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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
August 13, 2011

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Odd Chemicals Turn Up in Drinking Water
Older Women with Sleep-Disordered Breathing at Higher Risk for Cognitive Impairment
Does Circadian-Activity-Rhythm Architecture Predict Future Cognitive Decline?
Vertebroplasty Isn't Effective for Vertebral Compression Fractures
Antidepressant Prescriptions Without Psychiatric Diagnoses on the Rise
FDA Approves New Daily HIV Pill
Drug Shortages Also Affecting Pets
Depression Associated with Increased Risk for Stroke in Older Women
Smoking Confers Greater CHD Risk in Women Than in Men
Risk for Sudden Cardiac Death in Women
Is Folic Acid a Risk Factor for CRC?
Lifestyle's Effects on Absolute Risk for Breast Cancer
Botox Gets Green Light for Bladder Problem in European Union
Shorter Preshock Pauses During CPR Improve Survival
Sorting Out the Value of Mammography
Omega-3 DHA Boosted Infants’ Brains

Odd Chemicals Turn Up in Drinking Water
     Chicago drinking water has been shown to contain trace amounts of sex hormones, prescription drugs, flame retardants, and herbicides. In the latest round of testing, city officials discovered that more than two dozen pharmaceutical drugs and other unregulated chemicals pass through Chicago's massive treatment plants.
     Like other cities, Chicago must notify the public if its drinking water is shown to contain regulated contaminants, including lead, pesticides, and harmful bacteria; however, there is no such requirement if pharmaceuticals and other unregulated substances are detected.
     EPA's position is that it doesn't yet have sufficient evidence to limit pharmaceuticals and many other unregulated chemicals in drinking water. Water officials say not enough is known to justify spending millions of taxpayer dollars to upgrade treatment plants.
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MM: Here is another reference to sleep, cognition and what is not specifically addressed in this article, obesity. I am certain that this can be extended to men as well as women.
Older Women with Sleep-Disordered Breathing at Higher Risk for
Cognitive Impairment

     Older women with sleep-disordered breathing are more likely to develop cognitive impairment, according to a prospective study in JAMA.
     Some 300 U.S. women aged 65 or older without dementia underwent in-home polysomnography for one night; about one third demonstrated sleep-disordered breathing.
     During roughly 5 years' follow-up, 35% of all participants developed mild cognitive impairment or dementia. The incidence was significantly higher among women with than without sleep-disordered breathing (45% vs. 31%). Intermittent hypoxia (but not sleep fragmentation or duration) appeared to account for the elevated risk.
     Editorialists call for more research but conclude that "physicians of patients with mild cognitive impairment and sleep-disordered breathing for whom treatment with CPAP [continuous positive airway pressure] may be indicated should consider these results."
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MM: The old addage, “early to bed, early to rise makes a man healthy, wealthy & wise…” might be modified to comment further from this study. Sunlight, vitamin D3 and exercise appear to have a positive effect on brain function and cognition and these things appear to be even more important as we progreess in age.
Ann Neurol 2011
Does Circadian-Activity-Rhythm Architecture Predict Future Cognitive Decline?
A prospective, observational study in older women suggests that it does.
     To determine whether circadian activity rhythms, as measured by wrist actigraphy, are prospectively associated with incident dementia or mild cognitive impairment (MCI), researchers tracked 1282 cognitively normal, community-dwelling women (mean age, 83). Participants underwent wrist actigraphy at baseline and a comprehensive cognitive assessment about 5 years later, with cognition characterized as normal or meeting criteria for MCI or dementia.
     An actigraph, worn like a wristwatch on the nondominant upper limb, is an accelerometer, capturing movement data. The data reflect relative physical activity over time. The more movement a subject exhibits per minute, the higher the value (amplitude) of the signal during that minute. The investigators assessed peak amplitude (the peak to nadir difference in activity; an indicator of the strength of the rhythm), mesor (mean level of activity), robustness (a measure of goodness of fit to a cosine curve), and acrophase (timing of peak activity measured as time of day). (See Figure, graph A.) They examined participants' acrophase relative to 1 standard deviation from the population mean (1:34 PM–3:51 PM). An acrophase <1:34 PM is phase advanced, and an acrophase >3:51 PM is phase delayed.
     After adjustments for numerous potential confounders, older women in either the lowest amplitude quartile (see Figure, graph B) or the lowest robustness quartile (see Figure, graph C) were about 57% more likely to develop dementia or MCI than those in the highest quartiles. Women with phase-delayed acrophases had an 83% increased risk for dementia or MCI compared with those with average acrophases (see Figure, graph D). The authors conclude that women with decreased circadian-activity-rhythm amplitude and robustness and delayed rhythms are at increased risk for dementia and MCI. They suggest that interventions such as physical activity (reflected on actigraphy as increased amplitude, mesor, and robustness) or bright-light exposure in the early morning (reflected on actigraphy as advancing the phase) might reduce the risk for cognitive deterioration in elders.
     Comment: These findings underscore both the importance of studying associations between activity and cognition in elders and the utility of actigraphy itself. The data do not clarify the direction of the association. Does a decreased and delayed circadian rhythm contribute to cognitive decline, or do these rhythm changes represent degenerative or vascular changes in the brain that precede cognitive decline? Are other factors at play? Intervention studies with physical activity and bright-light therapy will clarify the direction of this association and perhaps indicate some readily available and inexpensive therapies to modify risk for cognitive decline.
— Bradley F. Boeve, MD Dr. Boeve is Professor of Neurology, Department of Neurology and Center for Sleep Medicine, Mayo Clinic, Rochester, MN.
Published in Journal Watch Neurology August 9, 2011
     Citation(s): Tranah GJ et al. Circadian activity rhythms and risk of incident dementia and MCI in older women. Ann Neurol 2011; [e-pub ahead of print].
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BMJ 2011 Jul 12; 343:d3952.
Vertebroplasty Isn't Effective for Vertebral Compression Fractures
A meta-analysis showed no benefit over sham injection.
     In two recent randomized trials, researchers compared vertebroplasty (injection of a cement-like substance into a vertebral fracture) with a sham procedure (injection of only local anesthetic at the fracture site). In both studies, the vertebroplasty and sham groups improved similarly, with no significant differences between groups (JW Gen Med Aug 5 2009). Some critics argued that patients were enrolled too late in the course of their pain and that inclusion of some patients without severe pain might have weakened the studies' power (JW Gen Med Sep 16 2010). To address these concerns, investigators conducted a meta-analysis of these two trials to determine the effectiveness of vertebroplasty in two subgroups of patients: 57 patients with at least one radiographically confirmed vertebral compression fracture and recent-onset pain (≤6 weeks) and 99 patients with severe baseline pain (score, ≥8 on a 10-point scale).
     Within both the recent-pain and severe-pain groups, no differences were found in pain or disability at 1 month between vertebroplasty and sham procedures. Notably, patients randomized to vertebroplasty were 25% more likely to be using opioid analgesics at 1 month than patients randomized to the sham procedure.
Comment: The results do not support routine use of vertebroplasty in patients with vertebral compression fractures, including those with recent-onset pain or severe pain at baseline. Strengths of this meta-analysis include its use of individual patient data and the blinding of patients to vertebroplasty or sham procedures. As noted by the authors, lack of blinding overestimates treatment benefit, which casts doubt on the results of a recent nonblinded randomized trial that suggested vertebroplasty is superior to conservative treatment (JW Gen Med Sep 2 2010).
Paul S. Mueller, MD, MPH, FACP Published in Journal Watch General Medicine August 4, 2011
     Citation(s):Staples MP et al. Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: Meta-analysis. BMJ 2011 Jul 12; 343:d3952. (http://dx.doi.org/10.1136/bmj.d3952)
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Antidepressant Prescriptions Without Psychiatric Diagnoses on the Rise
     Antidepressant prescribing without a recorded psychiatric diagnosis has increased substantially over the past decade, a Health Affairs study shows. The drugs seem to be given often for conditions such as tiredness, nonspecific pain, and headaches.
     Researchers looked at federal data on some 230,000 adult visits to office-based, nonpsychiatrist clinicians from 1996 to 2007. They found that antidepressant prescriptions were written in about 4% of visits in 1996, rising to 9% in 2007. Over that period, the proportion of prescriptions without a recorded psychiatric diagnosis increased from about 60% to almost 75%.
     The authors, noting that antidepressants are now the third most commonly prescribed drug class in the U.S., say their findings suggest that primary care clinicians overestimate the effectiveness of the drugs in treating mild conditions. They call for better communication between primary care clinicians and psychiatrists
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FDA Approves New Daily HIV Pill
     The FDA has approved a new fixed-dose combination — emtricitabine/rilpivirine/tenofovir DF (FTC/RPV/TDF) — for use in treatment-naive HIV-infected patients.
     The treatment, marketed as Complera, is a single pill that should be taken once daily. The pill is contraindicated with some anticonvulsants, antimycobacterials, and proton-pump inhibitors (see the FDA alert for a full list).
     Approval for the combination was based, in part, on data from previous phase III studies for rilpivirine, which the FDA approved in May. In his HIV and ID Observations blog, Dr. Paul Sax writes that data comparing rilpivirine with efavirenz demonstrate a trade-off between safety/tolerability (favoring rilpivirine) and efficacy (favoring efavirenz), and he wonders whether "this efficacy difference [will] be reduced now that the single-pill treatment is available — a question now being tested in an open-label clinical trial."

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Drug Shortages Also Affecting Pets
     With nearly 200 drugs approved (for humans) currently in short supply, veterinarians are also affected, as they are allowed to use FDA-approved human drugs off-label in pets under certain conditions. Also, there are sometimes shortages of specific veterinary drugs.
     A veterinarian at an animal medical center in Manhattan said there were four drugs the center didn't have in stock, with no idea of when they'd become available. The shortages include acetylcysteine inhalation solution, used in both humans and animals to break up mucus and as a partial antidote to acetaminophen poisoning (Pets often eat medication off the floor or their owners may give a drug to them without a vet's supervision).
     Also in short supply are doxorubicin and mechlorethamine. It is difficult to know the effect of these shortages and how they have compromised care. There are substitutes for some drugs.
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MM: Remember not all that long ago when Prozac was being touted as the “safest drug ever created”, and that “virtually everyone should be using an SSRI”? Well, today we find these SSRI’s in our water supply and now a statistical correlation with stroke. It appears that they are not as safe as previously touted and we don’t have much of a choice whether we get the drugs actively or by simply drinking from our water supply.
Depression Associated with Increased Risk for Stroke in Older Women
Both depression and antidepressant use are associated with increased risk for stroke, according to a prospective study in Stroke.
     More than 80,000 Nurses' Health Study participants aged 54 to 79 without a history of stroke were assessed for depression; nearly one quarter were considered depressed.
     During 6 years' follow-up, about 1000 strokes occurred. After multivariable adjustment, the risk for stroke was 29% higher among depressed than nondepressed women (0.3% for those reporting current depression vs. 0.2% without depression). In addition, antidepressant use, regardless of depression diagnosis, was associated with a significantly increased risk for stroke; the elevated risk was seen mainly with SSRIs.
     The authors say their findings "provide additional evidence that depression is associated with a moderately increased risk of incident stroke." They call for more research "to determine whether the risk associated with depression can be reduced by other therapies or preventive strategies."
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Smoking Confers Greater CHD Risk in Women Than in Men
The risk for coronary heart disease conferred by smoking is 25% greater among women than men, according to a meta-analysis published in the Lancet.
     Researchers examined data from 86 studies comprising some 4 million people and 67,000 CHD events. They found that after adjustment for cardiovascular risk factors, the female-to-male relative risk ratio for CHD associated with smoking versus not smoking was 1.25.
     The authors, noting that the excess CHD risk in female smokers increased by 2% for every extra year of follow-up, say their study "lends support to the idea of a pathophysiological basis for the sex difference." They add: "For example, women might extract a greater quantity of carcinogens and other toxic agents from the same number of cigarettes than men. This occurrence could explain why women who smoke have double the risk of lung cancer compared with their male counterparts."
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JAMA 2011 Jul 6; 306:62
Risk for Sudden Cardiac Death in Women
Most risk was attributed to four lifestyle factors.
     Sudden cardiac death (SCD) can be the first manifestation of coronary artery disease (CAD); thus, lifestyle factors that influence CAD risk might also affect risk for SCD. Investigators used data from the Nurses' Health Study to assess how SCD risk was affected by four modifiable lifestyle factors — smoking, weight, exercise, and diet — among nearly 82,000 women (age range at baseline, 30–55) without known CAD. The women, whose lifestyle factors were updated every 2 to 4 years, were considered to have one or more low-risk factors if they were not current smokers, had body-mass indexes <25 kg/m2, exercised ≥30 minutes daily, or scored in the top 40% of the cohort for adherence to a Mediterranean diet.
     During 26 years of follow-up, 321 SCDs occurred. Compared with women with no low-risk factors, SCD was significantly less likely to occur in women with one or more low-risk factors (relative risks, 0.54, 0.41, 0.33, and 0.08 for 1, 2, 3, and 4 factors, respectively). The total population-attributable risk for SCD was 81% for all four risk factors.
     Comment: The magnitude of reduced risk for SCD in women with one or more low-risk lifestyle factors is striking. Only 8% of the study population possessed all four low-risk factors, but their risk for SCD was lower by 92%. The population-attributable risk of 81% for all four factors emphasizes the relative importance of lifestyle over heredity as the primary risk factor for SCD in women.
Thomas L. Schwenk, MD Published in Journal Watch General Medicine July 26, 2011
     Citation(s): Chiuve SE et al. Adherence to a low-risk, healthy lifestyle and risk of sudden cardiac death among women. JAMA 2011 Jul 6; 306:62. (http://dx.doi.org/10.1001/jama.2011.907)
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Gastroenterology 2011 Jul; 141:98
Is Folic Acid a Risk Factor for CRC?
No type of folate, including folic acid, increased the risk for colorectal cancer.
     Epidemiologic studies of dietary folate intake have generally indicated an inverse relationship with colorectal cancer (CRC) risk. In the U.S., folic acid, a form of folate, is consumed through supplementation with vitamins and fortification of flour. Recently, the nature of the association between folate and CRC has been in doubt based on results of a randomized controlled trial showing an increased risk for advanced adenomas in a high-risk group taking folic acid supplements (JW Gastroenterol July 6 2007) as well as a documented uptick in CRC incidence after the fortification of flour began in the late 1990s (Cancer Epidemiol Biomarkers Prev 2007; 16:1325).
     To examine whether folic acid increases the risk for CRC, researchers evaluated data from the Cancer Prevention Study II Nutrition Cohort, involving 86,404 men and 97,786 women. For the current study, they determined folate intake from a food frequency questionnaire administered in 1999 and followed participants until 2007 — during which time mandatory folate supplementation in the U.S. was occurring. Folate types were categorized as natural (naturally occurring in food), dietary (natural plus intake from fortified foods), folic acid (from fortified foods and vitamins), and total (natural plus folic acid).
     In multivariate linear trend analyses, higher total folate intake was associated with reduced risk for CRC (P for trend, 0.047). Participants in the highest quintile of folate intake had a 19% lower risk for CRC (odds ratio, 0.81) than those in the lowest quintile. Although natural, dietary, and folic acid intake were each associated with reduced CRC risk, the results did not achieve statistical significance.
     Comment: These data provide reassuring evidence that neither dietary folate nor folic acid supplements increase the risk for colorectal cancer. In fact, total folate intake was associated with a reduced risk for CRC. A link between folate consumption and initiation and progression of tumors seems unlikely because CRC incidence did not increase in the first 2 years of treatment.
Douglas K. Rex, MD Published in Journal Watch Gastroenterology August 12, 2011
     Citation(s):Stevens VL et al. High levels of folate from supplements and fortification are not associated with increased risk of colorectal cancer. Gastroenterology 2011 Jul; 141:98.
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J Natl Cancer Inst 2011 Jul 6; 103:1037
Lifestyle's Effects on Absolute Risk for Breast Cancer
New model predicts the effects of modifying alcohol consumption, physical activity, and body-mass index.
     Certain lifestyle changes can lower risk for breast cancer. For counseling women about such preventive strategies, discussions of absolute rather than relative risk reduction can be particularly meaningful. Accordingly, National Cancer Institute researchers developed a model based on data from an Italian case-control study (J Natl Cancer Inst 1998; 90:389) to predict changes in absolute risk for breast cancer in relation to five unmodifiable risk factors (e.g., family history) and three modifiable lifestyle factors (alcohol consumption, exercise, and body-mass index [BMI]). The authors validated their model through comparisons with data from a different (prospective) Italian study.
     For individual women, magnitude of absolute reduction in breast cancer risk rose with age, baseline risk, and duration of risk projection. For example, a 45-year-old woman who eliminates alcohol consumption can lower her 10-year absolute risk from 15.0% to 14.6% (risk reduction, 0.4%), whereas a 65-year-old woman who achieves and maintains weight loss from BMI ≥30 kg/m2 to <25 can lower her 20-year risk from 29.3% to 23.7% (risk reduction, 5.6%). From a population perspective, lifestyle modifications could result in a 20-year absolute risk reduction of 1.6% for menopausal women overall and a risk reduction of 3.2% for women with family histories of breast cancer.
     Comment: As an editorialist notes, projections based on assumed rather than actual changes in lifestyle might be overly optimistic. Furthermore, this new model does not take into account the extent to which lactation can lower risk for breast cancer (JW Womens Health Oct 9 2002). In addition, these results might not apply to U.S. populations, in which breast cancer rates among older women are substantially higher than in Italy. Nonetheless, the model has the unique ability to estimate the effect of lifestyle changes on breast cancer risk in individuals as well as across entire populations of women. I agree with the authors' emphasis on absolute rather than relative risk when counseling patients about preventive interventions.
Andrew M. Kaunitz, MD Published in Journal Watch Women's Health July 14, 2011
     Citation(s):Petracci E et al. Risk factor modification and projections of absolute breast cancer risk. J Natl Cancer Inst 2011 Jul 6; 103:1037.
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Botox Gets Green Light for Bladder Problem in European Union
     Botox has been approved in Europe for treating certain patients with urinary incontinence; patients with overactive bladder problems caused by multiple sclerosis and spinal cord injury. This action clears the way for the approval of the drug in 14 countries, under the European Union's mutual recognition procedure.
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Circulation 2011 Jul 5; 124:58
Shorter Preshock Pauses During CPR Improve Survival
Both return of spontaneous circulation and survival to hospital discharge improve when the compression pause for shock delivery is shortened.
     Pulse checks interrupt chest compressions and no longer are recommended during cardiopulmonary resuscitation (CPR), but delivering a shock clearly requires a pause in compressions. In a study of 815 patients in Canada and the U.S. who received some 2400 shocks, researchers analyzed the association between pause duration and outcomes.
     The mean arrival time for responders was 5.9 minutes. The median preshock pause (time from cessation of CPR to shock delivery) was 15.6 seconds (range, 0–107 seconds), and the median postshock pause (time from shock delivery to resumption of CPR) was 8.3 seconds (range, 0–220 seconds); guidelines recommend pause duration ≤5 seconds. The odds of return of spontaneous circulation in the emergency department were 0.37 in patients with preshock pause ≥20 seconds (compared to those with preshock pause <10 seconds) and 0.52 for patients with perishock pause (total duration of the 2 pauses) ≥40 seconds (compared to those with perishock pause <20 seconds). The corresponding odds of survival to hospital discharge were 0.47 and 0.54 for preshock and perishock pauses, respectively. Preshock pause, but not postshock pause, was independently associated with mortality.
     Comment: The time is muscle paradigm is as applicable to CPR compressions as to more-sophisticated interventions. Shortening the preshock pause will not be easy and will require both team training and design improvements in defibrillators. Continuing compression while the defibrillator is charging might provide the most bang for the buck.
J. Stephen Bohan, MD, MS, FACP, FACEP Published in Journal Watch Emergency Medicine
July 29, 2011
     Citation(s): Cheskes S et al. Perishock pause: An independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation 2011 Jul 5; 124:58. http://www.ncbi.nlm.nih.gov/pubmed/21690495?dopt=Abstract
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BMJ 2011 Jul 28; 343:d4411
Sorting Out the Value of Mammography
Analysis of paired European countries suggests screening has little effect on breast cancer mortality.
     Mortality from invasive breast cancer continues to fall in North America, Australia, and most western European countries. To assess the relative effects on breast cancer mortality of mammographic screening and improved treatment, investigators paired selected European countries based on geographic contiguity, socioeconomic status, and quality of and access to healthcare services. For each of three pairs (Sweden and Norway; the Netherlands and Belgium; Northern Ireland [U.K.] and the Republic of Ireland), nationwide mammographic screening had been implemented by 1990 in the first country and substantially later in the second. Breast cancer mortality was compared for each pair.
     For example, national screening mammography was initiated in the mid-1980s in Sweden (countrywide coverage achieved by 1997) and the mid-1990s in Norway (countrywide coverage achieved by 2005). Despite the later introduction of screening in Norway, breast cancer mortality between 1989 and 2006 declined by 16% in Sweden and by 24% in Norway. Similar trends were observed in the other paired countries.
     Comment: This analysis of breast cancer mortality contrasts with a similar study of cervical cancer in Scandinavia: Although access to surgery and radiation therapy was comparable among all Nordic countries from 1965 through 1980, large reductions in cervical cancer mortality during this period were observed in countries with nationwide cytology screening but not in countries with delayed implementation of such screening. Authors of another recent study (JW Womens Health Sep 22 2010) have also made a credible argument that screening mammography plays a limited role in lowering breast cancer mortality. Improvements in breast cancer management (and access to treatment) seem to be more important. Overall, these observations should help clinicians to be comfortable adopting a flexible approach to when and how often women choose to be screened (JW Womens Health Jul 28 2011).
Andrew M. Kaunitz, MD Published in Journal Watch Women's Health August 11, 2011
     Citation(s): Autier P et al. Breast cancer mortality in neighbouring European countries with different levels of screening but similar access to treatment: Trend analysis of WHO mortality database. BMJ 2011 Jul 28; 343:d4411. (http://dx.doi.org/10.1136/bmj.d4411) http://www.ncbi.nlm.nih.gov/pubmed/21798968?dopt=Abstract
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Omega-3 DHA Boosted Infants’ Brains
DHA-fortified formula improved brain function at 12 months … prior research has had mixed results, likely due to the maternal DHA transferred to fetuses and nursing infants
by Craig Weatherby
     Health authorities worldwide agree that the long-chain omega-3 fatty acid called DHA is essential throughout pregnancy and nursing. Omega-3 DHA is needed to help prevent premature birth and its complications, and ensure proper brain and eye development and healthy birth weight. Accordingly, U.S. and international health agencies advise pregnant and nursing women to consume at least 200mg of DHA daily – by eating fatty fish or taking fish oil supplements – and DHA is added to many infant formulas.  
     Two years ago, researchers reviewed the clinical evidence, and as they wrote, “Numerous studies have found positive correlations between blood DHA levels and improvements in cognitive or visual function outcomes of breastfed and formula-fed infants.” (Hoffman DR et al. 2009). However, the evidence that supplemental DHA actually yields enhanced brain development – instead of just ensuring adequate development – is mixed. For example, in one of the largest trials published so far, the children of women who took 800mg of omega-3 DHA per day in the last half of pregnancy did not score higher on tests of thinking or language development through six months of age. For more on that study – and links to our reports about positive evidence – see “Babies See No Omega-3 Brain Gains”.
     The varying outcomes of studies testing the impact of supplemental DHA on child development could well be due to differences in study design and statistical power, the doses and duration of DHA supplementation, and other factors (Hoffman DR et al. 2009). Healthy, full-term infants generally receive adequate amounts of DHA from their mothers in the last trimester. In fact, mothers’ bodies strive to transfer as much DHA to fetuses and breast milk as possible … a fact that makes it hard to detect developmental advantages from DHA-fortified formula when pregnant/nursing mothers consume adequate amounts of this key omega-3. However, there is abundant evidence indicating that supplemental DHA benefits preterm infants and infants of mothers with low DHA levels … and that infants who are neither breastfed nor given DHA-fortified formula are at risk of suboptimal brain and eye development. For more information, see the “Omega-3s & Child Development” section of our news archive. Now, researchers from Texas and Canada report developmental advantages in infants fed DHA-fortified formula … thereby adding more positive evidence to the picture.
Texan-Canadian trial shows brain gains from DHA-fortified formula
     The international team conducted their trial in 141 infants, who were fed formula exclusively from birth through four to six months of age, and then received formula (and infant foods) until they were 12 months of age. The infants were assigned randomly to receive one of four infant formulas, each containing a different percentage of DHA:

     All of the DHA-supplemented formulas also contained 0.64% arachidonic acid (ARA), which is an omega-6 fatty acid essential to child development and human health. The infants were assessed for their mental, psychomotor, and behavioral development when they were 18 months of age, using a collection of developmental tests called the Bayley Scales of Infant Development II (BSID II).1 Compared with the infants fed un-supplemented formula, all of the infants who received DHA-fortified formula had significantly higher scores for mental development, language, and emotional regulation. No differences between DHA-supplemented and un-supplemented infants were seen in other parts of the BSID II cluster of tests. Nor were there any advantages seen in the infants receiving the higher levels of DHA (0.64% and 0.96%), which suggests that the standard level of DHA in infant formula – 0.32% – is enough to ensure optimal cognitive development in healthy infants. This fits with the conclusions of the 2009 review we quoted above: “Trials with formulas providing close to the worldwide human milk mean of 0.32% DHA were more likely to yield functional benefits attributable to DHA. We agree with several expert groups in recommending that infants receive at least 0.3% DHA, with at least 0.3% ARA, in infant feedings ...” (Hoffman DR et al. 2009)
      Sources: Auestad N, Scott DT, Janowsky JS, Jacobsen C, Carroll RE, Montalto MB, Halter R, Qiu W, Jacobs JR, Connor WE, Connor SL, Taylor JA, Neuringer M, Fitzgerald KM, Hall RT. Visual, cognitive, and language assessments at 39 months: a follow-up study of children fed formulas containing long-chain polyunsaturated fatty acids to 1 year of age. Pediatrics. 2003 Sep;112(3 Pt 1):e177-83. Carlson SE, et al. 1993a. Visual acuity development in healthy preterm infants: effect of marine-oil supplementation. Am. J. Clin. Nutr. 58:35-42. Champoux M, et al. 2002. Fatty acid formula supplementation and neuromotor development in rhesus monkey neonates. Pediatr Res 51:273-281. Cheatham CL, Colombo J, Carlson SE. N-3 fatty acids and cognitive and visual acuity development: methodologic and conceptual considerations. Am J Clin Nutr. 2006 Jun;83(6 Suppl):1458S-1466S. Review. Cheatham CL, Nerhammer AS, Asserhoj M, Michaelsen KF, Lauritzen L. 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