to elemental mercury, as opposed to methyl mercury from fish consumption. More testing is required before we can draw conclusions that might affect fish consumption guidelines for adult men.

Mercury and Fish: Key Points

· Pregnant and nursing women, women who may become pregnant, and young children should not eat shark, swordfish, king mackerel, or tilefish.
· The weekly consumption limit for sport-caught fish is 6oz of cooked fish for these women and 2 oz of cooked fish for children.
· Pregnant women, women who may become pregnant, and nursing mothers can safely eat up to 12 oz per week of all other cooked fish; no limit has yet been determined for children.

References:
1. Kris-Etherton PM, Harris WS, Appel LJ, et al. Fish Consumption, Fish Oil, Omega-3 Fatty Acids, and Cardiovascular Disease. Circulation; 2002; 106:2747-2757.
2. Bolger M and Schwetz BA, Mercury and Health. New England Journal of Medicine, 347(22); November 28, 2002; pp.1735-6.
3. [Online source]: www.epa.gov/waterscience/fish/.
4. [Online source]: www.cfsan.fda.gov/~dms/admehg.html or www.cfsan.fda.gov/~frf/sea-mehg.html or call 1-888-SAFEFOOD.
5. Guallar E, Sanz-Gallardo MI, Veer Pv't, et al., the Heavy Metals and Myocardial Infarction Study Group. Mercury, Fish Oils, and the Risk of Myocardial Infarction. N Engl J Med; 347(22); November 28, 2002; pp. 1747-54.
6. Yoshizawa K, Rimm EB, Morris JS, et al., Mercury and the Risk of Coronary Heart Disease in Men. N Engl J Med; 347(22); November 28, 2002; pp. 1755-60.
Source: Nutrition & the M.D. 29(3); March 2003; pp. 5-6.

REDUCING CHRONIC DISEASES AMONG MINORITY POPULATIONS

In recognition of the 17th annual National Minority Cancer Awareness Week, April 20-26, the Department of Health and Human Services (HHS) Secretary Tommy G. Thompson recently announc-ed several new efforts aimed at preventing cancer and reducing health disparities among minority populations. The initiatives focus on nutrition; colorectal cancer; preventive health care; and comprehensive cancer control programs.

“Cancer devastates millions of Americans each year, especially racial and ethnic minorities,” Secretary Thompson said. “Often, this major cause of death can be prevented through changes in our daily routines and by getting regular health care check-ups and screenings. We must close the gap in health care disparities in minority communities and reduce the incidence of cancer nationwide.”

Historically, racial and ethnic minorities have experienced a disproportionate burden of death and disease from chronic illnesses, particularly cancer. The public awareness efforts announced include the “African American 9 A Day” campaign; new “Screen for Life” public service announcements (PSAs); this year's “Take a Loved One to the Doctor Day,” and the Cancer Control PLANET Web portal.

African American 9 A Day campaign

Joined by National Cancer Institute (NCI) Director Dr. Andrew von Eschenbach, Secretary Thompson announced African American 9 A Day, a national campaign to encourage African American men to eat 9 servings of fruits and vegetables a day. African American men are among the most seriously affected by diet-related chronic diseases, and have the lowest overall consumption of fruits and vegetables.

The NCI will collaborate with African American health, faith-based, civic, and fraternal organizations to get the 9 A Day message out to African American men. The campaign also includes national radio spots, a new Web page for African American men (www.9aday.cancer.gov) and “Men: Eat 9 A Day,” a brochure specifically for African American men available through NCI's Cancer Information Service, 1-800-4-CANCER (1-800-422-6237).

Screen for Life public service announcements (PSAs)

Joined by Dr. Nancy C. Lee, director of cancer prevention and control at HHS' Centers for Disease Control and Prevention (CDC), Secretary Thompson also introduced new television PSAs and other educational materials designed to inform Americans, particularly African Americans, Hispanics, and people with Medicare coverage, about the benefits of colorectal cancer screening for all adults aged 50 or over. The PSAs are one component of Screen for Life, a National Colorectal Cancer Action Campaign.
Source: HHS Press Release; April 24, 2003.

THE FDA ISSUES GUIDANCE ON RACE AND ETHNICITY DATA

The Food and Drug Administration (FDA) already requires drug companies to submit race and ethnicity data in drug applications when appropriate. But for the first time, the agency is recommending specific methods for collecting and characterizing racial and ethnic information about clinical trial participants.

In January 2003, the FDA published a draft guidance that recommends collecting racial and ethnic data with methods and categories designated by the Federal Office of Management and Budget's (OMB) Directive 15, which was published in 1997. In this directive, OMB told all federal agencies to report statistics using these guidelines starting in January.

The recommended race and ethnicity categories include American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, and Hispanic or Latino. The FDA's draft guidance recommends that drug companies use the OMB categories when collecting data from study participants within the United States. For studies conducted either inside or outside the United States, more detailed race and ethnic identities may be used, provided that they can be traced back to the major classifications. For example, an Asian person may report having origins in Japan.

Based on the OMB's directive, the FDA recommends that people who participate in clinical trials self-report their racial and ethnic group whenever possible, and that people be permitted to designate a multiracial identity. When self-reporting is not possible, the information should be obtained from an immediate relative or other knowledgeable source.

In a 1998 regulation known as the Demographic Rule, the FDA addressed the importance of collecting data on clinical trial volunteers by gender, race, and age. “The FDA suggested using the OMB categories in the preamble to the Demographic Rule, and the new guidance recognizes these categories as reflecting the FDA's current thinking on how to characterize the data,” says Katherine Hollinger, a senior health promotions officer for the FDA's Office of Women's Health.

Using standard categories will make it easy to compare FDA data with health statistics collected by other federal agencies. “Another goal of the guidance,” Hollinger says, “is to enhance consistency in sub-population characterization. This improves our ability to assess potential differences in the ways various racial and ethnic groups respond to drugs.”

Some studies have shown racial differences in drug response. In the United States, whites are more likely than people of African or Asian heritage to have abnormally low levels of an enzyme that metabolizes drugs belonging to a variety of therapeutic areas, such as antidepressants, antipsychotics, and beta-blockers. Other studies have shown that blacks respond less to several classes of antihypertensive agents, including beta-blockers and angiotensin converting enzyme (ACE) inhibitors. Additionally, slower metabolism of some drugs in the psychotherapeutic class has been seen in people of Asian descent compared to whites and blacks. The differences are complex and may be due to genetic factors, diet, environmental exposure, sociocultural issues, or a combination of these factors.

Clyde Yancy, M.D., medical director of heart failure and transplantation at the University of Texas Southwestern Medical Center at Dallas, says when you look at heart disease, which disproportionately affects racial and ethnic minorities, you then have to ask: Are we confident that the treatment strategies we're using are effective?

“The fact that traditional therapies may have been less effective among blacks than whites points to a possible need for unique heart failure management strategies,” Yancy says. Yancy and other investigators began a clinical trial in 2001, which was the first heart failure trial exclusively for black patients. Results are expected in the next two years.

In another study published in the May 3, 2001, issue of The New England Journal of Medicine, Yancy found that the beta-blocking drug Coreg (carvedilol) was as effective in blacks as non-blacks. “It's reassuring and pertinent for medicine to be able to say that this regimen works in African American patients,” he says.

Despite reported differences in drug response, beta-blockers and ACE inhibitors are still the most appropriate therapy to treat heart failure in blacks for now, according to Yancy. “What we don't want is for doctors to make treatment decisions just by looking at people when they walk in the door,” he says. “Blacks represent a heterogeneous group, and given the substantial benefit of beta blockers and ACE inhibitors, it would be a disservice to limit treatment in this population.” The FDA's draft guidance on the collection of race and ethnicity data in clinical trials is www.fda.gov/cder/guidance/5054dft.pdf.
Source: FDA Consumer; 37(3); May-June 2003; p.36.

BREAKFAST: KIDS’ MOST IMPORTANT MEAL OF THE DAY

A growing number of children are missing breakfast or grabbing a sugary pastry, and experts say these habits are only worsening the problem of childhood obesity.

With a tripling in the number of children and adolescents overweight or obese, pediatricians are seeing alarming rates of kids with weight-related medical problems like type 2 diabetes, sleep apnea and high blood pressure. These rising statistics make nutrition and weight management all the more essential for youths.

And the American Dietetic Association (ADA) says a healthy breakfast should provide 25 percent to 33 percent of a child’s daily nutrient and energy needs, as well as a large portion of his or her calcium intake. Most sugary breakfasts, whether cereal or pastry, only provide energy in the form of numerous calories, and skimp on the nutrition needed to head into the day. Even worse, missing breakfast makes it much more difficult to get the adequate daily amount of fiber, vitamins, and minerals.

Studies have shown that children who skip breakfast can have trouble staying alert and concentrating during the first hours of the school day, according to the American Academy of Pediatrics’ Guide to Your Child’s Nutrition.

Beyond providing needed nutrients, eating breakfast helps thwart weight gain. Eating in the mornings help kids establish a regular eating pattern that’s important to weight control as children and adults. While children get some necessary calories in the morning, their overall daily consumption is spread throughout the day instead of being concentrated in one or two large meals.
As sports practices, rehearsals, and evening meetings fill up dinnertime; the ADA suggests families turn to breakfast for their daily family time. The breakfast table can become a place where schedules are reviewed and issues are discussed.

Despite parents’ best efforts, some children can’t face the idea of breakfast early in the morning. In that case, pack a box of chilled milk or calcium-fortified orange juice and a snack for the ride to school. Emphasize cereals, low-fat dairy foods and proteins.

Here are some suggestions for healthy breakfasts on the go:
· Cereal, ready to eat or hot, instant types, with fruit and yogurt or milk
· Toasted bagel or English muffin with peanut butter or low-fat cheese and a piece of fruit
· Whole wheat banana nut bread
· Fruit-filled breakfast bar and yogurt
· Toasted waffle topped with fruit and yogurt
· Blended milk, fruit, and yogurt for a breakfast shake
· Peanut butter and applesauce on whole-wheat toast
· Leftover: cheese pizza, slice beef, even pasta

For more information on healthy choices for meals, including easy-to-follow recipes, as well as other information on nutrition and health, visit ADA’s Web site at www.eatright.com.
Source: Erin Verkler. AAP News; February 2003; p. 88.

RESOURCES:

THE ADA OFFERS DIABETES BOOKLETS

The American Dietetic Association (ADA) updated a series of publications for dietitians that offer advice for diabetics. The eight items include a poster titled “The First Step in Diabetes Meal Planning,” which provides basic nutrition guidelines for people newly diagnosed with diabetes until they can see a dietitian. One book, Exchange Lists for Meal Planning, includes revised portion sizes and added many new foods to reflect consumer trends, and another book, Eating Right When You Have Diabetes, offers advice on eating well and staying healthy with diabetes.

“Healthy eating, weight loss, and active living are very important in maintaining good health,” ADA spokesperson Jeannette Jordan, RD, a certified diabetes educator, said. “These are great tools to have handy when you’re living with diabetes.”
Go to: www.eatright.org for more information.
Source: Nutrition Week; XXXIII (9); May 5, 2003; p. 6.

MEALTIME MEMO FOR CHILD CARE

The National Food Service Management Institute (NFSMI) at the University of Mississippi had developed Mealtime Memo for Child Care. There are a number of different memos focusing on the toddlers and children of pre-school age. Some of these memos include: Convenience Foods Provide Nutritious Options, Adults Influence What Children Eat, and Feeding Toddlers Can Be a Challenge. All of these memos provide basic information on a double-sided sheet of paper that a parent or childcare provider can easily reference. Each memo provides useful information such as food safety, fun activities, choking prevention, and much more. Below is an example a portion from one of the Mealtime Memo pamphlets.

Feeding Toddlers Can Be a Challenge
Making Mealtime Pleasant
Making mealtime as pleasant as possible for the toddler while providing supervision and encouragement is a constant challenge for both the parent and childcare provider. The term toddler is generally applied to children between the ages of eighteen months and three years because they are learning to walk and frequently “toddle” around on wobbly legs. However, age is less important than the developmental and social growth of the child. During the toddler stage many important things are happening to the child like walking, talking, problem solving, relating to others, and much more. Toddlers are learning to be independent and this is why they want to do things for themselves. The parents and childcare providers will hear the word “no” many times during this stage.

In asserting their independence, toddlers may decide what foods they “will” and “will not” eat. Frequently, these food likes and dislikes change daily or weekly. Regardless of this, parents and childcare providers can help children form sound eating habits by offering nutritious food choices and modeling good eating habits.

When planning meals, consider the flavor of the foods. Young children usually dislike strong flavors: toddlers do not want their foods to be too hot or too cold. When introducing new foods, do so with old favorites. Start out slowly and give the child some control by offering choices. For example, ask which vegetable they would like for dinner, either the carrots or the green peas.
During mealtime, sit with the toddler and eat the same meal. Have a positive attitude toward foods. Discuss what the foods are, where they come from, colors, textures, tastes, and the differences and similarities of foods you are eating.

This pamphlet also has a fun activity called Fishing for Food, and the backside talks about choking prevention and lists some foods that may cause choking.

If you would like more information about these Mealtime Memo pamphlets, contact the NFSMI at: 1-800-321-3054 or www.nfsmi.org.
Source: The National Food Service Management Institute; The University of Mississippi.

CHILDREN’S ORAL HEALTH CARE TIPS IN SPANISH

To assist Hispanic parents in caring for their children’s teeth, the US Centers for Disease Control and Prevention (CDC) has released pediatric oral health tips in Spanish, titled Refresque Sus Conocimientos sobre Dientes Sanos: Pasos Sencillos para Sonrias Infantiles (Refresh your Knowledge of Healthy Teeth: Simple Steps for Kids’ Smiles).

Pediatricians and others are encouraged to distribute the materials, which promote proper oral care habits starting in infancy. Hispanic children aged 2 to 5 years have more caries in their primary teeth than either white or black preschool children.
Request the materials at brushup@cdc.gov. For more information on oral health and the benefits of fluoride, visit www.cdc.gov/spanish/dental.htm (Espanol) or www.cdc.gov/oralhealth (English).
Source: AAP News; 22(4); February 2003; p. 177.

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