Primary source: The Cochrane Review
Source reference:
Goldenberg G, et al “Probiotics for the prevention of Clostridium difficile associated diarrhea in adults and children” (Review); DOI: 10.1002/14651858.CD006095.pub2.

Alarming levels of banned toxic found in substitutes makes local Cinnamon safer and desirable

A scientific research study four years in the making and just released in the US spells a major windfall for Sri Lanka’s cinnamon industry.
Appearing in the April issue of the prestigious Journal of Agricultural and Food Chemistry (JAFC), published by the American Chemical Society, the study by researchers at the University of Mississippi analyzing levels of the banned toxic chemical coumarin in cinnamon products affirms the superiority of Ceylon Cinnamon, AKA True Cinnamon, as compared to more widely used cinnamon substitutes.

High levels of coumarin, a chemical that naturally occurs in cinnamon, is a toxic to the liver, acts as an anticoagulant, and is known to cause cancer in rodents.
According to the researchers, experiments conducted using a variety of popular cinnamon flavored foods and cinnamon food supplements found in Ceylon Cinnamon to contain insignificant traces of coumarin whereas barks from cassia, imported from China, Vietnam and Indonesia and sold as cinnamon in the US, had substantial amounts of the toxic chemical.

“This is a great development that opens up many possibilities for Sri Lankan cinnamon growers”, said former Consul General Ananda Wickremasinghe (now living in Canada). He has been patiently awaiting the results ever since he took the initiative to get the study started in 2009 while serving as Consul General in Los Angeles. Wickremasinghe, an agricultural graduate who spent most of his career as an agriculture scientist spotted the potential for promoting Ceylon Cinnamon in the US after its lower coumarin content and superiority over substitutes was established by European as well as Sri Lankan researchers. “Some Sri Lankan exporters were already aware of Ceylon Cinnamon’s lower coumarin levels and studies have been conducted by the Industrial Technology Institute. However, to gain acceptance in the U.S., an independent study by American researchers was needed”.

He presented the proposal to Research Professor in Pharmaceutical Sciences at the University of Mississippi Dr. Dhammika Nanayakkara, one of the nation’s top pharmaceutical research colleges.  Dr. Nanayakkara eventually co-authored the study with research scientists Dr. Yan-Hong Wang (University of Mississippi),   Bharathi Avula (University of Mississippi), Jianping Zhao, and Ikhlas A Khan.

The research was supported in part by “Science Based Authentication of Dietary
Supplements” funded by the Food and Drug Administration, the United States Department of Agriculture, Agricultural Research Service, and the Global Research Network for Medicinal Plants (GRNMP), King Saud University.
The researchers analyzed coumarin and other compounds in authenticated cinnamon bark samples as well as locally bought cinnamon samples, cinnamon-flavored foods, and cinnamon-based food. “The experimental results indicated that C. verum bark (Ceylon Cinnamon) contained only traces of coumarin, whereas barks from all three cassia species, especially C. loureiroi (Vietnam Cinnamon) and C. burmannii (Indonesian Cinnamon), contained substantial amounts of coumarin”, the study said.

Researchers then analyzed 21 cinnamon-flavored foods such as cereals, snacks, bread, rolls, buns, swirl, bar and pastries all purchased from local stores. Except for cinnamaldehyde that is essential for cinnamon flavor, coumarin was detected in all cinnamon-flavored food products, varying in content from 0.05 to 2.4 mg per serving. Two cinnamon dietary supplements that contained powders of cinnamon bark were also analyzed and found to contain high coumarin levels – 2.5 and 3.9 mg per serving.
The identity of the cinnamon used in the samples was determined based on cinnamaldehyde and coumarin content, leading to the conclusion that most of the cinnamon used was of the Indonesian variety (C.burmannii) which has higher coumarin content, is cheaper, and accounts for 90% of US cinnamon imports in the past five years.

Surprisingly, despite cinnamon’s widespread use as a flavoring in a wide range of foods and its growing popularity as a ‘miracle cure’ for everything from diabetes to weight loss this is the first published study in the US that analyzes the coumarin content of cinnamon. As such this is also the first American study that affirms Ceylon Cinnamon’s low coumarin content – a fact long known to European researchers and industry insiders.

While coumarin has been banned in the US as a food additive since 1954, its presence is mostly associated with artificial vanilla (http://en.wikipedia.org/wiki/Vanilla). Coumarin was also banned as an adulterant in cigarettes by tobacco companies in 1997 but due to the lack of reporting requirements to the U.S. Department of Health and Human Services, it is still being used as a flavoring additive in pipe tobacco.
The JAFC article warns that ingesting substantial amounts of coumarin on a daily basis may pose a health risk to individuals who are more sensitive to the compound. The researchers are calling for the establishment of a Tolerable Daily Intake (TDI) and maximum limits for coumarin in foods marketed in the US.

European health agencies already recognize the adverse side effects of coumarin and EU regulations specify a TDI for coumarin of 0.1 milligrams of coumarin per kilogram for food products. But setting such limits doesn’t ensure compliance. Recent tests by a leading independent consumer protection group warned that coumarin levels in a variety of cookies, cereals and rice puddings sold in Germany were up to 20 times the European legal limit.

The US study, which establishes the occurrence of high coumarin levels in popular foods as well as health supplements, is bound to attract the attention of consumer groups and open the door to scrutiny of cinnamon additives by the Food and Drug Administration (FDA), the federal agency that oversees and sets guidelines for food safety.
Wickremasinghe believes Sri Lankan authorities should seize the opportunity and take proactive measures, such as promotional events by foreign missions, contacting food watchdogs, and making oversight bodies such as the FDA and Health Canada in North America aware of the study, in order to maximize the leverage potential of Ceylon Cinnamon.

Sri Lanka’s share of the world cinnamon market is around 22% while its share of the US market is slightly less than 6%.
Upping the statistics to 10% of the international market is well within reach says Wickremasinghe, adding that every measure must be taken to increase cinnamon production. “It will require doubling Sri Lanka’s current cinnamon growing area, improving agronomic practices, and extending cultivation into parts of the wet zone where cinnamon is not currently growing”, he says. He strongly believes coumarin free cinnamon plants could be found in Sri Lanka and that they could be used to introduce coumarin free cinnamon varieties.

Coincidentally, the study comes in the midst of a growing controversy over “The Cinnamon Challenge”, a prank that challenges teenagers to shovel a spoonful of ground cinnamon into their mouths. The fad has gone viral with over 40,000 videos posted on You Tube, nearly 3 million Google hits and on the flip side, dozens of challengers ending up in emergency rooms with serious problems such as collapsed lungs. Worried parents are scrambling to put a stop to it, while bloggers, talk show hosts, school authorities, and doctors are all weighing in. Surprisingly, doctors are coming out saying cinnamon is ‘totally harmless’ other than for an inert substance called cellulose which can lodge in the lungs. No mention of coumarin.

“What better time to start talking about the facts of cinnamon and the superiority of our cinnamon to the American public and pass the message along to other countries?” asks Wickremasinghe.
The planets are definitely lined up in favor of a big push for Ceylon Cinnamon.
(Hassina Leelarathna is a Los Angeles based writer.  Contact hassinal@gmail.com)

April 22, 2013

ST LOUIS (MD Consult) – High intake of calcium supplements is associated with an increased risk of death from cardiovascular causes in men, but not women, reports a study in the April 22, 2013, issue of JAMA Internal Medicine.

The analysis included prospective data on 388,220 U.S. men and women, aged 50 to 71 years, enrolled in the National Institutes of Health-AARP Diet and Health Study. Intake of calcium from dietary sources and supplements was assessed at enrollment in 1995-96. Deaths from cardiovascular disease were identified using the National Death Index.

Associations between calcium intake and death from cardiovascular disease (CVD) were assessed, with adjustment for demographic, lifestyle, and dietary factors. The lead author was Qian Xiao, PhD, of the National Cancer Institute.

Mean follow-up was 12 years, during which time there were 7,904 CVD deaths in men and 3,874 in women. Fifty-one percent of men and 70% of women in the sample took calcium supplements.

Use of calcium supplements was associated with an increased risk of death from CVD in men: risk ratio (RR) 1.20 at doses greater than 1,000 mg/d, compared to no calcium supplementation. The increase in risk was significant for death from heart disease, RR 1.19; but not cerebrovascular disease.

In women, supplemental calcium intake was unrelated to the risk of death from CVD, including heart disease. Dietary calcium intake was unrelated to CVD death in either sex.

Many people take calcium supplements because of their proposed benefits for bone health, particularly in older age groups. Some recent studies have suggested a possible increase in cardiovascular events among people with high calcium intake.

This study suggests a significant increase in CVD death in men, but not women, with high intake of dietary calcium. The increase in risk appears specific to heart disease; neither sex shows an increase in CVD death with higher dietary calcium intake. “Additional studies are needed to investigate the effect of supplemental calcium use beyond bone health,” the researchers write.

JAMA Intern Med. 2013;173:639-646. 

The study was sponsored by the Agency for Healthcare Research and Quality.

The authors reported no conflicts of interest.

Primary source: Pediatrics
Source reference:
Charach A, et al “Interventions for preschool children at high risk for ADHD: a comparative effectiveness review”Pediatrics 2013; DOI: 10.1542/peds.2012-0974.

Trash the Calcium, Save the Patient

A Best Evidence Review

Charles P. Vega, MD

Mar 07, 2013

Skip the Calcium, Save the Patient

The Study

Xiao Q, Murphy RA, Houston DK, Harris TB, Chow W, Park Y. Dietary and supplemental calcium intake and cardiovascular disease mortality: The National Institutes of Health-AARP Diet and Health Study. JAMA Intern Med. 2013;1-8. [Epub ahead of print]

Introduction

Scant evidence supports the notion that calcium supplements alone significantly decrease the risk for osteoporotic fracture, yet these supplements remain one of the most popular treatments taken by adults in the United States. In addition, there is increasing evidence that calcium may contribute to a higher risk for cardiovascular disease (CVD). The current study uses a large cohort of adults to examine how dietary calcium and calcium supplements affect the risk for CVD among women and men.

Background

A new review of supplement use, based on data from the National Health and Nutrition Examination Survey,^[1] concluded that nearly one half of adults in the United States use dietary supplements, but relatively few of these individuals take supplements on the recommendation of their physician or other healthcare provider. This study found that 49% of a sample of US adults had used of supplements in the past 30 days. Factors associated with a higher rate of supplement use included female sex, non-Hispanic white race, and a subjective measurement of health as very good or excellent.

Although the most popular reason for using supplements in this study was to improve or maintain health in general, “bone health” was cited by 25% of respondents as a reason for taking these agents. Products that contained calcium were the second most common supplements overall. However, only 23% of supplements were recommended by the individual’s physician.

What is the evidence for supplement use, particularly when it comes to calcium? A meta-analysis of 29 studies found that calcium use alone was associated with a nonsignificant reduction in the risk for fracture.^[2] However, the use of calcium with vitamin D reduced the risk for fracture by 12%. Vitamin D alone at doses of 800 IU or more daily also significantly reduced the risk for fracture (relative risk, 0.84; 95% confidence interval [CI], 0.75-0.94).

In another meta-analysis, total calcium intake did not alter the risk for hip or total nonvertebral fracture.^[3] More disturbing was the finding that calcium supplementation was associated with a higher risk for hip fracture compared with placebo.

Supplements are also frequently used to prevent poor health outcomes. There is limited evidence that high-dose treatment with vitamin D supplements can reduce the risk for incident cancer, particularly colorectal cancer.^[4] However, little evidence suggests that treatment with calcium alone or calcium with vitamin D has an effect on the risk for cancer.

Whereas the health benefits of calcium supplementation are questionable, growing evidence indicates that calcium supplementation may be associated with an increase in the risk for CVD. In a trial of over 1400 women who were randomly assigned to receive calcium citrate 1 g or placebo daily, the risk for the combined endpoint of myocardial infarction, stroke, or sudden death was nearly 50% higher in the calcium group during 5 years of treatment.^[5] Although data from the Women’s Health Initiative initially pointed to a lack of effect of calcium supplements on the risk for cardiovascular events, a separate analysis found that calcium supplements significantly increased the risk for these events, particularly myocardial infarction.^[6,7] In a meta-analysis, the use of calcium supplements vs placebo was associated with a hazard ratio for myocardial infarction of 1.31 (95% CI, 1.02-1.67).^[8] There were nonsignificant increases in the risks of stroke and a combined cardiovascular endpoint in women taking calcium vs placebo.

The data regarding any relationship between dietary calcium and the risk for CVD is weaker than that for calcium supplements.^[9] However, a recent study found a significant increase in the risk for mortality outcomes associated with calcium consumption among a cohort of 61,000 women who were followed for a median of 19 years.^[10] Compared with more modest consumption of dietary calcium, calcium intake of over 1400 mg/day was associated with a hazard ratio of 1.49 (95% CI, 1.09-2.02) for death from CVD, as well as a higher risk for death from any cause (hazard ratio, 1.40; 95% CI, 1.17-1.67).

The potential cardiovascular risk associated with calcium intake is an evolving field of inquiry. The current study uses a large database of older adults to add to the sum of evidence regarding this issue.

Study Design and Results

Researchers analyzed data from the National Institutes of Health-American Association of Retired Persons (AARP) Diet and Health Study. This research enrolled AARP members between 50 and 71 years of age in 8 states. Participants were generally healthy at baseline, and individuals at the extremes of total energy and dietary calcium intake were excluded from study analysis.

A 124-item food-frequency questionnaire was used to assess participants’ dietary calcium intake. This survey also queried the use of supplements, and participants completed a baseline questionnaire that included demographic, disease, anthropometric, and lifestyle information.

The main study outcome was the effect of calcium intake on the risk for CVD death, as defined by mortality caused by heart disease or stroke. National databases were used to access participants’ vital status and causes of death. A previous study found that the accuracy of this method was 95%. Researchers adjusted their results to account for potential confounding variables.

The analysis included data from 388,229 adults. In all, 56% of women and 23% of men reported using calcium supplements; and the respective proportions of women and men who took multivitamins containing calcium were 58% and 56%. Participants who used calcium supplements were more likely to be non-Hispanic white persons, have a college education, have healthier lifestyle habits, and report better overall self-rated health.

During a mean of 12 years of follow-up, there were 7904 CVD deaths among men and 3874 CVD deaths among women in the study. A significant trend was seen toward a reduction in the risk for death due to heart disease with greater dietary calcium intake among men, but dietary calcium intake did not affect the risks for stroke death in either sex or any CVD death among women.

Among men, daily supplemental calcium at a dosage of 1000 mg/day or more was associated with significant increases in the risks for overall CVD death (relative risk, 1.20; 95% CI, 1.05-1.36) and heart disease death (relative risk, 1.19; 95% CI, 1.03-1.37). There was a nonsignificant trend toward a higher risk for stroke death associated with the use of calcium supplements. The low number of deaths caused by stroke overall reduced the power of the study to evaluate this outcome.

Among women, calcium supplements did not independently affect the risks for death from CVD, heart disease, or stroke.

The risk for death among men who used calcium supplements appeared to be particularly high among smokers. There was a U-shaped curve relationship between total calcium intake and the risk for CVD mortality among men, but this was not found among women.

Commentary: The Gender Gap

No one should be more invested in the concept of wellness than the individual. Each patient has the autonomy to select health treatments, and clearly many adults use calcium to stay healthy. However, it is time for physicians to actively intercede of behalf of their patients’ safety when they make this choice regarding calcium.

The current study emphasizes the risk for CVD mortality associated with the use of calcium supplements among men, and any potential benefit of calcium supplementation is now outweighed by the risk for CVD in this group. The rate of osteoporosis among men is one-fifth that of women, and less than 40% of osteoporotic fractures occur among men.^[11] Although we cannot discount the potential grave impact of fragility fractures among older men, calcium supplements do not seem to be the answer to reducing this risk, particularly given their association with CVD.

Among women, the current study suggests a neutral effect of both dietary calcium and calcium supplements on the risk for CVD. Physicians should keep in mind, however, that vitamin D and not calcium is principally responsible for preserving bone and preventing osteoporosis among women. Vitamin D at a dose of at least 800 IU/day should be the primary treatment for women at average risk for osteoporosis. Until the questions regarding the long-term safety of calcium supplements in both sexes are better understood, it is reasonable to withhold calcium among women receiving preventive treatment for bone health.

Clinical Pearls

• Calcium-containing compounds are the second most popular complementary treatment among adults in the United States, yet most supplements are taken without a recommendation from a physician.
• It is questionable whether calcium supplements alone contribute to the prevention of fracture.
• A growing body of evidence suggests that calcium supplements, and perhaps even dietary calcium, can increase the risk for CVD.
• In the current study, the use of calcium supplements among men was associated with a higher risk for cardiovascular death and death related to heart disease.
• Calcium supplements did not significantly affect the risk for CVD mortality among women.
• Calcium supplements are unnecessary among men and should be evaluated critically among women at average risk for fracture.

Medscape Family Medicine © 2013  WebMD, LLC

Cite this article: Charles P. Vega. Trash the Calcium, Save the Patient. Medscape. Mar 07, 2013.

Adding fruits and vegetables to the diets of people with late-stage chronic kidney disease (CKD) is an effective alternative to sodium-based alkali supplementation therapy, according to findings from a study published online February 7 in theClinical Journal of the American Society of Nephrology.

The study was authored by Nimrit Goraya, MD, from the Texas A&M College of Medicine in Temple, and colleagues.

Sodium citrate is commonly used to help ameliorate metabolic acidosis in individuals with CKD, the investigators note. Even so, metabolic acidosis shows up most often in patients with CKD who have very low glomerular filtration rates. Such patients are most at risk for adverse effects of alkali therapy, which may include increased hypertension and/or volume control.

“Because diets typical of industrialized societies have high ratios of acid-producing to base-producing proteins, the latter being mostly fruits and vegetables, adding fruits and vegetables might improve metabolic acidosis in CKD and avoid complications of added Na⁺, ” the authors write.

To test that hypothesis, these researchers randomly assigned 71 patients with hypertensive stage 4 CKD to 1 of 2 groups.

One group added fruits and vegetables to their diets for 1 year. The vegetables were provided free by a food bank and prescribed by a dietitian. Participants in that group received no specific dietary instructions and added the fruits and vegetables to their diets as they wished.

Prescriptions emphasized fruits and vegetables such as apples, apricots, oranges, peaches, pears, raisins, strawberries, carrots, cauliflower, eggplant, lettuce, potatoes, spinach, tomatoes, and zucchini.

The other group was prescribed 1 year of daily oral sodium bicarbonate (1.0 mEq/kg/day).

Both treatment doses were aimed at cutting dietary acid by half.

After a year of intervention, both groups exhibited evidence of similar kidney function, the researchers say. Plasma total carbon dioxide levels increased in both groups, indicating improvement in metabolic acidosis. However, the investigators note, “Plasma [total carbon dioxide level] at 1 year was higher in the [oral sodium bicarbonate] group (21.2±1.3 versus 19.5±1.5 mM; P<0.01) and fruits and vegetables group (19.9±1.7 versus 19.3±1.9 mM; P<0.01).”

Both groups had lower indices of kidney damage at the end of the intervention.

In addition, the investigators note, although increased consumption of fruits and vegetables might be expected to drive up serum potassium levels, no significant change was evident in either group.

“A small group of highly motivated patients wishing to reduce their pill burden through dietary modification may benefit from the results of this study,” he writes. “However, many patients find it difficult to follow a diet high in fruits and vegetables and might therefore be more adherent to a supplement.”

This study was supported by the Larry and Jane Woirhaye Memorial Endowment in Renal Research the Texas Tech University Health Sciences Center, the Statistics Department of Scott and White Healthcare, and the Academic Operations Division at Scott and White Healthcare. The authors and editorialist have disclosed no relevant financial relationships.

Clin J Am Soc Nephrol. Published online February 7, 2013. Article abstract, Editorial

Specific Foods, Herbs, and Spices That May Help Fight Cancer and Reduce Treatment Side Effects

A great deal of research has been conducted on the impact of specific foods, herbs, and spices on cancer cells’ growth and spread (metastasis).  A great deal of this research has been done in animals rather than humans.  While results have been very promising, many more studies, and especially studies in humans, are needed in order to definitively prove the benefits of these foods against cancer in humans.  The following information reflects the most current research of foods that help fight cancer and/or prevent or reduce the side effects of cancer and its treatment.

• Green Tea – The ingredient epigallocatechin gallate (“EGCG”) in green tea is one of the most powerful nutritional molecules that has been shown to fight the formation of blood vessels by cancer cells.
• Olive Oil – Olive oil, along with other foods in the Mediterranean Diet, is believed to slow cancer growth.  For example, ingredients in olive oil been shown to protect against the cause of 20% of all breast cancers.
• Garlic – Garlic contains several key ingredients that are believed to fight the activity of cancer cells and toxins.
• Soy – Soy contains powerful chemicals that have been shown to fight against the survival and spread of cancer cells.  Soy has been shown to block the stimulation of certain sex hormone-related cancers such as breast (estrogen) and prostate (androgen) cancer.  In women who have eaten soy since adolescence, breast cancer tumors are usually less aggressive with higher survival rates.  However, the ability of soy to protect against breast cancer has been proven only in women who have eaten it since they were adolescents.  The same is true for prostate cancers. (However, soy is generally not recommended for estrogen-dependent breast cancer.)
• Turmeric (Curcumin) – Turmeric, the main spice in yellow curry, has the most powerful inflammatory properties of any food ingredient known today.  Turmeric has been shown in the laboratory to help fight cancer cells and make chemotherapy more effective.
• Mushrooms – Certain mushrooms, such as shiitake, maitake, and kawaratake, contain a molecule, lentinian, that stimulates the immune system directly.  In Japanese studies, the number and activity of immune cells increased notably in patients given mushroom extracts.
• Ginger – Ginger root is a powerful anti-inflammatory and antioxidant acting against cancer cells.
• Rosemary – Carnasol in rosemary affects the capability of cancer cells to invade neighboring tissues.
• Cruciferous Vegetables – including broccoli, cabbage, cauliflower, kale, and radishes – contain powerful anticancer molecules.

In addition to helping to prevent or reduce cancer growth and spread, good nutrition also has been shown to reduce treatment side effects.  For example:

• Rosemary – Rosemary extract has been shown to help chemotherapy penetrate cells, reducing resistance of breast cancer cells to treatment.
• EGCG – EGCG, present in green tea, has been shown to enhance the effect of radiotherapy on cancer cells. It also slows the growth of leukemia and breast, prostate, kidney, skin, and mouth cancer cells.
• Ginger – Ginger infusions have been shown to help alleviate nausea from chemotherapy.
• Turmeric (Curcumin) – Certain tumors have been shown to be more sensitive to chemotherapy when curcumin is taken. Curcumin has also been effective in treating cancer treatment-related mucositis.