• Mother's Kiss May Dislodge Objects Stuck in Children's Noses
• Vitamin D and Cognition: Shedding Light on the Subject?
• Do Vitamin D Supplements Improve Cardiovascular Risk Factors?
• Higher Calcium Intake Associated with Lower Risk for Hyperparathyroidism
• What You See Might Not Be What You Get: Prenatal Ultrasound Diagnosis in Obese Women
• Carbs Fog Aging Brains
• Aspirin for Prostate Cancer?
• Vitamin D's Effect on Calcium Absorption
• Study Halves Inappropriate Antibiotic Prescribing in Pediatric Practices
• Kids Consume Too Much Salt
• High-Dose Multivitamins Not Helpful, Possibly Harmful in Patients on Antiretroviral Therapy
• Can a Vitamin a Day Keep AIDS Away?
• White or Whole Grain: Does Glycemic Index Matter During Pregnancy?
Mother's Kiss May Dislodge Objects Stuck in Children's Noses
The "mother's kiss" technique may safely and effectively help dislodge a foreign body from a child's nose, according to a systematic review in the Canadian Medical Association Journal.
Researchers reviewed the results of eight case series or case reports in which the mother's kiss was used in hospitals, specialists' offices, or at home (in at-home case reports, parents were doctors). To perform the mother's kiss, parents place a finger over the nonoccluded nostril and put their mouth completely over the child's mouth. They blow in the child's mouth until they feel resistance — and then give a short puff of air to propel the object out of the nose.
The technique was effective about 60% of the time. Smooth and irregularly shaped objects were equally likely to be expelled. No adverse events were observed. In two studies, use of the technique was associated with lower rates of general anesthesia.
http://www.cmaj.ca/content/early/2012/10/15/cmaj.111864.full.pdf+html
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MM: This inconclusive review fails to determine whether or not increased Vitamin D levels truly benefit AD patients. As there are many other benefits to maintaining blood levels between 50-80 ng/ml. I would still recommebnd that AD patients shoot for those ranges.
Neurology 2012 Sep 25; 79:1397
Vitamin D and Cognition: Shedding Light on the Subject?
A systematic review and meta-analysis suggests an association between Alzheimer disease and Vitamin D levels.
Vitamin D has been implicated in many aspects of brain function, from altering genetic expression to affecting neuroprotection via modulation of trophic factors. An apparent epidemic of vitamin D deficiency affects patients in all demographics. Two recent systematic reviews have reported no clear association between vitamin D levels and cognitive function, although low vitamin D has been associated with many other neurological disorders, from multiple sclerosis to migraine. A new systematic review is less exclusive than prior publications. The authors searched five databases for English language studies that involved vitamin D and cognition and included a comparison group.
The review included 37 studies of variable design. Data from four studies (502 participants) were available to compare vitamin D levels in AD patients with levels in controls, revealing that the level of 25-hydroxyvitamin D (25[OH]D) in AD patients overall was 6.210 nmol/L lower than in controls. A second analysis using data from eight studies (2749 participants) compared mean Mini-Mental State Exam (MMSE) scores between participants with 25(OH)D concentrations 
50 nmol/L versus those with lower levels, a common, albeit nonstandardized, cutpoint. The average difference in MMSE score was 1.2 points; however, the authors calculated statistically significant heterogeneity among studies.
Comment: Pooling data does not negate confounders and biases in the original studies. This and previous meta-analyses are challenged by variability in vitamin D assays, lack of knowledge regarding true normal levels of vitamin D across populations, and a lack of standardization with regard to factors known to affect vitamin D levels, including dietary factors and, more obviously, sun exposure. As the authors observe, cognitive decline can lead to poor nutrition and lower levels of sun exposure, which could be driving the reported associations. Attending to these more fundamental issues rather than supplementing with vitamin D may represent the best approach for clinicians, given the current state of medical knowledge.
— Brandy R. Matthews, MD Published in Journal Watch Neurology October 16, 2012
CITATION(S): Balion C et al. Vitamin D, cognition, and dementia: A systematic review and meta-analysis. Neurology 2012 Sep 25; 79:1397.
http://www.ncbi.nlm.nih.gov/pubmed/23008220?dopt=Abstract
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MM: At the highest blood level in this study, these patients were still at only 27 ng/ml, which is an “insufficient” level of 25 (OH) D. Once again, faulty data has made it into the literature and the risk of tainting the reputation of a great nutritional supplement, Vitamin D3, is at risk.
J Clin Endocrinol Metab 2012 Oct; 97:3557
Do Vitamin D Supplements Improve Cardiovascular Risk Factors?
Supplements did not improve lipid levels, blood pressure, or C-reactive protein levels.
In observational studies, lower vitamin D levels have been associated with higher cardiovascular risk, so some clinicians (including cardiologists in my community) are advising patients to take vitamin D supplements explicitly to lower cardiovascular risk. However, randomized trials with hard clinical endpoints to support this practice do not exist.
To determine whether vitamin D supplements favorably alter conventional cardiovascular risk factors, U.K. researchers randomized 305 postmenopausal women (mean age, 64) without known cardiovascular disease to receive vitamin D3 supplements (either 400 or 1000 IU daily) or placebo. At baseline, mean 25-hydroxyvitamin D levels were 13.5 ng/mL. At 1 year, vitamin D levels had doubled in both supplement groups and remained unchanged in the placebo group. However, vitamin D supplementation did not significantly change lipid values, blood pressure, measures of insulin resistance, or levels of inflammatory markers (e.g., C-reactive protein) compared with placebo.
Comment: In this study, vitamin D supplementation did not improve any of the measured cardiovascular risk factors among women with relatively low baseline vitamin D levels. Vitamin D conceivably could confer cardiovascular benefit through other mechanisms. However, recommending supplementation for that purpose is inappropriate until we have prospective data showing that vitamin D supplements lower cardiovascular morbidity. A primary prevention trial that will address this question (the NIH-sponsored VITAL study) is under way.
— Allan S. Brett, MD Published in Journal Watch General Medicine October 16, 2012
Citation(s): Wood AD et al. Vitamin D3 supplementation has no effect on conventional cardiovascular risk factors: A parallel-group, double-blind, placebo-controlled RCT. J Clin Endocrinol Metab 2012 Oct; 97:3557.
(http://dx.doi.org/10.1210/jc.2012-2126)
http://www.ncbi.nlm.nih.gov/pubmed/22865902?dopt=Abstract
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MM: The risk and detriment of parathyroidism is likely to be less than that of heart disease and that is the comparison measure that should be in place when talking about high dose calcium supplementation. Calcium doses in excess of 1200mg daily have beendemonstrated to place the consumer at increased risk of heart disease. It still seems that low to moderate doses such as what is available in dietary consumption is the safest and best approach to calcium supplementation. It is more easily absorbed by the body and appears to have little or no detrimental effects yet provides the benefits that are consistent with adequate calcium intake.
Higher Calcium Intake Associated with Lower Risk for Hyperparathyroidism
Women consuming higher levels of calcium through diet or supplements show a decreased risk for primary hyperparathyroidism, according to a BMJ study. An editorialist says the results support encouraging women to take daily calcium supplements, in modest doses.
Researchers followed some 58,000 U.S. women — participants in the Nurses' Health Study — over a 22-year period. At the outset, none had a history of primary hyperparathyroidism. Calcium intake was estimated by regular food-frequency questionnaires, and on that basis the women were placed into one of five intake levels.
During follow-up, 277 women developed primary hyperparathyroidisim. The adjusted relative risk was 0.56 among those with the highest versus lowest dietary calcium intake. In women taking more than 500 mg/day of calcium supplements, the risk was 0.41 relative to those not taking supplements, after adjustment for dietary intake.
The authors speculate that calcium intake may influence the production of parathyroid hormone and, thus, the development of parathyroid adenomas
http://www.bmj.com/content/345/bmj.e6390
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MM: This is yet another reason to consider weight control associated with pregnancy and fertility. Inability to make an appropriate assessment of an anomaly in a fetus may prevent appropriate pre-natal or neo-natal treatment of the fetus.
BJOG 2012 Aug 20
What You See Might Not Be What You Get: Prenatal Ultrasound Diagnosis in Obese Women
Congenital anomalies are more likely to be missed in fetuses of women with high BMI.
Maternal obesity is associated with many adverse perinatal outcomes, including birth defects. Ultrasound detection of such anomalies in utero can be especially challenging in women with high body mass index, however. U.K. investigators analyzed results of a population-based survey of congenital anomalies to determine the likelihood of prenatal diagnosis among 2483 cases of birth defects.
Fetal anomalies went undetected prenatally in 40%, 47%, 52%, and 54% of underweight, normal weight, overweight, and obese women, respectively (P=0.007). Analysis adjusted for maternal socioeconomic status, age, pregestational diabetes, and multiple gestations showed that fetal anomalies were 23% less likely to be diagnosed in obese women than in women of normal weight (adjusted odds ratio, 0.77; P=0.046). Cardiovascular anomalies were the most common type of defect, though the least likely to be suspected antenatally; and such abnormalities were more likely to be detected in underweight women than in any other group. Overall, 31% of cases with birth defects detected antenatally ended in pregnancy termination.
Comment: Although the exact mechanism is unknown, obese women are more likely to have pregnancies complicated by fetal anomalies. As this study demonstrates, however, birth defects in these pregnancies are more likely to go undetected by prenatal ultrasound. This unfortunate paradox may deny obese women the opportunity to make informed choices with respect to pregnancy management, testing for genetic abnormalities, prenatal specialty consultation, and pregnancy termination. Inasmuch as the obesity epidemic is unlikely to be resolved soon, providers should be mindful of difficulties with prenatal diagnosis in this group. Transvaginal imaging, evaluation of fetal anatomy later during the second trimester, and repeated ultrasound examinations all can optimize diagnostic capability in this patient population.
— Allison Bryant, MD, MPH Published in Journal Watch Women's Health October 18, 2012
Citation(s): Best KE et al. Impact of maternal body mass index on the antenatal detection of congenital anomalies. BJOG 2012 Aug 20; [e-pub ahead of print].
(http://dx.doi.org/10.1111/j.1471-0528.2012.03462.x)
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http://www.vitalchoice.com/shop/pc/articlesView.asp?id=1938
Carbs Fog Aging Brains
Mayo Clinic study in seniors finds that diets high in sugars and starches promote brain fog and dementia
By Craig Weatherby
Fat became public enemy number one in the 1980’s. So fat was reduced in many processed foods, and the flavor loss was addressed by adding carbs and salt. Why did fat get villainized so vehemently? Fat carries twice the calories of carbs or protein, while excess saturated fat had been linked to heart disease. As is now clear, this fat-demonization was often unfair, failed to discriminate among the various kinds of fat, and led to excess intake of carbs. Ironically, it turns out that excess intake of carbs is likely a much greater threat … and sadly, that imbalance is now all too common.
Scrutiny puts carb-heavy diets on the spot
The term “carbs” is shorthand for carbohydrates – a category that includes fibers and sugars – but it’s usually meant to mean starch. Starch is the rapidly-digested, nutrient-poor stuff in breads, pasta, potatoes, baked goods, and other “white” foods. When it comes to health impacts, starches and sugars are very similar, and – when eaten to excess – about equally unhealthful. Diets overloaded with sugars and starches promote metabolic problems that lead to diabetes and cardiovascular disease (e.g., insulin resistance, high triglyceride levels). But it’s less well known that carb-dominated diets can also blunt your brain.
We’ve reported some intriguing research in this realm: See “Sugary Brain Damage Blunted by Omega-3s” and “Study 3: Omega-3 Shortage May Cut Brain’s Sugary Fuel Supply” in “Feel-Good Findings: Omega-3s Boost Mood, Reduce Anger, Ensure Brain’s Flow of Fuel”.
Those results dovetail with some we reported in “Blood-Starved Brains Shown Prone to Alzheimer’s”, which confirmed that when brain cells don’t get enough sugar (glucose) – due either to an extreme low-carb diet or lack of omega-3s or other nutrients needed for sugar-transport – this fuel shortage can hurt brain power. Now, research from a Mayo Clinic team suggests that carb-soaked diets run nearly four times the risk of developing mild cognitive impairment … or, as it’s commonly called, “brain fog”.
Among more than 1,200 people aged 70 to 89, those eating the highest-carb diets were nearly four times as likely to develop mild cognitive impairment (MCI). MCI is characterized by problems with memory, language, thinking, and judgment … mental difficulties greater than those seen with normal age-related brain changes. Unsurprisingly, the team’s findings also linked sugary diets to a similarly high risk of losing some mental acuity. Conversely, those who ate the most protein and fat relative to carbohydrates were much less likely to suffer a cognitive decline. As the lead author, Dr. Rosebud Roberts, said, “We think it's important that you eat a healthy balance of protein, carbohydrates and fat, because each of these nutrients has an important role in the body.” (MC 2012)
Study links excess carbs to fuzzy thinking
The Mayo Clinic researchers tracked 1,230 people aged 70 to 89 years (Roberts RO et al. 2012). At the outset, the participants reported what they’d eaten during the previous year, and their cognitive function was also evaluated by an expert panel. Of all the participants, only the 937 who showed no signs of cognitive impairment were asked to return for follow-up mental evaluations, every 15 months. About four years into the study, 200 of those 937 began to show mild cognitive impairment (MCI) ... and the mayo team detected these correlations between diet and brain fog:
- Those with the highest carbohydrate intake relative to total fat and protein intake were 3.6 times likelier to develop MCI.
- Those with the highest carbohydrate intake were 1.9 times likelier to develop MCI than those with the lowest intake of carbohydrates.
- Those with the highest sugar intake were 1.5 times likelier to experience MCI than those with the lowest levels.
- Compared to those with the lowest-fat diets, the highest-fat eaters were 42 percent less likely to develop MCI.
- Those who had the highest protein intake were 21 percent less likely to face MCI.
As the authors concluded, “A dietary pattern with relatively high caloric intake from carbohydrates and low caloric intake from fat and proteins may increase the risk of MCI or dementia in elderly persons.” (Roberts RO et al. 2012) Dr. Roberts put it this way (MC 2012):
“A high carbohydrate intake could be bad for you because carbohydrates impact your glucose and insulin metabolism.”
“Sugar fuels the brain — so moderate intake is good. However, high levels of sugar may actually prevent the brain from using the sugar — similar to what we see with type 2 diabetes.”
Clearly, balance is the key to a healthful diet … not too much or too little of any one component. You can get easily meet your brain’s fuel needs by eating lots of whole plant foods – beans, vegetables, fruits, whole grains – while minimizing refined, “white” carbs and added sugars.
Sources: Mayo Clinic (MC). Eating Lots of Carbs, Sugar May Raise Risk of Cognitive Impairment, Mayo Clinic Study Finds. Tuesday, October 16, 2012. Accessed at http://www.mayoclinic.org/news2012-rst/7128.html. Rosebud RO. Relative Intake of Macronutrients Impacts Risk of Mild Cognitive Impairment or Dementia. Accessed at http://www.j-alz.com/issues/32/vol32-2.html
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J Clin Oncol 2012 Oct 1; 30:3540
Aspirin for Prostate Cancer?
In an observational study of men with localized prostate cancer, aspirin use was associated with lower cancer-specific mortality.
Recently published data suggest that daily aspirin use can lower cancer incidence and mortality (JW Gen Med Apr 24 2012). In the present study, researchers examined whether aspirin improved outcomes in 6000 patients with localized prostate cancer who underwent radical prostatectomy or radiotherapy. The data came from the multicenter CaPSURE study, an observational investigation of men with prostate cancer, about a third of whom used aspirin.
During median follow-up of 6 years, 3.2% of participants died of prostate cancer. Unadjusted 10-year estimated prostate cancer–specific mortality was significantly lower among aspirin users than nonusers (2% vs. 8%). In multivariable analysis (with adjustment for clinical stage, Gleason score, and treatment modality), cancer-specific mortality remained significantly lower among aspirin users than among nonusers (hazard ratio, 0.43).
Comment: This report has numerous limitations, including a lack of information on duration of aspirin use, comorbidities, and overall mortality in aspirin users versus nonusers. Still, the results are sufficiently provocative and plausible that it seems reasonable to offer aspirin therapy to men with prostate cancer who have no strong contraindications.
— Allan S. Brett, MD Published in Journal Watch General Medicine October 18, 2012
Citation(s): Choe KS et al. Aspirin use and the risk of prostate cancer mortality in men treated with prostatectomy or radiotherapy. J Clin Oncol 2012 Oct 1; 30:3540.
(http://dx.doi.org/10.1200/JCO.2011.41.0308)
http://www.ncbi.nlm.nih.gov/pubmed/22927523?dopt=Abstract
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MM: This myopic view of the function of Vitamin D is two steps backward rather than any steps forward in the realm of understanding the function of Vitamin D and the human body. Looking at Vitamin D and its effect on calcium absorbtion alone is like looking at a forest and examining a single leaf from a single tree to determine the characteristics of the entire forest. It never ceases to amaze me how in an effort to maintain the status quo, researchers can get swallowed up by their own agendas.
J Clin Endocrinol Metab 2012 Oct; 97:3550
Vitamin D's Effect on Calcium Absorption
Supplemental vitamin D enhanced calcium absorption very little among women with mild vitamin D insufficiency.
In a recent randomized trial, 163 postmenopausal women with mild vitamin D insufficiency (mean 25[OH]D level, 16 ng/mL) received doses of vitamin D3 ranging from 400 IU to 4800 IU daily. Doses 
800 IU daily were sufficient to boost levels above 20 ng/mL in nearly all women who received these doses (JW Gen Med Apr 26 2012). Because a goal of vitamin D supplementation is to ensure adequate intestinal absorption of calcium, these researchers now present additional findings on the relation between vitamin D dosing and calcium absorption. Participants ingested a standard dose of radioactive calcium, and serum radiocalcium was measured 2 hours later.
At baseline, a mean 54% of ingested calcium was absorbed. After 1 year of vitamin D supplementation, the percent absorption rose by only about 3% on average, with trivial differences among the seven vitamin D dosages (range, 400–4800 IU daily). Moreover, among patients whose 25(OH)D levels exceeded 60 ng/mL after supplementation, calcium absorption was only 6% higher than in patients whose 25(OH)D levels reached only 20 ng/mL (58% vs. 52%).
Comment: Vitamin D supplementation at any dose enhanced calcium absorption very little among women with mild vitamin D insufficiency. The authors conclude that calcium malabsorption occurs only when 25(OH)D levels are very low (<10 ng/mL); the likely reason is that levels of 1,25(OH)2D — the active metabolite of 25(OH)D that facilitates intestinal calcium absorption — don't fall substantially until 25(OH)D levels are below 10 ng/mL.
— Allan S. Brett, MD
Published in Journal Watch General Medicine October 18, 2012
Citation(s): Gallagher JC et al. The effect of vitamin D on calcium absorption in older women. J Clin Endocrinol Metab 2012 Oct; 97:3550.
(http://dx.doi.org/10.1210/jc.2012-2020)
http://www.ncbi.nlm.nih.gov/pubmed/22855333?dopt=Abstract
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Study Halves Inappropriate Antibiotic Prescribing in Pediatric Practices
Providing pediatricians with regular reports on their prescribing habits, including how they measure up to national guidelines, can cut inappropriate antibiotic prescribing in half, according to a press release on a study presented at IDWeek in San Diego. (IDWeek is a joint meeting of four U.S. infectious disease societies.)
Eighteen pediatric practices in the northeast U.S. were randomized to an intervention or control group. Intervention practices received a brief refresher on the latest infectious disease prescribing guidelines, and subsequently, clinicians received quarterly reports describing their prescribing habits, how they compared with the guidelines, and how they compared with their colleagues. The control group received no intervention.
At baseline, 28% of all children inappropriately received prescriptions for broad-spectrum antibiotics for sinusitis, group A strep, or pneumonia. After 1 year, the rate fell to 14% in intervention practices (vs. 23% among controls).
"The intervention isn't complicated or high-tech, so it should be 'scalable' to large populations," a meeting chairperson said in the IDWeek press release.
http://www.idweek.org/pr-stewardship
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MM: Maybe I’m missing something but it seems that maybe we are looking at the wrong variable here. The study indicates that OBESE kids have a greater increase in BP (7.5 times greater!) with higher salt consumption. Perhaps we should be taking a better look at nutrition and overall dietary habits rather than simply salt intake.
Pediatrics 2012 Oct; 130:611
Kids Consume Too Much Salt
High sodium intake is associated with elevated risk for high blood pressure, especially in obese and overweight children.
High dietary sodium and obesity are considered risk factors for hypertension in children and adults. Researchers examined the association between usual dietary sodium intake and high blood pressure (BP) in 6235 children (age range, 8–18 years) enrolled in the National Health and Nutrition Examination Survey between 2003 and 2008. Sodium intake was determined by dietary recall.
Sodium intake averaged 3387 mg per day and increased with age. Sodium intake was higher in boys, normal-weight children, and non-Hispanic white children. Fifteen percent of the cohort had pre–high BP or high BP, and 37% were overweight or obese. Systolic BP, but not diastolic BP, increased by approximately 1 mm Hg per 1000 mg of sodium intake per day. The increase in BP associated with sodium intake was higher in obese and overweight children than in normal-weight children (1.5 mm Hg per 1000 mg/day vs. 0.2 mm Hg per 1000 mg/day), even after adjusting for physical activity. The adjusted risk for pre–high BP or high BP in obese and overweight children in the highest quartile of sodium intake was significantly higher than the risk in children in the lowest quartile of sodium intake (adjusted odds ratio, 3.5).
Comment: High dietary sodium intake increases the risk for pre–high BP and high BP, especially in overweight and obese children. The average intake in the study is as high as the average intake for adults and higher than the dietary guidelines (
2300 mg/day) for children. Counseling on lifestyle changes to reduce sodium intake is a priority in children as well as adults.
— F. Bruder Stapleton, MD Published in Journal Watch Pediatrics and Adolescent MedicineOctober 17, 2012
Citation(s): Yang Q et al. Sodium intake and blood pressure among US children and adolescents. Pediatrics 2012 Oct; 130:611.
(http://dx.doi.org/10.1542/peds.2011-3870)
http://www.ncbi.nlm.nih.gov/pubmed/22987869?dopt=Abstract
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MM: There is usually more than a single side to any study and the following 2 studies show just that. One shows great benefit to HIV patients using high dose multi vitamins. The other shows detriment. Only time and larger numbers of patients using these nutritional products will tell us what we eventually need to know.
High-Dose Multivitamins Not Helpful, Possibly Harmful in Patients on Antiretroviral Therapy
High-dose multivitamin supplementation in HIV-infected patients starting highly active antiretroviral therapy (HAART) does not reduce disease progression — and may cause harm — according to a JAMA study.
Some 3400 adults in Tanzania who were starting HAART were randomized to receive daily oral supplementation with vitamins B, C, and E at either standard or high doses.
The study was stopped early, after a median of 15 months, because the high-dose group showed significant elevations in alanine transaminase levels. At that time, the composite of HIV disease progression and all-cause mortality was the same in the two groups (72%). In addition, CD4 counts and viral loads did not differ between the groups.
Asked to comment, Paul Sax of Journal Watch HIV/AIDS Clinical Care said: "Patients with HIV derive such enormous health gains from antiretroviral therapy that in hindsight, it's not surprising that the high-dose vitamin strategy offered no additional benefit. The cautionary lesson is that these supplements can do harm."
http://jama.jamanetwork.com/article.aspx?articleid=1383231
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N Engl J Med. 2004 Jul 1; 351:23-32.
Can a Vitamin a Day Keep AIDS Away?
Pregnant and postpartum women in Tanzania who received a daily multivitamin had slower disease progression and better surrogate markers than women receiving placebo.
Observational studies have shown associations between micronutrient deficiency and more rapid progression of HIV (e.g., AIDS 1997; 11:613), and between vitamin use and slower HIV disease progression (e.g., Am J Epidemiol 1996; 143:1244), but these studies have not definitively proven that vitamin supplementation confers clinical benefit. One previous randomized, controlled trial of HIV-infected men and women in Thailand showed that multivitamin supplementation for 48 weeks was associated with lower mortality in persons with CD4 counts <200 cells/mm3 (AIDS 2003; 17:2461). If multivitamin supplementation indeed slows HIV disease progression and therefore delays the need for antiretroviral therapy, this could have significant implications worldwide.
Fawzi and colleagues randomized 1078 pregnant HIV-infected women in Tanzania in a double-blind fashion to one of four groups: receipt of daily multivitamin (vitamins B, C, and E), vitamin A alone, vitamin A plus multivitamin, or placebo alone. Antiretroviral treatment was not available at the time of the study. All but one woman breastfed (median duration, 20.5 months). Baseline characteristics in the four groups were similar. By pill counts, 79% of study doses were taken. Median duration of follow-up data on disease stage were available for 60 months and follow-up data on mortality were available for 71 months. Overall, 343 (31.8%) deaths occurred during follow-up, 243 of which were thought to be AIDS-related.
The primary outcome -- progression to WHO stage 4 disease or AIDS-related death -- occurred in 67 of 271 women who received multivitamins (24.7%), compared with 83 of 267 women who received placebo (31.1%; relative risk [RR], 0.71; 95% confidence interval [CI], 0.51-0.98). Compared with placebo recipients, women who took multivitamins had a lower risk of progression to WHO stage 4 disease (RR, 0.50; 95% CI 0.28-0.90) and to stage 3 disease or worse (RR, 0.72; 95% CI, 0.58-0.90), and a trend toward lower risk of AIDS-related death (RR, 0.73; 95% CI, 0.51-1.04). The beneficial effect of multivitamins on these outcomes was apparent within the first 12 to 24 months and persisted for at least 4 years. The effect of multivitamins did not differ by baseline nutritional status or CD4-cell count.
Multivitamin use was also associated with significantly fewer oral and gastrointestinal symptoms than placebo use. Mean follow-up CD4 count was significantly higher (+48 cells/mm3), and mean viral load was significantly lower (-0.18 log10, copies/mL) in women taking multivitamins than in placebo recipients.
Vitamin A was protective against progression to stage 3 disease or worse (RR, 0.81; 95% CI, 0.65-1.00), but not against other clinical or laboratory indicators of disease severity.
Comment: This well-designed trial showed that multivitamins (but not vitamin A) appear to slow HIV disease progression and, possibly, decrease AIDS-related mortality in populations that are particularly vulnerable to nutritional deficiency -- pregnant and postpartum breastfeeding women in developing countries -- in the absence of antiretroviral therapy. Whether multivitamins would have similar beneficial effects in HIV-infected men, in women who are not postpartum or breastfeeding, or in persons with greater or lesser degrees of baseline nutritional deficiency is unknown and deserves further investigation. However, there is likely little harm and numerous benefits to vitamin supplementation.
— Shahin Lockman, MD, MSc Published in Journal Watch HIV/AIDS Clinical Care August 1, 2004
Citation(s): A randomized trial of multivitamin supplements and HIV disease progression and mortality. N Engl J Med. 2004 Jul 1; 351:23-32.
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BMJ 2012 Aug 30; 345:e5605.
White or Whole Grain: Does Glycemic Index Matter During Pregnancy?
Adherence to a low-glycemic–index diet curbed maternal weight gain but did not lower incidence of neonatal macrosomia.
Fetal macrosomia is intimately tied to the obesity epidemic: Maternal obesity raises risk for fetal macrosomia, which in turn is a risk factor for obesity later in life. Investigators at the National Maternity Hospital in Dublin conducted a randomized, controlled trial of a low-glycemic–index diet and its effects on neonatal macrosomia and maternal outcomes in 800 women with prior macrosomic deliveries but no histories of gestational diabetes. Participants were randomized during early pregnancy to receive dietary education (with a special focus on glycemic index) or routine prenatal care.
Compared with women in the control group, those in the intervention group achieved lower dietary glycemic indexes, gained less weight during pregnancy (mean difference, 1.3 kg;P=0.01), and were less likely to experience glucose intolerance. Although a significant proportion of women in each group exceeded recommended gestational weight gain goals, women in the intervention group were less likely to do so (38% vs. 48%;P=0.01). However, neither mean birth weight nor incidence of macrosomia differed between groups. Rates of preterm or cesarean delivery also did not differ.
Comment: Although counseling and adherence to a low-glycemic–index diet had no effect on neonatal birth weight, this study adds evidence that nutritional counseling can curb gestational weight gain. Excessive weight gain is associated with other adverse maternal outcomes that this study might not have been powered to detect, and probably has consequences for women's health both between pregnancies and in the long term. Providing culturally appropriate nutritional counseling during pregnancy is a high priority, particularly for women at greatest risk for adverse weight-related outcomes.
— Allison Bryant, MD, MPH Published in Journal Watch Women's Health September 27, 2012
Citation(s): Walsh JM et al. Low glycaemic index diet in pregnancy to prevent macrosomia (ROLO study): Randomised control trial. BMJ 2012 Aug 30; 345:e5605.
(http://dx.doi.org/10.1136/bmj.e5605)
http://www.ncbi.nlm.nih.gov/pubmed/22936795?dopt=Abstract
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