FitSugar

Healthy Cooking Tip: Boil Potatoes Whole

FitSugar — Fri, 29 Aug 2008 14:30:00 -0700

Potatoes, reviled during the low-carb days of yore, are once again showing up on many American plates.

Labor Day means potato salad, and potato salad means boiling potatoes. I just read in the Berkeley Wellness Letter that you should boil your potatoes unpeeled and whole, which is easy to do if you buy the small red-skinned variety. Potatoes are a great source of potassium, especially the skin, which is why you should always eat the skin. But when cut for boiling, potatoes lose 50 percent of this valuable mineral as it leaches out into the water.

Save the potassium - boil your potatoes whole.

Source

Healthy Cooking Tip: Cook Your Carrots Whole

FitSugar — Fri, 19 Jun 2009 13:16:55 -0700

Orange and sweet, carrots rank as one of my favorite foods. Recent research has revealed that the carrot, similar to the potato, retains more of its cancer-fighting nutrients when cooked whole.

The anticancer properties of carrots are enhanced by 25 percent when not chopped preboil. When you chop a carrot, you increase the surface area of the veggie, so more nutrients leach into the water when boiled. The researcher wholeheartedly believe that carrots taste sweeter when cooked whole, for the root veggies retain their natural sugars.

While steaming carrots is my cooking method of choice, I am not sure I will try to steam mine whole. Roasting whole carrots, on the other hand, is something I already do. How do you cook your carrots? Will you be cooking them whole from now on?

Diabetes diet

FitSugar — Wed, 08 Oct 2008 17:35:01 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Lifestyle Changes Essential for People at Risk for Diabetes

Lifestyle interventions that include weight loss, dietary changes, and increased physical activity can definitely help prevent or delay the progression to diabetes among at-risk people, suggest several recent studies. Weight loss through diet and exercise is especially important for overweight people with pre-diabetes.

Grain Fiber Important for Diabetes Prevention

Eating whole-grain, fiber-rich, cereal foods may help reduce the risk of developing type 2 diabetes, indicates a 2007 study in the Archives of Internal Medicine. In the study, people who consumed the most fiber from grains and cereals had a 33% lower risk of developing diabetes than people with the lowest fiber intakes. The study also found an association between high magnesium intake and reduced diabetes risk. Although fruits and vegetables also contain fiber, they did not appear to affect diabetes risk.

Low-Fat Dairy Products

Incorporating low-fat dairy products (such as yogurt and milk) into a healthy diet may help reduce diabetes risk for women, suggests a study in Diabetes Care.

Beware of Internet Dietary Supplement Scams

In 2006, the FDA alerted consumers not to be misled by dietary supplements advertised on the Internet as treatments or cures for diabetes. These products have not been scientifically studied or approved.

Low-Glycemic Index Diets

Food low on the glycemic index -- such as whole grains, fruits, lentils, and soybeans -- can help promote weight loss and heart health. Illustrating the complexity of this area, a 2006 study in the New England Journal of Medicine indicated that a low-carb, low-glycemic index diet was beneficial while another study in the Archives of Internal Medicine suggested advantages for a high-carb, low-glycemic index diet.

Low-Fat Vegan Diets

A low-fat diet that excludes meat and dairy products may help improve glycemic control and increase insulin sensitivity, suggests a Diabetes Care study. Researchers think that the high fiber content of these diets, in addition to their reduced fat, may be a factor.

Introduction

The two major forms of diabetes are type 1, previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes, and type 2, previously called non-insulin-dependent diabetes mellitus (NIDDM) or maturity-onset diabetes. [See In-Depth Report #9: Diabetes - type 1 and In-Depth Report #60: Diabetes - type 2.]

Both type 1 and type 2 diabetes share one central feature: elevated blood sugar (glucose) levels due to absolute or relative insufficiencies of insulin, a hormone produced by the pancreas. Insulin is a key regulator of the body's metabolism. It normally works in the following way:

During and immediately after a meal the process of digestion breaks carbohydrates down into sugar molecules (of which glucose is one) and proteins into amino acids.
Right after the meal, glucose and amino acids are absorbed directly into the bloodstream, and blood glucose levels rise sharply. (Glucose levels after a meal are called postprandial levels.)
The rise in blood glucose levels signals important cells in the pancreas, called beta cells, to secrete insulin, which pours into the bloodstream. Within 10 minutes after a meal insulin rises to its peak level.
Insulin then enables glucose and amino acids to enter cells in the body, particularly muscle and liver cells. Here, insulin and other hormones direct whether these nutrients will be burned for energy or stored for future use. (The brain and nervous system are not dependent on insulin; they regulate their glucose needs through other mechanisms.)
When insulin levels are high, the liver stops producing glucose and stores it in other forms until the body needs it again.
As blood glucose levels reach their peak, the pancreas reduces the production of insulin.
About 2 - 4 hours after a meal both blood glucose and insulin are at low levels, with insulin being slightly higher. The blood glucose levels are then referred to as fasting blood glucose concentrations.

Click the icon to see an image of the liver.

In type 1 diabetes, the disease process is more severe than with type 2, and onset usually begins in childhood:

Beta cells in the pancreas that produce insulin are gradually destroyed. Eventually insulin deficiency is absolute.
Without insulin to move glucose into cells, blood glucose levels become excessively high, a condition known as hyperglycemia.
Because the body cannot utilize the sugar, it spills over into the urine and is lost.
Weakness, weight loss, and excessive hunger and thirst are among the consequences of this "starvation in the midst of plenty."

Click the icon to see an image of the pancreas.

Patients with type 1 diabetes need to take insulin. Dietary control in type 1 diabetes is very important and focuses on balancing food intake with insulin intake and energy expenditure from physical exertion. [See In-Depth Report #9: Diabetes - type 1.]

Type 2 diabetes is the most common form of diabetes, accounting for up to 95% of all diabetes cases. About 20 million Americans have type 2 diabetes, and half are unaware they have it. The disease mechanisms in type 2 diabetes are not wholly known, but some experts suggest that the disease may involve the following three stages in most patients:

The first stage in type 2 diabetes is the condition called insulin resistance. Although insulin can attach normally to receptors on liver and muscle cells, certain mechanisms prevent insulin from moving glucose (blood sugar) into these cells where it can be used. Most patients with type 2 diabetes produce variable, even normal or high, amounts of insulin, and in the beginning this amount is usually sufficient to overcome such resistance. Patients whose blood glucose levels are higher than normal, but not yet high enough to be classified as diabetes, are considered to have “pre-diabetes.” It is very important that people with pre-diabetes control their weight to stop or delay the progression to diabetes.
Over time, the pancreas becomes unable to produce enough insulin to overcome resistance. In type 2 diabetes, the initial effect of this stage is usually an abnormal rise in blood sugar right after a meal (called postprandial hyperglycemia). This effect is now believed to be particularly damaging to the body.
Eventually, the cycle of elevated glucose further impairs and possibly destroys beta cells, thereby stopping insulin production completely and causing full-blown diabetes. This is made evident by fasting hyperglycemia, in which elevated glucose levels are present most of the time.

Obesity is common in patients with type 2 diabetes and this condition appears to be related to insulin resistance. The primary dietary goal for overweight type 2 patients is weight loss and maintenance. Studies indicate that when people with type 2 diabetes maintain intensive exercise and diet modification programs, many can minimize or even avoid medications. Weight loss medications or bariatric surgery may be appropriate for some patients. [See In-Depth Report #60: Diabetes - type 2 and In-Depth Report #53: Weight control and diet.]

General Dietary Guidelines

For people who have pre-diabetes, or who are at high risk of developing type 2 diabetes, lifestyle changes of diet and exercise are extremely important. Several studies have shown that lifestyle interventions are very effective in preventing or postponing the progression to diabetes. These interventions are especially important for overweight people -- even moderate weight loss can help reduce diabetes risk.

The American Diabetes Association recommends that people at high risk for type 2 diabetes eat high-fiber (14g fiber for every 1,000 calories) and whole-grain foods. A 2007 study in the Archives of Internal Medicine also suggested that high intake of fiber and magnesium, especially from whole grain cereals and breads, can help reduce type 2 diabetes risk.

For people who have diabetes, the treatment goals for a diabetes diet are:

Achieve near normal blood glucose levels. People with type 1 diabetes and people with type 2 diabetes who are taking insulin or oral medication must coordinate calorie intake with medication or insulin administration, exercise, and other variables to control blood glucose levels. New forms of insulin are now allowing more flexibility in timing meals.
Protect the heart and aim for healthy lipid (cholesterol and triglyceride) levels and control of blood pressure.
Achieve reasonable weight. Overweight patients with type 2 diabetes who are not taking medication should aim for a diet that controls both weight and glucose. A reasonable weight is usually defined as what is achievable and sustainable, rather than one that is culturally defined as desirable or ideal. Children, pregnant women, and people recovering from illness should be sure to maintain adequate calories for health.
Manage or prevent complications of diabetes. People with diabetes, whether type 1 or 2, are at risk for a number of medical complications, including heart and kidney disease. Dietary requirements for diabetes must take these disorders into consideration.
Promote overall health.

Overall Guidelines. Overall Guidelines. There is no such thing as a single diabetes diet. Patients should meet with a professional dietitian to plan an individualized diet within the general guidelines that takes into consideration their own health needs.

For example, a patient with type 2 diabetes who is overweight and insulin-resistant may need to have a different carbohydrate-protein balance than a thin patient with type 1 diabetes in danger of kidney disease. Because regulating diabetes is an individual situation, everyone with this condition should get help from a dietary professional in selecting the best method.

Healthy eating habits along with good control of blood glucose are the basic goals in managing this complex disease, and several good dietary methods are available to meet them. General dietary guidelines for diabetes recommend:

Carbohydrates should provide 45 - 65% of total daily calories. The type and amount of carbohydrate are both important. Best choices are vegetables, fruits, beans, and whole grains. These foods are also high in fiber. Patients with diabetes should monitor their carbohydrate intake either through carbohydrate counting or meal planning exchange lists.
Fats should provide 25 - 35% of daily calories. Monounsaturated (olive, peanut, canola oils; avocados; nuts) and omega-3 polyunsaturated (fish, flaxseed oil, walnuts) fats are the best types. Limit saturated fat (red meat, butter) to less than 7% of daily calories. Choose nonfat or low-fat dairy instead of whole milk products. Limit trans-fats (hydrogenated fat found in snack foods, fried foods, commercially baked goods) to less than 1% of total calories.
Protein should provide 12 - 20% of daily calories, although this may vary depending on a patient’s individual health requirements. Patients with kidney disease should limit protein intake to less than 10% of calories. Fish, soy, and poultry are better protein choices than red meat.
Lose weight if body mass index (BMI) is 25 - 29 (overweight) or higher (obese).

Several different dietary methods are available for controlling blood sugar in type 1 and insulin-dependent type 2 diabetes:

Diabetic Exchange Lists (for maintaining a proper balance of carbohydrates, fats, and proteins throughout the day)
Carbohydrate Counting (for tracking the number of grams of carbohydrates consumed each day)
Glycemic index (for tracking which carbohydrate foods increase blood sugar)

Tests for Glucose Levels. Both low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia) are of concern for patients who take insulin. It is important, therefore, to monitor blood glucose levels carefully. Patients should aim for the following measurements:

Pre-meal glucose levels of 90 - 130 mg/dL
Bedtime levels of 110 - 150 mg/dL

In general, patients who are tightly controlling glucose levels need to take readings four or more times a day. Blood glucose levels are generally more stable in type 2 diabetes than in type 1, so experts usually recommend that these patients measure blood levels only once or twice a day. Different goals may be required for specific individuals, including pregnant women, very old and very young people, and those with accompanying serious medical conditions.

Tests for Glycosylated Hemoglobin. Another test examines blood levels glycosylated hemoglobin, also known as hemoglobin A1c (HbA1c). Measuring glycosylated hemoglobin is useful for determining the severity of diabetes. The test is not affected by food intake so it can be taken at any time. A home test has been developed that may make it easier to measure HbA1c. In general, measurements suggest the following:

Normal HbA1c levels should be below 7%
Levels of 11 - 12% glycolated hemoglobin indicate poor control of carbohydrates. High levels are also markers for kidney trouble.

Other Tests. Other tests are needed periodically to determine potential complications of diabetes, such as high blood pressure, unhealthy cholesterol levels, and kidney problems. Such tests may also indicate whether current diet plans are helping the patient and whether changes should be made. Annual urine tests showing even microscopic traces of a protein known as albumin can indicate a future risk for serious kidney disease.

For prevention of long-term complications of diabetes, experts now recommend that all patients with diabetes aim at keeping blood levels as close to normal as possible. Such intensive insulin treatment can increase the risk of hypoglycemia, which occurs when blood sugar is extremely low (below 60 mg/dL). The following tips may help avoid hypoglycemia or prepare for attacks.

Patients are at highest risk for hypoglycemia at night. Bedtime snacks may be helpful.
Patients who intensively control their blood sugar should monitor blood levels as often as possible, four times or more per day. This is particularly important for patients with hypoglycemia unawareness.
In adults, it is also particularly critical to monitor blood glucose levels before driving, when hypoglycemia can be very hazardous.
Patients on therapies that put them at risk for hypoglycemia should always carry hard candy, juice, sugar packets, or commercially available glucose substitutes designed for individuals with diabetes.

Food Labels. Every year thousands of new foods are introduced, many of them advertised as nutritionally beneficial. It is important for everyone, most especially people with diabetes, to be able to differentiate advertised claims from truth. The current food labels show the number of calories from fat, the amount of nutrients that are potentially dangerous (fat, cholesterol, sodium, sugars) as well as useful nutrients (fiber, carbohydrates, protein, vitamins).

Labels also show "daily values," the percentage of a daily diet that each of the important nutrients offers in a single serving. Unfortunately, the daily value is based on 2,000 calories, generally much higher than most patients with diabetes should have, and the serving sizes may not be equivalent to those on the Exchange Lists. Most people will need to recalculate the grams and calories listed on food labels to fit their own serving sizes and calorie needs.

Weighing and Measuring. Weighing and measuring food is extremely important in order to get the correct number of daily calories.

Along with measuring cups and spoons, choose a food scale that measures grams. (A gram is very small, about 1/28th of an ounce.)
Food should be weighed and measured after cooking.
After measuring all foods for a week or so, most people can make fairly accurate estimates by eye or by holding food without having to measure everything every time they eat.

Timing. Meals should not be skipped, particularly for those who are on insulin. Skipping meals can upset the balance between food intake and insulin and also can lead to weight gain if the patient eats extra food too often to offset low blood sugar levels.

The timing of meals is particularly important for people taking insulin:

Patients should coordinate insulin administration with calorie intake. In general, they should eat three meals each day at regular intervals. Snacks are often required.
They should try to take an insulin injection 30 minutes before they eat, although this timing could vary, depending on the form. Some experts recommend a fast acting insulin (insulin lispro) at each meal and a longer (basal) insulin at night.

Diabetes can lead to kidney disease and failure. People with early-stage kidney failure need to follow a special diet that slows the build-up of wastes in the bloodstream. The diet restricts protein, potassium, phosphorus, and salt intake. Fat and carbohydrate intake may need to be increased to help maintain weight and muscle tissue.

People who have late-stage kidney disease usually need dialysis. Once patients are on dialysis, they must have more protein in their diet. Patients must still be very careful about restricting salt, potassium, phosphorus, and fluids. Patients on peritoneal dialysis may have fewer restrictions on salt, potassium, and phosphorus than those on hemodialysis.

Major Food Components

Compared to fats and protein, carbohydrates have the greatest impact on blood sugar. Both the amount and type of carbohydrate affect blood glucose. Carbohydrate types are either complex (as in starches) or simple (as in fruits and sugars). One gram of carbohydrates equals four calories. The current general recommendation is that carbohydrates should provide between 40 - 65% of the daily caloric intake. Carbohydrate intake should not fall below 130 grams/day. Most experts do not recommend low-carb diets for diabetes management or weight control.

Vegetables, fruits, whole grains, and beans are good sources of carbohydrates. Whole grain foods provide more nutritional value than pasta, white bread, and white potatoes. Brown rice is a better choice than white rice. Patients should try to consume a minimum of 20 - 35 grams of fiber daily (ideally 50 grams/day), from vegetables, fruits, whole grain cereals, breads, nuts and seeds.

Complex Carbohydrates. Complex carbohydrates found in whole grains and vegetables are preferred over carbohydrates found in starch-heavy foods, such as pastas, white-flour products, and potatoes. Most of these are high in fiber, which is important for health. Whole-grains specifically are extremely important for people with diabetes or at risk for it. [For specific benefits, see Box Whole Grains, Nuts, and Fiber-Rich Foods and Table Some Examples of Healthy Foods.]

Simple Carbohydrates (Sugar). Sugars are generally one of two types:

Sucrose (table sugar). Sucrose has been associated with higher triglycerides and harmful cholesterol levels. A 2002 study suggested that a high level of sugar consumption may also reduce levels of HDL cholesterol, the so-called good cholesterol.
Fructose (sugar found in fruits). Fructose may produce a slower increase in blood sugar than sucrose, which may have some advantages for people with diabetes. Dark-colored fruits are rich in important vitamins and other nutrients, and studies continue to report their benefits for the heart and health in general. Other fruits, such as apples and grapes also have important beneficial food chemicals.

Sugar itself, either as sucrose or fructose, adds calories, increases blood glucose levels quickly, and provides no other nutrients. High levels of sugar consumption -- both fructose and sucrose -- have been associated with higher triglycerides and lower levels of HDL cholesterol, the so-called good cholesterol. The high consumption of sugar is most likely one of the factor in the current obesity epidemic. Soda, other sweetened beverages, and fruit juice in fact may be singled out as major contributors to childhood obesity.

People with diabetes should avoid products listing more than 5 grams of sugar per serving, and some doctors recommend limiting fruit intake. If specific amounts are not listed, patients should avoid products with either sucrose or fructose listed as one of the first four ingredients on the label. [See Box Fat Substitutes and Artificial Sweeteners.]

Of increasing interest to researchers is possible harm from sugar from advanced glycation end-products (called AGEs). These are end-products of the chemical reaction between sugar and protein. This reaction occurs most intensively when cooking at high temperatures -- particularly animal fats. (Steaming or cooking food in water does not produce these chemicals. Low, slow cooking also produces fewer AGEs.) AGEs can also be formed by chemical reactions in the body itself. They may promote factors in the inflammatory response that cause a number of diseases or their complications, including diabetes and other serious conditions (Alzheimer's, atherosclerosis, cataracts, and osteoporosis).

The Carbohydrate Counting System. Some people plan their carbohydrate intake using a system called carbohydrate counting. It is based on two premises:

All carbohydrates (either from sugar or starch) will raise blood sugar to a similar degree. In general, 1 gram of carbohydrates raises blood sugar by 3 points in people who weigh 200 pounds, 4 points for people who weigh 150 pounds, and 5 points for 100 pounds.
Carbohydrates have the greatest impact on blood sugar; fats and protein play only minor roles.

In other words, the amount of carbohydrates eaten (rather than fats or proteins) will determine how high blood sugar levels will rise. There are two options for counting carbohydrates: advanced and simple. Both rely on collaboration with a doctor, dietitian, or both. Once the patient learns how to count carbohydrates and adjust insulin doses to their meals, many find it more flexible, more accurate in predicting blood sugar increases, and easier to plan meals than other systems.

The basic goal is to balance insulin with the amount of carbohydrates eaten in order to control blood glucose levels after a meal. The steps to the plan are as follows:

The patient must first carefully record a number of factors that are used to determine the specific requirements for a meal plan based on carbohydrate grams:

Multiple blood glucose readings (taken several times a day)
The time of meals
Amount in grams of all the carbohydrates eaten
Time, type, and duration of exercise
The time, type, and dose of insulin or oral medications
Other relevant factors, such as menstruation, illness, and stress

The patient works with the dietitian for two or three 45 - 90 minute sessions to plan how many grams of carbohydrates are needed. There are three carbohydrate groups:

Bread/starch
Fruit
Milk

One serving from each group should contain 12 - 15 carbohydrate grams. (Patients can find the amount of carbohydrates in foods from labels on commercial foods and from a number of books and web sites.)

The dietitian creates a meal plan that accommodates the patient's weight and needs, as determined by the patient's record, and makes a special calculation called the carbohydrate to insulin ratio. This ratio determines the number of carbohydrate grams that a patient needs to cover the daily pre-meal insulin needs.

Eventually, patients can learn to precisely adjust their insulin doses to their meals.

Patients who choose this approach must still be aware of protein and fat content in foods. These food groups may add excessive calories and saturated fats. Patients must still follow basic healthy dietary principles.

The Glycemic Index. The glycemic index helps determine which carbohydrate-containing foods raise blood glucose levels more or less quickly after a meal. The index uses a scale of numbers for specific foods that reflect greatest to least delay in producing an increase in blood sugar after a meal. The lower the index number, the better the impact on glucose levels. Some evidence suggests that the benefit of foods with a low glycemic index is due to their ability to increase insulin levels quickly and so remove blood sugar rather than their ability to slow the release of blood sugar itself.

There are currently two indices in use. One uses a scale of 1 - 100 with 100 representing a glucose tablet, which has the most rapid effect on blood sugar [See Table The Glycemic Index of Some Foods]. The other common index uses a scale with 100 representing white bread (so some foods will be above 100).

A major 2003 analysis suggested that choosing foods with a low glycemic index scores may have a small but significant effect on controlling the surge in blood sugar after meals. Many of these foods are also high in fiber and so have heart benefits as well. Substituting low- for high-glycemic index foods may also help prevent weight gain.

One easy way to improve glycemic index is to simply replace starches and sugars with whole grains and legumes (dried peas, beans, and lentils). However, there are many factors that affect the glycemic index of foods, and maintaining a diet with low glycemic load is not straightforward. The following are some considerations:

The numbers attributed to each carbohydrate-rich food cannot be added to equal a certain number. In other words, adding All Bran cereal (index of 49) to a banana (index of 61) does not equal 110.
Adding certain fats to a food (for example butter to potato) can slow down the food's impact on blood sugar. One study reported that when patients ate fatty foods first, their blood glucose levels were significantly lower an hour after the meal than when carbohydrates were eaten first.
Adding foods with organic acids (pickles, yogurt) to meals may reduce the impact of foods with high glycemic scores on blood sugar. (It should be noted that yogurt alone, however, has the same high glycemic index as regular milk.)

No one should use the glycemic index as a complete dietary guide, since it does not provide nutritional guidelines for all foods. It is simply an indication of how the metabolism will respond to certain carbohydrates. Some experts believe it is too complicated to be practical and that simply tracking carbohydrates, eating healthily, and maintaining a healthy weight is sufficient. Nevertheless, a study on children with type 1 diabetes suggested that the glycemic index offered as many choices as the exchange diet, and they did not report feeling any greater limitations. [For additional information on low-glycemic index diets, see "Heart-Healthy Diets" section of this report.]

Fiber is an important component of many complex carbohydrates. It is almost always found only in plants, (particularly vegetables), fruits, whole grains, nuts, and legumes (dried beans, peanuts, and peas). (One exception is chitosan, a dietary fiber made from shellfish skeletons.) Fiber cannot be digested but passes through the intestines, drawing water with it and is eliminated as part of feces content. The following are specific advantages from high-fiber diets (up to 55 grams a day):

Insoluble fiber (found in wheat bran, whole grains, seeds, nuts, legumes, and fruit and vegetable peels) may help achieve weight loss. Consuming whole grains on a regular basis appears to provide many important benefits, especially for people with type 2 diabetes. Whole grains may even lower the risk for type 2 diabetes in the first place. Of special note, nuts, such as almonds, macadamia, and walnuts may be highly heart protective, independent of their fiber content. However, nuts are high in calories.
Soluble fiber (found in dried beans, oat bran, barley, apples, citrus fruits, and potatoes) has important benefits for the heart, particularly for achieving healthy cholesterol levels and possibly reducing blood pressure as well. Evidence on the heart benefits of beans continues to grow. For example, a 2001 study indicated that eating beans four or more times a week reduced the risk for heart disease by 22%.
Soluble fiber supplements, such as those that contain psyllium or glucomannan, may be beneficial. Psyllium is taken from the husk of a seed grown in India. It is found in laxatives (Metamucil), breakfast cereals (Bran Buds), and other products. In a 2002 study, patients with type 2 diabetes who consumed psyllium (Plantaben) for breakfast for 11 weeks experienced lower total and LDL cholesterol levels. There was no difference in glucose or HbA1c levels. Psyllium can increase sodium so people who increase their levels of soluble fiber should also increase water and fluid intake.

Replacing fats and sugars with substitutes may help many people who have trouble maintaining weight. In one 2003 study, people with type 2 diabetes used the artificial sweetener sucralose and a beta-glucan fat replacer (derived from oats) as part of a low-calorie diet. At the end of 4 weeks, they achieved better weight, glucose control, and HDL levels than those on a standard diabetic diet.

Fat Substitutes. Fat substitutes added to commercial foods or used in baking, deliver some of the desirable qualities of fat, but do not add as many calories. It should be stressed that eliminating all fats from your diet can be harmful to general health. Some fat substitutes include:

Stanols. Stanols are plant compounds used in margarines (Benecol, Take Control). Benecol is derived from pine bark and Take Control from soybeans. Two servings a day of either brand as part of a low-fat diet can lower LDL and total cholesterol by impairing its absorption in the intestinal tract. Some studies have reported that their use can allow lower doses of statins (cholesterol -lowering drugs). These products do not appear to block absorption of fat-soluble nutrients or vitamins, as olestra does. They can be hydrogenated, however, and can contain some trans-fatty acids.
Olestra (Olean) passes through the body without leaving behind any calories from fat. Studies suggest that it improves cholesterol levels and helps people lose weight when it is used to replace a third of normal dietary fats. (Simply adding snacks containing olestra do not appear to have any effect on cholesterol or weight loss.) However, it can cause cramping and diarrhea. Of greater concern is the fact that even small amounts of olestra deplete the body of certain vitamins and nutrients that may help protect against serious diseases, including cancer. The FDA requires that the missing vitamins be added back to olestra products, but not other nutrients. The adverse health effects, if any, are unknown.
Beta-glucan is a soluble fiber found in oats and barley. Products using this substance (Nu-Trim) may reduce cholesterol and have additional health benefits.

A number of other fat-replacers are also available. Although studies to date do not show any significant adverse health effects, their effect on weight control is uncertain, since many of the products containing them may be high in sugar.

Artificial Sweeteners. Many artificial or low-calories sweeteners are available. A 2002 study confirmed that people who consumed artificial sweeteners in beverages and foods and reduced their sugar intake weighed less over time than those who ate similar types and amounts of drinks and food containing sugar. However, using these artificial sweeteners should not give dieters a license to increase their fat intake. Studies indicate that consuming some sugar is not a significant contributor to weight gain as long as the total caloric intake is under control. There is some public concern about chemicals used to produce many of these sweeteners and adverse effects in studies using rats. Natural low-calorie sweeteners that may be more acceptable to many people are also available. Low-calorie sweeteners include:

Saccharin (Sugar Twin, Sweet n’Low, Sucaryl, and Featherweight). Saccharin has been used for years but is not used as commonly now. Some studies found that large amounts of saccharin caused bladder cancer in rats. Although the rats were fed huge amounts that do not apply to human diets, some evidence suggests that people who have six or more servings of saccharin per day may have an increased risk.
Aspartame (Nutra-Sweet, Equal, NutraTase). Aspartame has come under scrutiny because of rare reports of neurologic disorders, including headaches or dizziness, associated with its use. People with phenylketonuria (PKU), a rare genetic condition, should not use it. Studies have not reported any serious health dangers, but some people may be sensitive to it.
Sucralose (Splenda). Sucralose has no bitter aftertaste and works well in baking, unlike other artificial sweeteners. It is made from real sugar by replacing hydroxyl atoms with chlorine atoms. Some people are concerned because chlorinated molecules used in major industrial chemicals have been associated with cancer and birth defects. Over 100 studies have been conducted on sucralose over a 20-year period with no reports of such risks.
Acesulfame-potassium (Sweet One, SwissSweet, Sunette). It has been used in the US since 1988 with no reported adverse effects.
Neotame (Neotame). Neotame is a synthetic variation of aspartame but was developed to avoid its side effects. The association with aspartame has raised some concerns. Studies to date have reported no effects that would cause alarm, and it appears to be safe for general consumption.
D-tagatose (Tagatose). This reduced calorie sweetener is a novel low-calorie sweetener derived from lactose, which is found in dairy products and other foods. It may be specifically beneficial for people with type 2 diabetes and have additional benefits that aid the intestinal tract.
Alitame (Aclame) is formed from amino acids. It has the potential to be used in all products that contain sugar, including baked goods.
Stevioside (Stevia). This is a natural sweetener derived from a South American plant. It is available in health food stores. People with diabetes should avoid alcohol-based forms. It has not been rigorously tested.

Other artificial sweeteners being investigated include, glycyrrhizin (derived from licorice), and dihycrochalcones (derived from citrus fruits).


Based on 100 = a Glucose Tablet
BREADS
pumpernickel	49
sour dough	54
rye	64
white	69
whole wheat	72
GRAINS
barley	22
sweet corn	58
brown rice	66
white rice	72
BEANS
soy	14
red lentils	27
kidney (dried and boiled, not canned)	29
chickpeas	36
baked	43
DAIRY PRODUCTS
milk	30
ice cream	60
CEREALS
oatmeal	53
All Bran	54
Swiss Muesli	60
Shredded Wheat	70
Corn Flakes	83
Puffed Rice	90
PASTA
spaghetti-protein enriched	28
spaghetti (boiled 5 minutes)	33
spaghetti (boiled 15 minutes)	44
FRUIT
strawberries	32
apple	38
orange	43
orange juice	49
banana	61
POTATOES
sweet	50
yams	54
new	58
mashed	72
instant mashed	86
white	87
SNACKS
potato chips	56
oatmeal cookies	57
corn chips	72
SUGARS
fructose	22
refined sugar	64
honey	91
Note. These numbers are general values, but may vary widely depending on other factors, including if and how they are cooked and foods they are combined with.

Protein intake in diabetes is complicated. Protein recommendations vary among experts and depend on various factors. These factors include whether a patient has type 1, type 2, or pre-diabetes. There are additional guidelines for patients who show signs of kidney damage (nephropathy).

In general, diabetes dietary guidelines recommend that proteins should provide 12 - 20% of total daily calories. This daily amount poses no risk to the kidney in people who do not have kidney disease. Protein is important for strong muscles and bone. Some experts recommend a higher proportion of protein (20 - 30%) for patients with pre- or type 2 diabetes. They think that eating more protein helps people feel more full and thus reduces overall calories. In addition, protein consumption helps the body maintain lean body mass during weight loss.

Because protein causes the kidneys to work harder, patients with diabetic nephropathy need to limit their intake of protein. A typical protein-restricted diet limits protein intake to no more than 10% of total daily calories. Patients with kidney damage also need to limit their intake of phosphorus, a mineral found in dairy products, beans, and nuts. (However, patients on dialysis need to have more protein in their diets.) Potassium and phosphorus restriction is often necessary as well.

One gram of protein contains 4 calories. Protein is commonly recommended as part of a bedtime snack to maintain normal blood sugar levels during the night, although studies are mixed over whether it adds any protective benefits against nighttime hypoglycemia. If it does, only small amounts (14 grams) may be needed to stabilize blood glucose levels.

Good sources of protein include fish, skinless chicken or turkey, nonfat or low-fat dairy products, soy (tofu), and legumes (kidney beans, black beans, chick peas, lentils).

Fish. Fish is probably the best source of protein. Evidence suggests that eating moderate amounts of fish (twice a week) may improve triglycerides and help lower the risks for death from heart disease, dangerous heart rhythms, blood pressure, a tendency for blood clots, and the risk for stroke.

The most healthy fish are oily fish such as salmon, mackerel, or sardines, which are high in omega-3 fatty acids. Three capsules of fish oil (preferably as supplements of DHA-EPA) is about equivalent to eating one serving of fish.

Some studies have reported a higher incidence of heart attack in men who ate fish daily. Such findings may be due to mercury toxicity, which has harmful effects on the heart. High mercury content has been observed in swordfish and shark and, to some extent, in tuna, trout, pike, tilapia, and bass.

Fish oil supplements may also have some adverse effects on LDL levels and glucose control in type 2 diabetes. More research is needed to further define the risk and benefits of fish, but at this time most guidelines recommend eating fish two or three times a week.

Soy. Soy is an excellent food. It is rich in both soluble and insoluble fiber, omega-3 fatty acids, and provides all essential proteins. Soy proteins have more vitamins and minerals than meat or dairy proteins. They also contain polyunsaturated fats, which are better than the saturated fat found in meat. The best sources of soy protein are soy products (tofu, soy milk, soybeans). Soy sauce is not a good source. It contains only a trace amount of soy and is very high in sodium.

For many years, soy was promoted as a food that could help lower cholesterol and improve heart disease risk factors. But an important 2006 American Heart Association (AHA) review of studies found that soy protein and isoflavone supplement pills do not really have any effects on cholesterol or heart disease prevention. The AHA still encourages patients to include soy foods as part of an overall heart healthy diet, but does not recommend using isoflavone supplements.

Meat and Poultry. Lean cuts of meat are the best choice for heart health and diabetes control. Saturated fat in meat is the primary danger to the heart. The fat content of meat varies depending on the type and cut. For patients with diabetes, experts recommend choosing skinless chicken or turkey over red meat. (Fish is an even better choice.) A large, long-term 2006 study found that high heme iron intake from red meat increases the risk of developing type 2 diabetes in women. Another 2006 study suggested that replacing red meat with chicken improves kidney function and lipid levels in patients with diabetic nephropathy.

Dairy Products. A 2002 study reported that a high intake of dairy products can lower risk factors related to type 2 diabetes and heart disease (insulin resistance, high blood pressure, obesity, and unhealthy cholesterol). Some researchers suggest the calcium in dairy products may be partially responsible for these benefits. However, because many dairy products are high in saturated fats and calories, doctors recommend that patients choose low-fat and nonfat dairy items. Other studies have indicated that increasing the amount of low-fat diary products in a daily diet may help reduce type 2 diabetes risk, particularly for women.

Some fat is essential for normal body function. Fats can have good or bad effects on health, depending on their chemistry. New research suggests that the type of fat is more important than the total amount of fat when it comes to reducing heart disease.

Current dietary guidelines for diabetes and heart health recommend that total fat be 25 - 35% of total daily calories. Monounsaturated fats (olive oil, canola oil, peanut oil, nuts, avocados) and omega-3 polyunsaturated fats (fish, flaxseed, walnuts) should be the first choice for fats. Omega-6 polyunsaturated fats (corn oil, safflower, oil, sunflower oil, soybean oil) are the second choice. Limit saturated fat to less than 7% of total daily calories. Limit trans-fats (margarine, commercial baked goods, snack and fried foods) to less than 1% of total calories.

All fats, good or bad, are high in calories compared to proteins and carbohydrates. In order to calculate daily fat intake, multiply the number of fat grams eaten by nine (1 fat gram is equal to 9 calories, whether it's oil or fat) and divide by the number of total daily calories desired. One teaspoon of oil, butter, or other fats equals about 5 grams of fat. All fats, no matter what the source, add the same calories. The American Heart Association recommends that fats and oils have less than 2 grams of saturated fat per tablespoon.

Try to replace saturated fats and trans fatty acids with unsaturated fats from plant and fish oils. Omega-3 fatty acids, which are found in fish and plant sources, are a good source of unsaturated fats. Generally, two servings of fish per week provide a healthful amount of omega-3 fatty acids.

The Chemistry of Fats and Cholesterol.

Fatty Acids. All fats and oils found in foods are made up of chains of molecules called fatty acids. There are three major chains: saturated fatty acid (found mostly in animal products) and two unsaturated fatty acids -- monounsaturated and polyunsaturated fatty acids (found in plant products). The oils and fats that people and animals eat are nearly always mixtures of these three chains, but one type of fatty acid usually predominates in specific oils or fats.
Essential Fatty Acids. In addition, there are three chemical subgroups of polyunsaturated fatty acids called essential fatty acids: omega-3 and omega-6 polyunsaturated fatty acids, and omega-9 monounsaturated fatty acids.
Trans Fatty Acids. To complicate matters, there are also trans-fatty acids, which are not natural but are manufactured by adding hydrogen atoms to polyunsaturated fatty acids (called hydrogenation).

Harmful Fats. Reducing consumption of saturated fats and trans-fatty acids is the first essential step in managing cholesterol levels through diet.

Saturated Fats. Saturated fats are found predominantly in animal products, including meat and dairy products. They are strongly associated with higher cholesterol levels, and they may be even more dangerous in women than in men. High-fat meals are associated with sudden surges in triglyceride levels and other lipids along with impaired blood flow in the arteries to the heart. (Tropical oils such as palm, coconut, and cocoa butter are also high in saturated fats.)
Trans Fatty Acids. Trans fatty acids are manufactured fats created during a process called hydrogenation, which is aimed at stabilizing polyunsaturated oils to prevent them from becoming rancid and to keep them solid at room temperature. They are particularly dangerous for the heart and may pose a risk for certain cancers. These partially hydrogenated fats are even worse than saturated fats. Studies report that high consumption of these fats reduces HDL and raises LDL cholesterol levels, has harmful effects on the linings of the arteries, and may increase the risk for type 2 diabetes. Hydrogenated fats are used in stick margarine and in many fast foods and baked goods, including most commercially produced white breads. (Liquid margarine is not hydrogenated and is recommended.) The FDA ordered that food labels list the amount of trans fatty acids in food products beginning in January 2006.

Beneficial Fats and Oils. Some fat is essential for health, and fat is essential for healthy development in children. Public attention has mainly focused on the possible benefits or hazards of monounsaturated (MUFA) and polyunsaturated (PUFA) fats.

Polyunsaturated fats are found in safflower, sunflower, corn, and cottonseed oils and fish.
Monounsaturated fats are mostly present in olive, canola, and peanut oils and in most nuts. (Canola is the least saturated of all the fats.) Studies report that replacing carbohydrates with monounsaturated fats improves glucose control after meals and reduces triglycerides in people with type 2 diabetes. Oils are more calorie-dense, however, and such patients should be wary of weight gain.

Researchers are most interested in the smaller fatty-acid building blocks contained in both oils, which may have more specific effects on lipids. Three important fatty acids are the essential fatty acids omega-3, omega-6, and omega-9.

Omega-3 fatty acids are found in fish oil (docosahexaenoic and eicosapentaneoic acids) and plants (alpha-linolenic acid).

Docosahexaenoic (DHA) and Eicosapentaneoic (EPA) Acids. DHA and EPA are found in fish oils, and evidence suggests that they have significant benefits for the heart, including reducing sudden death from heart disease, inflammation, blood clotting factors, blood pressure, and improving triglyceride and HDL levels. Results from a study presented at the 2005 meeting of the American Heart Association suggested that daily EPA supplements plus statin therapy can protect against heart attack, angina, and coronary artery disease. However, although fish and fish oil are good for the heart, patients who have an implantable defibrillator should not take fish oil supplements.

Alpha-linolenic Acid. Alpha-linolenic acid is a plant precursor of DHA, which means the body can convert it to DHA. Sources include canola oil, soybeans, flaxseed, and certain nuts and seeds (walnut, flax, chia and sometimes pumpkin seed). Some, but not all, studies suggest that oils or foods containing these oils may also be heart-protective. Supplements or foods containing these oils may also protest the heart. For example studies have reported heart protection from flaxseed supplements and also from nuts, such as almonds, macadamia, and walnuts. Nuts are high in calories, however.

Omega-6 polyunsaturated fatty acids are found in corn, safflower, soybean, and sunflower oil. PUFA oils containing omega-6 fatty acids constitute most of the oils consumed in the US. Some omega-6 fatty acids are important for health. However, high intake of these fats may be associated with weight gain in the abdomen (the so-called apple shape), a risk factor for heart disease. High consumption is also associated with a higher risk for certain cancer and some chronic diseases.

Omega-9 monounsaturated fatty acids are contained in canola and olive oil, which help protect the heart.

Research suggests that a healthy balance of all these fats may be important and that our current Western diet contains an unhealthy ratio of omega-6 to omega-3 fatty acids (10 to 1). Omega-9 fatty acids may also contain chemicals that block harmful factors found in omega-6 fatty acids. Researchers suggest that the most benefits may be found in mixture of all three fatty acids found in both poly- and monounsaturated oils, but in modest amounts that do not add too many calories.

Fat Substitutes. Fat substitutes added to commercial foods or used in baking, deliver some of the desirable qualities of fat, but do not add as many calories. [See Box Fat Substitutes and Artificial Sweeteners.]

The story on cholesterol found in the diet is not entirely straightforward. The body produces cholesterol naturally or obtains it through meals. Animal-based food products contain cholesterol. High amounts occur in meat, dairy products, egg yolks, and shellfish. (Plant foods, such as fruits, nuts, grains, do not contain cholesterol.) The American Heart Association recommends no more than 300 mg of dietary cholesterol per day for the general population and no more than 200 mg daily for those with high cholesterol.

Antioxidant Vitamins. Vitamins C and E are most studied for their health effects because they serve as antioxidants. Antioxidants are chemicals that act as scavengers of particles known as oxygen-free radicals (also sometimes called oxidants). High intake of foods rich in these vitamins (as well as other food chemicals) have been associated with many health benefits, including prevention of heart problems.

Research on the effects of vitamin supplements on heart disease and diabetes, however, has been mixed. Although some research initially observed favorable effects from vitamin E in preventing blood clots and build-up of plaque on blood vessel walls, most studies found no heart protection from either vitamin E or C supplements. A 2005 Journal of the American Medical Association study found that vitamin E supplements can actually increase the risk of heart failure, especially for patients with diabetes or vascular diseases. In addition, vitamin E had no effect on preventing cancer or heart disease.

Because of the lack of scientific evidence for benefit, the American Diabetes Association does not recommend regular use of vitamin supplements, except for people who have vitamin deficiencies. Researchers, however, are still studying the treatment possibilities of antioxidants. A 2006 study suggested that alpha-lipoic acid, another type of antioxidant, may have promise as a treatment for diabetic peripheral neuropathy, the nerve damage condition that is a common complication of diabetes.

B Vitamins and Folic Acid. Deficiencies in the B vitamins folate (known also as folic acid), B6, and B12 have been associated with a higher risk for heart disease in some studies. Such deficiencies produce higher blood levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease, stroke, and heart failure.

Researchers have been studying whether vitamin B supplements can reduce homocysteine levels and, consequently, heart disease risks. Several major 2006 studies indicated that while B vitamin supplements help lower homocysteine levels, they have no effect on heart disease. The studies, published in the New England Journal of Medicine, examined patients who had either recently had a heart attack or who suffered from diabetes or heart disease. Results showed a similar number of heart attacks and strokes among patients who took folic acid, B6, and B12 vitamins and those who received placebo. Some experts think that homocysteine may be a marker for heart disease rather than a cause of it.

Niacin (vitamin B3) is used for lowering unhealthy cholesterol levels. Although vitamin B3 is available over the counter, it can have significant side effects. A doctor should prescribe niacin in order to ensure its safety and effectiveness.

Patients with type 2 diabetes who take metformin (Glucophage) should be aware that this drug can interfere with vitamin B12 absorption. Calcium supplements may help counteract metformin-associated vitamin B12 deficiency.

Most experts recommend salt restriction in people who have high blood pressure. Some people, however, are much more sensitive to harmful effects from salt than others:

People at Risk for Salt-Sensitivity. About half of people with hypertension have blood pressure that reacts significantly to salt. Such people are known as salt-sensitive. Among those at highest risk for salt sensitivity are African Americans, people with diabetes, and elderly people.
Overweight People. Overweight individuals may absorb and retain sodium differently from people with normal weights. One study reported that high sodium intake was associated with an increased risk of heart disease and all-cause mortality in overweight, but not in normal weight, people. Reducing sodium can also help reduce the risk of stroke in people who are overweight.

Simply eliminating table and cooking salt can be beneficial. Salt substitutes, such as Cardia, (containing mixtures of potassium, sodium, and magnesium) are available, but they are expensive. About 75% of the salt in the typical American diet comes from processed or commercial foods, not from food cooked at home, so the benefits of table-salt substitutes are likely to be very modest. Some sodium is essential to protect the heart, but most experts agree that the amount is significantly less than that found in the average American diet. If people cannot significantly reduce the amount of salt in their diets, adding potassium-rich foods might help to restore a healthy balance.

Calcium. Calcium supplements may be important in older patients with diabetes to help reduce the risk for osteoporosis, particularly if their diets are low in dairy products.

Potassium. Evidence strongly indicates that a potassium-rich diet can help achieve healthy blood pressure levels, and that potassium supplements can lower systolic blood pressure by 1.8 m Hg and diastolic blood pressure by 1 mm Hg. In fact, there is some evidence that a potassium-rich diet can reduce the risk of stroke by 22 - 40%. Current guidelines support the use of potassium supplements or enough dietary potassium to achieve 3,500 mg per day for people with normal or high blood pressure (who have no risk factors for excess potassium levels). This goal is particularly important in people who have high sodium intake. The best source of potassium is from the fruits and vegetables that contain them. Potassium-rich foods include bananas, oranges, pears, prunes, cantaloupes, tomatoes, dried peas and beans, nuts, potatoes, and avocados.

However, patients with diabetic nephropathy (kidney disease) and kidney failure need to restrict dietary potassium, as well as phosphorus. Kidney problems can cause potassium overload and medications commonly used in diabetes, (such as ACE inhibitors or potassium-sparing diuretics), also limit the kidney's ability to excrete potassium. No one should take potassium supplements without consulting a doctor. The best source of potassium is from the fruits and vegetables that contain them.

Magnesium. Magnesium deficiency may have some role in insulin resistance and high blood pressure. Research indicates that magnesium-rich diets may help lower type 2 diabetes risk. Whole grain breads and cereals, nuts (almonds, cashews, soybeans), and certain fruits and vegetables (spinach, avocados, beans) are excellent dietary sources of magnesium. Dietary supplements do not provide any benefit. Persons who live in soft water areas, who use diuretics, or who have other risk factors for magnesium deficiency may require more dietary magnesium than others.

Chromium. Some studies have reported an association between deficiencies in the mineral chromium and a higher risk for type 2 diabetes. Studies on fat rats that were given chromium reported improvement in insulin sensitivity and glucose metabolism. Most studies on type 2 patients, however, reported little or no effect on glucose metabolism and some even reported adverse side effects.

Selenium. Selenium, a trace mineral, does not reduce diabetes risk. In fact, it may increase it. In a 2007 study, researchers found that people who took selenium supplements had more than 1.5 times the risk of developing type 2 diabetes as those who did not take the supplements. The higher the blood level of selenium, the greater the risk. An average healthy diet supplies adequate amounts of selenium and there is no need to take dietary supplements.

Zinc. Many patients with type 2 diabetes are also deficient in zinc; more studies are needed to establish the benefits or risks of taking supplements. Zinc has some toxic side effects, and some studies have associated high zinc intake with prostate cancer.

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. Patients should always check with their doctors before using any herbal remedies or dietary supplements.

Traditional herbal remedies for diabetes include bitter melon, fenugreek, and Gymnema sylvestre. These herbs may have properties that help lower blood sugar. However, there have been few well-designed studies and there is not enough evidence to recommend them for prevention or treatment of diabetes.

Several recent preliminary studies suggest that cinnamon may help improve blood sugar and lipid levels. One small study found beneficial effects for people with type 2 diabetes who took between 1 - 6 grams (equivalent to 0.25 - 1.25 teaspoons) of cinnamon each day.

Various fraudulent products are often sold on the Internet as “cures” or treatments for diabetes. These dietary supplements have not been studied or approved. In 2006, the FDA and Federal Trade Commission (FTC) launched a crackdown on these scams. The FDA and FTC warn patients with diabetes not to be duped by bogus and unproven remedies.

Water. Many heart risk factors, especially those associated with blood clotting, are elevated with dehydration. In one study, drinking five or more glasses of water a day was significantly associated with a lower risk for fatal heart events than drinking two or fewer glasses a day.

Alcohol. A number of studies have found that light to moderate intake of alcohol may provide protection from heart disease and type 2 diabetes. Some research suggests that alcohol has anti-inflammatory properties that protect arteries from injury. Red wine in particular may have specific benefits for people with type 2 diabetes. It has strong antioxidant effects that benefit the heart. Some evidence also suggests that red wine may improve insulin sensitivity and reduce blood glucose levels and may even protect against type 2 diabetes. The American Diabetes Association recommends limiting alcoholic beverages to 1 drink per day for non-pregnant adult women and 2 drinks per day for adult men.

Tea. Although it contains caffeine, tea, both black and green, is often cited for its health benefits. Green tea is especially is rich in chemicals that offer protection against damaging forms of LDL. In one study, for example, higher intake, particularly by women, was associated with a lower risk for severe coronary artery disease. Black tea has also been associated with heart health. In one study oolong tea, a partially fermented tea, was specifically associated with lower blood sugar levels in patients with type 2 diabetes.

Coffee. Many studies have noted an association between coffee consumption and reduced risk for developing type 2 diabetes. A 2006 study of 29,000 postmenopausal women confirmed this reduced risk. Compared to non-coffee drinkers, women who drank at least 6 cups a day of coffee (either regular or decaf) were 22% less likely to develop type 2 diabetes. Decaffeinated coffee was even more beneficial -- women who drank at least 6 cups a day of decaf were 33% less likely to develop diabetes than women who did not drink coffee. Researchers are still not certain how coffee protects against diabetes. Neither the caffeine in coffee nor the mineral magnesium have a preventive effect. It may be that coffee contains antioxidant properties that protect the pancreas’ insulin-producing cells.

Weight Control for Type 2 Diabetes

The American Diabetes Association recommends that patients aim for a small but consistent weight loss of ½ - 1 pound per week. Most patients should follow a diet that supplies at least 1,000 - 1,200 kcal/day for women and 1,200 - 1,600 kcal/day for men.

Even modest weight loss can reduce the risk factors for heart disease and diabetes. There are many approaches to dieting and many claims for great success with various fad diets. They include calorie restriction, low-fat/high-fiber, or high protein and fat/low carbohydrates. Some evidence suggests that people may respond differently to specific diets depending on whether their weight is overly distributed around the abdomen.

Lifelong changes in eating habits, physical activity, and attitudes about food and weight are essential to weight management. Unfortunately, although many people can lose weight initially, it is very difficult to maintain weight loss. People with type 2 diabetes may have a particularly difficult time. Here are some general suggestions that may be helpful:

Start with realistic goals. When overweight people achieve even modest weight loss they reduce risk factors in the heart. Ideally, overweight patients should strive for 7% weight loss or better, particularly people with type 2 diabetes.
A regular exercise program is essential for maintaining weight loss. If there are no health prohibitions, choose one that is enjoyable. Check with a doctor about any health consideration. [See In-Depth Report #29: Exercise.]
Hunger pangs should not be taken as cues to eat. A stomach that has been stretched by large meals will continue to signal hunger for large amounts of food until its size reduces over time with smaller meals.
Be honest about how much you eat, and track calories carefully. Studies on weight control that depend on self-reporting of food intake frequently reveal that subjects badly misjudge how much they eat (typically underestimating high-calorie foods and overestimating low-calorie foods). In one study, even dietitians underreported their calorie intake by 10%. People who do not carefully note everything they eat tend to take in excessive calories when they believe they are dieting.
For patients who cannot lose weight with diet alone, effective weight-loss medications are now available, including orlistat (Xenical) and sibutramine (Meridia). Orlistat may have particular benefits for patients with type 2 diabetes. This drug may delay or even prevent the onset or progression of diabetes. It may also improve cholesterol levels, regardless of weight loss. A non-prescription form of orlistat, Alli, is now available. Sibutramine is also helpful in weight loss but should not be used by patients with high blood pressure or kidney or liver problems.
Once a person has lost weight, maintenance is required. To maintain a healthy weight, make careful decisions about how many calories you consume in food and how many calories you expend through physical activity. Such thinking will eventually become automatic.
A procedure known as bariatric surgery has been very helpful in producing rapid weight loss and improving insulin and glucose levels in people with diabetes.

Even repeated weight loss failure is no reason to give up. [See In-Depth Report #53: Weight control and diet.]

Calorie restriction has been the cornerstone of obesity treatment. Restricting calories in such cases also appears to have beneficial effects on cholesterol levels, including reducing LDL and triglycerides and increasing HDL levels.

The standard dietary recommendations for losing weight are:

As a rough rule of thumb, 1 pound of fat equals about 3,500 calories, so one could lose a pound a week by reducing daily caloric intake by about 500 calories a day. Naturally, the more severe the daily calorie restriction, the faster the weight loss. Very-low calorie diets have also been associated with better success, but extreme diets can have some serious health consequences.
To determine the daily calorie requirements for specific individuals, multiply the number of pounds of ideal weight by 12 - 15 calories. The number of calories per pound depends on gender, age, and activity levels. For instance a 50-year-old moderately active woman who wants to maintain a weight of 135 pounds and is mildly active might need only 12 calories per pound (1,620 calories a day). A 25-year old female athlete who wants to maintain the same weight might need 25 calories per pound (2,025 calories a day).
Fat intake should be no more than 30% of total calories. Most fats should be in the form of monounsaturated fats (such as olive oil). Avoid saturated fats (found in animal products).

Heart-Healthy Diets

In 2006, the American Heart Association (AHA) issued revised diet and lifestyle recommendations. The current guidelines recommend:

Balance calorie intake and physical activity to achieve or maintain a healthy body weight. (Controlling weight, quitting smoking, and exercising regularly are essential companions of any diet program. Try to get at least 30 minutes, and preferably 60 - 90 minutes, of daily exercise.)
Consume a diet rich in a variety of vegetables and fruits. Vegetables and fruits that are deeply colored (spinach, carrots, peaches, berries) are especially recommended as they have the highest micronutrient content.
Choose whole-grain, high-fiber foods. These include fruits, vegetables, and legumes (beans). Good whole grain choices include whole wheat, oats/oatmeal, rye, barley, brown rice, buckwheat, bulgur, millet, and quinoa.
Consume fish, especially oily fish, at least twice a week (about 8 ounces/week). Oily fish -- such as salmon, mackerel, and sardines -- are rich in the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Consumption of these fatty acids is linked to reduced risk of sudden death and death from coronary artery disease.
Limit daily intake of saturated fat (found mostly in animal products) to less than 7% of total calories, trans fat (found in hydrogenated fats, commercially baked products, and many fast foods) to less than 1% of total calories, and cholesterol (found in eggs, dairy products, meat, poultry, fish, shellfish) to less than 300 mg per day. Choose lean meats and vegetable alternatives (such as soy). Select fat-free and low-fat dairy products. Grill, bake, or broil fish, meat, and skinless poultry.
Use little or no salt in your foods. Reducing salt can lower blood pressure and decrease the risk of heart disease and heart failure.
Limit beverages and foods that contain added sugars (corn syrups, sucrose, glucose, fructose, maltrose, dextrose, concentrated fruit juice, honey).
If you consume alcohol, do so in moderation. The AHA recommends limiting alcohol to no more than 2 drinks per day for men and 1 drink per day for women.

[See In-Depth Report #43: Heart-healthy diet.]

Dietary guidelines from the National Cholesterol Education Program recommend:

Choose five or more servings of fresh fruits and vegetables and six or more servings of whole grains and legumes. Soluble fiber is preferred (from cereal grains, beans, peas, legumes, and many fruits and vegetables).
Fats can be up to 35% of daily calories, but no more than 7% should be from saturated fat. (People with high triglycerides or low HDL or both may need a higher fat intake.) Choose fats containing unsaturated fatty acids (from vegetables, fish, legumes, and nuts). Choose margarines containing sterols or stanols (such as Benecol or Take Control). Avoid trans fatty acids found in commercial products.
Protein choices should be fat-free and low-fat milk products, fish, legumes, skinless poultry, and lean meats.
Limit cholesterol intake to less than 200 mg per day.
Maintain healthy body weight and a healthy level of physical fitness.

There are several variations to the Mediterranean diet, but general recommendations include:

Limit red meats.
Drink one or two glasses of wine each day if alcohol is enjoyable and there are no reasons to restrict its use.
Limit dairy products.
Eat moderate amounts of fish and poultry. Fish is the diet's main protein source. Some studies suggest that fish is the primary heart-protective ingredient in this diet.
Eat plenty of fresh fruits and vegetables, nuts, legumes, beans, and whole grains.
Season foods with garlic, onions, and herbs.
Use virgin olive oil.

Low-carb diets, such as South Beach, The Zone, and Sugar Busters, rely on a concept called the "glycemic index (GI)," which ranks foods by how fast and how high they cause blood sugar levels to rise. Foods on the lowest end of the index take longer to digest. Slow digestion wards off hunger pains. It also helps stabilize insulin levels. Foods high on the glycemic index include white bread, white potatoes, and pasta while low-glycemic foods include whole grains, fruit, lentils, and soybeans.

A 2006 study indicated that a high-protein, low-glycemic index diet can help produce better reductions in total and LDL cholesterol than a high-protein, high-glycemic index diet. Reducing glycemic load may also help to promote weight loss, especially for women. However, another 2006 study suggested that low-glycemic index diets that are high in carbohydrates can also promote weight loss and reduce body fat.

A 2006 review of low-carbohydrate diets found that they did help weight loss in the short term. However, while these diets appeared to lower triglyceride levels and raise HDL (“good”) cholesterol levels, they also raised overall and LDL (“bad”) cholesterol levels. A 2007 Journal of the American Medical Association study that compared four different diet plans (Atkins, Zone, Ornish, and LEARN) found that the Atkins diet helped raise HDL levels, and reduce triglyciderides, but had no effect on LDL levels nor insulin or glucose measurements. Women who followed the Atkins diet also had improved blood pressure compared to patients on the other diets. The Atkins diet resulted in slightly better weight loss (an average of 10 pounds over the course of a year versus 4 - 6 pounds for the other diet plans), which in itself may have accounted for the improved heart risk factors. Some experts think that the main finding from this study is that even a moderate weight loss can help improve heart health.

Although low-carbohydrate diets may produce good short-term weight loss, they do not appear to help patients maintain weight loss in the long term. The American Diabetes Association does not recommend low-carb diets (less than 130 g of carbohydrates per day) for treatment of overweight and obesity.

Dietary guidelines recommend keeping total fat intake to 25 - 35% of total daily calories, with saturated fat less than 7% of calories. Low-fat diets generally restrict fat intake to 20% or less of total daily calories. The Ornish program, which is recommended for some heart disease patients, limits fats even more drastically. It aims at reducing saturated fats as much as possible, restricting total fat to 10%, and increasing carbohydrates to 75% of calories.

In 2006, the largest study to date on low-fat diets found that they did not help prevent heart disease or cancer. Women in the study reduced their fat consumption to 24 - 29% of total daily calories. Some critics say that the study did not do enough to distinguish between good types of fats (monounsaturated and omega-3 polyunsaturated) and bad fats (saturated and trans fats).

Another 2006 study indicated that low-fat, vegan diets may help improve glycemic control and increase insulin sensitivity. The higher fiber content of these diets, plus lower intake of total and saturated fat, may account for some of these benefits. A vegan diet eliminates all meat and dairy products.

The DASH diet (Dietary Approaches to Stop Hypertension) is proven to help lower blood pressure. Results are sometimes seen within a few weeks. Restricting sodium improves results. The diet appears to have antioxidant effects and may help lower LDL cholesterol levels, although beneficial HDL levels also decline. This diet is not only rich in important nutrients and fiber but also includes foods that contain far more electrolytes, potassium (4,700 mg/day), calcium (1,250 mg/day), and magnesium (500 mg/day) than are found in the average American diet.

The DASH diet recommends:

Limit salt intake to no more than 2,300 mg a day (a maximum intake of 1,500 mg a day is an even better goal).
Reduce saturated fat to no more than 6% of daily calories and total fat to 27% of daily calories. (But, include dairy products that are non- or low-fat. Low-fat dairy products appear to be especially beneficial for lowering systolic blood pressure.)
When choosing fats, select monounsaturated oils, such as olive or canola oils.
Choose whole grains over white flour or pasta products.
Choose fresh fruits and vegetables every day. In one study people who increased their intake of fruits and vegetables experienced a drop in blood pressure after 6 months. Many of these foods are rich in potassium, fiber, or both, which may help lower blood pressure.
Include nuts, seeds, or legumes (dried beans or peas) daily.
Choose modest amounts of protein (no more than 18% of total daily calories). Fish, skinless poultry, and soy products are the best protein sources.
Other daily nutrient goals in the DASH diet include limiting carbohydrates to 55% of daily calories and dietary cholesterol to 150 mg. Patients should try to get at least 30 g of daily fiber.

Slight changes to the DASH diet might help lower blood pressure even more, as well as improve cholesterol and lipid levels. Researchers reporting in the Journal of the American Medical Association and at the 2005 American Heart Association meeting said that replacing some carbohydrates in the DASH diet with more protein or monounsaturated fats may help reduce heart disease risk factors. [See In-Depth Report #14: High blood pressure.]

Diabetic Exchange Lists

The objective of using diabetic exchange lists is to maintain the proper balance of carbohydrates, proteins, and fats throughout the day. Patients should meet with a dietician or diabetes nutrition expert for help in learning this approach.

In developing a menu, patients must first establish their individual dietary requirements, particularly the optimal number of daily calories and the proportion of carbohydrates, fats, and protein. The exchange lists should then be used to set up menus for each day that fulfill these requirements.

The following are some general rules:

The diabetic exchanges are six different lists of foods grouped according to similar calorie, carbohydrate, protein, and fat content; these are starch/bread, meat, vegetables, fruit, milk, and fat. A person is allowed a certain number of exchange choices from each food list per day.
The amount and type of these exchanges are based on a number of factors, including the daily exercise program, timing of insulin injections, and whether or not an individual needs to lose weight or reduce cholesterol or blood pressure levels.
Foods can be substituted for each other within an exchange list but not between lists even if they have the same calorie count.
In all lists (except in the fruit list) choices can be doubled or tripled to supply a serving of certain foods. (For example 3 starch choices equal 1.5 cups of hot cereal or 3 meat choices equal a 3-ounce hamburger.)
On the exchange lists, some foods are "free." These contain less than 20 calories per serving and can be eaten in any amount spread throughout the day unless a serving size is specified.

The following are the categories on exchange lists:

Starches and Bread. Each exchange under starches and bread contains about 15 grams of carbohydrates, 3 grams of protein, and a trace of fat for a total of 80 calories. A general rule is that a half-cup of cooked cereal, grain, or pasta equals one exchange. One ounce of a bread product is 1 serving.

Meat and Cheese. The exchange groups for meat and cheese are categorized by lean meat and low-fat substitutes, medium-fat meat and substitutes, and high-fat meat and substitutes. Use high-fat exchanges a maximum of 3 times a week. Fat should be removed before cooking. Exchange sizes on the meat list are generally 1 ounce and based on cooked meats (3 ounces of cooked meat equals 4 ounces of raw meat).

Vegetables. Exchanges for vegetables are 1/2 cup cooked, 1 cup raw, and 1/2 cup juice. Each group contains 5 grams of carbohydrates, 2 grams of protein, and 2 - 3 grams of fiber. Vegetables can be fresh or frozen; canned vegetables are less desirable because they are often high in sodium. They should be steamed or cooked in a microwave without added fat.

Fruits and Sugar. Sugars are included within the total carbohydrate count in the exchange lists. Sugars should not be more than 10% of daily carbohydrates. Each exchange contains about 15 grams of carbohydrates for a total of 60 calories.

Milk and Substitutes. The milk and substitutes list is categorized by fat content similar to the meat list. A milk exchange is usually 1 cup or 8 ounces. Those who are on weight-loss or low-cholesterol diets shoudl follow the skim and very low-fat milk lists -- while avoiding the whole milk group. Others should use the whole milk list very sparingly. All people with diabetes should avoid artificially sweetened milks.

Fats. A fat exchange is usually 1 teaspoon, but it may vary. People, of course, should avoid saturated and trans fatty acids and choose polyunsaturated or monounsaturated fats instead.


Calories	1,200	1,500	1,800	2,000	2,200
Starch/Bread	5	8	10	11	13
Meat	4	5	7	8	8
Vegetable	2	3	3	4	4
Fruit	3	3	3	3	3
Milk	2	2	2	2	2
Fat	3	3	3	4	5

Exercise

Sedentary habits, especially watching TV, are associated with significantly higher risks for obesity and type 2 diabetes. Regular exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity and may play a significant role in preventing type 2 diabetes -- regardless of weight loss. An important study reported a 58% lower risk for type 2 diabetes in adults who performed moderate exercise for as little as 2.5 hours a week.

Aerobic Exercises. Aerobic exercise has significant and particular benefits for people with diabetes. Regular aerobic exercise, even of moderate intensity, improves insulin sensitivity. People with diabetes are at particular risk for heart disease, so the heart-protective effects of aerobic exercise are especially important. Moderate exercise protects the heart in people with type 2 diabetes, even if they have no risk factors for heart disease other than diabetes itself. (In general, patients with diabetes should aim for a heart rate target of 55 - 85% of their maximum heart rate when exercising.)

Strength Training. Strength training, which increases muscle and reduces fat, may also be helpful for people with diabetes.

Some Precautions for People with Diabetes Who Exercise. The following are precautions for all people with diabetes, both type 1 and type 2:

Because people with diabetes are at higher than average risk for heart disease, they should always check with their doctors before undertaking vigorous exercise. For fastest results, frequent high-intensity (not high-impact) exercises are best for people who are cleared by their doctors. For people who have been sedentary or have other medical problems, lower-intensity exercises are recommended.
Strenuous strength training or high-impact exercise is not recommended for people with uncontrolled diabetes. Such exercises can strain weakened blood vessels in the eyes of patients with retinopathy. High-impact exercise may also injure blood vessels in the feet.

Patients who are taking medications that lower blood glucose, particularly insulin, should take special precautions before embarking on a workout program:

Monitor glucose levels before, during, and after workouts (glucose levels swing dramatically during exercise).
Avoid exercise if glucose levels are above 300 mg/dl or under 100 mg/dl.
Inject insulin in sites away from the muscles used during exercise; this can help avoid hypoglycemia.
Drink plenty of fluids before and during exercise; avoid alcohol, which increases the risk of hypoglycemia.
Insulin-dependent athletes may need to decrease insulin doses or take in more carbohydrates prior to exercise, but may need to take an extra dose of insulin after exercise (stress hormones released during exercise may increase blood glucose levels).
Wear good, protective footwear to help avoid injuries and wounds to the feet.

Some blood pressure drugs can interfere with exercise capacity. Patients who use blood pressure medication should consult their doctors on how to balance medications and exercise. Patients with high blood pressure should also aim to breathe as normally as possible during exercise. Holding the breath can increase blood pressure. [See In-Depth Report #29: Exercise.]

Chronic stress has been associated with the development of insulin resistance, a primary factor in diabetes. Stress can also worsen existing diabetes by impairing the patient's ability to manage the disease effectively. Stress-relieving techniques include meditation, biofeedback, relaxation response, and yoga. One study reported that yoga helped patients with type 2 diabetes reduce their need for oral medications. Studies have also indicated that yoga and Tai Chi (an ancient Chinese exercise involving slow relaxing movements) may lower blood pressure almost as well as moderate-intensity aerobic exercises. [See In-Depth Report #31: Stress.]

Resources

www.diabetes.org -- American Diabetes Association
www.niddk.nih.gov -- National Institute of Diabetes and Digestive and Kidney Diseases
www.jdrf.org -- Juvenile Diabetes Research Foundation
www.kidney.org -- National Kidney Foundation
www.joslin.org -- Joslin Diabetes Center
www.eatright.org -- American Dietetic Association
www.nal.usda.gov/fnic -- Food and Nutrition Information Center
www.gourmetconnection.com/diabetic -- Diabetic Gourmet Magazine

References

American Diabetes Association. Nutrition recommendations and interventions for diabetes: A position statement of the American Diabetes Association. Diabetes Care. 2007 Jan;30 Suppl 1:S48-65.

American Heart Association Nutrition Committee; Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation. 2006 Jul 4;114(1):82-96. Epub 2006 Jun 19.

Barnard ND, Cohen J, Jenkins DJ, Turner-McGrievy G, Gloede L, Jaster B, et al. A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a randomized clinical trial in individuals with type 2 diabetes. Diabetes Care. 2006 Aug;29(:1777-83.

Gardner CD, Kiazand A, Alhassan S, Kim S, Stafford RS, Balise RR, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA. 2007 Mar 7;297(9):969-77.

Gillies CL, Abrams KR, Lambert PC, Cooper NJ, Sutton AJ, Hsu RT, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ. 2007 Feb 10;334(7588):299. Epub 2007 Jan 19.

Halton TL, Willett WC, Liu S, Manson JE, Albert CM, Rexrode K, et al. Low-carbohydrate-diet score and the risk of coronary heart disease in women. N Engl J Med. 2006 Nov 9;355(19):1991-2002.

Lindstrom J, Ilanne-Parikka P, Peltonen M, Aunola S, Eriksson JG, Hemio K, et al. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet. 2006 Nov 11;368(9548):1673-9.

Liu S, Choi HK, Ford E, Song Y, Klevak A, Buring JE, et al. A prospective study of dairy intake and the risk of type 2 diabetes in women. Diabetes Care. 2006 Jul;29(7):1579-84.

McMillan-Price J, Petocz P, Atkinson F, O'Neill K, Samman S, Steinbeck K, et al. Comparison of 4 diets of varying glycemic load on weight loss and cardiovascular risk reduction in overweight and obese young adults: a randomized controlled trial. Arch Intern Med. 2006 Jul 24;166(14):1466-75.

Schulze MB, Schulz M, Heidemann C, Schienkiewitz A, Hoffmann K, Boeing H. Fiber and magnesium intake and incidence of type 2 diabetes: a prospective study and meta-analysis. Arch Intern Med. 2007 May 14;167(9):956-65.

Stranges S, Marshall JR, Natarajan R, Donahue RP, Trevisan M, Combs GF, et al. Effects of long-term selenium supplementation on the incidence of type 2 diabetes: a randomized trial. Ann Intern Med. 2007 Jul 9; [Epub ahead of print]

Ting RZ, Szeto CC, Chan MH, Ma KK, Chow KM. Risk factors of vitamin B(12) deficiency in patients receiving metformin. Arch Intern Med. 2006 Oct 9;166(18):1975-9.

Ziegler D, Ametov A, Barinov A, Dyck PJ, Gurieva I, Low PA, et al. Oral treatment with alpha-lipoic acid improves symptomatic diabetic polyneuropathy: the SYDNEY 2 trial. Diabetes Care. 2006 Nov;29(11):2365-70.

Review Date:
7/20/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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adam.com

Heart-healthy diet

FitSugar — Wed, 08 Oct 2008 17:35:07 -0700

In This Report

Highlights
Introduction
Dietary Changes
Lifestyle Changes
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

General Dietary Guidelines

In 2006, the American Heart Association (AHA) revised its dietary and lifestyle recommendations. The new guidelines specifically recommend limiting daily saturated fat intake to less than 7% and trans fats to less than 1% of total daily calories.
The AHA recommends consuming plenty of deep-colored vegetables and fruits, eating oily fish at least twice a week, and including whole grains in your daily diet.

Fish

Women with existing heart disease may consider taking fish oil supplements, suggests 2007 AHA guidelines. Women should include a variety of low-mercury fish in their diet. Women who are of childbearing age or nursing should avoid high-mercury fish (such as swordfish) and limit tuna consumption to no more than 6 ounces a week.
The benefits of fish outweigh its risks, according to a 2006 Journal of the American Medical Association (JAMA) study. The researchers found that eating fish 1 – 2 times a week may help reduce the risk of heart-related death by 36%.

Diet Plans

Low-carbohydrate diets do not increase heart disease risks for women, indicates a 2006 New England Journal of Medicine study. A 2007 JAMA study found that people lost somewhat more weight on the Atkins diet compared with three other popular diet plans. The Atkins diet also helped raise HDL (“good”) cholesterol levels, reduce triglycerides, and improve blood pressure. Some experts think that the weight loss may have been the main factor for the heart benefits.
However, according to a 2006 study in the Archives of Internal Medicine, diets that are high in carbohydrates but low on the glycemic index may also help promote weight loss, reduce body fat, and improve heart disease risk factors.
The Mediterranean diet is better than a low-fat diet in quickly lowering blood pressure, cholesterol levels, and blood sugar levels, according to a 2006 Annals of Internal Medicine study.

Introduction

Heart-Healthy Goals. The goals of a heart-healthy diet are to eat foods that help obtain or maintain healthy levels of cholesterol and fatty molecules called lipids. You can achieve this by:

Reducing overall cholesterol levels and low-density lipoproteins (LDL), which are harmful to the heart
Increasing high-density lipoproteins (HDL), which are beneficial for the heart
Reducing other harmful lipids (fatty molecules), such as triglycerides and lipoprotein(a)

Any diet should also help keep blood pressure and weight under control.

General Recommendations

In 2006, the American Heart Association (AHA) issued revised diet and lifestyle recommendations. The current guidelines recommend:

Balance calorie intake and physical activity to achieve or maintain a healthy body weight. (Controlling weight, quitting smoking, and exercising regularly are essential companions of any diet program. Try to get at least 30 minutes, and preferably 60 – 90 minutes, of daily exercise.)
Consume a diet rich in a variety of vegetables and fruits. Vegetables and fruits that are deeply colored (spinach, carrots, peaches, berries) are especially recommended as they have the highest micronutrient content.
Choose whole-grain, high-fiber foods. These include fruits, vegetables, and legumes (beans). Good whole grain choices include whole wheat, oats/oatmeal, rye, barley, brown rice, buckwheat, bulgur, millet, and quinoa.
Consume fish, especially oily fish, at least twice a week (about 8 ounces/week). Oily fish such as salmon, mackerel, and sardines are rich in the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Consumption of these fatty acids is linked to reduced risk of sudden death and death from coronary artery disease.
Limit daily intake of saturated fat (found mostly in animal products) to less than 7% of total calories, trans fat (found in hydrogenated fats, commercially baked products, and many fast foods) to less than 1% of total calories, and cholesterol (found in eggs, dairy products, meat, poultry, fish, shellfish) to less than 300 mg per day. Choose lean meats and vegetable alternatives (such as soy). Select fat-free and low-fat dairy products. Grill, bake, or broil fish, meat, and skinless poultry.
Use little or no salt in your foods. Reducing salt can lower blood pressure and decrease the risk of heart disease and heart failure.
Cut down on beverages and foods that contain added sugars (corn syrups, sucrose, glucose, fructose, maltrose, dextrose, concentrated fruit juice, honey).
If you consume alcohol, do so in moderation. The AHA recommends limiting alcohol to no more than 2 drinks per day for men and 1 drink per day for women.

Women

The AHA guidelines for women are similar to the general dietary recommendations. However, the AHA suggests that women with existing heart disease consider taking omega-3 fatty acid supplements (850 - 1,000 mg/day of EPA and DHA). For women with high triglyceride levels, higher doses (2 - 4 g/day) may be appropriate. The AHA recommends against women taking antioxidant vitamin supplements (C, E, beta-carotene) or folic acid supplements for prevention of heart disease.

In addition, women who are pregnant or breast-feeding should avoid eating fish that is high in mercury content (shark, swordfish, mackerel, and tile fish). Choose fish and shellfish that are lower in mercury content and eat about 12 ounces/week. (The AHA recommends a higher weekly fish amount for women than for men. However, women of childbearing age should limit tuna to 6 ounces a week to reduce the risks for mercury contamination.)

Children

Atherosclerosis, the build-up of plaque in the arteries, begins in childhood. Experts stress the importance of heart-healthy dietary guidelines for children and adolescents to help prevent the development of heart disease later in life. Children should eat foods that are low in saturated fat, trans fat, and cholesterol. These foods include:

Fruits and vegetables
Whole grains
Low-fat and nonfat dairy products
Beans, fish, and lean meats

Cholesterol is a soft, waxy substance that is present in parts of the body including the nervous system, skin, muscle, liver, intestines, and heart. It is made by the body and obtained from animal products in the diet. Cholesterol is manufactured in the liver and is needed for normal body functions, including the production of hormones, bile acid, and vitamin D. Excessive cholesterol in the blood contributes to atherosclerosis and subsequent heart disease. The risk of developing heart disease or atherosclerosis increases as the level of blood cholesterol increases.

[See In-Depth Report #23: Cholesterol; Report #3: Coronary artery disease and angina; Report #14: High blood pressure; Report #53: Weight control and diet.]

All fats, good or bad, are high in calories compared to proteins and carbohydrates. In order to calculate daily fat intake, multiply the number of fat grams eaten by nine (one fat gram is equal to 9 calories, whether it's oil or fat) and divide by the number of total daily calories desired. One teaspoon of oil, butter, or other fats equals about 5 grams of fat. All fats, no matter what source they are from, add the same calories. The American Heart Association recommends that fats and oils have less than 2 grams of saturated fat per tablespoon.

The Chemistry of Fats and Cholesterol.

Fatty Acids. All fats and oils found in foods are made up of chains of molecules called fatty acids. There are three major chains: saturated fatty acid (found mostly in animal products) and two unsaturated fatty acids -- monounsaturated and polyunsaturated fatty acids (found in plant products). The oils and fats that people and animals eat are nearly always mixtures of these three chains, but one type of fatty acid usually predominates in specific oils or fats.
Essential Fatty Acids. In addition, there are three chemical subgroups of polyunsaturated fatty acids called essential fatty acids: omega-3 and omega-6 polyunsaturated fatty acids, and omega-9 monounsaturated fatty acids.
Trans Fatty Acids. Trans fatty acids are manufactured by adding hydrogen atoms to polyunsaturated fatty acids (a process called hydrogenation). This process helps keep foods fresh, or may be performed to produce a solid fat product, such as margarine.

Harmful Fats. Reducing consumption of saturated fats and trans fatty acids is the first essential step in managing cholesterol levels through diet.

Saturated Fats. Saturated fats are found predominantly in animal products, including meat and dairy products. They are strongly associated with higher cholesterol levels, and they may be even more dangerous in women than in men. High-fat meals are associated with sudden surges in triglyceride levels and other lipids along with impaired blood flow in the arteries to the heart. (Tropical oils such as palm, coconut, and cocoa butter are also high in saturated fats.) The American Heart Association recommends limiting saturated fat consumption to less than 7% of total calories per day.

Click the icon to see an image of saturated fats.

Trans Fatty Acids. Trans fatty acids are manufactured fats created during a process called hydrogenation, which is aimed at stabilizing polyunsaturated oils to prevent them from becoming rancid and to keep them solid at room temperature. They are particularly dangerous for the heart and may pose a risk for certain cancers. These partially hydrogenated fats are even worse than saturated fats. Studies report that high consumption of these fats reduces HDL cholesterol levels, has harmful effects on the linings of the arteries, and may increase the risk for type 2 diabetes. Hydrogenated fats are used in stick margarine and in many fast foods and baked goods, including most commercially produced white breads. (Liquid margarine is not hydrogenated and is recommended.) The FDA ordered that food labels list the amount of trans fatty acids in food products beginning in January 2006. The American Heart Association recommends limiting daily consumption of trans fats to less than 1% of total daily calories.

Click the icon to see an image of trans fatty acids.

Polyunsaturated fats are found in safflower, sunflower, corn, and cottonseed oils and fish.
Monounsaturated fats are mostly present in olive, canola, and peanut oils and in most nuts. (Canola is the least saturated of all the fats.) Studies report that replacing carbohydrates with monounsaturated fats improves glucose control after meals and reduces triglycerides in people with type 2 diabetes. Oils are more calorie-dense, however, and such patients should be wary of weight gain.

Researchers are most interested in the smaller fatty-acid building blocks contained in both oils, which may have more specific effects on lipids. Three important fatty acids are the essential fatty acids omega-3, omega-6, and omega-9.

Omega-3 fatty acids are found in fish oil (docosahexaenoic and eicosapentaneoic acids) and plants (alpha-linolenic acid).

Click the icon to see an image of omega-3 fatty acids.

Docosahexaenoic (DHA) and Eicosapentaneoic (EPA) Acids. DHA and EPA are found in fish oils, and evidence suggests that they have significant benefits for the heart, including reducing sudden death from heart disease, inflammation, blood clotting factors, blood pressure, and improving triglyceride and HDL levels. Results from a study presented at the 2005 meeting of the American Heart Association suggested that daily EPA supplements plus statin therapy can protect against heart attack, angina, and coronary artery disease. However, although fish and fish oil are good for the heart, patients who have an implantable defibrillator should not take fish oil supplements. A 2005 study suggested that these supplements may make heart rhythm problems worse in some patients.
Alpha-linolenic Acid. Alpha-linolenic acid is a plant precursor of DHA, which means the body can convert it to DHA. Sources include canola oil, soybeans, flaxseed, and certain nuts and seeds (walnut, flax, chia, and sometimes pumpkin seed). Some, but not all, studies suggest that oils or foods containing alpha-linolenic acid may also be heart-protective. Supplements or foods containing alpha-linolenic acid may also protest the heart. For example studies have reported heart protection from flaxseed supplements and also from nuts, such as almonds, macadamia, and walnuts. Nuts are high in calories, however.

Click the icon to see an image of different types of weight gain.

Omega-9 monounsaturated fatty acids are contained in canola and olive oil, which help protect the heart.

Fat Substitutes. Fat substitutes added to commercial foods or used in baking, deliver some of the desirable qualities of fat, but do not add as many calories.

Plants substances known as sterols, and their derivatives called stanols, reduce cholesterol by blocking its absorption in the intestinal tract. Margarines containing sterols (Benecol, Take Control) are available. Benecol is derived from pine bark and Take Control from soybeans. Two servings a day of either brand as part of a low-fat diet can lower LDL and total cholesterol. In one study, consuming a sterol-based margarine doubled the LDL-lowering effects of a statin (a common cholesterol-lowering drug) compared to a standard margarine. These products do not appear to block absorption of fat-soluble nutrients or vitamins, as olestra does. They may be hydrogenated and include some trans fatty acids, however.
Olestra (Olean) passes through the body without leaving behind any calories from fat. Studies suggest that it helps improve cholesterol levels and may help overweight people lose weight. Early reports of cramps and diarrhea after eating food containing olestra have not proven to be significant. Of greater concern is the fact that even small amounts of olestra deplete the body of certain vitamins and nutrients that may help protect against serious diseases, including cancer. The FDA requires that the missing vitamins be added back to olestra products, but not other nutrients.
Beta-glucan is a soluble fiber found in oats and barley. Products using this substance (Nu-Trim) may reduce cholesterol and have additional health benefits.

A number of other fat-replacers are also available. Although studies to date have not shown any significant adverse health effects, their effect on weight control is uncertain, since many of the products containing them may be high in sugar. One study suggested that people who consume foods that contain fat substitutes do not learn to dislike fatty foods, while people who learn to cook using foods naturally lacking or low in fat eventually lose their taste for high-fat diets.

Click the icon to see an image of foods that contain cholesterol.

Carbohydrates are either complex (as in starches) or simple (as in fruits and sugars). One gram of carbohydrates equals four calories. The current general recommendation is that carbohydrates should provide between 50 - 60% of the daily caloric intake. Many studies report that people can protect their heart and circulation by eating plenty of fruits and vegetables.

Complex Carbohydrates. Complex carbohydrates found in whole grains and vegetables are preferred over those found in starch-heavy foods, such as pastas, white-flour products, and potatoes. Most complex carbohydrates are high in fiber, which is important for health. Whole grains specifically are extremely important for people with diabetes or at risk for it.

Click the icon to see an image of complex carbohydrates.

Simple Carbohydrates (Sugar). Experts recommend that no more than 10% of daily calories should come from sugar. (Currently, Americans eat nearly half a pound of sugar a day on average, and sugar intake constitutes 25% of a day's calories.) Sugars are usually one of two types:

Click the icon to see an image of simple carbohydrates.

Sucrose. Source of most dietary sugar, found in sugar cane, honey, and corn syrup.
Fructose. Found in fruits and vegetables. Although fructose does not appear to be have any different effects in the body than sucrose, most of the fruits and vegetables that contain it are vital for good health.

High levels of sugar consumption -- whether fructose or sucrose -- have been associated with higher triglycerides and lower levels of HDL cholesterol, the so-called good cholesterol. The high consumption of sugar is most likely one of the factors in the current obesity epidemic. Soda, other sweetened beverages, and fruit juice are major contributors to childhood obesity.

Fiber is an important component of many complex carbohydrates. It is almost always found only in plants. (One exception is chitosan, a dietary fiber made from shellfish skeletons.) Fiber cannot be digested but passes through the intestines, drawing water with it, and is eliminated as part of feces content. High-fiber diets (up to 55 grams a day) can be very helpful. Different fiber types may have specific benefits:

Insoluble fiber (found in wheat bran, whole grains, seeds, nuts, legumes, and fruit and vegetable peels) may help achieve weight loss. Consuming whole grains on a regular basis may lower the risk for heart disease and heart failure, improve factors involved with diabetes, and lower the risk for type 2 diabetes. (Wheat bran taken as a supplement has not been associated with any benefits. The whole grain may be needed for good health.) High consumption of nuts (such as almonds, macadamia, and walnuts) may be highly heart protective, independent of their fiber content.
Soluble fiber (found in dried beans, oat bran, barley, apples, citrus fruits, and potatoes) may help achieve healthy cholesterol levels and possibly reduce blood pressure as well. For example, one study indicated that eating beans four or more times a week reduced the risk for heart disease by 22%. Oat bran has also been highly studied for its benefits on the heart.
Soluble fiber supplements, such as those that contain psyllium or glucomannan, may also be beneficial. Psyllium is taken from the husk of a seed grown in India and is very effective for lowering total and LDL cholesterol. It is found in laxatives (Metamucil), breakfast cereals (Bran Buds, Plantaben), and other products. However, some studies suggest that psyllium increases triglyceride levels in postmenopausal women. Sodium levels may also rise. People who increase intake of soluble fiber should also drink more water.

Click the icon to see an image of soluble and insoluble fiber.

In general, experts recommend that proteins should provide 12 - 20% of daily calories. One gram of protein contains four calories. Protein is important for strong muscles and bones and may have specific benefits on blood pressure. The best sources of protein are fish, poultry, and soy. Restrict intake of red meat or any meat that is not lean.

Fish. Fish is probably the best source of protein. Evidence suggests that eating moderate amounts of fish (twice a week) may improve triglyceride and HDL levels and help lower the risks for death from heart disease, dangerous heart rhythms, blood pressure, a tendency for blood clots, and the risk for stroke.

Click the icon to see an image of stroke.

The most healthy fish are oily fish, such as salmon, mackerel, or sardines, which are high in omega-3 fatty acids. A 2006 Journal of the American Medical Association (JAMA) study suggested that modest consumption of oily fish can reduce the risk of heart-related death by 36% and death from all causes by 17%. On average, three capsules of fish oil (preferably as supplements of DHA-EPA) is about equivalent to eating one serving of fish.

Most guidelines recommend eating fish at least twice a week. Doctors may recommend that people with existing heart disease or high triglyceride levels consume extra quantities or take DHA-EPA supplements.

Women of childbearing age or nursing mothers should avoid fish that contains high amounts of mercury (shark, swordfish, golden bass, king mackerel) and limit intake of tuna to 6 ounces/week. They should, however, try to eat at least 12 ounces/week of a variety of lower mercury-containing fish and shellfish (catfish, salmon, haddock, perch, tilapia, trout, crab, shrimp, scallops). According to the JAMA study, the benefits of fish intake (especially from low-mercury fish) outweigh the potential risks.

For many years, soy was promoted as a food that could help lower cholesterol and improve heart disease risk factors. But an important 2006 American Heart Association (AHA) review of studies found that soy protein and isoflavone supplement pills do not really have any effects on cholesterol or heart disease prevention. The AHA still encourages patients to include soy foods as part of an overall heart healthy diet but does not recommend using isoflavone supplements.

Meat and Poultry. For heart protection, choose lean meat. Saturated fat in meat is the primary danger to the heart. The fat content of meat varies depending on the type and cut. It is best to eat skinless chicken or turkey. However, the leanest cuts of pork (loin and tenderloin), veal, and beef are nearly comparable to chicken in calories and fat as well as their effect on LDL and HDL levels. However, even chicken and lean meat do not improve cholesterol levels and, in terms of heart health, fish is a more desirable choice.

Dairy Products. The best dairy choices are low-fat or fat-free products. A 2006 study indicated that consuming low-fat dairy products can help lower blood pressure. In the study, patients who ate the most low-fat dairy products had lower systolic blood pressure. A 2002 study also reported a lower incidence of factors related to type 2 diabetes and heart disease (insulin resistance, high blood pressure, obesity, and unhealthy cholesterol) with a high intake of dairy products. Some researchers suggest the calcium in dairy products may be partially responsible for these benefits. However, at least with high blood pressure, many studies indicate that the helpful effects of dairy products are not directly related to calcium.


Foods	Important Phytochemicals (Plant chemicals) Contained in the Foods	Vitamins and other valuable food components	Possible Benefits
Apples	Flavonoids	Fiber	May protect against certain cancers (lung), heart disease, asthma, and type 2 diabetes.
Avocados		Vitamin E, vitamin B6, folate	May be heart protective.
Beans	Flavonoids	Folate, iron, potassium and zinc, fiber	Some experts believe beans are the perfect food.
Berries, all kinds of dark colored (especially blueberries)	Ellagic Acid	Vitamin C, minerals	May protect the aging brain. (Many studies recommend blueberries.)
Broccoli (also kale, Brussels sprouts, cauliflower)	Flavonoids, Isothiocyanates	Vitamin C, folate, fiber, and selenium	Anticancer properties. Protects against heart disease and stroke.
Carrots and other bright yellow vegetables	Lutein, Beta carotene	Vitamin A (converted from carotenoids), vitamin C, fiber	Protect heart, eyes, lungs. (Cooking carrots may increase their benefits.)
Fish (particularly oily fish, such as mackerel, salmon, sardines)		Vitamins B3 and B12, essential fatty acids, selenium	Heart and brain protective.
Garlic	Allium (organosulfurs)		Although garlic does not appear to help lower cholesterol levels, it still may protect against heart disease. Possible infection fighter.
Ginger	Zingiberaceae		Cancer fighting properties.
Grains (whole)	Lignans (phytoestrogens)	Vitamin B, selenium (important antioxidant mineral), fiber, folate	May help reduce the ability of cancer cells to invade health tissue.
Grapes and red wine	Flavonoids, resveratrol		Fight heart disease and cancer. May have activity against asthma, and type 2 diabetes.
Nuts (such as almonds, macadamia, and walnuts)		Vitamin E, Vitamin B1, Essential fatty acids, folate, fiber	May lower cholesterol levels, reduce sudden death rates from heart disease, and help prevent stroke and type 2 diabetes.
Onions	Flavonoids, allium (organosulfurs)		May have activity against certain cancers (lung), heart disease, asthma, and type 2 diabetes.
Oranges and orange juice	Monoterpenes	Vitamin C, folate, potassium, fiber	Many health benefits. Increase HDL levels and helps maintain normal blood pressure.
Potatoes (Sweet)		Vitamins A, C, and E	Many health benefits.
Soy: Four ounces of tofu equals about 8 - 13 grams of soy. A soy burger contains about 18 grams of soy.	Isoflavones (phytoestrogens), flavonoids, phytosterol, phytate, saponins		May have effects similar to estrogen, including maintaining bone and benefiting the heart. May protect against prostate cancer and possibly other cancers. Possible protection against mental decline.
Spinach and other dark green leafy vegetables	Zeaxanthin, Beta carotene	Vitamin C, folate, vitamin A (converted from carotenoids)	Protects heart, lungs and brain.
Tomatoes	Lycopene, flavonoids	Vitamin C, biotin, minerals	Protects heart. Studies suggest reductions in prostate and other cancers. Infection fighters.

Antioxidant Vitamins E, C, and A. Vitamins E, C, and A are most studied for their health effects because they serve as antioxidants. Antioxidants are chemicals that act as scavengers of particles known as oxygen-free radicals (also sometimes called oxidants ). High intake of foods rich in these vitamins (as well as other food chemicals) have been associated with many health benefits, including prevention of heart problems.

Research on the effects of vitamin supplements on heart disease and diabetes, however, has been mixed. Although some research initially observed favorable effects from vitamin E in preventing blood clots and preventing build-up of plaque on blood vessel walls, most studies found no heart protection from either vitamin E or C supplements. A 2005 Journal of the American Medical Association study found that vitamin E supplements can actually increase the risk of heart failure, especially for patients with diabetes or vascular diseases. Results from the long-term Women’s Health Study, also released in 2005, showed that vitamin E supplements do not protect women from attacks or stroke.

Click the icon to see an image of the benefits of vitamin C.

Antioxidants are chemicals that act as scavengers of particles known as oxygen-free radicals (also sometimes called oxidants). These chemically active particles are by-products of many of the body's normal chemical processes. Their numbers are increased by environmental assaults, such as smoking, chemicals, toxins, and stress. In higher levels, oxidants can be very harmful:

Oxygen-free radicals can damage cell membranes and interact with genetic material, possibly contributing to the development of a number of disorders including diabetes, cancer, heart disease, cataracts, and even the aging process itself.

They can also enhance the dangerous properties of low-density lipoprotein (LDL) cholesterol, a major player in the development of coronary artery disease.

Antioxidant vitamins (A, C, and E), beta carotene, and many phytochemicals can neutralize free radicals and have been studies for possible benefits. It is clear that such vitamins are required to prevent deficiency diseases. In addition, foods rich in antioxidants are important disease fighters. To date, however, there is no strong evidence that antioxidant supplements offer any real protection.

Special Warning on High-Dose Antioxidant Supplements. Some studies suggest that excessive use of antioxidant supplements may interfere with other nutrients or convert into pro-oxidants and become harmful. Some of the findings are as follows:

A 2002 randomized study of postmenopausal women found a higher risk for heart disease in people who took vitamin E and C supplements. A 2005 study found that vitamin E supplements can increase the risk of heart failure, especially for patients with diabetes or vascular diseases.
Of particular concern are studies that have found an increase in lung cancer and overall mortality rate among smokers who took beta carotene supplements. A 2000 study further reported a higher risk for cancer in male smokers who took multivitamins plus A, C, or E. Even more worrisome, in people with existing cancer, high doses of antioxidant vitamins, such as vitamin C or beta carotene, may actually protect cancer cells (just as they do healthy cells).

Click the icon to see an image of a cataract.

Click the icon to see an image of coronary artery disease.

Click the icon to see an image of phytochemicals.

B Vitamins (Folic Acid). Deficiencies in the B vitamins folate (known also as folic acid), B6, and B12 have been associated with a higher risk for heart disease in some studies. Such deficiencies produce higher blood levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease, stroke, and heart failure. Researchers have been studying whether vitamin B supplements can reduce homocysteine levels and, consequently, heart disease risks.

Several major 2006 studies indicated that while B vitamin supplements help lower homocysteine levels, they have no effect on heart disease outcomes. The studies, published in the New England Journal of Medicine, examined patients who had either recently had a heart attack or who suffered from diabetes or heart disease. Results showed a similar number of heart attacks and strokes among patients who took folic acid and B6 and B12 vitamins and those who received placebo. And, the vitamins seemed to increase risks for patients who had undergone stenting. A 2006 Journal of the American Medical Association study also found that folic acid supplements did not help reduce the risk of heart disease or stroke in patients with a history of vascular disease. Some experts think that homocysteine may be a marker for heart disease rather than a cause of it.

Click the icon to see an image of sources of folate.

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

Potassium, Magnesium, and Calcium. Some experts believe that sufficient intake of minerals, particularly potassium, magnesium, and calcium, may be even more beneficial than salt restriction for reducing blood pressure.

Potassium. Evidence strongly indicates that a potassium-rich diet can help achieve healthy blood pressure levels, and that potassium supplements can lower systolic blood pressure by 1.8 m Hg and diastolic blood pressure by 1 mm Hg. Some evidence suggests that a potassium-rich diet can reduce the risk of stroke by 22 - 40%. Expert guidelines now support the use of potassium supplements or enough dietary potassium to achieve 3,500 mg per day for people who have no risk factors for excess potassium levels. (People who take potassium-sparing diuretics should not take potassium supplements.) This goal is particularly important for people who have a high sodium intake. The best source of potassium is from the fruits and vegetables that contain them. Potassium-rich foods include bananas, oranges, pears, prunes, cantaloupes, tomatoes, dried peas and beans, nuts, potatoes, and avocados.
Magnesium. Some studies report that magnesium supplements may cause small but significant reductions in blood pressure. The recommended daily allowance is 320 mg. People who live in soft water areas, who use diuretics, or who have other risk factors for magnesium loss may require more dietary magnesium than others. No major studies have been done on long-term benefits or risks of magnesium supplements.
Calcium. Calcium regulates the tone of the smooth muscles lining blood vessels. Studies have found that people who consume enough dietary calcium on a daily basis have lower blood pressure than those who do not. Hypertension increases calcium loss from the body. The effects of extra calcium on blood pressure, however, are mixed, with some showing higher pressure.

Click the icon to see an image of sources of calcium.

In the past, everyone was advised to consume less than 2,400 mg (about one teaspoon) of sodium (salt) each day. However, in February 2004, a long-awaited report by the Institute of Medicine (IOM) recommended that individuals slash their salt intake in half. The IOM report stressed that no one should consume more than 1,500 mg/day. Because blood pressure tends to rise with age, the Institute also suggested that people over 50 reduce their sodium intake to less than 1,300 mg daily; those over 70 should not eat more than 1,200 mg a day. Reducing sodium may also help protect against heart failure. Unfortunately many people find it very difficult to achieve these goals. Experts disagree on the overall benefits of salt restriction for everyone. Still, the following people should take particular measures to restrict salt:

People at Risk for Salt-Sensitivity. About half of people with hypertension have blood pressure that reacts significantly to salt. Such people are known as salt-sensitive. Among those at highest risk for salt sensitivity are African-Americans, people with diabetes, and elderly people.
Overweight People. Overweight individuals may absorb and retain sodium differently from people with normal weights. One study reported that high sodium intake was associated with an increased risk of heart disease and all-cause mortality in overweight, but not in normal weight, people. Reducing sodium can also help reduce the risk of stroke in people who are overweight.

Water. Many heart risk factors, especially those associated with blood clotting, are increased with dehydration. In one study, drinking five or more glasses of water a day was significantly associated with a lower risk for fatal heart events than drinking two or fewer glasses a day.

Alcohol. A number of studies have found heart protection from moderate alcohol intake (one or two glasses a day). The benefits reported include higher HDL levels, blood clot prevention, and anti-inflammatory properties plus lower rates of heart failure and heart attack. Although red wine is most often cited for healthful properties, any type of alcoholic beverage appears to have similar benefit.

On the negative side, an estimated 10% of hypertension cases are caused by alcohol abuse. Men with high blood pressure should limit their intake to an average of no more than one or two drinks a day, and women (especially those at risk for breast cancer) and lighter people should only have one drink a day. (A “drink” is equivalent to a 12-ounce bottle of beer, a 4-ounce glass of wine, or a 1.5-ounce shot of hard liquor.) Alcohol may raise a man’s risk for atrial fibrillation according to a study in the Archives of Internal Medicine. Pregnant women, people who can't drink moderately, and people with liver disease should not drink at all. People who are watching their weight should be aware that alcoholic beverages are very high in calories.

Caffeinated Beverages.

Tea. Although it contains caffeine, tea, both black and green, is often cited for its health benefits. Green tea especially is rich in chemicals that may offer protection against damaging forms of LDL. A 2006 study of Japanese adults who drank high amounts of green tea (3 or more cups a day) found that green tea consumption was associated with reduced risk of death from heart disease. Green tea did not, however, appear to offer any protection against cancer.
Coffee. Coffee, like red wine, contains phenol, which helps prevent oxidation of LDL cholesterol. However, unfiltered coffee (Turkish coffee, Scandinavian boiled or French pressed coffee, and espresso) contains an alcohol called cafestol, which may raise cholesterol and triglyceride levels. Filtered coffee does not contain this residue. Coffee drinking is associated with small increases in blood pressure, but the risk it poses is very small in people with normal blood pressure. Moderate coffee consumption (1 - 2 cups a day) poses no heart risks and a 2006 Circulation study found that long-term coffee consumption did not increase the risk for heart disease in most people, even if they consumed large daily amounts.

Dietary Changes

The Atkins diet restricts healthful complex carbohydrates in vegetables and particularly in fruits that are known to protect against heart disease. The Atkins diet also causes excessive calcium excretion in urine, which increases the risk for kidney stones and osteoporosis, and the release of ketones. An overload of ketones leads to ketosis, which can cause nausea, lightheadedness, and bad breath.

Low-carb diets such as South Beach, The Zone, and Sugar Busters rely on a concept called the "glycemic index," or GI, which ranks foods by how fast and how high they cause blood sugar levels to rise. Foods on the lowest end of the index take longer to digest. Slow digestion wards off hunger pains. It also helps stabilize insulin levels. Foods high on the glycemic index include bread, white potatoes, and pasta while low-glycemic foods include whole grains, fruit, lentils, and soybeans. A 2006 study indicated that a high-protein, low-glycemic index diet can help produce better reductions in total and LDL cholesterol than a high-protein, high-glycemic index diet. Reducing glycemic load may also help to promote weight loss, especially for women.

There has been debate about whether Atkins and other low-carbohydrate diets can increase the risk for heart disease, especially as people who follow these diets tend to eat more animal-saturated fat and protein and less fruits and vegetables. A 2006 New England Journal of Medicine study of over 80,000 women found that diets lower in carbohydrates and higher in protein do not increase heart disease risk. In fact, if people select vegetable sources of fat and protein (such as soy and nuts), these diets may even moderately reduce the risk of heart disease.

A 2006 review of low-carbohydrate diets found that they did help weight loss in the short term. However, while these diets appeared to lower triglyceride levels and raise HDL (“good”) cholesterol levels, they also raised overall cholesterol and LDL (“bad”) cholesterol levels. In contrast, a 2007 Journal of the American Medical Association study that compared four different diet plans (Atkins, Zone, Ornish, and LEARN) found that the Atkins diet helped raise HDL levels, and reduce triglyciderides (although it had no effect on LDL levels). Women who followed the Atkins diet also had improved blood pressure compared to patients on the other diets. The Atkins diet resulted in better weight loss (an average of 10 pounds over the course of a year versus 4 - 6 pounds for the other diet plans), which in itself may have accounted for the improved heart risk factors. Some experts think that the main finding from this study is that even moderate weight loss can help improve heart health.

The Mediterranean diet is rich in heart-healthy fiber and nutrients, including omega-3 fatty acids and antioxidants. The diet consists of fruits, vegetables, and unsaturated “good” fats, particularly olive oil. Olive oil has been associated with lower blood pressure, a lower risk for heart disease, and possible benefits for people with type 2 diabetes. Experts think that the main health benefit of olive oil is oleic acid, which is a type of monounsaturated fatty acid. Olive oil also contains polyphenol, which are phytochemicals that contain antioxidant properties. A 2006 study found that virgin olive oil, which comes from the first pressing of olives, contains a higher polyphenol content than refined olive oil, which comes from later pressings.

There are several variations to the Mediterranean diet, but general recommendations include:

Limit red meats.
Drink one or two glasses of wine each day if alcohol is enjoyable and there are no reasons to restrict its use.
Limit dairy products.
Eat moderate amounts of fish and poultry. Fish is the diet’s main protein source. Some studies suggest that fish is the primary heart-protective ingredient in this diet.
Eat plenty of fresh fruits and vegetables, nuts, legumes, beans, and whole grains.
Season foods with garlic, onions, and herbs.
Use virgin olive oil.

Positive Arguments. Even though fats make up about 40% of the calories found in the traditional Mediterranean diet, they are largely unsaturated. Growing evidence continues to support the heart-protective properties of the Mediterranean diet. Research has shown that such a diet reduces the risk for a second heart attack and helps cholesterol-lowering statin drugs work better.

Seniors who combine a Mediterranean diet with healthy lifestyle habits live longer lives, according to a 2004 study in The Journal of the American Medical Associationstudy. Researchers observed the effect of a Mediterranean diet on more than 2,000 elderly people for a period of 10 years, and measured the diet's effects on death rates alone and in combination with three risk factors: smoking, physical activity, and alcohol use. Overall, seniors who followed the Mediterranean diet decreased their risk of death from all causes by 23%. The elimination of each additional risk factor boosted their life expectancy rate even more. For example, non-smoking seniors on the diet who exercised regularly and drank only a moderate amount of alcohol reduced their death rates by 65%.

Negative Arguments. Weight gain due to a high intake of fats and risk for alcohol abuse can be problems with the Mediterranean diet. However, a 2006 study that compared several types of Mediterranean diets to a low-fat diet found that the Mediterranean diets were better at lowering blood pressure, cholesterol levels, and blood sugar levels after only 3 months. And, in research presented at the 2007 American College of Cardiology annual conference, the Mediterranean diet proved just as good as the American Heart Association low-fat diet for preventing recurrence of heart attack, stroke, or other heart events.

Other concerns include reduced iron levels and possible calcium loss resulting from a reduced consumption of dairy products. People on the diet should eat foods rich in iron or vitamin C, which aids in iron absorption. They should also ask their doctor if a calcium supplement may be needed because of a lack of dairy products. People should avoid wine if they have risk factors for complications from alcohol. Such people include women who are pregnant or at risk for breast cancer and anyone prone to alcohol abuse.

A diet that is effective in lowering blood pressure is called Dietary Approaches to Stop Hypertension (DASH).

DASH diet recommendations:

Limit salt intake to no more than 2,300 mg a day (a maximum intake of 1,500 mg a day is an even better goal.)
Reduce saturated fat to no more than 6% of daily calories and total fat to 27% of daily calories. (But, include calcium-rich dairy products that are non- or low-fat.)
When choosing fats, select monounsaturated oils, such as olive or canola oils.
Choose whole grains over white flour or pasta products.
Choose fresh fruits and vegetables every day. In one study people who increased their intake of fruits and vegetables experienced a drop in blood pressure after 6 months. Many of these foods are rich in potassium, fiber, or both which may help lower blood pressure.
Include nuts, seeds, or legumes (dried beans or peas) daily.
Choose modest amounts of protein (no more than 18% of total daily calories). Fish, skinless poultry, and soy products are the best protein sources.)
Other daily nutrient goals in the DASH diet include limiting carbohydrates to 55% of daily calories and dietary cholesterol to 150 mg. Patients should try to get at least 30 g of daily fiber.

Slight changes to the DASH diet might help lower blood pressure even more, as well as improve cholesterol and lipid levels. Researchers reporting in the Journal of the American Medical Association and at the 2005 American Heart Association meeting said that replacing some carbohydrates in the DASH diet with protein-rich foods from plant sources (nuts, seeds, soy) or monounsaturated fats (canola or olive oil) may help reduce heart disease risk factors.

Dietary guidelines recommend keeping total fat intake to 20 - 30% of total daily calories, with saturated fat less than 10% of calories. Low-fat diets generally restrict fat intake to 20% or less of total daily calories. The Ornish program, which is recommended for some heart disease patients, limits fats even more drastically. It aims at reducing saturated fats as much as possible, restricting total fat to 10%, and increasing carbohydrates to 75% of calories.

The Ornish program is a very demanding regimen:

It excludes all oils and animal products except nonfat yogurt, nonfat milk, and egg whites.
Foods stressed are whole grains, legumes, and fresh fruits and vegetables.
People in the program exercise for 90 minutes at least three times a week.
Stress reduction techniques are used.
People do not smoke or drink more than two ounces of alcohol per day.

Positive Arguments.

Low-fat programs may help keep weight off.
Low-fat diets that are high in fiber, whole grains, legumes, and fresh produce offer health advantages in addition to their effects on cholesterol. These foods are also lower on the glycemic index than high-glycemic foods such as bread, potatoes, and pasta. Lowering the glycemic index (by, for example, cutting down on starchy vegetables and replacing pasta with whole grains) may help increase weight loss and heart benefits for high-carbohydrate diets.
The Ornish program directors have reported a 91% reduction in angina after 1 year and a 72% reduction after 4 years in spite of significant HDL cholesterol reduction. One study reported that the diet reduced LDL levels to recommended levels without the addition of a cholesterol-lowering drug.

Negative Arguments.

In 2006, the largest study-to-date on low-fat diets found that they did not help prevent heart disease or cancer. Women in the study reduced their fat consumption to 24 – 29% of total daily calories. Some critics say that the study did not do enough to distinguish between good types of fats (monounsaturated omega-3 polyunsaturated) and bad fats (saturated and trans fats).
The American Heart Association notes that the Ornish program is so difficult to maintain that it will not benefit many people. In a 2007 study comparing various weight loss plans, patients on the Ornish diet lost slightly less weight than those on Atkins. The difficulty of the Ornish diet may have been one factor.
Very low-fat diets may reduce calcium absorption, which may be particularly harmful for women at risk for osteoporosis.
Many people who reduce their fat intake do not consume enough of the basic nutrients, including vitamins A and E, folic acid, calcium, iron, and zinc. People on low fat diets should consume a wide variety of foods and take a multivitamin if appropriate.

Calorie restriction has been the cornerstone of weight-loss programs. Restricting calories in such cases also appears to have beneficial effects on cholesterol levels, including reducing LDL and triglycerides and increasing HDL levels. At this point, reducing calories and increasing exercise is still the best method for maintaining weight loss and preventing serious conditions, notably diabetes. A 2006 study reported that a low-calorie, but nutritionally balanced, diet can help prevent an aging-associated change in heart function. Patients in the small study took in 1,400 - 2,000 calories a day for an average of 6 years.

The standard dietary recommendations for losing weight are:

As a rough rule of thumb, one pound of fat equals about 3,500 calories, so one could lose a pound a week by reducing daily caloric intake by about 500 calories a day. Naturally, the more severe the daily calorie restriction, the faster the weight loss.
To determine the daily calories requirements for specific individuals, multiply the number of pounds of ideal weight by 12 - 15 calories. The number of calories per pound depends on gender, age, and activity levels. For instance a 50-year old woman who wants to maintain a weight of 135 pounds and is mildly active might require only 12 calories per pound (1,620 calories a day). A 25-year-old female athlete who wants to maintain the same weight might require 25 calories per pound 2,025 (calories a day).
Fat intake should be no more than 30% of total calories. Most fats should be in the form of monounsaturated fats (such as olive oil). Saturated fats (found in animal products) should be avoided.

Start with realistic goals. When overweight people achieve even modest weight loss they reduce risk factors in the heart. Ideally, overweight patients should strive for 15% weight loss or better, particularly people with type 2 diabetes.
A regular exercise program is essential for maintaining weight loss. If there are no health prohibitions, choose one that is enjoyable. Check with a doctor about any health consideration. [See In-Depth Report #29:Exercise.]
Hunger pangs should not be taken as cues to eat. A stomach that has been stretched by large meals will continue to signal hunger for large amounts of food until its size reduces over time with smaller meals.
Be honest about how much you eat, and track calories carefully. Studies on weight control that depend on self-reporting of food intake frequently reveal that subjects badly misjudge how much they eat (typically underestimating high-calorie foods and overestimating low-calorie foods). In one study, even dietitians underreported their calorie intake by 10%. People who do not carefully note everything they eat tend to take in excessive calories when they believe they are dieting.
For patients who cannot lose weight with diet alone, effective weight-loss medications are now available, including sibutramine (Meridia) and orlistat (Xenical). Orlistat may have particular benefits for patients with type 2 diabetes. This drug may delay or even prevent the onset or progression of diabetes. It may also improve cholesterol levels, regardless of weight loss. Sibutramine is also helpful in weight loss but should not be used by patients with high blood pressure or kidney or liver problems.
Once a person has lost weight, maintenance is required. To maintain a healthy weight, make careful decisions about how many calories you consume in food and how many calories you expend through physical activity. Such thinking will eventually become automatic.
A procedure known as bariatric surgery has been very helpful in producing rapid weight loss and improving insulin and glucose levels in people with diabetes.

Even repeated weight loss failure is no reason to give up. [See In-Depth Report #53: Weight control and diet.]

Lifestyle Changes

Inactivity is a major risk factor for coronary artery disease, on par with smoking, unhealthy cholesterol, and high blood pressure. In fact, studies suggest that people who change their diet in order to control cholesterol lower their risk for heart disease only when they also follow a regular aerobic exercise program.

Research strongly supports the benefits of exercise on coronary artery disease:

People who maintain an active lifestyle have a 45% lower risk of developing heart disease than do sedentary people. Even moderate exercise reduces the risk of heart attack.
People who lose weight and exercise regularly have a significantly better chance of maintaining weight loss compared to those who do not exercise.
Some studies suggest that for the greatest heart protection, it is not the duration of the exercise that counts but the total daily amount of energy expended. Therefore, the best way to exercise may be in multiple short bouts of intense exercise.
Burning at least 250 calories a day (the equivalent of about 45 minutes of brisk walking or 25 minutes of jogging) seems to confer the greatest protection against coronary artery disease, particularly by raising HDL (the so-called good cholesterol) levels. (It may take up to a year of sustained exercise for HDL levels to show significant improvement, but in terms of raising HDL levels, more is better.)
Aerobic exercise also appears to open up the blood vessels and, in combination with a healthy diet, may improve blood-clotting factors.
Resistance (weight) training offers a complementary benefit by reducing LDL (the so-called bad cholesterol) levels.
Exercises that train and strengthen the chest muscles may be very important for patients with angina.

[See In-Depth Report #29: Exercise.]

Stress is always highly associated with negative effects on the heart and other parts of the body. A number of techniques are available to help people relax and reduce tension. [See In-Depth Report #31: Stress.]

Resources

www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
www.eatright.org -- American Dietetic Association
www.americanheart.org -- American Heart Association
www.acc.org -- American College of Cardiology
http://fnic.nal.usda.gov -- Food and Nutrition Information Center

References

Bazzano LA, Reynolds K, Holder KN, He J. Effect of folic acid supplementation on risk of cardiovascular diseases: a meta-analysis of randomized controlled trials. JAMA. 2006 Dec 13;296(22):2720-6.

Bryson CL, Mukamal KJ, Mittleman MA, Fried LP, Hirsch CH, Kitzman DW, et al. The association of alcohol consumption and incident heart failure: the Cardiovascular Health Study. J Am Coll Cardiol. 2006 Jul 18;48(2):305-11.

Covas MI, Nyyssonen K, Poulsen HE, Kaikkonen J, Zunft HJ, Kiesewetter H, et al. The effect of polyphenols in olive oil on heart disease risk factors: a randomized trial. Ann Intern Med. 2006 Sep 5;145(5):333-41.

Djousse L, Pankow JS, Hunt SC, Heiss G, Province MA, Kabagambe EK, et al. Influence of saturated fat and linolenic acid on the association between intake of dairy products and blood pressure. Hypertension. 2006 Aug;48(2):335-41.

Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvado J, Ruiz-Gutierrez V, Covas MI, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med. 2006 Jul 4;145(1):1-11.

Gardner CD, Lawson LD, Block E, Chatterjee LM, Kiazand A, Balise RR, et al. 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.

Halton TL, Willett WC, Liu S, Manson JE, Albert CM, Rexrode K, et al. Low-carbohydrate-diet score and the risk of coronary heart disease in women. N Engl J Med. 2006 Nov 9;355(19):1991-2002.

Kuriyama S, Shimazu T, Ohmori K, Kikuchi N, Nakaya N, Nishino Y, et al. Green tea consumption and mortality due to cardiovascular disease, cancer, and all causes in Japan: the Ohsaki study. JAMA. 2006 Sep 13;296(10):1255-65.

Lopez-Garcia E, van Dam RM, Willett WC, Rimm EB, Manson JE, Stampfer MJ, et al. Coffee consumption and coronary heart disease in men and women: a prospective cohort study. Circulation. 2006 May 2;113(17):2045-53.

McMillan-Price J, Petocz P, Atkinson F, O'Neill K, Samman S, Steinbeck K,et al. Comparison of 4 diets of varying glycemic load on weight loss and cardiovascular risk reduction in overweight and obese young adults: a randomized controlled trial. Arch Intern Med. 2006 Jul 24;166(14):1466-75.

Mosca L, Banka CL, Benjamin EJ, Berra K, Bushnell C, Dolor RJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007 Mar 20;115(11):1481-501.

Mozaffarian D, Prineas RJ, Stein PK, Siscovick DS. Dietary fish and n-3 fatty acid intake and cardiac electrocardiographic parameters in humans. J Am Coll Cardiol. 2006 Aug 1;48(3):478-84.

Mozaffarian D, Rimm EB. Fish intake, contaminants, and human health: evaluating the risks and the benefits. JAMA. 2006 Oct 18;296(15):1885-99.

Mukamal KJ, Chiuve SE, Rimm EB. Alcohol consumption and risk for coronary heart disease in men with healthy lifestyles. Arch Intern Med. 2006 Oct 23;166(19):2145-50.

Review Date:
4/9/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Conjunctivitis

FitSugar — Wed, 08 Oct 2008 17:35:25 -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

Conjunctivitis is an inflammation of the membrane covering the inside of your eyelids and the outer part of your eye. Commonly called "pink eye," conjunctivitis is generally not serious but can be highly contagious.

Signs and Symptoms

Conjunctivitis causes the following symptoms in one or both eyes:

Redness and tearing
Itching
Swollen eyelid
Discharge (watery or thick)
Crust that forms overnight
Sensitivity to light
Gritty feeling

What Causes It?

Conjunctivitis is most often the result of viruses, such as those that cause the common cold. Other causes can be bacterial infections, allergies, chemicals, irritation from contact lenses, or eye injury. Viral and bacterial conjunctivitis are very contagious.

What to Expect at Your Provider's Office

If you have conjunctivitis in both eyes, with itching and a clear discharge, allergies are likely the cause. Swollen glands and a clear or mucous usually indicate a virus, while a thick, crusty discharge is a sign of a bacterial infection.

Your health care provider may use a lamp for closer examination, or gently swab a stain across the surface of your eye. They may test your vision or measure the pressure in your eye, to rule out glaucoma.

Treatment Options

Conjunctivitis is generally not a serious problem and often will go away by itself. You should still, however, consult your health care provider. Chronic conjunctivitis, if left untreated, can cause permanent eye damage.

Treatment varies according to the cause of inflammation. Bacterial conjunctivitis is generally treated with antibiotics. Forms of conjunctivitis caused by viruses do not respond to antibiotics, but antihistamines and anti-inflammatory medications may help relieve your symptoms. Cool compresses may help reduce itching and swelling.

Drug Therapies

Viral conjunctivitis: Cool compresses three times daily for 1 - 3 weeks. You may also use antihistamines to relieve inflammation. Trifluridine 1% drops, every 2 hours. You may also need oral or topical acyclovir.
Allergic conjunctivitis: Avoid contact with allergen. Treat with cool compresses, over-the-counter or topical antihistamines, NSAIDs (particularly ketorolac), and possibly mild corticosteroids.
Bacterial conjunctivitis: Trimethoprim sulfate and polymixin B sulfate drops, 1 drop 3 times daily for 1 week, or polymixin B-bacitracin ointment. Fluoroquinolones as second-line therapy. Tobramycin (0.3%) or gentamicin as drops, or 10% sodium sulfacetamide as drops, every 4 hours.

Complementary and Alternative Therapies

Alternative therapies can help relieve your symptoms. You must, however, be careful that any solution or compress you put on your eye is sterile. Remember, too, that you can spread conjunctivitis from one eye to another, so avoid your other eye while treating the affected eye. If you have a mild case of conjunctivitis, begin with compresses. For a moderate case, use a compress and an eyewash. Many people find relief with a boric acid eyewash or compress. Boil 1 tsp. boric acid in 1 cup water, cool, and apply with a sterile eyecup or washcloth.

Nutrition and Supplements

Doses listed are for adults. Decrease by one-half to two-thirds for children, at the recommendation of a health care provider.

Vitamin A (10,000 IU per day), vitamin C (250 - 500 mg two times per day), and zinc (30 - 50 mg per day) strengthen your immune system and help you heal faster.

Herbs

Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Compresses and eye washes are external treatments. You can make a compress with a clean cloth, gauze pads, or cotton balls soaked in a solution and then applied over the eyes. You can apply eye washes with an eye cup or a sterile dropper.

Compress: Use five drops of tincture in ¼ cup boiling water or steep 1 tsp. herb in 1 cup boiling water for 5 - 10 minutes, strain, and cool. Soak cloth or gauze in solution, and apply over the closed eyes for 10 minutes, three to four times a day.

Eyebright (Euphrasia officinalis): helps fight infection and dry up excess fluid.
Chamomile (Matricaria recutita): helps fight infection.
Fennel seed (Foeniculum vulgare): helps fight infection.
Marigold (Calendula officinalis): soothes irritation.
Plantain (Plantago lanceolata, P. major): astringent and soothing. The fresh leaves are the most effective plant part.
Flaxseed (Linum usitat issimum): as a soothing poultice made with 1 oz. of bruised flaxseed steeped for 15 minutes in 4 oz. of water, wrapped in cheesecloth, then applied directly to the affected eye.
Grated fresh potato has astringent (drying and disinfecting) properties. Wrap in cheesecloth and apply.

Use above herbs singly or in combination: Mix equal parts together then steep 1 tsp. herb in 1 cup of boiling water to make a tea. Cool before administering to the eye.

Eyewash: goldenseal (Hydrastis canadensis) and boric acid: 10 drops of goldenseal tincture with 1 tsp. of boric acid in 1 cup of boiling water; strain, and cool.

Homeopathy

Although very few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of conjunctivitis based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account your constitutional type -- your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

Euphrasia -- for conjunctivitis with large volumes of watery tears that burn the face and may in time become a thick discharge. Despite the production of watery tears, the individual may complain of a dry, gritty sensation in the eyes.
Argentum nitricum -- for red, swollen eyes with pus-like discharge and splintering pains.
Pulsatilla-- for conjunctivitis with yellow-green discharge and itchy eyes that may accompany or immediately follow a cold. The eyelids tend to stick together, and symptoms generally improve with cold compresses. This remedy is most appropriate for individuals who tend to be irritable and have mood swings.
Belladonna -- for the first stages of conjunctivitis, including the sudden onset of burning, bloodshot eyes, swollen eyelids, and hypersensitivity to light. The eyes are generally hot and throbbing to the touch.
Sulphur -- for burning, pain, and redness of the eyes accompanied by a yellow discharge with foul odor. The eyes are often crusted together, and the individual is usually very hot and thirsty.
Apis mellifica -- for red, burning eyes and excessive swelling that feel better with cold applications.

Acupuncture

Treatment may be administered for pain relief and relieving congestion.

Following Up

Viral and bacterial conjunctivitis are both very contagious. Family members should use separate towels. Wash your hands often. Children should generally be kept home from school and day care.

Be sure to follow your health care provider's advice about using any medications, particularly if you have been given antibiotics or corticosteroids. If you wear contact lenses, keep them clean to avoid further irritation and future infections. Do not wear them until your eyes have healed.

People with allergy-related conjunctivitis sometimes develop a severe form with a stringy discharge, swollen eyelids, scaly skin, and significant discomfort. This needs aggressive treatment to prevent scarring of the cornea.

Special Considerations

In most U.S. hospitals, medication such as silver nitrate is routinely administered to the eyes of newborns to prevent conjunctivitis from developing from bacteria in the birth canal.

Supporting Research

Abelson MB, Casey R. How to manage atopic keratoconjunctivitis. Rev Ophthalmol. May 1996.

Abelson MB, McGarr P. How to diagnose and treat inclusion conjunctivitis. Rev Ophthalmol. March 1997.

Abelson MB, Richard KP. What we know and don't know about GPC. Rev Ophthalmol. August 1994.

Abelson MB, Welch D. How to treat bacterial conjunctivitis. Rev Ophthalmol. December 1994.

Acute conjunctivitis. Acupuncture.com. Accessed at http://www.acupuncture.com/conditions/conjunct.htm on January 29, 1999.

Carr AC, Frei B. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health effects in humans. Am J Clin Nutr. 1999;69(6):1086-1107.

Clinical imperatives of ocular infection. Primary Care Optometry News. Roundtable. March 1996.

Cummings S, Ullman D. Everybody's Guide to Homeopathic Medicines. 3^rd ed. New York, NY: Penguin Putnam; 1997: 90-91.

Friedlaender MH. Update on allergic conjunctivitis. Rev Ophthalmol. March 1997.

Homeopathic drops for allergy: ready or not? Primary Care Optometry News. May 1996.

Infectious Diseases and Immunization Committee. Canadian Pediatric Society. Recommendations for the prevention of neonatal ophthalmia. Can Med Assoc J. 1983; 129:554-555.

JAMA Patient Page. How much vitamin C do you need? JAMA. 1999;281(15):1460.

Johnston CS. Recommendations for vitamin C intake. JAMA. 1999;282(22):2118-2119.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 180-181.

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

Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:5, 28.

Pascucci S, Shovlin J. How to beat giant papillary conjunctivitis. Rev Ophthalmol. June 1994.

Rapoza PA, Francesconi CM. How to diagnose chronic red eye. Rev Ophthalmol. October 1997.

Stoss M, Michels C, Peter E, Beutke R, Gorter RW. Prospective cohort trial of Euphrasia single-dose eye drops in conjunctivitis. J Altern Complement Med. 2000 Dec;6(6):499-508.

Ullman D. Homeopathic Medicine for Children and Infants. New York, NY: Penguin Putnam; 1992: 67.

Review Date:
6/15/2006
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

Cystic fibrosis - nutritional considerations

admin — Thu, 04 Sep 2008 18:56:27 -0700

Overview

Definition
Function
Side Effects
Recommendations

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Cystic fibrosis (CF) is a potentially life-threatening disease that causes thick, sticky mucus to build up in the lungs and digestive tract. Persons with cystic fibrosis need to eat high calorie and high protein foods throughout the day.

This article discusses the nutritional needs for persons with CF. For specific information about the disease itself, see the article on cystic fibrosis.

Function

The collection of sticky mucus associated with cystic fibrosis leads to serious digestion problems, including malabsorption.

Pancreatic enzymes are prescribed to improve the digestion and absorption of fat, carbohydrates, and protein.

The dietary needs of a person with cystic fibrosis are based on the severity of the symptoms, specifically the amount of malabsorption and extent of lung disease. The goal is to provide adequate nutrients to achieve normal growth and development. Nutritious, high-calorie, high-protein foods are essential from infancy through adulthood. Calorie and protein needs can be 50 - 100% greater than the Recommended Daily Allowance.

Historically, low-fat diets were encouraged to reduce problems with fat malabsorption. With pancreatic enzyme treatment, fat can provide 35 - 45% of calories, depending on the person's ability to tolerate it. A multivitamin is also recommended, since persons with CF absorb fat-soluble vitamins (vitamins A, D, E, K) poorly. Liberal salt use is encouraged, since persons with CF lose large amounts of salt in their sweat.

Side Effects

The most serious complication of CF is infection in the lungs. Nutrition plays an important role in strengthening the patient's immune system to fight infection.

Recommendations

The following are methods for adding protein and calories to the diet. In addition to these tips, make sure that you are taking a multivitamin containing vitamins A, D, E and K:

Eat whenever you are hungry. This may mean eating several small meals throughout the day.
Keep a variety of nutritious snack foods around. Try to snack on something every hour. Try cheese and crackers, muffins, or trail mix.
Make an effort to eat regularly, even if it's only a few bites; or include a nutritional supplement or milkshake.
Be flexible. If you aren't hungry at dinner time, make breakfast, mid-morning snacks and lunch your main meals.
Add grated cheese to soups, sauces, casseroles, vegetables, mashed potatoes, rice, noodles or meat loaf.
Use whole milk, half and half, cream, or enriched milk in cooking or beverages. Enriched milk has non-fat dry milk powder added to it.
Spread peanut butter on bread products or use it as a dip for raw vegetables and fruit. Add peanut butter to sauces or use on waffles.
Skim milk powder adds protein -- try adding two tablespoons of dry skim milk powder in addition to the amount of regular milk in recipes.
Add marshmallows to fruit or hot chocolate. Add raisins, dates, or chopped nuts and brown sugar to hot or cold cereals or for snacks.
A teaspoon of butter or margarine adds 45 calories to foods. Mix it into hot foods such as soups, vegetables, mashed potatoes, cooked cereal, and rice. Serve it on hot foods -- hot breads, pancakes, or waffles absorb more butter than cool ones.
Sour cream or yogurt can be used on vegetables such as potatoes, beans, carrots, or squash. They can also be used as a dressing for fruit.
Breaded meat, chicken, and fish have more calories than broiled or plain roasted.
Add extra cheese on top of frozen prepared pizza.
Coarsely chopped hard cooked egg and cheese cubes are tasty in a tossed salad.
Serve cottage cheese with canned or fresh fruit.
Add grated cheeses, tuna, shrimp, crabmeat, ground beef, diced ham or sliced boiled eggs to sauces, rice, casseroles, and noodles.

Review Date: 7/5/2007

Reviewed By: William McGee, M.D., M.H.A., Chairman, Nutrition Committee, Baystate Medical Center, Springfield, MA and Assistant Professor of Medicine and Surgery,Tufts University School of Medicine, Boston, MA. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Source Doc: 1_002437

Healthy Recipe: Potato Salad With Cornichons and Capers

FitSugar — Sat, 30 Aug 2008 03:30:00 -0700

It is Labor Day weekend, and that means barbecues to celebrate the end of Summer. Potato salad is a barbecue staple, but this dish doesn't need to be laden with high-fat mayo.

This potato salad features a red wine vinegar and mustard vinaigrette, with salty capers and cornichons (the French version of gherkins) for added flavor. Capers may be tiny, but nutritionally speaking, they pack quite a punch for their size. These little green olive-like nuggets of flavor are not only high in antioxidants, but they also inhibit the formation of by-products created in the digestion of meat that have been linked to an increased risk of cancer and heart disease. Remember, to reap all the nutritional benefit of your potatoes, don't peel your spuds, and boil them whole.

To see the recipe, just read more.

Potato Salad With Cornichon and Capers
Adapted from Martha Stewart Living

Ingredients

2 pounds small red potatoes, uniform size as much as possible
2 tablespoons plus 1 1/2 teaspoons coarse salt
2 tablespoons red wine vinegar
1 tablespoon Dijon mustard
1/3 cup extra-virgin olive oil
2 shallots chopped fine (about 1/3 cup)
10 cornichons (small French pickles like gherkins), rinsed and sliced into thin rounds (about 1/4 cup)
4 tablespoons capers, rinsed
2 tablespoons coarsely chopped fresh flat-leaf parsley
freshly ground pepper to taste

Directions

Cover potatoes with water in a medium saucepan. Add 2 tablespoons salt. Bring to a boil; reduce heat, and simmer until tender, 11 to 15 minutes. Drain potatoes, reserving 1 tablespoon cooking water. Halve the potatoes; quarter them if they're large.
Make the vinaigrette: Whisk together vinegar, mustard, and reserved cooking water in a small bowl. Gradually add oil, whisking until emulsified. Transfer potatoes to a medium bowl, and drizzle with vinaigrette. Add shallots, cornichons, capers, parsley, remaining 1 1/2 teaspoons salt, and the pepper. Using a large spatula, gently stir to combine.

Serves 6

Print recipe with images | without images

Do you have a healthy snack or recipe to share? Then share it in the Lite'n it Up - Healthy Recipe Group and I might just post it on FitSugar.

Food poisoning

FitSugar — Wed, 08 Oct 2008 17:35:25 -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

Food poisoning is the result of eating food contaminated with bacteria or other toxins. Symptoms include diarrhea, vomiting, and stomach cramps, and generally start 4 - 36 hours after eating contaminated food. While many cases are caused by bacteria, some cases can result from eating poisonous plants (some mushrooms, for instance) and animals (pufferfish). Food poisoning is not uncommon, especially during summer when food may not be kept cold enough to prevent bacteria from growing.

Signs and Symptoms

The typical signs of food poisoning are nausea, vomiting, abdominal cramping, and diarrhea. Specific bacteria may cause these signs and symptoms:

Clostridium botulinum (C. botulinum, or botulism): weakness, blurred vision, sensitivity to light, double vision, paralyzed eye nerves, difficulty speaking, trouble swallowing, paralysis that spreads downward, respiratory failure, death
Salmonella spp., Shigella spp., and Campylobacter jejuni (C. jejuni): fever, chills, bloody diarrhea
Escherichia coli (E. coli): hemorrhagic colitis (diarrhea with very little stool and large amounts of blood). E. coli symptoms may appear as long as 3 days after eating contaminated food.
Mushroom poisoning can affect the liver, the neurological system (brain), or the gastrointestinal tract. Symptoms include stomach flu, delirium (confusion), vision difficulties, heart muscle problems, kidney failure, and death of liver tissue. It causes death in about half of the people affected unless treated right away.

Fish poisoning causes nausea, vomiting, diarrhea, abdominal pain, dizziness, and headache. Specific types of fish poisoning can cause other signs and symptoms, such as:

Ciguatera: numbness or tingling around the mouth, feeling of loose teeth, impaired touch sensation of hot as cold and cold as hot, itching, muscle and joint pain, slow heart rate, low blood pressure. Caused by toxins in some fish, including grouper, snapper, mackerel, barracuda.
Pufferfish poisoning: numbness or tingling around the mouth, trouble coordinating movement, difficulty swallowing, excess saliva, twitching, loss of ability to talk, convulsions, paralysis that spreads upward, respiratory failure, death
Shellfish poisoning: numbness or tingling around the mouth or in the arms and legs, trouble swallowing, difficulty speaking. Caused by toxins in algae that are then eaten by shellfish.

What Causes It?

Usually bacteria and algae cause food poisoning. But sometimes poisonous plants and animals are the cause.

Common bacterial toxins include:

E. coli in undercooked hamburger, unpasteurized apple juice or cider, raw milk, contaminated water (or ice), vegetables fertilized by cow manure; can be spread from person to person.
Listeria monocytogenes (L. monocytogenes) in cole slaw, dairy products (mostly soft cheeses from outside the United States), and cold, processed meats
Salmonella spp. in poultry, beef, eggs, or dairy products
Shigella spp. from raw vegetables or cool, moist foods (such as potato and egg salads) that are handled after cooking
Staphylococcus aureus(S. aureus) in salad dressing, ham, eggs, custard-filled pastries, mayonnaise, and potato salad. Usually from the hands of food handlers.
C. jejuni in raw milk and chicken
C. botulinum in improperly home-canned foods. In children under 1 year of age, mostly from honey but also from corn syrup.
Clostridium perfringens(C. perfringens) in meat and poultry dishes and gravies, mostly foods that were cooked more than 24 hours before eating and were not reheated well enough
V. cholerae in bivalve (two-shelled) shellfish (such as mussels, clams, oysters, and scallops), raw shellfish, and crustaceans (such as lobsters, shrimp, and crabs)

Common types of fish poisoning include:

Scombroid poisoning from bacteria in dark-meat fish (tuna, bonito, skipjack, mahi-mahi, mackerel) that are not refrigerated well
Ciguatera poisoning in tropical fish (grouper, surgeonfish, snapper, barracuda, moray eel) that have eaten toxic plankton
Puffer fish poisoning from the organs and flesh of puffer fish
Poisoning from shellfish that feed on certain algae

Mushroom poisoning occurs from eating wild poisonous mushrooms, especially Amanita phalloides.

Who's Most At Risk?

Infants and the elderly are at greater risk for food poisoning. Other risk factors include:

Having a pre-existing medical condition, such as chronic kidney failure or diabetes
Taking antibiotic or antihistamine medicines
Having sickle-cell anemia and other problems with red blood cells
Weakened immune system
Traveling in an area where contamination is more likely

Listeriosis is most common in pregnant women, fetuses, and people with immune problems. When a fetus is infected with listeria, the fetus may be born prematurely or die.

What to Expect at Your Provider's Office

Your health care provider will examine you for signs and symptoms of food poisoning, such as stomach problems, and of dehydration. Your health care provider may also ask about foods you have eaten recently, where you may have traveled, and if you have had contact with people showing similar symptoms. Tests of your vomit, blood, and stool can identify the cause. In the case of botulism, electromyography (a test to measure electric impulses in the muscles) may be done to confirm the diagnosis. A lumbar puncture (spinal tap) may be done to check for signs and symptoms related to central nervous system disorders.

Treatment Options

Prevention

These steps can help prevent food poisoning:

Wash your hands and clean any dishes or utensils when you are making or serving food.
Promptly refrigerate any food you will not be eating right away.
If you take care of young children, wash your hands often and dispose of diapers carefully so that bacteria can't spread to other surfaces or people.
If you make canned food at home, make sure to follow proper canning techniques to prevent botulism.
Don't feed honey to children under 1 year of age.
Don't eat wild mushrooms.
When traveling where contamination is more likely, eat only hot, freshly cooked food. Boil water before drinking. Don't eat raw vegetables or unpeeled fruit.
Always refrigerate fish.
Don't eat tropical fish caught during blooms of poison plankton.
Eat pufferfish only in specially licensed restaurants with chefs trained to cook it.
Don't eat shellfish exposed to red tides.

If others also may have eaten a food that made you sick, let them know. If you think the food was contaminated when you bought it from a store or restaurant, tell the staff and your local health department.

Treatment Plan

Treatment for most cases consists of rehydration -- replacing fluids and electrolytes (such as sodium, potassium, magnesium, and chloride). While experiencing vomiting and diarrhea, the person should avoid solid food but increase clear liquids. In more severe cases, a person may need help either breathing or stopping vomiting. In most cases, health care providers do not prescribe antibiotics because they may prolong diarrhea. If you have eaten certain toxins (such as from mushrooms or shellfish), your health care provider may take steps to clean out your stomach (a process called lavage, or pumping the stomach) and administer activated charcoal, which can help absorb the remaining toxin.

Drug Therapies

Depending on the symptoms and the cause of food poisoning, a health care provider may prescribe drugs, including:

Antibiotics, in certain cases
Antitoxin to neutralize toxins from C. botulinum (only given within the first 72 hours)
Amitriptyline to control the numbness and tingling from ciguatera poisoning
Apomorphine or ipecac syrup to cause vomiting and help rid the body of toxin
Atropine for mushroom poisoning
Diphenhydramine and cimetidine for fish poisoning
Mannitol for nerve-related symptoms of ciguatera poisoning

Complementary and Alternative Therapies

Anyone suffering from severe food poisoning should seek conventional medical treatment. Complementary and alternative therapies are best used to strengthen the body and aid in the prevention of food poisoning. For example, animal studies have shown that certain vitamins and nutrients may be effective in protecting against some food toxins while others may actually worsen the effects of toxins. Milk thistle is an herb commonly used in Europe as a primary treatment for mushroom poisoning. Homeopathy may help in the treatment of diarrhea in children (which is sometimes caused by food poisoning) in developing countries.

Nutrition

The following general nutritional guidelines may be helpful in the case of food poisoning:

Drink plenty of fluids (to prevent dehydration).
Drink barley or rice water (to soothe inflamed stomach or intestine).
Probiotics, such as Lactobacillus acidophilus and Lactobacillus bulgaricus, can help restore the balance of good bacteria in the intestine. If you are traveling to an area where the food and water may be contaminated, in addition to taking the precautions above, taking probiotics both before and during your trip may help maintain intestinal health.
Apple cider vinegar is a traditional remedy that has not been studied scientifically, but may have some antimicrobial properties. Mix 2 tsp. in one cup warm water and drink several times a day.

For specific types of food poisoning:

Alpha-lipoic acid -- Several reports indicate that alpha-lipoic acid, an antioxidant commonly found in broccoli, spinach, and beef, may be helpful in the treatment of Amanita (mushroom) poisoning, especially when combined with milk thistle (Silybum marianum). It is important to receive medical treatment if you suspect mushroom poisoning. Do not try to self-treat.
Vitamin A -- Studies with rats seem to show that vitamin A offered some protection against salmonella. Rats infected with Salmonella appeared to eliminate the bacteria from their bodies faster when pretreated with vitamin A than with placebo, according to one study. They also gained more weight and had a greater immune response than rats given placebo.
Calcium phosphate -- One animal study suggests that rats receiving calcium phosphate supplements may be protected from Salmonella poisoning. Researchers theorize that calcium phosphate helps boost Lactobacillus, the good bacteria found in the intestine, which helps fight off Salmonella.

Supplements to avoid:

Fish oil -- In a study of mice infected with the bacteria Listeria, animals that regularly consumed diets rich in fish oil had significantly more bacteria in their spleens than animals that consumed diets rich in lard or soybean oil. Until researchers can determine what these results mean to humans, people with Listeria infection should avoid foods containing fish oil.

Herbs

Various herbs have been used traditionally to treat different types of food poisoning, though in most cases scientific studies on their effectiveness are lacking.

Milk thistle (Silybum marianum) is often used for liver disorders and is widely used in Europe to treat Amanita mushroom poisoning. Studies have shown that patients with Amanita poisoning can be effectively treated with silibinin (the primary active component of milk thistle) up to 48 hours after eating the deadly mushrooms.

Animal studies of Chinese and Japanese combination herbal remedies used for Listeria suggest they may be effective for food poisoning. A few of the active ingredients include:

Asian ginseng (Panax ginseng)
Astragalus root (Astragalus membranaceus)
Chinese cinnamon bark (Cinnamomum aromaticum)
Ginger root (Zingiber officinale)
Licorice ( Glycyrrhiza glabra)
Peony root (Paeonia officinalis)
Skullcap (Scutellaria lateriflora)

Seek the advice of a trained and licensed herbalist or practitioner of Traditional Chinese Medicine who will guide your individual treatment. Do not self-treat with these herbs. Some of these herbs should not be taken if you have heart disease or high blood pressure or take blood-thinning medication. In addition, some of these herbs interact with other herbs, supplements, and prescription medications, so it is important to make sure all your health care providers know what you are taking.

Laboratory (test tube) studies suggest that the following herbs have antibacterial or antimicrobial properties, although there is no evidence they are effective for treating food poisoning in humans.

Bittervine (Mikania micrantha)
Goldenseal (Hydrastis canadensis)
Oregon grape (Mahonia aquifolium)
Chamomile (Matricaria recutita)

Barberry (Berberis vulgaris) has also been used traditionally to treat diarrhea from infectious causes such as E. coli and V. cholera.

Homeopathy

No studies have examined the effectiveness of homeopathic remedies for food poisoning. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual. Below are some more common remedies for food poisoning or diarrhea.

Arsenicum album -- for foul-smelling diarrhea from food poisoning or traveler's diarrhea with burning sensation in the abdomen and around the anus. This remedy is most appropriate for individuals who feel exhausted yet restless and whose symptoms tend to worsen in the cold and improve with warmth. Vomiting may also occur. Arsenicum may also be used to prevent diarrhea when traveling.
Chamomilla -- for greenish, frothy stool that smells like rotten eggs. Used primarily for children, especially those who are irritable, argumentative, and difficult to console.
Calcarea carbonica -- for children who fear being in the dark or alone and who perspire heavily while sleeping. Sools have a sour odor.
Podophyllum -- for explosive, gushing, painless diarrhea that becomes worse after eating or drinking. Exhaustion often follows bowel movements, and the individual for whom this remedy is appropriate may experience painful cramps in lower extremities.
Sulphur -- for irritable and weepy children. May have a red ring around the anus and diarrhea with the odor of rotten eggs.

Prognosis/Possible Complications

Most cases of food poisoning are mild and clear up on their own. However, with mushroom poisoning, up to half of people may die. With botulism, less than 10% die. Some people may need help breathing for months afterwards. More than half of poisonings from pufferfish are fatal. Death is rare in other fish poisonings, but nerve-related symptoms can continue for months.

The following are some possible after-effects of food poisoning:

After shigellosis, white blood cell problems and kidney problems
After E. coli infection, kidney problems and bleeding problems
After botulism, long hospital stays (1 - 10 months) with fatigue and difficulty breathing for 1- 2 years or respiratory failure
After salmonellosis, Reiter syndrome (an arthritis-like disease) and inflammation of the heart lining
After campylobacteriosis, Guillain-Barré syndrome (a nerve disease)

Following Up

For a severe case of food poisoning, you may need to stay in the hospital to receive fluids and electrolytes, and so health care providers can monitor your breathing. Doctors may need to intubate (insert a tube down the throat) or connect you to a machine to help with breathing. Dialysis may be required. Cathartics (substances that help the body remove waste), enemas, and lavage may help eliminate toxins.

Supporting Research

Beers MH, Porter RS, et al. The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, NJ: Merck Research Laboratories; 2006:1642-1644.

Blumenthal M, Goldberg A, Brinckmann J, eds. Herbal Medicine: Expanded Commission E Monographs. Boston, Mass: Integrative Medicine Communications; 2000:257.

Bovee-Oudenhoven IM, Wissink ML, Wouters JT, Van der Meer R. Dietary calcium phosphate stimulates intestinal lactobacilli and decreases the severity of a salmonella infection in rats. J Nutr. 1999;129:607-612.

Duncan SH, Flint HJ, Stewart CS. Inhibitory activity of gut bacteria against Escherichiacoli 0157 mediated by dietary plant metabolites. FEMS Microbiol Lett. 1998;164:238-288.

Facey PC, Pascoe KO, Porter RB, Jones AD. Investigation of plants used in Jamaican folk medicine for anti-bacterial activity. J Pharm Pharmacol. 1999;51:1455-1460.

Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of InternalMedicine. 14th ed. Vol. 1. New York, NY: McGraw-Hill; 1998:796-801, 876-880, 904-905.

Fritsche KL, Shahbazian LM, Feng C, Berg JN. Dietary fish oil reduces survival and impairs bacterial clearance in C3H/Hen mice challenged with Listeria monocytogenes. Clin Sci. 1997;92:95-101.

Gabriel EP, Lindquist BL, Abud RL, Merrick JM, Lebenthal E. Effect of vitamin A deficiency on the adherence of fimbriated and nonfimbriated Salmonella typhimurium to isolated small intestinal enterocytes. J Ped Gastroenterol Nutr. 1990;10:530-535.

Hatchigian EA, Santon JE, Broitman SA, Vitale JJ. Vitamin A supplementation improves macrophage function and bacterial clearance during experimental Salmonella infection. PSEBM. 1989;191:47-54.

Hruby K, Csomos G, Fuhrmann M, Thaler H. Chemotherapy of Amanita phalloides poisoning with intravenous silibinin. Hum Exp Toxicol. 1983;2(2):183-195.

Irons R, Anderson MJ, Zhang M, Fritsche KL. Dietary fish oil impairs primary host resistance against Listeria monocytogenes more than the immunological memory response. J. Nutr. 2003 Apr;133:1163-1169.

Jacobs J, Jiménez M, Malthouse S, Chapman E, Crothers D, Masuk M, Jonas WB. Homeopathic treatment of acute childhood diarrhea: results from a clinical trial in Nepal. J Altern Complement Med. 2000;6(2):131-139.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 218-220.

Murray PR, et al. Manual of Clinical Microbiology. 7th ed. Washington, DC: ASM Press; 1999:356-359.

Rabbani GH, Butler T, Knight J, Sanyal SC, Alam K. Randomized controlled trial of berberine sulfate therapy for diarrhea due to enterotoxigenic Escherichia coli and Vibrio cholerae. J Infect Dis. 1987 May;155(5):979-984.

Rosen P, et al. Emergency Medicine: Concepts and ClinicalPractice. 4th ed. Vol. 3. St. Louis, Mo: Mosby; 1998:1931-1938, 2513-2516, 2178-2179.

Sabeel AI, Kurkus J, Lindholm T. Intensive hemodialysis and hemoperfusion treatment of Amanita mushroom poisoning. Mycopathologia. 1995;131(2):107-114.

Ullman D. Homeopathic Medicine for Children and Infants. New York, NY: Penguin Putnam; 1992: 75-77.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin Putnam; 1995: 243-245.

Verma RJ, Shalini M. Ochratoxin A-induced cytotoxicity to human red blood cells and its prevention by certain vitamins. Med Sci Res. 1997;25(12):833-834.

Yonekura K, Kawakita T, Mitsuyama M, Miura O, Yumioka E, Suzuki A, Nomoto K. Induction of colony-stimulating factor(s) after administration of a traditional Chinese medicine, xiao-chai-hu-tang (Japanese name: shosaiko-to). Immunopharmacol Immunotoxicol. 1990;12(4):647-667.

Yonekura K, Kawakita T, Saito Y, Suzuki A, Nomoto K. Augmentation of host resistance to Listeria monocytogenes infection by a traditional Chinese medicine, ren-shen-yang-rong-tang (Japanese name: ninjin-youei-to). Immunopharmacol Immunotoxicol. 1992;14(1-2):165-190.

Review Date:
12/17/2006
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

Diarrhea

FitSugar — Wed, 08 Oct 2008 17:35:25 -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

Diarrhea is an increase in the wateriness, volume, or frequency of bowel movements. Although uncomfortable, most diarrhea is not serious and will go away in a few days without treatment. See a health care provider, however, if the feces contain blood, if the diarrhea is particularly severe, or if the diarrhea lasts more than a few days. Children and elderly people should see a health care provider sooner because they are at more risk of dehydration.

Signs and Symptoms

Diarrhea is a symptom of another ailment. Symptoms you might experience with diarrhea are as follows:

Frequent need to defecate
Abdominal pain, cramping
Fever, chills, general sick feeling
Thirst
Weight loss

What Causes It?

Most diarrhea is caused by an infection (viral, bacterial, or parasitic), often from food or water. Diarrhea produces watery stools and lasts only a few days. Eating local food and drinking local water during foreign travel can result in "traveler's diarrhea." Diarrhea can also be caused by reactions to medications (including some vitamins, minerals and herbs) and ingestion of milk or dairy products by people who are lactose-intolerant. A different type of diarrhea that results in blood in the stool, accompanied by fever or abdominal pain, could be caused by intestinal disorders such as inflammatory bowel disease or Crohn's disease, and requires a doctor's care.

What to Expect at Your Provider's Office

Your health care provider will question you about your symptoms. Your provider will also check if you are dehydrated and may feel your abdomen to see if it is tender, listen to your abdomen with a stethoscope, and give you a rectal exam.

Treatment Options

Drug Therapies

In many cases, diarrhea will disappear on its own. However, many drugs can treat symptoms of diarrhea. Your health care provider may suggest the following drugs for your diarrhea:

Opioid derivatives: diphenoxylate with atropine sulfate, and loperamide
Adsorbents: Bismuth salt (for traveler's diarrhea) and attapulgite
Bulk-forming medications: psyllium husk

Over the Counter

Since diarrhea is your body's way of getting rid of toxins, it's best to let it run its course. However, you may use over-the-counter anti-diarrheal remedies for convenience, including loperamide (Imodium), bismuth sub-salicylate (Pepto-Bismol), and attapulgite (Kaopectate). You should not take bismuth sub-salicylate with the herbs meadowsweet (Spirea ulmaria), white willow (Salix alba), or wintergreen (Gaultheria procumbens ).

Complementary and Alternative Therapies

Work with your health care provider to find remedies that are right for you.

Nutrition and Supplements

Drink plenty of liquids, and avoid solid foods, coffee, chocolate, dairy products, and strong spices. Introduce clear soup, crackers, white bread, rice, potatoes, applesauce, and bananas as diarrhea gets better.
Rice or barley water, fresh vegetable juices (especially carrot and celery), miso broth, or other clear broths help restore proper fluid and electrolyte balance. Make rice and barley water using 1 cup of raw grain to 1 quart of boiling water. Let steep for 20 minutes. Strain and drink throughout the day.
Lactobacillus acidophilus and/or bifidobacteria taken as powder or in capsules helps normalize bowel flora and may help cure your diarrhea. Take as directed. Active culture yogurt containing these probiotics may help prevent diarrhea.
A live yeast, Saccharomyces boulardii, is often used in Europe to prevent diarrheas associated with antibiotic use. Take 1 - 3 capsules per day (3 - 9 billion colony forming units). May be taken with other probiotics. Rare but serious cases of infection in seriously ill patients have been reported, so do not takeSaccraromyces boulardii without a doctor's supervision.
Bovine colostrum, the pre-milk fluid secreted by a cow's mammary glands just after giving birth, may help treat some kinds of infectious diarrhea (1,000 - 4,000 mg per day)
Glutamine (3,000 mg three times per day) is helpful in treating diarrhea that is caused by irritation of the intestinal lining.
If lactose intolerance is the cause of the diarrhea, use over-the-counter lactase enzyme supplements before consuming dairy products.

Herbs

Do not use herbs to treat diarrhea without talking to your health care provider first. If your diarrhea is caused by certain types of infections, herbal treatments could make it worse. The most common herbal remedies for diarrhea are described below. They can be used as teas unless otherwise noted. 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.

Astringent herbs:

Astringent herbs, such as blackberry leaf (Rubus fruticosus) or raspberry leaf (Rubus idaeus), help "dry up" the mucous membranes in the intestine. Make a tea with 1 heaping tsp. per cup. Drink a ½ cup per hour. These teas are safe for children.
Carob powder (Ceratonia siliqua), which is rich in fiber, may be taken at the rate of 1.5 g per 2.2 pounds or 1 kg of body weight.Dissolve powder into a hydrating solution such as Pedialyte.
Extract of bilberry (Vaccinum myrtillus) also has astringent properties (4 g, spread over several doses). Do not take bilberry if you take blood-thinning medication.
Agrimony (Agrimonia eupatorium) is a traditional remedy for diarrhea. Usual dosage is 3 g (about 1/2 tsp.) per day.

Inflammation reducers:

Quercetin (250 - 500 mg two to four times per day)
Chamomile (Matricaria recutita) is usually taken as a tea. Dissolve 3 - 4 g powder (about 3 tsp.) in 1 cup hot water, strain and cool. Drink three times per day.
Marshmallow root (Althea officinalis) as cold-water tea. Soak 2 tbs. root in 1 quart of water overnight. Strain.Drink throughout the day.
Slippery elm powder (Ulmus fulva) or marshmallow root powder (Althaea officinalis). Use 1 oz. powder to 1 quart of water. Make a paste with the powder and a small amount of water. Gradually add in the rest of the water and then simmer down to 1 pint. Take 1 tsp. every 30 - 60 minutes.

Infection fighters:

Plants containing berberine can be used for infectious diarrhea. These include barberry (Berberis vulgaris) 250 - 500 mg three times per day; goldenseal (Hydrastis canadensis) 250 - 500 mg three times per day; and Oregon grape (Berberis aquifolium ), 250 - 500 mg three times per day.

Homeopathy

Some evidence suggests that homeopathic treatment may help diarrhea. In one study, children with acute diarrhea who received an individualized homeopathic treatment for 5 days had diarrhea for significantly less time than children who had placebo. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual. Some of the most effective homeopathic remedies are as follows:

Arsenicum album -- for foul-smelling diarrhea from food poisoning or traveler's diarrhea with burning sensation in the abdomen and around the anus. This remedy is most appropriate for individuals who feel exhausted yet restless and whose symptoms tend to worsen in the cold and improve with warmth. Vomiting may also occur.; Arsenicum may also be used to prevent diarrhea when traveling.
Chamomilla -- for greenish, frothy stool that smells like rotten eggs. Used primarily for children, especially those who are irritable, argumentative, and difficult to console. Chamomilla is commonly recommended for colicky or teething infants.
Calcarea carbonica -- for children who fear being in the dark or alone and who perspire heavily while sleeping. Stools may have a sour odor.
Mercurius -- for foul-smelling diarrhea that may have streaks of blood accompanied by a sensation of incomplete emptying. This remedy is most appropriate for people who tend to feel exhausted following bowel movements, experience extreme changes in body temperatures, perspire heavily, and have a thirst for cold fluids.
Podophyllum -- for explosive, gushing, painless diarrhea that becomes worse after eating or drinking. Exhaustion often follows bowel movements and the individual for whom this remedy is appropriate may experience painful cramps in lower extremities.; Podophyllum is often used in infants for diarrhea experienced from teething.
Sulphur -- for irritable and weepy children. They may have a red ring around the anus and diarrhea with the odor of rotten eggs.
Veratrum album -- for profuse, watery diarrhea accompanied by stomach cramps, bloated abdomen, vomiting, exhaustion, and chills. The diarrhea is worsened by fruit, and the individual craves cold liquids.

Acupuncture

Although several studies in traditional Chinese medicine journals have reported success in treating childhood diarrhea, acupuncturists in the United States do not generally treat this condition in children. However, acupuncture may be used when conventional treatment has failed. In this case, acupuncturists would examine both the nutritional value and the "energetic" qualities of food that might be affecting digestion.

Acupuncture is also combined with conventional medicine in treating diarrhea in adults.

Acupuncturists treat people with diarrhea based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. In the case of diarrhea, a qi deficiency is usually detected in the spleen meridian. As a result, acupuncture treatments often focus on strengthening this meridian. Moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) is frequently used in the treatment of diarrhea because its effect is thought to reach deeper into the body than needling alone.

Following Up

If your diarrhea does not stop in 3 - 5 days, contact your health care provider.

Special Considerations

If you are pregnant, tell your doctor. Dehydration can cause you to go into labor early. Also, the diarrhea-related spasms may cause you to have contractions. Do not take goldenseal (Hydrastis canadensis), barberry (Berberis vulgaris), or high doses of vitamin A if you are pregnant.

Diarrhea can be serious, even fatal, for infants and elderly people because of dehydration and the loss of electrolytes.

Supporting Research

Andreoli TE, Bennett JC, Carpenter CCJ. Cecil Essentials of Medicine. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1993:271-277.

Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace Publishers; 1995:147.

Bensky D, Gamble A. Chinese Herbal Medicine. Seattle, Wash: Eastland Press; 1986:47-49.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:425, 464.

Berkow R. The Merck Manual of Medical Information. Whitehouse Station, NJ: Merck Research Laboratories; 1997:523-525.

Carr AC, Frei B. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health effects in humans. Am J Clin Nutr. 1999;69(6):1086-1107.

Dambro MR. Griffith's 5 Minute Clinical Consult. Baltimore, Md: Lippincott Williams & Wilkins; 1999:316-319.

Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Co; 1998:617-618, 621-622, 763-766, 1047-1050, 1061-1063, 1078-1079, 1103-1104, 1201-1202, 1226-1227.

Johnston CS. Recommendations for vitamin C intake. JAMA. 1999;282(22):2118-2119.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 218-220.

Khin-Maung-U, Myo-Khin, Nyunt-Nyunt-Wai, et al. Clinical trial of berberine in acute watery diarrhoea. Br Med J 1985;291:1601-5.

Kollaritsch H, Holst H, Grobara P, Widermann G. Prevention of traveler's diarrhea with Saccharomyces boulardii. Results of a placebo controlled double-blind study. Fortschr Med 1993;111:152-6.

Lin Y, Zhou Z, Shen W et al. Clinical and experimental studies on shallow needling technique for treating childhood diarrhea. J Tradit Chin Med. 1993;13(2):107-114.

Loeb H, Vandenplas Y, Wursch P, Guesry P. Tannin-rich carob pod for the treatment of acute-onset diarrhea. J Pediatr Gastroenterol Nutr. 1989 May;8(4):480-5.

Murray MT. Encyclopedia of Nutritional Supplements. Rocklin, Calif: Prima Publishing; 1996:431-439.

Patel AV, Rojas-Vera J, Dacke CG. Therapeutic constiuents and actions of Rubus species. Curr Med Chem. 2004 Jun;11(11):1501-12.

Saavedra J. Probiotics and infectious diarrhea. Am J Gastroenterol. 2000;95:S16-18.

Saaker SA, Casswall TH, Mahalanabis D, et al. Successful treatment of rotavirus diarrhea in children with immunoglobulin from immunized bovine colostrum. Pediatr Infect Dis J 1998;17:1149-54.

Spanier JA, Howden CW, Jones MP. A systematic review of alternative therapies in the irritable bowel syndrome. Arch Intern Med. 2003;163(3):265-74.

Stein JK, ed. Internal Medicine. 4th ed. St. Louis, Mo: Mosby-Year Book; 1994:436-440.

Stoller JK, Ahmad M, Longworth DL, eds. The Cleveland Clinic Intensive Review of Internal Medicine. Baltimore, Md: Williams & Wilkins; 1998:638-643.

Su Z. Acupuncture treatment of infantile diarrhea: a report of 1050 cases. J Tradit Chin Med. 1992;12(2):120-121.

Ullman D. Homeopathic Medicine for Children and Infants. New York, NY: Penguin Putnam; 1992: 75-77.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin Putnam; 1995: 243-245.

Walker LP, Brown EH. The Alternative Pharmacy. Paramus, NJ: Prentice Hall Press; 1998:147-150.

Review Date:
6/27/2006
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

Anemia

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

In This Report

Highlights
Introduction
Causes
Risk Factors
Complications
Symptoms
Diagnosis
Dietary Factors
Treatment
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

FDA Issues Labeling Changes for Drugs That Boost Red Blood Cells

In November 2007, the U.S. Food and Drug Administration (FDA) made several changes to the prescribing labels for erythropoiesis-stimulating drugs. These drugs -- epoietin alfa (Epogen, Procrit) and darbepoetin alfa (Aranesp) -- increase the production of red blood cells. They are used to treat anemia associated with chronic kidney failure, cancer chemotherapy, and antiretroviral HIV therapy.

The new labels have stronger warnings and updated dosing-related safety information. The FDA advises:

For cancer, erythropoiesis-stimulating drugs are used only to treat anemia associated with chemotherapy. Dosing should increase hemoglobin levels to no more than 12 g/dL. These drugs can shorten survival time and increase tumor growth when hemoglobin levels are raised beyond this point. Treatment should stop as soon as chemotherapy is completed. Erythropoiesis-stimulating drugs are not safe or appropriate for all patients undergoing chemotherapy. Patients should discuss the risks and benefits with their oncologists.
For chronic kidney failure, erythropoiesis-stimulating drugs should be used to maintain a hemoglobin level between 10 - 12 g/dL. Higher hemoglobin levels increase the risk for stroke, heart attack, heart failure, or death.
Erythropoiesis-stimulating drugs are used to increase red blood cell numbers and reduce the need for blood transfusions. They do not help improve anemia symptoms, fatigue, or quality of life for patients with cancer or HIV.
Patients who take these drugs should contact their doctors if they experience symptoms such as leg pain or swelling, increased shortness of breath, increased blood pressure, dizziness, or extreme fatigue.

Introduction

Anemia is an abnormal reduction in red blood cells.

This photmicrograph shows normal red blood cells (RBCs) as seen in the microscope after staining.

Anemia is a global problem, at its worst in developing countries. But it is by no means absent in industrialized nations. An estimated 3.4 million Americans suffer from anemia. Anemia is not a single disease but a condition, like fever, with many possible causes and many forms. Causes of anemia include nutritional deficiencies, inherited genetic defects, medication-related side effects, and chronic disease. It can also occur because of blood loss from injury or internal bleeding, the destruction of red blood cells, or insufficient red blood cell production. The condition may be temporary or long-term, and can manifest in mild or severe forms.

As it is impossible to discuss all types of anemia, this report focuses on three of the most common forms:

Iron deficiency anemia
Anemia of chronic disease (ACD)
Megaloblastic anemia (caused by deficiencies in the B vitamins folate, vitamin B12, or both)

Some less common causes and types of anemia are included in a table in this report.

Blood has two major components:

Plasma is a clear yellow liquid that contains proteins, nutrients, hormones, electrolytes, and other substances. It constitutes about 55% of blood.
White and red blood cells and platelets make up the balance of blood. The white cells are the infection fighters for the body, and platelets are necessary for blood clotting. The important factors in anemia, however, are red blood cells.

Red blood cells (RBCs), also known as erythrocytes, carry oxygen throughout the body to nourish tissues and sustain life. Red blood cells are the most abundant cells in our bodies. Men have about 5.2 million red blood cells per cubic millimeter of blood, and women have about 4.7 million per cubic millimeter of blood.

Hemoglobin and Iron

Each red blood cell contains 200 - 300 hemoglobin molecules. Hemoglobin is a complex molecule, and it is the most important component of red blood cells. It is composed of protein (globulin) and a molecule (heme), which binds to iron.

In the lungs, the heme component binds to oxygen in exchange for carbon dioxide. The oxygenated red blood cells are then transported to the body's tissues, where the hemoglobin releases the oxygen in exchange for carbon dioxide, and the cycle repeats. The oxygen is used in the mitochondria, the power source within all cells.

Red blood cells typically circulate for about 120 days before they are broken down in the spleen. Most of the iron used in hemoglobin can be recycled from there and reused.

Structure and Shape of Red Blood Cells

Red blood cells -- the erythrocytes -- are extremely small and look something like tiny, flexible inner tubes. This unique shape offers many advantages:

It provides a large surface area to absorb oxygen and carbon dioxide.
Its flexibility allows it to squeeze through capillaries, the tiny blood vessels that join the arteries and veins.

Abnormally shaped or sized erythrocytes are typically destroyed and eliminated.

Blood Cell Production (Erythropoiesis)

The actual process of making red blood cells is called erythropoiesis. (In Greek, erythro means "red," and poiesis means "the making of things.") The process of manufacturing, recycling, and regulating the number of red blood cells is complex and involves many parts of the body:

The body carefully regulates its production of red blood cells so that enough are manufactured to carry oxygen but not so many that the blood becomes thick or sticky (viscous).
Most of the work of erythropoiesis occurs in the bone marrow. In children younger than 5 years old, the marrow in all the bones of the body is enlisted for producing red blood cells. As a person ages, red blood cells are eventually produced only in the marrow of the spine, ribs, and pelvis.
If the body needs more oxygen (at high altitudes, for instance), the kidney triggers the release of the hormone erythropoietin (EPO), a hormone that acts in the bone marrow to increase the production of red blood cells.
The lifespan of a red blood cell is 90 - 120 days. The liver and the spleen remove old red blood cells are removed from the blood by the liver and spleen.
When old red blood cells are broken down for removal, iron is returned to the bone marrow to make new cells.

Click the icon to see an image of the formed elements of blood.

Click the icon to see an image of hemoglobin.

Causes

Iron deficiency anemia occurs when the body lacks mineral iron to produce the hemoglobin it needs to make red blood cells. In general, there are three stages leading from iron deficiency to anemia:

First, there is an insufficient supply of iron, which causes iron stores in the bone marrow to be depleted. This stage generally has no symptoms.
Second, iron deficiencies develop and begin to affect hemoglobin production. (Tests will show low hemoglobin and hematocrit levels.)
Hemoglobin production declines to the point where anemia develops.

Most of the iron used in the body can be recycled from blood and reused. Nevertheless, iron deficiency can occur from a number of conditions.

Inadequate Iron Intake. A healthy diet easily provides enough iron. In general, most people need just 1 mg, and menstruating women need 2 mg of extra iron each day. This means that lack of iron in the diet is not a common cause of iron deficiency anemia, except in infants. In fact, most American adults may be consuming too much iron in their diet. Most of the iron in red blood cells is recycled and reused. Iron-poor diets are a cause of anemia only in people with existing risks for iron deficiency. Children who have not yet eaten iron-fortified formulas or iron-enriched cereal may also become anemic.

Blood Loss. Iron deficiencies most commonly occur from internal blood loss due to other conditions that range in severity. These conditions include:

Peptic ulcers, which may be caused by H. pylori infections, or aspirin and drugs or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen. About 70% of long-term users of these medications have some sign of gastrointestinal bleeding, although it is rarely significant enough to cause anemia.
Duodenal ulcers
Hemorrhoids
Colon polyps
Colon, stomach, and esophageal cancer
Very heavy periods (menorrhagia) are the most common causes of anemia in premenopausal women.
Bleeding from esophageal varices, often present in alcoholics

Impaired Absorption of Iron. Impaired absorption of iron is caused by:

Certain intestinal diseases (inflammatory bowel disease, celiac disease)
Surgical procedures, particularly those involving removal of parts of the stomach and small intestine, can impair the ability of the stomach or intestine to absorb iron. (Such conditions also often impair folic acid absorption as well.)
Pica, the craving for non-food substances such as ice, starch, or clay, is a possible cause of iron deficiency. To complicate matters, pica (particularly ice cravings) may also be a symptom, rather than a cause, of anemia.
Certain intestinal infections, such as hookworm and other parasites.

Click the icon to see an image of inflammatory bowel disease.

Genetic Causes. Some people are born with iron deficiency. Certain cases may be due to a mutation of the Nramp2 gene, which regulates a protein responsible for delivering iron to the cells.

Anemia of chronic disease (ACD), also called anemia of chronic inflammation (ACI), is a common condition associated with a wide variety of persistent inflammatory diseases. It can be very severe and require transfusions.

The Inflammatory Process and ACD. ACD is not completely understood. In ACD, iron is not efficiently recycled from blood cells, and red blood cell survival is reduced. In addition, there is impaired response to erythropoietin, the hormone that acts in the bone marrow to increase the production of red blood cells. (Abnormal function and low levels of erythropoietin, in fact, may be the most important factor in ACD, with iron insufficiencies being a consequence.)

The process leading to ACD may occur in the following way:

The immune system activates white blood cells and releases various compounds during times of infection that are intended to fight invaders and heal wounds. Such an event causes an inflammatory state in the areas of the attack.
White blood cells called macrophages release small but powerful proteins known as cytokines, which are critical in the development of ACD. Cytokines are indispensable for healing. However, cytokines are overproduced often in chronic and inflammatory diseases, causing serious tissue injury and, in some cases, even organ damage. In the case of ACD, they prevent production of erythropoietin, the hormone that acts in the bone marrow to increase the production of red blood cells. Specific cytokines implicated in anemia are interleukin 1 (IL-1), tumor necrosis factor (TNF), and interferons.
As part of this process, mechanisms prevent the release of recycled iron needed in the bone marrow for the manufacturing of red blood cells. Iron absorption in the intestines is also blocked. Theoretically, this is a protective measure, since iron may help infectious organisms proliferate. In such cases, iron stores are high, but the usable iron in circulation is low.
Researchers have identified a peptide called hepcidin, which prevents iron absorption in the intestine and blocks the release of iron by immune factors for red blood cell production. Some experts believe high levels of the peptide may play a central role in preventing the release of iron during infection and inflammatory states, and is critical in ACD.

Diseases Associated with ACD and Inflammation. The chronic diseases that are associated with this process include:

Certain cancers. Examples include lymphomas and Hodgkin's disease.
Autoimmune diseases. Examples include rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, and polymyalgia rheumatica.
Long-term infections. Examples include chronic or recurrent urinary tract infections and osteomyelitis.
Hepatitis C. The liver cirrhosis associated with hepatitis C can reduce the production of red blood cells. Gastrointestinal bleeding may also contribute to blood loss.
Heart failure. Experts estimate that 25 - 60% of patients with heart failure also have anemia. However, it is unclear whether anemia actually causes or worsens heart failure. Recent research suggests it may actually be a sign (marker) of heart failure. Iron deficiency in heart failure can be due to a number of factors. It may be caused by a lack of nutrients in a person’s diet or by the body’s inability to absorb nutrients from food. Heart failure can also cause a back up of fluid (edema). This edema produces a higher volume of blood plasma (the liquid part of blood), which can dilute red blood cells and cause anemia.
Chronic kidney disease. The hormone erythropoietin (EPO) is produced in the kidneys and stimulates the bone marrow production of red blood cells. Diseased kidneys do not release sufficient amounts of EPO; anemia can result and is universal in end-stage renal disease. Chronic kidney disease is a common complication of diabetes.
HIV/AIDS. The inflammatory process associated with AIDS can adversely affect EPO levels and red blood cell production.
Anemia in critically ill patients. Evidence suggests similarities between ACD and severe anemia in patients who are in intensive care. Some experts believe that the cause of anemia in such critically ill patients may also be due to inflammatory responses that promote impaired responsiveness to erythropoietin.

Not all chronic diseases involve the inflammatory process and anemia. For example, high blood pressure is a chronic disease, but it does not affect red blood cells.

Treatment-Related Anemia. Anemia can also result from the therapies used to treat conditions. For example, anemia is a common side effect of cancer treatments. Chemotherapy and radiation can impair the bone marrow's production of red blood cells and contribute to the extreme fatigue that many patients experience during cancer therapy. Patients with hepatitis C frequently receive combination therapy of ribavirin and interferon; ribavirin can induce anemia. Hepatitis C also affects many patients with HIV or AIDS. In addition to ribavirin, patients with HIV or AIDS can develop anemia as a result of highly active anti-retroviral therapy (HAART) and, in particular, from the drug AZT.

Other medications that increase the risk for anemia are certain antibiotics, some antiseizure medications (phenytoin), immunosuppressive drugs (methotrexate, azathioprine), antiarrhythmic drugs (procainamide, quinidine), and anti-clotting drugs (aspirin, warfarin, heparin).

Megaloblastic anemia is the end-product of deficiencies in the B vitamins folate or vitamin B12 (also called cobalamin), or both. Such deficiencies produce abnormally large red blood cells (megaloblastic ) that have a shortened lifespan. Neurologic problems are also associated with these deficiencies. Several conditions can cause these deficiencies.

Click the icon to see an image of red blood cells seen in megaloblastic anemia.

Causes of Vitamin B12 Deficiency. Conditions that cause vitamin B12 deficiencies include:

Vitamin B12 deficiency from diet is very rare, since the liver stores over a 3-year supply. It usually does not occur even in alcoholism, vegetarianism, or in malnourished people with kidney failure or cancer. Since animal products are the chief source, however, true vegan vegetarians may need a supplement, fortified food, or appropriate food selection known to contain adequate amounts of this vitamin
Pernicious anemia. Pernicious anemia is an autoimmune disease in which antibodies are tricked into attacking stomach cells. This results in impaired production of intrinsic factor (IF), a compound that is critical for absorption of vitamin B12. Pernicious anemia is diagnosed in about 1% of people over age 60, with women having a higher risk than men.
Complications of gastrointestinal surgery. Surgeries such as stomach bypass or stapling, which remove part or all of the stomach, pose a 15 - 30% chance of causing vitamin B12 deficiencies.
Overgrowth of intestinal bacteria
Tropical sprue (an acquired malabsorption disease occurring in tropical climates)

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

Causes of Folate Deficiency. The body stores only about 100 times its daily requirements for folate and can exhaust this supply within about 3 months if the diet is deficient in folate.

Poor diet coupled with alcoholism is the most common cause of folate deficiency. Alcohol abuse not only contributes to malnutrition but also causes chemical changes that can result in lower folate levels.
Any condition that disturbs the small intestine and impairs its absorption ability can cause a deficiency. Such disorders include inflammatory bowel disease or celiac sprue (a sensitivity reaction to gluten)

Click the icon to see an image of foods that contain gluten.

Parasitic diseases such as giardiasis
Short bowel syndrome
Deficiencies can also arise due to high demand for folic acid caused by conditions such as cancer, pregnancy, severe psoriasis, severe hyperthyroidism, and hemolytic anemia.
Some drugs, including phenytoin, methotrexate, trimethoprim, and triamterene, may also hinder folate absorption.


Form of Anemia	Description and Diagnosis	Causes and Risk Factors	Treatments
Aplastic Anemia	Bone marrow fails to produce all types of blood cells. Symptoms, in addition to standard anemia, are bleeding in mucous membranes and skin, gingivitis, higher risk for infection, and shortness of breath.	Cause is unknown in half the cases. Known causes include hereditary conditions (Fanconi's anemia), viruses (HIV, hepatitis, Epstein-Barr), autoimmune diseases (lupus, rheumatoid arthritis), medications (valproic acid, tacrolimus, azathioprine) or chemicals (benzene, pesticides).	Transfusions, antibiotics, bone marrow or stem cell transplantation, immunosuppressant drugs. (This anemia used to be nearly always fatal, but survival rates now can reach 92% with successful transplants and up to 87% with immunosuppressants.)
Thalassemia	Genetic blood disease caused by a defect in the rate of production of hemoglobin. The two major forms are thalassemia minor and thalassemia major (Cooley's anemia, beta thalassemia). Thalassemia minor is the more common and milder form, in which lifespan is normal. Thalassemia major can be serious, but it is fortunately very rare.	Affects males and females equally. Most common in people of Mediterranean descent, especially Italians and Greeks. Both types of thalassemia are found in an area that extends from northern Africa and southern Europe to Thailand, including Iran, Iraq, Indonesia, and southern China. Thalassemia major is more common in families who intermarry.	Transfusions to supply enough red blood cells to achieve moderate anemia and avoid iron overload are standard approaches for thalassemia major. Investigations are ongoing to find alternatives to transfusions. Hydroxyurea, 5-azacytidine, erythropoietin, or butyrate analogues may help some patients. Bone marrow transplantation may be needed for some types of thalassemia.
Hemolytic Anemias: Acquired	Anemia caused by hemolysis (premature destruction of red blood cells). Diagnosis considered when there is marked increase in RBC production by bone marrow.	Autoimmune hemolytic anemia is the primary type, in which antibodies produced by the immune system damage RBCs. Cause unknown or associated with disorders such as systemic lupus erythematosus, lymphoma, and paroxysmal nocturnal hemoglobinuria. Other causes are high exposure to certain metals or chemicals (lead, copper, benzene, naphthalene), snake and insect bites, malaria, transfusions, post-surgical complications, and drugs such as methyldopa. In infants, blood group incompatibility between mother and child or infections in the womb.	Corticosteroids for autoimmune hemolytic anemia. Transfusions beneficial in many cases. Various immunosuppressive drugs may be tried, as well as splenectomy. Eculizumab (Soliris) is approved for treatment of paroxysmal nocturnal hemoglobinuria.
Hemolytic Anemias: Inherited	Hemolysis (premature destruction of RBCs) caused by sphere-shaped RBCs, which have difficulties circulating through the spleen.	Inherited defects include membrane defects, hemoglobin abnormalities, and enzyme deficiencies. Fava beans may trigger symptoms. More likely and more serious in males than females.	Blood transfusions may be necessary for some types of hemolytic anemia. Experimental trials use immune globulin. Removal of the spleen (splenectomy) or bone marrow transplantation may help some patients.
Sideroblastic Anemias	Group of anemias caused by impaired ability of bone marrow to produce normal RBCs. Normal-to-high iron levels, but iron cannot be used to make hemoglobin. In addition to the standard symptoms of anemia are jaundice, enlarged liver and spleen, fever, headache, loss of appetite, vomiting, and leg sores. Symptoms can be mild. Usually appears in childhood. Infections, trauma, and pregnancy may trigger symptoms.	Inherited or acquired after excessive alcohol use, certain medications, including chloramphenicol, or other disorders, including some cancers and rheumatoid arthritis. More common in the elderly.	Deferoxamine (Desferal) is used to remove iron. Effectiveness is increased when ascorbate is added to the regimen. Folate and pyridoxine are used, but their effectiveness is under question.
Sickle Cell Anemia	Serious, life-threatening, inherited disease. The sickle-shaped, inflexible RBC has impaired ability to squeeze through vessels. Short lifespan of RBC (10-20 days) causes anemia. In addition to anemia symptoms, joint and bone pain, infections, and heart failure can occur.	Disease occurs in 0.6% and the trait is found in the genetic makeup of 9% of African-Americans. Also occurs in people from India and Spanish-speaking and Mediterranean regions.	Measures to avoid cycling and control pain. Including hydration, hydroxyurea, NSAIDs and narcotic analgesics. Bone marrow transplantation. [For information, see In-Depth Report #58: Sickle-cell disease.]

Click the icon to see an image of red blood cells found in sickle cell anemia.

Risk Factors

Although nutritional iron-deficiency anemia has declined in industrialized nations, it affects an estimated 2 billion people worldwide. Even in the U.S., iron deficiency is the most prevalent nutritional deficiency. It is highly associated with poverty. People in lower socioeconomic groups have double the risk of those who are middle or upper class.

Among Americans with iron deficiency anemia, young children have the highest risk followed by premenopausal women. Adolescent and adult men and postmenopausal women have the lowest risk. Men, in fact, are at risk for iron overload, probably because of their higher meat intake.

General Risk Factors for Anemia in Infants and Children. Up to 20% of American children and 80% of children in developing countries become anemic at some point during their childhood and adolescence. Iron deficiency is the most common cause in children, but other forms of anemia, including hereditary blood disorders, can also cause anemia in this population. Hispanic American children have double the rates of iron deficiency as African-American and Caucasian children.

Iron deficiency affects about 9% of children younger than 2 years. About 3% of children in this age group are anemic as a result. Children in lower-income homes are at higher risk than those in higher income homes. In a study of low-income children, ages 6 months to 5 years, the prevalence of anemia was over 10%, and was nearly 18% in children younger than 2 years. However, children in any income group can develop iron deficiency.

Young children 9 - 18 months have the highest risk for iron deficiency anemia in the U.S. Such children also are at great risk for problems in mental development from anemia. Infant boys may have 10 times more risk than baby girls. In general, full-term, breast-fed infants have enough iron stores for their first 6 months of life. After that, they must rely on other sources for iron.

Iron-deficiency anemia in infants and small children can be due to one or more of the following factors:

Stopping breast-feeding too early or using formula that isn't iron-fortified.
Bottle-feeding too long. Studies indicate that the longer children are bottle-fed, the greater the risk for iron-deficiency and anemia. Toddlers 12 months and older should not drink more than 2 cups of milk a day. Cow’s milk is good for children, but it does not contain enough iron. Too much milk can decrease children’s appetite and prevent them from eating the iron-rich food they need. When babies who are bottle-fed are 7 - 9 months old, they should be weaned from bottles and given sippy cups. By the age of 12 months, all children should be using a cup instead of a bottle.
Toddlers’ preferences for iron-poor food. Parents should make sure that their children eat iron-rich foods, such as beans, meat, fortified cereals, eggs, and green leafy vegetables

Better social services and more accurate ways of diagnosing and monitoring anemia are needed in these high-risk groups. There is still considerable debate on how to define iron deficiency and anemia in infants. New research suggests that a reticulocyte hemoglobin content (CHr) test may be better than a standard hemoglobin test for detecting iron deficiency in babies. Reticulocytes are immature red blood cells. The CHr test measures the amount of hemoglobin in these cells.

Up to 10% or more of adolescent and adult women under 49 years are iron deficient. Hispanic American and African-American women have double the prevalence for anemia compared to Caucasian women. The risk for anemia in adolescent girls is about 3%. Anemia is generally mild in young women, however, and is more likely to occur with one or more of the following conditions:

Heavy menstruation for longer than 5 days
Abnormal uterine bleeding, such as from fibroids
Pregnancy. About 20% of women in industrialized countries have iron deficiency during pregnancy. Multiple pregnancies and births significantly increase the risk.

Although studies have reported various estimates on the prevalence of anemia in older adults, one survey suggested that anemia affects about 10% of adults aged 65 years and older, and more than 20% aged 85 years and older. The causes of anemia in older adults were equally distributed among nutritional deficiencies, chronic inflammatory disease, chronic renal disease, and unexplained anemia. Most cases were mild.

People with alcoholism are at risk for anemia both from internal bleeding as well as folate- and vitamin B deficiency-related anemias.

Although most Americans probably consume too much iron in their diets, some people may be at risk for diet-related iron deficiencies, including:

People whose diets are high in processed foods and lack any meat.
Strict vegetarians. Vegetarians who avoid all animal products may have a slightly higher risk for deficiencies in iron and some B vitamins. Although dried beans and green vegetables often contain iron, it is less easily absorbed from plants than from meat. Fortunately, most commercial cereals are fortified with vitamin B12 and folic acid (the synthetic form of folate).

Anyone with a chronic disease that causes inflammation or bleeding is at risk for anemia. Critical illness in the intensive care unit is also highly associated with anemia.

Working out regularly may cause some iron loss, which is comparable to that from menstruation and rarely worrisome. Dietary choices may account for most cases of sports anemia. Intense, sustained exercise, such as that performed by marathon runners, may cause a condition called sports anemia, which may be due to slight gastrointestinal bleeding, damaged red blood cells, low iron intake, or poor intestinal absorption of iron.

Iron deficiency occurs in 20% of pregnant women in developed countries. Even worse, 50% or more of women in nonindustrialized nations become iron deficient, and 30 - 50% are deficient in folic acid. Severe anemia is associated with a higher mortality rate among pregnant women. Mild-to-moderate anemia, however, does not pose any elevated risk.

Pregnancy increases the risk for anemia in different ways:

It increases the body's demand for folic acid and, therefore, poses a risk for deficiencies and an increased risk for megaloblastic anemia. Low levels of folate during pregnancy increase the risk of neural tube defects in newborns.
It increases the body's demand for iron, thus posing a risk for iron deficiency anemia. Pregnant or nursing women need 30 mg of iron per day. Maternal iron deficiency anemia is associated with increased weight or size of the placenta, a condition that may later pose a risk for high blood pressure in the offspring. Pregnant women with low hemoglobin levels (the iron-bearing component in the blood) have an elevated risk for pre-term or low birth weight infants.
Pregnancy is also associated with fluid retention, which in turn may produce high volumes of plasma (the fluid component of blood). This can dilute red blood cells, which may lead to anemia.
After delivery, heavy bleeding, which occurs in 5 - 10% of women who have given birth, can cause symptoms of anemia.

Diagnosing of Iron Deficiency During Pregnancy. A diagnosis of iron deficiency is problematic in pregnant women. The standard test is a measurement of ferritin levels, which are low in most people with iron deficiency. Pregnant women, however, may have high ferritin blood levels into their third trimester but still be iron deficient. A newer test that measures a factor called serum transferrin receptor may prove to be a useful way of diagnosing iron deficiency in women. Researchers are also investigating Doppler ultrasonography as an imaging technique for detecting anemia in the fetus. Traditionally, fetal anemia is diagnosed through amniocentesis. Doppler ultrasonography is a non-invasive method that does not risk causing a miscarriage or a worsening of fetal anemia.

Preventing Anemia in Pregnant Women.

Iron Supplements. For the past 40 years, iron supplements have been recommended for all pregnant women. This practice has been challenged recently, however. There is no clear-cut evidence that the mild iron deficiency most pregnant women experience is harmful. In addition, iron supplements cause gastrointestinal side effects and may not be completely harmless. Some experts suggest iron supplements for all pregnant women whose hemoglobin levels are less than 11 g/dl, and pregnant women whose serum ferritin levels are low, beginning in their 20th - 24th weeks of pregnancy.
Vitamin Supplements. Women who are trying to conceive, who are pregnant, and who are breast-feeding should take 400 mcg of folic acid a day. They should be sure this is folic acid and not folate. Folate is the natural form of folic acid, but 400 mcg supplements of folate are half as potent as the same dose of folic acid. Pregnant and nursing women who are vegetarians should be sure to have supplements of folic acid and other B vitamins as well, since many of these nutrients are found primarily in animal products. Vitamin B12 deficiencies during pregnancy can also produce anemia in both mother and child.
Diets Rich in Vitamin C. Eating foods rich in vitamin C can help absorb iron.

Treating Anemia During Pregnancy. Pregnant women who become anemic and need treatment may be given oral iron supplements, or blood transfusions in severe cases. Intravenous or intramuscular administration of iron helps improve blood levels better than oral iron supplements, but may cause more serious side effects.

Complications

Most cases of anemia are mild, including those that occur as a result of chronic disease. Nevertheless, even mild anemia can reduce oxygen transport in the blood, causing fatigue and a diminished physical capacity. Moderate-to-severe iron-deficiency anemia is known to reduce endurance. Some studies indicate that even iron deficiency without anemia can produce a subtle but still lower capacity for exercise.

Because a reduction in red blood cells decreases the ability to absorb oxygen from the lungs, serious problems can occur in prolonged and severe anemia that is not treated. Anemia can lead to secondary organ dysfunction or damage, including heart arrhythmia and heart failure.

Certain inherited forms of anemia, including thalassemia major, pernicious anemia, and sickle-cell anemia, can be life threatening. Thalassemia major and sickle-cell anemia affect children and are particularly devastating.

Pregnant women with significant anemia may have an increased risk for poor pregnancy outcomes, particularly if they are anemic in the first trimester.

In children, severe anemia can impair growth and motor and mental development. Children may exhibit a shortened attention span and decreased alertness. Children with severe iron-deficiency anemia may also have an increased risk for stroke.

Anemia is common in older people and can have significantly more severe complications than anemia in younger adults. Some studies have reported higher mortality rates in anemic individuals 85 and older compared to their non-anemic peers. (The rates were higher in anemic men than in women.) The following are examples of its effects from different studies:

Anemia may have adverse effects on the heart and increase the severity of cardiac conditions, including reducing survival rates from heart failure and heart attacks.
Elderly people with lower levels of hemoglobin are at an increased risk of death.
Anemia may be associated with an increased incidence of falls.
Even mild anemia may possibly lead to cognitive impairment. A 2006 study of elderly women found that mild anemia worsened problem-solving abilities and other cognitive functions. Anemia may worsen an already existing dementia.

In addition to anemia, vitamin B12 deficiency can cause neurologic damage, which can be irreversible if it continues for long periods without treatment.

Anemia is particularly serious in cancer patients. In people with many common cancers, the presence of anemia is associated with a shorter survival time.

Anemia is associated with higher mortality rates and possibly heart disease in patients with kidney disease.

The combination of anemia and heart failure can increase the risk of hospitalization or death by 30 - 60%. Patients with heart failure whose hemoglobin levels decline do worse than patients with stable levels.

Blood transfusions. Patients with certain types of anemia require frequent blood transfusions. These transfusions can cause iron overload. Patients are treated with iron chelation therapy, which uses a drug that binds to iron. Excess iron is then eliminated by the kidneys. The standard drug for iron chelation therapy, deferoxamine (Desferal), is injected intravenously through an infusion pump. The treatment can be difficult for many patients. In 2005, the FDA approved a new drug, deferasirox (Exjade), to treat iron overload due to blood transfusions. Patients dilute the pills in liquid once a day and drink the mixture.

Symptoms

Symptoms of anemia vary depending on the severity of the condition. Anemia may occur without symptoms and be detected only during a medical examination that includes a blood test. When they occur, symptoms may include:

Weakness and fatigue are the most common symptoms of even mild anemia. Even iron deficiency without anemia can reduce working capacity in some people.
Shortness of breath on exertion
Rapid heartbeat
Lightheadedness or dizziness
Headache
Ringing in the ears (tinnitus)
Irritability and other mood disturbances
Pale skin (however, healthy-looking skin color does not rule out anemia if a patient has risk factors and other symptoms of anemia)
Mental confusion
Loss of sexual drive

Pica. One odd symptom, in some cases a cause of iron deficiency, is pica. This is the habit of eating unusual substances, such as ice (called pagophagia), clay, cardboard, foods that crunch, or raw starch. For example, in one study, half of people whose pica took the form of pagophagia (eating at least one tray of ice every day for 2 months) or eating foods that crunch (such as raw potatoes, carrots, or celery) were iron deficient. The pica often stops, particularly in children, when iron supplements are given. Pica is difficult to detect because patients are often ashamed to admit to such cravings.

Frequent Breath Holding. Studies have also indicated that children who hold their breath frequently when angry or upset, even to the point of fainting, may be iron-deficient. In one study, taking iron supplements reduced this phenomenon in 88% of treated children.

Symptoms of Megaloblastic Anemia. The symptoms of megaloblastic anemia from vitamin B12 or folic acid deficiencies include not only standard anemic symptoms but also:

Inflammation of the mouth (stomatitis)
Inflammation of the tongue (glossitis), which involves shrinkage at the surface and edges of the tongue

Over time, psychiatric and neurologic problems develop. Vitamin B12 deficiencies cause neurologic symptoms (numbness and tingling, depression, memory loss, and irritability), and folate deficiency may result in depression and dementia (in severe cases).

Symptoms of Pernicious Anemia. Early neurologic symptoms of pernicious anemia are due to B12 deficiency. They include numbness and tingling, depression, memory loss, and irritability. Advanced nerve damage can cause loss of balance and staggering, confusion, dementia, spasticity, loss of bladder control, and erectile dysfunction. Folic acid deficiency does not cause neurologic damage, although people with this deficiency can be irritable, forgetful, and experience personality changes. Of concern for patients with pernicious anemia and B12 deficiency anemia is that folic acid supplements can mask the presence of this disease in its early stages but not cure it. The only cure is vitamin B12 supplementation.

Diagnosis

The first step in any diagnosis is a physical examination to determine if the patient has symptoms of anemia and any complications. Because anemia may be the first symptom of a serious illness, determining its cause is very important. This may be difficult, particularly in the elderly, malnourished, or people with chronic diseases, whose anemia may be caused by one or more factors. A detailed medical, personal, and dietary history should report:

Any family or personal history of anemia
A history of gallbladder disease, jaundice, or enlarged spleen
Heavy menstrual bleeding in women
Any occurrence of blood in the stool or other signs of internal bleeding. (Even if the patient has not observed any bleeding, nonvisible blood may be present, so a rectal exam and stool test are essential.)
Any dietary history, particularly in people who are elderly, poor, or both

The doctor should examine the patient carefully, especially checking for swollen lymph nodes, an enlarged spleen, and pale skin and nail color.

Specific blood tests are given to determine anemia from any cause.

Blood and Hemoglobin Counts. A complete blood count (CBC) test is performed to determine the presence of anemia. The red blood cells, or erythrocytes, and their iron-bearing component, hemoglobin, are measured.

For example, severe anemia in adults is defined by the World Health Organization as:

Hemoglobin concentrations below 12 g/dL (7.5 mmol/L) in women. (Some evidence suggests that in older women anemia should be diagnosed at 13 g/dL and below.)
Below 13 g/dL (8.1 mmol/L) in men.

A low red blood cell (RBC) count could indicate a number of problems, including bleeding or a failure by bone marrow to manufacture red blood cells.

Hematocrit. Calculating the percentage of red blood cells in blood plasma (a measurement called the hematocrit) is also important. Plasma is the liquid portion of blood. People with a high volume of plasma may be anemic even if their blood count is normal because the blood cells have become diluted.

Normal percentages are highest in the very youngest individuals and decline as people age. They also vary by gender. The following are some examples of normal range:

Newborns: 42 - 60%
Children: 35 - 45%
Adult males: 41 - 53%
Adult women: 36 - 46%

Normal value ranges may vary slightly among different laboratories.

Smokers, people at high altitudes, and those who are dehydrated tend to have higher than normal hematocrit levels. Those at greater risk for low hematocrit levels include pregnant women and patients with cirrhosis, heart failure, and splenomegaly.

Reticulocyte Count. Reticulocytes are immature red blood cells, and their count reflects the rate of red blood cell production. The upper normal limit is about 100,000/mL. A low count, when bleeding isn't the cause, suggests problems in production in the bone marrow. An abnormally high count indicates that the red blood cells are being destroyed in high numbers and indicates hemolytic anemia. New research suggests that the reticulocyte hemoglobin content (CHr) test may be more accurate than a standard hemoglobin test for detecting iron deficiency in infants. This test may help identify babies who are at risk for becoming anemic and help them get treated earlier.

Blood Morphology. A blood smear viewed under a microscope allows an expert to classify the blood by its color, size, and shape ( morphology ). Generally red blood cells are categorized as:

Pale-colored (hypochromic) and abnormally small (microcytic)
Normal colored and normal sized (normochromic, normocytic)
Abnormally large (macrocytic)

The shape of the red blood cells, which can be distorted in many blood disorders, is also important in determining a diagnosis.

There are two steps in making a diagnosis in patients with symptoms of iron deficiency anemia:

The first step is to determine if a person is actually deficient in iron.
If iron stores are low, the second step is to diagnose the cause of the iron deficiencies, which will help determine treatment.

Determining if Iron Stores are Low. The following findings are important in determining that a person is iron deficient:

Blood cells viewed under the microscope are pale (hypochromic) and abnormally small (microcytic). They are also mostly uneven in shape. (These findings suggest iron deficiency, but they can also appear in cases of anemia due to chronic disease and thalassemia.)
Hemoglobin and iron levels are low. (These findings further suggest iron deficiency, but they can also occur in cases of anemia due to chronic disease.)
Ferritin levels are low. Ferritin is a protein that binds to iron. Low levels typically mean reduced iron stores. High ferritin levels in the blood do not always mean sufficient iron stores. For example, pregnant women may have high ferritin levels into their third trimester but still be iron deficient. Ferritin levels may also be normal or even elevated in patients with inflammation from anemia due to chronic disease, even if they also have low iron stores.
In children with iron deficiencies, reticulocytehemoglobin levels are low. Reticulocytes are immature red blood cells, and this test may be the most effective approach for diagnosing iron deficiency in children.
A test that measures a factor called serum transferrin receptor (TfR) is proving to be very sensitive in identifying iron deficiency in problematic patients, including the elderly with chronic diseases and possibly pregnant women. (It is often very difficult to identify iron deficiencies in patients who also have anemia due to chronic diseases because their ferritin levels are often normal or even high.) For example, levels of TfR are high in patients with ACD and iron deficiency anemia, but they are normal or only slightly raised in ACD alone. The test is expensive, however, and some experts recommend it should be used only when there is a high suspicion of iron deficiency in the elderly.
Measuring erythrocyte zinc protoporphyrin (ZPP), a product of abnormal heme synthesis, is under investigation and may prove to be a simple and precise measure of iron deficiencies, particularly in children.

If internal bleeding is suspected as the cause, the gastrointestinal tract is usually the first suspect as the source. A diagnosis in these cases can often be made if the patient has noticed blood in the stools, which can be black and tarry or red-streaked. Often, however, bleeding may be present but not visible. If so, stool tests for this hidden (occult ) blood are required. Additional tests may then be needed to diagnose the precipitating condition. Endoscopy, in which a fiber optic tube is used to view into the gastrointestinal tract, is helpful in many patients, particularly when the source of bleeding is unclear. A colonoscopy may also be recommended to rule out colorectal cancer.

If the patient's diet suggests low iron intake and other causes cannot be established using inexpensive or noninvasive techniques, then the patient may simply be given a monthly trial of iron supplements. If the patient fails to respond, further evaluation is needed.

Usually anemia of chronic disease is recognized during the management of the primary disease and, if the anemia is mild, additional diagnostic tests are rarely needed. The following are typical findings in ACD:

The blood cells are normal looking.
Blood tests may typically show low levels of iron in the blood, but ferritin levels are normal or even high. (Low levels of ferritin, a protein that binds to iron, indicate iron deficiency.)

Doctors need a multi-step diagnostic procedure for determining vitamin B deficiencies and the anemias that cause or are caused by them. Doctors may arrive at a diagnosis of vitamin B12 or folic acid deficiencies from different routes:

They may diagnose deficiencies after detecting megaloblastic anemia from abnormal blood tests.
They may suspect vitamin deficiencies first from symptoms and history and then look for anemia.

Diagnosing Megaloblastic Anemia. Very large oval red blood cells indicate megaloblastic anemia. Abnormally shaped neutrophils (certain white blood cells) may also be present. Bone marrow aspiration may need to be performed if the disease is strongly suspected but the diagnosis is not clear.

Determining Vitamin Deficiency. Once megaloblastic anemia has been diagnosed, the doctor will need to determine which vitamin deficiency is causing it. This is extremely important, because if a vitamin B12-deficient patient receives folate replacement only, then irreversible nerve injuries may develop. Even if blood tests for megaloblastic anemia are normal, patients with neurologic and psychiatric abnormalities that have no detectable cause should still be tested for vitamin B12 deficiency.

Often, vitamin B deficiencies cannot be determined by a history or symptoms alone. Blood tests are the primary indicators of both vitamin B12 and folic acid deficiencies, but even blood tests for these vitamins are not always straightforward:

Folic acid and vitamin B12 levels must always be measured at the same time because each vitamin may affect the other.
Folate levels may be temporarily low in some people who are not truly deficient.
Folate levels may temporarily rise in deficient people if they have just eaten foods containing the vitamin.
Antibiotics can interfere with B12 levels.

Measuring methylmalonic acid and homocysteine, substances in the blood that increase when levels of one or both vitamins are low, improves accuracy.

Tests for Pernicious Anemia. Once a vitamin B12 deficiency has been established and the doctor has not found any intestinal abnormalities or other factors to account for the deficiency, the doctor presumes a diagnosis of pernicious anemia. Pernicious anemia may also be diagnosed through various blood (such as complete blood count) or urine tests.

Pernicious anemia is treated with vitamin replacement, but the condition is easily missed, particularly in patients whose diets are rich in folic acid. Folic acid can mask the early symptoms of pernicious anemia but not cure it. Consequently the disease may persist until serious neurologic symptoms occur. With folic acid now a required additive in many commercial foods, some experts are concerned about an increased incidence in pernicious anemia.

Dietary Factors

Iron found in foods is either in the form of heme or non-heme iron:

Heme Iron. Foods containing heme iron are the best sources for increasing or maintaining healthy iron levels. Such foods include (in decreasing order of iron-richness) clams, oysters, organ meats, beef, pork, poultry, and fish.
Non-Heme Iron. Non-heme iron is less well-absorbed. About 60% of the iron in meat is non-heme (although meat itself helps absorb non-heme iron). Eggs, dairy products, and iron-containing vegetables have only the non-heme form. Such vegetable products include dried beans and peas, iron-fortified cereals, bread, and pasta products, dark green leafy vegetables (chard, spinach, mustard greens, kale), dried fruits, nuts, and seeds.

The absorption of non-heme iron often depends on the food balances in meals. The following foods and cooking methods can enhance absorption of iron:

Meat and fish not only contain heme iron -- the best form for maintaining stores -- but they also help absorb non-heme iron.
Increasing intake of vitamin-C rich foods, such as orange juice, may enhance absorption of non-heme iron, although it is not clear if it improves iron stores in iron-deficient people. In any case, vitamin-C rich foods are healthy and include broccoli, cabbage, citrus fruits, melon, tomatoes, and strawberries.
Riboflavin (vitamin B2) may help enhance the response of hemoglobin to iron. Food sources include dairy products, liver, and dried fortified cereals.
Cooking methods can enhance iron stores. Cooking in cast iron pans and skillets is well-known to increase the iron content of food. According to one study, boiling, steaming, or stir-frying in utensils composed of any material significantly increased the release of non-heme iron stored in vegetables.
Vitamins B12 and folate are important for prevention of megaloblastic anemia and for good health in general. The only natural dietary sources of B12 are animal products, such as meats, dairy products, eggs, and fish (clams and oily fish are very high in B12). As is the case with other B vitamins, however, B12 is added to commercial dried cereals. The recommended daily allowance (RDA) is 2.4 mcg a day. Deficiencies are rare in young people, although the elderly may have trouble absorbing natural vitamin B12 and require synthetic forms from supplements and fortified foods.

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

Folate is best found in avocado, bananas, orange juice, cold cereal, asparagus, fruits, green, leafy vegetables, dried beans and peas, and yeast. The synthetic form, folic acid, is now added to commercial grain products. Vitamins are usually made from folic acid, which is about twice as potent as folate. Many experts now recommend that adults have 400 mcg of folic acid daily -- considerably higher than standard recommendations of 400 mcg of folate. Women who are trying to conceive, who are pregnant, and who are breast-feeding should take 400 mcg of folic acid.

Click the icon to see an image of sources of folate.

The Recommended Daily Allowance (RDA) of iron for people who are not iron deficient varies by age group and other risk factors. (Iron supplements are rarely recommended in people without evidence of iron deficiency or anemia.) The RDA recommends these daily amounts of iron:

Children 1 - 3 years old: 10 mg
Teenage boys: 12 mg
Teenage girls and premenopausal women: 15 mg
Pregnant or nursing women: 30 mg
Adult men (up to age 50): 10 mg
Older men and women (over age 50): 10 mg

The main source of iron for an infant from birth to 1 year of age is in milk, from breast milk, iron-fortified infant formula, or cereal. The best methods for preventing iron deficiency during infancy are:

Breast-feeding and Iron-Supplemented Formulas. Mothers should be encouraged to breast-feed their babies for their first year. Up to half of the iron in breast milk is absorbed by the baby and is sufficient to prevent anemia for the first 4 - 6 months, assuming that the mother had adequate iron stores during pregnancy. Breast milk itself is low in iron, but if the mother's diet is healthy, vitamin C and lactose in the breast milk may enhance iron absorption. Breast-fed babies should have iron supplements after 4 - 6 weeks, even if they are still nursing.

Infants who are not breast-fed should start with iron-fortified formulas (7-12 mg/L). Most experts strongly discourage the use of low-iron formulas (less than 4.0 mg/L). Parents should discuss the best formula with their doctor. Children given iron supplements may have a slightly higher risk for diarrhea. Experts advise against cow's milk for the first year of life. When cereals are begun, they should be iron fortified.

Recommendations for Toddlers. Toddlers who did not have iron supplements during infancy should be checked for iron deficiency. After the first year, children should be given a varied diet that is rich in sources of iron, B vitamins, and vitamin C. Milk does not contain enough iron and can decrease children's appetite for iron-rich foods. Toddlers older than 1 year should not drink more than 2 cups of milk a day. A preference for apple juice over vitamin-C rich orange juice does not reduce iron absorption in children with any otherwise healthy diet.

Treatment

Oral iron supplements are the best way to restore iron levels for people who are iron deficient, but they should be used only when dietary measures have failed. However, iron supplements cannot correct anemias that are not due to iron deficiency.

One study reported that doctors prescribed iron pills for 64% of patients with anemia, without performing tests to confirm whether iron deficiency was actually the cause. The study suggested that iron replacement was appropriate in less than half of these patients. Iron replacement therapy can cause gastrointestinal problems, sometimes severe ones. Excess iron may also contribute to heart disease, diabetes, and certain cancers. Experts generally advise against iron supplements in anyone with a healthy diet and no indications of iron deficiency anemia. However, one study suggested that supplements help reduce fatigue in women with low iron stores but no signs of anemia.

Treatment of Anemia of Chronic Disease. In general, the best treatment for anemia of chronic diseases is treating the disease itself. In some cases, iron deficiency accompanies the condition and requires iron replacement. Erythropoietin, most often administered with intravenous iron, is used for some patients.

Treatment of Megaloblastic Anemia. The standard treatments for megaloblastic anemia are vitamin B12 injections and folic acid replacement.

Supplement Forms. To replace iron, the preferred forms of iron tablets are ferrous salts, usually ferrous sulfate (Feosol, Fer-In-Sol, Mol-Iron). Other forms include ferrous fumarate (Femiron, FerroSequels, Feostat, Fumerin, Hemocyte, Ircon), ferrous gluconate (Fergon, Ferralet, Simron), polysaccharide-iron complex (Niferex, Nu-Iron), and carbonyl iron (Elemental Iron, Feosol Caplet, Ferra-Cap). Specific brands and forms may have certain advantages. The following are some examples:

Prolonged-release ferrous sulfate (Slow Fe) may enhance iron absorption with fewer side effects than standard ferrous sulfate pills.
FerroSequels contains a stool softener, which helps prevent constipation.
Polysaccharide-iron complex has fewer side effects and equal absorption rates compared to ferrous salts. It is very expensive, however.
Carbonyl iron is composed of very fine tiny uniform spheres of iron powder and may prove to be less toxic than ferrous iron.
Coated or combination pills do not appear to offer any additional advantages and may hinder absorption of the iron.

Regimen. The general guidelines for iron replacement are as follows:

For adults, doctors usually advise one ferrous sulfate tablet (300 mg) three times a day.
Iron replacement doses for children with deficiencies are significantly lower. In general, they are given as drops or syrup administered three times a day. A single-dose daily regimen is showing promise. IMPORTANT: As few as three adult iron tablets can poison children, even fatally. This includes any form of iron pill.
No one, even adults, should take a double dose of iron if one is missed.

Other tips for taking iron are as follows:

For best absorption, iron should be taken between meals. (Iron may cause stomach and intestinal disturbances, however, and some experts believe that low doses of ferrous sulfate can be taken with food and are still absorbed but with fewer side effects.)
Always drink a full 8 ounces of fluid with an iron pill. Taking orange juice with an iron pill may help increase iron absorption. (Some doctors also recommend taking a vitamin C supplement with the iron pill.)
Tablets should be kept in a cool place. (Bathroom medicine cabinets may be too warm and humid, which may cause the pills to disintegrate.)

Full recovery takes 6 - 8 weeks. Recovery will take longer in people with internal bleeding that is not under control. Iron replacement therapy must continue for about 6 months, even if anemia has been reversed. Treatment must be continued indefinitely for people with chronic bleeding; in such cases, iron levels should be closely monitored.

Side Effects. Common side effects of iron supplements include the following:

Constipation and diarrhea are very common. They are rarely severe, although iron tablets can aggravate existing gastrointestinal problems such as ulcers and ulcerative colitis.
Nausea and vomiting may occur with high doses, but can be controlled by taking smaller amounts. Switching to ferrous gluconate may help some people with severe gastrointestinal problems.
Black stools are normal when taking iron tablets. In fact, if they do not turn black, the tablets may not be working effectively. This tends to be a more common problem with coated or long-acting iron tablets.
If the stools are tarry looking as well as black, if they have red streaks, or if cramps, sharp pains, or soreness in the stomach occur, gastrointestinal bleeding may be causing the iron deficiency and the patient should call the doctor promptly.
Acute iron poisoning is rare in adults but can be fatal in children who take adult-strength tablets.

Interactions with Other Drugs. Certain medications, including antacids, can reduce iron absorption. Iron tablets may also reduce the effectiveness of other drugs, including the antibiotics tetracycline, penicillamine, and ciprofloxacin and the Parkinson's disease drugs methyldopa, levodopa, and carbidopa. At least 2 hours should elapse between doses of these drugs and iron supplements.

Supplements. The following vitamin and mineral supplements may improve iron absorption:

Adding either ascorbic acid (vitamin C) or succinic acid to ferrous sulfate therapy will improve absorption of iron stores.
Some studies have found that the addition of zinc to iron supplements increases hemoglobin levels more than iron alone. Some evidence for this suggests that zinc affects a hormone called insulin-like growth factor-I (IGF-I), which plays a role in the regulation of red blood cell production.

In some cases, iron is administered through muscular injections or intravenously. Intravenous iron has the advantage of causing less gastrointestinal discomfort and inconvenience. It may be in the form of iron dextran (Dexferrum, InFed), sodium ferric gluconate complex in sucrose (Ferrlecit), or iron sucrose (Venofer). Ferrlecit or Venofer are proving to be at least equally effective and safer than iron dextran.

Candidates. The injected or intravenous forms should be limited to the following patients with iron deficiency:

People with iron deficiency anemia in whom oral therapy has clearly failed.
Patients with bleeding disorders in which blood loss continues to exceed the rate at which oral iron is absorbed.
In emergencies, when people need red blood cells but transfusion is not appropriate or available.
In people with serious gastrointestinal disorders, such as inflammatory bowel disease, who cannot take iron therapy by mouth.
People undergoing hemodialysis who receive supplemental erythropoietin therapy. Sodium ferric gluconate complex in sucrose (Ferrlecit) or iron sucrose (Venofer) is specifically approved as first-line therapy for these patients.

Certain patients, even if they meet these qualifications, may not be appropriate candidates or should be monitored closely for complications. They include:

Patients with any underlying autoimmune disease.
Malnourished patients who also have an underlying infection.
Patients who are at risk for iron overload.

Side Effects. Some side effects differ depending on how the iron is administered and include the following:

Muscular injections include pain at the site.
Intravenous administration can cause pain in the vein, flushing, and metallic taste, all of which are brief.

For both methods, side effects and serious complications can include:

Blood clots
Fever
Joint aches
Headache
Rashes
A delayed reaction of joint and muscle aches, headache, and malaise occurs 1 - 2 days after the infusion (most commonly with iron dextran) in about 10% of patients. These symptoms respond quickly to NSAIDs, such as ibuprofen or naproxen, in most people.
Iron toxicity. Symptoms include nausea, dizziness, and a sudden drop in blood pressure. Sodium ferric gluconate in sucrose (Ferrlecit) or iron sucrose (Venofer) may pose a lower risk for toxicity than iron dextran.
Allergic reactions. Allergic reactions that occur with intravenous iron can be very serious and, in rare cases, even fatal. Iron dextran appears to pose a much higher risk than sodium ferric gluconate complex in sucrose or iron sucrose, although allergic reactions can also occur with the latter forms.

Oral and injected iron should never be given at the same time. Intravenous iron therapy may be appropriate for some pregnant women who meet these requirements, depending on the pregnancy term and other factors.

Transfusions are used to replace blood loss due to injuries and during certain surgeries. They are also commonly used to treat severely anemic patients who have thalassemia, sickle cell disease, myelodysplastic syndromes, or other types of anemia. Some patients require frequent blood transfusions. Iron overload can be a side effect of these frequent blood transfusions. If left untreated, iron overload can lead to liver and heart damage.

Iron chelation therapy is used to remove the excess iron caused by blood transfusions. Patients take a drug that binds to the iron in the blood. The excess iron is then removed from the body by the kidneys. For many years, deferoxamine (Desferal) was the only drug used in chelation therapy. This drug is usually injected intravenously, using an infusion pump. The infusion can last 8 - 12 hours and may be needed 5 - 7 days a week until iron levels are normal. A new drug, deferasirox (Exjade), was approved in 2005 for children and adults as a once-daily treatment for iron overload due to blood transfusions. It does not require injections. Patients mix the deferasirox tablets in liquid and drink the medicine. Doctors hope that this new drug may make it easier for patients to tolerate chelation therapy. Studies have shown that deferasirox works as well as deferoxamine in ridding the body of excess iron.

Bloodless Medicine. Bloodless medicine and surgery is a new field designed to reduce or minimize blood loss and transfusions. It also attempts to address the problems in treating certain religious groups, such as Jehovah's Witnesses, who refuse transfusions. Some techniques involved in this field include new surgical procedures or drugs that minimize blood loss, the use of erythropoietin, volume expanders (administration of fluids to dilute blood), using tiny blood samples for testing, and methods (Cell Saver) for recovering and recycling blood during surgery.

Erythropoietin is the hormone that acts in the bone marrow to increase the production of red blood cells. It has been genetically engineered as recombinant human erythropoietin (rHuEPO) and is available as epoetin alfa (Epogen, Procrit, and Eprex). Novel erythropoiesis stimulating protein (NESP), also called darbepoetin alfa (Aranesp), lasts longer in the blood than epoetin alfa and requires fewer injections. These medications are also called “erythropoiesis-stimulating drugs.”

Levels of erythropoietin are reduced in anemia of chronic disease. Injections of synthetic erythropoietin can help increase the number of red blood cells in order to avoid receiving blood transfusions. Erythropoietin is used to treat anemia. It does not help improve anemia symptoms, fatigue, or quality of life for patients with cancer or HIV. This drug can cause serious side effects, including blood clots, and is approved only for treating patients with anemia related to the following conditions:

Cancer. For select patients, erythropoietin is used to treat the anemia associated with chemotherapy.
Chronic kidney failure. Erythropoietin is an important anemia treatment for patients with chronic kidney failure, including those on dialysis.
HIV/AIDS. Erythropoietin helps treat the anemia caused by zidovudine (AZT) therapy.

In November 2007, the Food and Drug Administration (FDA) made major changes to the prescribing information for erythropoiesis-stimulating drugs. The new labels describe in detail the risks that Aranesp, Epogen, and Procrit can pose to patients with cancer and chronic kidney disease. The FDA has also established separate dosing recommendations for each of these conditions.

Erythropoiesis-Stimulating Drugs and Cancer. Erythropoietin should be used only to treat anemia caused by chemotherapy -- not anemia due to other causes in patients with cancer. Erythropoietin treatment does not help prolong survival. In fact, these drugs can shorten survival time and cause tumors to grow faster. Discuss with your doctor whether an erythropoiesis-stimulating drug is appropriate for you.

Survival and tumor growth risks are especially pronounced for patients with advanced breast, head and neck, lymphoid, or non-small cell lung cancer when dosing attempts to achieve a hemoglobin level of 12 g/dL or greater. However, there may be similar risks for patients dosed to less than 12 g/dL. (The American Society of Clinical Oncology and the American Society of Hematology recommend starting erythropoietin when a patient’s hemoglobin level falls to less than 10 g/dL.) The doctor should use the lowest effective dose and erythropoietin treatment should be stopped as soon as the chemotherapy course is completed.

Erythropoiesis-Stimulating Drugs and Chronic Kidney Failure. For patients with chronic kidney failure, the FDA recommends that erythropoiesis-stimulating drugs be used to maintain hemoglobin levels between 10 - 12 g/dL. (The exact level within this range varies by individual.) There is a greater risk of death and serious cardiovascular events, such as heart attack, stroke, and heart failure when these drugs are used to achieve higher hemoglobin levels (13.5 - 14g/dL) compared to lower hemoglobin levels (10- 11.3 g/dL).

Warning Symptoms. Contact your doctor if you experience any of the following symptoms while being treated with an erythropoiesis-stimulating drug:

Pain or swelling in the legs
Worsening in shortness of breath
Increases in blood pressure (be sure to regularly monitor your blood pressure)
Dizziness or loss of consciousness
Extreme fatigue
Blood clots in hemodialysis vascular access ports

H. pylori, the bacteria that cause peptic ulcers, is associated with anemias from vitamin B12 deficiency and iron deficiency. People whose anemia is associated with H. pylori infection, however, do not respond to iron therapy. Studies indicate that the eradication of H. pylori infection with antibiotics can reverse anemia in such patients and may lead to long-lasting recovery.

Vitamin B12 Therapy. Injections of vitamin B12 (usually formulations called cyanocobalamin or hydroxocobalamin), oral folic acid therapy, or both, rapidly reverse the production of abnormally large red blood cells. (Treatments still may not reverse neurologic symptoms if they are extensive or have continued for too long.)

A typical regimen for vitamin B12 replacement is as follows:

If diagnostic tests indicate pernicious anemia and neurologic symptoms are present, vitamin B12 therapy should begin immediately. (Usually vitamin therapy is not an emergency, however.)
Cyanocobalamin or hydroxocobalamin injections are given every day for up to 2 weeks. Only small doses are needed.
This is followed by injections twice a week for another month. (Hemoglobin levels rise in the first week of therapy and reach normal levels in 8 weeks.)
After that, injections are usually given monthly.
During recovery, there is a risk of potassium deficiency as the new red cells take up the existing supply, so potassium supplements may be needed.

Other forms of vitamin B12 are also available and can be used to treat B12 deficiency. Vitamin B12 nasal spray offers the same advantage of avoiding the need for absorbing the vitamin in the GI tract without the inconvenience of the injections. Some experts feel that even oral B12 in high doses (2,000 mcg/day) can maintain B12 levels once the deficiency is treated.

The injections are safe and have no adverse side effects, but they may mask an underlying medical or psychological condition.

Some doctors give vitamin B12 injections for fatigue and other vague symptoms of general mild discomfort. In one study, 10% of patients in a rural clinic were given regular B12 shots, with 6% of patients having no medical need for them.

Folic Acid Treatment. Folate deficiency is easily remedied in 4 - 5 weeks with daily oral doses of 1 - 2 milligrams of folic acid. Many doctors give vitamin B12 along with folic acid unless B12 deficiency is definitely ruled out.

Resources

www.anemia.org -- National Anemia Action Council
www.nhlbi.nih.gov -- National Heart, Lung and Blood Institute
www.irondisorders.org -- Iron Disorders Institute
www.thalassemia.org -- Cooley's Anemia Foundation
www.aamds.org -- Aplastic Anemia & MDS International Foundation
http://kidney.niddk.nih.gov/kudiseases/pubs/anemia -- National Kidney and Urologic Diseases Clearinghouse (Anemia in kidney disease and dialysis)

References

Brotanek JM, Gosz J, Weitzman M, Flores G. Iron deficiency in early childhood in the United States: risk factors and racial/ethnic disparities. Pediatrics. 2007 Sep;120(3):568-75.

Killip S, Bennett JM, Chambers MD. Iron deficiency anemia. Am Fam Physician. 2007 Mar 1;75(5):671-8.

Komajda M, Anker SD, Charlesworth A, et al. The impact of new onset anaemia on morbidity and mortality in chronic heart failure: results from COMET. Eur Heart J. 2006 Jun;27(12):1440-6. Epub 2006 May 22.

KDOQI. KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target. Am J Kidney Dis. 2007 Sep;50(3):471-530.

Maguire JL, deVeber G, Parkin PC. Association between iron-deficiency anemia and stroke in young children. Pediatrics. 2007 Nov;120(5):1053-7.

Martí-Carvajal AJ, Solà I. Treatment for anemia in people with AIDS. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD004776.

Notebaert E, Chauny JM, Albert M. Short-term benefits and risks of intravenous iron: a systematic review and meta-analysis. Transfusion. 2007 Oct;47(10):1905-18.

Reveiz L, Gyte GM, Cuervo LG. Treatments for iron-deficiency anaemia in pregnancy. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD003094.

Rizzo JD, Somerfield MR, Hagerty KL, et al. Use of epoetin and darbepoetin in patients with cancer: 2007 American Society of Clinical Oncology/American Society of Hematology Clinical Practice Guideline Update. J Clin Oncol. 2007 Dec 21 [Epub ahead of print]

Review Date:
1/1/2008
Reviewed By:
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M. Copyright

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