Health for life

Parents know its important for children to eat a wide variety of fruits and vegetables, low-fat dairy products, and whole grains. But its less clear whether spending the extra money on organic foods will bring a significant benefit to their childrens health.

To offer guidance to parents – and the pediatricians caring for their childrens health – the American Academy of Pediatrics (AAP) has conducted an extensive analysis of scientific evidence surrounding organic produce, dairy products and meat. The conclusion is mixed: While organic foods have the same vitamins, minerals, antioxidants, proteins, lipids and other nutrients as conventional foods, they also have lower pesticide levels, which may be significant for children. Organically raised animals are also less likely to be contaminated with drug-resistant bacteria because organic farming rules prohibit the non-therapeutic use of antibiotics.

However, in the long term, there is currently no direct evidence that consuming an organic diet leads to improved health or lower risk of disease. No large studies in humans have been performed that specifically address this issue.

"Whats most important is that children eat a healthy diet rich in fruits, vegetables, whole grains, and low-fat or fat-free dairy products, whether those are conventional or organic foods. This type of diet has proven health benefits," said Janet Silverstein, MD, FAAP, a member of the AAP Committee on Nutrition and one of the lead authors of the report. "Many families have a limited food budget, and we do not want families to choose to consume smaller amounts of more expensive organic foods and thus reduce their overall intake of healthy foods like produce."

The AAP report, "Organic Foods: Health and Environmental Advantages and Disadvantages," will be released at a news conference at 1 p.m. CT Monday, Oct. 22 at the AAP National Conference & Exhibition in New Orleans. It will be published in the November 2012 issue of Pediatrics (published online Oct. 22). The report outlines the research that has been conducted on organic foods, including convincing evidence of lower exposure to pesticides and less contamination of livestock with drug-resistant bacteria.

"At this point, we simply do not have the scientific evidence to know whether the difference in pesticide levels will impact a persons health over a lifetime, though we do know that children – especially young children whose brains are developing – are uniquely vulnerable to chemical exposures," said Joel Forman, MD, FAAP, a member of the AAP Council on Environmental Health and one of the lead authors of the AAP clinical report.

If cost is a factor, families can be selective in choosing organic foods, Dr. Forman said. Some conventionally grown fruits and vegetables tend to have lower pesticide residues. The AAP cites organic shoppers guides like those provided by Consumer Reports and the Environmental Working Group as erences for consumers. The AAP found no individual health benefit from purchasing organic milk, but emphasizes that all milk should be pasteurized to reduce the risk of bacterial infections. Raw milk increases the risk of serious infection with bacteria including Salmonella, E. coli, Listeria, Campylobacter and Brucella.

Purchasing meat from organic farms that do not use antibiotics for nontherapeutic uses has the potential to reduce antibiotic resistance in bacteria that infect people. The AAP calls for large, well-designed, prospective cohort studies that directly measure environmental exposures such as estrogen at low levels to understand the impact of hormonal exposure of children through milk and meat.

The AAP report also notes that the motivation to choose organic produce, meat and dairy products may be reasonably based on larger environmental issues, as well as human health impacts like pollution and global climate change.

"Pediatricians want families to have the information they need to make wise food choices," said Dr. Forman. "We hope that additional research will improve our understanding of these issues, including large studies that measure environmental exposures and neurodevelopment."

While aspirin has been shown to be effective in preventing heart attacks in men, it also increases the risk of gastrointestinal bleeding and possibly stroke, even at low doses. As such, national guidelines suggest that aspirin be used for prevention only in men at higher risk for cardiovascular events, so that the benefits of aspirin are greater than its adverse effects.

Recent data suggest that aspirin may also be effective for reducing cancer deaths. Would the possible combined health benefits of reducing heart attacks and cancer outweigh the risks of gastrointestinal bleeding and stroke for middle-aged men?

A research team, including UNC scientists, reports that including the positive effect of aspirin on cancer mortality influences the threshold for prescribing aspirin for primary prevention in men. The benefit of aspirin for cancer mortality prevention would help offset the risks and thus lower the age and increase the number of men for whom aspirin is recommended.

Their results were published in the June issue of the Journal of General Internal Medicine.

Michael Pignone, MD, MPH, and study lead author, says, “We found that including a risk reduction for cancer deaths had a substantial impact on the overall benefits of aspirin, especially for early middle-aged men from 45 to 55 years of age. Based on this effect, several million men who were not previously good candidates for aspirin prevention would now become eligible.

The U.S. Preventive Services Task Force, of which Dr. Pignone is a recently appointed member, recommends aspirin for primary prevention in men “when the potential benefit of a reduction in myocardial infarctions outweighs the potential harm of an increase in gastrointestinal hemorrhage.” This recommendation was issued in 2009, before the potential benefits for cancer reduction were recognized.

People who like to nap say it helps them focus their minds post a little shut eye. Now, a study from Georgetown University Medical Center may have found evidence to support that notion.

The research, presented at Neuroscience 2012, the annual meeting of the Society for Neuroscience, found that when participants in a study rested, the right hemisphere of their brains talked more to itself and to the left hemisphere than the left hemisphere communicated within itself and to the right hemisphere – no matter which of the participants hands was dominant. (Neuroscientists say right-handed people use their left hemisphere to a greater degree, and vice versa.)

Results of this study, the first known to look at activity in the two different hemispheres during rest, suggests that the right hemisphere "is doing important things in the resting state that we dont yet understand," says Andrei Medvedev, Ph.D., an assistant professor in the Center for Functional and Molecular Imaging at Georgetown. The activities being processed by the right hemisphere, which is known to be involved in creative tasks, could be daydreaming or processing and storing previously acquired information. "The brain could be doing some helpful housecleaning, classifying data, consolidating memories," Medvedev says. "That could explain the power of napping. But we just dont know yet the relative roles of both hemispheres in those processes and whether the power nap might benefit righties more then lefties."

To find out what happens in the resting state, the research team connected 15 study participants to near-infrared spectroscopy (NIRS) equipment. This technology, which is low cost and portable, uses light to measure changes in oxygenated hemoglobin inside the body.

The study participants wore a cap adorned with optical fibers that delivers infrared light to the outermost layers of the brain and then measures the light that bounces back. In this way, the device can "see" which parts of the brain are most active and communicating at a higher level based on increased use of oxygen in the blood and heightened synchronicity of their activities.

"The device can help delineate global networks inside the brain — how the components all work together," Medvedev says. "The better integrated they are, the better cognitive tasks are performed."

To their surprise, the researchers found that left and right hemispheres behaved differently during the resting state. "That was true no matter which hand a participant used. The right hemisphere was more integrated in right-handed participants, and even stronger in the left-handed," he says.

Medvedev is exploring the findings for an explanation. And he suggests that brain scientists should start focusing more of their attention on the right hemisphere. "Most brain theories emphasize the dominance of the left hemisphere especially in right handed individuals, and that describes the population of participants in these studies," Medvedev says. "Our study suggests that looking at only the left hemisphere prevents us from a truer understanding of brain function." The research was funded by the National Institutes of Health (grants # RR025786, GM103526 and EB006589). Medvedev and his co-authors report having no personal financial interests related to this study.

Remember that Affordable Care Act (ACA) "essential health benefit (EHB)?" 

While Disease Management Care Blog doesnt want to be reminded about it either, the topic bubbled into the health policy news cycle thanks to this sleeper bulletin recently released by HHS. Recall, despite the ACA requiring an approach based on a "typical" insurance plan covering ten categories of services, that the law set the stage for a requirement that every U.S. health insurer would have to potentially cover an expansive, complicated, expensive and controversial suite of services in each and every health insurance policy.  Any insurance plan not meeting the EHB would be excluded from the exchanges.

While the DMCB feared the unable-to-say-no amateurs in HHS would stumble their way into an unaffordable and one-size-fits-all package, it appears theyve blinked.  Thats because theyve discovered that the ACA misread things: while insurance policies typically cover a core set of services, they vary in coverage of other services.  That includes dental care, acupuncture, bariatirc surgery, hearing aids, tobacco cessation, in-vitro fertilization, certain autism services, a variety of mental health and substance use disorders and habilitative (yes, that was a new one for the DMCB too) services.

How does HHS intend to reconcile this?

"We intend to propose that EHB be defined by a benchmark plan selected by each State."  

Whoa.

In other words, there would be 50 EHBs.  As the DMCB understands it, each would be calculated using an intra-state combination of the largest small group plan, any of the largest thee state employee plans, any of the large three national FEHBP plans and the largest commercial plan.  If a state doesnt calculate the benefit, the Feds intend to use the one used by the largest small group insurance plan.  If the calculation doesnt include sufficient coverage in all the ten categories, the ultimate default is using whatever is in the states largest FEHBP plan.

Business groups and state leadership will probably find the local state-based approach a more palatable alternative, while some professional (for example) and patient advocacy (for example) may be disappointed.

We know olive oil is good for the heart. Its monounsaturated fats have a reputation for lowering LDL (bad cholesterol) and raising HDL (good cholesterol).

Now, researchers have found another benefit of olive oil - the ability to reduce pain and inflammation, much like non-steroidal anti-inflammatory drugs (NSAIDs) such as Advil® or Motrin® can.

This time the benefit is not due to olive oils monounsaturated fats, but to a newly discovered chemical the researchers named oleocanthal. It was found occurring naturally in the extra-virgin type of olive oil.

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For a summary of the researchers findings:
Olive Oil Contains Natural Anti-inflammatory Agent

The article appears in the September 1 issue of the journal Nature (editors summary only, subscription required for full article.):
Phytochemistry: Ibuprofen-like Activity in Extra-virgin Olive Oil

A small study from the Netherlands has failed to find blood sugar benefit from chromium supplementation. The study appears in last months issue of Diabetes Care.

Chromium had previously been shown to improve insulin sensitivity, but subsequent studies have been inconclusive.

This 6-month, double-blind, randomized trial tested treatment amounts of 500 or 1000 micrograms/day of chromium picolinate in 46 people with type 2 diabetes. Participants taking chromium had no change in A1C, weight, blood pressure, or lipid profile.

Although benefit was not seen in this study population - whose participants were obese (average BMI 34) with poorly controlled blood sugar (A1C > 8%) who took large amounts of insulin (more than 50 units/day) - it does not rule out benefit in populations with better glucose control.

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For the study:
Chromium Treatment Has No Effect in Patients With Poorly Controlled, Insulin-Treated Type 2 Diabetes in an Obese Western Population

Exercise may benefit people suffering from depression, according to an updated systematic review published in The Cochrane Library. The authors of the review found evidence to suggest that exercise reduces symptoms of depression, although they say more high quality trials are needed.

Worldwide, more than 120 million people suffer from depression. Antidepressants and psychological therapies are recommended as effective treatments for depression. However, antidepressants have side-effects and some people per not to receive, or may not have access to, psychological therapies. Physical exercise is also used as a treatment for depression. There are a number of reasons why it might work such as changing hormone levels that affect mood or providing a distraction from negative thoughts.

The previous version of the Cochrane review found only limited evidence of benefit for exercise in depression. However, more trials have now been completed, leading researchers to carry out a further update. Altogether, they reviewed the results of 39 trials involving 2,326 people diagnosed with depression. The severity of patients symptoms was assessed using standard scales of depression.

In 35 trials comparing exercise with control treatments or no treatment, the researchers saw moderate benefits of exercise for treating depression. Exercise was as effective as psychological therapy or taking antidepressants, although these findings were based on only a few, small, low quality trials.

"Our review suggested that exercise might have a moderate effect on depression," said one of the authors of the review, Gillian Mead of the Centre for Clinical Brain Sciences at the University of Edinburgh in Edinburgh, UK. "We cant tell from currently available evidence which kinds of exercise regimes are most effective or whether the benefits continue after a patient stops their exercise programme."

Conducting high quality trials involving exercise can be problematic. For example, it is difficult to conceal which patients have been allocated to treatment groups, and which have been allocated to control or no treatment groups. Theore, the researchers carried out a separate analysis focussing on the high quality trials. In these six trials, the effect of exercise was weaker.

"When we looked only at those trials that we considered to be high quality, the effect of exercise on depression was small and not statistically significant," said Mead. "The evidence base would be strengthened by further large-scale, high quality studies."

Carrying out general health checks does not reduce deaths overall or from serious diseases like cancer and heart disease, according to Cochrane researchers. The researchers, who carried out a systematic review on the subject for The Cochrane Library, warn against offering general health checks as part of a public health programme.

In some countries, general health checks are offered as part of standard practice. General health checks are intended to reduce deaths and ill health by enabling early detection and treatment of disease. However, there are potential negative implications, for example diagnosis and treatment of conditions that might never have led to any symptoms of disease or shortened life.

The researchers based their findings on 14 trials involving 182,880 people. All trials divided participants into at least two groups: one where participants were invited to general health checks and another where they were not. The number of new diagnoses was generally poorly studied, but in one trial, health checks led to more diagnoses of all kinds. In another trial, people in the group invited to general health checks were more likely to be diagnosed with high blood pressure or high cholesterol, as might be expected. In three trials, large numbers of abnormalities were identified in the screened groups.

However, based on nine trials with a total of 11,940 deaths, the researchers found no difference between the number of deaths in the two groups in the long term, either overall or specifically due to cancer or heart disease. Other outcomes were poorly studied, but suggested that offering general health checks has no impact on hospital admissions, disability, worry, specialist errals, additional visits to doctors or time off work.

"From the evidence weve seen, inviting patients to general health checks is unlikely to be beneficial," said lead researcher Lasse Krogsbøll of The Nordic Cochrane Centre in Copenhagen, Denmark. "One reason for this might be that doctors identify additional problems and take action when they see patients for other reasons."

"What were not saying is that doctors should stop carrying out tests or offering treatment when they suspect there may be a problem. But we do think that public healthcare initiatives that are systematically offering general health checks should be resisted."

According to the review, new studies should be focused on the individual components of health checks and better targeting of conditions such as kidney disease and diabetes. They should be designed to further explore the harmful effects of general health checks, which are often ignored, producing misleading conclusions about the balance of benefits and harm. Another problem is that those people who attend health checks when invited may be different to those who do not. People who are at a high risk of serious illness may be less likely to attend.

Two recent studies find no benefit to the heart from supplementing with vitamin D.

The most recent:

Vitamin D Therapy and Cardiac Structure and Function in Patients With Chronic Kidney Disease, The PRIMO Randomized Controlled Trial, Journal of the American Medical Association, February 2012

Found a lack of improvement in heart structure and function in patients taking the active vitamin D compound, paricalcitol. The trial included 227 patients with chronic kidney disease. It lasted 48 weeks.

"Conclusion: Forty-eight week therapy with paricalcitol did not alter left ventricular mass index or improve certain measures of diastolic dysfunction in patients with chronic kidney disease."

There were some negative effects from the vitamin D supplementation:

• Those taking vitamin D experienced more frequent episodes of hypercalcemia (high levels of calcium in the blood).
• Those taking vitamin D showed increased serum creatinine levels and decreased glomerular filtration rate (GFR, a measure of kidney function estimated from creatinine levels).

And this study from the end of last year:

A Prospective Randomized Controlled Trial of the Effects of Vitamin D Supplementation on Cardiovascular Disease Risk, November 2011, Presentation at American Heart Association 2011 Scientific Sessions

Found vitamin D supplementation (2500 IU vitamin D3) for four months had no significant effect on blood vessel function in postmenopausal women.

"Conclusions: Vitamin D supplementation did not improve endothelial function, vascular stiffness, or inflammation in healthy post-menopausal women. This study does not support the use of VitD supplementation to reduce cardiovascular disease risk."

Both of these studies were randomized, placebo-controlled trials, not epidemiological studies. Randomized trials are usually less biased and show a more clear picture of the effect of the intervention.

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