Clinical Briefs With Comments from Russell H. Greenfield, MD
Clinical Briefs
With Comments from Russell H. Greenfield, MD, Dr. Greenfield is Medical Director, Carolinas Integrative Health, Carolinas HealthCare System, Charlotte, NC, and Clinical Assistant Professor, School of Medicine, University of North Carolina, Chapel Hill, NC.
U.S. CAM Kids
Source: Wilson KM, et al. Use of complementary medicine and dietary supplements among U.S. adolescents. J Adolesc Health 2006;38:385-394.
Goal: To determine the prevalence and patterns of use of complementary and alternative medicine (CAM) therapies and dietary supplements among adolescents.
Study design: Online self-administered survey with questions taken from prior research on CAM use, and including a variety of CAM modalities.
Subjects: A total of 1,280 teens aged 14-19 years drawn from a national sample of approximately 200,000 Harris Poll Online (HPOL) and Harris Youth Query members who completed the on-line survey.
Methods: A stratified random sample was drawn from the HPOL database consistent with known age and gender divisions. E-mail invitations, together with a unique password, were sent to more than 12,000 teens to participate in a survey "about your thoughts and experiences with various health and medical care issues." Focus groups were also held with a convenience sample of teens to explore their knowledge and understanding of, as well as experience with, CAM. Data obtained were weighted with respect to U.S. demographics.
Results: More than three-quarters of respondents had used CAM during their lifetime, with an average of 2.2 modalities experienced, and with girls more likely than boys to have used CAM. Nearly 50% of respondents reported having used CAM during the past month. Approximately 46% of the teens reported lifetime use of at least one of the dietary supplements listed (not including vitamins), with the most commonly used including herbal or green teas, ginseng, zinc, St. John's wort, weight-loss supplements, and creatine. Nearly 30% of respondents reported use of a supplement within 30 days of completion of the survey tool, while 46% were currently using a vitamin. Within the prior month, almost 10% of teens reported using a prescription aid together with supplements. Caucasian teens were more likely to have used herbal remedies, African-Americans more likely to have used faith healing or prayer, and Hispanic adolescents to have experienced spinal manipulation. Teens living in the West were more likely to have used CAM than those living elsewhere in the United States. A positive attitude towards CAM significantly impacted lifetime use. Of note, most respondents believed that "doctors don't like CAM."
Conclusion: Nationally, many adolescents use CAM, and not in a manner limited by geography or specific sub-population. This includes a high prevalence of use of herbs and supplements.
Study strengths: Employed weighted variables as gleaned from information from prior adolescent survey trials, including likelihood of response and propensity to be on-line; survey was not advertised as dealing specifically with CAM, thus eliminating some bias.
Study weaknesses: Poor response rate; inherent weaknesses related to survey/incentive model, especially in adolescents; lack of generalizability.
Of note: Studies evaluating use of CAM therapies among adolescents that focused primarily on local samples or special populations reveal that 54-70% of teens have used CAM; respondents were offered incentive points for completing the survey that could be redeemed for merchandise; use of herbs and supplements were grouped together in the analysis; 66% of respondents were in middle or high school, 24% were enrolled in post-high school education, and 10% were not in school; 19.5% of respondents had been involved in counseling, group therapy, or psychotherapy; level of parent education was not associated with CAM or supplement use; teens who viewed themselves as belonging to a lower socioeconomic group were more likely to use CAM and supplements; middle adolescence (age 16-17) was found to be the period of most intense CAM/supplement use.
We knew that: Prior studies have shown that a significant number of children are exposed to and use CAM therapies; teens, like many adults, often do not disclose use of CAM therapies to their doctors; people who are homeless or relatively poor exhibit a high use of CAM therapies and/or supplements; parental use of CAM and supplements often predicts use by adolescents.
Comments: Whether the results of this study can be readily translated to our own locales or not, the same tone of prudent precaution is sounded that has been heard when addressing CAM and supplement use in adults—odds are, our patients are not sharing everything with us. Not only to help deepen the professional healing relationship between patient and health care provider, but also to appropriately help people of any age navigate the maze that sometimes is CAM and supplement use, practitioners must consistently inquire about the use of such therapies in a manner non-judgmental. Many issues arise during the adolescent years, notably those revolving around body image for young girls, and a health care partner who can help evaluate various CAM therapies is invaluable. Even if we don't know the supplement or therapy in question, we can offer to evaluate in partnership any information the patient brings to us. Indeed, the basis of health care is not in encyclopedic knowledge—it has always been in creating a relationship based in mutual respect and trust.
What to do with this article: Keep a copy on your computer.
First Do No Harm: Iron Supplements and Pregnancy
Source: Casanueva E, et al. Weekly iron as a safe alternative to daily supplementation for nonanemic pregnant women. Arch Med Res 2006;37:674-682.
Goal: To compare effectiveness and safety of daily vs. weekly iron, folic acid, and vitamin B12 supplementation in healthy, non-anemic pregnant women.
Study design: Prospective randomized comparison trial.
Subjects: Women with singleton pregnancies more than 20 weeks gestation (n = 116).
Methods: Subjects were randomized to receive daily supplementation with one tablet containing 60 mg elemental iron (ferrous sulfate), 200 mcg, and 1 mcg vitamin B12, or two of the same tablets once a week. Food frequency questionnaires were completed by the women, and maternal hemoglobin and ferritin concentrations were measured every four weeks from 20 to 36 weeks gestation.
Results: Hemoglobin levels were significantly higher in the daily supplementation group from weeks 28 to 36, resulting in lower frequency of anemia during weeks 32-36, but a significantly higher incidence of hemoconcentration at 28-36 weeks. Hemoconcentration occurred at gestational week 28 or later in 18% of women receiving daily supplementation as compared with only 7% receiving supplementation weekly. Low ferritin levels were more prevalent than anemia at every time point in both groups, but ferritin levels decreased more in the weekly supplementation group than in those receiving supplements daily. Assessment of pregnancy outcomes revealed that hemoconcentration at gestational week 28 was associated with a significantly higher relative risk of low birth weight (RR = 6.23) and premature delivery (RR = 7.78).
Conclusion: In non-anemic women receiving iron supplementation after 20 weeks gestation, daily administration is more successful than once a week administration at preventing mild anemia, although both regimens prevent severe anemia associated with perinatal risk. However, daily supplementation significantly increases the risk of hemoconcentration at 28 weeks, and to levels associated with low birth weight and premature delivery.
Study strengths: Regular evaluation and blood sampling; strong subject adherence to protocol.
Study weaknesses: Dose employed (60 mg elemental iron) is twice that typically recommended; does not address supplementation prior to gestational age 20 weeks, as often utilized in the United States (standard practice in Mexico is to begin iron supplementation at gestational age 20 weeks); compliance determined via supplementation diaries and pill counts.
Of note: Participants were women mainly from middle and low socioeconomic classes in Mexico City (17% were younger than age 16 years, but participants were "fairly well educated by Mexican standards"); subjects had not received any form of supplementation prior to gestational age 20 weeks; supplements were supplied at no cost to participants and were to be taken at least one hour after meals; the mucosal lining of the small intestine turns over every 5-6 days, and new cells may be programmed to absorb iron according to bodily iron stores; high intraluminal intestinal concentrations of iron actually result in decreased iron absorption; the present study was not fully blinded because the nutritionist dispensed tablets to the women and later judged adherence to supplement regimen; because the trial took place in Mexico City, altitude-adjusted norms for hemoglobin during pregnancy as put forth by the Centers for Disease Control and Prevention were utilized; compliance was only slightly higher in the weekly supplementation group; the total amount of iron ingested by the weekly supplementation group was only 28% of that taken by the daily supplementation group.
We knew that: Iron-deficiency anemia is common during pregnancy (iron requirements increase during pregnancy, mostly due to increased blood volume); iron-deficiency anemia early in pregnancy is associated with low birth weight and premature delivery; severe anemia near term also puts the expectant mother at significant health risk; epidemiological data suggest that daily and weekly iron supplementation programs are equally efficacious with respect to preventing iron-deficiency anemia; previous epidemiological and clinical studies have also shown that hemoconcentration is associated with an increased risk of low birth weight and premature delivery; ferritin levels typically decrease during pregnancy even in the face of iron supplementation, and can increase secondary to inflammatory conditions.
Comments: The results of this longitudinal trial would be disquieting were it not for the fact that the iron dose employed was quite high, but it is good to know that in select circumstances less frequent administration of iron can be effective at safely preventing iron-deficiency anemia. That said, some trials suggest that routine iron supplementation for non-anemic women during pregnancy does little more than improve hematologic parameters. The routine use of iron supplementation during pregnancy in at-risk populations is important, but what about in low-risk populations receiving good prenatal care? Certainly, significant anemia must be identified and treated, but perhaps not every non-anemic pregnant woman requires iron supplementation throughout her pregnancy. At this time, little would suggest harm in low-dose iron supplementation across the board, but it is at least a point of interest.
What to do with this article: Remember that you read the abstract.
Work Can Kill Us: Stress and the Metabolic Syndrome
Source: Chandola T, et al. Chronic stress at work and the metabolic syndrome: Prospective study. BMJ 2006;332:521-525. Epub 2006 Jan 20.
Goal: To investigate the association between chronic work stress and the metabolic syndrome.
Study design: Prospective cohort study using the job strain questionnaire.
Subjects: Men and women aged 35-55 years at baseline who were employed in 20 London civil service departments (n = 10,308 from the Whitehall II Study).
Methods: The Whitehall II study recruited participants from 1985 to 1988, then collected survey data through postal questionnaires in 1989, in 1991-1993, in 1995 (no questions about work stress or health behaviors), and again in 1997-1999. Data regarding cumulative exposure to work-based stress were taken from four of the five survey periods, and biological measures of the metabolic syndrome were obtained in 1997-1999. Data on health behaviors were also examined, including smoking, alcohol use, exercise, and regular ingestion of fruits and vegetables.
Results: A dose-response relationship was found between exposure to chronic job stress and the risk of metabolic syndrome independent of other relevant risk factors. Those with chronic work stress were more than twice as likely to develop metabolic syndrome than those without significant work stress (odds ratio 2.25). Both men and women from lower employment grades were more likely to have metabolic syndrome. While men experiencing chronic job stress were more likely to develop the syndrome compared to their relatively unstressed colleagues, women in similar circumstances were more than five times as likely to have the syndrome (however, their numbers were quite small). Especially among men, exposure to chronic job stress was also associated with health-damaging behavior. Multivariate analysis that combined data for both men and women and adjusted for age, employment grade, health behaviors, and baseline obesity revealed the same association between work stress and increased risk of developing metabolic syndrome.
Conclusion: Greater exposure to job stress over 14 years is associated with a greater risk of metabolic syndrome in a linear manner. A social gradient exists with respect to risk for metabolic exposure that can in part be explained through work stress.
Study strengths: Prospective nature of the trial; multiple measures of work stress; analysis that excluded obesity at baseline.
Study weaknesses: High dropout rate (by the last phase of the study participation rate was 75%), but potentially ameliorated through statistical analysis.
Of note: Components of the metabolic syndrome were not measured at baseline, though obesity, defined as BMI > 30 kg/m2, was used as an indicator of risk for the syndrome; chronic work stress was defined as experiencing iso-strain on three or more surveys during the 14 years of follow-up; relatively few participants, overall, had chronic work stress as defined in this study; the "social gradient," as noted by the authors, is important—those in the lowest employment grades had double the odds of the syndrome compared with those in the highest employment grades; there was little evidence that participation in unhealthy behaviors mediated or confounded the effect of work stress on risk of developing metabolic syndrome; as noted by the authors, overweight people may be more socially isolated at work and find working conditions more stressful; it is interesting to note the relatively low rate of significant job stress experienced by women in the study.
We knew that: While a precise definition of the metabolic syndrome has yet to be fully agreed upon, most experts agree that the syndrome represents a cluster of risk factors that increases risk of heart disease and Type 2 diabetes, including abdominal obesity, hypertension, insulin resistance with or without glucose intolerance, prothrombotic and pro-inflammatory states, and atherogenic dyslipidemia (elevated triglycerides, small LDL particle size, low HDL); work stress has been tied to development of heart disease in both prospective and retrospective studies, though the biological mechanisms remain unclear; the iso-strain model is based in the hypothesis that socially isolated (little support, high demands, little control, low reward) job strain puts people at the highest risk for heart disease; chronic job stress may impact the autonomic nervous system (increased sympathetic activity) as well as neuroendocrine activity, thereby impacting cortisol levels, lipoprotein metabolism, and insulin sensitivity, as well as heart rate variability.
Comments: Data have been accumulating for some time linking psychosocial stressors and risk for cardiovascular disease. Some, but importantly not all of the findings, can be tied to an increase in unhealthy behavior patterns in those under chronic stress. Results of this well-done, prospective trial add fuel to the fire. Although many employers are now paying attention to stress at work, many of those same employers are still seeking solutions (one need only examine corporate employee health expenditures on antidepressants to understand why). For all the data, for the sheer common sense of it all, it remains a mystery why more practitioners have not partnered with corporations to help ameliorate this situation. After all, if one thing is clear, stress management can no longer be considered optional; rather, it must be deemed an integral part of any health promotion program.
What to do with this article: Keep a hard copy in your file cabinet.
Greenfield RH. U.S. CAM kids. Altern Med Alert 2006;9:105-107. Greenfield RH. First do no harm: Iron supplements and pregnancy. Altern Med Alert 2006;9:107-108. Greenfield RH. Work can kill us: Stress and the metabolic syndrome. Altern Med Alert 2006;9:108.Subscribe Now for Access
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