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People taking the prescription blood thinner warfarin (Coumadin) may up their risk for health complications if they also take herbal or non-herbal supplements, new research reveals.

In fact, eight out of the 10 most popular supplements in the United States could spark safety concerns with respect to warfarin, while also impacting the drug’s effectiveness.

“I specifically looked at warfarin use, but the real issue is that even though herbal supplements fall under the category of food, and they’re not regulated like prescription drugs, they still have the effects of a drug in the body,” cautioned study author Jennifer L. Strohecker, a clinical pharmacist at Intermountain Medical Center in Salt Lake City.

“Warfarin is a very high-risk medication, which can be associated with severe consequences when it’s not managed properly,” she added. “However, warfarin is derived from a plant, sweet clover. In fact, many of our prescription drugs came from plants. So, it’s very important for patients to recognize that just because an herb is marketed not like a prescription drug [that] doesn’t mean it doesn’t have similar effects in the body.”

Strohecker and her colleagues are slated to present their findings Thursday at the Heart Rhythm Society annual meeting in Denver.

The authors note that almost 20 percent of Americans currently take some type of herbal or non-herbal supplement.

To gauge how these products might interact with warfarin, the researchers ranked the 20 most popular herbals and 20 most popular non-herbal supplements based on 2008 sales data, and then looked at how their use affected both clotting tendency and bleeding.

More than half of the herbal and non-herbal supplements were found to have either an indirect or direct impact on warfarin. Nearly two-thirds of all the supplements were found to raise the risk for bleeding among patients taking the blood thinner, while more than one-third hampered the effectiveness of the medication.

An increase in bleeding risk was specifically linked to the use of cranberry, garlic, ginkgo and saw palmetto supplements, the team said.

Glucosamine/chondroitin, essential fatty acids, multi-herb products, evening primrose oil, co-enzyme Q10, soy, melatonin, ginseng and St. John’s wort all affected warfarin’s effectiveness so much so that they prompted a need for adjustments in the drug’s prescribed dosage.

“I’m not against herbal supplement use at all,” Strohecker stressed. “But physicians need to proactively discuss this issue with their patients because of the consequences that can occur.”

Dr. Richard L. Page, a cardiologist and chair of medicine at University of Wisconsin, Madison, and president of the Heart Rhythm Society, believes the larger problem here is poor patient-doctor communication.

“Doctors don’t always know what their patients are taking,” he said. “Supplements may perform a very good service. Or they may not be providing the sort of care that patients are looking for when they’re essentially self-medicating. And where this becomes especially important is that these supplements can interact with the prescription drugs that your doctor may be giving you.”

“This report is important,” Page said, “because they look at a very common drug, warfarin, which has a narrow therapeutic window. Which means too much is bad cause you bleed, and too little is bad because it won’t do the job of thinning the blood that you want. So the bottom line is, be careful of adding new supplements if you are on existing prescription medications, and talk to your doctor if you do.”

A representative of the supplements industry took a slightly different view.

Duffy MacKay, vice president of scientific and regulatory affairs for the D.C.-based Council for Responsible Nutrition, the leading dietary supplement industry trade association, said that, “the issue here is really more with warfarin.”

“It’s just a very sensitive medication,” he said. “Warfarin itself has a huge list of drugs, foods and over-the-counters that it interacts with. If you take too much or too little, it can become dangerous.”

“So it’s sort of a form of sensationalism to suggest that here you have this situation with dietary supplements specifically,” MacKay added.

SOURCES: Jennifer L. Strohecker, Pharm.D., clinical pharmacist, Intermountain Medical Center, Salt Lake City, Utah; Richard L. Page, M.D., FHRS, cardiologist and chair, medicine, University of Wisconsin, Madison, and president of Heart Rhythm Society; Duffy MacKay, N.D., vice president, scientific and regulatory affairs, Council for Responsible Nutrition, Washington, D.C.;

A team from the U.S. Food and Drug Administration is investigating a farm in Arizona as a potential source of E. coli-tainted lettuce that has so far sickened 19 people nationwide, the Associated Press reported Friday.

Possible E. coli contamination prompted the recall of Freshway Foods’ romaine lettuce, which is sold in 23 states and the District of Columbia, the FDA announced Thursday.

The agency said the lettuce may be linked to cases of E. coli illness in Michigan, Ohio and New York that involved the hospitalization of 12 people, three with potentially life-threatening symptoms, the AP reported.

College students at the University of Michigan, Ann Arbor, Ohio State in Columbus and Daemen College in Amherst, N.Y., have been among those sickened in the outbreak, according to local state health departments.

The lettuce was sold to wholesalers, food service outlets, in-store salad bars and delis in Alabama, Connecticut, the District of Columbia, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Maryland, Massachusetts, Michigan, Missouri, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Virginia, West Virginia and Wisconsin, according to Ohio-based Freshway Foods.

The recall covers lettuce with a “best if used by” date of May 12 or earlier, as well as “grab and go” salads sold at Kroger, Giant Eagle, Ingles Markets and Marsh grocery stores, the AP reported.

The lettuce does not include any bulk or prepackaged romaine or bagged salad mixes in retail supermarkets, the company stressed.

“Freshway Foods does not produce bulk, prepackaged romaine or bagged salad mixes containing romaine for sale in supermarkets, and therefore these products are not included in this recall,” the company said in a news release.

According to the AP, Freshway Vice President Devon Beer, said the company has been working with FDA to trace the contaminated lettuce back to the (as yet unidentified) grower in Yuma, Ariz.

The health effects of E. coli infection can range from mild diarrhea to more severe illness, including kidney damage. According to the AP, the three patients with life-threatening illness have developed a condition called hemolytic uremic syndrome, which can trigger hemorrhage in the brain or kidneys.

Complicating matters is the fact that the strain identified in the lettuce is E.coli 0145, not the much more common and more easily identified and reported E.coli 0157, the AP said.

In the meantime, restaurants across the nation are rushing to assure customers that their salads are safe to eat. According to CNN, Yum! Brands — which owns chains such as KFC, Pizza Hut, Taco Bell and Long John Silver’s — has said that Freshway Foods does not supply lettuce to any of its restaurants.

SOURCES: 2010, news release, Freshway Foods;

If losing weight feels like a never-ending battle, new research may explain why: Diets that restrict calories can actually make it harder to lose weight and keep it off.

Cutting calories increases production of cortisol, the stress hormone, which is linked to added belly fat, a new study finds.

“For the first time in humans, we are finding out that cutting your calories increases cortisol,” said lead researcher A. Janet Tomiyama, a Robert Wood Johnson Foundation Health & Society Scholar at the University of California, San Francisco.

“We think this may be one reason dieters tend to have a hard time keeping weight off in the long-term,” she said.

People who count calories feel stressed, she said, but it’s the reduction in calories that increases cortisol, which, in turn, stresses the body and leads to weight retention.

“No matter how you cut calories, whether that’s doing it on your own, or doing something like Nutrisystem or Jenny Craig, it doesn’t matter, it’s still going to increase your cortisol level,” she said.

At any given time, 47 percent of U.S. adults are dieting, but up to 64 percent gain back more weight than they lost, according to background information in the report published online April 6 in Psychosomatic Medicine.

For the study, Tomiyama’s team randomly assigned 121 women to one of four diets. One group tracked their calories, keeping them to 1,200 a day; another group ate normally but recorded the number of calories they consumed; a third group ate 1,200 calories a day, but did not have to record them, and the fourth group ate normally without any calorie-tracking.

At the start and end of the three-week trial, the researchers measured each woman’s cortisol and stress levels. When calories were restricted, cortisol levels increased. In addition, calorie-counting also increased the women’s perceived stress, the researchers found.

“The term ‘dieting’ brings to mind deprivation, starvation, being miserable and uncomfortable and ultimately failing in weight loss efforts,” Samantha Heller, a dietitian, nutritionist and exercise physiologist who is familiar with the study, said.

Burning more calories than you consume is how your body loses weight, she said. “However, severe calorie restriction, diet fads, pills and potions, detox cleanses and other quacky approaches to weight loss only contribute to people’s diet failures and, in fact, may increase the likelihood of regaining even more weight than what was lost — if any,” Heller added.

The best way to drop unwanted pounds is to adopt healthy lifestyle behaviors that include eating a variety of healthy foods, physical activity, patience and a game plan, she said.

“Many people want to lose weight and do not know how to begin. Creating a step-by-step plan is one piece of the puzzle a lot of people forgo,” Heller said.

Starting a weight-loss program takes discipline, motivation and a desire to make behavioral changes and finding support can be very helpful, Heller added.

Another expert, Dr. David L. Katz, director of the Prevention Research Center at Yale University School of Medicine in New Haven, Conn., said while dieting isn’t easy, certain strategies can help reduce stress and achieve a healthier lifestyle.

“Food itself, a reliable source of immediate gratification, may be used to relieve stress,” Katz said. “When food intake is restricted, something else should replace it.”

In general, dieting alone is not all that useful, Katz added. “Eating well and being active for life is the way to go,” he said.

“By eating foods of higher overall nutritional quality, fullness can generally be achieved on fewer calories, eliminating the need for deprivation,” Katz said. “In addition, physical activity can accelerate weight loss, promote health and alleviate stress in the bargain.”

SOURCES: A. Janet Tomiyama, Ph.D., Robert Wood Johnson Foundation Health & Society Scholar, University of California, San Francisco; David L. Katz, M.D., M.P.H., director, Prevention Research Center, Yale University School of Medicine, New Haven, Conn.; Samantha Heller, M.S., R.D., dietitian, nutritionist, exercise physiologist, Fairfield, Conn;

Researchers have identified two gene variants that increase the risk of both the most common chronic liver disease in the United States as well as type 2 diabetes.

People who carry the variants of a gene for apolipoprotein C3 (APOC3), which produces an enzyme important in fat metabolism, have a higher incidence of nonalcoholic fatty liver disease and also insulin resistance, according to a report in the March 25 issue of the New England Journal of Medicine. The research group was led by Dr. Gerald I. Shulman, a professor of physiological chemistry, medicine and cellular and molecular physiology at Yale University.

Identification of the gene variants “might make it possible to screen individuals to see if they have a higher risk of fatty liver disease,” Shulman said. “It also can provide an ideal drug target to prevent development of fatty liver disease and insulin resistance.”

Fatty liver disease can be caused by excessive alcoholic consumption and obesity. Its incidence has increased in the United States, and more than 30 percent of Americans are estimated to have it, Shulman said.

In many cases, excess buildup of fat in the liver causes only minor problems. But it can progress to cause major, life-threatening deterioration of liver function. In the same way, insulin resistance can lead to type 2 diabetes, a major risk factor for heart attack, stroke and other cardiovascular problems.

Shulman and his colleagues first looked for the APOC3 gene variants in 95 lean Asian Indian men, an ethnic group in which the incidence of fatty liver disease is high, for unknown reasons. “Carriers of these gene variants had 5.5 percent fat in their liver, and were also markedly insulin-resistant,” Shulman said.

The variants cause higher levels of APO3C, which inhibits an enzyme that breaks down fats, Shulman said. The excess fats are deposited in the liver. Thirty-eight percent of the men with the gene variants had fatty liver disease.

The Yale group then did the same genetic study in a mixed ethnic group of 163 men and found a similar incidence of fatty liver disease and insulin resistance among those with the gene variants.

The next step in the Yale program will be an effort to learn why the condition is more common in East Asian men, Shulman said. But a longer-term goal is to put the finding to use to detect high-risk individuals, he noted.

“If you have a test, you can make them careful about their weight,” he said. “The good news is that we have shown that even modest weight reduction can reduce the risk. Dropping 15 pounds reverses fatty liver disease and insulin resistance.”

Beyond that would be a treatment aimed at the gene variants, Shulman said. “It’s even better if you have something you can do about it,” he said. “You could screen people, test for fatty liver and insulin resistance and treat that with agents.”

A screening test could help single out people whose fatty livers were not dangerous, said Dr. Anna Mae Diehl, chief of gastroenterology at Duke University, who wrote an accompanying editorial in the journal.

“Simply having extra fat in the liver is of unknown significance,” Diehl said. “Many people who have it are fine. Some get more advanced forms of liver disease. We want to know if this polymorphism is associated not only with fat, but also with damage.”

Such a determination now requires a biopsy to remove a segment of the liver for examination, Diehl said. “We still don’t have a noninvasive blood test,” she said. “That might help sort out who has more serious damage. We are hoping that in the next few years better tests become available.”

SOURCES: Gerald I. Shulman, M.D., Ph.D, professor, physiological chemistry, medicine, cellular and molecular physiology, Yale University, New Haven, Conn.; Anna Mae Diehl, M.D., professor, medicine, and chief, gastroenterology, Duke University, Durham, N.C.; New England Journal of Medicine

Brown rice is better than white rice at reducing the risk of type 2 diabetes, but whole grains are the most effective at lowering the risk, study findings show.

U.S. researchers analyzed data from 39,765 men in the Health Professionals Follow-up Study and 157,463 women in the Nurses’ Health Study I and II. None of the participants had diabetes, heart disease or cancer at the start of the studies. Their consumption of brown and white rice, as well as other foods, was assessed every two to four years.

During 3.3 million person-years of follow-up, there were 10,507 incidents of type 2 diabetes. After adjusting for a number of dietary and lifestyle risk factors, the researchers found that people who ate five or more servings per week of white rice were 17 percent more likely to develop type 2 diabetes than those who ate less than one serving of white rice per month.

In contrast, people who ate two or more servings of brown rice per week were 11 percent less likely to develop type 2 diabetes than those who ate less than one serving of brown rice per month, the study authors reported.

“We estimated that replacing 50 grams/day intake of white rice with the same amount of brown rice was associated with a 16 percent lower risk of type 2 diabetes, whereas the same replacement with whole grains as a group was associated with a 36 percent lower diabetes risk,” wrote Dr. Qi Sun, of Harvard School of Public Health in Boston, and colleagues.

The study was to be presented Wednesday at the American Heart Association’s Nutrition, Physical Activity and Metabolism Conference in San Francisco.

SOURCE: American Heart Association

Americans eat way too much salt and cutting down on that consumption should be a cornerstone of new public health efforts to curb hypertension.

That’s one of the key messages of an Institute of Medicine (IOM) report, commissioned by the U.S. Centers for Disease Control and Prevention and released Monday, that calls hypertension — or high blood pressure — a “neglected disease,” one that has fallen off the public health radar and needs to be put back on.

“High blood pressure and its consequences are too important to remain a neglected disease,” Dr. David Fleming, chairman of the committee that produced the report, said during a morning news conference. “It’s time to give our complete attention to take full advantage of known and promising interventions, and take concerted actions necessary to achieve prevention and control of hypertension.”

The public-health initiatives described by the report would refocus efforts from individual actions to so-called environmental considerations, such as stocking fresh produce in urban grocery stores, making streets safe to walk on, and enlisting the help of industry in manufacturing foods with lower salt content.

“Congress must give priority to adequate resources to implement a broad sweep of policy-based approaches at the state, local and federal levels,” said Fleming, who is director of public health for Seattle/King County, Washington.

According to the report, nearly one-third of U.S. adults have high blood pressure, and it accounts for about one in six adult deaths annually, a 25 percent increase from 1995 to 2005. High blood pressure usually has no symptoms: You can have it for years without knowing it, even though it can damage the heart, blood vessels, kidneys and other parts of the body, according to the U.S. National Institutes of Health.

“If you live long enough, you are almost guaranteed to get hypertension,” said Dr. Corinne Husten, a committee member who, at the time the report was being prepared, was executive vice president for program and policy at the Partnership for Prevention. She is now senior medical advisor at the U.S. Food and Drug Administration’s Center for Tobacco Products.

The report outlines several priorities.

The first would be to cut Americans’ salt intake — 80 percent of Americans currently eat more than the recommended amount and that number is growing. But given that 70 percent of Americans’ sodium comes from packaged foods and restaurants — not from the family salt shaker — the food industry needs to play a role here, Fleming said. “These efforts should be focused on making it easier for people to eat less salt,” he said.

Experts also need to better understand why many health-care providers fail to adhere to current treatment guidelines, despite knowing what the stakes are. Some people don’t even know they have high blood pressure, likely a failure of their doctor or other provider. “We are alarmed at the extent to which Americans have undiagnosed hypertension, equally the millions who have been diagnosed and are under the care of a provider but whose hypertension isn’t controlled,” Fleming said. Only one-third of people with the diagnosis have it under control.

The third area involves breaking down economic barriers that prevent patients from taking their medication. The committee recommended that the CDC work with the Centers for Medicare & Medicaid Services, pharmaceutical companies and businesses to help get medication to those who need it.

The committee also recommended that procedures be set up to measure performance in controlling hypertension and how much salt is actually being consumed. “There is really inadequate national data on trends,” said Dr. Walter Willett, chairman of nutrition and epidemiology at the Harvard School of Public Health.

American Heart Association President Dr. Clyde Yancy said in a prepared statement: “This Institute of Medicine report on hypertension now reinforces the need for a broad-based initiative in the science and public health spectrums to help individuals manage hypertension and perhaps even prevent the onset of hypertension.”

Yancy stated, “We support the IOM’s recommendations to make drug therapy more affordable for Medicaid and Medicare beneficiaries and boost funding for prevention programs that provide smoking-cessation counseling and screenings for high blood pressure and cholesterol for underserved populations.”

SOURCES: news release, American Heart Association; teleconference with David W. Fleming, M.D., director, public health, Seattle/King County, Wash.; Corinne Husten, M.D., former executive vice president for program and policy, Partnership for Prevention, and currently senior medical advisor, Center for Tobacco Products, U.S. Food and Drug Administration; Walter Willett, M.D., Dr.P.H., Fredrick John Stare Professor of Epidemiology and Nutrition, and chair, department of nutrition and epidemiology, Harvard School of Public Health, Boston; A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension

n intensive treatment strategy shows promise against locally advanced rectal cancer.

The phase 2 study included 105 patients with poor-risk rectal cancer, meaning they have a high likelihood of disease recurrence and poor survival odds despite receiving standard chemotherapy and optimum surgery.

For this study, the patients underwent 12 weeks of chemotherapy treatment with capecitabine and oxaliplatin, followed by chemoradiotherapy with capecitabine and surgery, followed by another 12 weeks of capecitabine treatment.

After three years, 68 percent of the patients had no cancer progression, and the overall survival rate was 83 percent. After five years, the overall survival rate was 75 percent.

“Tumor downstaging was shown in most patients receiving neoadjuvant treatment with a low incidence of involved [circumferential resection margins (CRMs)] in the surgical specimens. Before treatment, 90 percent of eligible patients had tumors with CRMs at risk or involved,” wrote David Cunningham, from the Royal Marsden Hospital in England, and colleagues.

“With no disease recurrences up to now in patients who achieved pathological complete response, this would be a valid endpoint to be used in future studies … our efficacy and safety findings justify further evaluation of neoadjuvant chemotherapy,” they concluded.

The study was published online

The stress of caring for a disabled spouse increases the risk of stroke substantially, and the increased risk is greater for husbands than for wives, a new study finds.

“We followed 767 people out of a large study who were caring for a spouse with any disabling condition,” said William E. Haley, a clinical psychologist who is a professor in the School of Aging Studies at the University of South Florida in Tampa. “The spouses who had the highest scores for strain had the highest risk scores for stroke.”

Strain was measured on a standard score by asking the participants how many days during the past week they had felt depressed, lonely, sad or had crying spells. The answers were matched to the Framingham Stroke Risk Score, which measures risk factors such as age, blood pressure, blood cholesterol levels, smoking and diabetes. The study is published in the Jan. 14 online edition of Stroke.

A high score on the measure of strain was associated with an overall 23 percent higher risk of stroke. The association was stronger in husbands than in wives. It was highest in black men with high caregiving strain, with a 26.9 percent increased risk of stroke in the next 10 years.

“We showed that African-American men have the highest risk for stroke of any demographic group,” Haley said. “The risk is nearly doubled for the highest-strain African-American men,” he added.

“For the most part, when men are caregivers they use more paid services,” Haley said. “It’s likely that men who are not getting help, African-American men in particular, experience tremendous strain. Women are more prepared to be caregivers, and show less risk tied to strain.”

It’s not clear whether the high-risk scores will result in an increased incidence of stroke, he noted. “We haven’t followed enough people for long enough to do that analysis,” Haley said. “Over the next several years, we will have the ability to see whether high degrees of strain lead to a higher incidence of stroke and mortality.”

Caregivers who feel the strain can and should seek help, he advised. “We do know already that caregivers can benefit from all sorts of counseling,” Haley said. “We encourage those caregivers to get additional assistance.”

Another study in the same issue of the journal, this one from Sweden, found that only half to three-quarters of people who survived strokes were still taking recommended drugs to prevent a new stroke two years later.

The study of more than 21,000 stroke survivors, average age 75, found that two years later, 26 percent had stopped taking drugs to control high blood pressure, 44 percent had stopped taking cholesterol-lowering statins, 36 percent had stopped taking clot-preventing medications and 55 percent were not taking the blood thinner warfarin.

It’s not clear whether the same pattern of noncompliance is true for the United States, wrote the neurologists from Umea University Hospital, but “it is very much so here,” said Dr. Bruce Ovbiagele, director of the stroke prevention program at the University of California, Los Angeles.

There are several possible explanations for failure to take such basic measures to prevent another stroke, Ovbiagele said. “On the part of the patients, many patients are not clear that they need to be on these medications indefinitely,” he noted.

Physicians can also be at fault, Ovbiagele added. “Some providers are not as insistent about educating patients about how long they need to be on these medications,” he said. “Most evidence of their value comes from relatively short studies, so providers may not think it is evident that they have to be continued.”

Patient compliance with medication instructions after a stroke is best when “there is some structured interventional program to support it,” Ovbiagele said.

SOURCES: William E. Haley, Ph.D., professor, School of Aging Studies, University of South Florida, Tampa; Bruce Ovbiagele, M.D., associate professor, neurology, and director, stroke prevention program, University of California, Los Angeles;

Three-quarters of patients undergoing surgery for stubborn sinusitis saw significant improvements in their quality of life, new research shows.

Most of the remaining 25 percent also saw some improvement, just not as dramatic, said Dr. Timothy Smith, lead author of a study appearing in the January issue of Otolaryngology — Head and Neck Surgery.

“Certainly this reinforces our belief that sinus surgery increases the quality of life of patients, and I see that clinically as well as scientifically,” added Dr. Jordan S. Josephson, a sinus and allergy specialist at Lenox Hill Hospital in New York City. “Previous studies have been single-center studies, and this is a bigger study using multiple centers and using a fairly large population, so it further says sinus surgery is a really good thing to do if you need it.”

Chronic rhinosinusitis (CRS) affects a sizable minority — 14 percent to 16 percent — of U.S. residents. The condition, marked by symptoms such as sinus pain and pressure, headache, stuffy nose and sneezing, can compromise quality of life more than even congestive heart failure, back pain or chronic obstructive pulmonary disease, the study authors said.

Endoscopic sinus surgery has been performed in the United States since the mid-1980s, said Smith, who is director of the Oregon Sinus Center at Oregon Health & Science University in Portland.

“It’s a minimally invasive type of surgery performed with a telescope that goes into the nostril,” then basically snips away abnormal and interfering tissue while leaving normal tissue behind, Smith explained.

Smith and his co-authors studied 302 patients with CRS from three academic medical centers, following them for an average of a year and a half after their surgery.

“These were patients who have chronic sinusitis so, by definition, they have at least three months of symptoms and they have evidence of an ongoing inflammation or infection of their nose and sinuses on either a CT scan or an examination of the nose and sinuses,” Smith said.

Following the surgery, about 76 percent of patients had “clinically significant” improvement in quality of life, as measured by various validated scales.

Patients with worse disease at the outset seemed to fare the best after the procedure, as did those undergoing surgery for the first time. This second finding is probably explained by the fact that people going for second or further surgeries were probably sicker to begin with, Josephson said.

None of which is to say that patients shouldn’t try medical therapies first, he added.

“I don’t think it means everyone with CRS should consider surgery. They should try medical therapy, and if medical therapy fails and the surgeon feels that part of the problem is anatomic, then surgery would be a good tool for them to use,” Josephson said. “Some people with stage 1 and 2 diseases may even get cured. This is a wonderful renewed hope of feeling better.”