Free ACT questionnaire may be superior to $3,000 FeNO device in determining asthma control in children

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This study from Turkey included 76 children 6 to 11 years of age (mean age 8.7) with asthma who completed Childhood Asthma Control Test (C-ACT) and underwent fractional concentration of exhaled nitric oxide (FeNO) and spirometric measurements during the monthly clinic visits.

A C-ACT score of 22 or less had 69% sensitivity and 77% specificity in determining not well-controlled asthma, whereas an FeNO value of 19 ppb or higher had 61% sensitivity and 59% specificity. Receiver operating characteristic curve analysis revealed that the C-ACT was better than FeNO for identifying patients with uncontrolled asthma.

A C-ACT score of 22 or less (odds ratio, 8.75) and an FeNO of 19 ppb or greater (odds ratio, 2.60) were indicators for uncontrolled asthma.

The authors concluded that C-ACT is superior to FeNO in determining the control status of children with asthma. Editor’s note: Measurement of fractional concentration of exhaled nitric oxide (FeNO) has its place in the care of adults and children and is incorporated in the asthma guidelines (http://ajrccm.atsjournals.org/content/184/5/602.abstract). However, considering the cost of the device (for example, Niox Mino is priced above $3,000 in the U.S.), the use of a simple paper- or computer-based C-ACT score test has obvious cost-saving advantages. It is encouraging to have the scientific evidence that supports that this cost-saving approach can also be more accurate in children with asthma.

References:

Identifying uncontrolled asthma in children with the childhood asthma control test or exhaled nitric oxide measurement. Yavuz ST, Civelek E, Sahiner UM, Buyuktiryaki AB, Tuncer A, Karabulut E, Sekerel BE. Ann Allergy Asthma Immunol. 2012 Jul;109(1):36-40. Epub 2012 May 31.

Childhood Asthma Control Test - Asthma.com by GSK http://bit.ly/RicZ8l

The Childhood Asthma Control Test∗: Retrospective determination and clinical validation of a cut point to identify children with very poorly controlled asthma. JACI, 2010 http://bit.ly/Rid5Nl

Comments from Twitter:

Dr John Weiner @AllergyNet: Reassuring. Many of us use ACT

Immunotherapy - 2012 COLA video lecture

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Immunotherapy Basics Part 1 - Dr. Jay Portnoy reviews the basics of allergen immunotherapy (allergy shots) starting with its history and the extracts used to administer it. Held on August 13, 2012.



Immunotherapy Basics Part 2 - Dr. Jay Portnoy describes the process for writing a prescription for allergen immunotherapy (allergy shots). Held on August 13, 2012.



The two lectures are part of the ACAAI COLA YouTube channels that features more than 100 online conferences focused on allergy and immunology. The project is hosted by the allergy and immunology department at Mercy Children's Hospital in Kansas City and features many outside speakers.

Mechanisms of allergen-specific immunotherapy (click to enlarge the image):

Immunotherapy - top articles for August 2012

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Here are my suggestions for some of the top articles about immunotherapy for August 2012:

Immunotherapy prescribed for 5 years by 75% of US-Canadian allergists, for 3 years by the rest of the world http://goo.gl/K0Cr7

Intralymphatic immunotherapy for cat allergy induces tolerance after only 3 injections - first human study ILIT with MAT–Fel d 1 http://goo.gl/jHAe9

Eosinophilic esophagitis induced by milk oral immunotherapy - 3 case reports http://goo.gl/NHljN

Allergen immunotherapy is a cost-effective treatment in modifying existing allergic respiratory diseases - Chest 2012 http://goo.gl/GdkbH

Therapies for allergic inflammation: refining strategies to induce tolerance - Nature Medicine 2012 review, full text http://goo.gl/te9XM

Fear needles? Looking away while you're getting an injection makes it hurt less (study) http://goo.gl/k7NSi

Allergen immunotherapy causes production of high-affinity allergen-specific blocking IgG(4) http://goo.gl/FvR0Z

Safety of Allergen Immunotherapy - 2012 Medscape review http://goo.gl/0ZsVx

Epinephrine in the treatment of anaphylaxis. Adult intramuscular dose is 0.3 to 0.5 ml of 1:1,000 concentration http://goo.gl/Qad6S

To expect clinical efficacy from SLIT for allergic rhinitis, sufficiently high doses have to be regularly administered for at least 3 consecutive years http://goo.gl/kl8Xx

Allergy shots: Do patients feel pain or fear? http://goo.gl/MlczE - Full text PDF: http://goo.gl/SVtLp

"Beat Allergies Drop by Drop" - WSJ - However, most insurers don't cover SLIT cost, typically $30-150/month http://goo.gl/71W2s

The articles were selected from my Twitter stream @Allergy and Google Reader RSS subscriptions. Some of the top allergy accounts on Twitter contributed links. I appreciate the curation provided by @JuanCIvancevich @AllergyNet @IgECPD4 @DrAnneEllis @AACMaven @AllergieVoeding @allergistmommy @mrathkopf @wheezemd.

Please feel free to send suggestions for articles to allergycases@gmail.com and you will receive acknowledgement in the next edition of this publication.

Image source: OpenClipArt.org, public domain.

Effect of childhood asthma and inhaled steroid on adult height: 1.2 cm lower height with budesonide vs. placebo

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The use of inhaled glucocorticoids (ICS) for persistent asthma causes a temporary reduction in growth velocity in prepubertal children. The resulting decrease in attained height 1 to 4 years after the initiation of inhaled glucocorticoids is thought not to decrease attained adult height.

This study published in the NEJM measured adult height in 943 participants in the Childhood Asthma Management Program (CAMP) at age 25. Starting at the age of 5 to 13 years, the participants had been randomly assigned to receive 400 μg of budesonide, 16 mg of nedocromil (not available in the U.S. since 2010), or placebo daily for 4 to 6 years.

Mean adult height was 1.2 cm lower in the budesonide group than in the placebo group (P=0.001) and was 0.2 cm lower in the nedocromil group than in the placebo group. A larger daily dose of inhaled glucocorticoid in the first 2 years was associated with a lower adult height (−0.1 cm for each microgram per kilogram of body weight) (P=0.007). The difference between ICS and placebo was noted only during the first two years of therapy and it was not progressive.

The initial decrease in attained height associated with the use of inhaled glucocorticoids in prepubertal children persisted as a reduction in adult height, although the decrease was not progressive or cumulative.

Editor's note: This study shows that more severe asthma that requires treatment with ICS is associated with lower height as an adult. Many chronic diseases during childhood affect adult height and asthma is no exception. A longer time since asthma diagnosis and atopy (any positive skin test) were independent risk factors for shorter adult height. When asthma and atopy impair growth, the deficit may persist into adulthood. The conclusion is not to "stop" the use of ICS but to use the lowest effective ICS dose for symptom control, which is in agreement with the current asthma guidelines.

By the way, the findings of the 2012 study in the NEJM contradict a 2000 study published in the same journal that did not show an effect of ICS on growth (Effect of Long-Term Treatment with Inhaled Budesonide on Adult Height in Children with Asthma - NEJM http://goo.gl/qM3Nf).



Asthma Inhalers (click to enlarge the image).

Comments by other physicians:

This article is an attempts to address sensational headlines (http://bit.ly/RLkhSv) such as: "Everybody Panic: Asthma Inhalers May Stunt Growth Permanently", "Asthma Drug Stunts Kids' Height for Life", "Asthma drug may stunt growth permanently", "Study: Asthma medications make you short", etc.

The benefits of ICS in asthma far outweigh a slight decrease in height. However, when compared with placebo and nedocromil, the effect of budesonide is demonstrated as a cause of reduced stature, since all patients were also asthmatic and atopic.

In the paper all the patientes were mild-to-moderate asthma, although the authors didn't take into account the difference of severity of asthma between groups, patients were randomly assigned to the three treatment groups and the differences between the groups were significant.

Andrew S Nickels, MD:

Looking at the original Childhood Asthma Management Program (CAMP) cohort, the baseline characteristics that are reported seem matched, which would suggest adequate randomization. (1) One lacking aspect of initial enrollment demographics in the original trial cohort is the initial tanner staging being reported. This is pointed out by Mary Ellen Wohl and Joseph A Majzoub in their editorial response to the initial trial.(2) This seems a crucial baseline statistic when assessing growth velocity and final height.

However, while the cohorts may have been similar at baseline, there were significant differences between the inhaled Budesonide and Placebo groups in regards to several outcomes. These include the following: course of oral Prednisone (70/100 person-years vs 122/100 person-years, P below 0.0001), Urgent care visits due to asthma (12/100 person-years vs 22/100 person-years, P below 0.0001), and Hospitalizations due to asthma (2.5/100 person-years vs 4.4100 person-years, p = 0.04). (1) Intuitively, one would expect the higher burden of asthma morbidity felt by the placebo group would negatively effect height,
but that conclusion is outside of the scope of these investigations. As pointed out by Wohl and Majzoub, growth is a complex and poorly understood process. (2) This study outlines a loose association at best between two groups whose developmental years are dissimilar. A larger cohort would be needed with tighter subgroup analysis to tease out this finding. This will be limited by the unethical nature of enrolling known asthmatic children in placebo control trials. (3)

1. The Childhood Asthma Management Program Research Group. Long Term Effects of Budesonide or Nedocromil in Children with Asthma. N Engl J Med 2000; 343:1054-1063.

2. Wohl M, Majzoub J. Asthma, Steroids, and Growth. N Engl J Med 2000; 343:1113-1114.

3. Coffey MJ, Wilfond B, Ross LF. Ethical assessment of clinical asthma trials including children subjects. Pediatrics. 2004; 113: 87-94

References:

Effect of Inhaled Glucocorticoids in Childhood on Adult Height. H. William Kelly, Pharm.D., Alice L. Sternberg, Sc.M., Rachel Lescher, M.D., Anne L. Fuhlbrigge, M.D., Paul Williams, M.D., Robert S. Zeiger, M.D., Ph.D., Hengameh H. Raissy, Pharm.D., Mark L. Van Natta, M.H.S., James Tonascia, Ph.D., and Robert C. Strunk, M.D. for the CAMP Research Group, September 3, 2012 (10.1056/NEJMoa1203229) (free full text).

Inhaling steroids stunts growth, but not much. "This is mostly good news. Now we know what it is. It is a half an inch" | Reuters  http://goo.gl/zkTpc

Image source: Image source: FDA and Wikipedia, public domain.

10 principles for clean air - what to do to achieve the goal?

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A recent analysis from the USA attributed 18,000,000 lost work days annually to PM2.5 exposure, and 11,000,000 school absence days to ozone exposure. Mortality increases by 6–8% for every 10 μg·m−3 increase in long-term PM2.5 concentrations in the community.

Here are the proposed 10 principles for clean air from the official journal of the European Respiratory Society:

1) Citizens are entitled to clean air, just like clean water and safe food.

2) Outdoor air pollution is one of the biggest environmental health threats today, leading to significant reductions of life expectancy and productivity.

3) Fine particles and ozone are the most serious pollutants. There is an urgent need to reduce their concentrations significantly.

4) Roadside pollution poses serious health threats that cannot be adequately addressed by regulating fine particle mass or ozone. Other metrics such as ultrafine particles and black carbon need to be considered in future research and so inform further regulation.

5) Non-tailpipe emissions (from brakes, tyres and road surfaces, etc.) pose a health threat for road users and subjects living close to busy roads.

6) Real-world emissions of nitrogen dioxide from modern diesel engines are much higher than anticipated. This may expose many road users, and subjects living on busy roads, to short-term peak concentrations during rush hours and periods of stagnating weather that may impact on health.

7) Global warming will lead to more heatwaves, during which air pollution concentrations are also elevated and during which hot temperatures and air pollutants act in synergy to produce more serious health effects than expected from heat or pollution alone.

8) Combustion of biomass fuel produces toxic pollutants. This is true for controlled fires, such as in fireplaces, woodstoves and agricultural burning, as well as for uncontrolled wildfires.

9) Compliance with current limit values for major air pollutants confers no protection for public health. In fact, very serious health effects occur at concentrations well below current limit values, especially those for fine particles.

10) Policies to reduce air pollution are needed that ultimately lead to air that is clean and no longer associated with significant adverse effects on the health. The benefits of such policies outweigh the costs by a large amount.

References:

Ten principles for clean air. B. Brunekreef et al. ERJ March 1, 2012 vol. 39 no. 3 525-528.


Image source: OpenClipArt, public domain.

Inflammatory Bowel Disease and Antibiotic Exposure: An Association Worth Knowing About

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Trying to understand factors that are associated with an increased risk of developing inflammatory bowel disease (IBD) is a subject of interest to many readers of our journal and in turn families of patients who experience this chronic gastrointestinal illness. It is for that reason I call your attention to an article by Kronman et al. (doi: 10.1542/peds.2011-3886) who report on a retrospective cohort study in the UK of more than 1 million children followed for the development of IBD in the setting of those exposed and not exposed to anti-aerobic antibiotics. The younger a child was when receiving an antibiotic, and the more courses received, the stronger the association with new onset IBD. As to what antibiotics demonstrated this association, and how usage of these drugs might play a role in the development of IBD, these are two great reasons to digest the information contained in this intriguing study.

A Possible Explanation Why Steroids Do Not Work in Treating Bronchiolitis

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There have been a number of articles in our journal and others discussing whether or not steroids have a role in the treatment of bronchiolitis. While the overall evidence currently suggests that steroids do not help, one wonders why this might be the case. Fortunately, Diaz et al. (doi: 10.1542/peds.2012-0160) test a hypothesis that RSV infected patients have receptors on cells that are unable to bind cortisol and hence reduce the anti-inflammatory response that ensues when this virus infects an infant’s respiratory tract. With an inability to bind the steroid, there is an inability for the steroid to make a difference. So does this hypothesis play out in vivo? Take a deep breath and look at the results coughed up in this fascinating study. If you are still thinking of using steroids to treat bronchiolitis, this study will make you think again.

The Cool Benefit of Epo for Neonatal Encephalopathy

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Finding ways to improve the outcomes in babies born with hypoxic-ischemic encephalopathy (HIE) continues to be a frequent focus of research for neonatologists and neurologists. This week we share the results of a promising phase 1 study by Wu et al. (doi: 10.1542/peds.2012-0498) looking at the safety and pharmacokinetics of erythropoietin (Epo) used along with hypothermia for treatment of HIE. Even if you are not a neonatologist, it is important to know about this therapeutic addition given the promising safety results shown in this study. Large efficacy trials are likely in progress already, and we hope we will be fortunate enough to receive the results of those trials in our journal. In the meantime, if you are unfamiliar with Epo and why it might be of benefit to these infants, this study is a must-read.

A Systematic Review of Medications for Treating Autism Spectrum Disorders in Teens and Young Adults

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More and more is being written about older children and adolescents with autism spectrum disorder (ASD) and this week, we are releasing a systematic review by Dove et al. (doi: 10.1542/peds.2012-0683) of medications used to treat ASD in this older age group. As you might imagine, the number of studies that provided evidence for or against various medications was small. I prescribe that you read this interesting review article so you are up to speed regarding what the literature does or doesn’t tell us about drugs that parents of your patients with ASD may ask you about.

Lions and Tigers and Bears and Horses?

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Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

My wife and I were recently hiking in the Southern California desert. At one of the trailheads, a large sign had warned us of the dangers of rattlesnakes. After a few hours of hiking my wife looked around a bit anxiously and asked me if there were mountain lions in the area. By this time, we had climbed about 2,300 feet and were miles from the trailhead. We had not seen another human on the trail and had seen lots of bighorn sheep scat. Since I am not allergic to bees, I tend not to worry about the dangers of wildlife while hiking. However, my wife’s anxiety got me to thinking about what animals really posed the most danger to humans.

 Interestingly enough, according to an article published in the journal Wilderness & Environmental Medicine (June 2012), hiking, walking, or working in Vermont may be more dangerous than hiking in the remote California high desert. Researchers queried the CDC WONDER Database for all animal-related fatalities between 1999 and 2007. The WONDER Database is a compilation of mortality and other epidemiologic data from death certificates in the United States. Inclusion criteria included all mortalities that were a result of bite, contact, attack, or envenomation. Animal attacks resulting in fatalities were divided into those resulting from nonvenomous and venomous causes.

Between 1999 and 2007, animals fatally injured 1,802 people: approximately 60% were nonvenomous and 40% were venomous animals. More than one-third of all deaths were due to “other mammals,” which consist primarily of farm animals such as horses, cows, and pigs. Hornets, wasps, and bees (28.2%) were the next most common, followed by dogs (13.9%). Venomous snakes and lizards only accounted for 3.3% of fatalities. The data are fairly clear that the biggest danger to humans is posed by those animals with whom we are in the most contact. The likelihood of running into a mountain lion while hiking is exceedingly remote. However, being kicked, crushed, or bitten by a farm animal or dog is much more likely given that so many of us are in close proximity to those animals every day. So, I reassured my wife that we were safer on this remote hilltop than back on our little farm in Vermont and we pushed on with our hike.

Noted by WVR, MD

*This filler excerpt can be found in the September 2012 Pediatrics print journal p. 556, or via online here.

Vitamin D deficiency increases risk of heart disease

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New research from the University of Copenhagen and Copenhagen University Hospital shows that low levels of vitamin D are associated with a markedly higher risk of heart attack and early death. The study involved more than 10,000 Danes and has been published in the well-reputed American journal Arteriosclerosis, Thrombosis and Vascular Biology.

Vitamin D deficiency has traditionally been linked with poor bone health. However, the results from several population studies indicate that a low level of this important vitamin may also be linked to a higher risk of ischemic heart disease, a designation that covers heart attack, coronary arteriosclerosis and angina. Other studies show that vitamin D deficiency may increase blood pressure, and it is well known that high blood pressure increases the risk of heart attack.

"We have now examined the association between a low level of vitamin D and ischemic heart disease and death in the largest study to date. We observed that low levels of vitamin D compared to optimal levels are linked to 40% higher risk of ischemic heart disease, 64% higher risk of heart attack, 57% higher risk of early death, and to no less than 81% higher risk of death from heart disease," says Dr. Peter Brøndum-Jacobsen, Clinical Biochemical Department, Copenhagen University Hospital.

The scientists have compared the 5% lowest levels of vitamin D (less than 15 nanomol vitamin per litre serum) with the 50% highest levels (more than 50 nanomol vitamin per litre serum). In Denmark, it is currently recommended to have a vitamin D status of at least 50 nanomol vitamin per litre serum.

The higher risks are visible, even after adjustment for several factors that can influence the level of vitamin D and the risk of disease and death. This is one of the methods scientists use to avoid bias.

Blood samples from more than 10,000 Danes
The population study that forms the basis for this scientific investigation is the Copenhagen City Heart Study, where levels of vitamin D were measured in blood samples from 1981-1983. Participants were then followed in the nationwide Danish registries up to the present.

"With this type of population study, we are unable to say anything definitive about a possible causal relationship. But we can ascertain that there is a strong statistical correlation between a low level of vitamin D and high risk of heart disease and early death. The explanation may be that a low level of vitamin D directly leads to heart disease and death. However, it is also possible that vitamin deficiency is a marker for poor health generally," says Børge Nordestgaard, clinical professor at the Faculty of Health and Medical Sciences, University of Copenhagen and senior physician at Copenhagen University Hospital.

Long-term goal is prevention
The scientists are now working to determine whether the connection between a low level of vitamin D and the risk of heart disease is a genuine causal relationship.

If this is the case, it will potentially have a massive influence on the health of the world population. Heart disease is the most common cause of adult death in the world according to the World Health Organization (WHO), which estimates that at least 17 million people die every year from heart disease.

"The cheapest and easiest way to get enough vitamin D is to let the sun shine on your skin at regular intervals. There is plenty of evidence that sunshine is good, but it is also important to avoid getting sunburned, which increases the risk of skin cancer. Diet with a good supply of vitamin D is also good, but it has not been proven that vitamin D as a dietary supplement prevents heart disease and death," says Børge Nordestgaard.

Eunuchs outlive other men

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Castrated men living in Korea centuries ago outlived other men by a significant margin. The findings, reported in the September 25 issue of Current Biology, a Cell Press publication, suggest that male sex hormones are responsible for shortening the lives of men, the researchers say.

The evidence comes after careful study of genealogy records of noble members of the Imperial court of the Korean Chosun dynasty (AD 1392-1910).

"This discovery adds an important clue for understanding why there is a difference in the expected life span between men and women," said Kyung-Jin Min of Inha University.

The castrated boys in Korea lost their reproductive organs in accidents—usually after being bitten by dogs—or underwent castration purposefully to gain early access to the palace. Eunuchs were allowed to marry and had families by adopting castrated boys or normal girls.

People in those days kept careful genealogy records as proof that they were of the noble class. By poring over those records, Min and colleague Cheol-Koo Lee of Korea University found that eunuchs lived 14 to 19 years longer than other men did. Amongst the 81 eunuchs they studied, three lived to the ripe old age of 100 or more, a feat of longevity that remains relatively rare even in developed countries today.

The incidence of centenarians among Korean eunuchs is at least 130 times greater than it is in the developed countries, Lee notes, and that can't be explained simply by the benefits of life in the palace, either. Most eunuchs spent as much time outside the palace as they did inside it. And, in fact, kings and male members of the royal family had the shortest lives of all, typically surviving only to their mid-forties.

The findings may offer some clues to life extension and, in the meantime, men might take heed, Min and Lee quip. "For better health and longevity, stay away from stresses and learn what you can from women."

Eating fish may reduce the risk of heart attack, but watch out for mercury

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Eating fish may reduce the risk of heart attack, but it is important to steer clear from the type of fish that contains the most amounts of mercury, according to experts from Umeå University in Sweden.

The researchers have worked together with teams from Finland and other countries in order to assess whether the advantages of heathy fatty acids outweigh the risks of mercury proportion.

Previous research has said that individuals who consume fish have a decreased risk of heart disease, compared to those who eat none or very little. However, certain types of fish carry pollutants from the environment, which can be detrimental to the health of humans.

Methyl mercury, which can be found in many types of fish, may actually raise the risk of cardiovascular disease. Therefore, consuming fish with a lot of mercury, or with ample amounts of pollutants, can severely increase the risk of heart problems. However, if people are too health conscious of fish, they increase their risk of the disease because they are not receiving the benefits of healthy fish.

A recent study said that tuna, which has high levels of mercury, should be given to children less often.

The current research, which will be published in the October 2012 issue of American Journal of Clinical Nutrition (AJCN), was carried out with the intention of finding a middle point between not eating any fish and eating too much, or types that are unhealthy.

The authors analyzed why heart attack risk is linked to the amount of mercury and omega-3 fats in the body due to fish consumption. They did so by measuring hair and blood samples of volunteers who had been involved in other trials in eastern Finland and northern Sweden. The blood samples of the Swedes were taken from the Medical Biobank in Umeå. Researchers compared blood from the patients who had suffered a heart attack after their check-up appointments and those who remained in good health with no heart attacks.

They found that while mercury content increased the chance of heart attack, omega-3 fatty acids decreased the risk. The researchers noted that higher risk of heart attack due to mercury consumption was only prevalent when there was a large amount of pollutants found in the body. If there was a high level of omega-3 fatty acids, the risk was low.

The findings suggest that it is important and beneficial to reach an equilibrium between healthy and unhealthy content found in fish. In this particular study, the environmental pollutant used was mercury. However, in regards to organic pollutants, such as dioxin and PCD, the results are the same. The authors note, though, that there has been no trial done thus far concerning these substances.

According to the Swedish National Food Agency, 2-3 servings of fish should be consumed per week. However, Swedes tend to eat predatory fish, which have a high amount of mercury and should not be eaten on a regular basis. In addition, a study conducted by the National Food Agency revealed that 7 out of 10 people in Sweden do not eat enough fish.

A 2011 study said that people who eat fish on a regular basis have lower blood glucose concentrations, and a lower risk of cardiovascular disease and type 2 diabetes. The researchers conclude that it is safe, as well as beneficial, to eat fish, but staying away from fish with high levels of pollutants is important in avoiding health problems.

Exercise Does a Body – and a Mind – Good

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We’ve heard it time and time again: exercise is good for us. And it’s not just good for physical health – research shows that daily physical activity can also boost our mental health. But what actually accounts for the association between exercise and mental health?

A new article in Clinical Psychological Science, a journal of the Association for Psychological Science, explores whether certain psychosocial factors may help to explain the benefits of daily physical activity for adolescents’ mental health.

Karin Monshouwer of the Trimbos Institute in the Netherlands and colleagues at Trimbos and VU University Medical Center specifically wanted to examine two existing explanations for the link between exercise and mental health. The self-image hypothesis suggests that physical activity has positive effects on body weight and body structure, leading to positive feedback from peers and improved self-image, and ultimately improving mental health. The social interaction hypothesis, on the other hand, holds that it’s the social aspects of physical activity – such as social relationships and mutual support among team members – that contribute to the positive effects of exercise on mental health.

Monshouwer and her colleagues surveyed over 7000 Dutch students, ages 11 to 16. The adolescents completed validated surveys aimed at assessing their physical activity, mental health problems, body weight perception, and participation in organized sports. The researchers also gathered data on the adolescents’ age, gender, and socioeconomic status; whether they lived at home with their parents; and whether they lived in an urban area.

The researchers found that adolescents who were physically inactive or who perceived their bodies as either “too fat” or “too thin” were at greater risk for both internalizing problems (e.g., depression, anxiety) and externalizing problems (e.g., aggression, substance abuse). Adolescents who participated in organized sports, on the other hand, were at lower risk for mental health problems.

Confirming both the self-image hypothesis and the social interaction hypothesis, adolescents’ body weight perception (i.e., “too heavy,” “good,” or “too thin”) and sports club membership each partially accounted for the relationship between physical activity and mental health, even after taking adolescents’ backgrounds into account.

These results suggest that certain psychosocial factors – body image and social interaction – may help to explain at least part of the connection between physical activity and mental health. The researchers acknowledge, however, that other factors, such as the physiological effects of exercise, are probably also at work.

“We think that these findings are important for policymakers and anyone who works in healthcare or prevention. Our findings indicate that physical activity may be one effective tool for the prevention of mental health problems in adolescence,” says Monshouwer.

Monshouwer and her colleagues hope that future studies will be able to examine similar questions while following participants over time. Such longitudinal studies could help researchers to understand how physical activity type and context might influence the relationship between exercise and mental health.

Eating Cherries Lowers Risk Of Gout Attacks By 35%

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A new study found that patients with gout who consumed cherries over a two-day period showed a 35% lower risk of gout attacks compared to those who did not eat the fruit. Findings from this case-crossover study published in Arthritis & Rheumatism, a journal of the American College of Rheumatology (ACR), also suggest that risk of gout flares was 75% lower when cherry intake was combined with the uric-acid reducing drug, allopurinol, than in periods without exposure to cherries or treatment.

Previous research reports that 8.3 million adults in the U.S. suffer with gout, an inflammatory arthritis triggered by a crystallization of uric acid within the joints that causes excruciating pain and swelling. While there are many treatment options available, gout patients continue to be burdened by recurrent gout attacks, prompting patients and investigators to seek other preventive options such as cherries. Prior studies suggest that cherry products have urate-lowering effects and anti-inflammatory properties, and thus may have the potential to reduce gout pain. However, no study has yet to assess whether cherry consumption could lower risk of gout attacks.

For the present study, lead author Dr. Yuqing Zhang, Professor of Medicine and Public Health at Boston University and colleagues recruited 633 gout patients who were followed online for one year. Participants were asked about the date of gout onset, symptoms, medications and risk factors, including cherry and cherry extract intake in the two days prior to the gout attack. A cherry serving was one half cup or 10 to 12 cherries.

Participants had a mean age of 54 years, with 88% being white and 78% of subjects were male. Of those subjects with some form of cherry intake, 35% ate fresh cherries, 2% ingested cherry extract, and 5% consumed both fresh cherry fruit and cherry extract. Researchers documented 1,247 gout attacks during the one-year follow-up period, with 92% occurring in the joint at the base of the big toe.

"Our findings indicate that consuming cherries or cherry extract lowers the risk of gout attack," said Dr. Zhang. "The gout flare risk continued to decrease with increasing cherry consumption, up to three servings over two days." The authors found that further cherry intake did not provide any additional benefit. However, the protective effect of cherry intake persisted after taking into account patients' sex, body mass (obesity), purine intake, along with use of alcohol, diuretics and anti-gout medications.

In their editorial, also published in Arthritis & Rheumatism, Dr. Allan Gelber from Johns Hopkins University School of Medicine in Baltimore, Md. and Dr. Daniel Solomon from Brigham and Women's Hospital and Harvard University Medical School in Boston, Mass. highlight the importance of the study by Zhang et al. as it focuses on dietary intake and risk of recurrent gout attacks. While the current findings are promising, Gelber and Solomon "would not advise that patients who suffer from gout attacks abandon standard therapies." Both the editorial and study authors concur that randomized clinical trials are necessary to confirm that consumption of cherry products could prevent gout attacks.

Chronic insomnia - Lancet 2012 review

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Insomnia is a common condition that can present independently or comorbidly with another medical or psychiatric disorder.

Treatment of chronic insomnia

Benzodiazepine-receptor agonists (BzRAs) and cognitive-behavioural therapy (CBT) are supported by the best empirical evidence.

Benzodiazepine-receptor agonists (BzRAs) are effective in the short-term management of insomnia, but evidence of long-term efficacy is scarce. Also, most hypnotic drugs are associated with potential adverse effects.

Cognitive-behavioural therapy (CBT) is an effective alternative for chronic insomnia.

CBT is more time consuming than drug management but it produces sleep improvements that are sustained over time.

However, CBT is not readily available in most clinical settings. Access and delivery can be made easier through:

- telephone consultations
- group therapy
- self-help approaches

How to succeed? Get more sleep



In this 4-minute talk, Arianna Huffington (founder of The Huffington Post) shares a small idea that can awaken much bigger ones: the power of a good night's sleep. Instead of bragging about our sleep deficits, she urges us to sleep our way to increased productivity and happiness -- and smarter decision-making.

References:

Chronic insomnia. The Lancet, Volume 379, Issue 9821, Pages 1129 - 1141, 24 March 2012.
Image source: A halo around the Moon. Wikipedia, GNU Free Documentation License.

Fertility Yogurt....As Good As Ice Cream!

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Here is a yogurt combination which I came up with myself when I wanted a healthy sweet alternative to ice cream.  All of the ingredients either help fertility or substitute other harmful substances.  I'm totally hooked and even though I'm not trying to conceive now, I still eat it every day.

Here is my recipe:

• 1/2-1cup Plain Unflavored, Unsweetened Yogurt (I use non-fat, but some sources claim that full-fat yogurt is better for female fertility - see the research here  )

• 1/3 -1/2 cup frozen blueberries (organic is better since berries have been shown to hold higher amounts of pesticides) See the benefits of blueberries here

• Liquid Stevia to taste (this is a sweetener which is a great alternative to sugar and other artificial sweeteners which some believe are dangerous)  Get the liquid stevia at your local healthfood store.  It should come with a dropper.  Put 1-2 squirts until it's sweet enough for you.  If you must add sugar, just sprinkle a little on the top, don't mix it in.  You will be able to taste it more this way and you'll use less.

• Add about a tablespoon of raw walnuts and a tablespoon of raw almonds to the yogurt.Buy these at your local healthfood store in the refrigerated section.  This will preserve the natural oils.  Do not buy roasted walnuts or almonds - this destroys the oils.These nuts have essential fatty acids which help your body to produce the "good" prostaglandins and walnuts have additionally been shown to help women with PCOS.

Mix together and eat before the blueberries melt.  It tastes like ice cream!

Some Reasons Why Women Can't Have Their Second Child

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Secondary infertility is a common problem and I hear from women all the time who have had one child but can't get pregnant with their second. Not only are these women frustrated because they can't get pregnant, but they find little support because women who are experiencing primary infertility feel they should be happy that they at least have one child. Here is an article that explains some reasons why women may experience secondary infertility:

www.guardian.co.uk

From the article:


There can be medical causes of SI, says West. "The thyroid is always something we check. Birth can put the thyroid out of kilter." Anwen, a woman in her 40s, tried for five years to have a second child. "I had my daughter when I was 30," she says, "which, at the time, seemed very early. I was the first among all our friends to have a baby." She decided to try for a second when her daughter was three. "But a year went by and nothing happened. I went to the GP and he told me not to worry. 'If you've already given birth, there won't be a problem,' he said. But my daughter turned five and I still wasn't pregnant." Eventually, Anwen persuaded her GP to refer her to a fertility consultant who, after some simple investigations, informed her she had polycystic ovarian syndrome. "He said I'd probably had it all my life and that my daughter was an amazing one-off. I had no idea that anything was wrong." She was given a prescription for the fertility drug Clomid; two months later, she conceived her son.

High FSH Doesn't Necessarily Mean You're Infertile

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One reason I left the "traditional" medical protocols for getting pregnant is because too much emphasis was put on the proverbial "numbers". If you're numbers fall outside the "acceptable" range, you're basically told to give up or to consider donor eggs. Here is an article that gives some detailed information about FSH levels and what they really mean. Read more:

highfshinfo.com

From the article:

High FSH does not preclude pregnancy. High FSH indicates that a woman is likely to be a poor responder to fertility medications. It does not necessarily mean that there aren’t any high quality eggs remaining and that pregnancy is impossible. It MAY mean that it will take a long time for her to become pregnant and that IUI/IVF may or may not increase her chances of pregnancy. If a young woman has prematurely high FSH, this woman MAY or MAY NOT suffer from premature ovarian failure or premature menopause.

High FSH can be caused by other factors besides DOR (Diminished Ovarian Reserve). Your RE should rule out other potential causes for high FSH before diagnosing you with DOR. Other causes are unusual but should be investigated nonetheless. FSH can rise due to autoimmune disorders, adrenal gland impairment, hereditary dizygotic twinning, discontinuing the use of oral contraceptives (FSH can rise temporarily after extended use of contraceptives), lactation, unilateral ovariectomy, recovery from hypothalmic amenorrhea and excessive smoking.

Fertility Food Plan From the UK

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I've written countless articles about what to eat when you're trying to conceive. This article from the Mirror (UK) talks about what men and women should be eating. Most of these food are no surprise, but they do address the reason why some foods should be eaten. Read more:

www.mirror.co.uk

From the article:

A Spanish study recently found that men could boost their sperm counts by eating less red meat and fatty food, and more fruit and veg.

Meanwhile, research at Harvard University also found that women who made dietary changes reduced their risk of infertility by as much as 80%.

“The food choices you and your partner make can have a major effect on improving fertility,” agrees fertility expert Dr Zita West, whose client list includes actresses Kate Winslet, Cate Blanchett and Davina McCall.
Here are the foods you – and your partner – need to eat...

How to do it
The first step to better fertility is to ensure you have a balanced diet and don’t cut out any major food groups.
“Make sure you both get adequate protein from lean meat and fish, essential fats from fish, nuts and seeds, wholemeal carbohydrates and lots fruit and veg,” says Zita.
Once you have the basics right you can then add the specific superfoods that researchers have found can boost egg and sperm production.
But be patient: you will both need to stick to a diet plan for at least three months before you will know if it has had any effect.
Here’s what should be eating...

Epinephrine autoinjectors are expensive, allergists suggest low-cost alternative: a prefilled syringe

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The wholesale price of 1 epinephrine autoinjector increased annually from $35.59 in 1986 to $87.92 in 2011 (147%). Among patients prescribed autoinjectors, only 40% of teens/adults and 60% of children less than 12 years of age had them refilled over a 6-year period. The retail price of the new "EpiPen 2-pak" that the patients often quote is more than $250 for each "pak". In August 2012, the FDA approved Auvi-Q - the first-and-only epinephrine autoinjector with audio and visual cues that guide patients and caregivers step-by-step through the injection process. No information about the price of Auvi-Q is available at this time but it is not expected to cost significantly less than EpiPen.

There are lower-cost alternatives to epinephrine autoinjectors. Recently, three allergists from the University of South Florida suggested in JACI thar prefilled epinephrine syringes made in a clinic can be safely provided to patients who cannot afford prescription autoinjectors.

Prefilled syringes are stable and sterile for 2 months in dry climates and 3 months in humid climates.

Materials needed to prepare a prefilled syringe are simple:

1. ampule containing 1 mg/mL epinephrine plus a preservative
2. disposable plastic 1-mL syringe
3. 23-gauge, 2.5-cm needle

Parents take 140 seconds to withdraw epinephrine from an ampule into a syringe, therefore a prefilled syringe is recommended.

Epinephrine is light sensitive, and the ampule and prefilled syringes should be protected from light by:

- wrapping them in aluminum foil
- keeping them in a light-free container, such as an eyeglasses case

This 2-minute video shows the Sanofi's new voice guided Auvi-Q epinephrine injector in action:



References:

Increasing cost of epinephrine autoinjectors. The Journal of Allergy and Clinical Immunology
Volume 130, Issue 3 , Pages 822-823, September 2012.

Image source: OpenClipArt.org, public domain.

Comments from Twitter:

Allergic Living @AllergicLiving: Would anyone prescribe epi syringe? + short shelf life. Should allergists press for a 1-pak too, as 1 better than 0? #foodallergy

‏@Allergy: As you know, EpiPen Single Packages were Discontinued 1 year ago. Only "2-paks" are available now: http://bit.ly/P7J0Ch

Allergic Living @AllergicLiving: That's my point, should they be "encouraged' to return as an additional option, perhaps by AAAAI?

Craig, CEN, CCRN @CraigCCRNCEN: My ANA kit with Benadryl also is cheaper and less painful to administer.

Tiffany @iknowtiffany: Yah, right. That's *perfect* for schools, parents in midst of crisis, carrying around at all times. #not

Neutrophilic inflammation as a possible explanation for a reduced treatment response in obese patients with asthma

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Increased number of neutrophils are present in the airways during the late-phase reaction after allergen challenge, in fatal or nocturnal asthma, and in severe asthma.

The incidence of asthma and obesity is increasing worldwide, and reports suggest that obese patients may have more severe asthma or reduced response to therapy. This study from the Netherlands included data from four asthma cohorts.

At baseline, FEV(1)  and bronchial hyperresponsiveness were comparable in 63 obese (BMI equal or more than 30 kg/m(2) ) and 213 lean patients (BMI  lower than 25 kg/m(2) ).

After a two-week treatment with corticosteroids, there was less corticosteroid-induced improvement in FEV(1) in obese patients (median 1.7% vs 6.3% respectively, P = 0.04). The percentage of sputum eosinophils improved significantly less with higher BMI.

The smaller improvement in FEV(1) and sputum eosinophils suggests a worse corticosteroid treatment response in obese asthmatics.

Editor’s note: Previous studies of anti-IL-5 agents showed benefit only in some asthmatic patients with predominantly eosinophilic inflammation. As a future research avenue, it would be interesting to see if localized anti-neutrophilic therapies can bring improvement in obese patients with asthma.

Question & Answer

In patients with asthma and chronic productive cough, polymorphonuclear (PMN) neutrophil leukocytes in sputum suggest:

(A) infection
(B) GERD
(C) presence of a foreign body
(D) exercise-induced asthma
(E) extrinsic asthma

Correct answers: A, B, C

References:

Obesity in asthma: more neutrophilic inflammation as a possible explanation for a reduced treatment response. Telenga ED, Tideman SW, Kerstjens HA, Hacken NH, Timens W, Postma DS, van den Berge M. Allergy. 2012 Aug;67(8):1060-8. doi: 10.1111/j.1398-9995.2012.02855.x. Epub 2012 Jun 12.

Image source: Wikipedia, free GNU license.

Practice parameter for allergy to furry animals

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Here are some excerpts from the new practice parameter for allergy to furry animals:

Patients with allergic disorders should be evaluated for sensitization to cat and dog allergens by skin prick testing or in vitro testing for cat and dog specific IgE.

Avoidance

Avoidance is the most effective way to manage cat and dog allergy. Patients should be advised to consider removing the cat or dog from the environment, if present, to improve respiratory health.

To reduce exposure to cat allergens with the cat still living in the house, a combination of measures, such as removing reservoirs, keeping the cat out of the bedroom, washing the cat, air cleaning with a HEPA room air cleaner, improving ventilation, and mattress and pillow covers, may be helpful.

Exposure to cat allergen

Complete removal of all cats is necessary to minimize cat allergen exposure in a home.

Cat characteristics, such as length of hair, sex, reproductive status, and time spent indoors, are not associated with levels of Fel d 1 in the environment.

To reduce transport of cat allergen, people should consider changing their clothes when traveling from a high cat allergen environment to a low cat allergen environment.

Hypoallergenic cats

Because 1 or more cat allergens are present in all cats, patients should not be advised that it is safe to obtain a hypoallergenic cat.

Exposure to dog allergen

Dogs should be excluded from rooms in which reduced exposure is desired.

Because 1 or more dog allergens are present in all dogs, patients should not be advised that it is safe to obtain a hypoallergenic dog.

Washing cats and dogs

Washing cats or dogs at least weekly can reduce airborne cat Fel d 1 or dog Can f 1; however, the clinical benefit is yet to be proven and the effect of washing is not sustained.

Primary prevention to avoid IgE sensitization

Although exposure to elevated cat or dog allergen concentrations before 3 months of age may reduce the likelihood of developing cat or dog sensitization, the risk reduction is not sufficient to justify a decision to get a cat or dog to avoid IgE sensitization.

Secondary prevention to avoid disease in IgE sensitized individuals

Cat and dog exposure should be minimized in cat sensitized individuals to reduce the likelihood of developing asthma.

Tertiary prevention to treat furry animal allergy

Exposure to cat and dog allergens should be minimized to reduce the likelihood of an asthma exacerbation in cat and dog sensitized schoolchildren and adults who already have asthma.

List of measure that are not proven efective to reduce clinical symptoms:

- washing the cat
- dry heat
- dust cleaning with vacuum cleaners
- air cleaning with a HEPA room air cleaner
- improving ventilation
- chemical treatments, such as tannic acid or hypochlorite bleach
- mattress and pillow covers


Animal Dander Avoidance (click to enlarge the image).

References:

Environmental assessment and exposure control: a practice parameter—furry animals. Annals of Allergy, Asthma & Immunology, Volume 108, Issue 4 , Pages 223.e1-223.e15, April 2012.
Image source: Wikipedia, GNU Free Documentation License.

Top Asthma Articles for September 2012

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Here are my suggestions for some of the top articles about asthma for September 2012:

Developing new asthma metrics: Rescue Index (RI) and Asthma Control Index (ACI) http://goo.gl/9L1tr

Nitric oxide (NO) is now considered an important biomarker for respiratory disease - 2012 review http://goo.gl/645wV

High pollen counts tied to ER visits for asthma | Reuters http://goo.gl/otggR

Galectin-10, a Potential Biomarker of Eosinophilic Airway Inflammation http://goo.gl/BcT2k

The co-occurrence of asthma and depression is a universal phenomenon (study) http://bit.ly/TAV4xu

Severe asthma: future treatments - 2012 full text update - Clinical & Experimental Allergy http://bit.ly/TIIiNf

"GSK drug halves attacks in hard-to-treat asthma" - anti-IL5 antibody mepolizumab for eosinophilic asthma http://goo.gl/Be6IU

30% of new prescriptions never get filled. Will smart pills boost drug compliance? http://goo.gl/omhjJ

Stopping the LABA in asthma controlled with ICS/LABA therapy results in increased asthma-associated impairment http://goo.gl/izDRe

Risk factors and characteristics of respiratory and allergic phenotypes in early childhood http://goo.gl/RWO4S

A common local adverse effect of ICS therapy for asthma is dysphonia: affects 5% to 58% of patients http://goo.gl/JoW0n

Comparison of Physician-, Biomarker (FeNO)-, Symptom-Based Adjustment of ICS in Adults With Asthma: No Difference http://buff.ly/SerAlH

Three Approaches "Equal" for Asthma Med Adjustment - Yet, there was almost double the treatment failure rate http://goo.gl/Ix9XO

The articles were selected from my Twitter stream @Allergy and Google Reader RSS subscriptions. Some of the top allergy accounts on Twitter contributed links. I appreciate the curation provided by @JuanCIvancevich @AllergyNet @IgECPD4 @DrAnneEllis @AACMaven @AllergieVoeding @allergistmommy @mrathkopf @wheezemd.

Please feel free to send suggestions for articles to allergycases@gmail.com and you will receive acknowledgement in the next edition of this publication.

Mobile Phone Spirometry with SpiroSmart App from University of Washington Computing Lab

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SpiroSmart is a mobile phone based platform that allows for the analysis of common lung function measures (FEV1, FVC, PEF). By analyzing lip reverberation, it is capable of monitoring pulmonary ailments such as asthma, chronic obstructive pulmonary disease, and cystic fibrosis.

From the manufacture's YouTube channel: SpiroSmart is a low-cost smartphone based system that performs "spirometry sensing" using the built-in iPhone microphone. It allows patients to keep track of their pulmonary "impairments" without going to the clinic. SpiroSmart can be effectively used by pulmonologists to diagnose varying degrees of obstructive lung ailments.



Home spirometry is gaining acceptance in the medical community because of its ability to detect pulmonary exacerbations and improve outcomes of chronic lung ailments. However, cost and usability are significant barriers to its widespread adoption. SpiroSmart is a low-cost mobile phone application that performs spirometry sensing using the built-in microphone. SpiroSmart was evaluated in 52 subjects, showing that the mean error when compared to a clinical spirometer is 5.1% for common measures of lung function.

To increase compliance, the target monitoring platform is the mobile phone, a sufficiently small device that is always with the patient. Additionally, the researchers are investigating methods to make the lung testing procedure part of a simple, yet engaging, game on the phone.

References:

Computing Lab - University of Washington http://bit.ly/Qtk8GY

See how healthy your lungs are -- just blow into your phone | Cutting Edge - CNET News http://cnet.co/Q8ucBP

Does Calorie Restriction Extend Lifespan in Mammals?

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Until about two years ago, the story went something like this: calorie restriction extends lifespan in yeast, worms, flies, and rodents.  Lifespan extension by calorie restriction appears to be biologically universal, therefore it's probably only a matter of time until it's demonstrated in humans as well.  More than 20 years ago, independent teams of researchers set out to demonstrate the phenomenon in macaque monkeys, a primate model closer to humans than any lifespan model previously tested.

Recent findings have caused me to seriously question this narrative.  One of the first challenges was the finding that genetically wild mice (as opposed to inbred laboratory strains) do not live longer when their calorie intake is restricted, despite showing hormonal changes associated with longevity in other strains, although the restricted animals do develop less cancer (1).  One of the biggest blows came in 2009, when researchers published the results of a study that analyzed the effect of calorie restriction on lifespan in 41 different strains of mice, both male and female (2).  They found that calorie restriction extends lifespan in a subset of strains, but actually shortens lifespan in an even larger subset.  Below is a graph of the effect of calorie restriction on lifespan in the 41 strains.  Positive numbers indicate that calorie restriction extended life, while negative numbers indicate that it shortened life:





If we take the results of this study at face value, it suggests that under the conditions of this experiment:

1. Calorie restriction is more likely to shorten life than lengthen it in mice. 
2. The effects of calorie restriction on lifespan depend on an animal's genetic background.
3. The calorie restriction literature may suffer from publication bias.

In 2009, researchers at the University of Wisconsin published preliminary results from the first primate calorie restriction experiment (3).  The analysis suggested that restricted macaques suffered fewer "age-related deaths".  Many people, including myself, found this somewhat questionable since total deaths from all causes were not significantly different (the experiment is ongoing, so there may eventually be a significant difference).  Also, the diet was appalling-- a refined feed made of sugar, isolated starch and other purified ingredients.  Animals in both groups died of gastrointestinal ailments.  The restricted group was protected from obesity, diabetes and cardiovascular disease, and they certainly looked much better.  Eating less of a poor diet seems to protect against disease, and may or may not extend life.

Today, a new study was published that casts further doubt on the idea that calorie restriction extends lifespan in mammals, including primates (4).  Researchers from the National Institute on Aging placed macaques on an unrefined (whole food based) diet for 26 years, with or without 30 percent calorie restriction.  They did this in two experiments, one starting with young monkeys and one starting with older monkeys.  Both experiments showed that calorie restriction does not extend lifespan under these conditions, although it does prevent obesity and cancer, and apparently maintains a youthful appearance.

It's worth mentioning that the control (unrestricted) monkeys in the first experiment were truly given as much food as they wanted to eat (ad libitum), while those in the second experiment were given an amount of food that allowed them to reach a normal weight but not become overweight.  Therefore, one could argue that the control group in the second experiment was slightly calorie restricted.  They certainly gained less fat than in the previous experiment, but their diet was also far superior.

I think when you consider all the evidence to date, the take-away message is that eating a nutritious diet and staying relatively lean will probably prolong your life, while calorie restriction may or may not.  It probably does reduce the risk of specific diseases however.  Currently, a number people around the world are restricting their calorie intake in the hope of living longer.  I wish these pioneers the best of luck.  Hopefully we'll have the answer to this question eventually, but if I were a bettin' man I wouldn't put my money on the idea that calorie restriction will extend lifespan at this point.

A Late Summer Harvest

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It's been a good year for gardening in Seattle, at least in my garden.  Thanks to great new tools* and Steve Solomon's recipe for homemade fertilizer, my house has been swimming in home-grown vegetables all summer.  I'm fortunate that a friend lets me garden a 300 square foot plot behind her house.  Here's a photo of part of today's harvest; various kale/collards, zucchini, tomatoes and the last of the pole beans:


Perfect for the Eocene diet.  


It's no secret that I like potatoes, especially growing them.  Potatoes are a lot of fun to grow, and they're more productive than any other garden crop in terms of calories harvested per area of land.  My friends know that if they just don't encourage me, I'll eventually stop talking about my potatoes.  Last year, my potatoes did poorly, and I had to suffer the indignity of driving past Western Washington's lush potato fields every few weeks on my way to Anacortes, so I was determined to be the Scrooge McDuck of potatoes this year.

With potatoes, you never know what you're going to get until they come out of the ground-- that's the excitement and anxiety of it.  The season is over, the vines have all died back, and you'll either find a profusion of large round tubers, seemingly floating unattached to anything in the soil around them, or you'll find a bunch of runted grape-sized nuggets barely fit for a snack. Here's what my garden fork dug up from about a quarter of my potato beds this year:


A five-gallon bucket 2/3 full with russet potatoes-- about 15 lbs.  Not bad.  They taste better than their parents did.  Must be the terroir.  Next up: Yukon Golds. 

Gardening in Seattle has its advantages and disadvantages.  The main disadvantage is that it doesn't get hot enough to grow heat-loving crops well.  I grow tomatoes (see above), but mostly cherry tomatoes and they didn't really start producing until about three weeks ago.  The main advantage is that it doesn't get very cold in the winter, so it's possible to garden year-round.  In particular, hardy greens like kale, collards, cabbage and arugula overwinter well.  This year, we planted an unreasonable amount of kale and collards, so we'll be dining on them all winter. 


* A sharp scuffle hoe by Rogue Hoes, a sharp Japanese hand hoe, and burlap sacks as weed-suppressing mulch.  These take most of the work out of weeding.

Calories and Carbohydrate: a Natural Experiment

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In the lab, we work hard to design experiments that help us understand the natural world.  But sometimes, nature sets up experiments for us, and all we have to do is collect the data.  These are called "natural experiments", and they have led to profound insights in every field of science.  For example, Alzheimer's disease is usually not considered a genetic disorder.  However, researchers have identified rare cases where AD is inherited in a simple genetic manner.  By identifying the genes involved, and what they do, we were able to increase our understanding of the molecular mechanisms of the disease.

The natural experiment I'll be discussing today began in 1989 with the onset of a major economic crisis in Cuba. This coincided with the loss of the Soviet Union as a trading partner, resulting in a massive economic collapse over the next six years, which gradually recovered by 2000. 

Unlike most industrialized nations, Cuba keeps systematic health records of its citizens, including the incidence of major diseases and deaths.  It has also performed surveys of body weight and height in several areas and at multiple timepoints.  This allows unbiased tracking of these factors over time in the population.  

The economic collapse resulted in major changes in diet, which Melissa McEwen recently brought to my attention.  The first was a decrease in energy intake from about 3,100 to 2,300 calories per person per day, according to FAO data (1, 2)  These numbers are probably not particularly accurate, but they serve to illustrate the trend.  The second change was a decrease in dietary fat and protein consumption, and increased reliance on inexpensive refined carbohydrate and sugar (2): 

The percentage of dietary fat in the energy intake decreased, while the contribution of carbohydrates (polished rice and refined cereals) increased from 64% in 1990 to 79.4% in 1993. Availability of essential dietary amino acids and fatty acids declined as a consequence of a reduced availability of animal protein and edible oils and fat. Sugar cane, a traditional source of energy in the Cuban diet, rose to 28% of total energy intake, almost three times that of the fat contribution.

In addition, a shortage of gasoline meant that people began walking and riding bicycles more, such that total physical activity increased (1, 2). 

OK, so we have 10 million people who are eating about one-quarter fewer calories overall, and exercising more, but the diet is heavily focused on refined carbohydrate and sugar (and monotonous).  Plus we have body weight and health statistics.  This is a great opportunity to see which factor is more important for obesity and chronic disease at the population level: refined carbohydrate/sugar, or calorie intake and exercise.  Make your guess!

There are at least two different data sets, and they show similar but not identical trends-- I'll try to synthesize them (1, 2).  During the economic crisis, the prevalence of obesity declined by about half, and overweight declined or stayed the same depending on which data you believe.  As calorie intake went back up during the economic recovery, obesity rebounded.  The prevalence of underweight increased, suggesting that a small fraction of people weren't getting enough calories to maintain weight.  Total mortality, diabetes, and coronary heart disease rates declined during the crisis. 

We're fortunate that something good came of the hard times in Cuba-- a natural experiment demonstrating the effects of a major nationwide change in diet and exercise.  Taken together, the data suggest that energy intake and physical activity are dominant factors in obesity, and major factors in the diseases of affluence, trumping the influence of refined carbohydrate and sugar at the population level.  The overconsumption of energy from food is at the core of obesity and strongly contributes to cardiometabolic disease.  Some of the harmful consequences of eating refined carbohydrate and sugar do not materialize when there is no calorie excess.  This natural experiment is consistent with a large body of evidence from controlled feeding trials in humans and animals.

That being said, refined carbohydrate and sugar are generally not healthy, and they do promote obesity and derail fat loss efforts.  Say what?  Although refined carbohydrate is secondary to energy intake when it comes to obesity, at any given level of energy intake, unrefined carbohydrate is generally superior to refined carbohydrate for overall health*.  Also, foods made with refined carbohydrate and sugar promote overeating**, so they contribute to the energy excess that drives obesity and chronic disease.


* Modest quantities of certain refined carbohydrates like white rice are probably fine in the context of a nutritious varied diet, but there are better foods to place at the center of the diet.

* Due to their high energy density, lack of fiber, and higher palatability and reward value.  The high palatability/reward value is partially due to the fact that refined carbohydrates are an ideal "blank slate" for creating energy-dense hyperpalatable foods like brownies, corn chips, cookies, deep-fried foods, and pastries. 

Nutrition Science Initiative (NuSI)

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Some of you may have heard of an ambitious new nutrition research foundation called the Nutrition Science Initiative (NuSI).  In this post, I'll explain what it is, why it matters, and how I feel about it-- from the perspective of an obesity researcher. 
What is NuSI?
NuSI is a nonprofit organization whose stated goal is to "facilitateand fund experimental research in nutrition with the goal of reducing theeconomic and social burden of obesity and obesity-related diseases."  In other words, its goal is to understand obesity more thoroughly so it can be prevented and reversed more effectively.  NuSI was founded by Dr. Peter Attia and Gary Taubes, and is funded by the Laura and John Arnold foundation and other sources.  Dr. Attia is primarily responsible for running the organization, and he's also the author of the blog The Eating Academy. 
NuSI is attempting two main things at this point: 1) bring together top scientists; 2) give them the funding to do ambitious research that has never been done before, or test questions more rigorously than they have been tested previously.  I can attest to the fact that they're accomplishing goal #1.  Dr. Attia has told me who they've involved at this point, and it includes some of the top scientists in obesity research-- people who I strongly support.  Whether goal #2 happens remains to be seen, but if everything goes according to plan, NuSI may end up being a major new funding mechanism for obesity research.  Apparently, the potential for funding is significant enough that NuSI has been able to draw the attention of certain senior researchers.
Why I Support NuSI
Dr. Attia and Taubes have asked for my support on this project.  As everyone reading this knows, I've had high-profile disagreements with Taubes.  Dr. Attia and I have had a few positive exchanges, and although I don't know him well, he strikes me as a reasonable and constructive person.  Both of them are proponents of the low-carbohydrate diet, and they have both had personal successes with this eating style.  Dr. Attia also has clinical experience with diet, including but not limited to low-carbohydrate diets.
NuSI is proposing major funding for some very ambitious experiments that have never been conducted before.  I'll let Dr. Attia give more details on this, but suffice it to say that the project could be very exciting if it materializes as planned.  
So the question arises, should I support an organization that's run in part by a person whose approach to scientific inquiry I disagree with?  It would be remiss of me not to question the wisdom of putting a major science funding mechanism into the hands of a journalist who is, shall we say, very attached to his ideas.  To put my conscience to rest, I contacted Dr. Kevin Hall, an obesity researcher who is acting as lead scientist on this initiative.  He explained to me that NuSI will have no control over research design, conduct, or reporting, and in fact he's contractually obligated to the National Institutes of Health not to allow NuSI to have any control over these things.  So although NuSI will get to choose what experiments it funds, it has no control over what happens after that, and so its potential to compromise research integrity seems low.
I may not always agree with NuSI's funding priorities (although I suspect I often will), but the bottom line is that it will increase funding for top scientists in a tough economic/political climate, potentially make experiments possible that were formerly inaccessible due to excessive cost, and add to human knowledge about diet and health.  That's why I support it.
My Concerns about NuSI
NuSI was organized ostensibly with the goal of promoting high-quality, objective scientific research.  However, reading the information on the website and press releases, it's obvious that the organization has strong preconceived notions about diet and obesity. 
The language of the website suggests an attitude that rejects currently existing nutrition research as invalid.  I've seen this attitude before, and it's typically an effort to discredit contradictory evidence so it doesn't have to be incorporated into one's worldview.  Here are some examples of this:

If people had the correct information- based on rigorously produced scientific evidence- about which foods predisposed them to obesity and its related diseases, most would make the correct choices and lead happier and healthier lives.

Poorly controlled experiments are considered sufficient basis on which to form dietary recommendations on the belief that they are the best science can offer, not because they are inherently rigorous enough to establish reliable knowledge.

There is more than a grain of truth to this, but the reality is that we already know a lot about how to prevent obesity and type 2 diabetes, and a fair amount about how to combat existing obesity.  Much of this knowledge comes from well controlled experiments in humans and animals spanning decades of research.  The average person doesn't eat donuts and pizza, drink sweetened beverages, and sit in front of the TV for hours a day because she thinks they're going to promote a leaner, healthier life.  There are certainly gaps in our knowledge.  But the main reason we have an obesity epidemic isn't that we lack the right information, it's that most people don't apply the information we already have!  This doesn't apply to all individuals, but at a population level it does apply.
The NuSI website goes on to attribute the obesity epidemic to the US government dietary recommendations since 1977, when Americans were advised to reduce fat intake and replace it with unrefined carbohydrate (the fact that the recommendation was for unrefined carbohydrate is not mentioned).  This is inappropriate for an organization whose stated goal is to objectively support research on what causes obesity-- they should be keeping their personal opinions to themselves.  The way the website is written, it sounds like they already have their minds made up about what causes obesity, and they're simply looking to drum up confirmatory evidence. 
The press release states that "despite following current dietary recommendations- for example, reducing fat intake- Americans are getting more and more obese".  Then comes the familiar graph of macronutrient changes over the last 40 years showing a decline in the percent energy from fat, and an increase in the percent energy from carbohydrate.  Yet what escapes mention is that the only reason the percentage of fat went down is that total carbohydrate (and calorie) intake went up.  The absolute, total amount of fat intake in grams stayed the same or increased over that time period (depending on the data source-- USDA food disappearance or NHANES surveys).  Does that count as "reducing fat intake"?  Below is a graph of macronutrient intake in the US between 1970 and 2006, expressed as calories not percentages, from USDA data adjusted for loss.  You be the judge.

If we go back to 1909, a time when obesity was less common than in 2012 or even 1970, the US diet was 57 percent carbohydrate, as opposed to 49 percent today.  Total carbohydrate intake in grams was also higher than today, and most of it came from white flour (1).  Why would carbohydrate cause an obesity epidemic today when it didn't 100 years ago, and it continues not to cause obesity in numerous high-carbohydrate cultures throughout the world?
The reality is that the USDA dietary guidelines since 1977 didn't tell Americans to:

• Increase our intake of sweetened soda by 41 percent
• Replace fresh potatoes with french fries and potato chips
• Increase added sugars by 16 percent
• Increase our intake of refined instead of unrefined carbohydrate
• Nearly double spending on fast food
• Eat more than twice as many snacks
• Increase total calorie intake by 20 percent

Are the USDA dietary guidelines perfect?  In my opinion, no.  Did they cause the obesity epidemic?  Absolutely not.  If everyone in this country ate strictly according to the USDA dietary guidelines, including the recommendation to favor unprocessed foods and avoid sweetened beverages, as a population we'd be leaner and healthier than we are right now. 
For these reasons among others, the materials released by NuSI do not scream "objectivity", which is troubling considering the organization's stated goals.  However, keep in mind that NuSI is a funding mechanism and will not have control over how research is conducted or reported in scientific journals.
The Bottom Line
I support NuSI, despite its flaws. It's hard to predict the long-term effects of something like this, but I think it has more potential to do good than to do harm.  I wish it well and I'm happy to help if help is requested.