Latest Results of Hormone Therapy

Final reports on the use of estrogen (alone) have now been released. The Women's Health Initiative (WHI) study included over 10 000 women (without a uterus so they could take estrogen without progestin). They were randomly assigned to estrogen or a placebo. After 6.8 years of follow-up the study was stopped because those receiving the estrogen had higher death rates from stroke.

Here are the studies findings. Estrogen use alone increased the risk for:

• Stroke (fatal and non-fatal)
• Venous thrombosis (blood clots, usually in a deep leg vein)
• Blood clots in the lungs

• Coronary heart disease (contrary to what was previously thought)
• Colon caner or any other cancer
• Death from any cause (no longevity advantage)

The researchers conclude the study with these recommendations. "These findings confirm that estrogen-alone therapy should not be used to prevent chronic disease". They further concluded by saying, "We believe the findings support current FDA recommendations that hormone therapy only be used to treat menopausal symptoms and that it be used at the smallest effective dose for the shortest possible time."

NIH News Release, April 13, 2004, and in the April 14, 2004 issue of JAMA

C-Reactive Protein and Risk of Colon Cancer

C-Reactive Protein (CRP) is being implicated as a biochemical marker for increased risk for many chronic diseases including heart disease, diabetes, Alzheimer's disease, and now colon cancer. A large prospective study (22,887 people) looked at blood CRP levels and risk of developing colon cancer over the next 10 years. When they compared people with the highest CRP levels (top 25%, CRP levels over 3.0 mg/dL) with those with the lowest CRP levels (bottom 25%, CRP levels less than 1.0 mg/dL) those with the higher CRP levels were 2.5 times more likely to develop colon cancer. The relative risk jumped to 3.5 times greater chance of developing colon cancer when similarly comparing nonsmokers.

These results indicate that inflammation is a risk factor for developing colon cancer in average individuals. Knowing this gives hope and a strategy for prevention. If you can make lifestyle changes that lower CRP, you may also reduce the risk of colon cancer (and other related risks such as coronary heart disease). Based on other studies, there are several ways that CRP levels (and inflammation) may be decreased:

• Losing excess body weight
• A regular, aerobic physical activity program
• Stopping smoking
• Use of aspirin (noted in several studies to protect against colon cancer, but get doctor's guidance before starting aspirin use)
• And possible a higher vitamin C intake (see study below)

The standards for CRP levels and risk of colon cancer are the same as for prevention of coronary heart disease.

CRP and the Risk of Colorectal Cancer, JAMA 291:585-90, Feb. 4, 2004

Lung Cancer Epidemic in Women

Lung cancer is the leading cause of death from cancer in US women. It is responsible for as many deaths as breast cancer and all other gynecological cancers combined. Yet, lung cancer is 85% to 90% preventable by not smoking!

In the life span of one generation (the past 67 years) deaths from lung cancer have increased 600%. It appears that women may be more susceptible than men to the carcinogenic affect of cigarette smoke. Yet the number of teenage girls that take up smoking is at an alarmingly high rate. One recent survey found that 30% of high school girls smoke. Many smoke to express independence or equality with adults. Some smoke because they think it will help them control their weight.

The increase in smoking among women is now a world wide trend. Smoking in Japan among women double in just a 5 year period. An estimated 20 million women have started smoking in China just since the 1990s. Similar trends are happening throughout Asia and Africa.

Over 80 000 women will develop lung cancer this year. Yet the tobacco companies are still allowed to promote smoking through advertising ($6.7 billion dollars annually). Much of this advertising is targeted directly toward young women. The American Medical Association featured this epidemic of lung cancer in women in their April 14 issue. They conclude their article by stating that cutting the increase of tobacco use in women is one of the "greatest opportunities for disease prevention in the world today". Let each person decide for themselves how they will relate to this epidemic and assist where possible to encourage young women not to take up smoking.  (See graph of increase in lung cancer in women.)

Lung Cancer in US Women, JAMA 291:1763-68, April 14, 2004

Actual Causes of Death in US

Modifiable behavioral risk factors are leading causes of death in the US. A recent article in the Journal of the American Medical Association quantified these risks (see chart below). Their overall conclusion is that about half of all deaths (2.4 million) that occur in the US each year are due to largely preventable behaviors and exposures.

This study did not include the effects of high blood pressure and high cholesterol levels on mortality. Much of these two very common problems are also modifiable through lifestyle changes. The writers point out that health care spending continues to outstrip overall growth in the economy (GDP) and that a change in our health care system is needed. "Findings in this study argue persuasively for the need to establish a more preventive orientation in health care and public health systems in the United States." See in chart form.

Mokdad AH, et al, Actual Causes of Death in the United States, 2000, JAMA 291:1238-45, Mar 10, 2004

Trends in Energy Intake

In the last 30 years, the prevalence of obesity has doubled (from 14.5% to 30.9%). This is due to a variety of factors, but primarily unhealthy diets and an increase in sedentary behavior. New data from CDC also shows that we are simply eating more calories than we used to.

From 1971 to 2000, men increased their energy intake from 2450 calories per day to 2618 calories per day, an increase of 168 calories per day. That doesn't seem like much, but 168 calories per day above the body's needs is equivalent to 17 pounds of extra fat in one year! Obviously the body is able to correct somewhat for this increase in calories, but not enough to prevent a significant increase in obesity.

During the same time period, the average energy intake for women increased from 1542 to 1877 calories per day, an increase of 335 calories per day. This increase in calories eaten comes primarily from an increase in carbohydrates eaten, an additional 62.4 grams per day for women and an additional 67.7 grams per day for men.

Further analysis shows that this increase in calories comes primarily from increased energy intake eaten away from home: fast food and regular restaurants, snack foods (salty snacks such as chips, soft drinks, and pizza), and from increased portion sizes (super sized restaurant meals and larger snack portions of chips, soft drinks, etc.).

Trends in Intake of Macronutrient US 1971-2000, MMWR 2004, JAMA Mar 10, 2004

Waist Girth Predicts Health Risks better than BMI

Research continues on the best way to evaluate your risk of overweight. A new report in the March issue of the American Journal of Clinical Nutrition suggests that waist girth is a better indicator of risk than body mass index (BMI) the standard that has been used for years.

Researchers analyzed both BMI and waist circumference (WC) in about 15,000 men and women from the NHANES III study. They concluded that a waist circumference measurement is a better marker for health risk than is BMI and consequently a greater emphasis should be placed on taking WC measurements than BMI determination.

They found that for every 1 inch increase in the waist circumference in men the risk for:

• High blood pressure increases by 10%
• High blood cholesterol level increases by 8%
• Low HDL cholesterol increases by 15%
• High blood fats (TG) increases by 18%
• And metabolic syndrome increases by 18%

Similar increases were found for women. What should your waist girth be? There isn't a consensus yet but NIH has suggested that a waist girth of  35+ inches for women and 40+ inches for men indicates high risk. Other studies recommend that a healthy waist girth (low risk) is less than 33 inches for women and less than 35 inches for men.

 Janssen Ian, et al, Waist circumference and  health risk, Amer J Clin Nutr 79:379-84, Mar 2004
ShanKuan Zhu, et al, Waist circumference and obesity-associated risk , Amer J of Clin Nu, 76:743-9

Vitamin D and Your Health

The protective role of vitamin D (the sunshine vitamin) is becoming more recognized as vital to your health. The importance of vitamin D was featured in the March 2004 issue of the American Journal of Clinical Nutrition. A listing of some of the health problems vitamin D may help prevent is quite impressive: cancer, type 1 diabetes, high blood pressure, and osteoporosis to name a few.

Studies have reported higher rates of death from chronic diseases including cancer for people living in Northern regions compared to the South. Examples include multiple sclerosis, colon cancer, prostate cancer, beast cancer, and hypertension. One study showed that blood pressure could be significantly lowered with 3 months of USB radiation treatment. Animal studies have shown vitamin D to be protective against Type 1 diabetes, rheumatoid arthritis, and multiple sclerosis.

Vitamin D is made from the sun (UVB rays) shining on the skin. However, in the Winter months (or early morning and evening) in northern regions, the sun rays are largely devoid of UVB and little or no vitamin D is made. You must then be sure to get adequate vitamin D in your diet. The few naturally occurring foods high in vitamin D are Cod liver oil and oily fish. Eating these foods 3-4 times per week will meet your needs. Fortified foods include fortified milk (100 IU/8 oz), fortified orange juice (100 IU/8 oz), and some cereals and bread. The body needs at least 200-600 IU daily (200 for younger adults, 600 for seniors), although the author of this article recommends 1000 IU daily for optimum health if you don't get regular exposure to direct sun light.

How much sunlight do you need? The author recommends exposure of hands, face, and arms (or arms and legs) to direct sun for about 1/4 the time it would take to develop a slight sunburn (skin turned pink). You want adequate sun exposure, but not enough to cause any sunburn.

Who is at risk of being vitamin D deficient?

• Nursing infants, if not given a vitamin D supplement (vitamin D is very low in human milk from most mothers)
• Elderly, especially if living in northern cities of the US and spending most of their time indoors. One study showed that as many as 30% to 42% of the elderly were low in vitamin D even at the end of August in Boston.
• African American women
• Adults who spend little time outdoors or always wear sun protection, especially those living in Northern cities. In Boston, the author found 32% of healthy adults aged 18-29 years of age vitamin D deficient at the end of winter in Boston.
• Obese individuals

Blood tests. You can have your blood tested for vitamin D. If you do, the author points out that it is important to test the correct form of vitamin D. You should test for 25(OH)D in the blood, not the active form of vitamin D called 1,25-dihydroxyvitamin D. The minimum levels of 25(OH)D in the blood should be 50 nmol/L, levels less than this indicates a deficiency. A level of 78-100 nmol/L is recommended for maximum bone health and prevention of chronic disease.

Holick Michael F, Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis, Amer Jour of Clinical Nutrition 79:362-71, Mar 2004

Whole Grains and Weight Gain

What kinds of foods are best to naturally help prevent excess weight gain? Researchers at Harvard University tackled this question by looking at the diets eaten by 74,000  women over a 12 year period. They found that women who chose whole grain breads and cereals gained less weight during the 12 year study than those women choosing white bread and refined cereals.

Over the entire follow-up period an increase in dietary fiber and whole grains was linked to significantly less weight gain. The opposite was true for the increased intake of refined grain products (such as white bread). Those women eating the most whole grains, gained the least weight. These findings were independent of age, physical activity, HRT use, smoking status, caffeine intake, alcohol consumption, and amount of fat or protein intake.

Those women who daily ate 12 g of fiber more than other women in the study, gained 8 pounds less over the 12 years. This protective effect of eating whole grains was greatest among those who were overweight at baseline. This means that eating whole grains is especially helpful for preventing further weight gain. Of the women who were overweight at the start of the study, those eating whole grains cut their weight gain in half compared to those not eating whole grains.

When comparing the women who ate the most fiber (top 20%) with those eating the least (bottom 20%), the high fiber diets cut the risk of major weight gain by 49%. This study shows the value of choosing whole grains over refined gains for long term weight management.

Liu S, Willett WC, Whole Grains and Body Weight, Amer J Clin Nutr 78:920-7, Nov 2003

Magnesium and Type 2 Diabetes Prevention

Two large population studies completed recently indicate that eating foods rich in magnesium may be helpful in preventing type 2 diabetes. The Women's Health Study (cohort of 39,345 healthy women) looked at the risk of developing diabetes over a six year period. They found an inverse association between dietary magnesium intake and risk of type 2 diabetes. Comparing those women eating the most magnesium (top 20%) to those eating the least (lowest 20%), they found a 22% reduction in risk of diabetes in women who were overweight (BMI 25+).

The second study analyzed data from the Nurses' Health Study (85,060 women followed 18 years) and the Health professionals' Follow-up Study (42,872 men followed 12 years). During this time, 5,418 people developed diabetes. When researchers compared the participants with the highest intake of magnesium from foods (top 20%) with those eating the least (lowest 20%) they saw a 34% lower risk of developing type 2 diabetes in women and 33% for men. (See graph of data.)

This is exciting news. These studies suggest that by simply eating more foods high in magnesium, you may reduce the risk of getting diabetes by 22-33%, that's preventing one-fifth to one-third of all cases of diabetes! If you are concerned about preventing diabetes, here is another positive preventive step you can take. Be sure you get adequate magnesium in your diet daily.

The recommended amount of magnesium in the diet (US RDA) is 310 to 420 mg/day (depending upon age and gender). Foods rich in magnesium include dark-green, leafy vegetables, whole grains, soy products, legumes and seeds, fruits such as bananas and avocados, and nuts such as almonds and cashews (see chart below).

Mike Mitka, Journal of the American Medical Association, 291:1056, Mar 3, 2004

Preserving Eye Health

How important is your vision to you? We don't often think about eye or other problems until they occur. A special feature in the Journal of the American Medical Association makes these recommendations for preventing blindness and serious visual loss:

Susannah R, et al, Preventing Visual Loss, JAMA 291:1487-96, Mar 31, 2004

Home Blood Pressure Measurements

A new study reveals that self monitoring of blood pressure at home proves to be more accurate in assessing risk of future cardiovascular events than blood pressures measured in the doctor's office. Nearly 5000 people monitored their blood pressures at home and at the doctor's office. The pressures taken at home were much more predictive of future complications than the pressures taken in the office. Here are some of their findings. (see graph of results.)

• For each 10 points increase in the home systolic BP reading, the risk of a future cardiovascular event increased by 17%.
• For each increase of 10 points systolic in the office BP measurement, there was no significant increase in risk.
• Patient with normal home blood pressures but high office pressures had only an 18% increased risk of cardiovascular events over the 3.2 year study.
• Persons with high blood pressure at home and normal BP at the office had a 206% increased risk.

Bobrie G, et al, Cardiovascular prognosis of BP self-measurement, JAMA 291:1342-9, Mar 17, 2004

QuickFacts  Important health facts you need to know and share.

Lutein Helps Eye Sight in AMD Suffers. Previous studies have shown that Lutein was helpful in preventing age related macular degeneration (AMD), a leading cause of blindness. New research now shows that lutein also helps enhance vision in people who already have AMD. Lutein is an antioxidant found in dark green vegetables such as spinach, kale, collard greens, etc. Eating these foods regularly may help you maintain healthy eyesight for a lifetime.
FoodNavigator.com, 4-9-04, and in Optometry, April 2004 issue.

Atkins Diet. An estimated 59 million adults in the United States are currently on the Atkins high protein diet! Keep in mind that just because something is popular, doesn't mean it's good. Let's see if the nation gets skinny. On the last "low fat fad" diet Americans simply got fatter. A balanced approach of healthy eating, watching portion sizes, and increased physical activity is a safer approach and one that can be followed for a lifetime. The problem with fad diets is that when you quit them and you haven't changed your lifestyle, the weight quickly comes back.   FoodNavigator.com, 4-9-04

Folate and Depression. Evidence continues to accumulate suggesting a link between a low blood folate (B vitamin) level and depression. The latest study included 3 000 people aged 15-39. The data shows that in those people with either major or mild forms of depression, blood folate levels are lower than in those people who have never been depressed. Getting adequate folate in your diet may help prevent or improve depression problems. Folic acid is found in legumes (especially lentils), leafy greens, whole grains, and oranges. The recommended intake is 400 micrograms per day. Other studies have found folate helpful in preventing colon cancer, birth defects, and ischemic strokes. (more...)
Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Apr 04

Lowering CRP Levels. High levels of C-Reactive Protein (CRP) in the blood have been linked to a higher risk of heart disease, diabetes, colon cancer, and even Alzheimer's disease. Now, for the first time, vitamin C has been shown to decrease levels of CRP. The study conducted by the University of California, Berkley studied 160 adults who were smokers or were regularly exposed to cigarette smoke.  They were randomly assigned to take a vitamin C supplement (500 mg/day) or a placebo. After 2 months, those taking vitamin C showed a significant drop (24%) in CRP levels in the blood compared to those taking the placebo. 

Eating more vitamin C, found in citrus fruits, peppers, tomatoes, and berries (plus all fresh fruits and vegetables), or taking a vitamin C supplement may help cut your risk of heart disease and diabetes. Other ways to lower CRP is to lose excess weight and get regular exercise.
Journal of the American College of Nutrition, April, 2004

Vitamin E and C and Cognitive Function. There is experimental data to suggest that oxygen free radicals are probably involved in the deterioration of cognitive process as we age. Harvard University studied nearly 15,000 elderly women and compared dietary records with mental functioning tests. They found that women who were long term and current users of vitamin C and E supplements (antioxidants) had significantly better mental performance on testing than women who didn't take vitamins C and E. This association was strongest in those women who had low dietary intakes of vitamin E.

The typical dosage of vitamin E was about 400 mg/day, and about 400-500 mg/day of vitamin C. Those taking very high doses didn't have any further benefit. Neither did those who took just vitamin E or vitamin C by itself. They had to be taken together to make a difference. Human studies have shown that vitamin E requires vitamin C for optimal metabolism. The authors concluded that there is currently support for a modest effect of supplementation with antioxidant vitamins (E and C) on cognitive function.
American Journal of Clinical Nutrition, April, 2003

n-3 fatty acids protect against cognitive decline. The kind of fats we eat may affect cognitive decline in older age. Cognitive decline was measured in a study of 246 elderly men and women. Researchers found a higher intake of n-3 fatty acids (sometimes called omega 3 fats) decreased the risk of cognitive decline by 41% over the 4 years of the study. A high intake of saturated fat (stearic acid) nearly doubled the risk of cognitive decline. A high intake of polyunsaturated fat also raised the risk of decline some, but monounsaturated fats like oleic acid (such as in olive and Canola oil), had no detrimental affect.

It appears that eating more foods high in n-3 fatty acids (walnuts, flax meal, Canola oil, fish), eating less saturated fat, and eating moderate amounts of polyunsaturated fat (linoleic acid) is best for preventing cognitive decline. This recommendation is in harmony with NIH's guidelines for good cardiovascular health. Choose healthy fats for heart health and mental acuity!  
American Journal of Clinical Nutrition, April 2003

Social Support and Heart Health. Close relationships help protect the heart, especially for persons who already have a heart problem. A British study screened 1 034 patients soon after they experienced a heart attack. They were then followed to see who would develop further heart problems. If they lacked social support -- not having a close friend/spouse and a close intimate relationship -- they were twice as likely to suffer from major heart problems in the next year.  This survival advantage provided by a close, supportive relationship held up even when the researchers adjusted for smoking, blood pressure, cholesterol and other potential confounders. Love mends broken hearts!  Heart, May 2004

Early Investment in Bone Health.  The American Academy of Pediatrics has issued a new policy statement urging physicians to contact schools in their communities and push for elimination of sweetened drinks there. Soft drinks are linked to an increase in obesity in children, and soft drinks replace milk in the diet setting the stage for fractures and osteoporosis later in life. Adolescence is a time of high bone accretion. Up to 90% of peak bone mass is acquired by age 18 years in females and by age 20 in males. USDA data shows that milk consumption has gone down and soft drink consumption up in our children diet in the US. Their statement emphasizes that the best approach to osteoporosis is prevention, especially during the early years. This includes "emphasizing a proper lifestyle -- get calcium and vitamin D in the diet, and exercise!"
Pediatrics 113:152-154, 2004

Vitamin E and Risk of Diabetes New data from Finland shows vitamin E to be protective against the development of type 2 diabetes. This study included over 4000 people. They analyzed their diets and then followed them for 23 years to see who would get diabetes. Those person eating the most vitamin E (top 25%) had a 31% decreased risk of getting diabetes compared to those eating the least (lowest 25%) vitamin E. The authors conclude, "This study supports the hypothesis that development of type 2 diabetes may be reduced by the intake of antioxidants in the diet." Some of the best sources of vitamin E are sunflower seeds, wheat germ, sunflower oil, soy oil, other vegetable oils, filberts, and other nuts.  (see chart of results.)   Diabetes Care 27:362-366, 2004

Epidemic of Diabetes type 2 in the Young.  "We are in the midst of an epidemic of lack of exercise, of obesity, of the insulin resistance syndrome (IRS), and of diabetes in young people," states a report in the medical journal Diabetes Care. The rate of increase in diabetes type 2 in young people is alarming. World wide, the number of persons with diabetes has tripled since 1985. Most alarming is the rapid increase of type 2 diabetes in young people. This is linked to the rapid increase of obesity in children coupled with lack of exercise. In 1970 only 4% of children 6-11 were obese (BMI exceeding the 95th percentile). Now the rate is over 15%, a three fold increase! Improving the eating and exercise habits of our children must become a national priority to stem this epidemic.
Diabetes Care, April 2004

Power Point Slides

The following slides are taken from studies reviewed in this newsletter and are available to view and download for your use in presenting health information in your local health promotion programs. Do not copy slides to distribute to other people.

• Dietary vitamin E and risk of type 2 diabetes
• Self-measurement of blood pressure, predictive value
• Dietary magnesium and risk of type 2 diabetes
• Waist girth measurements and health risks
• Social support and heart health
• Epidemic of lung cancer in women
• CRP and colon cancer risk
• Actual causes of death

Featured Health Links

May is National High Blood Pressure Education Month. Go to the NIH's site for great materials on high blood pressure education and prevention. They have a special BP Education Kit. Check it out! 

Helping Patients With Alcohol Problems.  An excellent 22 page guide designed for health professionals to screen for alcohol problems and how to advise people to cut down when needed. Just released in February.

Airborne Allergens. Bothered by Summer allergies? Here is an excellent educational guide on airborne allergens. It is a 40 page pdf. It's easy to read and very informative. Prepared by NIH, National Institute of Allergy and Infectious Diseases, April, 2003.

Worksite Wellness Programs in Action. Read about companies who are offering fitness and wellness programs at their worksite to help decrease health care expenses and improve productivity.

Trans Fats. The Food and Drug Administration (FDA) has an educational site on trans fats and how they will soon be added to food labels. This is a good site to educate people on trans fats and food labels.

Vitamin E Handout. Here is an excellent handout on vitamin E, how much you need, foods high in vitamin E, etc. Concise and easy to read. Developed by University of Florida, Extension. In PDF format.

Healthy Recipes

Looking for something new and good to eat? Here are a few ideas for you to try that are tasty and good for you!

• Black Beans on Rice - Rice and beans are a staple in many countries. Try this tasty, economical, and healthy meal.
• Hummus - Make your own hummus! It's a great Middle Eastern delight. Use it as a spread on breads and crackers.
• Nut and Seed Spreads - Try making your own nut spreads.
• Filbert Spread - Here is a good alternate to butter that tastes great!

New, Lifelong Weight Management
     Coordinator's Guide

The new Lifelong Weight Management™ program for health outreach is being released early May. During this 10-week lifestyle change program, attendees will develop knowledge and skills for controlling their weight. The principles are helpful for losing weight, maintaining a healthy weight, and preventing weight gain.

The program is designed for community leaders, and is appropriate for a class or home setting. The Coordinator’s Manual and CD include over 400 PowerPoint® slides with speaker notes for each, promotional masters, participant handout masters, and many additional resources.

Key aspects of the presentations include realistic goals, calorie controlled eating plans, physical activity, motivation, instruction in the principles of weight management and behavior change, problem solving, group support and accountability, a self-monitoring system for food intake and activity level, outcome measurements, and group interaction and support.

Developed by Don Hall, DrPH, CHES, at Wellsource, Inc., the Lifelong Weight Management™ program is available in the LifeLong Health product line as one of several resources for community health outreach. It is complete for $275.00. For more information call 503.557.9545 or 800.862.4395.