UNIVERSITY OF CALIFORNIA
COOPERATIVE EXTENSION
NUTRITION PERSPECTIVES
Volume 24, No. 3
May/June 1999
TABLE OF CONTENTS
Advising Patients about Herbal Therapies
Herbal Remedies in Psychiatric Illness
Herbal Use Among Patients with Cancer
USDA Recommends Safeguards for Consumers at Increased Risk for Listeriosis
New Processing Methods to Reduce Listeriosis Contamination
Dietary Zinc Recommendations for Lactation and Growth
Breakfast and Cognition in Children
Early Dieting Predicts Eating Disorders
Media Education Offers Help on Children's Body Image Problems
Clipsheet for Consumers: Overcome your Obstacles to Exercise
Clipsheet for Consumers: How Much Fiber is Enough?
Book Reviews:
The Complete German Commission E Monographs: Therapeutic Guide to Herbal
Medicines
The PDR for Herbal Medicines
Resources:
Herb-Related Organizations and Trade Associations
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,
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
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ADVISING PATIENTS ABOUT HERBAL THERAPIES
Almost 40 percent of adults in the US use at least one alternative therapy
such as relaxation techniques, chiropractic, massage, herbal medicines, or megavitamins
(1). Of the groups surveyed in a recent study of 1,539 adults in 1990, and 2,055 adults in
1997, use was more common in women especially those in the 35- to 49-year-old age bracket,
those with a college education, and those with an income greater than $50,000. The two
largest increases were in the use of herbal medicines and megavitamins. The majority of
alternative therapies were paid for out-of-pocket. Estimated expenditures for high-dose
vitamins increased to $3.3 billion annually, while herbal products generated an estimated
$5.1 billion annually in revenues.
High Use of Herbals
Eisenberg et al. extrapolated that an estimated 15 million adults in 1997 took
prescription medications concurrently with herbal medicines and/or high-dose vitamins. As
in the 1990 survey, 96 percent of the 1997 respondents who saw an alternative therapist
for a principal condition also saw a medical doctor during the prior 12 months. Less than
40 percent of alternative therapies were discussed with a physician. A substantial portion
of alternative therapies used for a principal medical condition (46 percent in 1990, and
51 percent in 1997) was used without guidance from either a medical doctor or alternative
therapist.
John Astin found similar results in a written survey (2). Forty percent reported using
some form of alternative health care during the past year. Users tended to be more
educated and had a more holistic approach toward health. Alternative therapies were used
not because of dissatisfaction with conventional medicine, but because health care
alternatives were more congruent with the users' values, beliefs, and philosophies.
Popular use of medical herbs makes it necessary for health care professionals to become
educated about the health benefits, risks, and uncertainties so they can educate their
patients (2). Patients are often unaware of the similarities and differences between
medicinal herbs and FDA-approved medications. Manufacturers of medicinal herbs are not
required to demonstrate safety or efficacy before marketing, nor are they regulated for
quality. Herbs often contain an array of chemicals whose concentration varies depending on
the genetics of the plants, growing conditions, plant parts used, time of harvest,
preparation, and storage.
Patient Counseling
David Eisenberg suggested a step-by-step approach to discuss alternative medical
treatments with patients proactively (3). He recommended that health care professionals
ask neutral questions about other therapies the patient might be using and avoid
terminology such as "alternative", "complementary", or
"unorthodox", which can be perceived as judgmental and thus inhibit discussion.
After exhausting conventional therapies or having a patient refuse conventional
therapeutic options, the physician should assist the patient in making a selection of a
qualified alternative therapist during the initial consultation. Sample questions that the
patient should inquire about include:
1. Is the provider's belief in the effectiveness of the therapy based on clinical
experience with similar patients?
2. Of what does the therapy consist?
3. What are the costs associated with the therapy?
4. How long does the therapy need to be used before a positive or negative result will be
seen?
5. Are there potential side effects?
Asking the patient to keep a symptom diary and to schedule follow-up visits to monitor for
potentially adverse effects are additional steps.
Patients already using alternative therapies may not wish to discuss them. This should be
documented in the medical record. A more challenging situation involves a new patient who
is currently using an alternative therapy but refuses a conventional evaluation.
Convincing the patient that an integrated approach is best is recommended. When this
fails, the practitioner may need to follow professional guidelines for referring the
patient to another health care professional for treatment and should not feel obligated to
assist the patient with alternative therapies in the absence of a conventional evaluation.
Practitioners need to feel comfortable discussing alternative therapies with patients and
to avoid the "don't ask, don't tell" approach that often characterizes
communication in this area. These discussions are opportunities for shared decision making
and education about potential benefits as well as problematic drug-drug interactions and
toxicities (4).
References: 1. Eisenberg DM, Davis RB, Ettner SL, Appel S, et al. Trends in alternative
medicine use in the United States, 1990-1997. JAMA 280(18): 1569-75, November 11, 1998.
2. Astin JA. Why patients use alternative medicine: results of a national study. JAMA
279(19): 548-53, May 20, 1998.
3. Eisenberg DM. Advising patients who seek alternative medical therapies. Ann Inter Med
127(1): 61-9, July 1 1997.
4. O'Hara MJ, Kiefer D, Farrell K, Kemper K. A review of 12 commonly used medicinal herbs.
Arch Fam Med 7(6): 523-36, Nov/Dec 1998.
Adapted from: Nutrition & the MD 25(5), May 1999.
HERBAL REMEDIES IN PSYCHIATRIC ILLNESS
Herbal remedies may be used to treat psychiatric symptoms. They may also
produce changes in mood, thinking, or behavior as a side effect, or they may interact with
psychiatric medications. Literature from sources found on MEDLINE and from the
alternative/complementary health field was thoroughly reviewed by Albert H. C. Wong MD, et
al. (1).
Each herb was assessed for its uses, physiological basis, efficacy, and safety in treating
target symptoms or diagnoses. In many cases, the quantity or quality of data were
insufficient to make definitive conclusions about efficacy or safety. More research is
required on most of the herbs reported here, but the information published to date is of
clinical interest to health care providers in diagnosing, counseling, and treating
patients who may be taking botanical remedies.
BLACK COHOSH (Cimicifuga racemosa):
Uses:
It has a history among North American native peoples as a treatment for the hot flashes,
anxiety, and dysphoria associated with menopause, as an analgesic, and as a promoter of
lactation and menses.
Physiological basis:
Its putative action is on the gonadotropin system, through estrogenic ligands that
suppress lutenizing hormone release, and through nonestrogenic ligands that appear to
decrease lutenizing hormone secretion with long-term use.
Efficacy:
A randomized study comparing a commercial product of Cimicifuga racemosa with conventional
hormone therapy for the treatment of ovarian insufficiency symptoms showed similar
efficacy for both treatments.
Safety:
The usual dose of black cohosh ranges from 40-200 mg daily and the onset of action is
about two weeks. Potential side effects include gastric upset, headaches, dysphoria, and
cardiovascular depression. Since this herb may interact with the sex hormone system,
caution is advised.
GERMAN CHAMOMILE (Matricaria recutita):
Uses:
It has been used to treat mild insomnia and anxiety.
Physiological basis:
The herb contains the flavonoid, apignin that may interact with the histamine system.
Efficacy/Safety:
No randomized studies have documented the efficacy and safety of this herb. Doses commonly
range from 2-4 g of dried flower heads three times daily prepared as a tea.
EVENING PRIMROSE (Oenothera biennis):
Uses:
It has been used in the treatment of schizophrenia, childhood hyperactivity, and dementia
on the basis of isolated reports of prostaglandin abnormalities in schizophrenia and
attention-deficit/hyperactivity disorder.
Physiological basis:
The constituents are essential and non-essential fatty acids. The empirical evidence for
changes in physiological fatty acid levels after oral administration is sparse.
Efficacy:
There is no scientific evidence to support this usage.
Safety:
The adult dose ranges from 6-8 g daily, normally given in divided doses. In general,
evening primrose oil is relatively safe, but it should be used with caution in mania and
epilepsy. There have been cases in which evening primrose oil appears to have exacerbated
epilepsy. Drugs that may interact adversely with evening primrose include phenothiazines,
nonsteroidal antiinflammatories, corticosteroids, beta-blockers, and anticoagulants.
GINKGO (Ginkgo biloba):
Uses:
It has been used for medicinal purposes in Europe and China. Its indications are varied
and include dementia, chronic cerebrovascular insufficiency, and cerebral trauma.
Physiological basis:
Standard commercial preparations usually contain the active constituents flavone
glycosides (24 percent), and terpenoids (6 percent).
Efficacy:
There is considerable evidence that ginkgo extracts can improve vascular perfusion.
Studies on ginkgo have found significant improvement in symptoms such as memory loss,
concentration difficulties, fatigue, anxiety, and depressed mood. Evidence from randomized
controlled trials shows that ginkgo extracts are effective in the treatment of
psychopathological conditions and memory impairment caused by Alzheimer's disease and
vascular dementia.
Safety:
The dose for most indications is 40 mg of standard extract three times daily, which must
be given for 1-3 months before the full therapeutic effects are apparent. Side effects of
gingko appear to be relatively uncommon, but include headache, gastrointestinal tract
upset, and skin allergy to the ginkgo fruit.
HOPS (Humulus lupulus):
Uses:
It is used in the brewing industry to produce beer. The female flowers of the plant also
have a long medicinal history as a mild sedative. Hops is also used as a mild hypnotic
agent.
Physiological basis:
Unclear
Efficacy:
There are no clinical studies of its use as a single agent to treat specific symptoms or
illnesses, such as insomnia or anxiety.
Safety:
Hops is commonly given before bed and three times daily as 0.5-1 g of dried flowers.
Adverse effects include allergy, and disruption of menstrual cycles. The use of hops
should be avoided in depression, pregnancy, and during lactation.
KAVA (Piper methysticum):
Uses:
It is used by the peoples of the South Pacific for both medicinal and cultural purposes.
Medically it has been reputed to have anxiolytic, anticonvulsant, sedative, and muscle
relaxation properties.
Physiological basis:
It has been reported to produce changes in EEG similar to those seen with diazepam.
Efficacy:
Kava products standardized for kavalactone content (70 percent) may be beneficial in the
management of anxiety and tension of nonpsychotic origin. Kava appears not to adversely
affect cognitive function, mental acuity, or coordination in comparison with oxazepam.
Safety:
Standardized preparation dosages range from 100-200 mg of kavalactones daily in divided
doses. Long-term administration with higher doses may result in scaling of the skin on the
extremities.
LEMON BALM (Melissa officinalis):
Uses:
It has a history of use as an anxiolytic.
Physiological basis:
Unclear
Efficacy/Safety:
Doses of lemon balm range from 1-4 g daily. No clinical studies demonstrate hypnotic or
anxiolytic effects. Lemon balm may potentiate the effects of other central nervous system
depressants, including alcohol, and may interact with thyroid medications or thyroid
disease.
PASSION FLOWER (Passiflora incarnata):
Uses:
It is native to the Americas where its perennial vine leaves have been used as a sedative
by indigenous people such as the Aztecs.
Physiological basis:
Unclear
Efficacy/Safety:
Its current use as a sedative/hypnotic is not supported in human trials. Passion flower is
commonly given three times daily as 0.25-1 g of dried herb usually prepared as a tea.
Hypersensitivity, vasculitis, and altered consciousness have been reported with products
containing passion flower. Passion flower may cause sedation.
SKULLCAP (Scutellaria):
Uses:
It has a long history of medicinal use with roots in Chinese medicine and with aerial
flower parts in western herbalism. It has been used as a sedative and an anticonvulsant.
Physiological basis:
Unclear
Efficacy/Safety:
It is usually taken three times daily as 1-2 g of dried herb. Adverse reactions include
giddiness, confusion, sedation, and seizures.
ST. JOHN'S WORT (Hypericum perforatum):
Uses:
It can be traced back to the texts of ancient Greek physicians. Contemporary usage has
been as an antidepressant, for which there is more rigorous evidence than for any other
herbal remedy.
Physiological basis:
The active ingredients responsible for antidepressant action are hypericin and
pseudohypericin. Hypericum extracts show affinity for a variety of neurotransmitter
receptors, including those for adenosine, GABA, serotonin, and monamines.
Efficacy:
There is evidence of efficacy in mild to moderate depression as reviewed by Linde et al.
in a meta analysis of 23 randomized trials with a total of 1,757 outpatients (2). St.
John's wort alone or in combination with other herbs was tested against placebo or
antidepressant drugs. St. John's wort was reported to be clearly superior to placebo and
comparable to conventional drug treatment, with fewer side effects and drop-out rates in
the hypericum group. Overall, there are inadequate data regarding long-term use and
efficacy in severe depression.
Safety:
Many commercial St. John's wort products are standardized extracts (0.3 percent hypericin)
of which 300-900 mg are given daily in three divided doses. This is equivalent to
approximately 2-4 mg of the dried herb. Adverse effects include photodermatitis, delayed
hypersensitivity, gastrointestinal tract upset, dizziness, dry mouth, sedation,
restlessness, and constipation. The use of St. John's wort during pregnancy is not advised
until the efficacy of St. John's wort for the treatment of major depressive disorder is
firmly established and its reproductive safety evaluated more thoroughly. The tricyclic
antidepressants and fluoxetine appear to be safer pharmacological alternatives (3).
VALERIAN (Valeriana officalis):
Uses:
It has a history of use throughout the world for a variety of indications with sedative,
hypnotic, and anxiolytic benefits similar to the benzodiazepines.
Physiological basis:
Unclear
Efficacy:
Studies have not evaluated the efficacy of valerian as a treatment for insomnia. Some
human studies have confirmed a mild sedative effect, although the exact effects on sleep
quality and EEG are inconsistent.
Safety:
Dosages range from 200 mg to several grams per day taken at bedtime or in divided doses.
References: 1. Wong AH, Smith M, Boon HS. Herbal remedies in psychiatric practice. Arch
Gen Psychiatry 55(11): 1033-44, Nov 1998.
2. Linde K, Ramirez G, Mulrow CD, Pauls A, et al. St John's wort for depression-an
overview and meta-analysis of randomized clinical trials. BMJ (Clinical Research Ed.)
313(7052): 253-8, Aug 3, 1996.
3. Grush LR, Nierenberg A, Keefe B, Cohen LS. St John's wort during pregnancy [letter].
JAMA 280(18): 1566, Nov 11, 1998.
Adapted from: Nutrition and the MD 25(5), May 1999.
HERBAL USE AMONG PATIENTS WITH CANCER
Increasing interest in complementary/alternative medicine (CAM) use among patients with
cancer is evident from the growth in the number of publications on this subject from a
single article in the 1970s to 16 articles between 1990 and 1997. The most commonly used
CAMs in the 1990s have included meditation, relaxation, hypnotherapy, visualization and
other imagery techniques, reflexology, dietary approaches including food supplements,
Chinese medications, botanical preparations, homeopathy, and spiritual healing. A total of
26 studies were found in the literature search on the prevalence of CAM use among patients
with cancer (1).
These articles were based on studies conducted in thirteen countries. The studies came
primarily from the US and Germany. However, the articles involving herbs and cancer were
from Norway, Austria, Finland, Germany, New Zealand, and Switzerland. In adults with
cancer, 50 percent of the studies reported up to 27 percent of respondents used CAMs, and
the remaining studies found that greater than 25 percent of the respondents tried CAM
therapies.
Prostate Cancer
Herbal mixtures are popular. Among patients with cancer, the use of unconventional
medicines including herbal therapies, has been reported to be from 5-60 percent. For
example, a commercially available combination of eight herbs (PC-SPES), an unregulated
herbal supplement, is used as a nonestrogenic treatment for cancer of the prostate. The
herbs in this product include chrysanthemum, isatis, licorice, Ganoderma lucidum, Panax
pseudo-ginseng, Rabdosia rubescens, saw palmetto, and Scutellaria (skull cap).
In a recent study, it was found that PC-SPES had potent estrogenic activity in yeast,
mice, and humans (2). In eight patients with prostate cancer, PC-SPES caused a clinically
significant reduction in serum testosterone and prostate-specific antigen. Additionally,
it resulted in side effects similar to pharmacologic doses of estrogen. All eight patients
had breast tenderness and loss of libido, and one had venous thrombosis. The study results
suggest that PC-SPES may prove useful in the treatment of hormonally sensitive prostate
cancer. PC-SPES, when used concurrently with standard or experimental therapies, may alter
the results of these therapies.
Leukemia
Low doses of arsenic trioxide induced complete remission in a study of 11 patients with
acute promyelocytic leukemia (APL) (3). Adverse effects were relatively mild and included
rash, light headedness, fatigue, and musculoskeletal pain. The median duration of therapy
in the patients that responded to the treatment was 33 days. The median daily dose was
0.16 mg per kilogram. Most of the patients in this study had had disease that was
resistant to conventional chemotherapy, retinoids, or bone marrow transplantation.
The data suggests that arsenic trioxide is active in APL at doses ranging from 0.06 to
0.20 mg per kilogram per day. No relation between dose and efficacy was obvious. Severe
toxic reactions, including flaccid paralysis and renal failure, have been observed with
higher doses.
Conclusion
Patients with cancer may be more apt to use CAM, including herbs, when conventional
therapies have been found ineffective or when there were side effects to conventional
cancer treatments. Herbs, however, are not regulated by the US Food and Drug
Administration, are not peer-reviewed by scientific panels, and do not undergo clinical
trials before being made available to the public. Caution needs to be exerted when using
CAM including unregulated herbs or herbal mixtures that may have biologic activity that
can affect disease, standard medical therapy, and general health.
References: 1. Ernst E, Cassileth BR. The prevalence of complementary/alternative medicine
in cancer: a systematic review. Cancer 83(4): 777-82, Aug 15, 1998.
2. DiPaola RS, Zhang H, Lambert GH, Meeker R, et al. Clinical and biologic activity of an
estrogenic herbal combination (PC-SPES) in prostate cancer. New Eng J Med 339(12): 785-91,
Sept 17, 1998.
3. Soignet SL, Maslak P, Wang ZG, Jhanwar S, et al. Complete remission after treatment of
acute promyelocytic leukemia with arsenic trioxide. New Eng J Med 339(19): 1341-8, Nov 5,
1998.
Adapted from: Nutrition & the MD 25(5), May 1999.
USDA RECOMMENDS SAFEGUARDS FOR CONSUMERS
AT INCREASED RISK FOR LISTERIOSIS
In a recent press release the US Department of Agriculture reminded consumers
who are at increased risk of illness from a foodborne bacteria called Listeria
monocytogenes to take extra precautions when eating certain foods including ready-to-eat
foods such as lunch meats and hot dogs. People who face increased risks from listeriosis
are pregnant women and newborns, older adults, and people with weakened immune systems
caused by certain cancer treatments, AIDS, diabetes, and kidney disease. People who are at
risk are more likely to become ill from bacteria that can be found in food and to suffer
severe health problems as a result. According to Under Secretary for Food Safety Catherine
Woteki, "If you feel you or someone in your family are at risk, we're advising that
you reheat ready-to-eat foods like lunch meats, or avoid them." To help reduce the
risk of illness, the USDA recommends that at-risk consumers and people who prepare their
food should:
¨ Reheat the following types of ready-to-eat foods until steaming hot: hot dogs, luncheon
meats, deli meats, cold cuts, fermented and dry sausage, and meat and poultry products. If
you cannot reheat these foods, do not eat them.
¨ Wash hands with hot, soapy water for at least 20 seconds after handling these types of
ready-to-eat foods. Also wash cutting boards, dishes, and utensils thoroughly. Washing
helps eliminate any bacteria that might get on your hands or other surfaces from food
before it has been reheated and keeps bacteria from spreading.
¨ Omit soft cheeses such as feta, Brie, Camembert, blue-veined varieties, or
Mexican-style cheeses from the diet. At-risk consumers can eat hard cheeses, processed
cheeses, cream cheese, cottage cheese, and yogurt.
¨ Omit raw, unpasteurized milk, or foods made from it such as unpasteurized cheese from
the diet.
¨ Observe all expiration dates for perishable items that are pre-cooked or ready-to-eat.
In addition, Bessie Berry, manager of the USDA Meat and Poultry Hotline, advises all
consumers to follow the four basic food safety rules that are part of the Partnership for
Food Safety Education's Fight BAC! food safety education program:
¨ Clean-Wash hands and surfaces often with hot, soapy water, rinse and dry. Periodically
clean the refrigerator thoroughly. Wipe up spills in the refrigerator immediately. Always
wash hands, cutting boards, dishes, and utensils with hot, soapy water after they come in
contact with raw meat, poultry, seafood, and eggs.
¨ Separate-Don't cross-contaminate. Raw meat, poultry, and seafood can contain dangerous
bacteria. As a result, keep these foods separate from vegetables, fruits, breads, and
other foods that are already prepared for eating.
¨ Cook-Cook to safe temperatures. If you are at risk for illness from Listeria
monocytogenes, reheat packaged luncheon meats, cold cuts, and other deli meats and poultry
until they are steaming hot.
¨ Chill-Refrigerate or freeze perishable foods, including ready-to-eat foods, within 2
hours of purchase or preparation.
Berry reminded consumers not to eat food that is recalled or ordered off grocery store
shelves. "Consumers should return the food to the place where they bought it,"
Berry said. Consumers with questions can call the USDA Meat and Poultry Hotline at
1-800-535-4555.
Source: Food Safety and Inspection Service USDA Press Release, May 25, 1999.
NEW PROCESSING METHODS TO REDUCE LISTERIOSIS CONTAMINATION
More than 1,000 US meat-packing plants that produce hot dogs and luncheon meats
must start using new processing methods to guard against potentially deadly listeria
bacteria. Carol Tucker Foreman of the Consumer Federation of America was quoted as saying,
"By requiring companies to handle this as part of their own hazard control programs,
the USDA is assuring that some action will be taken immediately." Mike Doyle, a food
safety expert at the University of Georgia, was quoted as saying, "I'm not convinced
that this is going to be very valuable because listeria coming off the assembly line is
most likely to be present in very small amounts. The listeria organism is unusual because
it can grow from just a few cells to millions of them during a few weeks in the
refrigerator." Doyle added that it's also a difficult bacteria to control because it
thrives on the inside walls of refrigerators, where it can easily spread to other foods,
and that a better approach, he said, might be for food-makers to offer single-serve
packages of meat products that are thrown away after use.
The National Food Processors Association was cited as saying that irradiation of
ready-to-eat foods is another way to fight listeria and the group is preparing a petition
asking the USDA to expand a current ruling designed to allow irradiation of raw meat. J.
Patrick Boyle, head of the American Meat Institute, which represents packers and
processors, which recently agreed to raise $5 million in special funds for food safety
research, was quoted as saying, "Like the government, the meat and poultry industry
is redoubling its efforts to battle this elusive pathogen."
Adapted from: Food Safety and Inspection Service USDA Press Release, May 25, 1999.
DIETARY ZINC RECOMMENDATIONS FOR LACTATION AND GROWTH
There is increasing recognition of the role that micronutrient deficiency
plays in children's cognitive performance and motor development. Although iron and iodine
deficiencies are more commonly known, recent evidence suggests that zinc deficiency may
also be associated with deficits in activity, attention, and motor function (1).
Children may be particularly vulnerable during periods of rapid growth and development.
This is especially true of children at risk, such as those who are born prematurely or who
have chronic diseases that interfere with absorption or growth. Inner-city children have
been found to have low concentrations of plasma zinc during infancy and adolescence, and
the dietary reports from middle-income families suggest moderate zinc deficiency during
infancy.
Lactation Levels of Zinc
Lactation poses a burden on maternal zinc homeostasis, particularly when the mother has a
chronically low dietary zinc intake (2). The zinc requirements during lactation are even
greater than those during pregnancy, especially during the early weeks postpartum when
excretion in the milk is 2-3 mg of zinc/day, declining to 1 mg by 2-3 months postpartum.
Evidence suggests that women generally increase their dietary zinc intake by only a modest
amount when lactating. However, these intakes are much less than the current RDA for
lactating women of 19 mg/day for the first six months postpartum.
Marginal zinc status at any time may have functional consequences, including milk
consumption and optimization of infant growth, development, and immune function. Although
breast-fed infants generally fare well in each of these areas, it is difficult to assess
to what extent marginal zinc deficiency may compromise an infant's health and development.
Zinc Supplementation During Infant Feeding
Because breast milk does not supply an abundant amount of zinc, supplementation in
conjunction with other micronutrients may be beneficial in some situations, especially
when a child's diet is low in animal products, which are a good bioavailable source of
dietary zinc (3). Supplementation should also be considered when a child's plasma zinc
concentration is found to be low or during episodes of persistent diarrhea. The World
Health Organization has proposed the following safe upper limits for zinc: for 0.5-1 year
of age, 13 mg/day; for 1-6 years of age, 23 mg/day; for 6-10 years of age, 28 mg/day; and
for 10-12 years of age, 32 and 34 mg/day, respectively, for girls and boys (4).
Reference: 1. Black, MM. Zinc deficiency and child development. Am J Clin Nutr, 68(2S):
464-9, Aug 1998.
2. Krebs, NF. Zinc supplementation during lactation. Am J Clin Nutr, 68(2S): 509-1S, Aug
1998.
3. Allen, LH. Zinc and micronutrient supplements for children. Am J Clin Nutr, 68(2S):
495-8, Aug 1998.
4. World Health Organization. Trace Elements in Human Nutrition and Health. Geneva: WHO,
1996.
Adapted from: Nutrition & the MD 25(4), April 1999.
BREAKFAST AND COGNITION IN CHILDREN
The decline in breakfast consumption over the last 25 years has become a significant
public health issue. Increasing numbers of individuals younger than age 10 regularly care
for themselves and are more likely to be responsible for their own meal preparation.
Skipping breakfast is a likely outcome if the child is responsible for himself or herself,
or if there is a lack of money to purchase food. Given the association between obesity,
which is increasing in children, and less frequent breakfast consumption among persons of
this age group, a renewed emphasis on the importance of breakfast has been advocated.
Breakfast Programs
Many countries, both developing and developed, have invested money in school feeding
programs to improve school attendance, student achievement levels, nutritional status, and
sometimes to provide extra income for poor families indirectly by reducing the amount of
money they must spend on food. Increasing numbers of children in developing countries are
enrolled in school, however, their achievement levels are often disappointing. It has been
suggested that poor health, hunger, and inadequate nutrition may hinder these children's
ability to learn.
New Research
A recent randomized controlled study was conducted to determine what effect providing
school breakfast might have on children's attendance, nutritional status, and achievement
in school, and whether nutritional status or age of the children modified the effect (1).
The undernourished group included 407 Jamaican nursery school children with weight-for-age
more than one standard deviation (SD) below the National Center for Health Statistics
reference mean. Four hundred and seven adequately nourished children (weight-for-age no
more than one SD below the mean) were matched for school and class. Children from both
groups were randomly assigned to breakfast or control groups. Breakfast was provided every
school day for one year, and consisted of a cheese sandwich or spiced bun, cheese, and
flavored milk, supplying 576-703 kcal and 27.1 g protein. The control group was given
one-quarter of an orange, supplying 18 kcal and 0.4 g protein.
Both groups made poor academic progress as measured by the Wide Range Achievement Test
scores. Younger children in the breakfast group improved in arithmetic. The provision of a
school breakfast produced small benefits in children's nutritional status and school
attendance. Children in this study were not severely under-nourished, however. Since their
nutritional status improved somewhat while receiving breakfast, the results suggest that
school feeding programs could be an effective way of improving nutritional status in
countries where undernutrition is a serious problem.
A Breakfast Symposium
An International Symposium on Breakfast and Performance held in 1995 was summarized and
integrated with data published since that time by E. Pollitt and R. Mathews (2). The data
suggest that children perform certain tasks of cognition more successfully after eating
breakfast than after fasting overnight. The pooled data suggest that omitting breakfast
interferes with cognition and learning, an effect that is more easily observed in
nutritionally at-risk children than in well nourished children. At the very least,
breakfast consumption improves school attendance and enhances the quality of the students'
diets.
Fasting as Metabolic Stress
Three separate experiments tested the effects of an overnight and morning fast on
cognition among 9- to 11-year-olds. These experiments tested the hypothesis that such an
extended fast interferes with attention and memory. The first two experiments were on well
nourished, middle-class boys and girls in the US; the third involved boys in Peru from
low-income families with and without nutritional risk. The children were admitted to a
research center on two different evenings, about seven days apart. After arrival, they ate
dinner. The next morning they were all awakened at 7:30 am and, by design, they were or
were not served a ~540-kcal breakfast. At 11 am they were given psychological testing to
assess recall from working memory and competence in discriminating visual stimuli.
The consequence of the overnight and morning fast, particularly among the children who
were nutritionally at-risk, included slower stimulus discrimination, increased errors, and
slower memory recall. The authors concluded that these alterations were a result of a
state of metabolic stress in which homeostatic mechanisms work to maintain circulating
glucose concentrations. However, the authors did not find evidence of an association
between blood glucose concentration and memory function. The authors concluded that the
nutritionally at-risk children were more vulnerable to the adverse effects of fasting than
well nourished children, which concurs with the previous report of Jamaican children (3).
Reference: 1. Powell CA, Walker SP, Chang SM, Grantham-McGregor SM. Nutrition and
education: a randomized trial of the effects of breakfast in rural primary school
children. Am J Clin Nutr 68(4): 873-9, October 1998.
2. Pollitt E, Mathews R. Breakfast and cognition: an integrative summary. Am J Clin Nutr
67(4S): 804-13, April 1998.
3. Pollitt E, Cueto S, Jacoby ER. Fasting and cognition in well- and undernourished
schoolchildren: a review of three experimental studies. American Journal of Clinical
Nutrition 67(4S): 779-84, April 1998.
Adapted from: Nutrition & the MD 25(4), April 1999.
EARLY DIETING PREDICTS EATING DISORDERS
Eating disorders usually appear during mid-adolescence. Lifetime risk in
women is estimated to be 8 percent for bulimic syndromes, and 3 percent for anorexic
syndromes. An Australian prospective cohort study examined risk factors for the
development of these syndromes (1). A total of 1,947 students, aged 14 to 15 years at
study entrance, were enrolled. Students completed a questionnaire and were interviewed and
briefly examined every six months during the ensuing three years.
The overall rate of development of new eating disorders per 1,000 person-years of
observation was 21.8 for females and 6.0 for males. About 8 percent of girls dieted at a
severe level and 60 percent at a moderate level. A high level of dieting was associated
with a 16-fold increase in risk for developing an eating disorder and moderate dieting was
associated with a nearly sevenfold increase in risk. Psychiatric morbidity was an
independent predictor of developing an eating disorder. Students in the highest morbidity
category had a nearly sevenfold increase in risk for developing an eating disorder.
Body-mass-index, extent of exercise, and sex did not predict increased risk, after
adjustment for dieting and psychiatric morbidity.
Dieting was the most important predictor of an eating disorder in this study. Adolescents
expressing concern about their weight should be advised to focus on exercise, which did
not appear to impart a risk for subsequent problems.
Reference: 1. Patton GC, Selzer R, Coffey C, Carlin JB, et al. Onset of adolescents eating
disorders: population based cohort study over 3 years. BMJ 318: 765-8, March 20, 1999.
Source: Journal Watch 19(9): 75, May 1, 1999.
MEDIA EDUCATION OFFERS HELP ON CHILDREN'S BODY IMAGE PROBLEMS
As pediatricians see increasing numbers of children and teens with eating disorders,
including anorexia nervosa, bulimia, and obesity, they should be gravely concerned about
the influence of the media on youth perception of ideal body shape and size. A new study
reinforces the concern that young girls are suffering from negative body image and are
engaging in unhealthy behaviors as a result (1). In the study, Exposure to the Mass Media
and Weight Concerns Among Girls, the authors use a cross-sectional survey of 548 girls in
5th through 12th grades to assess the influence of the media on weight concerns, weight
control behaviors, and perceptions of body weight and shape. A majority of girls, 59
percent, reported dissatisfaction with their body shape, and 66 percent expressed the
desire to lose weight. The prevalence of overweight in this study was 29 percent.
Girls were asked about their frequency of reading women's fashion magazines. Sixty-nine
percent reported that appearance of models in the magazines influenced their image of a
perfect female body, and 47 percent desired to lose weight because of the magazine
pictures. Frequent readers of women's fashion magazines (2-7 times a week) were more
likely to have dieted or exercised to lose weight because of a magazine article.
The article presents a concise review of these devastating health problems and rightfully
suggests that the print media aimed at young girls could serve a public health role by
refraining from relying on models who are severely underweight and printing more articles
on the benefits of physical activity. As fervently as one might hope for the media to
"do the right thing," and deliver socially conscious and health conscious images
and messages to youth, media education offers a simpler and more effective response.
Inclusion of media education as a powerful tool for countering the negative, unattainable,
unhealthy images in fashion magazines would have given this valuable article more
relevance.
The goal of media education is to understand the meaning and intent behind the media
images and messages seen and heard, every day, everywhere. With this in mind, the American
Academy of Pediatrics over the past many months has embarked on an ambitious, exciting
campaign for national media education: Media Matters. Its goal is media-educated families,
including parents, children and adolescents, who limit the amount of media used, and
proactively, purposefully, choose positive or educational offerings when a program or
activity is desired.
The Academy of Pediatrics is developing a new policy statement and guide for parents that
will suggest ways families can promote media education in the home, including:
¨ recommending no television in a child's bedroom.
¨ prohibiting media use during meals.
¨ encouraging parents to be positive media role models, and
¨ encouraging children to pursue a variety of other activities during leisure time,
especially reading.
Critical thinking and critical viewing habits are integral components of media education.
Adults can use bothersome media portrayals for conversation and discussion. "Do you
think that Wiley Coyote could really jump up after being hit in the head with a
boulder?" "Why does a beer company use little frogs to encourage people to buy
and drink beer?" "Does this fashion model look healthy? Energetic? Why would a
clothing company use a model like this to sell clothing?"
Media-educated children and youth should understand that behind all media products are
potent political, social and economic forces. Children feel very powerful when they
understand that all media products are constructed-carefully created for a purpose-to
sell, to persuade, to manipulate, to create a feeling.
Pediatricians continue to be concerned about the public health risks posed by mass media
images and messages for children and adolescents. Scores of studies teach about the impact
of viewing violence in the media. The outcomes range from increased aggressive behavior,
to desensitization to violence, to fear about living in a "mean, scary, world."
It is also known, through experience and research, that the media may teach and model
unhealthy sexual behaviors and normalize and glamorize use of tobacco, alcohol, and
illicit drugs. Heavy viewers and users of media tend to have problems in school. Excessive
time spent with media limits the valuable time a child spends in active play, creative
pursuits, socializing with family and friends, and reading.
Rather than depending on the media industry to self-correct, pediatricians and parents
must embrace media education as the best and simplest solution to the public health risks
presented by the media. More information and ideas on implementing media education
activities in homes, offices, clinics, schools, and communities are available from the AAP
Division of Public Education. For details, contact Jennifer Stone at (800) 433-9016, ext.
7870, or e-mail jstone@aap.org.
Adapted from: AAP News 15(5): 2, May 1999.
CLIPSHEET FOR CONSUMERS: OVERCOME YOUR OBSTACLES TO EXERCISE
What is stopping you from being more physically active? Below are some of the
most common obstacles to getting in shape, along with some tried-and-true-and a few
new-tactics for getting over the hurdles.
The test of time
Perhaps the most common excuse not to exercise is that there is just no time. Even short
bouts of exercise-10 minutes here or there-can help you stay in good health. It is an
exceptionally busy person who can not find 10 minutes to take a quick walk at lunch time.
If you are busy, work exercise into your life through daily activities such as taking the
stairs, walking the dog, cleaning the house, carrying the groceries, and raking the yard.
Or, find a workout that is both enjoyable and convenient. Walking can be done with little
planning and no special equipment, except for a pair of comfortable shoes. Many gyms
promote a thirty minute workout that combines cardiovascular exercise with weight
training. Finally, put a little pep into your leisure time. Instead of watching a movie
with a companion, why not walk together? You will be able to talk and get some exercise at
the same time.
Battling boredom
There seems to be two kinds of exercisers. Those who like to have a set routine and those
who get bored easily. If you fall into the latter category, try building variety into your
workout. Plan a week's worth of different workouts and switch the days around the next
week. Or, join a class such as water aerobics, yoga or dance that meets two or three days
a week and fill in other days with walks, bike rides or weight training. Try taking
lessons for a sport you find interesting. Focusing on improving skills at golf or tennis
can make you forget you are exer-cising.
Waiting on the weather
The change of seasons can provide either an excuse to stop exercising or an opportunity to
try something new. One way to make the transition from one season to the next is by
exercising through gardening. In the spring, prepare the soil and plant seeds, tend your
garden in the summer, and harvest in the fall. You can also look at a local community
calendar to get seasonal exercise ideas. There may be a spring planting activity, a summer
litter pick-up, a fall apple-picking outing, and a winter caroling expedition. Overcome
your obstacles and make this your season to get fit!
Adapted from: American Institute for Cancer Research Newsletter 63, Spring 1999.
CLIPSHEET FOR CONSUMERS: HOW MUCH FIBER IS ENOUGH?
Most health organizations agree that adults should consume between 20 and 35
grams of dietary fiber each day. If, like many Americans, you have not been consuming
enough fiber, it is probably best to gradually increase your intake. This should eliminate
minor problems some people experience with a rapid increase in fiber intake, including
stomach and intestinal discomfort, and gas.
With a little planning, it is easy to reach your dietary fiber intake goal. The dietary
fiber content of packaged foods is listed on the Nutrition Facts Panel. By taking a minute
to read food labels, you can begin to make good dietary fiber choices. Adding a serving of
red kidney beans (half cup) to your chili adds 6.5 grams of fiber. A wheat bran-rich
cereal can provide as much as 15 grams of fiber per serving. If you do not enjoy
high-fiber choices, mixing a high-fiber cereal with a low-fiber cereal is one way to get
some of the benefits of both.
Source: Food Insight, March/April 1999.
BOOK REVIEWS:
THE COMPLETE GERMAN COMMISSION E MONOGRAPHS:
THERAPEUTIC GUIDE TO HERBAL MEDICINES
Assuming that "natural" remedies must be safe, 60 million Americans
spent $3.24 billion medicating themselves with herbals in 1996. Yet there are reports
within the last two decades of more than 100 herbiogenic deaths and dozens of serious
complications including those that required renal dialysis, renal transplantation, or
liver transplantation after taking botanicals. Dangerous herbs are less likely to be sold
in Germany, thanks to strict surveillance by the German Commission E, founded in 1978. Of
the 129 herbal drugs disapproved in Germany, the risky ones were immediately withdrawn,
while others deemed nontoxic without "plausible evidence of efficacy" will be
phased out by 2004.
This book documents how phytotherapy in Germany has become rational, responsible, and well
integrated with conventional medicine. Herbal medicines comprise 30 percent of all drugs
sold in German pharmacies. More than half of these botanicals are prescribed by physicians
and paid for by health insurance. By January 1996, 254 herbals had been approved. Two
thirds of Germans pooled in 1997 used these products, and of that group 72 percent had at
least some college education. Similar demographics and attitudes toward natural remedies
in the United States have prompted US physicians and pharmacists to anticipate this
English translation of 380 monographs as the Holy Grail of herbal medicine. Is it?
Certainly worth studying, the Commission E Monographs detail which herbs are approved or
disapproved, along with their uses, dosages, contraindications, adverse effects, drug
interactions, and pharmacologic actions. The therapeutic, taxonomic, and chemical indexes
are helpful, as is the glossary. The 62-page introduction surveys market trends,
regulatory issues, behind-the-scenes information gleaned directly from Commission E
members, and developments (or lack thereof) at the US Food and Drug Administration.
While the real Holy Grail was said to have disappeared because its keepers were impure,
the fact that 49 phytopharmaceutical companies sponsored preparation of this text does not
seem to have tainted its contents. Toxic side effects, however, are less extensively
documented here than in The Lawrence Review of Natural Products or Ellenhorn's Medical
Toxicology. Although some Commission E monographs state or imply that certain herbs can
kill us (yellow jessamine, tansy, saffron, rue, male fern, citronella, jimsonweed,
delphinium flower, berberine, and oleander), others omit mentioning the possible fatal
reactions to arnica, eucalyptus oil, nutmeg, ephedra, monkshood, squill, mistletoe, mate,
comfrey, senecio, and mayapple. Thus, no matter how this book excels, it is not the final
source. Many monographs are briefer than terse. All lack literature references, which
denudes their value as believable wisdom. Such opacity is perplexing when one reads, for
instance, that Echinacea pallida root is contraindicated in patients with HIV. No reason
is given, let alone a reference, for this counterintuitive statement. Also missing is
exactly which brands were tested-an important detail when a monograph warns readers, for
example, regarding Ginkgo biloba leaf extract, that the extrapolation of experimental
results to extracts other than those investigated might not be valid.
Fortunately, the US editors have corrected some deficiencies. When the monograph on ginger
root states that it should not be administered "for morning sickness during
pregnancy," the US editors add: "A review of clinical literature could not
justify this claim. There is no evidence that ginger causes harm to the mother or
fetus." Certainly, as medicine goes back into the future, physicians must re-study
Galenicals along with Goodman and Gilman. This didactic guide can serve as a useful foil
to the recent caveat emptor approach to botanicals in the United States. It might even
stimulate the Food and Drug Administration to emulate Commission E. But for now, it needs
to be added to the ready reference shelves of outpatient clinics, hospitals, and
pharmacies.
Source: Marty AT. Herbal medicines. JAMA 281(19): 1852-3, May 19, 1999.
THE PDR FOR HERBAL MEDICINES
Physicians have come to expect the Physicians' Desk Reference (PDR) to
provide all the information essential for intelligent and informed decision making. But
the PDR for Herbal Medicines does not meet such expectations. No brand-name particulars
are given, so that prescribers can evaluate crucial data about herbal efficacy, quality,
and safety. The text does cover generic information about more than 600 phytomedicines,
and its focus on Latin names gives it a scientific aura. But the latinophilia becomes a
nuisance when one tries to look up popular natural remedies by their common names. Cats
claw, dong quai, kudzo, and grape seed extract are not mentioned, nor are any
fixed-combination herbal products. Even Saint John's wort is hard to find because it
appears un-alphabetically, 45 pages beyond where "saint' should be (under
"St").
Physicians could also question why detailed discussions are given about 300-odd botanicals
that the German Commission E either disapproved of or ignored. The PDR for Herbal
Medicines actually prides itself on discussing not only "scientifically verified
applications but also uninvestigated folk uses with varying degrees of promise." How
poison hemlock (Conium maculatum) was used in folk medicine might interest some readers,
for example, but a book that also gives its imprimatur to hemlock by describing what the
daily dose "should" be runs the risk of becoming an encyclopedia of
misinterpretable messages.
The authors, however, view inclusion of such details differently. They see their text as
"the product of one of the most thorough and inclusive examinations of the herbal
literature ever undertaken." Perhaps they are not aware of the Lawrence Review of
Natural Products, a more comprehensive compendium that backs up its statements with
several specific reference citations. In comparison, the PDR's bibliographies are more
like ornamental displays: they do not really cite articles or clearly document the points
made. Furthermore, the PDR's publisher "does not guarantee that every possible
hazard, adverse effect, contraindication, precaution, or consequence of overdose is
included." This admonition is stated with good reason, because much more is known
about herbal toxicology than is provided here (1). The PDR's drug-herb interaction index,
for example, only lists two herbs that interact with warfarin. Yet, as least 11 such herbs
are known to so interact, and still other botanicals either contain coumarin constituents,
inhibit platelet aggregation, or exhibit hemolytic activity (2, 3).
This PDR, to be sure, does have many positive features. It contains a superb
identification guide with clearly labeled, full-color photographs of 380 medicinal plants.
Seventy different botanicals that have caused fatalities in humans are detailed, along
with their lethal doses. And appropriate caution is also expressed about 27 other possibly
lethal botanicals. Perhaps best of all, this book challenges currently held rubrics about
single-molecule drugs and ultraspecific receptors. Garlic, for example, is here said to
help not just one but 15 different conditions. Such "indication pluralism"
tweaks the reader by contradicting conventional ideas about how drugs work. In the absence
of a data-driven editorial perspective, however, use of herbal medicine, as outlined here,
lacks credibility. More research and perhaps more regulation of phytomedicinals are
needed.
References: 1. Miller LG, Murray WJ, editors. Herbal Medicinals: A Clinician's Guide. New
York, NY: Pharmaceutical Products Press; 1998.
2. Miler LG. Herbal medicinals: Selected clinical considerations focusing on known or
potential drug-herb interactions. Arch Intern Med 158: 2200-11, May 19, 1999.
3. Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health Care
Professionals. London, England: The Pharmaceutical Press; 1996: 21, 45, 63, 282.
Source: Marty AT. Herbal medicines. JAMA 281(19): 1853-4, May 19, 1999.
RESOURCE: HERB-RELATED ORGANIZATIONS AND TRADE ASSOCIATIONS
American Botanical Council PO Box 144345, Austin, Texas 78714-4345; (512)
926-4900; www.herbalgram.org
American Herb Association PO Box 1673, Nevada City, CA 95959; (530) 265-9552
American Herbal Pharmacopoeia PO Box 5159, Santa Cruz, CA 95063; (831) 461-6317;
www.herbal-ahp.org
American Herbalists Guild (for professional herbalists) PO Box 70, Roosevelt, UT 84066;
(435) 722-8434; www.healthy.net/herbalists
Herb Research Foundation 1007 Pearl Street, Suite 200, Boulder, CO 80302; (303) 449-2265;
www.herbs.org
Herb Society of America 9019 Kirtland Chardon Rd., Mentor, OH 44094; (440) 256-0514;
www.herbsociety.org
US Pharmocopeia 5645 Fishers Lane, Rockville, MD 20852; (301) 881-0666; www.usp.org
Trade Asssociations:
American Herbal Products Association 8484 Georgia Ave. # 370, Silver Spring, MD 20901;
(301) 588-1171; www.ahpa.org
International Herb Association PO Box 206, Mechanicsburg, PA 17055; (717) 697-1500;
www.herb-pros.com/index.html
The Herb Growing and Marketing Network PO Box 245, Silver Spring, PA 17575; (717)
393-3295; www.herbnet.com
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