FitSugar

Stand Tall to Ease Back Pain: Alexander Technique Works

FitSugar — Mon, 25 Aug 2008 03:00:00 -0700

I have spent many a Pilates session teaching clients with severe back pain how to stand, sit, and walk. In these sessions, I have borrowed elements from the Alexander Technique. Learning basic body mechanics while unlearning bad postural habits seemed to help these clients out of pain, and now I have science backing me up on this.

New research from the UK found that patients with chronic back pain treated with the Alexander Technique had many more pain-free days than back patients treated with pain medication or massage.

Alexander patients experienced just three days of back pain a month compared to 14 days a month of pain experienced by patients who received massage, or 21 days of pain experience by patients using pain medication. The Alexander patients had 24 sessions to create this reduction in back pain, but retraining your body does come at a price. Private Alexander sessions come at a high price, upward of $80 for an hour lesson.

If you are interested in trying Alexander, you can find a teacher here. If you are in chronic pain, it might be worth investigating. Some practitioners offer group classes, which are considerably less expensive, or you can buy packages of classes for a reduced price.

Source

Cataracts

FitSugar — Wed, 08 Oct 2008 17:35:39 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Medical Societies Issue Tamsulosin (Flomax) Warning

In August 2006, the American Society of Cataract and Refractive Surgery (ASCRS), the American Academy of Ophthalmology, and the American Urological Association (AUA) issued a joint warning concerning Tamsulosin (Flomax). The societies advised patients to be sure to inform their eye surgeons if they are taking this drug. Tamsulosin is frequently prescribed to treat prostate enlargement.

The ACSRS has developed specific cataract surgery techniques for cataract patients who take this drug. Recent research suggests that these new techniques produce successful surgical outcomes.
The AUA warns that while men are primarily at risk, more women may be at risk in the future as Tamsulosin is increasingly being prescribed for urinary retention.

Cost of Cataracts

Cataracts cost the United States nearly $7 billion a year in medical services and pharmaceutical costs, according to a 2006 report in the Archives of Ophthalmology.

Can Statins Reduce Cataract Risk?

Statin drugs, which are used to manage cholesterol levels, are associated with a lower risk of nuclear cataract -- the most common type of age-related cataract -- according to a 2006 study in the Journal of the American Medical Association. Researchers think that the antioxidant properties of statins may account for this association.

Cataract Surgery

A new surgical technique, phacoviscocanalostomy, works well for patients who have both glaucoma and cataracts, suggests a 2006 study in the Journal of Cataract and Refractive Surgery.
Newer methods of administering local anesthesia are resulting in fewer complications than older methods, indicates a 2006 study in the British Journal of Ophthalmology.

Intraocular Lenses (IOLs)

The Tecnis ZM001 IOL helped produce better reading clarity and reading speed than several other newer multifocal IOLs, according to a 2006 comparison study. Multifocal IOLs are used for patients who need correction for both farsightedness and nearsightedness.

Introduction

A cataract is an opacity, or clouding, of the lens of the eye.

The lens of an eye is normally clear. If the lens becomes cloudy or is opacified, it is called a cataract.

The prevalence of cataracts increases dramatically with age. It typically occurs in the following way:

The lens is an elliptical structure that sits behind the pupil and is normally transparent. The function of the lens is to focus light rays into images on the retina (the light-sensitive tissue at the back of the eye).
In young people, the lens is elastic and changes shape easily, allowing the eyes to focus clearly on both near and distant objects.
As people reach their mid-40s, biochemical changes occur in the proteins within the lens, causing them to harden and lose elasticity. This causes a number of vision problems. For example, loss of elasticity causes presbyopia, or far-sightedness, requiring reading glasses in almost everyone as they age.
In some people, the proteins in the lens, notably those called alpha crystallins, may also clump together, forming cloudy (opaque) areas called cataracts. They usually develop slowly over several years and are related to aging. In some cases, depending on the cause of the cataracts, loss of vision progresses rapidly.
Depending on how dense they are and where they are located, cataracts can block the passage of light through the lens and interfere with the formation of images on the retina, causing vision to become cloudy.

Click the icon to see an image of eye anatomy.

Cataracts can form in any of three parts of the lens and are named by their location.

Nuclear cataracts. These form in the nucleus (the inner core) of the lens. This is the most common variety of cataract associated with the aging process.
Cortical cataracts. These form in the cortex (the outer section of the lens).
Posterior subcapsular cataracts. These form toward the back of a cellophane-like capsule that surrounds the lens. They are more frequent in people with diabetes, who are overweight, or those taking steroids.

Causes

Although older age is the primary risk factor for cataracts, experts are still not certain about the exact biologic mechanisms that tie cataracts to aging.

Researchers have been focusing on particles called oxygen-free radicals as a major factor in the development of cataracts. They cause harm in the following way:

Oxygen free radicals (also called oxidants) are molecules produced by natural chemical processes in the body. Toxins, smoking, ultraviolet radiation, infections, and many other factors can create reactions that produce excessive amounts of these oxygen free radicals.
Oxidants are missing an electron, so they are unstable and tend to chemically bind with other molecules in the body. When oxidants are overproduced, these chemical reactions can be very harmful to nearly any type of cell in the body. At times these reactions can even effect genetic material in cells.
Cataract formation is one of many destructive changes that can occur with overproduction of oxidants, possibly in concert with deficiencies of an important protective anti-oxidant called glutathione.
Glutathione occurs in high levels in the eye and helps clean up these free radicals. One theory posits that in the aging eye, barriers develop that prevent glutathione and other protective antioxidants from reaching the nucleus in the lens, thus making if vulnerable to oxidation.

Sunlight and Ultraviolet Radiation. Sunlight consists of ultraviolet (referred to as UVA or UVB) radiation, which penetrates the layers of the skin. Both have destructive properties that can promote cataracts. The eyes are protected from the sun by eyelids and the structure of the face (overhanging brows, prominent cheekbones, and the nose). Long-term exposure to sunlight, however, can overcome these defenses.

UVB radiation produces the shorter wavelength, and primarily affects the outer skin layers. It is the primary cause of sunburn. It is also the UV radiation primarily responsible for cataracts. Long-term exposure to even low levels of UVB radiation can eventually cause changes in the lens, including pigment changes, which contribute to cataract development. (UVB also appears to be responsible for macular degeneration, an age-related disorder of the retina.) Some scientists suggest that global warming and ozone depletion may increase people’s exposure to UVB, leading to a greater incidence of cataracts.
UVA radiation is composed of longer wavelengths. They penetrate more deeply and efficiently into the inner skin layers and are responsible for tanning. The main damaging effect of UVA appears to be the promotion of the release of oxidants.

Radiation Treatments. Cataracts are common side effects of total body radiation treatments, which are administered for certain cancers.

Electromagnetic Waves. Questions have been raised about the hazards of low-level radiation from computer screens. To date, no study has demonstrated an association between cataract development and video display terminals. It is a good idea, in any case, to sit at least a foot away from the front of a screen.

Cataracts are one of the many ill effects caused by smoking. Many studies have implicated smoking in the development of nuclear cataracts. The major damaging effects of cigarette smoke appear to be enhancement of free oxygen radicals, the chemical byproducts in the body that can damage cells, including those in the eye.

Corticosteroids. Long-term use of oral steroids is a well-known cause of cataracts. Studies have been conflicting, however, over whether inhaled and nasal-spray steroids increase the risk for cataracts. Information on cataract risk from inhaled steroids is important because they are commonly used by asthma patients, and steroid spray use is increasing among allergy sufferers. Studies have suggested a higher risk for cataracts among middle-aged and elderly patients treated with beclomethasone (Beclovent, Vanceril). However, newer inhaled steroids are available, and their effects on the eye are unclear. In children, cataracts are rare, and the benefits of inhaled steroids for asthma far outweigh any small additional risk.

Other Medications Associated with Cataracts.

Psoralens, a class of drugs used along with light therapy to treat skin disorders, such as psoriasis
Antipsychotic medications such as chlorpromazine (Thorazine)
Glaucoma medications

Many others drugs have been weakly associated with cataracts, including allopurinol, tamoxifen, amiodarone, tricyclic antidepressants, potassium-sparing diuretics (but not other diuretics), thyroid hormone, tetracyclines, sulfamidase, and mepacrine. According to a 2006 study in the Journal of the American Medical Association, statin drugs (used for managing cholesterol) may possibly reduce the risk for nuclear cataracts.

Click the icon to see an animation about cataracts.

Glaucoma. Glaucoma and its treatments, including certain drugs (notably miotics) and filtering surgery, pose a high risk for cataracts. The glaucoma drugs posing a particular risk for cataracts including demecarium (Humorsol), isoflurophate (Floropryl), and echothiophate (Phospholine).

Uveitis. Uveitis is chronic inflammation in the eye, which is often caused by an autoimmune disease or response. Often the cause is unknown. It is a rare condition that carries a high risk for cataracts.

A number of medical conditions appear to be associated with a higher risk for cataracts either because of a direct effect or because of the medications used for them, or both. They include the following:

Diabetes. Cataracts in patients with diabetes appear to form when high levels of blood sugar react with proteins in the eye to form byproducts that accumulate in the lens (sugar cataracts).
High blood pressure (hypertension).
Autoimmune diseases including rheumatoid arthritis, psoriasis, multiple sclerosis, systemic lupus erythematosus, Behcet's disease, and others.

Rarely, about 1 in every 10,000 births, a baby is born with cataracts (called congenital cataracts).

Inherited disorders are often involved in the development of congenital cataracts in children. Such cataracts are most often due to inborn abnormalities in the structure or shape of the lens, including its capsule. Dozens of variations can affect the lens causing, susceptibility to cataracts. Researchers are also investigating genetic factors that may cause mutations in alpha crystallins -- major proteins in the lens, which form cataracts. (Genetic factors also may play a role in some adult cataract cases. The exact hereditary predispositions have yet to be established.)
Infection during pregnancy can lead to cataracts.
Pregnant women who abuse alcohol or drugs increase the risk for cataracts (along with other more serious birth defects) in their infants.

Surgery in children with early-onset cataracts can help correct this problem in many cases, but it should be performed as soon as possible for full benefit. Experts recommend routine examination of the face of a fetus during ultrasound for abnormalities.

Symptoms

During the early stages, cataracts have little effect on vision. The symptoms of a cataract may include:

Cloudy vision, double vision, or both may be the first signs.
Images may take on a yellowish tint as color vibrancy diminishes.
Reading may become difficult over time because of a reduced contrast between letters and their background.
Sensitivity to bright lights may make it difficult or impossible to drive at night because of glare from the headlights of oncoming cars. (People with diffuse cataracts in the rear walls of their lenses are particularly prone to glare sensitivity because bright light tends to scatter in their lenses.)
In very advanced cases, the pupil, which is normally black, looks milky or yellowish. The patient's vision is reduced to being able only to distinguish light from dark.

This photograph shows a cloudy white lens (cataract) over the pupil. Cataracts are a leading cause of decreased vision in older individuals, but children may have congenital cataracts. With new surgical techniques, the cataract can be removed, a new lens implanted, and the person can usually return home the same day.

Nuclear Cataracts. Cataracts of the lens nucleus are most commonly associated with aging. Symptoms include:

Hazy distance vision and increasing glare.
Progressive nearsightedness and the need for frequent changes in eyeglass prescriptions. This effect may even temporarily counteract age-related farsightedness and provide a temporary improvement in overall vision in some people. The improvement fades when the cataract advances sufficiently to overwhelm the inherent farsightedness. Eventually, as the cataracts grow worse, stronger glasses can no longer correct the patient's vision.

Click the icon to see an image of normal, near, and farsighted vision.

Cortical Cataracts. Cortical cataracts usually start on the outside of the cortex (the outer area of the lens).

They have very little initial effect on vision.
Glare can develop as these cataracts increase and approach the center of the lens.
Problems with distance vision, contrast sensitivity, and clarity may occur as the cataracts progress further.

Posterior Subcapsular Cataracts. Posterior subcapsular cataracts typically start near the center of the back part of the capsule surrounding the lens. These cataracts often advance rapidly. For many patients, major impairment of eyesight, including near-vision problems and glare, develops within several months.

Prognosis

Some cataracts stop progressing after a certain point. Cataracts are never reversible, however, even after eliminating factors, (such as drugs or illnesses), which might have promoted their development. If extensive and progressive cataracts are left untreated they can cause blindness. In fact, cataracts are the leading cause of blindness among adults age 55 and older. About 20.5 million Americans have at least one cataract. By 2020, that number is expected to jump to 30.1 million.

Fortunately, cataracts nearly always can be successfully removed with surgery. However, surgery is unavailable in certain parts of the world, leaving millions at risk for vision loss. Even in the U.S., where surgery has greatly reduced the risk of blindness, tens of thousands still lose their sight and millions more have poor vision because of cataracts. Cataracts also exact a financial burden. According to 2006 data, cataracts cost the U.S. nearly $7 billion each year in medical services and drug treatments.

In a 2001 study, cataracts were associated with a significantly higher mortality rate in older women, although not older men. These higher rates did not seem to be caused by certain health risks (for example, diabetes) that are often associated with both cataracts and lower survival rates. A 2004 study published by scientists in Italy appears to confirm the association between shortened lifespan and cataracts, especially cataracts confined to the lens nucleus and those that had already required surgery. A few other studies have also linked cataracts and vision impairment with poorer survival, regardless of accompanying health problems. One study reported that even middle-aged people with cataracts, particularly those in ethnic minority groups, had lower survival rates than their peers, perhaps because of premature aging.

Effect on Survival by Location of the Cataract. Some studies have suggested poorer survival specifically in patients with nuclear or mixed cataracts but not in those with cataracts in the cortex or capsule. Not all studies have found these differences. In any case, nuclear cataracts are highly associated with smoking and diabetes, although some studies have found lower survival rates in patients with nuclear cataract regardless of these health risks.

A 2002 study reported twice the rate of automobile accidents in patients who do not have cataract surgery compared to those who had surgery. This finding, however, is obscured by the possibility that patients who choose not to have surgery may have other health problems that put them at risk for accidents. Also, driving skills decline with age in nearly everyone. Cataract surgery, then, is no insurance against age-related accidents.

Reduced vision ranks third only behind arthritis and heart disease as a cause of impaired function in older people. Extensive cataracts can compromise the ability to earn a living, read, drive, or live independently. Although vision loss has been associated with a number of major adverse effects, few studies have reported on the effect of vision on daily activities.

Both blurred vision and problems in seeing contrasts contribute to impaired activity. The degree of these impairments, however, may have different effects on disability depending on individual tasks and needs. For example, even a slight loss in vision sharpness and contrast can impair the ability to recognize faces or slow down reading speed. For those who read very quickly, this may not be significant, but it could be very disabling for slower readers. In one study, people under age 65 rated blurred vision as reducing their quality of life more than any other chronic medical problem except shortness of breath.

Nevertheless some people who have small cataracts can see well enough around the clouded areas to live normally. But for many people, cataracts are extensive enough to interfere greatly with daily activities.

Risk Factors

Aging is the primary risk factor for cataracts, but other factors are also involved.

Nearly everyone who lives long enough will develop cataracts to some extent. A major study reported that:

About 40% of people age 55 - 64 years had some opaque areas in their lenses, and 5% had fully-developed cataracts.
About 70% of people age 65 - 74 years had opaque areas, and 18% had cataracts.
More than 90% of people age 75 - 84 years had opaque areas, and almost 50% had cataracts.

One study indicated that posterior subcapsular cataracts are the most common type in people under 70 years old, while nuclear and mixed cataracts are most common in people over age 80. The risk for nuclear cataracts also increases with age.

Women face a higher risk than men. Women who started menstruating late are at an even higher risk.

Eye Features. People who are nearsighted and those with brown eyes may be at higher than average risk. (Not all studies, however, report a higher risk in people with darker eyes.)

Obesity and Height. Studies are now reporting obesity as a risk factor for cataracts, notably posterior subcapsular cataracts, which form toward the back of the lens. A study of 17,150 people found a specifically higher rate of cataracts in overweight people who are tall and whose fat distribution is primarily in the abdomen.

A 9-year population study, published in 2004, revealed that African Americans have nearly twice the risk of developing cataracts than do Caucasians. Analysis of the 3,000 participants also demonstrated for the first time that the risk of cortical cataracts is 3 times higher in African Americans than Caucasians. Earlier studies also identified a higher cataract risk in the black population, suggesting that it may be due to other medical illnesses, particularly diabetes. It has long been known that African Americans are much more likely to become blind from cataracts and glaucoma than Caucasians, mostly due to lack of treatment.

Hispanic Americans are also at increased risk for cataracts. In fact, cataracts are the leading cause of visual impairment among Hispanics. A 2005 study found that cataracts were about 3 times more common in Hispanic patients age 65 - 84 years than in similarly aged white or African Americans. (The study evaluated Hispanic patients of Mexican descent.) As with African Americans, Hispanic patients often face barriers to access to care.

People with certain medical conditions, notably diabetes, are at high risk for cataracts, either because of a direct effect of the disease, its treatments, or both.

Autoimmune Diseases and Conditions Requiring Steroid Use. Medical conditions requiring high use of corticosteroids (commonly called steroids) pose a particularly high risk. Many of these medical conditions are autoimmune diseases, including rheumatoid arthritis, psoriasis, multiple sclerosis, systemic lupus erythematosus, Behcet's disease, and others.

Diabetes and People with High Blood Glucose Levels. People with diabetes type 1 or 2 are at very high risk for cataracts and are much more likely to develop them at a younger age. They also have a higher risk for nuclear cataracts than nondiabetics. Cataract development is significantly related to high levels of blood sugar (called glycemia), and cataracts in people with diabetes are sometimes referred to as so-called sugar cataracts. Even people without diabetes but with higher-than-normal blood sugar levels are at high risk for cataracts. Some doctors now recommend that children with diabetes undergo an eye exam to check for cataracts at the time they are diagnosed.

Insulin is a hormone produced by the pancreas that is necessary for cells to be able to use blood sugar.

Exposure to even low-level UVB radiation from sunlight increases the risk for cataracts. A 2003 study published provided new evidence supporting the link between sun exposure and nuclear cataracts. The risk was highest among those who had significant sun exposure at a young age. Additional studies suggesting risk associated with sunlight exposure report:

The closer people live to the equator the greater the chance for cataracts. As suggested by a study in Southern France, sunlight exposure in these climates also increases the risk for severe cortical or mixed cataracts. In this study, even wearing sunglasses did not reduce the risk for these cataracts, although it did for posterior subcapsular cataracts.
People whose jobs expose them to sunlight for prolonged periods are at higher risk. People in southern climates whose occupations, such as fishing or oyster farming, exposed them to very intense sunlight were at high risk for all cataracts, including posterior subcapsular cataracts. (People in more northern climates with similar occupations may not have as high a risk.)
Occupational exposure to very intense artificial light, such as arc welding, increases the risk for cataracts.

Smokers. A study of nearly 18,000 doctors showed that those who smoked 20 or more cigarettes a day had approximately twice the risk of developing cataracts. Smokers are at particular risk for cataracts located in the nuclear portion of the lens, which limit vision more severely than cataracts in other sites. Quitting smoking may reverse some of this damage.

Alcohol Users. Chronic drinkers are at high risk for a number of eye disorders, including cataracts. Alcohol has been implicated in cataract development in a number of studies. Wine provided the least risk, and the more moderate the drinking the lower the risk. Alcohol may work directly on the proteins in the lens itself and indirectly by affecting absorption of nutrients important to the lens.

Long-term environmental lead exposure may increase the risk of developing cataracts according to a study published in the Journal of the American Medical Association. Researchers assessed bone lead levels in 795 men aged 60 years and older. Because lead tends to accumulate over time in the skeleton, the researchers measured lead levels in the men’s shin bones. Men with the highest levels of lead were three times more likely to have cataracts than men with the least amount of lead.

A poor diet may deprive the body of amino acids and B vitamins that are essential for eye health. A French study of elderly adults found that lower blood levels of the protein albumin were associated with an increased risk of cataracts.

Other conditions that can trigger the process leading to cataracts include:

Physical injury to the eye (such as a hard blow, cut, or puncture)
Chemical burns
Electrical shock injuries
Chronic exposure to intense heat or cold

Prevention

Although cataracts are not completely preventable, their occurrence can be delayed. Quitting smoking, avoiding overexposure to sunlight, drinking alcohol in moderation, and eating plenty of fresh fruits and vegetables can delay the formation of cataracts. No evidence exists that using eye drops or ointments or performing eye exercises will stem the onset of cataracts.

The simplest and most effective way to protect against ultraviolet (UV) radiation is to stay out of the sun. A hat and cover-up should be worn outside, particularly when the sun is most intense (10 AM - 3 PM). A wide-brimmed hat can reduce eye exposure to UVB radiation by 30 - 50%. Because the sun's rays are highly reflective, sitting in the shade or under an umbrella by itself does not guarantee protection.

Clothing that blocks or screens the harmful rays of the sun (UVA and UVB), in combination with wide-brimmed hats, sunglasses, and sunscreen, all help prevent damage to the eyes and skin. Any one of these by itself, even the sunscreen, may not be enough to prevent sun damage.

Note: Avoidance of the sun should not be taken to extremes. Some sunshine is desirable. Moderate sun exposure provides an important source of vitamin D, which is essential for healthy bones. There is a link between lack of sun exposure and depression (known as seasonal affective disorder, or SAD).

Click the icon to see an image of vitamin D.

Sunglasses. Protective sunglasses do not have to be expensive. Sunglasses are classified into three categories based on UVA and UVB protection:

Cosmetic purpose sunglasses block at least 70% UVB and up to 60% UVA. People should avoid these glasses if they have any risk for cataracts or eye problems.
General purpose sunglasses block at least 95% UVB and a minimum of 60% UVA. At the very least, people should purchase general purpose sunglasses that are labeled "Meets ANSI Z80.3 General Purpose UV Requirements." Labels should indicate that sunglasses block UV radiation up to 400 nm.
Special purpose sunglasses block at least 99% UVB and a minimum of 60% UVA rays. These are the optimal sunglasses for people at risk for cataracts. Ideally they should have the Skin Cancer Foundation's Seal of Recommendation for Sunglasses. Special purpose glasses should wrap around the head and block light coming from above, below, and both sides of the glasses. They should also fit snugly on the nose.
Lenses that are simply dark but not coated with UV-absorbing material may actually increase the risk of cataracts because the pupil widens to compensate for the shaded glass. This may allow more harmful ultraviolet waves to enter. Polarized glasses cut glare but have no effect on UV radiation. Mirror finishes without additional processing for UV blockage are also not fully protective. There is some controversy over whether blue light is harmful to the eyes. Some people prefer amber lenses, which block out the blue spectrum.

Antioxidant vitamins C and E. Because of the role oxidants may play in cataract formation, researchers are investigating the benefits of antioxidant vitamins and other food chemicals. Vitamins C, E, and riboflavin (a B vitamin), for example, are helpful in preserving levels of glutathione, an enzyme that helps protect against oxidation in the eye. Low levels of vitamin C in the lens of the eye have been particularly strong predictors of cataracts. Some evidence also suggests that ultraviolet B radiation interacts with deficiencies in certain antioxidants, such as vitamin E and zinc, to increase damage in the corneas and lenses of the eye.

Evidence on the benefits of supplements of vitamin E or C, or vitamin-rich foods, is conflicting. For example, in two identically constructed trials in the US and Britain, the American group derived apparent benefits from vitamins E, C, and beta carotene while the British group reported very little cataract protection. A 2005 study suggested that long-term use of vitamin E supplements may slow cataract development. However, in a major on-going American study called the Age-Related Eye Disease Study (AREDS), researchers reported no difference in the incidence of cataracts after 7 years in people who took the antioxidant vitamins compared to those who took sham vitamins.

High doses of vitamins may have harmful effects. It is always wise, in any case, to pursue a healthy diet that is low in fats, high in complex carbohydrates, and rich in fruits and vegetables.

B vitamins. Some studies report some protection from a number of B vitamins, including vitamins B1 (thiamin) B2 (riboflavin), B3 (niacin) and B12 (folate). Riboflavin, for example, plays a critical role in the production of glutathione, an enzyme that helps protect against oxidation in the eye. All forms of vitamin B are widely available in dairy products, fortified grains, and meat.

Carotenoids. Carotenoids are a group of more than 700 fat soluble nutrients that produce the colors in foods such as carrots, pumpkins, sweet potatoes, tomatoes, and other deep green, yellow, orange, and red fruits and vegetables. Many are proving to be very important for health. Different carotenoids may be more beneficial then others. They include:

Xanthophylls are compounds that form a particular category of carotenoids. The xanthophylls lutein and zeaxanthin are found in the lenses of the eye and may be of significant importance for people at risk for cataracts. Some evidence indicates supplements of xanthophyll-rich foods may help retard the aging process in the eye and protect against cataracts. In fact, some experts suggest that the higher risk of cataracts in women compared to men may be partly due to a lesser ability to transport these carotenoids from the blood into the eye. Xanthophylls can be obtained from dark green leafy vegetables (such as spinach), broccoli, and eggs.
Lycopene is an important carotenoid that may also play an important role in eye health as a person ages. Tomatoes are the importance sources of lycopene.
Beta carotene is the most widely studied carotenoid and is a powerful antioxidant. It has been specifically studied for cataract protection. Most studies, however, have found little or no benefits. A 2003 study did suggest that beta carotene may protect against cataracts in smokers, although it is important to note that other studies report a higher risk for lung cancer in smokers who take beta carotene.

Click the icon to see an image of folate sources.

Click the icon to see an image of vitamin B12 sources.

Click the icon to see an image of riboflavin sources.

Phytochemicals. Phytochemicals are substances in plants that have beneficial effects. Dark colored (green, red, purple, and yellow) fruits and vegetables usually have high levels of important plant chemicals and have been associated with a lower risk for cataracts. Tea contains certain plant chemicals called polyphenols that have been associated with protection against cataracts.

Click the icon to see an image of phytochemicals.

Diagnosis

Either an ophthalmologist or an optometrist can examine patients for cataracts, but only ophthalmologists are qualified to treat cataracts.

An ophthalmologist is a doctor who specializes in the medical and surgical care of the eye.
An optometrist is engaged in the practice of eye care, but is not a doctor and cannot prescribe medication or perform surgery.

The eye professional can observe cloudy areas on the lenses with a direct physical examination, even before the cataracts begin to interfere with vision. Cameras can measure the cataract density. Various vision tests are also performed.

Snellen Eye Chart. To determine how clearly a person can actually see, the Snellen eye chart is used, with rows of letters decreasing in size:

From a specified distance, usually 20 feet, a person reads the letters using one eye at a time.
If a person can read down to the small letters on the line marked 20 feet, then vision is 20/20 (normal vision).
If a person can read only down through the line marked 40 feet, vision is 20/40; that is, from 20 feet the patient can read what someone with normal vision can read from 40 feet.
If the large letters on the line marked 200 feet cannot be read with the better eye, even with glasses, the patient is considered legally blind.

The visual acuity test can be performed in many different ways. It is a quick way to detect vision problems and is frequently used in schools or for mass screening. Driver license bureaus often use a small device that can test the eyes individually and then together.

Other Tests. A number of other tests are used to diagnose cataracts or to determine if surgery is needed.

A chart similar to the Snellen chart, which has the same size letters, but in different contrasts with background, is used to test contrast sensitivity,
Glare sensitivity is tested by having the patient read a chart twice, with and without bright lights.
Tests of macular function, which evaluate the eye's acute vision center, can help the ophthalmologist determine the expected improvement from surgery.
The corneal endothelium, a layer of cells lining the cornea, is sensitive to surgical trauma and should be evaluated before any intraocular operation.
Patients with other eye disorders may require a number of other pre-operative tests.

Although eye tests aid in making a diagnosis for cataracts, results do not always reflect the quality of life and how effectively people function at home:

Some people with cataracts perform poorly on the tests yet appear to have no difficulty functioning normally day-to-day.
Others perform well on the tests but insist that their eyesight is bad enough to curtail ordinary activities, such as driving.

Standard eye tests, therefore, may not be useful for determining whether a patient actually needs cataract surgery.

In general, even if cataracts are diagnosed, the decision to remove them should be based on the patient's own perception of vision difficulties and needs and the effect of vision loss on normal activity. The patient should also be aware of all the risks and costs of surgery. In order to determine the quality of life, the patient may be given a questionnaire such as National Eye Institute Visual Function Questionnaire, which asks 39 questions related to vision and daily activities. This test or others may be useful for determining if eye disease is actually impairing the ability to function.

Treatment

Although surgery is the only remedy for cataracts, it is almost never an emergency. Most cataracts cause no problem other than reducing a person's ability to see, so there is no harm in delaying surgery.

Early cataracts may be managed with the following measures:

Stronger eyeglasses or contact lenses
Use of a magnifying glass during reading
Strong lighting
Medication that dilates the pupil. (May help some people with capsular cataracts, although glare might be a problem with this treatment.)

It is important to note, however, that no treatments will prevent cataract formation or progression or make a cataract disappear.

Progression of Cataracts. Patients and their families usually have plenty of time to consider options carefully and discuss them with an ophthalmologist. There is no constant rate at which cataracts progress:

Some develop to a certain point and then stop.
Even if a cataract does progress, it may be years before it interferes with vision.
Only in a very few, very rare circumstances is it necessary that cataract surgery be performed immediately.

Each year about 2.8 million cataract operations are performed, making it the most common operation in the U.S. for people over age 65. Cataract surgery may be the oldest procedure in the world, having been introduced to Europe from India by Alexander the Great's army.

In the past, cataract surgery was not performed until the cataract had become well developed. Newer techniques, however, have made it safer and even more efficient to operate in earlier stages. In fact, modern cataract techniques not only remove cataracts but are also becoming important procedures for correcting astigmatism. Cataract surgery improves vision in up to 95% of cases and prevents millions of Americans from going blind.

Nevertheless, considerable evidence suggests that, because of the ease and relative safety of the procedure, it may be performed more often than needed. Patients having operations now tend to have better preoperative vision than those operated on 10 or 20 years ago. In a study of 800 cataract operations, 25% of the patients said that clouding had had no obvious effect on their lives before the procedure.

Cataract surgery is very successful. It has the following advantages:

Nearly all patients enjoy better vision after surgery. Advanced procedures in lens development are allowing correction of astigmatism as well as cataract removal. (Patients with significant eye disease, such as glaucoma or corneal or retinal disease, may not experience the same degree of improvement.)
Many people experience significant improvement in quality of life after the operation.
Some studies indicate that better vision might even help slow down age-related health problems unrelated to the eyes.

In general, surgery is indicated for people with cataracts under the following circumstances:

The Snellen eye test reports 20/40 or worse, with the cataract being responsible for vision loss and glasses or visual aids no longer being helpful.
Everyday activities have become difficult to perform to the point that independence is threatened. Questionnaires that assess the effects of cataracts on quality of life have been developed.
The patient is at risk for falling in low light.

These guidelines are general, however. Whether surgery is appropriate or not further depends on the cataract patient's specific condition and needs. Some examples include the following:

Even if the criteria for surgery are met, a very sick, very elderly person in a nursing home may have less need for sharp vision than an active younger adult. Among very elderly patients (85 years and older), especially those with serious health problems, there are also higher risks for complications during surgery and poor outcomes afterward. Nevertheless, these cautions should not prevent the very elderly from having this procedure; vision improvement rates are still over 85%.
Even if the criteria for surgery are not met, some people with eye tests of 20/40 or better might want surgery because of problems with glare, double vision, or the need to have an unrestricted driver's license.
Even if the criteria for surgery are not met, if retinal disease is also suspected (usually a complication of diabetes), the doctor may perform cataract surgery in order to have a clear view of the eye.

Because of the risks, albeit small ones, of poorer vision or blindness, no one should be forced to have cataract surgery if they don't want it or are not strong enough to undergo the procedure. If there are any doubts about whether or not to undergo cataract surgery, a second opinion should be considered.

The patient should ask the ophthalmologist the following questions before agreeing to cataract surgery:

Is my cataract surgery an emergency?
Are the cataracts the only cause of my poor vision?
How much experience do you have with this procedure?
Do I have other eye diseases that might complicate surgery or reduce my benefit?
Do I have other health problems that might further complicate eye surgery?
Will you be able to implant an intraocular lens?
What type of procedure will you use?
Will I have to stay in the hospital overnight?
Afterwards, what are my chances of having poorer vision or becoming totally blind in that eye?
How well should I ultimately be able to see out of the operated eye?
How long will it take to heal?
How long will it take to achieve my best eyesight?
Will I have to wear glasses or contact lenses after surgery?
When will I get my final eyeglass prescription?
How soon after surgery will I be able to see well enough to go back to work? Drive a car? Return to full activity?
What will the surgery cost?

Cataract surgery is now usually done as an outpatient procedure under local anesthesia and takes less than an hour. Preoperative preparations may include:

Having a general physical examination is important for patients with medical problems such as diabetes. Diabetes can cause damage to the blood vessels of the eye’s retina, a condition called diabetic retinopathy. Recent research suggests that patients who have diabetic retinopathy and poor blood sugar control should not have their blood sugar rapidly corrected before cataract surgery. Correcting blood sugar too quickly before surgery can cause vision problems after surgery.
The ophthalmologist will use a painless ultrasound test to measure the length of the eye and determine the type of replacement lens that will be needed after the operation.
Topical application of so-called fluoroquinolone antibiotics (such as ofloxacin or ciprofloxacin) may be applied preoperatively to protect against postoperative infection.
Most healthy patients are given either a local injection or topical anesthetic. The patients who report the least pain during the operation are those given a sedative followed by a local injection rather than just the topical drug.
Some patients may require a general anesthetic, such as those who are very anxious, those who are unable to cooperate with the surgeon, and those who are allergic to local anesthetics.

All cataract procedures involve removal of the cataract-affected lens and replacing it with an artificial lens.

Phacoemulsification. Phacoemulsification (phaco means lens, emulsification means to liquefy) is now the most common cataract procedure in the United States and accounts for 85% of cases. Benefits are greater than with standard extracapsular surgery, and it may be particularly helpful for people with diabetes.

The procedure generally involves:

The surgeon makes an incision, which is much smaller than with standard cataract extraction.
Ultrasound is then used to break up the clouded lens into small fragments.
The tiny pieces are sucked out with a vacuum-like device.
A replacement lens is then usually inserted into the capsular bag where the natural lens used to be. In most cases, this is an intraocular lens (IOL), which is foldable and slips in through the tiny incision.
Because the incision is so small, it is often watertight and does not require a suture afterward, particularly if a foldable lens has been used. A suture may be needed if a tear or break occurs during the procedure or the surgeon inserts a rigid lens that requires a wider incision.

Click the icon to see an illustrated series detailing cataract surgery.

Phacoemulsification requires only local anesthesia. Newer methods for administering local anesthesia produce few complications. Most phacoemulsification procedures now take about 15 minutes, and the patient is usually out of the operating room in about an hour. There is little discomfort afterward and visual rehabilitation takes about 1 - 3 weeks.

Phacoemulsification is sometimes combined with viscocanalostomy, a glaucoma surgical procedure, for patients who have both glaucoma and cataracts. Recent research suggests that phacoviscocanalostomy (as this combined procedure is called) is safe and effective for this group of patients.

Surgeons in the U.S. and Europe are currently investigating Microphaco, a new approach to cataract surgery that uses two smaller (micro) incisions. The smaller incisions measure about 1.6 mm compared to the traditional 3 mm. Experts say this procedure is expected to revolutionize refractive and cataract surgery.

Other Lens Removal Techniques. The AquaLase device uses pulses of fluid to wash away the clouded lens. Some experts believe this approach causes less trauma to the eye, and allows for a quicker recovery time for the patient, than the ultrasound used in phacoemulsification.

Extracapsular or Intracapsular Cataract Extraction. Extracapsular cataract extraction was the original standard procedure, but is now generally used only in patients who have an extremely hard lens. It typically involves the following steps:

The ophthalmologist works under an operating microscope to make a small incision in the cornea of the eye.
The surgeon then extracts the clouded lens through this incision.
The capsule is left in place, which adds structural strength to the eye and enhances the healing process. (Less commonly, in intracapsular cataract extraction, the surgeon removes the lens and the entire capsule. There are greater risks with this procedure for swelling and retinal detachment.)
A replacement lens is then usually inserted.
A small suture is needed to stitch the incision together.

It takes about 2 - 4 weeks to completely restore vision.

With the clouded lens removed, the eye cannot focus a sharp image on the retina. A replacement lens or eyeglass are therefore needed:

Intraocular Lenses (IOL). In about 90% of cataract operations, an artificial lens, known as an intraocular lens (IOLs), is inserted. Until recently, IOLs used a pair of little spring-loaded loops to hold the lens in place. Most IOLs are now foldable, which makes insertion easier. In fact, a prefolded lens is now available that unrolls to fit the eye as body temperature warms it.

IOLs are available as monofocal or multifocal. Monofocal lenses correct only one type of vision range (such as distance vision). Multifocal lenses are designed for patients who need correction for a range of vision. A 2006 study suggested that the Tecnis IOL works particularly well for patients who require a multifocal IOL.

Although all the lens materials are presumably chemically inert, there are some reports of specific problems, notably a risk for causing a reaction that leads to the development of secondary cataracts, a condition called posterior capsular opacification. IOLs include the following materials:

Acrylic: The majority of IOLs are made from acrylic, which allows a controlled unfolding of the lens. Evidence indicates that this material provides a better visual outcome and fewer complications than other standard IOLs.
Polymethylmethacrylate (PMMA): Has the longest safety record. A PMMA IOL coated with heparin, a blood thinner drug, helps protect against the development of a secondary cataract after surgery.
Silicone: Can be inserted through a smaller incision than other materials. It has the highest rates of secondary cataracts. Newer forms of silicon IOLs may pose a lower risk.

Other materials are under investigation.

IOL brands include:

Crystalens: The FDA approved the Crystalens IOL in 2003. It is made from a form of silicone called Biosil. The Crystalens uses "hinges" that allow the lens to move, mimicking the eye's natural ability to focus automatically and seamlessly at all distances. Studies indicate that when used along with standard cataract removal methods, the Crystalens can restore a full range of functional vision, from distance to reading vision, without total dependence on glasses or contact lenses.
Array: The Array lens also uses silicon. It is one of a number of so-called second-generation IOLs that is available as a multifocal lens to help correct presbyopia (nearsightedness).
Tecnis: The Tecnis foldable IOL was specifically designed to improve functional vision of cataract surgery patients. Tecnis has a patented surface that reduces light scattering (spherical aberration) of the cornea, which can negatively affect vision. In April 2004, The FDA approved new labeling claims for Tecnis, stating the lens may help improve driving safety for senior cataract patients. In clinical trials, simulated night driving and visual acuity (20/20, 20/40) results were significantly better in eyes implanted with the Tecnis IOL. In addition, spherical aberrations were significantly less when compared to the traditional lens with the spherical optic.
AcrySof Natural: Approved in 2003, the yellow-tinted Acrysof Natural IOL was the first foldable lens to filter ultraviolet and blue-light. Eliminating both UV and portions of the high-energy blue light help prevent retinal damage. This lens also conforms to the natural shape of the human lens capsule so it remains centered over the eye.
AcrySof ReSTOR: The AcrySof ReSTOR IOL is approved in the U.S. for patients with and without presbyopia. The lens enhances vision at near, intermediate, and distant ranges. In clinical trials, 80% of patients who received the lens did not require glasses after cataract surgery. The FDA approved the AcrySof ReSTOR in March 2005.

IOLs are designed to improve specific aspects of vision. The choices include:

Lenses that address a single fixed focal point. Such lenses are suitable either for reading or for distance vision, but not both. If a distance lens is implanted, the surgeon prescribes glasses or contact lenses for reading. If a reading lens is implanted, lenses for seeing distances will be prescribed.
Lenses that address multifocal points. Multifocal lenses can focus at different points for both reading and distance vision. One study reported that more than 80% of patients with multifocal lenses were able to see 20/40 or better without correction. However, contrast may be reduced and some patients experience glare and halos, particularly at night.
Lenses are available that will correct astigmatism after cataract surgery.

The patients and the doctor must make these decisions based on specific visual needs.

Contact Lenses or Cataract Glasses. A few patients do not receive a new lens and rely solely on corrective eyeglasses or contact lenses. Such patients may include:

Patients who are extremely near-sighted
Patients with other eye disorders

In such cases, the patient typically returns to the ophthalmologist for a check up the day after surgery, and three additional check-ups are scheduled over a 2-month period. The ophthalmologist can usually give a final prescription for eyeglasses or contact lenses about three months after surgery.

Choosing Contact Lenses. Contact lenses allow clear vision but do not magnify, so those who choose contact lenses after surgery may have to wear reading glasses. Contacts can be prescribed either for use only during the day or for extended-wear. Occasionally contact lenses cause problems, such as infection. Those who wear them should call their eye doctor if they have red or watery eyes, pain, or sensitivity to light.
Cataract Glasses. Until the advent of contact lenses, people who had cataract surgery had no choice but to wear glasses with thick lenses, sometimes called Coke-bottle glasses. These glasses have gotten thinner and lighter in recent years, but they may still be cumbersome. Cataract glasses are different from ordinary glasses and are sometimes difficult to adjust to. Images can seem distorted and may appear suddenly within the peripheral vision. Distances may be hard to judge.

Sometimes a patient has two cataracts and needs to wear glasses between the first and second operation. They are particularly troublesome during this period. The treated eye will see images magnified while the other eye will view them as they actually are, and the brain cannot blend the two images. This is a temporary state that is resolved by the second operation.

Modern cataract surgery is one of the safest of all surgical procedures. Most complications, even if they occur, are not serious. They can include the following:

Swelling and inflammation. Risk is about 1%. This complication is particularly harmful for patients with existing uveitis (chronic inflammation in the eye, which can be due to various conditions).
Glare. Patients may experience glare after surgery from light scattering at the edges of the new lens, particularly with square-edged IOLs, which are typically used with posterior capsular cataracts. In most cases, this is a temporary problem that resolves after a few weeks. Sometimes, the problem persists, and the patient requires another operation. Some research suggests that glare can be significantly reduced by texturizing the edges of the square lens.
Materials used in some lenses trigger an immune response in about half of patients. This causes inflammation and tiny deposits of tissue in the eye that lead to secondary cataracts -- called posterior capsule opacification. Studies suggest that silicone implants pose the highest rates for inflammation and secondary cataracts, particularly in patients with other eye diseases. Newer silicon IOLs pose less risk. In one study, the lowest rates were with IOLs made of acrylic and heparin-coated PMMA.
Retinal detachment. In rare cases, the retina at the rear of the eye can become detached. Risk is very low (0.1%), and phacoemulsification poses less of a risk for this than standard surgery.
Atonia (loss of muscle tone that results in a disturbing glare). (Phacoemulsification poses less of a risk than standard surgery.)
Glaucoma. This is an eye condition in which the pressure of fluids inside the eye rises dangerously. Risk is very low, but patients should be sure to avoid activities after surgery that increase pressure.

Glaucoma is a condition of increased fluid pressure inside the eye. The increased pressure causes compression of the retina and the optic nerve which can eventually lead to nerve damage. Glaucoma can cause partial vision loss, with blindness as a possible eventual outcome.

Infection. This is very rare (0.2%), but is devastating if it does develop.
Blisters on the cornea. There is a higher risk of rupture with phacoemulsification, but the risk is extremely low, particularly for experienced eye surgeons. In 2004, the FDA approved the StabilEyes Capsular Tension Ring (CTR) to help support the eye's capsular bag during cataract surgery, especially in those with weak or broken eye fibers (zonules). A CTR is an open ring made of polymethylmethacrylate (PMMA). The ring goes into the capsular bag itself, stabilizing the eye.
Bleeding can develop inside the eye. Risk is about 1% for minor bleeding and 1 in 10,000 for severe bleeding.
An implanted IOL can become damaged or dislocated. Risk is very low.
The surgery itself can produce vision loss or impairment. The risk for this is 1 in 1,000. (Phacoemulsification poses less of a risk than standard surgery.)
Macular degeneration. Macular degeneration, in which the retina breaks down, is a common cause of vision loss in the elderly. In a 5-year study, people who underwent cataract surgery had twice the risk for progression of age-related macular degeneration. Interestingly, another study reported that cataract surgery significantly helped patients who had existing macular degeneration. More research is needed to refute or confirm this finding.

Click the icon to see an image of macular degeneration.

Phacoemulsification does have some specific complications, although they are rare, particularly with experienced eye surgeons. They include:

Rupture of the lens capsule.
Loss of the lens nucleus into the eye fluid. (This will require removal by a specialist and may result in poorer vision.)
Flying fragments of the lens can damage the cornea or threaten the retina.
Pre- and postoperative changes in blood pressure, which are generally not a problem, should be observed carefully, since in some cases the changes may be extreme.

In about 30% of cases patients develop secondary cataracts within 1 - 5 years after either procedure, which require different treatment choices.

Preventing Infection and Reducing Swelling. The ophthalmologist may prescribe the following medications:

A topical antibiotic (neomycin or, more effectively, gentamicin). This drug protects against infection.
Corticosteroid eyedrops or ointments are often used to reduce swelling. Corticosteroids (commonly called steroids) are potent anti-inflammatory drugs. However, they also pose a risk for pressure in the eye and infection. One study reported less visual sharpness with the use of steroids compared to antibiotics. Some newer steroids such as rimexolone, loteprednol, and fluorometholone may pose a lower risk for abnormal pressure.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, ketorolac, naproxen, and voltaren, also reduce swelling and do not pose the same risks as steroids. Newer NSAIDS that have been approved to treat pain and swelling after cataract surgery include bromfenac (Xibrom) and nepafenac (Nevanac).

In one study, applying an ice pack for 2 hours immediately after phacoemulsification improved comfort level and reduced inflammation, even days after the operation. This simple procedure has no adverse effects and patients should discuss it with their surgeons before the operation.

Factors That Increase Risk for Complications. The risks of complications are greater for the following people:

Patients who have other eye diseases.
People with diabetes. Intracapsular and extracapsular cataract extraction are known to pose a high risk for the development or worsening of retinopathy, a known eye complication of diabetes. Experts have hoped that phacoemulsification would pose a lower risk, but a 2001 study reported a high percentage of retinopathy progression after this procedure. The amount of experience a surgeon has plays a role in whether or not a patient has this complication.
People who have taken tamsulosin (Flomax) or other alpha-1 blocker drugs. Tamsulosin is a muscle relaxant prescribed for treatment of several urinary conditions including benign prostatic hyperplasia (BPH). In 2005, a leading ophthalmologic association and the FDA warned that tamsulosin may cause intraoperative floppy iris syndrome (IFIS), a loss of muscle tone in the iris that can cause complications during eye surgery. Problems have been reported both for patients who were taking the drug during surgery as well as those who had stopped taking the drug weeks or months before surgery. Men who have taken tamsulosin or similar drugs should inform their eye surgeon. The surgeon may need to use different techniques to minimize the risk of IFIS. A 2006 study indicated that patients can have safe and successful surgeries with these modified techniques.

Returning Home and Follow-up Visits.

Patients usually leave the surgical site within an hour of surgery. Cataract surgery almost never requires an overnight hospital stay.
They need to have someone drive them home and stay with them for a few days until their vision is acclimated.
The patient is usually examined the day after surgery and then during the following month. Additional visits are made as required.
Vision usually remains blurred for a while but gradually clears, usually over a 2 - 6 week period. (It can take longer.)
When the doctor decides the condition has stabilized, the patient will receive a final prescription for glasses or contacts.

Protecting the Eye. Postoperative protection of the eye typically involves:

The ophthalmologist usually tapes a bandage over the eye to protect it during the healing process.
When changing the bandage, the eye can be cleaned gently using a washcloth dipped in warm water without soap. A new bandage can then be positioned and taped.
It is very important not to press or rub the eye during this procedure.
An eye shield may be placed over the bandage at night.

Avoiding Glaucoma. Cataract surgery can cause glaucoma, a condition in which the pressure of fluids inside the eye rises dangerously. It is very important to minimize any activity that increases internal eye pressure. Postoperative cataract patients take the following precautions:

Minimize vigorous exercise.
Put on shoes while sitting and without lifting up the feet.
Kneel instead of bending over to pick something up.
Avoid lifting.
Limit reading since it requires eye movement (watching television is all right).
Sleep on the back or on the unoperated side.

Cataracts and Glaucoma. For patients with both glaucoma and cataracts, experts recommend:

In patients with cataracts and poorly controlled glaucoma, a two-step procedure for both eye conditions is needed. The patient first receives a trabeculectomy for glaucoma, followed by cataract surgery. Fluid leakage and the presence of blood in the back chamber of the eye are potential complications of this combined procedure. Phacoemulsification has improved success rates and reduced high complication rates of the double procedure compared with extracapsular cataract extraction. New advances that replace trabeculectomy with nonpenetrating glaucoma surgery may prove to be beneficial.
In patients who have cataracts plus either closed-angle glaucoma or open angle glaucoma that is stabilized with medication, the cataract may be able to be extracted and medication continued for the glaucoma.
A major 2002 analysis suggested that the combined approach generally offers better control over eye pressure for patients with both cataracts and glaucoma. The best surgical procedure, however, is still uncertain.

Cataracts and Corneal Disease. Patients who have both cataracts and corneal disease may undergo one of the following:

Combination Procedure. A single operation that combines three procedures. The combined procedure has been used since the late 1970s and employs extracapsular cataract extraction and intraocular lens insertion with corneal transplantation (called penetrating keratoplasty).
Sequential Procedure. An operation that uses two procedures sequentially. The sequential option performs the cataract procedures and the corneal transplantation separately.

Recovery of vision is usually much more rapid after the combined procedure than after the sequential procedures. Performing the procedures sequentially may also carry a higher rejection rate of the implant, although a 2003 study found no differences in failure rates between the two approaches after a year.

In any case, many experts recommend that for most patients the sequential procedures may be the better option because it appears to have fewer of the following complications than with the combined procedure:

Posterior capsule rupture
Eye fluid loss
Postoperative refractive errors, which result in abnormal distribution of light patterns

The rate of these errors still depends on the skill of the surgeon and the power of the implanted lens no matter what approach is used.

About 30% of patients who undergo extracapsular cataract surgery develop a secondary "after-cataract" called posterior capsular opacification. Posterior capsular opacification generally occurs because of the following events:

After surgery, there are still some natural lens cells left behind that proliferate on the back of the capsule.
The capsule gradually becomes cloudy and interferes with clear vision the same way the original cataract did.

According to a 2001 study, the probability of developing a secondary cataract was 6% at 1 year, 15% at 2 years, 23% at 3 years, and 38% at 9 years. The risk is lower with phacoemulsification. Secondary cataracts are more likely to occur in younger patients, in those with diabetes, or when cataract surgery is combined with vitrectomy (clearance of debris from the fluid in the eye).

Preventing Posterior Capsular Opacification. Studies suggest that acrylic lenses pose the lowest risk for posterior capsular opacification. A number of substances to prevent posterior capsular opacification are under investigation, including tranilast eyedrops, new lens materials, special capsular rings inserted during phacoemulsification, and new coatings on the implanted lens.

Treatment Decisions for Cataracts in the Second Eye. If a person has a cataract in a second eye, the issues for decision making are the same as for the first eye. The time of the procedure in the case of two cataracts is unclear. Doctors have long recommended that surgery on the second eye should be postponed until the first eye has healed and the results known (about a year).

One study has called this recommendation into question. It was conducted in England, where for budgetary reasons, there are long waits for second-eye cataract surgeries. In the study, patients who waited 7 - 12 months for the second-eye surgery reported significant difficulty in reading and performing ordinary tasks during the waiting period. Only 1% of patients who had the second surgery within 6 weeks reported having trouble seeing. In addition, 70% of those who waited experienced problems in depth perception, which can cause difficulty in walking and driving; only 12% who didn't wait reported this problem. Patients with double cataracts should discuss all options with their surgeon.

Treatment for Posterior Capsular Opacification. The standard treatment is laser surgery known as a YAG capsulotomy. (Capsulotomy means cutting into the capsule, and YAG is an abbreviation of yttrium aluminum garnet, the laser most often used for this procedure.)

This is an outpatient procedure and involves no incision.
Using the laser beam, the ophthalmologist makes an opening in the clouded capsule to let light through.
After the procedure the patient should remain in the doctor's office for an hour to be sure that pressure in the eye is not elevated.
An eye examination for any complications should follow within 2 weeks.

Complications. Laser surgery has become so commonplace that some ophthalmologists use it after cataract surgery to prevent later clouding. However, laser surgery carries its own risks and possible complications, similar to those of cataract surgery itself, and can also lead to poorer vision or blindness. About 1% of laser surgery patients develop a detached retina, which is much higher than the risk from the original cataract surgery.

Click the icon to see an image of a detached retina.

In some people, particularly those with glaucoma or who are severely nearsighted, the pressure in the eye may spike after laser surgery. Certain drugs used for treating glaucoma, such as dorzolamide (Trusopt) or apraclonidine (Iopidine), may helpful for preventing this occurrence. It is strongly recommended, however, that this surgery not be performed to prevent a secondary cataract, but only if the lens capsule clouds up again.

Infants. Treatment of infants first depends on whether one or both eyes are affected:

For infants born with cataracts in one eye, the American Academy of Ophthalmology recommends surgery as soon as possible, by 4 months or ideally even earlier. The procedure is followed by contact lens correction and patching of the unaffected eye. Although this approach is successful in many cases, some children still become blind in the affected eye. There is also a high risk for glaucoma after surgery.
In infants with cataracts in both eyes, surgery is not always an option. In some cases, it may be performed sequentially, with the second eye operated on a few days after the first. Phacoemulsification appears to pose a much higher risk for secondary cataracts than standard lens removal.

Toddlers and Older Children. Intraocular lens replacement is now becoming standard treatment for children 2 years and older.

Resources

www.ascrs.org -- The American Society of Cataract and Refractive Surgery
www.aao.org -- American Academy of Ophthalmology
www.nei.nih.gov -- National Eye Institute
www.eyesurgeryeducation.com -- Eye Surgery Education Council
www.lighthouse.org -- Lighthouse International
www.aao.org/aao/find_eyemd.cfm -- Find an ophthalmologist

References

Eke T, Thompson JR. Serious complications of local anaesthesia for cataract surgery: a one-year national survey in the United Kingdom. Br J Ophthalmol. 2006 Nov 23; [Epub ahead of print]

Hutz WW, Eckhardt HB, Rohrig B, Grolmus R. Reading ability with 3 multifocal intraocular lens models. J Cataract Refract Surg. 2006 Dec;32(12):2015-21.

Klein BE, Klein R, Lee KE, Grady LM. Statin use and incident nuclear cataract. JAMA. 2006 Jun 21;295(23):2752-8.

Rein DB, Zhang P, Wirth KE, Lee PP, Hoerger TJ, McCall N, et al. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol. 2006 Dec;124(12):1754-60.

Wishart MS, Dagres E. Seven-year follow-up of combined cataract extraction and viscocanalostomy. J Cataract Refract Surg. 2006 Dec;32(12):2043-9.

Review Date:
3/1/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

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adam.com

Asthma in children and adolescents

FitSugar — Wed, 08 Oct 2008 17:35:28 -0700

In This Report

Highlights
Introduction
Causes
Prognosis
Risk Factors
Symptoms
Diagnosis
Treatment
Quick-Relief Medications...
Long-Term Relief Medication...
Other Treatments
Managing Asthma
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Drug Warning

In 2007, the FDA requested the manufacturers of omalizumab (Xolair) to include a “boxed warning” emphasizing that this drug may cause a severe and life-threatening allergic reaction (anaphylaxis). Health care providers need to carefully observe patients for 2 hours after they receive an omalizumab injection. However, because an allergic reaction can occur up to 24 hours after the injection, patients need to know the signs and symptoms of anaphylaxis and how to self-administer emergency treatment. Omalizumab is approved for patients ages 12 and older who have moderate-to-severe asthma related to allergies.

Drug Approval

In 2006, budesonide/formoterol (Symbicort) was approved for patients age 12 years and older. Symbicort combines a corticosteroid and a long-acting beta2-agonist into a single inhaler.

Inhaled Corticosteroids

Inhaled corticosteroids may help reduce wheezing in young children with breathing problems, but they do not help prevent the development of asthma, according to several 2006 studies in the New England Journal of Medicine.
Inhaled corticosteroids work better than a corticosteroid/long-acting beta2-agonist combination or a leukotrine receptor antagonist drug in treating children with mild-to-moderate asthma, suggests a 2007 study in the Journal of Allergy and Clinical Immunology.

Long-Acting Beta2-Agonists

Long-acting beta2-agonist drugs such as salmeterol (Serevent Diskus) and formoterol (Foradil Aerolizer) may worsen asthma symptom severity and increase the risk for asthma-related death, indicates a 2006 review in the Annals of Internal Medicine.
Products that contain salmeterol and formoterol now have strengthened warning labels detailing these risks.

Childhood Asthma Statistics

Asthma death rates among children have largely declined since 1999 while doctors’ office visits for asthma treatment have more than doubled, indicates a recent report from the U.S. Centers for Disease Control and Prevention.

Introduction

The word asthma originates from an ancient Greek word meaning panting. Essentially, asthma is an inability to breathe properly. When any person inhales, the air travels through the following structures:

Air passes into the lungs and flows through progressively smaller airways called bronchioles. The lungs contain millions of these airways.
All bronchioles lead to alveoli, which are microscopic sacs where oxygen and carbon dioxide are exchanged.

The major features of the lungs include the bronchi, the bronchioles, and the alveoli. The alveoli are the microscopic blood vessel-lined sacks in which oxygen and carbon dioxide gas are exchanged.

Asthma is a chronic condition in which these airways undergo changes when stimulated by allergens or other environmental triggers. Such changes appear to be two specific responses:

The hyperreactive response (also called hyperresponsiveness)
The inflammatory response

These actions in the airway cause patients to cough, wheeze, and experience shortness of breath (dyspnea), the classic symptoms of asthma.

In the hyperreactive response, smooth muscles in the airways constrict and narrow excessively in response to inhaled allergens or other irritants. Airways in everyone's lungs respond by constricting when exposed to allergens or irritants but there are major differences in the hyperreactive response that occurs in people with asthma:

When people without asthma breathe in and out deeply, the airways relax and open in order to rid the lungs of the irritant.
When people with asthma try to take those same deep breaths, their airways do not relax but instead narrow, causing the patients to pant for breath. Smooth muscles in the airways of people with asthma may have a defect, perhaps a deficiency in a critical chemical that prevents the muscles from relaxing.

The hyperreactive stage is followed by the inflammatory response, which generally contributes to asthma in the following way:

The immune system responds to allergens or other environmental triggers by delivering white blood cells and other immune factors to the airways.
These so-called inflammatory factors cause the airways to swell, fill with fluid, and produce a thick sticky mucus.

Click the icon to see an image of a normal versus asthmatic bronchiole.

This combination of events results in wheezing, breathlessness, inability to exhale properly, and a phlegm-producing cough.

Inflammation appears to be present in the lungs of all patients with asthma, even those with mild cases, and plays a key role in all forms of the disease.

Causes

Asthma occurs in about 5 million American children. Each year about 200,000 of them are hospitalized. It is the most common chronic childhood illness. About half of all cases of asthma develop before the age of 10, and about 80% of patients develop symptoms before they are 5 years old.

The mechanisms that cause asthma are complex and vary among population groups and even individuals. For example, asthma in children is highly associated with allergies. However, only a minority of children with allergies have asthma, and allergic response cannot explain all cases of asthma. Other factors, such as genetics or environmental conditions are probably involved in the development of asthma. Most likely, several genes combine to make a child susceptible to environmental triggers, not only allergens but also possibly infections, dietary patterns, or air pollution. Physical factors, particularly having smaller lungs, affect the chances for later asthma.

Asthma and allergies often coexist, and the allergic response plays a strong role in childhood asthma. About 70 - 85% of children with asthma also have allergies. Some studies suggest that children who have allergies are also at greater risk for developing asthma as adults. A 2006 study found that children who are allergic to dust mites are three times more likely to later develop asthma than children who were not allergic.

However, the evidence is clearly mixed. Several other 2006 studies suggested that avoiding dust mites does not help prevent asthma and, in fact, early exposure to dust mites may even protect children from developing asthma and allergic responses. Some experts think that giving immunotherapy (“allergy shots”) to children with allergies may help prevent asthma development.

An asthma attack can be induced or aggravated by direct irritants to the lungs. Studies indicate that the more indoor allergens a child is allergic to, the higher the risk for severe asthma. Important irritants or allergens include the following:

Dust mites, specifically mite feces, which are coated with enzymes that contain a powerful allergen. These are the primary allergens in the home.
Animal dander. Cats harbor significant allergens, which can even be carried on clothing; dogs usually present fewer problems.
Molds.
Cockroaches. Cockroaches are major asthma triggers and may reduce lung function even in people without a history of asthma.
Pollen. An asthma attack from an allergic response to pollen is more likely to occur during extreme air changes, such as thunderstorms. Major weather changes, such as El Nino, can affect the timing of allergy seasons because they cause seasonal changes (and pollen) to start earlier.
Food allergies. About 8 - 10% of children with asthma also have food allergies. These children also appear to have a high risk for very serious reactions to such foods. In infants and toddlers, allergy to eggs appears to be a predictor of asthma.
Fossil Fuels. Certain chemicals may trigger allergic rhinitis. Some experts believe that refined fossil fuels, such as diesel fuel and particularly kerosene, may be important triggers for allergic rhinitis. In people who already have allergies or asthma, exposure to such fossil fuels may worsen symptoms.

The Allergic Response. The allergic process, called atopy, and its connection to asthma are not completely understood. It involves various airborne allergens or other triggers that set off a cascade of events in the immune system leading to inflammation and hyperreactivity in the airways. One description is as follows:

The conductor in an orchestra of immune factors that contribute to allergies and asthma appears to be a category of white blood cells known as helper T cells, in particular a subgroup called Th2 cells.
Th2 cells overproduce interleukins (ILs), immune factors that are molecular members of a family called cytokines, which are involved in the inflammatory process.
Interleukins 4, 9, and 13, for example, may be responsible for a first-phase asthma attack. These interleukins stimulate the production and release of antibody groups known as immunoglobulin E (IgE). (People with both asthma and allergies appear to have a genetic predisposition for overproducing IgE.)
During an allergic attack, these IgE antibodies can bind to special cells in the immune system called mast cells, which are generally concentrated in the lungs, skin, and mucous membranes. This bond triggers the release of a number of active chemicals, importantly potent molecules known as leukotrienes. These chemicals cause airway spasms, overproduce mucus, and activate nerve endings in the airway lining.
Another cytokine, interleukin 5, appears to contribute to a late-phase inflammatory response. This interleukin attracts white blood cells known as eosinophils. These cells accumulate and remain in the airways after the first attack. They persist for weeks and mediate the release of other damaging particles that remain in the airways.

Researchers are investigating the role that T cells play in asthma. T cells are white blood cells that are involved in the immune response. Researchers had focused on the T cell called type 2 helper (ThH2) cells. However, a 2006 breakthrough study in the New England Journal of Medicine suggested that a different type of T cell may play a stronger role in asthma than previously thought.

Researchers discovered that these cells, called natural killer T cells, are far more common in the lungs of people with asthma than in the lungs of healthy people. Natural killer T cells are very rare, but researchers found them in 60% of people with moderate-to-severe persistent asthma. While this research is preliminary, it may explain why corticosteroid drugs do not work well for some patients with asthma: Steroid drugs target Th2 and other inflammatory cells, not natural killer T cells. Researchers think that further investigation of natural killer T cells may lead the way to new types of asthma drugs. If these cells prove to be involved in asthma, then drugs that eliminate them might become an important new treatment.

Over the course of years the repetition of the inflammatory events involved in asthma can cause irreversible structural and functional changes in the airways, a process called remodeling. The remodeled airways are persistently narrow and can cause chronic asthma. Researchers are trying to determine how this process occurs:

Interleukins. Some researchers are looking at potent immune factors, including interleukins 11 and 13. They have been linked to a number of processes possibly involved in remodeling, including scarring in the airways and overgrowth of cells in the smooth muscles that line the airways.

Growth Factors. Compounds known as vascular endothelial growth factor (VEGF) have been observed in the airways of patients with asthma. VEGF is a powerful promoter of cell growth in blood vessel linings and some researchers believe it may be major factor in remodeling.

About one-third of all persons with asthma share this condition with another member of their immediate family. Asthma may be more likely to be passed to children from the mother than from the father. Both allergies and asthma are strongly associated with hereditary factors, sharing certain genetic markers, but they are not always inherited together.

Research on the genetics of these conditions is confusing. Of some significant promise, researchers have identified a gene (ADAM33), which has been linked to asthma. The gene regulates one of the enzymes called metalloproteases, which are involved with the smooth muscle in the airway. A mutation of this gene could play a role in airway changes that occur after inflammation.

The role of early childhood respiratory and intestinal infections is very complex. Viral respiratory infections certainly worsen existing asthma, but the most common ones are unlikely to be causes of childhood asthma. In fact, early respiratory and intestinal infections may offer some protection against asthma.

Early Respiratory Infections as Causes of Asthma. Studies suggest that most respiratory infections are not important causes of asthma in children, except in certain cases. An important exception is the respiratory syncytial virus (RSV), which has been implicated in the development of asthma. RSV is the major viral cause of infant pneumonia. Studies also indicate that infants who have reduced lung function within a few days after birth are at increased risk of developing asthma by the time they are 10 years old.

Common Respiratory Infections Worsen Asthma. Common respiratory infections viruses that cause colds (such as the rhinovirus) may in some cases be associated with the development of asthma. A 2007 study suggested that children who have a wheezing rhinovirus during infancy are at increased risk for developing asthma by age 6. Even if these viruses do not directly cause asthma, they can worsen asthma in children who already have it. Rhinovirus has been reported to be the most common infection associated with asthma attacks. In one study, it was associated with 61% of asthma worsening in children. Some research suggests that colds promote inflammation in patients with existing asthma and increase the intensity of airway responsiveness for weeks.

The Hygiene Theory: Early Infections as Protection Against Asthma. Another blames the dramatic increase in asthma on the reductions in childhood infections that have occurred with modern hygiene and antibiotic use. The basic theory rests on the idea that infections stimulate production of specific immune factors called Th1 cells. As these cells build up, they replace other immune factors called Th2 cells, which react to allergens -- a less serious threat to the body. Without infections to stimulate the production of the Th1 infection fighters, the Th2 allergen fighters are not replaced, and they persist at high levels, making the growing child more susceptible to allergies and asthma.

A number of different studies support this theory:

Some studies suggest that being part of a large family or attending day care increases the risk for early respiratory infections but reduces the risk of childhood asthma. The occasional cold, then, may be protective.
In one study, researchers measured levels of bacterial byproducts called endotoxins in the mattress dust of 812 children. Those with the highest levels had 80% lower rates in allergies and asthma.
Another study further found a strong association between allergy development and the absence of certain beneficial bacteria (called probiotics) carried in the infant's intestines. Infants who were born in more hygienic environments tended to lack these bacteria. Antibiotic overuse and modern hygiene may be reducing these helpful organisms. (Probiotics can be obtained in active yogurt cultures and in supplements, which are being studied for protection.)

The standard vaccinations against serious childhood infections, according to several important studies, pose no risk for asthma. One of the studies even reported some lower risk for asthma and allergies in the second and third years after vaccinations. Infections killed thousands of children every year before immunization became widespread. Asthma, although serious, is rarely fatal in children. No one should stop giving their children vaccinations against childhood killers.

GERD. At least half of patients with asthma also have gastroesophageal reflux disease (GERD), the cause of heartburn. It is not entirely clear which condition causes the other or whether they are both due to common factors.

Heartburn is a condition where the acidic stomach contents back up into the esophagus causing pain in the chest area. This reflux usually occurs because the sphincter muscle between the esophagus and stomach is weakened. Standing or sitting after a meal can help reduce the reflux which causes heartburn. Continuous irritation of the esophagus lining as in gastroesophageal reflux disease is a risk factor for the development of adenocarcinoma.

Some theories for the causal connection between GERD and asthma are:

Acid leaking from the lower esophagus in GERD stimulates the vagus nerve, which runs through the gastrointestinal tract. This stimulated nerve, in turn, triggers the nearby airways in the lung to constrict, causing asthma symptoms.
Acid back-up that reaches the mouth may be inhaled into the airways (aspirated). Here, the acid triggers a reaction in the airways that cause asthma symptoms.

GERD is sometimes hard to detect and might be suspected as a contributor in the following patients:

Those who do not respond to asthma treatments.
Those whose asthma attacks follow episodes of heartburn.
Those whose attacks are worse after eating or exercise.
Those whose coughs follow episodes of acid reflux. (One study found that GERD was associated with about half of the episodes of coughs and wheezes in patients with asthma.)

Treating GERD symptoms with anti-acid drugs may resolve asthma in some (but not all) patients who share both conditions. A small 2005 observational study found that while GERD was common in patients with asthma, treatment of GERD had no effect on asthma symptoms. [See In-Depth Report #85: Heartburn and gastroesophageal reflux disease.]

Sinusitis. Almost half of children and adults with allergic asthma have sinus abnormalities, and in various studies, between 17 - 30% of patients with asthma develop true sinusitis. The presence of sinusitis, however, does not appear to increase the severity of asthma.

Click the icon to see an image of sinusitis.

Parental Migraines and Childhood Asthma. Some studies have reported a link between childhood asthma and parental migraines, with one small study suggesting that children are about five times more likely to develop asthma if their parents have a history of migraines.

Exercise-induced asthma (EIA) is a limited form of asthma in which exercise triggers coughing, wheezing, or shortness of breath.

About 10% of adults and some fewer children have aspirin-induced asthma (AIA). With this condition, asthma gets worse when patients take aspirin. Aspirin is one of the drugs known as nonsteroidal anti-inflammatory drugs (NSAIDs). Although aspirin is used to reduce inflammation in other disorders, it appears to have the opposite effect in many asthma cases. It is not wholly known why this occurs. AIA often develops after a viral infection. It is a particularly severe asthmatic condition and is associated with up to 25% of asthma-related hospitalizations. In about 5% of cases, aspirin is responsible for a syndrome that involves multiple attacks of asthma, sinusitis, and nasal congestion. Such patients also often have polyps (small benign growths) in the nasal passages.

Patients with aspirin-induced asthma (AIA) should avoid aspirin and most likely NSAIDs, including ibuprofen (Advil) and naproxen (Aleve).

Acetaminophen (Tylenol) has been the traditional alternative for relief of minor pain for patients who are aspirin-sensitive. Unfortunately, recent evidence has muddied these recommendations. Moreover, some asthmatic episodes have been linked to high consumption of acetaminophen among adults. And a study of children with asthma reported that those who took ibuprofen were less likely to be hospitalized for asthma than those taking acetaminophen. This is of particular concern, since acetaminophen is the pain reliever of choice in small children.

Asthma occurs primarily at night (nocturnal asthma) in as many as 75% of patients with the condition. Attacks often occur between 2 - 4 a.m. Factors that might play role in nocturnal asthma may include one or more of the following:

Chemical and temperature changes in the body during the night that increase inflammation and narrowing of the airways
Delayed allergic responses from exposure to allergens during the day
The wearing off of inhaled medications toward the early morning
An increase in acid reflux (back up of stomach acid) that causes airways to narrow
Postnasal drip that occurs during sleep
Conditions relating to sleep, such as sleep apnea or sleeping on one's back, which may worsen any asthma attack that occurs at night

Some experts believe that nocturnal asthma may actually be a unique form of asthma with its own specific biologic mechanisms that occur only at night and which reduce natural steroid hormones (which block inflammation).

Exercise-induced asthma (EIA) is a limited form of asthma in which exercise triggers coughing, wheezing, or shortness of breath. This condition generally occurs in children and young adults, most often during intense exercise in cold dry air. Symptoms are generally most intense about 10 minutes after exercising and then gradually resolve.

EIA is triggered only by exercise and is distinct from ordinary allergic asthma in that it does not produce a long duration of airway activity, as allergic asthma does. (However, some people have both forms of asthma.) People who have only EIA do not appear to require long-term maintenance therapy. A study of military recruits with EIA also reported that the condition does not hinder a person's overall physical performance.

Medications. Cromolyn, a mild anti-inflammatory drug, or short-acting beta2-agonists have been the treatments of choice for preventing EIA. Newer approaches for people who work out regularly include pretreatment with long-acting beta2-agonists, such as salmeterol (Serevent) or the regular use of inhaled corticosteroids.

Hints for Reducing EIA. EIA occurs only after exercise and is more likely to occur with regular paced activities in cold, dry air. The following are some suggestions for reducing its impact:

Warm-up and cool-down periods are important.
Patients with EIA might do better with activities that involve short bursts of exercise (tennis, football) than with exercises involving long-duration regular pacing (cycling, soccer, and distance running).
Breathing through a scarf or through the nose helps warm up the airways.
Restricting dietary salt might help reduce EIA.

Click the icon to see an image of exercise-induced asthma.

Prognosis

Asthma is the third major cause of hospitalization in children under age 15. The condition can be very serious in children, particularly those younger than age 5, because their airways are very narrow.

The severity of asthma is graded as mild intermittent and mild, moderate, and severe persistent. A patient in any of these categories, even mild intermittent, can still experience a severe and even life-threatening attack. According to one report, 30% of asthma deaths occur in patients with mild asthma.

Asthma is rarely fatal in children, with only 187 asthma deaths reported in 2002 in children under age 18. In fact, a 2006 study from the U.S. Centers for Disease Control and Prevention reported that asthma death rates for children have steadily declined since 1999. (During the same time, the number of doctor visits for asthma treatment more than doubled.) Even low mortality numbers are unacceptable, however, since asthma deaths are largely preventable.

Factors associated with an increased risk of death from asthma in children include:

Previous life-threatening episodes of asthma
Lack of adequate and ongoing health care. (Most likely the reason for the higher fatalities rates in minority children.)
Significant behavioral problems
Underestimating the severity of an acute attack poses the greatest threat. Unfortunately, one study of children found that nearly 40% of them were unaware of asthmatic symptoms when they occurred.

African American children have more than six times the death rate of Caucasians in the age groups of 4 years and younger and 15 - 24 years. Hispanic children also have a higher risk.

The following signs and symptoms may indicate a life-threatening situation:

As the chest labors to bring enough air into the lungs, breathing often becomes shallow.
Lacking sufficient oxygen, the skin becomes bluish.
The flesh around the ribs of the chest appears to be sucked in.
The patient may begin to lose consciousness.

Asthma often progresses very slowly to a serious condition or may develop to a fatal or near-fatal attack within a few minutes. It is very difficult to predict when an attack will become very serious. Early symptoms or lack thereof do not always reflect the ultimate severity of an attack. Some studies even suggest that people at high risk for fatal or near-fatal asthma attacks are those with poor awareness of their own reduced ability to breathe and who are slow in seeking help. Monitoring peak flow rates is, therefore, an important management component, since it provides a more accurate assessment of lung function than symptoms alone.

In a 2003 study, researchers followed people with asthma for longer than 30 years. About a third of children had outgrown their asthma in adulthood. In general, the more severe the childhood asthma, the greater the likelihood that it will persist. For example, only 23% of children who experienced wheezy bronchitis (wheezing during respiratory infections) suffered from frequent or persistent asthma in adulthood.

There is evidence that severe asthma can cause long-lasting damage and possibly permanent scarring in some patients. The risk for such injury is highest, however, when asthma strikes children in the first 3 - 5 years. There does not appear to be any significant risk for long-term lung damage for children who develop mild-to-moderate persistent asthma between ages 5 - 12. Children adapt well to living with asthma, and even with severe asthma they can function as well as healthy children in virtually all areas of life.

Studies are mixed over the effects of emotional disorders on the severity of asthma. One study indicated that parents of children with asthma may suffer greater psychological stress than their children. A 2000 study reported that mild-to-moderate asthma does not significantly affect the psychological well-being of most children ages 5 - 12. Teenagers and preteens may have particular difficulty coping with what they perceive as the social stigma of asthma. Parents and older children should not hesitate to seek help from support groups, doctors, friends, or family members. Support programs may help children to better manage their asthma and even reduce hospitalization.

Although there have been few studies on the effects of asthma on schooling, a 2000 study reported that nocturnal (nighttime) asthma affected school attendance and performance in children and work attendance in their parents.

Risk Factors

Asthma affects about 5 million American children between the ages of 5 - 14. Asthma has dramatically increased worldwide over the last few decades, in both developed and developing countries. From 1980 - 1994, asthma increased 160% in American children younger than 4 years and has also dramatically risen worldwide. Experts are puzzling over the cause of this phenomenon. Possible causes and risk factors that are suspects in the dramatic rise in asthma in children include:

Survival rates are now higher in low-birth-weight babies, who may be more susceptible to asthma.
Declining rates in nursing may be a contributor. Breast milk contains important anti-inflammatory substances, such as omega-3 fatty acids, which might protect against asthma.
Western dietary habits (which commonly include more fast foods and less fruits, vegetables, fiber, minerals, and other nutrients) may contribute to the development of childhood asthma.
Children are spending more time indoors watching television, playing video games, or using the computer and are, therefore, overexposed to indoor allergens.
The trend of making homes more energy-efficient may result in dust mites being trapped inside them.

Among younger children, asthma develops twice as frequently in boys as in girls, but after puberty it may be more common in girls.

Urban Life. Urban life is strongly associated with a higher risk. Although poverty plays a significant role, urban life has been associated with a higher risk for asthma in any income group and among both children and adults. In some urban areas, as many as 25% of children have asthma or show signs of wheezing. In fact, it may be greatly underdiagnosed in city children. A 1999 study reported that almost a third of children in inner-city kindergartens had asthma symptoms without a diagnosis of the disorder; 10% had actually been diagnosed with asthma, mainly because their symptoms were severe.

Ethnicity. Since 1980, asthma rates have risen the most dramatically among African American children, and they have significantly higher rates of asthma than Caucasian children. Hispanic children are also at higher risk. Both groups of minority children are more likely to have fatal asthma than Caucasian children.

Some studies indicate that the difference in risk exists simply because African Americans and other minority groups are more likely to live in urban areas. Poverty and lack of access to health care also play a role. However, Caucasian children who live in cities also face a high risk for asthma, and rural African American children do not.

Urban life and socioeconomic factors, however, may not fully explain the ethnic disparity.

Low Birth Weight. Infants of low birth weight are at higher risk for lung problems and asthma.

Winter Birth. Children born in the winter may have a greater risk for asthmatic allergies to cockroaches than children born at other times of the year.

Vitamin D. A 2006 study suggested a link between vitamin D intake during pregnancy and development of early childhood asthma. Pregnant women who had a higher intake of vitamin D were less likely to give birth to children who developed asthma.

Breast Feeding. Most studies on breastfeeding report some protection against wheezing and asthma in the first year of life. Breastfeeding has many other benefits for the child as well. The American Academy of Pediatrics recommends exclusively breastfeeding for the child's first 6 months of life.

Complications of Pregnancy. According to a 2000 study, complications of pregnancy, specifically those involving the mother's uterus (such as post-birth hemorrhage, pre-term contractions, insufficient placenta, and restricted growth of the uterus), are associated with an increased risk of childhood asthma. Another study reported that delivery procedures such as Cesarean section, the use of vacuum extraction or forceps also raised the risk of childhood asthma.

In both adults and children, the incidence of obesity and asthma has been increasing over recent years. Studies report a strong association between the two conditions. Some experts suggest that excess weight pressing on the lungs may trigger the hyperreactive response in the airways typical of asthma. Others believe that asthma leads to obesity by inhibiting physical activity, although several studies have found no difference in activity levels between people with or without asthma. Some studies suggest that many obese people may be misdiagnosed as having asthma when they are simply short of breath, possibly because of the increased effort required for breathing.

In any case, there is evidence that losing weight can relieve asthma symptoms. Some evidence also suggests that people who are overweight (body mass index greater than 25) have more difficulty getting their asthma under control. Weight loss in anyone who is obese and has asthma or shortness of breath reduces airway obstruction and improves lung function. [See In-Depth Report #53: Weight control and diet.].

Damp Homes. Studies suggest that children who live in damp homes have a much higher risk for asthma.

Mental Health. Research indicates that poor mental health of parents and children are significant predictors of more severe symptoms in childhood asthma. A 2000 study suggested that high stress levels can predict the onset and severity of asthma in children genetically at risk for the condition.

Symptoms

In children with asthmatic symptoms, it is important to first consider as a possible cause inhaled foreign objects such as peanuts; viral infections such as croup; and bacterial infections, which may be accompanied by high fever and progress rapidly. Any child who has frequent coughing or respiratory infections should be checked for asthma.

The classic symptoms of an asthma attack include:

Wheezing when breathing out is nearly always present during an attack. Usually the attack begins with wheezing and rapid breathing, and, as it becomes more severe, all breathing muscles become visibly active.
Shortness of breath (dyspnea). Shortness of breath is a major source of distress in patients with asthma, although severe dyspnea does not always reflect a serious attack or reduced lung function.
Coughing. In some people, the first symptom of asthma is a nonproductive cough.
Chest tightness or pain. Initial chest tightness without any other symptoms may be an early indicator of a serious attack.
Neck muscles may tighten, and talking may become difficult or impossible.
Rapid heart rate
Sweating
Chest pain occurs in about 75% of patients. It can be very severe, although its intensity is not necessarily related to the severity of the asthma attack itself.

The end of an attack is often marked by a cough that produces thick, stringy mucus. After an initial acute attack, inflammation persists for days to weeks, often without symptoms. (The inflammation itself must still be treated, however, because it usually causes relapse.)

Diagnosis

The doctor will consider a diagnosis of asthma if a child has a history of periodic attacks of shortness of breath, coughing, and wheezing, perhaps accompanied by tightness in the chest. The parent should describe the pattern of symptoms and possible precipitating factors, including:

Whether symptoms are more frequent during the spring or fall (allergy seasons)
Whether exercise, a respiratory infection, or exposure to cold air has ever triggered an attack
Any family history of asthma or allergic disorders such as eczema, hives, or hay fever

A number of disorders may cause some or all of the symptoms of asthma. Panic disorder can coincide with asthma or be confused with it. Other diseases that must be considered during diagnosis are pneumonia, bronchitis, severe allergic reactions, psychosomatic illnesses, and certain rare disorders (such as tapeworm and trichomoniasis).

If symptoms and a patient's history are indicative of asthma, the doctor will usually perform tests known as pulmonary function tests to confirm the diagnosis and determine the severity of the disease.

Using a spirometer, an instrument that measures the air taken into and exhaled from the lungs, the doctor will determine several values:

Vital capacity (VC), which is the maximum volume of air that can be inhaled or exhaled.
Peak expiratory flow rate (PEFR), commonly called the peak flow rate, which is the maximum flow rate that can be generated during a forced exhalation.
Forced expiratory volume (FEV1), the maximum volume of air expired in 1 second.

If the airways are obstructed, these measurements will fall. Depending on the results, the doctor will take the following steps:

If measurements fall, the doctor typically asks the patient to inhale a bronchodilator. This drug is used in asthma to open the air passages. The measurements are taken again. If the measurements are more normal, the drug has most likely cleared the airways, and a diagnosis of asthma is strongly suspected.
If measurement results fail to show airway obstruction, but asthma is still suspected, the doctor may perform a challenge test. It involves administering a specific drug (histamine or methacholine) that usually increases airway resistance only when asthma is present.

The patient may be given skin or blood allergy tests, particularly if a specific allergen is suspected and available for testing. Allergy skin tests may be the best predictive test for allergic asthma, although they are not recommended for people with year-round asthma.

One of the most common methods of allergy testing is the scratch test or skin prick test. The test involves placing a small amount of the suspected allergy-causing substance (allergen) on the skin (usually the forearm, upper arm, or the back), and then scratching or pricking the skin so that the allergen is introduced under the skin surface. The skin is observed closely for signs of a reaction, which usually includes swelling and redness of the site. With this test, several suspected allergens can be tested at the same time, and results are usually available within about 20 minutes.

Tests that either rule out other diseases or obtain more information about the causes of asthma include the following:

A complete blood count
Chest and sinus x-rays
Computed tomography (CT) scans. CT scans may be helpful in certain cases, such as for determining wall thickness in airways in patients who are difficult to treat, which could signify a higher risk for lung damage.
Examination of the patient's sputum for eosinophils (white blood cells that in high levels are associated with severe allergic asthma).
Researchers are investigating measurements of certain chemicals in sputum or exhaled air that indicate airway inflammation. Such chemical markers include nitric oxide and hydrogen peroxide. For example, high levels of nitric oxide may prove to be a simple and noninvasive way of diagnosing asthma.

Treatment

Treating an Acute Attack in the Hospital. An acute attack may require hospitalization. Laboratory tests, an electrocardiogram (ECG), and a chest x-ray are performed to determine lung function, oxygen levels, and other indications of severity or rule out other causes. Depending on the results, the following treatments may be given:

Beta2-agonists are the standard therapy. They are typically administered with a nebulizer (a device that administers the drug in a fine spray). Studies suggest, however, that even very small children may be able to use metered-dose inhalers (MDIs), which are just as effective and more convenient than nebulizers. (Intravenous delivery is not recommended in most cases.)
An anticholinergic drug (ipratropium) is sometimes added to improve symptoms.
A corticosteroid (commonly called a steroid) given within the first hour helps reduce the need for hospitalization. Steroids may be administered intravenously, as a shot, or orally. Children may respond well to oral steroids.
Oxygen is usually administered, and can be life saving in severe cases.
Infusions of magnesium sulfate open airways and are an important emergency treatment for adults. Its benefits for children need to be further demonstrated.
In life-threatening situations, the patient may require mechanical ventilation.

Antibiotics are not useful for asthma attacks if there is no strong evidence of the presence of a bacterial infection. Viral infections, most often colds and the flu, are more likely to trigger an asthma attack. In such cases, antibiotics are not helpful and may have adverse effects.

Discharge and Relapse After Hospitalization. It typically takes about 3 - 4 hours to determine if a patient can be safely sent home or if they need to stay. Patients are generally discharged when:

Symptoms are gone or minimal, and
The peak expiratory flow rate is 70% or more of the predicted rate

Despite reasonable precautions, between 12 - 16% of patients relapse within 2 weeks of leaving the hospital. Receiving a steroid shot at discharge or taking an oral corticosteroid for a few days can reduce this risk.

Avoiding allergens, following appropriate drug treatments, and home monitoring are key elements in preventing dangerous asthma attacks and hospitalization. In addition, good communication between the doctor and patient is a key factor in a successful management program.

Medications for asthma fall into two categories:

Rescue Medications. Medications that open the airways (bronchodilators, or inhalers) are used to quickly relieve any moderate or severe asthma attack. These drugs are usually short-acting beta-adrenergic agonists (beta2-agonists). Other drugs used in special cases include corticosteroids taken by mouth and anticholinergic drugs. None of these drugs have any effect on the disease process itself. They are only useful for treating symptoms.
Maintenance Medications. Simply coping with asthma symptoms without also controlling the damaging inflammatory response is a common and serious error. For adults and children over age 5 with moderate-to-severe persistent asthma, experts now recommend inhaled corticosteroids and long-acting beta2-agonists.

Parents can greatly reduce the frequency and severity of their children’s asthma attacks by understanding the difference between coping with asthma attacks and controlling the disease over time. Unfortunately, many patients do not understand the difference between medications that provide rapid, short-term relief and those that are used for long-term symptom control. Many patients with moderate or severe asthma overuse their short-term medications and underuse their corticosteroid medications. The overuse of bronchodilators can have serious consequences; not using steroids can lead to permanent lung damage.

Patients need to understand that asthma symptoms can change quickly over time and that treatment strategies may need to change in response. In 2005, the two leading U.S. allergy associations published joint guidelines on controlling asthma. The guidelines emphasize that asthma treatment decisions need to be made on an individual basis. It is important that patients have a close relationship with their doctor. The doctor needs to evaluate a patient’s asthma symptoms at each visit to determine any need for changes in medication. According to the guidelines, asthma management is classified as either “well-controlled” or “not well-controlled.” The doctor may need to change some medications, or increase or decrease the dosage, depending on whether a child’s asthma is well-controlled or not well-controlled.

These are the signs of well-controlled asthma:

Asthma symptoms occur twice a week or less
Rescue bronchodilator medication is used twice a week or less
Symptoms do not cause nighttime or early morning awakening
Symptoms do not limit work, school, or exercise activities
Peak flow meter readings are normal or the patient’s personal best
Both the doctor and the patient consider the asthma to be well controlled


Classification	Symptom Frequency	Children Age 5 Years and Younger: Recommended Treatment	Children Older Than 5 Years: Recommended Treatment
Mild intermittent	At least 2 days per week. At least 2 nights per month.	No daily medication.	No daily medication. If severe attacks occur, systemic corticosteroids recommended.
Mild Persistent	More than 2 days per week, but less than once per day. More than 2 nights per month.	Preferred treatment: Low-dose inhaled corticosteroids with nebulizer, or MDI with holding chamber with or without face mask. Alternative treatment: Cromolyn or leukotriene-antagonist.	Preferred treatment: Low-dose corticosteroids. Alternative treatment: Cromolyn, leukotriene modifier, nedocromil, OR sustained release theophylline.
Moderate Persistent	Daily daytime symptoms. More than 1 night per week.	Preferred treatment: Low-dose inhaled corticosteroids and long-acting beta2-agonists OR medium-dose inhaled corticosteroids. Alternative treatment: Low-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline. If needed (especially if severe attacks occur): Medium-dose inhaled corticosteroids and long-acting beta2-agonists; medium-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline.	Preferred treatment: Low-to-medium dose inhaled corticosteroids and long-acting beta2-agonists. Alternative treatment: Low-to-medium dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline, or increased medium dose inhaled corticosteroids. If needed (especially if severe attacks occur): Increase dosage of medium-dose inhaled corticosteroids with add-on long-acting beta2-agonists. Alternatively, increase dosage of medium-dose inhaled corticosteroids plus either leukotriene receptor antagonist or theophylline.
Severe Persistent	Continual daytime symptoms. Frequent nighttime symptoms.	Preferred treatment: High-dose inhaled corticosteroids and long-acting beta2-agonists plus (if needed) oral corticosteroids.	Preferred treatment: High-dose inhaled corticosteroids combined with long-acting inhaled beta2-agonists. Add, if needed: Oral corticosteroids. Repeat attempts should be made to reduce use of systemic corticosteroid and maintain control with inhaled corticosteroid.
Adapted from National Asthma Education and Prevention Program (NAEPP) Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma – Update on Selected Topics 2002 (EPR-2 Update).

Most asthma drugs are inhaled using various forms of inhalers or nebulizers. Inhaled drugs must be used regularly as prescribed and the patient carefully trained in their use in order for them to be effective and safe. Studies suggest that many children fail to use the devices properly, although newer devices are easier to use than others. The basic devices are the metered-dose inhaler (MDI), breath-actuated inhalers, dry powder inhalers, and nebulizers.

MDIs have used chlorofluorocarbons (CFCs) as their propellants. CFCs are damaging to the environment and are now being replaced with other propellants (hydrofluoroalkane) that are more environmentally safe, and do not chill the device as CFCs do. Devices that don't use any propellants are also now available.

Metered-Dose Inhaler. The standard device for administering any asthma medication is the metered-dose inhaler (MDI). This device, particularly when used with a spacer, allows precise doses to be delivered directly to the lungs. (The spacer is a tube that is attached to the inhaler. It serves as a holding chamber for the medication that is sprayed by the inhaler.) MDI-delivered drugs must be used regularly as prescribed and the patient carefully trained in their use in order for them to be effective and safe. Some patients hold the MDI too close to their mouths, or even inside them. Others may exhale too forcefully before inhalation.

The spacer helps improve medication delivery by allowing the patient additional time to inhale. They vary, however, in their effectiveness. It should be noted that MDIs can continue to deliver propellant even after the drug has been used up. Patients should track their medicine and throw the device away when the last dose has been administered.

Nebulizers (not MDIs) are typically used in very small children, both at home and in the emergency room. However, recent studies suggest spacers may be better than nebulizers for children and shorten the time spent in emergency rooms. Studies also indicate that with the use of a face mask and a spacer, the MDI works well even for infants in the emergency room and may prove to be useable at home.

Click the icon to see an illustrated series detailing a metered dose inhaler.

Breath-Actuated Inhalers. Breath-actuated rotary inhalers (Easi-Breathe and Autohaler) deliver the drug directly to the back of the throat as the user inhales. Their primary advantage over the MDI is their ease of use. They also do not use CFCs as propellants. In comparison studies, patients have been very successful with the breath-actuated inhalers. They are not recommended for children under 8 years old.

Dry Powder Inhalers. Dry powder inhalers (DPIs) deliver a powdered form of beta2-agonists or corticosteroids directly into the lungs. Such devices include Rotahaler, Spinhaler, Turbohaler, Clickhaler, Easyhaler, Diskhaler, Discus, Twisthaler, Spiros, and others. DPIs are as effective as the older devices, and generally have a better taste and are easier to manage. They may differ among themselves, however, in their ability to deliver drugs into the airways. In one study, for example, the Turbohaler was easier to use than the Diskhaler and so achieved better delivery.

Humidity or extreme temperatures can affect DPIs' performance, so they should not be stored in humid places (bathroom cabinets) or locations subject to high temperatures (glove compartments during summer months).

Dry-powder may cause tooth erosion. Children are advised to rinse their mouths out right after using these inhalers and to brush twice a day with a fluoride toothpaste.

Other Hand-Held Inhalers. Respimat delivers a fine-mist spray that is created by forcing the liquid medication through nozzles. It does not use any propellant.

Nebulizers. A nebulizer is a machine that delivers a fine spray of medication-containing liquid. Nebulizers are often used for children younger than 3 years and sometimes for older children who have difficulty using the MDI. It takes 5 - 10 minutes to administer medication using a nebulizer. Because the spray is less targeted than with the inhaler, it must deliver large amounts of the drug. This increases the risk for toxicity and severe side effects. Nebulizers should not be used by children who can manage an inhaler. Their use has been associated with a higher rate of hospitalizations and longer duration of symptoms than inhalers. A 2007 study also suggested that the misuse of home nebulizers may be an important factor in asthma deaths in children and young adults. If children must use an albuterol nebulizer, parents should be sure that it does not contain the preservative benzalkonium, which actually narrows the airways.

Click the icon to see an illustrated series detailing the use of a nebulizer.

Asthma triggers a vicious emotional-physical cycle:

Breathlessness and wheezing incite a fear of suffocation and death, even in very small children.
This anxiety produces further constriction on the muscles surrounding the airways, which makes breathing even more difficult.

Caregivers must first focus on alleviating their own anxiety, which can heighten a child's own fears. The next step is to help the child relax. One method for this is as follows:

The child sits comfortably, bending slight forward with the eyes closed.
The hands are placed gently over the navel.
The child is then told to pretend the stomach is a balloon.
The "balloon" must be "blown up" by inhalation, not exhalation. The child can tell if this working because the hands will move slightly apart.
When the child breathes out, the "balloon" will be made flat.

This exercise both relaxes the child and discourages shallow, oxygen-poor breathing. Massaging the child in gentle circles on the chest is relaxing and may also loosen mucus.

Other recommendations include:

A child may also find relief by lying stomach-down on several pillows so that the head is slightly lower than the chest while the caregiver gently pats the back between the shoulder blades.
Warm liquids, such as soup or hot cider, are effective in loosening mucus and may also relax bronchial muscles. Cold fluids, like cold air, should be avoided.
Overhydration (too much liquid) can be harmful, however, so these drinks should not be forced on the child.
Warm, moist air from vaporizers can greatly ease and moderate asthma attacks.
Daily massages and breathing and relaxation techniques to reduce stress can be very helpful.

Many adults self-manage their asthma using daily monitoring of peak air flow with adjustments of the medications as needed. This involves the use of a peak flow meter, which measures peak expiratory flow rate (PEFR).

Click the icon to see an image of a peak flow meter.

Studies suggest, however, that for most children with asthma, an educational program is just as effective for managing the condition as monitoring. Most children do not need to monitor their peak air flow on any regular basis.

Quick-Relief Medications

These medications quickly control acute asthma attacks.

Beta2-agonists do not reduce inflammation or airway responsiveness but serve as bronchodilators, relaxing and opening constricted airways during an acute asthma attack. A short-acting inhaled beta2-agonist, taken as needed, is often the only medication used by children with chronic mild asthma.

Asthma is a disease in which inflammation of the airways causes airflow into and out of the lungs to be restricted. When an asthma attack occurs, mucus production is increased, muscles of the bronchial tree become tight, and the lining of the air passages swells, reducing airflow and producing the characteristic wheezing sound.

Specific short-acting beta2-agonists include:

Albuterol (Proventil, Ventolin), called salbutamol outside the U.S., is the standard short-acting beta2-agonist in America. Other similar beta2-agonists are isoproterenol (Isuprel, Norisodrine, Medihaler-Iso), metaproterenol (Alupent, Metaprel), pirbuterol (Maxair), terbutaline (Brethine, Brethaire, Bricanyl), and bitolterol (Tornalate). Isoetharine (Bronkometer, Bronkosol) is available in nebulizers.
Newer beta2-agonists, including levalbuterol (Xopenex), have more specific actions than the standard drugs. Xopenex is administered with a nebulizer, and studies have indicated that it is as effective as albuterol with fewer side effects. The original formulation of Xopenex was administered with a nebulizer. A new metered-dose inhaler formulation was launched at the end of 2005. It is approved for children age 4 years and older.

Short-acting bronchodilators are generally administered through inhalation and are effective for 3 - 6 hours. They relieve the symptoms of acute attacks, but they do not control the underlying inflammation. If asthma continues to worsen with the use of these drugs, a doctor may prescribe corticosteroids or other drugs to treat underlying inflammation.

Side Effects of Beta2-Agonists. Side effects of all beta2-agonists may include:

Anxiety
Tremor
Restlessness
Headache
Fast and irregular heartbeats. A doctor should be notified immediately if this side effect occurs.
These drugs should be taken with caution by children with diabetes or a history of seizures.
Beta2-agonists have serious interactions with certain drugs and parents should tell the doctor about any other medications their child is taking.

Loss of Effectiveness and Overdose. There has been some concern that short-acting beta2-agonists become less effective when taken regularly over time, increasing the risk for overuse. Over time, some patients may become tolerant to many effects of short-acting beta2-agonists. The degree to which this affects the airways is uncertain. In some studies, the duration of action has declined but the peak effect appears to be preserved, making these drugs still useful for acute attacks. Regular use of long-acting beta2-agonists may increase the chances of a reduced effect from the short-acting forms.

A 2005 landmark study suggested that patients’ differing clinical response to albuterol may be based on their genotype. Albuterol targets the beta-adrenergic receptor. In the Beta-Adrenergic Response by Genotype (BARGE) trial, researchers studied the effects of albuterol on patients with two different forms of this receptor. The results suggested that patients with the arginine form of the receptor did not respond to albuterol. These patients’ asthma symptoms actually improved when albuterol was not used. By contrast, patients with the glycine form of the receptor had improved asthma control with albuterol.

Inhaled ipratropium bromide (Atrovent) acts as a bronchodilator over time. Ipratropium bromide alone is only modestly beneficial for acute asthma attacks. In fact, the drug is not approved specifically for asthma. Some parents report benefit for treating wheezing in infants. It is also sometimes used in the emergency room to treat children with severe asthma to enhance the effects of intravenous beta2-agonists.

Common oral corticosteroids include prednisone/prednisolone, dexamethasone, methylprednisolone, and hydrocortisone. They reduce inflammation very effectively. A 2006 study indicated that oral prednisolone worked better than inhaled fluticasone for treating mild-to-moderate asthma attacks in children in emergency rooms. However, children often have difficulty taking these drugs because they have a bitter taste and can cause vomiting. Taking oral dexamethasone for 2 days may be as effective and more tolerable than the standard 5-day regimen of prednisone/prednisolone. Prolonged use of oral steroids has widespread and sometimes serious side effects, so they are not generally give to children for longer than a few days.

[See In-Depth Report #4: Asthma in adults.]

Long-Term Relief Medications

These medications are taken on a regular basis to prevent asthma attacks and control chronic symptoms.

Corticosteroids, also called glucocorticoids or steroids, are powerful anti-inflammatory drugs. Steroids are not bronchodilators (they do not relax the airways) and have little effect on symptoms. Instead, they work over time to reduce inflammation and prevent permanent injury in the lungs. They can also help prevent asthma attacks from occurring. Many studies have shown that the use of inhaled corticosteroids in patients with moderate-to-severe asthma significantly reduces the rate of rehospitalizations and deaths from asthma.

Inhalation of corticosteroids makes it possible to provide effective local anti-inflammatory activity in the lungs with minimal systemic effects. (By contrast, oral steroids have considerable side effects throughout the body.) Inhaled corticosteroids are recommended as the primary therapy under the following circumstances:

For any asthmatic condition more serious than occasional episodes of mild asthma. (Low-doses of inhaled steroids may even be safe and effective for some people with mild asthma, particularly those who find themselves using beta2-agonists daily.)
When treatment with bronchodilators is not effective.

Examples of inhaled corticosteroids:

Inhaled steroids include fluticasone (Flovent), budesonide (Pulmicort), triamcinolone (Azmacort and others), and flunisolide (AeroBid). In general, the newer drugs are more powerful than the older generation of inhaled drugs. Budesonide (Pulmicort Respules) is available in a jet nebulizer for children from 12 months to 8 years. It is the first such medication to be approved for children in this age group.
The FDA approved a new inhaled corticosteroid, mometasone furoate (Asmanex) was approved in 2005 for patients age 12 and older.
The older corticosteroid inhalants are beclomethasone (Beclovent, Vanceril) and dexamethasone (Decadron Phosphate Respihaler and others). They are less powerful than the newer steroids when delivered with standard inhalers. New inhalers that use very fine sprays (QVAR, Autohaler) to deliver the drugs deep into the lungs may prove to be as effective as the newer, more potent steroids.
Inhalers that combine both long-acting beta2-agonists and corticosteroids are also available. These include Symbicort (budesonide/formoterol), which was approved in 2006 for patients ages 12 years and older.

Expert guidelines recommend inhaled corticosteroids as the preferred first-line therapy for children with mild-to-moderate asthma. Nevertheless, they are still significantly underprescribed in the patients who need them most. An important 2007 study of 6 - 14 year old children with asthma compared inhaled corticosteroid therapy (fluticasone) with an inhaled corticosteroid/long-term beta2 agonist (fluticasone/salmeterol) and a leukotrine receptor antagonist (montelukast). The results indicated that fluticasone alone worked better than the other two treatments.

Researchers have been investigating whether early treatment with corticosteroids can help prevent the development of asthma in at-risk children. Two important 2006 studies in the New England Journal of Medicine suggested that while inhaled corticosteroids helped ease symptoms and reduce breathing problems in pre-school children at risk for asthma, they did not help protect against asthma development.

For now, experts caution against corticosteroids for infants and toddlers with mild asthma and urge close monitoring especially for children under age 5 with severe asthma who are receiving high doses. Because the newer potent drugs, particularly fluticasone, may produce major side effects similar to oral steroids, it is important when treating all children to aim for the lowest effective dose possible. Fortunately, studies suggest that low doses of fluticasone may achieve the same benefits as with high ones, thus reducing risks for serious side effects. Better delivery methods may also allow lower doses.

Side effects of inhaled steroids may include:

The most common side effects are throat irritation, hoarseness, and dry mouth. These effects can be minimized or prevented by using a spacer device and rinsing the mouth after each treatment.
Rashes, wheezing, facial swelling (edema), fungal infections (thrush) in the mouth and throat, and bruising are also possible but not common with inhalators.
Some children experience changes in mood, memory, and behavior. These changes are not permanent.
Some studies have suggested a higher risk for gum inflammation.
Oral steroids reduce bone density. Research reports that inhaled steroids -- both older and newer drugs -- may also affect bone growth and density. However, a number of studies report only a slight effect (about half an inch) on children's growth, which may be only temporary. It is still unknown if these drugs have any significant long-term effect on bone density. Calcium supplements may help prevent bone loss that is due to inhaled steroids.
It is not yet known whether inhaled steroids affect lung growth in very young children. Steroids administered using nebulizers are of particular concern.
There is also some concern that the stronger drugs, particularly fluticasone, suppress the adrenal system to a greater degree than other steroid inhalants. This effect, in turn, reduces levels of natural steroids -- notably cortisol, the major stress hormone. (This is a serious side effect of oral steroids).

Long-acting beta2-agonists are used in combination with inhaled corticosteroids for treating children with moderate-to-severe asthma. These drugs include include salmeterol (Serevent Diskus) and formoterol (Foradil Aerolizer). A single inhaler (Advair Diskus) that combines both salmeterol and the corticosteroid fluticasone is available for children age 4 years and older, and an inhaler (Symbicort) combining formoterol and the corticosteroid budesonide is approved for children age 12 years and older.

Long-acting beta2-agonists are used for preventing an asthma attack (not for treating attack symptoms). The effects of one dose of a long-acting beta2-agonist last for about 12 hours, so they are particularly effective during the night. These drugs also may be used for prevention of exercise-induced asthma in people and to protect against aspirin-induced asthma.

However, research indicates that long-acting beta2-agonists can worsen asthma by increasing symptom severity. These drugs may also increase the risk for asthma-related deaths. Experts are still trying to determine when long-acting beta2-agonists should be added to an asthma treatment plan. If a child’s symptoms do not improve or if symptoms worsen with this type of drug, the doctor will recommend discontinuing it. Patients should not, however, stop taking this drug or other asthma medications without first talking with their doctors.

Side Effects. Side effects of long-acting beta2-agonists are similar to the short-acting drugs.

Specific Warning on Salmeterol and Formoterol. In 2003 a "black box" warning was added to product packaging for drugs that contain salmeterol, including Serevent Diskus, and Advair Diskus. Serevent and Advair are approved for patients age 12 years and older. The warning was based on a study that demonstrated more serious and even fatal asthma episodes in patients who used the drug than in patients who used a placebo.

In 2006, the FDA updated the warning to include formoterol (Foradil Aerolizer, approved for patients 5 years and older). Warnings for salmeterol and formoterol products emphasize that these medicines can increase the risk of severe asthma episodes. Long-acting beta2-agonists require up to 20 minutes to achieve effectiveness, and there is a danger of overdose if a patient is not aware of this delay and takes additional doses to achieve faster relief. The FDA recommends that patients:

Use long-acting beta2-agonists only if other medicines (such as steroids) have not helped control asthma.
Use a short-acting bronchodilator, not a long-acting beta2-agonist, to treat sudden wheezing.
Do not use long-acting beta2-agonists to treat wheezing that is getting worse. Call your doctor if this situation occurs.
Do not stop using any asthma medicines without first talking to your doctor.

Cromolyn sodium (Intal) is both an anti-inflammatory drug and has antihistamine properties that block asthma triggers such as allergens, cold, or exercise. Cromolyn has been the anti-inflammatory drug of choice for prevention of asthma attacks in children over age 4 with chronic moderate asthma. It is not as effective as inhaled corticosteroids, however, for reducing hospitalization rates, improving symptoms, and reducing the use of beta2-agonists in children with persistent asthma. Still, cromolyn has a well-known long-term safety record, while the long-term adverse effects of corticosteroids in children are still not fully known. Many children who need asthma maintenance therapy will still do well on cromolyn. (It may not provide any real benefit for children under age 4.)

Nedocromil (Tilade) is similar to cromolyn and needs to be taken only once a day. It also prevents asthmatic reactions to cold and exercise. It is not used in very young children. A cromolyn nasal spray called Nasalcrom has been approved for over-the-counter purchase, but only to relieve nasal congestion caused by allergies. Patients should not use it for self-medication without the advice of a doctor.

Side Effects. Side effects of cromolyn include nasal congestion, coughing, sneezing, wheezing, nausea, nosebleeds, and dry throat. Nedocromil has an unpleasant taste, and some people have complained of nausea, headache, and spasms in the airways, but no serious side effects have been reported.

Leukotriene-antagonists (also called anti-leukotrienes or leukotriene modifiers) are oral medications that block leukotrienes. Leukotrienes are powerful immune system factors that, in excess, produce a battery of damaging chemicals that can cause inflammation and spasms in the airways of people with asthma. As with other anti-inflammatory drugs, leukotrienes are used for prevention and not for treating acute asthma attacks.

Leukotriene-antagonists include zafirlukast (Accolate), montelukast (Singulair), zileuton (Ziflo), and pranlukast (Ultair, Onon). These drugs are proving helpful for long-term prevention of asthma, including exercise-induced asthma and aspirin (or NSAID) -induced asthma. However, most studies to date have reported better success with inhaled corticosteroids than with the leukotriene-antagonists. A 2006 study of children with mild-to-moderate persistent asthma indicated that the corticosteroid fluticasone worked better than the leukotriene-antagonist montelukast in controlling symptoms. Nevertheless, some studies suggest that montelukast, which comes in a chewable tablet, may be particularly useful for managing asthma in small children (ages 2 - 5), since they have trouble with inhaled steroids.

Side Effects and Complications. Gastrointestinal distress is the most common side effect of leukotriene-antagonists. Very few other side effects have been reported. In general, these drugs appear to be safe and well-tolerated.

Of some concern are reports of Churg-Strauss syndrome in a few people taking zafirlukast or montelukast. Churg-Strauss syndrome is very rare, but it causes blood vessel inflammation in the lungs and can be life threatening. Oral steroids quickly resolve the problem. In fact, usually the syndrome has occurred in patients who were tapering off steroids and changing over to the leukotriene-antagonists. Some experts believe that, in such cases, the steroids may simply have masked the presence of the disorder, which then developed when the steroid drugs were withdrawn. Symptoms include severe sinusitis, flu-like symptoms, rash, and numbness in the hands and feet.

Other concerns are indications of liver injury in patients taking zileuton and zafirlukast when taken at higher than standard doses. No adverse effects on the liver have been reported to date with montelukast.

Theophylline (Theo-Dur, Theolair, Slo-Phyllin, Slo-bid, Constant-T, Respbid) is a mild-to-moderate bronchodilator that has been used to treat childhood asthma for more than 30 years. It is useful for treating nocturnal asthma and may also have anti-inflammatory qualities even in low doses.

Available in tablet, liquid, and injectable forms, some theophylline sustained-release tablets and capsules have a long duration of action and can therefore be taken once or twice a day with good results.

Side effects may include changes in behavior, mood, and memory. If theophylline is not taken exactly as prescribed, an overdose can easily occur. Toxicity can cause nausea, vomiting, headache, insomnia, and, in rare cases, disturbances in heart rhythm and convulsions. Contact a doctor immediately if any of these side effects occur.

The risks for these adverse effects are small if the drug is taken exactly as prescribed but the following precautions should be noted:

Infants tend to metabolize the drug extremely slowly and, therefore, should receive very low doses.
By the time children reach age 1, however, they metabolize the drug faster than adults. There is a risk, therefore, of toxic effects.
Fever and certain antibiotics may slow down the rate at which theophylline is eliminated from the body. In such cases, the doctor may want to reduce the dosage of theophylline.

If a child is taking theophylline on an ongoing basis, the doctor should monitor the drug level at the start of therapy and at regular intervals thereafter.

Omalizumab (Xolair) is FDA-approved for patients age 12 and older who have moderate-to-severe persistent asthma related to allergies. The first drug of this type to be approved for asthma, omalizumab is a monoclonal antibody (MAb), a genetically developed drug designed to attack very specific targets. Omalizumab is administered by injection every 2 - 4 weeks. It is used only to treat patients whose symptoms are not controlled by inhaled corticosteroids.

Omalizumab prevents the antibody immunoglobulin E (IgE) from triggering the inflammatory events that lead to asthmatic attacks. Studies have shown excellent benefits of the drug, including a reduced need for corticosteroids, fewer hospitalizations, and significant symptomatic improvements.

However, about 1 in 1,000 patients who take omalizumab develop anaphylaxis (a life-threatening allergic reaction). In 2007 the FDA requested the manufacturers of omalizumab to put a “boxed warning” on the medicine’s label emphasizing the drug’s risk for anaphylaxis. The boxed warning notes that patients can develop anaphylaxis after any dose of omalizumab, even if they had no reaction to a first dose. Anaphylaxis may occur up to 24 hours after the dose is given.

The FDA recommends that healthcare providers observe patients for at least 2 hours after an injection. Patients should also carry emergency self-treatment for anaphylaxis (such as an Epi-Pen) and know how to administer it. With an Epi-Pen, or similar auto-injector device, patients can quickly give themselves a life-saving dose of epinephrine.

Anaphylaxis symptoms include:

Difficulty breathing
Chest tightness
Dizziness
Fainting
Itching and hives
Swelling of the mouth and throat

[See In-Depth Report #4: Asthma in adults.]

Other Treatments

Alternative therapies are widely used by children, adolescents, and adults with asthma. In one study, nearly half of asthma or allergy sufferers resorted to alternative treatments. To date, however, evidence does not support most alternative therapies, including high-dose vitamins, urine injections, homeopathic remedies, and most herbal remedies.

Relaxation and Stress-Reduction Techniques. Patients report benefits from many stress reduction and physical techniques, such as acupuncture, hypnosis, breathing relaxation techniques, the Alexander technique, massage therapy, and meditation practices. There have been very few well-conducted studies supporting their use, however.

Acupuncture, hypnosis, and biofeedback are alternative ways to control pain. Acupuncture involves the insertion of tiny sterile needles, slightly thicker than a human hair, at specific points on the body.

Breathing Exercises. Some studies have suggested that breathing exercises or training may be helpful. A number of different methods are available. One example is the Buteyko breathing method, an experimental approach designed to increase levels of carbon dioxide in the body. To do this, patients are trained to reduce their volume of breath and to avoid hyperventilation (over-breathing). Some studies report that patients using this method reduce their use of medications and improve their quality of life. The system originated in Australia and is not yet widely available in the U.S.

Probiotics. Probiotics are beneficial bacteria that may possibly help protect against allergies and asthma. Antibiotic overuse and modern hygiene may specifically be reducing these helpful organisms. Look for probiotics in active yogurt cultures and in supplements, which are being studied for protection.

Herbal Remedies. Butterbur (also known as Petasites hybridus, butter dock, blatterdock, bog rhubarb, and exwort), is a traditional herbal remedy used for seasonal allergies and asthma. In a 2002 study, it was as effective and less sedating than a commonly prescribed antihistamine for treating seasonal allergies over a 2-week period. However, little research exists on its effect on asthma. Overall, there is scant evidence supporting the benefits of herbs and nutritional supplements for asthma control.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Managing Asthma

The more allergies a child has, the more severe the asthma. Making lifestyle changes to reduce allergy attacks and other triggers is extremely important.

House dust is a reservoir for pollen and dust mites. Some experts believe that reducing household allergens and pollutants in the home could reduce asthma in children by 40%.

Controlling for Dust. Spray furniture polish is very effective for reducing both dust and allergens. Air cleaners, filters for air conditioners, and vacuum cleaners with High Efficiency Particular Air (HEPA) filters can help remove particles and small allergens found indoors. Neither vacuuming nor the use of anti-mite carpet shampoo, however, is effective in removing mites in house dust. Vacuuming actually stirs up both mites and cat allergens. If possible, avoid carpets and rugs.

Click the icon to see an image of a HEPA air filter.

Bedding and Curtains. Many experts recommend reducing exposure to dust mites by enclosing mattresses and pillows in semipermeable coverings. (Vinyl mattress covers limit airflow and may also worsen, or even cause, asthma in children. Synthetic pillows may pose a significantly higher risk for severe asthma attacks in children than feather or no pillows.) However, several 2005 studies suggested that such covers do not prevent asthma or allergies. Replace curtains with shades or blinds, and wash bedding using the highest temperature setting.

Click the icon to see an image of dust mite prevention.

One study found that children sleeping in bottom bunk beds are significantly more likely to develop asthma than siblings occupying the upper bunks. Families with children who have asthma or allergies should avoid bunk beds or be sure that children with asthma sleep in the top bunk. Even with standard beds, it may be useful to have them sleep as high off the floor as possible.

Exterminating Pests (Cockroaches and Mice). Use professional exterminators to eliminate cockroaches. (One study reported that ridding a home of cockroaches and cleaning the house using standard housecleaning techniques failed to eliminate the cockroach allergens themselves.) Exterminate mice, and attempt to remove all dust, which might contain mouse urine and dander.

Reducing Humidity in the House. Although warm, moist air from vaporizers can greatly ease and moderate asthma attacks, living in a damp house is counterproductive. Dust mites thrive in humidity and damp houses increase the risk for mold, so on-going humidifiers can be unhelpful. If they are used, humidity levels should not exceed 40%, and humidifier should be cleaned daily with a vinegar solution.

Controlling Pets. People with asthma who already have pets and are not allergic to them probably have a low risk for developing such allergies later on. When children are exposed to more than one dog or cat during their first year, they have a much lower risk for allergies and asthma.

For children who have an existing allergy to pets, however, the pets should be given away or kept outside. If this isn't possible, they should at least be confined to carpet-free areas outside the bedroom. Cats harbor significant allergens, which can even be carried on clothing; dogs usually present fewer problems. Washing animals once a week can reduce allergens. Dry shampoos, such as Allerpet, are now available for both cats and dogs to remove allergens from skin and fur and are easier to administer than wet shampoos.

Many of the same substances trigger both allergies and asthma. Common allergens include pollen, dust mites, mold and pet dander. Other asthma triggers include irritants like smoke, pollution, fumes, cleaning chemicals, and sprays. Asthma symptoms can be substantially reduced by avoiding exposure to known allergens and respiratory irritants.

Preventing Exposure to Cigarette and Cooking Smoke. Parents who smoke are strongly urged to quit. Studies indicate that exposure to second-hand smoke in the home increases the risk for asthma and asthma-related emergency room visits in children. Even smoky cooking can worsen asthma.

Parental smoking has been shown to increase the airway responsiveness of infants as early as the first 2 - 10 weeks of life. This extends even to the fetus of pregnant women who smoke. Such mothers tend to have babies born at a low birth weight, which affects lung function and increases babies' risks for asthma.

Avoiding Outdoor Allergens. The following are some recommendations for avoiding allergens outside:

Avoid scheduling camping and hiking trips during times of high pollen count (generally, May and June for grass pollen and mid-August to October for ragweed).
Patients should avoid strenuous activity when ozone levels are highest, which usually occur in early afternoon, particularly on hot hazy summer days. Levels are lowest in early morning and at dusk.
Asthma attacks are often higher during thunderstorms. Some evidence points to a build-up of ozone that accompanies such storms. Other evidence suggests that the changing airflow patterns bring a sudden downdraft of air containing concentrations of pollens, small particles and allergens.
Patients who are allergic to mold should avoid barns, hay, raking leaves, and mowing grass.
Exposure to automobile fumes may worsen asthma. Fungi in car air conditioners can also be a problem.

Reducing Exposure to Air Pollution. Children breathe faster than adults, taking in more pollutants, and therefore are particularly susceptible to soot and other small particles in the air. A 2001 study found an association between higher rates of asthma and other health problems in children who were exposed to high levels of specific pollutants (particularly sulfur dioxide and nitrogen dioxide). Diesel fuel exhaust has also been associated with worsening asthma in children.

Some experts point out that asthma rates in North America have increased over recent years while the prevalence of many common air pollutants have declined. So pollution is unlikely to be a primary cause of asthma. Regardless of whether pollution is an important cause of asthma, evidence strongly suggests that it can affect existing asthma.

Patients with asthma and chronic allergic rhinitis may require daily medications. Patients with severe seasonal allergies may be advised to start medications a few weeks before the pollen season, and to continue it until the season is over.

Immunotherapy ("allergy shots") may help reduce asthma symptoms, and the use of asthma medications, in patients with known allergies. They may also help prevent the development of asthma in children with allergies. Immunotherapy poses some risk for severe allergic reactions, especially for children with poorly controlled asthma, so it is important that the doctor carefully evaluates the child’s asthma condition.

[See In-Depth Report #77: Allergic rhinitis.]

Weight Loss. Children who are both asthmatic and overweight may reduce asthma symptoms simply with weight loss.

Fruits, Vegetables, and Whole Grains. Healthy foods are important for lung function. Specific foods that may be important for healthy lungs contain antioxidants (deep green and yellow-orange fruits and vegetables), selenium (fish, red meat, grains, eggs, chicken, liver, garlic), plant chemicals called flavonoids (apples, onions), and magnesium (green leafy vegetables, nuts, whole grains, milk, and meats).

Fish Oil. Omega-3 fatty acids, found in cold water oily fish and in supplements (preferably DHA-EPA, the important compounds in fish oil) have anti-inflammatory effects. Some evidence suggests they may be helpful for people with asthma.

Caffeine. Caffeine has properties that are similar to the asthma drug theophylline. A major analysis of studies reported that caffeine improved lung function for up to 4 hours after consumption. Although tea and coffee are the major sources of caffeine, some sodas contain it and should be avoided when children have an asthma attack. (People who are going to have their lung function tested should avoid drinking coffee, tea, or other caffeinated beverages for at least 4 hours beforehand.)

Food Allergies. Although about 70% of people with asthma believe their symptoms are aggravated by food allergies, studies indicate that this belief may be true in only 5% of cases. If young children show signs of or test positive for food allergies, however, parents should be extra cautious in preventing exposure to any asthma trigger. Some doctors now counsel all children with asthma to avoid nuts entirely, and, of course, children who experience reactions to any foods should avoid them.

Chemicals that may pose some risk for an allergic reaction are monosodium glutamate, or MSG (found in some canned soups, cheese, and certain vegetables), and sulfites (preservatives in foods, such as frozen potatoes and tuna). Contrary to what many believe, dairy products do not appear to worsen asthma symptoms in people who are not already allergic to them.

Asthma is no reason to avoid exercise. Historically, about 10% of Olympic athletes have asthma. Some studies indicate that long-term exercise may help control asthma and reduce hospitalization.

Encourage children with asthma to swim and play sports, such as baseball, that will present less difficulty for them. Intense activities lasting less than 2 minutes, such as sprinting or competitive swimming, may cause fewer problems than longer-lasting exercises.

Young people who enjoy running should probably choose an indoor track to avoid pollutants. Swimming is excellent for people with asthma. Yoga practice, which uses both stretching, breathing, and meditation techniques, may have particular benefits. One study reported that two-thirds of patients who practiced yoga regularly were able to reduce or stop taking their asthma medications.

Patients should consult their doctors before starting any exercise program. Exercise-induced asthma is a limited condition that has specific recommendations.

People with asthma should try to minimize their risk for respiratory tract infections. Washing hands is a very simple but effective preventive measure.

Patients with asthma should ask their doctor about getting the influenza ("flu") vaccine and also whether they should receive the vaccination against pneumococcal pneumonia.

Zanamivir, a new drug used for treating influenza, is considered safe for patients with asthma 12 years of age or older. In one study, patients with asthma treated with zanamivir experienced fewer flu symptoms, and their lung function improved.

People with asthma have no higher rate of anxiety or depression than the general population. However, such emotions interact with the effects of asthma and its treatments in important ways:

Negative emotions can discourage compliance with medication and the ability to cope.
Poor control of asthma symptoms, in turn, increases the risk for negative emotions.
Stress and depression have been associated with more severe symptoms and even an increased risk of fatal asthma attacks.

Some evidence suggests that stress reduction techniques, a positive attitude, and relaxation techniques may be very helpful in the long-term management of asthma.

Resources

www.lungusa.org -- The American Lung Association
www.acaai.org -- American College of Allergy, Asthma & Immunology
www.aaaai.org -- American Academy of Allergy, Asthma, and Immunology
www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
www.asthma-carenet.org -- Childhood Asthma Research and Education Network
www.njc.org -- National Jewish Center for Immunology and Respiratory Medicine
www.aafa.org -- Asthma and Allergy Foundation of America
www.aanma.org -- Allergy and Asthma Network, Mothers of Asthmatics

References

Akinbami L; Centers for Disease Control and Prevention National Center forHealth Statistics. The state of childhood asthma, United States, 1980-2005. Adv Data. 2006 Dec 12;(381):1-24.

Bisgaard H, Hermansen MN, Loland L, Halkjaer LB, Buchvald F. Intermittent inhaled corticosteroids in infants with episodic wheezing. N Engl J Med. 2006 May 11;354(19):1998-2005.

Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD000052.

Douwes J, van Strien R, Doekes G, Smit J, Kerkhof M, Gerritsen J, et al. Does early indoor microbial exposure reduce the risk of asthma? The Prevention and Incidence of Asthma and Mite Allergy birth cohort study. J Allergy Clin Immunol. 2006 May;117(5):1067-73.

Guilbert TW, Morgan WJ, Zeiger RS, Mauger DT, Boehmer SJ, Szefler SJ, et al. Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med. 2006 May 11;354(19):1985-97.

Haland G, Carlsen KC, Sandvik L, Devulapalli CS, Munthe-Kaas MC, Pettersen M, et al. Reduced lung function at birth and the risk of asthma at 10 years of age. N Engl J Med. 2006 Oct 19;355(16):1682-9.

Marks GB, Mihrshahi S, Kemp AS, Tovey ER, Webb K, Almqvist C, et al. Prevention of asthma during the first 5 years of life: a randomized controlled trial. J Allergy Clin Immunol. 2006 Jul;118(1):53-61.

National Asthma Education and Prevention Program Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics -- 2002. Rockville, MD. National Heart, Lung, and Blood Institute, US Dept of Health and Human Services; 2003. NIH publications 02-5074.

O'Byrne PM, Pedersen S, Busse WW, Tan WC, Chen YZ, Ohlsson SV, et al. Effects of early intervention with inhaled budesonide on lung function in newly diagnosed asthma. Chest. 2006 Jun;129(6):1478-85.

Salpeter SR, Buckley NS, Ormiston TM, Salpeter EE. Meta-analysis: effect of long-acting beta-agonists on severe asthma exacerbations and asthma-related deaths. Ann Intern Med. 2006 Jun 20;144(12):904-12.

Schuh S, Dick PT, Stephens D, Hartley M, Khaikin S, Rodrigues L, Coates AL. High-dose inhaled fluticasone does not replace oral prednisolone in children with mild to moderate acute asthma. Pediatrics. 2006 Aug;118(2):644-50.

Sorkness CA, Lemanske RF Jr, Mauger DT, Boehmer SJ, Chinchilli VM, Martinez FD, et al. Long-term comparison of 3 controller regimens for mild-moderate persistent childhood asthma: the Pediatric Asthma Controller Trial. J Allergy Clin Immunol. 2007 Jan;119(1):64-72.

Review Date:
3/26/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Hypertension

FitSugar — Wed, 08 Oct 2008 17:34:55 -0700

Overview

Signs and Symptoms
Causes
Risk Factors
Diagnosis
Preventive Care
Treatment
Other Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Hypertension, or high blood pressure, is a serious condition that affects 50 million Americans -- one in four adults. It is defined as an average systolic blood pressure above 140 mm Hg, a diastolic blood pressure above 90 mm Hg, or both. High blood pressure increases the risk of heart disease and stroke, the first and third most common causes of death among Americans. In the early and middle adult years, men are more likely than women to develop the condition, but as men and women age, the reverse is true -- more women older than the age of 55 have high blood pressure than men of the same age. While hypertension generally develops in people older than 20 years of age, more than half of all Americans over the age of 65 have the condition.

Signs and Symptoms

Most people who have high blood pressure do not know they have it because they generally experience no symptoms at all. Occasionally, some individuals may experience a mild headache when their blood pressure is high. Serious cases of hypertension, which happen infrequently, may produce the following symptoms:

Severe headache
Confusion
Nausea
Visual disturbances
Seizure

Causes

There are two major types of hypertension: essential (primary) and secondary. Essential hypertension is by far the most common, accounting for more than 95% of all cases. The cause of this form of hypertension is not known for certain, but is likely a combination of factors, including:

Genes for high blood pressure
Low levels of nitric oxide, a naturally occurring agent responsible for the dilation of blood vessels (African Americans are believed to have low levels of this substance)
Insulin resistance
Obesity

The causes of secondary hypertension include:

Kidney disorders
Endocrine disorders, such as Cushing's syndrome
Obstructive sleep apnea (episodes during sleep when breathing stops due to obstruction of the air passages)
Stress
Chronic heavy alcohol consumption (accounts for 10% of cases of secondary high blood pressure)
Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), particularly in the elderly
Use of certain medications, including oral contraceptives, pseudoephedrine, hormone replacement therapy, and steroids
Heavy coffee drinking (5 or more cups per day), particularly in those who have previously had high blood pressure
Use of cocaine, nicotine, or other stimulants or the herb licorice (Glycyrrhiza glabra) can cause or worsen existing hypertension.

Risk Factors

The following factors increase an individual's risk for high blood pressure:

Family history of hypertension
Alcohol abuse
High sodium intake
Inactive lifestyle
Being overweight
Mood disorders, particularly depression and anxiety. They may have a direct impact on blood vessels or they may lead to unhealthy behaviors such as alcohol and substance abuse or poor weight management.
Hypertension is more common among African Americans than Whites. This may be due to nitric oxide levels or to social factors such as chronic life stressors.

Diagnosis

Blood pressure is the force of the blood pushing against the walls of the arteries. Each time the heart beats, or contracts, it pumps blood into the arteries. This is called systolic blood pressure, when blood pressure is at its maximum at this time. When the heart is at rest, between beats, the blood pressure falls, which is known as the diastolic pressure. A person with hypertension has an average systolic blood pressure above 140 mm Hg and/or a diastolic blood pressure above 90 mm Hg (usually written as 140/90).

To diagnose hypertension, a physician will obtain a blood pressure measurement during a routine physical examination. An inflatable cuff is wrapped around the arm, and the person taking the blood pressure listens with a stethoscope over the artery. If blood pressure is elevated, the doctor will check the pulse rate, examine the neck for swollen veins or an enlarged thyroid gland, listen to the heart for murmurs, feel the abdomen, and examine the eyes for damaged blood vessels in the retina. If the doctor suspects hypertension, additional laboratory and blood tests will help determine if it is secondary hypertension or essential hypertension.

Preventive Care

Studies suggest that the following lifestyle factors can help prevent hypertension:

Maintaining a desirable weight

According to several large-scale, population-based studies, being overweight is one of the strongest predictors of development of high blood pressure, including in adolescents and young adults. Similarly, maintaining a normal body weight is one of the most effective ways to prevent high blood pressure. Therefore, weight reduction, in overweight individuals of any age, should be a priority goal in the prevention of hypertension.

Reducing salt intake

Although population-based studies suggest a link between salt intake and prevalence of high blood pressure in particular groups of people (African Americans, for example), how each individual responds to sodium in his or her diet is quite variable. Since reducing dietary salt is generally considered safe, however, low-salt diets are recommended, particularly for those at risk for developing hypertension or heart disease.

Increasing physical activity

Several studies suggest that physically inactive people may be at an increased risk for developing hypertension. According to some population-based studies, men who lead physically active lives can reduce their risk of developing hypertension by 35 - 70 %. Although the duration and frequency of exercise necessary to prevent or treat hypertension is not well established, some evidence suggests that low to moderate intensity exercise may be more effective than higher intensity exercise training.

Limiting alcohol consumption

Studies suggest that people who consume three or more alcoholic beverages per day increase their risk for developing hypertension. If an individual is going to drink alcohol, therefore, intake should be limited to no more than two drinks per day. Also, drinking red wine may have more health benefits than other forms of alcoholic beverages.

Eating a diet rich in fruits and vegetables

People who consume vegetarian diets have significantly lower blood pressure than those who do not. The specific nutrients responsible for lowered blood pressure remain largely unknown, however.

Treatment

The goal in treating hypertension is to reduce the risk of serious complications, including heart disease and stroke. While the optimum blood pressure is 120/80 mm Hg, even partial reduction in blood pressure is beneficial. Prescription medications are often needed to treat hypertension, but lifestyle modifications -- including diet, exercise, and relaxation -- are necessary with or without medications.

A National Institute of Health (NIH) statement issued in 1996 asserts that behavioral and relaxation therapies must be integrated into conventional medical treatment of high blood pressure. Examples of relaxation techniques include biofeedback, massage, meditation, and qi gong. Often, in the early stages of hypertension when blood pressure elevation is mild, the doctor will recommend lifestyle modifications alone for a period of 6 - 12 months. After this time, if blood pressure is still high, medication will likely be prescribed.

Medications

Medication is recommended for people with sustained systolic pressure above 160 mm Hg or diastolic pressure above 100 mm Hg. There are several medications available to treat hypertension, and the medications prescribed depend on each individual case. Ten percent of hypertension patients may require as many as three drugs to control their condition.

Some of the most commonly prescribed medications include:

Diuretics

Diuretics help the kidneys eliminate sodium and water from the body. This decreases the volume of blood in the body and lowers blood pressure.

There are three types of diuretics: thiazide, loop, and potassium-sparing. The effects of these and other types of medications used to treat hypertension follow.

Thiazide diuretics (such as hydrochlorothiazide) -- tend to deplete potassium and may increase cholesterol and blood sugar.
Loop diuretics (such as furosemide and bumetanide) -- also tend to lower potassium levels
Potassium-sparing diuretics (such as spironolactone) -- this class does not lower potassium

Other medications used to treat hypertension include:

Beta-blockers (such as acebutolol, atenolol, metoprolol, nadolol, and propranolol) -- slow the heart rate down (thereby reducing the workload on the heart) and diminish stress hormones in the body (which allows blood vessels to relax).
Angiotensin-converting enzyme (ACE) inhibitors (such as benazepril, captopril, enalapril, lisinopril, and ramipril) -- by inhibiting a chemical reaction in the body, these drugs decrease production of a substance in the body that, in susceptible individuals, increases blood pressure.
Calcium-channel blockers (such as amlodipine, felodipine, nifedipine, nicardipine, and verapamil) -- relax blood vessels, thereby lowering blood pressure. Side effects may include constipation, nausea, and headache.
Angiotensin II receptor blockers (such as losartan, valsartan, candesartan, irbesartan, and telmisartan) -- block the effects of a particular chemical in the body, thereby preventing it from increasing blood pressure.

Nutrition and Dietary Supplements

Generally, small frequent meals are recommended for individuals prone to motion sickness. A comprehensive treatment plan for recovering from motion sickness may include a range of complementary and alternative therapies. Ask your team of health care providers about the best ways to incorporate these therapies into your overall treatment plan. Always tell your health care provider about the herbs and supplements you are using or considering using.

Following these nutritional tips may help reduce symptoms and improve overall health:

Try to eliminate potential food allergens, including dairy, wheat (gluten), corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes) and vegetables (such as squash and bell peppers).
Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables.
Avoid refined foods, such as white breads, pastas, and especially sugar.
Limit your salt intake.
Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy), or beans for protein.
Use healthy oils in foods, such as olive oil or vegetable oil.
Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
Avoid coffee and other stimulants, alcohol, and tobacco.
Drink 6 - 8 glasses of filtered water daily.
Exercise at least 30 minutes daily, 5 days a week.

You may address nutritional deficiencies with the following supplements:

A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium.
Magnesium citrate, 200 - 400 mg daily, for blood pressure regulation.
Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil one to three times daily, to help decrease inflammation and help with immunity. Cold-water fish, such as salmon or halibut, are good sources.
Resveratrol (from red wine), 50 - 200 mg daily, to help decrease inflammation and for antioxidant effects.
SAMe (s-adenosyl-L-methionine), 100 - 200 mg before breakfast daily, for stress and mood improvement.
Lycopene, 5 mg one to three times daily, for antioxidant and blood pressure lowering activity.
Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, blood pressure lowering, and muscular support.
L-theanine, 200 mg one to three times daily, for stress and nervous system support.
L-arginine, 1 -2 gm three times daily, for blood vessel and immune support.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

Green tea (Camellia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant and heart health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
Ginkgo (Ginkgo biloba) standardized extract, 40 - 80 mg three times daily, for antioxidant and heart health support.
Reishi mushroom (Ganoderma lucidum), 150 - 300 mg two to three times daily, for blood pressure support. You may also take a tincture of this mushroom extract, 30 - 60 drops two to three times a day.
Garlic (Allium sativum), standardized extract, 400 mg two to three times daily, for heart health.
Rhodiola (Rhodiola rosea ) standardized extract, 100 - 600 mg daily, for stress reducing activity.

Acupuncture

Several studies involving small numbers of people with hypertension showed a reduction in blood pressure with the use of acupuncture. While these clinical trials were conducted over a short period of time, the encouraging results suggest that it would be worthwhile for scientists to conduct long-term research of acupuncture for treating high blood pressure.

Chiropractic

Preliminary evidence suggests that people with high blood pressure who receive spinal manipulation receive a significant reduction in their blood pressure, but more research is needed to confirm its use for hypertension. In fact, on rare occasions, a spinal manipulation session may actually cause extremely low blood pressure leading to dizziness or lightheadedness.

Massage and Physical Therapy

Massage may be particularly helpful for people with hypertension brought on by stress. This is because the beneficial effects of massage are due at least in part to a reduction in stress. One recent study revealed that people with hypertension who receive massage showed significant reductions in blood pressure and steroid hormones, an indicator of stress. Although more studies are needed to evaluate the long-term safety and effectiveness of massage, people with hypertension who tend to have high levels of stress in their lives may benefit from massage therapy. In addition, massage tends to help people stick with healthy behaviors such as eating healthfully and not smoking.

Mind-Body Medicine

Although the association between ongoing life stress and hypertension is complex and somewhat controversial, many believe that relaxation techniques may be helpful in alleviating feelings of stress, which is often a contributing factor to hypertension. While the results of studies investigating this relationship have been mixed, one study of older African Americans living in an urban setting found that those who participated in a transcendental meditation (TM) or progressive muscle relaxation (PMR) program had a significant reduction in blood pressure compared to those who participated in a lifestyle education program. While both techniques were beneficial, TM was twice as effective as PMR.

In addition to TM and PMR, other mind-body techniques such as self-hypnosis and biofeedback have shown promising results in recent studies. Biofeedback in particular may reduce elevated blood pressure from stress and help individuals achieve healthful lifestyle modifications, such as stopping smoking and losing weight.

Other Considerations

Pregnancy

Blood pressure is monitored frequently during pregnancy because some women may develop high blood pressure for the first time while pregnant. If this occurs, medication may be needed. In addition, a condition known as preeclampsia is very serious and even life-threatening. Preeclampsia is high blood pressure during pregnancy that occurs along with other symptoms and signs, such as swelling of the ankles and legs, blurred vision, liver test abnormalities, and protein in the urine.

Warnings and Precautions

Avoid fish high in mercury, which may increase blood pressure.
The use of cocaine, nicotine, or licorice (Glycyrrhiza glabra) can cause or worsen existing hypertension.
Caffeine can exacerbate high blood pressure.

Prognosis and Complications

If left untreated, hypertension can cause several serious complications, including:

Stroke
Coronary artery disease and heart attack
Congestive heart failure
Kidney disorder
Disorders of the retina, which can ultimately lead to blindness
Impotence in men and decreased orgasm in women
Memory impairment and dementia

Fortunately, there are several treatment options for hypertension. Comprehensive treatment, including lifestyle modifications and blood pressure medications, usually results in much lower risk for complications and a generally good prognosis.

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Yong LC, Kuller LH, Rutan G, Bunker C. Longitudinal study of blood pressure: changes and determinants from adolescence to middle age. The Dormont High School follow-up study, 1957-1963 and 1989-1990. Am J Epidemiol 1993;138:973-83.

Yoon JH, Baek SJ. Molecular targets of dietary polyphenols with anti-inflammatory properties. Yonsei Med J. 2005;46(5):585-96.

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Review Date:
10/20/2006
Reviewed By:
Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Class Act: Nia

FitSugar — Fri, 16 Jan 2009 10:00:00 -0800

As part of my New Year's resolutions, I vowed to try new things, so there I was - barefoot and in a room full of happy, chatty ladies, about to take a Nia class for the first time. I was excited because I had heard it integrated some of my favorite movements: dance, martial arts, and yoga. Once the music started, the instructor began demonstrating some simple movements to open the body. Tapping the toes, bending the knees, rocking the hips, waving the arms, wiggling the fingers, and rolling the neck were meant to activate "all 13 joints," meaning our entire bodies.

We continued to move through several short 10- to 15-minute dance segments, which were a fusion of these nine movement forms:

Martial arts: T’ai Chi, Tae Kwon Do, Aikido
Dance arts: jazz dance, modern dance, Duncan dance
Healing arts: yoga, Alexander Technique, the teachings of Moshe Feldenkrais

To hear more about Nia and see a video clip, read more.

The best way I can describe Nia is that it's a spiritual low-impact aerobics class. The instructor leads you through a simple choreographed move, like a jazz square, but you're encouraged to move your body in the unique and playful way your body wants to move. Nia is all about exploring your space and how your body moves in it. It's about sensory awareness, self expression, and finding joy. What I loved about the class is that it reminded me of yoga in that you're only concerned with your own body and not worried about what other people think. Although I was sweating a little, it wasn't a really intense workout, so if you're looking for a light workout to awaken your spirit and get those feel-good endorphins buzzing, give Nia a try.

If you want more information about this type of bodywork, check out the Nia website. They'll also help you find a class.

Atherosclerosis

FitSugar — Wed, 08 Oct 2008 17:34:56 -0700

Overview

Signs and Symptoms
What Causes It?
Risk Factors
What to Expect at Your Provider's Office
Preventive Care
Treatment Options
Other Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Atherosclerosis is a slow disease in which arteries become clogged and hardened. Fat, cholesterol, calcium, and other substances form plaque, which builds up in arteries. Hard plaque narrows the passage that blood flows through and causes arteries to become hard and inflexible (atherosclerosis is also known as hardening of the arteries). It leads to cardiovascular disease, which is the leading cause of death in people over 45. Soft plaque is more likely to break free from the artery wall and cause a blood clot, which can block blood flow to vital organs.

The effects of atherosclerosis differ depending upon which arteries in the body narrow and become clogged with plaque. If the arteries that bring oxygen-rich blood to your heart are affected, you may have coronary artery disease, chest pain, or a heart attack. If the arteries to your brain are affected, you may have a transient ischemic attack (TIA) or a stroke. If the arteries in your arms or legs are affected, you may develop peripheral artery disease. You may also develop a bulge in the artery wall (aneurysm).

Lowering blood pressure and LDL ("bad") cholesterol levels, quitting smoking, losing weight, and getting more exercise can prevent atherosclerosis.

Signs and Symptoms

Often, there are no symptoms of atherosclerosis until a significant percentage (40%) of an artery becomes clogged with plaque. Symptoms vary depending upon which arteries are affected.

Coronary Artery Disease

Symptoms of coronary artery disease (obstruction of the heart arteries) are usually triggered by physical exercise, sexual activity, exposure to cold weather, anger, or stress. The most common symptoms include:

Chest pain (generally a heavy, squeezing, or crushing sensation with possible burning or stabbing pains)
Abdominal, neck, back, jaw, or shoulder/arm pain
Weakness
Perspiration
Shortness of breath

Cerebrovascular Disease

Cerebrovascular disease (obstruction of the arteries that supply the brain with blood) can cause transient ischemic attack (a sudden loss of brain function with complete recovery within 24 hours) and stroke. Symptoms may include:

Weakness or paralysis on one side of the body
Trouble speaking or understanding speech
Loss of vision in one eye
Muscle weakness
Sudden trouble walking
Dizziness
Loss of balance or coordination
Sudden severe headache

Peripheral Artery Disease

Peripheral artery disease affects the arteries that supply the arms and legs with oxygen-rich blood. Symptoms may include:

Pain, aching, cramps, numbness or sense of fatigue in the leg muscles (intermittent claudication)
"Bruits" (blowing sounds your doctor can hear with a stethoscope that indicate turbulence in blood flow)
Hair loss
Thickened nails
Smooth, shiny skin surface
Skin that is cold to the touch
Gangrene

What Causes It?

No one knows the exact cause of atherosclerosis. Many researchers believe it begins with an injury to the innermost layer of the artery, known as the endothelium. The following factors are thought to contribute to the damage:

High blood pressure
Elevated LDL ("bad") cholesterol
An accumulation of homocysteine (an amino acid produced by the human body, thought to be a risk factor for heart disease, stroke, osteoporosis, diabetes, and dementia)
Smoking
Diabetes
Inflammation

Once the artery is damaged, blood cells called platelets accumulate there to try and repair the injury. Over time, fats, cholesterol, and other substances also build up at the site, which thickens and hardens the artery wall. The amount of blood that flows through the artery is decreased, and the oxygen supply to organs also decreases. Blood clots may form, blocking the artery or entering your bloodstream and blocking blood supply to other organs.

Because many people do not have the classic risk factors of atherosclerosis (such as cigarette smoking and high blood pressure), it is possible that there may be other causes, such as an infection. Research is continuing to find the causes.

Risk Factors

Being male
If female, being past menopause
High blood pressure
High LDL ("bad) cholesterol or triglycerides (fats in the blood)
Diabetes
Being overweight
Smoking
A family history of heart disease
Elevated homocysteine levels
Sedentary lifestyle
Diets high in saturated fat and trans fatty acids (trans fats)
Depression

What to Expect at Your Provider's Office

Your doctor can determine your risk for heart disease by conducting a variety of tests. Blood tests can detect high levels of cholesterol, homocysteine, and blood clotting factors. A stress test (otherwise known as an exercise tolerance test) monitors your heart rate and blood pressure while you walk on a treadmill or ride a stationary bicycle. An electrocardiogram (ECG) is used during a stress test to detect abnormal heart rhythms, scar tissue in the heart muscle from a prior heart attack, and areas of decreased blood flow to the heart. Imaging techniques used during a stress test (such as an ultrasound) can determine precise areas where blood flow to the heart may be decreased. An angiogram (or angiography), where your doctor injects a dye into your arteries and then performs a chest x-ray, can reveal areas of damage and plaque buildup.

Preventive Care

Atherosclerosis can be prevented by adopting health lifestyle choices.

Stop smoking.
Exercise at least 30 minutes a day, 6 days a week.
Eat healthy foods, such as fruits, vegetables and whole grains that are low in saturated fat and high in fiber.
Maintain a normal weight (or lose weight if you need to).
Reduce stress.
If you have high blood pressure, high cholesterol, diabetes or another chronic condition, work with your doctor to keep it in check.

Treatment Options

Healthy lifestyle choices (see "Preventive Care" section) are important in preventing and treating atherosclerosis. Your doctor may prescribe drugs to lower cholesterol or blood pressure and to prevent complications. Nutrition and dietary supplements may be helpful when used in addition to certain medications. Some herbs have also shown promise in lowering cholesterol levels and reducing the risk of heart disease.

Drug Therapies

Cholesterol-Lowering Drugs

If, after making adjustments to your diet and exercise habits, your LDL ("bad") cholesterol remains high, your doctor may prescribe medications to lower it. If your cholesterol is extremely elevated (more than 200 mg/dL), you may start drug therapy at the same time you make lifestyle changes. Drugs commonly used to treat high cholesterol include:

Statins (such as lovastatin, pravastatin, simvastatin, atorvastatin, rosuvastatin, and fluvastatin) -- These are usually the drugs of choice as they are easy to take and have few interactions with other drugs. People who are pregnant or have liver disease should not take statins.
Niacin (nicotinic acid) -- in prescription form, is sometimes used to lower cholesterol. Dietary supplements of niacin should not be used instead of prescription niacin, as it can cause side effects. Take niacin for high cholesterol only with your doctor's supervision.
Bile acid sequestrants (such as cholestyramine, colestipol, and colesevelam) -- People who have high levels of triglycerides (fats in the blood) should not take bile acid sequestrants.
Fibric acid derivatives (such as gemfibrozil and clofibrate) -- effective at lowering triglyceride levels, and moderately effective at lowering LDL.

If you do not respond to one class of drugs, you doctor may use a combination of drugs from two classes.

Blood Pressure-Lowering Drugs

If, after making adjustments to your diet and exercise habits, your blood pressure remains high, your doctor may prescribe medications to lower it. Among the drugs used to lower blood pressure are:

Beta-blockers (such as acebutolol or Sectral, atenolol or Tenormin, bisoprolol or Zebeta, carteolol or Cartrol, metoprolol or Toprol XL, nadolol or Corgard, and propranolol or Inderal) -- slow the heart rate, thus lowering blood pressure.
Angiotensin-converting enzyme (ACE) inhibitors (such as benazepril or Lotensin, captopril or Capoten, enalapril or Vasotec, fosinoprol or Monopril, lisinopril or Prinivil, and ramipril or Altace) -- expand blood vessels, allowing blood to flow more freely and decreasing the burden on the heart.
Diuretics (chlorothiazide or Diuril, furosemide or Lasix, hydrochlororthiazide or Esidrix/Hydrodiuril, indapamide or Lozol) -- rid the body of excess fluid and sodium, lowering blood pressure.
Angiotensin-2 (AT-2) receptor agonists (such as candesartan or Atacand, eprosartan or Teveten, irbesartan or Avapro, losartan or Cozaar, telmisartan or Micardis) -- have results similar to ACE inhibitors but have fewer side effects.
Calcium-channel blockers (such as amlodipine or Norvasc, bepridil or Vascor, diltiazem or Cardizem, felodipine or Plendil, nifedipine or Procardia, nisoldipine or Sular, and verapamil or Calan/Isoptin/Verelan) -- block calcium from moving into the heart and blood vessels.

Sometimes drugs from these classes may be combined.

Blood-Thinning Drugs

Blood-thinning drugs -- antiplatelet agents and anticoagulants -- are used to keep blood clots from forming.

Aspirin -- reduces risk of transient ischemic attack (TIA), stroke, and heart attacks
Ticlodipine -- for people who cannot take aspirin (due to allergies, for example) or do not improve from aspirin; has more side effects than aspirin
Dipyridamole -- not as effective as aspirin when used alone but may be used in combination with aspirin or warfarin (another blood thinner)
Clopidogrel -- reduces risk of heart attacks
Glycoprotein IIb/IIIa receptor agonists (such as abciximab, eptifibatide, lamifiban, and tirofiban) -- used when awaiting or just following an angioplasty
Heparin -- anticoagulant; given by injection
Warfarin (Coumadin) -- often used after a heart attack

Surgery and Other Procedures

Several different procedures (surgical and non-surgical) may be performed depending upon the location and severity of atherosclerosis.

Non-surgical techniques

Angioplasty -- used to widen narrowed arteries. A surgeon inserts a catheter with a deflated balloon into the narrowed part of the artery. The balloon is inflated, widening the blood vessel so blood can flow more easily. The balloon is then deflated, and the catheter is removed. A permanent stent (wire mesh) may be inserted to hold the artery open and improve blood flow.
Atherectomy -- a procedure to remove plaque from the arteries using a laser catheter or a rotating shaver.

Surgical Procedures

Bypass surgery -- A surgeon uses a blood vessel from another part of your body or an artifical tube to reroute blood around clogged arteries.
Minimally invasive bypass surgery -- uses a small incision rather than the broad opening in the chest wall created during regular bypass surgery.
Endarterectomy -- used to remove plaque in the carotid (neck) or peripheral arteries.

Complementary and Alternative Therapies

Nutrition and Supplements

Healthy eating habits can help reduce high cholesterol, high blood pressure, and overweight -- three of the major risk factors for heart disease. The American Heart Association (AHA) has developed dietary guidelines that help lower fat and cholesterol intake and reduce the risk of heart disease. The AHA does not recommend very low-fat diets, because research shows that people benefit from unsaturated ("good") fats, such as those found in olive oil, in their diet.

Many fad diets are popular, but they may not help you lose weight and keep it off -- and in some cases, they may not even be healthy. Any healthy diet will include a variety of foods. If a diet bans an entire food group (such as carbohydrates), it's probably not healthy.

The AHA recommends the following for healthy eating:

Grains: 6 - 8 servings per day (half should be whole grains)
Vegetables: 3 - 5 servings per day
Fruits: 4 - 5 servings per day
Fat-free or low-fat dairy: 2 - 3 servings per day
Lean meat, poultry, seafood: 3 - 6 oz. per day (about the size of a deck of cards)
Fats and oils: 2 - 3 tbsp. per day (use unsaturated fats such as olive oil or canola oil)
Nuts, seeds, legumes: 3 - 5 servings per week
Sweets, sugars: 5 or fewer servings per week (the fewer, the better)

In addition, the AHA also recommends eating 2 servings of fatty fish (such as salmon or lake trout) per week; holding sodium (salt, including salt already added to food) to less than 2,400 mg per day; and limiting alcohol intake to one drink a day for women and two for men.

Diets for People with High Blood Pressure

People with high blood pressure especially need to lower the amount of sodium in their diet. The DASH diet (Dietary Approaches to Stop Hypertension) emphasizes a diet rich in fruits, vegetables, and low-fat or non-fat dairy products that provide high intake of potassium, magnesium, and calcium sources. Sodium intake should be between 1,500 - 2,400 mg per day (the lower, the better). Weight loss, regular physical activity, and limiting alcohol are also very important factors for lowering blood pressure.

Mediterranean Diet

The Mediterranean style siet concentrates on whole grains, fresh fruits and vegetables, fish, olive oil, and moderate, daily wine consumption. The Mediterranean style diet is not low-fat. Instead, it is low in saturated fat but high in monounsaturated fat. It appears to be heart-healthy: In a long-term study of 423 patients who had a heart attack, those who followed a Mediterranean style diet had a 50 - 70% lower risk of recurrent heart disease compared with people who received no special dietary counseling.

Supplements and Vitamins

Talk with your doctor before taking any of these vitamins, minerals, or supplements to make sure they are right for you; to establish the proper dose for your condition; and to make sure they do not interact with any prescription drugs, or herbs or supplements you also might be taking.

Folic acid (400 mcg per day), vitamin B6 (25 - 100 mg per day), vitamin B12 (2 - 100 mcg per day) -- The B vitamins help the body break down homocysteine, an amino acid that's been linked to increased risk of heart disease and stroke. Researchers believe that homocysteine may also contribute to atherosclerosis by damaging artery walls, thus causing blood clots to form -- but so far they haven't found a definite link. Researchers also don't yet know whether taking B vitamins reduces the risk of atherosclerosis or heart disease, nor do they know how much might have an effect. If you have a number of risk factors for heart disease, talk to your doctor about checking your homocysteine levels and whether your doctor would recommend a B complex vitamin supplement. In the meantime, be sure to get enough B vitamins through your diet by eating fruits and leafy green vegetables every day.

Omega-3 fatty acids, found in fish oil (1 - 4 g per day) -- There is good evidence that omega-3 fatty acids (namely EPA and DHA) found in fish oil can help prevent and treat atherosclerosis by preventing the development of plaque and blood clots. Omega-3s can also help prevent heart disease, lower blood pressure, and reduce the level of triglycerides (fats) in the blood. The AHA recommends that people eat at least two servings of fatty fish (such as salmon) per week. For people with heart disease or those who need to lower triglycerides, fish oil supplements may be necessary. Because fish oil at high doses can increase the risk of bleeding, talk to your doctor before taking a high dose (more than 1 g per day), especially if you already take blood-thinning medication.

Beta-sitosterol (800 mg to 6g per day in divided doses about 30 minutes before meals) -- Beta-sitosterol is a plant sterol, a compound that can stop cholesterol from being absorbed by the intestines. A number of well-designed scientific studies have shown that beta-sitosterol does lower LDL ("bad") cholesterol levels in the body. Beta-sitosterol may lower the amount of vitamin E and beta-carotene absorbed by the body, so you may want to ask your doctor if you need to take extra E or beta-carotene.

Potassium -- Potassium is necessary to keep the electrolyte balance in the body and for nerves to function properly. Some diuretics may cause the body to get rid of too much potassium. If you take a prescription diuretic, your doctor may also recommend a potassium supplement.

Policosanol (5 - 10 mg two times per day) -- Policosanol is a mix of waxy alcohols usually derived from sugar cane and yams. Several studies have indicated it may lower LDL ('bad") cholesterol and possibly even raise HDL ("good") cholesterol. One study found that policosanol was equivalent to fluvastatin (Lescol) and simvastatin (Zocor) in lowering cholesterol levels. It may also inhibit blood clots from forming. However, most studies have been conducted in Cuba by a research group that uses a proprietary form of policosanol and is funded by the manufacturer, so it is hard to evaluate the evidence. Policosanol may increase the risk of bleeding, and should not be taken by people who also take blood-thinning medication.

Antioxidant vitamins (beta-carotene, C, E) -- Some large, observational studies have suggested that people who consume more antioxidant vitamins have a lower risk of heart disease than those who consumer lower amounts. However, no studies have shown a cause-and-effect relationship.

Beta-carotene -- While some studies suggest that eating a diet high in beta-carotene (found in yellow, orange, and dark green vegetables) may protect against atherosclerosis, other studies show it may increase the risk for people who smoke or drink a lot of alcohol. Researchers theorize that eating vegetables with beta-carotene also provides the body with other carotenoids (similar antioxidants) that may have the protective effect, while simply taking a supplement does not.
Vitamin C -- Several studies suggest that eating a diet high in vitamin C can help protect against heart disease, but evidence is lacking that taking extra vitamin C through a supplement will help.
Vitamin E -- One recent randomized, placebo-controlled study failed to show any reduction in heart disease among people who took vitamin E.

Selenium (100 - 200 mcg per day) -- Some studies show that people who consume more selenium in their diet have a lower risk of heart disease, but again, researchers haven't shown a cause-and-effect relationship. Talk to your doctor before taking extra selenium.

Coenzyme Q10 (CoQ10) -- Researchers believe that CoQ10 may inhibit blood clot formation and boost levels of antioxidants. One study found that people who received daily CoQ10 supplements within 3 days of a heart attack were much less likely to experience subsequent heart attacks and chest pain and were also less likely to die of the condition than those who did not receive the supplements. Still, more research is needed to say whether CoQ10 has any role in preventing or treating atherosclerosis. People who take statins may have lower amounts of CoQ10 in their bodies and may consider taking a supplement. If you take statins, ask your doctor if you need a CoQ10 supplement.

Polyphenols -- Polyphenols are chemical substances found in plants that have antioxidant properties. Test tube, animal, and some population-based studies suggest that the flavonoids quercetin, resveratrol, and catechins (all found in high concentration in red wine) may help reduce the risk of atherosclerosis by protecting against the damage caused by LDL cholesterol. However, more studies in humans are needed to confirm these findings.

One study of resveratrol in mice found that it protected against age-related damage to vital organs, including the heart and liver, even when the mice ate a high-fat diet. Although this study is promising, researchers need to confirm its findings and to determine whether resveratrol would have the same effect in humans. To equal the rate at which the mice were given resveratrol, humans would have to consume enormous quantities. In addition, resveratrol may have estrogen-like effects, and researchers don't yet know whether it would pose the same risks as estrogen supplements.

Vitamin D -- Some preliminary studies suggest that vitamin D may also help protect against heart disease, but researchers aren't sure why. One observational study found that women over the age of 65 who took vitamin D supplements to protect against osteoporosis had one-third less risk of dying from heart disease as women who did not take the supplements.

Herbs

Hawthorn (Crataegus monogyna, 160 - 1,800 mg per day in two or three divided doses) -- Hawthorn contains the polyphenols rutin and quercetin, and was used traditionally to treat cardiovascular diseases. Animal and laboratory studies show that hawthorn has antioxidant properties that help protect against the formation of plaques and may help lower high cholesterol and high blood pressure. Talk to your doctor before taking hawthorn, as it can interact with other drugs taken for heart disease and high blood pressure.
Garlic (Allium sativum, 900 mg per day of garlic powder, standardized to 0.6% allicin) -- Some clinical trials have shown that fresh garlic and garlic supplements may lower cholesterol levels, prevent blood clots, and destroy plaque. However, other studies show mixed evidence, and one 2007 study showed no effect at all. Garlic can increase the risk of bleeding and should not be taken if you are also taking blood-thinning medication.
Red yeast (Monascus purpureus, 1,200 mg two times per day with meals) -- Several studies indicate that a proprietary form of red yeast (Cholestin) can lower cholesterol levels, and that the herb acts like the prescription drugs statins (See "Medications" section). For that reason, you should not take red yeast without a doctor's supervision, especially if you already take statins to lower cholesterol.
Psyllium (Plantago psyllium, 10 - 30 g per day in divided doses taken 30 - 60 minutes after meals) -- Taking psyllium, a type of fiber, helps lower cholesterol levels as well as blood sugar levels. If you take medicine for diabetes, talk to your doctor before taking psyllium.
Guggul (Commiphora mukul, 3 - 6 g per day) -- Guggul is used in Ayurvedic medicine to treat high cholesterol levels. Scientific studies have found mixed results -- guggul appears to work in Indian populations, but not in people who eat Western-style, high-fat diets.

Acupuncture

Acupuncture may be useful for reducing risk factors for heart disease. It can help people who wish to quit smoking and some studies indicate that it may aid in weight loss as well as lowering cholesterol and blood pressure.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic remedies, professional homeopaths would recommend appropriate treatments to reduce the risk of atherosclerosis based on their knowledge and experience. Homeopathic prescriptions for atherosclerosis would include remedies to lower high blood pressure and cholesterol. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath would assess all of these factors when determining the most appropriate remedy for each individual.

Other Considerations

Prognosis and Complications

Some complications of atherosclerosis include:

Heart disease
Heart failure
Abnormal heart rhythms
Stroke
Heart attack
Inadequate blood supply to certain parts of the body (such as the legs or intestines)
Kidney failure
Death

The outlook for atherosclerosis varies from person to person. People with atherosclerosis should work closely with their doctor to make sure they make the right lifestyle changes and, if needed, take the proper medications to control their condition and avoid complications.

Supporting Research

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Anderson JW, Allgood LD, Turner J, et al. Effects of psyllium on glucose and serum lipid responses in men with type 2 diabetes and hypercholesterolemia. Am J Clin Nutr. 1999;70:466-73.

Anderson JW, Johnstone BM, Cook-Newell ME. Meta-analysis of the effects of soy protein intake on serum lipids. N Engl J Med. 1995;333:276-282.

Bleys J, Miller ER 3rd, Pastor-Barriuso R, Appel LJ, Guallar E. Vitamin-mineral supplementation and the progression of atherosclerosis: a meta-analysis of randomized controlled trials. Am J Clin Nutr. 2006 Oct;84(4):880-7.

Boushey CJ, Beresford SA, Omenn GS, Motulsky AG. A quantitative assessment of plasma homocysteine as a risk factor for vascular disease. JAMA. 1995;274:1049-1057.

Brown BG, Zhao XQ, Chalt A, et al. Simvastatin and niacin, antioxidant vitamins, or the combination for the prevention of coronary disease. N Engl J Med. 2001;345(22):1583-1592.

Castillo-Richmond A, Schneider RH, Alexander CN, et al. Effects of stress reduction on carotid atherosclerosis in hypertensive African Americans. Stroke. 2000;31(3):568-573.

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Fernandez JC, Mas R, Castano G, et al. Comparison of the efficacy, safety and tolerability of policosanol versus fluvastatin in elderly hypercholesterolaemic women. Clin Drug Invest. 2001;21:103–13.

Gardner CD, Lawson LD, Block E, Chatterjee LM, Kiazand A, Balise RR, Kraemer HC. Effect of raw garlic vs commercial garlic supplements on plasma lipid concentrations in adults with moderate hypercholesterolemia: a randomized clinical trial. Arch Intern Med. 2007 Feb 26;167(4):346-53.

GISSI-Prevenzione Investigators. Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Lancet. 1999;354:447-455.

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Hayek T, Fuhrman B, Vaya J, Rosenblat M, Belinky P, Coleman R et al. Reduced progression of atherosclerosis in apolipoprotein E-deficient mice following consumption of red wine, or its polyphenols quercetin or catechin, is associated with reduced susceptibility of LDL to oxidation and aggregation. Ateriosclerosis, Thrombosis, and Vascular Biology. 1997;17(11):2744-2752.

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Levine GN, Frei B, Koulouris SN, Gerhard MD, Keaney FJ, Vita JA. Ascorbic acid reverses endothelial vasomotor dysfunction in patients with coronary artery disease. Circulation. 1996;93:1107-1113.

Levine M, Rumsey SC, Daruwala R, Park JB, Wang Y. Criteria and recommendations for vitamin C intake. JAMA. 1999;281(15):1415-1453.

Malinow MR, Bostom AG, Krauss RM. Homocyst(e)ine, diet, and cardiovascular disease. A statement for healthcare professionals from the nutrition committee, American Heart Association. Circulation. 1999;99:178-182.

Mashour NH, Lin GI, Frishman WH. Herbal medicine for the treatment of cardiovascular disease. Arch Intern Med. 1998;158:2225-2234.

Neil HA, Meijer GW, Roe LS. Randomised controlled trial of use by hypercholesterolaemic patients of a vegetable oil sterol-enriched fat spread. Atherosclerosis. 2001;156:329-37.

Nyyssonen K, Parviainen MT, Salonen R, Tuomilehto J, Salonen JT. Vitamin C deficiency and risk of myocardial infarction: prospective population study of men from eastern Finland. BMJ. 1997;314:634-638.

Osganian SK, Stampfer MJ, Rimm E, Spiegelman D, Hu FB, Manson JE, Willett WC. Vitamin C and risk of coronary heart disease in women.. J Am Coll Cardiol. 2003 Jul 16;42(2):246-52.

Pruthi S, Allison TG, Hensrud DD. Vitamin E supplementation in the prevention of coronary heart disease. Mayo Clin Proc. 2001;76:1131-1136.

Rimm EB, Willett WC, Hu FB, et al. Folate and vitamin B6 from diet and supplements in relation to risk of coronary heart disease among women. JAMA. 1998;279:359-364.

Robinson K, Arheart K, Refsum H, et al. Low circulating folate and vitamin B6 concentrations. Risk factors for stroke, peripheral vascular disease, and coronary artery disease. Circulation. 1998;97:437-443.

Serebruany VL, Ordonez JV, Herzog WR, et al. Dietary coenzyme Q10 supplementation alters platelet size and inhibits human vitronectin (CD51/CD61) receptor expression. J Cardiovasc Pharmacol. 1997;29:16-22.

Singh I, Mok M, Christensen AM, Turner AH, Hawley JA. The effects of polyphenols in olive leaves on platelet function. Nutr Metab Cardiovasc Dis. 2007 Mar 6; [Epub ahead of print]

Singh RB, Niaz MA, Ghosh S. Hypolipidemic and antioxidant effects of Commiphora mukul as an adjunct to dietary therapy in patients with hypercholesterolemia. Cardiovasc Drug Ther. 1994;8:659-664.

Singh RB, Wander GS, Rastogi A,. et al. Randomized, double-blind placebo-controlled trial of coenzyme Q10 in patients with acute myocardial infarction. Cardiovasc Drug Ther. 1998;12:347-353.

Suarna C, Wu BJ, Choy K, Mori T, Croft K, Cynshi O, Stocker R. Protective effect of vitamin E supplements on experimental atherosclerosis is modest and depends on preexisting vitamin E deficiency. Free Radic Biol Med. 2006 Sep 1;41(5):722-30.

Tribble DL. Antioxidant consumption and risk of coronary heart disease: emphasis on vitamin C, vitamin E, and beta-carotene. Circulation. 1999;99:591-595.

Vermeulen EGJ, Stehouwer CDA, Twisk JWR, et al. Effect of homocysteine-lowering treatment with folic acid plus vitamin B6 on progression of subclinical atherosclerosis: a randomised, placebo-controlled trial. Lancet. 2000;355:517-522.

Virtamo J, Rapola JM, Ripatti S, et al. Effect of vitamin E and beta carotene on the incidence of primary nonfatal myocardial infaction and fatal coronary heart disease. Arch Intern Med. 1998;158:668-675.

Von Schacky C, Angere P, Kothny W, Theisen K, Mudra H. The effect of dietary omega-3 fatty acids on coronary atherosclerosis. Ann Intern Med. 1999;130:554-562.

Walker SE, Adams MR, Franke AA, Register TC. Effects of dietary soy protein on iliac and carotid artery atherosclerosis and gene expression in male monkeys. Atherosclerosis. 2007 Mar 14; [Epub ahead of print]

Watson KE, Abrolat ML, Malone LL, et al. Active serum vitamin D levels are inversely correlated with coronary calcification. Circulation. 1997;96(6):1755-1760.

Zhao G, Etherton TD, Martin KR, Gillies PJ, West SG, Kris-Etherton PM. Dietary alpha-linolenic acid inhibits proinflammatory cytokine production by peripheral blood mononuclear cells in hypercholesterolemic subjects. Am J Clin Nutr. 2007 Feb;85(2):385-91.

Review Date:
3/26/2007
Reviewed By:
Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Parkinson's disease

FitSugar — Wed, 08 Oct 2008 17:35:11 -0700

Overview

Signs and Symptoms
What Causes It?
What to Expect at Your Provider's Office
Treatment Options
Following Up
Special Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Parkinson's disease is a progressive disorder of the central nervous system. Nerve cells in the brain that control movement deteriorate and die, causing problems with movement, especially tremors in the hands and rigidity in the face. The disease affects men and women equally, primarily after age 60. However, about 10% of people with the disease are under age 40. Symptoms become worse over time, although the disease usually progresses gradually. No cure is available, but drug therapy can help alleviate the symptoms.

Signs and Symptoms

Tremor, often beginning with a mild shaking in the hand
Loss of balance
Stiffness and rigid limbs
Walking problems
Slow movement
Not blinking

Secondary symptoms may include the following:

Memory loss
Constipation
Sleep disturbances
Dementia
Speech, breathing, swallowing problems
Stooped posture

What Causes It?

The cause of Parkinson's disease is unknown. The disease, however, is characterized by loss of brain cells that produce the neurotransmitter (brain chemical) dopamine, which affects muscle activity. Risk factors include having a relative with Parkinson's, being exposed to certain pesticides and herbicides, age, and reduced levels of estrogen in women.

What to Expect at Your Provider's Office

Since no test can positively identify Parkinson's, your health care provider will rely largely on interviews with you and your family. Your health care provider may order brain scans to measure dopamine activity. Genetic testing may help identify a specific illness (like Huntington's disease) linked to the disease. Tests may be needed to rule out other disorders that cause similar symptoms.

Treatment Options

Exercise, especially intensive exercise, has been shown to improve symptoms and help maintain balance and mobility. Walking, swimming, jogging, or even dancing can be beneficial. Because people with Parkinson's disease have low levels of vitamin D, they are at risk of osteoporosis. Lifting weights can help reduce that risk. Your doctor may recommend an exercise program for you.

Drug Therapies

Several drugs treat the symptoms of Parkinson's, but they do not cure the disease. It is quite common for your health care provider to change medications and adjust dosages. Certain drugs used for the treatment of other diseases, especially glaucoma, heart disease, and high blood pressure, can influence the treatment of Parkinson's disease. Sometimes doctors may try to delay drug therapy, because the drugs tend to become less effective over time. Among the drugs used are:

Levodopa (L-dopa) and carbidopa, which increase amounts of dopamine in the brain. With long-term use, the period where the drug is effective gets shorter (wearing off effect), and some people may experience involuntary movements, called dyskinesia. Continuous infusion of levodopa into the small intestine of Parkinson's patients markedly reduces motor fluctuations over oral therapy.
Selective monoamine oxidase type (MAO-B) inhibitors, which can delay the intro of levodopa by about 9 months.
Dopamine agonists, which mimic the effects of dopamine in the brain.
Selegiline (Eldepryl), which delays the breakdown of dopamine and increases the effectiveness of levodopa and carbidopa.
Catechol-O-methyltransferase (COMT) inhibitors, which block an enzyme that breaks down dopamine.
Botulinum toxin, which may reduce jaw tremor, dystonia, and other conditions associated with Parkinson's.
Anticholinergic drugs, which help control symptoms.
Amantadine, which improves muscle control and lessens stiffness

Psychotherapy can help you cope with associated conditions such as depression. Speech, physical, and occupational therapy may help.

Complementary and Alternative Therapies

Alternative therapies may provide some relief of symptoms and slow progression of the disease.

Nutrition and Supplements

A low protein diet helps the body use levodopa and carbidopa most efficiently, so people who take these drugs are advised to control their intake of protein, and eat most protein in the evening and very little at breakfast or lunch. Your doctor should monitor your diet to make sure you get enough nutrients. In addition, a fiber supplement may help avoid constipation, which is a common symptom of Parkinson's.

Because many supplements may interact with medications you take for Parkinson's, or may only be effective at particular doses, do not take any supplements, even vitamins, without your doctor's guidance.

Coenzyme Q10. Several studies suggest that supplementing with coenzyme Q10 (1,200 mg per day), a substance made by the body that helps cells get energy from oxygen, can slow the progress of Parkinson's, especially in the early stages.
In one study, high doses of antioxidants vitamin C (1,000 mg three times a day) and vitamin E (800 IU four times per day) helped postpone the need for drug therapy. But taking vitamin E alone did not seem to have the same effect. More studies are needed to confirm the benefits.
Cytidinediphosphocholine, or CDP-choline, is another substance made in the body that appears to increase dopamine levels. In one study, people who took 400 mg three times per day were able to lower their levodopa dose.
L-tyrosine is an amino acid that converts to levodopa in the body. One preliminary study showed good results with 45 mg per pound of body weight as a dose, but more research is needed. L-tyrosine should NOT be taken with levodopa.
L-methionine (5 g per day), another amino acid, may also reduce some symptoms, but it may interfere with the action of levodopa.
Phosphatidylserine (PS), a phospholipid, is made by the body and is important to brain function. People with Parkinson's often have low levels of PS. One study showed that taking 100 mg of PS three times per day improved mood and brain function in people with Parkinson's.
Omega-3 fatty acids (1 tbs. per day or 1,000 mg one to two times per day), such as those found in fish oil, help maintain neurological health. High doses can have a blood-thinning effect, so make sure all prescribing doctors are aware that it is being used. Use a formula with low levels of vitamin A to avoid toxic levels of vitamin A when taking high doses of fish oil.
NADH (5 mg per day), the active form of vitamin B3, helps raise levels of dopamine in the brain, but studies in Parkinson's disease have shown mixed results, and some have used injections rather than oral doses.
Glutathione, an antioxidant produced by the body, has been given as a supplement intravenously to reduce symptoms. The treatment is controversial, however, because evidence for its effectiveness is lacking.
Vitamin D (400 - 1,000 IU ) is often deficient in people with Parkinson's. Supplements can be helpful in preventing osteoporosis.
S-adenosylmethionine or SAMe (400 - 1,600 mg per day) occurs naturally in the body and may be lowered by taking levodopa. SAMe may be effective in treating depression in people with Parkinson's. Long-term use, however, might decrease the effectiveness of levodopa.
Vitamin B6 (pyridoxine) has been used to treat Parkinson's disease, but not without some controversy. Vitamin B6 can actually interfere with the metabolism of certain Parkinson's medications, making them less effective. Some naturally oriented physicians have used vitamin B6 specifically for this reason, to reduce the side effects of these medications. If your doctor suggests such an approach, the treatment should be done only by prescription and with the knowledge of all prescribing doctor.
Creatine can enhance the benefits of resistance training and improve functional performance.
Coffee and caffeine may lower the risk and progression of Parkinson's.
Fava beans (Vicia faba) can have both beneficial and harmful effects in people with Parkinson's diesase. Fava beans contain levodopa. Some additional levodopa from a dietary source may help some patients, while in others it may cause a dangerous overdose. Consult a qualified botanical prescriber before using fava beans, and make sure all prescribing doctors know about adding them to your diet.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to diagnose your problem before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink two to four cups per day. You may use tinctures alone or in combination as noted.

Ginkgo (Ginkgo biloba) is an antioxidant that improves blood flow to the brain and may help with dopamine delivery (as a supplement 80 mg two times per day).
Cowhage (Mucuna pruriens) contains levodopa. One small study showed that it had better results than the form of levodopa given as prescription medication. Doses ranged from 22.5 - 67.5 g per day divided in 2 - 5 doses. More studies are needed.
Brahmi (Bacopa monniera) is an Ayurvedic herb that is often used to treat people with Parkinson's. Studies have pointed to its effectiveness as an antioxidant for the brain and suggest that it improves circulation to the brain, as well as improving mood, cognitive function, and general neurological function. Dosage guidelines vary among practitioners, but 100 - 200 mg twice daily is often recommended.

Homeopathy

Consult a trained homeopath who can determine the appropriate remedy and change it as often as symptoms change.

Argentum nitricum for ataxia (loss of muscle coordination), trembling, awkwardness, painless paralysis
Causticum for Parkinson's with restless legs at night
Mercurius vivus for Parkinson's that is worse at night, especially with panic attacks
Plumbum metallicum especially with arteriosclerosis
Zincum metallicum for great restlessness, and depression

Massage

May help with increasing circulation and decreasing muscle spasm. Cranio-sacral therapy, an osteopathic form of body work that focuses on the brain and spinal column, may decrease tremors and improve function.

Movement Therapies

May help people with Parkinson's improve motor skills and balance, and help them walk better.

Music therapy: A recent study showed symptoms improved with music and dance therapy compared to physical therapy.
Alexander Technique: emphasizes posture and balance. May help improve mobility and gait.
Feldenkrais Method: aims to re-educate the body about movements that are difficult. May improve gait.

Mind-Body Therapies

Tai chi and yoga can improve balance, flexibility, and range of motion in people with Parkinson's disease. They may also improve emotional well-being.

Traditional Chinese Medicine and Acupuncture

Traditional Chinese Medicine views disease as caused by internal imbalances. It has historically been used to treat Parkinson's with acupuncture and individually prepared herbal remedies. One study showed that acupuncture improved symptoms significantly in a small group of people with Parkinson's. In particular, scalp acupuncture and acupuncture with electrical stimulation have shown positive results in some cases. People with Parkinson's also experience sleep and rest benefits from acupuncture. If you consult a Traditional Chinese Medicine practitioner, make sure your doctor is aware of any suggested treatment.

Following Up

Since Parkinson's disease advances with time, you will need to be under constant medical care. Drug treatments often become less effective over time, and you must keep a close eye on your symptoms.

Special Considerations

Exercise will also help you improve mobility.

Supporting Research

Hass CJ, Collins MA, Juncos JL. Resistance training with creatine monohydrate improves upper-body strength in patients with Parkinson's disease: A randomized trial. Neurorehabil Neural Repair. 2007;21(2):107-15.

Hauser RA, Zesiewicz TA. Advances in the pharmacologic management of early Parkinson disease. Neurologist. 2007;13(3):126-32.

Lees A. Alternatives to levodopa in the initial treatment of early Parkinson's disease. Drugs Aging. 2005;22(9):731-40.

Samantha J, Hauser RA. Duodenal levodopa infusion for the treatment of Parkinson's disease. Expert Opin Parmacother. 2007;8(5):657-64.

Sheffield JK, Jankovic J. Botulinum toxin in the treatment of tremors, dystonias, sialorrhea and other symptoms associated with Parkinson's disease. Expert Rev Neurother. 2007;7(6)637-47.

Review Date:
1/17/2008
Reviewed By:
Steven D. Ehrlich, NMD, private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Skin cancer

FitSugar — Wed, 08 Oct 2008 17:35:04 -0700

Overview

Signs and Symptoms
What Causes It?
Who's Most At Risk?
What to Expect at Your Provider's Office
Treatment Options
Prognosis/Possible Complications
Following Up
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Skin cancer is generally a result of too much exposure to the sun. While skin cancer is the most common form of cancer, many types are both preventable and treatable. Skin cancer is classified into five different types:

Basal cell carcinoma (BCC) is the most common form and accounts for 90% of all skin cancers. It originates in the basal cells, at the bottom of the epidermis (outer skin layer), and is caused by long-term exposure to sunlight.
Squamous cell carcinoma (SCC) is the second most common type. It originates in the epidermis, eventually penetrating the underlying tissue if not treated. In a small percentage of cases, this cancer spreads (metastasizes) to other parts of the body.
Malignant melanoma (MM) is a form of skin cancer that currently is affecting an more and more people. Each year, more than 53,000 cases are diagnosed in the U.S. MM is a very serious type of skin cancer, but the cure rate is quite good if it is diagnosed and removed early. Melanoma originates in moles or other growths on normal skin.
Paget's disease (PD) is a rare type of skin cancer. It generally appears on the nipple, and is associated with an underlying breast cancer. It may also appear in the groin or near the anus, possibly originating in the sweat glands.
Kaposi's sarcoma (KS) is caused by a virus in the herpes family. An aggressive AIDS-related form affects about one third of AIDS patients. A more slow growing form occurs in elderly men of Italian or Jewish ancestry.

Signs and Symptoms

Skin cancer is accompanied by the following signs and symptoms:

A new skin lesion or open sores that bleed, ooze, or crust, and fail to heal in an expected time frame
Enlargement of an existing skin lesion
Change in color, size, shape or texture of a mole
A new mole
Reddish patch or irritated area, frequently occurring on the chest, shoulders, arms, or legs
Shiny bump that is pearly or translucent
Poorly defined borders of a skin lesion

What Causes It?

Exposure to ultraviolet (UV) radiation from the sun is the primary cause of skin cancer. A virus causes Kaposi's sarcoma, while Paget's disease is related to underlying breast cancer.

Who's Most At Risk?

People at risk for developing skin cancer may have the following conditions or characteristics:

Light skin color
Spend a lot of time outdoors in work or leisure activities
History of severe sunburn
Family history of skin cancer
Large dark-colored birthmark known as congenital melanocytic nevus
Certain non-cancerous skin conditions, such as actinic keratosis, which can predispose a person to skin cancer
HIV (human immunodeficiency virus) -- a risk for Kaposi's sarcoma specifically

What to Expect at Your Provider's Office

Your health care provider will examine your skin for new, changed, or unusual moles. This may involve the use of a dermatoscope, which is used for close examination of skin growths. Your health care provider will take a biopsy of any growths that appear cancerous. This involves removing a small piece of skin for microscopic examination. A biopsy can confirm whether or not you have skin cancer.

Treatment Options

Prevention

Skin cancer is a preventable disease. If you are at high risk, avoid sun exposure. When you have to be in the sun, protect yourself by covering up, wearing a hat, and applying sunscreen with an SPF of at least 30. You should also have regular skin cancer screenings with your primary health care provider or a skin specialist (dermatologist).

Treatment Plan

The primary goals of treatment are to remove the cancerous growth and stop the spread of the disease.

Drug Therapies

Melanoma that is deep or has spread and AIDS-related Kaposi's sarcoma may be treated with chemotherapy.

Surgical and Other Procedures

Most skin cancer can be surgically removed.
When surgery is not possible, cryotherapy (freezing), topical chemotherapy, or radiation may be used. If the cancer is on or close to the skin's surface, photodynamic therapy (laser) may be used.
Paget's disease of the nipple usually requires mastectomy (removal of breast tissue).

Complementary and Alternative Therapies

Alternative treatments are focused on preventing rather than treating skin cancer. In addition, some CAM treatments may reduce the side effects of conventional treatments. Finally, while many CAM treatments have not yet undergone rigorous scientific research, evidence suggests that some treatments may be useful when applied along with conventional treatments for skin conditions, including skin cancer. You should never rely on alternative therapies alone for treating skin cancer.

Nutrition

Eating certain foods or following therapeutic diets may help prevent skin cancer. It is hard to test the role of nutrients in protecting against various forms of skin cancer, but several studies have investigated the role of antioxidants (including vitamin C, vitamin E, beta-carotene, zinc, and vitamin A), folic acid, fats and proteins, and a variety of whole foods. While results are not absolutely clear, there may be some protective effect from antioxidants. There may also be a protective effect from foods such as fish, beans, carrots, chard, pumpkin, cabbage, broccoli, and vegetables containing beta-carotene and vitamin C. Studies on animals suggest that lignans, substances found in foods such as soy and flaxseed, may also help fight cancer in general, including the spread of melanoma from one part of the body to another.

Other substances found in plants may help protect the skin from sun-related damage. These include

Apigenin, a flavanoid in vegetables and fruits, including broccoli, celery, onions, tomatoes, apples, cherries and grapes, and in tea and wine
Curcumin, in the spice turmeric
Resveratrol, in grape skins, red wine, and peanuts
Quercetin, a flavanoid in apples and onions

Selenium has been touted as an antioxidant that might help prevent skin cancer. One study, however, suggests that selenium might actually increase the risk of developing squamous cell cancer.

Therapeutic diets may also help with skin cancer. An example the Gerson diet, which is customized for each patient. This diet may enhance treatment of melanoma. It strives for a low-fat, low-salt diet, hourly feedings of highly concentrated raw fruit and vegetable juice nutrients, and strategies to speed up metabolism (the breakdown and use of food), such as exercise, taking supplements, and restricting calories. Castor oil, administered every other day for several weeks, and coffee enemas given as frequently as every 4 hours over a 24-hour period, are thought to alleviate pain and improve nutritional status.

Herbs

Naturopathic doctors and botanists recommend a number of herbs and herbal combinations to prevent and treat cancer in general. To identify appropriate herbs to use in your treatment for skin cancer, see a trained herbalist, who will consider your condition and may prescribe herbs to support your care.

Green tea (Camellia sinensis) contains polyphenols, compounds that are potent antioxidants. Antioxidants eliminate free radicals, harmful by-products of cells' metabolism that are thought to play a role in cancer. The main polyphenol in green tea is epigallocatechin gallate (EGCG). Scientific studies suggest that EGCG and green tea polyphenols may prevent the onset and growth of skin tumors.

Other herbs with antioxidant and skin-protecting effects include bilberry (Vaccinium myrtillus), ginkgo (Ginkgo biloba), milk thistle (Silybum marianum), ginger (Zingiber officinale), and hawthorn (Crataegus laevigata ).

For Kaposi's sarcoma, some naturopaths recommend a paste made from lemon balm (Melissa officinalis) cream, several drops of Hoxsey-like formula (a mixture of herbs and potassium iodide thought to be effective against cancer), and powdered turmeric applied to lesions twice a day.

An animal study conducted in China investigated the effects of Cordyceps sinensis on natural killer cells. These are white blood cells that attack cancer and other harmful substances in the body. The study found that Cordyceps sinensis was effective against malignant melanoma by promoting natural killer activity and inhibiting tumor formation.

You should remember that certain herbs and nutrients can alter the way medications, including chemotherapy, act in your body. Make sure you keep your conventional and alternative health care providers informed about all the supplements, therapies, and medications you are using.

Homeopathy

Homeopathy is widely used among patients with melanoma, and warrants scientific investigation. An experienced homeopath considers your individual case and recommends treatments that address both your underlying condition andany symptoms you may be having.

Acupuncture

While acupuncture is not used as a treatment for cancer itself, evidence suggests it can be a valuable therapy for cancer-related symptoms (particularly nausea and vomiting that often accompanies chemotherapy treatment). Some studies have indicated that acupuncture may help reduce pain and shortness of breath.

Acupressure (pressing on rather than needling acupuncture points) has also proved useful in controlling breathlessness. Acupressure is technique that patients can learn and use to treat themselves.

Some acupuncturists prefer to work with a patient only after they have completed conventional medical cancer therapy. Others will provide acupuncture or herbal therapy during active chemotherapy or radiation. Acupuncturists treat cancer patients based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. In many cases of cancer-related symptoms, a qi deficiency is usually detected in the spleen or kidney meridians.

Massage

Massage is generally not recommended for those who have been diagnosed with skin cancer.

Prognosis/Possible Complications

Prognosis varies depending on the type of skin cancer:

Basal cell carcinoma: generally excellent.
Squamous cell carcinoma: excellent for small lesions removed early and completely.
Malignant melanoma: 5-year survival is almost 100 percent for very superficial lesions removed early. However, thick lesions and melanoma that has spread to other organs have poor prognosis.
Paget's disease: depends on the extent and cell type of the underlying breast cancer.
Kaposi's sarcoma: good for superficial lesions of the slow-growing form in the elderly of Italian or Jewish ancestry. The course of AIDS-related Kaposi's sarcoma depends on the status of the person's immune system.

Following Up

See your provider regularly for screenings to check for a recurrence of skin cancer.

Supporting Research

Abdaimi KE, Papavasiliou V, Rabbani SA, Rhim JS, Goltzman D, Kremer R. Reversal of hypercalcemia with the vitamin D analogue EB1089 in a human model of squamous cancer. Cancer Res. 1999;59:3325-3328.

Alimi D, Rubino C, Leandri EP, Brule SF. Analgesic effects of auricular acupuncture for cancer pain [letter]. J Pain Symptom Manage. 2000;19(2):81-82.

Baglia MS, Katiyar SK. Chemoprevention of photocarcinogenesis by selected dietary botanicals. Photochem Photobiol Sci. 2006 Feb;5(2):243-53.

Bain C, Green A, Siskind V, Alexander J, Harvey P. Diet and melanoma: an exploratory case-control study. Ann Epidemiol. 1993;3:235-238.

Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck & Co.; 1999:842-849.

Birt DF, Pelling JC, Nair S, Lepley D. Diet intervention for modifying cancer risk. Prog Clin Bio Res. 1996;395:223-234.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:107,169-170,491.

Boik J. Cancer & Natural Medicine: A Textbook of Basic Science and Clinical Research. Princeton, Minn: Oregon Medical Press; 1996:64, 66,67,76.

Brinker F. The Hoxsey treatment: cancer quackery or effective physiological adjuvant? J Naturopathic Med. 1996;6(1):9-23.

Combs GF Jr, Clark LC, Turnbull BW. Reduction of cancer risk with an oral supplement of selenium. Biomed Environ Sci. 1997;10(2-3):227-234.

Duffield-Lillico AJ, Slate EH, Reid ME, Turnbull BW, et al. Selenium supplementation and secondary prevention of nonmelanoma skin cancer in a randomized trial. J Natl Cancer Inst. 2004 Feb. 18;96(4):333-4; author reply 334.

Eisenberg D. Alternative therapies for cutaneous disorders. Arch Dermatol. 1997;133(3):379-380.

Ezzo J, Berman B, Hadhazy VA, Jadad AR, Lao L, Singh BB. Is acupuncture effective for the treatment of chronic pain? A systematic review. Pain. 2000;86:217-225.

Ferrini RL, Hill LM. American College of Preventive Medicine practice policy statement: screening for skin cancer. Am J Prev Med. 1998;14:80-86.

Filshie J, Penn K, Ashley S, Davis CL. Acupuncture for the relief of cancer-related breathlessness. Palliat Med. 1998;10:145-150.

Frieling UM, Schaumberg DA, Kupper TS, Muntwyler J, Hennekens CH. A randomized, 12-year primary-prevention trial of beta carotene supplementation for nonmelanoma skin cancer in the Physicians' Health Study. Arch Dermatol. 2000;136(2):179-184.

Gensler HL. Prevention of photoimmunosuppression and photocarcinogenesis by topical nicotinamide. Nutr Cancer. 1997;29(2):157-162.

Greenberg ER, Baron JA, Stukel TA, et al. A clinical trial of beta carotene to prevent basal-cell and squamous-cell cancers of the skin. The Skin Cancer Prevention Study Group. N Engl J Med. 1990;323(12):825-827,789-795.

Hildenbrand GLG, Hildenbrand LC, Bradford K, Cavin SW. Five-year survival rates of melanoma patients treated by diet therapy after the manner of Gerson: a retrospective review. Altern Ther Health Med. 1995;1(4):29-37.

Katiyar SK, Ahmad N, Mukhtar H. Green tea and skin. Arch Dermatol. 2000;136(:989-94.

Katiyar, SK, Korman NJ, Mukhtar H, Agarwal R. Protective effects of silymarin against photocarcinogenesis in a mouse skin model. J Natl Cancer Inst. 1997 Apr 16;89(:556-66.

Kirkpatrick CS, White E, Lee JA. Case-control study of malignant melanoma in Washington State. II. Diet, alcohol, and obesity. Am J Epidemiol. 1994;139:869-880.

Kune GA, Bannerman S, Field B, et al. Diet, alcohol, smoking, serum beta-carotene, and vitamin A in male nonmelanocytic skin cancer patients and controls. Nutr Cancer. 1992;18:237-244.

Maa SH, Gauthier D, Turner M. Acupressure as an adjunct to a pulmonary rehabilitation program. J Cardiopulm Rehabil. 1997;17(4):268-276.

Manson JE, Hunter DJ, Buring JE, Hennekens CH. Letter to the editor. N Engl J Med. 1991;324(13):924.

Monique RTM, et al. A systematic review of treatment modalities for primary basal cell carcinoma. Arch Derm. 1999;135:1177-1183.

Moon TE, Levine N, Cartmel B, et al. Effect of retinol in preventing squamous cell skin cancer in moderate-risk subjects: a randomized, double-blind, controlled trial. Cancer Epidemiol Biomarkers Prev. 1997;6(11):949-956.

Morrill JS. Letter to the editor. N Engl J Med. 1991;324(13):923-924.

Moss RW. Alternative pharmacological and biological treatments for cancer: ten promising approaches. J Naturopathic Med. 1996;6:23-32.

National Institutes of Health. Diagnosis and treatment of early melanoma. NIH Consensus Statement. 1992 January 27-29;10(1):1-26.

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Review Date:
6/15/2006
Reviewed By:
Steven D. Ehrlich, NMD, private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

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