April 2002

• Hepatitis A Vaccine is Safe and Effective for Children
• New Guidelines for Rheumatoid Arthritis Treatment
• New Diabetes Guidelines from the ADA
• New Cancer Prevention Guidelines

Hepatitis A Vaccine is Safe and Effective for Children

Hepatits A is a virus transmitted by contaminated food and is a common cause of inflammation of the liver (hepatitis). This illness may be associated with fever, yellowing of the skin and eyes (jaundice), loss of appetite, nausea, vomiting, and tiredness. In many parts of the world, hepatitis A is so common that almost every adult has been infected at some point in his or her life. A vaccine to protect against hepatitis A infection was licensed in the United States by the Food and Drug Administration in 1995 for individuals 2–12 years of age.

A recent study published in the Journal of the American Medical Association showed that the hepatitis A vaccine was highly effective in preventing hepatitis A outbreaks among a large group of children who received it. The study also found the vaccine to be quite safe. Out of the nearly 30,000 children who received the vaccine, no serious side effects were reported. Mild adverse reactions were reported in a small percentage of cases, including injection site reactions, fever, and rash.

Should your child be immunized? In the United States, there actually are certain areas of the country with higher than average rates of hepatitis A. Speak with your child's pediatrician because the hepatitis A vaccine is currently recommended for:

• Children living in areas with consistently higher rates of hepatitis A. This includes 11 states where the prevalence of hepatitis A is greater than twice the national average: Alaska, Arizona, California, Idaho, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, and Washington. (Routine vaccination can also be considered in six states where the prevalence of the disease is less than double but greater than the national average: Arkansas, Colorado, Texas, Missouri, Montana, and Wyoming.)
• Children traveling to countries where the disease is highly prevalent. This includes all countries other than Canada, Japan, Australia, New Zealand, Scandinavia, and those in Western Europe.
• Children with chronic liver disease or blood-clotting disorders.

April 2002 Update

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New Guidelines for Rheumatoid Arthritis Treatment

Rheumatoid arthritis (RA) is a chronic autoimmune disease affecting more than 2 million people in the United States. It causes pain, stiffness, and swelling in the joints, as well as inflammation in organs. Guidelines for the management of the disease were first created in 1996, but significant developments since then prompted the American College of Rheumatology to publish an updated version in the February 2002 issue of its journal, Arthritis & Rheumatism.

A key addition to the new guidelines is the emphasis on early diagnosis and treatment. Recent studies have confirmed that if RA is treated early and aggressively, the course can be altered and the onset of joint destruction can be delayed. The report advises patients to consider nonsteroidal antiinflammatory drugs (aspirin, ibuprofen), glucocorticoid injections, or prednisone to control symptoms once diagnosed. But the new guidelines recommend most people begin treatment with the more potent disease-modifying antirheumatic drugs (DMARDs) within three months of diagnosis. If prognosis is poor, however, DMARDs should be initiated as soon as the diagnosis is confirmed.

The guidelines give information on the efficacy, potential side effects, cost, and administration methods of several new drugs being used in the treatment of RA. These new therapies include three genetically engineered biologic response modifiers (entanercept, infliximab, and anakinra) which target chemicals that cause inflammation. The use of entanercept and infliximab, which work by blocking important inflammation messenger proteins, represent a major advancement in RA treatment. Also presented is a new DMARD, Leflunomide, which slows the structural damage brought on by RA. The guidelines recommend using the aggressive drugs in combination — for example, a biological agent plus a DMARD or two DMARDs.

These new therapeutic options are already being used in the treatment of RA. But for physicians who treat the disorder, the primary value of the new guidelines is the parameters they set for RA therapy and medications.
April 2002 Update

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New Diabetes Guidelines from the ADA

In the January 2002 supplemental issue of Diabetes Care, the American Diabetes Association (ADA) released a compilation of all its position statements on diabetes care, including three new ones. It includes the first update of the ADA's nutrition guidelines since 1994.

One of the reports, Evidence-Based Nutrition Principles for the Treatment and Prevention of Diabetes, outlines changes as to how diabetics should approach carbohydrate intake, giving them more dietary freedom. Previously, diabetics were advised to avoid eating simple sugars and fast-acting carbohydrates like table sugar because these were believed to be more rapidly absorbed than complex starches found in such foods as potatoes, thus aggravating hyperglycemia. But there is little scientific evidence to support this theory. In fact, the simple sugar sucrose is no worse for a diabetic than starch, so the ADA now recommends simply using the carbohydrate terms sugar, starch, and fiber instead.

The new guidelines also advise that it's more important for people with diabetes to monitor and adjust their insulin requirements according to the total amount of carbohydrates in food rather than the source or type. They therefore dismiss the practical value of the glycemic index, which calculates how quickly the carbohydrate content of a person's overall diet raises blood sugar levels. Nevertheless, some carbohydrate sources are healthier than others, so the ADA recommends diabetics get their carbohydrates from whole grains, fruits, and vegetables because they are also rich in fiber, vitamins, and minerals.

Diets rich in carbohydrates and low in fats used to be recommended for all patients with diabetes but this has changed since the discovery that diets rich in monounsaturated fatty acids lead to improvements in HDL ("good") cholesterol levels, triglyceride levels, and overall diabetes control.

The use of fructose as an added sweetener is not recommended, but natural fructose in fruits and other sweeteners like saccharin and aspartame appear to be safe. The guidelines address many other important nutrition issues, but specifically they recommend that diabetics get 60%–70% of their caloric intake from carbohydrates and monounstaturated fats, 15%–20% from protein, and less than 10% from saturated fats. Overall, these new options afford diabetics more choices in their diets-choices that will provide a diet more people can adhere to.

Another of the reports, Treatment of Hypertension in Adults with Diabetes, addresses hypertension, which occurs in up to 60% of diabetics and substantially increases the risk of vascular problems, such as coronary heart disease and other serious complications. The most recent evidence supports the use of aggressive hypertension treatment to avoid these complications. The ADA recommends people with diabetes aim for a blood pressure (BP) of less than 130/80 mm Hg. If a diabetic's BP is 130–139/80–89, the report suggests adopting behavioral changes such as reducing salt intake, losing weight, and becoming more physically active. However, if his or her BP is greater than 140/90, drug treatment should be started. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), diuretics, and beta blockers are recommended as first-line treatments. In many cases, patients will need three or more drugs to control their BP.

The third report, Standards of Medical Care for Patients with Diabetes Mellitus, is a comprehensive guide intended to provide an overview of the components of diabetes care, treatment goals, and tools to evaluate the quality of care. It also goes over strategies for successful guideline implementation. For instance, successful programs give patients access to nurses for case management services, diabetes educators, and group visits.

For the complete reports, go to http://care.diabetesjournals.org/content/vol25/suppl_1/.
April 2002 Update

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New Cancer Prevention Guidelines

While some risk factors for developing cancer, such as family history, can not be changed, there are ways for people to reduce their chances. The American Cancer Society (ACS) recently released new dietary and physical activity guidelines for cancer prevention.

One of the most basic tenets of a healthy diet is eating plenty of fruits and vegetables. The ACS recommends eating no less than 5 servings of a variety of fruits and vegetables every day. Many people have heard of antioxidants but aren't sure exactly what they are or what they do. Antioxidant nutrients (such as vitamin C, vitamin E, and carotenoids) protect the body against the tissue damage that occurs as a result of normal metabolism. Because such damage is associated with increased cancer risk, the antioxidant nutrients are thought to protect against cancer. Studies suggest that people who eat more vegetables and fruits, which are rich sources of these antioxidants, have a lower risk for some types of cancer, but studies of antioxidant supplements have not yet shown a reduction in cancer risk.

Choosing whole grains over processed (refined) grains and sugars will also help, so stick to whole grain rice, bread, pasta, and cereals. Also, limit your red meat intake. When you do eat it, choose the way you cook it carefully. While adequate cooking is necessary to kill harmful microorganisms in meat, some research suggests that frying, broiling, or grilling it at very high temperatures creates chemicals that might increase cancer risk. Braising, steaming, and poaching meats cuts down on the production of these chemicals.

Drinking too much alcohol is an established cause of cancers of the mouth, throat, liver, and breast. Therefore, the ACS recommends limiting alcoholic consumption to 2 drinks per day for men and 1 drink per day for women.

The ACS also reminds people to remember that "low fat" or "fat free" snacks like cakes and cookies are often high in calories. High sugar intake can lead to obesity and elevated insulin levels, conditions that increase cancer risk.

Physical activity is also an important component in the prevention of cancer. Adults should engage in moderate-to-vigorous activity (walking, leisurely bicycling, running, swimming) for 30 minutes or more at least 5 days a week.

Simple additions to your daily routine such as taking the stairs instead of the elevator, taking 10-minute exercise breaks at work, and walking to visit co-workers instead of emailing them are simple ways to increase your activity level.

An unhealthy diet and lack of exercise can lead to weight gain and obesity, conditions that are associated with developing cancers of the breast, colon, endometrium, esophagus, gallbladder, pancreas, and kidney.

In addition to the general guidelines set forth by the ACS, there are also answers to frequently asked questions about the rumored or theoretical relationships between cancer and such substances as aspartame, beta-carotene, calcium, coffee, fish oils, fluorides, folic acid, saccharin, and tea.

The ACS suggests that public, private, and community organizations create environments that support the adoption and maintenance of these healthful eating and physical activity behaviors. People should have access to healthful foods in schools, at work sites, and when on daily outings in their town or city.

For a copy of the complete set of guidelines, call the American Cancer Society at 1-800-ACS-2345.
April 2002 Update

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