Taking Charge of Your Health - Health Updates

News on blood pressure drugs

Published: September, 2003

Behind the scenes at your doctor's office debate continues about which drug should be the first line of treatment for high blood pressure. Diuretics (also known as water pills) have been around for decades, but the makers of newer, more specialized — and more costly — drugs have been wooing physicians and their patients. The question isn't whether these drugs work effectively to lower blood pressure; they do. But evidence indicating which is best at reducing heart disease and other cardiovascular events has been missing — until now.

The ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) study was designed to compare a diuretic to three other commonly prescribed classes of antihypertensive drugs — calcium channel blockers (CCBs), alpha-adrenergic blockers, and angiotensin-converting enzyme (ACE) inhibitors. The study involved 42,000 patients over the age of 55 with hypertension and one other risk factor for heart disease, such as previous heart attack or stroke. Each of the patients was randomly assigned to receive one of the study drugs for four to eight years. Researchers monitored the patients' blood pressures and recorded evidence of heart disease and cardiovascular events.

Part of the study was halted early when evidence showed patients taking the alpha-adrenergic blocker had higher rates of cardiovascular disease and heart failure than patients taking the diuretic.

The primary results of the comparison of the ACE inhibitor lisinopril and the CCB amlodipine to the diuretic chlorthalidone were striking. The occurrence of death from heart disease was the same across each of the groups, and the rate of nonfatal heart attack was also similar. However, a slightly higher percentage of patients taking the diuretic chlorthalidone achieved better blood pressure control. Chlorthalidone was also better at preventing heart failure than amlodipine, the CCB. Patients taking the ACE inhibitor lisinopril had a higher risk of stroke, angina, and heart failure. In particular, black participants who took lisinopril had a 40% higher risk of stroke than black participants who took the diuretic.

The findings of the ALLHAT study indicate that when it comes to drugs for high blood pressure, newer and more costly does not mean better. In fact, diuretics should be the first line of treatment for many people with high blood pressure. Not only are they better at controlling high blood pressure while preventing major cardiovascular events, diuretics also cost less than the other drugs. A one-year supply of Chlorthalidone costs about $96, while the CCB amlodipine would set you back $480. Lisinopril costs $384 a year for the brand name drug (either Zestril or Prinovil), and $240 for the generic.

What should you do with these study results? If you're just starting drug treatment for high blood pressure, you might want to try a diuretic first. If you, like most people, need a combination of drugs to keep your blood pressure in check, one should probably be a diuretic. If you're already taking a different kind of medicine and it is working well for you, there's no need to switch. However, if you want to cut down your drug bills, you might want to talk to your doctor about a diuretic.

(Journal of the American Medical Association, December 18, 2002)

February 2003 Update

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Killer snow

Every winter, about 1,200 Americans die from a heart attack or some other cardiac event during or after a big snowstorm, and shoveling is often the precipitating event.

Why is shoveling so hazardous?

  • Shoveling uses your shoulders and arms, and upper body exercise tends to put strain on the heart because those muscles aren't well conditioned.
  • Working in an upright position adds to the arduousness because blood pools in the legs and feet, so to maintain blood pressure, your heart must work harder.
  • Much of snow shoveling is isometric exercise: your muscles are working, but there's little actual movement until you finally heave a shovelful up on the bank. During isometric exercise of any type, your heart rate goes up, and your blood vessels constrict, presumably to send more blood to the straining muscles. As a result, your blood pressure goes up.
  • Without knowing it, shovelers sometimes perform a version of the Valsalva maneuver, bearing down as they would during a bowel movement while holding their breath. Waiting to exhale while straining like that can lead to abrupt changes in your heartbeat and blood pressure.
  • First thing in the morning, the time when many people dig out from a storm, stress hormone levels tend to be higher, platelets in the blood "stickier," and heart attacks more likely.
  • Shoveling involves exposure to the cold, another cardiac stressor.
  • People who are out of shape often shovel, making the sudden intense exercise even harder on the heart.
  • Most people don't warm up before they shovel or cool down afterward.

If you have a heart condition, you shouldn't shovel under any circumstances. People older than 50 should also try to avoid it. Contact your local council on aging to see if they provide a list of teens in your neighborhood who you can hire to do the job for you. Or buy a snow blower. If you must shovel, take it easy. Rest often. Dress warmly and stay well hydrated. Wherever possible, push the snow rather than lift it. Clear only the snow that blocks your path into the house, the rest will melt on its own. And of course, listen to your body. Head home if you experience potential signs of heart trouble, including chest pain, palpitations, undue shortness of breath, fatigue, lightheadedness, or nausea. Also stop if your fingers or toes get numb or hurt — you could have frostbite.

January 2003 Update

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Medications for postmenopausal osteoporosis prevention

Risk of osteoporosis increases after menopause, when levels of estrogen — which helps preserve bone density — drop. Until recently, most doctors recommended long-term hormone replacement therapy (HRT) to treat postmenopausal women who need medication to prevent bone loss. But things changed after results from a large trial on a common HRT drug showed that estrogen plus progestin (as the medication Prempro) did more harm than good. An increased risk for breast cancer and cardiovascular events outweighed the benefits of less colorectal cancer and fewer fractures. (See the Update from July 2002 for more information on the trial.)

Health experts now encourage most women who have been taking long-term HRT for osteoporosis prevention to consider an alternative. Fortunately there are several options. Each of the FDA-approved treatments (see chart) has potential benefits and risks that women and their doctors should weigh before making a decision. Even with HRT's proven risks, it may still be a good choice for certain women — especially in lower doses, which recent data have shown to have bone benefits comparable to higher, standard doses.

Approved medications for osteoporosis prevention


How to take it

Bone benefits

Side effects


Alendronate (Fosamax)

Orally, once daily in the morning or as a larger dose once a week; take with 6–8 ounces of water and stay upright for 30 minutes.

Increases bone density at the spine and hip; reduces spinal and hip fracture risk. Side effects uncommon.

Heartburn, nausea, inflammation of the esophagus, muscle pain.

Interferes with cells that break down bone. Well-tolerated when taken properly.

Risedronate (Actonel)

Orally, once daily in the morning or as a larger dose once a week; take with 6–8 ounces of water and stay upright for 30 minutes.

Increases bone density at the spine and hip; reduces spinal and hip fracture risk. Side effects uncommon.

Abdominal pain, nausea, constipation, joint pain.

Interferes with cells that break down bone. Well-tolerated when taken properly.

Raloxifene (Evista)

Orally, once daily, any time.

Increases bone density (but less so than alendronate or risedronate); reduces spinal fracture risk. Side effects uncommon.

Hot flashes, leg cramps, deep-vein blood clots.

Acts like estrogen in bone but is an anti-estrogen in breast tissue; may reduce breast cancer risk.

Estrogen (Premarin, Estrace, other brands)

Orally, once daily, any time; or weekly by skin patch.

Increases bone density; some evidence for fracture reduction.

Increases the risk for breast cancer (after 4–5 years) and cardiovascular events when combined with a progestin (as Prempro) and taken orally.

May be recommended if other medications are not tolerable or menopausal symptoms persist.

Sources: Boosting Bone Strength: A Guide to Preventing and Treating Osteoporosis, Harvard Health Publishing, Boston, 2000; Managing Osteoporosis, Part 3: Prevention and Treatment of Postmenopausal Osteoporosis, American Medical Association, 2000; Osteoporosis: Guide to Prevention, Diagnosis, and Treatment, Brigham and Women's Hospital, Boston, 2002

December 2002 Update

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Living independently — and safely — in your later years

The majority of older people remain independent well into later life. Most seniors want to remain in their own homes, a goal that's easier to accomplish if they adapt their lives and homes to accommodate their aging bodies. Some tips for independent living include:

Redecorate. The average home is riddled with obstacles that older eyes and feet might not be able to maneuver around. Removing slippery throw rugs, using night lights, putting nonskid mats in the bathroom and kitchen, not using high-gloss floor polishes, and installing handrails that extend beyond the bottom stair can all help. You can often fit your bathrooms with items like walk-in showers, grab bars, and higher toilet seats. Ramps, elevators, and other devices can help you handle stairs. Keep often-needed items in the handiest cabinets and use a grasping tool to get things that are out of reach instead of climbing on a chair or ladder.

Lifestyle changes. Wearing rubber-soled shoes and getting regular exercise can help keep you upright. Activities like tai chi or yoga especially help since they work on balance and strength, and are not jarring on muscles or bones. Limit your alcohol intake and learn whether any of your medications might cause dizziness or affect your balance.

Seek helping hands. Shopping for groceries and other essentials can be accomplished over the phone and via the Internet these days. Meal preparation, transportation, home repair, housecleaning, and help with financial or personal tasks such as paying bills and bathing might be hired out if you can afford it, shared among friends and family, or included in the repertoire of elder services offered in your community or through insurance.

Plan for emergencies. Who can check in on you regularly? Whom can you call in an emergency? What would happen if you fell and couldn't reach the phone? Keep emergency numbers near each phone or, better still, on speed dial. Carry a cell phone or consider investing in a personal alarm system, if necessary. Look into companionship services or simple visits and phone checks from a local agency on aging or religious group. To find agencies near you, call the Eldercare Locator at 1-800-677-1116 or visit their web site at www.aoa.dhhs.gov/elderpage/locator.html.

October 2002 Update

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Physical activity benefits all ages

The frail health often associated with aging is in large part due to physical inactivity, according to a report released by the U.S. Department of Health and Human Services (HHS). It also advises that it's never too late to benefit from becoming physically active.

The report cites that even moderate levels of activity — such as washing a car or raking leaves — can produce considerable benefits that can be even more noticeable in older adults. Regular exercise improves cholesterol levels, reduces blood pressure, cuts body fat, and lowers blood sugar. Physical activity also improves bone and muscle strength. All in all, people who exercise live longer — and they also live better.

Current guidelines recommend at least 30 minutes of moderate physical activity a day. However, few older Americans reach this level. Lack of physical activity and poor diets are the major causes of obesity, an epidemic that is affecting people of all ages.

In the '70s and '80s, doctors were telling Americans to run; now, they are asking people to walk. Walking can be a moderately intense aerobic activity. But even at a more relaxed pace, walking has huge benefits. The distance actually seems more important than the pace — and it doesn't take heroic distances to get real benefit. In 1993, the Harvard Alumni study found that men who walked just 1.3 miles a day had a 22% lower death rate than those who walked less than 0.3 mile a day.

Strong muscles also improve your health. So set aside 15 minutes two or three times a week for resistance or strength training as well as 10–15 minutes at least three times a week for stretching exercises.

The HHS report provides strategies that individuals, doctors, and even communities can follow to promote physical activity. Individuals are encouraged to take part in activities that they enjoy and to make them a daily part of life. Doctors should help patients start and continue these regimens and overcome any difficulties they encounter. Communities can establish programs tailored to seniors' physical activity needs and improve walking or bike trails.

The complete report is available at www.ahrq.gov/ppip/activity.htm

August 2002 Update

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How to apply sunscreen for maximum protection

Most families follow common medical advice and take along a bottle of sunscreen when they're spending a day in the sun. But how do you know if you're applying enough? Most people don't, but a letter published in the June 22, 2002, issue of the British Medical Journal may help clarify the amount of sunscreen you should use and how often you should apply it.

The letter, written by Drs. Steve Taylor and Brian Diffey, suggests people follow the "rule of nines" to get the sun protection factor (SPF) that's listed on the bottle. According to the rule, you should divide your body into 11 different sections, each making up about 9% of your total surface area:

  • Head, neck, and face
  • Left arm
  • Right arm
  • Upper back
  • Lower back
  • Upper front torso
  • Lower front torso
  • Left upper leg and thigh
  • Right upper leg and thigh
  • Left lower leg and foot
  • Right lower leg and foot

For sufficient protection, use a two-finger approach: cover each of the 11 sections with enough sunscreen to span the length of your pointer and middle fingers.

The authors admit that this is more sunscreen than most people feel comfortable wearing, so they suggest that people put on half that amount at one time, and then apply another dose a half hour later. Studies have shown that sunscreen users do not apply enough sunscreen to protect the whole body. As a result, the actual SPF is close to half that on the product label.

It's also worth noting that according to the American Academy of Dermatologists, staying out of the sun is the best way to prevent skin cancer. Because harmful sun rays like UVA and infrared get through sunscreen, you shouldn't think of it as a shield against the sun or use it as an excuse to stay out longer. Although sunscreen is an important part of sun protection, it is second to wearing a shirt and hat and avoiding sun exposure altogether (especially between the hours of 10 a.m. and 4 p.m.).

August 2002 Update

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No link found between prostate cancer and vasectomy

Good news for the millions of men worldwide who've had vasectomies: a new study disputes a link between this birth-control operation and prostate cancer. Two 1990 studies that connected prostate cancer and vasectomies caused men to question the procedure, even though no medical explanation for the connection could be found. Other research has both confirmed and denied the association in the past 10 years.

But the new study, published in the June 19, 2002, Journal of the American Medical Association, should ease men's minds. It involved over 2,000 men of European descent living in New Zealand, the country with the highest rate of vasectomies.

Researchers asked 953 men with prostate cancer and 1,260 who were cancer free about their medical histories — including whether they had had a vasectomy. It turned out that slightly fewer men with prostate cancer had undergone the surgery, which supports claims that going under the knife doesn't cause cancer. The same held true for the 38% of men studied who had had the procedure more than 25 years ago, which suggests that there are no long-term effects.

One reason why the link may have been found in earlier studies is that men who have vasectomies generally see their urologists more often, which may lead to more tumors being found in these men as compared to others, the researchers said. The study also found no link between prostate cancer and history of sexually transmitted disease, smoking, drinking alcohol, and number of children.

Prostate cancer will be diagnosed in 198,000 Americans this year, and it will take 31,500 lives. Although prostate cancer lags behind heart attacks, strokes, and lung cancer as the leading cause of death in American men, it's the disease many men fear most.

August 2002 Update

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New Developments in Hormone Replacement Therapy

In July 2002, the government halted a major study of hormone therapy three years early because of a slight but significant increase in the risk of invasive breast cancer. Researchers concluded that the long-term risks of taking hormones outweigh the benefits for a woman who still has her uterus.

More than 16,000 women took part in the study, known as the Women's Health Initiative, the largest to compare postmenopausal hormones with a placebo. The therapy was a combination of estrogen and progestin (Prempro), a treatment used by an estimated six million women to replace the declining levels of hormones at menopause.

The study sought to determine whether this combination hormone therapy could prevent such ailments as osteoporosis and heart disease. But while there were small decreases in hip fractures and colorectal cancer, the increases in breast cancer, heart attacks, strokes, and blood clots were too unsettling.

The data suggested that for every 10,000 women on the estrogen-progestin combination, an additional 8 will develop invasive breast cancer, when compared with women not taking the therapy. An additional 7 will have cardiovascular disease, 8 will have a stroke, and 8 will have blood clots in the lungs (pulmonary embolism).

In the aftermath of the trial, it seems that many doctors will be reconsidering prescribing estrogen and progestin. Some women may want to lower their doses or limit the duration of the use of these combinations, while others will elect to try other treatments to combat their hot flashes, vaginal dryness, and other menopausal symptoms.

However, it is important for women already on hormone replacement therapy (HRT) to know that there is no urgency to stop, and waiting until an annual exam to discuss it with a doctor is fine. There is also no harm in stopping immediately, if a woman is more comfortable doing so.

It's important to remember that only combination therapy appears to have these effects. Estrogen alone taken by women who have had a hysterectomy has not displayed such risks. A separate trial, with 10,000 women who have had a hysterectomy randomly assigned to either estrogen or a placebo, has not indicated an increased breast cancer risk. The trial is scheduled to go until 2005.

The full report on the Women's Health Initiative appeared in the Journal of the American Medical Association on July 17, 2002.

July 2002 Update

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Drinking Tea Benefits Heart and Bones

The health benefits of drinking tea have been well publicized lately, and recent studies point to two newly discovered advantages to consuming this beverage. One shows that drinking tea can help prevent death after a heart attack. The other reports that tea may increase bone mineral density, which helps prevent fractures and osteoporosis.

In the first study, published in Circulation, researchers questioned 1,900 patients hospitalized for heart attacks about the amount of caffeinated tea they drank in the past year. After adjusting for age, gender, and other variables, researchers found that those who drank 14 or more cups of tea per week were 39% less likely to die of cardiovascular disease in the 3.8 years following their heart attack than non-tea drinkers. Patients who consumed 1–14 cups of tea per week were 31% less likely to die from cardiovascular causes during that period than non-tea drinkers.

When researchers further looked into subjects' caffeine intake, they found that caffeine from sources other than tea did not affect death rates.

In the second study, published in the Archives of Internal Medicine, researchers surveyed 1,037 men and women age 30 and older about their tea consumption. Subjects who drank tea at least once a week for the preceding six months were labeled "habitual tea drinkers." This group was asked about their tea-drinking history, the kind of tea they drank, how often they drank it, and how much they drank in each sitting.

Researchers then measured the bone mineral density (BMD) of the lumbar spine, hip, neck, and total body of both the habitual tea drinkers and the non-drinkers.

The researchers found that people who consumed tea regularly for more than 10 years had the highest BMD scores compared to the other groups, after they adjusted for sex, age, weight, and lifestyle variables that may affect BMD. Those who drank tea regularly for the past 6–10 years also had significantly higher lumbar spine BMDs than the nonhabitual tea drinkers. People who consistently drank tea for the past 1–5 years did not have any significant differences in BMD score compared to the nonhabitual drinkers.

It didn't seem to matter what type of tea the person drank, and neither did the amount of tea consumed each time. Only duration of habitual tea consumption was an independent predictor of BMD score. Tea contains several components, including fluoride and flavonoids, which may work separately or in concert to maintain or restore bone density.

Although BMD score is often a good gauge of the risk of fracture from osteoporosis, this study did not actually test the link between tea consumption and bone fracture.

July 2002 Update

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Aspirin and heart disease

Should you take aspirin to prevent a heart attack? According to a new study, aspirin helps lower cardiovascular risk, but whether or not you should take it depends on a bevy of factors.

The study, published in the May 9, 2002, issue of the New England Journal of Medicine, analyzes the major trials on the subject. Four out of five of the randomized trials show a reduction in cardiovascular events (especially heart attacks) with aspirin use. (In randomized trials, researchers randomly assign patients to one of the treatments being tested.) But the studies' statistics vary wildly. For example, risk reduction ranged from 4%–44%, depending on the study. All but one trial showed that aspirin use increased the risk of bleeding, most commonly in the stomach.

Two large observational studies also showed that aspirin use decreased coronary events in both people with and without heart disease. (In observational studies, researchers simply monitor subjects' behaviors and health, they do not test a specific treatment on them.) Subjects' ages had an impact in both studies, with aspirin's benefit on the heart kicking in when subjects hit 50 years old in one, 60 years old in the other. Other trials have found that aspirin has the greatest effect on patients with high risk for heart disease.

So what should you do? That depends a lot on your heart disease risk. To calculate your risk go to this downloadable scoring system on the National Institutes of Health Web site.

Then, if you answer yes to any of these questions, talk to your doctor about starting aspirin therapy:

  • Is your risk for heart disease 1.5% or higher per year?
  • Is your risk between 0.7% and 1.4% per year? If so, and you answer yes to one or more of the following questions, ask your doctor about treatment:
    • Are you in poor physical shape?
    • Do you have diabetes or high blood pressure and damage to your organs?
    • Do you strongly want to start aspirin therapy?

But if your risk is 0.6% or lower per year, you're probably not a good candidate for aspirin therapy. You should also avoid the therapy if you're allergic to aspirin, prone to bleeding, or suffer from platelet disorders or ulcers. Your own preference is another important factor in making this decision.

Keep in mind that if you have high blood pressure, you'll need to take extra care to control it in order to get the most benefits from aspirin. Also, besides stomach bleeding, aspirin use may cause hemorrhagic stroke.

July 2002 Update

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Healthy Diet Eradicates Need for Trendy Supplements in Elderly

Magazine ads and television commercials tout dietary supplements that claim to be a veritable fountain of youth for seniors. Images of grandparents able to keep up with their grandkids convince older adults that shakes, energy bars, and special vitamins will help boost energy and decrease signs of aging.

Health experts, however, stress that a well-balanced diet rich in fruit and vegetables is just as effective and probably safer. But many older adults skip meals and eat small amounts of fruits and vegetables, citing reasons ranging from rotten teeth to unhappiness with eating alone.

While doctors acknowledge that nutritional shakes and energy bars are helpful for seniors who need to gain weight or have trouble chewing or swallowing, those who eat a balanced diet or stay active do not need them.

In spite of what the experts have said, the savvy advertisements are convincing millions of seniors that they need these expensive supplements, some of which have not even been proven safe.

Herbs are also a source of concern. Saw palmetto, an extracts made from the fruit of the saw palmetto plant, is promoted as a treatment for an enlarged prostate. Many people believe that herbs are natural and therefore safe but this is not the case. In fact, as with most nonprescription herbal products, the composition of the extract and the dosage have not been standardized and the supplement is not regulated by the FDA. If you decide to use saw palmetto, tell your doctor in order to alert him or her to possible interactions between it and other medications you may be taking.

People who are on strict diets — like those prescribed for kidney disease, heart disease, or diabetes — must be especially wary of adding any special supplements to their diet. Regardless of whether health problems are present, you should always consult a physician before starting any dietary regimen.

May 2002 Update

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Fish for Good Health

In April, three studies delivered powerful evidence that fish is good for you — and could even save your life. The key is omega-3 (or n-3) fatty acids, beneficial polyunsaturated fats provided by many kinds of fish and certain plant foods.

Researchers in the Nurses' Health Study examined 16 years of data involving almost 85,000 women and found an association between fish intake and a lower risk for heart disease and death. Women who ate fish just once a week had a heart attack risk 29% lower than those who ate it less than once a month. Women who ate fish five times a week had nearly half the risk of death from a heart attack.

The Harvard's Physicians' Health Study, which involves more than 22,000 male doctors who initially had no heart disease, analyzed blood levels of omega-3 fatty acids and risk for sudden cardiac death. Researchers found that such deaths were 81% less likely in men with the highest levels of omega-3s. Over half of such deaths occur in people without prior symptoms of heart disease — a compelling reason for adding more fish to your diet.

Finally, Italian researchers reported that heart attack survivors who took fish-oil supplements had a lower risk of sudden death. This trial studied omega-3 fatty acids and vitamin E in 11,000 men and women who had recently suffered heart attacks. Researchers found that 1 gram of omega-3 fatty acids daily reduced the risk for sudden coronary death by up to 42%. This benefit apparently reflects their calming effect on arrhythmias, potentially fatal heartbeat irregularities. Omega-3 fatty acids may also inhibit clotting and improve blood vessel function. The American Heart Association recommends four servings of fish per week but doesn't endorse supplements because of too few data on the subject.

May 2002 Update

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Asthma Education Leads to Improvement in Children

Managing your child's asthma should include meeting with an asthma educator a few times, according to a follow-up study. Presented at the meeting of the American Academy of Allergy, Asthma, and Immunology, the study reports that after attending an interactive training program three times patients felt less worried about their asthma and had fewer asthma-induced awakenings during the night. Both patients and their caregivers, who also took part in the program, made better decisions about asthma care.

The 30 subjects, asthmatic children ages 6–12, underwent ACE IT! (Asthma Care Education: Intensive Training), an interactive, small-group education program. The sessions included a motivational talk by a teenage athlete with asthma and a pharmacist's discussion of medications. A nurse and asthma specialist also taught the participants about the clinical nature of asthma, environmental controls, relaxation techniques, and asthma action plans.

Researchers evaluated the children at the beginning and end of the training, after six months, and again a year later. After the courses, the number of patients reporting two or more nocturnal awakenings per month dropped from 9 to 5, and the number of symptom-free days also improved, from an average of 20 days per month to over 25 days per month.
The patients were more willing to use the tools available to them, such as medications and peak flow meters, devises that asthmatics breath into to help detect airway changes. They also worked harder to avoid things that triggered their asthma, such as pets or dust.

The researchers plan to continue tracking these 30 children to study the long-term effects on quality of life, morbidity, and cost of treatment. A previous study published in the Journal of Allergy and Clinical Immunology in 2000, found that the training program was much more effective than simply handing out educational materials.

May 2002 Update

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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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Home visitation program improve seniors' lives

Though many countries have nationalized home visitation programs for the elderly, controversy exists over whether they actually help improve the quality of participants' lives. A group of researchers recently analyzed much of the published data to try to put the subject to rest, and the news is favorable. The meta-analysis, published in the Feb. 27, 2002, issue of the Journal of American Medical Association (JAMA), focused on 18 trials that included over 13,000 participants.

As part of each program studied, elderly people received visits from health care workers who tried to help them prevent functional impairment and admission into nursing homes. The workers asked about health care issues like immunization and exercise, looked for untreated health problems, and reviewed the proper use of any medications the patient was taking.

Programs that evaluated many aspects of the senior's life (medical, functional, psychological, social situation, safety of the home) and included follow-up visits seem to be the most beneficial, according to the analysis. Participants in this type of program kept their independence the longest, remaining able to perform acts like dressing themselves and going to the bathroom without assistance. All types of programs appear to reduce mortality, but the older the patient, the less impact any program has on death rates. Short-term visitation programs had no significant effects on nursing home admissions. However, the rate of admission was significantly lower in people whose program included nine or more visits over a two- to three-year period.

Though the authors of the JAMA study admit that it has its limits because the comparisons made in any meta-analysis must be confirmed by other studies, they do believe it has important policy implications. They recommend that countries with home visit programs in place analyze them to see if they include the components the researchers found to be effective. They also suggest that countries that do not have such programs, like the United States, consider implementing them.
April 2002 Update

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Immunizations for 2002

Vaccinations against childhood illnesses are arguably one of the most significant medical achievements of the twentieth century. One hundred years ago, approximately half of all children born in the United States died before the age of 5, many of them from diseases that today can be prevented by vaccines. With proper immunization, the number of cases of these diseases has been reduced dramatically.

Although no new vaccines have been added to the 2002 recommended childhood immunization schedule, this year's schedule highlights vaccines for pre-adolescents and "catch-up" vaccines for children who have fallen behind the currently recommended schedule.

In addition, due to unusual national shortages of the pneumococcal and diphtheria/tetanus/pertussis vaccines, the 2002 immunization schedule also includes a link to information from the Centers for Disease Control (CDC), which explains the necessary modifications to the recommended schedule for these vaccines. These vaccine shortages will hopefully only be temporary.

Please discuss your child's immunization history with the doctor to insure that his or her immunizations are up to date in accordance with the current 2002 Recommended Childhood Immunization Schedule, approved annually by the CDC, the American Academy of Pediatrics, and the American Academy of Family Physicians. For additional reliable and up-to-date information about vaccines and their importance, visit the National Immunization Program website at http://www.cdc.gov/nip or the American Academy of Pediatrics website at http://www.aap.org/.
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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Periodontitis and Heart Disease

The question of whether gum disease is associated with heart disease is controversial. The first research to suggest a connection, published in 1989, found that even after controlling for such cardiovascular disease risk factors as smoking and diabetes, heart-attack patients had significantly worse dental health than control subjects. Since then, several studies have also suggested a link, but the nature of the relationship — is it causative or coincidental? — remains in question.

In 2001, researchers sought an answer to this question, examining data from 4,027 people who participated in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. During 17 years of follow-up, there were 1,238 cases of heart disease, 538 of which proved fatal. The rate of heart disease was three times higher in those with periodontitis than in those with healthy gums.

However, the connection became less prominent once investigators adjusted the numbers to account for other risk factors for cardiovascular disease — smoking, cholesterol levels, high blood pressure, and diabetes. After this adjustment, the heart disease risk among people with and without chronic dental infections was similar.

In fact, even those people who had eliminated any potential of dental infection through extraction of all teeth didn't have a lower heart disease risk when compared to those diagnosed with periodontitis (inflammation of the gums). The risk of developing CHD didn't decrease over time among those with no dental infections or increase over time among people with periodontitis.

A higher rate of other heart-disease risk factors among people with periodontitis might explain this relationship between gum disease and heart disease. For example, those with periodontitis were more likely to have high blood pressure and diabetes, and to smoke cigarettes.

These findings support the theory that the presence of periodontitis may occur coincidentally with increased cardiovascular risk but it is not its cause.
March 2002 Update

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Obesity in Children is on the Rise

A recent study published in the Journal of the American Medical Association showed that American children are heavier now than ever before. In 1998, 12%, 21%, and 22% of Caucasion, African American, and Hispanic children, respectively, were classified as overweight. In fact, between 1986 and 1998, the prevalence of overweight children rose steadily among these groups.

The reason behind childhood obesity — that kids are taking in more calories than they're expending — is easy to understand. But diagnosing obesity is more complicated. It cannot be diagnosed simply by looking at someone because ideal body images differ among individuals, and different body shapes carry weight differently.

And changing lifestyles that create obesity may be even harder. Children are spending more time than ever watching television, playing video games, and surfing the Internet instead of being active. Their parents are busier than ever, too, making it harder to cook nutritious meals.

This is all problematic, as obesity is a risk factor for many health problems, both in childhood and later in life. Children who are overweight are more likely to develop high blood pressure, high cholesterol, and heart disease as adults than kids of normal weight. Long-term obesity also increases the risk of arthritis, heart disease, diabetes, and certain kinds of cancer.

So what can you do? First, talk with your child's doctor. Objective standards have been developed for defining and measuring obesity. He or she will use the body mass index (BMI), calculated from your child's weight and height, and compare it with national growth charts.

There are also tangible things parents can do to help prevent (and treat) obesity in their children as well as in themselves. Begin by establishing healthier eating habits and promoting a more active lifestyle. For example, you can plan daily family activities that involve exercise; limit television, computer, and video game use; eat meals together as a family whenever possible; and when eating out, choose lower fat items on the menu.
March 2002 Update

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Birth Control Patch

The first skin patch approved for birth control by the U.S. Food and Drug Administration will be available by prescription in 2002. Ortho Evra works by slowly releasing progestin and estrogen, the same hormones used in birth control pills, into the bloodstream. Its efficacy lies in the prevention of ovulation and the thickening of the cervical mucus, which makes it harder for sperm to enter the uterus.

Ortho Evra is 99% effective in preventing pregnancy. However, the side effects include an increased risk of blood clots, heart attack, and stroke. This risk is even higher for cigarette smokers. In three clinical trials involving over 3,000 women taking Ortho Evra, 5% of participants had at least one patch that detached from their skin and 2% withdrew from the trial due to skin irritation. Also, the patch appeared to be less effective in women weighing more than 198 pounds.

The regimen is similar to that of birth control pills. The patch is changed once a week for three weeks. The patch-free fourth week allows for a menstrual period. The small (less than two square inches) and paper-thin design makes Ortho Evra easy to hide beneath clothing. It can be applied to the buttocks, abdomen, upper torso (front or back), and the upper outer arm, and be worn in a different place each week.
February 2002 Update

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Bicycle Helmets Save Lives

Although bicycling is one of the most popular sports, injuries associated with bicycling are the leading cause of emergency room visits for children and adolescents. Unfortunately, many of these injuries include head trauma.

Previous studies have shown helmets can sharply reduce the serious head injuries that can occur with cycling. But the majority of children (and their parents) still don't use helmets regularly. Why? Reasons suggested include discomfort, lack of style, peer pressure, and not recognizing the importance of helmets on short rides.

The American Academy of Pediatrics recently published a statement emphasizing the importance of correct bicycle helmet use. In these recommendations, all bicyclists (children and parents alike) should wear proper helmets every time they ride. A helmet made after March 1999 should be used. These newer helmets meet US Consumer Product Safety Commissions standards.

Children should be properly fitted because helmets come in several sizes. Keep in mind that:

  • In its correct position, the helmet should sit low on the forehead and be parallel to the ground.
  • Velcro pads should be placed in, or removed from, the inside of the helmet as needed to make the helmet fit snugly.
  • The chinstrap should be adjusted so that no more than two fingers can be placed between the strap and the chin.
  • The helmet should not shift or come off when the child shakes his head.
  • All helmets should be replaced every five years.

February 2002 Update

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Advanced Macular Degeneration and Nutritional Supplements

Nutritional supplements may help slow the progression of advanced macular degeneration (AMD), the most common cause of vision loss in people over age 55, a new study suggests.

The Age-Related Eye Disease Study (AREDS), reported in the October 2001 Archives of Ophthalmology, is the largest clinical trial to have tested the impact of nutritional supplements on AMD and cataracts. AREDS involved nearly 5,000 women and men, ages 55-80, at 11 clinical centers nationwide. Participants in the macular degeneration portion of the study were divided into groups depending upon the severity of their condition. They received one of the following daily regimens: 1) antioxidants (500 mg vitamin C, 400 IU vitamin E, 15 mg beta-carotene), 2) zinc (80 mg, plus 2 mg copper to prevent anemia), 3) a combination of the antioxidants and zinc, or 4) a placebo. Participants were evaluated every six months for vision loss and annually for retinal changes.

Over the seven-year study, combined antioxidants and zinc reduced the risk for progression to advanced AMD by 25%, compared with placebo, among those who already had extensive intermediate or large drusen or advanced AMD in one eye. This treatment also reduced the AMD-related loss of visual acuity by about 19%. Antioxidants or zinc alone reduced the risk, but to a lesser extent. AREDS subjects with early or no AMD got no measurable benefit from the supplements. In the companion study of cataract development, antioxidants and zinc (separately or in combination) had no beneficial effect.

Though participants reported no major side effects, the long-term consequences of taking these nutrients at levels above the Recommended Dietary Allowance (RDA), as AREDS participants did, are unknown.
January 2002 Update

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White-Coat Hypertension

Most people feel a bit anxious during a doctor's visit. But for some people, their anxiety causes temporary high blood pressure, detectable during the time of the visit. Physicians have been debating whether or not they should treat this phenomenon, referred to as "white-coat" hypertension. Some believe the short-lived blood pressure elevation is harmless, while others believe it should be treated like persistent high blood pressure.

In a recent study, researchers compared changes in the heart's function and size among people with persistent, untreated high blood pressure, "white coat" high blood pressure, and normal blood pressure. Participants were carefully matched by age, sex, and weight, as well as in-clinic and out-of- clinic blood pressures. Results of the study show participants with "white coat" hypertension, when compared to participants with normal blood pressure, had thicker walls in portions of their hearts, increased heart mass, and alterations in the diastolic (relaxing) portion of the heartbeat. Those people with persistent high blood pressure had even greater changes in the heart. These findings suggest "white coat" hypertension, while a temporary condition, may cause damage to the heart. This study reinforces the argument for treating "white coat" hypertension.

If you experience this condition, you should consult your doctor about treatment options. Simple lifestyle changes may be all you need or medication might be necessary. In any case, the possible benefits will outweigh the risks.
January 2002 Update

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Long or Irregular Menstrual Period and Diabetes Risk

Women with long or highly irregular menstrual periods face twice the risk of developing adult-onset diabetes compared with women with regular periods, a new study suggests.

More than 100,000 women with no prior history of diabetes recorded their menstrual cycles and were tracked for eight years as part of the Nurse's Health Study.

One in every 95 subjects with cycles 40 days or longer developed diabetes, while only 1 in every 297 women with cycles of 26 to 31 days did. Women with cycles too irregular to measure also showed a significant increase in the occurrence of diabetes. The risk was modestly greater for women with a cycle length less than 21 days, though there were few women in this category and the connection was only found when there was a family history of the disease.

The link between a long menstrual cycle and diabetes was even stronger in obese women. Oral contraception use had no effect on risk. This was particularly interesting, because oral contraceptives may adversely affect insulin sensitivity and glucose tolerance, therefore increasing the woman's risk for diabetes.

In light of these findings, researchers suggest women with irregular or long menstrual cycles make an extra effort to control other risk factors for diabetes, such as excessive weight and lack of exercise.
January 2002 Update

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Sugar and Tooth Decay

"If you eat too much candy your teeth will rot!" We've known about the link between sugar consumption and tooth decay for centuries. The bacteria in dental plaque feeds on sugar, and the acid produced by the bacteria attacks the protective enamel surface of the teeth, allowing for tooth decay to proceed. But since the advent of fluoride in water, toothpaste, dental treatments, and even processed foods, do we still need to restrict how much sugar we eat?

A recent review answers this question. Researchers examined the results of 36 studies conducted in countries where fluoride exposure is widespread. Only two of the studies showed people who consumed high amounts of sugar had a high risk of tooth decay. The remaining studies showed only a moderate to weak association. Does this mean we can eat all the candy we want and not have to worry about tooth decay? Not quite. Moderation is still key, because while the risk is much less than it was during the pre-fluoride era, consuming sugar was still found to be a moderate to mild risk factor for tooth decay.

If sugar has a role in tooth decay, can sugar substitutes have a role in the prevention of tooth decay? A review of fourteen studies showed a 30 to 60 percent decrease in the rate of tooth decay among study participants who used sugar substitutes compared to participants using sugar. In the studies, participants chewed gum or used toothpaste containing either sugar or the sugar substitutes xylitol or sorbitol. Xylitol gave the largest decrease in tooth decay. Sugar-free gums, particularly those containing xylitol, may help prevent tooth decay by decreasing acid production and promoting the flow of saliva to clear sugars from the mouth.
January 2002 Update

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Vaccine safety: no link between thimerosal and neurodevelopmental disorders

Parents should feel confident and safe when having their children immunized. No evidence exists that proves a link between thimerosal-containing vaccines and neurodevelopemental disorders, such as autism, attention deficit-hyperactivity disorder, or speech and language delay. The Institute of Medicine recently reported these findings, consistent with the recommendations of the American Academy of Pediatrics.

Thimerosal, a mercury-containing preservative, was used for many years in vaccines to prevent contamination. Taking in a high dose of mercury is toxic to the human nervous system. But because of the increasing number of vaccines routinely recommended for infants, concern was raised in 1999 by the Food and Drug Administration that the total amount of mercury contained in the vaccinations could be exceeding the recommended mercury levels for infants.

Although there's no data to suggest thimerosal caused any harm, the American Academy of Pediatrics and the U.S. Public Health Service have requested manufacturers remove thimerosal from vaccines. As a result, most, if not all, childhood vaccines are now thimerosal-free.

The Institute of Medicine's recommendations emphasized the importance and continued safety of childhood vaccination. Parents should definitely be reassured that all routine childhood immunizations are in their children's best interests, as they clearly have been shown to prevent potentially life-threatening diseases.
November 2001 Update

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Lyme Disease Update

Can antibiotics catch Lyme disease before it develops? Do antibiotics alleviate the lingering symptoms after the infection is cured? Two recent studies published in The New England Journal of Medicine shed light on these two controversial questions.

In the first study, conducted in Westchester County, New York, an area with high rates of Lyme disease, researchers gave a single dose of either an antibiotic or a placebo to patients who were bitten by deer ticks in the previous 72 hours.

The researchers found the antibiotic doxycycline prevented the disease form developing. However, only 3.2% of the untreated patients developed the characteristic bull's eye rash around the tick bite. This suggests the risk of Lyme disease is low even in Westchester County. The study also found the infection was more likely to develop from bites by ticks in the nymph stage, and if the tick was attached for 72 hours or more.

This study suggests preventive treatment is only worthwhile in areas with a particularly high incidence of the disease or if you are bitten by a nymphal deer tick that has been attached for three days or more. You should save the tick in a jar of alcohol so it may be identified to help you and your physician make that decision.

In the second study, researchers investigated whether prolonged treatment with antibiotics reduces the fatigue, muscle and joint pain, and mood or memory disturbances that some people experience even after the infection has cleared. But the study was discontinued early when preliminary results showed prolonged antibiotic treatment was no more effective than a placebo at improving the persistent symptoms.

If you are experiencing post-Lyme disease symptoms, long-term use of antibiotics is unlikely to help. But there is hope your condition will improve — the study found symptoms improved in 36% of the untreated patients.
September 2001 Update

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Flu Vaccine and Recurrent Heart Attack Risk

Late each fall, the call goes out to remind people to get their flu vaccinations. Most healthy people equate the flu with a week of being miserable. However for the elderly or people with chronic illnesses, the complications of influenza, such as pneumonia, can be life threatening. Good enough reason to get the shot, but now research suggests the vaccination may also lower heart attack risk.

The study, conducted by researchers at the University of Texas-Houston, questioned whether getting a flu shot could reduce the risk of a second heart attack in people with coronary artery disease. Scientists have been studying a potential link between cardiovascular disease and infection, and some of their work suggests upper respiratory infections, such as the flu, might be a risk factor for heart attack.

The investigators evaluated 218 individuals with previous heart attacks who were seen in the university's cardiology outpatient clinic during the 1997-98 flu season. Of the patients who met the study criteria, 109 experienced a heart attack during the study period. These volunteers were matched with 109 controls with coronary artery disease, but had not experienced a second heart attack during the same period.

Of those who had had new myocardial infarctions, the rate of flu vaccination during the current season was 47%, versus 71% among those who did not have new heart attacks. After adjusting for differences between these groups, the researchers found the risk of heart attack was reduced by two-thirds among patients who had gotten a flu shot that season. This study showed no evidence that use of multivitamins or physical exercise changed risk for recurrent heart attack.

No one knows how flu vaccination might reduce a person's risk of heart attack. Perhaps exposure to the flu might cause atherosclerotic plaques to become less stable or the stress of this illness might dangerously increase the heart's workload for people with cardiovascular disease. Other theories include an increased tendency for blood clots during the flu or that the flu may contribute to poor blood vessel function. Whatever the cause and effect, people with coronary artery disease (and who are not allergic to the vaccine) should strongly consider getting a flu shot this season.
September 2001 Update

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Take Low-Dose Aspirin and Skip Vitamin E to Prevent Cardiovascular Disease

For more than 100 years aspirin has helped relieve headaches and other pain, and now new evidence from the Primary Prevention Project backs the claim it also helps prevent heart attacks and other cardiovascular events. The same study also found the antioxidant vitamin E didn't help.

The theory that anti-platelet/anti-inflammatory drugs like aspirin and antioxidant nutrients like vitamin E might interfere with atherosclerosis and prevent cardiovascular disease is not new. But previous research on both possibilities has come up with mixed results. In an attempt to resolve the debates, Italian researchers randomized 4,495 people (2583 females and 1912 men) with an average age of 64.4 to receive low-dose aspirin (100mg/day) or no aspirin and vitamin E supplements (300mg/day) or no vitamin E. They limited their investigation to people over 50 with one or more of the major cardiovascular risk factors: hypertension, high blood cholesterol, diabetes, obesity, family history of early heart attacks or individuals who were elderly.

Aspirin proved to be beneficial with respect to all of the criteria measured. It reduced the risk of a cardiovascular death by 44% and the risk of cardiovascular events or disease by 23%. However, severe gastrointestinal bleeding was more frequent in the aspirin group than in the non-aspirin group (1.1% vs 0.3%). Consistent with the negative results of other large published trials, vitamin E provided no significant improvements in any of the criteria.

The study was stopped prematurely after a mean follow-up of 3.6 years because evidence from two other studies involving a total of 24,289 patients concurred that aspirin is beneficial in primary prevention.
August 2001 Update

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Early Childcare and Communicable Illnesses

All kids get sick, but young children in day care are at increased risk for infection.

The National Institute of Child Health and Human Development recently examined rates of ear infections, gastrointestinal tract illnesses, and upper respiratory tract infections in children participating in the Institute's Study of Early Child Care. The study is following 1200 children from birth to age three in ten locations across the county. The researchers found the rates for each illness were higher for children in day care than for those reared exclusively at home during the first two years of life. But this difference disappeared by the time they were three years old.

The number of hours per week children spent in day care generally had little to do with their likelihood of getting sick. Instead, the great the number of children enrolled in a facility, the greater a child's risk of illness. But being sick more frequently didn't have developmental consequences. Some parents felt that sickly children had increased behavioral problems, but this was likely the result of increased stress.
July 2001 Update

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Walk, Don't Run for Weight Loss

People often disrupt their sedentary lifestyles with bouts of high-intensity exercise, like running or aerobics, to avoid gaining weight or developing heart disease. But a new study shows spending some of your day engaged in moderate activity, like biking, walking, or even taking the stairs at work, may be more a successful method for boosting daily calorie expenditure and losing weight.

The study, published in Nature, involved 30 healthy, non-obese women and men. For two weeks, the participants’ energy expenditure was measured, while their activity levels were tracked using portable motion sensors and activity diaries. The investigator found the amount of moderate activity, not vigorous exercise, was a significant predictor of total energy expenditure. He hypothesized that moderate activity usually occupies a larger portion of the day compared to more vigorous exercise. For instance, studies on obese subjects have found adding intense exercise to diet didn’t enhance weight loss because the extra energy expenditure didn’t offset the reduced time spent on other physical activities.

This small, but informative study provides strong evidence that exchanging some of time you sit in front of a TV for moderate activity increases total daily energy expenditure and metabolic rate. Short bursts of vigorous activity in an otherwise inactive and unhealthy lifestyle is not enough. So take the stairs, not the elevator, and go for a walk at lunch. But don’t be discouraged from going for a run. Aerobic activities, like jogging, swimming and brisk walking, help make your heart stronger and more efficient, which can lower your heart disease risk still further.
June 2001 Update

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National Cholesterol Education Program Releases New Guidelines for Treating and Preventing High Cholesterol

On May 15, 2001, the National Cholesterol Education Program (NCEP) — coordinated by the National Heart, Lung, and Blood Institute (NHLBI) — released the first major revision of its recommendations for detecting and lowering high cholesterol in adults since 1993.

One of the fundamental features of the new guidelines is the accurate assessment of heart disease risk using a new "global risk assessment tool" that combines multiple risk factors into a measure of a person's absolute risk of developing coronary heart disease within the next 10 years. According to the guidelines, patients who have a risk of 20% or higher should receive aggressive therapy to control cholesterol levels. In addition to aggressive treatment of high LDL cholesterol, as laid out in the 1993 report, the revised guidelines also recommend a more assertive treatment approach for diabetes, low HDL levels, and high triglyceride levels.

Specific changes include:

  • Treating high cholesterol more aggressively for those with diabetes, even if they do not have heart disease.
  • A full lipid profile (which measures total cholesterol, LDL, HDL, and triglycerides) as the first test for high cholesterol (rather than simply testing total cholesterol and HDL and performing a full lipid profile only if total cholesterol is high).
  • A new level at which low HDL becomes a major risk factor for heart disease. The 1993 guidelines defined a low HDL as less than 35 mg/dL; now it is less than 40 mg/dL.
  • More aggressive treatment of high triglyceride levels.
  • Advising against the hormone replacement therapy (HRT) as an alternative to cholesterol-lowering drugs for post-menopausal women.

Another key change in the guidelines is intensified lifestyle recommendations regarding nutrition, exercise, and weight control to treat high cholesterol. The updated diet advises that less than 7% of daily calories come from saturated fat and limits dietary cholesterol to less than 200 mg per day. It also allows up to 35% of daily calories from total fat, provided most come from unsaturated or monounsaturated fat, which doesn't raise cholesterol levels. Additionally, the guidelines strongly underscore the need for weight control and physical activity, both of which improve various heart disease risk factors.

The revised recommendations also emphasize careful attention to the metabolic syndrome, a particular cluster of cardiovascular risk factors that is becoming increasingly common in the United States. Characteristics of metabolic syndrome include too much abdominal fat, high blood pressure, high blood sugar, elevated triglycerides, and low HDL.

For more information, see the "Live Healthier, Live Longer" Web site by going to the NHLBI home page at www.nhlbi.nih.gov and clicking on ATP III Cholesterol Guidelines under Highlights.

2001 Cholesterol Guidelines
Total Cholesterol Level Total Cholesterol Category
Less than 200 mg/dL Desirable
200-239 mg/dL Borderline High
240 mg/dL and above High
LDL Cholesterol Level LDL Cholesterol Category
Less than 100 mg/dL Optimal
100-129 mg/dL Near optimal/above optimal
130-159 mg/dL Borderline high
160-189 mg/dL High
190 mg/dL and above Very high
Trigylceride Level Triglyceride Category
Less than 150 mg/dL Normal
150-199 mg/dL Borderline high
200-499 High
Greater than or equal to 500 Very high
HDL Cholesterol Level HDL Cholesterol Category
Less than 40 mg/dL Low (representing increased risk)
60 mg/dL and above High (heart protective)
Three Categories of Risk that Modify
LDL Cholesterol Goals
Risk Category
LDL Goal (mg/dL)
Coronary Heart Disease (CHD) and CHD equivalents Less than 100
Multiple (2+) risk factors Less than 130
0-1 risk factor Less than 160
Risk factors (exclusive of LDL cholesterol): cigarette smoking; blood pressure greater than or equal to 140/90 mm Hg or on antihypertensive medication; HDL cholesterol less than 40 mg/dL; a family history of coronary heart disease before age 55 in a father or brother or age 65 in a mother or sister; age above 45 for men and 55 for women

May 2001 Update

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Study Shows Fish Consumption Protects Against Stroke, But FDA Suggests Pregnant Women Should Take Caution

A large study in the Journal of the American Medical Association (JAMA) recently showed that regularly eating fish might protect against ischemic stroke, which is the most common type of stroke. Numerous studies have already shown an association between fish consumption and a reduced risk of heart disease. But there is a caveat. The Food and Drug Administration (FDA) recently warned that pregnant women and women who are of childbearing age who may become pregnant, should avoid certain types of fish that contain high levels of mercury, which may be harmful to their unborn children.

Results of the Nurses' Health Study, published in the JAMA article, involved nearly 80,000 women. It showed that women who ate fish two to four times a week had a 48% lower risk of ischemic stroke — the kind caused by blood clots — than women who ate fish less than once per month. Even women who ate fish only once a week or less had a risk reduction, but it was not statistically significant. These results held true primarily among women who did not regularly take aspirin, which prevents the formation of blood clots. Omega-3 fatty acids, the protective substances found in fish, reduce levels of fats related to cardiovascular disease and help prevent blood clotting. Dark, oily fish such as mackerel, salmon, and sardines are a good source of omega-3 fatty acids.

Although pregnant women need not give up fish — and its beneficial health effects — altogether, they should be careful about what types of fish they eat. The FDA has advised that pregnant women and those who may become pregnant stop eating shark, swordfish, king mackerel, and tilefish. These large, long-living fish contain hazardous levels of methyl mercury, a form of mercury that can accumulate in a woman's body and affect the developing central nervous system of an unborn child. This can lead to babies with slower cognitive development. As an extra precaution, the FDA advised that nursing mothers and young children also avoid these fish. Mercury gets into both fresh and salt water through industrial pollution.

Some critics feel the FDA's mercury warnings are not strong enough. A report by the National Academy of Sciences suggested the exposure limits for mercury should be four times stricter.

While this controversy remains unresolved, the FDA encouraged pregnant women to continue to eat a variety of other fish, containing very low levels of mercury, as part of a balanced diet. Among other health benefits, the fatty acids in fish enhance brain development. According to the FDA, women can safely eat up to 12 ounces of fish per week. Fish that contain low levels of mercury include shellfish, canned fish, smaller ocean fish, and farm-raised fish. Women who eat fish caught by family or friends should contact their local health department for advice on the safety of fish from local waters.
May 2001 Update

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Reducing Your Risk of Deep Vein Thrombosis During Airline Travel

Deep vein thrombosis (DVT), recently featured in the news as "economy class syndrome," is the formation of a blood clot in the deep veins of the legs while sitting — particularly in the cramped seats of an airplane (be it economy class or first class), car, bus, or train — for long periods. You move less in tight quarters, causing circulation to decrease and allowing blood to collect and form a clot. The blood clot may cause pain and swelling in the legs. Serious, even fatal complications can occur if the blood clot breaks loose in the blood stream and travels to the heart or lungs. Older people, and those who are obese or have a family history of DVT tend to be at the highest risk.

While a blood clot can result from a number of causes, some studies suggest an association between blood clots and airplane travel. Many doctors believe this connection is simply a result of being unable to move around, and not from sitting in economy class seats or in an airplane, per se. However, it is possible that pressurized air and dehydration may also play a role in the connection between air travel and blood clots.

Many airlines have already begun to address this health issue by preparing warning pamphlets for their passengers, including articles in their in-flight magazines, posting notices on their Websites, or creating in-flight videos offering exercises aimed at prevention. A member of the parliament in Australia has even called for treadmills to be installed in airplanes that carry passengers for six or more hours.

While treadmills may or may not appear on airplanes in the near future, you can address this issue on your next lengthy flight by taking a few simple measures to help prevent blood clotting.

  • Wear loose-fitting, comfortable clothing during the flight.
  • Eat a small meal and drink plenty of fluids to help increase blood circulation. Avoid alcohol and caffeine, as these contribute to dehydration.
  • Do not cross your legs while seated and make sure you adjust your position every half hour.
  • You may want to wear elastic support hose to increase circulation in your legs.
  • Most importantly, try to walk up and down the aisle at least once an hour. Even standing in front of your seat and gently shaking out your legs or slowly rising up on your toes can help.
  • If you can’t get out of your seat, you can do the following exercises in your seat to increase blood circulation. Perform each exercise for 15 seconds, once an hour.
  • Ankle rotations: Draw a circle with your toes, rotating clockwise and then counterclockwise with both feet.
  • Foot pumps: Slowly alternate between flexing and pointing your toes.
  • Leg lifts: With your knee bent, lift your leg up off the seat and hold for a few seconds. Alternate legs.
  • Head and shoulder rotations: Gently roll your head clockwise and then counterclockwise, keeping your shoulders relaxed. Then gently roll your shoulders forwards and backwards.
  • Toe reach: Slowly bend forward and extend your arms down towards your toes and then gently sit back up.
  • People who are at high risk for blood clotting due to other conditions should speak with their physician for additional advice before traveling.

Studies do not agree on how long a flight needs to be to pose a risk of blood clotting. A few studies even suggest that there is no association between blood clots and air travel. Clearly, more research is necessary. However, while we wait for a definitive answer to these questions, heeding these simple instructions may help prevent problems.
March 2001 Update

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Pet Reptiles and Salmonella

Between 1996 and 1998, approximately 16 state health departments reported salmonella infections in persons who had direct or indirect contact with reptiles (i.e., lizards, snakes, or turtles) to the Centers for Disease Control and Prevention.

Salmonella infection can result in severe illness and even death, particularly in infants, young children, and anyone with a compromised immune system. The CDC issued the following recommendations to reduce the chances of anyone in your family contracting this potentially deadly infection from these increasingly popular exotic pets:

  • Pet store owners, veterinarians, and pediatricians should provide information to owners and potential purchasers of reptiles about the risk of acquiring salmonellosis from reptiles.
  • People should always wash their hands thoroughly with soap and water after handling reptiles or reptile cages.
  • People at increased risk for infection or serious complications of salmonellosis (e.g., children younger than age 5 and immunocompromised persons) should avoid contact with reptiles.
  • Pet reptiles should be kept out of households where children younger than age 5 and immunocompromised persons live. Families expecting a new child should remove the pet reptile from the home before the infant arrives.
  • Pet reptiles should not be kept in childcare centers.
  • Pet reptiles should not be allowed to roam freely throughout the home or living area.
  • Pet reptiles should be kept out of kitchens and other food-preparation areas to prevent contamination.
  • Kitchen sinks should not be used to bathe reptiles or to wash their dishes, cages, or aquariums. If bathtubs are used for these purposes, they should be cleaned thoroughly and disinfected with bleach.

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Starve a Cold, Feed a Fever, Take a Pill for the Flu?

The height of the flu season is starting to wane, but we seem to be at the peak of print and television ads promoting new treatments. Late in 1999, the U.S. Food and Drug Administration approved two new anti-influenzal drugs zanamivir (Relenza) and oseltamivir (Tamiflu). Both work by interfering with an enzyme needed for the flu virus to reproduce. Both offer an option for treating uncomplicated cases of the flu.

In clinical trials, when taken within two days of the onset of flu symptoms, Relenza was shown to make people feel better a little (about 36 hours) sooner. This drug is administered in an inhaler twice daily for five days. Relenza has not been proved effective for people who have severe asthma or chronic breathing problems, and in fact may cause bronchial spasms in these individuals. Tamiflu comes in pill form (taken twice a day for five days) and can reduce the length and severity of flu symptoms if it is taken within two days of the onset of symptoms, but not by much.

Patients participating in two clinical trials reported feeling better about one day sooner than patients taking a placebo. The most common side effects of Tamiflu included upset stomach, vomiting, trouble sleeping, and dizziness. Neither drug can prevent people from passing the flu on to others. These medications may offer some relief to flu sufferers, but getting a flu vaccine remains the best way to minimize your chances of getting this virus in the first place. This is true for healthy people and especially for people at high risk for complications from the flu (the elderly and people with compromised immune systems or chronic lung diseases).

In fact, the safety and effectiveness of these new flu treatments are unproven in these populations. What's more, Tamiflu and Relenza are effective only against influenza types A and B, but not type C (a very common, less severe flu) and many upper respiratory infections caught during the winter are viral, and not the flu.

The bottom line is that these medications are helpful in only a handful of situations. An extra day of fluids and bed rest may be all you can do.

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Bone benefits

Increases bone density at the spine and hip; reduces spinal and hip fracture risk. Side effects uncommon.

Increases bone density at the spine and hip; reduces spinal and hip fracture risk. Side effects uncommon.

Increases bone density (but less so than alendronate or risedronate); reduces spinal fracture risk. Side effects uncommon.

Increases bone density; some evidence for fracture reduction.

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