Making Healthy Choices™

Don Hall DrPH, CHES
Founder of Wellsource, Inc.

• Too Much Vitamin-A Increases Hip Fracture Rate

• Homocysteine Levels and Alzheimer's Disease

• Antibiotics in Animal Feed--Time to Stop

• Impact of Excess Weight on Chronic Disease

• Hostility and Coronary Artery Calcification

• Exercise Capacity and Survival

• Physical Activity and Prevention of Disability

• What's New? HealthStyle Index

• About this Newsletter

To lower your risk of hip fractures, get most of your vitamin A from beta-carotene or plant sources rather than from retinol in animal products and fortified foods.

High homocysteine in the blood is a strong, independent risk factor for dementia and Alzheimer's disease.

Folic acid alone or in combination with vitamin B-12 and B-6 can reduce homocysteine levels in the blood.

Too Much Vitamin-A Increases Hip Fracture Risk

Many people taking vitamin pills daily think they are improving their health. If it's the right kinds, they may be, but if they are getting too much vitamin A it can damage bone health and increase the risk of hip fracture.

Excess vitamin A seems to stimulate osteoclasts, scavenger cells that break down bone, and to suppress osteoblasts, cells that build up bone. High levels of vitamin A also interferes with vitamin D which is crucial for calcium absorption and metabolism.

In a recent report from the Nurses Health Study, researchers analyzed the relationship between intake of vitamin A and hip fracture rates in 72,337 post menopausal women for 18 years. They divided the women into 5 equal groups from lowest intake of vitamin A to highest intake. Those 20% who had the highest intake (top 20%) of vitamin A had a 48% increased risk of hip fracture, compared to women with the lowest intake (bottom 20%). It's also interesting to note that the average age for hip fractures was only 64 years.

Vitamin A comes from two sources. Retinol is the form of Vitamin A that comes from animal sources, primarily milk, butter, and liver. Retinol is also added to many foods including margarine, breakfast cereals, skim milk, cheese, and vitamin supplements. Beta-carotene is is the other source being converted into vitamin A in the body if needed. It comes from highly colored plant foods such as carrots. When comparing the two sources, only retinol was significantly associated with hip fracture risk. If you compared dietary intake of only retinol, those eating the most (top 20%) had nearly twice the risk (1.9 times) of hip fractures compared to those eating the least (bottom 20%).

How much is too much? Those women who had the lowest rates of hip fractures consumed less than 500 micrograms of retinol daily. If you also included beta-carotene, the intake of vitamin A (called retinol equivalents) was less than 1250 micrograms daily (which is equivalent to a little over 4,000 IU of vitamin A daily). The current recommendation for vitamin A is 700 micrograms per day for women (a little more for men).

Those with the high risk of hip fracture were eating about 2000 micrograms of retinol per day, or with the added beta-carotene, over 3000 retinol equivalents daily (or about 10,000 IU of vitamin A). The current upper limit for safe intake is less than 3000 micrograms per day so about 20% of the women were exceeding this upper limit. Most of the vitamin A (retinol) in these women with the high intake was coming from ordinary vitamin pills.

Here is the bottom line. To prevent hip fractures, limit your retinol intake to less than 500 micrograms (1650 IU) per day. Get the rest of your vitamin A needs from beta-carotene (brightly colored fruits and vegetables) which has many protective benefits to your health and doesn't increase risk of hip fractures. If you take vitamins with vitamin A in them, make sure it comes primarily from beta-carotene and not retinol (if it doesn't say, it's most likely from retinol). If your intake is high, as it was in 20% of the women in this study, following these new guidelines has the potential of cutting your risk of a hip fracture in half. What a remarkable savings in suffering, health care costs, and years of productive life that would be!

Reference: Diane Feskanich, et al, "Vitamin A intake and hip fractures among postmenopausal women, JAMA 287:47-54, Jan. 2, 2002

Homocysteine Levels and Alzheimer's Disease

Maintaining a good mind and mental ability throughout life is a real blessing. We've all known people who develop dementia or Alzheimer's disease later in life and how tragic it can be for the whole family. Alzheimer's accounts for more than 70% of all dementia. Is there any way to prevent it?

Researchers at Boston University studied this problem in 1092 seniors in the Framingham Study. All subjects, men and women, were healthy and had no dementia at the start of the study. After eight years they did a follow-up study and found 111 people had developed dementia, 83 were diagnosed with Alzheimer's disease.

They found that the plasma homocysteine levels were a strong predictor of who got Alzheimer's. Persons with high levels of homocysteine in the blood (>14 micro mol/L) had nearly double the risk (RR 1.9) of getting Alzheimer's.

Numerous studies have shown that vitamin therapy with folic acid alone or in combination with vitamin B-12 and B-6 can reduce plasma homocysteine levels. While this is an early study and it needs a clinical trial to confirm these findings, it does give us hope of knowing one way that may help us maintain a healthy, clear mind throughout life.

Taking B vitamins or eating foods high in folic acid is no health hazard and may be an effective preventive strategy against dementia. These B vitamins have also been shown to help prevent birth defects, prevent colon cancer, and help prevent heart disease. Foods high in folic acid include: lentils (1 cup nearly supplies a days full requirement), beans, asparagus, greens, orange juice, wheat germ, and food yeast. Most other fruits and vegetables contribute fair amounts too. For health of body and mind, be sure you get your B vitamins!

Reference: New Eng J Medicine 346:476-83, Feb. 14, 2002

Over 80% of infections with salmonella and campylobacter bacteria in humans are acquired from food animals.

These bacteria cause 3.8 million cases of illness due to infection in the U.S. every year.

26% to 54% of these bacteria are resistant to one or more antibiotics.

Antibiotics in Animal Feed -- Time to Stop

Antibiotics are often added to animal feed to help animals grow faster and enhance food efficiency. The Union of Concerned Scientists recently estimated that 24.6 million pounds of antibiotics are added to animal foods yearly in the U.S. Contrast that with 3 million pounds for human use.

This large use of antibiotics in animal feed, used simply to increase profit margins, is of great concern to many medical groups. They say it is contributing to the alarming increase of antibiotic resistant infections occurring in the U.S.

One recent study found that 20% of samples of ground meat obtained in supermarkets were contaminated with salmonella bacteria and that 84% of the bacteria isolates were resistant to one or more antibiotics.

Another study looked at chicken. They found at least 17% of chickens obtained from supermarkets in four states had bacteria that were already resistant to the most recently released new antibiotics. This is alarming news.

Over 80% of infections with salmonella and campylobacter (bacteria) in humans are acquired from food animals. These bacteria cause an estimated 3.8 million cases of illness from infections each year in the U.S. When a study was done to see what percent of these bacteria were resistant to antibiotics, 26% to 54% (depending upon which bacteria was studied) were resistant to one or more antibiotic. The overuse of antibiotics in humans also adds to this problem.

Drug resistant bacteria increase the frequency and severity of infections in humans, limit treatment options, and raise health care costs. Many European nations have banned the routine use of antibiotics in animal feed. Medical groups in the U.S. are now saying, "Use of these agents [antibiotics] to promote growth and feed efficiency should be banned."

Prevention strategy. One approach is to move more towards a plant based diet. This has many other health advantages as well. If you do eat meats, be sure they are thoroughly cooked in order to kill any bacteria that may be on the meat.

Reference Editorial, Antimicrobial Use in Animal Feed -- Time to Stop, The New England Journal of Medicine 345:1202-03, Oct. 18, 2001

Persons who are excessively overweight increase their risk for diabetes by as much a 20 times.

Maintaining a healthy weight is good preventive medicine!

22% of pre school children are now considered overweight; 10% are obese.

Childhood obesity is the most serious and prevalent nutritional disorder in the United States.

Impact of Excess Weight on Chronic Disease

Everyone knows that excess weight can increase health risks, but to what extent? To answer this question, researchers analyzed 10 years of data from two large studies, the Nurses Health Study and the Health professional Follow-up study.

They found that people who were moderately overweight (BMI of 25-29.9) had the following increased risks:

Most people are not aware of the major increase in health problems excess body weight can cause. Maintaining a healthy weight is a positive health practice that will pay good health dividends.

Also keep in mind, that even a weight loss of 10-15 pounds can make a big health improvement. People who exercise regularly and develop high fitness also eliminate most of the increased risk from excess fat weight.

A new report on weight and diabetes risk points out that the number of children (pre school age) in the U.S. who are overweight is now 22%; 10% are considered obese. This is a marked increase in excess weight in children. In this editorial in the New England Journal of Medicine, the writer states, "Childhood obesity is the most serious and prevalent nutritional disorder in the United States."

One researcher looked at the number of risk factors for coronary heart disease in a group of obese adolescents. He found that 97% of them already had four or more major risk factors for heart disease such as high blood cholesterol, high blood pressure, low HDLs, high triglycerides, etc.

Obese children also have a higher prevalence of type 2 Diabetes. One report shows that with increased obesity in youth there has been a 10 fold increase in type 2 diabetes over a 12 year period. While type 2 diabetes used to be rare in children, now as many as one-third of all cases of new diabetes in children 10-19 years of age can be classified as type 2.

When obese children (4-10 years) were studied they found 25% already had impaired glucose tolerance, a precursor to diabetes, and 4% of those studied already met the criteria for type 2 diabetes. Investigators in this study comment that considering the epidemic of childhood obesity and the high rate of impaired glucose tolerance, it appears there will soon be a pediatric epidemic of type 2 diabetes and increased diabetes among U.S. Adults.

The strategy for prevention must include greater levels of physical activity for our children and teens, better eating habits, and weight control efforts. Let's start in our own homes with our own children and grand children.

References
Archives of Internal Medicine 161:1581-6, Jul 9, 2001
Editorial, Childhood Obesity and a Diabetic Epidemic, The New England Journal of Medicine 346:854-5, Mar 14, 2002.

This prospective study suggests that high hostility levels contribute to early coronary artery disease in young adults.

Hostility and Coronary Artery Calcification

High hostility levels have been linked to increase risk of heart disease in a number of studies as well as restenosis after coronary angioplasty (artery plugging up again after a procedure to open it up), high blood pressure, and all cause mortality. A recent innovative study links hostility to calcification of the coronary arteries in young men and women (ages 18-30).

Measuring coronary artery calcification is a new test to measure early development of coronary artery disease before symptoms occur. Researchers wanted to see if damage to arteries due to high hostility could be detected by this new test. 374 young men and women took a hostility test and then had their arteries scanned for calcium deposits (signs of early disease).

Here's what they found. Persons with higher than average hostility scores were 2.38 times more likely to have any measurable calcium deposits in their arteries, and 9.56 times more likely to have high levels of calcium deposits.

There was a positive, graded association between hostility scores and coronary artery calcification, even after adjusting for other coronary risk factors, education level, and alcohol consumption. This finding suggests that anger and aggression may be involved in the development of early cardiovascular disease. The authors mentioned several ways hostility may damage the heart:

• Blood pressure surge

• Increased platelet activation (increases chance of clotting)

• Higher epinephrine levels (stress hormone) can damage artery walls

Therapy directed at hostility has been shown to reduce the risk of heart attack, by as much as 50%. Regular exercise has also been shown to be helpful in reducing hostility and enhancing heart health.

Prevention strategy. Reduce anger with with an attitude of tolerance and acceptance of other views and ways of living. Practice patients, love, and forgiveness. Release strong emotions with nondestructive physical activity. Dissolve tension with humor. Walk away from disturbing situations or angry people. You don't have to make other people's problems, your problems. You will be doing your heart a favor and life will be more enjoyable.

Reference: Carlos Iribarren, et al, Association of Hostility with Coronary Artery Calcification in Young Adults, JAMA 283:2546-2551, May 17, 2000

Peak aerobic capacity was the best predictor of mortality from any cause, even better than smoking, high cholesterol, high blood pressure, abnormal ECG, diabetes, or history of
heart attack.

Persons with PEAK aerobic capacity less than 6 METS were high risk for early
death, 8+ METS was low risk, 13+ METS was was very low risk.

Exercise is an effective strategy for preventing disability in an older population, both strengthening and aerobic exercises, even if they have arthritis.

Exercise Capacity and Survival

What is the best test to determine your likelihood of still being alive six years from now? A new study of over 6000 people looked at this question. They found that a persons fitness level or peak aerobic capacity (measured in METs) was the best predictor. In people without heart disease, aerobic capacity was a better predictor of survival than smoking, high blood pressure, diabetes, or cholesterol level.

Among people with heart disease, aerobic capacity was also the best predictor of survival, even better than history of heart disease, smoking, abnormal ECG tests, diabetes, high blood pressure, or cholesterol.

Researchers tested the peak aerobic capacity level of 6213 consecutive men referred for treadmill exercise testing. Then followed these people for over 6 years to see who survived and who didn't. When they divided all the men without any heart disease into quintiles (5 equal groups based on fitness levels) those in the least fit group (bottom 20%, MET level less than 6) had a mortality rate 4.5 times higher than the most fit men (top 20%, MET levels of 13 or higher).

When they divided those with a history of heart disease into quintiles based on their fitness level, they found a similar outcome. The least fit men in this group were 4.2 times more likely to die than those in the most fit group (MET level of 10.7 or higher).

In both groups, the higher the fitness level, the lower the risk of death from any cause. As shown in other studies, the greatest health benefits of exercise is achieved by increasing physical activity among the least fit persons.

The investigators observed that for each 1-MET increment in peak aerobic capacity, mortality dropped by 12% overall, and by 16% for those without any history of heart disease.

The good news is that aerobic capacity can be readily improved with regular exercise. The researchers conclude by suggesting that physical activity needs the same emphasis as treatment for diabetes, high blood pressure, and stopping smoking for enhancing health and decreasing mortality. Regular physical activity is powerful medicine.

Reference: Jonathan Meyers et al, "Exercise capacity and mortality among men referred for exercise testing, New England Journal of Medicine 346:793-801, Mar. 14, 2002

Physical Activity and Prevention of Disability

An important component in maintaining quality of life as we grow older is preventing disability in activities of daily living (ADL). Dr. Penninx and colleagues at the Sticht Center on Aging studied this problem in a group of 250 participants aged 60 or older who had arthritis of the knee but no ADL disabilities at the start of the study.

Participants were then assigned into one of three groups: an aerobic exercise program, a resistance exercise program, or an "attention" control group (no exercise but received regular attention and general health care). These three groups were then followed for 18 months and assessed quarterly for any developing limitations in daily living (ADLs) such as getting out of bed or a chair, dressing, using the toilet, bathing, eating etc.

At the end of 18 months, the group that developed the most disabilities (being able to take care of themselves) was the control group. They had nearly twice as many ADL disabilities as those in the exercise groups.

Both exercise programs prevented ADL disabilities but of the two, aerobic exercise was slightly more effective. A combination of both would probably have shown even better results. The lowest ADL disability risks were found in those people who had the highest compliance with their exercise program. Exercise is an effective strategy for preventing ADL disabilities in an older population, even if they have arthritis, and prolonging independence and quality of life.

Reference: Archives of Internal Medicine 161:2309-16, 2001

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About Making Healthy Choices

Making Healthy Choices is written by Don Hall, DrPH, CHES president of Wellsource Inc. with contribution from associated health professionals. It is available as a resource to Wellsource clients and other select organizations involved in promoting health.

Content is general health information from evidence based research. Its purpose is not to treat disease but to promote healthy lifestyles. Persons with health problems should consult their physician for specific guidance.

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