Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet

CONTEXT

Lead, mercury, and arsenic have been detected in a substantial proportion of Indian-manufactured traditional Ayurvedic medicines. Metals may be present due to the practice of rasa shastra (combining herbs with metals, minerals, and gems). Whether toxic metals are present in both US- and Indian-manufactured Ayurvedic medicines is unknown.

OBJECTIVES

To determine the prevalence of Ayurvedic medicines available via the Internet containing detectable lead, mercury, or arsenic and to compare the prevalence of toxic metals in US- vs Indian-manufactured medicines and between rasa shastra and non-rasa shastra medicines.

DESIGN

A search using 5 Internet search engines and the search terms Ayurveda and Ayurvedic medicine identified 25 Web sites offering traditional Ayurvedic herbs, formulas, or ingredients commonly used in Ayurveda, indicated for oral use, and available for sale. From 673 identified products, 230 Ayurvedic medicines were randomly selected for purchase in August-October 2005. Country of manufacturer/Web site supplier, rasa shastra status, and claims of Good Manufacturing Practices were recorded. Metal concentrations were measured using x-ray fluorescence spectroscopy.

MAIN OUTCOME MEASURES

Prevalence of medicines with detectable toxic metals in the entire sample and stratified by country of manufacture and rasa shastra status.

RESULTS

One hundred ninety-three of the 230 requested medicines were received and analyzed. The prevalence of metal-containing products was 20.7% (95% confidence interval [CI], 15.2%-27.1%). The prevalence of metals in US-manufactured products was 21.7% (95% CI, 14.6%-30.4%) compared with 19.5% (95% CI, 11.3%-30.1%) in Indian products (P = .86). Rasa shastra compared with non-rasa shastra medicines had a greater prevalence of metals (40.6% vs 17.1%; P = .007) and higher median concentrations of lead (11.5 microg/g vs 7.0 microg/g; P = .03) and mercury (20,800 microg/g vs 34.5 microg/g; P = .04). Among the metal-containing products, 95% were sold by US Web sites and 75% claimed Good Manufacturing Practices. All metal-containing products exceeded 1 or more standards for acceptable daily intake of toxic metals.

CONCLUSION

One-fifth of both US-manufactured and Indian-manufactured Ayurvedic medicines purchased via the Internet contain detectable lead, mercury, or arsenic.

Children's bone health, calcium and vitamin D--how much do nurses and health visitors know?

Two focus groups of health visitors, practice nurses and community nursery nurses were held to find out how much health visitors and nurses know about children's bone nutrition, and whether they are able to identify dietary sources of these nutrients. Results showed that these professionals spend a significant part of their time giving nutritional advice about children and young people and answering questions on a range of dietary matters. They were well informed about the importance for bone health of calcium, vitamin D, exercise and a healthy, balanced diet. The biggest misconception was that dairy products in the UK contain vitamin D. Most of the professionals knew that bone strength develops quickly during childhood, and some that it does so in adolescence but few were aware that 90% of the full genetic potential for bone strength is achieved before adulthood. The groups reported confusion over the Government's initiatives for vitamin D supplements, and lack of guidance from Primary Care Trusts on making Healthy Start vitamins available at clinics for mothers and babies. Overall, health visitors and nurses have a good knowledge of bone health but there are gaps and more educational resources are needed, including on dietary sources of vitamin D. The Government needs to give clear guidelines about its initiatives for vitamin D supplements for mothers and children aged under five years. It is disappointing that the Dairy Council's 3-a-Day message on meeting essential calcium needs through three daily servings of dairy foods has not got through.

Avaliação de políticas públicas de segurança alimentar e combate à fome no período 1995-2002. 3 - o Programa Nacional de Controle da Deficiência de Vitamina A

A distribuição de vitamina A em Dias Nacionais de Vacinação ocorre desde 1983; o Brasil foi pioneiro nesse tipo de intervenção. O estudo avaliou o programa no período de 1995-2002 na perspectiva de estrutura-processo-resultado. A metodologia envolveu pesquisa documental, entrevistas com gestores e estudo de caso em 44 municípios da Bahia, resultando em 1.344 questionários domiciliares. Em relação à estrutura, o programa operou sem instrumento normativo a partir de 1998, decorrente da extinção do Instituto Nacional de Alimentação e Nutrição. Melhorias nos processos de aquisição e distribuição do suplemento impactaram positivamente na sua cobertura; em 2002, foram distribuídas 3,5 milhões de cápsulas (cobertura 72%). Nas 2.546 crianças estudadas na Bahia, não houve regularidade na distribuição e a cobertura anual variou de 8% a 26%. As limitações de tempo e recursos humanos, informadas pelos gestores, corroboram a hipótese de que essa estratégia não contribui para esclarecer a população sobre a importância da vitamina. Os achados mostram ser necessária a articulação sistemática entre esferas de governo para que o programa seja executado e monitorado em sua plenitude.

Should folic acid fortification be mandatory? Yes

The UK's Food Standards Agency recently recommended mandatory folic acid fortification of some foods. Nicholas Wald and Godfrey Oakley argue that it's a safe effective way of preventing spina bifida and anencephaly—but Richard Hubner and colleagues say that more research into the harms is needed

Should folic acid fortification be mandatory? No

The UK's Food Standards Agency recently recommended mandatory folic acid fortification of some foods. Nicholas Wald and Godfrey Oakley argue that it's a safe effective way of preventing spina bifida and anencephaly—but Richard Hubner and colleagues say that more research into the harms is needed

National vitamin A supplementation coverage survey among 6-59 months old children in Guinea (West Africa)

BACKGROUND

Vitamin A deficiency (VAD) is a major contributor to child mortality in sub-Saharan Africa. Sustained control of VAD is essential to meet the Millennium Development Goal (MDG) for reduction of child mortality in Guinea. Since, twice yearly vitamin A supplementation (VAS), either coupled with National Immunization Days or stand-alone has been adopted as a key strategy to combat VAD in 6-59 months old children.

OBJECTIVES

The objectives of this survey were to describe national VAS coverage rates and related factors affecting VAS coverage among 6-59 months old Guinean children.

METHODS

In July 2003, a VAS coverage survey was implemented in Guinea. A cross-sectional random cluster survey was conducted to select Guinean children (n = 1950, 390 mother-child pairs per zone) aged 6-59 months. The country was divided into four agro-ecological zones with 30 clusters chosen per zone. Within each cluster, a random selection of 13 households with at least one child was carried out with random selection of one child per household. Data on characteristics of children, receipt of VAS, caregivers' socio-economic characteristics, vitamin A knowledge and practices of caregivers were collected by questionnaire.

RESULTS

The national coverage rate of 68% is much lower than the official coverage rate of 93%. Middle Guinea, the region most affected by VAD, had the lowest coverage rate (58%).

CONCLUSION

In order to increase overall VAS coverage and reduce regional disparities, it is suggested that mass VAS be organized on a regional level, prioritizing rural regions (Middle and Upper Guinea) and the city of Conakry.

Availability of weight-loss supplements: Results of an audit of retail outlets in a southeastern city

The sale of nonprescription weight-loss products accounts for millions of dollars spent by Americans trying to lose weight, yet there is little evidence for effectiveness and there are multiple safety concerns. The purpose of this study was to determine what products, and ingredients within products, were available at retail outlets in a metropolitan area. A purposive sampling strategy identified 73 retail outlets. An audit form was used to collect information from product labels. The audit identified 402 products containing 4,053 separate ingredients. The mean number of ingredients per product was 9.9+/-8.96 (range = 1 to 96). A database search was conducted regarding evidence for effectiveness, safety precautions, and side effects for the 10 ingredients that appeared most often across products. Modest evidence of effectiveness exists for green tea (Camellia sinensis), chromium picolinate, and ma huang (Ephedra major). For the remaining seven (ginger root [Zingiber officinale], guarana [Paullinia cupana], hydroxycitric acid [Garcinia cambogia], white willow [Salix alba], Siberian ginseng [Eleutherococcus senticosus], cayenne [Capsicum annuum], and bitter orange/zhi shi [Citrus aurantium]), inadequate or negative evidence exists. Although precautions and contraindications were found for all 10 ingredients, the strongest concerns in the literature appear for ma huang, bitter orange, and guarana. Our audit revealed numerous weight-loss products available to consumers, yet there is little evidence to support the effectiveness of the top 10 ingredients identified and many potential adverse reactions; therefore, food and nutrition professionals should discuss dietary supplement use with their clients.

Amphetamine lacing of an Internet-marketed neutraceutical

A 25-year-old woman presented with abdominal pain after taking an imported herbal weight-loss product. A urinary toxicology screen was positive for amphetamine, which the patient denied taking. On further investigation, the neutraceutical was found to contain an amphetamine derivative banned by the US Food and Drug Administration (FDA). Although the patient had discontinued use of the supplement before hospitalization and her symptoms steadily improved with appropriate treatment, a report was made to the FDA. Similar reports from cities across the United States prompted the FDA to confiscate shipments of the product before it could be distributed further nationally while they investigate claims against the product.

Vitamin A supplementation in Tanzania: the impact of a change in programmatic delivery strategy on coverage

BACKGROUND

Efficient delivery strategies for health interventions are essential for high and sustainable coverage. We report impact of a change in programmatic delivery strategy from routine delivery through the Expanded Programme on Immunization (EPI+) approach to twice-yearly mass distribution campaigns on coverage of vitamin A supplementation in Tanzania

METHODS

We investigated disparities in age, sex, socio-economic status, nutritional status and maternal education within vitamin A coverage in children between 1 and 2 years of age from two independent household level child health surveys conducted (1) during a continuous universal targeting scheme based on routine EPI contacts for children aged 9, 15 and 21 months (1999); and (2) three years later after the introduction of twice-yearly vitamin A supplementation campaigns for children aged 6 months to 5 years, a 6-monthly universal targeting scheme (2002). A representative cluster sample of approximately 2,400 rural households was obtained from Rufiji, Morogoro Rural, Kilombero and Ulanga districts. A modular questionnaire about the health of all children under the age of five was administered to consenting heads of households and caretakers of children. Information on the use of child health interventions including vitamin A was asked.

RESULTS

Coverage of vitamin A supplementation among 1-2 year old children increased from 13% [95% CI 10-18%] in 1999 to 76% [95%CI 72-81%] in 2002. In 2002 knowledge of two or more child health danger signs was negatively associated with vitamin A supplementation coverage (80% versus 70%) (p = 0.04). Nevertheless, we did not find any disparities in coverage of vitamin A by district, gender, socio-economic status and DPT vaccinations.

CONCLUSION

Change in programmatic delivery of vitamin A supplementation was associated with a major improvement in coverage in Tanzania that was been sustained by repeated campaigns for at least three years. There is a need to monitor the effect of such campaigns on the routine health system and on equity of coverage. Documentation of vitamin A supplementation campaign contacts on routine maternal and child health cards would be a simple step to facilitate this monitoring.

Research of stimulants and anabolic steroids in dietary supplements

The purpose of this study was to analyze the composition of 103 dietary supplements bought on the internet. The supplements were dispatched in four different categories according to their announced contents [creatine, prohormones, "mental enhancers" and branched chain amino acids (BCAA)]. All the supplements were screened for the presence of stimulants and main anabolic steroids parent compounds. At the same time, the research was focused on the precursors and metabolites of testosterone and nandrolone. The study pointed out three products containing an anabolic steroid, metandienone, in a very high amount. The ingestion of such products induced a high quantity of metandienone metabolites in urines that would be considered as a positive antidoping test. The results have also shown that one creatine product and three "mental enhancers" contained traces of hormones or prohormones not claimed on the labels and 14 prohormone products contained substances other than those indicated by the manufacturer. The oral intake of the creatine product revealed the presence of the two main nandrolone metabolites (19-norandrosterone and 19-noretiocholanolone) in urine.

[The effect of tobacco smoking during pregnancy on concentration of vitamin A and beta-carotene in matched-maternal cord pairs]

Tobacco smoking causes oxidant stress in pregnant women and may have a similar effect in fetus. Vitamin A and beta-carotene are natural factors protecting cells from damaging influence of free oxygen species.Therefore the aim of the study was to estimate the effect of tobacco smoking during pregnancy on concentration of vitamin A and beta-carotene in blood of mother and newborn. Healthy women in III trimester of pregnancy were divided into non-smoking (n = 40) and smoking group (n = 35) according to the concentration of cotinine in serum and urine. Level of carotenoids was measured by HPLC (high pressure liquid chromatography) method in plasma of matched-maternal cord pairs. We observed that, in smoking women group concentration of vitamin A was lower in plasma of mothers as well as in cord blood of newborn (p < 0.001) and amounted respectively only 80% and 70% of that observed in non-smoking mother and their child. In smoking group plasma level of beta-carotene was significantly lower (by 30%; p < 0.0001) as compared with non-smoking matched-maternal cord pairs. Plasma level of vitamin A was significantly correlated with concentration of pcarotene both in smoking and non-smoking pregnant women (r = 0.70, p < 0.001; r = 0.57, p < 0.001). The similar correlation was observed in umbilical cord blood in both groups (r = 0.81 and r = 0.82; p < 0.001). Reduced concentration of vitamin A and beta-carotene in matched-maternal cord pairs suggest that consumption of this antioxidant for neutralization of free radicals present in cigarette smoking is enhanced.

Evaluation of Herbal Dietary Supplements Marketed on the Internet for Recreational Use

BACKGROUND:

The Internet is a popular tool for marketing and purchasing herbal dietary supplements (DS). Various Web sites sell these products purely for recreational use.

Objective:

To describe the content of Web sites that advertise and market herbal DS for recreational use (ie, for the purpose of altering mood/behavior/or perception, “getting high,” or as a substitute for a drug of abuse).

METHODS:

Four major search engines and the search terms “buy herbal high” and “buy legal high” were used to identify Web sites selling herbal DS for recreational use. Web sites were evaluated for their country of origin and for compliance with the Dietary Supplement Health and Education Act (DSHEA). Products were evaluated for their ingredient lists, effect claims, comparisons with illicit drugs, adverse effects, drug interactions, and contraindications.

RESULTS:

Twenty-eight unique Web sites with 119 products were evaluated. Most sites were in the US (54%) and were in compliance with DSHEA. Forty-seven percent of the products were likened to illicit drugs, typically marijuana (48%) or 3-,4-methylene dioxyamphetamine (Ecstasy; 23%). The most common product ingredients were ephedra alkaloids (27%), Salvia divinorum (17%), kava (10%), guarana (10%), Acorus calamus (10%), and damiana (10%). Effect claims frequently involved the products' use as a hallucinogen (51%) or stimulant (39%). Sixty-four percent of the sites mentioned adverse effects, and 54% mentioned drug interactions.

CONCLUSIONS:

This study demonstrates that herbal DS are being marketed for use as legal alternatives to illicit drugs of abuse. Healthcare professionals need to be aware of this trend and the products that are involved.

The impact of vitamin A supplementation on mortality inequalities among children in Nepal

OBJECTIVE

This paper examines gender, caste and economic differentials in child mortality in the context of a cluster-randomized trial of vitamin A distribution, in order to determine whether or not the intervention narrowed these differentials.

DESIGN

The study involved secondary analysis of data from a placebo-controlled randomized field trial of vitamin A supplements. The study took place between 1989-1991 in rural Sarlahi District of Nepal, with 30,059 children age 6 to 60 months. The main outcome measures were differences in mortality between boys and girls, between highest Hindu castes and others, and between the poorest quintile and the four other quintiles.

RESULTS

Without vitamin A, girls in rural Nepal experience 26.1 deaths per 1000, which is 8.3 deaths more than the comparison population of boys. With vitamin A the mortality disadvantage of girls is nearly completely attenuated, at only 1.41 additional deaths per 1000 relative to boys. Vitamin A supplementation also narrowed mortality differentials among Hindu castes, but did not lower the concentration of mortality across quintiles of asset ownership. The vitamin A-related attenuation in mortality disadvantage from gender and caste is statistically significant.

CONCLUSIONS

We conclude that universal supplementation with vitamin A narrowed differentials in child death across gender and caste in rural Nepal. Assuring high-coverage vitamin A distribution throughout Nepal could help reduce inequalities in child survival in this population.

Endocrine and cognitive effects of short-time soybean consumption in women

BACKGROUND

Soy phytoestrogens are known to influence the hormonal status acting as partial estrogen agonists. Soy-derived food supplements are advised for hormone replacement therapy, prevention of atherosclerosis, age-related cognitive decline and even hormone-dependent cancer, although results from clinical studies are controversial. Whether increased soybean intake can affect the endocrine status and cognitive abilities is largely unknown.

AIM

To observe the effects of 1 week of increased soybean intake on sex hormone levels and spatial cognitive abilities in women.

SUBJECTS AND METHODS

16 young healthy female volunteers were asked to eat 900 g of soybeans within 1 week. Salivary testosterone (T), free and total plasma T, salivary and plasma estradiol (E) were measured by radioimmunoassay before and after the study period. Mental rotation (MR) and spatial visualization (SV) psychological tests were done at the days of sampling.

RESULTS

Soybean intake increased total plasma T levels (p < 0.02) while decreasing salivary T (p < 0.01) and not altering free plasma T levels. Salivary and plasma E levels were not changed. The results of MR and SV tests were improved after the study period.

CONCLUSION

Short-time increased soybean intake alters the level of total plasma and salivary T and improves spatial cognition in women. Whether this effect is mediated by modulation of estrogen receptors, changes in sex hormone-binding globulin production or changes in activity of steroid-competent enzymes needs further study.

Internet marketing of herbal products

CONTEXT

Passage of the Dietary Supplement Health and Education Act in 1994 restricted the Food and Drug Administration's control over dietary supplements, leading to enormous growth in their promotion. The Internet is often used by consumers as a source of information on such therapies.

OBJECTIVE

To assess the information presented and indications claimed on the Internet for the 8 best-selling herbal products.

DATA SOURCES

We searched the Internet using the 5 most commonly used search engines. For each, we entered the names of the 8 most widely used herbal supplements (ginkgo biloba, St John's wort, echinacea, ginseng, garlic, saw palmetto, kava kava, and valerian root). We analyzed the health content of all Web sites listed on the first page of the search results.

STUDY SELECTION

We analyzed all accessible, English-language Web sites that pertained to oral herbal supplements. A total of 522 Web sites were identified; of these, 443 sites met inclusion criteria for the analysis.

DATA EXTRACTION

The nature of the Web site (retail or nonretail), whether it was a sponsored link, and all references, indications, claims, and disclaimers were recorded. Two reviewers independently categorized medical claims as disease or nondisease according to Food and Drug Administration criteria.

DATA SYNTHESIS

Among 443 Web sites, 338 (76%) were retail sites either selling product or directly linked to a vendor. A total of 273 (81%) of the 338 retail Web sites made 1 or more health claims; of these, 149 (55%) claimed to treat, prevent, diagnose, or cure specific diseases. More than half (153/292; 52%) of sites with a health claim omitted the standard federal disclaimer. Nonretail sites were more likely than retail sites to include literature references, although only 52 (12%) of the 443 Web sites provided referenced information without a link to a distributor or vendor.

CONCLUSIONS

Consumers may be misled by vendors' claims that herbal products can treat, prevent, diagnose, or cure specific diseases, despite regulations prohibiting such statements. Physicians should be aware of this widespread and easily accessible information. More effective regulation is required to put this class of therapeutics on the same evidence-based footing as other medicinal products.

Risk factors for early infant mortality in Sarlahi district, Nepal

OBJECTIVES

Early infant mortality has not declined as rapidly as child mortality in many countries. Identification of risk factors for early infant mortality may help inform the design of intervention strategies.

METHODS

Over the period 1994-97, 15,469 live-born, singleton infants in rural Nepal were followed to 24 weeks of age to identify risk factors for mortality within 0-7 days, 8-28 days, and 4-24 weeks after the birth.

FINDINGS

In multivariate models, maternal and paternal education reduced mortality between 4 and 24 weeks only: odds ratios (OR) 0.28 (95% confidence interval (CI) = 0.12-0.66) and 0.63 (95% CI = 0.44-0.88), respectively. Miscarriage in the previous pregnancy predicted mortality in the first week of life (OR = 1.98, 95% CI = 1.37-2.87), whereas prior child deaths increased the risk of post-neonatal death (OR = 1.85, 95% CI 1.24-2.75). A larger maternal mid-upper arm circumference reduced the risk of infant death during the first week of life (OR = 0.88, 95% CI = 0.81-0.95). Infants of women who did not receive any tetanus vaccinations during pregnancy or who had severe illness during the third trimester were more likely to die in the neonatal period. Maternal mortality was strongly associated with infant mortality (OR = 6.43, 95% CI = 2.35-17.56 at 0-7 days; OR = 11.73, 95% CI = 3.82-36.00 at 8-28 days; and OR = 51.68, 95% CI = 20.26-131.80 at 4-24 weeks).

CONCLUSION

Risk factors for early infant mortality varied with the age of the infant. Factors amenable to intervention included efforts aimed at maternal morbidity and mortality and increased arm circumference during pregnancy.