Category Archives: Science and Medicine

Food Security for Children vs Interests of Pharmaceuticals

Food security, not vitamin supplements, is vital for public health

2001 – A year ago, Unicef’s vitamin A campaign in Assam caused the death of 30 children and sent over 1,000 to hospital with vitamin A toxicity. The larger question is whether such mass campaigns to combat malnutrition-related deficiencies in India are still required. Or do we need a more sustainable approach?

On a single day last year, health workers gave 3.2 million children vitamin A syrup in the Indian state of Assam. The mass administration of syrup was part of Unicef’s vitamin A campaign, a much-publicised effort to counter vitamin A deficiency among children in developing countries. That night, about 1,000 children who were administered the syrup fell ill, showing symptoms of vitamin A toxicity, including vomiting, nausea and headache. Children in the more remote villages were unable to access medical care in time. Ritu Konwar, a two-year-old girl died that night, and the next day local hospitals overflowed with sick children. Over one week around 29 children died of acute dehydration.

The children’s deaths sparked off a debate amongst scientists about the validity of the vitamin A campaign in India.

Is vitamin A deficiency among children a public health concern in India? Does the country need vitamin A campaigns at all? This has been the subject of controversy between Indian scientists and Unicef for over decade. Scientists in India argue that vitamin A deficiency in children is no longer a concern, except in isolated, geographical `pockets’ of the country. According to Unicef, such campaigns are necessary as they help reduce child mortality significantly in India.

After considering both arguments, the central government issued directions to discontinue the campaign in 2000. Despite this, Unicef launched a campaign in Assam last year.

Indian scientists say such campaigns are merely `short-term fixes’ and that vitamin A deficiency is better combated by educating people about eating food rich in the vitamin and by making these foods available to them.

Malnutrition is a serious problem among children in developing countries. Caused by lack of food, improper diet and unsafe drinking water, malnutrition leads to deficiencies in micronutrients such as iron, iodine and vitamins. Of these, vitamin A deficiency is the most lethal.

Children are vulnerable to vitamin A deficiency from the time they are born right upto three years of age. During this time, vitamin A deficiency can cause permanent blindness, even death. The risks become less in older children, but vitamin A deficiency reduces overall immunity and makes all children susceptible to diseases like measles and diarrhoea. Unicef estimates that vitamin A deficiency is a public health concern in 72 countries in Asia and Africa.

According to World Health Organisation (WHO) guidelines, vitamin A deficiency is a public health concern if the mortality rate of children below five years is greater than 70/1,000. This means that the death of more than 70 of every 1,000 children indicates vitamin A deficiency. In 1970, the mortality rate of children under five years in India was 130/1,000, thereby making vitamin A deficiency a public health concern (Hindu Health, December 8, 2001).

The Indian government began its campaigns to combat vitamin A deficiency in 1970. Supported by Unicef, the campaigns gave children between the ages of six months and five years vitamin A every six months. Besides this, the government also supplied kits containing vitamin A, folic acid and iron to villagers as part of its regular healthcare programme. However, since their launch, the campaigns covered only 30 per cent of the targeted children.

Though campaign coverage is low, vitamin A deficiency in India is no longer a public health concern, according to studies conducted by the National Nutrition Monitoring Bureau of India. The mortality rate of children under five years is down from 130/1,000 in 1970 to 70/1,000 in 1997. This suggests that factors other than vitamin A deficiency contributed to reducing child mortality since 1970.

Poverty in India has come down in the last 30 years. Healthcare has improved and food availability increased. The number of malnourished children has declined from 15 per cent in 1970 to six per cent in 1997.

Bitot’s spots — the appearance of foamy grey spots in the whites of the eyes — are an early symptom of vitamin A deficiency. The incidence of these spots has gone down significantly: although 1.8 per cent of children had Bitot’s spots in 1975, the figure is now down to 0.7 per cent. Also, immunisation campaigns against communicable diseases such as measles, that reached just seven per cent of children in 1970, now cover almost 80 per cent. This means that fewer children suffering from vitamin A deficiency succumb to diseases.

Unicef, however, maintains that campaigns are responsible for reducing child mortality. Werner Schultink, officer-in-charge of nutrition at Unicef, says that vitamin A supplementation through campaigns reduces child mortality from measles by 50 per cent, and from diarrhoea by 40 per cent. Overall, supplementation reduces child mortality by 23 per cent (Vitamin A Global Initiative).

Based on studies showing a decline in malnutrition and vitamin A deficiency, Indian scientists urged the government to reconsider the necessity of campaigns. In September 2000, the ministry of health and welfare organised a panel of paediatricians, nutritionists, Unicef and WHO representatives, and government officials. Called the National Consultation, the panel assessed the efficacy of vitamin A campaigns in India.

The National Consultation decided that vitamin A deficiency was a problem only in certain drought-prone parts of India. It also noted the lack of strong evidence linking vitamin A supplementation with reduced child mortality. The panel directed state governments to discontinue vitamin A campaigns. It also said that in areas where deficiency is a concern, supplements should be given using approaches other than campaigns.

Still, Unicef launched a campaign in Assam through the state government’s department of health, on November 11, 2001. The irony is that Unicef did not consider WHO guidelines whilst launching the campaign. According to the WHO, vitamin A deficiency is a concern if Bitot’s spots are seen in more than 0.5 per cent of children. A survey conducted just months before the campaign, by the Indian Council of Medical Research, found Bitot’s spots in only 0.3 per cent of the 11,000 children examined in each district of Assam. Also, Unicef did not implement the `Triple A’ approach that it recommends for assessing the seriousness of a problem. Triple A is short for `Assessment, Analysis, Action’. In Assam, Unicef skipped the first two.

The cause of the deaths of children following the campaign remains a mystery. Until now, Unicef administered vitamin A syrup using two ml spoons. In Assam, these spoons were replaced with five ml cups. Health workers, not used to the cups, may have administered an overdose. Dr Umesh Kapil, professor of nutrition at the All India Institute of Medical Sciences, says that because health workers gave 3.2 million children the syrup in a single day, they may have become negligent and overdosed the children. However, according to Kapil, vitamin A is a `safe drug’ and the amount of overdose that could cause toxicity and prove lethal has still not been established.

It’s possible that an overdose did not cause the deaths. But what is striking is that the illnesses were not uniformly spread across the state, but occurred in clusters.

India spends about Rs 120 million a year on Vitamin A that it buys from multinationals like Roche. This is besides the vitamin A donated to India by foreign agencies.

Unicef’s aim may be charitable, but such campaigns benefit pharmaceutical companies like Roche that are exploiting vitamin A deficiency in developing countries, says Kapil. However, the larger issue is whether these campaigns are still required in India.

Indian nutritionists have long argued that more sustainable approaches are needed to combat malnutrition-related deficiencies like vitamin A deficiency. Nutritionists like Kapil say that vitamin A should come from such foods as papaya and mango rather than a pill or syrup. For this, India will have to achieve `food security’ where every person is able to access and afford a balanced diet.

Achieving food security in India is a challenge. Food production has increased and malnutrition has decreased over the past 30 years. But the food produced is mostly carbohydrate-rich wheat and rice. Foods rich in vitamin A are still in short supply. The paradox is that many cannot afford even the available food. According to James Levinson, director of the International Food and Nutrition Center at Tufts University, the poorest 65 per cent in India do not even get enough food to eat. This year, India’s granaries had an excess of 55 million tonnes of grain; yet 200 million people went hungry.

Thus far, the Indian government has addressed food insecurity quite diligently. The Integrated Child Development Programme is the largest of its kind in the world and covers 80 per cent of rural India. The programme provides nutritional supplements to children less than two years of age, education to mothers about child nutrition, and vitamin A supplements to pregnant mothers. Another programme provides free mid-day meals to schoolchildren. However, Ahmad Akhtar, a nutritionist at the International Food and Policy Research Institute, says the latter programme has backfired. Because children get free meals at school, they are not fed properly at home.

For people who cannot afford food at market prices, the government has set up the Public Distribution System that sells food at half the market price. This programme cost the Indian government Rs 53 billion in 1994, making it the costliest anti-poverty programme in India. However, according to Levinson, only 50 per cent of the food meant for low-income groups actually reaches them. The rest, through corrupt officials, is sold elsewhere or ends up in the free market.

Fortification of food with vitamin A is another approach that nutritionists suggest. But this is possible only where food is sold centrally. In rural India, most people grow and consume their own food. Or food is bought and sold locally, making fortification difficult. Fortifying commodities like sugar will probably work. But ensuring that children consume enough sugar to get their supply of vitamins is not easy.

The National Institute of Nutrition in India has a programme to support and educate people about growing and consuming foods rich in vitamin A. Nutritionists educate people on the importance of vitamin A intake. Agriculturists provide the technical support to grow fruits and vegetables in home gardens. Gopalan, the institute’s director says that vitamin A deficiency is now rare around Hyderabad where the programme was implemented.

Programmes like that of the National Institute of Nutrition have serious limitations. Most people in India do not own land for home gardens. Also, vitamin A in nature is present in an inactive form called beta-carotene that is converted into active vitamin A, called retinal, in the body. Studies suggest that only one-fourth of beta-carotene is converted into retinol. In malnourished children this is even less. Moreover, fat is required for the absorption of retinol in the body, and in India people get only five per cent of their calorie requirements from fat; the recommended amount is 20 per cent. Consuming vitamin A, therefore, does not ensure its utilisation in the body.

There is no single solution to combating vitamin A deficiency in India. The government launched campaigns in 1970, aiming to replace them with food-based approaches in a couple of years. But the campaigns have continued, as they are easier than enticing people to grow and consume vitamin A foods. Campaigns are not a long-term solution. Providing capsules and syrups of vitamin A without educating people on why they need the vitamin makes them dependent on the government.

Campaigns are necessary where vitamin A deficiency is a proven public health concern. Unicef must assess and determine this before launching a campaign. Campaigns are an emergency solution, not an alternative to consuming vegetables and fruits. The money spent by the Indian government and international agencies on campaigns could be used to improve the quality and quantity of subsidised food and perhaps start the free distribution of food. If this money were used to raise the salaries of poorly paid government officials, levels of corruption may decrease, thereby largely improving the effectiveness of food programmes already underway.

CANCER: More exercise, rest, cut risk in women

Past studies have shown that exercise offers protection against cancer, and other studies have shown that cutting back on sleep can, among other things, compromise immunity. Until now, no one, however, has looked at the effect of inadequate sleep on the benefits of exercise in reducing cancer risk.

A group of researchers funded by the John Hopkins School of Public Health and led by James McClain, a Cancer Prevention Fellow from the National Cancer Institute, followed almost 6,000 cancer-free women for 10 years. The women reported on their levels of physical activity and sleep through questionnaires.

At the end of the study period, researchers found that exercise reduced cancer risk among the most active women. But this benefit was diminished in younger and more active women who tended to sleep less than seven hours a night. The cancer risk in these women increased by 47 percent compared with women sleeping at least seven hours a night or more. No such relation was observed in older women, and sleep alone did not reduce cancer risk.

“Exercise may reduce cancer risk by improving immunity, regulating insulin and glucose levels, and by maintaining normal sex hormone levels,” said McClain. “Inadequate sleep, on the other hand, might have the opposite effect.” BOTTOM LINE: The benefit of physical activity in reducing cancer risk is diminished by a lack of sleep among younger women. WHAT’S NEXT: Confirm these findings in a larger group of women and try to understand how lack of sleep may be increasing cancer risk. CAUTIONS: This is the first study of its kind and more work is needed to confirm these findings. WHERE TO FIND IT: The study was presented at the American Association for Cancer Research conference on Frontiers in Cancer Prevention and can be found at http://www.aacr.org/home/public–media/news.aspx?d=1191

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CLIMATE: Monsoons shaped dynasties’ fate?, The Boston Globe, Health and Science

CLIMATE

Monsoons shaped dynasties’ fate?

Monsoons may have played a role in the rise and fall of Chinese dynasties, a new study finds.

Researchers from the University of Minnesota in Minneapolis and Lanzhou University in China, led by R. Lawrence Edwards, have reconstructed 1,810 years of the Asian monsoon, moisture-laden winds that blow north from the Indian Ocean bringing rain to many Asian regions, especially India and China. The winds bring with them the rain needed for a bountiful growing season.

Edwards and colleagues looked at a stalagmite, a rock column formed by the solidification of minerals from water, that had grown continuously from 190 to 2003 A.D. a kilometer inside the Wanxiang Cave in China. They first measured uranium and thorium in the stalagmite to date the different layers, and then measured the ratio of two different isotopes of oxygen in the stalagmite. The source of oxygen was dripping water from the cave roof which in turn came from the rain, and a measure of the ratio helped them calculate the rainfall during a particular time period.

They found that a drop in monsoon rains coincided with the declines of three dynasties. Rainfall was low between 850 and 930 A.D., spanning the time when the Tang dynasty declined and collapsed. This time also coincided with dry weather in the Americas and the demise of the Mayans. Similar dry periods in the late 14th and early 17th centuries coincided with the demise of the Yuan and Ming dynasties.

A period when the monsoon was strong – between 960 and 1020 A.D. – was a “golden age” in China when the Northern Song dynasty flourished, the population doubled and rice cultivation expanded.

BOTTOM LINE: There is evidence suggesting that climate played a role in the rise and fall of Chinese dynasties. CAUTIONS: This is the first study of its kind and more work is needed to confirm these findings. WHAT’S NEXT: Researchers will look further back in history to see if the same trend appears. WHERE TO FIND IT: Science, Nov. 7

BIRTH CONTROL: Pill appears to control against breast cancer, The Boston Globe, Health and Science

Birth control pills give long-term protection against ovarian cancer, a new study finds. Past work has shown that birth control pills afford some protection against ovarian cancer, but researchers did not know how long this beneficial effect lasted. In a new study led by Valerie Beral from the Cancer Research UK Epidemiology Unit at Oxford University, researchers compiled data from 45 previous studies that included about 23,000 women with ovarian cancer and 87,000 without it. Just over 30 percent of the women with cancer and 37 percent of those without cancer had taken the pill for some period of time. They found that using the pill for a decade or more reduced ovarian cancer risk by almost one-third and the protection lasted 30 years after pill usage had stopped. They also found that the longer a woman was on the pill the more it reduced cancer risk. This beneficial effect was consistent, regardless of ethnicity, education, or alcohol and tobacco consumption, they found.

BOTTOM LINE: “Women do not have to worry about bad side effects from taking the pill,” said Beral. “We know now that the pill actually offers protection against ovarian cancer.”

CAUTIONS: This is the first study to look at long-term benefits of the pill and more work is needed to confirm the results. The study also looks at just ovarian cancer; other side effects have to be taken into consideration to fully understand whether the positives outweigh the negatives.

WHAT’S NEXT: Beral’s group wants to look at the effect of the pill in reducing endometrial cancer risk.

WHERE TO FIND IT: The Lancet, Jan. 26

PROSTATE CANCER: Hair-loss drug makes screening less accurate, The Boston Globe, Health and Science

Propecia, a drug widely used by men for hair loss, artificially lowers prostate cancer screening test results, a new study finds. Screening for prostate cancer involves testing blood for prostate specific antigen levels, or PSA. Higher-than-normal levels of the PSA protein suggests cancer in the prostate. Past research showed that Proscar, a drug used to treat enlarged prostate glands, “falsely” lowers PSA levels, perhaps allowing a tumor to go undetected until it is more advanced and therefore more dangerous. Propecia has the same active ingredient as Proscar but is taken at a lower dose. Dr. Anthony D’Amico at Brigham and Women’s Hospital and a colleague recently followed 355 men between the ages of 40 and 60, 285 of whom were taking Propecia. They tested participants’ PSA levels every 12 weeks over 48 weeks and found that in the 40-49 age group, PSA levels were 40 percent lower in men taking Propecia than those not on the drug. In the 50-60 age group, levels were 50 percent lower in drug users.
BOTTOM LINE: Men getting screened for prostate cancer should tell their doctors if they are using Propecia for hair loss.
CAUTIONS: The study lasted one year; longer studies are required to see long-term effects of Propecia on blood PSA levels.
WHAT’S NEXT: The authors want to see if men taking Propecia are more likely to be diagnosed with late-stage prostate cancer, suggesting cancer may have been overlooked earlier.
WHERE TO FIND IT: Lancet Oncology Online, Dec. 5
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PEDIATRICS: Children’s brains can be reshaped by stress, The Boston Globe, Health and Science

Severe stress can change the structure of a child’s brain, a new study finds, potentially limiting the child’s ability to cope with the crisis. Levels of the hormone cortisol are known to rise with stress, and past studies in adults have suggested an association between higher emotional stress and a smaller hippocampus – a brain region closely connected to the emotion center and involved with memory storage and processing. A group of researchers led by Dr. Victor Carrion from Stanford University looked at the brain structures and bedtime cortisol levels of 15 children, ages 7 to 13, who were suffering from post-traumatic stress disorder. Twelve to 18 months later, participants were assessed again, and researchers found that hippocampus volumes were reduced more in children with more severe stress symptoms and higher bedtime cortisol levels. Because the hippocampus is so important in memory and emotion processing, researchers think that its reduced volume will lower a child’s coping ability. This, in turn, will raise stress and cortisol levels, further damaging the hippocampus and continuing the vicious cycle.
BOTTOM LINE: Dr. Carrion said that current psychiatric therapies may work less well in children with post-traumatic stress disorder because of their compromised coping abilities. “We need to develop more focused therapeutic interventions that take this into consideration,” he said.
WHAT’S NEXT: The researchers want to see if the functional ability of the hippocampus is also reduced over time by high cortisol levels.
CAUTIONS: This is a small pilot study. More and larger studies are required to confirm its findings. The study does not compare brain structure before and after trauma, or between children with and without post-traumatic stress disorder.
WHERE TO FIND IT: Pediatrics, March 2007
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ARCHEOLOGY: Chili peppers on the menu for at least 6,000 years, The Boston Globe, Health and Science

The cultivation of chili peppers originated in the Americas about 6,100 years ago, a new study finds. Every plant species has its own characteristic starch grain – like a fingerprint – that can be used as a marker to identify the plant species. Now, by routinely analyzing fossilized starch samples from seven archeological sites in Central and South America, researchers have identified the distinctive starch microfossil for chili peppers, and unintentionally documented the history of the peppers from about 6,000 years ago to 500 years ago. The researchers, led by Linda Perry of the Smithsonian National Museum of Natural History, also found that starch microfossils from chili peppers and from maize coexisted, which means the two plants “traveled” together in the tropics just like the corn-beans-squash trio did in North America.
BOTTOM LINE: Though researchers knew that chili peppers were important in many ancient cuisines, they had not known the origin and domestication history of these plants. “We now have the starch microfossil marker for chili peppers and we can trace its use in ancient American cuisines,” said Perry.
CAUTIONS: More work is required to clearly establish the earliest dates and specific regions associated with the origin of chili peppers and their evolution with society.
WHAT’S NEXT: In future projects, researchers hope to document exactly when chili peppers were first used and first domesticated. They also hope to identify the distinctive starch microfossils of the five different Capsicum species – which include jalapenos, bell peppers, and anaheims. So far Perry has identified only one – that of the hot rocoto pepper still grown in the Peruvian highlands.
WHERE TO FIND IT: Science, Feb. 16.
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ARTHRITIS: Exercise doesn’t hurt knees; doesn’t help either, The Boston Globe, Health and Science

Moderate exercise neither increases nor decreases risk of knee osteoarthritis, a new study finds. In knee osteoarthritis, the cartilage at the joint wears down, causing bones to rub against each other leading to pain, swelling, and stiffness. Some past studies had suggested that exercise can reduce the risk of developing this form of arthritis by making knee-joint cartilage stronger, whereas other studies suggested that when older people exercise they can injure their knee joints and actually increase osteoarthritis risk, especially if they are overweight. But a recent study led by Dr. David Felson at the Boston University School of Medicine suggests that moderate exercise has no effect on the risk of developing knee osteoarthritis. For the study, Felson and colleagues took knee X-rays of 1,279 people, ranging in age from their 20s to their 80s and also asked them to report knee pain, stiffness, and level of physical activity. After nine years, the participants were reassessed. Researchers found that moderate exercise had no bearing on the risk of developing knee osteoarthritis.
BOTTOM LINE: Older people – even those who are overweight – will not damage their knees by getting moderate exercise. “This is a good thing because exercise is important for older people,” Felson said.
CAUTIONS: The study is the first to show that exercise does not affect knee osteoarthritis risk. More research is needed to confirm these findings.
WHAT’S NEXT: Felson hopes someone will investigate how more vigorous exercise affects knee osteoarthritis risk.
WHERE TO FIND IT: Arthritis Care & Research, February.
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ARTHRITIS: Massage effective against pain and joint stiffness, The Boston Globe, Health and Science

Massage helps reduce pain and joint stiffness in osteoarthritis patients, a new study finds. As many as 21 million Americans suffer from osteoarthritis, the most common form of arthritis, which affects the hands, feet, spine, hip and knee joints. For the study, 68 patients with osteoarthritis of the knee were enrolled: 34 were offered eight weeks of massage twice a week for the first four weeks and once a week for the next four weeks, and the rest were not. All participants continued with previously prescribed medications and treatments. After eight weeks, the pain, stiffness, and range of knee motion was assessed in both groups. Participants who had received massage reported less pain, joint stiffness, and improved mobility in the knees, whereas the control group reported no change in symptoms. From week nine to 16, the control group also received massage therapy and they reported a decrease in pain and stiffness as well. The first group was assessed again two months after discontinuing massage and reported still feeling its benefits, a finding that, according to senior researcher Dr. David Katz of the Yale School of Medicine, makes this study especially worthwhile because massage requires time and money and if it can be used less it becomes more affordable.
BOTTOM LINE: Massage can help arthritis patients cut back on their medications.
WHAT’S NEXT: The researchers want to study the extent to which massage can reduce medication use and to determine its cost-effectiveness as an alternative, or adjunct to, current drug treatments.
CAUTIONS: This is the first study of its kind, and larger and longer studies are required to confirm this finding and to assess how long massage benefits last.
WHERE TO FIND IT: Archives of Internal Medicine, Dec. 11.
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CANCER: Effects of ‘chemobrain’ seem to disappear after a few , The Boston Globe, Health and Science

“Chemobrain,” the fuzziness some people experience after having chemotherapy, disappears within three years of treatment, a new study finds. Past research showed that some chemotherapy patients saw a decline in cognitive abilities like memory, judgment, comprehension, and learning – but why this happened was not clear. Now a group of researchers led by Dr. Masatoshi Inagaki at the National Cancer Center Hospital East in Chiba, Japan, have compared brain structure in cancer survivors who received chemotherapy to those who did not. Using MRI, they looked at volumes of different brain regions in 105 cancer survivors who had undergone cancer surgery less than a year ago. Of these, 51 had received chemotherapy and 54 had not. They then did the same thing with 132 cancer survivors who had undergone cancer surgery more than three years ago – 73 had received chemotherapy and the rest had not. They found that within a year of surgery, chemotherapy recipients had smaller volumes of certain brain areas involved in cognition compared with subjects who had received no chemotherapy. These differences, however, disappeared when cancer survivors were seen three years after surgery. The researchers also compared brain structures of cancer survivors and healthy subjects and found no significant difference, indicating that the cancer itself does not affect brain structure.
BOTTOM LINE: Chemotherapy could have a temporary effect on brain structure and, therefore, memory and learning, but this side effect will disappear within three years of cancer surgery.
CAUTIONS: A more detailed and larger study is necessary to confirm these findings.
WHAT’S NEXT: “These results can provide new insights for future research to improve the quality of life for cancer patients undergoing chemotherapy,” said Inagaki.
WHERE TO FIND IT: Cancer, online, Nov. 27.
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