To determine the impact of contaminant iron and geophagy on iron intake and status of persons living in developing countries.

Literature for review was identified by searching Medline and Agricola, from appropriate other texts and from three reports from the Opportunities for Micronutrient Interventions (OMNI) Project of USAID.

The dietary intake of iron by people living in developing countries is generally high but iron deficiency remains prevalent. This apparent paradox is because the iron being consumed is predominantly in the non-haem form, which is poorly absorbed. Some of this non-haem iron is from contamination of food with iron from soil, dust and water; iron leaching into food during storage and cooking; contamination during food processing such as milling; and the practice of geophagy.

Although the contribution of contaminant iron to overall iron intake is well documented, its absorption and thus its impact on iron status is not. To be available for absorption, contaminant iron must join the common non-haem pool, i.e. be exchangeable. The absorption of exchangeable contaminant iron is subject to the same interactions with other constituents in the diet as the non-haem iron that is intrinsic to food. The limited available evidence suggests wide variation in exchangeability. In situations where a significant fraction of the contaminating iron joins the pool, the impact on iron status could be substantial. Without a simple method for predicting exchangeability, the impact of contaminant iron on iron status in any particular situation is uncertain.

Interventions known to increase the absorption of iron intrinsic to foods will also increase absorption of any contaminant iron that has joined the common pool. Any positive effect of geophagy resulting from an increased intake of iron is highly unlikely, due to inhibiting constituents contained in soils and clays. The efficacy of approaches designed to increase the intake of contaminant iron remains encouraging but uncertain. An approach using multiple interventions will continue to be essential to reduce iron deficiency anaemia.

To assess whether alcoholic and caffeinated beverages are associated with risk of fractures in women.

Population-based sample surveyed by post.

A total of 34703 postmenopausal Iowan women aged 55–69 years were surveyed.

A cohort of women reported alcoholic and caffeinated beverage intake and were followed for 6.5 years for fracture occurrence. Relative risks (RR) and 95% confidence intervals (CI) were computed using Cox proportional hazards regression. Covariates included age, tobacco use, physical activity, body mass index (BMI), waist to hip ratio (WHR), oestrogen use and calcium intake.

At least one fracture was reported by 4378 women (389 upper arm, 288 forearm, 1128 wrist, 275 hip, 416 vertebral and 2920 other fractures). The adjusted RR for highest versus lowest caffeine intake quintiles was 1.09 (95% CI 0.99–1.21) for combined fracture sites. Wrist fractures were associated positively (RR for extreme quintiles 1.37, 95% CI 1.11–1.69) and upper arm fractures were negatively associated (RR 0.67, 95% CI 0.48–0.94) with caffeine intake. The age-adjusted RR of total fractures for highest versus lowest frequency of beer usage was 1.55 (95% CI 1.25–1.92) and for liquor was 1.25 (95% CI 1.03–1.54). No other association was found between any specific fracture site and alcohol intake.

We found a modest increase in fracture risk associated with highest caffeine intake, varying by site. Alcohol intake was low, but it also showed a weak positive association with fracture risk.

Hepatic impairment resulting from the use of conventional drugs is widely acknowledged, but there is less awareness of the potential hepatotoxicity of herbal preparations and other botanicals, many of which are believed to be harmless and are commonly used for self-medication without supervision. The aim of this paper is to examine the evidence for hepatotoxicity of botanicals and draw conclusions regarding their pathology, safety and applications.

Current literature on the hepatotoxicity of herbal drugs and other botanicals is reviewed. The aetiology, clinical picture and treatment of mushroom (Amanita) poisoning are described.

Hepatotoxic effects have been reported for some Chinese herbal medicines (such as Jin Bu Huan, Ma-Huang and Sho-saiko-to), pyrrolizidine alkaloid-containing plants, germander (Teucrium chamaedrys), chaparral (Larrea tridentata), Atractylis gummifera, Callilepsis laureola, and others. The frequency with which botanicals cause hepatic damage is unclear. There is a lack of controlled treatment trials and the few studies published to date do not clarify the incidence of adverse effects. Many plant products do not seem to lead to toxic effects in everyone taking them, and they commonly lack a strict dose-dependency. For some products, such as Sho-saiko-to, the picture is confused further by demonstrations of hepatoprotective properties for some components. Mushroom poisoning is mostly due to the accidental consumption of Amanita species. Treatment with silymarin, thioctic acid, penicillin and liver transplantation have been shown to be effective but require early diagnosis.

Severe liver injury, including acute and chronic abnormalities and even cirrhotic transformation and liver failure, has been described after the ingestion of a wide range of herbal products and other botanical ingredients, such as mushrooms. It is concluded that in certain situations herbal products may be just as harmful as conventional drugs.

To examine the associations between the consumption of fruit and vegetables and other markers of cancer risk.

A cross-sectional survey within the population-based prospective Malmö Diet and Cancer (MDC) Study. Information on food habits was collected through the modified diet history method designed and validated for the MDC Study. Data on smoking and alcohol habits, leisure time physical activity, birth country, education, socioeconomic status and cohabitation status were collected through a questionnaire.

Malmö, the third largest city in Sweden.

All subjects who entered the MDC Study during winter 1991 to summer 1994 (men and women living in Malmö, aged between 46 and 68 years), with a total of 15 173.

Women consumed more fruit and vegetables than men. Low consumption of both fruits and vegetables was associated with unfavourable nutrient profiles: higher percentage of energy from fat and lower intakes of antioxidant nutrients and dietary fibre. Low consumption was also associated with smoking, low leisure time physical activity, low education and being born in Sweden. High age was associated with low vegetable consumption in both genders. Alcohol intake was positively associated with vegetable consumption in both genders, while both zero and high alcohol consumers had low fruit consumption. Men residing without a partner consumed less fruits and vegetables than other men. There were very weak or no independent associations between socioeconomic status and fruit/vegetable consumption.

This study indicates that several established risk markers and risk factors of cancer may be independently associated with low fruit and vegetable consumption. The findings suggest that the adverse effects of factors such as smoking, low physical activity and a high-fat diet could partly be explained by low consumption of fruit or vegetables. The implied health benefits of a low or moderate alcohol consumption may be similarly confounded by high consumption of fruit or vegetables.

Previously recorded rates of obesity in the Baltic Republics have been among the highest in the world although little is known about how they vary within the population. This study investigates the distribution of body mass index (BMI) and obesity in these countries.

Three cross-sectional surveys conducted in the summer of 1997.

Estonia, Latvia and Lithuania.

Representative national samples of adults with measured weight and height (Estonia: n = 1154; Latvia: n = 2292; Lithuania: n = 2096).

Between-country differences are particularly large among women: women from Latvia and Lithuania are approximately three times as likely to be obese as those from Estonia (17.4%, 18.3%, 6.0% respectively); only about one-third of this difference is explained by the sociodemographic and behavioural factors studied. In men, the prevalence of obesity varied only slightly among countries (Estonia: 9.9%; Latvia: 9.5%; Lithuania: 11.4%). While the prevalence of obesity increases with age within each republic, particularly in women, it is not associated with nationality or urban/rural region, and no consistent association is observed with income. Obesity is inversely related to education in Latvia and in Lithuanian women. Latvian men and women and Lithuanian men who smoked had a lower prevalence of obesity than non-smokers. Leisure time physical activity was not associated with obesity.

Obesity is a major health problem in the Baltic Republics, particularly among Latvian and Lithuanian women. The lack of association between obesity and most demographic, socioeconomic and behavioural factors suggests that the problem is generalized. Health promotion strategies aiming at preventing and controlling excess weight gain in the Baltic Republics will need to target the general population.

This paper provides a comprehensive review of the changes in the prevalence and the extent of anaemia among different population groups in Bangladesh up to the present time. The report also focuses on various factors in the aetiology of anaemia in the country.

All the available data have been examined in detail, including data from national nutrition surveys, as well as small studies in different population groups.

Over the past three decades a number of studies including four national nutrition surveys (1962/64; 1975/76; 1981/82 and 1995/96) have been carried out to investigate the prevalence of anaemia among different population groups in Bangladesh, and have demonstrated a significant public health problem. Since the 1975/76 survey the average national prevalence of anaemia has not fallen; in 1995/96, 74% were anaemic (64% in urban areas and 77% in rural areas). However, age-specific comparisons suggest that the rates have fallen in most groups except adult men: in preschool children in rural areas it has decreased by about 30%, but the current level (53%) still falls within internationally agreed high risk levels. Among the rural population, the prevalence of anaemia is 43% in adolescent girls, 45% in non-pregnant women and 49% in pregnant women. The rates in the urban population are slightly lower compared with rural areas, but are high enough to pose a considerable problem. It appears that severe anaemia in the Bangladeshi population is less frequent, possibly present among only 2–3% of the population. The data on the aetiology of anaemia reveal that iron deficiency may be a substantial cause of anaemia in the Bangladeshi population. Other dietary factors in addition to parasitic infestations may also precipitate the high prevalence of anaemia.

While the overall prevalence of anaemia among the Bangladeshi population is still very high, the rates of severe anaemia are almost non-existent. A large proportion of anaemia can be attributed to iron deficiency. There is a need for a comprehensive strategy for the prevention and control of anaemia in Bangladesh.

While iron deficiency is regarded as the major cause of nutritional anaemia, changes in vitamins A, B12, C and E, folic acid and riboflavin status have also been linked to its development and control. This paper provides a systematic review of vitamin supplementation trials relating to the control of nutritional anaemia.

A MEDLINE search was used to find reports of vitamin supplementation trials that reported changes in anaemia or iron status.

Vitamin A can improve haematological indicators and enhance the efficacy of iron supplementation. Both folate and vitamin B12 can cure and prevent megaloblastic anaemia. Riboflavin enhances the haematological response to iron, and its deficiency may account for a significant proportion of anaemia in many populations. Vitamin C enhances the absorption of dietary iron, although population-based data showing its efficacy in reducing anaemia or iron deficiency are lacking. Vitamin E supplementation given to preterm infants has not reduced the severity of the anaemia of prematurity. Vitamin B6 effectively treats sideroblastic anaemia. Multivitamin supplementation may raise haemoglobin (Hb) concentration, but few studies have isolated the effect of multivitamins from iron on haematological status.

In general, the public health impact of vitamin supplementation in controlling anaemia is not clear. Neither are the complex interactions involving multiple vitamins in haematopoiesis sufficiently understood to explain the observed variability in haematological responses to vitamins by age, population, vitamin mixture and dosages. Further research is needed to understand the roles of individual and combined vitamin deficiencies on anaemia to design appropriate micronutrient interventions to prevent anaemia.

To investigate the impact of intensive group education on the Mediterranean diet on dietary intake and serum total cholesterol after 16 and 52 weeks, compared to a posted leaflet with the Dutch nutritional guidelines, in the context of primary prevention of cardiovascular disease (CVD).

Controlled comparison study of an intervention group given intensive group education about the Mediterranean diet and a control group of hypercholesterolaemic persons given usual care by general practitioners (GPs).

A socioeconomically deprived area in the Netherlands with an elevated coronary heart disease (CHD) mortality ratio.

Two hundred and sixty-six hypercholesterolaemic persons with at least two other CVD risk factors.

After 52 weeks, the intervention group decreased total and saturated fat intake more than the control group (net differences were 1.8 en% (95%CI 0.2–3.4) and 1.1 en% (95%CI 0.4–1.9), respectively). According to the Mediterranean diet guidelines the intake of fish, fruit, poultry and bread increased in the intervention group, more than in the control group. Within the intervention group, intake of fish (+100%), poultry (+28%) and bread (+6%) was significantly increased after 1 year (P < 0.05). The intensive programme on dietary education did not significantly lower serum cholesterol level more (−3%) than the posted leaflet (−2%) (net difference 0.06 mmol l−1, 95%CI −0.10 to 0.22). Initially, the body mass index (BMI) decreased more in the intervention group, but after 1 year the intervention and control group gained weight equally (+1%).

Despite beneficial changes in dietary habits in the intervention group compared with the control group, after 1 year BMI increased and total fat and saturated fat intake were still too high.

To study the association between lifetime alcohol consumption and the risk of breast cancer.

A case–control study carried out in eastern Finland. Information about alcohol consumption was obtained by two methods: a self-administered food frequency questionnaire (FFQ) including alcohol consumption during the previous 12 months, and a lifetime alcohol consumption questionnaire (AQ) which was administered by the study nurse.

The study consisted of 301 breast cancer cases (25–75 years old) and 443 population controls.

The subjects reported higher current alcohol consumption in the AQ compared to the FFQ. According to the AQ, premenopausal cases consumed on average 28 g and controls 24 g alcohol week−1; in postmenopausal women the values were 15 and 14 g, respectively. About 30% of premenopausal and 60% of postmenopausal women were classified as non-drinkers. The correlation for current alcohol consumption between the FFQ and the AQ was 0.80 in premenopausal women but only 0.40 in postmenopausal women. Current alcohol consumption seemed to influence the reporting of total lifetime alcohol consumption. Current alcohol consumption was not associated with the risk of breast cancer either in premenopausal or postmenopausal women; neither were associations found between alcohol consumption at age of first use, use before the age of 30, or total lifetime alcohol consumption and the risk of breast cancer.

On average, one to three drinks per week did not increase the risk of breast cancer in this study. Consumption levels were, however, too low to exclude increased risk with high regular consumption. Further research is necessary on lifetime alcohol consumption.

To identify risk factors for variation in serum retinol levels in children younger than 2 years of age in a rural South African community.

Children (n=97), 6–24 months of age, were divided into two groups according to their serum retinol levels, using 20 μg dl−1 as the cut-off point. The chi-square test, Fischer exact two-tailed test and analysis of variance were used to identify related variables which were significantly different between the two groups. To evaluate simultaneously the association between several potential risk factors and low serum retinol levels, a multiple regression model for categorical data was developed which included potential risk factors that were statistically significant in the bivariate analysis as the independent variables, and either low or normal vitamin A status as the dependent variable.

There was an association between serum retinol levels and: (i) the place of birth (hospital vs. home deliveries); (ii) the attitude of the care-giver towards family life; and (iii) the health status of the child. Although not included in the multiple variable model because of small numbers, all children who had a previous episode of measles, all underweight children, and all children of widowed care-givers were in the low serum retinol group.

The care-giver's attitude towards family life was positively associated with the child's vitamin A status, while home deliveries were associated with a low vitamin A status.

To investigate the protective association between seasonality of consumption of fresh fruit or salad vegetables and cancer and cardiovascular disease (CVD) development.

Face-to-face interviews, including a food frequency questionnaire, were conducted on 1489 men and 1900 women, aged 35–75 years, who were respondents in the British Health and Lifestyle Survey 1984/85 (HALS1). CVD and cancer morbidity and mortality were determined from the 1991/92 British Health and Lifestyle Survey (HALS2) and by NHS Register ‘flagging’.

Risk was assessed by odds ratio (OR) for trend per frequency category. In men, frequent winter salad vegetable consumption was more closely protective than that in summer for cancer (winter OR = 0.79 [0.62–0.99], P = 0.045, summer OR = 0.83 [0.69–1.01], NS) and CVD (winter OR = 0.85 [0.72–1.00], P = 0.049, summer OR = 0.95 [0.82–1.10], NS). Fresh fruit consumption showed no significant protection. In women, frequent salad vegetable consumption at any season was significantly protective of CVD (winter OR = 0.76 [0.65–0.89], P < 0.001, summer OR = 0.76 [0.65–0.89], P < 0.001), although not of cancer. Frequent fresh fruit consumption in women was significantly protective of CVD (winter OR = 0.84 [0.74–0.94], P = 0.004, summer OR = 0.85 [0.74–0.97], P = 0.014) but not quite significant, and only in winter, for cancer (winter OR = 0.87 [0.76–1.00], P = 0.052, summer OR = 0.88 [0.75–1.02], P = 0.097). Maintenance of salad vegetable consumption from summer to winter, to within one frequency category, was associated with further protection for cancer in men (P = 0.050) and CVD in women (P = 0.024).

Diets high in fresh fruit and salad vegetables appear protective against cancer and CVD. It is important to take into account the seasonality of consumption in estimating and establishing significance of risk.

Because the percentage of missing portion sizes was large in the Aerobics Center Longitudinal Study (ACLS), careful consideration of the accuracy of standard portion sizes was necessary. The purpose of the present study was to investigate the consequences of using standard portion sizes instead of reported portion sizes on subjects' nutrient intake.

In 2307 men and 411 women, nutrient intake calculated from a 3-day dietary record using reported portion sizes was compared with nutrient intake calculated from the same record in which standard portion sizes were substituted for reported portion sizes.

The standard portion sizes provided significantly lower estimates (> 20%) of energy and nutrient intakes than the reported portion sizes. Spearman correlation coefficients obtained by the two methods were high, ranging from 0.67 to 0.93. Furthermore, the agreement between both methods was fairly good. Thus, in the ACLS the use of standard portion sizes rather than reported portion sizes did not appear to be suitable to assess the absolute intake at the group level, but appeared to lead to a good ranking of individuals according to nutrient intake. These results were confirmed by the Continuing Survey of Food Intake by Individuals (CSFII), in which the assessment of the portion size was optimal. When the standard portion sizes were adjusted using the correction factor, the ability of the standard portion sizes to assess the absolute nutrient intake at the group level was considerably improved.

This study suggests that the adjusted standard portion sizes may be able to replace missing portion sizes in the ACLS database.

To identify influences on type of milk consumed and the impact of milk choice on calcium intakes in Australian women of pre- and postmenopausal age.

Questionnaires covering calcium intake, health-related dietary issues and priorities self-completed in a group setting.

A total of 300 women recruited from community groups and government departments.

Mean milk and calcium intake were higher in older (≥50 years) compared to younger women. Milk provided over 50% of calcium intake for both groups. Participants rated the importance of eating foods low in fat, energy or cholesterol, high in calcium or dietary fibre or of ‘limiting their intake of added sugar or sugary foods’. Younger and older women ranked eating foods low in fat as the most important food habit for their health, then ranked dietary fibre next in importance. Calcium ranked third for younger women, and fourth for older women. These rankings were reflected in the higher proportion of older women choosing fat-reduced milk in general, and skim milk in particular. This concern about eating foods low in fat was consistent with the choices made of skim, reduced fat/higher calcium or whole milk.

Results from this study suggest that concerns about fat are prejudicing the type of milk and amount of calcium consumed. Public health strategies targeting calcium intake need to address age-related differences in quantity and type of milk consumed, including the food attribute conflicts influencing these.

To systematically review the existing evidence regarding the efficacy and safety of phytotherapeutic compounds used to treat men with symptomatic benign prostatic hyperplasia (BPH).

Randomized trials were identified searching MEDLINE (1966–1997), EMBASE, Phytodok, the Cochrane Library, bibliographies of identified trials and review articles, and contact with relevant authors and drug companies. The studies were included if men had symptomatic benign prostatic hyperplasia, the intervention was a phytotherapeutic preparation alone or combined, a control group received placebo or other pharmacologic therapies for BPH, and the treatment duration was at least 30 days. Key data were extracted independently by two investigators.

A total of 44 studies of six phytotherapeutic agents (Serenoa repens, Hypoxis rooperi, Secale cereale, Pygeum africanum, Urtica dioica, Curcubita pepo) met inclusion criteria and were reviewed. Many studies did not report results in a method allowing meta-analysis. Serenoa repens, extracted from the saw palmetto, is the most widely used phytotherapeutic agent for BPH. A total of 18 trials involving 2939 men were reviewed. Compared with men receiving placebo, men taking Serenoa repens reported greater improvement of urinary tract symptoms and flow measures. Serenoa repens decreased nocturia (weighted mean difference (WMD)=−0.76 times per evening; 95% CI=−1.22 to −0.32; n=10 studies) and improved peak urine flow (WMD=1.93 ml s−1; 95% CI=0.72 to 3.14, n=8 studies). Men treated with Serenoa repens rated greater improvement of their urinary tract symptoms versus men taking placebo (risk ratio of improvement=1.72; 95% CI=1.21 to 2.44, n=8 studies). Improvement in symptoms of BPH was comparable to men receiving the finasteride. Hypoxis rooperi (n=4 studies, 519 men) was also demonstrated to be effective in improving symptom scores and flow measures compared with placebo. For the two studies reporting the International Prostate Symptom Score, the WMD was −4.9 IPSS points (95% CI=−6.3 to −3.5, n=2 studies) and the WMD for peak urine flow was 3.91 ml s−1 (95% CI=0.91 to 6.90, n=4 studies). Secale cereale (n=4 studies, 444 men) was found to modestly improve overall urological symptoms. Pygeum africanum (n=17 studies, 900 men) may be a useful treatment option for BPH. However, review of the literature has found inadequate reporting of outcomes which currently limit the ability to estimate its safety and efficacy. The studies involving Urtica dioica and Curcubita pepo are limited although these agents may be effective combined with other plant extracts such as Serenoa and Pygeum. Adverse events due to phytotherapies were reported to be generally mild and infrequent.

Randomized studies of Serenoa repens, alone or in combination with other plant extracts, have provided the strongest evidence for efficacy and tolerability in treatment of BPH in comparison with other phytotherapies. Serenoa repens appears to be a useful option for improving lower urinary tract symptoms and flow measures. Hypoxis rooperi and Secale cereale also appear to improve BPH symptoms although the evidence is less strong for these products. Pygeum africanum has been studied extensively but inadequate reporting of outcomes limits the ability to conclusively recommend it. There is no convincing evidence supporting the use of Urtica dioica or Curcubita pepo alone for treatment of BPH. Overall, phytotherapies are less costly, well tolerated and adverse events are generally mild and infrequent. Future randomized controlled trials using standardized preparations of phytotherapeutic agents with longer study durations are needed to determine their long-term effectiveness in the treatment of BPH.